Respir Care Clin N Am
· 2005 Mar · PMID 15763223
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We illustrate the benefits and limitations of administrative data when trying to understand diseases such as CAP. Administrative data provide an understanding of care provided or risk factors in unselected patients under...We illustrate the benefits and limitations of administrative data when trying to understand diseases such as CAP. Administrative data provide an understanding of care provided or risk factors in unselected patients under actual practice conditions. Administrative data can supplement understandings gained from randomized trials in a timely and cost-efficient manner using data previously collected. As the use of administrative data increases, the type of data collected will change to reflect these new uses. Administrative data use may represent a practical solution in monitoring quality of care for entire populations.
Respir Care Clin N Am
· 2005 Mar · PMID 15763222
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Some of the key features of Hendra and Nipah viruses are summarized in Table 1. The appearance of these new viruses over the last 10 years emphasizes a number of issues. (1) Epidemics of human infectious diseases can occ...Some of the key features of Hendra and Nipah viruses are summarized in Table 1. The appearance of these new viruses over the last 10 years emphasizes a number of issues. (1) Epidemics of human infectious diseases can occur unexpectedly and with high impact in terms of morbidity and mortality. (2) We do not know what epidemiologic factors conspire to allow these viruses to stray out of their bat reservoirs into the two different intermediate hosts (horses and pigs) and then into humans. (3) We do not know how long these viruses have been present in the bat population, where they originated from, or if they are present in other parts of the world. (4)There may be other viruses waiting for similar opportunities to cross species.(5) It is unlikely that we have seen the last of these and related viruses.
Respir Care Clin N Am
· 2005 Mar · PMID 15763221
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It seems that with climatic and geoecologic changes, Hantaviruses have re-emerged as human pathogens related to increases in interaction between humans and rodent reservoirs. Infection with SNV in North America and the A...It seems that with climatic and geoecologic changes, Hantaviruses have re-emerged as human pathogens related to increases in interaction between humans and rodent reservoirs. Infection with SNV in North America and the Andes virus in South America can produce infection manifest initially as a flu-like illness. In the setting of a history of possible exposure to rodents or their excreta, clinical symptoms and laboratory clues such as thrombocytopenia should raise the suspicion of HPS. Clinical deterioration can be rapid, so patients should be hospitalized and transported to tertiary care centers where mechanical ventilation is available if necessary. Presumptive treatment for other forms of sepsis should be considered before confirmation of diagnosis. Survival seems to be determined in part by viral and host factors. Canadian and South American data suggest that there may be species variations influencing clinical manifestations and course of disease. Because the pathogenesis seems to be based on immunologic injury, future treatments will likely focus on interventions other than antiviral medications. Prevention strategies should be emphasized, particularly when recognized climatic conditions favor rodent abundance. Physicians should remain alert to the possibility of such a diagnosis when evaluating a patient with CAP and should request appropriate serology while supporting the patient in a closely monitored setting. The declining mortality rates seen over the past decade may be a consequence of improved medical management or better recognition of cases, including those less severe than originally described.
Respir Care Clin N Am
· 2005 Mar · PMID 15763220
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Using the Internet, it is possible to perform multicenter international projects easier, faster, and less expensive than in the past. Making large international databases available to investigators from around the world...Using the Internet, it is possible to perform multicenter international projects easier, faster, and less expensive than in the past. Making large international databases available to investigators from around the world will greatly expand the possibilities to obtain new knowledge in the areas of community-acquired pneumo-nia (CAP) research and quality. By closing the gap between clinical research and clinical practice, the management of patients with CAP will improve worldwide.
Respir Care Clin N Am
· 2005 Mar · PMID 15763219
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Tuberculosis (TB) is often mistaken for community-acquired pneumonia (CAP). To avoid missing the diagnosis, we recommend that any CAP patient with upper lobe infiltrate, cavitation, miliary pattern, hemoptysis or >1 mont...Tuberculosis (TB) is often mistaken for community-acquired pneumonia (CAP). To avoid missing the diagnosis, we recommend that any CAP patient with upper lobe infiltrate, cavitation, miliary pattern, hemoptysis or >1 month of any of cough, fever, malaise,weakness, night sweats, or significant weight loss, should have sputa submitted for Mycobacterium tuberculosis smear and culture. Any CAP patient failing or relapsing after empiric therapy should be investigated for TB. In the presence of HIV with low CD4 count (< or = 200 cells/mL), the presentation may be atypical, and therefore sputa should be submitted for M tuberculosis. Any HIV patient, regardless of CD4 count, with a known history of positive tuberculin skin test, previous TB, or recent exposure to TB, who presents with CAP, should be investigated for TB.
