Resp Care
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Asthma is an important health care problem; over 12 million people in the United States suffer from asthma, the majority of whom are young patients. Presentations of acute asthma to emergency departments are common. In the United States, acute asthma presentations account for close to 2 million emergency department visits annually, and these patients often exhibit acute and chronic markers of severe asthma; so controlling asthma is important from many perspectives. ⋯ Linking a discharge plan to close follow-up and asthma education (especially an action plan) needs to be encouraged. Acute asthma is a common problem and treatment has improved dramatically over the past 10 years. Employing the evidence-based practice outlined above should reduce the burden of acute asthma on patients and the health care system.
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Mechanical ventilation incurs substantial morbidity, mortality, and costs. Both premature extubation and delayed extubation can cause harm. Therefore, weaning that is both expeditious and safe is highly desirable. ⋯ We did not uncover any consistently powerful weaning predictors, suggesting that formal use of predictors in patients being considered for reduction or discontinuation of mechanical support is unlikely to improve patient care. The likely explanation is that clinicians already fully consider information from weaning predictors in choosing patients for trials of reduction or discontinuation of mechanical ventilation. Finally, implementation of respiratory therapist- or nurse-driven protocols may be useful for all phases of weaning, and clinicians should adopt daily assessment for a trial of unassisted breathing as a safe method to reduce the duration of mechanical ventilation.
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We provide an evidence-based approach to managing patients with acute lung injury and acute respiratory distress syndrome (ARDS). We searched MEDLINE and the Cumulative Index to Nursing and Allied Health for randomized trials evaluating lung-protective ventilation strategies, inhaled nitric oxide, prone positioning, and late-phase corticosteroids for managing these patients, and for additional literature related to long-term follow-up of ARDS survivors. The results of our review suggest that pressure- and volume-limited ventilation, according to the ARDS Network protocol, can reduce mortality for patients with acute lung injury, and so may an "open lung" approach to mechanical ventilation. ⋯ The role of corticosteroids in the late phase of ARDS is unclear and remains a very important unanswered question. With respect to long-term follow-up, we found that pulmonary dysfunction is probably not a major source of morbidity for ARDS survivors, whereas neuropsychological dysfunction is prominent. Ongoing research may suggest interventions to improve the outcome of ARDS and of critical illness in general.
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The increased polarity of evidenced-based medicine has changed the approach to evaluation of medical interventions and treatments, either placing them on firm scientific foundations or suggesting that evidence is inadequate to strongly support current or innovative practices. Airway management devices and techniques are essential and common components of clinical care. It is the purpose of this review to identify the levels of evidence that support common and novel techniques in airway management. ⋯ Substantial evidence supports the use of noninvasive ventilation, subglottic endotracheal tube secretion removal, changing ventilator circuits no more frequently than every 7 days, and the use of selective digestive decontamination with systemic antibiotics to reduce the incidence of ventilator-associated pneumonia. Little evidence supports using other measures such as elevating the head of the bed to 30% (but this costs nothing and is intrinsically attractive), use of heat and moisture exchangers, kinetic bed therapy, early tracheotomy, or lung secretion removal techniques to reduce ventilator-associated pneumonia. Percutaneous tracheotomy currently can only be recommended over open surgical tracheotomy based on cost, convenience and late stomal complications; it may be associated with a slightly higher morbidity and mortality.