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Background Decreasing the length of stay after thoracic surgery provides both clinical and financial benefits to both the patient and the clinical system. Since 2017, our institution has seen advancements in the care of patients undergoing thoracic surgery after utilising our protocol Enhanced Recovery After Thoracic Surgery (ERATS). Methods The protocol we implemented is comprehensive, including the patient’s pain management, thoracostomy tube drainage, physical therapy and rehabilitation, ventilator support and pulmonary care, as well as other features of preoperative, intraoperative, and postoperative care. In a retrospective review, we compared the overall length of stay prior to the protocol implementation to the length of stay after initiating the changes. Results We identified a median decrease of 2 days (from 6 days to 4 days) following the implementation of this protocol for all types of thoracic surgical procedures (p Conclusions Upon implementation of the ERATS protocol, we appreciated a decrease in the length of stay of thoracic surgery patients at our institution.

Background Delirium, a disorder of consciousness, often occurs for a period of time during hospitalisation. It is characterised by a disturbance of attention or awareness. Hyperactive delirium may lead to accidental removal of medical equipment, while hypoactive delirium may inhibit patients from participating in nursing interventions, medical treatment, and physical therapy. However, there are limited relevant studies of the strain of care of nurses in China when caring for patients with delirium. This study, thus, aimed to investigate the subjective level of the strain of care experienced by pulmonary and critical care nurses when caring for patients with delirium. Methods This was a descriptive, cross-sectional study. A survey was conducted with 100 nurses in the Chinese pulmonary and critical care medical (PCCM) department in 2018. The Strain of Care for Delirium Index (SCDI) was used to measure nurses’ strain of care. Participants were instructed to rate the degree of perceived difficulty in managing patients who displayed the behaviours listed in the SCDI, on a scale from 1 (quite easy) to 4 (very difficult). The mean ± standard deviation (SD) scores of the ranked difficulty scores were calculated. Results In our sample, 47 % of the nurses had received delirium-related training previously. The three wards with the highest strain of care scores when caring for patients with delirium were the chronic obstructive pulmonary disease ward (3.29 ± 0.72), interstitial lung disease ward (3.11 ± 1.31), and respiratory intensive care unit (3.02 ± 0.78). The three types of patient behaviours associated with the highest degree of nursing strain of care were being uncooperative and difficult to manage (3.37 ± 0.84), pulling out tubes and tearing out dressings (3.33 ± 0.98), and irritability (3.22 ± 0.95). Conclusions This study is the first to focus on nurses’ subjective strain of care when caring for patients with delirium in PCCM departments in China. The findings suggest the need to pay more attention to the working status of Chinese nurses. Further trials with large samples assessing relevant outcomes of patients with delirium are warranted.

Objective To provide a systematic review of the existing pediatric decannulation protocols, including the role of polysomnography, and their clinical outcomes. Methods Five online databases were searched from database inception to May 29, 2020. Study inclusion was limited to publications that evaluated tracheostomy decannulation in children 18 years of age and younger. Data extracted included patient demographics and primary indication for tracheostomy. Methods used to assess readiness for decannulation were noted including the use of bronchoscopy, tracheostomy tube modifications, and gas exchange measurements. After decannulation, details regarding mode of ventilation, location, and length of observation period, and clinical outcomes were also collected. Descriptive statistical analyses were performed. Results A total of 24 studies including 1395 children were reviewed. Tracheostomy indications included upper airway obstruction at a well-defined anatomic site (35%), upper airway obstruction not at a well-defined site (12%) and need for long-term ventilation and pulmonary care (53%). Bronchoscopy was routinely used in 23 of 24 (96%) protocols. Tracheostomy tube modifications in the protocols included capping (n = 20, 83%), downsizing (n = 14, 58%), and fenestrations (n = 2, 8%). Measurements of gas exchange included polysomnography (n = 13/18, 72%), oximetry (n = 10/18, 56%), blood gases (n = 3,17%), and capnography (n = 3, 17%). After decannulation, children in 92% of protocols were transitioned to room air. Observation period of 48 h or less was used in 76% of children. Conclusions There exists large variability in pediatric decannulation protocols. Polysomnography plays an integral role in assessing most children for tracheostomy removal. Evidence-based guidelines to standardize pediatric tracheostomy care remain an urgent priority.

Advancement in technology has improved recognition of genetic etiologies of disease, which has impacted diagnosis and management of rare disease patients in the pediatric pulmonary clinic. This review provides an overview of genetic conditions that are likely to present with pulmonary features and require extensive care by the pediatric pulmonologist. Increased familiarity with these conditions allows for improved care of these patients by reducing time to diagnosis, tailoring management, and prompting further investigation into these disorders.

COVID-19 pandemic has devastated large urban areas across the country. Most rural areas have so far been able to avoid the initial surge in cases due to the low population density. However, as the pandemic advances, rural areas are at an increased risk for the second wave of the epidemic. Rural areas are especially vulnerable due to the older population, higher comorbidities, and lack of access to healthcare. This field report discusses the experiences and issues faced by the rural Appalachian community during the ongoing COVID-19 pandemic.

