Current opinion in critical care
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Acute lung injury and its extreme manifestation, acute respiratory distress syndrome, complicate a wide variety of serious medical and surgical conditions, only some of which affect the lung directly. Despite recent evidence-based advances in clinical management, acute lung injury and acute respiratory distress syndrome are associated with significant mortality. Detailed epidemiology is essential in guiding the recruitment of patients into trials of new therapeutic interventions, thereby improving outcome and allowing directed allocation of scarce resources. ⋯ Recent epidemiologic studies of the incidence of acute lung injury and acute respiratory distress syndrome have indicated a similar incidence in developed societies, and they confirm that mortality is falling in comparison with a decade ago. The awaited publication of new consensus guidelines for the definition of acute lung injury and acute respiratory distress syndrome may render new studies necessary.
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Curr Opin Crit Care · Feb 2005
ReviewMechanical ventilation in acute respiratory failure: recruitment and high positive end-expiratory pressure are necessary.
To review as best the critical care clinicians can recruit the acute respiratory distress syndrome (ARDS) lungs and keep the lungs opened, assuring homogeneous ventilation, and to present the experimental and clinical results of these mechanical ventilation strategies, along with possible improvements in patient outcome based on selected published medical literature from 1972 to 2004 (highlighting the period from June 2003 to June 2004 and recent results of the authors' group research). ⋯ Stepwise PEEP recruitment maneuvers can open collapsed ARDS lungs. Higher levels of PEEP are necessary to maintain the lungs open and assure homogenous ventilation in ARDS. In the near future, thoracic CT associated with high-performance monitoring of regional ventilation (electrical impedance tomography) may be used at the bedside to determine the optimal mechanical ventilation of ARDS patients.
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Mechanical ventilation is usually provided in acute lung injury to ensure alveolar ventilation and reduce the patients' work of breathing without further damaging the lungs by the treatment itself. Although partial ventilatory support modalities were initially developed for weaning from mechanical ventilation, they are increasingly used as primary modes of ventilation, even in patients in the acute phase of pulmonary dysfunction. The aim of this paper is to review the role of spontaneous breathing ventilatory modalities with respect to their physiologic or clinical evidence. ⋯ On the basis of currently available data, the authors suggest the use of techniques of mechanical ventilatory support that maintain, rather than suppress, spontaneous ventilatory effort, especially in patients with severe pulmonary dysfunction.
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Curr Opin Crit Care · Feb 2005
ReviewPulmonary and extrapulmonary acute respiratory distress syndrome: are they different?
Acute respiratory distress syndrome has been considered a morphologic and functional expression of lung injury caused by a variety of insults. Two distinct forms of acute respiratory distress syndrome/acute lung injury are described, because there are differences between pulmonary acute respiratory distress syndrome (direct effects on lung cells) and extrapulmonary acute respiratory distress syndrome (reflecting lung involvement in a more distant systemic inflammatory response). This article will focus on the differences in lung histology and morphology, respiratory mechanics, and response to ventilatory strategies and pharmacologic therapies in pulmonary and extrapulmonary acute respiratory distress syndrome. ⋯ The understanding of acute respiratory distress syndrome needs to take into account its origin. If each pathogenetic mechanism were to be considered, clinical management would be more precise, and probably the outcome could include real amelioration.