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Compliance with the CURB-65 score and the consequences of non-implementation.

BACKGROUND: The CURB-65 (confusion, urea >7 mmol/l, respiratory rate ≥30 breaths/min, low blood pressure and age ≥65 years) score is a simple, wellvalidated tool for the assessment of severity in communityacquired pneumonia (CAP). It is unknown whether it is used routinely in China.

OBJECTIVE: To determine the frequency of use of the CURB-65 score in routine hospital practice and the consequences of non-implementation.

METHODS: A retrospective analysis of medical records from 1230 in-patients with CAP in a Chinese medical college-affiliated hospital.

RESULTS: No CAP patient underwent the CURB-65 test at admission. Based on the British Thoracic Society guidelines, the 716 (58.2%) in-patients with a CURB65 score of 0 and the 402 (32.7%) in-patients with CURB-65 score of 1 should have received ambulatory treatment, whereas the 14 (1.2%) patients with CURB65 scores of ≥3 should have been admitted to the critical care unit. The maximum excess total annual costs for managing CAP patients with CURB-65 scores of 0 and 1 were estimated at respectively US$94 383.12 and US$66 313.92 in the hospital.

CONCLUSIONS: The CURB-65 scoring tool in patients with CAP was not applied in routine hospital practice, resulting in inappropriate hospitalisation and excess costs.

Bench studies evaluating devices for non-invasive ventilation: critical analysis and future perspectives.

PURPOSE: Because non-invasive mechanical ventilation (NIV) is increasingly used, new devices, both ventilators and interfaces, have been continuously proposed for clinical use in recent years. To provide the clinicians with valuable information about ventilators and interfaces for NIV, several bench studies evaluating and comparing the performance of NIV devices have been concomitantly published, which may influence the choice in equipment acquisition. As these comparisons, however, may be problematic and sometimes lacking in consistency, in the present article we review and discuss those technical aspects that may explain discrepancies.

METHODS: Studies concerning bench evaluations of devices for NIV were reviewed, focusing on some specific technical aspects: lung models and simulation of inspiratory demand and effort, mechanical properties of the virtual respiratory system, generation and quantification of air leaks, ventilator modes and settings, assessment of the interface-ventilator unit performance.

RESULTS: The impact of the use of different test lung models is not clear and warrants elucidation; standard references for simulated demand and effort, mode of generation and extent of air leaks, resistance and compliance of the virtual respiratory system, and ventilator settings are lacking; the criteria for assessment of inspiratory trigger function, inspiration-to-expiration (I:E) cycling, and pressurization rate vary among studies; finally, the terminology utilized is inconsistent, which may also lead to confusion.

CONCLUSIONS: Consistent experimental settings, uniform terminology, and standard measurement criteria are deemed to be useful to enhance bench assessment of characteristics and comparison of performance of ventilators and interfaces for NIV.

Recognizing asthma mimics and asthma complications.

Asthma is a chronic inflammatory disorder of the airways characterized by airflow obstruction, bronchial hyperreactivity, and underlying inflammation. Two common reasons asthmatics fail standard therapy are incorrect diagnosis and failure to recognize underlying contributing factors.

A correct diagnosis of asthma is of great importance to military practitioners since misdiagnosis or uncontrolled asthma affects an individual's operational readiness or determines whether one can receive a medical waiver to enlist in military service.

This article presents four cases of patients with dyspnea that have conditions which mimic asthma or complicate asthma management: vocal cord dysfunction misdiagnosed as asthma, respiratory bronchiolitis interstitial lung disease mistaken as asthma, difficult-to-control asthma because of bronchiectasis and allergic bronchopulmonary aspergillosis, and difficult and fatal asthma. Asthma is contrasted to other respiratory disorders, and an outlined approach to asthma diagnosis and management is presented using the Global Initiative for Asthma guidelines.

Role of oxidants in interstitial lung diseases: pneumoconioses, constrictive bronchiolitis, and chronic tropical pulmonary eosinophilia.

Oxidants such as superoxide anion, hydrogen peroxide, and myeloperoxidase from activated inflammatory cells in the lower respiratory tract contribute to inflammation and injury.

Etiologic agents include inorganic particulates such as asbestos, silica, or coal mine dust or mixtures of inorganic dust and combustion materials found in World Trade Center dust and smoke. These etiologic agents are phagocytosed by alveolar macrophages or bronchial epithelial cells and release chemotactic factors that recruit inflammatory cells to the lung.

Chemotactic factors attract and activate neutrophils, eosinophils, mast cells, and lymphocytes and further activate macrophages to release more oxidants. Inorganic dusts target alveolar macrophages, World Trade Center dust targets bronchial epithelial cells, and eosinophils characterize tropical pulmonary eosinophilia (TPE) caused by filarial organisms. The technique of bronchoalveolar lavage in humans has recovered alveolar macrophages (AMs) in dust diseases and eosinophils in TPE that release increased amounts of oxidants in vitro. Interestingly, TPE has massively increased eosinophils in the acute form and after treatment can still have ongoing eosinophilic inflammation.

A course of prednisone for one week can reduce the oxidant burden and attendant inflammation and may be a strategy to prevent chronic TPE and interstitial lung disease.

Pulmonary mechanics during mechanical ventilation.

The use of mechanical ventilation has become widespread in the management of hypoxic respiratory failure. Investigations of pulmonary mechanics in this clinical scenario have demonstrated that there are significant differences in compliance, resistance and gas flow when compared with normal subjects.

This paper will review the mechanisms by which pulmonary mechanics are assessed in mechanically ventilated patients and will review how the data can be used for investigative research purposes as well as to inform rational ventilator management.

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