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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.

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.

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.

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

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.

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.

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.

To investigate the effects of progressive resistive loading on accessory expiratory muscles in tetraplegia, 40 such patients undergoing standard pulmonary rehabilitation were randomly assigned to control (n = 20) and experimental (n = 20) groups. In total there were 8 women and 32 men with an average age of 31 years. Their lesions were between the fifth and eighth cervical segments. The majority of the patients sustained their injury during motor vehicle accidents.Prior to training, measurements of maximum expiratory mouth pressure and vital capacity were obtained from each group. The experimental group underwent eight weeks of training. The training involved the use of the PFLEX muscle trainer which allowed the patient to expire against a predetermined resistance. The initial resistive load was set at a level equivalent to 60 percent of the patient’s maximum expiratory mouth pressure. Each subject was required to train for half an hour each day for six days a week. The resistive load was increased at two weekly intervals to ensure optimal loading throughout the training period the control group was excluded from any form of strenuous training but continued with the standard pulmonary care which involved conventional breathing exercises and assistance in coughing.The eight weeklong course of progressive resistive loading on accessory expiratory muscle showed a significant improvement in mean vital capacity from 1.48 L to 1.98 L (p = 0.0001) and a dramatic improvement in mean expiratory muscle strength from 43.76 cmH20 to 68 cmH2o) (p = 0.0001). Comparison of the values in the control group which were obtained eight weeks apart, showed no significant changes.The present finding that expiratory muscle strength in tetraplegics can be improved with specific training has important therapeutic implications. The increased PEmax should enable these subjects to generate higher intrathoracic pressure swings during coughing.Long term controlled studies should now be performed to determine the effects of this procedure on the clearance of bronchial secretions in such subjects.

SummaryWe report two cystic fibrosis patients with symptomatic cholelithiasis who were successfully treated by laparoscopic cholecystectomy. The procedure is safe, but it is essential that careful attention is paid to pulmonary care before and after surgery.

Summary A 32-year-old man with myotonic dystrophy underwent a thoracotomy for removal of a mediastinal thymoma. Pre-operative examination reilealed features of myotonic dystrophy, the only other abnormality was mild restrictive pulmonary disease. Anaesthesia was induced with thiopentone and maintained with enflurane, nitrous oxide, oxygen and curare. Following surgery, the patient was mechanically ventilated for sereral hours and remained intubated for 9 hours. The anaesthesia and surgery were tolerated well; howeoer, postoperative complications included refractory dysrhythmias, hypoxia, pneumoccocal pneumonia and pulmonary emboli. More intensive preoperatiue pulmonary eiialuation and physiotherapy coupled with more aggressiiv postoperatiire pulmonary care might have resulted in a smoother recovery phase.

During the 12-month period January through December 1978, 148 thermally injured patients were aeromedically transported to our burn unit by either helicopter or fixed-wing aircraft. One hundred twenty-nine patients (87%) were evacuated within 48 hours of injury. Treatment by a general surgeon and ICU nurse sent to the local hospital consisted of: insertion of 87 catheters, immediate pulmonary care in 20 patients, escharotomy in six patients, and adjustment of intravenous fluid administration in 42 patients. Thirty-six per cent of patients were considered too unstable clinically to transport until therapy had been rendered. No patients died in flight, and six per cent of all patients aeromedically evacuated were considered clinically unstable when they arrived on the burn ward. Overall mortality was not adversely affected by transportation of acutely burned patients over long distances.

Better understanding of the pathophysiology of neonatal illnesses has improved the management of sick newborns and infants, especially in the area of pulmonary care. Simultaneous advances in surgical techniques, such as optical magnification, microsurgery, and deep hypothermia, have made cardiac surgery in infants easier and safer.

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