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Respiratory Care Aug 2023The utilization of extracorporeal membrane oxygenation (ECMO) for cardiopulmonary support continues to increase globally, with > 190,000 ECMO cases reported to the... (Review)
Review
The utilization of extracorporeal membrane oxygenation (ECMO) for cardiopulmonary support continues to increase globally, with > 190,000 ECMO cases reported to the international Extracorporeal Life Support Organization Registry. The present review aims to synthesize important contributions to the literature surrounding the management of mechanical ventilation, prone positioning, anticoagulation, bleeding complications, and neurologic outcomes for infants, children, and adults undergoing ECMO in 2022. Additionally, issues related to cardiac ECMO, Harlequin syndrome, and anticoagulation during ECMO will be discussed.
Topics: Adult; Infant; Child; Humans; Extracorporeal Membrane Oxygenation; Respiration, Artificial; Registries; Patient Positioning; Anticoagulants; Retrospective Studies
PubMed: 37402582
DOI: 10.4187/respcare.10929 -
Critical Care (London, England) Jul 2023This narrative review explores the physiology and evidence-based management of patients with severe acute respiratory distress syndrome (ARDS) and refractory hypoxemia,... (Review)
Review
This narrative review explores the physiology and evidence-based management of patients with severe acute respiratory distress syndrome (ARDS) and refractory hypoxemia, with a focus on mechanical ventilation, adjunctive therapies, and veno-venous extracorporeal membrane oxygenation (V-V ECMO). Severe ARDS cases increased dramatically worldwide during the Covid-19 pandemic and carry a high mortality. The mainstay of treatment to improve survival and ventilator-free days is proning, conservative fluid management, and lung protective ventilation. Ventilator settings should be individualized when possible to improve patient-ventilator synchrony and reduce ventilator-induced lung injury (VILI). Positive end-expiratory pressure can be individualized by titrating to best respiratory system compliance, or by using advanced methods, such as electrical impedance tomography or esophageal manometry. Adjustments to mitigate high driving pressure and mechanical power, two possible drivers of VILI, may be further beneficial. In patients with refractory hypoxemia, salvage modes of ventilation such as high frequency oscillatory ventilation and airway pressure release ventilation are additional options that may be appropriate in select patients. Adjunctive therapies also may be applied judiciously, such as recruitment maneuvers, inhaled pulmonary vasodilators, neuromuscular blockers, or glucocorticoids, and may improve oxygenation, but do not clearly reduce mortality. In select, refractory cases, the addition of V-V ECMO improves gas exchange and modestly improves survival by allowing for lung rest. In addition to VILI, patients with severe ARDS are at risk for complications including acute cor pulmonale, physical debility, and neurocognitive deficits. Even among the most severe cases, ARDS is a heterogeneous disease, and future studies are needed to identify ARDS subgroups to individualize therapies and advance care.
Topics: Humans; Pandemics; COVID-19; Respiration, Artificial; Respiratory Distress Syndrome; Continuous Positive Airway Pressure; Ventilator-Induced Lung Injury; Hypoxia
PubMed: 37464381
DOI: 10.1186/s13054-023-04572-w -
Anesthesia and Analgesia Feb 2024Mechanical ventilation (MV) has played a crucial role in the medical field, particularly in anesthesia and in critical care medicine (CCM) settings. MV has evolved...
