Respiratory care
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Ventilator-induced lung injury (VILI) results from injury to the blood-gas barrier caused by mechanical ventilation. The determinants of VILI are more complex than originally thought, and include the nature, duration, and intensity of the exposure, as well the pattern of initial insult to the lung. ⋯ The purpose of this review is to provide a comprehensive assessment of the pathogenesis of VILI and its determinants. We also discuss the best preventive approach in patients with or at risk for ARDS and critically appraise the most recent evidence, expert opinion, and implementation of the acquired knowledge to the bedside.
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Sedation is used almost universally in the care of critically ill patients, especially in those who require mechanical ventilatory support or other life-saving invasive procedures. This review will focus on the sedation strategies for critically ill patients and the pharmacology of commonly used sedative agents. The role of neuromuscular blocking agents in the ICU will be examined and the pharmacology of commonly used agents is reviewed. Finally a strategy for rational use of these sedative and neuromuscular blocking agents in critically ill patients will be proposed.
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Mechanically ventilated patients in respiratory failure often require adjunct therapies to address special needs such as inhaled drug delivery to alleviate airway obstruction, treat pulmonary infection, or stabilize gas exchange, or therapies that enhance pulmonary hygiene. These therapies generally are supportive in nature rather than curative. Currently, most lack high-level evidence supporting their routine use. ⋯ Similar low-level evidence suggests that heliox is effective in reducing airway pressure and improving ventilation in various forms of lower airway obstruction. These therapies generally are supportive and may facilitate patient management. However, because they have not been shown to improve patient outcomes, it behooves clinicians to use these therapies parsimoniously and to monitor their effectiveness carefully.
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Intra- and inter-hospital transport is common due to the need for advanced diagnostics and procedures, and to provide access to specialized care. Risks are inherent during transport, so the anticipated benefits of transport must be weighed against the possible negative outcome during the transport. Adverse events are common in both in and out of hospital transports, the most common being equipment malfunctions. ⋯ It is recommended that portable ventilators be used for transport, because studies show that use of a manual resuscitator alters blood gas values due to inconsistent ventilation. The performance of new generation transport ventilators has improved greatly and now allows for seamless transition from ICU ventilators. Diligent planning for and monitoring during transport may decrease adverse events and reduce risk.
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Patient-ventilator synchrony and patient comfort are assumed to go hand in hand, yet few studies provide support for this common sense idea. In reality, synchrony between the patient and ventilator is complex and can be affected by the ventilator settings, type of ventilator, patient-ventilator interface, and sedation. ⋯ There is a clear association between asynchrony, ventilator-induced diaphragmatic dysfunction, and duration of mechanical ventilation. Whether these are cause and effect or simply associated remains to be determined.