Articles: mechanical-ventilation.
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Am. J. Physiol. Regul. Integr. Comp. Physiol. · Sep 2013
ReviewVentilator-induced diaphragm dysfunction: cause and effect.
Mechanical ventilation (MV) is used clinically to maintain gas exchange in patients that require assistance in maintaining adequate alveolar ventilation. Common indications for MV include respiratory failure, heart failure, drug overdose, and surgery. Although MV can be a life-saving intervention for patients suffering from respiratory failure, prolonged MV can promote diaphragmatic atrophy and contractile dysfunction, which is referred to as ventilator-induced diaphragm dysfunction (VIDD). ⋯ Recent investigations have identified calpain, caspase-3, autophagy, and the ubiquitin-proteasome system as key proteases that participate in MV-induced diaphragmatic proteolysis. The challenge for the future is to define the MV-induced signaling pathways that promote the loss of diaphragm protein and depress diaphragm contractility. Indeed, forthcoming studies that delineate the signaling mechanisms responsible for VIDD will provide the knowledge necessary for the development of a pharmacological approach that can prevent VIDD and reduce the incidence of weaning problems.
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Ventilator-associated pneumonia (VAP) is one of the most frequent hospital-acquired infections occurring in intubated patients. Because VAP is associated with higher mortality, morbidity, and costs, there is a need to solicit further research for effective preventive measures. VAP has been proposed as an indicator of quality of care. ⋯ A different approach proposes ETT modifications to limit the leakage of oropharyngeal secretions: subglottic secretion drainage and cuffs innovations have been addressed to reduce VAP incidence. Moreover, coated-ETTs have been shown to prevent biofilm formation, although there is evidence that ETT clearance devices (Mucus Shaver) are required to preserve the antimicrobial properties over time. Here, after reviewing the most noteworthy issues in VAP definition and pathophysiology, we will present the more interesting proposals for VAP prevention.
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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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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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Open Access Emerg Med · Jan 2012
ReviewManagement of critically ill patients receiving noninvasive and invasive mechanical ventilation in the emergency department.
Patients requiring noninvasive and invasive ventilation frequently present to emergency departments, and may remain for prolonged periods due to constrained critical care services. Emergency clinicians often do not receive the same education on management of mechanical ventilation or have similar exposure to these patients as do their critical care colleagues. The aim of this review was to synthesize the evidence on management of patients requiring noninvasive and invasive ventilation in the emergency department including indications, clinical applications, monitoring priorities, and potential complications. ⋯ Lung-protective ventilation with low tidal volumes based on determination of predicted body weight and control of plateau pressure has been shown to reduce mortality in patients with acute respiratory distress syndrome, and some evidence exists to suggest this strategy should be used in patients without lung injury. Monitoring of the invasively ventilated patient should focus on assessing response to mechanical ventilation and other interventions, and avoiding complications, such as ventilator-associated pneumonia. Several key aspects of management of noninvasive and invasively ventilated patients are discussed, with a particular emphasis on initiation and ongoing monitoring priorities focused on maintaining patient safety and improving patient outcomes.