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Getting dark, too dark to see
No full textDr. Levy and colleagues
in their extremely important article, NIV
may help our patients to pass over with
less distress (better in a private room as
suggested in the editorial) or give them a
chance, if they wish, to survive a few
more days or months
Ethics, attitude and practice in end-of-life care decision: an European perspective
No full textOnly in the last decade in Europe has there been increased attention dedicated to the end-of-life care in the hospital, especially in the Intensive Care Unit (ICU). The definitions of the potential decision are extremely important. Withholding is a planned decision not to institute therapies that were otherwise warranted, Withdrawal is the discontinuation of treatments that had been started, Terminal sedation consists of pain and symptom treatment with the possible side effect of shortening life, while Euthanasia means that a doctor is intentionally killing a person who is suffering unbearably and hopelessly at the latter's explicit informed request. The overall incidence of these practices in Europe is only partially known, but there are important differences between Countries or regions, reflecting the absence of a common strategy even within the European Community. Only <15% of ICU patients retain decision making capacity, allowing the impossibility of discussing the decision with them. It is rare that the patient's family is involved in the decision and when such case does arise, the relatives rate the communication with hospital staff poor. The "shared decision" taken together by physicians, nurses, and the patient's family may be the best approach for end-of-life decision, therefore common European guidelines are needed
Preoperative inspiratory muscle training and postoperative complications
No full textFinally, the authors did not mention the potential risks
of IMT. It has been shown in animal studies3 and human
studies4 that IMT may be deleterious and may produce injury
of the diaphragm, even though it may benefit the external
intercostal muscles.
Invited Review Series Introduction
No full textThe presence of acute or chronic respiratory failure is often seen and considered as a terminal phase of COPD
At present, however, we do not have firm predictive parameters of mortality in COPD patients. In a review, Curtis speculated that a patient with two or more of the following characteristics has a bad prognosis in a time frame of 1 to 3 years: FEV1 70 yrs.
At this stage of the disease, it seems that no pharmacological treatment is able to influence the survival of these patients, except the use of long term oxygen therapy (LTOT) and possibly home noninvasive ventilation (NIV
Causes of failure of noninvasive mechanical ventilation
No full textWith selected patients noninvasive positive-pressure ventilation (NPPV) can obviate endotracheal intubation and thus avoid the airway trauma and infection associated with intubation. With patients who can cooperate, NPPV is the first-line treatment for mild-to-severe acute hypercapnic respiratory failure. NPPV is also used for hypercapnic ventilatory failure and to assist weaning from mechanical ventilation, by allowing earlier extubation. Some patients do not obtain adequate ventilation with NPPV and therefore require intubation. Also, some patients will initially benefit from NPPV (for one-to-several days) but will then deteriorate and require intubation. It is not always apparent which patients will initially benefit from NPPV, so researchers have been looking for variables that predict NPPV success/failure. The reported NPPV failure rate is 5-40%, so the necessary staff and equipment for prompt intubation should be readily available. Absolute contraindications to NPPV are: cardiac or respiratory arrest; nonrespiratory organ failure (eg, severe encephalopathy, severe gastrointestinal bleeding, hemodynamic instability with or without unstable cardiac angina); facial surgery or trauma; upper-airway obstruction; inability to protect the airway and/or high risk of aspiration; and inability to clear secretions. The NPPV training and experience of the clinician team partly determines whether the patient will succeed with NPPV or, instead, require intubation. Greater clinician-team NPPV experience and expertise are associated with a higher percentage of patients succeeding on NPPV and with NPPV success with sicker patients (than will succeed with a less-experienced clinician team). With patients suffering hypercapnic respiratory failure the best NPPV success/failure predictor is the degree of acidosis/acidemia (pH and P(aCO(2)) at admission and after 1 hour on NPPV), whereas mental status and severity of illness are less reliable predictors. With patients suffering hypoxic respiratory failure the likelihood of NPPV success seems to be related to the underlying disease rather than to the degree of hypoxia. For example, the presence of acute respiratory distress syndrome or community-acquired pneumonia portends NPPV failure, as does lack of oxygenation improvement after an hour on NPPV. All the proposed NPPV success/failure predictors should be used cautiously and need further study. We predict that further study and team experience will improve the NPPV success rate and allow successful NPPV-treatment of sicker patients
Mask ventilation and cardiogenic pulmonary edema: "Another brick in the wall"
No full textnot availabl
Noninvasive Ventilation in Acute Hypercapnic Respiratory Failure
No full textNoninvasive mechanical ventilation (NIV) improves gas exchange and clinical outcome in various types of acute respiratory failure. Acute exacerbation of chronic obstructive pulmonary disease is a frequent cause of acute hypercapnic respiratory failure (AHRF). According to several randomized controlled trials, the addition of NIV to standard medical therapy reduces mortality, intubation rate, and hospital length of stay in these patients. Indications for the use of NIV have expanded over the past decade. In this article, we discuss the clinical indications and goals of NIV in the management of AHRF
Patient-ventilator interaction during noninvasive positive pressure ventilation
No full textThe interaction between the patient and the ventilator is complex,especially in a "semi-open" system as for noninvasive ventilation(NIV). Air leaks around the mask are likely to occur, and they affect patient-ventilator synchrony. Several variables may be responsible for the mismatch between the start of the neural output and that of ventilatory aid during NIV. The most common mode of ventilation is pressure support ventilation (PSV), which may result in a number of inspiratory efforts not being followed by ventilator aid. New modes of ventilation, such as proportional assist ventilation, maybe useful in improving patient tolerance to ventilation without affecting clinical outcome. The ventilatory settings are important during PSV to determine the synchrony. The inspiratory trigger function may be influenced by the amount of leaks, whereas a better synchrony may be achieved if the termination of the inspiratory phase is time cycled instead of flow cycled. A high pressurization rate results in poor compliance. Care should be paid in the choice of the interfaces because leaks in the system are associated with a substantial breath-to-breath inspiratory variation independent from the patient effort. Last, NIV should be delivered with turbine- or piston-based ventilators that are able to compensate for air leaks. With respect to the problem of sedation, we point out the importance of optimizing the environmental conditions, avoiding excessive light and noise, assuring patient comfort, and providing reassurance. When sedation is needed, we suggest the use of low doses of analgesics and neuroleptic agents in selected cases
Non-invasive ventilation in acute respiratory failure
No full textNon-invasive mechanical ventilation has been increasingly used to avoid or serve as an alternative to intubation. Compared with medical therapy, and in some instances with invasive mechanical ventilation, it improves survival and reduces complications in selected patients with acute respiratory failure. The main indications are exacerbation of chronic obstructive pulmonary disease, cardiogenic pulmonary oedema, pulmonary infiltrates in immunocompromised patients, and weaning of previously intubated stable patients with chronic obstructive pulmonary disease. Furthermore, this technique can be used in postoperative patients or those with neurological diseases, to palliate symptoms in terminally ill patients, or to help with bronchoscopy; however further studies are needed in these situations before it can be regarded as first-line treatment. Non-invasive ventilation implemented as an alternative to intubation should be provided in an intensive care or high-dependency unit. When used to prevent intubation in otherwise stable patients it can be safely administered in an adequately staffed and monitored ward
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