Resp Care
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Case Reports
Portable pulse-dose oxygen concentrators should not be used with noninvasive ventilation.
An increasing number of patients, mainly COPD and overlap-syndrome patients, simultaneously use home oxygen therapy and noninvasive ventilation (NIV) at night. Usually the oxygen source is a stationary concentrator. We report a patient who, without a medical recommendation, was using a portable oxygen concentrator during nocturnal NIV. ⋯ We tested ventilator inspiratory pressures of 10, 14, and 18 cm H(2)O, and expiratory pressures of 4 and 6 cm H(2)O. The portable oxygen concentrator did not detect the patient's inspiratory effort or deliver the required oxygen flow at any of the tested settings. We recommended that the patient not use the portable oxygen concentrator during nocturnal NIV.
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Low-tidal-volume ventilation reduces mortality in patients with ARDS, but there are often challenges in implementing lung-protective ventilation, such as acidosis from hypercapnia. In a patient with severe ARDS we achieved adequate ventilation with a very low tidal volume (4 mL/kg ideal body weight) by inducing mild hypothermia (body temperature 35-36°C).
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Chylothorax is suspected when milky white turbid fluid is obtained from thoracocentesis. Conservative management usually involves intercostal tube drainage, dietary restriction, and total parenteral nutrition. ⋯ We describe a young woman with idiopathic chylothorax who failed conservative therapy but refused surgery. We instilled intrapleural streptokinase, which improved her condition.
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Intubation and mechanical ventilation can impair mucociliary clearance and cause secretion retention, airway occlusion, atelectasis, and pneumonia. Animal and laboratory work has demonstrated that mechanical ventilator settings can generate a flow bias (inspiratory or expiratory) that may result in mucus movement either away from the ventilator (deeper into the lungs) or toward the ventilator (toward the mouth), respectively. An absolute difference of 17 L/min, and a relative difference of ≥ 10%, between the expiratory and inspiratory flow have been reported as thresholds for mucus movement. ⋯ Commonly used mechanical ventilator settings generate an inspiratory flow bias that may promote secretion retention.
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The combination of high PEEP and low tidal volume (V(T)) decreases some risks of mechanical ventilation, including pulmonary overdistention, damage due to cyclic opening and closing of the alveoli, and inflammatory responses that can lead to multiple-organ dysfunction. We hypothesized that high V(T) and high PEEP induce mesenteric microcirculatory disturbances and that those disturbances would be attenuated by pentoxifylline, which is anti-inflammatory. ⋯ Low V(T) with high PEEP was lung-protective, and early pentoxifylline reduced the inflammatory response to high V(T) with high PEEP (and presumed lung overdistention) during mechanical ventilation.