Respiratory care
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As defined by the American Association for Respiratory Care, respiratory care protocols are "guidelines, usually written in algorithmic form, for providing respiratory therapy services." The need for protocols has been framed by the frequent occurrence of misallocation of respiratory care, consisting both of over-ordering (ie, prescribing respiratory care that is unlikely to confer benefit) and under-ordering services (ie, failing to prescribe services that would be expected to offer benefit). In this context, the current paper reviews available studies regarding the effectiveness of respiratory care protocols. Such studies can be organized into those assessing respiratory care treatments in the ICU, and those addressing non-ICU respiratory care. ⋯ Furthermore, 2 concordant randomized controlled trials have shown that comprehensive respiratory care protocol programs can enhance the allocation of respiratory care services, with concomitant savings and no excess adverse outcomes. Overall, while the overwhelming weight of available evidence supports the effectiveness of respiratory care protocols, gaps in current understanding remain, especially regarding settings outside the acute care hospital (eg, geriatric care, palliative care, and extended care facilities). In the same spirit that engendered the Sugarloaf Conference to assess the effectiveness of respiratory care, further assessment of the effectiveness of respiratory care protocols is encouraged and expected.
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Aspiration of colonized oropharyngeal secretions is a major factor in the pathogenesis of ventilator-associated pneumonia (VAP). A tapered-cuff endotracheal tube (ETT) has been demonstrated to reduce aspiration around the cuff. Whether these properties are efficacious in reducing VAP is not known. ⋯ In the setting of a VAP rate very near the average of ICUs in the United States, and where there was high adherence to a VAP prevention bundle, the use of a tapered-cuff ETT was not associated with a reduction in the VAP rate.
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Assessment of the degree of air-flow obstruction is important for determining the treatment strategy in COPD patients. However, in some elderly COPD patients, measuring FVC is impossible because of cognitive dysfunction or severe dyspnea. In such patients a simple test of airways obstruction requiring only a short run of tidal breathing would be useful. We studied whether the spontaneous expiratory flow-volume (SEFV) curve pattern reflects the degree of air-flow obstruction in elderly COPD patients. ⋯ Concavity of the SEFV curve obtained during tidal breathing may be a useful test for determining the presence of very severe obstruction in elderly patients unable to perform a satisfactory FVC maneuver.
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Cystic fibrosis (CF) related diabetes is an increasingly common comorbidity in CF patients, with scarce data on end-stage complications in the CF population. We report the case of a 32-year-old with poorly controlled diabetes presenting with sub-acute leg pain and focal quadriceps tenderness. Neuromuscular testing and extensive workup revealed diabetic myonecrosis. To our knowledge, this is the first reported case of diabetic myonecrosis in a patient with CF, and highlights the need for pulmonary physicians to recognize this diabetic complication in CF patients, which is associated with a poor long-term prognosis and existing microvascular complications.
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Conventional sputum suctioning is a routine clinical practice, but complications may arise from the blind manipulation of the catheter. Recently, a visual sputum suctioning system (VSSS) was developed, and we tested this new system in a laboratory setting. ⋯ Sputum suctioning with the VSSS was feasible. Because of its real-time imaging guidance, the efficiency of the VSSS procedure was greater than that of the conventional single-lumen catheter. Therefore, this system may provide a new platform for sputum suctioning.