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To ventilate, oscillate, or cannulate?
J Crit Care. 2013 Oct; 28(5):655-62.JC

Abstract

Ventilatory management of acute respiratory distress syndrome has evolved significantly in the last few decades. The aims have shifted from optimal gas transfer without concern for iatrogenic risks to adequate gas transfer while minimizing lung injury. This change in focus, along with improved ventilator and multiorgan system management, has resulted in a significant improvement in patient outcomes. Despite this, a number of patients develop hypoxemic respiratory failure refractory to lung-protective ventilation (LPV). The intensivist then faces the dilemma of either persisting with LPV using adjuncts (neuromuscular blocking agents, prone positioning, recruitment maneuvers, inhaled nitric oxide, inhaled prostacyclin, steroids, and surfactant) or making a transition to rescue therapies such as high-frequency oscillatory ventilation (HFOV) and/or extracorporeal membrane oxygenation (ECMO) when both these modalities are at their disposal. The lack of quality evidence and potential harm reported in recent studies question the use of HFOV as a routine rescue option. Based on current literature, the role for venovenous (VV) ECMO is probably sequential as a salvage therapy to ensure ultraprotective ventilation in selected young patients with potentially reversible respiratory failure who fail LPV despite neuromuscular paralysis and prone ventilation. Given the risk profile and the economic impact, future research should identify the patients who benefit most from VV ECMO. These choices may be further influenced by the emerging novel extracorporeal carbon dioxide removal devices that can compliment LPV. Given the heterogeneity of acute respiratory distress syndrome, each of these modalities may play a role in an individual patient. Future studies comparing LPV, HFOV, and VV ECMO should not only focus on defining the patients who benefit most from each of these therapies but also consider long-term functional outcomes.

Authors+Show Affiliations

Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital, The University of Queensland, Brisbane, Queensland, Australia. Electronic address: kiran_shekar@health.qld.gov.au.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Review

Language

eng

PubMed ID

23827735

Citation

Shekar, Kiran, et al. "To Ventilate, Oscillate, or Cannulate?" Journal of Critical Care, vol. 28, no. 5, 2013, pp. 655-62.
Shekar K, Davies AR, Mullany DV, et al. To ventilate, oscillate, or cannulate? J Crit Care. 2013;28(5):655-62.
Shekar, K., Davies, A. R., Mullany, D. V., Tiruvoipati, R., & Fraser, J. F. (2013). To ventilate, oscillate, or cannulate? Journal of Critical Care, 28(5), 655-62. https://doi.org/10.1016/j.jcrc.2013.04.009
Shekar K, et al. To Ventilate, Oscillate, or Cannulate. J Crit Care. 2013;28(5):655-62. PubMed PMID: 23827735.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - To ventilate, oscillate, or cannulate? AU - Shekar,Kiran, AU - Davies,Andrew R, AU - Mullany,Daniel V, AU - Tiruvoipati,Ravindranath, AU - Fraser,John F, Y1 - 2013/07/02/ PY - 2012/12/06/received PY - 2013/03/09/revised PY - 2013/04/17/accepted PY - 2013/7/6/entrez PY - 2013/7/6/pubmed PY - 2014/5/28/medline KW - ARDS KW - CV KW - ECLS KW - EIT KW - Extracorporeal membrane oxygenation KW - HFOV KW - High-frequency oscillatory ventilation KW - Lung-protective ventilation KW - NO KW - RM KW - Refractory hypoxemia KW - Rescue therapies KW - VILI KW - Ventilator-associated lung injury KW - acute respiratory distress syndrome KW - conventional ventilation KW - electric impedance tomography KW - extracorporeal life support KW - high-frequency oscillatory ventilation KW - nitric oxide KW - recruitment maneuver KW - ventilator-induced lung injury SP - 655 EP - 62 JF - Journal of critical care JO - J Crit Care VL - 28 IS - 5 N2 - Ventilatory management of acute respiratory distress syndrome has evolved significantly in the last few decades. The aims have shifted from optimal gas transfer without concern for iatrogenic risks to adequate gas transfer while minimizing lung injury. This change in focus, along with improved ventilator and multiorgan system management, has resulted in a significant improvement in patient outcomes. Despite this, a number of patients develop hypoxemic respiratory failure refractory to lung-protective ventilation (LPV). The intensivist then faces the dilemma of either persisting with LPV using adjuncts (neuromuscular blocking agents, prone positioning, recruitment maneuvers, inhaled nitric oxide, inhaled prostacyclin, steroids, and surfactant) or making a transition to rescue therapies such as high-frequency oscillatory ventilation (HFOV) and/or extracorporeal membrane oxygenation (ECMO) when both these modalities are at their disposal. The lack of quality evidence and potential harm reported in recent studies question the use of HFOV as a routine rescue option. Based on current literature, the role for venovenous (VV) ECMO is probably sequential as a salvage therapy to ensure ultraprotective ventilation in selected young patients with potentially reversible respiratory failure who fail LPV despite neuromuscular paralysis and prone ventilation. Given the risk profile and the economic impact, future research should identify the patients who benefit most from VV ECMO. These choices may be further influenced by the emerging novel extracorporeal carbon dioxide removal devices that can compliment LPV. Given the heterogeneity of acute respiratory distress syndrome, each of these modalities may play a role in an individual patient. Future studies comparing LPV, HFOV, and VV ECMO should not only focus on defining the patients who benefit most from each of these therapies but also consider long-term functional outcomes. SN - 1557-8615 UR - https://www.unboundmedicine.com/medline/citation/23827735/To_ventilate_oscillate_or_cannulate L2 - https://linkinghub.elsevier.com/retrieve/pii/S0883-9441(13)00118-4 DB - PRIME DP - Unbound Medicine ER -