To revise the current nonpharmacologic methods used in the care of patients undergoing lung volume reduction surgery (LVRS).

RECENT FINDINGS: A recent report of the unquestionable palliative role of LVRS awakened a renewed interest in the procedure as a valid treatment alternative in selected patients with severe emphysema.

SUMMARY: A detailed description of the foundations of the approach to patients undergoing LVRS is described to provide guidance for daily practice.

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Interactions between the heart and lungs are magnified in patients undergoing mechanical ventilation and the consequences of these interactions always need to be considered when managing ventilated patients. In patients with normal lungs and normal cardiovascular function monitoring needs are minimal, but when oxygenation and cardiac function are compromised careful assessment of the consequences of changes in ventilator settings needs to be considered to ensure that adequate oxygen delivery is maintained.

RECENT FINDINGS: Primary determinants of heart-lung interactions are first reviewed and then approaches to the use of simple hemodynamic measurements such as respiratory variations in central venous and pulmonary artery occlusion, or arterial pressure are described for assessing oxygen delivery, volume responsiveness as well as indicators of ventilatory mechanics.

SUMMARY: Use of simple measurements available during routine monitoring can be very helpful to the informed clinician for optimizing hemodynamic performance as well as patient ventilator interactions.

Despite improvements in outcome due to lung protective ventilation strategies using low tidal volumes, the mortality rate from acute respiratory distress syndrome (ARDS) remains unacceptably high, ranging from 34 to 64%. The predominant cause of death in ARDS is not severe hypoxemia, which is one of the defining criteria of ARDS, but multiple organ failure (MOF).

RECENT FINDINGS: In view of the relationship between ARDS and MOF, two different but complementary pathophysiological perspectives will be developed in this article: ARDS as a consequence of MOF, and ARDS as the cause of MOF. This framework may be useful in guiding the development of novel therapeutic strategies that ultimately improve the outcome of ARDS and sepsis patients.

SUMMARY: ARDS is a severe lung disease characterized by a very complex pathophysiology, involving not only the respiratory system but also nonpulmonary distal organs. Elucidation of the pathophysiological mechanisms bi-directionally linking MOF to ARDS appears to be a promising area of research that hopefully will lead to improved outcomes for these devastating conditions.

To describe a physiopathological-based approach to clinical management of severely hypoxemic patients that integrates the most recent findings on the use of rescue therapies.

RECENT FINDINGS: Several techniques are available to improve oxygenation in severely hypoxemic patients. Survival benefits have not been proved for most of these techniques. In a recent randomized trial, centralization of acute respiratory distress syndrome patients to a specialized center able to provide extracorporeal membrane oxygenation showed better survival as compared to conventional treatment. Randomized trials failed to prove survival benefits with the use of high levels of positive end-expiratory pressure (PEEP) or prone positioning. However, pooled data from two meta-analyses showed significant higher survival in the most severe patients both with the use of higher PEEP and prone positioning.

SUMMARY: Treatment of severely hypoxemic patients should aim to improve oxygenation while limiting ventilator-induced lung injury. A physiopathological approach that accounts for the underlying mechanisms of hypoxemia, and physiological and clinical effects of different treatments is likely the best guide we have to treat severely hypoxemic patients.