Resp Care
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The management of patients with traumatic brain injury has evolved in the last several years, due to the introduction of new, invasive monitoring devices. The ability to monitor parameters other than measurements related to pressures has generated substantial interest. Brain tissue oxygenation monitoring has been consistently shown to provide prognostic information, as indicated by poor prognosis associated with low brain tissue oxygen values. ⋯ Retrospective studies suggest benefit, while prospective studies have shown a higher intensity of therapeutic interventions with no outcome differences. Data from high quality randomized trials are necessary to determine if brain-oxygenation-guided therapy is beneficial. An oxygen challenge (transient increase in F(IO(2)) to 0.6 up to 1.0) to assess the responsiveness of the monitoring and ascertain the presence of technical malfunction is an accepted practice.
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Fiberoptic bronchoscopy and lung biopsy are important diagnostic tools in patients with diffuse pulmonary infiltrates. However, these patients often have hypoxemic respiratory failure that makes this procedure hazardous. Noninvasive ventilation (NIV) has been shown to improve oxygenation in hypoxemic patients. ⋯ NIV-assisted bronchoscopic lung biopsy is a novel method for obtaining diagnosis in hypoxemic patients with diffuse lung infiltrates. However, this approach should be reserved for centers with extensive experience in NIV. More studies are required to define the utility of this approach.
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The ventilator discontinuation process is an essential component of overall ventilator management. Undue delay leads to excess stay, iatrogenic lung injury, unnecessary sedation, and even higher mortality. On the other hand, premature withdrawal can lead to muscle fatigue, dangerous gas exchange impairment, loss of airway protection, and also a higher mortality. ⋯ More recent developments have focused on the utility of computer decision support to guide these processes and the importance of linking sedation reduction protocols to ventilator discontinuation protocols. These guidelines are standing the test of time, and practice patterns are evolving in accordance with them. Nevertheless, there is still room for improvement and need for further clinical studies, especially in the patient requiring prolonged mechanical ventilation.
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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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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.