1,721,166 research outputs found
Filtering out the noise: evaluating the impact of noise and sound reduction strategies on sleep quality for ICU patients
Full text linkThe review article by Xie and colleagues examines the impact of noise and noise reduction strategies on sleep quality for critically ill patients. Evaluating the impact of noise on sleep quality is challenging, as it must be measured relative to other factors that may be more or less disruptive to patients' sleep. Such factors may be difficult for patients, observers, and polysomnogram interpreters to identify, due to our limited understanding of the causes of sleep disruption in the critically ill, as well as the challenges in recording and quantifying sleep stages and sleep fragmentation in the intensive care unit. Furthermore, most research in this field has focused on noise level, whereas acousticians typically evaluate additional parameters such as noise spectrum and reverberation time. The authors highlight the disparate results and limitations of existing studies, including the lack of attention to other acoustic parameters besides sound level, and the combined effects of different sleep disturbing factors
Ventilator-induced lung injury
No full textThe purpose of mechanical ventilation is to rest the respiratory muscles while providing adequate gas exchange. Ventilatory support proved to be indispensable during the 1952 polio epidemic in Copenhagen, decreasing mortality among patients with paralytic polio from more than 80% to approximately 40%.1 Despite the clear benefits of this therapy, many patients eventually die after the initiation of mechanical ventilation, even though their arterial blood gases may have normalized.
This mortality has been ascribed to multiple factors, including complications of ventilation such as barotrauma (i.e., gross air leaks), oxygen toxicity, and hemodynamic compromise.2,3 During the polio epidemic, investigators noted that mechanical ventilation could cause structural damage to the lung.4 In 1967, the term “respirator lung” was coined to describe the diffuse alveolar infiltrates and hyaline membranes that were found on postmortem examination of patients who had undergone mechanical ventilation.5 More recently, there has been a renewed focus on the worsening injury that mechanical ventilation can cause in previously damaged lungs and the damage it can initiate in normal lungs. This damage is characterized pathologically by inflammatory-cell infiltrates, hyaline membranes, increased vascular permeability, and pulmonary edema. The constellation of pulmonary consequences of mechanical ventilation has been termed ventilator-induced lung injury.
The concept of ventilator-induced lung injury is not new. In 1744, John Fothergill discussed a case of a patient who was “dead in appearance” after exposure to coal fumes and who was successfully treated by mouth-to-mouth resuscitation.6 Fothergill noted that mouth-to-mouth resuscitation was preferable to using bellows because “the lungs of one man may bear, without injury, as great a force as those of another man can exert; which by the bellows cannot always be determin'd.” Fothergill clearly understood the concept that mechanical forces generated by bellows (i.e., a ventilator) could lead to injury.
However, it was not until early in this century that the clinical importance of ventilator-induced lung injury in adults was confirmed by a study showing that a ventilator strategy designed to minimize such injury decreased mortality among patients with the acute respiratory distress syndrome (ARDS).7 Given the clinical importance of ventilator-induced lung injury, this article will review mechanisms underlying the condition, its biologic and physiological consequences, and clinical strategies to prevent it and mitigate its effects
Transpulmonary pressure targets for open lung and protective ventilation: Response to Dr. Graf's comment
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Lung transplantation: is it still an experimental procedure?
No full textThe number of lung transplants performed worldwide is low and early and late results are worse in comparison with other solid organ transplants. The present review will focus on these two aspects analyzing the causes and describing the possible strategies to overcome these limitations.
RECENT FINDINGS:
The use of grafts from marginal and from nonheart-beating donors may increase the number of lung transplantation (LTx) with good results. Implementation of donor protocol and optimization of donor management have been reported to be effective in increasing the pool of suitable grafts. Ex-vivo reconditioning technique may be also helpful to better evaluate and recondition usually rejected lungs. This may allow a significant increase in the number of lung transplants performed worldwide. Early and late results of LTx are mainly affected by primary graft dysfunction and the onset of obliterative bronchiolitis. Different strategies have been adopted to reduce the incidence of these two complications with controversial results.
