Respir Care Clin N Am
· 2004 Sep · PMID 15458730
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This article reviews the available published literature on the ARDSnet and summarizes the debate that occurred over the major ARDSnet trials. It discusses the challenges its organizers, supporters, and detractors faced....This article reviews the available published literature on the ARDSnet and summarizes the debate that occurred over the major ARDSnet trials. It discusses the challenges its organizers, supporters, and detractors faced. It reviews how uncertainty in research evolves and how it affects large trials of national or international scope. It also considers how the outcome of a scientific disagreement is shaped by the science and by how the debate is framed. The authors hope to illustrate some of the obstacles to performing outcome studies and clinical trials involving critically ill patients with complex syndromes that currently lack effective treatments.
Respir Care Clin N Am
· 2004 Sep · PMID 15458729
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An inappropriate tidal volume setting can overstretch and injure the lung. Maximal stretch, tidal stretch, frequency of stretch, and rate of stretch are all implicated in such injury. Moreover, the stretch injury produce...An inappropriate tidal volume setting can overstretch and injure the lung. Maximal stretch, tidal stretch, frequency of stretch, and rate of stretch are all implicated in such injury. Moreover, the stretch injury produces systemic injury by liberating cytokines and translocating bacteria in the lung. Clinical trials have shown that limiting maximal and tidal stretch improves outcomes, even if gas exchange is partially compromised. Current strategies should focus on limiting tidal and maximal stretch as much as possible.
Respir Care Clin N Am
· 2004 Sep · PMID 15458728
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Airspace collapse is a hallmark of parenchymal lung injury. Strategies to reopen and maintain patency of these regions offer three advantages: improved gas exchange, less ventilator-induced lung injury, and improved lung...Airspace collapse is a hallmark of parenchymal lung injury. Strategies to reopen and maintain patency of these regions offer three advantages: improved gas exchange, less ventilator-induced lung injury, and improved lung compliance. Elevations in intrathoracic pressure to achieve these goals, however, may overdistend healthier lung regions and compromise cardiac function. Positive end-expiratory pressure is a widely used technique to maintain alveolar patency, but its beneficial effects must be balanced against its harmful effects. Mechanical approaches to achieve this balance are clinically difficult to do. Thus gas exchange algorithms with modest PaO2 goals are commonly used today. Recruitment maneuvers and long inspiratory time strategies may be useful adjuncts.
Respir Care Clin N Am
· 2004 Jun · PMID 15177251
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This article introduces clinicians and managers to general legal principles. The purpose of the article is to present an overview of health care law to those involved in the clinical practice and management of respirator...This article introduces clinicians and managers to general legal principles. The purpose of the article is to present an overview of health care law to those involved in the clinical practice and management of respiratory care.
Respir Care Clin N Am
· 2004 Jun · PMID 15177250
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Capital equipment and technology administration, as outlined in this article, is one of many responsibilities for managers of respiratory care. Planning for 1, 5, and 10 years, strategic budgeting, and systematic evaluat...Capital equipment and technology administration, as outlined in this article, is one of many responsibilities for managers of respiratory care. Planning for 1, 5, and 10 years, strategic budgeting, and systematic evaluation of existing and future devices will assist in creating a successful equipment and technology program. A successful capital equipment and technology program will enable respiratory care practitioners to treat patients effectively with the proper tools for success.
Respir Care Clin N Am
· 2004 Jun · PMID 15177249
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Health care organizations are complex adaptive systems, a set of connected or interdependent parts or agents that include caregivers, patients, and processes. Consequently, health care organizations are prone to problems...Health care organizations are complex adaptive systems, a set of connected or interdependent parts or agents that include caregivers, patients, and processes. Consequently, health care organizations are prone to problems and are not always predictable environments. Fundamental changes are needed in the organization and in the delivery of health care in the United States. This article presents a proven method of instituting and tracking the changes that can ensure a respiratory care department is delivering the appropriate level of care.
Respir Care Clin N Am
· 2004 Jun · PMID 15177248
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An essential responsibility of the modern respiratory care manager is to establish and monitor a particular level of quality and service being provided by a department. Focusing on quality and performance improvement fos...An essential responsibility of the modern respiratory care manager is to establish and monitor a particular level of quality and service being provided by a department. Focusing on quality and performance improvement fosters an environment that empowers and encourages all employees to be innovative and resolve roadblocks that limit organizational performance. This article discusses the issues regarding quality and performance improvement that arise in the daily operations of a respiratory care department.
