Respiratory care
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The rate of re-intubation after endotracheal extubation for all indications is estimated at ∼20%. This high rate is related, in part, to the development of postoperative complications that leads to acute respiratory failure that requires re-intubation. In general, 5-10% of all surgical patients develop postoperative respiratory failure, and, in patients who require abdominal surgery, up to 40% develop respiratory failure. ⋯ From an analysis of the data, it is clear that patients at high risk of re-intubation require CPAP, noninvasive ventilation, or high-flow nasal cannula after extubation to allow for a smooth transition to spontaneous breathing and to minimize the need for re-intubation. CPAP is most indicated in patients with atelectasis in which high levels of PEEP are needed, noninvasive ventilation is indicated in the patient unable to maintain an adequate minute ventilation without excessive work of breathing, and high-flow nasal cannula is indicated in the patient with severe hypoxemia that was not a result of marked atelectasis or severe ARDS. It is also clear that there are insufficient data to support the use of any of these therapies in patients at low risk for re-intubation or the development of postoperative pulmonary complications.
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Noninvasive respiratory support at the end of life is controversial, although it is becoming increasingly common. Supplemental oxygen is widely prescribed for palliative care and may help with hypoxemic respiratory failure. Noninvasive ventilation has a well-established evidence-based role in the management of respiratory failure due to exacerbations of COPD and cardiogenic pulmonary edema. ⋯ High-flow nasal cannula oxygen therapy is a new strategy for which there is evidence to support its use for hypoxemic respiratory failure. However, any benefit of the use of high-flow nasal cannula oxygen therapy in the palliative setting is unknown at this time. This review examined evidence relating to the use of noninvasive respiratory support at the end of life.
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Noninvasive ventilation (NIV) has a number of physiologic effects similar to invasive ventilation. The major effects are to augment minute ventilation and reduce muscle loading. These effects, in turn, can have profound effects on the patient's ventilator control system, both acutely and chronically. ⋯ By reducing venous return, it can help in patients with heart failure or fluid overload, but it can compromise cardiac output in others. NIV can also increase right ventricular afterload or function to reduce left ventricular afterload. Potential detrimental physiologic effects of NIV are ventilator-induced lung injury, auto-PEEP development, and discomfort/muscle overload from poor patient-ventilator interactions.
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Neuromuscular diseases are a heterogeneous group of neurologic diseases that affect a number of neural structures including the motor nerves, neuromuscular junctions, or the muscles themselves. Although many of the diseases are rare, the total number of individuals who present to a pulmonologist or respiratory care provider is significant. Approaches to care include regular and careful clinical follow-up of symptoms of sleep-disordered breathing, daytime hypoventilation, as well as cough and swallowing effectiveness. ⋯ Support of cough function with manual assistance, a resuscitator bag, and/or mechanical insufflation-exsufflation can help prevent and treat infection. Referral for swallowing evaluation and treatment is very important for those with impaired bulbar function. This comprehensive respiratory care approach to individuals with neuromuscular disease and respiratory system involvement is essential to maintaining the health and longevity of these individuals.
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The use of noninvasive ventilation (NIV) is common in adult acute care. As evidence to support the use of NIV has developed, there has been a concurrent proliferation of NIV technology. Efforts have been made to improve patient-ventilator synchrony, monitoring capabilities, and portability of devices used to deliver NIV. ⋯ Although this technology is generally superior to that of the past, a great deal of variation exists between devices. Clinicians need to be accustomed to the devices available to them to maximize the potential for clinical improvement and patient tolerance. The purpose of this paper is to review current technology, current literature comparing devices, and various clinical considerations associated with NIV use in adult acute care.