Current opinion in critical care
-
Curr Opin Crit Care · Feb 2020
ReviewPatient self-inflicted lung injury and positive end-expiratory pressure for safe spontaneous breathing.
The potential risks of spontaneous effort and their prevention during mechanical ventilation is an important concept for clinicians and patients. The effort-dependent lung injury has been termed 'patient self-inflicted lung injury (P-SILI)' in 2017. As one of the potential strategies to render spontaneous effort less injurious in severe acute respiratory distress syndrome (ARDS), the role of positive end-expiratory pressure (PEEP) is now discussed. ⋯ To prevent P-SILI in ARDS, it seems feasible to facilitate 'safe' spontaneous breathing in patients using a higher PEEP strategy in severe ARDS.
-
Curr Opin Crit Care · Feb 2020
ReviewThe role of computer-based clinical decision support systems to deliver protective mechanical ventilation.
Mechanical ventilation of adults and children with acute respiratory failure necessitates balancing lung and diaphragm protective ventilation. Computerized decision support (CDS) offers advantages in circumstances where complex decisions need to be made to weigh potentially competing risks, depending on the physiologic state of the patient. ⋯ Goals for achieving compliance and physiologic objectives can be met when CDS instructions are simple and explicit, provide the clinician with the underlying rule set, permit acceptable reasons for declining and allow for iterative adjustments.
-
Accurate monitoring of the mechanical properties of the respiratory system is crucial to understand the pathophysiological mechanisms of respiratory failure in mechanically ventilated patients, to optimize mechanical ventilation settings and to reduce ventilator-induced lung injury. However, although the assessment of respiratory mechanics is simple in patients undergoing fully controlled ventilation, it becomes quite challenging in the presence of spontaneous breathing activity. Aim of the present review is to describe how the different components of respiratory mechanics [resistance, static compliance, and intrinsic positive end-expiratory pressure (PEEP)] can be measured at the bedside during assisted modes of ventilation. ⋯ Assessment of respiratory mechanics in spontaneously breathing patients, with some limitations, is feasible and should be included in everyday clinical practice; however, more data are needed to understand the clinical relevance of the measures obtained during assisted ventilation.
-
Complications of mechanical ventilation, such as ventilator-induced lung injury (VILI) and ventilator-induced diaphragmatic dysfunction (VIDD), adversely affect the outcome of critically ill patients. Although mostly studied during control ventilation, it is increasingly appreciated that VILI and VIDD also occur during assisted ventilation. Hence, current research focuses on identifying ways to monitor and deliver protective ventilation in assisted modes. This review describes the operating principles of proportional modes of assist, their implications for lung and diaphragm protective ventilation, and the supporting clinical data. ⋯ Physiological rationale and clinical data suggest a potential role for proportional modes of assist in providing and monitoring lung and diaphragm protective ventilation.
-
Diaphragm weakness can impact survival and increases comorbidities in ventilated patients. Mechanical ventilation is linked to diaphragm dysfunction through several mechanisms of injury, referred to as myotrauma. By monitoring diaphragm activity and titrating ventilator settings, the critical care clinician can have a direct impact on diaphragm injury. ⋯ A ventilator strategy that results in appropriate levels of diaphragm activity has the potential to be diaphragm-protective and improve clinical outcome. Monitoring respiratory effort during mechanical ventilation is becoming increasingly important.