ABSTRACT
The timely integration of palliative medicine is an important component in the treatment of various advanced diseases. While a German S3-guideline on palliative medicine exists for patients with incurable cancer, a recommendation for non-oncological patients and especially for palliative patients presenting in the emergency department or intensive care unit is missing to date. Based on the present consensus paper, the palliative care aspects of the respective medical disciplines are addressed. The timely integration of palliative care aims to improve quality of life and symptom control in clinical acute and emergency medicine as well as intensive care.
Subject(s)
Emergency Medicine , Quality of Life , Humans , Consensus , Critical Care , Palliative CareABSTRACT
The timely integration of palliative medicine is an important component in the treatment of various advanced diseases. While a German S3-guideline on palliative medicine exists for patients with incurable cancer, a recommendation for non-oncological patients and especially for palliative patients presenting in the emergency department or intensive care unit is missing to date. Based on the present consensus paper, the palliative care aspects of the respective medical disciplines are addressed. The timely integration of palliative care aims to improve quality of life and symptom control in clinical acute and emergency medicine as well as intensive care.
Subject(s)
Emergency Medicine , Quality of Life , Humans , Consensus , Critical Care , Intensive Care UnitsABSTRACT
The timely integration of palliative medicine is an important component in the treatment of various advanced diseases. While a German S-3-guideline on palliative medicine exists for patients with incurable cancer, a recommendation for non-oncological patients and especially for palliative patients being treated in the emergency department or intensive care unit is missing to date. Based on the present consensus paper, the palliative care aspects of the respective medical disciplines are addressed. The timely integration of palliative care aims to improve quality of life and symptom control in clinical acute and emergency medicine as well as intensive care.
Subject(s)
Emergency Medicine , Quality of Life , Humans , Consensus , Critical Care , Palliative CareABSTRACT
The integration of palliative medicine is an important component in the treatment of various advanced diseases. While a German S3 guideline on palliative medicine exists for patients with incurable cancer, a recommendation for non-oncological patients and especially for palliative patients presenting in the emergency department or intensive care unit is missing to date. Based on the present consensus paper, the palliative care aspects of the respective medical disciplines are addressed. The timely integration of palliative care aims to improve quality of life and symptom control in clinical acute and emergency medicine as well as intensive care.
Subject(s)
Emergency Medicine , Quality of Life , Humans , Consensus , Critical Care , Intensive Care Units , Palliative CareABSTRACT
We report on a patient with refractory Myasthenia gravis with acetylcholine receptor antibodies with two prior myasthenic crises suffering from COVID-19 with rapid evolving weakness and respiratory failure. Respiratory failure developed and prolonged mechanical ventilation was necessary. After plasmapheresis, residual, severe generalized and bulbar weakness persisted. Complement inhibition with eculizumab was, therefore, introduced and lead to rapid recovery. In refractory myasthenic crisis individualised therapies could be successful.
Subject(s)
COVID-19 , Myasthenia Gravis , Respiratory Insufficiency , Humans , Myasthenia Gravis/complications , Myasthenia Gravis/drug therapy , Receptors, Cholinergic , SARS-CoV-2ABSTRACT
BACKGROUND: The term early rehabilitation is defined as a rehabilitation that begins in the early phase after acute illness and is statutory positioned in §â39SGB V. Aim of this investigation is to describe the quality of outcome of pulmonary early rehabilitation. METHOD: Prospective census of functional parameters, status of ventilation and discharge-disposition in a specialized unit for early pulmonary rehabilitation over a period of one year. RESULTS: Out of 190 patients 179 (94.2â%) were previously invasively ventilated. During the treatment period of 39â±â17 days, FAM-Index increased from 84.4â±â19.8 to 118.5â±â23.3 (Ci 30.9â-â37.3, Cohen'd 1.58; pâ<â0.001), Barthel-Index from 30.5â±â13.8 to 58.3â±â16.2 (Ci 25.4â-â33.8, Cohen's d 1.4; pâ<â0.001) six minute walking distance from 12.9â±â40.1âm to 131.4â±â85.2âm (Ci 105.6â-â131.4âm, Cohn's d 1.78; pâ<â0.001). Patients were less likely to be receive further post-discharge rehabilitation if they were ventilated. CONCLUSION: Patients admitted to the early pulmonary rehabilitation unit were severely compromised, however quality of outcome was favourable and independent of the breathing status (spontaneously breathing vs. non-invasive ventilation or invasive ventilation). Finding discharge dispositions appeared to be more difficult if patients were ventilated.
Subject(s)
Respiration, Artificial , Respiratory Function Tests , Aged , Female , Humans , Male , Middle Aged , Patient Discharge , Prospective Studies , Rehabilitation , Respiration, Artificial/adverse effects , Respiration, Artificial/methods , Respiration, Artificial/statistics & numerical data , Ventilator Weaning , Walking/physiologyABSTRACT
BACKGROUND: Inhaled bronchodilators are frequently used in patients with chronic obstructive pulmonary disease (COPD). However, there has been no efficient way to administer the long-acting anticholinergic tiotropium to mechanically ventilated patients. The aim of this in vitro study was to compare the fine particle dose (FPD) output of a specifically designed adapter with other accessory devices for the delivery of bronchodilators using the Respimat® (RMT) inhaler by simulating the specific inhalation flow profiles of patients with COPD. METHODS: Using characteristic flow profiles from COPD patients being weaned off mechanical ventilation, an in vitro study was performed analyzing the FPD achieved with different accessory devices (connectors, spacers, AeroTrachPlus valved holding chamber), which can be used to deliver drugs from pressurized metered dose inhalers (pMDI) and RMT inhalers to artificial airways. Fenoterol pMDI, tiotropium RMT, and a fixed-dose combination of salbutamol and ipratropium delivered by pMDI or RMT, were used as bronchodilators. Aerosols were collected by a next-generation impactor. RESULTS: The RMT inhaler, combined with a new in-line adapter, was superior to other inhaler device connector or spacer combinations in FPD delivery during simulated mechanical ventilation (p<0.01). The outcome with the RMT inhaler/RMT adapter combination during simulation of mechanical ventilation was comparable to the measurements with the RMT/AeroTrachPlus valved holding chamber during simulation of spontaneous breathing. The delivery rates of the RMT adapter were not significantly affected by the administered bronchodilators or by the type of artificial airway (endotracheal or tracheostomy tube) employed. CONCLUSIONS: The RMT inhaler combined with the prototype in-line adapter was better than the other accessory device combinations in fine particle deposition of inhaled bronchodilators during mechanical ventilation. Further research is required to determine the clinical relevance of these in vitro findings.
