Respiratory Care Clinics Of North America[JOURNAL]
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200 papers
Indirect calorimetry: relevance to patient outcome.
McClave SA
Respir Care Clin N Am · 2006 Dec · PMID 17150436 · Publisher ↗
Indirect calorimetry provides an important adjunctive monitor for the provision of nutrition support in the critically ill patient. Accuracy in determining caloric requirements may serve to optimize benefit from nutritio...
Indirect calorimetry provides an important adjunctive monitor for the provision of nutrition support in the critically ill patient. Accuracy in determining caloric requirements may serve to optimize benefit from nutrition therapy and improve patient outcome. A number of strategies in nutrition management in the intensive care setting (eg, dosing of enteral nutrition, monitoring cumulative caloric balance, and deliberate but "permissive" underfeeding) necessitate the determination of a fairly specific goal for caloric provision. Inaccuracy leading to inappropriate under- or overfeeding may generate additional morbidity and adverse clinical consequences for patients already at high risk from hypermetabolic stress response to injury.
Indirect calorimetry: applications in practice.
Wooley JA
Respir Care Clin N Am · 2006 Dec · PMID 17150435 · Publisher ↗
IC is the standard for determining energy expenditure in critically ill patients. The measured REE is an objective, patient-specific caloric reference that serves as the most accurate method of determining energy expendi...
IC is the standard for determining energy expenditure in critically ill patients. The measured REE is an objective, patient-specific caloric reference that serves as the most accurate method of determining energy expenditure. Protocols addressing IC methodology are necessary to ensure technical accuracy and clinically useful results. The measured REE should be the caloric target without the addition of stress or activity factors for nutrition support regimens in the ICU. The RQ should be used primarily as an indicator of test validity. Optimal nutrition intervention requires continuous evaluation of all pertinent clinical data and careful monitoring of each patient's response to therapy.
Strategies to prevent aspiration-related pneumonia in tube-fed patients.
Metheny NA
Respir Care Clin N Am · 2006 Dec · PMID 17150434 · Publisher ↗
It is improbable that aspiration and aspiration-pneumonia can be entirely prevented, but application of one or more of the strategies described in this article probably can reduce these potentially life threatening condi...
It is improbable that aspiration and aspiration-pneumonia can be entirely prevented, but application of one or more of the strategies described in this article probably can reduce these potentially life threatening conditions. Fortunately, many of these strategies are relatively easy and inexpensive to incorporate into routine care.
Feeding the critically ill obese patient: the role of hypocaloric nutrition support.
Miller JP, Choban PS
Respir Care Clin N Am · 2006 Dec · PMID 17150433 · Publisher ↗
Obesity and its many metabolic and physiologic comorbidities are becoming more common. Thus, a strategy to approach the nutritional needs of obese critically ill patients is warranted. The adverse effect of obesity on th...
Obesity and its many metabolic and physiologic comorbidities are becoming more common. Thus, a strategy to approach the nutritional needs of obese critically ill patients is warranted. The adverse effect of obesity on the respiratory system is well established. The obesity may be an inciting event or merely an additional burden in the obese critically ill patient. A strategy of hypocaloric nutrition support avoids the many detrimental effects of overfeeding and has been considered for all critically ill patients. In the obese patient, the strategy addresses the additional problem of the excessive fat store and has the additional benefit of fat reduction while sparing lean body mass. In the patient with normal renal and hepatic function, hypocaloric nutrition support simplifies care and may improve outcome.
Nutrition support for the long-term ventilator-dependent patient.
Cresci G, Cué JI
Respir Care Clin N Am · 2006 Dec · PMID 17150432 · Publisher ↗
This article discusses issues related to nutrition support for the critically ill (CCI), especially those who are dependent on ventilators for long periods. A large and growing population of patients survives acute criti...
This article discusses issues related to nutrition support for the critically ill (CCI), especially those who are dependent on ventilators for long periods. A large and growing population of patients survives acute critical illness only to become CCI with profound debilitation, weeks to months of hospitalization, and often permanent dependence on mechanical ventilation and other life-sustaining modalities. Despite resource-intensive treatment, outcomes for CCI remain poor. Topics addressed in this article include neuroendocrine profiles in CCI patients, allostatic overload, causes of prolonged mechanical ventilation, and the metabolism of chronic ventilator dependence. The article also describes issues related to assessing the nutrition, determining nutrition requirements, and deciding the route of nutrient delivery for CCI patients.
