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Respiratory Care Nov 2022Mechanical ventilation is commonly used in the pediatric intensive care unit. This paper reviews studies of pediatric mechanical ventilation published in 2021. Topics... (Review)
Review
Mechanical ventilation is commonly used in the pediatric intensive care unit. This paper reviews studies of pediatric mechanical ventilation published in 2021. Topics include physiology, ventilator modes, alarms, disease states, airway suctioning, ventilator liberation, prolonged ventilation, and others.
Topics: Humans; Child; Respiration, Artificial; Intensive Care Units, Pediatric; Respiratory Therapy; Respiration; Suction; Ventilator Weaning; Airway Extubation
PubMed: 36100276
DOI: 10.4187/respcare.10311 -
Respiratory Care May 2017The fundamental goals of mechanical ventilation are to improve pulmonary gas exchange and relieve respiratory distress, thus permitting lung and airway healing, while at... (Review)
Review
The fundamental goals of mechanical ventilation are to improve pulmonary gas exchange and relieve respiratory distress, thus permitting lung and airway healing, while at the same time lessening the risk for iatrogenic complications. This review will summarize some of the advances in mechanical ventilation in 2016, with a particular focus on ventilator-associated clinical challenges and outcomes.
Topics: Humans; Pulmonary Gas Exchange; Respiration, Artificial; Respiratory Distress Syndrome; Ventilator Weaning; Ventilator-Induced Lung Injury
PubMed: 28442589
DOI: 10.4187/respcare.05545 -
Current Opinion in Critical Care Feb 2019This review focuses on the emerging body of literature regarding the management of acute respiratory failure in low- and middle-income countries (LMICs). The aim is to... (Review)
Review
PURPOSE OF REVIEW
This review focuses on the emerging body of literature regarding the management of acute respiratory failure in low- and middle-income countries (LMICs). The aim is to abstract management principles that are of relevance across a variety of settings where resources are severely limited.
RECENT FINDINGS
Mechanical ventilation is an expensive intervention associated with considerable mortality and a high rate of iatrogenic complications in many LMICs. Recent case series report crude mortality rates for ventilated patients of between 36 and 72%. Measures to avert the need for invasive mechanical ventilation in LMICs are showing promise: bubble continuous positive airway pressure has been demonstrated to decrease mortality in children with acute respiratory failure and trials suggest that noninvasive ventilation can be conducted safely in settings where resources are low.
SUMMARY
The management of patients with acute respiratory failure in LMICs should focus on avoiding intubation where possible, improving the safety of mechanical ventilation and expediting weaning. Future directions should involve the development and trialing of robust and context-appropriate respiratory support technology.
Topics: Child; Continuous Positive Airway Pressure; Humans; Noninvasive Ventilation; Respiration, Artificial; Respiratory Distress Syndrome; Respiratory Insufficiency
PubMed: 30531535
DOI: 10.1097/MCC.0000000000000568 -
Jornal Brasileiro de Pneumologia :... 2015Patients with obstructive lung disease often require ventilatory support via invasive or noninvasive mechanical ventilation, depending on the severity of the... (Review)
Review
Patients with obstructive lung disease often require ventilatory support via invasive or noninvasive mechanical ventilation, depending on the severity of the exacerbation. The use of inhaled bronchodilators can significantly reduce airway resistance, contributing to the improvement of respiratory mechanics and patient-ventilator synchrony. Although various studies have been published on this topic, little is known about the effectiveness of the bronchodilators routinely prescribed for patients on mechanical ventilation or about the deposition of those drugs throughout the lungs. The inhaled bronchodilators most commonly used in ICUs are beta adrenergic agonists and anticholinergics. Various factors might influence the effect of bronchodilators, including ventilation mode, position of the spacer in the circuit, tube size, formulation, drug dose, severity of the disease, and patient-ventilator synchrony. Knowledge of the pharmacological properties of bronchodilators and the appropriate techniques for their administration is fundamental to optimizing the treatment of these patients.
