Severe respiratory failure: advanced treatment options.

BACKGROUND: Severe respiratory failure (including acute lung injury and acute respiratory distress syndrome) continues to be associated with significant mortality and morbidity in patients of all ages.

OBJECTIVE: To review the laboratory and clinical data in support of and future directions for the advanced treatment of severe respiratory failure.

DATA SOURCES: MEDLINE/PubMed search of all relevant primary and review articles.

DATA SYNTHESIS: Our understanding of lung pathophysiology and the role of ventilator-induced lung injury through basic science investigation has led to advances in lung protective strategies for the mechanical ventilation support of patients with severe respiratory failure. Specific modalities reviewed include low-tidal volume ventilation, permissive hypercapnia, the open lung approach, recruitment maneuvers, airway pressure release ventilation, high-frequency oscillatory ventilation, prone positioning, and extracorporeal life support. The pharmacologic strategies (including corticosteroids, surfactant, and nitric oxide) investigated for the treatment of severe respiratory failure are also reviewed.

CONCLUSION: In patients with severe respiratory failure, an incremental approach to the management of severe hypoxemia requires implementation of the strategies reviewed, with knowledge of the evidence base to support these strategies.