Current Opinion in Critical Care最新文献

Purpose of review: Survival rates following liver transplantation now exceed 90% at one year. However, the patient group undergoing liver transplantation is increasingly complex, requiring continued focus on improving perioperative care to sustain these survival outcomes. This review highlights recent advances in the postoperative care of the liver transplantation patient.

Recent findings: Modern care integrates Enhanced Recovery After Surgery (ERAS) principles, which emphasise early mobilisation and device minimisation. Risk stratification has become increasingly sophisticated, with frailty and cardiopulmonary exercise testing providing powerful prognostic information; emerging machine learning approaches may further refine personalised risk prediction.Goal-directed haemodynamic management is advocated, with restrictive fluid strategies and viscoelastic haemostatic assays to minimise transfusion. Advances in graft optimisation have expanded the donor pool: normothermic regional perfusion reduces ischaemic cholangiopathy in donation after cardiac death grafts, while machine perfusion systems show promise in improving early graft function.Advanced organ support (extracorporeal membrane oxygenation) requires careful graft-conscious management. Infection prevention strategies include tailored prophylaxis approaches. Nutrition and structured prehabilitation/rehabilitation programmes support recovery, reduce complications and address persistent functional deficits.

Summary: Collectively, these developments reflect a shift toward personalised, multidisciplinary postoperative care, aimed at improving both survival and quality of life for liver transplantation recipients.

Purpose of review: This review aims to synthetize current evidence on the management of septic shock in patients with cirrhosis. It highlights the unique characteristics and the limitations of conventional strategies in this population.

Recent findings: The distinct pathophysiological profile of septic shock in patients with cirrhosis and different endothelial dysfunction phenotypes were explored in recent studies. Hemodynamic targets and resuscitation strategies may need to be adjusted in this population, but no definitive parameters have been identified. Trials evaluating fluid therapy have shown mixed results regarding the use of albumin, with no clear long-term survival benefit over crystalloids. Prognostic tools incorporating dynamic assessments are gaining traction but require further validation.

Summary: Septic shock in patients with cirrhosis presents unique diagnostic and therapeutic challenges due to underlying hemodynamic changes and immune dysfunction. Conventional approaches to sepsis management may be insufficient or unreliable in this population, necessitating tailored strategies for fluid resuscitation and vasopressor use. High-quality evidence remains limited, and many current practices are based on extrapolation from the general population. Continued research is essential to develop targeted interventions and improve outcomes for this particularly vulnerable group.

Purpose of review: Mechanical ventilation in acute brain injury (ABI) requires simultaneous protection of the brain, lungs, and diaphragm. Recent studies have questioned whether conventional lung-protective settings are optimal in this population. This review summarizes emerging evidence and evolving strategies to personalize MV across the phases of ABI - from controlled ventilation to extubation and tracheostomy.

Recent findings: The PROLABI randomized trial and the VENTIBRAIN study indicate that excessively low tidal volumes or high positive end-expiratory pressure may worsen outcomes in isolated ABI, highlighting the need for "protective windows" for ventilation. Dynamic indices such as driving pressure and mechanical power predict prognosis even in nonacute respiratory distress syndrome (ARDS) ABI. Novel approaches - including automated ventilation, respiratory drive monitoring, and individualized CO2 and O2 targets - are reshaping mechanical ventilation in ABI. Extubation failure remains frequent (~20%), largely due to impaired airway protection rather than gas-exchange parameters.

Summary: Optimal mechanical ventilation in ABI demands individualized strategies balancing brain-lung-diaphragm interactions. Incorporating multimodal neuromonitoring, objective airway, drive assessment, and early rehabilitation may enhance patient safety, reduce secondary brain and pulmonary injury, and support timely liberation from mechanical ventilation.

Purpose of review: Mechanical ventilation (MV) is central to the management of acute respiratory distress syndrome (ARDS). In refractory cases, veno-venous extracorporeal membrane oxygenation (VV-ECMO) can provide adequate gas exchange and facilitate protective ventilation. Effective management requires systematic monitoring of both the native lung (NL) and the membrane lung (ML). This review outlines an approach to monitoring ventilated patients, integrating physiological principles with clinical assessment.