Background The COVID-19 pandemic has boosted the use of forced expiratory volume in 1 second (FEV1) telemonitoring in pediatric asthma, but a consensus on its most efficient and effective implementation is still lacking. To find answers, it is important to study how such an intervention is perceived, experienced, and used by both patients and health care professionals (HCPs). Objective The aim of this study was to provide perspectives on how FEV1 home monitoring should be used in pediatric asthma. Methods This is a qualitative, multicenter, prospective, observational study which included patients with asthma aged 6-16 and HCPs. Primary outcomes were results of 2 surveys that were sent to all participants at study start and after 3-4 months. Secondary outcomes consisted of FEV1 device usage during 4 months after receiving the FEV1 device. Results A total of 39 participants (26 patients and 13 HCPs) were included in this study. Survey response rates were 97% (38/39) at the start and 87% (34/39) at the end of the study. Both patients and HCPs were receptive toward online FEV1 home monitoring and found it contributive to asthma control, self-management, and disease perception. The main concerns were about reliability of the FEV1 device and validity of home-performed lung function maneuvers. FEV1 devices were used with a median frequency of 7.5 (IQR 3.3-25.5) during the 4-month study period. Conclusions Patients and HCPs are receptive toward online FEV1 home monitoring. Frequency of measurements varied largely among individuals, yet perceived benefits remained similar. This emphasizes that online FEV1 home monitoring strategies should be used as a means to reach individual goals, rather than being a goal on their own.

In the present COVID-19 pandemic situation, there is a gradual increase in number of patients with post-COVID-19 sequalae. The present study is a retrospective analysis of these post-COVID-19 patients presenting to one of the units of Viswanathan Chest Hospital, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi in the period from 17 June 2020 to 22 October 2020. We analysed the demographic profile, history, functional assessment and all investigations of this study cohort. Out of the 2,165 patients provided consultation, there were 35 patients of post-COVID-19, which were included in the present study. These patients had a mean duration of 47 days from discharge to first visit to our hospital. Pre-existing respiratory comorbidity was present in 63%. History of hospitalisation was present in 52%. Fatigue (65%) was the most common symptom followed by breathlessness (60%), cough (45.71%) and chest pain (28.57%). Three patients had significant desaturation on 6-minute walk test and one patient had type 2 respiratory failure on presentation. Chest X-ray was abnormal in 34.28% (n=12). On CT thorax (n=17) the most common finding was diffuse reticulations (52.94%) followed by diffuse ground glass opacities (GGOs) (35.29%). One patient each were newly diagnosed as pulmonary tuberculosis and tubercular unilateral hilar lymphadenopathy. Conclusively, post-COVID-19 patients may have remnant symptoms like fatigue, breathlessness and cough. Also, patients with pre-existing respiratory diseases are more symptomatic and even may suffer from deterioration in the clinical course. Further we need to be alert of alternate diagnosis or infections like tuberculosis (TB) in these patients, especially in TB endemic countries like India. Simultaneously, the use of immunosuppressant drugs like steroids for COVID-19 management, predisposes to TB. A proper evaluation with holistic and standardised management plan is the need of the hour for post-COVID-19 patients, until its time course, evolution and manifestations are unravelled.

Background Variation in CF pulmonary outcomes is multifactorial, but a significant component appears to be dependent upon differences in CF Center care. Previous investigations suggest that high performing CF centers are more consistent and proactive in the treatment of pulmonary exacerbations. We incorporated this approach into a program that could be bundled and shared with other CF Centers. Methods The reorganization of CF pulmonary care at the Children's Hospital of Richmond included the development of a pulmonary algorithm to define a standard response to changes in lung function and run charts to track process and outcome measures. We calculated the rolling average of the best percent predicted FEV1 (ppFEV1) over the previous 12 months as our primary outcome measure. Results The mean of the best ppFEV1 in the previous 12 months rose from 87% predicted (65% predicted for those 13–18 years, 97% predicted for those 6–13 years) in January 2013 to 98% predicted (95% predicted for those 13–18 years, 110% predicted for those 6–13 years) in January 2018. The ppFEV1 difference between children 6–13 years and adolescents 13–18 years dropped from 34 to 14 during that time. Conclusions Improvements in pulmonary outcomes can be accomplished rapidly using basic quality improvement principles, including interdisciplinary team goal setting, standardized and proactive approaches that ensure consistent recognition and treatment of pulmonary exacerbations, and the use of data to follow the effectiveness of the process. We believe that the steps involved would be easy for other CF Centers to adapt to their own settings.

Background: Telemedicine is an expanded term in health information technology that comprises procedures for transmitting medical information electronically to improve patients’ health status. The objective of this research is to evaluate the cost-effectiveness of telemedicine interventions in various specialty areas. Methods: The Cochrane Library and Centre for Review and Dissemination were searched up to February 2013 using Mesh. Studies that compared any kind of telemedicine with any other routine care technique and used cost per health utility unit’s outcomes were included. Results: Twenty-one articles were included. According to the included studies, it seems that using telemedicine in cardiology can be effective and cost-effective enough but pre-hospital telemedicine diagnostics program are likely to have little impact on acute myocardial infarction fatality. In pulmonary, telemedicine can be a cost-effective strategy for delivering outpatient pulmonary care to rural populations which have limited access to specialized services, but telemedicine is not cost- effective in asthma and airways cancer. In ophthalmology, especially in the diagnosis of diabetic retinopathy, the use of telemedicine is a cost-effective tool. In dermatology, telemedicine is not cost-effective enough in comparison of conventional cares. In other fields such as physical activity and diet, eating disorder, tele-ICU, psychotherapy for depression and telemedicine on ships, telemedicine can be used as a cost-effective tool for treatments or cares. Conclusion: Most of the included studies confirmed that telemedicine is cost-effective for applying in major medical fields such as cardiology; but in dermatology, papers could not confirm the positive capability of telemedicine.

