Critical care clinics
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Pulmonary arterial hypertension is common in patients with SSc. Fig. 1 shows the diagnostic and therapeutic approach to PAH in SSc. Doppler echocardiography may suggest the diagnosis, but RHC is necessary to confirm PAH and to measure vasoreactivity. ⋯ Esophageal dysmotility is often associated with aspiration, leading to pulmonary fibrosis, pneumonia, or ARDS. Diffuse bowel involvement may result in pseudo-obstruction, bacterial overgrowth, or malabsorption. Prokinetic agents, antibiotics, and parenteral nutrition may be required.
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The intensivist should be aware of the upper airway manifestations of the common rheumatologic disorders which may lead to ICU admission or which may potentially pose a problem during airway management. Information should be obtained from the patient, the patient's family, and the patient's primary physician, if possible. One should be fully prepared with various options in case a problem arises with an airway. ⋯ One should make a concentrated and serious effort to be as gentle as possible and to avoid even minimal trauma to the mucosa in these patients, because they are at risk for mucosal edema and subsequent postextubation stridor. In cases of stridor, helium-oxygen mixtures may be of help and may eliminate the need for reintubation. When difficulty in establishing an airway is anticipated, it is prudent to attempt airway control in the operating room with surgical assistance standing by should cervical tracheotomy is required.
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Rheumatoid arthritis (RA) is a systemic, debilitating disease characterized by chronic polyarticular inflammation that leads to erosion of joint and bones and to significant extra-articular, systemic, and cardiopulmonary manifestations. RA affects the patient's psychologic and social well-being as well as physical activity. ⋯ This article discusses the basic pathophysiology and clinical manifestations of RA and the extra-articular disorders that bring these patients to an ICU. The management of these patients in ICU is discussed, with emphasis on airway management and outcome.