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Diagnosis and Treatment of COVID-19
Published in Wenguang Xia, Xiaolin Huang, Rehabilitation from COVID-19, 2021
Salvage treatment: For patients with severe acute respiratory distress syndrome (ARDS), it is recommended to perform lung expansion. Prone ventilation should be performed for more than 12 hours per day. When the patient is in the prone position, mechanical ventilation is not effective; if possible, extracorporeal membrane pulmonary oxygenation (ECMO) should be performed as soon as possible. Related indications: When FiO2 > 90%, the oxygenation index is less than 80 mmHg, which lasts more than 3–4 hours.When the airway plateau pressure ≥35 cmH2O. For patients with simple respiratory failure the VV-ECMO mode is preferred; if circulatory support is needed, then VA-ECMO mode should be used. When the underlying disease is under control and cardiopulmonary function shows signs of recovery, a weaning test should be considered.
Critical Care of the Trauma Patient
Published in Kenneth D Boffard, Manual of Definitive Surgical Trauma Care: Incorporating Definitive Anaesthetic Trauma Care, 2019
Ventilatory support should be instituted earlier rather than later; select a mode of ventilation tailored to the patient's need using appropriate tidal volumes and amounts of positive end-expiratory pressure (PEEP): Pressure support ventilation (PSV) – poorly tolerated following severe injury.Lung protective ventilation (LPV) with low volume and low peak pressures is frequently not possible early in resuscitation due to severe hypoxia and low compliance, use adequate volumes despite the frequent requirement for higher pressures.High positive end-expiratory pressure PEEP (>10 up to 20–25 cm H2O may be required) to recruit alveoli.ECMO (extracorporeal membrane oxygenation) may be considered where appropriate (see also Section 17.3).Non-invasive ventilatory support in selected cases only.A safe strategy is to maintain a driving pressure (plateau pressure – PEEP) of <15 cm water while accounting for lung injury.4
Pediatric ICU management
Published in David E. Wesson, Bindi Naik-Mathuria, Pediatric Trauma, 2017
Jason O. Robertson, Adam M. Vogel
Lung-protective ventilation describes a strategy to achieve adequate (not necessarily normal) gas exchange by using low VT to prevent overdistention of the lung, PEEP to reduce atelectasis, and minimal required FiO2 to avoid oxidative stress. These practices have largely been extrapolated from studies of adult ICU patients with ARDS [42], although there is also significant interest in the neonatal population where lung-protective strategies have been shown to reduce risk for bronchopulmonary dysplasia and retinopathy of prematurity [43]. In general, VT should be 6 mL/kg of body weight, PEEP should range between 5 and 12 cm H2O, and FiO2 should be maintained at the lowest possible level to keep oxygen saturation between 88% and 94%. Plateau pressure should not exceed 30 cm H2O; however, higher pressures may be tolerated in patients with chest wall trauma that reduces compliance. Permissive hypercapnia, as appropriate, allows us to maintain low VT ventilation.
Lung and diaphragm protective ventilation: a synthesis of recent data
Published in Expert Review of Respiratory Medicine, 2022
Vlasios Karageorgos, Athanasia Proklou, Katerina Vaporidi
The pressure that develops within the respiratory system at the end of inspiration, the plateau pressure, was the first indicator of lung stress used in clinical practice [4]. The ratio of tidal volume (VT) to respiratory system compliance (CRS), termed driving pressure (ΔP, calculated as the difference between passive Pplat and PEEP), better reflects the lung stress since the respiratory system compliance is strongly related to the functional lung size [13]. Retrospective analysis of large patient datasets [13,14] and prospective studies have identified a threshold of ΔP above 15 cmH2O to be associated with adverse patient outcomes [13,15]. Importantly, a recent analysis showed an association with improved mortality when pre-specified changes in ventilator settings resulted in a decrease of ΔP, but not, when they only resulted in an increase in PaO2/FiO2, again emphasizing the potential benefit of targeting driving pressure in clinical practice [16].
Lifestyle and rehabilitation during the COVID-19 pandemic: guidance for health professionals and support for exercise and rehabilitation programs
Published in Expert Review of Anti-infective Therapy, 2021
Cássia Da Luz Goulart, Rebeca Nunes Silva, Murilo Rezende Oliveira, Solange Guizilini, Isadora Salvador Rocco, Vanessa Marques Ferreira Mendez, José Carlos Bonjorno, Flavia Rossi Caruso, Ross Arena, Audrey Borghi-Silva
Due to the potential severity of pulmonary lesions associated with SARS-CoV-2, infected patients may evolve to severe SARS in a few hours post hospital admission [86]. This observation underlines the clinical recommendation of early invasive mechanical ventilation. Protective ventilatory strategies are highly recommended in these patients by early adoption of the following: 1) lower tidal volume (between 4 to 6 ml/kg of predicted body weight for severe ARDS and 4 to 8 ml/kg for mild to moderate SARS); 2) controlled positive end expiratory pressure (PEEP) by PEEP table of ART Study (preference of high PEEP levels) [92] or by an individual lung compliance best threshold; 3) driving pressure lower than 15 cmH2O (plateau pressure minus PEEP); 4) plateau pressure below 27 cmH2O; and 5) inspiratory fraction of oxygen combined with PEEP management to achieve a SpO2 between 92 to 95% [93]. Moreover, following intubation, attention regarding the degree of SARS is required. It is recommended to pay closer attention to some parameters, such as the ratio of SpO2 and O2 inspired fraction offered (PaO2/FiO2) for mechanical ventilation management. Studies report that, even with early adoption of protective lung ventilation and closer adjustment of PEEP, patients often preset with a PaO2/FiO2 below 150 mmHg [94]. Therefore, it is important to detect these alterations within 4 hours after intubation for early adoption of the prone position strategy.
Effectiveness, safety and efficacy of INTELLiVENT–adaptive support ventilation, a closed–loop ventilation mode for use in ICU patients – a systematic review
Published in Expert Review of Respiratory Medicine, 2021
M. Botta, E.F.E. Wenstedt, A.M. Tsonas, L.A. Buiteman-Kruizinga, D.M.P. van Meenen, H.H.M. Korsten, J. Horn, F. Paulus, A.G.J.H. Bindels, M.J. Schultz, A.J.R. De Bie
Both driving pressure, the difference between the plateau pressure and PEEP, and mechanical power of ventilation, a mathematical approach that captures various ventilator settings including VT, driving pressure, flow and respiratory rate, have an association with outcomes in patients with ARDS, as well as patients without ARDS [26–31]. While these two parameters certainly must be seen as biomarkers for existing lung injury, it could still be that simple adjustments of certain ventilator settings affect these parameters, possibly resulting in better outcomes. For instance, driving pressure could be reduced by using a lower VT, respiratory rate could be kept low when accepting a certain level of hypercapnia, and PEEP could be used so that atelectasis is minimized while preventing overdistension.