Chest
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Comparative Study
Improved survival in ARDS patients associated with a reduction in pulmonary capillary wedge pressure.
The survival and ICU length of stay of 40 ARDS patients admitted to the ICU were analyzed to determine if a management strategy of lowering the pulmonary capillary wedge pressure (Ppw) was associated with an increased survival or a decreased ICU length of stay. ARDS was defined as three or four quadrant alveolar filling roentgenographically, a PaO2 less than 80 mm Hg with an FIO2 greater than .5 and a Ppw less than 18 mm Hg. ⋯ This difference remained statistically significant after stratifying patients by age and the APACHE II severity of illness index. We conclude that this retrospective analysis supports the notion that treatment of low pressure pulmonary edema with reduction of Ppw is associated with an increased survival.
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Two anatomic subsets of patients with stage IIIa non-small cell cancer of the lung are candidates for definitive surgical treatment. The first group includes patients with T1, T2, or T3 primary tumors and regional lymph node metastases confined to the ipsilateral mediastinal and subcarinal lymph nodes (N2 disease). There is controversy over the selection of this group of patients for surgery; some physicians do not believe that resection is an option if there is any evidence of mediastinal lymph node involvement. ⋯ A five-year cumulative survival rate of 28 percent was documented for 198 consecutive patients undergoing complete resection for stage IIIa non-small cell lung cancer, 21 percent for the T1-3 N2 group, and 39 percent for the T3 N0-N1 patients. Cell type was not a statistically significant variable for survival; however, a superior outcome was observed for patients with squamous cell carcinoma in every TNM category. The results support surgical treatment as a valid option for selected patients with extrapulmonary extension of the disease.
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Bedside testing offers a unique opportunity for earlier and more specific diagnosis, faster and more frequent monitoring, and the opportunity to improve patient care and reduce hospital costs. However, if abused it may not improve patient care and may increase hospital costs. In the future, more clinical studies will need to be performed to determine which tests are cost-effective.
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Randomized Controlled Trial Comparative Study Clinical Trial
Treatment of multiple rib fractures. Randomized controlled trial comparing ventilatory with nonventilatory management.
We studied the treatment of multiple rib fractures in NIC, comparing ventilatory with nonventilatory methods in 69 patients who were randomly allocated to one of the following two treatments: (1) a CPAP mask combined with regional analgesia (n = 36); or (2) endotracheal intubation and mechanical ventilation with PEEP (n = 33). Clinical outcome was as follows: mean duration of treatment, 4.5 +/- 2.3 days for the group with CPAP and 7.3 +/- 3.7 days for the intubated group (p = 0.0003); mean number of days spent in intensive care, 5.3 +/- 2.9 days and 9.5 +/- 4.4 days, respectively (p = less than 0.0001); mean period of hospitalization, 8.4 +/- 7.1 days and 14.6 +/- 8.6 days, respectively (p = 0.0019); and patients developing complications: 28 percent (10/36) and 73 percent (24/33), respectively. Infections caused the difference in complications, primarily pneumonias, which occurred in 14 percent (5/36) of the group with CPAP but in 48 percent (16/33) of the intubated group. We conclude that treatment with a CPAP mask combined with regional analgesia can shorten and simplify treatment in these patients, mainly through a decreased infection rate, when compared with intubation and mechanical ventilation, and we recommend this treatment in patients similar to our sample.