Chest
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Successful extubation conventionally necessitates the passing of spontaneous breathing trials (SBTs) and ventilator weaning parameters. We report successful extubation of patients with neuromuscular disease (NMD) and weakness who could not pass them. ⋯ Continuous volume-cycled NIV via oral interfaces and masks and MAC with oximetry feedback in ambient air can permit safe extubation of unweanable patients with NMD.
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Comparative Study
Comparison of plethysmographic and helium dilution lung volumes: which is best for COPD?
Theoretical considerations and limited scientific evidence suggest that whole-body plethysmography overestimates lung volume in patients with severe airflow obstruction. We sought to compare plethysmography (Pleth)-, helium dilution (He)- and CT scan-derived lung volume measurements in a sample containing many patients with severe airflow obstruction. ⋯ In the setting of airflow obstruction, Pleth systematically overestimates lung volume relative to He or thoracic imaging despite adherence to current recommendations for proper measurement technique.
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Multicenter Study
A prospective multicenter study of competency metrics and educational interventions in the learning of bronchoscopy among new pulmonary fellows.
Learning medical procedures relies predominantly on the apprenticeship model, and competency is established based on the number of performed procedures. Our study aimed to establish bronchoscopy competency metrics based on performance and enhanced learning with educational interventions. ⋯ Performance-based competency metrics can be used to evaluate bronchoscopy skills. Educational interventions, such as simulation-based training, accelerated the acquisition of bronchoscopy skills among first-year pulmonary fellows as assessed by a validated objective assessment tool.
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The current article surveys an assortment of legal issues identified by the editors that relate to the malpractice sphere. However, this represents only a small part of the total legal medicine picture. The interaction of law and medical care in the United States today encompasses a broad array of specific points of contact between physicians' professional activities and various public bodies and private entities. Several articles by other authors will appear in subsequent issues of CHEST and flesh out much more comprehensively both the topics outlined briefly here and other legal questions that concern contemporary members of the medical profession.
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Approximately 16% of deaths in patients with ARDS results from refractory hypoxemia, which is the inability to achieve adequate arterial oxygenation despite high levels of inspired oxygen or the development of barotrauma. A number of ventilator-focused rescue therapies that can be used when conventional mechanical ventilation does not achieve a specific target level of oxygenation are discussed. A literature search was conducted and narrative review written to summarize the use of high levels of positive end-expiratory pressure, recruitment maneuvers, airway pressure-release ventilation, and high-frequency ventilation. ⋯ The optimal time to initiate rescue therapies, if needed, is within 96 h of the onset of ARDS, a time when alveolar recruitment potential is the greatest. A variety of ventilatory approaches are available to improve oxygenation in the setting of refractory hypoxemia and ARDS. Which, if any, of these approaches should be used is often determined by the availability of equipment and clinician bias.