Resp Care
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Ventilator-associated pneumonia (VAP) is a common complication of ventilatory support for patients with acute respiratory failure and is associated with increased morbidity, mortality, and costs. Awareness of the microbiology of VAP is essential for selecting optimal antibiotic therapy and improving these outcomes. The specific microbial causes of VAP are many and varied. ⋯ In conclusion, information about the microbiology of VAP serves to guide optimal antibiotic therapy. The risk of antibiotic-resistant pathogens can be estimated using simple clinical features and awareness of local microbiology patterns. The roles of atypical bacterial and nonbacterial pathogens in VAP are incompletely understood and should be investigated further.
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There has long been a controversy about whether to use a clinical or microbiologic approach to diagnose ventilator-associated pneumonia (VAP) and about which approach to use in managing patients. Although the clinical approach has often been criticized, a number of recent studies have shown that it is possible to use such an approach to effectively manage patients. This approach involves using all available clinical data to define the presence of pneumonia and then to initiate empiric therapy in a timely fashion, based on therapy guidelines, modified by local microbiologic data. ⋯ Based on this assessment, in conjunction with the results of tracheal aspirate cultures, therapy can be either modified or continued. A number of studies have shown that the clinical approach leads to a large number of patients receiving adequate empiric therapy, while still permitting de-escalation of antibiotic regimens, along with short durations of therapy. Thus a clinical approach to management can be successful in allowing for effective management of VAP, without promoting the unnecessary use of broad-spectrum antimicrobial therapy.
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Hospital-associated pneumonia (HAP) is one of the most common infections acquired among hospitalized patients. HAP is associated with excess mortality and increased medical care costs. The rise in HAP due to antibiotic-resistant bacteria has resulted in more common administration of inappropriate antimicrobial treatment, with an associated increased risk of hospital mortality. ⋯ Physicians treating patients with HAP and VAP should be aware of the predominant local pathogens associated with these infections and their antimicrobial susceptibility patterns. This will allow more appropriate initial antibiotic selection in order to optimize treatment regimens and clinical outcomes. Additionally, clinical strategies aimed at the prevention of HAP and VAP should be employed in all hospital settings caring for patients at risk for these infections.
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Nasal cannulas are commonly used to deliver oxygen in acute and chronic care settings; however, there are few data available on delivered fraction of inspired oxygen (F(IO(2))). The purposes of this study were to determine the delivered F(IO(2)) on human subjects using low-flow and high-flow nasal cannulas, and to determine the effects of mouth-closed and mouth-open breathing on F(IO(2)). ⋯ F(IO(2)) increased with increasing flow. Subjects who breathed with their mouths open attained a significantly higher F(IO(2)), compared to those who breathed with their mouths closed.
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Randomized Controlled Trial Comparative Study Clinical Trial
Positive expiratory pressure device acceptance by hospitalized children with sickle cell disease is comparable to incentive spirometry.
The pulmonary complication in sickle cell disease known as acute chest syndrome (ACS) has potential for high morbidity and mortality. A randomized trial demonstrated that incentive spirometry (IS) reduces the rate of ACS, leading to a role for respiratory therapy in hospital management of sickle cell pain. However, use of IS can be limited by chest wall pain, or by difficulty with the coordinated inspiration in a young child. Intermittent positive expiratory pressure (PEP) therapy may be easier for a child's coordination and more comfortable than IS for a child with chest wall pain. ⋯ These preliminary results show no difference in the primary outcomes in the 2 groups. Intermittent PEP therapy warrants further study as an alternative to IS for sickle cell patients at high risk for ACS, as effective preventive respiratory therapy.