Chest
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Randomized Controlled Trial Multicenter Study
Efficacy and safety of inhaled aztreonam lysine for airway pseudomonas in cystic fibrosis.
We assessed the short-term efficacy and safety of aztreonam lysine for inhalation (AZLI [an aerosolized monobactam antibiotic]) in patients with cystic fibrosis (CF) and Pseudomonas aeruginosa (PA) airway infection. ⋯ In patients with CF, PA airway infection, moderate-to-severe lung disease, and no recent use of antipseudomonal antibiotics or azithromycin, 28-day treatment with AZLI significantly improved respiratory symptoms and pulmonary function, and was well tolerated.
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In the ICU where critically ill patients receive aggressive life-sustaining interventions, suffering is common and death can be expected in up to 20% of patients. High-quality pain management is a part of optimal therapy and requires knowledge and skill in pharmacologic, behavioral, social, and communication strategies grounded in the holistic palliative care approach. This contemporary review article focuses on pain management within comprehensive palliative and end-of-life care. These key points emerge from the transdisciplinary review: (1) all ICU patients experience opportunities for discomfort and suffering regardless of prognosis or goals, thus palliative therapy is a requisite approach for every patient, of which pain management is a principal component; (2) for those dying in the ICU, an explicit shift in management to comfort-oriented care is often warranted and may be the most beneficial treatment the health-care team can offer; (3) communication and cultural sensitivity with the patient-family unit is a principal approach for optimizing palliative and pain management as part of comprehensive ICU care; (4) ethical and legal misconceptions about the escalation of opiates and other palliative therapies should not be barriers to appropriate care, provided the intention of treatment is alleviation of pain and suffering; (5) standardized instruments, performance measurement, and care delivery aids are effective strategies for decreasing variability and improving palliative care in the complex ICU setting; and (6) comprehensive palliative care should addresses family and caregiver stress associated with caring for critically ill patients and anticipated suffering and loss.
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Review Case Reports
Thrombolytic therapy for acute pulmonary embolism: a critical appraisal.
Pulmonary embolism (PE) is a prevalent condition that may account for > 300,000 deaths annually in the United States alone. Although thrombolytics have been studied as a treatment for acute PE since the 1960s, to date there have been only 11 randomized controlled trials comparing thrombolytic therapy to conventional anticoagulation, and the numbers of patients included in these trials has been small. Many studies confirm that thrombolytic therapy leads to rapid improvement in hemodynamic aberrations associated with PE, and this approach to massive PE with cardiogenic shock is a guideline-based practice. ⋯ Further efforts at risk stratification may better determine who is in need of aggressive therapy. This article reviews historical aspects of and current evidence for thrombolytic therapy in acute PE with specific attention to bleeding risk, and data regarding hemodynamic parameters and mortality. We also discuss risk stratification techniques and propose a clinical algorithm for the incorporation of thrombolytic therapy.
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The role of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) following integrated PET/CT scanning in mediastinal staging of non-small cell lung cancer (NSCLC) has not been assessed. ⋯ EBUS-TBNA was an effective invasive method following PET/CT scanning in the mediastinal staging of potentially operable NSCLC. In mediastinal PET/CT scan-positive cases, EBUS-TBNA was an excellent tool for detecting mediastinal metastasis. Even in mediastinal PET/CT scan-negative cases, EBUS-TBNA can be useful for confirming mediastinal metastases, especially in adenocarcinoma.
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Randomized Controlled Trial
Prophylactic nasal continuous positive airway pressure following cardiac surgery protects from postoperative pulmonary complications: a prospective, randomized, controlled trial in 500 patients.
Continuous positive airway pressure is a noninvasive respiratory support technique that may prevent pulmonary complications following cardiac surgery. This study was conducted to determine the efficacy of prophylactic nasal continuous positive airway pressure (nCPAP) compared with standard treatment. The primary end points were pulmonary adverse effects defined as hypoxemia (Pao(2)/fraction of inspired oxygen [Fio(2)] <100), pneumonia, and reintubation. The secondary end point was the readmission rate to the ICU or intermediate care unit (IMCU). ⋯ The long-term administration of prophylactic nCPAP following cardiac surgery improved arterial oxygenation, reduced the incidence of pulmonary complications including pneumonia and reintubation rate, and reduced readmission rate to the ICU or IMCU. Thus noninvasive respiratory support with nCPAP is a useful tool to reduce pulmonary morbidity following elective cardiac surgery.