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Chronic Respiratory Disease 2024This state-of-the-art review provides an overview of the history of home mechanical ventilation (HMV), including early descriptions of mechanical ventilation from... (Review)
Review
This state-of-the-art review provides an overview of the history of home mechanical ventilation (HMV), including early descriptions of mechanical ventilation from ancient and Renaissance perspectives and the mass development of ventilators designed for long-term use during the poliomyelitis epidemic. Seminal data from key clinical trials supports the application of HMV in certain patients with chronic obstructive pulmonary disease, neuromuscular disease and obesity-related respiratory failure. Innovative engineering coupled with refined physiological understanding now permits widespread delivery of home mechanical ventilation to a global population, using portable devices with advanced ventilatory modes and telemonitoring capabilities. Exponential growth in digital technology continues, and ongoing research is needed to understand how to harness clinical and physiological data to benefit patients and healthcare services in a clinically- and cost-effective manner.
Topics: Humans; Respiration, Artificial; Obesity; Pulmonary Disease, Chronic Obstructive
PubMed: 38512223
DOI: 10.1177/14799731241240776 -
Multimedia Manual of Cardiothoracic... Aug 2023Patients with acute respiratory failure who are anticipated to have a significant recovery and require prolonged mechanical ventilation, defined as ventilation lasting 7...
Patients with acute respiratory failure who are anticipated to have a significant recovery and require prolonged mechanical ventilation, defined as ventilation lasting 7 days or longer, should be evaluated for the potential need for a tracheostomy. A tracheostomy reduces the necessity for sedation and aids in the process of weaning patients. The popularity of percutaneous tracheostomy techniques, which can be carried out at the patient's bedside, has increased due to their ability to save costs associated with time in the operating room. This video tutorial provides a comprehensive guide comprising 10 sequential steps, demonstrating the process of performing a percutaneous tracheostomy. The technique highlighted in the tutorial uses the Seldinger method alongside serial dilators, while also covering the essential anatomical aspects and necessary equipment.
Topics: Humans; Tracheostomy; Respiration, Artificial; Vascular Surgical Procedures
PubMed: 37577785
DOI: 10.1510/mmcts.2023.046 -
Respiratory Care Nov 2023Mechanical ventilation is a lifesaving intervention that may also induce further lung injury by exerting excessive mechanical forces on susceptible lung tissue, a... (Review)
Review
Mechanical ventilation is a lifesaving intervention that may also induce further lung injury by exerting excessive mechanical forces on susceptible lung tissue, a phenomenon termed ventilator-induced lung injury (VILI). The concept of mechanical power (MP) aims to unify in one single variable the contribution of the different ventilatory parameters that could induce VILI by measuring the energy transfer to the lung over time. Despite an increasing amount of evidence demonstrating that high MP values can be associated with VILI development in experimental studies, the evidence regarding the association of MP and clinical outcomes remains controversial. In the present review, we describe the different determinants of VILI, the concept and computation of MP, and discuss the experimental and clinical studies related to MP. Currently, due to different limitations, the clinical application of MP is debatable. Further clinical studies are required to enhance our understanding of the relationship between MP and the development of VILI, as well as its potential impact on clinical outcomes.
Topics: Humans; Lung; Respiration; Respiration, Artificial; Ventilator-Induced Lung Injury; Computers
PubMed: 37935527
DOI: 10.4187/respcare.11462 -
Medical Science Monitor : International... Sep 2023Mechanical ventilation (MV) provides basic organ support for patients who have acute hypoxemic respiratory failure, with acute respiratory distress syndrome as the most... (Review)
Review
Mechanical ventilation (MV) provides basic organ support for patients who have acute hypoxemic respiratory failure, with acute respiratory distress syndrome as the most severe form. The use of excessive ventilation forces can exacerbate the lung condition and lead to ventilator-induced lung injury (VILI); mechanical energy (ME) or power can characterize such forces applied during MV. The ME metric combines all MV parameters affecting the respiratory system (ie, lungs, chest, and airways) into a single value. Besides evaluating the overall ME, this parameter can be also related to patient-specific characteristics, such as lung compliance or patient weight, which can further improve the value of ME for characterizing the aggressiveness of lung ventilation. High ME is associated with poor outcomes and could be used as a prognostic parameter and indicator of the risk of VILI. ME is rarely determined in everyday practice because the calculations are complicated and based on multiple equations. Although low ME does not conclusively prevent the possibility of VILI (eg, due to the lung inhomogeneity and preexisting damage), individualization of MV settings considering ME appears to improve outcomes. This article aims to review the roles of bedside assessment of mechanical power, its relevance in mechanical ventilation, and its associations with treatment outcomes. In addition, we discuss methods for ME determination, aiming to propose the most suitable method for bedside application of the ME concept in everyday practice.