Mechanical ventilation (MV) has played a crucial role in the medical field, particularly in anesthesia and in critical care medicine (CCM) settings. MV has evolved significantly since its inception over 70 years ago and the future promises even more advanced technology. In the past, ventilation was provided manually, intermittently, and it was primarily used for resuscitation or as a last resort for patients with severe respiratory or cardiovascular failure. The earliest MV machines for prolonged ventilatory support and oxygenation were large and cumbersome. They required a significant amount of skills and expertise to operate. These early devices had limited capabilities, battery, power, safety features, alarms, and therefore these often caused harm to patients. Moreover, the physiology of MV was modified when mechanical ventilators moved from negative pressure to positive pressure mechanisms. Monitoring systems were also very limited and therefore the risks related to MV support were difficult to quantify, predict and timely detect for individual patients who were necessarily young with few comorbidities. Technology and devices designed to use tracheostomies versus endotracheal intubation evolved in the last century too and these are currently much more reliable. In the present, positive pressure MV is more sophisticated and widely used for extensive period of time. Modern ventilators use mostly positive pressure systems and are much smaller, more portable than their predecessors, and they are much easier to operate. They can also be programmed to provide different levels of support based on evolving physiological concepts allowing lung-protective ventilation. Monitoring systems are more sophisticated and knowledge related to the physiology of MV is improved. Patients are also more complex and elderly compared to the past. MV experts are informed about risks related to prolonged or aggressive ventilation modalities and settings. One of the most significant advances in MV has been protective lung ventilation, diaphragm protective ventilation including noninvasive ventilation (NIV). Health care professionals are familiar with the use of MV and in many countries, respiratory therapists have been trained for the exclusive purpose of providing safe and professional respiratory support to critically ill patients. Analgo-sedation drugs and techniques are improved, and more sedative drugs are available and this has an impact on recovery, weaning, and overall patients' outcome. Looking toward the future, MV is likely to continue to evolve and improve alongside monitoring techniques and sedatives. There is increasing precision in monitoring global "patient-ventilator" interactions: structure and analysis (asynchrony, desynchrony, etc). One area of development is the use of artificial intelligence (AI) in ventilator technology. AI can be used to monitor patients in real-time, and it can predict when a patient is likely to experience respiratory distress. This allows medical professionals to intervene before a crisis occurs, improving patient outcomes and reducing the need for emergency intervention. This specific area of development is intended as "personalized ventilation." It involves tailoring the ventilator settings to the individual patient, based on their physiology and the specific condition they are being treated for. This approach has the potential to improve patient outcomes by optimizing ventilation and reducing the risk of harm. In conclusion, MV has come a long way since its inception, and it continues to play a critical role in anesthesia and in CCM settings. Advances in technology have made MV safer, more effective, affordable, and more widely available. As technology continues to improve, more advanced and personalized MV will become available, leading to better patients' outcomes and quality of life for those in need.
Topics: Humans; Aged; Respiration, Artificial; Ventilator Weaning; Artificial Intelligence; Quality of Life; Positive-Pressure Respiration
PubMed: 38215710
DOI: 10.1213/ANE.0000000000006701 -
Journal of Perinatology : Official... Oct 2023Meconium aspiration syndrome (MAS) is a complex respiratory disease that continues to be associated with significant morbidities and mortality. The pathophysiological... (Review)
Review
Meconium aspiration syndrome (MAS) is a complex respiratory disease that continues to be associated with significant morbidities and mortality. The pathophysiological mechanisms of MAS include airway obstruction, local and systemic inflammation, surfactant inactivation and persistent pulmonary hypertension of the newborn (PPHN). Supplemental oxygen and non-invasive respiratory support are the main therapies for many patients. The management of the patients requiring invasive mechanical ventilation could be challenging because of the combination of atelectasis and air trapping. While studies have explored various ventilatory modalities, evidence to date does not clearly support any singular modality as superior. Patient's pathophysiology, symptom severity, and clinician/unit expertise should guide the respiratory management. Early identification and concomitant management of PPHN is critically important as it contributes significantly to mortality and morbidities.
Topics: Female; Humans; Infant, Newborn; Meconium Aspiration Syndrome; Respiration, Artificial; Persistent Fetal Circulation Syndrome; Pulmonary Surfactants; Morbidity
PubMed: 37543651
DOI: 10.1038/s41372-023-01708-2 -
Respiratory Care Nov 2023Mechanical ventilation is ubiquitous in critical care, and duration of ventilator liberation is variable and multifactorial. While ICU survival has increased over the... (Review)
Review
Mechanical ventilation is ubiquitous in critical care, and duration of ventilator liberation is variable and multifactorial. While ICU survival has increased over the last two decades, positive-pressure ventilation can cause harm to patients. Weaning and discontinuation of ventilatory support is the first step in ventilator liberation. Clinicians have a wealth of evidence-based literature at their disposal; however, more high-quality research is needed to describe outcomes. Additionally, this knowledge must be distilled into evidence-based practice and applied at the bedside. A proliferation of research on the subject of ventilator liberation has been published in the last 12 months. Whereas some authors have reconsidered the value of applying the rapid shallow breathing index in weaning protocols, others have begun to investigate new indices to predict liberation outcomes. New tools such as diaphragmatic ultrasonography have begun to appear in the literature as a tool for outcome prediction. A number of systematic reviews with both meta-analysis and network meta-analysis that synthesize the literature on ventilator liberation have also been published in the last year. This review describes changes in performance, monitoring of spontaneous breathing trials, and evaluations of successful ventilator liberation.
Topics: Humans; Critical Care; Respiration, Artificial; Systematic Reviews as Topic; Ventilator Weaning; Ventilators, Mechanical; Meta-Analysis as Topic
PubMed: 37402584
DOI: 10.4187/respcare.11114 -
JAMA Internal Medicine Feb 2024Hospital-acquired pneumonia (HAP) is the most common and morbid health care-associated infection, but limited data on effective prevention strategies are available.