Recent findings: Monitoring respiratory mechanics and inspiratory effort during controlled or assisted ventilation is essential to minimize the risk of ventilator-induced lung injury (VILI) and patient self-inflicted lung injury (P-SILI). New bedside methods have been validated, linking these measurements to both risk of injury and clinical outcomes. During VV-ECMO, accurate monitoring of ML function enables reduction in the intensity of MV and, subsequently, modulation of respiratory drive and effort.

Summary: Monitoring the respiratory system during MV and VV-ECMO in ARDS is essential to understand the interplay between the native and membrane lungs, both in controlled and assisted ventilation, where respiratory drive and effort are often unmeasured and overlooked. Careful selection and application of monitoring strategies therefore remain a cornerstone of safe management in these complex patients.

Purpose of review: Mechanical ventilation is essential in acute hypoxemic respiratory failure (AHRF), yet excessive respiratory drive and inspiratory effort may aggravate injury, a phenomenon termed patient self-inflicted lung injury (P-SILI). This review summarizes mechanistic insights, preclinical and clinical evidence, and current strategies to prevent P-SILI while preserving diaphragmatic function.

Recent findings: Preclinical experimental studies show that vigorous inspiratory efforts amplify pleural pressure swings, regional overdistension, pendelluft, and inflammation, with damage involving both lung and diaphragm. positive end-expiratory pressure (PEEP) and continuous positive airway pressure (CPAP) can homogenize ventilation, reduce strain-rate, and protect diaphragmatic mechanics, whereas uncontrolled effort worsens outcomes. Clinical investigations confirm that high drive and effort increase total lung stress despite protective tidal volumes and are linked to mortality, ventilator dependence, and complications such as pneumomediastinum. Emerging approaches include titrated pressure support and sedation and ventilatory assistance, neuromuscular blockade, phrenic nerve block, pharmacological drive modulation, prone positioning, and extracorporeal CO 2 removal. Strategies aimed at preserving diaphragm activity, such as electrical phrenic stimulation or inspiratory muscle training, further broaden protective options.

Summary: P-SILI arises when excessive inspiratory effort translates into injurious lung and diaphragm stress. Preventive strategies should not abolish but shape effort, integrating ventilatory settings, sedation, and drive-modulating interventions across the continuum from the acute phase to weaning and rehabilitation.

Purpose of review: The process of weaning from venovenous extracorporeal membrane oxygenation (V-V ECMO) is a critical step in the recovery of patients with severe acute respiratory distress syndrome (ARDS), yet clinical practice is highly variable and lacks strong evidence-based guidance. This review summarizes the current understanding and emerging data on weaning from V-V ECMO while highlighting key areas for future research.

Recent findings: While several single-center studies have evaluated structured weaning protocols, no definitive multicenter trial with patient-centered outcomes has been completed. Recent work has highlighted physiologic predictors of successful weaning such as tidal volume, carbon dioxide clearance, and diaphragm function, as well as the challenges posed by ICU-acquired weakness, prolonged ECMO runs, and severe lung injury. Importantly, even patients requiring extended ECMO support can often be weaned successfully, and premature decisions about irreversibility should be avoided.

Summary: The optimal strategy for weaning V-V ECMO remains an area of clinical uncertainty. Protocolized approaches, careful physiologic monitoring, and patience may improve outcomes. Ongoing trials and future research will be critical in shaping evidence-based guidelines for liberation from ECMO support.

Purpose: One of the most common causes of intensive care unit admission in the immunocompromised population is acute respiratory failure. This population has many unique characteristics that render their respiratory failure risk factors, etiologies, and management different from the general nonimmunocompromised population. While mortality rates have improved in the setting of invasive mechanical ventilation, it remains higher than the general population, making prevention of intubation a key area of interest.

Recent findings: Acute respiratory failure in immunocompromised patients is common, complex, and associated with a high case-fatality rate. Ventilatory strategies should be tailored to the clinical context and to the prognosis of the underlying condition. In eligible patients, early ICU admission, a thorough work up to identify the etiology and invasive mechanical ventilation should not be delayed once criteria for intubation are met, despite attempts at noninvasive oxygenation. Future research should aim move beyond a binary definition of immunosuppression and account for its complexities to identify sub-phenotypes most likely to benefit from specific therapeutic strategies, thereby advancing the personalization of care.