A nutritional strategy to improve oxygenation and decrease morbidity in patients who have acute respiratory distress syndrome.
DeMichele SJ, Wood SM, Wennberg AK
Respir Care Clin N Am · 2006 Dec · PMID 17150431 · Publisher ↗
Enteral nutrition is increasingly becoming the standard of care for critically ill patients with the goal of providing nutritional support that prevents nutritional deficiencies and reduces morbidity. Furthermore, the de...
Enteral nutrition is increasingly becoming the standard of care for critically ill patients with the goal of providing nutritional support that prevents nutritional deficiencies and reduces morbidity. Furthermore, the development of nutritional strategies that dampen inflammation is an encouraging advance in the management of patients who have acute respiratory distress syndrome. This article discusses evidence from randomized, controlled studies that the use of a specialized nutritional formula containing eicosapentaenoic acid plus gamma-linolenic acid and elevated antioxidants offer physiologic and anti-inflammatory benefits over standard formulas.
Nutrition support in the acutely ventilated patient.
Oltermann MH
Respir Care Clin N Am · 2006 Dec · PMID 17150430 · Publisher ↗
Although the nutrition support literature is limited and therefore does not provide robust evidence to promote grade A or strong recommendations, there is a "signal" from all of these studies taken a a whole that critica...
Although the nutrition support literature is limited and therefore does not provide robust evidence to promote grade A or strong recommendations, there is a "signal" from all of these studies taken a a whole that critically ill patients may benefit from nutritional manipulation. The acutely ventilated patient that is likely to still be intubated by day three is a classic example of the critically ill patient who has the potential to achieve positive outcomes with nutritional support. Initiating nutrition support early improves the chances of benefit. However, nutrition cannot be provided in a vacuum. It is only one part of a multitude of treatments and therapies that must be optimally applied by a multidisciplinary team of professionals dedicated to the care of ICU patients. The exact makeup of the enteral (or parenteral) formula that is most likely to improve survival is unclear. More research is needed. Further study may demonstrate the possibility for nutritional manipulation to be one of the most important treatments physicians can offer to critically ill ventilated patients. Nutrition may have as much survival benefit as activated protein C, a drug costing over $7000 per course of therapy. No longer can it be said that nutrition makes no difference.
Malnutrition in chronic obstructive pulmonary disease.
Schwartz DB
Respir Care Clin N Am · 2006 Dec · PMID 17150429 · Publisher ↗
Malnutrition in patients with COPD is associated with an impaired pulmonary status, reduced diaphragmatic mass, lower exercise capacity, and higher mortality rate when compared with adequately nourished individuals with...
Malnutrition in patients with COPD is associated with an impaired pulmonary status, reduced diaphragmatic mass, lower exercise capacity, and higher mortality rate when compared with adequately nourished individuals with COPD. Deterioration in patients with COPD may be the result of malnutrition. In addition, malnutrition could be a sign of other factors directly altered by the disease.
Do all mechanically ventilated pediatric patients require continuous capnography?
Hamel DS, Cheifetz IM
Respir Care Clin N Am · 2006 Sep · PMID 16952808 · Publisher ↗
With most patients in modern ICUs requiring mechanical ventilation, any technology that may lead to more optimal ventilatory strategies would be invaluable in the management of critically ill patients. The focus of most...
