Resp Care
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Advances in treating the critically ill have resulted in more patients requiring prolonged airway intubation and respiratory support. If intubation is projected to be longer than several weeks, tracheostomy is often recommended. Tracheostomy offers the potential benefits of improved patient comfort, the ability to communicate, opportunity for oral feeding, and easier, safer nursing care. ⋯ Based on the available data, we think it is reasonable to perform early tracheostomy in all patients projected to require prolonged mechanical ventilation. Unfortunately, identifying those patients can be difficult, and for many patient populations we lack the necessary tools to predict prolonged ventilation. We propose an early-tracheostomy decision algorithm.
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Review
Should prone positioning be routinely used for lung protection during mechanical ventilation?
Prone positioning has been known for decades to improve oxygenation in animals with acute lung injury and in most patients with acute respiratory distress syndrome (ARDS). The mechanisms of this improvement include a more uniform pleural-pressure gradient, a smaller volume of lung compressed by the heart, and more uniform and better-matched ventilation and perfusion. ⋯ However, several randomized trials have failed to show improvements in clinical outcomes of ARDS patients, other than consistently better oxygenation. Because each of these trials had design problems or early termination, prone positioning remains a rescue therapy for patients with acute lung injury or ARDS.
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The acute respiratory distress syndrome (ARDS) is characterized by intense inflammation and alveolar-capillary disruption that can progress to a state of unresolving inflammation and disordered fibrosis, referred to as fibroproliferative, late-stage, or persistent ARDS. These pathophysiologic features may be responsive to corticosteroids, but early high-dose, short-duration therapy was proven ineffective. More recently, several small and one moderate-size multicenter randomized controlled trial (RCT) investigated low-to-moderate-dose prolonged corticosteroid treatment. ⋯ Importantly, the aforementioned studies have methodological limitations, and the number of subjects enrolled was small. Experts differ in their recommendations regarding corticosteroids for late-stage ARDS, although one consensus group supported a "weak" recommendation of low-to-moderate-dose corticosteroids for ARDS of < 14 days duration. If corticosteroids are administered, infection surveillance, avoidance of neuromuscular blockers, and gradual taper of corticosteroids are recommended.
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For many years the greatest barrier to the diagnosis and treatment of obstructive sleep apnea (OSA) was recognizing the disease. That obstacle is now fading as more physicians of all types are aware of the high prevalence of OSA and the consequences of untreated OSA. Sleep-laboratory polysomnography has long been considered the accepted standard for OSA diagnosis and has become a lucrative practice. ⋯ Over the last 2 decades many scientific studies have supported a strong correlation between the findings from home polysomnography and sleep-laboratory polysomnography. However, limited data are available from good outcomes-oriented studies, so controversy surrounds home polysomnography in the diagnosis of OSA. We review the evidence and debate whether sleep studies are appropriately done in the home.