SUMMARY:
LTx maintains some features of experimental procedure especially in terms of number of performed procedures and early and late results. The various strategies to overcome the limited number of available grafts appear effective but not universally applied and accepted. The different treatments of PDG and obliterative bronchiolitis are still disappointing. To date, the onset of PDG and obliterative bronchiolitis after LTx still significantly impacts on outcomes. A better understanding of the underlying mechanisms in the pathogenesis of primary graft dysfunction and obliterative bronchiolitis may provide improved therapeutic strategies
Role and potentials of low-flow CO2 removal system in mechanical ventilation
No full textPURPOSE OF REVIEW:
An analysis of the technological implementation of extracorporeal CO(2) removal (ECCO(2)R) techniques and of its clinical application. A new classification of ECCO(2)R, based on technological aspects, clinical properties and physiological performance, is proposed.
RECENT FINDINGS:
The use of a ventilation with lower tidal volumes has been proved successful in acute respiratory distress syndrome (ARDS) patients but can be extremely problematic, especially when dealing with respiratory acidosis. The implementation of ECCO(2)R devices can represent the missing link between the prevention of ventilator-induced lung injury and pH control. ECCO(2)R has attracted increasing interest because of new less-invasive approaches allowing an easier management of ARDS patients. Recent studies have also shown that ECCO(2)R can also be used in patients with exacerbation of chronic obstructive pulmonary disease (COPD) and as a bridge to lung transplantation.
SUMMARY:
The future ventilatory management of patients with acute respiratory failure may include a minimally invasive extracorporeal carbon dioxide removal circuit associated with the least amount of ventilatory support (noninvasive in COPD and/or invasive in ARDS) to minimize sedation, prevent ventilator-induced acute lung injury and nosocomial infections. Randomized clinical trials in the pipeline will confirm this fascinating hypothesis
Extracorporeal membrane oxygenation in adult patients with acute respiratory distress syndrome
No full textPurpose of review
To examine the role of extracorporeal membrane oxygenation (ECMO) as potential therapeutic option for
severe cases of acute respiratory distress syndrome (ARDS).
Recent findings
The use of ECMO to treat acute respiratory failure dramatically increased. Factors that may explain this
increase in the use of ECMO are H1N1 pandemic influenza, results of recent clinical trials and not lastly
the technological development and consequently the commercial pressure of the industry. Under these
circumstances, clinicians urgently need clinical trials and formal indication, contraindication and rules for
implementation to provide reproducible results.
Summary
Guidelines from the Extracorporeal Life Support Organization still indicate ECMO for acute severe
pulmonary failure potentially reversible and unresponsive to conventional management. The new definition
of ARDS (Berlin definition) addresses clinicians to the best treatment options in respect of the severity of
illness and allocates ECMO as a potential therapeutic option for patients with severe ARDS and a P/F ratio
lower than 100 and proposed that the indication of ECMO may be shifted from the treatment of choice for
refractory hypoxemia to the treatment of choice to minimize ventilator-induced lung injury
Overview of ventilator-induced lung injury mechanisms
No full textPURPOSE OF REVIEW: Mechanical ventilation is the main supportive therapy for patients with acute respiratory distress syndrome. As with any therapy, mechanical ventilation has side effects and may induce lung injury. This review will focus on stretch-dependent activation of alveolar epithelial and endothelial cells and polymorphonuclear leukocytes, and apoptosis/necrosis balance. RECENT FINDINGS: The past year has seen important research in the area of mechanotransduction and lung native immunity, suggesting further mechanisms of lung inflammation and injury in ventilator-induced lung injury. Research in the past year has also stressed the importance of inflammatory response by alveolar cells and role of polymorphonuclear leukocytes in stretch-induced lung injury and has suggested a role for apoptosis in the maintenance of the alveolar epithelium. SUMMARY: The proportion of patients receiving protective ventilatory strategies remains modest. If efforts to minimize the iatrogenic consequences of mechanical ventilation are to succeed, there must be a greater understanding of the signal transduction mechanisms and the development of potential pharmacologic targets to modulate the molecular and cellular effects of lung stretch
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