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Background Mechanical ventilation (MV) is a life-saving technology that restores or assists breathing. Like any treatment, MV has side effects. In some patients it can cause diaphragmatic atrophy, injury, and dysfunction (ventilator-induced diaphragmatic dysfunction, VIDD). Accumulating evidence suggests that VIDD makes weaning from MV difficult, which involves increased morbidity and mortality. Methods and analysis This paper describes the protocol of a randomized, controlled, open-label, multicenter trial that is designed to investigate the safety and effectiveness of a novel therapy, temporary transvenous diaphragm pacing (TTVDP), to improve weaning from MV in up to 88 mechanically ventilated adult patients who have failed at least two spontaneous breathing trials over at least 7 days. Patients will be randomized (1:1) to TTVDP (treatment) or standard of care (control) groups. The primary efficacy endpoint is time to successful extubation with no reintubation within 48 h. Secondary endpoints include maximal inspiratory pressure and ultrasound-measured changes in diaphragm thickness and diaphragm thickening fraction over time. In addition, observational data will be collected and analyzed, including 30-day mortality and time to discharge from the intensive care unit and from the hospital. The hypothesis to be tested postulates that more TTVDP patients than control patients will be successfully weaned from MV within the 30 days following randomization. Discussion This study is the first large-scale clinical trial of a novel technology (TTVDP) aimed at accelerating difficult weaning from MV. The technology tested provides the first therapy directed specifically at VIDD, an important cause of delayed weaning from MV. Its results will help delineate the place of this therapeutic approach in clinical practice and help design future studies aimed at defining the indications and benefits of TTVDP. Trial registration ClinicalTrials.gov, NCT03096639 . Registered on 30 March 2017.

The history of the use of the pulmonary-artery catheter (PAC) illustrates a great deal about physicians' often uncritical acceptance of technology in clinical applications. In 1956, Forssmann, Cournand, and Richards were awarded the Nobel Prize in Physiology or Medicine for the development of heart catheterization and consequent discoveries in cardiac pathophysiology. Forssmann performed the first right heart catheterization, on himself, in 1929. The catheterization work of Cournand and Richards at the Bellevue Hospital Chest Service began in the 1940s, and it initiated a new era in cardiopulmonary physiology, providing important insights into hemodynamics, gas exchange, and heart–lung interactions. Their studies . . .

In 1996, a large, prospective, observational cohort study of PAC use in critical care settings indicated that PAC use might increase mortality as well as morbidity.3 The response to this study triggered a multidisciplinary workshop sponsored by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health and the FDA, to examine the use of catheters and clinical outcomes.4 The workshop called for the development of educational programs by professional societies and for clinical trials in several areas in which PAC use was extensive.

Transbronchial needle aspiration (TBNA) is a valuable, minimally invasive procedure for diagnosing and staging lung cancer in patients, but it is underutilized by practicing pulmonologists. To assess the approach to TBNA of current pulmonary Fellows, we recorded their computerized interactive responses during the 1995 American College of Chest Physicians Fellows' Conference. Among 109 Fellows attending, only 10% reported that they routinely (> or = 85% of cases) performed TBNA to diagnose or stage malignant disease, and 40% noted that they rarely (< or = 5% of cases) performed it. They estimated their diagnostic TBNA yields in patients with mediastinal cancer as follows: > or = 80% by 2% of Fellows; between 25% and 80% by 54% of Fellows; and < 25% by 45% of Fellows. They noted that the main limitations of TBNA at their institutions were suboptimal bronchoscopy technique (30%), technician support (1%), cytopathology support (14%), all of these factors (25%), or the belief that TBNA is not useful (30%). TBNA is currently underutilized and/or underemphasized at bronchoscopy training programs. Major modifications of Fellow experiences are necessary if TBNA is to impact optimally on patient management.

Transbronchial needle aspiration (TBNA) is a valuable, minimally invasive procedure for diagnosing and staging lung cancer in patients, but it is underutilized by practicing pulmonologists. To assess the approach to TBNA of current pulmonary Fellows, we recorded their computerized interactive responses during the 1995 American College of Chest Physicians Fellows' Conference. Among 109 Fellows attending, only 10% reported that they routinely (≥85% of cases) performed TBNA to diagnose or stage malignant disease, and 40% noted that they rarely (≤5% of cases) performed it. They estimated their diagnostic TBNA yields in patients with mediastinal cancer as follows: ≥80% by 2% of Fellows; between 25% and 80% by 54% of Fellows; and <25% by 45% of Fellows. They noted that the main limitations of TBNA at their institutions were suboptimal bronchoscopy technique (30%), technician support (1%), cytopathology support (14%), all of these factors (25%), or the belief that TBNA is not useful (30%). TBNA is currently underutilized and/or underemphasized at bronchoscopy training programs. Major modifications of Fellow experiences are necessary if TBNA is to impact optimally on patient management.

Main carinal biopsy was carried out in 58 consecutive patients with endobronchial (endoscopically visible) bronchogenic carcinoma. Overall, the results of the biopsy were positive in 8 of 58 patients (13.8%). The biopsy results were positive in 6 of 15 (40%) patients whose carina appeared abnormal as compared with 2 of 43 (4.7%) whose carina appeared normal (P = .0025). In those patients with subtle carinal abnormalities (carinal widening or erythema) but without gross tumor involvement, the biopsy findings were positive in 5 of 14 (36%). Unlike in previous studies, a significant percentage of positive carinal biopsy findings was associated with left upper lobe lesions. There were no complications associated with the procedure. Although the yield on blind carinal biopsies (visually normal carina) with the flexible fiberoptic bronchoscope is lower than that previously reported with the rigid bronchoscope, it remains a low-risk procedure that can spare a number of patients the morbidity and expense of more invasive surgical staging when applied as a routine part of diagnostic bronchoscopy in patients with endoscopically visible bronchogenic carcinoma.

While respiratory failure has been reported in miliary tuberculosis, acute cavitary pulmonary tuberculosis is not commonly associated with hypercapnic respiratory failure. The authors report a patient in whom persistent respiratory failure did develop, the mechanism being shown to be a large, well-ventilated cavity that created a significant ventilatory dead space.