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Respiratory Care Nov 2014The American Association for Respiratory Care has declared a benchmark for competency in mechanical ventilation that includes the ability to "apply to practice all... (Review)
Review
The American Association for Respiratory Care has declared a benchmark for competency in mechanical ventilation that includes the ability to "apply to practice all ventilation modes currently available on all invasive and noninvasive mechanical ventilators." This level of competency presupposes the ability to identify, classify, compare, and contrast all modes of ventilation. Unfortunately, current educational paradigms do not supply the tools to achieve such goals. To fill this gap, we expand and refine a previously described taxonomy for classifying modes of ventilation and explain how it can be understood in terms of 10 fundamental constructs of ventilator technology: (1) defining a breath, (2) defining an assisted breath, (3) specifying the means of assisting breaths based on control variables specified by the equation of motion, (4) classifying breaths in terms of how inspiration is started and stopped, (5) identifying ventilator-initiated versus patient-initiated start and stop events, (6) defining spontaneous and mandatory breaths, (7) defining breath sequences (8), combining control variables and breath sequences into ventilatory patterns, (9) describing targeting schemes, and (10) constructing a formal taxonomy for modes of ventilation composed of control variable, breath sequence, and targeting schemes. Having established the theoretical basis of the taxonomy, we demonstrate a step-by-step procedure to classify any mode on any mechanical ventilator.
Topics: Humans; Respiration, Artificial; Ventilators, Mechanical
PubMed: 25118309
DOI: 10.4187/respcare.03057 -
Current Opinion in Critical Care Aug 2021Mechanical ventilation is frequently needed in patients with cardiogenic shock. The aim of this review is to summarize and discuss the current evidence and the... (Review)
Review
PURPOSE OF REVIEW
Mechanical ventilation is frequently needed in patients with cardiogenic shock. The aim of this review is to summarize and discuss the current evidence and the pathophysiological mechanism that a clinician should consider while setting the ventilator.
RECENT FINDINGS
Little attention has been placed specifically to ventilatory strategies in patients with cardiogenic shock undertaking mechanical ventilation. Lung failure in patients with cardiogenic shock is associated with worsening outcome as well as a delay in mechanical ventilation institution. The hemodynamic profile and cardiogenic shock cause, considering the preload dependency of the failing heart, must be defined to adjust ventilatory setting.
SUMMARY
Evidence is growing regarding the role of lung failure as adverse prognostic factor and beneficial effect of positive pressure ventilation as part of first-line treatment in patients with cardiogenic failure.
Topics: Heart Failure; Heart-Assist Devices; Humans; Positive-Pressure Respiration; Respiration, Artificial; Shock, Cardiogenic
PubMed: 33929345
DOI: 10.1097/MCC.0000000000000836 -
Current Opinion in Critical Care Jun 2022Due to heart, lung and diaphragm interactions during weaning from mechanical ventilation, an ultrasound integrated approach may be useful in the detection of... (Review)
Review
PURPOSE OF REVIEW
Due to heart, lung and diaphragm interactions during weaning from mechanical ventilation, an ultrasound integrated approach may be useful in the detection of dysfunctions potentially leading to weaning failure. In this review, we will summarize the most recent advances concerning the ultrasound applications relevant to the weaning from mechanical ventilation.
RECENT FINDINGS
The role of ultrasonographic examination of heart, lung and diaphragm has been deeply investigated over the years. Most recent findings concern the ability of lung ultrasound in detecting weaning induced pulmonary edema during spontaneous breathing trial. Furthermore, in patients at high risk of cardiac impairments, global and anterolateral lung ultrasound scores have been correlated with weaning and extubation failure, whereas echocardiographic indexes were not. For diaphragmatic ultrasound evaluation, new indexes have been proposed for the evaluation of diaphragm performance during weaning, but further studies are needed to validate these results.
SUMMARY
The present review summarizes the potential role of ultrasonography in the weaning process. A multimodal integrated approach allows the clinician to comprehend the pathophysiological processes of weaning failure.
Topics: Airway Extubation; Diaphragm; Humans; Respiration, Artificial; Ultrasonography; Ventilator Weaning
PubMed: 35653254
DOI: 10.1097/MCC.0000000000000941 -
Anaesthesiology Intensive Therapy 2019Daily sedation interruption (DSI) is a method used since the beginning of the millennium to streamline sedation in critically ill patients under mechanical ventilation... (Review)
Review
Daily sedation interruption (DSI) is a method used since the beginning of the millennium to streamline sedation in critically ill patients under mechanical ventilation and improve clinical outcomes. The purpose was to assess whether there is a correlation between DSI and weaning from mechanical ventilation. We designed a literature review via searching PubMed, UpToDate and Google Scholar for relevant key terms from inception until March 2019. Literature retrieved included nine randomized controlled trials. When compared to usual practice, it is superior in terms of duration of mechanical ventilation, stay in the intensive care unit, hospitalization, adverse effect occurrence and total cost of therapy. Comparison with other sedation protocols produces conflicting results. DSI, and protocolized sedation in general, are safe methods to perform to facilitate earlier weaning and improved clinical outcomes. Future research should focus on minimizing bias by conducting double-blinded studies and studying different patient subgroups.
