Chest
POSTGRADUATE EDUCATION CORNERCONTEMPORARY REVIEWS IN CRITICAL CARE MEDICINESevere Hypoxemic Respiratory Failure: Part 2—Nonventilatory Strategies
Section snippets
Neuromuscular Blocking Agents
From 25% to 55% of patients with ALI enrolled in contemporary multicenter randomized controlled trials (RCTs) received neuromuscular blocking agents (NMBAs),1, 2, 3, 4 a prevalence that increases further with use of nonconventional modes of ventilation, such as high-frequency oscillatory ventilation.5 The most common reason for using an NMBA is to promote patient-ventilator synchrony and improve oxygenation.6 Data that directly examine the impact of NMBAs on oxygenation using an RCT design in
Conservative Fluid Management
Fluid administration increases hydrostatic pressure in the lungs and promotes fluid filtration and edema formation, particularly in states of increased microvascular permeability, such as ARDS.88, 89 Additionally, the administration of blood products can contribute to circulatory overload or pulmonary edema as a result of ALI (ie, transfusion-related ALI). Worsening pulmonary edema is associated with progressive hypoxemia. Patients with ARDS generally accumulate about 1 L of fluid per day with
Summary
Figure 1 summarizes a proposed algorithmic nonventilatory approach to management of severe hypoxemic respiratory failure. Severe refractory hypoxemia is a common challenge in the management of patients with ARDS. Adjustments to mechanical ventilation and nonventilatory interventions can produce improvements in oxygenation that may be life saving. The use of NMBAs, iNO, prone positioning, and/or ECLS may improve oxygenation in some patients. Given the risk of adverse effects and/or high cost of
Acknowledgments
Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Hess has received royalties from Impact. He was a consultant for Respironics and Pari. He also has relationships with Cardinal (CaseFusion) and Ikaria. Drs Raoof, Esan, Goulet, and Sessler report that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.
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2014, Emergency Medicine Clinics of North AmericaCitation Excerpt :These treatments may find a role in the EM management of ARDS and severe respiratory failure. Further information on each can be found in references.38,42,43 Neuromuscular blocking agents (NMBAs) are used in patients with severe respiratory failure to facilitate ventilator synchrony.44
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