Respiratory care
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Mechanical ventilation is a well-established and commonly employed modality of treatment for critically ill patients in the ICU. Pneumonia is a frequent complication in mechanically ventilated patients. Patients who develop ventilator-associated pneumonia (VAP) incur higher medical costs, have prolonged ICU and hospital stays, and have increased mortality risk. ⋯ There are several clinical settings in which aerosolized antibiotics could be used for treating pneumonia, including their use for prevention, as monotherapy, as adjunctive therapy with systemic antibiotics, and for treatment of extensively drug-resistant or pan drug-resistant pathogens. However, aerosolized antibiotics have not been uniformly effective for improving clinical outcomes of patients with VAP, and local and systemic side effects could complicate their use. Moreover, many questions about aerosolized antibiotics, such as optimal formulations and dosage and treatment regimens, remain unanswered and warrant future investigations.
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There have been many innovations to the standard endotracheal tube over the years, many of which were intended to reduce the incidence of ventilator-associated pneumonia (VAP). Ventilator-associated events are associated with the objective outcomes of increased duration of mechanical ventilation, length of ICU and hospital stay, and increased risk of mortality. Many specialty tubes have been associated with a reduction in the clinical diagnosis of VAP, but studies have failed to show differences in objective outcomes. This article reviews the evidence related to specialty tubes and discusses their role in improving objective outcomes associated with ventilator-associated events.
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Observational Study
Reference Equations for the ADL-Glittre Test in Pediatric Subjects.
The ADL-Glittre test (TGlittre) was initially proposed to evaluate the activities of daily life (ADL) of adults with COPD that involve activities with the upper limbs in addition to walking. Recently, the test has been adapted for children (TGlittre-P), but no reference values have been proposed for its use in this population. The main objective of this study was to develop reference equations for the pediatric adaptation of the TGlittre. ⋯ TGlittre-P reference equations were developed for females and males, with age being the most influential predictive variable in the test performed by children.
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The 6-min walk test (6MWT) encompasses potential and untapped information related to exercise capacity. However, this test does not yield any information about gait pattern. Recently, we used a ventilatory polygraph to reveal respiratory adaptation during the 6MWT with subjects having high or low body mass index (BMI). In this study, we aimed to determine gait parameters with the same device, which integrates an accelerometer. ⋯ Our results demonstrated that a ventilatory polygraph with an embedded accelerometer can be used to detect steps and U-turns, and to calculate 6MWD. This method is sufficiently sensitive to characterize significant BMI-dependent differences in gait pattern during a 6MWT and appears to be a promising tool for routine clinical use.
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Recent literature suggests that optimization of tidal driving pressure (ΔP) would be a better variable to target for lung protection at the bedside than tidal volume (VT) or plateau pressure (Pplat), the traditional indicators of ventilator-induced lung injury. However, the usual range or variability of ΔP over time for any subject category have not been defined. This study sought to document the ΔP ranges observed in current practice among mechanically ventilated subjects receiving routine care for diverse acute conditions in a community hospital environment. ⋯ Suggested safety thresholds for ΔP are often violated by a strategy that focuses on only VT and Pplat. Our data suggest that ΔP is lower for passive versus triggered breathing cycles. Vigilance is especially important in the initial stages of mechanical ventilator support, and attention should be paid to triggering efforts when interpreting and comparing machine-determined numerical values for ΔP.