RESUMO
Mechanical ventilation can cause acute diaphragm atrophy and injury, and this is associated with poor clinical outcomes. Although the importance and impact of lung-protective ventilation is widely appreciated and well established, the concept of diaphragm-protective ventilation has recently emerged as a potential complementary therapeutic strategy. This Perspective, developed from discussions at a meeting of international experts convened by PLUG (the Pleural Pressure Working Group) of the European Society of Intensive Care Medicine, outlines a conceptual framework for an integrated lung- and diaphragm-protective approach to mechanical ventilation on the basis of growing evidence about mechanisms of injury. We propose targets for diaphragm protection based on respiratory effort and patient-ventilator synchrony. The potential for conflict between diaphragm protection and lung protection under certain conditions is discussed; we emphasize that when conflicts arise, lung protection must be prioritized over diaphragm protection. Monitoring respiratory effort is essential to concomitantly protect both the diaphragm and the lung during mechanical ventilation. To implement lung- and diaphragm-protective ventilation, new approaches to monitoring, to setting the ventilator, and to titrating sedation will be required. Adjunctive interventions, including extracorporeal life support techniques, phrenic nerve stimulation, and clinical decision-support systems, may also play an important role in selected patients in the future. Evaluating the clinical impact of this new paradigm will be challenging, owing to the complexity of the intervention. The concept of lung- and diaphragm-protective ventilation presents a new opportunity to potentially improve clinical outcomes for critically ill patients.
Assuntos
Diafragma/lesões , Atrofia Muscular/prevenção & controle , Respiração Artificial/métodos , Lesão Pulmonar Induzida por Ventilação Mecânica/prevenção & controle , Consenso , Cuidados Críticos , Sistemas de Apoio a Decisões Clínicas , Terapia por Estimulação Elétrica , Oxigenação por Membrana Extracorpórea , Humanos , Atrofia Muscular/etiologia , Nervo Frênico , Respiração Artificial/efeitos adversos , Lesão Pulmonar Induzida por Ventilação Mecânica/etiologiaAssuntos
Cuidados Críticos/tendências , Ventilação não Invasiva/tendências , Síndrome do Desconforto Respiratório do Recém-Nascido/terapia , Síndrome do Desconforto Respiratório/terapia , Adolescente , Adulto , Gasometria , Baixo Débito Cardíaco/complicações , Criança , Pré-Escolar , Cuidados Críticos/métodos , Ciclosporinas/farmacologia , Ciclosporinas/uso terapêutico , Dexmedetomidina/administração & dosagem , Dexmedetomidina/farmacologia , Mortalidade Hospitalar , Humanos , Oxigenoterapia Hiperbárica , Hipnóticos e Sedativos/administração & dosagem , Hipnóticos e Sedativos/farmacologia , Lactente , Recém-Nascido , Monitorização Fisiológica/métodos , Monitorização Fisiológica/tendências , Ventilação não Invasiva/efeitos adversos , Ventilação não Invasiva/mortalidade , Avaliação de Processos e Resultados em Cuidados de Saúde , Respiração Artificial/efeitos adversos , Respiração Artificial/métodos , Respiração Artificial/tendências , Síndrome do Desconforto Respiratório/complicações , Síndrome do Desconforto Respiratório/etiologiaAssuntos
Cuidados Críticos/métodos , Estado Terminal , Hemodinâmica/fisiologia , Monitorização Fisiológica/métodos , Injúria Renal Aguda/fisiopatologia , Injúria Renal Aguda/terapia , Doenças do Sistema Nervoso Autônomo/fisiopatologia , Doenças do Sistema Nervoso Autônomo/terapia , Lesões Encefálicas/fisiopatologia , Lesões Encefálicas/terapia , Humanos , Terapia Nutricional/métodos , Embolia Pulmonar/fisiopatologia , Embolia Pulmonar/terapiaRESUMO
Acute respiratory distress syndrome (ARDS) is a severe form of respiratory failure that is characterized by marked hypoxemia, bilateral infiltrates on chest radiograph, and no clinical evidence of left ventricular failure. Mechanical ventilation with positive end-expiratory pressure (PEEP) is a cornerstone therapy for ARDS patients. Because the fundamental aim of supportive treatment is to improve arterial oxygenation, several alternatives to mechanical ventilation with PEEP have been used. One of these alternative therapies is prone positioning, which has been used safely to improve oxygenation in many patients with ARDS. Despite encouraging results, however, the use of prone positioning is not widely accepted as an adjunct to therapy in hypoxemic patients because, aside from temporarily improving gas exchange, it does not seem to affect the outcome of these patients. This article reviews the rationale for using prone positioning in ARDS patients who require intubation and mechanical ventilation.