摘要:

&NA;Recent investigations into the pathogenesis of asthma have highlighted the importance of airway inflammation in this disorder. Although currently approved anti‐inflammatory compounds including glucocorticoids and antireleasing agents have become first‐line therapy in the treatment of asthma, several alternative anti‐inflammatory agents have been evaluated, especially for patients who are steroid‐dependent. These agents—including gold salts, methotrexate, cyclosporin, and others—are postulated to have anti‐inflammatory mechanisms of activity. Although some patients have improved on these agents, drug‐related side effects have been a significant problem, and generalized use of these agents is not appropriate at this time. This article reviews the rationale for use of and accumulated experience with these drugs.

ISSN:1068-0640    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

&NA;The incidence of tuberculosis, especially multidrug‐resistant tuberculosis (MDR‐TB), has increased significantly in recent years. Outbreaks of MDR‐TB have occurred in hospitals, homeless shelters, and correctional institutions. MDR‐TB is frequently associated with human immunodeficiency virus infection and prior antituberculous therapy.To minimize emergence of resistance, a four‐drug regimen for initial, empiric treatment of tuberculosis is recommended. Susceptibility testing should be performed on all isolates to guide further therapy and define local resistance patterns. Directly observed therapy administered twice or thrice weekly can be used to ensure compliance. For resistant organisms, treatment with at least two drugs to which the organism is sensitive is recommended. Cure of MDR‐TB is difficult to achieve and mortality is high. Surgery may provide a useful adjunctive therapy in advanced cases. The optimal prophylactic regimen for exposure to MDR‐TB and/or skin test conversion remains to be determined.Current efforts to control intra‐institutional transmission of tuberculosis have focused on prompt case identification, use of disposable particulate respirator masks, and negative air flow ventilation (when available). Ultraviolet germicidal irradiation has been advocated as an effective and economical means of reducing institutional transmission.

ISSN:1068-0640    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

&NA;Massive inhalation of toxic gases is usually accidental and unpredictable. Irritant gases can result in immediate death from asphyxia, acute upper airways inflammation, or delayed pulmonary edema requiring mechanical ventilation. Currently, most patients are expected to survive and recover with little or no residual dysfunction regardless of the severity of the initial event. However, in some cases, long‐term sequelae such as chronic bronchitis, air flow obstruction, bronchial hyperreactivity, asthmalike disease (e.g., reactive airways disease syndrome [RADS]), bronchiolitis obliterans, or residual psychophysiologic dyspnea can occur. Asphyxiants and neurotoxins cause severe neuromuscular deficits with respiratory muscle failure and hemorrhagic pulmonary edema. Febrile syndromes from inhalation of chemical fumes are disturbing but benign without long‐term sequelae.No specific therapy is available for direct chemical pulmonary injury. Therapy should follow the general principles for treatment of upper and lower airway obstruction, noncardiogenic pulmonary edema, hemorrhagic pneumonitis, and/or respiratory muscle paralysis. Early endotracheal intubation and mechanical ventilation can be lifesaving and provide life support while spontaneous healing and recovery occur. The role of corticosteroids and other anti‐inflammatories in altering the course and outcome of the disease remains controversial.

ISSN:1068-0640    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

&NA;Misallocation of respiratory care services is widespread with both overordering and underordering reported. Specifically, available studies suggest that between 20% and 50% of respiratory care services ordered have low likelihood of providing clinical benefit. In a prior series at our institution, frequent overordering also was offset by underordering of respiratory care services (i.e., failing to provide appropriate services).To minimize misallocation of respiratory care services, recent attention has turned to the concept of therapist‐driven protocols or a Respiratory Therapy Consult Service, in which respiratory therapists evaluate patients and use sign/symptom‐based algorithms to prescribe respiratory care services. This article recommends the structure and function of a Respiratory Therapy Consult Service, citing our experience at the Cleveland Clinic Foundation. An ongoing observational prospective study has suggested that the rate of misallocation can be decreased substantially with a Respiratory Therapy Consult Service.

ISSN:1068-0640    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

&NA;Critical care services consume a large share of health‐care resources, many of which are devoted to the care of ventilator‐dependent patients who often require prolonged support. The precise determination of costs of mechanical ventilation is quite complex and may even be elusive. This results from several factors, including the difficulty inherent in separating the “technology” of mechanical ventilation from the reason for its use, variable cost accounting methodologies used by different institutions, and the overlap between direct and indirect costs that accrue. Furthermore, cost determinations of ventilator dependency must be distinguished from cost effectiveness, the latter linking clinical outcome and utility to the amount of resources expended. In view of the heightened concern for cost containment, impending health care reform, and changes in health care reimbursement, the pulmonary and critical care physician must become familiar with the economics of mechanical ventilation. Doing so will facilitate financial savings without sacrificing clinical quality.

ISSN:1068-0640    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

&NA;Although anticoagulation has been the cornerstone of treatment of acute pulmonary embolism for the past 30 years, there has been no further reduction in the mortality rate for this condition. The use of thrombolytic therapy for pulmonary embolism has been shown in randomized controlled trials to accelerate clot lysis, pulmonary reperfusion, and hemodynamic improvement. In addition, recent preliminary findings suggest that thrombolysis confers greater long‐term clinical benefit than does treatment with heparin alone. No effect of thrombolytic therapy on mortality has been shown, but only small‐scale trials have been performed.Fear of bleeding complications has limited the use of thrombolysis for pulmonary embolism; major bleeding is still seen in 10‐15% of patients. However, recent data suggest that shorter infusion times and elimination of routine pulmonary angiograms in some patients may further reduce the incidence of bleeding. Three agents have been shown to be effective for pulmonary embolism: urokinase, streptokinase, and tissue‐type plasminogen activator. Relative efficacy of the three agents is difficult to assess, given the different dosing regimens employed in previous studies. More rapid or “bolus” infusions of each agent have shown promising results, with equivalent safety profiles.Thrombolytic therapy is recommended in cases of pulmonary embolism with hemodynamic compromise, lobar or multisegmental involvement, or in the setting of smaller emboli in patients with prior cardiopulmonary disease. In contrast with its use for myocardial infarction, thrombolytic therapy may be administered as late as 14 days after onset of symptoms of pulmonary embolism. Greater familiarity with the use of these agents, coupled with the broad window of time available for their use, has resulted in increasing interest in this therapeutic option.

ISSN:1068-0640    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

&NA;The spread of malignancies to the lung occurs frequently. The usual route of spread is either through the vascular or lymphatic route, with resulting lung nodules, tumor emboli, large airway involvement, and lymphangitic carcinoma. This article reviews the pathogenesis and clinical manifestations of pulmonary metastases, as well as details about tumors seen frequently.

ISSN:1068-0640    

出版商:OVID    

年代:1994

数据来源: OVID

ISSN:1068-0640    

出版商:OVID    

年代:1994

数据来源: OVID