Topics: Humans; Respiration, Artificial; Respiration; Aggression; Respiratory Distress Syndrome; Thorax; Ventilator-Induced Lung Injury
PubMed: 37669252
DOI: 10.12659/MSM.941287 -
Cardiology Clinics May 2024This review aims to enhance the comprehension and management of cardiopulmonary interactions in critically ill patients with cardiovascular disease undergoing mechanical... (Review)
Review
This review aims to enhance the comprehension and management of cardiopulmonary interactions in critically ill patients with cardiovascular disease undergoing mechanical ventilation. Highlighting the significance of maintaining a delicate balance, this article emphasizes the crucial role of adjusting ventilation parameters based on both invasive and noninvasive monitoring. It provides recommendations for the induction and liberation from mechanical ventilation. Special attention is given to the identification of auto-PEEP (positive end-expiratory pressure) and other situations that may impact hemodynamics and patients' outcomes.
Topics: Humans; Emergencies; Respiration, Artificial; Positive-Pressure Respiration; Ventilators, Mechanical; Lung
PubMed: 38631793
DOI: 10.1016/j.ccl.2024.02.010 -
Intensive Care Medicine Oct 2023The aim of this study was to characterize differences in directives to limit treatments and discontinue invasive mechanical ventilation (IMV) in elderly (65-80 years)... (Observational Study)
Observational Study
Differences in directives to limit treatment and discontinue mechanical ventilation between elderly and very elderly patients: a substudy of a multinational observational study.
PURPOSE
The aim of this study was to characterize differences in directives to limit treatments and discontinue invasive mechanical ventilation (IMV) in elderly (65-80 years) and very elderly (> 80 years) intensive care unit (ICU) patients.
METHODS
We prospectively described new written orders to limit treatments, IMV discontinuation strategies [direct extubation, direct tracheostomy, spontaneous breathing trial (SBT), noninvasive ventilation (NIV) use], and associations between initial failed SBT and outcomes in 142 ICUs from 6 regions (Canada, India, United Kingdom, Europe, Australia/New Zealand, United States).
RESULTS
We evaluated 788 (586 elderly; 202 very elderly) patients. Very elderly (vs. elderly) patients had similar withdrawal orders but significantly more withholding orders, especially cardiopulmonary resuscitation and dialysis, after ICU admission [67 (33.2%) vs. 128 (21.9%); p = 0.002]. Orders to withhold reintubation were written sooner in very elderly (vs. elderly) patients [4 (2-8) vs. 7 (4-13) days, p = 0.02]. Very elderly and elderly patients had similar rates of direct extubation [39 (19.3%) vs. 113 (19.3%)], direct tracheostomy [10 (5%) vs. 40 (6.8%)], initial SBT [105 (52%) vs. 302 (51.5%)] and initial successful SBT [84 (80%) vs. 245 (81.1%)]. Very elderly patients experienced similar ICU outcomes (mortality, length of stay, duration of ventilation) but higher hospital mortality [26 (12.9%) vs. 38 (6.5%)]. Direct tracheostomy and initial failed SBT were associated with worse outcomes. Regional differences existed in withholding orders at ICU admission and in withholding and withdrawal orders after ICU admission.
CONCLUSIONS
Very elderly (vs. elderly) patients had more orders to withhold treatments after ICU admission and higher hospital mortality, but similar ICU outcomes and IMV discontinuation. Significant regional differences existed in withholding and withdrawal practices.
Topics: Humans; Aged; Respiration, Artificial; Renal Dialysis; Ventilator Weaning; Noninvasive Ventilation; Respiration; Intensive Care Units; Airway Extubation
PubMed: 37736783
DOI: 10.1007/s00134-023-07188-4 -
Journal of Critical Care Aug 2023Neurally adjusted ventilatory assist mode (NAVA) benefit in mechanical ventilation (MV) patients with regard to clinically outcomes is still uncertain. Recent randomized... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
Neurally adjusted ventilatory assist mode (NAVA) benefit in mechanical ventilation (MV) patients with regard to clinically outcomes is still uncertain. Recent randomized clinical trials (RCTs) have addressed this issue, making it important to assess the real impact of NAVA in relation to these outcomes.
MATERIALS AND METHODS
We performed a systematic review and meta-analysis of RCTs comparing NAVA ventilation mode versus the standard ventilation mode in critically ill adult patients admitted to the ICU with invasive MV. The main outcome was 28-days ventilatory free-days (VFD). Secondary outcomes were weaning failure, mortality, ICU and hospital length of stay and need for tracheostomy.
RESULTS
We included 5 RCTs (643 patients). The patients in the NAVA group had increased VFDs compared to the control group: mean difference (MD) 3.42 (95% CI 1.21 to 5.62, I = 0%). NAVA and control groups did not differ in ICU mortality [OR 0.58 (95% CI 0.33 to 1.03), I2 = 41%]. NAVA mode was associated with a reduced incidence of weaning failure [OR 0.51 (95% CI 0.29 to 0.88), I = 0%]. NAVA and control groups did not differ in the number of MV days: MD -1.9 days (95% CI -4.2 to 0.3, I = 0%).
CONCLUSIONS
NAVA mode has a modest impact on MV-free days and weaning success, with no association with improvements in other relevant clinical outcomes.
