Resp Care
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Practice Guideline
AARC Clinical Practice Guidelines. Endotracheal suctioning of mechanically ventilated patients with artificial airways 2010.
An electronic literature search for articles published between January 1990 and October 2009 was conducted by using MEDLINE, CINAHL, and Cochrane Library databases. The update of this clinical practice guideline is the result of reviewing a total of 114 clinical trials, 62 reviews and 6 meta-analyses on endotracheal suctioning. The following recommendations are made following the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria: (1) It is recommended that endotracheal suctioning should be performed only when secretions are present, and not routinely; (2) It is suggested that pre-oxygenation be considered if the patient has a clinically important reduction in oxygen saturation with suctioning; (3) Performing suctioning without disconnecting the patient from the ventilator is suggested; (4) Use of shallow suction is suggested instead of deep suction, based on evidence from infant and pediatric studies; (5) It is suggested that routine use of normal saline instillation prior to endotracheal suction should not be performed; (6) The use of closed suction is suggested for adults with high F(I)O2, or PEEP, or at risk for lung de-recruitment, and for neonates; (7) Endotracheal suctioning without disconnection (closed system) is suggested in neonates; (8) Avoidance of disconnection and use of lung recruitment maneuvers are suggested if suctioning-induced lung de-recruitment occurs in patients with ; (9) It is suggested that a suction catheter is used that occludes less than 50% the lumen of the endotracheal tube in children and adults, and less than 70% in infants; (10) It is suggested that the duration of the suctioning event be limited to less than 15 seconds.
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Case Reports
A case of pneumomediastinum in a patient with acute respiratory distress syndrome on pressure support ventilation.
During mechanical ventilation for acute respiratory distress syndrome, tidal volume (V(T)) must be reduced. Once switched to pressure-support ventilation, there is a risk that uncontrolled large V(T) may be delivered. A 63-year-old man with community-acquired pneumonia required tracheal intubation and mechanical ventilation, with a V(T) of 6 mL/kg predicted body weight, PEEP of 10 cm H2O, a respiratory rate of 30 breaths/min, and F(IO2) of 0.60. ⋯ V(T) received over the previous 3 days had averaged 14 mL/kg predicted body weight. The patient was put back onto volume-controlled mode, and 2 days later there were no air leaks. In pressure-support ventilation, V(T) must be closely monitored to ensure lung-protective mechanical ventilation.
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Randomized Controlled Trial Comparative Study
Comparison of settings used for high-frequency chest-wall compression in cystic fibrosis.
Cystic fibrosis (CF) patients commonly use a high-frequency chest-wall compression (HFCWC) device for airway clearance that generates oscillatory flow with a sine-wave configuration. Typical HFCWC settings combine a lower Vest inflation pressure setting (eg, 5 on the Vest's arbitrary 1-10 scale for the setting that controls the background pressure of the inflatable vest) with mid-range frequency (14-16 Hz) (lower-pressure/mid-frequency HFCWC). ⋯ In adult CF patients, single-session higher-pressure/variable-frequency HFCWC resulted in greater sputum expectoration by wet weight, but not other differences, compared to the commonly used lower-pressure/mid-frequency settings. Longer-term comparisons are needed in a larger, more diverse population to determine whether sustained use of the higher-pressure/variable-frequency settings results in clinically important differences in outcomes.
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Though people are generally averse to change, change and innovation are critically important in respiratory care to maintain scientific and clinical progress. This paper reviews the issue of change in respiratory care. I summarize several available models of organizational and personal change (ie, those of Kotter and of Silversin and Kornacki, and the Intentional Change Theory of Boyatzis), review the characteristics of change-avid respiratory therapy departments, offer an example of a change effort in respiratory care (implementation of respiratory care protocols) and then analyze this change effort as it took place at one institution, the Cleveland Clinic, using these models. ⋯ Further analysis of features of change-avid respiratory therapy departments indicates 11 highly desired features, of which four that especially characterize change-avid departments include: having an up-to-date leadership team; employee involvement in change; celebrating wins; and an overall sense of progressiveness in the department. This analysis suggests that understanding and embracing change is important. To anchor change in our profession, greater attention should be given to developing a pipeline of respiratory care clinicians who, by virtue of their advanced training, have the skills to innovate in respiratory care in various ways.
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Deaths and injuries related to accidental ventilator disconnection occur in complex ways. A death related to accidental ventilator disconnection is presented from a subacute ventilator facility, and corrective action is discussed. Single-limb ventilators are now equipped with a flow-bypass coupling that prevents patient-side occlusion during disconnect and therefore prevents low-pressure alarm malfunction. Physicians and respiratory therapists can consider this device to prevent partial or total occlusion of the ventilator tracheostomy adapter, thus allowing a low-pressure alarm in the event of a disconnect.