摘要:

Objective measurement of airway function is a fundamental aspect of the diagnosis and management of asthma. Documenting reversible airway obstruction in a patient presenting with compatible symptoms establishes a diagnosis of asthma and helps to determine the appropriate level of therapy. Spirometry is the gold standard test of airway function. Bronchoprovocation testing and serial peak expiratory flow monitoring can also provide clinically useful measurements of the variable airflow obstruction characteristic of asthma. Home peak flow monitoring is often used as a component of longitudinal asthma management. Although it has many recognized limitations, peak flow monitoring has been shown to positively affect asthma outcomes, especially in patients with more severe disease.

ISSN:1068-0640    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Pneumonia is an important cause of morbidity and mortality in severe burn patients. Risk factors associated with pneumonia are the severity of the thermal injury and the presence of inhalation injury. Most pneumonias are endogenous, that is, infection of the respiratory tract is preceded by colonization of the digestive tract, oropharynx, and/or gut. Strategies to prevent pneumonia are based on strict proper airway management. Selective digestive decontamination may play an important role in the prophylaxis of pneumonia. Severely ill burn patients have a higher incidence of pneumonia than other generally critically ill patients. Because burn trauma and inhalation injury induce a marked systemic inflammatory response syndrome, the diagnosis of infectious pneumonia in these patients is especially difficult. Nevertheless, the same criteria used in other subsets of critically ill patients should be used in burn patients for the diagnosis of pneumonia. Clinicians should be aware of pharmacokinetic alterations when prescribing systemic antibiotics.

ISSN:1068-0640    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Acute inhalation injury is a common problem that is responsible for 4.9% of workplace deaths. Gas solubility and chemical reactivity are the major explanation for the site of action and severity of a toxic inhalation. Corrosive irritant gases such as ammonia, sulfur dioxide, or methyl isocyanate produce intense upper airway symptoms including severe coughing, substernal burning, burning in the nose and throat, as well as conjunctivitis, and often superficial burning of the facial skin. Intense eye, nasal, and upper airway physical findings and symptoms suggest a severe exposure and the possibility of lower airway damage and the subsequent development of pulmonary edema. Patients with intense upper airway signs and symptoms are also at risk for laryngeal edema and upper airway compromise. The estimation of the severity of exposure is determined not only by duration of exposure and gas concentration but also by gas reactivity and water solubility. Other factors include gas density and the height of the patient, gas temperature, breathing pattern, oronasal versus mouth breathing, and conditions that affect breathing pattern, such as nasal congestion, coughing, preexisting asthma, or chronic obstructive pulmonary disease. Host factors such as orthopedic problems, tripping, or falling may prevent quick evacuation from the area of exposure. The long-term effects of an acute toxic inhalation include chronic bronchitis, bronchiectasis, bronchiolitis obliterans, bronchostenosis, reactive airways dysfunction syndrome, obstructive and restrictive disease, as well as an isolated residual volume. Management for a toxic inhalation is primarily supportive, but treatment strategies vary with specific agents on the basis of the propensity of the toxic inhalant to cause bronchiolitis obliterans and airway damage as well as pulmonary edema. Gases that are chemical asphyxiants require agent-specific therapy.

ISSN:1068-0640    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Critically ill patients form a population with a special necessity for allogeneic blood transfusions (AT). Multiple observational studies, most done in patients undergoing surgery for colorectal cancer, have associated AT with a higher rate of postoperative infections. This association has also been studied and proven in critically ill patients undergoing cardiac surgery, suffering polytrauma, septicemia, and transplantation. These studies have included local infections (the surgical wound), infections distant from the surgical site (pneumonia, urinary tract infection), and systemic infections (septicemia). The transfusion-related immunomodulation seems to be the cause of the immunologic changes in the recipient, leading to the acquirement of postoperative infections, the upregulation of the humoral immune response (Th2), and the downregulation of the cellular immune response (Th1). Observational studies can, however, prove an association that is not necessarily causal between transfusion and postoperative infection. The randomized, controlled trials designed to prove a causal relationship have yielded contradictory results. In three of these studies, the rate of infection was greater in patients transfused with allogeneic blood, whereas in the other three studies, the infection rate was not greater. The meta-analyses did not demonstrate a causal relationship between infection and transfusion. In summary, the allogeneic transfusion of packed red blood cells could be involved in a greater risk for postoperative infection in critically ill patients. Awaiting the confirmation of a causal relationship, the possibility of a transfusion-mediated postoperative infection should make AT a considered risk factor for infection.

