Starting Media Center is easy, click start and then Windows Media Center. If you have a “green button” remote, you can simply press the green button and it will start. This is the screen you see when starting Media Center the first time.
We chose to run an express configuration, there is still a bit of info that is required here.
We’ll start off with the Live TV setup. Windows will detect what type of capture card you have installed (if you have one) and try to detect what is connected to it. In this case we only have the ATSC (over the air HD) antenna connected.
Media Center does a good job of finding the type of source you have and will pick out the basic channel lineup when hooked to cable. WMC downloads guide data automatically in 2 week increments for both your cable and OTA HD (Over The Air).
ATSC requires your zip code to reference a database for the broadcasts available in your area.
Here we see Silverlight PlayReady being installed and configured. Oh how we love DRM! Luckily we haven’t run into a situation where this has inhibited anything we were trying to do.
Once PlayReady has completed installation we’re ready to watch and/or record live TV or check out the guide. The screen shot above gives you an idea of what the default guide looks like. There are ways to customize this, just as there are for Media Center’s other functions, the sky is the limit! Find something that works for you and stick with it!


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Sprint just announced that it will begin taking online preorders for the Samsung Galaxy S3 on June 5th. They’ll have it in stores June 21st.
Sprint will offer two versions of the Galaxy S3: a 16GB model priced at $199.99 and a 32GB version for $249.99 (both require a two-year contract.) Sprint also announced that they will be the only U.S. carrier with a pre-loaded Google Wallet, an app that uses Near Field Communication (NFC) to ensure the safety of purchases at more than 100,000 participating retailers. .
Fared Adib, vice president of product development at Sprint said, “Sprint and Samsung take another leap forward together in bringing our customers the best in mobile technology with Galaxy S3 on the Sprint 4G LTE network. Sprint is the only U.S. carrier to offer this device with the simplicity of unlimited data plans. Our customers will appreciate being able to use the robust features and capabilities of this device without worrying about data caps, throttling or silly overage charges.”
Why wait around for Samsung to get its accessories on line when they’re already available? Outfit your new device with a selection of top brand cell phone accessories from Bags and Sleeves, Batteries, Bluetooth Headsets and Bluetooth Car Kits, Car Holders, Cases and Skins, Data Cables, Earbuds and Headsets, Keyboard and Protectors, Memory Cards, Screen Protectors, Speakers and Docks as well as Stylus and Pens.

domain: news


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Spill Eater Bioactive Eco Absorbent is manufactured locally from recycled organic cellulose products that would otherwise be burnt or end up in landfills. The size and nature of the particles contained in Spill Ready Organic Absorbent rapidly encapsulates liquids and stops them from leaching back into waterways and ground water. Naturally occurring microbes, contained in the cellulose material, consume hydrocarbons like fuel, oil and grease and gradually convert them into a composted material. Plants grow back in affected soil areas, making Spill Eater Bioactive Eco Absorbent, one of the most natural products to use, ideal in spill kits, workshops as a spill station and service vehicles.
Superior results with petroleum, oils, fuels, solvents, paints, cooking oils, sewerage and coolants. Ideal in spill kits, workshop spill stations and vehicles. Soaks up quickly and absorbs far more liquid then mineral and clay products.
- Absorbs up to 4 times per kg more liquid than most clay & mineral based absorbents, making it more cost effective
- Absorbs faster so road traffic can resume, staff are less likely to be exposed and there is less chance of runoff into waterways
- Effective in rainy weather as water won’t wash the oil out the product
- Used on a wide range of materials including oil, fuel, paint, blood, urine, vomit, pesticides & coolants
- Can be composted
- Does a superior job leaving surfaces dryer and less slippery
- Does not contain crystalline silica (Classified Group 1 Carcinogenic to humans)
- Do not use on strong oxidising agents, acids or caustic solutions
- Ensure disposal of this product is according to Local and State Government Waste Management Guidelines

domain: chemistry


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WahooArt.com - Diego Velazquez
Arts & Entertainment > Hobbies & Creative Arts > Artwork
Christ in the House of Martha and Mary by Diego Velazquez (1599-1660, Spain) | Painting Copy | WahooArt.com
Kitchen Scene in the House of Martha and Mary dates from Velázquez's Seville period, painted shortly after he completed his apprenticeship with Pacheco. At this time, Velázquez was experimenting with the potential of the bodegone, a form of painting which was frequently used to relate scenes of contemporary Spain to themes and stories from the Bible. Often they contained depictions of people working with food and drink. In this case, Velázquez has painted the interior of a kitchen with two half-length women to the left (one an old woman who appeared in his Old Woman Cooking Eggs from the same period). On the table are a number of foods, perhaps the ingredients of an Alioli (a garlic mayonnaise made to accompany fish). These have been prepared by the maid. Extremely realistic, they were probably painted from the artist's own household as they appear in other bodegones from the same time. The foods are shown prepared in ways typical of Spanish cookery at the time. His painstaking attention to detail show how important Velázquez considered it to represent realistic scenes.

domain: artistic


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About WebOss Paintball
Welcome to WebOss Extreme Ground : PaintBall
Rate: 350.00 per person
Minimum Players: 2 players
Maximum Players: we can cater upto 25 players or more, we will manage it by grouping the players by team with 6 to 8 members, each team will then compete against the other team, like a tournament game.
- free 60 paintballs (5.00 each per additional paintballs.)
- use of the whole game-site area during the game
- use of paintball markers (guns)
- use of basic protective gears – masks and vest
- Morning (8:00 am to 11:30 am)
- Afternoon (1:00 pm to 5:30 pm)
- Official Bookings - For official booking, a minimum of 1,000 pesos non-refundable down-payment is required – we will then block the whole morning or afternoon schedule you preferred and will not accept any walk-ins during the blocked schedule.
- Rescheduled bookings are allowed only if players will contact Weboss Paintball Management ahead of schedule.
- Walk-in Players - If no down-payment, you will be considered as walk-in players – you can always go directly to the game-site within the allowed schedule but if ever there is a reserved schedule, the one with official reservation will be prioritized first.
- Reservation can be submitted online or through text and call but will only be official when the 1,000 pesos down-payment is forwarded to Weboss Paintball Management or Staff.
Requirements to Play:
- wearing shorts or sleeveless is not allowed – preferrably long sleeve
- sleepers are not allowed – preferrably rubber shoes
- no alcoholic beverages are allowed inside the game-site and during the game
- no smoking is allowed
- before the game starts, we required the players to read the reminders and game rules we display inside the game-site, and sign our separate waiver form
Game Type setup: we don’t particularly set a game type for the players because we let our players decide how they want to run their game, our umpires may suggest, but they are only there to referee the game you want.
Game Reservation Calendar:
- all official bookings and confirmed walk-in players will be posted in our calendar for everyone’s reference.
- please check Calendar below for availability.
Game Reservations – Schedule
|AM game - 8:00 ~ 11:30 am|
|PM Game - 1:00 ~ 5:30 pm|