Respir Care Clin N Am
· 2004 Jun · PMID 15177247
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Respiratory care (RC) protocols are widely regarded as the most appropriate method for properly allocating and delivering most forms of respiratory therapy. The use of protocols has increased steadily over the past 15 ye...Respiratory care (RC) protocols are widely regarded as the most appropriate method for properly allocating and delivering most forms of respiratory therapy. The use of protocols has increased steadily over the past 15 years, but, despite the successes and modest implementation of RC protocols across the country, there is room for improvement in adopting RC protocols for the effective use of respiratory care services. It also seems that many physicians have yet to be won over, and RC managers need to take the first step toward protocol development and implementation. This article addresses some of the issues surrounding the development of respiratory care protocols and the impact that their implementation may have based on experience gained to date.
Respir Care Clin N Am
· 2004 Jun · PMID 15177246
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Respiratory care directors are now becoming experts in staffing models that are unique to services provided through allied health professionals. The basic human resource management tenets of attract, retain, and motivate...Respiratory care directors are now becoming experts in staffing models that are unique to services provided through allied health professionals. The basic human resource management tenets of attract, retain, and motivate remain at the core of management focus; however, time standards, volumes, staffing variables, and flexible budgets are the current twists added to the litany of labor management terms. Optimizing resource consumption and establishing measurable patient outcomes to justify staff use will also be part of the manager's challenges related to health care delivery in the twenty-first century.
Respir Care Clin N Am
· 2004 Jun · PMID 15177245
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Today there a shortage of qualified health care professionals, and the current reshaping of the health care delivery system demands that quality care be provided at a lower cost. Many health care managers are finding tha...Today there a shortage of qualified health care professionals, and the current reshaping of the health care delivery system demands that quality care be provided at a lower cost. Many health care managers are finding that that they must re-think and change their traditional departmental concepts to become a multidisciplinary service. How department managers may better manage a multidisciplinary department in this new and changing work environment is the topic of this discussion.
Respir Care Clin N Am
· 2004 Jun · PMID 15177244
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The assessment of competency for respiratory care practitioners involves a thorough understanding of what defines competence, the development of a well-planned, continuous process that starts with new employee orientatio...The assessment of competency for respiratory care practitioners involves a thorough understanding of what defines competence, the development of a well-planned, continuous process that starts with new employee orientation, and a clearly communicated set of staff expectations. Career ladders are a tool that can be used to aid staff retention and recruitment, thereby reducing multiple costs associated with a high employee turnover rate, and to encourage professional development and accountability while achieving important departmental objectives.
Respir Care Clin N Am
· 2004 Jun · PMID 15177243
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Leadership is an elusive concept. Although no one best definition exists, some common characteristics, such as charisma and influence, tend to dominate most discussions on leadership qualities and traits. This article pr...Leadership is an elusive concept. Although no one best definition exists, some common characteristics, such as charisma and influence, tend to dominate most discussions on leadership qualities and traits. This article presents an overview of the findings of and pitfalls in research on leadership, in its varied and multifaceted contexts. It explores both personal and contextual attributes of leadership.
Respir Care Clin N Am
· 2004 Jun · PMID 15177242
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Managing in a health care environment is not for the frail of heart or weak of spirit. Health care is a system in crisis that is exacerbated because it got there by doing what once made it successful. From 1900 to 2004,...Managing in a health care environment is not for the frail of heart or weak of spirit. Health care is a system in crisis that is exacerbated because it got there by doing what once made it successful. From 1900 to 2004, focus of health care has shifted from controlling infectious diseases to episodic care and to present-day chronic and perspective care. The system has moved from issues of mortality, to morbidity, to mobility, to quality of life, to feeling good and, finally, to looking good. Managing the delivery of health care, if you choose to accept it, is not an impossible mission, but it will be a challenging job. Obviously, the focus of managers is how the system can be designed to innovate and improve care. Organizations and professions must change not only structures and processes, but national priorities for improvement with better methods of disseminating and applying knowledge. Managers of respiratory care departments must foster the use of information technology in clinical care, must create payment policies that encourage innovation and tested performance, and must enhance education programs to strengthen and retain the health care work forces.
