Respiratory care clinics of North America
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The development of regional techniques of analgesia has revolutionized the management of blunt thoracic trauma. The standard of care has evolved from intubation and mechanical ventilation for all patients to optimization of pain control combined with chest physiotherapy. ⋯ It still remains for improvement in outcome to be demonstrated when epidural analgesia is used, but it is clear that subjective patient comfort is increased and that pulmonary parameters can be improved. In appropriately selected patients, those without head injury or who have been adequately evaluated for intra-abdominal injury, epidural analgesia is currently the preferred method for pain control following severe thoracic trauma.
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Airway clearance techniques are indicated for specific diseases that have known clearance abnormalities (Table 2). Murray and others have commented that such techniques are required only for patients with a daily sputum production of greater than 30 mL. The authors have observed that patients with diseases known to cause clearance abnormalities can have sputum clearance with some techniques, such as positive expiratory pressure, autogenic drainage, and active cycle of breathing techniques, when PDPV has not been effective. ⋯ Long-term controlled trials are urgently needed to help establish the best types of treatment for patients with CF and bronchiectasis. Such studies will become more complicated by the introduction of new treatments, such as DNase and other therapies that alter secretions, and may begin to change mucociliary or cough clearance. The selection of appropriate outcome measures is central to studying these questions, and it is unclear which are the most important. (ABSTRACT TRUNCATED)
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Respir Care Clin N Am · Jun 1996
ReviewNoninvasive positive pressure ventilation. Equipment and techniques.
Successful application of noninvasive positive pressure ventilation is largely dependent on available equipment and the approaches used to apply it. Third-generation intensive care unit ventilators and portable volume and pressure ventilators may be used for noninvasive positive pressure ventilation. A variety of facial interfaces currently are manufactured, and all should be available. A well-trained therapist with available time is the final ingredient for successful use of noninvasive positive pressure ventilation.
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Respir Care Clin N Am · Jun 1996
ReviewNoninvasive ventilation for postoperative support and facilitation of weaning.
Noninvasive ventilation includes continuous positive airway pressure with mask, positive pressure ventilation with mask, and negative pressure body ventilation. Noninvasive ventilation is a ventilatory support mode intermediate in both effectiveness and potential complications between oxygen administration and intubation with mechanical ventilation. ⋯ In addition, the use of noninvasive ventilation as an aid to weaning of patients from mechanical ventilation is discussed. This use of noninvasive ventilation has not yet been extensively reported, although it appears to be potentially useful.
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Noninvasive PPV has been employed for decades in patients with chronic respiratory failure. Increasing use in patients with acute respiratory failure is a more recent phenomenon, mainly because of advances in noninvasive interfaces and ventilator modes. Noninvasive PPV delivered by nasal or oronasal mask has been demonstrated to reduce the need for endotracheal intubation, decrease lengths of stay in the ICU and hospital, and possibly reduce mortality. ⋯ Moreover, the authors favor conservative management with expeditious intubation in patients who have other conditions that place them at risk during use of noninvasive ventilation or in patients failing to respond to noninvasive PPV. Noninvasive PPV clearly represents an important addition to the techniques available to manage patients with acute respiratory failure; however, because most studies have been retrospective and uncontrolled, many issues remain unresolved. Further controlled studies are needed to confirm the safety and efficacy of noninvasive PPV, evaluate the most appropriate selection of patients and timing of intervention, define the best type of interface, and assess the costs of noninvasive PPV in comparison with conventional therapy.