Seminars in respiratory and critical care medicine
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Semin Respir Crit Care Med · Aug 2014
ReviewNoninvasive Ventilation in Withdrawal from Mechanical Ventilation.
Patients with chronic airflow obstruction and difficult or prolonged weaning are at increased risk for prolonged invasive mechanical ventilation (IMV). Several randomized controlled trials mainly conducted in patients who had pre-existing lung disease have shown that the use of noninvasive ventilation (NIV) to advance extubation in patients with difficult and prolonged weaning can result in reduced periods of endotracheal intubation, complication rates, and improved survival. ⋯ By contrast, NIV immediately after extubation is effective in avoiding respiratory failure after extubation and improving survival in patients at risk for this complication, particularly those with chronic respiratory disorders, cardiac comorbidity, and hypercapnic respiratory failure. Finally, both continuous positive airway pressure and NIV can improve clinical outcomes in patients with postoperative acute respiratory failure, particularly abdominal and thoracic surgery.
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Traditionally, critically ill patients undergoing mechanical ventilation (MV) have received sedation. Over the last decade, randomized controlled trials have questioned continued use of deep sedation. Evidence shows that a nurse-driven sedation protocol reduces length of MV compared with standard strategy with sedation. ⋯ Moreover, delirium has gained increased focus in recent years with development of validated tools to detect both hyperactive and hypoactive forms of delirium. Using validated tools for detecting delirium is important in monitoring and detecting acute brain dysfunction in critically ill patients. Evidence from randomized trials also cites a beneficial effect of early mobilization with respect to length of MV and delirium.
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Semin Respir Crit Care Med · Aug 2014
Noninvasive Ventilation in Acute Hypercapnic Respiratory Failure.
Noninvasive mechanical ventilation (NIV) improves gas exchange and clinical outcome in various types of acute respiratory failure. Acute exacerbation of chronic obstructive pulmonary disease is a frequent cause of acute hypercapnic respiratory failure (AHRF). ⋯ Indications for the use of NIV have expanded over the past decade. In this article, we discuss the clinical indications and goals of NIV in the management of AHRF.
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Semin Respir Crit Care Med · Aug 2014
Review Comparative StudyVentilator-Associated Lung Injury during Assisted Mechanical Ventilation.
Assisted mechanical ventilation (MV) may be a favorable alternative to controlled MV at the early phase of acute respiratory distress syndrome (ARDS), since it requires less sedation, no paralysis and is associated with less hemodynamic deterioration, better distal organ perfusion, and lung protection, thus reducing the risk of ventilator-associated lung injury (VALI). In the present review, we discuss VALI in relation to assisted MV strategies, such as volume assist-control ventilation, pressure assist-control ventilation, pressure support ventilation (PSV), airway pressure release ventilation (APRV), APRV with PSV, proportional assist ventilation (PAV), noisy ventilation, and neurally adjusted ventilatory assistance (NAVA). ⋯ Furthermore, during assisted MV, the following parameters should be monitored: inspiratory drive, transpulmonary pressure, and tidal volume (6 mL/kg). Further studies are required to determine the impact of novel modalities of assisted ventilation such as PAV, noisy pressure support, and NAVA on VALI.