domain: game


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A therapy developed at St. Jude Children’s Research Hospital has increased survival rates by more than 20 percentage points for children with high-risk neuroblastoma.
The treatment includes a novel monoclonal antibody manufactured on the St. Jude campus.
Neuroblastoma is a cancer of immature nerve cells in the sympathetic nervous system. Survival rates for the high-risk form of neuroblastoma had been at 51 percent for a decade. But the chemoimmunotherapy developed in the labs and clinics at St. Jude bumped three-year survival to 74 percent. That’s encouraging news for the roughly 700 children diagnosed with neuroblastoma each year in the U.S., many of them under 5 years old.
“This is really exciting for me as an oncologist,” said Sara M. Federico, MD, a St. Jude faculty member and senior author of the study. “When I came to St. Jude to do my fellowship… if a new patient came in with high-risk neuroblastoma and they asked what the cure rate was, the answer was about 30 percent, and that of course was unacceptable.
"By the time my fellowship ended (in 2011) it was 51 percent, but here we are 10 years after my fellowship and we are seeing a big jump, where we have a three-year event-free survival rate of 74 percent. It’s remarkable,” she said.
The study findings were published in the Journal of Clinical Oncology.
“I have never seen results like this in high-risk patients," said Wayne Furman, MD, a St. Jude faculty member who led the study and has cared for patients with neuroblastoma for more than 30 years. "This is the best result published to date for patients with high-risk neuroblastoma, period.”
The chemoimmunotherapy described in the study could become standard treatment for patients with high-risk disease, Furman said, if the findings are confirmed in a larger, multi-center clinical trial.
Neuroblastoma commonly grows on young adrenal glands over the kidneys, dodging recognition by the immune system and growing unchecked. But the monoclonal antibody manufactured on the St. Jude campus and used in a clinical trial serving 64 patients was designed to seek out an antigen called GD2 found on neuroblastoma cells. The antibody binds to GD2 and flags neuroblastoma cells so the immune system can find and destroy them.
Treatment for neuroblastoma is grueling with high-dose chemotherapy, radiation, surgery and bone marrow transplants — and even that’s not enough to wipe it out for patients with a high-risk form that has spread. But the new monoclonal antibody therapy given at the beginning and end of treatment along with other medicines is showing hopeful improvement for these patients.
This therapy could also show promise in treatment of osteosarcoma, Ewing sarcoma and in adult malignancies like melanoma and certain lung cancers, whose cells also present with GD2.
“The future steps are to validate these results and to build on it. What else can we do to make this therapy more effective?” Federico said.
The encouraging results of the trials remind Federico of a picture she saw of a neuroblastoma patient of hers, Slater.
It’s one of him standing next to his big brother on a street in front of their Florida home watching the Inspiration4 space mission launch into orbit earlier this year. Three years ago, Slater had been too weak to walk when he and his family first sought help from St. Jude in 2018 after he was diagnosed with Stage IV neuroblastoma. And this year, here he was, standing strong and dreaming of space travel after receiving the monoclonal antibody treatment Federico and her colleagues had been developing and studying.
“What is the limit? There are no limits. Just seeing him standing in the street watching a cancer survivor blast off into space. It just shows you there are no limits to what we can achieve,” Federico said. “That photo just sums up my motivation.”

domain: medical


Edited by: Prof Jianhua Wang
Optical coherence tomography angiography (OCTA) is an imaging modality for imaging the vessel with depth information and commonly used for imaging the retinal vasculature. Recent applications for imaging the anterior segment open a new era for aiding the diagnosis of vascular lesions of the anterior eye. For example, the conjunctival vascular network can be easily visualized, and quantitative analysis of the vessel may further boost the use of OCTA for the anterior segment of the eye. This thematic series focuses on the recent applications of OCTA for vascular imaging of the anterior segment and aims to publish review articles and original research of the latest discovery and applications in the field.


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- Is there any career in animation?
- Can I be an animator if I can’t draw?
- Can I get a job in animation without a degree?
- Which animation course is best for job?
- Is learning animation easy?
- Is animation hard to learn?
- Is it hard to get a job in animation?
- Is animator a good career?
- Do animators get paid well?
- Does animation require coding?
- How do I get my first animation job?
- Which country is best for animation jobs?
- What is the starting salary in animation?
- Do animators work at home?
Is there any career in animation?
Nowadays, animation and special effects have a great demand in Television and Movies as well as in the advertising industry.
The animation industry has massive career scope for those who want to bring their imagination to life and for those who love telling fascinating stories..
Can I be an animator if I can’t draw?
There are many professional 3D animators that can create amazing animations without drawing. … You can have an excellent animation that is done with just stick figures, and it’s still going to look good regardless of whether or not you spent hours on each drawing.
Can I get a job in animation without a degree?
Yes and no. You can be a successful animator without a degree, but having one will make you more competitive. Many companies will require a degree in Animation, Graphic Design, or a related field. However, freelancing is a way to build that all-important portfolio.
Which animation course is best for job?
Type of Animation Courses:Name of the CourseType of CourseDurationBachelor of Fine Arts in Animation, Graphics, and Web DesignBachelor’s Degree3 yearsB.Sc. in Animation and GamingBachelor’s Degree3 yearsB.Sc. in Animation and VFXBachelor’s Degree3 yearsDiploma in 2D AnimationDiploma Course1 year18 more rows•Apr 6, 2020
Is learning animation easy?
Easy to learn, hard to Master. It’s easier to get into animation today than ever before. Software’s getting cheaper (or even free), and most modern computers can handle the more simple animation tasks (mostly 2D).
Is animation hard to learn?
Yes, it can be hard to learn animation without proper guidance. Animation is a of part of education where one have to use practical knowledge and talent to create great content. Animation learning becomes very simple and easy once you’re trained under good educational institutes.
Is it hard to get a job in animation?
It’s fairly hard to break into animation, but once you are in, as long as you can play nice with others, you are ‘in’. Most jobs animators get are because of referrals from other animators. If there is a posted spot, there will be a lot of competition.
Is animator a good career?
A career in animation is one of the most lucrative and most-sought-after courses these days. With attractive salaries and the personal freedom it offers, a career in animation could be the right choice for you. Both movies, video games, and other forms of media use computer animation.
Do animators get paid well?
BLS data lists the 2017 median pay for animators at $70,530 a year. Glassdoor has the national average a bit higher at $74,000. Like many other fields, compensation for animators also depends on experience: it’s not uncommon for senior-level animators or art directors to earn well into six figures.
Does animation require coding?
It is not necessary for every person working on an animation project to have coding experience. There should be someone in the team that does. These are the technical directors, who can create job-specific tools or do special rigging. The combination of artistic skills and coding ability in one person is unusual.
How do I get my first animation job?
How to find your first job in the animation industryRule No 1 – Get really good at what you do. … Rule No 2 – Have a great demo reel. … Rule No 3 – make your work easy to find. … Rule No 4 – polish your CV or resume. … Rule No 5 – do your research – find out who is hiring. … Rule No 6 – sign up for job alerts. … Rule No 7 – Start applying for jobs.More items…•
Which country is best for animation jobs?
Top 20 Cities Worldwide for Animation CareersNumberCityCountry1MadridSpain2TokyoJapan3ParisFrance4SeoulSouth Korea16 more rows•Feb 8, 2018
What is the starting salary in animation?
Pay Scale/Salary of AnimatorJob ProfileStarting Salary per annum (in INR)Mid Level Salary per annum (in INR)Background ArtistRs. 1,50,000Rs. 3,00,000Story Board ArtistRs. 3,00,000Rs. 6,00,000Character AnimatorRs. 1,50,000Rs. 3,00,000Special Effects ArtistRs. 1,50,000Rs. 3,00,0001 more row
Do animators work at home?
These professionals often work from home, contracting with film, animation or video game production studios, cartoon networks, advertising agencies, web design firms, graphic design firms, and mobile technology companies. Some self-employed animators may work in office settings.