In the 1970s, both the Urokinase Pulmonary Embolism and Urokinase-Streptokinase Pulmonary Embolism trials began the quest to develop thrombolytic therapy for the treatment of acute massive and submassive pulmonary embolism (PE). The goals of these studies were the immediate reduction in clot burden, restoration of hemodynamic stability, and improved survival. Major bleeding became the major barrier for clinicians to employ these therapies. From 1980s to the present time, a number of studies using recombinant tissue-type plasminogen activator for achieving these same above outcomes were completed but major bleeding continued to remain an adoption barrier. Finally, the concept of bringing the thrombolytic agent into the clot has entered the quest for the Holy Grail in the treatment of PE. This article will review all the major trials using peripheral thrombolysis and provide insight into the need for a team approach to pulmonary care (Pulmonary Embolism Response Team), standardization of pulmonary classification, and the need for trials designed for both short- and long-term outcomes using thrombolysis for selected PE populations.

Premature babies are often put on respirators due to their lack of lung development and functionality. However, there is not much data that specifically pinpoints when it is safe to take a child off a respirator. Therefore, the main focus question is: how does the pulmonary vasculature develop as the child grows and can we determine the exact time-point to take him/her off a respirator. In this study, Chest CT scans were retrospectively gathered from pediatric patients at different follow-up times from the UF Shands Pulmonary Care Pediatric Center from 2005-2012. In-house software built upon the NIH ImageJ platform was used to count blood vessels as a function of size in each patient’s lungs. Nine datasets were analyzed from subjects 1 week to 22 years of age. It was observed that the number of vessels increased as a patient aged however the data points were spread greatly, preventing our being able to make additional inferences. Limitations of this initial work include that often patients were scanned only in instances of lung infections which hinders the assessment of lung vasculature; the number of repeated scans per patient was low; and the image slice thickness and in-plane pixel resolution varied across scans, which affects vessels count. Future extensions of this work include selecting a larger cohort of subjects with multiple follow-ups and similar imaging parameters, along with an age-matched control group.

Background Surgical quality improvement programs can provide meaningful benefits for patient outcomes, but sustainability of initial success is rarely described. In response to data that revealed a greater than predicted likelihood of postoperative pulmonary complications in one hospital, the study team designed a standardized program to improve care. This study offers a long-term perspective of the effort, including special challenges and lessons learned about sustaining success. Methods A before-after study was conducted at an academic safety-net hospital. A multidisciplinary team developed tactics to reduce pulmonary complications, designated by the acronym I COUGH: Incentive spirometry, Coughing/deep breathing, Oral care, Understanding (education), Getting out of bed, and Head of bed elevation. Clinical practices were audited and compared to actual and risk-adjusted pulmonary outcomes. Results Improvements in compliance with the I COUGH elements were initially promising, but baseline behaviors eventually returned. Adverse outcomes have inversely correlated with process adherence in "sawtooth" patterns. Rejuvenation efforts have successively extended beyond the literal principles of the acronym to foster broader institutional commitment to perioperative pulmonary care, restoring favorable trends in both process and outcomes. A more comprehensive I COUGH program now extends beyond the acronym, applying numerous concepts to support the original program. Conclusion I COUGH, a standardized perioperative pulmonary care program, initially improved performance and reduced pulmonary complications. However, loss of early program momentum corresponded with a return to baseline outcomes. Fortunately, an overall favorable trend has resulted from a coordinated rededication to I COUGH that requires steadfast commitment and creative responses to numerous cultural barriers.

The design of computational methods for detection of abnormal lung sounds (e.g., wheeze) associated with the advent of a pulmonary attack (e.g., asthma) and subsequent characterization of the 'severity' or progressive exacerbation in pulmonary patients is a relevant problem in ubiquitous computing. While a few recent works have been done on on-body sensor and smartphone sensor based lung activity detection, designing a comprehensive architecture for the detection and characterization of abnormal lung sounds (e.g., wheeze) is an open issue. In this paper, we present mLung++, which is a comprehensive pulmonary care system for respiration cycle based detection and subsequent characterization of wheezing in chronic pulmonary patients using audio and inertial sensors embedded on a smartphone. For the design, training, and evaluation, we use audio and Inertial Measurement Unit (IMU) data collected by smartphone and watch from 131 human subjects (91 pulmonary patients, 40 healthy control). We show empirical evidence that the performance of mLung++ for characterizing abnormal lung sounds (accuracy 93.4% and f1_score 77.94%) is comparable with that of high-quality on-body sensor based characterization, which is usually done in a hospital or clinical setup.

