October - 2012
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Avoiding invasive mechanical ventilation by extracorporeal carbon dioxide removal in patients failing noninvasive ventilationStefan Kluge, Stephan A. Braune, Markus Engel, et al Intensive Care Med, 2012, 38:1632–1639 This page is only available to Crit-IQ subscribers. To view the rest of this review and gain access to our vast array of critical care teaching tools including podcasts, vodcasts, modules, exam preparation tools, teaching aids and much more, login here, or Become a Member to register |
October |
Previous Comments
| First of all this is NOT a clinical breakthrough but a technological advancement. This leads me to the next question and a philosophical one. What is going to be your patient selection in whom you will use this intervention? a) would you use it in COPD patients on home oxygen, knowing fully well the median survival time is 2 to 3 years in these patients. b) Would you use this intervention in patients who still smoke and have had numerous ICU admissions with intubations and ventilations in the past, and with limited exercise tolerance. c) would you extend the indications to those with severe neuromuscular probems with an acute respiratory infective process that worsens the pre existing type 2 resp failure d) How many times would you institute the intervention in the same patient for eg. if the patient is readmitted for a similar issue within 3 months? e) Would you never talk or discuss end of life issues and use this intervention as an easy cop out? Just a few thoughts. I would like to know what others think. While this intervention might feel like "manna from heaven" we must never lose sight of what good medicine is. Just because we have the technology doesnt mean we must abuse it. I have know young patients who have been put on ECMO for not very strong reasons only to find that the patient rapidly recovered and was weaned from ECMO the very next day. A total abuse of wonderful technology. I think we all get lost in this wonderful world of wanting to be "the first" or 'the best" and we lose total logic and common sense. I am sure there will be many heated responses to try and counter my response. At least i will have started a debate ! | |
| devil's advocate-23 Oct, 2012 10:26:12 PM | |
| I certainly agree with your sentiments, and you make your points very well. It certainly appears to me that we cannot continue to provide care with the same intensity as we previously have, and perhaps be more discerning. This is a major undertaking though, as it involves realigning the views of intensivists, general specialists, patients, families and advocate groups. I don't see that happening any time soon. As for this therapy in particular, I'm not sure it will change my practice overly. You're still dependent on a machine to make you breathe, so the same discussions with the patient and family are required. BTW, this has some crossover with the podcast with the medical ethicist (I've forgotten her name). | |
| Astrid-29 Oct, 2012 11:43:13 AM | |
| Stein's Law (paraphrased): "Things that can't go on forever, don't" | |
| Andrew Stapleton-30 Oct, 2012 10:56:15 AM | |
Comment
The theory behind this study is that the avoidance of invasive mechanical ventilation will prevent associated complications (VAP, VILI). Patients with COPD represent a high-risk group, with proven benefit from NIV to escape intubation. They extend the argument to the use of a type of ECMO...