Resp Care
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To examine physician practice in, and the costs of, prescribing inhaled bronchodilators to mechanically ventilated patients who do not have obstructive lung disease. ⋯ A substantial proportion of mechanically ventilated patients without obstructive lung disease received inhaled bronchodilators.
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We present a case of a patient with severe chronic obstructive pulmonary disease who developed dramatic mediastinal and subcutaneous emphysema, without pneumothorax, following a difficult intubation. Misdiagnosis of tracheal rupture as barotrauma from alveolar overdistention initially delayed intervention and caused persistence of subcutaneous emphysema. Despite efforts to minimize tidal volume and airway pressure, the large airway disruption and positive-pressure ventilation resulted in tension subcutaneous emphysema with near-fatal hemodynamic compromise, oliguria, and respiratory acidosis. Decompression with subcutaneous vents immediately reversed the life-threatening circulatory and respiratory compromise and stabilized the patient until surgical correction of the tracheal tear could be accomplished.
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High-frequency ventilation can be delivered with either oscillatory ventilation (HFOV) or jet ventilation (HFJV). Traditional clinician biases may limit the range of function of these important ventilation modes. We hypothesized that (1) the jet ventilator can be an accurate monitor of mean airway pressure (P (aw)) during HFOV, and (2) a mathematical relationship can be used to determine the positive end-expiratory pressure (PEEP) setting required for HFJV to reproduce the P (aw) of HFOV. ⋯ HFJV is an accurate monitor during HFOV. These measurements can be used to calculate the predicted PEEP necessary to match P (aw) on the 2 ventilators. Replicating the P (aw) with adequate PEEP on HFJV may help simplify transitioning between ventilators when clinically indicated.
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Expert management of tracheal intubation has become fundamental to the routine practice of pulmonary physicians who work in respiratory intensive care units (ICUs). In Italy, tracheal intubation is not included as part of the training in respiratory medicine, and pulmonary physicians are usually dissuaded from managing intubations. ⋯ Pulmonary physicians trained in tracheal intubation can have a high success rate in performing intubation in the respiratory ICU. Collaborative efforts between anesthesiologists and pulmonary physicians are necessary to optimize the training, skill-retention, and back-up for advanced airway management in the respiratory ICU.