With most patients in modern ICUs requiring mechanical ventilation, any technology that may lead to more optimal ventilatory strategies would be invaluable in the management of critically ill patients. The focus of most ventilator strategies is protecting the lung from the deleterious effects of mechanical ventilation. Every effort is made to minimize the duration of mechanical ventilation while optimizing the potential for successful extubation. A concise organized plan based on objective criteria that is adjusted to meet changes in patient status is clearly recommended. Continuous capnographic monitoring provides clinicians with clear, precise, objective data that may prove beneficial in the design and implementation of mechanical ventilatory strategies. There are no clear-cut methods for achieving the optimal ventilator strategy for a specific patient. Although guidelines and management theories exist throughout the medical literature, in practice, they often merely serve as loose guidelines. The dynamic properties of an acutely ill patient make the management of mechanical ventilation an ongoing process requiring clinical assessment and planning by multidisciplinary members of the patient care team. Comprehensive evaluation of ventilatory management strategies and patient responses must be made by a collaborative effort of physicians, respiratory care practitioners, and nurses. An objective, consistent approach to the overall management is essential. Although still controversial, it is the authors' opinion that volumetric capnograph provides the data necessary to establish adequate gas delivery, optimal PEEP, and effective ventilation with the least amount of mechanical assistance, regardless of clinician or institutional preferences.
The role of inhaled nitric oxide and heliox in the management of acute respiratory failure.
Gentile MA
Respir Care Clin N Am · 2006 Sep · PMID 16952807 · Publisher ↗
The application of positive-pressure mechanical ventilation is one of the cornerstones of support for patients with acute respiratory failure. Unfortunately, the clinical condition of some patients does not improve, desp...
The application of positive-pressure mechanical ventilation is one of the cornerstones of support for patients with acute respiratory failure. Unfortunately, the clinical condition of some patients does not improve, despite escalating ventilatory support. Adjunctive therapies to mechanical ventilation such as nitric oxide and heliox have been explored for the purposes of minimizing injurious settings and supporting adequate gas exchange. As specific therapies continue to evolve, clinicians should have a clear understanding of the physiologic basis and evidence before deciding to use any adjunctive therapy. This article discusses the role of nitric oxide and heliox as adjunct therapies to mechanical ventilation. Many questions remain about the role of these unique gases in the management of pediatric patients with acute respiratory failure. Should nitric oxide be used outside of its approved indication, and should heliox be used at all due to the lack of definitive evidence?
What is the role of airway pressure release ventilation in the management of acute lung injury?
Petsinger DE, Fernandez JD, Davies JD
Respir Care Clin N Am · 2006 Sep · PMID 16952806 · Publisher ↗
The lack of published evidence supporting the use of APRV in the pediatric critical care patient population may diminish its effective application in respiratory failure. The effect of APRV on the number of ventilator da...
The lack of published evidence supporting the use of APRV in the pediatric critical care patient population may diminish its effective application in respiratory failure. The effect of APRV on the number of ventilator days, ICU stay, and mortality still remains to be studied. Further application of APRV in the role of rest settings for ECMO especially in the pediatric cardiac patient population needs to be investigated. Will the use of APRV decrease the time for adequate lung recruitment, decrease sheer trauma, and/or promote earlier decannulation upon the restoration of tolerable cardiac function? Can APRV be utilized as a re-recruitment maneuver? A comparison of APRV over sustained in a randomized-controlled fashion, will there be a significant difference in ventilator days, length of ICU stay, and/or mortality? Does re-recruitment at plateau pressures during suctioning, patient position changes, or in the face of increased airway resistance decrease the number of ventilator days, length of ICU stay, and/or mortality? Does the use of continuous monitoring of carbon dioxide production aid in optimizing P(high)? The list of questions, both speculative and scientific are too numerous to list. Speculation leads to inquiry which over time drives science. More focus is needed on randomized, controlled trials. Initially the comparison of APRV to HFOV needs to be the primary focus for a proactive approach for ALI. Once a comfort level is established with this modality, further scientific inquires will follow. In the meantime, its use is likely to remain controversial.
Extubation criteria in infants and children.
Wratney AT, Cheifetz IM
Respir Care Clin N Am · 2006 Sep · PMID 16952805 · Publisher ↗
Predictors of extubation outcome attempt to provide objective data that may help to modify clinical decision making at the bedside. This article reviews the subjective and objective extubation readiness predictors tested...
Predictors of extubation outcome attempt to provide objective data that may help to modify clinical decision making at the bedside. This article reviews the subjective and objective extubation readiness predictors tested in the pediatric medical literature. An understanding of the predictive capacity of the extubation criteria is vital for the critical care physician. No test is likely to predict the extubation outcome for an individual patient with absolute certainly. Therefore, weaning and extubation practices in the pediatric critical care setting remain variable, and teh development of standardized protocols for extubation remains controversial. Perhaps future well-designed, large-scale trials will provide more accurate predictors of extubation readiness to guide the safe and timely extubation of the pediatric patient.
