Respiratory care clinics of North America
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A large randomized, controlled study of NIV plus LTOT versus LTOT in patients with COPD is needed that evaluates morbidity, mortality, quality of life, and health economic impact. It is to be hoped that funding for this type of study will be forthcoming. ⋯ A subgroup of patients with severe hypercapnia, poor tolerance of LTOT, marked nocturnal hypoventilation, or recurrent infective exacerbations may benefit from domiciliary NIV. Systematic evaluation is required in patients with CF or bronchiectasis.
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The development of sleep-disordered breathing is common in patients with chronic respiratory insufficiency due to neuromuscular and restrictive disorders, as well as in those with COPD. Nocturnal hypoventilation and obstructive and central apneas result in daytime symptoms of hypersomnolence and fatigue, and contribute to abnormalities in awake gas exchange. Long-term mechanical ventilation, delivered invasively by tracheostomy or more recently by NPPV, has been shown to eliminate sleep-disordered breathing and correct abnormalities in nocturnal gas exchange, resulting in an improvement in sleep quality. Improved daytime symptoms and gas exchange, with the suggestion of a decrease in morbidity and mortality, support the use of long-term mechanical ventilation during sleep in selected patients with these disorders.
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Respir Care Clin N Am · Dec 2002
ReviewCare of the patient requiring invasive mechanical ventilation.
Patients who require prolonged invasive mechanical ventilation pose a unique set of circumstances to the pulmonary and critical care practitioner. This requires a delineation of the primary cause for respiratory failure, and, in most cases, a comprehensive multidisciplinary approach to the treatment of not only the primary disturbance causing respiratory failure, but the consequences that immobility, illness, and prolonged ventilation have on swallowing and ambulatory function, psychosocial interaction, and the ability to wean from mechanical ventilation. The development of multidisciplinary rehabilitative units for patients requiring prolonged mechanical ventilation have showed not only a reduction in hospital costs and lengths of stay, but also an improvement in patient survival, functional status, reduction in ventilator days or need for mechanical ventilation at discharge, and, overall, the achievement of a satisfactory quality of life.
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Respir Care Clin N Am · Sep 2002
ReviewChoice of ventilator types, modes, and settings for long-term ventilation.
Ventilator-associated issues are important for optimum short- and long-term outcome in patients treated with long-term mechanical ventilation, and may even influence compliance. This article discusses the individual choice of type, modeand settings ventilators, based on the efficacy of the intervention and patient-related factors, such as the patient's comfort and safety. Although this strategy may cause some overlap, from a methodological point of view it seems reasonable to deal separately with types, modes and different ventilator settings.
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Maintaining optimal lung recruitment has a marked effect on the outcome of patients who suffer from ARDS. RMs superimposed on mechanical ventilation have the potential to recruit atelectatic lungs in the course of general anesthesia; however, the physiologic benefits are less evident in ARDS patients who are ventilated at low VT values and high PEEP levels. ⋯ Although RMs are transient, they may be associated with complications such as hypotension, bradycardia, and barotrauma. Moreover, further studies are needed to compare the efficacy of periodic high-pressure RMs that are superimposed on mechanical ventilation with ventilation using high PEEP levels and low VT values without RMs in patients who have early ARDS after initial hemodynamic stabilization.