Resp Care
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Extracorporeal membrane oxygenation, a form of artificial circulatory support, continues to evolve beyond its well-established neonatal applications. It is often the most aggressive aspect of treatment algorithms in the management of severe respiratory and cardiac failure. While its use is relatively infrequent and executed in a small number of centers, it remains an important supportive measure while organ function is preserved and restored. Refinements in equipment and techniques continue to develop; patient-selection has changed, in adults and children, and cardiac applications have gained prominence.
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Postoperative pulmonary hypertension is a challenging and feared complication of many types of surgery, including lung and heart transplantation, pulmonary thromboendarterectomy, congenital-heart-disease repair, and others. The most severe manifestation is acute right heart syndrome, characterized by right heart failure and cardiovascular collapse-a daunting therapeutic challenge associated with a high mortality. Patients with postoperative pulmonary hypertension must be carefully evaluated to identify reversible contributing factors such as fluid and metabolic imbalance, hypoxemia, and right heart ischemia. ⋯ Basic principles of management include maintenance of systemic perfusion pressure, optimization of cardiac inotropy, use of lung-protective ventilator strategies, and attempting to reduce right-ventricular afterload using pulmonary vasodilators. Unfortunately, controlled trials upon which to base therapy are lacking, and most approaches are supported only by uncontrolled or anecdotal evidence. Better understanding of the pathophysiology of right heart failure and controlled trials testing therapeutic approaches are needed if we are to make progress in treating this heretofore highly mortal condition.
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Disease management has been implemented for patients with asthma in various ways. We describe the approaches to and components of adult asthma disease-management interventions, examine the outcomes evaluated, and assess the quality of published studies. ⋯ Few well-designed studies with rigorous evaluations have been conducted to evaluate disease-management interventions for adults with asthma. Current evidence is insufficient to recommend any particular intervention.
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The discovery that carbon monoxide (CO)-a highly publicized toxic gas molecule-can have powerful benefits and curative effects not only changed how we view CO, but has, with tremendous contradiction, resulted in clinical trials of CO for the treatment of various pathologies. There is sound preclinical evidence that, at a low concentration, CO has benefits in numerous and diverse diseases in rodents, large animals, and humans. ⋯ As CO moves ahead in the clinic, we continue to advance our understanding of how it functions, especially as the number of potential clinical applications expands. CO's mechanisms of action at the cellular level depend on the disease and the experimental focus, but the one constant is that CO reestablishes homeostasis.
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Respiratory therapist (RT) driven protocols decrease ventilator days and resource utilization in the intensive care unit (ICU). Protocols have been studied in non-ICU settings, but their effect on mortality has been incompletely studied. ⋯ Our RT-evaluate-and-treat protocol for non-ICU surgery patients was associated with more patients receiving respiratory treatments but decreased ICU and hospital stay and lower total hospital costs. Routine RT-driven assessment of non-ICU patients may reduce pulmonary complications in high-risk patients.