Respir Care Clin N Am
· 2005 Mar · PMID 15763218
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Many patients with CAP are seen in the ER and treated as outpatients.History, physical examination, selected lab tests, and chest radiography must be routinely undertaken in patients with "presumptive" pneumonia to make...Many patients with CAP are seen in the ER and treated as outpatients.History, physical examination, selected lab tests, and chest radiography must be routinely undertaken in patients with "presumptive" pneumonia to make the diagnosis and allow for appropriate risk stratification. There is wide disagreement among physicians on the presence or absence of CAP on chest radiographs, and a chest radiograph that shows "no pneumonia" may not be sufficient to rule out the diagnosis. Furthermore, even patients with "ambulatory" pneumonia may have important laboratory abnormalities and a moderate risk of hypoxemia. Diabetes mellitus and stress hyper-glycemia are important comorbidities and must be accounted for in any rational discharge plan. All of the aforementioned observations need to be understood in the context of an increasingly older and frailer patient population that may still be eligible for appropriate outpatient treatment. It is likely that guidelines and clinical pathways for outpatient treatment of CAP that standardize medical care and mandate careful and regular follow-up of patients discharged home will decrease unnecessary practice variation while improving the overall quality of care.
Respir Care Clin N Am
· 2005 Mar · PMID 15763217
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Successful guideline implementation programs need to understand local barriers, incorporate multiple component interventions, and proceed within a framework of continuous quality improvement. We found few intervention st...Successful guideline implementation programs need to understand local barriers, incorporate multiple component interventions, and proceed within a framework of continuous quality improvement. We found few intervention studies to improve CAP guideline adherence and no controlled studies that used certain practice changes strategies that have proven effective for other conditions, such as face-to-face educational outreach, use of local opinion leaders, and individualized audit with peer-comparison feedback. Future studies in CAP management need to use rigorous study designs, use multiple evidence-based strategies to change practice, and convincingly demonstrate to front-line health care providers that the suggested interventions are safe and improve patient outcomes. Paper does not change practice, and the creation and mailing out of a practice guideline for the treatment of CAP is only the first necessary step in translating good evidence into everyday clinical practice.
Respir Care Clin N Am
· 2004 Dec · PMID 15585183
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A constant awareness of the risk to the living donors must be maintained with any live-donor organ transplantation program, and comprehensive short- and long-term follow-up should be strongly encouraged to maintain the v...A constant awareness of the risk to the living donors must be maintained with any live-donor organ transplantation program, and comprehensive short- and long-term follow-up should be strongly encouraged to maintain the viability of these potentially life-saving programs. There has been no perioperative or long-term mortality following lobectomy for living lobar lung transplantation, and in the authors' series the perioperative risks associated with donor lobectomy are similar to those seen with standard lung resection. These risks might increase if the procedure were offered on an occasional basis and not within a well-established program. Further long-term outcome data, similar to data for live-donor renal and liver transplantation, are needed. Therefore, the authors still favor performing living lobar lung transplantation only for the patient with a clinically deteriorating condition. They believe that prospective donors should be informed of the morbidity associated with donor lobectomy and the potential for mortality, as well of potential recipient outcomes in regard to life expectancy and quality of life after transplantation. A major question regarding lobar lung transplantation that has been unanswered during the last decade has been defining when a potential recipient is too ill to justify placing two healthy donors at risk of donor lobectomy. Recipient age, gender, indication for primary transplant, prehospitalization status, preoperative steroid usage, relationship of donor to recipient, and the presence or absence of rejection episodes postoperatively do not seem to influence overall mortality. Patients receiving mechanical ventilation preoperatively and those undergoing retransplantation after either a previous cadaveric or lobar lung transplantation have significantly elevated odds ratios for postoperative death. The authors therefore recommend caution in these subgroups of patients. This experience is similar to the cadaveric experience in which intubated patients have higher I-year mortalities and patients undergoing retransplantation have decreased 3- and 5-year survival. A similar experience with a smaller number of lobar transplants has been reported by the Washington University group. Despite the high-risk patient population, this alternative procedure has been life saving in severely ill patients who would die or become unsuitable recipients before a cadaveric organ becomes available. Although cadaveric transplantation is preferable because of the risk to the donors, living lobar lung transplantation should continue to be used under properly selected circumstances. Although there have been no deaths in the donor cohort, a risk of death between 0.5% and 1% should be quoted pending further data. These encouraging results are important if this procedure is to be considered as an option at more pulmonary transplant centers in view of the institutional, regional, and intra- and international differences in the philosophical and ethical acceptance of the use of organs from live donors for transplantation.
