Executive Summary Introduction Methodology Used to Prepare the Guideline Epidemiology Incidence Etiology Major Epidemiologic Points Pathogenesis Major Points for Pathogenesis Modifiable Risk Factors Intubation and Mechanical Ventilation Aspiration, Body Position, and Enteral Feeding Modulation of Colonization: Oral Antiseptics and Antibiotics Stress Bleeding Prophylaxis, Transfusion, and Glucose Control Major Points and Recommendations for Modifiable Risk Factors Diagnostic Testing Major Points and Recommendations for Diagnosis Diagnostic Strategies and Approaches Clinical Strategy Bacteriologic Strategy Recommended Diagnostic Strategy Major Points and Recommendations for Comparing Diagnostic Strategies Antibiotic Treatment of Hospital-acquired Pneumonia General Approach Initial Empiric Antibiotic Therapy Appropriate Antibiotic Selection and Adequate Dosing Local Instillation and Aerosolized Antibiotics Combination versus Monotherapy Duration of Therapy Major Points and Recommendations for Optimal Antibiotic Therapy Specific Antibiotic Regimens Antibiotic Heterogeneity and Antibiotic Cycling Response to Therapy Modification of Empiric Antibiotic Regimens Defining the Normal Pattern of Resolution Reasons for Deterioration or Nonresolution Evaluation of the Nonresponding Patient Major Points and Recommendations for Assessing Response to Therapy Suggested Performance Indicators

Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia the official statement of the American Thoracic Society and the Infectious Disease Society of America (特集 救急診療ガイドライン) -- (海外のガイドライン)

This fifth edition continues the tradition of excellence with thorough coverage of recent trends and changes in the clinical diagnosis and treatment of CNS diseases, detailed relevant neuropathologic, genetic, and clinical findings, and how those changes relate to MRI findings. It remains a comprehensive, internationally acclaimed, state-of-the-art reference for all who have an interest in neuroradiology – trainees to experts in the field, basic science researchers, and clinicians.

Magnetic Resonance Imaging of the Brain and Spine

Objective:To review the use of airway pressure release ventilation (APRV) in the treatment of acute lung injury/acute respiratory distress syndrome.Data Source:Published animal studies, human studies, and review articles of APRV.Data Summary:APRV has been successfully used in neonatal, pediatric, an

Other approaches to open-lung ventilation: airway pressure release ventilation.

Prone Positioning in Severe Acute Respiratory Distress Syndrome

Lung injury resulting from inhalation of smoke or chemical products of combustion continues to be associated with significant morbidity and mortality. Combined with cutaneous burns, inhalation injury increases fluid resuscitation requirements, incidence of pulmonary complications and overall mortality of thermal injury. While many products and techniques have been developed to manage cutaneous thermal trauma, relatively few diagnosis-specific therapeutic options have been identified for patients with inhalation injury. Several factors explain slower progress for improvement in management of patients with inhalation injury. Inhalation injury is a more complex clinical problem. Burned cutaneous tissue may be excised and replaced with skin grafts. Injured pulmonary tissue must be protected from secondary injury due to resuscitation, mechanical ventilation and infection while host repair mechanisms receive appropriate support. Many of the consequences of smoke inhalation result from an inflammatory response involving mediators whose number and role remain incompletely understood despite improved tools for processing of clinical material. Improvements in mortality from inhalation injury are mostly due to widespread improvements in critical care rather than focused interventions for smoke inhalation. Morbidity associated with inhalation injury is produced by heat exposure and inhaled toxins. Management of toxin exposure in smoke inhalation remains controversial, particularly as related to carbon monoxide and cyanide. Hyperbaric oxygen treatment has been evaluated in multiple trials to manage neurologic sequelae of carbon monoxide exposure. Unfortunately, data to date do not support application of hyperbaric oxygen in this population outside the context of clinical trials. Cyanide is another toxin produced by combustion of natural or synthetic materials. A number of antidote strategies have been evaluated to address tissue hypoxia associated with cyanide exposure. Data from European centers supports application of specific antidotes for cyanide toxicity. Consistent international support for this therapy is lacking. Even diagnostic criteria are not consistently applied though bronchoscopy is one diagnostic and therapeutic tool. Medical strategies under investigation for specific treatment of smoke inhalation include beta-agonists, pulmonary blood flow modifiers, anticoagulants and antiinflammatory strategies. Until the value of these and other approaches is confirmed, however, the clinical approach to inhalation injury is supportive.

