Resp Care
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Evidence-based medicine has assumed a major place in establishing the standard of care for many diseases. Yet practices based largely on clinical experience have often been difficult to change, even when clearly associated with patient harm. In this paper, based on the 27th Philip Kittredge Memorial Lecture, we highlight respiratory care practices that have clearly failed the tests of time and evidence yet sometimes tenaciously persist. We also discuss the appropriate use and potential abuse of evidence-based medicine.
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Randomized Controlled Trial
Automated oxygen flow titration to maintain constant oxygenation.
One century after the introduction of the oxygen flow meter into clinical practice, we have developed a device, FreeO(2), that automatically titrates the oxygen flow delivered to spontaneously breathing patients, with the aim of maintaining a stable S(pO(2)). We evaluated this system in healthy subjects during induced hypoxemia. ⋯ In this model of induced hypoxemia, the FreeO(2) system that automatically titrates the oxygen flow was more efficient at maintaining the S(pO(2)) target, while ensuring a statistically significant reduction in the rates of severe hypoxemia and hyperoxia, in comparison with air or constant oxygen flow. These beneficial results were obtained with less oxygen, in comparison to a constant oxygen flow.
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Asthma and COPD are obstructive airway diseases related to chronic airway inflammation. However, it is known that in real practice the 2 diseases overlap. ⋯ We have identified and characterized an intermediate type between asthma and COPD in clinical characteristics. Further investigations are required to determine whether these 3 conditions are part of the chronic obstructive airway diseases spectrum or are rather distinct clinical entities.
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Inadvertent ventilator triggering can occur for various reasons. Leaks in the ventilator circuit, endotracheal tube leaks, tracheal cuff leaks, cardiac oscillations, water condensate causing oscillations in the circuit tubing, ventilator expiratory valve integrity, and overly sensitive triggering mechanism settings may precipitate this phenomena. We present a case of inadvertent ventilator triggering caused by electrical stimulation of the diaphragm from surgically placed pacing wires post cardiothoracic surgery. ⋯ Further adjustment of the pressure trigger sensitivity to -3 cm H(2)O eliminated the autotriggering. Clinical assessment found the pacing wires were responsible for stimulating the patient's diaphragm, therefore causing airway pressure decreases and premature breath delivery. Once the electrical amplitude of the pacemaker was decreased, the inadvertent ventilator triggering resolved and normal trigger sensitivity and pH was restored.
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Many children with cystic fibrosis (CF) adhere poorly to airway clearance techniques (ACTs), and would rather play video games that challenge their dexterity and visual tracking skills. We developed gaming technology that encourages forced expiratory maneuvers. ⋯ Spirometer games elicit forced expiratory breath maneuvers in pediatric CF patients. Improvement in PFTs may be due to improved test performance technique, though improved obstructive/restrictive lung function due to game play cannot be excluded. A formal clinical trial of this approach is planned.