Simposio 15: Otras afecciones y diabetesDiabetes en la fibrosis quísticaLa fibrosis quística es un desorden autosómico recesivo muy frecuente caracterizada por la función severamente alterada o ausente del CFTR (canal regulador transmembrana de transporte de cloro y bicarbonato). Con los avances en el cuidado nutricional y pulmonar, y la prolongación de la supervivencia hasta la adultez, la CFRD ha emergido como una comorbilidad común principalmente en los sujetos con insuficiencia pancreática. La CFRD es el estadio final de un espectro lento y progresivo de alteraciones en el metabolismo hidrocarbonado que se caracteriza por una insulinopenia temprana, que produce un deterioro nutricional y declinación pulmonar.Durante décadas los equipos de atención de pacientes con fibrosis quística hemos diagnosticado CFRD a través de la PTOG con puntos de corte para complicaciones microvasculares (como en DM1 y DM2). Por ser el pulmón el órgano principalmente en riesgo en CF, tal vez debería definirse la CFRD por el nivel de glucemia en el que se desarrolla la pulmonopatía. Es probable que la insulinopenia con el catabolismo consecuente juegue un rol fundamental en el deterioro pulmonar y que la hiperglucemia postprandial temprana (altos niveles glucémicos en puntos intermedios pero normales a las 2 h) pueda usarse como indicador de la necesidad de indicar insulinoterapia de precisión.

Rib fractures are reported in at least 10% of all trauma admissions. The associated morbidity and mortality worsen with advanced age and increasing number of rib fractures. In this population, the risk of nosocomial pneumonia has been documented to be as high as 29%. The utilization of clinical care pathways results in favorable outcomes. Despite this evidence, the medical management of rib fractures is yet to be truly standardized. At the core of recommended clinical care pathways is the identification of high-risk patients, appropriate patient disposition, multimodal pain control, aggressive pulmonary care, nutritional support, and early mobilization.

Introduction Evidence-based interventions to counsel tobacco users have been validated and successfully implemented in a multitude of clinical, community, educational, and work-place settings in the United States. In FYROM, before such a program can be systematically introduced and evaluated, formative research can identify important cultural and societal factors to guide in the program’s adaptation and implementation. Material and Methods Qualitative research is a reliable and valid method to obtain information that is contextual and subjective. Over three weeks in November 2016, five trained research assistants conducted 39 in-depth, qualitative interviews with patients and health providers from pulmonary clinics within Skopje, FYROM, lasting 52 minutes on average. Interviews were recorded, transcribed translated into English, coded, and thematically analyzed. Results Data reveal salient issues to the adaptation of a tobacco counseling program. Respondents had limited information about pharmacological therapies and their availability in FYROM. They noted a lack of public education about the risks associated with tobacco use and they perceived current outreach efforts as being ineffectual. There was a lack of critical attention toward the needs of the elderly or those considered to be severly addicted. Health providers noted the need for more one-on-one time with patients to counsel them about tobacco use. Conclusions Culturally competent approaches to program design are an effective means of applying evidence-based modalities in new settings. Qualitative research is an essential component of program adaptation within the core elements of an intervention and provides opportunity for collaborative decisions regarding content and delivery within a new socio-cultural context. Funding Pfizer Independent Grants for Learning and Change

Postoperative pulmonary complications are a major cause of postoperative morbidity and mortality. The perioperative positive pressure ventilation bundle could help at further reducing postoperative pulmonary complications.

Perioperative medicine is a growing area of research that brings together internists, anesthesiologists, surgeons, and hospitalists. A medical team approach to ensure the best possible patient outcomes has fostered collaborative strategies across disciplines. Perioperative pulmonary complications are common and can be associated with significant morbidity and mortality. Effective strategies to identify and reduce risks of pulmonary complications can improve patient outcomes. We review the new literature (2013 to early 2014) in the field of perioperative pulmonary medicine that reports new strategies to improve outcomes in the area of perioperative pulmonary care.

Surgery and general anesthesia directly affect the respiratory system. Postoperative pulmonary complications occur after upper abdominal surgery.. Breathing and chest wall physiotherapy have been used to prevent atelectasis. The study aimed to identify the methods of pulmonary care used to avoid occurrence of atelectasis in the first year of life of infant undergoing abdominal surgeries, determine effect of pulmonary care on the occurrence of atelectasis in the first year of life undergoing abdominal surgeries. The study consist of 60 infant undergoing to abdominal surgery in surgical unit at Tanta University Hospital. Five tool were used for data collection Preoperative Assessment Sheet ,Intraoperative Assessment sheet Postoperative Assessment Sheet, pulmonary Care Sheet. Pulmonary Care Evaluation Sheet. Results: their was a statistical significant difference in oxygen saturation after breathing exercise. It was observed that the highest value of oxygen saturation was in third day at fifth position and the lowest value of oxygen saturation was observed in the first day . There was a statistical significant difference in oxygen saturation after three days . It was concluded that chest physiotherapy performed in postoperative period following upper abdominal surgery improved the oxygen-hemoglobin saturation and reduced pulmonary complication. Recommendation. In service training Program should be conducted for the nurses about effect of chest physiotherapy in prevention of postoperative pulmonary complication. Kay wards: Pulmonary Care, postoperative , and Pulmonary Complication

Perioperative medicine is an increasing area of research focus that brings together internists, anesthesiologists, surgeons, and hospitalists. A medical team approach to ensure the best possible patient outcomes has fostered collaborative strategies across areas of patient care. We review 8 seminal articles in the field of perioperative medicine. Each article was published in either 2011 or 2012 and adds to care strategies in the areas of perioperative cardiac medicine, pulmonary care, blood transfusion decision making, and medication management.