High-frequency jet and oscillatory ventilation for neonates: which strategy and when?
Courtney SE, Asselin JM
Respir Care Clin N Am · 2006 Sep · PMID 16952804 · Publisher ↗
Both HFOV and HFJV are important adjuncts to the ventilatory care of sick infants and children. Today, it is important that neonatologists, pediatric intensivists, and respiratory care practitioners understand these vent...
Both HFOV and HFJV are important adjuncts to the ventilatory care of sick infants and children. Today, it is important that neonatologists, pediatric intensivists, and respiratory care practitioners understand these ventilators and the options they provide. It is no longer necessary to continue the use of damaging pressures and volumes with CV simply because no other option is available. The clinician who understands not only the pathology and physiology of the underlying lung condition but also understands the available choices in ventilators, how each ventilator functions, and what potential advantage it may offer his patients is able to provide the best possible care to these critically ill patients.
Is high-frequency ventilation more beneficial than low-tidal volume conventional ventilation?
Ten IS, Anderson MR
Respir Care Clin N Am · 2006 Sep · PMID 16952803 · Publisher ↗
The ventilator goals of the ICU clinician faced with caring for a critically ill child who has ALI/ARDS remain relatively simple: provide adequate ventilation and oxygenation without overdistending alveoli or furthering...
The ventilator goals of the ICU clinician faced with caring for a critically ill child who has ALI/ARDS remain relatively simple: provide adequate ventilation and oxygenation without overdistending alveoli or furthering lung injury. How one obtains these goals is much less simple. The current use of CV calls for the use of relatively low V(T)s and limiting peak inspiratory pressure and plateau pressure while accepting a certain degree of respiratory acidosis. The ICU team can also often achieve these same goals with HFOV. How, then, does one use evidenced-based medicine to pick the best mode of mechanical ventilation for a particular patient? The answer is controversial, to say the least. Does one start with a gentle, open-lung mode of CV then switch to HFOV if the child deteriorates? Or does one use HFOV from the very early stages of ALI? Animal data appear to point to advantages of HFOV when used early in the course of ALI. Most of these studies report a beneficial effect of HFOV when applied on expanded lungs in the early stages of the disease process. These beneficial effects encompass improved gas exchange, oxygenation, lung tissue morphology and pulmonary mechanics. The studies by Arnold and colleagues in the pediatric population also help to answer our questions. In their work, the early initiation of HFOV was associated with improved gas exchange and a trend toward a lower mortality. In adults, Derdak and colleagues demonstrated the superiority of HFOV in terms of gas exchange and oxygenation; however, no statistical significant difference was found for mortality. So, where is the clinician left after a review of these data? It would appear that (1) low-V(T) CV remains a cornerstone of therapy for the pediatric patient who has ALI/ARDS; (2) HFOV is a safe and well-tolerated mode of mechanical ventilation; (3) early use of HFOV (as opposed to the rescue use of this mode) may be of benefit based on animal and human data; and (4) like so many areas of pediatric critical care, clinicians must await new data and trials that will help them continue to improve the care they provide.
The role of noninvasive ventilation for acute respiratory failure.
Hamel DS, Klonin H
Respir Care Clin N Am · 2006 Sep · PMID 16952802 · Publisher ↗
The use of NIV has been shown to facilitate discontinuing ventilatory dependence as well as provide support for adult patients with chronic lung disease without the need for endotracheal intubation. In fact, NIV has rece...
