विवरण
The intensive care unit (ICU) management of interstitial lung disease (ILD) involves addressing respiratory distress, optimizing oxygenation, and treating underlying causes, such as infections or exacerbations. Mechanical ventilation strategies, including positive end-expiratory pressure (PEEP) and lung-protective ventilation, are employed, and meticulous attention is given to fluid balance and hemodynamic stability. Corticosteroids and immunosuppressive agents may be used for specific ILD types, and collaborative efforts between pulmonologists and intensivists are crucial for tailored care, monitoring complications, and achieving optimal outcomes in critically ill ILD patients.
सारांश
- Interstitial lung diseases (ILDs) are a diverse group causing lung scarring. Acute exacerbation of ILD, similar to COPD or asthma, leads to respiratory failure requiring ICU management. Etiologies can be known, like asbestos exposure, drug-induced, radiation-induced, or CTD-related, or unknown, like idiopathic pulmonary fibrosis (IPF), the most common type.
- Managing ILD in the ICU requires a multidisciplinary approach, encompassing meticulous physical examination, identification of exacerbating factors, and consideration of serological diagnosis based on patient presentation. Respiratory failure in ILD is primarily type 1, characterized by hypoxemia due to impaired gas exchange caused by thickening of alveolar membranes.
- Potential reversible causes of acute deterioration include pulmonary edema, pneumonia, aspiration, pulmonary hemorrhage, and pulmonary embolism. A suggested decision-making approach involves assessing baseline conditions, involving palliative care early, and considering high-flow nasal cannula (HFNC) for type 1 respiratory failure.
- Treatment strategies include targeted therapy for identifiable triggers, such as diuretics for pulmonary edema. For idiopathic acute exacerbation, particularly in IPF, options range from non-invasive ventilation for non-transplant candidates to invasive mechanical ventilation or hospice care. Lung transplant candidacy is also considered.
- Acute exacerbations necessitate ruling out secondary causes like heart failure, pulmonary embolism, or pneumothorax. Lung protective ventilation is advocated, mimicking ARDS protocols. Empiric antibiotics, considering opportunistic infections, are often administered. Bronchoscopy is also considered for directed therapy.
- The guidelines state that pulse therapies with corticosteroids haven't proved beneficial. Recommended doses of corticosteroids remain 1 to 2 mg per kg of body weight. The use of cyclophosphamide is no longer recommended due to increased mortality. Trials of plasma exchange are ongoing.
- In transplant candidates, the focus shifts to preventing critical illness myopathy and optimizing organ function. The "to intubate or not to intubate" decision should be made considering the type of ILD, etiology, general health status, and potential for acute exacerbating factors to resolve.
- While antifirotic medications are now prescribed for many lung conditions in their stable state, guidelines around if they should continue being taken in ICU patients or restarted in ICU are still not fully defined.
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