Critical care clinics
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Maintenance of the patient-ventilator system is the primary role of the respiratory care practitioner in the intensive care unit. Patient-ventilator system checks should include monitoring the patient's response to ventilation, evaluating function of the ventilator, maintaining ventilator settings according to physician orders, setting appropriate alarms, maintaining the integrity of the ventilator circuit and humidifier, and documenting all of the above. The concept of ventilator checks should be expanded and thus, the name changed to patient-ventilator system check to emphasize the importance of evaluating the patient. This article reviews the rationale for performing patient-ventilator system checks and measurements.
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Emphasis is on the mechanical properties of the spontaneously breathing patient. The occasional reference to mechanically ventilated patients is used to clarify and provide additional insight to the topic of spontaneously breathing individuals. Reference to the basic principles of mechanics are to establish the foundation for an integrated description of lung mechanics. Finally, a brief review of the "state of the art" respiratory monitoring parameters shown to have direct clinical applications.
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When to intervene and control the airway is the critical decision the physician must make. The technical expertise and confidence of each physician determine the particular airway modality chosen. The medications used depend on each clinical setting and can significantly impact the outcome of airway management. To control the airway and breathing and move on to circulation requires a broad knowledge of alternative airway management techniques and the challenging task of placing each into the appropriate clinical setting.
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Understanding the various delivery systems of the most commonly used therapies in the critical care setting will help avoid iatrogenic problems and enhance ability to deliver effective goal-oriented critical care. Rational use of oxygen is a result of understanding the goals, complications, and risks of oxygen therapy.
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Even routine airway management requires specific skills that are best acquired in a controlled setting, before "trial by fire" in an emergency situation. Furthermore, recognition of a potential difficult airway and appropriate preparation prior to initiating airway intervention are critical steps in avoiding airway catastrophes in the intensive care or emergency setting. Familiarity with a difficult airway algorithm and various alternate techniques for endotracheal intubation is a mandatory requirement for all practitioners involved in airway management, and should be incorporated in critical care curricula. ⋯ In general, "less is more" in the intensive care unit, and techniques that preserve spontaneous ventilation during airway interventions are desirable, particularly in patients with anticipated difficult airways. All intubating sites should have a portable storage unit for equipment for managing difficult airways readily available. Correct ETT placement always should be verified by detection of exhaled CO2, and by chest radiography if prolonged intubation is planned.