ISSN:1068-0640    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Over the last several decades, consensus has developed that medical treatment decisions should be based on the values, goals, and preferences of the patient. Ethically, such an approach is supported by the principle of autonomy, which has a rich tradition in Western philosophy. In the intensive care unit (ICU), however, patients are frequently unable to directly exercise autonomous choice. Multiple tools and methods, including advance directives and surrogate decision-making, have been advanced in an attempt to extend individual autonomy into a future where the capacity for autonomous choice has been lost. Such attempts are severely constrained by philosophical and practical limitations. In opposition to the ascendancy of patient autonomy, the concept of medical futility has been introduced, attempting to define circumstances where patient preference is irrelevant to medical decision-making. Additionally, the respect accorded the concept of autonomy itself can be attacked as culture-specific. Medical decision-making in the ICU, then, rarely represents a straightforward exercise of patient choice. The limitations of autonomy in the ICU setting have required other methods for optimal decision-making that demand an active participation on the part of physicians. Surrogate decision-makers remain invaluable but not infallible, requiring physicians to make independent assessments of the best interests of patients. Shared decision-making, where physicians contribute medical expertise and judgment while surrogates provide an intimate understanding of the values and goals of the patient, offers a practical model for optimizing decisions in the ICU.

ISSN:1068-0640    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

We describe our method of transporting critically ill patients in both fixed-wing aircraft and ground ambulances. The transport of critically ill patients has evolved from the military need to evacuate patients away from the battlefield. Trauma patients benefit from speedy transfers to tertiary centers. In “medical” patients, stabilization before transfer seems to be more important than speed. Specially equipped air and ground ambulances can function as mobile intensive care units. Our transport teams are composed of a physician, nurse, and respiratory therapist. Transfers are made from rural hospitals to tertiary care centers. Physicians trained in critical care can stabilize patients before transfer and decrease the risk of transport. Knowledge of the pitfalls of practicing medicine in ground and air ambulances can decrease adverse outcomes. Physiologic changes associated with flight in fixed-wing aircraft are easily managed when recognized. Public policy for the transfer of patients has been described in the 1986 Consolidated Omnibus Budget Reconciliation Act (COBRA), and this knowledge can help physicians avoid liability during inter-hospital patient transfers.

ISSN:1068-0640    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

The transplantation of peripheral blood stem cells and bone marrow (BMT) has been increasing at an enormous pace as the procedure becomes the standard of care for many diseases. Pulmonary complications are common and the most fatal of specific organ failures. Complications are diverse, but the time frame of presentation can narrow the differential diagnosis considerably. Pulmonary edema can be hydrostatic, owing to volume overload or cardiac dysfunction, or nonhydrostatic, owing to capillary leak from cytokine release. Bacterial pneumonia is most common in the first month after transplant. Fungal pneumonia can occur early, as a result of neutropenia, or later, as a result of immunosuppressive therapy. The most common invasive respiratory fungal infection in the BMT population is aspergillosis. Treatment usually requires high doses of amphotericin B and possibly surgery to resect residual disease. Cytomegalovirus (CMV) is the most common cause of interstitial pneumonia after BMT, especially in patients who are seropositive for CMV before transplantation. Other respiratory viral infections have also been reported after BMT. Most pneumonias in the first month after transplant do not have a documented infection and are termed idiopathic pneumonia syndrome. The cause may be related to the conditioning regimen or occult viral infection. Mortality is roughly 80|X%, and the use of steroids for treatment is controversial. Severe airways obstruction, including bronchiolitis obliterans, is a late complication of BMT and is related to chronic graft-versus-host disease. The outcome of patients with respiratory failure who require mechanical ventilation is dismal, but survival has been improving over the last decade. Pulmonary function tests have been used to stratify risk for respiratory complications with varying success, and none are strong enough predictors to absolutely exclude a patient from BMT.

ISSN:1068-0640    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

SYNOPSIS: Neurologic impairment is frequently seen after cardiac surgery and remains a major cause of postoperative morbidity. BhaskerRao et al evaluated cerebral dysfunction after cardiac surgery both on and off pump in a 322-patient study sample undergoing coronary artery bypass graft (CABG). Of the group, 305 were on pump; 17 were never on pump. They found that the number of micro-emboli generated is significantly higher in those on pump. They quantified cerebral dysfunction, and found this to be significantly lower in the off-pump group.SOURCE: BhaskerRao B et al. Evidence for improved cerebral function after minimally invasive bypass surgery. J Card Surg 1998;13:27–31.

ISSN:1068-0640    

出版商:OVID    

年代:1999

数据来源: OVID

ISSN:1068-0640    

出版商:OVID    

年代:1999

数据来源: OVID