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Primary Care Sep 2023Dysphagia is an important clinical symptom that increases in prevalence with age. Both oropharyngeal and esophageal processes can contribute to dysphagia, and these can... (Review)
Review
Dysphagia is an important clinical symptom that increases in prevalence with age. Both oropharyngeal and esophageal processes can contribute to dysphagia, and these can be differentiated with a careful history. Neuromuscular processes are more prevalent than structural causes in oropharyngeal dysphagia, therefore, investigation should start with a modified barium swallow. In contrast, structural processes dominate in esophageal dysphagia, and endoscopy can offer biopsy and therapy by way of dilation. Manometry is performed for esophageal dysphagia when no structural etiology is found. Specific management of dysphagia is dependent on the etiology and mechanism of dysphagia.
Topics: Humans; Deglutition Disorders; Biopsy; Manometry
PubMed: 37516505
DOI: 10.1016/j.pop.2023.03.001 -
Primary Care Sep 2023Symptoms potentially attributable to gastroesophageal reflux disease are among those most commonly reported to primary care providers in the outpatient setting. In this... (Review)
Review
Symptoms potentially attributable to gastroesophageal reflux disease are among those most commonly reported to primary care providers in the outpatient setting. In this review, we discuss clinical approaches to the evaluation and management of these symptoms, including proton pump inhibitor trials as well as specific indications or clinical settings that warrant referral to Gastroenterology specialists.
Topics: Humans; Esophageal pH Monitoring; Retrospective Studies; Gastroesophageal Reflux; Proton Pump Inhibitors
PubMed: 37516506
DOI: 10.1016/j.pop.2023.03.002 -
Critical Care (London, England) Jul 2023This narrative review explores the physiology and evidence-based management of patients with severe acute respiratory distress syndrome (ARDS) and refractory hypoxemia,... (Review)
Review
This narrative review explores the physiology and evidence-based management of patients with severe acute respiratory distress syndrome (ARDS) and refractory hypoxemia, with a focus on mechanical ventilation, adjunctive therapies, and veno-venous extracorporeal membrane oxygenation (V-V ECMO). Severe ARDS cases increased dramatically worldwide during the Covid-19 pandemic and carry a high mortality. The mainstay of treatment to improve survival and ventilator-free days is proning, conservative fluid management, and lung protective ventilation. Ventilator settings should be individualized when possible to improve patient-ventilator synchrony and reduce ventilator-induced lung injury (VILI). Positive end-expiratory pressure can be individualized by titrating to best respiratory system compliance, or by using advanced methods, such as electrical impedance tomography or esophageal manometry. Adjustments to mitigate high driving pressure and mechanical power, two possible drivers of VILI, may be further beneficial. In patients with refractory hypoxemia, salvage modes of ventilation such as high frequency oscillatory ventilation and airway pressure release ventilation are additional options that may be appropriate in select patients. Adjunctive therapies also may be applied judiciously, such as recruitment maneuvers, inhaled pulmonary vasodilators, neuromuscular blockers, or glucocorticoids, and may improve oxygenation, but do not clearly reduce mortality. In select, refractory cases, the addition of V-V ECMO improves gas exchange and modestly improves survival by allowing for lung rest. In addition to VILI, patients with severe ARDS are at risk for complications including acute cor pulmonale, physical debility, and neurocognitive deficits. Even among the most severe cases, ARDS is a heterogeneous disease, and future studies are needed to identify ARDS subgroups to individualize therapies and advance care.