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VOLUSIA COUNTY, Fla. –Erosion from superstorm Sandy has revealed the skeleton of the rare beaked whale.
WESH reports than a Florida couple was out looking for sand dollars when they spotted a piece of bone sticking out from an eroded dune. Upon further digging they found a huge skeleton that researchers believe has been buried for decades.
The bones were submitted to the county and will be studied for research.
In November, CNN reported that a pair of dead whales that washed ashore in New Zealand in 2010 were confirmed to be spade-toothed beaked whales, one of the rarest species in the world.
“It was a bit like finding the holy grail,” said Anton van Helden, the collection manager of marine mammals at the Museum of New Zealand Te Papa Tongarewa, told CNN.
Data on the species was so rare that it took scientists two years to positively identify the whales.
The results were stunning because only three partial specimens of the species were known to exist — two collected in New Zealand in 1872 and in the 1950s and a third found on Robinson Crusoe Island off the coast of Chile in 1986.
The spade-toothed beaked whale looks similar to a large black, white and gray dolphin with its long pointed snout. Scientists believe they grow to be about 17 feet long. Adult males have large exposed teeth as the name suggests.
“This is the species of whale that we know the least about in the world,” a scientist told CNN. “It has never been seen before, as far as we know, and for the first time we have an idea of what it looks like.”
***CNN wire contributed to this report.

domain: biology


text:
Rumours have begun to circulate about the missing Malaysia airlines flight after it emerged two men thought to have been on the flight had their passports stolen on separate occasions in Thailand.
The two Italian and Austrian men were unaware of the fraudulent activity until their names were listed as missing passengers in recent news reports.
Authorities are now investigating the possibility of foul play, including the possibility of a terror attack.
The flight en route to Beijing from Kuala Lumpur lost contact with air traffic authorities soon after take-off yesterday and has since disappeared.
Vietnamese authorities yesterday afternoon spotted two oil slicks off the southern coast country and believed to be “consistent with the kinds that would be produced by the two fuel tanks of a crashed jetliner.”
Malaysia Airlines initially reported seven Australians were on board, but the number was quickly revised to six. There were 239 passengers on board.
If worst outcome is true and all have perished, it will be the world’s worst air tragedy in a decade.
Read more here.
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Hey there, time traveller!
This article was published 14/9/2009 (2873 days ago), so information in it may no longer be current.
WINNIPEG - Greg Selinger, the former finance minister, received an endorsement from Water Stewardship Minister Christine Melnick today for the NDP leadership and pledged to use the floodway to prevent summer rains from inundating the river walkway at The Forks.
At a noon press conference, Selinger said any action to use the floodway to reduce riverbank flooding would ensure people who live upstream of the floodway would either be protected from or compensated for any floodway use that has an impact on their properties.
"Any action on floodway use must take seriously the impact on people who live upstream," he said. "We will do everything in our power to ensure they are not adversely affected by artificial flooding."
Meanwhile, Steve Ashton's campaign officials announced today that they have signed up or renewed 1,100 party memberships over the past several days and suggested the Thompson MLA is in the lead in attracting delegate support.
Further, they said Ashton could narrowly win the leadership on the first ballot.
Before the leadership race began, the provincial NDP had about 5,500 members, according to party officials. As of Sunday, the party had about 7,500 members.
Ashton campaign chairman Transcona Coun. Russ Wyatt, who turned over 250 new memberships at NDP headquarters on Portage Avenue this afternoon, said Ashton is selling memberships across the province, with most in the city of Winnipeg.
Andrew Swan, the former competitiveness minister, meanwhile, promised not to implement a harmonized sales tax (HST) for the remainder of the government’s term in office, if he is elected leader. Under new fixed election dates, the next provincial election will be held Oct. 4, 2011.
Swan also pledged Monday to increase the base rate paid to welfare recipients, which has not been adjusted since 1999. Meanwhile, living costs have gone up 21 per cent in the past decade, he said in a news release this morning.
"Our government has made progress through adjustments to the shelter allowance and other benefits but the base rate for social assistance has remained the same," he said.
On a new HST, Swan said it was not the time to burden consumers and businesses with extra taxes.
"From listening to Manitobans and seeing what other provinces have gone through in implementing this, I can’t burden consumers with more taxes, especially in times of economic uncertainty" he said in a statement.
The NDP is holding a leadership race to replace the departing Gary Doer, who will become the Canadian ambassador to the United States.


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Corporate and International Orders
Cyprea International Inc., is a local manufacturer and exporter of Philippine costume jewelry, accessories, bags, and footwear.
Costume jewelry making in the Philippines began because the demand of puka shells soared during the 1970s, and Cebu became the focal-point of that burgeoning accessory-making market. Janet Chua saw this as an opportunity, and by the early 1980s, Cyprea started making and exporting jewelry to the United States and Europe.
Paired with a league of local creative workers, they were able to capitalize on the abundance of natural resources available in their hometown Cebu, Philippines. They made use of these natural components in creating their
products; elements like bamboo, coconut, wood, and shells.
An experienced wholesale manufacturing company for 30 years, Cyprea has a significant extent of knowledge and know-how in artisan manufacturing and exporting.
They eventually evolved and further added bags, footwear, and resort apparel to their brand, which was their foray into starting their own label, Island Girl.
Do you accept custom orders?
The best we can do is personalize existing Island Girl styles for wholesale orders. However, if you wish to collaborate, please feel free to shoot us an email at firstname.lastname@example.org and we will be more than glad to entertain possible ideas on how we can work together.
Do you have special wholesale/corporate rates?
We have a tiered discount scheme for wholesale and corporate transactions depending on the total gross amount.
Is there a minimum order quantity?
No there is not, but if you are wondering, our wholesale is based on the total gross amount of the entire order.
How do we inquire?
You may get in touch with us by emailing us at email@example.com.
We will try our very best to get back to you, and answer your inquiries as soon as we can.
Can you send me a sample?
You may purchase a sample of your order from us first, to ensure its quality, and that it fulfills your desired design.
How long does it take to fulfill wholesale/corporate orders?
It usually takes us about a week to develop your “personalized” bag, following your preferred Island Girl design.
A production timeline will be provided once the design has been approved, and purchase order has been placed.
We accept wholesale and corporate orders from anywhere in the world. You may coordinate with us by send us an email at firstname.lastname@example.org.

domain: economics


text:
EXCITING NEWS!!!!! RiverLife will be joining Hmong MN Day at the State Fair on Sept 7! We'll have a booth from 9am to 6pm (in Carousel Park, outside the Grandstand, near where they sell the turkey legs) and our very own worship band will be playing at 1pm. For more info about Hmong MN Day, visit their Facebook page.
Visit our booth and get very own BLESSING ON A STICK! It's the blessing that Pastor Greg says at the end of every service. We've got 1,000 of them, and when they're gone, they're gone. So, come early and pick up yours.


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Well, that game was something else. The 49ers 13-6 win over the Seattle Seahawks was truly a tale of two halves as San Francisco made some sizable adjustments in multiple phases of the game to secure a hard-fought, much needed divisional victory. The 49ers improve to 5-2, while the Seahawks drop to 4-3. More importantly for Seattle, they are 0-3 in divisional games, and even with three divisional home games left, they can do no better than .500 in the division.
The 49ers could not have looked much worse in the first half, as they could get nothing going on offense, and the defense was getting gashed by Marshawn Lynch. Fortunately, the team figured some things out in the locker room and controlled much of the second half. Alex Smith threw an awful interception in the fourth quarter, but thankfully the 49ers defense stepped up big to prevent Seattle from doing anything with it.
The two big stars of this game have to be Frank Gore and Ted Ginn Jr. Frank Gore thoroughly dominated the Seahawks on the ground, rushing 16 times for 131 yards. He got banged up late, but Kendall Hunter provided solid enough relief work. It was incredibly frustrating seeing the 49ers go away from the run for much of the second quarter, but thankfully they realized the error of their ways in the second half.
Ginn deserves kudos, even though the 49ers only managed three points off his big punt returns. He returned three punts for 70 yards, doing a great job for a special teams unit that was looking for plays.
It wasn't a pretty win by any stretch, but the 49ers gutted it out and got a crucial home divisional win. Now they have some extra rest time to get ready for an even bigger divisional road game. The 49ers travel to Glendale to face the Arizona Cardinals in Week 8. Given how this division is shaping up, the first team to win a road division game might end up as the team to beat in the NFC West.


