Invasive Mechanical Ventilation
Invasive mechanical ventilation allows clinicians to support gas exchange and work of breathing in patients with respiratory failure. However, there is also potential for iatrogenesis. By understanding the benefits and limitations of different modes of ventilation and goals for gas exchange, clinicians can choose a strategy that provides appropriate support while minimizing harm. The ventilator can also provide crucial diagnostic information in the form of respiratory mechanics. These, and the mechanical ventilation strategy, should be regularly reassessed. (Source: Critical Care Clinics)
Source: Critical Care Clinics - February 9, 2024 Category: Intensive Care Authors: Jennifer C. Szafran, Bhakti K. Patel Source Type: research

Physical and Cognitive Impairment in Acute Respiratory Failure
Recent research has brought renewed attention to the multifaceted physical and cognitive dysfunction that accompanies acute respiratory failure (ARF). This state-of-the-art review provides an overview of the evidence landscape encompassing ARF-associated neuromuscular and neurocognitive impairments. Risk factors, mechanisms, assessment tools, rehabilitation strategies, approaches to ventilator liberation, and interventions to minimize post –intensive care syndrome are emphasized. The complex interrelationship between physical disability, cognitive dysfunction, and long-term patient-centered outcomes is explored. This rev...
Source: Critical Care Clinics - February 7, 2024 Category: Intensive Care Authors: Jonathan Taylor, Mary Elizabeth Wilcox Source Type: research

Fluid Management in Acute Respiratory Failure
Fluid management in acute respiratory failure is an area of uncertainty requiring a delicate balance of resuscitation and fluid removal to manage hypoperfusion and avoidance of hypoxemia. Overall, a restrictive fluid strategy (minimizing fluid administration) and careful attention to overall fluid balance may be beneficial after initial resuscitation and does not have major side effects. Further studies are needed to improve our understanding of patients who will benefit from a restrictive or liberal fluid management strategy. (Source: Critical Care Clinics)
Source: Critical Care Clinics - February 6, 2024 Category: Intensive Care Authors: Shewit P. Giovanni, Kevin P. Seitz, Catherine L. Hough Source Type: research

Ventilator Weaning and Extubation
Increasing evidence supports specific approaches to liberate patients from invasive ventilation including the use of liberation protocols, inspiratory assistance during spontaneous breathing trials (SBTs), early extubation of patients with chronic obstructive pulmonary disease to noninvasive ventilation, and prophylactic use of noninvasive support strategies after extubation. Additional research is needed to elucidate the best criteria to identify patients who are ready to undergo an SBT and to inform optimal screening frequency, the best SBT technique and duration, extubation assessments, and extubation decision-making. A...
Source: Critical Care Clinics - February 6, 2024 Category: Intensive Care Authors: Karen E.A. Burns, Bram Rochwerg, Andrew J.E. Seely Source Type: research

Acute Respiratory Failure in Severe Acute Brain Injury
Acute respiratory failure is commonly encountered in severe acute brain injury due to a multitude of factors related to the sequelae of the primary injury. The interaction between pulmonary and neurologic systems in this population is complex, often with competing priorities. Many treatment modalities for acute respiratory failure can result in deleterious effects on cerebral physiology, and secondary brain injury due to elevations in intracranial pressure or impaired cerebral perfusion. High-quality literature is lacking to guide clinical decision-making in this population, and deliberate considerations of individual pati...
Source: Critical Care Clinics - February 2, 2024 Category: Intensive Care Authors: Zachary Robateau, Victor Lin, Sarah Wahlster Source Type: research

Prolonged Mechanical Ventilation, Weaning, and the Role of Tracheostomy
Depending on the definitional criteria used, approximately 5% to 10% of critical adults will require prolonged mechanical ventilation with longer-term outcomes that are worse than those ventilated for a shorter duration. Outcomes are affected by patient characteristics before critical illness and its severity but also by organizational characteristics and care models. Definitive trials of interventions to inform care activities, such as ventilator weaning, upper airway management, rehabilitation, and nutrition specific to the prolonged mechanical ventilation patient population, are lacking. A structured and individualized ...
Source: Critical Care Clinics - February 2, 2024 Category: Intensive Care Authors: Louise Rose, Ben Messer Source Type: research

Acute Respiratory Failure in Pregnancy
Respiratory failure may affect up to 1 in 500 pregnancies, due to pregnancy-specific conditions, conditions aggravated by the pregnant state, or other causes. Management during pregnancy is influenced by altered maternal physiology, and the presence of a fetus influencing imaging, and drug therapy choices. Few studies have addressed the approach to invasive mechanical ventilatory management in pregnancy. Hypoxemia is likely harmful to the fetus, but precise targets are unknown. Hypocapnia reduces uteroplacental circulation, and some degree of hypercapnia may be tolerated in pregnancy. Delivery of the fetus may be considere...
Source: Critical Care Clinics - January 30, 2024 Category: Intensive Care Authors: Stephen E. Lapinsky, Daniela N. Vasquez Source Type: research

