Resp Care
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Unplanned extubation represents a threat to patient safety, and risk factors and prevention strategies for unplanned extubation have not been fully explored. ⋯ We identified perceived risk factors and defined "near misses" for unplanned extubation. Our findings should inform strategies for prevention of unplanned extubation.
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We report a complication of the novel H1N1 influenza A viral infection not yet described during this 2007-2009 pandemic. Pulmonary hemorrhage is a known complication of influenza pneumonia, including well documented reports from previous pandemics. A 57-year-old African American female presented with fevers, progressive shortness of breath, and cough. ⋯ Our case highlights one of the more feared complications that may have been more common in prior outbreaks, such as the 1918 "Spanish Flu." Autopsy studies from the 1918 influenza pandemic found severe tracheobronchitis (oftentimes hemorrhagic), septal edema, necrotizing bronchiolitis, alveolitis, and extensive hemorrhage, as opposed to the more benign laryngitis and tracheobronchitis that is commonplace in other influenza infections. Similar pathology appearances, including pulmonary hemorrhage, have also been described in H5N1 outbreaks in China and Thailand. It is crucial for pandemic preparedness planning that additional careful and complete autopsy study of this present pandemic influenza infection be performed and reported to answer questions regarding the natural history, pathology, and pathogenesis of this novel H1N1 influenza.
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Case Reports
Alveolar dead-space response to activated protein C in acute respiratory distress syndrome.
We report a complicated case of acute respiratory distress syndrome (ARDS) from severe sepsis, in which we measured the ratio of physiologic dead space to tidal volume (V(D)/V(T)) with volumetric capnography prior to, during, and after therapy with human recombinant activated protein C. Previous studies hypothesized that early in ARDS, elevated V(D)/V(T) primarily reflects increased alveolar V(D), probably caused by pronounced thrombi formation in the pulmonary microvasculature. This may be particularly true when severe sepsis is the cause of ARDS. ⋯ Thus, improved alveolar perfusion persisted despite signs of alveolar de-recruitment. This suggests that activated protein C may have reduced microvascular obstruction. This report provides indirect evidence that microvascular obstruction may play an important role in elevated V(D)/V(T) in early ARDS caused by severe sepsis.