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Subacute bronchial toxicity induced by an electronic cigarette: take home message

The case-based discussion of an adult smoker with respiratory symptoms and worsened pulmonary function shortly after switching to an electronic cigarette (e-cig) can be interpreted differently.

Ironically, some people experience transient (days/weeks) worsening of respiratory symptoms (cough, wheezing, chest tightness) after quitting.

Cough and breathlessness have been reported when switching to e-cigs, but progressive improvement in respiratory symptoms is usually observed with regular use of these products.

Significant risk reduction and harm reversal are expected in smokers who switch from tobacco to e-cigs. Signs and symptoms compatible with contact dermatitis around the mouth or in the oral mucosa may occur in predisposed e-cig users exposed to propylene glycol (PG) in the vapour, but the e-liquid used by this patient contained glycerol, not PG. Hypersensitivity response to glycerol has never been reported to our knowledge. Consequently, performing...

Noninvasive Ventilation in Severe Acute Asthma.

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Noninvasive ventilation (NIV) in severe acute asthma is controversial but may benefit this population by preventing intubation.

We report on a 35-year-old male asthma patient who presented to our emergency department via emergency medical services. The patient was responsive, diaphoretic, and breathing at 35 breaths/min on 100% oxygen with bag-mask assistance, with SpO2 88%, heart rate 110-120 beats/min, blood pressure 220/110 mm Hg, and temperature 35.8°C. NIV at 12/5 cm H2O and FIO2 0.40 was applied, and albuterol at 40 mg/h was initiated. Admission arterial blood gas revealed a pH of 6.95, PaCO2 126 mm Hg, and PaO2 316 mm Hg. After 90 min of therapy, PaCO2 was 63 mm Hg. Improvement continued, and NIV was stopped 4 h following presentation. NIV tolerance was supported with low doses of lorazepam. The patient was transferred to the ICU, moved to general care the next morning, and discharged 3 days later.

We attribute our success to close monitoring in a critical care setting and the titration of lorazepam.

The changing landscape of adult home noninvasive ventilation technology, use, and reimbursement in the United States.

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There has been an exponential increase in the use of home noninvasive ventilation (NIV). Despite growing use, there is a paucity of evidence-based guidelines and practice standards in the United States to assist clinicians in the initiation and ongoing management of home NIV. Consequently, home NIV practices are being influenced by complicated local reimbursement policies and coding.

This article aims to provide a practice management perspective for clinicians providing home NIV, including Local Coverage Determination reimbursement criteria for respiratory assist devices, Durable Medical Equipment coding, and Current Procedural Terminology coding to optimize clinical care and minimize lost revenue. It highlights the need for further research and development of evidence-based clinical practice standards to ensure best practice policies are in place for this rapidly evolving patient population.

Open circuit mouthpiece ventilation: Concise clinical review.

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In 2013 new "mouthpiece ventilation" modes are being introduced to commercially available portable ventilators. Despite this, there is little knowledge of how to use noninvasive intermittent positive pressure ventilation (NIV) as opposed to bi-level positive airway pressure (PAP) and both have almost exclusively been reported to have been used via nasal or oro-nasal interfaces rather than via a simple mouthpiece.

Non-invasive ventilation is often reported as failing because of airway secretion encumbrance, because of hypercapnia due to inadequate bi-level PAP settings, or poor interface tolerance. The latter can be caused by factors such as excessive pressure on the face from poor fit, excessive oral air leak, anxiety, claustrophobia, and patient-ventilator dys-synchrony. Thus, the interface plays a crucial role in tolerance and effectiveness. Interfaces that cover the nose and/or nose and mouth (oro-nasal) are the most commonly used but are more likely to cause skin breakdown and claustrophobia. Most associated drawbacks can be avoided by using mouthpiece NIV.

Open-circuit mouthpiece NIV is being used by large populations in some centers for daytime ventilatory support and complements nocturnal NIV via "mask" interfaces for nocturnal ventilatory support. Mouthpiece NIV is also being used for sleep with the mouthpiece fixed in place by a lip-covering flange. Small 15 and 22mm angled mouthpieces and straw-type mouthpieces are the most commonly used. NIV via mouthpiece is being used as an effective alternative to ventilatory support via tracheostomy tube (TMV) and is associated with a reduced risk of pneumonias and other respiratory complications. Its use facilitates "air-stacking" to improve cough, speech, and pulmonary compliance, all of which better maintain quality of life for patients with neuromuscular diseases (NMDs) than the invasive alternatives.

Considering these benefits and the new availability of mouthpiece ventilator modes, wider knowledge of this technique is now warranted. This review highlights the indications, techniques, advantages and disadvantages of mouthpiece NIV.

PMID: 24841239 [PubMed - as supplied by publisher]

Beta Blockers Eyed for PAH Therapy

The use of beta blockers for treatment of idiopathic pulmonary arterial hypertension (PAH) appeared to be safe in early clinical trials, and also improved right ventricular ejection fraction, researchers said here.

In the trial that included 18 patients – 17 of them women –right ventricular ejection fraction was improved 4% among patients treated with beta blockers (P=0.019), said Jasmijn van Campen, MD, a staff pulmonologist at VU University Medical Center in Amsterdam.

Treatment also resulted in a reduction of heart rate by 10 beats per minute (P<0.0001), and quality of life improved significantly (P=0.027) as assessed by the Minnesota quality of life questionnaire, van Campen said in her oral, late-breaking presentation at the annual meeting of the American Thoracic Society. She said that 14 of 17 patients who were evaluable achieved heart-rate reductions of greater than 10%. ...

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