Current opinion in critical care
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Curr Opin Crit Care · Feb 2024
ReviewSetting positive end-expiratory pressure: role in diaphragm-protective ventilation.
With mechanical ventilation, positive end-expiratory pressure (PEEP) is applied to improve oxygenation and lung homogeneity. However, PEEP setting has been hypothesized to contribute to critical illness associated diaphragm dysfunction via several mechanisms. Here, we discuss the impact of PEEP on diaphragm function, activity and geometry. ⋯ Setting PEEP could play an important role in both lung and diaphragm protective ventilation. Both high and low PEEP levels could potentially introduce or exacerbate diaphragm myotrauma. Today, the impact of PEEP setting on diaphragm structure and function is in its infancy, and clinical implications are largely unknown.
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Curr Opin Crit Care · Feb 2024
ReviewAirway pressure release ventilation for lung protection in acute respiratory distress syndrome: an alternative way to recruit the lungs.
Airway pressure release ventilation (APRV) is a modality of ventilation in which high inspiratory continuous positive airway pressure (CPAP) alternates with brief releases. In this review, we will discuss the rationale for APRV as a lung protective strategy and then provide a practical introduction to initiating APRV using the time-controlled adaptive ventilation (TCAV) method. ⋯ APRV using the TCAV method is a paradigm shift in protective lung ventilation, which primarily aims to stabilize the lung and gradually reopen collapsed tissue to achieve lung homogeneity eliminating the main mechanistic drivers of VILI.
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Positive end-expiratory pressure (PEEP) is required in the Berlin definition of acute respiratory distress syndrome and is a cornerstone of its treatment. Application of PEEP increases airway pressure and modifies pleural and transpulmonary pressures according to respiratory mechanics, resulting in blood volume alteration into the pulmonary circulation. This can in turn affect right ventricular preload, afterload and function. At the opposite, PEEP may improve left ventricular function, providing no deleterious effect occurs on the right ventricle. ⋯ The quest for optimal PEEP settings has been a prominent goal in ARDS research for the last decades. Intensive care physician must maintain a high degree of vigilance towards hemodynamic effects of PEEP on cardiac function and end-organs circulation.
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Curr Opin Crit Care · Feb 2024
ReviewSetting positive end-expiratory pressure: lung and diaphragm ultrasound.
The purpose of this review is to summarize the role of lung ultrasound and diaphragm ultrasound in guiding ventilator settings with an emphasis on positive end-expiratory pressure (PEEP). Recent advances for using ultrasound to assess the effects of PEEP on the lungs and diaphragm are discussed. ⋯ Lung and diaphragm ultrasound are useful for diagnosing the cause of respiratory failure and subsequently setting the ventilator including PEEP. Effects of PEEP on lung and diaphragm can be monitored using ultrasound.
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Curr Opin Crit Care · Feb 2024
ReviewThe place of positive end expiratory pressure in ventilator-induced lung injury generation.
Describe the rationale for concern and accumulating pathophysiologic evidence regarding the adverse effects of high-level positive end expiratory pressure (PEEP) on excessive mechanical stress and ventilator-induced lung injury (VILI). ⋯ The potentially adverse effects of PEEP on VILI can be considered in three broad categories. First, the contribution of PEEP to total mechanical energy expressed through mechanical power, raised mean airway pressure, and end-tidal hyperinflation; second, the hemodynamic consequences of altered cardiac loading, heightened pulmonary vascular stress and total lung water; and third, the ventilatory consequences of compromised carbon dioxide eliminating efficiency. Minimizing ventilation demands, optimized body positioning and care to avoid unnecessary PEEP are central to lung protection in all stages of ARDS.