BACKGROUND: African-American smokers experience disproportionate COPD morbidity. As a front-line COPD behavioral management strategy, smoking cessation is less prevalent among African-American smokers. Identifying barriers and predictors to smoking cessation in this population is important to bridging this disparity. METHODS: In this study, the predictors of enrollment and attendance to a 3-session urban hospital smoking cessation program were examined. A retrospective chart review was conducted for all pulmonary clinic patients who smoked and were referred to the cessation program between June 2013 and May 2014. Demographic, smoking behavior, cardiopulmonary, and health status variables were extracted (N = 253). Second, a qualitative assessment of the beliefs and barriers for smoking cessation and physical activity were examined in a sub-sample of the population (n = 41). RESULTS: One-hundred forty-seven of the pulmonary subjects (58%) enrolled in the cessation program, and 40 attended all sessions (16% of the total sample). Participants with COPD (odds ratio = 4.65, P = .030), or had a mother who had cancer (odds ratio = 4.49, P = .027), were more likely to attend the program. Qualitatively, pulmonary care patients who wanted to quit smoking and be more physically active cited: strong beliefs about the inability to engage in these behaviors, belief that quitting and increased activity might exacerbate poor health, and an inability to obtain pharmacotherapy as barriers to adopting these behaviors. CONCLUSIONS: Smoking cessation program attendance in this sample of mostly African-American smokers was poor. Increased knowledge about cessation benefits and access to full-course pharmacotherapy, particularly in those without a COPD diagnosis and who do not have a maternal history of cancer, may be high-priority targets to promote cessation program uptake in this population. Increased knowledge and access to safe forms of physical activity may also be beneficial.

Shortly after the introduction of assisted ventilation in the newborn, bronchopulmonary dysplasia (BPD) was first described. Northway and coworkers described a group of preterm infants who developed chronic respiratory failure and characteristic radiographic changes after prolonged mechanical ventilation. The prevention and management of BPD in infants at risk is challenging due to the complex pathogenesis of multiple contributing factors that include prematurity, supplemental oxygen exposure, mechanical ventilation, patent ductus arterious, inflammation, genetic predisposition and postnatal infection. Treatment of existing BPD requires a coordinated approach including optimal nutrition, careful fluid management, evidence-based drug therapy, and gentle respiratory techniques aimed at minimizing lung injury. The best respiratory support strategy remains unclear and requires further investigation but includes avoidance of ventilator-induced lung injury (barotraumas and volutrauma), hyperoxemia, and hypocapnea. Among the available interventions antenatal steroids, caffeine, and surfactant have the best risk-benefit profile. Systemic postnatal corticosteroids should be used only in ventilated infants unable to be weaned from the ventilator. Quality improvement techniques may have a role towards improvement of hospital systems geared toward reduction of BPD.

Prolonged stay in Intensive Care Unit (ICU) can cause muscle weakness, physical deconditioning, recurrent symptoms, mood alterations and poor quality of life. Physiotherapy is probably the only treatment likely to increase in the short- and long-term care of the patients admitted to these units. Recovery of physical and respiratory functions, coming off mechanical ventilation, prevention of the effects of bed-rest and improvement in the health status are the clinical objectives of a physiotherapy program in medical and surgical areas. To manage these patients, integrated programs dealing with both whole-body physical therapy and pulmonary care are needed. There is still limited scientific evidence to support such a comprehensive approach to all critically ill patients; therefore we need randomised studies with solid clinical short- and long-term outcome measures. Resumo: Uma estadia prolongada na Unidade de Cuidados Intensivos (UCI) pode causar fraqueza muscular, descondicionamento físico, sintomas recorrentes, alterações de humor e má qualidade de vida. A fisioterapia é, provavelmente, o único tratamento com potencial para aumentar nos cuida-dos a curto e longo prazo aos pacientes internados nestas unidades. A recuperação das funções físicas e respiratórias, retirar a ventilação mecânica, prevenção de efeitos do repouso na cama e melhoria do estado de saúde são objectivos clínicos de um programa de fisioterapia nas áreas médicas e cirúrgicas. Para tratar estes pacientes, são necessários programas integrados que englobem tanto a fisioterapia global como os cuidados respiratórios necessários. A evidência científica para apoiar esta abordagem abrangente para todos os doentes críticos é ainda limitada; portanto, são necessários estudos aleatorizados com medidas de resultados a curto e longo prazo. Keywords: Rehabilitation, Mechanical ventilation, Physiotherapy, Weaning, Palavras chave: Reabilitação, Ventilação mecânica, Fisioterapia, Desmame

Multiple rib fractures from trauma are common and nonoperative management, including pain control and aggressive pulmonary care, are the mainstay of treatment. However, patients with hindered pulmonary function despite maximal medical therapy, either from acute pain or chest wall instability (flail chest) should be considered for surgical rib stabilization. Additionally, patients with persistent pain or with rib fractures that do not heal (nonunion) should also be considered for surgery. Indications, contraindications, surgical considerations, complications, and future directions of surgical stabilization of rib fractures are reviewed here.

