Resp Care
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Noninvasive support of ventilation is commonly needed in patients with neuromuscular disease. Body ventilators, which are used rarely, function by applying intermittent negative pressure to the thorax or abdomen. More commonly, noninvasive positive-pressure ventilation (NPPV) is used. ⋯ Selection of settings can also be based on the results of physiologic studies or sleep studies. The use of NPPV in this patient population is likely to expand, particularly with increasing evidence that it is life-prolonging in patients with diseases such as amyotrophic lateral sclerosis. Appropriate selection of equipment and settings for NPPV is paramount to the success of this therapy.
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The clearance of airway secretions from the lungs is normally supported by the mucociliary escalator and by cough. These protective mechanisms provide an effective means of pulmonary-hygiene maintenance in healthy individuals. Patients with neuromuscular disease that affects the respiratory pump (the muscles of breathing) can experience mild to profound limitation in both ventilation and cough. ⋯ Unfortunately, the need to support cough clearance is not always addressed, and few guidelines for the management of cough insufficiency have existed until relatively recently. An understanding of neuromuscular respiratory pathophysiology and the modes of effective noninvasive cough support are key in the evaluation and management of neuromuscular diseases. This review is meant to provide a basic understanding of cough mechanics, and the pathophysiology and management of neuromuscular cough insufficiency.
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Respiratory dysfunction is a major cause of morbidity and mortality in spinal cord injury (SCI), which causes impairment of respiratory muscles, reduced vital capacity, ineffective cough, reduction in lung and chest wall compliance, and excess oxygen cost of breathing due to distortion of the respiratory system. Severely affected individuals may require assisted ventilation, which can cause problems with speech production. Appropriate candidates can sometimes be liberated from mechanical ventilation by phrenic-nerve pacing and pacing of the external intercostal muscles. ⋯ An important clinical problem in SCI is weak cough, which causes retention of secretions during infections. Methods for secretion clearance include chest physical therapy, spontaneous cough, suctioning, cough assistance by forced compression of the abdomen ("quad cough"), and mechanical insufflation-exsufflation. Recently described but not yet available for general use is activation of the abdominal muscles via an epidural electrode placed at spinal cord level T9-L1.
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Randomized Controlled Trial
Effects of syringe material, sample storage time, and temperature on blood gases and oxygen saturation in arterialized human blood samples.
The practice of on-ice storage of arterial-blood samples in plastic syringes for delayed analysis continues, and the effects of storage time and temperature on the measurement of blood-oxygen-saturation values (S(aO2)) have not been adequately described. ⋯ For accurate arterial-blood-gas results, samples drawn in plastic syringes should be analyzed immediately. If the analysis is going to be delayed, the samples should be drawn and stored in glass.
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Rounded atelectasis is atelectasis of the peripheral part of the lung, typically in contact with thickened pleura, featuring characteristic computed tomography findings. In this case, a 61-year-old man with history of asbestos exposure presented with a right-middle-lobe nodule on chest radiograph, with computed tomography findings suspicious for neoplasm. The patient underwent surgical resection, which revealed rounded atelectasis. Our case raises a question about the sensitivity of radiographic criteria used in identifying rounded atelectasis, and it emphasizes the need to keep rounded atelectasis in the differential diagnosis of a single pulmonary nodule in a patient with a history of asbestos exposure.