Prone Positioning for ARDS. still misunderstood and misused

Acute respiratory distress syndrome (ARDS) is a clinical syndrome characterized by a non-cardiogenic pulmonary edema with bilateral chest X-ray opacities and hypoxemia refractory to oxygen therapy and low level of positive end-expiratory pressure (1). Recently, a large observational study reported an ARDS prevalence of 10.4% of all ICU admissions and of 23.4% of all subjects receiving mechanical ventilation (2). Despite these alarming numbers, according to the most recent literature, ARDS is still under-recognized, undertreated, and associated with a mortality rate that in the most severe forms is close to 50% (2)

When pressure does not mean volume? Body mass index may account for the dissociation

Low tidal volume (VT 6 ml/predicted body weight) pressure limited (plateau pressure <30 cmH2O) protective ventilation as proposed by the ARDS Network was associated with an improvement in mortality and is considered the gold standard for acute respiratory distress syndrome (ARDS) ventilation strategies. Limiting plateau pressure minimizes ventilator-induced lung injury by reducing the trans-pulmonary pressure, which is the real alveolar distending pressure. However, in the presence of chest wall elastance impairment, as observed in obese patients, plateau pressure underestimates the trans-pulmonary pressure and derecrutiment at low distending pressure could occur. Moreover, low tidal volume to keep plateau pressure <30 cmH2O could be associated with large differences compared to measured total lung capacity. Quantitative bedside techniques that are able to measure lung volumes together with trans-pulmonary pressure could expand our chances to tailor mechanical ventilation in ARDS patients

Phosphorylation mechanisms in intensive care medicine

INTRODUCTION: The phosphorylation states of proteins, lipids, carbohydrates, amino acids, and nucleotides control the mechanisms behind nearly all cellular functions. Therefore, not surprisingly, recent findings have shown that alterations in these phosphorylation pathways play a central role in the development and progression of many disease states. This review provides a brief summary of the function and activity of various phosphorylation mechanisms, outlines some of the major phosphorylation signaling cascades, and describes the role of these phosphorylation mechanisms in intensive care medicine. METHODS: This article will comprise a comprehensive review of the literature in the context of intensive care medicine. Specifically, we will discuss the involvement of phosphorylation in the pathogenesis, diagnosis, and treatment of heart failure, myocardial infarction, stroke, respiratory failure, ventilation-induced lung injury, traumatic brain injury, acute organ failure, systemic sepsis, and shock. CONCLUSION: Phosphorylation mechanisms clearly play an important role in many pathologies and treatment strategies of intensive care and therefore further understanding of these mechanisms may lead to the development of novel therapies and improved patient care

Regulation of advance directives in Italy: a bad law in the making.

PURPOSE: The Advance Directives (ADs) have been adopted in many countries to defend patients' autonomy. In Italy, the role of ADs has recently been the subject of heated debate involving political parties and the Roman Catholic Church. In February 2009, the conservative government coalition presented a bill of law on this issue. It has been passed by the Low Chamber and is now being discussed in the Senate. The purpose of the article is to highlight any possible bill's contradiction with Italian Constitution, Italian Code of Medical Ethics (ICME), and Oviedo Convention contents, relevant for intensivists. METHODS: Analysis of bill's content in the light of Italian Constitution, ICME, Oviedo Convention articles and in comparison with French legislation regarding end of life (Leonetti law). RESULTS: In the Authors' point of view the bill's articles -limit the moral and judicial importance of four main issues as informed consent, permanent incapacity, artificial nutrition/hydration, and withdraw/withhold treatments. CONCLUSIONS: In the Authors' opinion the ADs must represent informed preferences made freely by patients within the relationship with their physicians, as part of an advance care planning. When this relationship develops in accordance with the ICME rules, it contains all of the ethical/professional dimensions to legitimate right choices in each case. The law should draw inspiration from ICME principles, assigning them a juridical power, acknowledging their validity in legitimating end-of-life decisions, and defining a framework of juridical legitimacy for these decisions without infringing on patients' right to autonomy with prescriptions on the care

Extracorporeal membrane oxygenation as &quot;bridge&quot; to lung transplantation: what remains in order to make it standard of care?

Since its introduction into clinical practice, lung transplantation (LTx) is gradually becoming a worldwide standard treatment for patients with a broad spectrum of end-stage respiratory diseases (1\u20133). From 1995 to 2010, more than 30,000 LTx have been performed, and it is worth noting that in recent years the number of LTx has been progressively increasing to more than 3,000/year in 2010, with a post-transplant graft half-life that went from 4.7 in the 1990s to 5.9 in the new millennium (4). However, the crude mortality rate of patients awaiting LTx is higher than mortality for other solid organs. Mortality rate in 2009 for patients on the waiting list for LTx was about 14.1% in North America (www.srtr.org) and 14.7% in Italy (www.airt.it). What are the reasons for these unacceptable mortality rates? First, patients have to wait for the graft longer than patients waiting for other organs because of the small number of lungs suitable for transplantation (5). Second is the lack of supportive therapies that are able to replace respiratory function when the primary pulmonary diseases evolve from \u201crespiratory insufficiency\u201d to \u201crespiratory failure,\u201d characterized by refractory hypoxemia and hypercapnia

Mechanical ventilation during acute lung injury: current recommendations and new concepts

Despite a very large body of investigations, no effective pharmacological therapies have been found to cure acute lung injury. Hence, supportive care with mechanical ventilation remains the cornerstone of treatment. However, several experimental and clinical studies showed that mechanical ventilation, especially at high tidal volumes and pressures, can cause or aggravate ALI. Therefore, current clinical recommendations are developed with the aim of avoiding ventilator-induced lung injury (VILI) by limiting tidal volume and distending ventilatory pressure according to the results of the ARDS Network trial, which has been to date the only intervention that has showed success in decreasing mortality in patients with ALI/ARDS. In the past decade, a very large body of investigations has determined significant achievements on the pathophysiological knowledge of VILI. Therefore, new perspectives, which will be reviewed in this article, have been defined in terms of the efficiency and efficacy of recognizing, monitoring and treating VILI, which will eventually lead to further significant improvement of outcome in patients with ARDS