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• Delve into the rich layers of Jordan’s history, from the grand colonnades of Rome to the castles of the crusaders
• Marvel at the awe-inspiring stronghold of Petra, carved from rock by the Nabataeans more than 2000 years ago
• Journey through the desert landscape of western Arabia, discovering the prehistoric rock engravings of Wadi Rum
BA, BD, FSAScot
specialist in archaeology and ancient history
Depart London Heathrow 1605, arriving Amman 2320. Transfer to Amman Marriott Hotel for three nights.
Whole day excursion to Madaba for Church of St George (6th century mosaic floor map of the Holy Land and Jerusalem) and Mount Nebo for mosaic museum, Sanctuary of Moses and decorated early churches.
Whole day excursion to the Hellenistic and Roman city of Jerash in northern Jordan: early Byzantine remains, oval forum, theatres, colonnaded Roman streets and restored Precinct of Artemis.
Transfer to Petra via Dhiban (where the famous Mesha Stele was found), Wadi Mujib and the crusader town of Kerak. Four nights at Mövenpick Resort, Petra.
Visits in Petra: rock-cut tombs, Al Khazneh (the Treasury), ancient Roman remains, theatre, colonnaded street, the Great Temple and the Nabataean temple of Qasr al-Bint. Optional walk to Al Deir (rock-cut monastery with preserved tombs).
Morning: Siq al-Barid (‘Little Petra’) for well-preserved Nabataean tombs and archaeological site of Al-Beidha (Neolithic ruins dating back 9000 years). Afternoon: optional return visit to Petra for ascent to the High Place of Sacrifice.
Whole day excursion to southern Jordan into the Wadi Rum Protected Area (safari drive in 4x4s to see the prehistoric rock engravings and magnificent desert landscapes) and Nabataean temple.
Transfer to the edge of the Dead Sea for visit to Bethany (traditional baptismal site of Jesus). Overnight at Dead Sea Jordan Valley Marriott Resort & Spa.
Return to Amman by road for two nights at Amman Marriott Hotel. Afternoon: Jordan Archaeological Museum, Roman Theatre and Citadel.
Whole day excursion to the Umayyad Desert Castles of Qasr al-Kharana (8th century inscriptions), Qasr al-Hallabat (2nd century mosaics) and Azraq (oasis and headquarters of Lawrence of Arabia). Continue to Umayyad hunting lodge of Qasr Amra (remarkable frescoes).
Depart Amman 0805, arriving Heathrow 1140.
28 Mar — 7 Apr 2022
If you would like to upload your photos to our gallery click here
“…excellent value for money. Well planned, led and informative”
“Very good tour leader, Andrew Wilson, with an encyclopedic knowledge of the area”
- ACE customers on 2019 Jordan tour with Andrew Wilson
Please note that some of the walks in Petra take in long, steep and demanding gradients, and a good level of fitness is required for this tour.
Cost of £3365 includes: return airfare, group visa, accommodation based on sharing a twin or double bedded room, breakfast, nine lunches, dinner with water, excursions & admissions, gratuities.
Not included: travel insurance, double room for single use supplement £825.
Own flight reduction: £490.

domain: history


text:
Casey's Sugar House is about an injured raccoon who was found by a farmer in Stowe, Vermont. Learn about how the farmer helps Casey and about the friendship they create. This story was written to share real life events passed down from the author's mother who resided in Stowe Hollow. Great for young readers to develop their love for reading and for parents to spend quality time passing on a tradition. A wonderful story for imaginations young and old.
Sara Brunetti was born in Berlin, Vermont on March 25, 1975. Her father is Richard Herbert Crowley and mother is Lorelei Lang Frohman (both of whom still reside in Vermont). Sara's stories were created to share real life events her mother shared with her while growing up on a farm in Stowe Hollow.