術前呼吸ケアの目的は全身状態の改善および術後の重篤な肺合併症を予防し早期離床を達成することである。このため術前評価と術後合併症を予測し，術式による呼吸機能障害の程度を把握する。喫煙者は非喫煙者と比較して有意に術後肺炎の発症が多いため少なくとも術前1カ月以上前に禁煙させることが推奨される。気道クリアランスについてのシステマチックレビューでは排痰法の有用性についての高いエビデンスは示されていない。このため個々の排痰法は患者の病態に合わせその利点，欠点を理解し施行することが重要である。またインセンティブスパイロメトリーは手術後に日常的に使用されているが，術後の有用性について高いエビデンスは示されていない。ところで肺癌，食道癌，頭頸部領域の癌は喫煙との関与が濃厚でありchronic obstructive pulmonary disease (COPD) を合併していることが多い。COPDにおける気流制限と術後肺合併症の頻度は関連するため，COPD合併例では術前から呼吸機能の改善も含めた包括的な呼吸ケアを実施する意義は大きい。これまで術前からの吸気筋トレーニングを含めた呼吸ケアは術後肺合併症を低下させることが多数報告されている。今後は質の高いエビデンス構築が必要である。

ResumenLas infecciones asociadas a la atención en salud representan un problema de salud pública y son un indicador de la calidad en prestación y gestión en salud. En este contexto, los programas de vigilancia y control epidemológico de estas enfermedades, y la adaptación e implementación de guías para su prevención son estrategias que pueden mejorar la seguridad del paciente y deben ser una prioridad para las instituciones. Un panel de expertos de las áreas de infectología, cuidados intensivos, neumología, enfermería, terapia respiratoria y farmacia, preparó una guía de práctica clínica para la prevención de las infecciones asociadas a dispositivos médicos, mediante un proceso de adaptación de otras guías por medio de una estrategia de búsqueda sistemática basada en la “evidencia”.Se propone que estas guías sean utilizadas por los trabajadores de la salud con el fin de establecer estrategias que prevengan la aparición de infecciones hospitalarias relacionadas con dispositivos de uso prioritario durante el cuidado intensivo. Se hacen recomendaciones basadas en información científica y adaptadas a nuestro medio en temas generales, como la introducción de listas de chequeo, el lavado de manos y los sistemas de vigilancia y supervisión; se formulan recomendaciones específicas para la prevención de las infecciones del torrente sanguíneo asociadas a dispositivos intravasculares, de las infecciones respiratorias asociadas al uso de asistencia respiratoria mecánica y de las infecciones urinarias asociadas al uso de catéteres urinarios.AbstractHealthcare associated infections (HAI) are an important public health problem and an indicator of the quality of healthcare and management. In this scenario, surveillance and epidemiologic control programs and the adaptation and implementation of clinical guidelines for HAI prevention are estrategies that can improve the safety of patient care and should be prioritized in the institutions. Evidence based clinical practice guidelines for the prevention of infections asociated with invasive medical devices were prepared by an expert panel in infectious diseases, critical care, pulmonary care, nursery, respiratory therapy and pharmacy by means of a process of adaptation of other guidelines available through a systematic review of the literature. These guidelines are intended to be used by healthcare workers with the aim of establishing estrategies to prevent HAI related to invasive medical devices. Recommendations based of scientific evidence adapted to our setting are made related to general estrategies such as checklists, hand washing, surveillance and supervision systems. Specific recommendations to prevent bloodstream infections related to intravascular catheters, respiratory infections related to mechanical ventilation and urinary tract infections related to urinary catheters are made.

Traumatic injuries are a leading cause of death and significant morbidity. Children who survive can suffer from respiratory failure and need for chronic ventilatory support. Care of children following trauma or severe neurologic injury includes providing for adequate ventilation, optimizing pulmonary care with airway clearance and prevention of recurrent pneumonias. There are several options for ventilatory support including positive pressure ventilation which is the most common, noninvasive positive pressure ventilation (NPPV) and diaphragm pacing. In this chapter, we review the pulmonary complications of trauma, the pathophysiology of respiratory failure, and the care of trauma survivors needing chronic assisted ventilation and respiratory care.

Introduction: Asthma and COPD contribute significantly to morbidity, mortality, and social-economic burden. Integrative Pulmonary Care center (IPCC) is a specialized program that has an integrative approach to respiratory care. Notably, eligible patients may receive a novel plant based therapeutic option (Jeeva®) in addition to standard of care. Jeeva® integrates several nutraceuticals known to have immune-modulatory, anti-inflammatory andantioxidantproperties. Methods: An evaluation of patient records was performed for all asthma/COPD patients enrolled in the IPCC program who had consented to consume Jeeva®. Demographic data, past medical history, and spirometry data (FEV1, FVC, FEV1/FVC, FEV1% predicted, FVC% predicted, FEV1/FVC% predicted) were collected along with a survey-based assessment of quality-of-life. The primary endpoint was the maximum change in FEV1 and FVC pre-bronchodilator after Jeeva® initiation. A paired students’ t-test was utilized to compare the maximum change post- Jeeva® from baseline. Intent-to-treat analysis was performed using the last-observation carried forward methodology. Results: A total of 26 patients were included for analyses. Median duration of Jeeva® consumption was approximately 6 months (range 1–12 months). There was a statistically significant change in FEV1 and FVC from baseline [1.64 ± 0.72 L to 1.80 ± 0.72 L; (p=0.019) and 2.26 ± 0.80L to 2.50 ± 0.74 L (p=0.004) respectively]. Quality-oflife improved statistically significantly and there was a notable decrease in medication burden. Conclusion: Patients receiving Jeeva® as part of the IPCC significantly improved pre-bronchodilator FEV1 and FVC from baseline. A small improvement in quality-of-life and medication burden was evident. Further studies looking at Jeeva® in a randomized, placebo-controlled, clinical-trial is warranted.

