Resp Care
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Patient-ventilator synchrony is a common problem with all patients actively triggering the mechanical ventilator. In many cases synchrony can be improved by vigilant adjustments by the managing clinician. ⋯ Proportional assist ventilation (PAV) and neurally adjusted ventilatory assist (NAVA) were both developed to improve patient-ventilator synchrony by proportionally unloading ventilatory effort and turning control of the ventilatory pattern over to the patient. This paper discusses PAV's and NAVA's theory of operation, general process of application, and the supporting literature.
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Permissive hypoxemia is a lung-protective strategy that aims to provide a patient with severe acute respiratory distress syndrome (ARDS) a level of oxygen delivery that is adequate to avoid tissue hypoxia while minimizing the detrimental effects of the often toxic ventilatory support required to maintain normal arterial oxygenation. However, in many patients with severe ARDS it can be difficult to achieve a balance between maintaining adequate tissue oxygenation and avoiding ventilator-induced lung injury (VILI). ⋯ Although it has not yet been studied, this approach is theorized to improve clinical outcomes of critically ill patients with severe ARDS. We stress that the goal of this article is not to convince the reader that this approach is necessarily correct, as data are clearly lacking, but rather to provide a basis for continued thought, discussion, and potential research.
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Sleep-disordered breathing (mainly obstructive sleep apnea [OSA]) and COPD are among the most common pulmonary diseases, so a great number of patients have both disorders; this "overlap syndrome" causes more severe nocturnal hypoxemia than either disease alone. This common combination of OSA and COPD has important implications for diagnosis, treatment, and outcome. Specifically, patients with COPD and OSA have a substantially greater risk of morbidity and mortality, compared to those with either COPD or OSA alone. ⋯ Many questions remain, however, with regard to disease definition, prognosis, and optimal treatment. Treatment currently consists of continuous positive airway pressure, and oxygen as needed. Noninvasive ventilation may be helpful in overlap syndrome patients, but this has not yet been well studied.
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Obesity hyoventilation syndrome (OHS) is defined as the triad of obesity, daytime hypoventilation, and sleep-disordered breathing in the absence of an alternative neuromuscular, mechanical or metabolic explanation for hypoventilation. During the last 3 decades the prevalence of extreme obesity has markedly increased in the United States and other countries. With such a global epidemic of obesity, the prevalence of OHS is bound to increase. ⋯ Effective treatment can lead to significant improvement in patient outcomes, underscoring the importance of early diagnosis. This review will include disease definition and epidemiology, clinical characteristics of the syndrome, pathophysiology, and morbidity and mortality associated with it. Lastly, treatment modalities will be discussed in detail.
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Clinicians are becoming more aware of the risks of sleep deprivation and unrecognized sleep-disordered breathing in hospitalized patients, most importantly in those patients planning to undergo surgical procedures. Polysomnography is difficult to perform in the hospital setting, such that actigraphy or urinary metabolites of melatonin are often used as surrogate measures, and show that sleep is markedly impaired. Patients in the medical intensive care unit with sepsis or requiring mechanical ventilation may show complete absence of the normal circadian rhythm pattern, and many centers have initiated sleep-enhancement protocols. ⋯ Protocols to evaluate patients that determine the need and process for positive-airway-pressure treatment in the hospital patient with OSA are being developed. An obstructive apnea systematic intervention strategy protocol to deal with patients with suspected OSA can help guide diagnostic and therapeutic decision making. Hospitals that are proactive in the development of protocols for identification and management of patients with sleep-disordered breathing are likely to be rewarded with reduced complications and costs, and the issue is sure to be incorporated in future pay-for-performance evaluations.