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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Oxygen is both lifesaving and toxic. Appropriate use of oxygen aims to provide a balance between the two effects. ⋯ The role of hyperoxemia in mechanically ventilated patients, in the face of non-toxic inspired oxygen concentrations, is less clear. This paper will review the data for and against the use of conservative oxygen targets and the avoidance of hyperoxemia in mechanically ventilated patients.
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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.
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Weaning from mechanical ventilation involves the reduction or withdrawal of ventilatory support in proportion to the patient's ability to sustain spontaneous ventilation. Protocolized weaning has been shown to reduce weaning duration; however, its weakness lies in the reliance on human intervention. Automated weaning is theoretically superior to manual weaning because of its ability to rapidly recognize deviations from desired behavior and enforce compliance with a standardized weaning strategy unencumbered by external influences. Whether currently available methods for automated weaning fulfill that potential to achieve superiority depends on patient type, care environment, and cause of ventilator dependence.