CE: Tripti; MCC/230610; Total nos of Pages: 8;
MCC 230610
REVIEW URRENT C OPINION
Acute life-threatening hypoxemia during mechanical ventilation Thomas Piraino a,b and Eddy Fan c,d
Purpose of review To describe current evidence-based practice in the management of acute life-threatening hypoxemia in mechanically ventilated patients and some of the methods used to individualize the care of the patient. Recent findings Patients with acute life-threatening hypoxemia will often meet criteria for severe ARDS, for which there are only a few treatment strategies that have been shown to improve survival outcomes. Recent findings have increased our knowledge of the physiological effects of spontaneous breathing and the application of PEEP. Additionally, the use of advanced bedside monitoring has a promising future in the management of hypoxemic patients to fine-tune the ventilator and to evaluate the individual patient response to therapy. Summary Treating the patient with acute life-threatening hypoxemia during mechanical ventilation should begin with an evidence-based approach, with the goal of improving oxygenation and minimizing the harmful effects of mechanical ventilation. The use of advanced monitoring and the application of simple maneuvers at the bedside may assist clinicians to better individualize treatment and improve clinical outcomes. Keywords acute hypoxemia, lung-protective ventilation, mechanical ventilation, severe acute respiratory distress syndrome
INTRODUCTION Managing acute and life-threatening hypoxemia in the patient receiving mechanical ventilation can be a challenging task for the bedside clinician. Early recognition and identifying the underlying cause is extremely important for deciding the right strategy to treat the patient. Severe hypoxemia sustained for even a short period can be life-threatening, and may also result in long-term morbidity [1]. This review will summarize the initial approach to the ventilated patient with acute life-threatening hypoxemia, current evidence-based management of these patients, and some novel methods that are being developed based on our growing knowledge of the factors contributing to ventilator-induced lung injury (VILI).
DEFINITION The severity of hypoxemia referenced in the current literature considers the absolute level of PaO2 and commonly, also the PaO2/FiO2 ratio. Unfortunately, there is no commonly accepted definition of lifethreatening or refractory hypoxemia. This makes epidemiology of the subject difficult for determining
the prevalence, and also difficult for deciding inclusion criteria for studies. Many studies of patients in hypoxemic respiratory failure secondary to acute respiratory distress syndrome (ARDS) have used PaO2/FiO2 rather than the PaO2 level as the hypoxemic component for inclusion (other ARDS criteria must also be met for inclusion). The Berlin Definition of ARDS classifies severe ARDS as a PaO2/FiO2 that is less than 100 mmHg, with a mortality of close to 50% [2]. In a posthoc analysis of patients with a PaO2/FiO2 less than 100 mmHg, however, those with higher compliance (>20 ml/cmH2O) and lower corrected minute ventilation (
MCC 230610
REVIEW URRENT C OPINION
Acute life-threatening hypoxemia during mechanical ventilation Thomas Piraino a,b and Eddy Fan c,d
Purpose of review To describe current evidence-based practice in the management of acute life-threatening hypoxemia in mechanically ventilated patients and some of the methods used to individualize the care of the patient. Recent findings Patients with acute life-threatening hypoxemia will often meet criteria for severe ARDS, for which there are only a few treatment strategies that have been shown to improve survival outcomes. Recent findings have increased our knowledge of the physiological effects of spontaneous breathing and the application of PEEP. Additionally, the use of advanced bedside monitoring has a promising future in the management of hypoxemic patients to fine-tune the ventilator and to evaluate the individual patient response to therapy. Summary Treating the patient with acute life-threatening hypoxemia during mechanical ventilation should begin with an evidence-based approach, with the goal of improving oxygenation and minimizing the harmful effects of mechanical ventilation. The use of advanced monitoring and the application of simple maneuvers at the bedside may assist clinicians to better individualize treatment and improve clinical outcomes. Keywords acute hypoxemia, lung-protective ventilation, mechanical ventilation, severe acute respiratory distress syndrome
INTRODUCTION Managing acute and life-threatening hypoxemia in the patient receiving mechanical ventilation can be a challenging task for the bedside clinician. Early recognition and identifying the underlying cause is extremely important for deciding the right strategy to treat the patient. Severe hypoxemia sustained for even a short period can be life-threatening, and may also result in long-term morbidity [1]. This review will summarize the initial approach to the ventilated patient with acute life-threatening hypoxemia, current evidence-based management of these patients, and some novel methods that are being developed based on our growing knowledge of the factors contributing to ventilator-induced lung injury (VILI).
DEFINITION The severity of hypoxemia referenced in the current literature considers the absolute level of PaO2 and commonly, also the PaO2/FiO2 ratio. Unfortunately, there is no commonly accepted definition of lifethreatening or refractory hypoxemia. This makes epidemiology of the subject difficult for determining
the prevalence, and also difficult for deciding inclusion criteria for studies. Many studies of patients in hypoxemic respiratory failure secondary to acute respiratory distress syndrome (ARDS) have used PaO2/FiO2 rather than the PaO2 level as the hypoxemic component for inclusion (other ARDS criteria must also be met for inclusion). The Berlin Definition of ARDS classifies severe ARDS as a PaO2/FiO2 that is less than 100 mmHg, with a mortality of close to 50% [2]. In a posthoc analysis of patients with a PaO2/FiO2 less than 100 mmHg, however, those with higher compliance (>20 ml/cmH2O) and lower corrected minute ventilation (
