Resp Care
-
Many acute and chronic respiratory diseases are associated with increased respiratory secretions in the airways. Narrative reviews and a few systematic reviews of secretion clearance techniques have been published. These reviews raise concerns regarding the lack of evidence to support the various secretion clearance techniques. ⋯ Most of the studies were small, most used crossover designs, and few used sham therapy. Many studies were limited to short-term outcomes such as sputum clearance with a single treatment session. Despite the clinical observation that retained secretions are detrimental to respiratory function and despite anecdotal associations between secretion clearance and improvements in respiratory function, there is a dearth of high-level evidence to support any secretion clearance technique.
-
Outcomes research seeks to understand the end results of particular health care interventions. End results include effects that people experience and care about, such as change in ability to function. The modern outcomes movement in the United States had its beginnings in the early 1980s, with an official start when Congress created the Agency for Health Care Policy and Research in 1989. ⋯ For example, outcomes research is population-centered rather than disease-centered, deals more with processes of care than drugs and devices, and relies less on the "hard sciences" such as physics and biochemistry and more on the social sciences such as economics, behavioral sciences, and epidemiology. Appropriate outcomes measures may be classified as (A) clinical, such as physiologic measures and mortality; (B) economic, such as direct and indirect costs of care; or (C) humanistic, such as quality of life and patient satisfaction with care. Respiratory therapists need to be familiar with outcomes research issues in order to be educated consumers of (and to participate in) future studies.
-
The ARDS (acute respiratory distress syndrome) Network study found 22% lower mortality in acute lung injury and ARDS patients ventilated with low tidal volumes (V(T)) than in those ventilated with traditional V(T) ventilation. Several points should be considered when using the low V(T) protocol for clinical practice. Prior to implementation, hemodynamic and acid-base status, minute ventilation, and adequacy of sedation should be assessed to minimize the potential for intolerance. ⋯ Evaluation for weaning should occur when adequate oxygenation can be maintained on 40% oxygen and a positive end-expiratory pressure of 8 cm H(2)O. Pressure support levels between 5 and 20 cm H(2)O (above 5 cm H(2)O positive end-expiratory pressure) are used for weaning and titrated to keep the respiratory rate < 35 breaths/min. Pressure support levels should be weaned aggressively, as long as the protocol's weaning tolerance criteria can be maintained.
-
A patient with extensive burns was intubated with an 8.0 mm internal diameter endotracheal tube (ETT) equipped with a subglottic suction port (Mallinckrodt HiLo Evac). The ETT was secured to a left upper molar with wire sutures throughout the hospitalization course to ensure airway stability. On the 40th day of intubation, the patient exsanguinated and died from a tracheo-innominate artery fistula. Postmortem examination revealed a 1 cm lesion of the left anterior tracheal wall at the position of the ETT tip. The prolonged stationary position of the ETT was considered the primary factor responsible for the fistula. Yet tracheo-innominate artery fistula normally is associated with high cuff pressures rather than with the tube tip. The special ETT construction required for the subglottic suction feature was suspected to have increased tube rigidity and may have played a contributory role. ⋯ This case of fatal tracheo-innominate artery fistula formation associated with an ETT tip was unusual because of the extended duration of endotracheal intubation and the complexity of the patient's airway management problems. Our data suggest that the higher rigidity of the HiLo Evac ETT may have contributed to fistula development at the tube tip. However, we do not believe that the higher rigidity of the HiLo Evac ETT necessarily poses any greater risk than other ETTs under normal circumstances, in which the tube tip is not fixed in a stationary position for an extended period.
-
Case Reports
Airway pressure release ventilation with a short release time in a child with acute respiratory distress syndrome.
Airway pressure release ventilation (APRV) allows ventilation and oxygenation to occur at lower peak and mean airway pressures than conventional positive pressure ventilation. The use of APRV in adults is an effective method of ventilation for patients with acute lung injury and acute respiratory distress syndrome. However, the use of APRV in children is less established. We report the use of APRV with a short release time of 0.2 s in a child with acute respiratory distress syndrome secondary to respiratory syncytial virus pneumonia.