Resp Care
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Comparative Study
Changing patterns of inpatient respiratory care services over a decade at the Cleveland Clinic: challenges posed and proposed responses.
Changing characteristics of hospitalized patients over the last decade have created challenges for all health-care providers in delivering optimal care. In the specific case of respiratory care, trends that hospitalized patients have generally become sicker over time and that average lengths of stay have generally become shorter have posed the challenge of meeting demands for more services delivered with greater immediacy. We undertook the current analysis to assess how the delivery of respiratory care services at a tertiary-care academic medical center, the Cleveland Clinic Foundation Hospital, has evolved over the decade 1991 to 2001. In this observational study, we examined concurrent departmental trends and speculated that the capability to increase clinical activity with maintained or improved clinical outcomes, preserved costs, and a lower turnover rate among respiratory therapists reflects features of the professional environment within our Section of Respiratory Therapy. ⋯ This analysis shows that trends of growing demands for respiratory care services have been accompanied by generally improving clinical outcomes and favorable retention of respiratory therapists in our section. We believe that a focus on the process of care, including enhanced professionalism, communication, and participation, has permitted a favorable response to these rising demands.
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Review Comparative Study
Noninvasive positive-pressure ventilation and ventilator-associated pneumonia.
There is much interest in the use of noninvasive positive-pressure ventilation (NPPV) to prevent intubation and afford a survival benefit for patients. The risk of pneumonia in patients receiving NPPV has been reported in 12 studies. Compared to patients receiving invasive mechanical ventilation (4 studies), the pneumonia rate is lower with the use of NPPV (relative risk [RR] 0.15, 95% confidence interval [CI] 0.04 to 0.58, p = 0.006). ⋯ One randomized controlled trial of continuous positive airway pressure compared with standard treatment in patients who developed acute hypoxemia after elective major abdominal surgery reported a lower rate of pneumonia with continuous positive airway pressure (2% vs 10%, RR 0.19, 95% CI 0.04 to 0.88, p = 0.02). In patients who are appropriate candidates for NPPV or continuous positive airway pressure, the available evidence suggests a benefit in terms of a lower risk of pneumonia. Perhaps "endotracheal-tube-associated pneumonia" is a better term than "ventilator-associated pneumonia."
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The gastrointestinal tract is believed to play an important role in ventilator-associated pneumonia (VAP), because during critical illness the stomach often is colonized with enteric Gram-negative bacteria. These are the same bacteria that frequently are isolated from the sputum of patients with VAP. Interventions such as selective decontamination of the digestive tract (SDD), use of sucralfate for stress ulcer prophylaxis, and enteral feeding strategies that preserve gastric pH, or lessen the likelihood of pulmonary aspiration, are used to decrease the incidence of VAP. ⋯ Rather, therapy should be focused on strategies other than antibiotic prophylaxis. Second, in patients who are at risk for clinically important gastrointestinal bleeding, a histamine-2 receptor antagonist should be used for stress ulcer prophylaxis, rather than sucralfate, because histamine-2 receptor antagonist provides substantially better protection without substantially increasing the risk of VAP. Third, post-pyloric enteral feeding may reduce the incidence of VAP.
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Rotational beds, prone position, and semi-recumbent position have been proposed as procedures to prevent ventilator-associated pneumonia (VAP). Rotational therapy uses a special bed designed to turn continuously, or nearly continuously, the patient from side to side; specific designs include kinetic therapy and continuous lateral rotation therapy. A meta-analysis of studies evaluating the effect of rotational bed therapy shows a decrease in the risk of pneumonia but no effect on mortality. ⋯ One study reported a lower rate of VAP in patients randomized to semi-recumbent compared to supine position. Although each of the techniques discussed in this paper has been shown to reduce the risk of VAP, none has been shown to affect mortality. The available evidence suggests that semi-recumbent position should be used routinely, rotational therapy should be considered in selected patients, and prone position should not be used as a technique to reduce the risk of VAP.