Respiratory care clinics of North America
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Respir Care Clin N Am · Jun 2004
ReviewPractitioner competency assessment and career ladders as a recruiting and retention tool.
The assessment of competency for respiratory care practitioners involves a thorough understanding of what defines competence, the development of a well-planned, continuous process that starts with new employee orientation, and a clearly communicated set of staff expectations. Career ladders are a tool that can be used to aid staff retention and recruitment, thereby reducing multiple costs associated with a high employee turnover rate, and to encourage professional development and accountability while achieving important departmental objectives.
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Respir Care Clin N Am · Dec 2003
ReviewHemodynamic monitoring in acute lung injury and acute respiratory distress syndrome.
Hemodynamic monitoring of critically ill patients, especially those who have ALI or ARDS, is a widely practiced compilation of techniques that largely have not been demonstrated to improve patient outcomes. Indeed, some techniques, such as use of the PAC, may actually be harmful. ⋯ Rather it seems more likely that operator errors in gathering and interpreting hemodynamic data and in selecting the appropriate treatment strategies are the culprits. There is promise that ongoing clinical trials and better provider education will soon result in evidence-based recommendations for monitoring the circulation in this patient population.
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Respir Care Clin N Am · Dec 2003
ReviewEmerging systemic pharmacologic approaches in acute respiratory distress syndrome.
The increased understanding of the pathophysiology of ALI that has been achieved over the last decade has led to several new pharmacologic approaches for the prevention and management of ALI and ARDS. Based on in vitro information and animal model data, many of these strategies seem quite compelling. Nevertheless, to date, no specific pharmacologic approach for the prevention or treatment of ARDS has been conclusively validated in clinical trials. Active basic and clinical research continues, and it is hoped that these investigations will lead to new therapies that can be applied by the clinician to improve clinical outcomes for patients who have ALI and ARDS.
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The ultimate efficacy of prone positioning in ARDS is difficult to evaluate because of heterogeneous study populations, the variances in the duration of the prone position, and the small sample sizes used in most studies. Prone positioning offers an easy, readily available treatment option for refractory hypoxemia. Although there is a rationale supporting the hypothesis that prone ventilation could reduce the mortality of ARDS patients, currently there are insufficient clinical data to support this hypothesis.
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Respir Care Clin N Am · Dec 2003
ReviewLung recruitment maneuvers in acute respiratory distress syndrome.
In the experimental setting, repeated derecruitments of the lungs of ARDS models accentuate lung injury during mechanical ventilation, whereas open lung concept strategies can attenuate the injury. In the clinical setting, recruitment manuevers that use a continuous positive airway pressure of 40 cmH2O for 40 secs improve oxygenation in patients with early ARDS who do not have an impairment in the chest wall. High intermittent positive end-expiratory pressure (PEEP), intermitent sighs, or high-pressure controlled ventilation improves short-term oxygenation in ARDS patients. ⋯ Recruitment maneuvers that used continuous positive airway pressure levels of 35-40 cmH2O for 40 secs, with PEEP set at 2 cmH2O above the lower inflection point of the pressure-volume curve, and tidal volume < 6 mL/kg were associated with a 28-day intensive care unit survival rate of 62%. This contrasted with a survival rate of only 29% with conventional ventilation (defined as the lowest PEEP for acceptable oxygenation without hemodynamic impairment with a tidal volume of 12 mL/kg), without recruitment manuevers (number needed to treat = 3; p < 0.001). In the near future, thoracic computed tomography associated with high-performance monitoring of regional ventilation may be used at the bedside to determine the optimal mechanical ventilation of the ARDS keeping an opened lung with a homogenous ventilation.