Respiratory care
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Historical Article
Pulmonary Rehabilitation: A Look Back, a Look Forward.
Pulmonary rehabilitation (PR) is a comprehensive approach to the management of patients with chronic lung disease that encompasses exercise, education, and psychosocial support. The development of PR programs began in the mid-20th century with the appreciation that exercise provided real benefit in chronic lung disease and that effective disease management involved patient education focused on medications, lifestyle changes, and lifelong regular exercise. Initially PR was primarily facility-based, but today PR is extending into the home with telemedicine, and this is encouraging a real partnership of patients and professionals supporting self-management. ⋯ Access is still very limited for a variety of reason (logistics, financial, patient motivation) that need to be addressed. More focused and personalized exercise programs and monitoring strategies that encourage a patient's lifetime commitment to the principles of PR need to be developed and refined. The opportunity to really impact important clinical outcomes exists with PR, and this needs to be exploited.
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Center-based pulmonary rehabilitation is positioned as the accepted standard for pulmonary rehabilitation. There, however, are several barriers to its utilization, and usage rates remain as low as 4%, despite decades of trying to improve access. The question then arises as to who is really benefiting from center-based pulmonary rehabilitation as this therapy is barely available to eligible patients. ⋯ Meta-analyses indicate that these alternate modes are associated with clinical improvements comparable with center-based pulmonary rehabilitation in several outcomes that are important for patients, including the 6-min walk distance, dyspnea, and quality of life. These modes are also associated with better adherence to the intervention than center-based pulmonary rehabilitation. Telehealth pulmonary rehabilitation and home-based pulmonary rehabilitation, therefore, are attractive alternatives to center-based pulmonary rehabilitation and will exponentially increase pulmonary rehabilitation capacity.
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High-flow tracheal oxygen (HFTO) is being used as supportive therapy during weaning in tracheostomized patients difficult to wean from invasive mechanical ventilation. There is, however, no clinical evidence for such a strategy. Therefore, we conducted a systematic review to summarize studies evaluating the physiologic effects of HFTO during tracheostomy-facilitated weaning and to identify potential areas for future research in this field. ⋯ The main physiological effect of HFTO as compared to conventional O2 therapy in tracheostomized subjects weaning from mechanical ventilation was improved oxygenation that is probably flow-dependent. Respiratory effort, lung aeration, neuroventilatory drive, and ventilation were similar for HFTO and conventional O2 therapy. Future studies on HFTO should be performed early in the weaning process and should evaluate its effect on sputum clearance and patient-centered outcomes like dyspnea.