Respir Care Clin N Am
· 2004 Dec · PMID 15585182
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Bronchoscopy is an integral piece in the complex multidisciplinary approach to the care of lung transplant recipients. Although the use of surveillance bronchoscopies is controversial, bronchoscopy undoubtedly provides v...Bronchoscopy is an integral piece in the complex multidisciplinary approach to the care of lung transplant recipients. Although the use of surveillance bronchoscopies is controversial, bronchoscopy undoubtedly provides valuable information in patients with respiratory symptoms or functional decline. Therapeutic bronchoscopic interventions offer effective and safe therapy for complications of anastomotic sites. Further research is needed to address critical questions regarding the role of bronchoscopy in this selected patient population. The objectives of the research should be to increase the yield of bronchoscopy, improve its safety, and decrease procedure-related discomfort. Only randomized, multicenter clinical trials with full commitment from lung transplant centers can accomplish these goals.
Respir Care Clin N Am
· 2004 Dec · PMID 15585181
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Infections remain a serious and common problem in lung transplant recipients. Recent years have seen an explosion in the knowledge regarding this major cause of morbidity and mortality. Novel diagnostic and therapeutic t...Infections remain a serious and common problem in lung transplant recipients. Recent years have seen an explosion in the knowledge regarding this major cause of morbidity and mortality. Novel diagnostic and therapeutic techniques are revolutionizing the approach to infectious diseases in transplant recipients. Multicenter trials will expand the scope of diagnosis and management of these infections. A team approach by transplant physicians and infectious diseases experts is critical to the success of managing these complex patients.
Respir Care Clin N Am
· 2004 Dec · PMID 15585180
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Lung transplantation is associated with a great number of major medical complications that act in concert to limit the long-term success of this difficult treatment option for advanced lung disease. Close and parallel at...Lung transplantation is associated with a great number of major medical complications that act in concert to limit the long-term success of this difficult treatment option for advanced lung disease. Close and parallel attention to pulmonary and nonpulmonary medical complications and management of lung transplant recipients by a multidisciplinary team are the most important ingredients of optimal long-term outcomes.
Respir Care Clin N Am
· 2004 Dec · PMID 15585179
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During the last 20 years improvements in perioperative care have led to improved outcomes for lung transplant recipients. Although uncommon, technical complications can be the source of significant morbidity and mortalit...During the last 20 years improvements in perioperative care have led to improved outcomes for lung transplant recipients. Although uncommon, technical complications can be the source of significant morbidity and mortality. Infections and ischemia-reperfusion injury continue to have the greatest impact on short-term outcomes of lung transplant recipients, and research into the prevention and treatment of these two entities will be necessary to improve these patients' outcomes significantly.
Respir Care Clin N Am
· 2004 Dec · PMID 15585178
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The current availability of lung donors is far exceeded by the number of potential transplant recipients who are waiting for an organ. This disparity results in significant morbidity and mortality for those on the waitin...The current availability of lung donors is far exceeded by the number of potential transplant recipients who are waiting for an organ. This disparity results in significant morbidity and mortality for those on the waiting list. Although it is desirable to increase overall consent rates for organ donation, doing so requires an intervention to affect societal response. In contrast, increased procurement of organs from marginal donors and improved donor management may be realized through increased study and practice changes within the transplant community. Transplantation of organs from marginal or extended-criteria donors may result in some increase in complications or mortality, but this possibility must be weighed against the morbidity and risk of death risk faced by individuals on the waiting list. The effects of this trade-off are currently being studied in kidney transplantation, and perhaps in the near future lung transplantation may benefit from a similar analysis. Until that time, the limited data regarding criteria for donor acceptability must be incorporated into practice to maximize the overall benefits of lung transplantation.
Respir Care Clin N Am
· 2004 Dec · PMID 15585177
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Improvement in quality of life is a major reason patients choose to undergo lung transplantation. This article reviews the present state of knowledge regarding the effects of lung transplantation on health-related qualit...Improvement in quality of life is a major reason patients choose to undergo lung transplantation. This article reviews the present state of knowledge regarding the effects of lung transplantation on health-related quality of life (HRQL), and the cost-effectiveness of lung transplantation. Lung transplantation has been found to im-prove many measures of HRQL. Bronchiolitis obliterans syndrome adversely affects HRQL. Studies of cost effectiveness are few in number, and cost-effectiveness estimates vary widely. More data regarding the HRQL benefits of lung transplantation will allow these concepts to be used in lung transplantation decision-making.
