Severe Hypoxemic Respiratory Failure Part 2-Nonventilatory Strategies
Division of Pulmonary and Critical Care Medicine, New York Methodist Hospital, 506 Sixth St, Brooklyn, NY 11215, USA.Chest (Impact Factor: 7.48). 06/2010; 137(6):1437-48. DOI: 10.1378/chest.09-2416
ARDS is characterized by hypoxemic respiratory failure, which can be refractory and life-threatening. Modifications to traditional mechanical ventilation and nontraditional modes of ventilation are discussed in Part 1 of this two-part series. In this second article, we examine nonventilatory strategies that can influence oxygenation, with particular emphasis on their role in rescue from severe hypoxemia. A literature search was conducted and a narrative review written to summarize the use of adjunctive, nonventilatory interventions intended to improve oxygenation in ARDS. Several adjunctive interventions have been demonstrated to rapidly ameliorate severe hypoxemia in many patients with severe ARDS and therefore may be suitable as rescue therapy for hypoxemia that is refractory to prior optimization of mechanical ventilation. These include neuromuscular blockade, inhaled vasoactive agents, prone positioning, and extracorporeal life support. Although these interventions have been linked to physiologic improvement, including relief from severe hypoxemia, and some are associated with outcome benefits, such as shorter duration of mechanical ventilation, demonstration of survival benefit has been rare in clinical trials. Furthermore, some of these nonventilatory interventions carry additional risks and/or high cost; thus, when used as rescue therapy for hypoxemia, it is important that they be demonstrated to yield clinically significant improvement in gas exchange, which should be periodically reassessed. Additionally, various management strategies can produce a more gradual improvement in oxygenation in ARDS, such as conservative fluid management, intravenous corticosteroids, and nutritional modification. Although improvement in oxygenation has been reported with such strategies, demonstration of additional beneficial outcomes, such as reduced duration of mechanical ventilation or ICU length of stay, or improved survival in randomized controlled trials, as well as consideration of potential adverse effects should guide decisions on their use. Various nonventilatory interventions can positively impact oxygenation as well as outcomes of ARDS. These interventions may be considered for use, particularly for cases of refractory severe hypoxemia, with proper appreciation of potential costs and adverse effects.
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- "The presence of ground glass lesions did not affect the final outcome of patients. Management of respiratory treatment improves outcome, and death due to respiratory failure tends to decrease. We hypothesized that most of the ground glass lesions in our present patients were lung edema based on the transient disturbance of the blood–gas barrier, and ground glass lesions were easily cured. "
ABSTRACT: To clarify the epidemiological findings and characteristics of ground glass lesions on chest computed tomography (CT) after blunt trauma. A medical college hospital and retrospective study. We retrospectively investigated all blunt chest trauma patients who were admitted from January 2004 to December 2010. The inclusion criteria were patients with: (1) chest CT examination on arrival, (2) intrathoracic traumatic lesions confirmed by initial CT, and (3) a second chest CT examination within 7 days from admission. We divided the subjects into two groups. A GG group included subjects who had ground glass lesions on initial chest CT and a control group included subjects who did not have the ground glass appearance. The average age in the GG group was significantly lesser than that in the control group. The ratio of improvement for the value of SpO(2)/FiO(2) between on arrival and the second hospital day and ratio of improvement for CT findings between on arrival and the second CT examination in the GG group was greater than in the control group. The ground glass appearance on chest CT after blunt trauma was not rare, and the patients with ground glass lesions were younger and tended to have a better improvement of oxygenation and CT images in comparison with the patients without these characteristic lesions.Journal of Emergencies Trauma and Shock 07/2012; 5(3):238-42. DOI:10.4103/0974-2700.99693
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- "Preventing fluid overload is important in children post-HSCT, because it has been identified as a risk factor for PICU admission in a retrospective study . Moreover, fluid overload worsens the prognosis of patients with hypoxemic respiratory failure , a leading cause of PICU admission for children post-HSCT. "
ABSTRACT: Cancer is a leading cause of death in children. In the past decades, there has been a marked increase in overall survival of children with cancer. However, children whose treatment includes hematopoietic stem cell transplantation still represent a subpopulation with a higher risk of mortality. These improvements in mortality are accompanied by an increase in complications, such as respiratory and cardiovascular insufficiencies as well as neurological problems that may require an admission to the pediatric intensive care unit where most supportive therapies can be provided. It has been shown that ventilatory and cardiovascular support along with renal replacement therapy can benefit pediatric hemato-oncology patients if promptly established. Even if admissions of these patients are not considered futile anymore, they still raise sensitive questions, including ethical issues. To support the discussion and potentially facilitate the decision-making process, we propose an algorithm that takes into account the reason for admission (surgical versus medical) and the hemato-oncological prognosis. The algorithm then leads to different types of admission: full-support admission, "pediatric intensive care unit trial" admission, intensive care with adapted level of support, and palliative intensive care. Throughout the process, maintaining a dialogue between the treating physicians, the paramedical staff, the child, and his parents is of paramount importance to optimize the care of these children with complex disease and evolving medical status.Annals of Intensive Care 06/2012; 2(1):14. DOI:10.1186/2110-5820-2-14 · 3.31 Impact Factor
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- "Extracorporeal membrane oxygenation (ECMO) has the capacity to support gas exchange as well as haemodynamics and is, therefore, a rescue therapeutic option for life-threatening respiratory and/or cardiac failure. ECMO has been tested in acute respiratory distress syndrome (ARDS) [1,2] and before and after lung transplantation . Another potential use of ECMO could be the management of life-threatening hypoxaemia in patients with hepatopulmonary syndrome (HPS), selected for orthotopic liver transplantation (OLT). "
ABSTRACT: Combined with massive lung aeration loss resulting from acute respiratory distress syndrome, hepatopulmonary syndrome, a liver-induced vascular lung disorder characterized by diffuse or localized dilated pulmonary capillaries, may induce hypoxaemia and death in patients with end-stage liver disease. The case of such a patient presenting with both disorders and in whom an extracorporeal membrane oxygenation was used is described. A 51-year-old man with a five-year history of alcoholic cirrhosis was admitted for acute respiratory failure, platypnoea and severe hypoxaemia requiring emergency tracheal intubation. Following mechanical ventilation, hypoxaemia remained refractory to positive end-expiratory pressure, 100% of inspired oxygen and inhaled nitric oxide. Two-dimensional contrast-enhanced (agitated saline) transthoracic echocardiography disclosed a massive right-to-left extracardiac shunt, without patent foramen ovale. Contrast computed tomography (CT) of the thorax using quantitative analysis and colour encoding system established the diagnosis of acute respiratory distress syndrome aggravated by hepatopulmonary syndrome. According to the severity of the respiratory condition, a veno-venous extracorporeal membrane oxygenation was implemented and the patient was listed for emergency liver transplantation. Orthotopic liver transplantation was performed at Day 13. At the end of the surgical procedure, the improvement in oxygenation allowed removal of extracorporeal membrane oxygenation (Day 5). The patient was discharged from hospital at Day 48. Three months after hospital discharge, the patient recovered a correct physical autonomy status without supplemental O2. In a cirrhotic patient, acute respiratory distress syndrome was aggravated by hepatopulmonary syndrome causing life-threatening hypoxaemia not controlled by standard supportive measures. The use of extracorporeal membrane oxygenation, by controlling gas exchange, allowed the performing of a successful liver transplantation and final recovery.Critical care (London, England) 09/2011; 15(5):R234. DOI:10.1186/cc10476 · 4.48 Impact Factor
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