Topics: Critical Illness; Drug Administration Schedule; Humans; Hypnotics and Sedatives; Intensive Care Units; Randomized Controlled Trials as Topic; Respiration, Artificial; Time Factors; Ventilator Weaning
PubMed: 31893604
DOI: 10.5114/ait.2019.90921 -
JAMA Oct 2021
Topics: Humans; Noninvasive Ventilation; Pneumonia; Pulmonary Disease, Chronic Obstructive; Respiration, Artificial
PubMed: 34636861
DOI: 10.1001/jama.2021.13084 -
Respiratory Care May 2020Respiratory support of the critically ill neonate has steadily shifted from invasive to noninvasive forms of support. There have recently been a number of important... (Review)
Review
Respiratory support of the critically ill neonate has steadily shifted from invasive to noninvasive forms of support. There have recently been a number of important advances in our understanding of the changes to neonatal resuscitation practices as they pertain to clinically important outcomes, mechanisms of gas exchange for high-flow nasal cannula, and best use of noninvasive ventilation and predicting response. Although the proportion of infants requiring intubation and mechanical ventilation has decreased, the most severely ill often still require intubation and ventilation. Recently, volume-targeted ventilation, high-frequency ventilation, and different methods of assessing weaning and extubation have been investigated. This review summarizes a number of important advances that have been made in the management of prematurity and neonatal respiratory distress syndrome.
Topics: Airway Extubation; Cannula; Continuous Positive Airway Pressure; Humans; Infant, Newborn; Infant, Premature; Noninvasive Ventilation; Respiration, Artificial; Respiratory Distress Syndrome, Newborn; Resuscitation; Ventilators, Mechanical
PubMed: 32209710
DOI: 10.4187/respcare.07720 -
Intensive Care Medicine Oct 2022Treatment of respiratory failure has improved dramatically since the polio epidemic in the 1950s with the use of invasive techniques for respiratory support: mechanical... (Review)
Review
Treatment of respiratory failure has improved dramatically since the polio epidemic in the 1950s with the use of invasive techniques for respiratory support: mechanical ventilation and extracorporeal respiratory support. However, respiratory support is only a supportive therapy, designed to "buy time" while the disease causing respiratory failure abates. It ensures viable gas exchange and prevents cardiorespiratory collapse in the context of excessive loads. Because the use of invasive modalities of respiratory support is also associated with substantial harm, it remains the responsibility of the clinician to minimize such hazards. Direct iatrogenic consequences of mechanical ventilation include the risk to the lung (ventilator-induced lung injury) and the diaphragm (ventilator-induced diaphragm dysfunction and other forms of myotrauma). Adverse consequences on hemodynamics can also be significant. Indirect consequences (e.g., immobilization, sleep disruption) can have devastating long-term effects. Increasing awareness and understanding of these mechanisms of injury has led to a change in the philosophy of care with a shift from aiming to normalize gases toward minimizing harm. Lung (and more recently also diaphragm) protective ventilation strategies include the use of extracorporeal respiratory support when the risk of ventilation becomes excessive. This review provides an overview of the historical background of respiratory support, pathophysiology of respiratory failure and rationale for respiratory support, iatrogenic consequences from mechanical ventilation, specifics of the implementation of mechanical ventilation, and role of extracorporeal respiratory support. It highlights the need for appropriate monitoring to estimate risks and to individualize ventilation and sedation to provide safe respiratory support to each patient.
Topics: Extracorporeal Membrane Oxygenation; Humans; Iatrogenic Disease; Respiration, Artificial; Respiratory Distress Syndrome; Respiratory Insufficiency; Ventilator-Induced Lung Injury
PubMed: 35690953
DOI: 10.1007/s00134-022-06749-3 -
American Journal of Respiratory and... May 2017This document provides evidence-based clinical practice guidelines on the use of mechanical ventilation in adult patients with acute respiratory distress syndrome (ARDS).
An Official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical Practice Guideline: Mechanical Ventilation in Adult Patients with Acute Respiratory Distress Syndrome.
BACKGROUND
This document provides evidence-based clinical practice guidelines on the use of mechanical ventilation in adult patients with acute respiratory distress syndrome (ARDS).
METHODS
A multidisciplinary panel conducted systematic reviews and metaanalyses of the relevant research and applied Grading of Recommendations, Assessment, Development, and Evaluation methodology for clinical recommendations.