Rheumatoid arthritis (RA) is a systemic disease, characterized by symmetric joint involvement, but it can also affect other organ systems, including the lungs. The better-known pulmonary manifestations of RA are interstitial lung disease, rheumatoid nodules, and pleural effusions. Less common manifestations include bronchiolitis obliterans and crycoarytenoid arthritis. Management of these conditions involves, by and large, supportive pulmonary care and control of the underlying articular process. Other pulmonary manifestations in RA patients can ensue as a result of the treatments used for it, mainly methotrexate. This article discusses the most common pulmonary manifestations of RA and their treatment. A discussion about the increasing impact that cigarette smoking is having on RA is also provided.

Asthma and chronic obstructive pulmonary disease (COPD) continue to impose noteworthy public health burdens. In the United States, COPD is the third leading cause of death, claiming approximately 138,000 lives annually, while asthma exacerbations contribute to over 1.8 million emergency room visits

Background: Smoking is the most important cause of illness and death, mainly related cancer. Our program started in 2012, in the Methodological Centre for Smoking Cessation Support located at the National Koranyi Institute for Tuberculosis and Pulmonology. Our aim was to provide professional, methodological background for individual and group cessation support based at pulmonary care facilities andsupport clients individually or in groups. Materials and methods: We have contacted 5788 individuals. The average was 47 years. We analyzed the data of the support provided by the Call center based on 2014.Success rate of smoking cessation amongst those who received support via our call center.The program operates with trained counsellors, call the client six times proactively and provides counselling in a systematic manners. Results: Most of the clients were based in the countryside, 47% of them who enter the program, displayed the signs of being highly dependent on the substance. We registered 1332 cases, who successfully completed four sessions via phone. Based on our follow up examination, 885 clients reported being non smoker after twelve months. Based on these studies 15,3% success was rate with the phone supported smoking cessation programme. Even though these numbers may not be fully accurate, because we lost contact with some of our clients and our data is based on phone verbal feedback. Conclusion: With our helpline, we could reach a heavily approachable group of people, and we could provide the right kind of support in their fight for quitting smoking, that they might not get from any other sources.

Lung disease has been a leading cause of significant morbidity and mortality since neonates first drew breath. Over the past few decades, many treatment options have evolved to aid us in our ability to support neonatal breathing. The history of neonatal pulmonary care, both its successes and controversies, can teach us a great deal about the future of this dynamic field. As new developments occur, we constantly modify the therapies we offer to preterm and term infants. Understanding traditional therapeutic options and knowing what may be on the horizon can help caregivers to better match treatment plans with individual infants. This article reviews advances in mechanical ventilation, adjuvant therapies, and respiratory drugs through the past few decades and speculates on future directions in this field.

Summary Primary structural deformities of the spine and thorax were at one time rare and reportable in case series. With the development of new “growth friendly” implantable devices, children with these disorders are living longer and receiving both surgical and pulmonary care. As a result, there has been growing interest in the functional cardiopulmonary consequences of these deformities, the current surgical and non-surgical treatments, and the role of long-term supportive care. This article reviews current literature in this rapidly changing field, where new devices are developed and outcomes are changing. The respiratory consequences of early-onset thoraco-spinal disorders are emphasized and the roles of the pulmonologist and surgeons are discussed. There are more questions than answers as no long-term outcome data yet exists.

Perioperative Positive Pressure Ventilation: An Integrated Approach to Improve Pulmonary Care Emmanuel Futier;Emmanuel Marret;Samir Jaber; Anesthesiology

The objective of this project was the development of a systematic preventative approach toward the treatment of respiratory complications among the trauma population. The team used and documented existing treatment regimens within specific study groups, to determine an effective structure to combat respiratory complications. The project included retrospective data collected from the Trauma Registry of an American College of Surgeons verified Level 1, adult rural, academic facility. Review data indicated significant inconsistencies in the pulmonary treatment among the trauma population. Pulmonary hygiene orders lacked consistency, and the patient-focused standards of care led to the creation of nonspecific or omitted orders. The results of the analysis revealed that the overall rate of unplanned upgrades to the higher level of care and intubations due to respiratory compromise were significantly impacted by the design of a collaborative pulmonary care regimen defining role delineation, timelines, and education. This project provided support to the credence of the designated pathway.

Bronchoscopy represents an integral part of the diagnostic tools in pulmonary medicine. Recently, it has also gained considerable attention for its therapeutic properties. To elucidate equipment, indications and procedural techniques of bronchoscopy units, a retrospective survey of 1232 hospitals and practices is conducted. 687 questionnaires are received back (response rate 56%). 681 of which are statistically evaluated. Two thirds of the physicians in charge are internists, one third are pulmonary care specialists. A total of 200,596 endoscopic procedures is included. The majority of procedures is done with an average of 3 bronchoscopists and in over 57% (388) of cases with an average number of 100 or less procedures per year. The five main indications are tumor, hemoptysis, infection or pneumonia, drainage of secretions and suspected interstitial disease. Overall complication rate amounts to 2.7% with an incidence of 4.6% minor and 0.7% major complications and a bronchoscopy-related mortality of 0.02%. The patterns seen in premedication, intra- and post-procedural monitoring, disinfection practices as well as documentation are quite heterogeneous. It is suggested to establish revised and updated standards for bronchoscopy, which should take the data collected into particular account. Those standards should provide the basis for a high level bronchological care throughout Germany.

