Respiratory care
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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.
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A respiratory therapy consult service (RTCS) may reduce misallocation of treatments. Misallocation consists of over-ordering (ie, therapy not indicated but ordered) or under-ordering (ie, therapy indicated but not ordered). The rate of agreement with RTCS-based orders is defined as the percentage of patients with no misallocation. This study was undertaken to compare current misallocation and agreement with historical benchmark rates at a hospital with an RTCS (ie, the Main Campus, or "on-MC") and 2 hospitals that did not have an RTCS (ie, off-Main Campus, or "off-MC"). ⋯ While the overall rate of agreement was lower with the RTCS currently than in the past, the decline seems solely attributable to a decline in the appropriateness of orders for bronchopulmonary hygiene. In addition, the rate of agreement for non-RTCS-based orders on-MC (71%), where the RTCS has been available for over 20 years, was higher than agreement rate for non-RTCS-based therapies off-MC (20%), where the RTCS has not yet been available. These findings suggest continued efficacy of the RTCS with the need for ongoing vigilance to assure optimal RTCS performance.
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Acute right ventricular dysfunction is a challenging problem in the immediate postoperative period following orthotopic heart transplantation. There are no prior reports of the use of inhaled iloprost in the setting of acute right ventricular dysfunction and acute pulmonary hypertension. Our hypothesis was that the use of inhaled iloprost in heart transplant recipients would be associated with a reduction in the duration of mechanical ventilation compared to patients being treated with continuous inhaled epoprostenol. Additionally, we hypothesized that the change in inhaled vasodilatory therapy would not be associated with a significant change in postoperative bleeding or use of vasoactive medications. ⋯ Use of inhaled iloprost was associated with shorter duration of mechanical ventilation compared to inhaled epoprostenol, without safety concerns.