Seminars in respiratory and critical care medicine
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Semin Respir Crit Care Med · Jun 2013
ReviewLung transplantation for cystic fibrosis and bronchiectasis.
Lung transplantation has become an excellent treatment option for patients with cystic fibrosis (CF) and bronchiectasis with very advanced lung disease. Despite the challenges that the CF patients present, survival is more favorable than that seen in patients with chronic obstructive pulmonary disease and pulmonary fibrosis. Although those CF and bronchiectasis patients with severe respiratory disease are often infected with organisms that display in vitro resistance to the commonly used antibiotics, they usually have successful outcomes with transplantation, which are reported to be the same as in those patients with less resistant bacteria. ⋯ Efforts to increase the donor pool, such as low tidal volume ventilation, are effective in allowing a greater percentage of offered organs to be accepted. Perhaps the most encouraging development, however, is that of ex vivo lung perfusion. This permits not only the ability to measure the function of the lungs, something of great value for lungs from donors with circulatory death (donation after cardiac death), but also the potential to introduce lung repair and convert a nonusable lung to one that can be safely used for transplantation.
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Semin Respir Crit Care Med · Jun 2013
ReviewThe role of surveillance bronchoscopy post-lung transplantation.
Surveillance bronchoscopies with transbronchial lung biopsies (TBBx) are often performed post-lung transplantation, but the clinical value and impact on outcomes remain controversial. Given the cost and risks associated with TBBx, some centers only perform bronchoscopy for specific clinical indications or events. Although the presence of specific histological features (especially acute cellular rejection or lymphocytic bronchiolitis) have been associated with higher risk of chronic lung allograft rejection, the routine use of mandated TBBx has not been shown to alter clinical outcomes. ⋯ Further, there are limited published data regarding the value of performing follow-up TBBx to ensure resolution of prior rejection events. On the other hand, putative benefits of TBBx include the ability to fine tune immune suppression and detect infection and large airway stenoses that may require more aggressive measures to minimize development of strictures and thereby prevent downstream post obstructive bronchiectasis. This review discusses the technique of TBBx, histological criteria for allograft rejection (acute and chronic), complications associated with TBBx (particularly pneumothoraces, hypoxemia, and bleeding), and putative benefits associated with mandated surveillance TBBx in this complex patient population.
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Semin Respir Crit Care Med · Apr 2013
Pediatric critical care perceptions on analgesia, sedation, and delirium.
Critically ill children suffer from pain and anxiety additionally in the face of severe organ dysfunction. The critical care environment challenges pediatric patients' emotional and developmental capabilities. Disease-focused therapy is a priority and usually requires separation of patient from family and completion of invasive procedures. ⋯ Recently, the diagnosis of pediatric delirium has been enhanced by the validation of bedside tools that encourage monitoring within the critical care setting. Though there are likely many similarities in delirium among adults and children, there is much to learn in regard to unique risk factors and outcomes for children. Perhaps, considering the neurodevelopmental and psychosocial capacities of a child, a creative approach to assess and control pain and anxiety, while optimizing disease-related therapies, may ultimately minimize the risk for the development of delirium or other long-term complications of critical illness.
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Semin Respir Crit Care Med · Apr 2013
ReviewA validated approach to evaluating psychometric properties of pain assessment tools for use in nonverbal critically ill adults.
A valid pain assessment is the foundation of adequate pain management. Pain assessment can be challenging, especially in adult intensive care unit (ICU) patients who are unable to self-report. In such situations, relying on observational assessment tools is an alternative strategy. ⋯ Each pain assessment tool was scored independently by two reviewers. Of the eight behavioral pain scales developed for use in adult ICU patients, the Behavioral Pain Scale (BPS) and the Critical-Care Pain Observation Tool (CPOT) are considered to be the most valid and reliable for this purpose, according to the available evidence. Behavioral pain scales may be viable alternatives to assessing pain in ICU patients who are unable to self-report, but only valid, reliable, and feasible scales should be used for this purpose.