Topics: Adult; Humans; Respiration, Artificial; Interactive Ventilatory Support; Ventilator Weaning; Tracheostomy; Hospitalization
PubMed: 36958129
DOI: 10.1016/j.jcrc.2023.154287 -
Seminars in Respiratory and Critical... Apr 2024Due to higher survival rates with good quality of life, related to new treatments in the fields of oncology, hematology, and transplantation, the number of... (Review)
Review
Due to higher survival rates with good quality of life, related to new treatments in the fields of oncology, hematology, and transplantation, the number of immunocompromised patients is increasing. But these patients are at high risk of intensive care unit admission because of numerous complications. Acute respiratory failure due to severe community-acquired pneumonia is one of the leading causes of admission. In this setting, the need for invasive mechanical ventilation is up to 60%, associated with a high hospital mortality rate of around 40 to 50%. A wide range of pathogens according to the reason of immunosuppression is associated with severe pneumonia in those patients: documented bacterial pneumonia represents a third of cases, viral and fungal pneumonia both account for up to 15% of cases. For patients with an undetermined etiology despite comprehensive diagnostic workup, the hospital mortality rate is very high. Thus, a standardized diagnosis strategy should be defined to increase the diagnosis rate and prescribe the appropriate treatment. This review focuses on the benefit-to-risk ratio of invasive or noninvasive strategies, in the era of omics, for the management of critically ill immunocompromised patients with severe pneumonia in terms of diagnosis and oxygenation.
Topics: Humans; Noninvasive Ventilation; Quality of Life; Pneumonia; Respiration, Artificial; Pneumonia, Bacterial; Immunocompromised Host; Community-Acquired Infections; Intensive Care Units
PubMed: 38266998
DOI: 10.1055/s-0043-1778137 -
Seminars in Fetal & Neonatal Medicine Dec 2023The introduction of exogenous surfactant in the 1980s has resulted in an improved survival of very preterm infants with respiratory distress syndrome (RDS). Randomized... (Review)
Review
The introduction of exogenous surfactant in the 1980s has resulted in an improved survival of very preterm infants with respiratory distress syndrome (RDS). Randomized controlled trials conducted before 2000 have shown that the magnitude of this beneficial effect strongly depends on the timing of surfactant treatment, i.e. the earlier surfactant is administered after birth the better. However, the initial mode of respiratory support in infants with RDS has changed dramatically over the last decades, moving from invasive to non-invasive support. Furthermore, new, less invasive techniques to administer surfactant have been introduced to match this non-invasive approach. This review summarizes the evidence on how these practice changes impacted the effect of surfactant timing on mortality and morbidity in preterm infants with RDS.
Topics: Infant; Infant, Newborn; Humans; Infant, Premature; Surface-Active Agents; Respiratory Distress Syndrome, Newborn; Pulmonary Surfactants; Respiration, Artificial; Continuous Positive Airway Pressure; Lipoproteins
PubMed: 38012889
DOI: 10.1016/j.siny.2023.101495 -
British Journal of Anaesthesia Jul 2024Invasive mechanical ventilation is a key supportive therapy for patients on intensive care. There is increasing emphasis on personalised ventilation strategies. Clinical... (Review)
Review
Invasive mechanical ventilation is a key supportive therapy for patients on intensive care. There is increasing emphasis on personalised ventilation strategies. Clinical decision support systems (CDSS) have been developed to support this. We conducted a narrative review to assess evidence that could inform device implementation. A search was conducted in MEDLINE (Ovid) and EMBASE. Twenty-nine studies met the inclusion criteria. Role allocation is well described, with interprofessional collaboration dependent on culture, nurse:patient ratio, the use of protocols, and perception of responsibility. There were no descriptions of process measures, quality metrics, or clinical workflow. Nurse-led weaning is well-described, with factors grouped by patient, nurse, and system. Physician-led weaning is heterogenous, guided by subjective and objective information, and 'gestalt'. No studies explored decision-making with CDSS. Several explored facilitators and barriers to implementation, grouped by clinician (facilitators: confidence using CDSS, retaining decision-making ownership; barriers: undermining clinician's role, ambiguity moving off protocol), intervention (facilitators: user-friendly interface, ease of workflow integration, minimal training requirement; barriers: increased documentation time), and organisation (facilitators: system-level mandate; barriers: poor communication, inconsistent training, lack of technical support). One study described factors that support CDSS implementation. There are gaps in our understanding of ventilation practice. A coordinated approach grounded in implementation science is required to support CDSS implementation. Future research should describe factors that guide clinical decision-making throughout mechanical ventilation, with and without CDSS, map clinical workflow, and devise implementation toolkits. Novel research design analogous to a learning organisation, that considers the commercial aspects of device design, is required.
Topics: Humans; Respiration, Artificial; Decision Support Systems, Clinical; Clinical Decision-Making; Critical Care; Ventilator Weaning
PubMed: 38637268
DOI: 10.1016/j.bja.2024.03.011