domain: library


The trusted source for
healthcare information and
Mechanical Ventilation in the Emergency Department
Authors: Howard Friedland, DO, FACEP, FACOEP, Newark Beth Israel Medical Center, Osteopathic Program Director, Department of Emergency Medicine, Newark, NJ; and Dana Emery, MD, PhD, Department of Emergency Medicine, Newark Beth Israel Medical Center, Newark, NJ.
Peer Reviewers: Peter M.C. DeBlieux, MD, LSUHSC Director of Faculty and Resident Development, LSUHSC Professor of Clinical Medicine, Tulane University Professor of Clinical Surgery, New Orleans, LA; and Mohamed Y. Rady, MD, PhD, FRCS (Eng.), FRCP (U.K.), FCCM, Professor, Critical Care Medicine, Mayo Clinic College of Medicine, Consultant, Department of Critical Care Medicine, Mayo Clinic Hospital, Mayo Clinic Arizona.
Endotracheal intubation is one of the core procedures for emergency medicine. Traditionally patients who require mechanical ventilation were rushed to the intensive care units often before they were placed on a ventilator. However with the current hospital crowding problem, such patients may spend a large portion of their intensive respiratory care time in the ED. Today's emergency physicians may find themselves responsible for initiating, sustaining, and even weaning patients on mechanical ventilation. This review will assist the emergency physician in providing quality respiratory support to these critically ill patients.
Mechanical ventilation is a life-saving therapy that has become the mainstay of management for patients with acute respiratory failure. The objectives of this review will be to understand indications for mechanical ventilation, to understand the anatomy and physiology of how positive pressure ventilation helps reduce the work of breathing and restore adequate gas exchange, and to understand the basics of both non-invasive positive pressure ventilation (NIPPV) and invasive positive pressure ventilation (IPPV), including lung-protective strategies intended to reduce iatrogenic injury from mechanical ventilation. Common problems and complications will also be identified and addressed.
Since the widespread use of mechanical ventilation began in Scandinavia and the United States in the mid-1950s for the treatment of respiratory distress secondary to paralysis from poliomyelitis, the understanding of the mechanisms of gas exchange, pulmonary mechanics, and heart-lung interactions in relation to mechanical ventilation has increased tremendously. So, too, has the understanding of the complications of mechanical ventilation, which consequently has resulted in changes in recommendations regarding the way in which ventilation is delivered.
Respiratory complaints are present in 12% of emergency department (ED) visits in the United States. Asthma rates are increasing, and patients for whom the ED is their primary source of medical care often may present late during asthma exacerbations. It is thus the responsibility of every emergency physician to be familiar with management techniques involving mechanical ventilation.
—Sandra M. Schneider, MD, FACEP, Editor
Basic Pulmonary Physiology
Understanding basic pulmonary physiology is essential to understanding how to initiate mechanical ventilation; it ensures that the method of gas delivery meshes with the patient' s underlying physiology to avoid ventilator-induced lung injury.
A review of minute volume and alveolar ventilation:
Minute volume: VE = VT x f, where VT = tidal volume and f = frequency (breaths per minute). The amount of air that moves in and out of a patient' s lungs per minute is termed the minute volume (VE).
Tidal volume: VT = VA + VD, where VA = alveolar volume and VD = dead space volume. Normal anatomic dead space volume is calculated as 2.2 mL/kg of ideal body weight, and consists of the volume of the trachea and larger airways in a healthy person. In disease states, in addition to the anatomic dead space, there may be a variable amount of additional "pathologic" dead space consisting of bronchioles and alveoli that are not perfused. Calculation of alveolar minute volume accounts for dead space volume by subtracting it from tidal volume:
Alveolar minute volume: VA = (VT – VD) x f
The alveolar minute volume and the rate of CO2 production by the body determine the partial pressure of CO2 in alveoli (PACO2). Partial pressure of CO2 in systemic arterial blood (PaCO2) is accepted as being approximately the same as partial pressure of CO2 in alveoli (PACO2):
PaCO2 ~ PACO2 = k x (VCO2 / VA)
In which k = 0.863 (at 37°C at normal atmospheric pressure when saturated with water vapor), and where VCO2 = rate of CO2 production by the body (in mL/min) and VA = alveolar minute ventilation (in L/min).
A clinician must keep in mind the effects of a chosen mode of mechanical ventilation as they relate to the patient' s underlying disease state. Parameters to consider (covered in further detail below) include: peak airway pressure, mean airway pressure, tidal volume, frequency of delivered breaths, underlying lung compliance, and inspiratory/expiratory ratio.
Airway pressures during mechanical ventilation:
|Paw||= airway pressure|
|Paw-peak||= peak airway pressure|
|Paw-mean||= mean airway pressure|
|TI||= length of time over which inspiration occurs|
Peak airway pressure (Paw-peak) occurs during inspiration, and is measured in cm H2O. A Paw-peak greater than 35 cm H2O leads to alveolar over-distention and injury. In a pressure-volume curve, increases in pressure without concomitant increase in volume should thus be avoided.
Mean airway pressure (Paw-mean) corresponds to the area under the curve in a pressure over time curve, and correlates with achieved oxygen delivery. The longer the length of time over which inspiration occurs (TI), the greater the Paw-mean, and thus the higher the oxygen delivery per ventilation. In a pressure-volume curve, the area under the curve should thus be maximized. A challenge for the clinician is to avoid excessive Paw-mean while continuing to deliver adequate oxygen delivery per ventilation.
Indications for Mechanical Ventilation
Respiratory failure is a unifying characteristic of conditions that benefit from mechanical ventilation. In the patient with hypercarbic respiratory acidosis, both non-invasive positive pressure ventilation (NIPPV) and invasive positive pressure ventilation (IPPV) have utility in reducing the patient' s work of breathing and thus preventing respiratory muscle fatigue, or alternatively, speeding recovery of respiratory muscles when fatigue is already present. In the patient with hypoxic respiratory failure, both NIPPV and IPPV can help correct hypoxemia by allowing delivery of a high inspired oxygen fraction (FiO2) and reduction of shunting by maintaining flooded or collapsed alveoli open. In a patient with an unprotected or unstable airway (as may accompany a decreased level of consciousness), intubation followed by IPPV allows securing of the airway, reduction of risk of aspiration, and ability to maintain adequate alveolar ventilation.
Respiratory failure can be identified by several definitions:
Examples of hypoxemic respiratory failure include exacerbations of chronic obstructive pulmonary disease (COPD) or asthma, pneumonia, pulmonary edema, pneumothorax, pulmonary embolism, and acute respiratory distress syndrome (ARDS). Likewise, hypercapnic respiratory failure may also be found with COPD, severe asthma, pulmonary edema, ARDS, as well as in cases of drug overdose, poisoning, neuromuscular disease, or central nervous system (CNS) injury.
Indications for invasive mechanical ventilation also may be divided into emergent, urgent, delayed, and elective.1 Emergent intubation is indicated for patients that require immediate airway protection and mechanical ventilation on arrival. Urgent intubation is performed for patients with impending airway loss, increased work of breathing with worsening hypoxia and increasing hypercarbia, and/or injuries that may compromise the airway or chest. Delayed intubation is appropriate when a patient is stable enough for primary and secondary assessment, but subsequently requires mechanical ventilation due to progression of disease, inadequate improvement with treatment, or need for transport to a non-critical-care area (for instance, to undergo CT scanning).2 Elective intubation and mechanical ventilation may also prove necessary for airway protection and control during invasive procedures.
Modes of Ventilation
Modes of ventilation may be divided into non-invasive positive pressure ventilation (NIPPV) and invasive positive pressure ventilation (IPPV). NIPPV modes do not utilize an invasive artificial airway; rather, NIPPV requires an awake, alert patient who is cooperative and has an intact respiratory drive and airway. In contrast, IPPV modes utilize an invasive artificial airway such as an endotracheal tube, a nasotracheal tube, or a tracheostomy tube. Both NIPPV and IPPV strategies are discussed in detail below.
Non-Invasive Positive Pressure Ventilation (NIPPV). Over the past several years, non-invasive ventilatory strategies such as continuous positive airway pressure (CPAP) and biphasic positive airway pressure (BIPAP) have come to offer an alternative to traditional invasive ventilation, especially during early presentation of certain respiratory complaints, with greatest benefit noted for patients with COPD, acute pulmonary edema, and immunocompromise.3 Non-invasive ventilation requires an awake, alert patient who is cooperative, has an intact respiratory drive, and has a patent airway. Non-invasive modes of ventilation can provide a temporary bridge during which the patient may improve with therapy and possibly avoid intubation and invasive PPV.