OBJECTIVE: To evaluate the oral steroid-sparing effect of inhaled fluticasone propionate (FP) in eight children with steroid-dependent asthma. DESIGN AND SETTING : Treatment protocol study at a tertiary pulmonary care centre at a children’s hospital. PATIENTS: Eight children with severe persistent steroid dependent asthma (mean age 11.6 years [range 10 to 13 years], mean duration of asthma 8.37 years [range three to 11 years]) were enrolled in the study. MEASUREMENTS: Inhaled FP 880 g/day (two puffs of 220 g/puff, two times a day) was added to the children’s asthma treatment, and attempts were made to reduce the dose of oral steroids by 20% every two weeks over a six-month period. After this six-month period, in the patients responding to inhaled FP, the dose of inhaled FP was reduced to 440g/day (two puffs of 110 g/puff, two times a day) for the next six months. The mean percentage predicted values for forced expiratory volume in 1 s (FEV1) and maximal mid-expiratory flow rate (FEF25%-75%) were compared during the first month, at two to six months, and at seven to 12 month intervals before and after starting FP. The number of asthma exacerbations, emergency room visits, hospital admissions and number of school days lost were also compared. RESULTS: Within three months of starting inhaled FP, the mean alternate-day oral steroid dose decreased from 38 mg to 2.5 mg. In addition, six patients (66%) were able to discontinue the use of oral steroids. There was significant improvement in the number of mean emergency room visits per patient (P=0.016), mean asthma exacerbations per patient (P=0.016), mean hospital admissions per patient (P=0.016) and mean number of school days lost per patient (P=0.004) while patients were receiving high dose inhaled FP compared with oral steroids. There was no deterioration of any of the above mentioned parameters during the six month period when the dose of inhaled FP was reduced. The mean FEV1 and FEF25%-75% during the two- to six-month and seven- to 12-month periods showed significant improvement, while the patients were receiving FP compared with oral steroids (P

Duchenne muscular dystrophy (DMD) is a degenerative neuromuscular disease leading to progressive muscle weakness and loss. This review discusses advances in understanding the natural history of DMD, as well as recent pharmacotherapies. Decline in expiratory and inspiratory pulmonary function results in ineffective airway clearance, sleep-disordered breathing and nocturnal and daytime respiratory failure. Routine measures of pulmonary function include forced vital capacity (FVC) and peak expiratory flow (PEF). Both measures follow parallel trajectories and relentlessly decline, reaching the lower limit of normal of 80% of predicted at early teenage years. Moreover, decline in PEF and FVC are closely correlated with respiratory complications and clinically relevant thresholds for FVC are defined in standard of care recommendations. Glucocorticoids (GCs) delay the onset of pulmonary function decline, but once patients have reached the 80% of predicted threshold the decline of FVC and PEF in GC users and patients not using GCs is comparable. In the successful phase III DELOS trial in DMD patients not using GCs, the short-chain benzoquinone idebenone (Raxone®, Santhera Pharmaceuticals, Liestal, Switzerland) has demonstrated statistically significant and clinically relevant efficacy on expiratory and inspiratory function in patients in the pulmonary function decline stage. These results indicate that idebenone can modify the natural course of respiratory disease progression, which is relevant in clinical practice where loss of respiratory function continues to be a predominant cause of early morbidity and mortality in DMD.

The traditional extracorporeal membrane oxygenation circuit uses a centrifugal pump. These pumps require close monitoring and are subject to complications. In addition, they do not take advantage of the potential benefits of pulsatile flow. These extracorporeal membrane oxygenation circuits use a single pump with an inline oxygenator. If cardiac failure persists after respiratory recovery has occurred, removal of the oxygenator requires an additional procedure to convert the patient to biventricular support. This report describes a circuit in which an oxygenator is connected to a pulsatile ventricular assist device. Single and dual circuit configurations are illustrated. Recommendations for pulmonary care during support are also described.

Purpose of review Lung transplantation has been one of the great medical advances as the last option for the treatment of end-stage pulmonary disease. Optimal pulmonary care of potential donors and recipients can definitely increase the number of successful lung retrievals and reduce the incidence of complications. Recent findings The use of a lung-protective ventilatory strategy, associated with recruitment maneuvers, has a profound clinical impact, doubling the number of lungs available for transplant. Postoperatively, it is important to use a lung-protective ventilation strategy, whereas for patients with life-threatening reperfusion injury, extracorporeal membrane oxygenation can ensure a survival rate between 50 and 80%. Pumpless extracorporeal carbon dioxide removal system allows the maintenance of normal gas exchange and can be maintained in the perioperative period. Summary Perioperative ventilatory care of the transplanted patient still represents a challenge for the ICU clinician. The lung-protective strategy and the early application of carbon dioxide removal systems can increase the number of lung donor eligibility. Further studies are needed to increase the viability of other organs and to develop new strategies that reduce the risk of ischemia-reperfusion injury, which still represents the most common complication in the postoperative period.