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By: Neal H Cohen, MD, MS, MPH
- Professor, Department of Anesthesia and Perioperative Care, University of California, San Francisco, School of Medicine, San Francisco, California
Cheifetz: There was discussion on this topic at the consensus conference meetings erectile dysfunction condom purchase 20 mg apcalis sx with mastercard, but it did not result in any recommendations erectile dysfunction protocol diet cheap 20 mg apcalis sx with amex. It was not a key component of the consensus process erectile dysfunction age 60 purchase apcalis sx 20mg without prescription, and there are not much data that directly address this point in pediatrics erectile dysfunction bph purchase apcalis sx 20 mg free shipping. A challenging aspect of patient-ventilator asynchrony in the clinical environment is how to objectively define it. And if keeping them awake, do you run into the risk of potential asynchrony versus putting them to sleep? There have been some adult data about asynchrony leading to longer length of stay and potentially higher mortality. Cheifetz: Neuromuscular blockade was discussed in the non-pulmonary treatments section. Panitch: Ira, you mentioned management in the absence of measuring transpulmonary pressure; could you comment on the role of esophageal manometry? Cheifetz: Personally, I believe esophageal manometry should be used more than it currently is, and it could be very helpful, especially in patients with more severe lung disease. For reasons that are not totally clear, this approach has never gained traction in pediatrics. Years ago, there was a push to use esophageal manometry, and there were folks using it, but the technology and the catheters had real limitations. Some of the catheters were nearly impossible to place in the appropriate position. Walsh: I wanted to comment on that too, because it says "in the absence of" like everybody uses it. The catheters you can get from 2 different manufacturers, but the device that actually measures is only one ventilator. I believe the problem is that the whole weaning/extubation process from peak lung injury to extubation is too long. Rehder: Same thing about the Bateman data5; if I remember correctly, it was duration of ventilation and not ventilator-free days that was longer. Rehder: So, suggesting that the oscillator potentially keeps patients alive longer but ultimately does not change the outcome. Cheifetz: So, survival outcomes are the same, but patients who receive early oscillation are on the vent longer. One should wean based on physiology and pathophysiology and what the patient needs, not based on a predetermined rate that is not supported by any data. Particularly in our older patients, we end up having to use those, whereas in neonates, they can spontaneously breathe on high frequency and even extubate from high frequency. First, I have no conflict of interest, as I have no ties to the device or the company at all. What happens when you increase the mean airway pressure in a patient who is hemodynamically unstable? They are not going to do well, as rightventricular preload falls and cardiac output deteriorates. One patient scenario in which I would not use the oscillator is septic shock with hemodynamic instability, at least until the capillary leak and need for fluid resuscitation improve. Simply stated, I generally do not oscillate a child in septic shock until they are hemodynamically stabilized. But, I do agree that after all these years, we may not be managing the oscillator in an optimal fashion. And yet we continue to use these antiquated modes of ventilation that historically we have used. Obviously, any of us can argue for whatever mode we like, and someone else across the room will argue for a different mode- both right or both wrong simply depending on perspective, not data! Rehder: You can certainly make an argument, but there are no data to support either side. There are certainly some things that you can argue are in favor of pressure support ventilation as well. Smallwood: At the risk of derailing the discussion, I want to get your thoughts on the technological limitations of the oscillator in terms of monitoring sophistication- being able to measure dynamic changes in gas exchange and/or tidal volume.
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