IMPORTANCE
Hospital-acquired pneumonia (HAP) is the most common and morbid health care-associated infection, but limited data on effective prevention strategies are available.
OBJECTIVE
To determine whether daily toothbrushing is associated with lower rates of HAP and other patient-relevant outcomes.
DATA SOURCES
A search of PubMed, Embase, Cumulative Index to Nursing and Allied Health, Cochrane Central Register of Controlled Trials, Web of Science, Scopus, and 3 trial registries was performed from inception through March 9, 2023.
STUDY SELECTION
Randomized clinical trials of hospitalized adults comparing daily oral care with toothbrushing vs regimens without toothbrushing.
DATA EXTRACTION AND SYNTHESIS
Data extraction and risk of bias assessments were performed in duplicate. Meta-analysis was performed using random-effects models.
MAIN OUTCOMES AND MEASURES
The primary outcome of this systematic review and meta-analysis was HAP. Secondary outcomes included hospital and intensive care unit (ICU) mortality, duration of mechanical ventilation, ICU and hospital lengths of stay, and use of antibiotics. Subgroups included patients who received invasive mechanical ventilation vs those who did not, toothbrushing twice daily vs more frequently, toothbrushing provided by dental professionals vs general nursing staff, electric vs manual toothbrushing, and studies at low vs high risk of bias.
RESULTS
A total of 15 trials met inclusion criteria, including 10 742 patients (2033 in the ICU and 8709 in non-ICU departments; effective population size was 2786 after shrinking the population to account for 1 cluster randomized trial in non-ICU patients). Toothbrushing was associated with significantly lower risk for HAP (risk ratio [RR], 0.67 [95% CI, 0.56-0.81]) and ICU mortality (RR, 0.81 [95% CI, 0.69-0.95]). Reduction in pneumonia incidence was significant for patients receiving invasive mechanical ventilation (RR, 0.68 [95% CI, 0.57-0.82) but not for patients who were not receiving invasive mechanical ventilation (RR, 0.32 [95% CI, 0.05-2.02]). Toothbrushing for patients in the ICU was associated with fewer days of mechanical ventilation (mean difference, -1.24 [95% CI, -2.42 to -0.06] days) and a shorter ICU length of stay (mean difference, -1.78 [95% CI, -2.85 to -0.70] days). Brushing twice a day vs more frequent intervals was associated with similar effect estimates. Results were consistent in a sensitivity analysis restricted to 7 studies at low risk of bias (1367 patients). Non-ICU hospital length of stay and use of antibiotics were not associated with toothbrushing.
CONCLUSIONS
The findings of this systematic review and meta-analysis suggest that daily toothbrushing may be associated with significantly lower rates of HAP, particularly in patients receiving mechanical ventilation, lower rates of ICU mortality, shorter duration of mechanical ventilation, and shorter ICU length of stay. Policies and programs encouraging more widespread and consistent toothbrushing are warranted.
Topics: Adult; Humans; Toothbrushing; Respiration, Artificial; Intensive Care Units; Anti-Bacterial Agents; Incidence
PubMed: 38109100
DOI: 10.1001/jamainternmed.2023.6638 -
Critical Care (London, England) Aug 2023Few specific methods are available to reduce the risk of diaphragmatic dysfunction for patients under mechanical ventilation. The number of studies involving... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Few specific methods are available to reduce the risk of diaphragmatic dysfunction for patients under mechanical ventilation. The number of studies involving transcutaneous electrical stimulation of the diaphragm (TEDS) is increasing but none report results for diaphragmatic measurements, and they lack power. We hypothesised that the use of TEDS would decrease diaphragmatic dysfunction and improve respiratory muscle strength in patients in ICU.
METHODS
We conducted a controlled trial to assess the impact of daily active electrical stimulation versus sham stimulation on the prevention of diaphragm dysfunction during the weaning process from mechanical ventilation. The evaluation was based on ultrasound measurements of diaphragm thickening fraction during spontaneous breathing trials. We also measured maximal inspiratory muscle pressure (MIP), peak cough flow (PEF) and extubation failure.
RESULTS
Sixty-six patients were included and randomised using a 1:1 ratio. The mean number of days of mechanical ventilation was 10 ± 6.8. Diaphragm thickening fraction was > 30% at the SBT for 67% of participants in the TEDS group and 54% of the Sham group (OR1.55, 95% CI 0.47-5.1; p = 0.47). MIP and PEF were similar in the TEDS and Sham groups (respectively 35.5 ± 11.9 vs 29.7 ± 11.7 cmH0; p = 0.469 and 83.2 ± 39.5 vs. 75.3 ± 34.08 L/min; p = 0.83). Rate of extubation failure was not different between groups.
