Chest
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The prognosis of patients with COPD requiring admission to the ICU is generally believed to be poor. There is a paucity of long-term survival data. We undertook a study to examine both the in-hospital and 5-year mortality rates and to identify the clinical predictors of these outcomes. ⋯ We support previous findings of good early survival and significant but acceptable long-term mortality rates in patients who have been admitted to the ICU for acute exacerbation of COPD. Increased age, previous history of MV, poor nutritional status, and higher APACHE II score on ICU admission could be identified as risk factors associated with increased mortality rates. Long-term survival of patients with COPD who required MV for an acute exacerbation of their disease cannot be predicted simply from data available at the time of intubation. Physicians should incorporate these factors in their decision-making process.
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To investigate the effect of volitional pursed-lips breathing (PLB) on breathing pattern, respiratory mechanics, operational lung volumes, and dyspnea in patients with COPD. ⋯ PLB can have a variable effect on dyspnea when performed volitionally during exercise by patients with COPD. The effect of PLB on dyspnea is related to the combined change that it promotes in the tidal volume and EELV and their impact on the available capacity of the respiratory muscles to meet the demands placed on them in terms of pressure generation.
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Of the 128 articles evaluated on the overall topic of atrial fibrillation (AF) after cardiac surgery, only 19 studies dealing with pharmacologic heart rhythm control were relevant for inclusion in this analysis, indicating the relative paucity of evidence-based studies addressing this topic. We found limited data on guiding treatment for the rhythm control of AF following cardiac surgery in patients who do not require urgent cardioversion; therefore, the choice of an antiarrhythmic drug needs to be guided by patient characteristics. Based on limited available evidence, amiodarone is recommended for pharmacologic conversion of postoperative AF and AFL in patients with depressed left ventricular function who do not need urgent electrical cardioversion. ⋯ Sotalol and class 1A antiarrhythmic drugs are reasonable choices for patients with coronary artery disease who do not have congestive heart failure. There are currently no definitive data to guide the decision about the duration of antiarrhythmic drug therapy for patients with AF following cardiac surgery. Most protocols continue therapy with the antiarrhythmic drug for 4 to 6 weeks following surgery, but evidence from randomized studies is lacking.
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Peripherally inserted central venous catheters (PICCs) are now widely used for intermediate and long-term access in current-day health care, especially in the inpatient setting, where they are increasingly supplanting conventional central venous catheters (CVCs) placed percutaneously into the internal jugular, subclavian, or femoral veins. Data on the risk of PICC-related bloodstream infection (BSI) with PICCs used in hospitalized patients are limited. ⋯ This prospective study shows that PICCs used in high-risk hospitalized patients are associated with a rate of catheter-related BSI similar to conventional CVCs placed in the internal jugular or subclavian veins (2 to 5 per 1,000 catheter-days), much higher than with PICCs used exclusively in the outpatient setting (approximately 0.4 per 1,000 catheter-days), and higher than with cuffed and tunneled Hickman-like CVCs (approximately 1 per 1,000 catheter-days). A randomized trial of PICCs and conventional CVCs in hospitalized patients requiring central access is needed. Our data raise the question of whether the growing trend in many hospital hematology and oncology services to switch from use of cuffed and tunneled CVCs to PICCs is justified, particularly since PICCs are more vulnerable to thrombosis and dislodgment, and are less useful for drawing blood specimens. Moreover, PICCs are not advisable in patients with renal failure and impending need for dialysis, in whom preservation of upper-extremity veins is needed for fistula or graft implantation.
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New-onset atrial fibrillation (AF) occurs frequently after cardiac surgery. The utility of prophylactic atrial pacing to prevent AF following cardiac surgery has been investigated in a number of trials, but clinical guidelines for its use are lacking. Trials of prophylactic atrial pacing to prevent AF following cardiac surgery were identified by searching PubMed, the Cochrane database, selected medical journals, and references in selected articles. ⋯ Prophylactic biatrial pacing (BAP) reduced the incidence of AF significantly in four studies, reduced it nonsignificantly in one study, and had no effect in one study. On the basis of the literature that was reviewed and graded for quality, it was concluded that prophylactic atrial pacing to prevent AF after cardiac surgery is safe. We recommend that BAP be considered, particularly in patients who are at high risk for the development of postoperative AF.