Respir Care Clin N Am
· 2004 Dec · PMID 15585176
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This article reviews the history of organ transplantation, specifically focusing on the advances leading to the first successful human lung transplant. It also provides an overview of the com-mon indications and general...This article reviews the history of organ transplantation, specifically focusing on the advances leading to the first successful human lung transplant. It also provides an overview of the com-mon indications and general selection criteria for lung transplant recipients, highlights areas of current controversy in pulmonary transplantation, reviews current approaches to posttransplantation immunosuppression, and discusses common complications seen intransplant recipients.
Respir Care Clin N Am
· 2004 Sep · PMID 15458735
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It is likely that the first responder to a medical emergency in space will be a nonphysician. Terrestrial experience has shown that even under optimal conditions experienced clinicians can have difficulty establishing an...It is likely that the first responder to a medical emergency in space will be a nonphysician. Terrestrial experience has shown that even under optimal conditions experienced clinicians can have difficulty establishing an airway. Establishing and maintaining a patent airway is essential to ensuring a successful outcome from cardiopulmonary resuscitation or respiratory failure secondary to trauma or acute illness. A patent airway is required to provide a pathway for ventilation and oxygenation. For minimally trained care providers the airway will also be the first route of administration of resuscitative pharmacologic agents. It is therefore of paramount importance that the method for securing and airway permit a successful outcome when used by nonphysician crewmembers during medical emergencies in space. This article evaluates airway management in the microgravity environment and applies to both the International Space Station and the Space Shuttle, whether operating independently or docked.
Respir Care Clin N Am
· 2004 Sep · PMID 15458734
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As part of a Crew Health Care Maintenance System onboard the International Space Station, the National Aeronautics and Space Administration has included a Respiratory Support Pack (RSP) to resuscitate or sustain a crew m...As part of a Crew Health Care Maintenance System onboard the International Space Station, the National Aeronautics and Space Administration has included a Respiratory Support Pack (RSP) to resuscitate or sustain a crew member with an acute impairment in pulmonary function. This article provides a critical appraisal of the RSP and of current strategies for mechanical ventilation in space. Various closed-loop ventilation strategies are reviewed,and their appropriateness for respiratory support in space is explored. Recommendations are made for enhancing and upgrading the current RSP to provide an injured crew member with the best possible chance of survival.
Respir Care Clin N Am
· 2004 Sep · PMID 15458733
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Pulse oximetry is a ubiquitous monitor in anesthesia and critical care and is often considered the fifth vital sign. Under conditions of normal perfusion and temperature, the finger probe is the most common and effective...Pulse oximetry is a ubiquitous monitor in anesthesia and critical care and is often considered the fifth vital sign. Under conditions of normal perfusion and temperature, the finger probe is the most common and effective sensor. In the presence of hypotension, hypoperfusion,and hypothermia, however, the finger sensor is often unable to detect a pulsatile signal. Another site and sensor are necessary to monitor these patients effectively. This article describes the search for this site, the choice of the forehead, and preliminary data regarding the use of this sensor site.
Respir Care Clin N Am
· 2004 Sep · PMID 15458732
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Ventilator-associated pneumonia is a common cause of morbidity and mortality in critically ill patients. Inappropriate initial antimicrobial therapy is associated with poor outcome. An initial aggressive strategy using b...Ventilator-associated pneumonia is a common cause of morbidity and mortality in critically ill patients. Inappropriate initial antimicrobial therapy is associated with poor outcome. An initial aggressive strategy using broad-spectrum antibiotics based on the local distribution of pathogens, patient risk factors, and antimicrobial characteristics; followed by focused therapy based on microbiologic studies, will help minimize the chance of inappropriate therapy and the emergence of resistance.
Respir Care Clin N Am
· 2004 Sep · PMID 15458731
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The goal of positive-pressure mechanical ventilation is to provide respiratory support to a patient while allowing the underlying diseased lungs to heal. Research using both animal models and humans suggests that positiv...The goal of positive-pressure mechanical ventilation is to provide respiratory support to a patient while allowing the underlying diseased lungs to heal. Research using both animal models and humans suggests that positive-pressure ventilation can injure the lung through both overdistension and under recruitment. Theoretically,the ultimate lung-protective strategy would consist of very small tidal volumes to avoid pressure swings while maintaining alveolar recruitment. High-frequency ventilation provides such a strategy of mechanical ventilation. This article examines the utility of using high-frequency modes of mechanical ventilation in supporting the patient with ARDS.