Annals of the American Thoracic Society
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Since its original description in 1967, acute respiratory distress syndrome (ARDS) has been recognized as a devastating condition associated with significant morbidity and mortality. Advances in critical care medicine and ARDS management have led to a substantial increase in the number of ARDS survivors. Long-term cognitive impairment after critical illness is a significant public health concern. ⋯ An approach targeted to subnormal oxygenation values (partial pressure of arterial oxygen, 55-80 mm Hg) has emerged as a means to accomplish these aims. In this perspective, we critically evaluate this strategy from short- and long-term perspectives, with a focus on the potential long-term cognitive effects of the strategy. We conclude with a proposal to consider resetting the target range for arterial oxygenation higher (85-110 mm Hg) as a potential strategy to improve the long-term outcomes of ARDS survivors.
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Despite the 2002 Institute of Medicine report that described the moral and financial impact of health care disparities and the need to address them, it is evident that health care disparities persist. Recommendations for addressing disparities include collecting and reporting data on patient race and ethnicity, supporting language interpretation services, increasing awareness of health care disparities through education, requiring cultural competency training for all health care professionals, and increasing diversity among those delivering health care. The Accreditation Council on Graduate Medical Education places strong emphasis on graduate medical education's role in eliminating health care disparities by asking medical educators to objectively evaluate and report on their trainees' ability to practice patient-centered, culturally competent care. ⋯ A diverse physician workforce is another strategy for mitigating health care disparities, and using strategies to enhance faculty diversity should also be a priority of graduate medical education. Transparent data about institutional diversity efforts should be provided to interested medical students, residents, and faculty. Graduate medical education has a clear charge to ensure a generation of physicians who are firmly grounded in the principles of practicing culturally competent care and committed to the reduction of health care disparities.
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Because the frequency of major risk factors for respiratory diseases (e.g., tobacco use) differs across demographic groups (defined by socioeconomic status, race/ethnicity, sexual orientation, health care access, occupation, or other characteristics), health disparities are commonly encountered in pediatric and adult pulmonary, critical care, and sleep medicine. As part of its policy on respiratory health disparities, the American Thoracic Society (ATS) Executive Committee created a Health Equality Subcommittee of the Health Policy Committee, with an initial mandate of defining respiratory health equality and, as a subsequent task, providing recommendations to the ATS leadership as to how our society may help attain such equality in the United States. After receiving input from the ATS assemblies and committees, the subcommittee developed this document on respiratory health equality. ⋯ Attainment of respiratory health equality requires the ending of respiratory health disparities, which can be achieved only through multidisciplinary efforts to eliminate detrimental environmental exposures while promoting a healthy lifestyle, implementing all components of high-quality health care (prevention, screening, diagnosis, and treatment), and conducting research that will lead to better prevention and management of respiratory diseases for everyone. The ATS recognizes that such efforts must include all stakeholders: members of society at large, governmental and nongovernmental organizations, and other professional societies. The ATS urges all of its members and those of sister societies to work to achieve this laudable goal.
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The Affordable Care Act was intended to address systematic health inequalities for millions of Americans who lacked health insurance. Expansion of Medicaid was a key component of the legislation, as it was expected to provide coverage to low-income individuals, a population at greater risk for disparities in access to the health care system and in health outcomes. Several studies suggest that expansion of Medicaid can reduce insurance-related disparities, creating optimism surrounding the potential impact of the Affordable Care Act on the health of the poor. ⋯ Moreover, relative to many private plans, Medicaid is an imperfect program suffering from lower reimbursement rates, fewer covered services, and incomplete acceptance by preventive and specialty care providers. These constraints will reduce the potential impact of the expansion for patients with respiratory and sleep conditions or critical illness. Despite its imperfections, the more than 10 million low-income individuals who gain insurance as a result of Medicaid expansion will likely have increased access to health care, reduced out-of-pocket health care spending, and ultimately improvements in their overall health.
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Between 10% and 57% of lung transplant (LTx) recipients develop primary graft dysfunction (PGD) within 72 hours of LTx. PGD is clinically and histologically analogous to the acute respiratory distress syndrome. In patients at risk for or with acute respiratory distress syndrome, lung-protective ventilation strategies (low tidal volume and positive end-expiratory pressure) improve outcomes. There is, however, little information available on mechanical ventilation strategies after LTx. ⋯ Most respondents reported using lung-protective approaches to mechanical ventilation after lung transplantation. Low tidal volumes based on recipient characteristics were frequently chosen. Donor characteristics often were not considered and frequently were not known by the team managing mechanical ventilation after LTx.