Continuous Positive Airway Pressure (CPAP). CPAP is a useful NIPPV modality for treatment of hypoxemic respiratory failure; by increasing compliance, the patient' s work of breathing is decreased. The use of CPAP requires a tight-fitting mask (either nasal or facial). Starting with a pressure of 0-15 cm H2O, and increasing as tolerated to decrease FiO2 is a recommended strategy.
Biphasic Positive Airway Pressure (BIPAP). BIPAP is a combination of CPAP and positive support ventilation; its use is beneficial in the fatigued patient because BIPAP allows greater support during inspiration. Inspiration is pressure limited and can be triggered either by inspiratory effort or by a timed cycle. The use of BIPAP requires a tight-fitting facemask. Inspiratory positive airway pressure (IPAP) is usually set between 8-20 cm H2O, and expiratory positive airway pressure (EPAP) between 0-15 cm H2O. For this therapy to be effective, there must be a pressure gradient of at least 5 cm between IPAP and EPAP. IPAP should be increased gradually, as tolerated, up to 20 cm H2O, to alleviate dyspnea, decrease respiratory rate, increase tidal volume, and establish patient-ventilator synchrony.
Benefits of NIPPV include improved alveolar ventilation, and decreased work of breathing, mortality, morbidity, length of hospital stay, and need for invasive mechanical ventilation.3 Similar to noninvasive pressure support ventilation (an adjunct used with some modes of IPPV to provide positive airway pressure during inspiration), noninvasive positive airway pressure during expiration can decrease the work of breathing by partially overcoming intrinsic positive end-expiratory pressure; the result is that less patient effort is required to trigger ventilator-assisted breaths. The mortality benefit conferred by NIPPV is likely due in part to a decrease in the incidence of nosocomial infections, especially pneumonia and sepsis.4 The risks of NIPPV include possible barotrauma, pressure necrosis from an ill-fitting mask, and gastric dilatation; NIPPV does not protect against aspiration, and there is no access to the airway for suctioning.
Systematic reviews and meta-analyses of randomized trials of NIPPV have demonstrated its efficacy in treatment of COPD exacerbations.5 A consensus statement from the American Association for Respiratory Care endorses the early use of NIPPV when two or more of the following are present and no contraindications exist:6
In comparison, a systematic review of randomized trials of NIPPV in acute severe asthma exacerbations was less conclusive regarding benefits of NIPPV in this situation: the single included trial on 30 patients showed benefit with NIPPV when compared to usual medical care alone, with significant improvement in hospitalization rate, number of patients discharged from the ED, percent predicted forced expiratory volume in one minute (FEV1), forced vital capacity (FVC), peak expiratory flow rate (PEFR), and respiratory rate.7 These promising preliminary results have yet to be replicated in larger, randomized controlled trials.
Evidence of the beneficial effects of NIPPV in patients presenting with acute respiratory distress syndrome (ARDS), consisting of bilateral pulmonary infiltrates, impaired oxygenation (with PaO2/FiO2 < 200), and absence of elevated left pulmonary artery pressure or elevated pulmonary capillary wedge pressure) has recently been expanded. In a recent multi-center survey, NIPPV improved gas exchange and avoided intubation in 54% of patients presenting with ARDS, and avoidance of intubation was consequently associated with less ventilator-associated pneumonia and a lower intensive care unit mortality rate.8
Contraindications to NIPPV include cardiac or respiratory arrest, non-respiratory organ failure, severe encephalopathy (GCS < 10), severe upper gastrointestinal bleeding, hemodynamic instability or unstable cardiac arrhythmia, facial surgery or trauma or deformity, upper airway obstruction, inability to cooperate/protect the airway, inability to clear respiratory secretions, and high risk for aspiration.9 Respiratory acidosis is not a contraindication to NIPPV. In a case-control study of 64 patients with COPD and severe hypercapnic respiratory failure (mean pH 7.18) who received NIPPV, 38% never required endotracheal intubation, and those who failed NIPPV and required intubation were not harmed by the delayed intubation and prolonged acidemia.10
Both CPAP and BIPAP require careful patient observation; not all patients willingly tolerate these therapies, and of those who do, not all will improve using NIPPV modalities. Some will subsequently require intubation and IPPV. Improvements in pH and PCO2 occurring within two hours predict the eventual success of NIPPV. If stabilization or improvement has not been achieved during this period, the patient should be considered an NIPPV failure and intubation must be considered strongly. Other criteria for a failed NIPPV trial include: worsened encephalopathy or agitation, inability to clear secretions, inability to tolerate any available mask, hemodynamic instability, and worsened oxygenation.
Invasive Positive Pressure Ventilation (IPPV). For patients in respiratory failure who require emergent, urgent, delayed, or elective intubation (including patients who fail a trial of NIPPV), a variety of modes exist for the delivery of oxygen via invasive mechanical ventilation. Each of these includes three key variables: the triggering event that begins inspiration, the parameter that limits air flow, and the method of cycling that ends inspiration. In volume-cycled ventilator modes, the ventilator seeks to deliver a constant preset tidal volume; the parameter that ends inspiration is completion of delivery of that preset VT. Purely volume-cycled ventilatory modes do not, in general, take into account lung compliance. Conversely, in pressure-cycled ventilator modes, the ventilator alters gas flow to achieve a preset airway pressure over a preset inspiratory time (TI), and the targeted airway pressure is achieved with variable gas flow. The ventilator will not exceed the preset pressure limit; as a consequence, variable volume is delivered. The advantage of a pressure-cycled ventilation strategy is that it reduces alveolar over-distention and thus decreases ventilator-induced lung injury.11,12
Pressure and volume targeted ventilation obey the same principles. In pressure-targeted (pressure-controlled) ventilation, an airway pressure target and inspiratory time are preset, while flow and tidal volume become the dependent variables. In volume targeted (volume controlled) ventilation, a target volume and flow (or inspiratory time in certain ventilators) are preset, while pressure and inspiratory time (or flow in the ventilator where inspiratory time is preset) become the dependent variables. Types of invasive mechanical ventilation strategies include those that are primarily volume-controlled, those that are primarily pressure-controlled, and those that offer a combination of pressure and volume control. Common ventilator modes include:
Controlled mechanical ventilation (CMV) should be used only for apneic or paralyzed patients. The ventilator provides breaths at a set rate, regardless of patient effort. The ventilator is set to deliver either a set VT or a set pressure. This mode is rarely used anymore.
In assist control (AC) ventilation, the ventilator delivers preset tidal volume at a set minimum rate. If the patient attempts to draw a breath, the ventilator detects the attempt as a negative pressure below its sensitivity setting; it then delivers a full breath at the preset volume/pressure. Sensitivity may be pressure- or flow-triggered. Since the tidal volume is preset, the patient will receive that volume through a demand valve; the patient cannot reduce the tidal volume. AC is a common initial setting in ventilatory management of intubated patients. The only work of breathing occurs if a patient breathes above the preset respiratory rate, in which case all breaths will be patient initiated. If the patient makes inspiratory efforts at a rate below the preset respiratory rate, these breaths will be assisted and interspersed with machine-initiated breaths. A drawback that must be observed with caution with AC is that if the patient is tachypneic, the minute volume delivered can become too high. AC also covers a host of new modes such as pressure control (PC) or volume control (VC).
In intermittent mandatory ventilation (IMV), which now rarely is used, the ventilator provides breaths at a preset, time-based rate. The patient can initiate spontaneous breaths, but unlike AC, receives only a tidal volume proportional to the time and depth of the patient-initiated inspiration. The patient receives no support for non-mandatory breaths; the tidal volume is completely controlled by the patient. Mandatory breaths are delivered at the preset volume/pressure setting of the ventilator.
With synchronized intermittent mandatory ventilation (SIMV), mandatory breaths are delivered at the preset volume/pressure setting of the ventilator, but the ventilator also coordinates spontaneous and machine breaths. Pressure support is also available for the patient' s spontaneous breaths. The effect of this synchronization is to prevent delivery of a scheduled breath on top of a spontaneous breath or during exhalation. If the patient makes a spontaneous inspiratory effort during the next machine-delivered breath, the delivered breath is synchronized with the patient' s effort. If the patient makes an inspiratory effort not in synchronization with the preset machine breaths, the patient receives an unassisted breath determined by effort.
