New management strategies in ARDS:
Gespeichert in:
| Format: | Buch |
|---|---|
| Sprache: | English |
| Veröffentlicht: |
Philadelphia [u.a.]
Saunders
2002
|
| Schriftenreihe: | Critical care clinics
18,1 |
| Schlagworte: | |
| Online-Zugang: | Inhaltsverzeichnis |
| Beschreibung: | XI, 201 S. Ill., graph. Darst. |
Internformat
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| 245 | 1 | 0 | |a New management strategies in ARDS |c Mitchell M. Levy, guest ed. |
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| 650 | 7 | |a Respiratory distress syndrome |2 gtt | |
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Datensatz im Suchindex
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| adam_text | NEW MANAGEMENT STRATEGIES IN ARDS
CONTENTS
Preface xi
Mitchell M. Levy
Mechanical Ventilation in Acute Lung Injury and
ARDS: Tidal Volume Reduction 1
Roy G. Brower
Traditional mechanical ventilation practices used generous tidal
volumes in patients with acute lung injury and acute respiratory
distress syndrome (ALI/ARDS). This approach may have caused
overdistention of aerated lung units, thus exacerbating lung in¬
jury in some patients. Several recent clinical trials of traditional
versus lower tidal volume strategies in ALI/ARDS yielded dispa¬
rate results. In the largest study, the lower tidal volume approach
was associated with lower mortality and more ventilator free
days. This article reviews the rationale for tidal volume reduction
in ALI/ARDS and the differences between the studies. Several
different interpretations of the recent clinical trial results are ad¬
dressed.
PEEP in ARDS: Changing Concepts and
Current Controversies 15
Mitchell M. Levy
From many recently performed studies, it is clear that a criterion
standard for determining the optimal positive end expiratory
pressure (PEEP) level in patients with acquired respiratory dis¬
tress syndrome (ARDS) does not exist. What is evident and con¬
sistent, however, are several points such the optimal PEEP level
ultimately represents a balance between regional areas of overs¬
tretching and regional derecruitment; higher levels of PEEP may
be required early in ARDS, independent of oxygenation require
CRITICAL CARE CLINICS
VOLUME 18 • NUMBER 1 • JANUARY 2002 V
merits; and the exact method for titrating PEEP in patients with
ARDS remains to be determined. These points and others are
delineated and discussed in this article.
Effects of Prone Position Ventilation in ARDS: An
Evidence Based Review of the Literature 35
Nicholas S. Ward
In the many studies done on prone position ventilation (PPV),
the technique has been shown to improve oxygenation most of
the time. The mechanisms behind this effect are probably numer¬
ous and have not been elucidated completely. In addition, PPV is
a safe procedure that rarely worsens a patient s respiratory status
or causes other complications; thus it is a welcome additional
therapeutic option in the treatment of patients with acute respira¬
tory distress syndrome (ARDS). Despite the recent large, random¬
ized controlled trial showing no overall improvement in mortality
rate or organ dysfunction, evidence exists that suggests that PPV
may be most beneficial in more severely ill patients. Further
studies of this technique will be useful.
Inhaled Nitric Oxide in ARDS 45
James R. Klinger
The role of nitric oxide (NO) in numerous physiologic systems
only recently has been discovered. When used as a gas, inhaled
NO (1NO) has many unique properties that cause immediate
improvements in pulmonary hemodynamics and oxygenation.
Acute benefits in physiologic parameters have been demonstrated
in numerous studies of iNO in acute respiratory distress syn¬
drome (ARDS), but recent randomized controlled trials have
failed to show improvement in outcome. The addition of other
treatments that prolong or enhance the affect of iNO or its use
with other ventilator modalities such as prone positioning or
high frequency ventilation offer hope that iNO may be beneficial
in select groups of patients.
