Articles: mechanical-ventilation.
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It has been shown that mechanical ventilation by itself can cause lung injury and affect outcomes. Ventilator-induced lung injury is associated with high tidal volumes in lungs afflicted with ARDS. However, the question is: Do high tidal volumes have this same effect in normal lungs or lungs that have respiratory compromise stemming from something other than ARDS? Many clinicians believe that a tidal volume strategy of 6 mL/kg predicted body weight should be standard practice in all patients receiving mechanical ventilation. There is a growing body of evidence related to this issue, and this is the debate that will be tackled in this paper from both pro and con perspectives.
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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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ICU-acquired weakness is a major complication of critical illness requiring mechanical ventilation. Early mobilization has been shown to decrease the negative consequences of ICU-acquired weakness. ⋯ Additional staffing needs might have a negative financial impact. This review examines whether early mobilization should be routinely performed in mechanically ventilated patients.
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Intermittent mandatory ventilation (IMV) was introduced nearly 50 years ago. Despite the initial fanfare and early adoption by many, the role of IMV continues to be questioned. ⋯ Spontaneous breathing, however, has a number of salutatory effects on gas exchange, the distribution of ventilation, and hemodynamics. These issues will be explored in light of a growing body of evidence.
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World J Crit Care Med · May 2016
ReviewEfficacy of prone position in acute respiratory distress syndrome patients: A pathophysiology-based review.
Acute respiratory distress syndrome (ARDS) is a syndrome with heterogeneous underlying pathological processes. It represents a common clinical problem in intensive care unit patients and it is characterized by high mortality. The mainstay of treatment for ARDS is lung protective ventilation with low tidal volumes and positive end-expiratory pressure sufficient for alveolar recruitment. ⋯ The factors that individually influence the time course of alveolar recruitment and the improvement in oxygenation during prone positioning have not been well characterized. Although patients' response to prone positioning is quite variable and hard to predict, large randomized trials and recent meta-analyses show that prone position in conjunction with a lung-protective strategy, when performed early and in sufficient duration, may improve survival in patients with ARDS. This pathophysiology-based review and recent clinical evidence strongly support the use of prone positioning in the early management of severe ARDS systematically and not as a rescue maneuver or a last-ditch effort.