Respiratory care clinics of North America
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Management of mechanical ventilation is a complex process with outcomes affected by multiple patient and caregiver variable. Well-constructed protocols represent the synthesis of best available evidence regarding ventilator management. In adults, protocols improve important outcomes such as duration of mechanical ventilation, length of stay, and complication rates; however, protocols are not uniformly successful. ⋯ It is hoped that future research will further define the appropriate use of protocols in the general PICU population. Although specific protocols cannot be routinely recommended, a multidisciplinary team approach to synthesizing available literature and determining best practice is a useful model. This approach will foster "team ownership" of ventilator management by all involved, thus engendering the best possible outcomes for critically ill children who require mechanical ventilation.
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Respir Care Clin N Am · Sep 2006
ReviewThe role of inhaled nitric oxide and heliox in the management of acute respiratory failure.
The application of positive-pressure mechanical ventilation is one of the cornerstones of support for patients with acute respiratory failure. Unfortunately, the clinical condition of some patients does not improve, despite escalating ventilatory support. Adjunctive therapies to mechanical ventilation such as nitric oxide and heliox have been explored for the purposes of minimizing injurious settings and supporting adequate gas exchange. ⋯ This article discusses the role of nitric oxide and heliox as adjunct therapies to mechanical ventilation. Many questions remain about the role of these unique gases in the management of pediatric patients with acute respiratory failure. Should nitric oxide be used outside of its approved indication, and should heliox be used at all due to the lack of definitive evidence?
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Predictors of extubation outcome attempt to provide objective data that may help to modify clinical decision making at the bedside. This article reviews the subjective and objective extubation readiness predictors tested in the pediatric medical literature. ⋯ Therefore, weaning and extubation practices in the pediatric critical care setting remain variable, and teh development of standardized protocols for extubation remains controversial. Perhaps future well-designed, large-scale trials will provide more accurate predictors of extubation readiness to guide the safe and timely extubation of the pediatric patient.
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Respir Care Clin N Am · Sep 2006
ReviewIs permissive hypercapnia a beneficial strategy for pediatric acute lung injury?
It is clear that mechanical ventilation strategies influence the course of lung disease, and the choice of a ventilation strategy that avoids volutrauma and atelectrauma is firmly based on experimental literature and clinical experience. The application of a lung-protective strategy with reduced tidal volumes, effective lung recruitment, adequate PEEP to minimize alveolar collapse during expiration, and permissive hypercapnia has been shown to be advantageous in adult patients who have ARDS, although it has not been systematically studied in children. A significant body of literature confirms the beneficial effects of hypercapnic acidemia in the setting of acute lung injury. ⋯ This acceptance should be tempered with the recognition that a low-stretch, reduced-tidal volume strategy without hypercapnia has also been shown to improve outcomes in adults who have ARDS and that HFOV can generally provide lung-protective ventilation without necessarily inducing hypercapnia. Thus, a synthesis of the available clinical and research data strongly supports a graded approach to managing patients who have acute lung injury requiring intubation. The highest priority should be a mechanical ventilation strategy that limits the tidal volume, with the allowance of hypercapnia to a degree that does not compromise hemodynamic status.
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Respir Care Clin N Am · Sep 2006
ReviewIs high-frequency ventilation more beneficial than low-tidal volume conventional ventilation?
The ventilator goals of the ICU clinician faced with caring for a critically ill child who has ALI/ARDS remain relatively simple: provide adequate ventilation and oxygenation without overdistending alveoli or furthering lung injury. How one obtains these goals is much less simple. The current use of CV calls for the use of relatively low V(T)s and limiting peak inspiratory pressure and plateau pressure while accepting a certain degree of respiratory acidosis. ⋯ In their work, the early initiation of HFOV was associated with improved gas exchange and a trend toward a lower mortality. In adults, Derdak and colleagues demonstrated the superiority of HFOV in terms of gas exchange and oxygenation; however, no statistical significant difference was found for mortality. So, where is the clinician left after a review of these data? It would appear that (1) low-V(T) CV remains a cornerstone of therapy for the pediatric patient who has ALI/ARDS; (2) HFOV is a safe and well-tolerated mode of mechanical ventilation; (3) early use of HFOV (as opposed to the rescue use of this mode) may be of benefit based on animal and human data; and (4) like so many areas of pediatric critical care, clinicians must await new data and trials that will help them continue to improve the care they provide.