Resp Care
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Mass casualty events and disasters, both natural and human-generated, occur frequently around the world and can generate scores of injured or ill victims in need of resources. Of the available medical supplies, oxygen remains the critical consumable resource in disaster management. Strategic management of oxygen supplies in disaster scenarios remains a priority. ⋯ The Strategic National Stockpile supplies medications, medical supplies, and equipment to disaster areas, but it does not supply oxygen. Contracted vendors can deliver oxygen to alternate care facilities in disaster areas, in the form of concentrators, compressed gas cylinders, and liquid oxygen. Planning for oxygen needs following a disaster still presents a substantial challenge, but alternate care facilities have proven to be valuable in relieving pressure from the mass influx of patients into hospitals, especially for those on home oxygen who require only an electrical source to power their oxygen concentrator.
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Fiberoptic bronchoscopy and lung biopsy are important diagnostic tools in patients with diffuse pulmonary infiltrates. However, these patients often have hypoxemic respiratory failure that makes this procedure hazardous. Noninvasive ventilation (NIV) has been shown to improve oxygenation in hypoxemic patients. ⋯ NIV-assisted bronchoscopic lung biopsy is a novel method for obtaining diagnosis in hypoxemic patients with diffuse lung infiltrates. However, this approach should be reserved for centers with extensive experience in NIV. More studies are required to define the utility of this approach.
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Weaning comprises 40 percent of the duration of mechanical ventilation. Protocols to reduce weaning time and to identify candidates at the earliest possible moment have been introduced to reduce complications and costs. Increased demand for mechanical ventilation, an increase in the number of patients requiring prolonged ventilation, and resource/staffing issues have created an environment where automated weaning may play a role. ⋯ Preliminary research has demonstrated mixed results. Current systems continue to be evaluated in different patient populations and environments. Automated weaning is part of the ICU armamentarium, and identification of the patient populations most likely to benefit needs to be further defined.
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Mechanical ventilation is a life-saving supportive therapy, but it can also cause lung injury, diaphragmatic dysfunction, and lung infection. Ventilator liberation should be attempted as soon as clinically indicated, to minimize morbidity and mortality. The most effective method of liberation follows a systematic approach that includes a daily assessment of weaning readiness, in conjunction with interruption of sedation infusions and spontaneous breathing trials. ⋯ Checklists can be used to reinforce application of the protocol, or possibly in lieu of one, particularly in environments where the caregiver-to-patient ratio is high and clinicians are well versed in and dedicated to applying evidence-based care. There is support for integrating best-evidence rules for weaning into the mechanical ventilator so that a substantial portion of the weaning process can be automated, which may be most effective in environments with low caregiver-to-patient ratios or those in which it is challenging to consistently apply evidence-based care. This paper reviews evidence for ventilator liberation protocols and discusses issues of implementation and ongoing monitoring.
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Review
The ventilator liberation process: update on technique, timing, and termination of tracheostomy.
Tracheostomy is one of the most commonly performed procedures in the ICU. Despite the frequency of the procedure, there remains controversy regarding selection of patients who should undergo tracheostomy, the optimal technique, timing of placement and decannulation, as well as impact on outcome associated with the procedure. A growing body of literature demonstrates that percutaneous tracheostomy performed in the ICU is a safe procedure, even in high risk patients. ⋯ Although there was initial enthusiasm in support of early tracheostomy to improve patient outcomes, repeated studies have been unable to produce robust benefits. The question of optimal timing and location of decannulation has not been answered, but there is some reassurance that in aggregate, across a variety of ICUs, patients do not appear to be harmed by transfer to ward with tracheostomy. Future research into techniques, timing, and termination of tracheostomy is warranted.