The use of NIV has been shown to facilitate discontinuing ventilatory dependence as well as provide support for adult patients with chronic lung disease without the need for endotracheal intubation. In fact, NIV has recently described as a potential support strategy following extubation failure. Therefore, using NIV as a bridge to liberation from mechanical ventilation may decrease many of the complications associated with long-term use of invasive airway devices as well complications from reinsertion of an artificial airway. Although firm data supporting the use of NIV in the adult population exists, the use of NIV in the pediatric population is based primarily on a series of case studies, retrospective chart reviews, and extrapolation from the adult data. The use of NIV for infants and children remains controversial. The important question to be asked is why there is a lack of randomized controlled trials on NIV in pediatrics? The answer lies somewhere between the lack of equipment designed specifically for pediatrics and the smaller number of patients available compared with adults. Data from the adult population may be more readily adapted to older children; however, it remains difficult to determine the criteria for noninvasive ventilatory use in infants and young children. In fact, this lack of data makes the formulation of firm selection guidelines for infants and children essentially impossible. However, for a select groups of pediatric patients with acute respiratory failure for whom an appropriate noninvasive device with interface is available, a trial of NIV may be seem reasonable to avoid the known negative effects of intubation and invasive mechanical ventilation.
To stop or not to stop: how much support should be provided to mechanically ventilated pediatric bone marrow and stem cell transplant patients?
Martin PL
Respir Care Clin N Am · 2006 Sep · PMID 16952801 · Publisher ↗
Every publication to date reporting the outcome of intensive care support for pediatric SCT patients must be viewed with caution because all are single-institution, retrospective reports. Nevertheless, some of the conclu...
Every publication to date reporting the outcome of intensive care support for pediatric SCT patients must be viewed with caution because all are single-institution, retrospective reports. Nevertheless, some of the conclusions made by these investigators appear to be clinically relevant. First, an SCT patient who requires intensive care support does not automatically have a dismal chance of survival. Survival rates in recent reports range from 15% to 36%, which is reasonable when the overall post-transplant survival rate for non-ICU patients may be only 50%. Second, adverse risk factors differ from center to center, likely due to the wide variation in patient populations, donor source, and transplant preparation regimens. Third, MSOF is a consistent adverse risk factor for survival. An additional conclusion that can be drawn from the data presented in this article is that patients who do not show significant, objective improvement by the second week of PICU care are unlikely to survive. The limitation or withdrawal of life-sustaining medical support should be recommended to the patient, the patient's family, and the patient's doctors. Although there are no predictive models that are 100% reliable for these clinical situations, in the author's experience, most families and physicians view critical care support beyond 2 weeks, in the absence of clinical improvement, as futile care. It is clear that better data are needed in the form of prospective, multi-institutional studies that include the therapeutic efficacy of interventions such as high-frequency oscillatory ventilation, continuous venovenous hemodialysis, early use of noninvasive ventilation (ie, noninvasive positive pressure ventilation), the use of biologic agents to decrease inflammation, the impact of new antifungal medications, and lung-protective ventilation with permissive hypercapnia. Of these potential therapies, the author is aware of only one multi-institutional study involving continuous venovenous hemodialysis at this time.
Ventilator management protocols in pediatrics.
Graham AS, Kirby AL
Respir Care Clin N Am · 2006 Sep · PMID 16952800 · Publisher ↗
Management of mechanical ventilation is a complex process with outcomes affected by multiple patient and caregiver variable. Well-constructed protocols represent the synthesis of best available evidence regarding ventila...
Management of mechanical ventilation is a complex process with outcomes affected by multiple patient and caregiver variable. Well-constructed protocols represent the synthesis of best available evidence regarding ventilator management. In adults, protocols improve important outcomes such as duration of mechanical ventilation, length of stay, and complication rates; however, protocols are not uniformly successful. In pediatrics, the available evidence does not suggest that ventilator management protocols should be adopted routinely, which may be due to pediatric-specific attributes such as a generally shorter weaning duration. Evidence suggests support for protocols to carefully titrate sedation. In addition, daily assessment of SBTs improves patient outcomes and should be more uniformly adopted in pediatrics. Ventilator-related outcomes may be affected by other confounding factors such as nutrition and fluid balance. Specific subpopulations, such as children who have congenital heart disease, may present opportunities for focused use of ventilator management protocols. Protocolized ventilation has an important place in trials of new therapeutic strategies such as surfactant or proning. It is hoped that future research will further define the appropriate use of protocols in the general PICU population. Although specific protocols cannot be routinely recommended, a multidisciplinary team approach to synthesizing available literature and determining best practice is a useful model. This approach will foster "team ownership" of ventilator management by all involved, thus engendering the best possible outcomes for critically ill children who require mechanical ventilation.
