Chest
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To evaluate the frequency with which advance directives (ADs) are available at the time of admission and their impact on subsequent care in a medical intensive care unit (MICU) setting before and 9 months after the implementation of the Patient Self-Determination Act (PSDA). ⋯ Advanced directives were infrequently available and had little impact on the pattern of care.
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Diaphragmatic flutter is a rarely reported disorder in which the diaphragm involuntarily contracts at a rapid rate. We report a unique case in which diaphragmatic flutter was associated with inspiratory stridor and was severely disabling. A new approach to the treatment of this condition, phrenic nerve crush, provided an optimal outcome, with resolution of symptoms and the return of normal diaphragmatic function. Pathophysiology and treatment of this condition are discussed.
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Randomized Controlled Trial Comparative Study Clinical Trial
Noninvasive pressure support ventilation in patients with acute respiratory failure. A randomized comparison with conventional therapy.
The benefit of noninvasive pressure support ventilation (NIPSV) in avoiding the need for endotracheal intubation and reducing morbidity and mortality associated with endotracheal intubation was evaluated in 41 patients who presented with acute respiratory failure not related to chronic obstructive pulmonary disease (COPD). Patients were randomly assigned to receive conventional therapy (n = 20) or conventional therapy plus NIPSV (n = 21). NIPSV was delivered to the patient by a face mask connected to a ventilator (Puritan-Bennett 7200a) set in inspiratory pressure support (IPS) mode. ⋯ Post hoc analysis suggested that in patients with PaCO2 > 45 mm Hg (n = 17), NIPSV was associated with a reduction in the rate of endotracheal intubation (36 vs 100%, p = 0.02), in the length of ICU stay (13 +/- 15 days vs 32 +/- 30 days, p = 0.04), and in the mortality rate (9 vs 66%, p = 0.06). We conclude that NIPSV is of no benefit when used systematically in all forms of acute respiratory failure not related to COPD. A subgroup of patients, characterized by acute ventilatory failure and hypercapnia, may potentially benefit from this therapy and further studies are needed to focus on this aspect.
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To examine the effects of diaphragmatic plication on respiratory mechanics during spontaneous breathing, we grouped 28 dogs into left phrenicotomy and plication (group L, n = 11), bilateral phrenicotomy and plication (group B, n = 9), and sham operations (group C, n = 8). In groups L and B, phrenicotomy caused significant (p < 0.05) decreases in tidal volume (VT), transdiaphragmatic pressure (delta Pdi), the ratio of gastric to esophageal pressure (delta Pga/delta Pes) and dynamic lung compliance (Cdyn), and significant (p < 0.05) increases in esophageal pressure (delta Pes), and the work of breathing (WOB) per liter of ventilation. ⋯ In eight left-phrenicotomized open-chest dogs, transdiaphragmatic pressure (Pdi) and fractional shortening (FS) of right hemidiaphragm by right phrenic nerve stimulation increased significantly (p < 0.05) after plication, compared with the phrenicotomy condition, suggesting more effective kinetics of the right hemidiaphragm after plication of the left hemidiaphragm. Our results showed that diaphragmatic plication for unilateral paralysis is more effective than for bilateral paralysis, indicating that an improvement in kinetics of the intact hemidiaphragm plays an important role in functional recovery.