Minerva anestesiologica
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Minerva anestesiologica · Apr 2004
Review[Non invasive mechanical ventilation in acute cardiogenic pulmonary edema: is it all done?].
The aim of the paper is to critically analyse the results obtained by recent literature concerning the most important aspects of application of Non Invasive Mechanical Ventilation for the treatment of Acute Cardiogenic Pulmonary Edema, and to elaborate a definition of what is, on the whole, widely accepted, focusing the attention on those issues which still remain unanswered and therefore require further studies. MEDLINE was searched and the bibliography of a selected group of articles was perused. The literature was analysed and the information gathered has proved to address the questions in a systematic way. ⋯ A good deal of favorable experimental evidence supports the use of non invasive ventilation in the acute pulmonary edema and guarantees safety when used in intensive care units. Very few trials have been carried out in order to explore application on severe pulmonary edema outside intensive care unit. A whole new world of old and new issues on patient selection criteria, ventilation times, type of ventilation and predictability of failure, could be discovered.
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Primary Acute Lung Injury (ALI) after lung resection (or "post-pneumonectomy pulmonary edema") is a rare form of acute respiratory failure characterized by dyspnea, hypoxemia, diffuse infiltrates on chest radiogram, and rapid evolution often unresponsive to therapy. ALI occurs almost exclusively following pneumonectomy, within 3 days from surgery and without a preceding cause. ⋯ There is no specific therapy. Suggested measures in the perioperative care include the meticulous maintenance of physiological stability, judicious fluid restriction, and the limitation of ventilatory volumes and pressures.
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The authors briefly review the clinical applications of non-invasive ventilation (NIV) in patients with chronic obstructive pulmonary disease (COPD), mostly focusing on the application of NIV in the intensive care setting. After a short discussion of the main pathophysiologic aspects of NIV administration in patients with acute exacerbation of COPD, the most relevant clinical trials are shortly reviewed, particularly focussing on prospective randomised trials. NIV application is analysed both in its early administration, as a tool to prevent endotracheal intubation and its main complication, and as a technique alternative to endotracheal intubation in patients requiring mechanical ventilation. Finally, the main contraindications for NIV are reviewed and discussed.
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The concept of analgo-sedation in intensive care medicine has changed considerably since the last decades. Deep sedation, keeping patients artificially unconscious, is not necessary anymore, it postpones weaning from mechanical ventilation, it provokes complications, and prolongs the length of ICU stay. On the other hand, recent surveys have shown that patients recall their intensive care experience still as stressing and painful. ⋯ Regularly repeated assessment of the sedation level (e.g. by Ramsay score) is mandatory; a sedation protocol seems advantageous. To avoid inadvertent accumulation and overdose, it is recommended to keep the patient at a sedation level at which communication is still possible. A daily interruption of the sedation has shown to shorten the duration of mechanical ventilation and the length of ICU stay.
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Minerva anestesiologica · Apr 2004
ReviewMicrovasculature in ventilator-induced lung injury: target or cause?
Clinicians managing acute lung injury must reconcile the competing objectives of ensuring adequate oxygen delivery and minimizing the adverse effects of ventilatory support. Judging from our experimental work, microvascular stresses appear to be a potent cofactor in the development of pulmonary edema as well as in the expression of lung damage resulting from an injurious pattern of ventilation. ⋯ Raising ventilation frequency may also have cost. Such observations imply that reducing the demands for blood flow and ventilation are important considerations in formulating a lung protective approach to mechanical ventilation of ARDS.