TY  - CHAP
M1  - Book, Section
TI  - Acute-on-Chronic Respiratory Failure
A1  - Douglas, Ivor S.
A2  - Hall, Jesse B.
A2  - Schmidt, Gregory A.
A2  - Kress, John P.
PY  - 2015
T2  - Principles of Critical Care, 4e
AB  - Acute-on-chronic  respiratory  failure  (ACRF)  occurs  when  often  minor,  although  commonly  multiple,  insults  cause  acute  deterioration  in  a  patient  with  chronic  respiratory  insufficiency.ACRF  is  usually  seen  in  patients  known  to  have  severe  chronic  obstructive  pulmonary  disease  (COPD),  but  occasionally  it  manifests  as  cryptic  respiratory  failure  or  postoperative  ventilator  dependence  in  a  patient  with  no  known  lung  disease.The  wide  variety  of  causes  of  ACRF  may  be  compartmentalized  into  causes  of  incremental  load,  diminished  neuromuscular  competence,  or  depressed  drive,  superimposed  on  a  limited  ventilatory  reserve.Intrinsic  positive  end-expiratory  pressure  (PEEPi)  is  a  central  contributor  to  the  excess  work  of  breathing  in  patients  with  ACRF.The  most  important  therapeutic  interventions  are  administration  of  oxygen,  bronchodilators,  corticosteroids,  and  noninvasive  positive-pressure  ventilation  (NIV).NIV  can  be  used  in  most  patients  to  avoid  intubation  and  has  been  shown  to  improve  survival.The  decision  to  intubate  a  patient  with  ACRF  benefits  from  clinical  judgment  and  a  bedside  presence.  Hypotension  and  severe  alkalemia  commonly  complicate  the  immediate  periintubation  course,  but  they  are  usually  avoidable.  However,  delaying  intubation  when  NIV  is  ineffective  may  worsen  outcomes.Ventilator  settings  should  mimic  the  patient’s  breathing  pattern,  with  a  modest  respiratory  rate  (eg,  20/min)  and  small  tidal  volume  (eg,  450  mL);  some  positive  end-expiratory  pressure  (eg,  5  cm  H2O)  should  be  added.Prevention  of  complications  such  as  gastrointestinal  hemorrhage,  venous  thrombosis,  and  nosocomial  infection  is  a  crucial  component  of  the  care  plan.The  key  to  liberating  the  patient  from  the  ventilator  is  to  increase  neuromuscular  competence  while  reducing  respiratory  system  load.In  selected  patients,  extubation  to  NIV  despite  failed  spontaneous  breathing  trials  reduces  ventilator  and  ICU  days  and  further  improves  survival.  
SN  - 
PB  - McGraw-Hill Education
CY  - New York, NY
Y2  - 2024/04/16
UR  - accesssurgery.mhmedical.com/content.aspx?aid=1107719081
ER  -