Resp Care
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Ventilator-associated pneumonia (VAP) is a pervasive and expensive nosocomial infection that is largely related to instrumentation of the airway with an endotracheal tube (ETT), followed by microaspiration of contaminated secretions. VAP prevention will probably be most effective via a multifaceted approach, which includes meticulous attention to basic infection-control methods during patient care, proper patient positioning, oral hygiene, and removal of the ETT as soon as indicated. ⋯ Most importantly, cost-effectiveness data are lacking for modified ETTs designed to prevent VAP. It is critical that future studies of ETTs designed to prevent VAP be adequately powered to demonstrate efficacy on important patient outcomes and safety, in addition to cost-effectiveness.
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Emergency airway management is associated with a high complication rate. Evaluating the patient prior to airway management is important to identify patients with increased risk of failed airways. Pre-oxygenation of critically ill patients is less effective in comparison to less sick patients. ⋯ Supervision of emergency airway management by attending physicians significantly decreases complications. Standardized algorithms may increase the success of emergency intubation. Attention should be paid to cardiopulmonary stability in the immediate post-intubation period.
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To determine the impact of the 2005 American Heart Association cardiopulmonary resuscitation (CPR) guidelines, including use of an impedance threshold device (ITD), on survival after in-hospital cardiac arrest. ⋯ Implementation of improved ways to increase circulation during CPR increased the in-hospital discharge rate by 60%, compared to historical controls in 2 community hospitals. These data demonstrate that immediate care with improved means to circulate blood during CPR significantly reduces hospital mortality from inhospital sudden cardiac arrest.
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Tracheostomy tubes are placed for a variety of reasons, including failure to wean from mechanical ventilation, inability to protect the airway due to impaired mental status, inability to manage excessive secretions, and upper-airway obstruction. A tracheostomy tube is required in approximately 10% of patients receiving mechanical ventilation and allows the patient to move to a step-down unit or long-term care hospital. The presence of a tracheostomy tube in the trachea can cause complications, including tracheal stenosis, bleeding, infection, aspiration pneumonia, and fistula formation from the trachea to either the esophagus or the innominate artery. Final removal of the tracheostomy tube is an important step in the recovery from chronic critical illness and can usually be done once the indication for the tube placement has resolved.