Update in Management of Severe Hypoxemic Respiratory Failure.

Autor: Narendra DK; Section of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Baylor College of Medicine, Houston, TX., Hess DR; Massachusetts General Hospital and Harvard Medical School, Boston, MA., Sessler CN; Division of Pulmonary Diseases and Critical Care Medicine, Virginia Commonwealth University Health System, Richmond, VA., Belete HM; Department of Medicine, Lenox Hill and Northwell Hofstra School of Medicine, New York, NY., Guntupalli KK; Section of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Baylor College of Medicine, Houston, TX., Khusid F; Respiratory Therapy and Pulmonary Physiology Center, New York Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY., Carpati CM; Surgical ICU, Lenox Hill Hospital, New York, NY., Astiz ME; Departments of Internal Medicine and Critical Care Medicine, Lenox Hill Hospital, New York, NY., Raoof S; Division of Pulmonary Medicine, Lenox Hill Hospital, and Hofstra Northwell School of Medicine, New York, NY. Electronic address: suhailraoof@gmail.com.
Jazyk: angličtina
Zdroj: Chest [Chest] 2017 Oct; Vol. 152 (4), pp. 867-879. Date of Electronic Publication: 2017 Jul 14.
DOI: 10.1016/j.chest.2017.06.039
Abstrakt: Mortality related to severe-moderate and severe ARDS remains high. We searched the literature to update this topic. We defined severe hypoxemic respiratory failure as Pao 2 /Fio 2  < 150 mm Hg (ie, severe-moderate and severe ARDS). For these patients, we support setting the ventilator to a tidal volume of 4 to 8 mL/kg predicted body weight (PBW), with plateau pressure (Pplat) ≤ 30 cm H 2 O, and initial positive end-expiratory pressure (PEEP) of 10 to 12 cm H 2 O. To promote alveolar recruitment, we propose increasing PEEP in increments of 2 to 3 cm provided that Pplat remains ≤ 30 cm H 2 O and driving pressure does not increase. A fluid-restricted strategy is recommended, and nonrespiratory causes of hypoxemia should be considered. For patients who remain hypoxemic after PEEP optimization, neuromuscular blockade and prone positioning should be considered. Profound refractory hypoxemia (Pao 2 /Fio 2  < 80 mm Hg) after PEEP titration is an indication to consider extracorporeal life support. This may necessitate early transfer to a center with expertise in these techniques. Inhaled vasodilators and nontraditional ventilator modes may improve oxygenation, but evidence for improved outcomes is weak.
(Copyright © 2017 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)
Databáze: MEDLINE
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