Resp Care
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Whether defined as chronically critically ill, long-term mechanical ventilator dependent (or otherwise chronically medically supported), or medically fragile, a population of infants and children with chronic illness clearly exists. Infants and children with chronic healthcare needs are at an increased risk for physical, developmental, behavioral, and/or emotional conditions and generally require healthcare services of a type or amount beyond that of a general pediatric or adult population. ⋯ Attention will be paid to defining the population, describing trends over time, reviewing their special needs, and discussing outcomes. Increased focus and an increasing quantity of resources for this subgroup of infants and children are needed, as the number of such pediatric patients continues to grow.
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Chronic critical illness (CCI) is syndrome of neuromuscular weakness, brain dysfunction, malnutrition, endocrinopathies, and symptom distress. Two conceptual themes may be useful in discussing CCI. The first is a clinical roadmap in which a patient suffers an acute critical illness, survives the initial insult, but yet is unable to be liberated from the ventilator. ⋯ Given the association between common CCI antecedents and inflammation, attempts to control and balance the pro-inflammatory and anti-inflammatory mediators should begin as early as possible and continue throughout the ICU stay. Since surrogate measures such as biomarkers often fail to predict the effect of interventions, the focus should be on the outcomes patients experience. As of now, providing evidence-based, high quality ICU management of patients at risk for CCI appears to be the best strategy of care.
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The chronically critically ill (CCI) comprise a rapidly growing population of patients who have survived acute critical illness, only to be left with ongoing organ dysfunctions requiring high levels of specialized care for months or years. In many ways, CCI is an "iatrogenic" process, reflecting the ability of modern life support technologies to keep patients alive for prolonged periods of time despite ongoing life threatening illness. ⋯ Importantly, CCI patients transition among these venues frequently, reflecting the nature of CCI to be punctuated with episodes of acute critical illness. Management of the CCI population requires a special combination of intensive care and rehabilitative skills.
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This paper reviews management strategies for patients undergoing prolonged mechanical ventilation (PMV). Topics covered include how to identify and correct barriers to weaning, the systematic approach to weaning trials, when to cease weaning trials and proceed with life-long support, managing the tracheostomy tube during PMV, and, finally, how to select a suitable mechanical ventilator for PMV.
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An estimated 2-3% of all hospitalized patients become critically ill. These patients are in a state of relative immune exhaustion, which cripples their response to infections. Patients are sicker, have many comorbidities, and undergo complex procedures. ⋯ In addition, specific attention is required to environmental services and surface and equipment cleaning. A well organized infection control program and an antimicrobial stewardship program have become indispensable to achieve these goals. All of these key principles and recommendations are also relevant to the chronically ill patient in acute care hospital ICUs and step-down units.