Topics: Humans; Pandemics; COVID-19; Respiration, Artificial; Respiratory Distress Syndrome; Continuous Positive Airway Pressure; Ventilator-Induced Lung Injury; Hypoxia
PubMed: 37464381
DOI: 10.1186/s13054-023-04572-w -
European Respiratory Review : An... Jun 2023There is a well-recognised importance for personalising mechanical ventilation settings to protect the lungs and the diaphragm for each individual patient. Measurement... (Review)
Review
There is a well-recognised importance for personalising mechanical ventilation settings to protect the lungs and the diaphragm for each individual patient. Measurement of oesophageal pressure ( ) as an estimate of pleural pressure allows assessment of partitioned respiratory mechanics and quantification of lung stress, which helps our understanding of the patient's respiratory physiology and could guide individualisation of ventilator settings. Oesophageal manometry also allows breathing effort quantification, which could contribute to improving settings during assisted ventilation and mechanical ventilation weaning. In parallel with technological improvements, monitoring is now available for daily clinical practice. This review provides a fundamental understanding of the relevant physiological concepts that can be assessed using measurements, both during spontaneous breathing and mechanical ventilation. We also present a practical approach for implementing oesophageal manometry at the bedside. While more clinical data are awaited to confirm the benefits of -guided mechanical ventilation and to determine optimal targets under different conditions, we discuss potential practical approaches, including positive end-expiratory pressure setting in controlled ventilation and assessment of inspiratory effort during assisted modes.
Topics: Humans; Respiration, Artificial; Lung; Respiratory Mechanics; Ventilators, Mechanical; Monitoring, Physiologic
PubMed: 37197768
DOI: 10.1183/16000617.0186-2022 -
Journal of Clinical Medicine Jan 2024Diaphragm Dysfunction (DD) is a respiratory disorder with multiple causes. Although both unilateral and bilateral DD could ultimately lead to respiratory failure, the... (Review)
Review
Diaphragm Dysfunction (DD) is a respiratory disorder with multiple causes. Although both unilateral and bilateral DD could ultimately lead to respiratory failure, the former is more common. Increasing research has recently delved into perioperative diaphragm protection. It has been established that DD promotes atelectasis development by affecting lung and chest wall mechanics. Diaphragm function must be specifically assessed for clinicians to optimally select an anesthetic approach, prepare for adequate monitoring, and implement the perioperative plan. Recent technological advancements, including dynamic MRI, ultrasound, and esophageal manometry, have critically aided disease diagnosis and management. In this context, it is noteworthy that therapeutic approaches for DD vary depending on its etiology and include various interventions, either noninvasive or invasive, aimed at promoting diaphragm recruitment. This review aims to unravel alternative anesthetic and operative strategies that minimize postoperative dysfunction by elucidating the identification of patients at a higher risk of DD and procedures that could cause postoperative DD, facilitating the recognition and avoidance of anesthetic and surgical interventions likely to impair diaphragmatic function.
PubMed: 38256653
DOI: 10.3390/jcm13020519 -
Intensive Care Medicine Jun 2024
Topics: Humans; Esophagus; Monitoring, Physiologic; Pressure; Manometry
PubMed: 38602514
DOI: 10.1007/s00134-024-07401-y -
Frontiers in Physiology 2023A rhythmic expression of clock genes occurs within the cells of multiple organs and tissues throughout the body, termed "peripheral clocks." Peripheral clocks are... (Review)
Review
A rhythmic expression of clock genes occurs within the cells of multiple organs and tissues throughout the body, termed "peripheral clocks." Peripheral clocks are subject to entrainment by a multitude of factors, many of which are directly or indirectly controlled by the light-entrainable clock located in the suprachiasmatic nucleus of the hypothalamus. Peripheral clocks occur in the gastrointestinal tract, notably the epithelia whose functions include regulation of absorption, permeability, and secretion of hormones; and in the myenteric plexus, which is the intrinsic neural network principally responsible for the coordination of muscular activity in the gut. This review focuses on the physiological circadian variation of major colonic functions and their entraining mechanisms, including colonic motility, absorption, hormone secretion, permeability, and pain signalling. Pathophysiological states such as irritable bowel syndrome and ulcerative colitis and their interactions with circadian rhythmicity are also described. Finally, the classic circadian hormone melatonin is discussed, which is expressed in the gut in greater quantities than the pineal gland, and whose exogenous use has been of therapeutic interest in treating colonic pathophysiological states, including those exacerbated by chronic circadian disruption.
PubMed: 37711458
DOI: 10.3389/fphys.2023.1239278