老年人呼吸危重症监护

老年人呼吸危重症监护是指对收治的老年人呼吸危重病患者,运用各种先进的医疗技术、现代化的监护和抢救设备,对其实施集中的加强治疗和护理,以最大限度地确保患者的生存及随后的生命质量。由于老年人基础疾病多、呼吸肌肌力下降、肺顺应性降低、呼吸道过滤功能下降、呼吸器协同功能差、肺通气及换气功能降低、对缺氧和二氧化碳刺激反应下降,老年人呼吸危重症往往具有来势凶、进展快、极易诱发多脏器功能衰竭、病情复杂等特点。     

急性呼吸窘迫综合征，危重医学的重点

急性肺损伤facutelunginiury,ALI）／急性呼吸窘迫综合征（acuterespiratorydistresssyndrome．ARDS）是死亡率很高的疾患．已经成为危重医学的重点。尽管经过多年的基础和临床研究．其死亡率仍居高不下。据报道上海重症监护病房（ICU）收治的ARDS患者病死率高达70％．这除了诊断偏晚外,也与缺乏新的治疗方法有关。因此,行之有效的实用方法是纠正可逆的诱发因素和发展新的治疗策略。     

Teaching and evaluating critical thinking in respiratory care

The capacity to perform critical thinking in respiratory care may be enhanced through awareness and education to improve skills, abilities, and opportunities. The essential skills for critical thinking in respiratory care include prioritizing, anticipating, troubleshooting, communicating, negotiating, decision making, and reflecting. In addition to these skills, critical thinkers exhibit certain characteristics such as critical evaluation, judgment,insight, motivation, and lifelong learning. The teaching of critical thinking may be accomplished though problem-based learning using an evidenced-based approach to solve clinical problems similar to those encountered in professional practice. Other traditional strategies such as discussion, debate, case study, and case presentations can be used. Web-based curriculum and technologic advances have created opportunities such as bulletin boards, real-time chats, and interactive media tools that can incorporate critical thinking. Many concerns and controversies surround the assessment of critical thinking, and individuals who administer critical thinking tests must be aware of the strengths and limitations of these assessment tools, as well as their relevance to the workplace. The foundational works reported in this article summarize the current status of assessment of critical thinking and can stimulate further investigation and application of the skills, characteristics, educational strategies, and measurement of critical thinking in respiratory care.     

Reengineering respiratory support following extubation: avoidance of critical care unit costs.

STUDY OBJECTIVE: We prospectively investigated alternative clinical practice strategies for critically ill trauma patients following extubation to evaluate the cost-effectiveness of these maneuvers. The primary change was elimination of the routine use of postextubation supplemental oxygen, with concurrent utilization of noninvasive positive pressure ventilatory support (NPPV) to manage occurrences of postextubation hypoxemia. DESIGN: Prospective, consecutive accrual of patients undergoing extubation. SETTING: Trauma ICU in a university hospital. INTERVENTIONS AND MEASUREMENTS: All patients received mechanical ventilation using pressure support ventilation (PSV) with continuous positive airway pressure (CPAP) as the primary mode. The patients were extubated to room air following a 20-min preextubation trial of 5 cm H(2)O CPAP at FIO(2) of 0.21, and demonstrating a spontaneous respiratory rate /= 7.30, PaCO(2) /= 50 mm Hg. The subgroup of patients who became hypoxemic (pulse oximetric saturation < 88%) within 24 h of extubation were treated with NPPV for up to 48 h duration. Patients who failed NPPV were reintubated. Four hundred fifty-one (84%) patients were successfully extubated to room air. Seventy-two patients (13%) became hypoxemic within 24 h, and NPPV was administered. Fifty-two patients (72% of those who were hypoxemic) responded to NPPV, while 20 patients failed to respond to therapy, were reintubated, and received mechanical ventilation for a mean of 4 days. Thirteen additional patients (2%) were reintubated for reasons other than hypoxemia. The overall reintubation rate for the group (n = 536) was 6.2%; for the postextubation hypoxemic group who failed NPPV, the reintubation rate was 3.7%. The elimination of routine supplemental oxygen via nasal cannula following extubation resulted in a potential direct cost avoidance of $50,006.88 for 451 patient days. Moreover, the 52 patients who were spared reintubation and mechanical ventilation provided an additional potential cost avoidance of $19,740.24 in unused ventilator days per patient. CONCLUSION: Eliminating the routine use of supplemental oxygen and employing NPPV as a method to prevent reintubation can facilitate a more aggressive, cost-effective strategy for the management of the trauma ICU patient who has been extubated.     

