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Therapeutic Approaches in Acute Heart Failure
Published in Andreas P. Kalogeropoulos, Hal A. Skopicki, Javed Butler, Heart Failure, 2023
Getu Teressa, Rachel A. Bright, Andreas P. Kalogeropoulos
Acute respiratory failure is defined as hypoxia (SpO2<90% or PaO2<60 mmHg), respiratory distress (increased work of breathing, respiratory rate >25 breaths/minute), or hypercapnia (PaCO2 >50 mmHg and arterial pH <7.35). Signs of increased work of breathing are subjective assessments that include accessory muscle use and retractions, paradoxical abdominal breathing, inability to speak full sentences (or sentences interrupted by labored breath), which may be associated with diaphoresis, restlessness/agitation, or decline in mental status.
The Paediatric Consultation
Published in R James A England, Eamon Shamil, Rajeev Mathew, Manohar Bance, Pavol Surda, Jemy Jose, Omar Hilmi, Adam J Donne, Scott-Brown's Essential Otorhinolaryngology, 2022
A compromised airway has to be addressed as a matter of extreme urgency because it quickly affects all the organ systems. Airway compromise leads to an increase in the work of breathing. The key signs of increased work of breathing include: Stertor (snoring sound)Stridor (high-pitched sound—can be inspiratory or expiratory)Wheeze (usually expiratory)Use of accessory muscles of breathingTracheal tuggingNostril flaringFatigueSilent chestDecreased level of consciousnessOpisthotonic position (sign of severe obstruction)
The patient with acute respiratory problems
Published in Peate Ian, Dutton Helen, Acute Nursing Care, 2020
When gas exchange is compromised in the lungs, then the body must compensate to maintain homeostasis. The work of breathing will increase as a result of increased airway resistance, reduced compliance or both. As a consequence, the cardiovascular system will also attempt to restore balance by increasing heart rate, blood pressure and cardiac output. This altered physiology will be reflected in the patient’s changing vital signs, and ongoing assessment is crucial so that these developments can be detected early and appropriate corrective measures taken (see respiratory assessment section).
In memoriam of Dr. Joseph Milic-Emili
Published in Canadian Journal of Respiratory, Critical Care, and Sleep Medicine, 2022
Over the course of his storied career, Milic made myriad foundational contributions to our understanding of respiratory physiology in both health and disease. A very incomplete list of his accomplishments includes: 1) description of the cardinal features of ventilation-perfusion relationships in the lung;1,2 2) development of novel tools and concepts in the analysis of control of breathing and lung mechanics;3 and 3) dissection of the dynamic mechanical properties of the respiratory system that determine the work of breathing and flow limitation.4,5 These basic discoveries carried over into the clinical realm, helping to explain the basis of hypercapnia during treatment with high levels of oxygen, why proning improves gas exchange in intensive care unit patients, and how intrinsic PEEP increases the work of breathing along with strategies to mitigate its adverse effects in patients during spontaneous breathing or mechanical ventilation.
High flow nasal cannula in the pediatric intensive care unit
Published in Expert Review of Respiratory Medicine, 2022
Jason A. Clayton, Katherine N. Slain, Steven L. Shein, Ira M. Cheifetz
A second mechanism proposes that HFNC significantly reduces the entrainment of ambient air, thereby increasing the effective fraction of inspired oxygen (FiO2), contrary to low-flow oxygen delivery systems. Third, HFNC is postulated to flush the carbon dioxide-rich gas from the nasopharynx and replace it with oxygen-enriched gas from the HFNC system. This reduces the carbon dioxide that is rebreathed, thus facilitating improved minute ventilation participating in gas exchange. By improving carbon dioxide clearance, work of breathing may also be reduced [25,26]. Fourth, work of breathing is improved by decreasing the pressure × rate product, which is a validated measure of work of breathing [26–29]. Fifth, the application of high-flow gas reduces airway resistance during inspiration [16,21,24,30]. Experimental placement of pharyngeal pressure transducers has demonstrated that distending pressures of up to 6–8 cm H2O can be obtained with flow rates up to 2 L/kg/min [21,23,28,31]. This may effectively stent the soft palate and pharyngeal structures. Overall, careful titration of flow rate contributes to several important characteristics toward making HFNC effective.
A comprehensive review of the use and understanding of airway pressure release ventilation
Published in Expert Review of Respiratory Medicine, 2020
Despite the advantages of spontaneous breathing, there is concern that exposure to high trans-pulmonary and trans-vascular pressures, created by negative intrathoracic pressure generated during spontaneous inspiration using conventional ventilation, may increase the risk of lung injury and worsen pulmonary edema [42]. This becomes a particular concern when ventilating with APRV, as the work of spontaneously breathing in APRV can be high, requiring the patient to generate a high pleural pressure gradient particularly when taking a spontaneous breath when at PH [40,43,44]. Findings from two recent animal studies [45,46]support the use of high PEEP to offset the injurious effects of spontaneous breathing on the lung by reducing spontaneous effort and improving recruitment. However, it is difficult to apply these findings to APRV, because, as discussed above, the auto-PEEP generated by APRV distributes lung volume differently than a set PEEP in a lung with heterogeneous disease. Increased work of breathing will also increase overall oxygen consumption, which may be detrimental in a state of acute critical illness. Uyar et al. compared oxygen cost of breathing in patients spontaneously breathing using APRV vs pressure-support ventilation and found no difference, although these patients did not have significant lung disease; so, these findings may not apply to the ARDS population [47].