Critical care clinics
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Critical care clinics · Apr 2007
Review"The use of positive end-expiratory pressure in mechanical ventilation".
An improvement in oxygenation for patients who have acute respiratory failure using PEEP was described close to 40 years ago. Since then, a considerable amount of research has allowed clinicians to use this therapeutic modality in various ways. In patients receiving mechanical ventilation, the term positive end-expiratory pressure (PEEP) refers to pressure in the airway at the end of passive expiration that exceeds atmospheric pressure. ⋯ It has been shown that this helps the respiratory muscles to decrease the work of breathing and the amount of infiltrated-atelectatic tissues. The beneficial effects of the use of PEEP include: the improvement of oxygenation, recruitment of lung units, and improvement of compliance. Other effects can be adverse, like decreasing cardiac output, increased risk of barotrauma, and the interference with assessment of hemodynamic pressures.
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The rational for using closed loop ventilation is becoming strong and stronger. Studies are now available supporting the hypothesis that patient outcome is improved by using closed loop ventilation. ⋯ Introducing novel graphical user interfaces and providing data displays that are pertinent, integrative and dynamic will reduce cognitive resources of the clinician and have the potential to make ventilation safer. They may be the key to adopt closed loop ventilation in everyday practice.
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Critical care clinics · Apr 2007
ReviewThe open lung concept of mechanical ventilation: the role of recruitment and stabilization.
This article describes the pathophysiologic basis and clinical role for lung recruitment maneuvers. It reviews the literature and presents the authors' clinical experience of over 15 years in the collaboration between Erasmus MC and the University of Rochester. The authors are hopeful that these lung-protective strategies are presented in a useful format that may be useful to the practicing intensivist, thus bringing laboratory and clinical research to bedside practice.
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Postoperative lung injury is a common, although decreasing, complication of cardiac surgery. This article discusses various means to prevent and minimize postoperative lung injury. These include lung-protective strategies, pharmacologic strategies, and mechanical ventilation.
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Critical care clinics · Apr 2007
ReviewDiscontinuation of mechanical ventilation at end-of-life: the ethical and legal boundaries of physician conduct in termination of life support.
End-of-life care in the ICU generally encompasses both the withholding and withdrawal of life support and the administration of palliative care. There is little practical distinction in the specific technology or life-support modality that is limited or removed with respect to the subsequent medical, ethical, or legal analysis. The important ethical issues pertinent to end-of-life care in the ICU at the point-of-life support discontinuation are: (1) the distinction between allowing patients to die in accordance with their wishes and causing them die, (2) the fine line between respecting a patient's wish to die with dignity and control and the risk of subsequent allegations of euthanasia or physician-assisted suicide, and (3) the adjunctive use of medications that simultaneously provide comfort but also may hasten death. The medical and legal issues are summarized, and an algorithm for the discontinuation of mechanical ventilatory support at the end of life is presented.