Respiratory care
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Noninvasive respiratory support at the end of life is controversial, although it is becoming increasingly common. Supplemental oxygen is widely prescribed for palliative care and may help with hypoxemic respiratory failure. Noninvasive ventilation has a well-established evidence-based role in the management of respiratory failure due to exacerbations of COPD and cardiogenic pulmonary edema. ⋯ High-flow nasal cannula oxygen therapy is a new strategy for which there is evidence to support its use for hypoxemic respiratory failure. However, any benefit of the use of high-flow nasal cannula oxygen therapy in the palliative setting is unknown at this time. This review examined evidence relating to the use of noninvasive respiratory support at the end of life.
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For more than 40 years, noninvasive ventilation has been the first-line preferred therapy for acute-on-chronic conditions, such as COPD and cardiogenic pulmonary edema. The use of noninvasive ventilation in the treatment of hypoxemic respiratory failure, however, has been met with mixed results associated with higher risks of intubation (failure of therapy) and with higher risks of mortality. The purpose of this review was to describe the current evidence and important considerations when patients with hypoxemic respiratory failure are managed with noninvasive ventilation.
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Neuromuscular diseases are a heterogeneous group of neurologic diseases that affect a number of neural structures including the motor nerves, neuromuscular junctions, or the muscles themselves. Although many of the diseases are rare, the total number of individuals who present to a pulmonologist or respiratory care provider is significant. Approaches to care include regular and careful clinical follow-up of symptoms of sleep-disordered breathing, daytime hypoventilation, as well as cough and swallowing effectiveness. ⋯ Support of cough function with manual assistance, a resuscitator bag, and/or mechanical insufflation-exsufflation can help prevent and treat infection. Referral for swallowing evaluation and treatment is very important for those with impaired bulbar function. This comprehensive respiratory care approach to individuals with neuromuscular disease and respiratory system involvement is essential to maintaining the health and longevity of these individuals.
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Noninvasive ventilation (NIV) has a number of physiologic effects similar to invasive ventilation. The major effects are to augment minute ventilation and reduce muscle loading. These effects, in turn, can have profound effects on the patient's ventilator control system, both acutely and chronically. ⋯ By reducing venous return, it can help in patients with heart failure or fluid overload, but it can compromise cardiac output in others. NIV can also increase right ventricular afterload or function to reduce left ventricular afterload. Potential detrimental physiologic effects of NIV are ventilator-induced lung injury, auto-PEEP development, and discomfort/muscle overload from poor patient-ventilator interactions.
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Randomized Controlled Trial Comparative Study
Neurally-Adjusted Ventilatory Assist for Noninvasive Ventilation via a Helmet in Subjects With COPD Exacerbation: A Physiologic Study.
In patients with COPD exacerbation, noninvasive ventilation (NIV) is strongly recommended. NIV is generally delivered by using patient triggered and flow-cycled pressure support through a face mask. A specific method to generate neurally-controlled pressure support has been shown to improve comfort and patient-ventilator interaction. In addition, the helmet interface was better tolerated by patients compared with a face mask. Herein, we compared neurally-controlled pressure support through a helmet with pressure support through a face mask with respect to subject comfort, breathing pattern, gas exchange, pressurization and triggering performance, and patient-ventilator synchrony. ⋯ In the subjects with COPD with exacerbation, NAVA through a helmet improved comfort, triggering performance, and patient-ventilator synchrony compared with pressure support through a face mask.