Chest
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Rapid assessment and treatment (RAT) calls, facilitated by Rapid Response Teams (RRTs), have become vital to the care of hospitalized patients whose conditions are deteriorating outside of the ICU in many institutions worldwide. A significant body of data has recognized the efficacy of rapid response systems (RRSs) in improving patient care; however, there is no standardized protocol that all RRSs practice. Even when the recognition of patient clinical deterioration is rapidly noted, further treatment may be delayed because of issues with clinical knowledge and communication between parties present, especially in training institutions. ⋯ Finally, we reassessed our responses to RAT calls postintervention. We found that an educational intervention improved patient outcomes and several key process measures in our RRS. This article describes the process and lessons learned from our initiative.
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The integration of nurse practitioners (NPs) and physician assistants (PAs) into the medical ICU (MICU) is becoming increasingly vital due to the rising number of critically ill patients and the shortage of board-certified intensivists. Successful recruitment and utilization of NPs and PAs in the MICU setting require a unique understanding of potential variations of the scope of practice based on state law and educational backgrounds, as well as the implementation of best practices around training and leadership support. The purpose of this article was to review the best strategies for creating a MICU team with NPs and PAs. ⋯ There are variations in state laws and institutional policies that affect NP and PA practice that should be understood by the organization to manage expectations for the NP and PA job responsibilities. Effective productivity measurement methods are proposed to accurately assess the contributions of NPs and PAs in the MICU. This article provides comprehensive strategies for successfully hiring, onboarding, and integrating these professionals into MICU teams, ensuring high-quality care delivery in critical care settings.
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COPD-associated expiratory central airway collapse (ECAC) is a frequently overlooked benign airway obstructive disease with complex causes and unclear pathologic and physiologic mechanisms. Although interventions such as noninvasive positive pressure ventilation, airway stenting, and tracheobronchoplasty have shown definite efficacy in the treatment of COPD-associated ECAC, the diagnosis and treatment of this disease remain challenging. This review provides a systematic evaluation and outlook on the epidemiologic features, cause, pathophysiologic characteristics, clinical manifestations, diagnosis, and treatment of COPD-associated ECAC. ⋯ Although COPD-associated ECAC is attracting considerable attention, its pathophysiologic mechanisms, diagnosis, and management are full of challenges. In the future, randomized controlled trials on different therapies using patient-centered outcomes, cost-effective analysis on different interventions, and consensus guidelines on COPD-associated ECAC are needed urgently.
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Lymphangioleiomyomatosis (LAM) is a rare cystic lung disease affecting women and is characterized by the proliferation of abnormal smooth muscle-like cells within the lungs, kidneys, and lymphatic system. FEV1 and diffusing capacity of the lungs for carbon monoxide (Dlco) are 2 commonly used markers for evaluating the status of LAM, although the disease may be associated predominantly with changes in only 1 of these parameters. In this special feature, we trace the historical evolution of Dlco and FEV1 in LAM up to their current uses, beginning with their relationship in early studies with histopathologic features and imaging. ⋯ The LAM histologic score, which measures the involvement of cysts and LAM cells in the lung via biopsy, relates to disease stages and aligns more with Dlco than FEV1. The cyst score, calculated from high-resolution CT (HRCT) scans, is a measure of the lung parenchyma occupied by cysts and correlates with disease progression. Large cysts as visualized by HRCT imaging predominantly influence FEV1, whereas smaller cysts, which impact a greater surface area of the lung and may be underestimated, tend to affect Dlco.
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The advances in minimally invasive lung cancer diagnostics of the last decade have transformed patient care but have also raised important concerns about the regulatory processes used to approve new devices and the best way to generate data to support their use. Disruptive technologies, such as robotic bronchoscopy, have been widely adopted by interventional pulmonologists in the absence of robust data demonstrating improved patient outcomes. ⋯ Pragmatic clinical trials, which integrate trial procedures into routine clinical care, represent an appealing alternative approach for generating much-needed data to inform clinical care. In this article we illustrate the advantages and disadvantages of these research paradigms, using two recently completed randomized controlled trials in navigational bronchoscopy, and highlight the barriers and facilitators to using pragmatic trials to address the gap in comparative effectiveness research: these include the need for increased clarity of research regulations for pragmatic trials, adequate federal and private funding for such research, and alignment of incentives between clinicians, researchers, regulators, and industry.