American journal of respiratory and critical care medicine
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Am. J. Respir. Crit. Care Med. · Nov 2013
ReviewPatient Ventilator Interactions: Implications for Clinical Management.
Assisted/supported modes of mechanical ventilation offer significant advantages over controlled modes in terms of ventilator muscle function/recovery and patient comfort (and sedation needs). However, assisted/supported breaths must interact with patient demands during all three phases of breath delivery: trigger, target, and cycle. Synchronous interactions match ventilator support with patient demands; dyssynchronous interactions do not. ⋯ These include adjustments of the trigger variable, the use of pressure versus fixed flow targeted breaths, and a number of manipulations of the cycle variable. Clinicians need to know how to use these modalities and monitor them properly, especially understanding airway pressure and flow graphics. Future strategies are emerging that have theoretical appeal but they await good clinical outcome studies before they become commonplace.
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Am. J. Respir. Crit. Care Med. · Nov 2013
Cardiovascular Risk, Myocardial Injury and Exacerbations of Chronic Obstructive Pulmonary Disease.
Patients with chronic obstructive pulmonary disease (COPD) have elevated cardiovascular risk, and myocardial injury is common during severe exacerbations. Little is known about the prevalence, magnitude, and underlying mechanisms of cardiovascular risk in community-treated exacerbations. ⋯ Frequent COPD exacerbators have greater arterial stiffness than infrequent exacerbators. Arterial stiffness rises acutely during COPD exacerbations, particularly with airway infection. Increases in arterial stiffness are related to inflammation, and are slow to recover. Myocardial injury is common and clinically significant during COPD exacerbations, particularly in those with underlying ischemic heart disease.
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Am. J. Respir. Crit. Care Med. · Nov 2013
Antibiotics for Acute and Chronic Respiratory Infection in Patients with Chronic Obstructive Pulmonary Disease.
Prevention and effective treatment of exacerbations are major objectives in the management of patients with chronic obstructive pulmonary disease (COPD). Antibiotics are mainstay treatment for patients with severe COPD with an acute exacerbation that includes increased sputum purulence and worsening shortness of breath. Although such treatment is associated with clinical benefit, treatment failure and relapse rates may be high, particularly in cases of inadequate antibiotic therapy through incomplete resolution of the initial exacerbation and persistent bacterial infection. ⋯ These effects may be achieved by reducing bacterial load in the airways in stable state and/or bronchial inflammation. Although systemic antibiotics are likely to remain the core treatment for patients with moderate to severe exacerbated COPD, inhaled antibiotics may represent a more optimal approach for the treatment and prevention of COPD exacerbations in the future. Regardless of the route of administration, further studies are required to evaluate the potential long-term adverse events of antibiotics and the development of bacterial resistance.