Chest
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Noninvasive ventilation (NIV), the provision of ventilatory assistance without an artificial airway, has emerged as an important ventilatory modality in critical care. This has been fueled by evidence demonstrating improved outcomes in patients with respiratory failure due to COPD exacerbations, acute cardiogenic pulmonary edema, or immunocompromised states, and when NIV is used to facilitate extubation in COPD patients with failed spontaneous breathing trials. Numerous other applications are supported by weaker evidence. ⋯ Patients begun on NIV should be monitored closely in an ICU or other suitable setting until adequately stabilized, paying attention not only to vital signs and gas exchange, but also to comfort and tolerance. Patients not having a favorable initial response to NIV should be considered for intubation without delay. NIV is currently used in only a select minority of patients with acute respiratory failure, but with technical advances and new evidence on its proper application, this role is likely to further expand.
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To determine the clinical effectiveness of implementing early goal-directed therapy (EGDT) as a routine protocol in the emergency department (ED). ⋯ Implementation of EGDT in our ED was associated with a 9% absolute (33% relative) mortality reduction. Our data provide external validation of the clinical effectiveness of EGDT to treat sepsis and septic shock in the ED.
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Massive pulmonary embolism (PE) is a life-threatening condition with a high early mortality rate due to acute right ventricular failure and cardiogenic shock. As soon as the diagnosis is suspected, an IV bolus of unfractionated heparin should be administered. In addition to anticoagulation, rapid initiation of systemic thrombolysis is potentially life-saving and therefore is standard therapy. ⋯ In these patients, catheter or surgical embolectomy are helpful for rapidly reversing right ventricular failure. Catheter thrombectomy appears to be particularly useful if surgical embolectomy is not available or the patient has contraindications to surgery. Although no controlled clinical trials are available, data from cohort studies indicate that the clinical outcomes after surgical and catheter embolectomy may be comparable.
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Systemic air embolism is recognized as a potentially fatal but extremely rare complication following percutaneous transthoracic needle biopsy. However, its incidence might be underestimated by missing systemic air in patients without cardiac or cerebral symptoms. ⋯ Systemic air embolism following CT scan-guided transthoracic needle biopsy was encountered more frequently than would be expected. The considerable attention we gave to this complication enabled us to recognize it in patients without cardiac or cerebral symptoms. No sequelae were observed in the three patients in whom systemic air embolism was detected, and the therapy was initiated immediately, whereas missing systemic air led to cerebral embolism in one patient in our four cases.
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The hallmark of COPD is airflow obstruction, but this can develop on the basis of airway disease, emphysema, or both. There are gender differences in the natural history of COPD, and these may in part be explained by differences in the pathophysiology of airflow obstruction. We aimed to determine if there are gender differences in the severity of CT emphysema among COPD patients. ⋯ At all stages of COPD severity, men have more CT emphysema than women. This difference in radiologic expression may in part explain gender differences in the presentation and natural history of COPD. The NLST (NCT00047385) is registered at www.clinicaltrials.gov. Registered at www.clinicaltrials.gov; no.NCT00047835.