Respiratory care
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In the following perspective, we will highlight seemingly remote, downstream consequences of common ventilator management decisions. For example, a change in PEEP may alter venous return, blood pressure, cardiac output, arterial and venous blood gas tensions, metabolic rate, respiratory sensations, breathing pattern, and the work of breathing. If providers consider any of these changes dangerous or maladaptive, they may initiate additional interventions in the form of vasoactive agents, intravenous fluids, and/or sedatives, all of which have their own risk/benefit profile. ⋯ Therefore, it is often impossible to infer intervention-specific mechanisms of action and/or identify the phenotype of responders and nonresponders in such trials. On the flip side, in preclinical research intended to uncover mechanisms, experimental animals are rarely treated the way a critically ill patient would be. For respiratory therapists, this knowledge gap stresses the imperative to think beyond the lungs and to communicate ventilator management decisions with all members of the healthcare team.
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Pacemaker endocarditis has a high rate of morbidity and mortality and is associated with substantial health-care cost. To maximize the effectiveness of treatment, diagnosis of pacemaker endocarditis should be made as early as possible. Medical treatment alone is not successful, and the removal of the entire artificial pacing system is often required. ⋯ Transesophageal echocardiography showed a mass that was adherent to the pacemaker lead. The therapeutic approach consisted of surgical removal of the complete pacing system along with long-term antibiotic therapy and implantation of a new device with an epicardial lead. Serial follow-up echocardiograms for a 1-y period did not show any recurrence, and the subsequent course was uneventful.
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Observational Study
Procalcitonin kinetics and nosocomial pneumonia in older patients.
Early identification of treatment failure for nosocomial pneumonia remains a major challenge. The goal of this study was to test whether procalcitonin kinetics can be used to assess the clinical efficacy in older critically ill patients with nosocomial pneumonia. ⋯ Procalcitonin levels were not influenced by aging, and procalcitonin kinetics might help to identify treatment failure. ΔPCT(d3)% in combination with the Clinical Pulmonary Infection Score has been shown to be a marker of clinical efficacy at an earlier stage.
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Capnography is a graphic representation of the carbon dioxide concentration in the airways plotted against time. We report an unusual biphasic-shaped capnogram in a single-lung transplant recipient. In keeping with the only 2 prior reports of which we are aware, we ascribe the unusual biphasic pattern to differential emptying of the native and transplanted lungs. This experience reminds respiratory clinicians of the value of capnometry as a monitoring tool and hopefully will heighten awareness regarding the diagnostic value of usual and unusual capnographic patterns.