Current opinion in critical care
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Curr Opin Crit Care · Feb 2015
ReviewExtracorporeal life support for severe acute respiratory distress syndrome.
To provide a summary of the recent literature on extracorporeal membrane oxygenation (ECMO) in adults with severe acute respiratory distress syndrome (ARDS), focusing on advances in equipment, current conventional and unconventional indications, complications, and future applications. ⋯ High-quality evidence for the routine use of ECMO for management of adult patients with severe ARDS is still lacking. An ongoing randomized controlled trial (ECMO to rescue lung injury in severe ARDS) will contribute valuable data to guide clinical decisions to opt for this supportive therapy.
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Multiple clinical and laboratory studies have been conducted to illustrate the effects of hypercapnia in a range of injuries, and to understand the mechanisms underlying these effects. The aim of this review is to highlight and interpret information obtained from these recent reports and discuss how they may inform the clinical context. ⋯ Experiments involving hypercapnia have covered a wide range of illness models with varying degrees of success. It is becoming evident that deliberate hypercapnia in the clinical setting should seldom be used, except wherever necessitated to avoid ventilator-associated lung injury. A more complete understanding of the molecular mechanisms must be established.
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Curr Opin Crit Care · Feb 2015
ReviewDiscontinuation of ventilatory support: new solutions to old dilemmas.
Weaning from mechanical ventilation implies two separate but closely related aspects of care, the discontinuation of mechanical ventilation and removal of artificial airway, which implies routine clinical dilemmas. Extubation delay and extubation failure are associated with poor clinical outcomes. We sought to summarize recent evidence on weaning. ⋯ There is an interesting body of clinical research in the discontinuation of mechanical ventilation. Recent randomized controlled studies provide high-level evidence for the best approaches to weaning, especially in patients who fail the first spontaneous breathing trial or targeted populations.
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Compared with the conventional forms of partial support, neurally adjusted ventilatory assist was repeatedly shown to improve patient-ventilator synchrony and reduce the risk of overassistance, while guaranteeing adequate inspiratory effort and gas exchange. A few animal studies also suggested the potential of neurally adjusted ventilatory assist in averting the risk of ventilator-induced lung injury. Recent work adds new information on the physiological effects of neurally adjusted ventilatory assist. ⋯ Several studies nowadays prove the physiological benefits of neurally adjusted ventilatory assist, as opposed to the conventional modes of partial support. Whether these advantages translate into improvement of clinical outcomes remains to be determined.
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The present review summarizes developments in the field of respiratory muscle monitoring, in particular in critically ill patients. ⋯ Respiratory muscle dysfunction develops rapidly in selected critically ill patients and is associated with adverse outcome. Recent technological advances allow real-time monitoring of respiratory muscle activity in these patients. Although this field is in its infancy, from a physiological perspective, it is reasonable to assume that monitoring respiratory muscle activity improves outcome in these patients.