Resp Care
-
Review
Managing acute respiratory failure during exacerbation of chronic obstructive pulmonary disease.
Exacerbations of chronic obstructive pulmonary disease (COPD) are a major health problem, causing more than half a million hospital admissions per year in the United States. Although overall mortality is low, it is substantially higher with severe exacerbations that require intensive care and mechanical ventilation. The majority of COPD exacerbations result from infection, with typical bacterial organisms most commonly identified. ⋯ Randomized controlled trials also demonstrate that noninvasive ventilation can decrease the incidence of intubation, shorten stay, reduce infectious complications, and improve survival. Although patients who require intubation have the worst prognosis, the vast majority of them can be successfully liberated from mechanical ventilation. For invasively ventilated patients the clinical emphasis should be on improving patient-ventilator interaction and avoiding dynamic hyperinflation (intrinsic positive end-expiratory pressure).
-
The principles underlying evidence-based practice are that treatments are effective and can offer benefit to patients. At the same time, optimal practice also avoids offering treatments for which evidence of efficacy is not available. In this regard, the goal of respiratory care protocols is to optimize the allocation of respiratory care services by prescribing to each patient treatments likely to confer benefit and avoiding those that do not. As reviewed in this paper, currently available evidence suggests that protocols (1). help minimize unnecessary arterial blood sampling, placement of arterial catheters, and bronchopulmonary hygiene therapies, (2). help optimize the process of weaning patients from mechanical ventilation, (3). help minimize waste of oxygen, (4). allocate respiratory care services better than does physician-directed care.
-
This report explores the efficacy of existing therapies for acute lung injury (ALI) and acute respiratory distress syndrome (ARDS), primarily in terms of clinically important outcomes such as the duration of mechanical ventilation and hospital mortality. Of the 15 therapies reviewed, the strongest evidence suggests that ALI/ARDS should be managed with a low-tidal-volume, pressure-limited approach, with either low or moderately high positive end-expiratory pressure. ⋯ However, there is relatively strong evidence to support conservative fluid management and high-fat, anti-oxidant nutritional formulations. Although most pharmacologic ALI/ARDS therapies have been ineffective, high-dose methylprednisolone is indicated in the subgroups of ALI/ARDS patients who have pneumonia or are at risk of ARDS due to fat embolization.
-
Noninvasive positive-pressure ventilation (NPPV) is increasingly being used in the care of patients suffering acute respiratory failure. High-level evidence supports the use of NPPV to treat exacerbation of chronic obstructive pulmonary disease (COPD). NPPV has also been successfully used with selected patients suffering acute hypoxemic respiratory failure and to allow earlier extubation of mechanically ventilated COPD patients. ⋯ Any ventilator and ventilator mode can be used to apply NPPV, but portable pressure ventilators and pressure-support mode are most commonly used. Inhaled bronchodilators can be administered during NPPV, and NPPV can be delivered with helium-oxygen mixture. Institution-specific practice guidelines may be useful to improve NPPV success.
-
The principles of evidence-based medicine provide the tools to incorporate the best evidence into everyday practice. Evidence-based medicine is the integration of individual clinical expertise with the best available research evidence from systematic research and the patient's values and expectations. A hierarchy of evidence can be used to assess the strength of evidence upon which clinical decisions are made, with randomized studies at the top of the hierarchy. ⋯ High-level studies of a therapy are prospective, randomized, blinded, placebo-controlled, have a concealed allocation, have a parallel design, and assess patient-important outcomes. Metrics used to assess the evidence for a therapy include event rate, relative risk, relative risk reduction, absolute risk reduction, number needed to treat, and odds ratio. Although not all tenets of evidence-based medicine are universally accepted, the principles of evidence-based medicine nonetheless provide a valuable approach to respiratory care practice.