Monaldi archives for chest disease = Archivio Monaldi per le malattie del torace / Fondazione clinica del lavoro, IRCCS [and] Istituto di clinica tisiologica e malattie apparato respiratorio, Università di Napoli, Secondo ateneo
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Elderly patients are increasingly opting for intensive care unit (ICU) treatment with mechanical ventilation (MV). The aim of this study was to review specific aspects of MV in the older elderly (80-yrs-old and older). We retrospectively studied all patients who underwent MV during a 2-year-period in our respiratory ICU. ⋯ This selection enables us to obtain results from older populations which are as good as those from nonselected younger populations. When its use is practicable, noninvasive ventilation is associated with less discomfort, fewer complications and better short-term results than is endotracheal ventilation. In all cases, the long-term prognosis is poor.
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The prone position, initially introduced into respiratory therapy to improve the drainage of secretions, has been suggested to improve oxygenation in anaesthetized and paralysed subjects. Here we report on the results obtained using the prone position in 17 normal subjects, 10 obese subjects and 16 patients with acute respiratory failure (ARF). In normal subjects, the prone position did not alter respiratory system compliance (Crs,st, 80.9 +/- 16.6 versus 75.9 +/- 13.2 mL.cmH2O-1), while it did improve arterial oxygen tension (Pa,O2, 21.3 +/- 4.9 versus 26.5 +/- 2.1 kPa, p < 0.01), this improvement being paralleled by an increase in functional residual capacity (FRC, 1.935 +/- 0.576 versus 2.921 +/- 0.681 L, p < 0.01). ⋯ In ARF patients, no difference between the supine and prone position was found either in FRC (1.17 +/- 0.41 versus 1.29 +/- 0.57 L), or in Crs,st (38.4 +/- 13.7 versus 35.9 +/- 10.7 mL.cmH2O-1) or CL,st (52.4 +/- 23.3 versus 53.9 +/- 23.6 mL.cmH2O-1) despite a significant reduction in Ccw,st being observed (204.8 +/- 97.4 versus 135.9 +/- 52.5, p < 0.01). In this group of patients, the use of the prone position resulted in a significant increase in Pa,O2 (13.7 +/- 3.2 versus 17.2 +/- 4.4 kPa, p < 0.05), being the oxygenation improvement induced by the prone position relative to the baseline Ccw,st, according to the relationship: Pa,O2 = -32.4 + (0.24 x Ccw,st); r = 0.82, p < 0.01). The mechanisms which can be hypothesized to justify the modifications reported above are discussed.
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Every intubated and mechanically-ventilated patient should be clinically evaluated, at least on a daily basis, by a skilled team in order to speed up the weaning process as much as possible. Again, it should be emphasized that the adoption of an active clinical strategy when faced with "difficult" to wean patients is of paramount importance. In one study, performed in Spain, analysing the prevalence of mechanical ventilation in intensive care units [3], reported the mean number of days that patients spent on mechanical ventilation was 27. ⋯ These data suggest that there are still some patients being on mechanical ventilation for a longer than necessary period of time. Finally, very recent advances in technological areas such as artificial intelligence, are proving to be useful in the management of the weaning process. When such systems are applied to modern microprocessor-controlled mechanical ventilators they can significantly help in the process of weaning [42] by automatically reducing the ventilatory assistance and by indicating the optimal time to withdraw the patient from the ventilator and proceed with extubation.
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Monaldi Arch Chest Dis · Jun 1998
ReviewInvasive mechanical ventilation in exacerbations of chronic obstructive pulmonary disease.
Exacerbations of chronic obstructive pulmonary disease are appropriately treated when severe airflow obstruction does not respond to intensive therapy, including, at times, noninvasive mechanical ventilation. Ventilatory strategies include avoidance of the ventilatory complications of dynamic pulmonary hyperinflation with its resultant intrinsic positive end-expiratory pressure, thereby decreasing the risk of hypotension and barotrauma. ⋯ Further adjustments are made on the basis of gas exchange and pulmonary mechanics. Medical therapies include beta-agonists and corticosteroids.