Curricular framework: core competencies in multicultural geriatric care

Strategies to reduce the documented disparities in health and health care for the rapidly growing numbers of older patients from diverse ethnic populations include increased cultural competence of providers. To assist geriatric faculty in medical and other health professional schools develop cultural competence training for their ethnogeriatric programs, the University of California Academic Geriatric Resource Program partnered with the Ethnogeriatric Committee of the American Geriatrics Society to develop a curricular framework. The framework includes core competencies based on the format of the Core Competencies for the Care of Older Patients developed by the Education Committee of the American Geriatrics Society. Competencies in attitudes, knowledge, and skills for medical providers caring for elders from diverse populations are specified. Also included are recommended teaching strategies and resources for faculty to pursue the development of full curricula.     

Effectiveness of a critical care nursing course: preparing students for practice in critical care

Experiences in critical care in an undergraduate program provide an opportunity for students to develop beginning knowledge and skills for practice in this setting, gain exposure to the role of the nurse in critical care, and acquire competencies essential for care of any acutely ill patient regardless of health problem and setting. The purposes of this study were to (1) examine the acquisition of basic critical care nursing knowledge after completion of an undergraduate course in critical care, (2) compare the differences in learning between students who completed only the theory component of the course and those who completed both theory and clinical practice in critical care, (3) examine learner perceptions toward critical care nursing, and (4) examine the impact of the course on selection by new graduates of critical care as their practice specialty. A quasi-experimental pretest-posttest design was used with two experimental groups: lecture only and lecture and clinical practice, and a randomized control group. Subjects were 85 senior nursing students in a baccalaureate program in a large metropolitan area in the Midwest. Data were collected by using a demographic data sheet, the Basic Knowledge Assessment Tool (BKAT), the Perceptions of Critical Care Nursing Questionnaire (PCCNQ), and follow-up interviews of graduates who completed the course. Both experimental groups demonstrated a statistically significant increase in learning from pretest and posttest, as measured by the BKAT. There were no significant differences in BKAT scores between the lecture and lecture-clinical practice groups. Mean scores on the BKAT at posttest for the experimental groups, who participated in the course, were significantly higher than the control.(ABSTRACT TRUNCATED AT 250 WORDS)     

Approach to therapy of respiratory infections in the critical care setting

Therapy of pneumonia in the critical care setting includes intravenous antibiotics and supportive care. Since the etiologic agent of infection may not be clear, empiric broad-spectrum antibiotic regimens are often used. Combinations of beta-lactam and aminoglycoside agents are particularly popular regimens due to the high incidence of gram-negative bacillary and Staphylococcus aureus pneumonias in the critical care unit. Several new approaches to treatment of pneumonia in the critical care setting are being evaluated, including single-agent empiric coverage using a broad-spectrum beta-lactam agent; broad-spectrum quinolones, such as ciprofloxacin; intrabronchial aminoglycoside instillation therapy; and passive immune therapy with immunoglobulins and monoclonal antibodies.     

Aligning quality and payment for heart failure care: defining the challenges

Hospitals may not support programs that improve the quality of care delivered to heart failure patients because these programs lower readmission rates and empty beds, and therefore further diminish already-declining revenues. A conflict between the highest quality of care and financial solvency does not serve the interests of patients, physicians, hospitals, or payers. In principle, resolution of this conflict is simple: reimbursement systems should reward higher quality care. In practice, resolving the conflict is not simple. A recent roundtable discussion sponsored by the Heart Failure Society of America identified 4 major challenges to the design and implementation of reimbursement schemes that promote higher quality care for heart failure: defining quality, accounting for differences in disease severity, crafting novel payment mechanisms, and overcoming professional parochialism. This article describes each of these challenges in turn.     

Endoscopic approach to pulmonary diseases: Bronchoscopy for critical respiratory care in neonates, infants, and children

Of the 605 pediatric patients admitted to our intensive care unit during the past 6 years, 90 underwent 380 bronchoscopies for diagnostic and therapeutic purposes. The indications for bronchoscopy were atelectasis/retention of airway secretion (n = 52), pneumonia (n = 31), airway bleeding (n = 14), pulmonary edema (n = 11), tracheobronchomalacia/airway stenosis (n = 11), and airway foreign body/aspiration (n = 7). Visualization of the airway was helpful for the diagnosis of respiratory problems; in 9 infants, bronchoscopy revealed tracheobronchial stenosis which other diagnostic modalities failed to detect. In 25 of the 31 patients with pneumonia, specimens taken by bronchoscopy were positive for specific pathogens. Bronchoscopy also proved to have significant therapeutic value, especially for airway cleaning; bronchial suctioning resulted in immediate reexpansion of the collapsed lung in 25 of 34 cases of physiotherapy-resistant atelectasis. A rigid bronchoscope was used to remove airway foreign body in 2 cases. Prototype channeled-ultrathin fiberscopes were utilized in 99 of 380 bronchoscopies. No complications were noted except for severe hypoxia and bradycardia in one infant. We conclude that bronchoscopy is a safe and useful modality for the critical respiratory care of infants and children.