Respir Care Clin N Am
· 2004 Mar · PMID 15062232
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Although the Geneva protocol that prohibits the use of chemical and biologic weapons was ratified in 1925, many countries failed to accept this protocol: others stipulated retaliation, and some, like the United States, d...Although the Geneva protocol that prohibits the use of chemical and biologic weapons was ratified in 1925, many countries failed to accept this protocol: others stipulated retaliation, and some, like the United States, did not ratify the protocol for decades. This delay allowed the continued development of chemical and biologic agents. Members of the health care community are responsible for determining the best way to protect society from the potentially devastating effects of these biologic agents. Ideally,these diseases would be prevented from ever developing into systemic illnesses. In the past, vaccination has been a successful means of eradicating disease. Vaccines remain a hopeful therapy for the future, but time is short,and there are many obstacles.Information regarding bioterrorism agents and their treatments comes mainly from dated data or from in vitro or animal studies that may not apply to human treatment and disease. Additionally, the current threat of bioterrorism does not allow enough time for accurate, well-designed,controlled studies in humans before the release of investigational vaccines. Furthermore, some human studies would not be safe or ethical. Finally,many members of society suffer from illnesses that would put them at high risk to receive prophylactic vaccination. It is therefore naive to believe that vaccines would be the ultimate protection from these agents. In addition to vaccine development, there must be concurrent investigations into disease management and treatment. Even in instances in which vaccination is known to be an effective means of disease protection. biologic agents may be presented in a manner that renders vaccines ineffective. Virulent strains of organisms may be used, more than one organism may be used in tandem to increase virulence, and strains may be selected for antibiotic and vaccine resistance. Genetically engineered strains may use virulence factors other than those targeted in vaccines, and high concentrations of organisms may overcome vaccine protection. Finally,exposure may not be immediately noted until it is too late to vaccinate, as was the case with anthrax. Even in a case, such as smallpox, in which postexposure vaccination is possible, patients will still develop disease, and the health care system may be overwhelmed. The United States government has been defensively planning and researching the use of vaccines and chemoprophylaxis against any potential biologic agents since at least 1953, and resources are still lacking. There are inadequate stockpiles of vaccine to protect the entire population. The pharmaceutical industry also lacks a means of mass producing vaccines ina short timeframe. There is no policy in place for the use of vaccines that are yet unlicensed and experimental but may be the only therapy in the event ofa terrorist attack. Investigations into these solutions have been instituted only after the September 11, 2001, attacks heightened the awareness of terrorism. Although vaccination is an effective means of prophylaxis and a means of terminating epidemics or treating active disease, there is also resistance from the general public. In some instances there is a lack of acceptance of vaccines, or the risk of side effects is too great. In other cases, a questionable benefit does not justify the expense of mass vaccination. Because of this uncertainty, mass vaccination is deemed an impractical solution to the threat of bioterrorism. Extending vaccination with most vaccines to include all members of society who may be first responders in the event of an attack should be considered. In all instances, the benefit-to-risk must be weighed ratio when deciding how and when to offer preemptive prophylaxis to protect society from a real but unknown threat.
Respir Care Clin N Am
· 2004 Mar · PMID 15062231
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Incomplete participation in the 1972 Biological Weapons Convention treaty and noncompliance by several signatory nations makes the malicious use of aerosolized biologic toxins a continuing threat. Unfortunately,prompt di...Incomplete participation in the 1972 Biological Weapons Convention treaty and noncompliance by several signatory nations makes the malicious use of aerosolized biologic toxins a continuing threat. Unfortunately,prompt diagnosis of toxin exposure may be confounded by a paucity of pathognomonic features and limited diagnostics, but the scenario of patients presenting en masse with a similar pulmonary syndrome should alert the clinician to the possibility of aerosolized toxin exposure. As knowledge of these agents increases, so too should the capabilities for detection,protection, diagnosis, and therapy. This improved understanding, coupled with ongoing public education and awareness and with detailed proactive planning will provide the framework for a prepared community.
Respir Care Clin N Am
· 2004 Mar · PMID 15062230
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Brucella, Q fever, tularemia, and smallpox are all rare infections in the United States but are potential agents of biologic terrorism. The pulmonary manifestations of these infections range from uncommon (brucella and s...Brucella, Q fever, tularemia, and smallpox are all rare infections in the United States but are potential agents of biologic terrorism. The pulmonary manifestations of these infections range from uncommon (brucella and smallpox) to expected (Q fever and tularemia). and all have clinical and radiologic presentations that can be confused with other, more endemic,diseases. Once the release of these agents has been determined, the diagnosis of presenting patients will be straightforward. The onus is on the clinician,however, to be able to recognize the first few, unexpected cases, because early identification will be paramount in helping curb the effect of the outbreak.