Diagnosis and Management of Acute Respiratory Failure
Acute hypoxemic respiratory failure is defined by Pao2 less than 60  mm Hg or SaO2 less than 88% and may result from V/Q mismatch, shunt, hypoventilation, diffusion limitation, or low inspired oxygen tension. Acute hypercapnic respiratory failure is defined by Paco2 ≥ 45 mm Hg and pH less than 7.35 and may result from alveolar hypoventilation, increased fracti on of dead space, or increased production of carbon dioxide. Early diagnostic maneuvers, such as measurement of SpO2 and arterial blood gas, can differentiate the type of respiratory failure and guide next steps in evaluation and management. (Source: Critical Care Clinics)
Source: Critical Care Clinics - January 25, 2024 Category: Intensive Care Authors: Madeline Lagina, Thomas S. Valley Source Type: research

Acute Respiratory Failure: Problems Solved and Unsolved
Acute respiratory failure (ARF) is a critical medical condition caused by various disease processes and is characterized by abnormal lung mechanics or function, impaired gas exchange, or disturbances in pulmonary circulation that results in the inability of the respiratory system to meet the oxygenation, ventilation, or metabolic demands of the body. This results in life-threatening metabolic and acid-base derangements, often leading to extrapulmonary organ failures and other complications. ARF is one of the most common conditions encountered in the intensive care unit (ICU), present in up to 56% to 69% of ICU admissions. ...
Source: Critical Care Clinics - January 13, 2024 Category: Intensive Care Authors: Philip Yang, Annette M. Esper Tags: Preface Source Type: research

Acute Respiratory Distress Syndrome
Acute respiratory distress syndrome (ARDS) is an acute inflammatory lung injury characterized by severe hypoxemic respiratory failure, bilateral opacities on chest imaging, and low lung compliance. ARDS is a heterogeneous syndrome that is the common end point of a wide variety of predisposing conditions, with complex pathophysiology and underlying mechanisms. Routine management of ARDS is centered on lung-protective ventilation strategies such as low tidal volume ventilation and targeting low airway pressures to avoid exacerbation of lung injury, as well as a conservative fluid management strategy. (Source: Critical Care Clinics)
Source: Critical Care Clinics - January 3, 2024 Category: Intensive Care Authors: Philip Yang, Michael W. Sjoding Source Type: research

Pharmacologic Treatments in Acute Respiratory Failure
Acute respiratory failure relies on supportive care using non-invasive and invasive oxygen and ventilatory support. Pharmacologic therapies for the most severe form of respiratory failure, acute respiratory distress syndrome (ARDS), are limited. This review focuses on the most promising therapies for ARDS, targeting different mechanisms that contribute to dysregulated inflammation and resultant hypoxemia. Significant heterogeneity exists within the ARDS population. Treatment requires prompt recognition of ARDS and an understanding of which patients may benefit most from specific pharmacologic interventions. The key to find...
Source: Critical Care Clinics - December 29, 2023 Category: Intensive Care Authors: Elizabeth Levy, John P. Reilly Source Type: research

Diagnosis and Epidemiology of Acute Respiratory Failure
Acute respiratory failure is a common clinical finding caused by insufficient oxygenation (hypoxemia) or ventilation (hypocapnia). Understanding the pathophysiology of acute respiratory failure can help to facilitate recognition, diagnosis, and treatment. The cause of acute respiratory failure can be identified through utilization of physical examination findings, laboratory analysis, and chest imaging. (Source: Critical Care Clinics)
Source: Critical Care Clinics - December 26, 2023 Category: Intensive Care Authors: Lingye Chen, Craig R. Rackley Source Type: research

Adjunctive Therapies in Acute Respiratory Distress Syndrome
Despite significant advances in understanding acute respiratory distress syndrome (ARDS), mortality rates remain high. The appropriate use of adjunctive therapies can improve outcomes, particularly for patients with moderate to severe hypoxia. In this review, the authors discuss the evidence basis behind prone positioning, recruitment maneuvers, neuromuscular blocking agents, corticosteroids, pulmonary vasodilators, and extracorporeal membrane oxygenation and considerations for their use in individual patients and specific clinical scenarios. Because the heterogeneity of ARDS poses challenges in finding universally effecti...
Source: Critical Care Clinics - December 23, 2023 Category: Intensive Care Authors: Megan Trieu, Nida Qadir Source Type: research

Design and Execution of Clinical Trials in the Cardiac Intensive Care Unit
Clinical practice in the contemporary cardiac intensive care unit (CICU) has evolved significantly over the last several decades. With more frequent multisystem organ failure, increasing use of advanced respiratory support, and the advent of new mechanical circulatory support platforms, clinicians in the CICU are increasingly managing patients with complex comorbid disease in addition to their high-acuity cardiovascular illnesses. Here, the authors discuss challenges associated with traditional trial design in the CICU setting and review novel clinical trial designs that may facilitate better evidence generation in the CIC...
Source: Critical Care Clinics - November 15, 2023 Category: Intensive Care Authors: Jacob B. Pierce, Willard N. Applefeld, Balimkiz Senman, Daniel B. Loriaux, Patrick R. Lawler, Jason N. Katz Source Type: research

Preface
Critical care cardiology is an exciting new field that is evolving at a rapid pace to optimize management of patients with complex cardiovascular problems. Care of those patients in cardiac and cardiovascular surgery intensive care units (CVICU) requires a deep understanding not only of cardiologic and critical care aspects of their problems but also of ways in which different organ systems interact. The interplay between cutting-edge technologies and the intricate pathophysiology requires a broad multidisciplinary approach to diagnosis and treatment. (Source: Critical Care Clinics)
Source: Critical Care Clinics - November 15, 2023 Category: Intensive Care Authors: Steven M. Hollenberg, Jos é L. Díaz-Gómez Source Type: research