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Prone positioning has been used for over 30 years in the management of patients with acute respiratory distress syndrome (ARDS). This maneuver has consistently proven capable of improving oxygenation in patients with acute respiratory failure. Several mechanisms can explain this observation, including possible intervening net recruitment and more homogeneously distributed alveolar inflation. It is also progressively becoming clear that prone positioning may reduce the nonphysiological stress and strain associated with mechanical ventilation, thus decreasing the risk of ventilator-induced lung injury, which is known to adversely impact patient survival. The available randomized clinical trials, however, have failed to demonstrate that prone positioning improves the outcomes of patients with ARDS overall. In contrast, the individual pati...
Ashbaugh et al. (1967) proposed the first ARDS description, based on refractory hypoxemia, bilateral pulmonary infiltrates (X-ray), low respiratory system compliance, increased lung weight. In the years other definitions have been introduced, being the most widely accepted one the definition proposed by the American-European Consensus Conference which relies primarily on PaO2/FiO2 < 300 and bilateral infiltrates. Despite the diagnostic accuracy of these definitions has been validated they resulted in quite poor sensitivity/specificity. All the definitions available include the presence of bilateral pulmonary infiltrates as a surrogate of inflammatory lung edema. Unfortunately, the chest X-ray “infiltrates” may derive from atelectasis, interstitial or intra-acinar edema or consolidation. In contrast analysis of Computed Tomography (CT) ...
ECMO è l’abbreviazione di Extra Corporeal Memnbrane Oxygention, una tecnica che consente di garantire supporto respiratorio e/o circolatorio tramite polmone e/o cuore artificiale in caso di insufficienza cardiopolmonare refrattaria al trattamento convenzionale. L’ECMO non è, di per sé, una cura per la patologia ma un modo per garantire la sopravvivenza del paziente durante la diagnosi e la risoluzione della stessa. La metodica è, perciò, consigliata in caso di elevato rischio di mortalità e in caso di reversibilità della patologia da cui il paziente è affetto. I primi tentativi di ossigenare il sangue tramite un supporto extracorporeo risalgono alla fine del 1800, quando Frey e Gruber tentarono di per fondere organi isolati. Nomi eccellenti come Gibbons, Kolff e Berk, Clowes, Kammermeyer, Larm e Kolobow hanno contribuito all’evoluzione...
Prone positioning has been used for over 30 years in the management of patients with acute respiratory distress syndrome (ARDS). This maneuver has consistently proven capable of improving oxygenation in patients with acute respiratory failure. Several mechanisms can explain this observation, including possible intervening net recruitment and more homogeneously distributed alveolar inflation. It is also progressively becoming clear that prone positioning may reduce the nonphysiological stress and strain associated with mechanical ventilation, thus decreasing the risk of ventilator-induced lung injury, which is known to adversely impact patient survival. The available randomized clinical trials, however, have failed to demonstrate that prone positioning improves the outcomes of patients with ARDS overall. In contrast, the individual pati...
The extracorporeal support was first applied in 1972. The first randomized trial performed in ALI/ARDS patients showed a mortality equal to about 90% in patients treated with extra-corporeal support, not different to that of patients conventionally treated. In the eighties the extracorporeal CO2 removal was introduced, aiming at the lung rest. Different randomized studies did not show any survival benefit with extracorporeal CO2 removal support. It must be pointed out, however, that the technology available at that time was likely inadequate while, nowadays, it has been greatly improved and there are increasing numbers of reports describing simple forms of extracorporeal support, primarily aiming at CO2 removal. It is important to highlight that the need of ventilation is associated to the problem of VILI, which may be greatly reduced ...
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