Topics: Administration, Inhalation; Bronchodilator Agents; Drug Delivery Systems; Female; Humans; Lung; Male; Nebulizers and Vaporizers; Pulmonary Disease, Chronic Obstructive; Respiration, Artificial
PubMed: 26578139
DOI: 10.1590/S1806-37132015000000035 -
Respiratory Care Oct 2012Mechanical ventilation is a life-saving supportive therapy, but it can also cause lung injury, diaphragmatic dysfunction, and lung infection. Ventilator liberation... (Review)
Review
Mechanical ventilation is a life-saving supportive therapy, but it can also cause lung injury, diaphragmatic dysfunction, and lung infection. Ventilator liberation should be attempted as soon as clinically indicated, to minimize morbidity and mortality. The most effective method of liberation follows a systematic approach that includes a daily assessment of weaning readiness, in conjunction with interruption of sedation infusions and spontaneous breathing trials. Protocols and checklists are decision support tools that help ensure consistent application of key elements of evidence-based practice. A majority of studies of weaning protocols applied by non-physician healthcare providers suggest faster weaning and shorter duration of ventilation and ICU stay, and some suggest reduced failed extubation and ventilator-associated pneumonia rates. Checklists can be used to reinforce application of the protocol, or possibly in lieu of one, particularly in environments where the caregiver-to-patient ratio is high and clinicians are well versed in and dedicated to applying evidence-based care. There is support for integrating best-evidence rules for weaning into the mechanical ventilator so that a substantial portion of the weaning process can be automated, which may be most effective in environments with low caregiver-to-patient ratios or those in which it is challenging to consistently apply evidence-based care. This paper reviews evidence for ventilator liberation protocols and discusses issues of implementation and ongoing monitoring.
Topics: Decision Support Techniques; Humans; Predictive Value of Tests; Respiration, Artificial; Respiratory Function Tests; Ventilator Weaning
PubMed: 23013902
DOI: 10.4187/respcare.01895 -
Mechanical ventilation in aneurysmal subarachnoid hemorrhage: systematic review and recommendations.Critical Care (London, England) Sep 2020Mechanical ventilation (MV) has a complex interplay with the pathophysiology of aneurysmal subarachnoid hemorrhage (aSAH). We aim to provide a review of the physiology...
OBJECTIVE
Mechanical ventilation (MV) has a complex interplay with the pathophysiology of aneurysmal subarachnoid hemorrhage (aSAH). We aim to provide a review of the physiology of MV in patients with aSAH, give recommendations based on a systematic review of the literature, and highlight areas that still need investigation.
DATA SOURCES
PubMed was queried for publications with the Medical Subject Headings (MeSH) terms "mechanical ventilation" and "aneurysmal subarachnoid hemorrhage" published between January 1, 1990, and March 1, 2020. Bibliographies of returned articles were reviewed for additional publications of interest.
STUDY SELECTION
Study inclusion criteria included English language manuscripts with the study population being aSAH patients and the exposure being MV. Eligible studies included randomized controlled trials, observational trials, retrospective trials, case-control studies, case reports, or physiologic studies. Topics and articles excluded included review articles, pediatric populations, non-aneurysmal etiologies of subarachnoid hemorrhage, mycotic and traumatic subarachnoid hemorrhage, and articles regarding tracheostomies.
DATA EXTRACTION
Articles were reviewed by one team member, and interpretation was verified by a second team member.
DATA SYNTHESIS
Thirty-one articles met the inclusion criteria for this review.
CONCLUSIONS
We make recommendations on oxygenation, hypercapnia, PEEP, APRV, ARDS, and intracranial pressure monitoring.
Topics: Humans; Prone Position; Respiration, Artificial; Respiratory Distress Syndrome; Subarachnoid Hemorrhage
PubMed: 32972406
DOI: 10.1186/s13054-020-03269-8 -
Pulmonology 2021In this part of the review series "Tricks and tips for home mechanical ventilation", we will discuss the evidence with regard to the place and manner of home mechanical... (Review)
Review
In this part of the review series "Tricks and tips for home mechanical ventilation", we will discuss the evidence with regard to the place and manner of home mechanical ventilation initiation and follow-up. Outsourcing more and more of this chronic care to the home situation is a big challenge for the future: especially for the home situation, monitoring has to be non-invasive, reliable and easy to use, data security needs to be ensured, signals need to be integrated and preferably automatically processed and algorithms need to be developed based on clinically relevant outcomes.
Topics: Algorithms; Computer Security; Follow-Up Studies; Home Care Services; Humans; Monitoring, Physiologic; Noninvasive Ventilation; Outsourced Services; Oximetry; Polysomnography; Reproducibility of Results; Respiration Disorders; Respiration, Artificial
PubMed: 32912752
DOI: 10.1016/j.pulmoe.2020.08.002 -
Respiratory Care Jan 2018Spontaneous breathing trials (SBTs) and daily sedation interruptions (DSIs) reduce both the duration of mechanical ventilation and ICU length of stay (LOS). The impact... (Comparative Study)
Comparative Study
BACKGROUND
Spontaneous breathing trials (SBTs) and daily sedation interruptions (DSIs) reduce both the duration of mechanical ventilation and ICU length of stay (LOS). The impact of these practices in patients with ARDS has not previously been reported. We examined whether implementation of SBT/DSI protocols reduce duration of mechanical ventilation and ICU LOS in a retrospective group of subjects with ARDS at a large, urban, level-1 trauma center.
