Respiratory care
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The use of neuromuscular blocking agents (NMBAs) early in the development of ARDS has been a strategy of interest for many years. The use of NMBAs with a concomitant deep sedation strategy can increase oxygenation and possibly decrease mortality when used in the early stages of ARDS. ⋯ The use of NMBA and deep sedation for these patients is not without consequence. This discussion describes the rationale and evidence behind the use of NMBAs in the setting of ARDS.
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The United States Centers for Disease Control and Prevention replaced their longstanding ventilator-associated pneumonia (VAP) definitions with ventilator-associated event (VAE) definitions in 2013. Controversy abounds as to whether VAE definitions are potentially suitable to serve as quality indicators for ICUs. On the pro side, VAE definitions overcome many of the weaknesses of traditional VAP surveillance. ⋯ Potential strategies to prevent VAEs are highly aligned with accepted best practices in critical care. VAE surveillance therefore has the potential to catalyze better care and to help hospitals track outcomes in ventilated patients more rigorously and more efficiently. On the con side, the complete VAE definition set with subtiers is complicated, neither sensitive nor specific for VAP, non-physiological compared with other ICU metrics, susceptible to gaming, and may bring about changes in clinician behavior that could paradoxically end up harming patients.
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For the past 4 decades, the prone position has been employed as an occasional rescue option for patients with severe hypoxemia unresponsive to conventional measures applied in the supine orientation. Proning offers a high likelihood of significantly improved arterial oxygenation to well selected patients, but until the results of a convincing randomized trial were published, its potential to reduce mortality risk remained in serious doubt. Proning does not benefit patients of all disease severities and stages but may be life-saving for others. Because it requires advanced nursing skills and escalation of monitoring surveillance to deploy safely, its place as an early stage standard of care depends on the definition of that label.
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Movement of the mechanically ventilated patient may be for a routine procedure or medical emergency. The risks of transport seem manageable, but the memory of a respiratory-related catastrophe still gives many practitioners pause. The risk/benefit ratio of transport must be assessed before movement. During transport of the ventilated patients, should we always use a transport ventilator? What is the risk of using manual ventilation? How are PEEP and FIO2 altered? Is there an impact on the ability to trigger during manual ventilation? Is hyperventilation and hypoventilation a common problem? Does hyperventilation or hypoventilation result in complications? Are portable ventilators worth the cost? What about the function of portable ventilators? Can these devices faithfully reproduce ICU ventilator function? The following pro and con discussion will attempt to address many of these issues by reviewing the current evidence on transport ventilation.
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In patients with ventilator-associated pneumonia, systemic use of antibiotics is the cornerstone of medical management. Supplemental use of aerosolized antibiotics with intravenous antibiotics in both experimental and clinical studies has been shown to have the following pharmacologic benefits: (1) aerosolized antibiotics reach the infected lung parenchyma without crossing the pulmonary alveolar capillary barrier; (2) aerosolized antibiotics increase anti-bacterial efficacy through increased local antibiotic concentration; and (3) aerosolized antibiotics decrease systemic toxicity. These benefits may be particularly beneficial to treat pneumonia caused by multidrug-resistant pathogens. ⋯ Studies to date have not clearly shown improvements in time to extubation, mortality, or other patient-centered outcomes. At present, amikacin, colistin, and ceftazidime are the most frequently used and studied aerosolized antibiotics. This review summarizes the characteristics of aerosolized antibiotics, reviews the advantages and disadvantages of using aerosolized antibiotics, and calls for future investigations based on animal study data.