Mechanical Ventilation, Past, Present, and Future.

Mechanical ventilation (MV) has played a crucial role in the medical field, particularly in anesthesia and in critical care medicine (CCM) settings. MV has evolved significantly since its inception over 70 years ago and the future promises even more advanced technology. In the past, ventilation was provided manually, intermittently, and it was primarily used for resuscitation or as a last resort for patients with severe respiratory or cardiovascular failure. The earliest MV machines for prolonged ventilatory support and oxygenation were large and cumbersome. They required a significant amount of skills and expertise to operate. These early devices had limited capabilities, battery, power, safety features, alarms, and therefore these often caused harm to patients. Moreover, the physiology of MV was modified when mechanical ventilators moved from negative pressure to positive pressure mechanisms. Monitoring systems were also very limited and therefore the risks related to MV support were difficult to quantify, predict and timely detect for individual patients who were necessarily young with few comorbidities. Technology and devices designed to use tracheostomies versus endotracheal intubation evolved in the last century too and these are currently much more reliable. In the present, positive pressure MV is more sophisticated and widely used for extensive period of time. Modern ventilators use mostly positive pressure systems and are much smaller, more portable than their predecessors, and they are much easier to operate. They can also be programmed to provide different levels of support based on evolving physiological concepts allowing lung-protective ventilation. Monitoring systems are more sophisticated and knowledge related to the physiology of MV is improved. Patients are also more complex and elderly compared to the past. MV experts are informed about risks related to prolonged or aggressive ventilation modalities and settings. One of the most significant advances in MV has been protective lung ventilation, diaphragm protective ventilation including noninvasive ventilation (NIV). Health care professionals are familiar with the use of MV and in many countries, respiratory therapists have been trained for the exclusive purpose of providing safe and professional respiratory support to critically ill patients. Analgo-sedation drugs and techniques are improved, and more sedative drugs are available and this has an impact on recovery, weaning, and overall patients' outcome. Looking toward the future, MV is likely to continue to evolve and improve alongside monitoring techniques and sedatives. There is increasing precision in monitoring global "patient-ventilator" interactions: structure and analysis (asynchrony, desynchrony, etc). One area of development is the use of artificial intelligence (AI) in ventilator technology. AI can be used to monitor patients in real-time, and it can predict when a patient is likely to experience respiratory distress. This allows medical professionals to intervene before a crisis occurs, improving patient outcomes and reducing the need for emergency intervention. This specific area of development is intended as "personalized ventilation." It involves tailoring the ventilator settings to the individual patient, based on their physiology and the specific condition they are being treated for. This approach has the potential to improve patient outcomes by optimizing ventilation and reducing the risk of harm. In conclusion, MV has come a long way since its inception, and it continues to play a critical role in anesthesia and in CCM settings. Advances in technology have made MV safer, more effective, affordable, and more widely available. As technology continues to improve, more advanced and personalized MV will become available, leading to better patients' outcomes and quality of life for those in need.

Basic and advanced echocardiography in advanced heart failure: an overview.

Advanced chronic heart failure (ACHF) is the last phase in the evolution of heart failure and is characterized by high hospitalization and mortality rates and is refractory to medical therapy, therefore requiring more aggressive therapies, such as mechanical circulatory support or heart transplantation. Over the last years, the incidence of ACHF was continuously growing, together with the increase in population survival rates. Therefore, the early recognition of the transition to ACHF is of crucial importance in HF patients, which also helps in prognostication of such patients, since advanced therapeutic options are limited to selected patients and they also have some important risk implications. Echocardiography is the gold standard tool for the evaluation of patients with HF; moreover, the recent technological advances provided new structural and functional indices of the four cardiac chambers that showed to be comparable to advanced imaging or invasive hemodynamic parameters. This allows us to operate an accurate study of ACHF with first- and second-level echocardiographic techniques, which are now being integrated in daily clinical practice. The present review presents an overview of the currently available tools for the echocardiographic examination of patients with ACHF, with its advantages and limitations, based on the latest supporting evidences.

Safe performance of echocardiography during the COVID-19 pandemic: a practical guide.

Coronavirus disease-2019 (COVID-19) outbreak has become a worldwide healthcare emergency, with continuously growing number of infected subjects. Considering the easy virus spread through respiratory droplets produced with cough, sneezes or spit or through close contact with infected people or surfaces, healthcare workers are further exposed to COVID-19. Particularly, echocardiography remains an essential diagnostic service which, due to the close contact with patients during the exam, provides echocardiographers high-risk of contagion. Therefore, the common modalities of performing echocardiography should be improved in this scenario, avoiding performing unnecessary exams, using the appropriate personal protective equipment depending on patients' status and location, optimizing time-effectiveness of the echocardiographic study and accurately sanitizing the environment and devices after each exam. This paper aims to provide a simple guide for the clinicians to balance between providing the best care to each patient and protecting themselves and other patients from the spread of the virus. It also proposes the use of the mnemonic PREVENT to resume the crucial indications to be followed for the execution of appropriate echocardiographic examination during the COVID-19 pandemic.

Multimodality imaging for the evaluation and management of patients with long-term (durable) left ventricular assist devices.

Left ventricular assist devices (LVADs) are gaining increasing importance as therapeutic strategy in advanced heart failure (HF), not only as bridge to recovery or to transplant but also as destination therapy. Even though long-term LVADs are considered a precious resource to expand the treatment options and improve clinical outcome of these patients, these are limited by peri-operative and post-operative complications, such as device-related infections, haemocompatibility-related events, device mis-positioning, and right ventricular failure. For this reason, a precise pre-operative, peri-operative, and post-operative evaluation of these patients is crucial for the selection of LVAD candidates and the management LVAD recipients. The use of different imaging modalities offers important information to complete the study of patients with LVADs in each phase of their assessment, with peculiar advantages/disadvantages, ideal application, and reference parameters for each modality. This clinical consensus statement sought to guide the use of multimodality imaging for the evaluation of patients with advanced HF undergoing LVAD implantation.

EACVI survey on the management of patients with patent foramen ovale and cryptogenic stroke.

AIMS: The European Association of Cardiovascular Imaging (EACVI) Scientific Initiatives Committee performed a global survey to evaluate the current practice for the assessment and management of patients with suspected patent foramen ovale (PFO) and cryptogenic stroke. METHODS AND RESULTS: In total, 79 imaging centres from 34 countries across the world responded to the survey, which comprised 17 questions. Most non-invasive investigations for PFO were widely available in the responding centres, with the exception of transcranial colour Doppler which was only available in 70% of sites, and most commonly performed by neurologists. Standard transthoracic echocardiography, with or without bubbles, was considered the first-level test for suspected PFO in the majority of the centres, whereas transoesophageal echocardiography was an excellent second-level modality. Most centres would rule out atrial fibrillation (AF) as a source of embolism in all patients with cryptogenic stroke (63%), with the remainder reserving investigation for patients with multiple AF risk factors (33%). Cardiac magnetic resonance was the preferred tool for identifying other unusual aetiologies, like cardiac masses or thrombi. After PFO closure, there was variation in the use of antiplatelet therapy: a quarter recommended treatment for life, while only 12% recommended 5 years as stipulated in the guidelines (12%). Antibiotic prophylaxis prior to dental or endoscopic procedures was not recommended in 41% of centres, contrary to what the guidelines recommended. CONCLUSION: Our survey revealed a variable adherence to the current recommendations for the diagnosis and management of patients with cryptogenic stroke and PFO. Efforts should focus on optimizing and standardizing diagnostic tests and treatment of this condition.