The clinical applications of ventilation and the use of specific modes during the acute stage of illness focus on protecting the lung and improving the patient outcomes.
Acute respiratory distress syndrome (ARDS), the most severe presentation of acute lung injury, results from an acute insult to the body that may be direct or indirect (pneumonia vs sepsis). The release of mediators and a host of other toxic substances affect the alveolar- capillary permeability adversely and result in a noncardiac pulmonary edema. Pathology includes decreased compliance, shunting, and refractory hypoxemia. No definitive treatment, but the therapy focus on managing the underlying condition and on supportive mechanical ventilation.
Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the United States.
Conventional COPD treatments:
Inhaled bronchodilator therapy: metered-dose inhalers and spacers, dry powder inhalers, or wet nebulizers
Inhaler technique should be assessed to ensure that a patient is able to use a device effectively.
The combination of a long-acting anticholinergic with an as-needed short-acting beta-agonist is a standard initial approach.
For many patients with advanced COPD, the addition of a combination inhaler containing a long-acting beta-agonist and an inhaled corticosteroid to a long-acting anticholinergic agent provides benefit in terms of symptom management and quality of life.
Death rattle – as patients near death, they are unable to cough to clear secretions that begin to pool in the oropharynx and bronchi, resulting in rales (“death rattles”). Because the sound is often distressing to family members, an anticholinergic (glycopyrrolate or atropine) may be given subcutaneously to relieve respiratory distress. A hyoscine hydrobromide transdermal patch is also available, but action is slower, 12 hours compared to 1 minute for injections. Risks associated with anticholinergics include xerostomia (dry mouth), increased sedation, and increased delirium. Elevating the head of the bed or turning the patient to the side may also relieve rattling. Patients normally stop taking fluids as they near death, resulting in dehydration and drying of the mucous membranes of the mouth. The death rattle also begins to lessen.
Palliative care is a form of specialized medical care which aims to optimize the quality of life and alleviate the suffering of patients through early identification and treatment of new symptoms along with management of those that prove refractory.
Excessive secretions can cause the frequently noted ” death rattle” in patients that are actively dying. This is caused by relaxation of the oropharyngeal muscles leading to a pooling of secretion in the throat. While it is typically not distressing for the patient, it does often make family members and other visitors uncomfortable. Anticholinergic agents, especially sublingual atropine drops, can be administered to assist in secretion reduction. Anticholinergic agents have multiple side effects, including decreased/ absent bowel sounds, decreased sweating, hot skin, and mydriatic pupils (dilated pupils).
An extremely common skin disorder described as superficial inflammatory, erythematous, pruritic, and eruptive
In adults, it is usually localized and chronic
It is in many ways a cyclic disorder, starting as a constant pruritis causing scratching, which in turns causes a rash that causes of atopic dermatitis are unclear, although there is often intolerance to environmental irritants’.
Exacerbation of atopic dermatitis may be caused by conditions that are common to patients near the end of life, including emotional stress, temperature changes, and bacterial skin infections, and for this reason it is important to consider these factors as a potential etiology of dermatitis in these patients.
avoidance of rubbing on the skin, minimization of scratching, and decreasing exposure to triggering stimuli in the environment.
The skin should be kept well lubricated
Medications that are useful in reducing symptoms are similar to those used for pruritis and include hydroxyzine, diphenhydramine, and topical steroids. If lesions are resistant to this therapy then superimposed infection may be present.
For such patients, antibiotic treatment directed against S. aureus may be of benefit.