Summary: This review explores the literature on noninvasive respiratory support, invasive mechanical ventilation, and extracorporeal life support and the unique considerations in the immunocompromised population.

Purpose of review: Helmet noninvasive ventilation (NIV) has gained attention for the management of hypoxemic patients, owing to physiological and potential clinical benefits. We summarize the recent advances on the topic.

Recent findings: Compared to facemasks, helmets facilitate application of higher positive end-expiratory pressure (PEEP) for prolonged treatments: this improves oxygenation and may mitigate injurious inflation patterns related to lung heterogeneity. The large, highly compliant interface reduces ventilator triggering performance, causing pressure support to be partially out of phase with patient's inspiratory effort; however, it allows patients to breathe from the internal air reservoir, resulting in formally asynchronous breaths that may help attenuate surges in lung stress and tidal volume without causing flow starvation. Through physiological monitoring, ventilator settings can be individualized to modulate inspiratory effort while limiting increases in dynamic transpulmonary driving pressure and tidal volume.

Summary: Helmet NIV may offer a valuable strategy for noninvasive management of hypoxemic patients, particularly when applied early, for prolonged periods, and with settings aimed at minimizing injurious inflation in moderate-to-severe (PaO 2 /FiO 2 < 200 mmHg) cases. Interface peculiarities affecting patient-ventilator interaction may constitute key differences with facemask NIV for prevention of injurious inflation patterns. Ongoing trials will clarify whether these physiological advantages improve clinical outcomes.

Purpose of review: Mechanical ventilation is life-saving, but is increasingly recognized to be involved in adverse neurological outcomes. Ventilator-associated brain injury (VABI) refers to primary brain dysfunction directly attributable to mechanical ventilation, independent of sedation, hypoxemia, or sepsis. This review summarizes current evidence on the pathophysiology, clinical impact, monitoring strategies, and potential therapeutic interventions for VABI.

Recent findings: A growing number of preclinical and clinical studies suggest that mechanical ventilation contributes to hippocampal apoptosis, maladaptive vagal and purinergic signaling, neuroinflammation, blood-brain barrier disruption, altered CO 2 regulation, and nasal airflow abolition. Clinically, VABI may manifest as delirium, disordered sleep, prolonged weaning, and long-term cognitive impairment. Monitoring tools such as electroencephalography, near-infrared spectroscopy, cerebral biomarkers, Doppler ultrasound, and MRI offer complementary but indirect insights. As of today, preventive and therapeutic strategies focus on lung-protective ventilation, limited sedation, early mobilization, and good quality sleep promotion. Some innovative approaches such restoration of nasal airflow, phrenic and vagal stimulation remain experimental.

Summary: VABI is increasingly recognized as a critical research frontier in critical care medicine. Awareness of its mechanisms and clinical impact should prompt ICU clinicians to integrate brain-oriented practices into routine care. Future trials are needed to evaluate preventive strategies and improve long-term cognitive and functional outcomes for ICU survivors.

Purpose of review: In recent years, respiratory muscle training and neurostimulation have emerged as strategies to prevent or reverse respiratory muscle weakness. This review evaluates the latest evidence for respiratory muscle training and neurostimulation as targeted interventions.

Recent findings: Inspiratory muscle training (IMT) improves physiological parameters including maximal inspiratory and expiratory pressures, peak expiratory flow, and diaphragm thickness, though clinical trials have not consistently shown benefits in weaning success, ventilator duration, or survival. Evidence for expiratory muscle training (EMT) in ICU patients is scarce, but combined IMT and EMT may improve outcomes. Neurostimulation of the diaphragm and expiratory muscles has advanced from feasibility to early clinical trials. Diaphragm neurostimulation has been demonstrated to improve diaphragm strength and weaning success. Preliminary experimental evidence suggests that diaphragm neurostimulation may also influence lung mechanics, haemodynamics, and brain function.

Summary: Respiratory muscle training and neurostimulation may attenuate critical illness-associated respiratory muscle weakness. While IMT improves physiological parameters, consistent clinical benefits have not yet been demonstrated. Neurostimulation represents a promising intervention, but further research is required to establish its impact on clinically relevant outcomes and to exclude potential harms when applied in the early phase of critical illness.