Clinics in chest medicine
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Tracheostomy has become one of the most commonly performed procedures in the critically ill patient. Variations in technique and expertise have led to a wide range of reported procedural related morbidity and rarely mortality. ⋯ In such a setting, the risk-benefit ratio of prolonged translaryngeal intubation versus tracheostomy begins to weight heavily in favor of surgical tracheostomy. At exactly what point this occurs remains undefined, but certainly by the tenth day of intubation, if extubation is not imminent, arrangements should be made for surgical tracheostomy by a team experienced with the chosen technique.
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Sleep apnea is associated with several cardiovascular disease conditions. A causal relationship between sleep apnea and each of these diseases is likely, but remains to be proven. ⋯ The diagnosis of OSA always should be considered in patients with refractory heart failure, resistant hypertension, nocturnal cardiac ischemia, and nocturnal arrhythmias, especially in individuals with risk factors for sleep apnea (e.g., central obesity, age, and male gender). Treating sleep apnea may help to achieve better clinical control in these diseases and may improve long-term cardiovascular prognosis.
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Automatic positive airway pressure devices are the most technologically advanced positive airway pressure devices available for use in OSA. Although heterogeneous, they have in common the ability to detect and respond to changes in upper airway resistance. Data cannot necessarily be extrapolated from one device to another, and the field is rapidly advancing. ⋯ APAP also can be used in an attended setting to titrate an effective pressure for use in long-term conventional CPAP therapy, also with similar results to CPAP in many patients. APAP devices are more expensive than CPAP devices, but the cost may be outweighed if a group of patients who can be diagnosed, treated, or titrated safely in the unattended setting can be identified. Although diagnostic and therapeutic algorithms for APAP have been proposed, the best candidates for this modality must be defined better.
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Clinics in chest medicine · Jun 2003
ReviewBehavioral and pharmacologic therapy of obstructive sleep apnea.
Previous attempts at using pharmacologic agents in the treatment of OSA have been disappointing. Medroxyprogesterone has not been found to be useful in the treatment of OSA. Use of protriptyline is limited by frequent side effects, but its role in mild and REM-related OSA must be clarified. ⋯ A recent systematic review of drug treatments for OSA concluded that the current data do not support the use of any drug as an alternative to CPAP [92]. Of 56 studies identified, only 9 studies met methodologic criteria. Clearly, basic research and adequately powered clinical trials are needed to identify an effective medication for OSA.
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Clinics in chest medicine · Mar 2003
ReviewLocal and systemic thrombolytic therapy for acute venous thromboembolism.
Thrombolytic therapy unquestionably leads to more rapid and complete clot lysis with a significantly higher risk of bleeding when compared with anticoagulation. The most definite indication for thrombolytic therapy in patients with VTE is massive PE associated with hemodynamic instability. ⋯ Routine use of thrombolytic therapy in all other cases of PE and DVT cannot be justified. Future research using randomized controlled studies should focus on the following key questions: Do hemodynamically stable patients with PE and right ventricular dysfunction benefit from thrombolysis, and, if so, is there a subset of patients within this group who are most likely to benefit? Does thrombolytic therapy improve long-term outcomes of DVT with a favorable risk-to-benefit ratio, and, if so, which patients are most likely to benefit long-term? What is the precise role of catheter-directed thrombolysis in the treatment of VTE, particularly the use of a low-dose thrombolytic agent in conjunction with mechanical clot disruption to minimize bleeding in patients at high risk? Until these questions are answered, clinicians must approach decision-making regarding the use of thrombolytic therapy in PE and DVT with careful consideration of the potential risks and benefits for the patient within the framework of currently available data.