Current Opinion in Critical Care最新文献

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.

Purpose of review: P-SILI (patient self-inflicted lung injury) is a radically new idea based on the claim that patients taking larger tidal volumes (in response to respiratory stimuli) can cause alveolar injury. This review lays bare the lack of robust experimental data to establish the actual existence of P-SILI.

Recent findings: At the height of the COVID-19 pandemic, world-renowned investigators argued that P-SILI was responsible for much of the lung injury in COVID-19 and recommended radical alterations in ventilator management: avoidance of noninvasive ventilation, preemptive intubation, widespread use of neuromuscular blockers to decrease patient-generated tidal volume, and postponement of ventilator weaning. When debated to provide proof for the existence of P-SILI, proponents imparted sparse unconvincing rejoinders.

Summary: In a scientific debate, the party making a new claim carries the burden of proof, not the side defending the preexisting state of knowledge (analogous to a defendant's presumption of innocence until evidence is produced to the contrary). Claims for the existence of P-SILI are based on the shakiest of circumstantial evidence. Six decades of research on how to prudently select settings and remove/wean the ventilator at the earliest time were abrogated during a pandemic on the warrant of an unproven hypothetical entity.

Purpose of review: This review aims to provide an overview of lung morphology classification in acute respiratory distress syndrome (ARDS) and morphology-guided mechanical ventilation. It discusses the distinct morphological subphenotypes, focal and nonfocal, and how they affect the selection and effectiveness of ventilation strategies.

Recent findings: Computed tomography (CT) imaging has traditionally been used to differentiate ARDS morphologies, revealing that focal and nonfocal patterns respond differently to ventilation strategies such as positive end-expiratory pressure (PEEP) titration, recruitment maneuvers, and prone positioning. The Lung Imaging for Ventilator Setting (LIVE) trial highlighted the importance of correct morphology classification, showing that misclassification can obscure survival benefits from personalized ventilation. Lung ultrasound (LUS) has recently emerged as a viable, noninvasive tool for identifying morphological subtypes, with multiple classification methods demonstrating high accuracy. An ongoing trial is now evaluating LUS-based morphology classification to guide personalized mechanical ventilation.

Summary: Accurate assessment of lung morphology is critical for morphology-guided mechanical ventilation in ARDS. LUS represents a promising tool to implement morphology-guided strategies at the bedside, but further validation is needed to ensure clinical benefit.

Purpose of review: Substantial effort has been put into research and development to advance traumatic brain injury (TBI) care in tertiary care facilities, but the largest volume of TBI worldwide is unquestionably managed initially in the far-forward, austere environment with resource constraints.

Recent findings: Proper diagnosis of the underlying lesion in the absence of CT is a significant hurdle to providing targeted interventions in austere TBI, but adjunct diagnostic devices, such as quantitative pupillometry, near-infrared spectroscopy, optic nerve sheath ultrasound and trans cranial doppler ultrasound are allowing for enhanced diagnostic capability in the austere setting.

Summary: Treatment nihilism is present in cases of severe TBI even in highly resourced environments. It is likely that this is even more prevalent in far-forward, austere environments. There are diagnostic aids and interventions that are possible in austere severe TBI, and the critical care provider in this setting may be able to diagnose the underlying pathophysiology and render life-saving care until transport to a higher level of care is available.

Purpose of review: To review the role and clinical implications of omics-based approaches to advance the field of acute brain injury research.

Recent findings: Acute brain injury (ABI) comprises heterogeneous injury patterns and diseases for which there are not widespread targeted and disease-modifying therapeutics. Substantial advances in the outcomes of ABI patients have stagnated. Currently, supportive measures aimed at optimizing neural tissue oxygen delivery and metabolism form the cornerstones of ABI management. Recently, there has been increasing interest in focusing upon phenotyping various ABI to accelerate insights into disease mechanisms. In doing so, omics-based strategies have emerged as viable tools to accomplish both goals. The continuum encompassing genomics, transcriptomics, proteomics, and metabolomics provides innumerable opportunities to identify novel and key cellular pathways responsible for disease pathophysiology and reveal diagnostic biomarkers that can be used to identify disease severity or response to therapies. Such a nuanced approach is currently lacking in ABI clinical care but research within this paradigm could open avenues of personalized management schema.

Summary: ABI diseases lack widespread and generalized methods to rapidly phenotype injury severity and patterns of disease pathophysiology. Integration of multipronged omics-based strategies can accomplish both goals and may lead to personalized management strategies.

Purpose of review: This review examines recent literature on the pathogenesis, diagnosis, and management of acalculous cholecystitis (AAC), emphasizing evolving imaging, interventional techniques, and risk stratification. Although patients may present a clinical picture of inflammation of the gallbladder without radiographic evidence of calculi within the gallbladder, there is a select group of critically ill patients with unexplained sepsis that require special attention. A major distinction in etiology starts with possible obstructive vs. nonobstructive cholecystitis. Nonobstructive causes of cholecystitis, both from biliary stasis and ischemia, are important for the diagnosis and management of AAC.

