Resp Care
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The principles underlying evidence-based practice are that treatments are effective and can offer benefit to patients. At the same time, optimal practice also avoids offering treatments for which evidence of efficacy is not available. In this regard, the goal of respiratory care protocols is to optimize the allocation of respiratory care services by prescribing to each patient treatments likely to confer benefit and avoiding those that do not. As reviewed in this paper, currently available evidence suggests that protocols (1). help minimize unnecessary arterial blood sampling, placement of arterial catheters, and bronchopulmonary hygiene therapies, (2). help optimize the process of weaning patients from mechanical ventilation, (3). help minimize waste of oxygen, (4). allocate respiratory care services better than does physician-directed care.
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This report explores the efficacy of existing therapies for acute lung injury (ALI) and acute respiratory distress syndrome (ARDS), primarily in terms of clinically important outcomes such as the duration of mechanical ventilation and hospital mortality. Of the 15 therapies reviewed, the strongest evidence suggests that ALI/ARDS should be managed with a low-tidal-volume, pressure-limited approach, with either low or moderately high positive end-expiratory pressure. ⋯ However, there is relatively strong evidence to support conservative fluid management and high-fat, anti-oxidant nutritional formulations. Although most pharmacologic ALI/ARDS therapies have been ineffective, high-dose methylprednisolone is indicated in the subgroups of ALI/ARDS patients who have pneumonia or are at risk of ARDS due to fat embolization.
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Noninvasive positive-pressure ventilation (NPPV) is increasingly being used in the care of patients suffering acute respiratory failure. High-level evidence supports the use of NPPV to treat exacerbation of chronic obstructive pulmonary disease (COPD). NPPV has also been successfully used with selected patients suffering acute hypoxemic respiratory failure and to allow earlier extubation of mechanically ventilated COPD patients. ⋯ Any ventilator and ventilator mode can be used to apply NPPV, but portable pressure ventilators and pressure-support mode are most commonly used. Inhaled bronchodilators can be administered during NPPV, and NPPV can be delivered with helium-oxygen mixture. Institution-specific practice guidelines may be useful to improve NPPV success.