Is permissive hypercapnia a beneficial strategy for pediatric acute lung injury?
Rotta AT, Steinhorn DM
Respir Care Clin N Am · 2006 Sep · PMID 16952799 · Publisher ↗
It is clear that mechanical ventilation strategies influence the course of lung disease, and the choice of a ventilation strategy that avoids volutrauma and atelectrauma is firmly based on experimental literature and cli...
It is clear that mechanical ventilation strategies influence the course of lung disease, and the choice of a ventilation strategy that avoids volutrauma and atelectrauma is firmly based on experimental literature and clinical experience. The application of a lung-protective strategy with reduced tidal volumes, effective lung recruitment, adequate PEEP to minimize alveolar collapse during expiration, and permissive hypercapnia has been shown to be advantageous in adult patients who have ARDS, although it has not been systematically studied in children. A significant body of literature confirms the beneficial effects of hypercapnic acidemia in the setting of acute lung injury. As a corollary, experimental evidence indicates that buffering hypercapnic acidosis abrogates its protective effects. The use of permissive hypercapnia as part of a lung-protective strategy in children should be accepted and perhaps even desired, provided it does not result in significant hemodynamic instability. This acceptance should be tempered with the recognition that a low-stretch, reduced-tidal volume strategy without hypercapnia has also been shown to improve outcomes in adults who have ARDS and that HFOV can generally provide lung-protective ventilation without necessarily inducing hypercapnia. Thus, a synthesis of the available clinical and research data strongly supports a graded approach to managing patients who have acute lung injury requiring intubation. The highest priority should be a mechanical ventilation strategy that limits the tidal volume, with the allowance of hypercapnia to a degree that does not compromise hemodynamic status.
Is permissive hypoxemia a beneficial strategy for pediatric acute lung injury?
Cheifetz IM, Hamel DS
Respir Care Clin N Am · 2006 Sep · PMID 16952798 · Publisher ↗
The adverse effects of high oxygen levels have been widely reported, and clinicians have struggled for many years to find the ideal balance between inspired oxygen levels and acceptable arterial oxygen saturation. Howeve...
The adverse effects of high oxygen levels have been widely reported, and clinicians have struggled for many years to find the ideal balance between inspired oxygen levels and acceptable arterial oxygen saturation. However, when asked "what is an acceptable oxygen saturation," one is hard pressed to find a definitive answer. Permissive hypoxemia is a concept similar to the well-described strategy of permissive hypercapnia. It is a strategy that allows the arterial oxygen saturation to be less than normal in an attempt to minimize the amount of artificial support provided to the lungs by mechanical ventilation. It must be noted that this concept is predominantly based on physiology, as data in the medical literature are very limited. Permissive hypoxemia as an approach to acute lung injury remains controversial in the clinical setting.
Application of the acute respiratory distress syndrome network low-tidal volume strategy to pediatric acute lung injury.
Hanson JH, Flori H
Respir Care Clin N Am · 2006 Sep · PMID 16952797 · Publisher ↗
In summary, most of the available data suggest that pediatric patients should be ventilated with low tidal volumes. The 6-mL/kg IBW tidal volume strategy as used in the ARDSNet studies is a reasonable target, having sinc...
In summary, most of the available data suggest that pediatric patients should be ventilated with low tidal volumes. The 6-mL/kg IBW tidal volume strategy as used in the ARDSNet studies is a reasonable target, having since been rigorously tested in several large, clinical trials (adult and pediatric). The mortality associated with ALI in these studies has never been lower, certainly supporting continued use of the 6 mL/kg target tidal volume as the "gold standard" and, thus, eliminating any equipoise in designing a pediatric trial comparing 6 mL/kg to a larger tidal volume. With mortality rates in children from ALI nearing 8% to 22% and with no clear surrogate outcomes identified to date, the sample sizes needed to show a significant clinical effect would be prohibitively large. Nonetheless, future research should compare 6 mL/kg IBW to even smaller tidal volumes or to high frequency ventilation in an attempt to further reduce the mortality associated with ALI and ARDS in the pediatric population.
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