Chest
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Lung transplantation is an effective therapy for many patients with end-stage lung disease. Few centers across the United States offer this therapy, as a successful lung transplant program requires significant institutional resources and specialized personnel. Analysis of the United Network of Organ Sharing database reveals that the failure rate of new programs exceeds 40%. ⋯ In May of 2007, we started a new lung transplant program at the University of Iowa Hospitals and Clinics and have performed 101 transplants with an average recipient 1-year survival of 91%, placing our program among the top in the country for the past 5 years. Herein, we review internal and external factors that impact the viability of a new lung transplant program. We discuss the use of four prospectively identified quality measures: volume, recipient outcomes, financial solvency, and academic contribution as one approach to achieve programmatic excellence.
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The proportion of critically ill patients awaiting lung transplantation has increased since the implementation of the Lung Allocation Score (LAS) in 2005. Critically ill patients comprise a sizable proportion of wait-list mortality and are known to experience increased posttransplant complications. These critically ill patients have been successfully bridged to lung transplantation with extracorporeal membrane oxygenation (ECMO), but historically these patients have required excessive sedation, been immobile, and have had difficult functional recovery in the posttransplant period and high mortality. ⋯ Ambulatory ECMO programs of this nature have been developed in an attempt to provide rehabilitation, physical therapy, and minimization of sedation prior to lung transplantation to improve both surgical and posttransplant outcomes. Favorable outcomes have been reported using this novel approach, but how and where this strategy should be implemented remain unclear. In this commentary, we review the currently available literature for ambulation and rehabilitation during ECMO support as a bridge to lung transplantation, discuss future directions for this technology, and address the important issues of resource allocation and regionalization of care as they relate to ambulatory ECMO.
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Pain is emerging as a clinical complication in COPD, but the clinical impact of this comorbidity and the measurement properties of instruments used to assess pain require evaluation. ⋯ In people with COPD, pain has negative clinical associations with symptoms and quality-of-life measures. Further research exploring the measurement properties of instruments assessing pain is required.
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Comparative Study Clinical Trial
PERCUTANEOUS DILATATIONAL TRACHEOSTOMY WITH A DOUBLE LUMEN ENDOTRACHEALTUBE: A COMPARISON OF FEASIBILITY, GAS-EXCHANGE AND AIRWAY PRESSURES.
Gas exchange and airway pressures are markedly altered during percutaneous dilatational tracheostomy (PDT). A double-lumen endotracheal tube (DLET) has been developed for better airway management during PDT. The current study prospectively evaluated the in vivo feasibility, gas exchange, and airway pressures during PDT with DLET compared with a conventional endotracheal tube (ETT). ⋯ PDT with DLET can be performed safely without difficulties limiting the technique. Furthermore, during PDT, the use of the DLET resulted in more stable gas exchange, airway pressures, and ventilation than PDT with a conventional ETT.
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The Hospital Readmissions Reduction Program (HRRP) penalizes hospitals for 30-day readmissions and was extended to COPD in October 2014. There is limited evidence available on readmission risk factors and reasons for readmission to guide hospitals in initiating programs to reduce COPD readmissions. ⋯ Medicare patients with COPD exacerbations are usually not readmitted for COPD, and these reasons differ depending on PAC use. Readmitted patients are more likely to be dually enrolled in Medicare and Medicaid, suggesting that the addition of COPD to the readmissions penalty may further worsen the disproportionately high penalties seen in safety net hospitals.