Recent findings: Recent studies indicate a rising incidence of AAC, likely reflecting an aging population and longer ICU stays in critically ill patients. Diagnostic tools such as ultrasonography and computed tomography remain first-line, whereas hepatobiliary scintigraphy is reserved for indeterminate cases. Emerging trends focus on prevention, improving timely diagnosis, refining risk stratification, and expanding minimally invasive drainage options - including percutaneous and endoscopic approaches - for patients unfit for surgery. Early broad-spectrum antibiotics and preventive strategies are critical to improving outcomes.

Summary: AAC is a complex and heterogeneous disease with evolving diagnostic and therapeutic paradigms. Preventive strategies are likely to emerge as specific etiology becomes more apparent. Future research should refine predictive algorithms, clarify etiologic distinctions, and optimize interventional management to reduce morbidity in high-risk populations.

Purpose of review: Survivorship of severe acute brain injuries is increasing worldwide, with many of these injuries resulting in disorders of consciousness (DOC). We aim to review current challenges in achieving goal-concordant care for patients with DOC, while highlighting recent advancements to guide neurologic prognostication.

Recent findings: Prognostic uncertainty, cognitive biases among clinicians and surrogate decision-makers (SDM), and a paucity of nuanced neurologic assessments in many settings pose major barriers to accurate prognostication. Short observation times and large variations in the use of life-sustaining treatments limit diagnosis and evaluation of prognostic tools. Multimodal assessments enhance prognostic accuracy but are vastly underutilized. Innovative neurodiagnostic techniques and dynamic modeling are currently limited by availability and lack of rigorous validation. There is a growing understanding of the complex needs of SDM and factors that impact communication of prognosis, ultimately determining care decisions.

Summary: Prognostic science may improve with newer neurodiagnostic technologies, but thoughtful validation and implementation is needed to limit perpetuation of methodological biases. Attention to cognitive errors in shared decision-making and efforts to enhance prognosis communication may improve goal-concordant decisions. A sharpened focus on the experiences of SDM and understanding the dyadic SDM-patient longitudinal outcomes is needed to guide goal-concordant decisions.

Purpose of review: Traumatic brain injury (TBI) is a highly heterogeneous disease. Description of relevant phenotypes and endotypes could be essential for patient characterization, identification of pathobiological mechanisms, and development of tailored management.

Recent findings: A new approach to characterizing TBI patients has recently been proposed. It is based on a multidimensional framework (including clinical data, radiological findings, biomarkers, and modifiers) that could improve the scientific accuracy and the reproducibility of future phenotyping studies. TBI is a dynamic condition, and recent studies have shown that longitudinal data could provide additional insights into phenotypes and endotypes identification. Moreover, new studies have identified different phenotypes focusing on inflammation and coagulopathies which represent relevant mechanisms of secondary brain injury. Importantly, modern multiomics technologies have been used to explore TBI heterogeneity at the deepest level.

Summary: Strategies for identifying TBI phenotypes are rapidly evolving. They have the potential to provide an accurate characterization that could be helpful for tailored treatments. Further research is needed to translate phenotypes into clinical practice.

Purpose of review: Advances in critical care have improved survival rates after severe brain injuries, yet many patients experience prolonged disorders of consciousness, resulting in significant care burdens and ethical challenges. Therefore, a systematic review of current treatment strategies for these disorders following acute brain injury is essential to provide evidence-based guidance for clinicians, ultimately aiming to enhance patient prognosis and quality of life.

Recent findings: Research has rapidly evolved beyond traditional drugs like amantadine and zolpidem, with significant breakthroughs in neuromodulation techniques such as spinal cord stimulation, transcranial direct current stimulation, and brain-computer interfaces. These innovations are reshaping clinical practice by transitioning from theoretical concepts to validated interventions, enabling more precise, individualized treatment protocols. This shift moves clinical management from empirical medication toward targeted neural circuit modulation, while technologies detecting covert consciousness are helping redefine diagnostic standards. The differential effects of these interventions are also advancing fundamental research, deepening understanding of consciousness networks and shifting focus from single targets to whole brain dynamic regulation.

Summary: These developments collectively highlight the need for integrated multimodal assessment and multilevel interventions, pointing toward a future of personalized, precision medicine for arousal promotion that offers tangible hope for improving patient recovery outcomes and quality of life.

Purpose of review: Point-of-care ultrasound (POCUS) has transformed emergency medicine by providing a noninvasive, accessible, repeatable, efficient, and cost-effective imaging tool to the bedside. This article is a narrative review of the most impactful POCUS literature over the past 18 months, identifying and highlighting the most common emerging themes.

Recent findings: We identified five main themes in the recent POCUS literature: ultrasound-guided regional anesthesia, POCUS in resuscitation, diagnostic POCUS, technology and artificial intelligence, and POCUS governance and administration.

Summary: The recent body of literature strengthens the utility of POCUS in emergency medicine, demonstrating its efficacy, safety, and efficiency across multiple clinical scenarios. The literature continues to expand the scope of POCUS by covering new diagnostic applications and integrating emerging technologies, while continuing to build a robust governance framework. Future research should focus on patient-oriented outcomes, implications of POCUS protocolization and clinical application, and the impact of POCUS at hospital and healthcare systems levels.