07/11/2017
Focus on ventilation and airway management in the ICU
http://rdcu.be/x44B
Airway and ventilation management are particularly challenging in the intensive care unit (ICU), and are associated with high morbidity and mortality [1]. Figure 1 summarizes some of the more recent findings from the literature [1].
Summary of the more recent findings from the literature. (1) Noninvasive ventilatory therapies for treating ARF. In immunocompromised patients with hypoxemic ARF, new evidence suggests that HFNC could be used in ARF de novo, including in immunocompromised patients [3]. In the case of NIV, the helmet–NIV interface may be of particular interest [7]. However, the role of NIV in ARF has yet to be determined. The main challenge remains avoiding a delay in intubation, which is associated with increased mortality [9]. (2) Preoxygenation: a new preoxygenation strategy was recently reported, which features the coupling of NIV and HFNC (OPTINIV) to reduce respiratory complications of intubation [11]. It was found to be more effective in reducing oxygen desaturation in severely hypoxemic patients than the reference method of NIV alone [11]. (3) Invasive mechanical ventilation: new studies have suggested that high driving pressure (above 13 cmH2O) is associated with increased mortality in ARDS [1, 12]. Most of the ventilatory parameters might be summarized using the “mechanical power” concept [13]. For the first time, it was shown that patient–ventilator asynchrony was detected in all patients and in all ventilator modes, and was associated with mortality [14]. Reducing the incidence of asynchrony is crucial in optimizing the patient for extubation, which must be considered even in patients with ICU-acquired weakness: researchers reported that half of all patients with ICU-acquired weakness were successfully extubated [15]. The ability to identify such patients, however, remains elusive. (4) Avoidance of reintubation: NIV is advised in patients with hypoxemic ARF following abdominal surgery, as it reduces the risk of tracheal reintubation compared to standard oxygen therapy [4]. Recent studies suggest that in a preventive setting, HFNC could be considered in high- and low-risk intubated patients [5, 6]. The effect of alternating HFNC with NIV remains unclear. The extracorporeal membrane carbon dioxide removal (ECCO2R) system might be used to avoid or minimize the need for invasive ventilation, particularly in patients with hypercapnia and obstructive disorder [8]. ECCO2R is of potential interest and remains to be assessed at each stage of airway and ventilatory management of the ICU patient. ARDS acute respiratory distress syndrome, ARF acute respiratory failure, NIV noninvasive ventilation, HFNC high-flow nasal cannula oxygen, Pplat plateau pressure, PEEP positive end-expiratory pressure, ICU intensive care unit, ECCO2R extracorporeal carbon dioxide removal
