Acute Respiratory Distress Syndrome Definition, Causes, and Pathophysiology.

First successfully described in 1967, acute respiratory distress syndrome has since garnered much interest and debate. Extensive studies and clinical trials have been carried out in efforts to address the associated high mortality; however, it remains a significant burden on health care. Despite the heterogeneous etiologies that lead to the development of acute respiratory distress syndrome, this rapidly progressing form of respiratory failure, characterized by severe hypoxemia and nonhydrostatic pulmonary edema, has a recognizable pattern of lung injury. In this chapter, we will review the clinical manifestations, definitions, causes, and a brief overview of the pathophysiology of this complex syndrome.

Acute Kidney Injury in the Context of Acute Respiratory Distress Syndrome.

Acute kidney injury is a heterogeneous syndrome defined by rapid (hours to days) decline in the glomerular filtration rate leading to retention of metabolic waste products including creatinine and urea, resulting in declination of the body's ability to manage fluid status and acid-base regulation. Acute kidney injury is seen commonly in acute respiratory distress syndrome and this article will explore the relationship between the 2 entities.

Acute Respiratory Distress Syndrome From an Infectious Disease Perspective.

Acute respiratory distress syndrome (ARDS) is an inflammatory form of lung injury in response to various clinical entities or inciting events, quite frequently due to an underlying infection. Morbidity and mortality associated with ARDS are significant. Hence, early recognition and targeted treatment are crucial to improve clinical outcomes. This article encompasses the most common infectious etiologies of ARDS and their clinical presentations and management, along with commonly encountered infectious complications in such patients.

Acute Respiratory Distress Syndrome Novel Therapies.

Acute respiratory distress syndrome (ARDS) was first described in 1967. Since then, several landmark studies have been published that have greatly influenced the way we diagnose and treat patients with ARDS. Despite extensive research and advancements in ventilator strategies, moderate-severe ARDS has been associated with high mortality rates. Current treatment remains primarily supportive with lung-protective ventilation strategies. Pharmacological therapies that reduce the severity of lung injury in vivo and in vitro have not yet translated into effective clinical treatment options. Currently, the mortality rate of severe ARDS remains in the range of 30% to 40%. To review, the mainstay of ARDS management includes mechanical ventilation with low tidal volumes to decrease barotrauma, prone ventilation, conservative fluid management, and neuromuscular blockade. ARDS survivors tend to have long-term and potentially permanent neuromuscular, cognitive, and psychological symptoms, affecting patient's quality of life posthospitalization. These long-term effects are likely secondary to prolonged hospitalizations, prolonged mechanical ventilation, utilization of prone strategies, utilization of paralytic drugs, and occasionally steroids. Therefore, several novel therapies outside the realm of advanced ventilation and prone positioning methods are being studied. In this article, we discuss a few of these novel therapies including prophylactic aspirin, inhaled nitric oxide, mesenchymal stem cells, and intravenous ß-agonists. Steroids and extracorporeal membrane oxygenation have been discussed in a previous article.

A Pilot Study of the Effect of an Educational Web Application on Asthma Control and Medication Adherence.

BACKGROUND: An Asthma Adherence Pathway (AAP) application, which is an Internet application that combines patient and clinician education strategies to promote adherence to asthma therapy, has been developed. OBJECTIVE: The primary objective of this pilot study was to evaluate the effectiveness of the AAP application with electronic adherence monitors on asthma control. Secondary objectives evaluated the effect of AAP and monitors on medication adherence, asthma symptoms, quality of life, psychosocial factors, and barriers to treatment. METHODS: Adult patients with asthma were randomly assigned either to intervention (n = 19) or control (n = 20) groups in this 3-month prospective study, and they completed the Asthma Control Questionnaire (ACQ). Intervention patients completed the AAP software and were given barrier-specific motivational interviewing adherence strategies and a SmartTrack device to monitor mometasone furoate/formoterol (MF/F) use. Clinicians in the interventional group received adherence management training. Interventional patients were given feedback regarding adherence findings at each visit. Treatment adherence was determined by the mean of 4 measures of doses taken over 3 months. Control patients were not monitored for MF/F adherence. RESULTS: The mean MF/F adherence in the intervention group was 81%. The intervention and control groups did not differ on the mean baseline ACQ. Thirteen intervention patients achieved the minimal important difference (defined as an improvement ≥0.5 units on the ACQ) compared with 6 control patients (P = .016). The intervention group showed greater improvement in the ACQ (0.75) than the control group (0.19) representing a moderate-to-large effect size of d = 0.638. CONCLUSIONS: The AAP was effective in promoting adherence and helped to improve asthma control. These findings provide preliminary validation of the AAP model.