Respir Care Clin N Am
· 2004 Mar · PMID 15062229
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In the United States, plague poses a threat to humans from the infected animals in the endemic areas of the Western states. Plague may also be used in the near future as an agent of warfare or terrorism. Although the pre...In the United States, plague poses a threat to humans from the infected animals in the endemic areas of the Western states. Plague may also be used in the near future as an agent of warfare or terrorism. Although the presentation of bubonic plague may be less of a problem, the septicemic and pneumonic forms present challenges to early diagnosis and prompt treatment. The major threat of plague as an agent of terrorism will probably be through the inhalational route. which could result in many cases of the pneumonic form, requiring early recognition and initiation of appropriate therapy. In a mass-casualty scenario, the clinician should be aware of the potential agents of biowarfare and be familiar with the treatment and prophylaxis recommendations outlined by the CDC. It is also prudent to employ universal precautions and respiratory isolation when treating patients with any unknown exposure. In endemic areas, personal protective measures such as use of insecticides, insect repellants, and prompt prophylaxis in cases of exposure to plague are recommended for reducing the incidence of infection. The author also recommends review of CDC website on bioterrorism (http://www.bt.cdc.gov) to keep informed of plague updates.
Respir Care Clin N Am
· 2004 Mar · PMID 15062228
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Anthrax remains a real threat. In a spore form, it is highly infectious and dispersible. The initial symptoms are similar to those of influenza, and the early stage of inhalational anthrax may not be recognized. Early an...Anthrax remains a real threat. In a spore form, it is highly infectious and dispersible. The initial symptoms are similar to those of influenza, and the early stage of inhalational anthrax may not be recognized. Early antibiotic treatment is important to achieving a good outcome. Contrary to historical experience. many patients with even advanced anthrax can be saved with aggressive medical care. Prevention of anthrax infections requires vigilant infection control methods as well as a rational prophylactic plan. All health care providers should be familiar with the symptoms and treatment of this disease. It is hoped that future research will clarify tests for early diagnosis, the best methods of prophylaxis, and the most effective treatments. Unfortunately the threat of bioterrorism, and anthrax in particular, is unlikely to go away.
Respir Care Clin N Am
· 2004 Mar · PMID 15062227
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The respiratory system plays a major role in the pathogenesis of nerve agent toxicity. It is the major route of entry and absorption of nerve agent vapor, and respiratory failure is the most common cause of death follow-...The respiratory system plays a major role in the pathogenesis of nerve agent toxicity. It is the major route of entry and absorption of nerve agent vapor, and respiratory failure is the most common cause of death follow-ing exposure. Respiratory symptoms are mediated by chemical irritation,muscarinic and nicotinic receptor overstimulation, and central nervous system effects. Recent attacks have demonstrated that most patients with an isolated vapor exposure developed respiratory symptoms almost immediately. Most patients had only mild and transient respiratory effects, and those that did develop significant respiratory compromise did so rapidly. These observations have significant ramifications on triage of patients in a mass-casualty situation, because patients with mild-to-moderate exposure to nerve agent vapor alone do not require decontamination and are less likely to develop progressive symptoms following initial antidote therapy. Limited data do not demonstrate significant long-term respiratory effects following nerve agent exposure and treatment. Provisions for effective respiratory protection against nerve agents is a vital consideration in any emergency preparedness or health care response plan against a chemical attack.
Respir Care Clin N Am
· 2004 Mar · PMID 15062226
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Terrorism poses a clear and present danger to civilian populations. Although terrorist cells may gain access to traditional chemical weapons,there are literally thousands of other industrial chemicals to choose from. Com...Terrorism poses a clear and present danger to civilian populations. Although terrorist cells may gain access to traditional chemical weapons,there are literally thousands of other industrial chemicals to choose from. Common chemicals used on a daily basis in an industrialized society can be readily obtained from the local shopping center, rail yard. or from nearby industrial parks. and terrorists may choose to use these agents in an attack. The medical implications of a major incident involving the accidental or intentional release of a dangerous chemical are significant, and all healthcare facilities should have a plan in place to manage the casualties of such an event. This plan should include event recognition, crowd control, primary triage, emergency treatment, decontamination of injured and uninjured patients, and secondary triage. Emergency health care providers should be prepared to respond to classic chemical agents such as mustard,chlorine, and phosgene and must also work carefully with law enforcement and public health agencies to keep abreast of new threats. The ability to recognize an event promptly, triage patients, decontaminate casualties,administer antidotes when available, and provide best supportive care will minimize the adverse outcomes.