摘要:

Chlamydia pneumoniaehas been recently recognized as a common respiratory tract infectious agent. ChronicC. pneumoniaeinfection has been found to be common in chronic bronchitis and could contribute to disease progression through its toxic effect on bronchial epithelial cells, with ciliostasis and increasing chronic inflammation through proinflammatory cytokine production.C. pneumoniaeseems to be significantly related to wheezing in children, particularly in patients with a history of recurrent episodes, and to adult-onset nonatopic asthma. Specific antibiotic therapy may improve the course of reactive airway disease.

ISSN:1068-0640    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

The acute respiratory distress syndrome (ARDS) is a devastating clinical syndrome characterized by acute onset, hypoxemia (Pao2/Fio2<200 mm Hg) with bilateral infiltrates on chest radiography, and absence of evidence of left atrial hypertension. Pneumonia is now the most common infection acquired in intensive care unit patients during mechanical ventilation, and it has a high associated mortality. ARDS shares with nosocomial pneumonia etiologic, physiopathologic, and diagnostic properties. Alterations of pulmonary surfactant and formation of hyaline membranes are common processes in ARDS and pneumonia. The incidence of nosocomial pneumonia during ARDS is very high, and it seems, at least from the clinical data, that it is more related to long-term mechanical ventilation rather than a predisposition to infection caused by ARDS. However, data on the incidence of pneumonia in patients with ARDS vary widely because of the lack of a standard diagnostic test for nosocomial pneumonia, which is particularly difficult to diagnose in patients with ARDS. With a high underlying mortality, no study to date has demonstrated an increased mortality attributable to pulmonary infection or colonization in patients with ARDS.

ISSN:1068-0640    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

Delirium in the intensive care unit (ICU) is a frequent but poorly understood disorder. Most of the concepts regarding the etiology and management of delirium in the ICU have been extrapolated from other populations and case series. ICU delirium seems to be independently associated with worse outcomes, such as prolonged ventilator dependence and ICU stays. Neuroleptics, either alone or in combination with lorazepam, are most commonly used in the management of the symptom of agitation in the delirious patient, but this practice has not been properly evaluated. Studies in non-ICU populations suggest that delirium can be prevented. Evaluation of preventive strategies and management of delirium in ICU patients needs to be targeted for future research to improve outcomes in these patients.

ISSN:1068-0640    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

The use of tracheostomy tubes has become common practice in the last few decades. Early in the twentieth century, tracheostomy tubes were being placed almost exclusively for acute or impending upper airway obstruction. Indications for their placement have now become much broader and include, but are not limited to, mechanical ventilation, both in the setting of prolonged translaryngeal intubation and chronic progressive respiratory insufficiency, as occurs in neuromuscular diseases, excessive pulmonary secretions and airway suctioning, and sleep apnea. There are various types of tracheostomy methods described. Percutaneous dilational tracheostomy can now be performed at the bedside with or without bronchoscopic guidance, with a low complication rate in experienced hands. Minitracheostomy has been used in postoperative situations where airway secretions are excessive. Cricothyrotomy is the procedure of choice in emergency situations. Alternative, less-invasive measures to tracheostomy are widely available. These are used in different clinical settings and include: (1) the use of noninvasive ventilation in weaning after acute respiratory failure, (2) noninvasive ventilation in chronic respiratory failure with a special emphasis on neuromuscular weakness, and (3) noninvasive cough assistance devices in patients with excessive airway secretions.

ISSN:1068-0640    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

Although creation of a tracheostomy does facilitate suctioning of the airway and often simplifies usage of mechanical ventilation (as discussed in Part I), numerous complications can occur. Some occur immediately after tracheostomy placement (e.g., bleeding, laryngeal nerve damage, and pneumomediastinum) and others during long-term follow-up (e.g., tracheoesophageal fistula, tracheal stenosis, tracheomalacia, swallowing dysfunction, and aspiration). Therefore, in each patient in whom this procedure is performed, the potential long-term risks and possible benefits must be carefully weighed. In some patients, tracheostomy usage will be needed on a life-long basis. In others, once the primary process that led to the placement of the tracheostomy is reversed or when alternative noninvasive measures are thought to be adequate, decannulation should be contemplated. However, the procedure of decannulation and the timing should be individualized. Some guidelines are provided in this article and are based, when possible, on objective data. For many of the issues regarding tracheostomy usage (e.g., timing of decannulation, best decannulation approach, and best approach to dealing with swallowing dysfunction induced by tracheostomy), additional studies are needed to objectively define the best therapeutic approaches.

ISSN:1068-0640    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

Patients with chronic airflow obstruction and difficult weaning from mechanical ventilation are at increased risk of intubation-associated complications and mortality because of prolonged invasive mechanical ventilation. Noninvasive positive-pressure ventilation may reverse most of the pathophysiologic mechanisms associated with weaning failure in these patients. Although randomized controlled trials show that the use of noninvasive ventilation to advance extubation in difficult to wean patients or in patients who develop respiratory failure after apparently successful extubation can result in reduced periods of endotracheal intubation, improvement in complication rates, and survival, this is not a consistent finding. The published data with outcome as a primary variable are exclusively from patients who had preexisting lung disease. In addition, the patients were hemodynamically stable, with a normal level of consciousness, no fever, and a preserved cough reflex. It remains to be seen whether noninvasive positive-pressure ventilation has a role in other patient groups and situations. The technique is, however, a usual addition to the therapeutic armamentarium for a group of patients who pose a significant clinical and economic challenge.

ISSN:1068-0640    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

Massive pulmonary embolism (PE) is distinct from submassive PE by hemodynamic compromise secondary to mechanical obstruction. Present literature defines massive PE based on occlusion area, which may or may not be proportional to hemodynamic changes, depending on the status of cardiopulmonary reserve in a particular patient. The pathophysiology of massive PE is characterized by a sudden elevation in the afterload to right ventricle (RV) from obstruction of pulmonary vasculature, which causes RV ischemia and dysfunction. The acutely dilated RV displaces the interventricular septum toward the left ventricle (LV) and in turn leads to LV compression and shock. Accordingly, the principles of management of massive PE are to reverse obstruction, maintain perfusion pressure to the right coronary artery, and be cautious with fluid resuscitation. Thrombolysis has been proven effective in resolving the embolus and in improving pulmonary blood flow. Previous studies on thrombolysis for PE have not documented mortality benefit. However, these studies included all cases of PE, among whom most had submassive PE, which is of low mortality. Presently, management of massive PE has to be individualized in that a clear understanding of its hemodynamic consequences is critical to guide clinical decision.

ISSN:1068-0640    

出版商:OVID    

年代:2002

数据来源: OVID

ISSN:1068-0640    

出版商:OVID    

年代:2002

数据来源: OVID