Resp Care
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Critically ill patients requiring mechanical ventilation are frequently subjected to long periods of physical inactivity, leading to skeletal muscle atrophy and muscle weakness. Disuse muscle atrophy is the result of complex mechanisms, including altered protein turnover and disturbed redox signaling. These ICU-acquired complications are associated with longer duration of mechanical ventilation, prolonged ICU and hospital stays, and poorer functional status at hospital discharge. ⋯ Physical rehabilitation, when started at the onset of mechanical ventilation, has been associated with shorter periods of mechanical ventilation, decreased ICU and hospital stay, and improved physical function at hospital discharge. This review summarizes the impact of both physical inactivity and mechanical ventilation on skeletal and diaphragmatic muscles structure and function. Also reviewed is the growing evidence demonstrating the feasibility and safety of early physical rehabilitation interventions for mechanically ventilated patients, as well as their benefit on patient outcomes.
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In recent years, there has been increasing interest in the use of noninvasive ventilation (NIV) in the post-extubation period to shorten the length of invasive ventilation, to prevent extubation failure, and to rescue a failed extubation. The purpose of this review is to summarize the evidence related to the use of NIV in these settings. NIV can be used to allow earlier extubation in selected patients who do not successfully complete a spontaneous breathing trial (SBT). ⋯ In this setting, NIV is indicated only in patients with hypercapnic respiratory failure. Reintubation should not be delayed if NIV is not immediately successful in reversing the post-extubation respiratory failure. Evidence does not support routine use of NIV post-extubation.
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Review
The ventilator liberation process: update on technique, timing, and termination of tracheostomy.
Tracheostomy is one of the most commonly performed procedures in the ICU. Despite the frequency of the procedure, there remains controversy regarding selection of patients who should undergo tracheostomy, the optimal technique, timing of placement and decannulation, as well as impact on outcome associated with the procedure. A growing body of literature demonstrates that percutaneous tracheostomy performed in the ICU is a safe procedure, even in high risk patients. ⋯ Although there was initial enthusiasm in support of early tracheostomy to improve patient outcomes, repeated studies have been unable to produce robust benefits. The question of optimal timing and location of decannulation has not been answered, but there is some reassurance that in aggregate, across a variety of ICUs, patients do not appear to be harmed by transfer to ward with tracheostomy. Future research into techniques, timing, and termination of tracheostomy is warranted.
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Weaning comprises 40 percent of the duration of mechanical ventilation. Protocols to reduce weaning time and to identify candidates at the earliest possible moment have been introduced to reduce complications and costs. Increased demand for mechanical ventilation, an increase in the number of patients requiring prolonged ventilation, and resource/staffing issues have created an environment where automated weaning may play a role. ⋯ Preliminary research has demonstrated mixed results. Current systems continue to be evaluated in different patient populations and environments. Automated weaning is part of the ICU armamentarium, and identification of the patient populations most likely to benefit needs to be further defined.
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Mechanical ventilation is a life-saving supportive therapy, but it can also cause lung injury, diaphragmatic dysfunction, and lung infection. Ventilator liberation should be attempted as soon as clinically indicated, to minimize morbidity and mortality. The most effective method of liberation follows a systematic approach that includes a daily assessment of weaning readiness, in conjunction with interruption of sedation infusions and spontaneous breathing trials. ⋯ Checklists can be used to reinforce application of the protocol, or possibly in lieu of one, particularly in environments where the caregiver-to-patient ratio is high and clinicians are well versed in and dedicated to applying evidence-based care. There is support for integrating best-evidence rules for weaning into the mechanical ventilator so that a substantial portion of the weaning process can be automated, which may be most effective in environments with low caregiver-to-patient ratios or those in which it is challenging to consistently apply evidence-based care. This paper reviews evidence for ventilator liberation protocols and discusses issues of implementation and ongoing monitoring.