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Reçu le 4 avril 2015 ; accepté le 2 juin 2015 © SRLF et Lavoisier SAS 2015 Résumé Les comorbidités (bronchopneumopathie chronique obstructive, hypertension artérielle, diabète, coronaropathie et insuffisance cardiaque) plus fréquentes chez les patients obè-ses, les changements physiologiques respiratoires comme la baisse de la compliance du système respiratoire, les atelectasies et l'hypoxémie liées à la diminution de CRF et la limitation de débit expiratoire, ainsi qu'une dysfonction diaphragmatique, contribuent aux difficultés et échecs de sevrage et d'extubation des patients obèses. La position demi-assise ou assise est un prérequis indispensable au sevrage de ces patients. Des explorations fonctionnelles respiratoires réali-sées au lit du patient peuvent aider à la gestion du sevrage : capacité vitale et pression inspiratoire maximale pour juger de la sevrabilité ; en cas de sevrage difficile, on prend les mêmes paramètres et la pression expiratoire maximale comme prére-quis avant d'envisager une extubation. Le mode AI-PEP est privilégié dans les sevrages difficiles. En raison de la triade atélectasie/shunt pulmonaire/hypoxémie et de la nécessité de contrebalancer une PEP intrinsèque, le sevrage de la PEP ne pourra être que progressif. L'utilisation de la VNI prophylactique chez ces sujets diminue les échecs d'extubation et peut être recommandée. Un impact sur la survie est observé chez certains obèses hypercapniques et la VNI prophylactique, pendant 48 h après l'extubation, devrait être systématique dans cette situation. Mots clés Obésité · Physiopathologie · Réanimation · Sevrage · Ventilation non invasiveAbstract Comorbidities (chronic obstructive pulmonary disease, hypertension, diabetes, coronary artery disease and heart failure) more frequent in obese patients, respiratory physiological changes such as decreased compliance of the respiratory system, atelectasis and hypoxemia related to decreased functional residual capacity and limitation of expiratory flow, and diaphragmatic dysfunction, contribute to difficulties or failures of weaning and extubation in obese patients. The half-sitting or sitting position is a necessary prerequisite for the weaning of these patients. Some pulmonary function tests performed at the bedside can help in the management of weaning: vital capacity and maximum inspiratory pressure to assess the readiness to wean. In difficult weaning, the same parameters and maximum expiratory pressure are suggested as a prerequisite before considering extubation. The PS-PEEP mode is preferred in difficult weaning. Because of the triad atelectasis / pulmonary shunt / hypoxemia and the need to counterbalance intrinsic PEEP, PEEP withdrawal will be gradual. The use of prophylactic NIV in these patients reduces extubation failure and may be recommended. An impact on survival is observed in some hypercapnic obese patients, and prophylactic NIV for 48 hours after extubation should be systematic in this situation.
Reçu le 4 avril 2015 ; accepté le 2 juin 2015 © SRLF et Lavoisier SAS 2015 Résumé Les comorbidités (bronchopneumopathie chronique obstructive, hypertension artérielle, diabète, coronaropathie et insuffisance cardiaque) plus fréquentes chez les patients obè-ses, les changements physiologiques respiratoires comme la baisse de la compliance du système respiratoire, les atelectasies et l'hypoxémie liées à la diminution de CRF et la limitation de débit expiratoire, ainsi qu'une dysfonction diaphragmatique, contribuent aux difficultés et échecs de sevrage et d'extubation des patients obèses. La position demi-assise ou assise est un prérequis indispensable au sevrage de ces patients. Des explorations fonctionnelles respiratoires réali-sées au lit du patient peuvent aider à la gestion du sevrage : capacité vitale et pression inspiratoire maximale pour juger de la sevrabilité ; en cas de sevrage difficile, on prend les mêmes paramètres et la pression expiratoire maximale comme prére-quis avant d'envisager une extubation. Le mode AI-PEP est privilégié dans les sevrages difficiles. En raison de la triade atélectasie/shunt pulmonaire/hypoxémie et de la nécessité de contrebalancer une PEP intrinsèque, le sevrage de la PEP ne pourra être que progressif. L'utilisation de la VNI prophylactique chez ces sujets diminue les échecs d'extubation et peut être recommandée. Un impact sur la survie est observé chez certains obèses hypercapniques et la VNI prophylactique, pendant 48 h après l'extubation, devrait être systématique dans cette situation. Mots clés Obésité · Physiopathologie · Réanimation · Sevrage · Ventilation non invasiveAbstract Comorbidities (chronic obstructive pulmonary disease, hypertension, diabetes, coronary artery disease and heart failure) more frequent in obese patients, respiratory physiological changes such as decreased compliance of the respiratory system, atelectasis and hypoxemia related to decreased functional residual capacity and limitation of expiratory flow, and diaphragmatic dysfunction, contribute to difficulties or failures of weaning and extubation in obese patients. The half-sitting or sitting position is a necessary prerequisite for the weaning of these patients. Some pulmonary function tests performed at the bedside can help in the management of weaning: vital capacity and maximum inspiratory pressure to assess the readiness to wean. In difficult weaning, the same parameters and maximum expiratory pressure are suggested as a prerequisite before considering extubation. The PS-PEEP mode is preferred in difficult weaning. Because of the triad atelectasis / pulmonary shunt / hypoxemia and the need to counterbalance intrinsic PEEP, PEEP withdrawal will be gradual. The use of prophylactic NIV in these patients reduces extubation failure and may be recommended. An impact on survival is observed in some hypercapnic obese patients, and prophylactic NIV for 48 hours after extubation should be systematic in this situation.
Background The coronavirus (SARS-COV-2) pandemic has provoked the global healthcare industry by potentially affecting more than 20 14 million people across the globe, causing lasting damage to the lungs, notably pneumonia, ARDS (acute respiratory distress 15 syndrome), and sepsis with the rapid spread of infection. To aid the functioning of the lungs and to maintain the blood oxygen 16 saturation (SpO 2 ) in coronavirus patients, ventilator assistance is required. Materials and methods The main purpose of this article is to outline the need 17 for the introduction of a non-invasive negative pressure ventilator (NINPV) as a promising alternative to positive pressure 18 ventilator (PPV) by elucidating the cons of non-invasive ventilators in clinical conditions like ARDS. Another motive is to 19 profoundly diminish the rate of infection spread by the employment of oxygen helmets, instead of endotracheal intubation in 20 invasive positive pressure ventilator (IPPV) or non-invasive positive pressure ventilator (NIPPV) like face masks and high-flow 21 nasal cannula (HFNC). Result and conclusion The integration of oxygen helmet with NPV would result in a number of notable facets including the 22 degree of comfort delivered to patients who are exposed to various ventilator-induced lung injuries (VILI) in the forms of 23 atelectasis, barotrauma, etc. Likewise, preventing the aerosol-generating procedures (AGP) diminishes the rate of nosocomial 24 infections and providing a better environment to both the patients and the healthcare professionals.
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