Respiratory care
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Intra- and inter-hospital transport is common due to the need for advanced diagnostics and procedures, and to provide access to specialized care. Risks are inherent during transport, so the anticipated benefits of transport must be weighed against the possible negative outcome during the transport. Adverse events are common in both in and out of hospital transports, the most common being equipment malfunctions. ⋯ It is recommended that portable ventilators be used for transport, because studies show that use of a manual resuscitator alters blood gas values due to inconsistent ventilation. The performance of new generation transport ventilators has improved greatly and now allows for seamless transition from ICU ventilators. Diligent planning for and monitoring during transport may decrease adverse events and reduce risk.
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The evolution of critical care and mechanical ventilation has been dramatic and rapid over the last 10 years and can be expected to continue at this pace into the future. As a result, the competencies of the respiratory therapist regarding mechanical ventilation in 2015 and beyond are expected to also markedly increase. ⋯ This requires an expanded education in a number of areas. To achieve these levels of competency, as recommended by the third "2015 and Beyond" conference, the entry level education of the respiratory therapist of the future must be at the baccalaureate level.
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The ventilator discontinuation process is an essential component of overall ventilator management. Undue delay leads to excess stay, iatrogenic lung injury, unnecessary sedation, and even higher mortality. On the other hand, premature withdrawal can lead to muscle fatigue, dangerous gas exchange impairment, loss of airway protection, and also a higher mortality. ⋯ This evidence base is growing, but the earlier guidelines are standing the test of time. Indeed, practice patterns are evolving in accordance with them. Nevertheless, there is still room for improvement, and further clinical studies, especially in the patient requiring PMV, are needed.
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Mechanically ventilated patients in respiratory failure often require adjunct therapies to address special needs such as inhaled drug delivery to alleviate airway obstruction, treat pulmonary infection, or stabilize gas exchange, or therapies that enhance pulmonary hygiene. These therapies generally are supportive in nature rather than curative. Currently, most lack high-level evidence supporting their routine use. ⋯ Similar low-level evidence suggests that heliox is effective in reducing airway pressure and improving ventilation in various forms of lower airway obstruction. These therapies generally are supportive and may facilitate patient management. However, because they have not been shown to improve patient outcomes, it behooves clinicians to use these therapies parsimoniously and to monitor their effectiveness carefully.
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Asthma is more prevalent in obese, compared with normal weight, subjects. Our aim has been to review current knowledge of the impact of obesity on asthma severity, asthma control, and response to therapy. Several studies have shown that overweight and obesity is associated with more severe asthma and impaired quality of life, compared with normal weight individuals. ⋯ Most studies show that overweight and obesity is associated with less favorable response to asthma therapy, with regard to symptoms, level of FEV1, fraction of exhaled nitric oxide, and airway responsiveness. Some studies suggest that asthma in the obese patient might be more responsive to leukotriene modifiers, orchestrated by leptin and/or adiponectin derived from adipose tissue, than to inhaled corticosteroids, possibly reflecting differences in the underlying airway inflammation in obese versus non-obese asthmatics. In conclusion, overweight and obesity is associated with poorer asthma control and, very importantly, overall poorer response to asthma therapy, compared with normal weight individuals.