Respiratory care
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We aimed to investigate the association between noninvasive ventilation (NIV) initiated in the emergency department and patient outcomes for those requiring invasive mechanical ventilation so that we could understand the effect of extended NIV use (ie, > 4 h) prior to invasive mechanical ventilation on patient outcomes. ⋯ Although any exposure to NIV prior to invasive mechanical ventilation did not appear to affect morbidity and mortality, extended NIV use prior to invasive mechanical ventilation was associated with worse patient outcomes, suggesting a need for additional study to better understand the ramifications of duration of NIV use prior to failure on outcomes. Given this early timeframe for intervention, future studies should be collaborations between the emergency department and ICU.
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Editorial
COPD Care Bundle in Emergency Department Observation Unit Reduces Emergency Department Revisits.
COPD exacerbations lead to accelerated decline in lung function, poor quality of life, and increased mortality and cost. Emergency department (ED) observation units provide short-term care to reduce hospitalizations and cost. Strategies to improve outcomes in ED observation units following COPD exacerbations are needed. We sought to reduce 30-d ED revisits for COPD exacerbations managed in ED observation units through implementation of a COPD care bundle. The study setting was an 800-bed, academic, safety-net hospital with 700 annual ED encounters for COPD exacerbations. Among those discharged from ED observation unit, the 30-d all-cause ED revisit rate (ie, the outcome measure) was 49% (baseline period: August 2014 through September 2016). ⋯ Reliable adherence to a COPD care bundle reduced 30-d ED revisits among those treated in the ED observation unit.
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Automatic cuff pressure (Pcuff) control devices for artificial airways are available, yet there are no standards or data to support their use. We hypothesized that airway pressure oscillations during mechanical ventilation are transmitted to Pcuff; and that the change in mean Pcuff (ΔPcuff) is zero during mechanical ventilation with controlled or uncontrolled Pcuff. ⋯ Automatic devices do not regulate ventilatory pressure oscillations, but they do control mean Pcuff and keep ΔPcuff well below a clinically important threshold. The large ΔPcuff seen with uncontrolled Pcuff warrants periodic monitoring. Further studies are needed to determine the source of ΔPcuff and the physiologic effects of Pcuff oscillations during mechanical ventilation.
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Use of negative pressure ventilation is neither well described nor widespread in pediatric critical care; existing data are from small, specialized populations. We sought to describe a general population of critically ill subjects with acute respiratory failure supported with negative pressure ventilation to find predictors of response or failure. ⋯ Negative pressure ventilation successfully supported 69% of pediatric subjects with all-cause acute respiratory failure. Oxygen requirement was lower in subjects who were responsive to negative pressure ventilation within 1 h of initiation. Standardized negative pressure ventilation protocols should include weaning of supplemental oxygen to determine responsiveness.
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The difference between Bohr and Enghoff dead space are not well described in ARDS patients. We aimed to analyze the effect of PEEP on the Bohr and Enghoff dead spaces in a model of ARDS. ⋯ Bohr dead space was associated with lung stress, whereas Enghoff dead space was partially affected by the shunt effect.