Current opinion in critical care
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Curr Opin Crit Care · Feb 2007
ReviewTracheostomy in the critically ill: indications, timing and techniques.
Tracheostomy is one of the most common procedures performed in the intensive care unit. Indications, risks, benefits, timing and technique of the procedure, however, remain controversial. The decision of when and how to perform a tracheostomy is often subjective, but must be individualized to the patient. The following review gives an update on recent literature related to tracheostomy in the critically ill. ⋯ Due to increased experience and advanced techniques, percutaneous tracheostomy has become a popular, relatively safe procedure in the intensive care unit. The question of appropriate timing, however, has not been definitely answered with a randomized controlled trial. Instead, a number of retrospective studies and a single prospective study have shed some light on this issue. Most reports favor the performance of tracheostomy within 10 days of respiratory failure.
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The coupling between ventilator delivered inspiratory flow and patient's demands both in terms of timing and drive is a challenging task that has become largely feasible in recent years. This review addresses the new advances to modulate and treat patient-ventilator dyssynchrony. ⋯ Patient-ventilator dyssynchrony may affect patients' outcome. New modes of assisted mechanical ventilation have been introduced and represent a major step forward in modulating patient-ventilator dyssynchrony.
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Curr Opin Crit Care · Feb 2007
ReviewInsights in pediatric ventilation: timing of intubation, ventilatory strategies, and weaning.
Mechanical ventilation is a common intervention provided by pediatric intensivists. This fact notwithstanding, the management of mechanical ventilation in pediatrics is largely guided by a few pediatric trials along with careful interpretation and application of adult data. ⋯ Mechanical ventilation with pressure limitation and low tidal volumes has become customary in pediatric intensive care units, and this lung protective approach will continue into the foreseeable future. Further investigation is warranted regarding use of high frequency oscillatory ventilation, airway pressure release ventilation, and surfactant to assist pediatric intensivists in application of these therapies.
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Curr Opin Crit Care · Feb 2007
ReviewModulating cofactors of acute lung injury 2005-2006: any closer to 'prime time'?
Considerable progress has recently been made in understanding the modulation of acute lung injury by cofactors that are not traditionally considered 'pulmonary' in nature. We will review findings regarding some of these extrapulmonary cofactors, focusing on those most readily manipulated in the current clinical setting. ⋯ There are a number of simple, low-cost, and rapidly deployable approaches to reducing the severity of acute lung injury that are not directly pulmonary in origin. These interventions could be rapidly implemented in any intensive care unit, once evidence for their efficacy and safety is adequate.
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Curr Opin Crit Care · Feb 2007
ReviewManagement of ventilator-associated pneumonia caused by multiresistant bacteria.
The inappropriate choice of antibiotics (in nearly one third of episodes) is the most important risk factor for death. Traditionally, a narrow-spectrum drug was used first, and the most potent drugs were reserved for subsequent use. ⋯ As ventilator-associated pneumonia increases, empiric therapy should be based on local pathogen etiology and antibiotic resistant patterns. A new approach to consider is to start with a high-dose, broad-spectrum antibiotic and then tailor the individual therapy based on microbiological results and clinical resolution. With the use of broad-spectrum antibiotics available in empiric therapy tailored after reassessment of the patient, there is hope for reducing costs, length of stay and mortality whereas the emergence of resistance will be minimized.