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Intensive Care Management of Major Trauma
Published in Ian Greaves, Keith Porter, Jeff Garner, Trauma Care Manual, 2021
Ian Greaves, Keith Porter, Jeff Garner
Even in the presence of isolated trauma, other organ dysfunction can develop. Complications common to all critically ill patients include the development of sepsis, ventilator-associated lung injury with pneumonia, and renal dysfunction.
Severe Non-influenza Viral Pneumonia in the Critical Care Unit
Published in Cheston B. Cunha, Burke A. Cunha, Infectious Diseases and Antimicrobial Stewardship in Critical Care Medicine, 2020
David Waldner, Thomas J. Marrie, Wendy Sligl
Invasive respiratory support is fundamental to the treatment of viral pneumonia complicated by severe respiratory failure. Among mechanically ventilated patients with ARDS, the importance of preventing ventilator-associated lung injury is crucial. Lung protective ventilation using lower tidal volumes (4–8 mL/kg predicted body weight) and lower inspiratory plateau pressures (<30 cm H2O) is recommended in ARDS patients. based on the results of several trials showing a reduction in mortality when compared with conventional strategies [129,130]. Additionally, venovenous ECMO has proven to be an effective means of respiratory support during severe acute respiratory failure [131]. Among patients with severe ARDS during the 2009 H1N1 pandemic, the use of ECMO was associated with a reduction in mortality compared with conventional therapy [132]. Although prospective trials are lacking, venoarterial ECMO appears to be effective in patients with HCPS, with one case series reporting a survival rate of 67% among patients who failed conventional interventions [91]. However, the optimal timing for initiating ECMO in HCPS is currently unknown [133].
Diagnosis and management of critical illness in patients with interstitial lung disease
Published in Muhunthan Thillai, David R Moller, Keith C Meyer, Clinical Handbook of Interstitial Lung Disease, 2017
Multiple studies have previously reported significant morbidity and mortality associated with intubation and mechanical ventilation in patients admitted with AE (25,26,83). Earlier series report a mortality of 85% (83) to 100% (25,26,84), with a more recent series suggesting 94% mortality (27). Mechanical ventilation was also independently predictive of in-hospital death in both IPF and non-IPF patients in one series (13). The morbidity associated with mechanical ventilation has not been correlated with either a greater severity of baseline disease (and therefore required support) or the direct consequences of ventilator-associated lung injury and its sequelae. No studies have identified an optimal mode of ventilator support, but given the similarity of an AE event to ARDS, a low tidal volume strategy is commonly applied (27). Recent cohort studies have suggested considerable variation in the duration of mechanical ventilation and its use as a predictor of hospital outcome (13,83,85), with some patients surviving for at least several weeks after planned tracheostomy and long-term ventilator weaning protocols. Indeed, given the poor outcome of patients requiring mechanical ventilation, it has been suggested that mechanical ventilation should only be used as a bridge to rescue transplantation (26,86), as it offers little short or long-term benefit.
Optimizing Physiology During Prehospital Airway Management: An NAEMSP Position Statement and Resource Document
Published in Prehospital Emergency Care, 2022
Daniel P. Davis, Nichole Bosson, Francis X. Guyette, Allen Wolfe, Bentley J. Bobrow, David Olvera, Robert G. Walker, Michael Levy
Early survivors of cardiac arrest and trauma are at high risk for in-hospital death from pulmonary complications that include ventilator-associated pneumonia, ventilator-associated lung injury (VALI), and ARDS (61,62). Strategies should be considered to reduce the prehospital contribution to those complications. Wang et al. performed a Cochrane review, concluding that elevation of the head and torso above 30 degrees is associated with a decreased incidence of ventilator-associated pneumonia in the intensive care unit (ICU) compared to the supine position but noted the conflicting data encountered in the review (63). Klompas suggested that the variability may have to do with the types of diseases studied and the definition of ventilator-associated pneumonia (64). Alexiou et al. found that protection was offered only when the angle was 45 degrees, as compared to either 15 or 30 degrees (65). In the absence of contraindications, it seems prudent to elevate the EMS stretcher to maintain the torso at 45 degrees after EMS placement of an advanced airway.
Ventilator-induced lung injury during controlled ventilation in patients with acute respiratory distress syndrome: less is probably better
Published in Expert Review of Respiratory Medicine, 2018
Fernanda Ferreira Cruz, Lorenzo Ball, Patricia Rieken Macedo Rocco, Paolo Pelosi
Mechanical ventilation is required to support respiratory function in ARDS, but it may cause lung damage, a phenomenon known as ventilator-induced lung injury (VILI). While often used interchangeably, the term ‘ventilator-associated lung injury’ (VALI) refers to the presence of lung injury during mechanical ventilation when a causal link is not ascertained. VILI can also occur in noninjured lungs, but it has particular relevance in ARDS and has been extensively studied in these patients. Several mechanisms of VILI have been described, such as: inspiratory and/or expiratory stress inducing overdistension (volutrauma); interfaces between collapsed or edema-filled alveoli and surrounding open alveoli, acting as stress raisers; alveoli that continuously open and close with tidal breathing; and peripheral airway dynamics (atelectrauma) [6]. Therefore, mortality in patients with ARDS has an iatrogenic component due to mechanical ventilation itself. The goal of respiratory support should thus be to improve gas exchange while minimizing VILI and preventing the progression of lung damage.
Mechanical ventilation in Guillain–Barré syndrome
Published in Expert Review of Clinical Immunology, 2020
Pei Shang, Mingqin Zhu, Matthew Baker, Jiachun Feng, Chunkui Zhou, Hong-Liang Zhang
In general MV, control mode ventilation with tidal volumes around 10 ml/kg body weight (BW) is applied initially, and then it is quickly shifted to synchronized intermittent mandatory ventilation with pressure support to maintain adequate oxygenation and oxygen fraction in inspired air (FiO2 < 0.5, PO2 > 60 mmHg) after stabilization. Lower tidal volume (< 10 ml/kg BW) had been correlated with the development of atelectasis during the first 3 days of MV [49]. However, lower tidal volume and higher positive end-expiratory pressure (PEEP) were later utilized in patients with GBS, which did not introduce a significant change in atelectasis incidence, VAP incidence, MV duration, ICU stay, and mortality [50]. A lower tidal volume could benefit the obstructive lung disease and prevent ventilator-associated lung injury while higher tidal volumes may benefit partial lung collapse [49]. Nonetheless, more investigations need to be performed to demonstrate the protective effects of lower tidal volumes and higher PEEP in MV-dependent GBS patients. Interestingly, mathematical models can be utilized in analyzing tidal volume, tidal pressure, or tidal power to optimize the advanced modes of adaptive support ventilation (ASV), adaptive ventilation mode 2 (AVM2), and mid-frequency ventilation (MFV) [51]. Additionally, prone ventilation lasting 18–20 h may improve oxygenation and decrease mortality in patients with early ARDS [52]. The prone position may decrease pressure palsies commonly developed in MV-dependent GBS patients [26]. Nutritional support, asepsis, humidification of inspired air, chest physiotherapy, regular endotracheal toileting, and repositioning may further lower the risks of atelectasis, pressure sores, and other MV-associated complications [53].