Annals of the American Thoracic Society
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Right ventricular (RV) failure occurs when the RV fails to maintain enough blood flow through the pulmonary circulation to achieve adequate left ventricular filling. This can occur suddenly in a previously healthy heart due to massive pulmonary embolism or right-sided myocardial infarction, but many cases encountered in the intensive care unit involve worsening of compensated RV failure in the setting of chronic heart and lung disease. Management of RV failure is directed at optimizing right-sided filling pressures and reducing afterload. ⋯ Systemic systolic arterial pressure should be kept close to RV systolic pressure to maintain RV perfusion. When these efforts fail, the judicious use of inotropic agents may help improve RV contractility enough to maintain cardiac output. Extracorporeal life support is increasingly being used to support patients with acute RV failure who fail to respond to medical management while the underlying cause of their RV failure is addressed.
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Review
Will Choosing Wisely® improve quality and lower costs of care for patients with critical illness?
In 2009, a group of experts convened by the Institute of Medicine estimated that 30% of health care costs amounted to waste, including a substantial share from nonbeneficial and often harmful services. Professional organizations and medical ethicists subsequently called on specialty groups to generate "top five" lists of expensive tests or treatments without known benefits. Responding to this call, the American Board of Internal Medicine launched its Choosing Wisely campaign, with the top-five Choosing Wisely lists for pulmonary medicine and critical care released in 2014. ⋯ Although the campaign addresses some limitations of past efforts to improve quality and reduce waste, we believe it will do little to change provider behavior. Even if the top-five list for critical care were to change the behavior of providers, its ultimate impact on costs and quality will be lower than anticipated. Here we suggest several strategies for stakeholders to increase the impact of the critical care top-five list, and further discuss that despite limitations of the campaign it is still imperative for advancing best practice in critical care.
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Multicenter Study
Associations between physical activity and 30-day readmission risk in chronic obstructive pulmonary disease.
Efforts to reduce 30-day readmission have mostly concentrated on addressing deficiencies in care transitions and outpatient management after discharge. There is growing evidence to suggest that physical inactivity is associated with increased hospitalizations. ⋯ Our findings further support the importance of physical activity in the management of COPD across the care continuum. Although it is possible that lower physical activity is a reflection of worse disease, promoting and supporting physical activity is a promising strategy to reduce the risk of readmission.
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Transbronchial needle aspiration (TBNA) remains an invaluable diagnostic tool in the evaluation of mediastinal and hilar abnormalities, specifically in the evaluation of patients with lung cancer. Training in TBNA has remained integral in pulmonary fellowship programs, but unfortunately the training methods, volumes, and outcomes have been variable. ⋯ However, with this new technology, many questions have surfaced regarding training methods, volumes, and who should receive training. Within this context, we describe the history, current state, and future directions of the education of TBNA during pulmonary fellowship training.
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The focused ultrasound examination has become increasingly recognized as a safe and valuable diagnostic tool for the bedside assessment of the critically ill patient. We implemented a dedicated on-site critical care ultrasonography curriculum with the goal of developing a model for teaching ultrasound skills to pulmonary and critical care medicine fellows. ⋯ At one academic medical center, the knowledge of eight adult pulmonary and critical care fellowship trainees regarding critical care ultrasound was high at baseline; however, bedside image acquisition skills were poor. A dedicated 6-week educational intervention resulted in highly significant improvements in subject knowledge and image acquisition skills. These preliminary results warrant validation studies at other medical centers.