In pressure regulated volume control (PRVC), a guaranteed tidal volume is delivered using a "pressure control" waveform, meaning that the pressure target is adjusted to the least value that satisfies the targeted tidal volume minimum. In this mode, the minimum VE, the minimum frequency, and the inspiratory time per cycle are all preset. An advantage of PRVC is that the ventilator automatically adjusts to compliance changes in the patient' s lungs; it dynamically titrates the pressure needed to reach to the preset tidal volume via a decelerating inspiratory flow pattern. This characteristic of PRVC permits a guaranteed tidal volume, yet limits trauma from excessive volumes and prevents hypoventilation. A disadvantage of PRVC is that the pressure delivered is dependent on the tidal volume achieved on the previous breath; if the patient intermittently makes a significant respiratory effort, this can result in very variable tidal volumes with both high and low volumes being delivered.
Continuous positive airway pressure (CPAP) is used only for spontaneously breathing patients, and is covered in further detail above as a mode of NIPPV. CPAP may be used for non-invasive ventilation or for weaning from invasive ventilation. Continuous positive airway pressure reduces the effort of inhalation, and holds airways open during exhalation.
Pressure support ventilation (PSV) is an adjunct used with SIMV or with CPAP, and also only in spontaneously breathing patients. The pressure support is given on the patient-initiated breaths. Gas flow accompanies each inspiration to overcome the resistance of the ventilator circuit and reach the desired VT. The usual starting setting is 10 cm H2O. Support stops when the flow rate reaches 25% of maximum. Variants of pressure support, such as volume support, also exist.
Choosing Initial Ventilator Settings in IPPV
Ventilator settings that the clinician will need to select for a patient requiring IPPV include mode, rate, FiO2, volume vs. pressure control, initial VT, and initial pressure. Additionally, waveform, flow, inspiration to expiration (I:E) ratio, sensitivity to patient-triggered breaths, and positive end-expiratory pressure (PEEP) may be modified to optimize treatment in accordance with the patient' s underlying pathology.
Mode of Ventilation. The initial mode of ventilation will most often be either AC (PRVC in some centers) or SIMV; AC is the most common initial mode of ventilation. The preset rate of breath delivery (in the patient without special considerations such as severe asthma or ARDS) is most often 10-12 breaths/minute. The initial FiO2 is usually 95-100%, followed by attempts to wean to 60% to reduce oxygen toxicity. The choice of volume controlled vs. pressure-controlled ventilation may depend upon the patient' s underlying lung compliance.
Tidal Volume. Initial tidal volume for a patient without underlying lung disease is usually calculated at approximately 8-10 mL/kg of ideal body weight. In patients with severe asthma or ARDS, lung-protective ventilatory strategies have evolved that utilize a smaller VT of 6-8 mL/kg of ideal body weight, higher frequency, and permissive hypercapnea (covered further below). If using pressure support ventilation in conjunction with IMV/SIMV, the usual starting value is 10 cm H2O and may be titrated up to 30 cm H2O.
Ventilator Waveform. In selecting the ventilator waveform for optimal ventilation of a patient, consider the differences between a square waveform and a decelerating (ramp) waveform. In a square waveform, once the maximum inspiratory flow rate is achieved, a constant flow rate continues until the preset volume is delivered. The advantage of a square waveform is that it allows for a longer time of expiration (TE), and is thus better suited for patients with COPD or brain injury who can benefit from a longer TE. In contrast, in a decelerating (ramp) waveform, once the maximum inspiratory flow rate is achieved, the rate of gas delivery slows; the result is a longer inspiratory time (TI), lower peak airway pressures (Paw-peak), and higher mean airway pressures (Paw-mean). In summary, the decelerating waveform can provide higher oxygenation with less pulmonary trauma in a patient who does not require a longer TE.
Ventilator Flow Rate. In selecting the ventilator flow rate (the rate of gas delivery in L/min), a customary starting value is 60 L/min, and may range from 10-160 L/min. The advantage of a faster flow rate is that it permits a longer passive exhalation time; however, this must be tempered with the possibility of a decreased inspiratory time leading to hypoxia. Caution must be used if increasing flow rate, as increased flow leads to turbulent flow in the airways, causing increased airway pressures.
Inspiration:Expiration Ratio. In normal spontaneous breathing, the inspiration:expiration (I:E) ratio is approximately 1:4. In intubated patients, the I:E ratio is usually 1:2 to 1:4. A ratio with more inspiration time may improve oxygenation, but can lead to air trapping, elevated intrapulmonary pressures, and CO2 retention. In patients with outflow-restrictive conditions such as COPD or severe asthma, an I:E ratio with greater time allowed for expiration time is therefore beneficial. If the ventilator does not allow direct setting of TI, the I:E ratio may be indirectly set either by lowering the respiratory rate per minute or by increasing the flow rate; since TI equals tidal volume divided by flow rate, increasing the flow rate decreases TI and consequently increases TE.
Sensitivity. The sensitivity of the ventilator is the negative pressure required to trigger delivery; this value is usually set at 1-2 cm H2O. If this ventilator setting is too sensitive, an adverse consequence is that the ventilator may auto-cycle causing an artificial tachypnea. The patient may become tachypneic from unintended triggering. Conversely, if this ventilator setting is too insensitive, a high work of breathing will be required from the patient to trigger delivery of a breath. Flow-triggered breaths are available on many modern ventilators. The mechanism for triggering a breath is a decrease in the background flow generated by the ventilator. This may be set as liters per minute, or percent decrease, depending upon the ventilator manufacturer.
Positive End Expiratory Pressure (PEEP). Positive end expiratory pressure (PEEP) may be generated extrinsically by the ventilator (PEEPE), or may arise intrinsically when exhalation is incomplete (PEEPI). Intrinsic PEEP increases in the setting of airway obstruction, insufficient exhalation time, and consequent air trapping, and may cause the ventilator to be less able to sense respiratory effort by the patient. The benefit of either physiological or extrinsically generated PEEP is that it helps keep the large non-cartilaginously supported airways and the smaller alveoli open in order to prevent collapse, atelectasis, and hypoxia at the end of expiration. This triad of collapse, atelectasis, and hypoxia worsens lung compliance and is associated with ventilator-induced lung injury. PEEP can increase functional residual capacity and improve oxygenation; however, PEEP does not increase CO2 clearance. Initial PEEP ventilator settings range from 3-20 cm H2O4; it is customary to start with 5 cm H2O (sometimes described as replicating "physiological" PEEP), and increase PEEPE until hypoxia improves, with the accompanying goal of weaning to FiO2 less than 60%.
Another way to evaluate whether adequate PEEP is present is to observe the pressure–volume loops generated by the ventilator. In Figure 1,1 the lower arrow denotes inspiration while the upper arrow indicates exhalation. Note that as soon as there is delivered pressure to the airway, there is an increase in measured tidal volume. This indicates that the airways are open and do not need to be forced open by increasing the pressure in the airway; "optimal PEEP" has been achieved. In contrast, the pressure-volume loop in Figure 21 indicates inadequate PEEP. Compare the curve in Figure 2 to that in Figure 1: Note that the lower segment of this loop (denoting inspiration) is initially flat along the X-axis, indicating that there is inadequate PEEP to keep smaller airways open. Once the airway pressure is high enough to open the alveolar units, then each increase in airway pressure is matched by a corresponding increase in tidal volume.
|Figure 1. Dynamic Pressure-Volume Loop|
|The lower arrow denotes inspiration while the upper arrow indicated exhalation. Note that as soon as there is delivered pressure to the airway, there is an increase in measured tidal volume. This indicates that the airways are open and do not need to be forced open by increasing the pressure in the airway. If this latter case were true (see Figure 2), then the P-V loop would initially be flat along the X-axis. (Used with permission from Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine. 4th edition. Philadelphia: Elsevier Inc.; 2004: 146-170.)|
|Figure 2. Inadequate PEEP and the Pressure-Volume Loop|
|Compare this curve to that in Figure 1: Note that the lower segment of this loop (denoting inspiration) is initially flat along the X-axis, indicating that there is inadequate PEEP to keep smaller airways open. Once the airway pressure is high enough to open the alveolar units, then each increase in airway pressure is matched by a corresponding increase in tidal volume. (Used with permission Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine. 4th edition. Philadelphia: Elsevier Inc.;2004:146-170.)|
Be cautious regarding side effects of PEEP. Increased PEEP can cause hemodynamic compromise via increased intrathoracic pressure, decreased venous return, and thus decreased cardiac output.14 Desired levels of PEEP may not be possible because of deleterious effects of cardiac compression and collapse. Since volume depletion compounds this problem, it is essential that a patient be adequately volume resuscitated. Please see Insert for suggested settings for common conditions requiring mechanical ventilation.