New Management Strategies in ARDS:
Immunomodulation 69
Jean Louis Vincent
Acute respiratory distress syndrome (ARDS) is a disease process
associated with many causes, but the key feature to all is inflam¬
mation. Increased understanding of the pathophysiology of ARDS
in recent years has formed the basis for attempts to modulate this
inflammatory response. Here the author provides an overview of
the rationale behind various immunomodulating strategies and
the results from trials of some of these agents in patients with
ARDS.
vi CONTENTS
Corticosteroids in ARDS: An Evidence Based Review 79
John M. Luce
In general, a rule for corticosteroids in preventing or relieving
the acute respiratory distress syndrome (ARDS) has yet to be
established, although these drugs are indicated for conditions
such as Pneumocystis carinii pneumonia. High dose corticoste¬
roids have not been shown to reduce mortality through their anti
inflammatory properties when given early to patients with sepsis,
septic shock, or ARDS. Corticosteroids have been shown, how¬
ever, to reduce mortality in patients with late ARDS only in one
small, inconclusive study. More recent investigators have focused
on the usefulness of low dose corticosteroids in reducing mortal¬
ity in patients with sepsis or septic shock who may have relative
adrenal insufficiency, but these studies also are inconclusive, and
it is unclear that low dose corticosteroids affect the development
of ARDS in these patients.
New Therapies for Adults with Acute Lung Injury:
High Frequency Oscillatory Ventilation 91
Niall D. Ferguson and Thomas E. Stewart
Theoretically, high frequency oscillatory ventilation (HFOV)
seems ideal for the treatment of patients with acquired respiratory
distress syndrome (ARDS). It allows adequate oxygenation and
ventilation to be maintained without causing further damage to
the already injured lung. It also seems a sound strategy for
improving oxygenation in patients who no longer respond to
conventional mechanical ventilation. Currently, HFOV should be
used in the adult intensive care unit as one of many ancillary
therapies available for the treatment of extremely ill, hypoxemic
patients with ARDS. Future research may define the role of HFOV
as a more routine strategy for preventing ventilator associated
lung injury in this patient population.
Ventilator Associated Pneumonia: Prevention, Diagnosis,
and Therapy 107
Dean P. Keenan, Daren K. Heyland, Michael J. Jacka,
Deborah Cook, and Peter Dodek
Ventilator associated pneumonia occurs in 10% to 65% of critically
ill patients and is associated with increased length of stay in the
intensive care unit and increased risk of death. Prevention of
this condition includes strategies designed to minimize bacterial
contamination of the airway, ventilator circuit, and secretions and
strategies designed to minimize aspiration of gastric contents. The
best strategy for the diagnosis of ventilator associated pneumonia
remains controversial; it remains to be proved that use of bron
choscopic specimens is associated consistently with improved
outcomes. Initial treatment for ventilator associated pneumonia is
CONTENTS vii
equally controversial. Recent work, however, suggests that the
provision of adequate coverage with broad spectrum antibiotics
is associated with better clinical outcomes than the use of more
narrow spectrum agents that may be inadequate.
ARDS and the Multiple Organ Dysfunction Syndrome 127
Rachel G. Khadaroo and John C. Marshall
The multiple organ dysfunction syndrome (MODS) is a common,
but poorly understood, complication of critical illness. Although
the cellular mechanisms remain elusive, processes such as in¬
flammation thrombosis, apoptosis, and tissue repair contribute to
its clinical expression. In the lung, the syndrome is seen as ac¬
quired respiratory distress syndrome (ARDS); similar processes
in other organs are responsible for the systemic syndrome. Ther¬
apy, in the absence of a better understanding of pathologic mecha¬
nism, is supportive; however, iatrogenic factors contribute to its
evolution and highlight the need for clinicians to be aware of the
potential for harm inherent in every intensive care unit interven¬
tion.
ARDS: Monitoring Tissue Perfusion 143
Stephan M. Jakob and Jukka Takala
Tissue perfusion is at risk in acquired respiratory distress syn¬
drome (ARDS) for several reasons: metabolic demands often are
increased, hemodynamic instability is common, and arterial hy
poxemia may limit the delivery of oxygen to the tissues if the
cardiovascular reserves are compromised and cannot compensate
for the reduction of arterial oxygen content. Impaired tissue oxy
genation, especially in the splanchnic region, plays a central role
not only in the pathogenesis of multiple organ dysfunction but
also in the development of complications in various groups of
intensive care patients. This article briefly reviews the abnormali¬
ties in systemic and regional circulation and metabolic demands
in ARDS, discusses the methods available for the assessment of
the adequacy of systemic and regional tissue perfusion, and then
outlines strategies to maintain and improve tissue perfusion in
ARDS.
