Respiratory care
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In 2013, the United States Centers for Disease Control and Prevention redefined surveillance for quality of care in ventilated patients by shifting from ventilator-associated pneumonia (VAP) definitions to ventilator-associated event (VAE) definitions. VAE definitions were designed to overcome many of the limitations of VAP definitions, including their complexity, subjectivity, limited correlation with outcomes, and incomplete capture of many important and morbid complications of mechanical ventilation. VAE definitions broadened the focus of surveillance from pneumonia alone to the syndrome of nosocomial complications in ventilated patients, as marked by sustained increases in ventilator settings after a period of stable or decreasing ventilator settings. ⋯ Risk factors for VAEs include sedation with benzodiazepines or propofol, volume overload, high tidal-volume ventilation, high inspiratory driving pressures, oral care with chlorhexidine, blood transfusions, stress ulcer prophylaxis, and patient transport. Potential strategies to prevent VAEs include minimizing sedation, paired daily spontaneous awakening and breathing trials, early mobility, conservative fluid management, conservative transfusion thresholds, and low tidal-volume ventilation. A limited number of studies that have tested subsets of these interventions have reported substantial decreases in VAEs; no group, however, has thus far assessed the impact of a fully optimized VAE prevention bundle that includes all of these interventions upon VAE rates and other outcomes.
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Sleep-disordered breathing affects a significant portion of the population worldwide. It is associated with many comorbid conditions, including heart failure and depression. Advances in the field regarding the diagnosis and treatment of sleep-disordered breathing are occurring on an increasing basis. This review will discuss the latest findings in the field with an emphasis on people who have obstructive sleep apnea.
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Implementation of ventilator bundles is associated with reductions in ventilator-associated pneumonia (VAP). However, the new surveillance model of ventilator-associated events (VAEs) has shifted the focus from VAP to objective, generalized signs of pulmonary decompensation not specific to VAP. This raises the question of whether the ventilator bundle also is effective in reducing VAE. ⋯ The largest study found significant reductions in duration of intubation with weaning, sedation, and head of bed elevation, as well as reduced mortality risk with weaning and sedation bundle elements. Nonetheless, these studies should be useful in designing future prospective controlled studies to determine what elements of a future prevention bundle might be effective in reducing VAEs. At this juncture, and based on the limited evidence to date, it appears that incorporating daily sedation interruptions and spontaneous breathing trials are the factors most likely to reduce VAEs.
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Mechanical ventilation is a well-established and commonly employed modality of treatment for critically ill patients in the ICU. Pneumonia is a frequent complication in mechanically ventilated patients. Patients who develop ventilator-associated pneumonia (VAP) incur higher medical costs, have prolonged ICU and hospital stays, and have increased mortality risk. ⋯ There are several clinical settings in which aerosolized antibiotics could be used for treating pneumonia, including their use for prevention, as monotherapy, as adjunctive therapy with systemic antibiotics, and for treatment of extensively drug-resistant or pan drug-resistant pathogens. However, aerosolized antibiotics have not been uniformly effective for improving clinical outcomes of patients with VAP, and local and systemic side effects could complicate their use. Moreover, many questions about aerosolized antibiotics, such as optimal formulations and dosage and treatment regimens, remain unanswered and warrant future investigations.
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There have been many innovations to the standard endotracheal tube over the years, many of which were intended to reduce the incidence of ventilator-associated pneumonia (VAP). Ventilator-associated events are associated with the objective outcomes of increased duration of mechanical ventilation, length of ICU and hospital stay, and increased risk of mortality. Many specialty tubes have been associated with a reduction in the clinical diagnosis of VAP, but studies have failed to show differences in objective outcomes. This article reviews the evidence related to specialty tubes and discusses their role in improving objective outcomes associated with ventilator-associated events.