Resp Care
-
This report explores the efficacy of existing therapies for acute lung injury (ALI) and acute respiratory distress syndrome (ARDS), primarily in terms of clinically important outcomes such as the duration of mechanical ventilation and hospital mortality. Of the 15 therapies reviewed, the strongest evidence suggests that ALI/ARDS should be managed with a low-tidal-volume, pressure-limited approach, with either low or moderately high positive end-expiratory pressure. ⋯ However, there is relatively strong evidence to support conservative fluid management and high-fat, anti-oxidant nutritional formulations. Although most pharmacologic ALI/ARDS therapies have been ineffective, high-dose methylprednisolone is indicated in the subgroups of ALI/ARDS patients who have pneumonia or are at risk of ARDS due to fat embolization.
-
Noninvasive positive-pressure ventilation (NPPV) is increasingly being used in the care of patients suffering acute respiratory failure. High-level evidence supports the use of NPPV to treat exacerbation of chronic obstructive pulmonary disease (COPD). NPPV has also been successfully used with selected patients suffering acute hypoxemic respiratory failure and to allow earlier extubation of mechanically ventilated COPD patients. ⋯ Any ventilator and ventilator mode can be used to apply NPPV, but portable pressure ventilators and pressure-support mode are most commonly used. Inhaled bronchodilators can be administered during NPPV, and NPPV can be delivered with helium-oxygen mixture. Institution-specific practice guidelines may be useful to improve NPPV success.
-
The principles of evidence-based medicine provide the tools to incorporate the best evidence into everyday practice. Evidence-based medicine is the integration of individual clinical expertise with the best available research evidence from systematic research and the patient's values and expectations. A hierarchy of evidence can be used to assess the strength of evidence upon which clinical decisions are made, with randomized studies at the top of the hierarchy. ⋯ High-level studies of a therapy are prospective, randomized, blinded, placebo-controlled, have a concealed allocation, have a parallel design, and assess patient-important outcomes. Metrics used to assess the evidence for a therapy include event rate, relative risk, relative risk reduction, absolute risk reduction, number needed to treat, and odds ratio. Although not all tenets of evidence-based medicine are universally accepted, the principles of evidence-based medicine nonetheless provide a valuable approach to respiratory care practice.