METHODS
All ARDS survivors from 2002 to 2016 ( = 1,053) were partitioned into 2 groups: 397 in the pre-SBT/DSI group (June 2002-December 2007) and 656 in the post-SBT/DSI group (January 2009-April 2016). Patients from 2008, during the protocol implementation period, were excluded. An additional SBT protocol database (2008-2010) was used to assess the efficacy of SBT in transitioning subjects with ARDS to unassisted breathing. Comparisons were assessed by either unpaired tests or Mann-Whitney tests. Multiple comparisons were made using either one-way analysis of variance or Kruskal-Wallis and Dunn's tests. Linear regression modeling was used to determine variables independently associated with mechanical ventilation duration and ICU LOS; differences were considered statistically significant when < .05.
RESULTS
Compared to the pre-protocol group, subjects with ARDS managed with SBT/DSI protocols experienced pronounced reductions both in median (IQR) mechanical ventilation duration (14 [6-29] vs 9 [4-17] d, respectively, < .001) and median ICU LOS (18 [8-33] vs 13 [7-22] d, respectively < .001). In the final model, only treatment in the SBT/DSI period and higher baseline respiratory system compliance were independently associated with reduced mechanical ventilation duration and ICU LOS. Among subjects with ARDS in the SBT performance database, most achieved unassisted breathing with a median of 2 SBTs.
CONCLUSION
Evidenced-based protocols governing weaning and sedation practices were associated with both reduced mechanical ventilation duration and ICU LOS in subjects with ARDS. However, higher respiratory system compliance in the SBT/DSI cohort also contributed to these improved outcomes.
Topics: Adult; Clinical Protocols; Conscious Sedation; Female; Humans; Intensive Care Units; Length of Stay; Male; Middle Aged; Respiration, Artificial; Respiratory Distress Syndrome; Retrospective Studies; Time Factors; Treatment Outcome; Ventilator Weaning
PubMed: 29018041
DOI: 10.4187/respcare.05270 -
Respiratory Care Feb 2012
Topics: Female; Humans; Male; Positive-Pressure Respiration; Respiration, Artificial; Respiratory Insufficiency; Sleep Apnea Syndromes; Ventilator Weaning
PubMed: 22304801
DOI: 10.4187/respcare.01723 -
Critical Care (London, England) Jun 2016Acute respiratory distress syndrome (ARDS) is characterized by a noncardiogenic pulmonary edema with bilateral chest X-ray opacities and reduction in lung compliance,... (Review)
Review
BACKGROUND
Acute respiratory distress syndrome (ARDS) is characterized by a noncardiogenic pulmonary edema with bilateral chest X-ray opacities and reduction in lung compliance, and the hallmark of the syndrome is hypoxemia refractory to oxygen therapy. Severe hypoxemia (PaO2/FiO2 < 100 mmHg), which defines severe ARDS, can be found in 20-30 % of the patients and is associated with the highest mortality rate. Although the standard supportive treatment remains mechanical ventilation (noninvasive and invasive), possible adjuvant therapies can be considered. We performed an up-to-date clinical review of the possible available strategies for ARDS patients with severe hypoxemia.
MAIN RESULTS
In summary, in moderate-to-severe ARDS or in the presence of other organ failure, noninvasive ventilatory support presents a high risk of failure: in those cases the risk/benefit of delayed mechanical ventilation should be evaluated carefully. Tailoring mechanical ventilation to the individual patient is fundamental to reduce the risk of ventilation-induced lung injury (VILI): it is mandatory to apply a low tidal volume, while the optimal level of positive end-expiratory pressure should be selected after a stratification of the severity of the disease, also taking into account lung recruitability; monitoring transpulmonary pressure or airway driving pressure can help to avoid lung overstress. Targeting oxygenation of 88-92 % and tolerating a moderate level of hypercapnia are a safe choice. Neuromuscular blocking agents (NMBAs) are useful to maintain patient-ventilation synchrony in the first hours; prone positioning improves oxygenation in most cases and promotes a more homogeneous distribution of ventilation, reducing the risk of VILI; both treatments, also in combination, are associated with an improvement in outcome if applied in the acute phase in the most severe cases. The use of extracorporeal membrane oxygenation (ECMO) in severe ARDS is increasing worldwide, but because of a lack of randomized trials is still considered a rescue therapy.
CONCLUSION
Severe ARDS patients should receive a holistic framework of respiratory and hemodynamic support aimed to ensure adequate gas exchange while minimizing the risk of VILI, by promoting lung recruitment and setting protective mechanical ventilation. In the most severe cases, NMBAs, prone positioning, and ECMO should be considered.
Topics: Extracorporeal Membrane Oxygenation; Humans; Hypoxia; Respiration, Artificial; Respiratory Distress Syndrome; Tidal Volume; Ventilator-Induced Lung Injury
PubMed: 27255913
DOI: 10.1186/s13054-016-1304-7