Subject(s)
Bronchodilator Agents/administration & dosage , Nebulizers and Vaporizers , Pulmonary Disease, Chronic Obstructive/drug therapy , Respiration, Artificial , Aerosols , HumansABSTRACT
RATIONALE: Non-invasive ventilation (NIV) has been shown to improve clinical outcomes in acute and chronic hypercapnic respiratory failure. A new timed, automated, auto-adaptive non-invasive ventilatory mode (TA-mode) has been recently introduced. OBJECTIVE: To investigate the degree of respiratory muscle unloading with this new mode in comparison to assisted (S-mode) NIV in healthy individuals. METHODS: Work of breathing, pressure time product and transdiaphragmatic pressure time product were measured during unassisted breathing, assisted and TA-mode-NIV in eight healthy, awake volunteers at inspiratory pressures of 20 and expiratory pressures of 4hPa. RESULTS: Assisted and TA-mode-NIV reduced the work of breathing by 50 and 89.1%, pressure time product by 61.5 and 72.6% and transdiaphragmatic pressure time product by 77 and 88.7%, respectively when compared to unassisted breathing. The degree of respiratory muscle unloading was higher during TA-mode-NIV when compared to assisted non-invasive ventilation (work of breathing p<0.001, pressure time product p=0.04 and transdiaphragmatic pressure time product p=0,01). CONCLUSION: TA-mode-NIV achieved significant higher levels of respiratory muscle unloading in healthy individuals when compared to assisted non-invasive ventilation.
Subject(s)
Positive-Pressure Respiration/instrumentation , Respiratory Insufficiency/physiopathology , Respiratory Mechanics/physiology , Respiratory Muscles/physiology , Work of Breathing/physiology , Adult , Female , Humans , Lung Compliance , Male , Masks , Models, Biological , Pilot Projects , Respiratory Insufficiency/rehabilitation , Therapy, Computer-Assisted/methods , Treatment OutcomeABSTRACT
BACKGROUND: Noninvasive positive-pressure ventilation (NPPV) unloads respiratory muscles. Spontaneous-breathing ventilation modes require patient effort to trigger the ventilator, whereas controlled modes potentially economize on patient triggering effort and thus achieve more complete respiratory muscle rest. Data on controlled NPPV have not been published to date. We hypothesize that controlled ventilation is feasible in patients with hypercapnic chronic obstructive pulmonary disease. METHODS: We measured blood gas values, respiratory muscle strength, spontaneous breathing pattern, and lung function before and after a 3-month period of NPPV in 305 patients (213 male, mean +/- SD age 61.3 +/- 8.6 y). The subjects used a controlled NPPV mode when they could tolerate it. RESULTS: Ninety-one percent of the patients were able to adapt to a controlled NPPV mode. In those patients, daytime P(CO(2)) decreased from 56.7 +/- 7.5 mm Hg to 47.5 +/- 6.6 mm Hg (p < 0.001) and P(O(2)) increased from 49.2 +/- 8.8 mm Hg to 56.2 +/- 8.5 mm Hg (p < 0.001). Their mean maximum inspiratory pressure increased from 42.3 +/- 16.9 cm H(2)O to 48.4 +/- 18.0 cm H(2)O (p < 0.001). Their mean vital capacity increased from 1.89 +/- 0.62 L to 1.99 +/- 0.67 L (p = 0.004). And their spontaneous breathing pattern became less rapid and shallow. CONCLUSIONS: Controlled NPPV is feasible in patients with hypercapnic chronic obstructive pulmonary disease. We observed improved blood gas values, lung function, and inspiratory muscle strength.
Subject(s)
Positive-Pressure Respiration/methods , Pulmonary Disease, Chronic Obstructive/therapy , Respiratory Insufficiency/etiology , Aged , Chronic Disease , Germany , Humans , Middle Aged , Outcome Assessment, Health Care/methodsABSTRACT
BACKGROUND: Tracheostomy decreases airway resistance and work of breathing. No comprehensive data are available on respiratory mechanics after tracheostomy decannulation. We evaluated respiratory mechanics after decannulation. METHODS: Twenty-five patients with tracheostomy were included. Measurement of arterial blood gases, air-flow, and esophageal pressure during spontaneous breathing were evaluated. RESULTS: Overall arterial blood gas parameters as well as flow and pressure measurements including work of breathing and airway resistance were not affected by the intervention. Inspiratory time fraction increased from 40.0 + or - 0.04 to 43% + or - 0.05% (p = .007). We observed marked individual differences. Postdecannulation change in work of breathing is best predicted by change in airway resistance (R = 0.869, R(2) = 0.755, p < .0001) CONCLUSION: Inspiratory time increased after decannulation, and arterial blood gas levels and respiratory mechanics did not change for the whole cohort. Individual changes in work of breathing are considerable and correlate closely to changes in airway resistance.
