Current opinion in critical care
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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 paucity of effective therapeutic interventions in patients with the acute respiratory distress syndrome (ARDS) combined with overwhelming evidence on the importance of timely implementation of effective therapies to critically ill patients has resulted in a recent shift in ARDS research. Increasingly, efforts are being directed toward early identification of patients at risk with a goal of prevention and early treatment, prior to development of the fully established syndrome. The focus of the present review is on the prevention of ARDS in patients without this condition at the time of their healthcare encounter. ⋯ Recent improvements in clinical care delivery have been associated with a decrease in the incidence of hospital-acquired ARDS. Despite the initial challenges, research in ARDS prevention has become increasingly feasible with several randomized controlled trials on ARDS prevention completed or on the way.
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This article reviews the use of noninvasive ventilation (NIV) in patients with acute respiratory failure (ARF), with a critical review of the most recent literature in this setting. ⋯ Although patients with severe hypoxemic ARF are, in general, less likely to be intubated when NIV is used, the efficacy is different among these heterogeneous populations. Therefore, NIV is not routinely recommended in all patients with severe hypoxemic ARF.