Too Little Oxygen: Ventilation, Prone Positioning, and Extracorporeal Membrane Oxygenation for Severe Hypoxemia

Abstract

Severe hypoxemia is associated with untoward outcomes in acute respiratory distress syndrome patients. Nevertheless, in and of itself, correction of hypoxemia is not an adequate surrogate outcome for mortality and clear evidence-based targets for correction of hypoxemia remain to be determined. At present, clinical management is directed toward achieving sufficient oxygenation while minimizing toxicity of ventilator-induced lung injury. The gold standard remains lung-protective mechanical ventilation, using lower-tidal volumes and pressure-limited ventilator titration. Notable progress in care includes further refinements in mechanical ventilation, consideration of salutatory effects of early prone positioning and neuromuscular blockade, and exploration of adjunctive extrapulmonary support with extracorporeal membrane oxygenation. This review focuses on three specific aspects: the evolving trend toward open lung ventilation, tempered by the recent cautionary experience with high-frequency oscillation ventilation; the evolution of prone positioning as a treatment for the most hypoxemic patients; and the continued future promise of extracorporeal support as a true rescue therapy.

Major abdominal surgery for Jehovah’s Witnesses: Challenge while practicing bloodless medicine in a middle income country

“…Although there is conflicting evidence, several surgical specialties have postoperative wound drainage systems that enable the autotransfusion of drained blood, minimizing any loss. 21 , 22 Hyperbaric and extracorporeal oxygen therapies are further treatments for patients who have suffered significant intraoperative blood loss, although these are not commonly used, 23 , 24 and we did not use any in our presented case.…”

Effect of postoperative oxygen therapy regimen modification on oxygenation in patients with acute type A aortic dissection

“…The use of higher oxygen inhalation concentrations is not conducive to the early weaning and extubation of patients; therefore, the ventilator settings should be lowered early.A nurse-led protocol for ventilator adjustment and patient extubation facilitates this process [ 17 ].In the current study, correction of hypoxemia did not significantly reduce patient mortality, however the gold standard for clinical management remains lung-protective ventilation strategy. Low tidal volumes, acceptable PEEP, FiO 2 restriction, and airway plateau pressure can achieve adequate oxygenation while reducing ventilator-induced lung injury [ 30 ].…”

Major abdominal surgery in Jehovah’s Witnesses

“…In certain surgical specialties, postoperative wound drainage systems have been designed to allow the autotransfusion of drained blood, minimising any loss, although the evidence for this is contradictory. 22,33 Other techniques for patients who have experienced severe intraoperative blood loss include hyperbaric 23 and extracorporeal oxygen therapy 34 but these are not in widespread use.…”