Current opinion in critical care
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New data on the efficacy of low tidal volume ventilation for acute lung injury, noninvasive ventilation for chronic obstructive pulmonary disease exacerbation, weaning from mechanical ventilation, and prevention of ventilator-associated pneumonia provide, for perhaps the first time in respiratory care, compelling evidence for clinicians to change practice. However, experience from every other field in medicine suggests that there will be significant barriers to changing clinical practice at the bedside. Studies on implementation of effective practice in medicine shows that a multifaceted, team-oriented approach incorporating reminders, efficient use of non-physician personnel, protocols, and education is required to change clinical practice. ⋯ Unfortunately, there are no studies exploring community-based implementation of mechanical ventilation guidelines and only a few studies to inform clinicians as to why ventilator practice may be difficult to change. As the evidence base grows for effective critical care practice, so does the responsibility to translate practices that improve outcome from research journals to patients' bedsides. Strategies for doing this are presented in the review.
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Community-acquired pneumonia remains a common and serious condition worldwide. Severe community-acquired pneumonia requiring ICU admission is a distinct entity with different pathogens, outcomes, and management. ⋯ These guidelines have developed prediction tools to direct clinicians in the management of community-acquired pneumonia, including when to admit a patient to the ICU and selecting appropriate investigations and antimicrobial therapy. The individual recommendations of these guidelines and the guidelines as a whole require further studies.
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Curr Opin Crit Care · Feb 2004
ReviewSurfactant therapy for acute lung injury/acute respiratory distress syndrome.
Currently, three phase III surfactant replacement trials for acute lung injury (ALI)/acute respiratory distress syndromes (ARDS) patients are underway. Although the efficacy of surfactant replacement therapy will first have to be proved in these phase III trials, recent reports indicate some enticing possibilities for the future of surfactant therapy. ⋯ If surfactant therapy fulfills the promises expected from the ongoing phase III trials, future surfactant preparations may even enhance therapy efficacy and restore the altered endogenous surfactant pool as soon as possible.
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Curr Opin Crit Care · Feb 2004
ReviewMechanical ventilation in children with acute respiratory failure.
Acute respiratory failure requiring mechanical ventilation continues to contribute to mortality and affect long-term functional outcomes in patients admitted to the pediatric intensive care unit (ICU). Studies in adults with acute respiratory distress syndrome (ARDS) far outnumber those conducted in the pediatric age group, and pediatric intensivists are left with the task of carefully selecting and critically appraising relevant adult data and extrapolating results to their domain of practice. ⋯ Mechanical ventilation strategies aiming for optimal alveolar recruitment with the judicious use of positive end-expiratory pressure (PEEP) and low tidal volumes will remain the mainstay for managing respiratory failure in children. Dexamethasone may prevent postextubation stridor. Prone positioning, surfactant therapy, HFOV, and inhaled NO are used sporadically and need to be evaluated for their effect on mortality and duration of ventilation.