Chest surgery clinics of North America
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Significant advances have occurred in the knowledge of the pathogenesis of ARDS. It is now recognized that ARDS is a manifestation of a diffuse process that results from a complicated cascade of events following an initial insult or injury. Mechanical ventilation and PEEP are still important components of supportive therapy. ⋯ Apart from the challenge of testing these agents in experimental models, it seems likely that determination of the optimum combination of agents will become an equally important endeavor. A particular challenge is to develop better methods of predicting which of the many at-risk patients will go on to full-blown ARDS and MODS, thereby targeting subgroups of patients most likely to benefit from anti-inflammatory therapies. Similarly, the adverse effects of immunosuppressive therapy may be diminished by improved, perhaps molecular, techniques to detect microbial pathogens and permit differentiation between Systemic inflammatory response syndrome and sepsis.
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Chest Surg. Clin. N. Am. · May 2002
ReviewExtracorporeal membrane oxygenation for severe respiratory failure.
The use of extracorporeal technology to accomplish gas exchange with or without cardiac support is based on the premise that "lung rest" facilitates repair and avoids the baso- or volutrauma of mechanical ventilator management. Extracorporeal membrane oxygenation (ECMO), a modified form of cardiopulmonary bypass, has been shown to decrease mortality of neonatal, pediatric and adult respiratory failure and is capable of total gas exchange. In neonates, over 20,638 patients have been treated with an overall survival of 77% in a population thought to have 78% mortality.
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Despite the increasing obesity of the American population, many chronically ill patients are malnourished. When this malnutrition is combined with the hypermetabolic response and protein catabolism of an acute event, such as an operation, nutritional support becomes an important facet for optimal critical care. This chapter reviews the basic tenants of nutritional support with special emphasis on patients with pulmonary compromise. Important aspects of caloric and protein support are discussed and enteral nutrition is emphasized because of its numerous advantages and documented improvement in outcome.
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Aspiration of tracheobronchial foreign bodies occurs more commonly in children, but under certain circumstances, it also can occur in adults. The most common symptoms are choking followed by a protracted cough. Physical examination findings include fever, stridor, retractions, and decreased breath sounds. ⋯ The procedure is generally safe and well tolerated. Many patients are managed under general anesthesia, but foreign bodies often can be removed with a flexible bronchoscope with the patient under local anesthesia. Surgery should be performed only as a last resort and rarely is necessary.
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Since the development of the flexible bronchoscope in late 1960s, its use in the management of various pulmonary disorders, especially lung Ca, has expanded tremendously. It is not only of great diagnostic value, with the recent development of various therapeutic modalities such as Nd:YAG laser, tracheobronchial stents, and cryotherapy, but also its value in management of terminal lung Ca has improved dramatically. ⋯ More importantly, because of lack of the training in RB and widespread usage of FB, it is more likely that its role in the various interventional procedures, such as Nd:YAG laser therapy, tracheobronchial stent deployment, brachytherapy, and cryotherapy, will grow exponentially. Because of availability of a variety of therapeutic modalities, such as APC, PDT, and balloons, interventional pulmonologists are well equipped to improve the quality of life of terminally ill patients with cancer and maybe to cure early stage lung Ca.