Respiratory care clinics of North America最新文献

We illustrate the benefits and limitations of administrative data when trying to understand diseases such as CAP. Administrative data provide an understanding of care provided or risk factors in unselected patients under actual practice conditions. Administrative data can supplement understandings gained from randomized trials in a timely and cost-efficient manner using data previously collected. As the use of administrative data increases, the type of data collected will change to reflect these new uses. Administrative data use may represent a practical solution in monitoring quality of care for entire populations.

The most commonly used measures of quality of care for hospitalized pneumonia patients are process measures as opposed to outcome measures.For a process measure to be useful in assessing quality of care, it must be linked to a desired outcome. For patients hospitalized with pneumonia, the obtaining of blood cultures, the timely use of appropriate antibiotics, and the delivery of the influenza and pneumococcal vaccines are the process measures most widely used for assessing quality of care in relation to clinical outcomes. The admission decision and the length of time that intravenous antibiotics are used are process measurements that directly affect financial outcomes.

There are many potential mechanisms by which nutritional deficiencies can predispose to an increased risk and worse outcome for CAP. The elderly population is particularly vulnerable. There is a relative lack of data on the effect of nutrition on risk and outcome of CAP. More research is needed to better delineate the impact of nutrition on risk and outcome of CAP.

This article reviews the history of organ transplantation, specifically focusing on the advances leading to the first successful human lung transplant. It also provides an overview of the com-mon indications and general selection criteria for lung transplant recipients, highlights areas of current controversy in pulmonary transplantation, reviews current approaches to posttransplantation immunosuppression, and discusses common complications seen intransplant recipients.

Lung transplantation is associated with a great number of major medical complications that act in concert to limit the long-term success of this difficult treatment option for advanced lung disease. Close and parallel attention to pulmonary and nonpulmonary medical complications and management of lung transplant recipients by a multidisciplinary team are the most important ingredients of optimal long-term outcomes.

During the last 20 years improvements in perioperative care have led to improved outcomes for lung transplant recipients. Although uncommon, technical complications can be the source of significant morbidity and mortality. Infections and ischemia-reperfusion injury continue to have the greatest impact on short-term outcomes of lung transplant recipients, and research into the prevention and treatment of these two entities will be necessary to improve these patients' outcomes significantly.

Infections remain a serious and common problem in lung transplant recipients. Recent years have seen an explosion in the knowledge regarding this major cause of morbidity and mortality. Novel diagnostic and therapeutic techniques are revolutionizing the approach to infectious diseases in transplant recipients. Multicenter trials will expand the scope of diagnosis and management of these infections. A team approach by transplant physicians and infectious diseases experts is critical to the success of managing these complex patients.

A constant awareness of the risk to the living donors must be maintained with any live-donor organ transplantation program, and comprehensive short- and long-term follow-up should be strongly encouraged to maintain the viability of these potentially life-saving programs. There has been no perioperative or long-term mortality following lobectomy for living lobar lung transplantation, and in the authors' series the perioperative risks associated with donor lobectomy are similar to those seen with standard lung resection. These risks might increase if the procedure were offered on an occasional basis and not within a well-established program. Further long-term outcome data, similar to data for live-donor renal and liver transplantation, are needed. Therefore, the authors still favor performing living lobar lung transplantation only for the patient with a clinically deteriorating condition. They believe that prospective donors should be informed of the morbidity associated with donor lobectomy and the potential for mortality, as well of potential recipient outcomes in regard to life expectancy and quality of life after transplantation. A major question regarding lobar lung transplantation that has been unanswered during the last decade has been defining when a potential recipient is too ill to justify placing two healthy donors at risk of donor lobectomy. Recipient age, gender, indication for primary transplant, prehospitalization status, preoperative steroid usage, relationship of donor to recipient, and the presence or absence of rejection episodes postoperatively do not seem to influence overall mortality. Patients receiving mechanical ventilation preoperatively and those undergoing retransplantation after either a previous cadaveric or lobar lung transplantation have significantly elevated odds ratios for postoperative death. The authors therefore recommend caution in these subgroups of patients. This experience is similar to the cadaveric experience in which intubated patients have higher I-year mortalities and patients undergoing retransplantation have decreased 3- and 5-year survival. A similar experience with a smaller number of lobar transplants has been reported by the Washington University group. Despite the high-risk patient population, this alternative procedure has been life saving in severely ill patients who would die or become unsuitable recipients before a cadaveric organ becomes available. Although cadaveric transplantation is preferable because of the risk to the donors, living lobar lung transplantation should continue to be used under properly selected circumstances. Although there have been no deaths in the donor cohort, a risk of death between 0.5% and 1% should be quoted pending further data. These encouraging results are important if this procedure is to be considered as an option at more pulmonary transplant centers in view of the institutional, regional, and intra- and international differences in the philosophical a

The current availability of lung donors is far exceeded by the number of potential transplant recipients who are waiting for an organ. This disparity results in significant morbidity and mortality for those on the waiting list. Although it is desirable to increase overall consent rates for organ donation, doing so requires an intervention to affect societal response. In contrast, increased procurement of organs from marginal donors and improved donor management may be realized through increased study and practice changes within the transplant community. Transplantation of organs from marginal or extended-criteria donors may result in some increase in complications or mortality, but this possibility must be weighed against the morbidity and risk of death risk faced by individuals on the waiting list. The effects of this trade-off are currently being studied in kidney transplantation, and perhaps in the near future lung transplantation may benefit from a similar analysis. Until that time, the limited data regarding criteria for donor acceptability must be incorporated into practice to maximize the overall benefits of lung transplantation.

Bronchoscopy is an integral piece in the complex multidisciplinary approach to the care of lung transplant recipients. Although the use of surveillance bronchoscopies is controversial, bronchoscopy undoubtedly provides valuable information in patients with respiratory symptoms or functional decline. Therapeutic bronchoscopic interventions offer effective and safe therapy for complications of anastomotic sites. Further research is needed to address critical questions regarding the role of bronchoscopy in this selected patient population. The objectives of the research should be to increase the yield of bronchoscopy, improve its safety, and decrease procedure-related discomfort. Only randomized, multicenter clinical trials with full commitment from lung transplant centers can accomplish these goals.