Cytopathic Hypoxia: Is Oxygen Use Impaired in Sepsis
as a Result of an Acquired Intrinsic Derangement in
Cellular Respiration 165
Mitchell P. Fink
Accumulating data support the view that sepsis is associated
with an acquired intrinsic derangement in cellular respiration, a
phenomenon that might be called cytopathic hypoxia. Several
different biochemical mechanisms have been postulated to ac¬
count for cytopathic hypoxia in sepsis, including reversible inhibi
viii CONTENTS
tion of cytochrome oxidase by nitric oxide, irreversible inhibition
of one or more mitochondrial respiratory complexes by peroxyni
trite. Perhaps the most important mechanism underlying the de¬
velopment of cytopathic hypoxia is activation of the nuclear en¬
zyme, poly (ADP ribosyl) polymerase (PARP), which catalyzes
the formation of homopolymers consisting of repeating adenosine
nucleotide subunits and leads to depletion of cellular stores of
nicotinamide adenine dinucleotide (NAD+/NADH). If cytopathic
hypoxia is pathophysiology of sepsis and multiple organ dysfunc¬
tion syndrome, then clinical strategies designed to improve tissue
perfusion and oxygen delivery are doomed to failure. Rather,
efforts in the future will need to focus on pharmacologic interven¬
tions designed to preserve normal mitochondrial function and
energy production in sepsis.
ARDS: The Future 177
Hector R. Wong
Knowledge derived from the disciplines of molecular biology and
genetics has the potential to improve the course and outcome of
patient with acquired respiratory distress syndrome (ARDS) in
the future. Through genomics based research we may gain a more
comprehensive understanding of ARDS and characterize the im
munophenotypes of individual patients. This type of information
then can be used to modulate host inflammatory response more
rationally, either in the form of anti inflammatory therapies or of
strategies to augment host inflammatory immune mechanisms
when clinically appropriate. In addition, future advances in mo¬
lecular biology may allow for therapeutic strategies that incorpo¬
rate powerful endogenous cellular defense molecules and mecha¬
nisms.
Index 197
Subscription Information Inside Back Cover
CONTENTS ix
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| spelling | New management strategies in ARDS Mitchell M. Levy, guest ed. Philadelphia [u.a.] Saunders 2002 XI, 201 S. Ill., graph. Darst. txt rdacontent n rdamedia nc rdacarrier Critical care clinics 18,1 Respiratory distress syndrome gtt Respiratory Distress Syndrome, Adult therapy Therapie (DE-588)4059798-2 gnd rswk-swf ARDS (DE-588)4221275-3 gnd rswk-swf (DE-588)4143413-4 Aufsatzsammlung gnd-content ARDS (DE-588)4221275-3 s Therapie (DE-588)4059798-2 s DE-604 Levy, Mitchell M. 1950- Sonstige (DE-588)13691411X oth Critical care clinics 18,1 (DE-604)BV000019838 18,1 HBZ Datenaustausch application/pdf http://bvbr.bib-bvb.de:8991/F?func=service&doc_library=BVB01&local_base=BVB01&doc_number=009758656&sequence=000002&line_number=0001&func_code=DB_RECORDS&service_type=MEDIA Inhaltsverzeichnis |
| spellingShingle | New management strategies in ARDS Critical care clinics Respiratory distress syndrome gtt Respiratory Distress Syndrome, Adult therapy Therapie (DE-588)4059798-2 gnd ARDS (DE-588)4221275-3 gnd |
| subject_GND | (DE-588)4059798-2 (DE-588)4221275-3 (DE-588)4143413-4 |
| title | New management strategies in ARDS |
| title_auth | New management strategies in ARDS |
| title_exact_search | New management strategies in ARDS |
| title_full | New management strategies in ARDS Mitchell M. Levy, guest ed. |
| title_fullStr | New management strategies in ARDS Mitchell M. Levy, guest ed. |
| title_full_unstemmed | New management strategies in ARDS Mitchell M. Levy, guest ed. |
| title_short | New management strategies in ARDS |
| title_sort | new management strategies in ards |
| topic | Respiratory distress syndrome gtt Respiratory Distress Syndrome, Adult therapy Therapie (DE-588)4059798-2 gnd ARDS (DE-588)4221275-3 gnd |
| topic_facet | Respiratory distress syndrome Respiratory Distress Syndrome, Adult therapy Therapie ARDS Aufsatzsammlung |
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