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Palliative Care and Advanced Directives in Heart Failure
Published in Andreas P. Kalogeropoulos, Hal A. Skopicki, Javed Butler, Heart Failure, 2023
Melissa I. Owen, Debbie A. Gunter
Opioids should be selected based on patient-specific variables including renal and hepatic function. At lower doses of opioids, there is no alteration in respiratory drive, but, with higher doses, respiratory depression and decreased level of consciousness can occur. Patients with severe dyspnea are more likely to respond to opioid therapy. Consistent use of opioids decreases gastrointestinal motility and requires close attention to be paid to bowel function and usually the initiation of an aggressive bowel regimen.16
Basics of Ventilator Settings
Published in Kajal Jain, Nidhi Bhatia, Acute Trauma Care in Developing Countries, 2023
A/CV allows the patient to initiate a breath which is then assisted to a preset limit variable (pressure or volume). If the patient is unable to generate a breath, then the ventilator delivers control breaths at a preset rate. Hence there are two types of breath: one is patient triggered and the other being time triggered (Figure 30.3). But all breaths whether patient or time triggered have the same set TV (in V-A/CV) or same inspiratory pressure (in P-A/CV). Generally, it works well in patients with reduced respiratory drive by providing adequate ventilator support. But in patients with high respiratory drive leading to frequent breath triggering, it may result in hyperventilation and generation of auto-PEEP due to inadequate time for exhalation.
Diaphragm Ultrasound in Patients with Neuromuscular Disorders
Published in Massimo Zambon, Ultrasound of the Diaphragm and the Respiratory Muscles, 2022
In patients with neuromuscular diseases, the onset of weakness of the inspiratory muscles and weakness of the expiratory muscles leads progressively to a reduction of lung volumes (pulmonary vital capacity, total lung capacity, functional residual capacity). In addition, chest wall compliance decreases in relation to stiffening of thorax and scoliosis, particularly in patients with Duchenne muscular dystrophy. Furthermore, lung compliance decreases, due to microatelectasia and recurrent aspirations (6). The upper airway is also affected in NMD and the presence of hypotonia may increase upper airway resistance that contributes to the increase of the respiratory workload (7). In response to respiratory muscle weakness, the respiratory drive increases. However, hypoventilation occurs when the compensatory mechanism becomes insufficient to cope with the increase of the respiratory load (8). Finally, cough function is altered and the eventual presence of swallowing derangement increases the risk of aspiration and the risk of acute respiratory failure (6).
Endothelialitis plays a central role in the pathophysiology of severe COVID-19 and its cardiovascular complications
Published in Acta Cardiologica, 2021
Christiaan J. M. Vrints, Konstantin A. Krychtiuk, Emeline M. Van Craenenbroeck, Vincent F. Segers, Susanna Price, Hein Heidbuchel
Several factors besides expansion of the viral pneumonia and its immune response may contribute to the pathogenesis of the worsening respiratory failure. The intravascular micro- and macro-thrombosis within the pulmonary circulation will lead to increased dead-space ventilation [33]. This, combined with increased metabolic demand may result in a marked increase of the respiratory drive during spontaneous breathing increased rate and augmented transpulmonary pressure and strain. The combination of high negative inspiratory intrathoracic pressures and increased lung permeability can exacerbate interstitial and pulmonary edema leading to worsening of pulmonary infiltrates and respiratory failure. The consequent in part patient self inflicted lung injury that may occur during high-flow oxygen therapy or non-invasive ventilation, may be attenuated by intubation, potentially indicated once deep negative swings in intra-esophageal pressure are observed [34,35], but has to be balanced against the risks of intubation and ventilation, as well as ventilator-induced lung injury. At a later stage, dense consolidation and progressive fibroproliferation will result in decreased recruitability by positive end-expiratory pressure (PEEP) ventilation or positioning of the patient in a prone position [36].
Acute respiratory distress syndrome (ARDS) caused by the novel coronavirus disease (COVID-19): a practical comprehensive literature review
Published in Expert Review of Respiratory Medicine, 2021
Francisco Montenegro, Luis Unigarro, Gustavo Paredes, Tatiana Moya, Ana Romero, Liliana Torres, Juan Carlos López, Fernando Esteban Jara González, Gustavo Del Pozo, Andrés López-Cortés, Ana M Diaz, Eduardo Vasconez, Doménica Cevallos-Robalino, Alex Lister, Esteban Ortiz-Prado
A second possibility is related to self-inflicted patient lung injury (P-SILI) caused by the respiratory effort made by patients with respiratory failure when breathing spontaneously or with the support of noninvasive mechanical ventilation (NIMV), since the high respiratory impulse generates large tidal volumes (VT) with potential to cause transpulmonary pressure changes. Zones closed by lung damage are temporarily opened and closed again, generating stress injury (pressure changes) and strain injury (changes by deformation), which is known as a ‘Pendelluft phenomenon’ [33]. The different forces generated by muscular work cause damage to already injured lungs, increasing vascular leakage by increasing transmural pulmonary vascular pressure. The high respiratory drive may be due to increased stimulation of juxtacapillary receptors or inhibition of slowly adapting pulmonary stretch receptors (Hering-Breuer reflex) [34].
Development of a Cascade of Care for responding to the opioid epidemic
Published in The American Journal of Drug and Alcohol Abuse, 2019
Arthur Robin Williams, Edward V. Nunes, Adam Bisaga, Frances R. Levin, Mark Olfson
Individuals who are high risk for developing OUD include those prescribed opioids as long-term opioid therapy for non-cancer pain or those receiving more than 90 mg morphine equivalents daily, with a history of substance use disorders (SUDs), psychiatric comorbidity, problematic substance use (such as binge drinking or cocaine use), prior overdose, or prior criminal arrest (13,14). These risk factors are especially predictive of addiction risk among young males 18–35 years of age (14). Concomitant use or prescription of other sedating medications such as benzodiazepines or medical comorbidities that impair respiratory drive (e.g. sleep apnea, congestive health failure) also increase risk of opioid overdose. Individuals at risk for OUD can be identified through routine screening, such as under an Screening, Brief Intervention, and Referral to Treatment (SBIRT) model, in primary care or in acute care settings (15). Additionally, surveillance through prescription drug monitoring programs and intermittent urine drug screening can help identify patients with aberrant opioid use behaviors warranting further assessment. Harm reduction approaches, such as needle exchange, naloxone distribution, and supervised injection facilities assist, identify affected individuals who have not yet engaged in treatment or in high-risk areas for outbreaks of infectious disease, such as HIV or hepatitis C (16). The Centers for Disease Control and Prevention has recently identified 220 vulnerable counties across the country (17).