Despite considerable research and constantly emerging treatment modalities, the mortality associated with acute respiratory distress syndrome (ARDS) has remained virtually unchanged over the last decade. Clinical studies have been unable to show a reduction in mortality for most therapeutic interventions except for low tidal volume ventilation. Failure to prove a mortality benefit might be a result of the varying severity of ARDS in the patients studied. Nevertheless, positive responses to single supportive measures (inhaled nitric oxide, prone positioning and extracorporeal membrane oxygenation) have been demonstrated in multiple trials. Criteria for administration, weaning and discontinuation of these supportive interventions have never been described in detail. In this context, implementation of an evidence-based algorithm might facilitate clinical management of severe ARDS. This review summarizes the current evidence base and proposes a new treatment algorithm that aims to prioritize the administration of advanced strategies in a multimodal approach for ARDS.
Elimination of CO(2) by p-ECLA therapy allowed reduction of ventilator-induced shear stress through ventilation with tidal volumes below 4 ml/kg predicted body weight in pneumonia patients with severely impaired pulmonary compliance during late-phase ARDS. p-ECLA treatment supported control of breathing pattern while sedation requirements were reduced and facilitated the implementation of assisted spontaneous breathing.
Patients with bronchial tree lesions feature, in particular, a high risk for developing bronchial fistulae after surgical repair when the clinical situation is complicated by acute lung injury (ALI)/acute respiratory distress syndrome (ARDS) and mechanical ventilation is needed. The current authors hypothesised that extracorporeal carbon dioxide removal would significantly decrease inspiratory airway pressures, thus promoting the protection of surgical bronchial reconstruction.Four patients were studied after surgical reconstruction of bronchial fistulae in whom ALI/ARDS developed and mechanical ventilation with positive end-expiratory pressure was required. Gas exchange, tidal volumes, airway pressures, respiratory frequency, vasopressor and sedation requirements were analysed before and after initiation of a pumpless extracorporeal lung assist device (pECLA; NovaLung1, Talheim, Germany). Initiation of pECLA treatment enabled a reduction of inspiratory plateau airway pressures from 32.4 to 28.6 cmH 2 O (3.2 to 2.8 kPa), effectively treated hypercapnia (from 73.6 to 53.4 mmHg (9.8 to 7
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