CONCLUSION
TEDS did not prevent diaphragm dysfunction or improve inspiratory muscle strength in mechanically ventilated patients.
TRIAL REGISTRATION
Prospectively registered on the 20th November 2019 on ClinicalTrials.gov Identifier NCT04171024.
Topics: Humans; Diaphragm; Transcutaneous Electric Nerve Stimulation; Respiration, Artificial; Thorax; Respiratory Muscles
PubMed: 37649092
DOI: 10.1186/s13054-023-04597-1 -
Critical Care (London, England) Jul 2023During the COVID-19 pandemic, several centers had independently reported extending prone positioning beyond 24 h. Most of these centers reported maintaining patients in... (Review)
Review
During the COVID-19 pandemic, several centers had independently reported extending prone positioning beyond 24 h. Most of these centers reported maintaining patients in prone position until significant clinical improvement was achieved. One center reported extending prone positioning for organizational reasons relying on a predetermined fixed duration. A recent study argued that a clinically driven extension of prone positioning beyond 24 h could be associated with reduced mortality. On a patient level, the main benefit of extending prone positioning beyond 24 h is to maintain a more homogenous distribution of the gas-tissue ratio, thus delaying the increase in overdistention observed when patients are returned to the supine position. On an organizational level, extending prone positioning reduces the workload for both doctors and nurses, which might significantly enhance the quality of care in an epidemic. It might also reduce the incidence of accidental catheter and tracheal tube removal, thereby convincing intensive care units with low incidence of ARDS to prone patients more systematically. The main risk associated with extended prone positioning is an increased incidence of pressure injuries. Up until now, retrospective studies are reassuring, but prospective evaluation is needed.
Topics: Humans; Prone Position; Pandemics; Retrospective Studies; Respiratory Distress Syndrome; COVID-19; Respiration, Artificial; Patient Positioning
PubMed: 37408074
DOI: 10.1186/s13054-023-04526-2 -
European Respiratory Review : An... Jun 2023There is a well-recognised importance for personalising mechanical ventilation settings to protect the lungs and the diaphragm for each individual patient. Measurement... (Review)
Review
There is a well-recognised importance for personalising mechanical ventilation settings to protect the lungs and the diaphragm for each individual patient. Measurement of oesophageal pressure ( ) as an estimate of pleural pressure allows assessment of partitioned respiratory mechanics and quantification of lung stress, which helps our understanding of the patient's respiratory physiology and could guide individualisation of ventilator settings. Oesophageal manometry also allows breathing effort quantification, which could contribute to improving settings during assisted ventilation and mechanical ventilation weaning. In parallel with technological improvements, monitoring is now available for daily clinical practice. This review provides a fundamental understanding of the relevant physiological concepts that can be assessed using measurements, both during spontaneous breathing and mechanical ventilation. We also present a practical approach for implementing oesophageal manometry at the bedside. While more clinical data are awaited to confirm the benefits of -guided mechanical ventilation and to determine optimal targets under different conditions, we discuss potential practical approaches, including positive end-expiratory pressure setting in controlled ventilation and assessment of inspiratory effort during assisted modes.
Topics: Humans; Respiration, Artificial; Lung; Respiratory Mechanics; Ventilators, Mechanical; Monitoring, Physiologic
PubMed: 37197768
DOI: 10.1183/16000617.0186-2022 -
Seminars in Perinatology Mar 2024Despite strong evidence of important benefits of volume-targeted ventilation, many high-risk extremely preterm infants continue to receive traditional... (Review)
Review
Despite strong evidence of important benefits of volume-targeted ventilation, many high-risk extremely preterm infants continue to receive traditional pressure-controlled ventilation in the United States and elesewhere. Reluctance to abandon one's comfort zone, lack of suitable equipment and a lack of understanding of the subtleties of volume-targeted ventilation appear to contribute to the relatively slow uptake of volume-targeted ventilation. This review will underscore the benefits of using tidal volume as the primary control variable, to improve clinicians' understanding of the way volume-targeted ventilation interacts with the awake, breathing infant and to provide information about evidence-based tidal volume targets in various circmstances. Focus on underlying lung pathophysiology, individualized ventilator settings and tidal volume targets are essential to successful use of this approach thereby improving important clinical outcomes.
Topics: Infant, Newborn; Humans; Respiration, Artificial; Lung; Tidal Volume; Infant, Extremely Premature
PubMed: 38553330
DOI: 10.1016/j.semperi.2024.151886