/pdf/inhalation-injury-epidemiology-pathology-treatment-2172mxv3rt.pdf

Inhalation injury: epidemiology, pathology, treatment strategies

Airway pressure release ventilation was introduced to clinical practice about two decades ago as an alternative mode for mechanical ventilation; however, it had not gained popularity until recently as an effective safe alternative for difficult-to-oxygenate patients with acute lung injury/ acute respiratory distress syndrome This review will cover the definition and mechanism of airway pressure release ventilation, its advantages, indications, and guidance

Airway pressure release ventilation.

Airway pressure release ventilation (APRV) is inverse ratio, pressure controlled, intermittent mandatory ventilation with unrestricted spontaneous breathing. It is based on the principle of open lung approach. It has many purported advantages over conventional ventilation, including alveolar recruitment, improved oxygenation, preservation of spontaneous breathing, improved hemodynamics, and potential lung-protective effects. It has many claimed disadvantages related to risks of volutrauma, increased work of breathing, and increased energy expenditure related to spontaneous breathing. APRV is used mainly as a rescue therapy for the difficult to oxygenate patients with acute respiratory distress syndrome (ARDS). There is confusion regarding this mode of ventilation, due to the different terminology used in the literature. APRV settings include the “P high,” “T high,” “P low,” and “T low”. Physicians and respiratory therapists should be aware of the different ways and the rationales for setting these variables on the ventilators. Also, they should be familiar with the differences between APRV, biphasic positive airway pressure (BIPAP), and other conventional and nonconventional modes of ventilation. There is no solid proof that APRV improves mortality; however, there are ongoing studies that may reveal further information about this mode of ventilation. This paper reviews the different methods proposed for APRV settings, and summarizes the different studies comparing APRV and BIPAP, and the potential benefits and pitfalls for APRV.

http://rc.rcjournal.com/content/respcare/57/2/282.full.pdf

Airway pressure release ventilation: what do we know?

The predictive value of airway occlusion pressure at 100 msec (P0.1) on successful weaning from mechanical ventilation: A systematic review and meta-analysis.

Most clinicians pay attention to tidal volume and airway pressures and their curves during mechanical ventilation. On the other hand, inspiratory-expiratory flow curves also provide a plethora of information, but much less attention is paid to them. Flow curves chronologically show the velocity and direction of inspiration and expiration and are influenced by the respiratory mechanics, the patient's effort, and the mode of ventilation and its settings. When the ventilator setting does not synchronize with the patient's respiratory pattern, the patient can easily have worsening breathing effort, patient-ventilator asynchrony, which can lead to prolonged ventilator support or lung injury. The information provided by the flow curves during mechanical ventilation, such as respiratory mechanics, the patient's effort, and patient-ventilator interactions, are very helpful when adjusting the ventilator setting. If clinicians can monitor and assess the flow curves information appropriately, it can be a useful diagnostic and therapeutic tool at the bedside. There may be association between inspiratory effort and flow, and this may further guide us, especially in the weaning process and when patients are not synchronizing with the ventilator. In this review, we try to gather information about "flow" that is scattered around in the literature and textbooks in one place. We will summarize the different flow waveforms utilized in commonly used ventilator modes with their advantages and disadvantages, information gained by the flow curves (i.e., flow-time, flow-volume, and flow-pressure), how to detect and manage asynchronies, and some ideas for future uses. Flow waveforms shapes and patterns are very beneficial for the management of patients undergoing mechanical ventilatory support. Attention to those waveforms can potentially improve patient outcomes. Clinicians should be familiar with this information and how to act upon them.

/pdf/go-with-the-flow-clinical-importance-of-flow-curves-during-5d1y7kmzg1.pdf

Go with the flow-clinical importance of flow curves during mechanical ventilation: A narrative review.

The harmful effects are more theoretical than observed. On the other hand, there are also no convincing data to support the benefit of this therapy.

https://www.ccjm.org/content/ccjom/78/3/168.full.pdf

Ehab Daoud

Papers

Airway pressure release ventilation.

Airway pressure release ventilation: what do we know?

The predictive value of airway occlusion pressure at 100 msec (P0.1) on successful weaning from mechanical ventilation: A systematic review and meta-analysis.

Go with the flow-clinical importance of flow curves during mechanical ventilation: A narrative review.

Q: Is iron therapy for anemia harmful in the setting of infection?