Acute Exacerbations of Chronic Obstructive Pulmonary Disease With a Low Procalcitonin Concentration: Impact of Antibiotic Therapy.

BACKGROUND: Patients admitted with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) often are prescribed antibiotics. Studies have shown that the use of procalcitonin (PCT) to guide the decision to initiate antibiotic therapy in AECOPD has resulted in less antibiotic use and similar outcomes compared with standard of care. We evaluated patients with AECOPD and low PCT concentrations to determine whether antibiotic therapy was associated with improved outcomes. METHODS: We retrospectively evaluated adult patients admitted with AECOPD who had a peak PCT concentration <0.25 µg/mL. Patients were evaluated based on their antibiotic exposure: ≤24 hours vs >24 hours. We also evaluated outcomes based upon the duration of azithromycin therapy: ≤24 hours vs >24 hours. The primary outcome was all-cause 30-day readmissions. Secondary outcomes included length of stay (LOS) and COPD-related 30-day readmissions. RESULTS: One hundred sixty-one and 195 patients received ≤24 hours vs >24 hours of antibiotic therapy, respectively. The cohort with ≤24 hours of antibiotics had a shorter LOS (2.8 vs 3.7 days; P = .01). There were no differences in all-cause 30-day readmissions (15.5% vs 17.4%; P = .63) or COPD-related 30-day readmissions (11.2% vs 12.3%; P = .74). Additionally, patients receiving ≤24 hours of azithromycin had a shorter LOS (3.0 vs 3.8 days; P = .002) and there were no differences in all-cause 30-day readmissions (16.2% vs 17.1%; P = .82) or COPD-related 30-day readmissions (11.9% vs 11.6%; P = .94). CONCLUSIONS: For adult patients hospitalized with nonsevere AECOPD and low PCT concentrations, antibiotic therapy beyond 24 hours did not improve outcomes.

Deep Venous Thrombosis of the Upper and Lower Extremity.

Upper and lower extremity deep venous thrombosis (DVT) is defined as a blood clot within the deep veins of the affected extremities. These blood clots can either occur spontaneously or be associated with specific risk factors. Regardless of the cause, DVT is associated with significant morbidity and mortality and has the potential for lethal complications. The most notable complication is the potential for development of pulmonary embolism from a lower extremity DVT. As studies have reported, more than 90% of acute pulmonary emboli arise from the proximal veins. Venous thromboembolism is also associated with a significant economic burden on the health care system and the individual patient. In this article, we review DVT of the upper and lower extremity including risk factors, signs and symptoms, diagnosis, and management.

Consequences of Venous Thromboembolism, Including Chronic Thromboembolic Pulmonary Hypertension.

Venous thromboembolism includes both deep vein thrombosis and pulmonary embolism. They pose a significant risk for morbidity and mortality. In an appropriate clinical setting, invasive interventions, including administration of thrombolytics, anticoagulation, and placement of vena cava filter, are warranted. Bleeding, postthrombotic syndrome, recurrence, and filter-associated complications are few of the complications of this disease. More recently, chronic thromboembolic pulmonary hypertension has gained clinical interest in patients with pulmonary embolism and has warranted close follow-up.

Prophylaxis for Venous Thromboembolism.

Venous thromboembolisms are major risk factors for many of our hospitalized patients. These events, however, can be prevented with prophylactic measurements when administered appropriately and on a timely basis. As patients are admitted, discharged, transferred, and scheduled for procedures on an hourly basis, anticoagulation and deep vein thrombosis prophylaxis are held or discontinued in anticipation for possible procedures. This results in delay of care and intervals where patients may not be covered with any prophylactic measurements. Similarly, alterations in clinical status can quickly change such as an increase in creatinine levels or the development of a new bleed, thus requiring a revision in their deep vein thrombosis prophylaxis. Nurses, therefore, play an integral role in not only administering the medicine but also routinely assessing the patients' clinical status and, therefore, their deep vein thrombosis prophylactic regimens as well. This article will review the indications, scoring systems, common prophylactic methods, and special populations at increased risks for venous thromboembolisms.