RESULTS
For all patients with ARDS, the recommendation is strong for mechanical ventilation using lower tidal volumes (4-8 ml/kg predicted body weight) and lower inspiratory pressures (plateau pressure < 30 cm HO) (moderate confidence in effect estimates). For patients with severe ARDS, the recommendation is strong for prone positioning for more than 12 h/d (moderate confidence in effect estimates). For patients with moderate or severe ARDS, the recommendation is strong against routine use of high-frequency oscillatory ventilation (high confidence in effect estimates) and conditional for higher positive end-expiratory pressure (moderate confidence in effect estimates) and recruitment maneuvers (low confidence in effect estimates). Additional evidence is necessary to make a definitive recommendation for or against the use of extracorporeal membrane oxygenation in patients with severe ARDS.
CONCLUSIONS
The panel formulated and provided the rationale for recommendations on selected ventilatory interventions for adult patients with ARDS. Clinicians managing patients with ARDS should personalize decisions for their patients, particularly regarding the conditional recommendations in this guideline.
Topics: Adult; Chest Wall Oscillation; Extracorporeal Membrane Oxygenation; Humans; Positive-Pressure Respiration; Prone Position; Respiration, Artificial; Respiratory Distress Syndrome
PubMed: 28459336
DOI: 10.1164/rccm.201703-0548ST -
Expert Review of Respiratory Medicine Apr 2022: To adhere to the Hippocratic Oath, to 'first, do no harm', we need to make every effort to minimize the adverse effects of mechanical ventilation. Our understanding of... (Review)
Review
INTRODUCTION
: To adhere to the Hippocratic Oath, to 'first, do no harm', we need to make every effort to minimize the adverse effects of mechanical ventilation. Our understanding of the mechanisms of ventilator-induced lung injury (VILI) and ventilator-induced diaphragm dysfunction (VIDD) has increased in recent years. Research focuses now on methods to monitor lung stress and inhomogeneity and targets we should aim for when setting the ventilator. In parallel, efforts to promote early assisted ventilation to prevent VIDD have revealed new challenges, such as titrating inspiratory effort and synchronizing the mechanical with the patients' spontaneous breaths, while at the same time adhering to lung-protective targets.
AREAS COVERED
This is a narrative review of the key mechanisms contributing to VILI and VIDD and the methods currently available to evaluate and mitigate the risk of lung and diaphragm injury.
EXPERT OPINION
Implementing lung and diaphragm protective ventilation requires individualizing the ventilator settings, and this can only be accomplished by exploiting in everyday clinical practice the tools available to monitor lung stress and inhomogeneity, inspiratory effort, and patient-ventilator interaction.
Topics: Diaphragm; Humans; Lung; Respiration; Respiration, Artificial; Ventilator-Induced Lung Injury; Ventilators, Mechanical
PubMed: 35354361
DOI: 10.1080/17476348.2022.2060824 -
Paediatric Anaesthesia Feb 2022Studies have shown that up to 63% of pediatric intensive care unit patients admitted with acute respiratory or cardiorespiratory illness require mechanical ventilation.... (Review)
Review
Studies have shown that up to 63% of pediatric intensive care unit patients admitted with acute respiratory or cardiorespiratory illness require mechanical ventilation. Mechanical ventilator support can be divided into three phases: initiation, escalation, and resolution. Noninvasive ventilation is typical during the initiation phase in the management of acute pediatric respiratory failure. The major advancements in the use of noninvasive ventilation involve the emergence of high-flow nasal cannula and how widespread the use of high-flow nasal cannula has become in pediatric critical care practice. When high-flow nasal cannula fails, escalation to continuous positive airway pressure or bi-level positive airway pressure is the next step in respiratory care progression. Careful clinical assessment is necessary to avoid delayed escalation between forms of noninvasive support or escalation to intubation and invasive mechanical ventilation. Advancements in conventional mechanical ventilation are centered on optimizing ventilator settings and customizing monitoring with the overarching goal to reduce complications of mechanical ventilation, such as ventilator-induced lung injury. New mechanical ventilator strategies integrating esophageal pressure monitoring, volumetric capnography, and neurally adjusted ventilator assist help to optimize conventional ventilator support. Nonconventional modes of ventilation in the intensive care unit are high-frequency modes and airway pressure release ventilation. Extracorporeal pulmonary support via extracorporeal membrane oxygenation or paracorporeal lung assist devices provides rescue options when conventional and nonconventional methods fail. During resolution of a course of mechanical ventilator support, reliable weaning strategies and extubation readiness testing are lacking in pediatric critical care. Further, timing of tracheostomy, risk reduction in ventilator-induced lung injury, and decreased sedation requirements in pediatric patients requiring mechanical ventilation in the pediatric intensive care unit are areas of ongoing research.
Topics: Airway Extubation; Cannula; Child; Humans; Intensive Care Units, Pediatric; Noninvasive Ventilation; Respiration, Artificial
PubMed: 34882910
DOI: 10.1111/pan.14374