Resp Care
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Endotracheal intubation can lead to iatrogenic trauma to the upper airways. Superficial mucosal tears in the mouth, pharynx, or larynx are common and can cause secondary infection and acute respiratory distress due to massive air leak. We report a patient who sustained a severe 5-cm tracheal laceration and subcutaneous emphysema after intubation. She was successfully weaned from the ventilator after adjustment of the endotracheal cuff, therapy with broad-spectrum antibiotics, and continuous airway humidification.
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Review
Optimizing the respiratory pump: harnessing inspiratory resistance to treat systemic hypotension.
We review the physiology and affects of inspiration through a low level of added resistance for the treatment of hypotension. Recent animal and clinical studies demonstrated that one of the body's natural response mechanisms to hypotension is to harness the respiratory pump to increase circulation. That finding is consistent with observations, in the 1960s, about the effect of lowering intrathoracic pressure on key physiological and hemodynamic variables. ⋯ While breathing has traditionally been thought primarily to provide gas exchange, studies of the mechanisms involved in animals and humans provide the physiological underpinnings for "the other side of breathing": to increase circulation to the heart and brain, especially in the setting of physiological stress. The existing results support the use of the intrathoracic pump to treat clinical conditions associated with hypotension, including orthostatic hypotension, hypotension during and after hemodialysis, hemorrhagic shock, heat stroke, septic shock, and cardiac arrest. Harnessing these fundamental mechanisms that control cardiopulmonary physiology provides new opportunities for respiratory therapists and others who have traditionally focused on ventilation to also help treat serious and often life-threatening circulatory disorders.
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Randomized Controlled Trial
Remifentanil improves breathing pattern and reduces inspiratory workload in tachypneic patients.
Properly titrated opiates decrease respiratory rate but do not affect tidal volume or induce respiratory acidosis. ⋯ Remifentanil improved respiratory pattern and decreased inspiratory muscles effort in patients with tachypnea or rapid shallow breathing, but did not affect oxygenation or sedation. Though the acid-base balance did not show clinically relevant changes on average, we cannot exclude the possibility that remifentanil might prolong weaning in hypercapnic patients. (Clinical-Trials.gov registration NCT00665119.)
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Persistent hydropneumothorax was diagnosed in a 62-year-old female with a history of blunt trauma, although she was treated with chest tube and closed underwater seal drainage. Computed tomography and fiberoptic bronchoscopy findings were consistent with "fallen lung" syndrome. ⋯ Forceps biopsy of the cavitary lesion indicated bronchogenic carcinoma. Our final diagnosis was tracheobronchial complete rupture and fallen lung syndrome secondary to malignancy.
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The Boussignac continuous positive airway pressure (CPAP) device effectively treats acute pulmonary edema, but data on airway pressure with the Boussignac CPAP system are sparse. ⋯ With CPAP, pressure changes are considered to be associated with increased work of breathing. The device's pneumatic performance is adequate during normal breathing with low air flow, but during forced breathing (high air flow) it did not maintain stable airway pressure, which could increase the work of breathing and cause respiratory fatigue. Thus, the Boussignac CPAP system might be less suitable for a patient breathing at a higher frequency.