Current opinion in critical care
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Curr Opin Crit Care · Feb 2019
ReviewNew physiological insights in ventilation during cardiopulmonary resuscitation.
In the setting of cardiopulmonary resuscitation (CPR), classical physiological concept about ventilation become challenging. Ventilation may exert detrimental hemodynamic effects that must be balanced with its expected benefits. The risks of hyperventilation have been thoroughly addressed, even questioning the need for ventilation, emphasizing the need to prioritize chest compression quality. However, ventilation is mandatory for adequate gas exchange as soon as CPR is prolonged. Factors affecting the capability of chest compressions to produce alveolar ventilation are poorly understood. In this review, we discuss the conventional interpretation of interactions between ventilation and circulation, from the perspective of novel physiological observations. ⋯ Recent advances in the understanding of ventilatory physiology during CPR shows that capnogram analysis not only provides information on the quality of resuscitation but also on the amount of ventilation produced by chest compressions and on the total amount of ventilation.
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Diaphragm dysfunction is common in mechanically ventilated patients and predisposes them to prolonged ventilator dependence and poor clinical outcomes. Mechanical ventilation is a major cause of diaphragm dysfunction in these patients, raising the possibility that diaphragm dysfunction might be prevented if mechanical ventilation can be optimized to avoid diaphragm injury - a concept referred to as diaphragm-protective ventilation. This review surveys the evidence supporting the concept of diaphragm-protective ventilation and introduces potential routes and challenges to pursuing this strategy. ⋯ Mechanical ventilation can cause diaphragm injury and weakness. A novel diaphragm-protective ventilation strategy, avoiding the harmful effects of both excessive and insufficient inspiratory effort, has the potential to substantially improve outcomes for patients.
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Curr Opin Crit Care · Feb 2019
ReviewRecent advances in venovenous extracorporeal membrane oxygenation for severe acute respiratory distress syndrome.
To summarize results of the most recent trials on venovenous extracorporeal membrane oxygenation (VV-ECMO) in severe acute respiratory distress syndrome (ARDS) and to elaborate on the unmet needs regarding VV-ECMO management in this setting. ⋯ VV-ECMO is a reasonable therapeutic option for patients with severe ARDS and major hypoxemia or excessive pressures. Future trials should be designed to optimize patients' management while on VV-ECMO support.
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Curr Opin Crit Care · Feb 2019
ReviewBedside respiratory physiology to detect risk of lung injury in acute respiratory distress syndrome.
The most effective strategies for treating the patient with acute respiratory distress syndrome center on minimizing ventilation-induced lung injury (VILI). Yet, current standard-of-care does little to modify mechanical ventilation to patient-specific risk. This review focuses on evaluation of bedside respiratory mechanics, which when interpreted in patient-specific context, affords opportunity to individualize lung-protective ventilation in patients with acute respiratory distress syndrome. ⋯ Quantifying patient-specific risk of VILI requires understanding each patient's pulmonary mechanics in context of biological predisposition. Tailoring support at bedside according to these factors affords the greatest opportunity to date for mitigating VILI and alleviating associated morbidity.
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Curr Opin Crit Care · Feb 2019
ReviewPhenotypes in acute respiratory distress syndrome: moving towards precision medicine.
To provide an overview of the current research in identifying homogeneous subgroups and phenotypes in ARDS. ⋯ Identification of distinct subgroups or phenotypes in ARDS may impact future conduct of clinical trials and can enhance our understanding of the disorder, with potential future clinical implications.