Respiratory care
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Noninvasive respiratory support has been a proven intervention for patients with acute respiratory failure. CPAP, noninvasive ventilation, and high-flow nasal cannula have been effectively used to support the respiratory needs of this patient population. ⋯ This paper reviews these factors, along with other issues that may impact tolerance of these devices. By addressing these factors and tailoring the intervention to the needs of the individual patient, the clinician can improve the likelihood of successful management of the respiratory condition in the patient with acute respiratory failure who receives noninvasive respiratory support.
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The rate of re-intubation after endotracheal extubation for all indications is estimated at ∼20%. This high rate is related, in part, to the development of postoperative complications that leads to acute respiratory failure that requires re-intubation. In general, 5-10% of all surgical patients develop postoperative respiratory failure, and, in patients who require abdominal surgery, up to 40% develop respiratory failure. ⋯ From an analysis of the data, it is clear that patients at high risk of re-intubation require CPAP, noninvasive ventilation, or high-flow nasal cannula after extubation to allow for a smooth transition to spontaneous breathing and to minimize the need for re-intubation. CPAP is most indicated in patients with atelectasis in which high levels of PEEP are needed, noninvasive ventilation is indicated in the patient unable to maintain an adequate minute ventilation without excessive work of breathing, and high-flow nasal cannula is indicated in the patient with severe hypoxemia that was not a result of marked atelectasis or severe ARDS. It is also clear that there are insufficient data to support the use of any of these therapies in patients at low risk for re-intubation or the development of postoperative pulmonary complications.
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CPAP is a spontaneous mode of ventilation that maintains a constant airway pressure during the inspiratory and expiratory phases. This therapeutic modality is used across the continuum of care from pre-hospital treatment to intensive and acute care units to the home care environment to treat a host of acute and chronic clinical conditions. A variety of devices are currently available for the delivery of CPAP, including oxygen-conserving valved systems, continuous-flow generators, portable demand-flow devices, and mechanical ventilators. ⋯ If undetected, this can contribute to adverse patient outcomes. Considerations for device selection depend on the setting (eg, pre-hospital, acute care, critical care, home care), length of therapy (ie, short vs long-term), patient safety (eg, alarms, monitoring devices), and comfort. Understanding the science and clinical application of CPAP delivery systems can assist clinicians in a variety of care settings with selecting the type of device that best matches the clinical setting, and thus with optimizing therapeutic effectiveness by maximizing patient comfort, safety and stability of pressure, and FIO2 delivery.
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Ventilator-induced lung injury (VILI) is a central confounder to improving outcomes from use of positive-pressure ventilation in critical illness. Therefore, with increasing use of positive-pressure ventilation, awareness to prevent VILI has grown. Because VILI cannot be diagnosed at the bedside, its prevention can only be attained by identifying the clinical mechanisms of harm, such as high tidal volume, high plateau pressure, and so forth, which, in turn, are derived from decades of laboratory work. ⋯ Although noninvasive ventilation prevents the complications of intubation, it has potential to cause harm, especially in patients with de novo respiratory failure. This review covers some of the classic and emerging concepts of VILI genesis and their role during noninvasive ventilation. Combined modulation of these mechanisms could have a potential to impact outcomes.
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The use of noninvasive ventilation (NIV) is common in adult acute care. As evidence to support the use of NIV has developed, there has been a concurrent proliferation of NIV technology. Efforts have been made to improve patient-ventilator synchrony, monitoring capabilities, and portability of devices used to deliver NIV. ⋯ Although this technology is generally superior to that of the past, a great deal of variation exists between devices. Clinicians need to be accustomed to the devices available to them to maximize the potential for clinical improvement and patient tolerance. The purpose of this paper is to review current technology, current literature comparing devices, and various clinical considerations associated with NIV use in adult acute care.