Resp Care
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Ventilator management of a patient who is recovering from acute respiratory failure must balance competing objectives. Discontinuing mechanical ventilation and removing the artificial airway as soon as possible reduces the risk of ventilator-induced lung injury, nosocomial pneumonia, airway trauma from the endotracheal tube, and unnecessary sedation, but premature ventilator-discontinuation or extubation can cause ventilatory muscle fatigue, gas exchange failure, and loss of airway protection. In 1999 the McMaster University Outcomes Research Unit conducted a comprehensive evidence-based review of the literature on ventilator-discontinuation. ⋯ With patients who continue to require support, the support strategy should maximize patient comfort and provide muscle unloading. 4. Patients who require prolonged ventilatory support beyond the intensive care unit should go to specialized facilities that can provide more gradual support reduction strategies. 5. Ventilator-discontinuation and weaning protocols can be effectively carried out by nonphysician clinicians.
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Review
Managing acute respiratory failure during exacerbation of chronic obstructive pulmonary disease.
Exacerbations of chronic obstructive pulmonary disease (COPD) are a major health problem, causing more than half a million hospital admissions per year in the United States. Although overall mortality is low, it is substantially higher with severe exacerbations that require intensive care and mechanical ventilation. The majority of COPD exacerbations result from infection, with typical bacterial organisms most commonly identified. ⋯ Randomized controlled trials also demonstrate that noninvasive ventilation can decrease the incidence of intubation, shorten stay, reduce infectious complications, and improve survival. Although patients who require intubation have the worst prognosis, the vast majority of them can be successfully liberated from mechanical ventilation. For invasively ventilated patients the clinical emphasis should be on improving patient-ventilator interaction and avoiding dynamic hyperinflation (intrinsic positive end-expiratory pressure).
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Critical care is entering a phase of rapid introduction of treatments that have demonstrated efficacy for reducing mortality and morbidity. Until recently the principal question facing intensivists was "Does this treatment work?" Though that question is still important, we now must address the same challenges other fields, notably cardiology, face in.
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The principles of evidence-based medicine provide the tools to incorporate the best evidence into everyday practice. Evidence-based medicine is the integration of individual clinical expertise with the best available research evidence from systematic research and the patient's values and expectations. A hierarchy of evidence can be used to assess the strength of evidence upon which clinical decisions are made, with randomized studies at the top of the hierarchy. ⋯ High-level studies of a therapy are prospective, randomized, blinded, placebo-controlled, have a concealed allocation, have a parallel design, and assess patient-important outcomes. Metrics used to assess the evidence for a therapy include event rate, relative risk, relative risk reduction, absolute risk reduction, number needed to treat, and odds ratio. Although not all tenets of evidence-based medicine are universally accepted, the principles of evidence-based medicine nonetheless provide a valuable approach to respiratory care practice.
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In 2002 the National Asthma Education and Prevention Program published evidence-based guidelines for the diagnosis and management of asthma, but there are some unresolved asthma-management issues that need further research. For asthmatic children inhaled corticosteroids are more beneficial than as-needed use of beta(2) agonists, long-acting beta(2) agonists, theophylline, cromolyn sodium, nedocromil, or any combination of those. Leukotriene modifiers are an alternative but not a preferred treatment; they should be considered if the medication needs to be administered orally rather than via inhalation. ⋯ The asthma care plan should include a written asthma action plan for the patient, but there is inadequate evidence as to whether the asthma action plan should be based on symptoms or on peak flow monitoring. There is low-level evidence that helium-oxygen mixture (heliox) may be of benefit in the first hour of an acute asthma attack but less advantageous after that first hour. Metered-dose inhalers are no more or less effective, overall, than other aerosol-delivery devices for the delivery of beta(2) agonists or inhaled corticosteroids, so the least expensive delivery method should be chosen.