Resp Care
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Case Reports
Severe acute respiratory distress syndrome in a child with malaria: favorable response to prone positioning.
We present the case of a 4-year-old boy with malaria who developed acute respiratory distress syndrome with severe hypoxemia refractory to mechanical ventilation and inhaled nitric oxide. Placing the patient in prone position immediately and persistently improved oxygenation: the ratio of P(aO(2)) to fraction of inspired oxygen rose from 47 to 180 mm Hg and the oxygenation index decreased from 40 to 11. The patient survived, with no respiratory sequelae.
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Comparative Study
Publication, citations, and impact factors of leading investigators in critical care medicine.
Critical care medicine research is reported in major medical journals that can be accessed via computerized search engines such as PubMed (National Library of Medicine) or Web of Science (Thomson ISI [Institute for Scientific Information]). The crediting of report citations to specific journals or individuals is a rapidly developing and highly controversial evaluative process. ⋯ From criteria selected to attribute original work to specific authors we identified 20 leading critical care medicine investigators, as measured by number of publications, citations, and impact factors. We also report a country factor based on posters (on mechanical ventilation) presented at the 2001-2003 international conferences of the American Thoracic Society.
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Case Reports
The use of high positive end-expiratory pressure for respiratory failure in abdominal compartment syndrome.
We report a case in which a non-trauma patient suffering hematemesis and undergoing massive volume resuscitation developed abdominal compartment syndrome (ACS). The abdominal distension severely compromised his pulmonary functioning: a chest radiograph showed low lung volumes and dense bilateral parenchymal opacities. His blood oxygen saturation reached as low as 32%. ⋯ On the contrary, high-pressure ventilation can be harmful in the setting of acute lung injury and acute respiratory distress syndrome, so we do not advocate high PEEP for all patients with hypoxemia and ACS, especially considering that many of the conditions associated with ACS can also precipitate acute lung injury and acute respiratory distress syndrome. As well, high-pressure ventilation can increase the risk of hypotension by impairing venous return. However, our case suggests that high PEEP may temporize in certain situations in which ACS causes life-threatening hypoxia but surgical decompression is not possible.
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With selected patients noninvasive positive-pressure ventilation (NPPV) can obviate endotracheal intubation and thus avoid the airway trauma and infection associated with intubation. With patients who can cooperate, NPPV is the first-line treatment for mild-to-severe acute hypercapnic respiratory failure. NPPV is also used for hypercapnic ventilatory failure and to assist weaning from mechanical ventilation, by allowing earlier extubation. ⋯ For example, the presence of acute respiratory distress syndrome or community-acquired pneumonia portends NPPV failure, as does lack of oxygenation improvement after an hour on NPPV. All the proposed NPPV success/failure predictors should be used cautiously and need further study. We predict that further study and team experience will improve the NPPV success rate and allow successful NPPV-treatment of sicker patients.
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Accidental hypothermia is defined as an unintentional decrease in core body temperature to below 35 degrees C. Hypothermia causes hundreds of deaths in the United States annually. Victims of accidental hypothermia present year-round and in all climates with a potentially confusing array of signs and symptoms, but increasing severity of hypothermia produces a predictable pattern of systemic organ dysfunction and associated clinical manifestations. ⋯ The paucity of randomized clinical trials with hypothermic patients precludes creation of evidence-based treatment guidelines, but a clinically sound management strategy, tailored to individual patient characteristics and institutional expertise and resources, can nonetheless be gleaned from the literature. This article reviews the epidemiology, pathophysiology, clinical presentation, and treatment of accidental hypothermia. Initial evaluation and stabilization, selection of a rewarming strategy, and criteria for withholding or withdrawing support are discussed.