Complications Associated with IPPV
Complications associated with invasive mechanical ventilation may result from the endotracheal tube or tracheostomy15; alternatively, ventilator-associated pneumonia,16,17 oxygen toxicity,18 or mechanical lung injury may occur.19-21 Specific complications from ventilator malfunction and operator error include inappropriate ventilator settings, alarm failure, accidental disconnection from the ventilator, inadequate humidification of inspired air, and over or under heating of inspired air. Detrimental effects of PPV can include decreased cardiac output secondary to increased intrathoracic pressure and decreased venous return,22,23 as well as trauma to the lungs themselves. It is essential to adequately sedate any patient undergoing mechanical ventilation in order to avoid agitation.
Types of Lung Injuries Resulting from IPPV. Barotrauma, which has been suggested to occur in 10-20% of patients on mechanical ventilation,29 refers to gross air leaks that are due to the development of an excessive pressure difference between an alveolus and its adjacent bronchovascular sheath.25,26 Barotrauma is often due to overdistention from high PEEPE or PEEPI (as mentioned above), rather than to high Paw-peak, and includes sequelae such as pneumothorax, pneumomediastinum, subcutaneous emphysema, and pneumoperitoneum. Pneumoperitoneum has been observed in 4% of patients receiving high PEEP.27 The detrimental consequences of mechanical ventilation on cardiac output are more pronounced in the setting of concurrent hypovolemia and/or decreased vascular tone (as seen, for instance, with sepsis or neurogenic shock).
Volutrauma refers to a more subtle type of lung injury that can occur secondary to pulmonary over-distention induced by mechanical ventilation; the critical variable for injury is not the airway pressure itself, but rather the volume that results in excessive end-inspiratory lung stretch.28-32 Excessive inspiratory lung stretch can lead to development of pulmonary edema, diffuse alveolar damage, and increased epithelial and microvascular permeability.33-35 Pressure-volume loops are also useful in identifying alveolar overdistention. In Figure 3,1 increases in airway pressure without accompanying increases in measured tidal volume lead to a plateau of the P-V curve, known as the "bird's beak" profile. This profile is a reasonable indicator of alveolar overdistension and airway injury.
|Figure 3. Alveolar Overdistention|
|Alveolar overdistention is reflected in this pressure-volume curve in which there is an increase in airway pressure at the end of inspiration without any concomitant increase in tidal volume. This pressure-volume curve pattern approximates a "bird's beak" profile, which is a reasonable indicator of airway injury. (Used with permission from Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine. 4th edition. Philadelphia: Elsevier Inc.; 2004: 146-170.)|
Atelectrauma refers to the damage that can occur when lungs are allowed to become atalectatic and then are re-expanded. Collapse and re-expansion of alveoli has been shown to be a critical factor causing injury.31,36 Ventilator (or volume)-induced lung injury (VILI) involves damage to lung parenchyma. High inflation pressures place patients at risk for VILI; patients especially at risk include those with poor lung compliance who require higher pressures to ventilate (for example, patients with pulmonary edema, obstructive pulmonary disease, or ARDS). Overdistention of alveoli causes injury and release of cytokines, chemokines, and activation of endothelial factors, which combine to cause an inflammatory cascade called biotrauma.19,37
While the additional inflammatory response and lung injury that results from mechanical ventilation of injured lungs leads to an increase in lung cytokines, under conditions in which there is increased lung permeability, these cytokines may translocate from the alveolar space to the systemic circulation.38 Cytokines produced during lung injury include tumor necrosis factor (TNF), a key mediator in the systemic inflammatory response syndrome that may play a role in multi-organ failure. Release of cytokines and/or inflammatory mediators into the systemic circulation may be a mechanism by which mechanical ventilation might effect systemic consequences and lead to the development of end-organ failure.39,40 In a randomized controlled trial in ARDS patients ventilated with either a conventional ventilatory strategy (tidal volume of 10-12 mL/kg, PEEP set at lowest value to maintain adequate oxygenation) or a protective strategy designed to minimize lung stress, there was a significant decrease in lavage and serum cytokines in the ventilator group treated with the protective strategy.41 The concept of biotrauma may be the missing link that explains why most patients who die with ARDS succumb not because their lungs fail, but because of the development of multiple organ dysfunction syndrome.39,42
Lung-Protective Ventilation in ARDS. How can ventilator-induced lung injury be reduced? The ARDS (Acute Respiratory Distress Syndrome) Network compared a more conventional VT of 12 mL/kg with a plateau airway pressure limit of 50 cm H20 with a "lung protective" strategy of a VT of 6 mL/kg and a plateau airway pressure limit of 30 cm H2O, with the option to use a VT as low as 4 mL/kg and give NaHCO3 for acidosis. In the ARDS Network study, the lung-protective strategy resulted in a 22% reduction in mortality and 20% fewer days requiring ventilation, and the study was stopped early to extend these benefits.42 The current lung-protective ventilatory strategy in treatment of patients with ARDS incorporates a low VT, an increased respiratory rate, limiting the plateau airway pressure to 30 cm H2O, permissive hypercapnea, PEEP, and decreased I:E ratio.
The use of PEEP in patients with ARDS can help achieve adequate hemoglobin saturation and decrease the requirement for a high FiO2. In this setting, the application of PEEP results in an increase in functional residual capacity (also referred to as "recruitment" of alveoli), which decreases intrapulmonary shunting of blood through regions with collapsed alveoli and improves ventilation/perfusion matching.43 The degree of PEEP-induced alveolar recruitment further correlates with improvement in PaO2.44 Although applied PEEP is beneficial to oxygenation, a higher PEEP strategy has not yet been shown to confer additional reduction in mortality when ventilation with low tidal volumes (6 mL/kg ideal body weight) is used in unselected ARDS patients.45
Lung-Protective Ventilation in Obstructive Airway Disease. Patients with obstructive airway disease experience air trapping and hyperinflation of lungs, which leads to both elevated peak and elevated plateau airway pressures, and places these patients at high risk for VILI. The current improved ventilatory strategy employed in treating such patients also incorporates a low VT, but is different than the strategy used for ARDS in that patients with obstructive airway disease require a low respiratory rate and high flow rate to maximally increase their expiratory time.46,47 This strategy of permissive hypercapnea/controlled hypoventilation with resultant acidosis is thought to be safer than experiencing the high airway pressures noted during conventional ventilation of patients with obstructive airway disease.48 Controlled hypoventilation becomes even more important for an intubated asthmatic patient than a patient with COPD, as asthmatic patients who require intubation already have relatively high long-term mortality rates.49,50 Also essential for continued treatment of this type of respiratory failure are continued in-line administration of bronchodilators via a large diameter oral endotracheal tube,51 and adequate sedation and paralysis, as agitation/discomfort from ventilation on awake patients can lead to tachypnea, overbreathing, and dyssynchrony with the ventilator.
Permissive Hypercapnea Strategy. Acute hypercapnia can lead to severe acidemia and neurological dysfunction. However, when carbon dioxide levels are allowed to increase gradually, the resulting acidosis is less severe because of renal buffering, and the elevation in arterial PCO2 is generally well tolerated. The use of supplemental oxygen and PEEP during a permissive hypercapnic ventilation strategy allows for substantial reduction of minute ventilation without jeopardizing oxygenation.52 Furthermore, hypercapnic acidosis shifts the oxyhemoglobin curve to the right, promoting oxygen release at the tissue level. Negative systemic effects of permissive hypercapnic ventilation strategies include cerebral vascular dilatation (which can increase ICP), and lowering of the seizure threshold. Therefore, permissive hypercapnic ventilation is considered to be contraindicated in patients with cerebrovascular disease and in those with a seizure disorder because of its effects on cerebrovascular tone and seizure threshold.52
In evaluation of permissive hypercapnea as a strategy for invasive ventilatory management of obstructive airway disease, it was found that although patients tolerate a pH as low as 7.25, a pH less than 7.2 requires treatment.52,53 Treatment may be attempted by increasing the respiratory rate. If this is not feasible, treat with NaHCO3 (150 mEq/L of IV fluid).
Effective IPPV requires a number of related systems to all be functioning properly. In troubleshooting the patient on IPPV, it is important to systematically review these systems to determine the cause of an apparent malfunction. The first system is the delivery of utilities to the ventilator itself. This includes electricity for the ventilator, oxygen, and possibly air to drive the ventilator. The next system is the ventilator itself. After the ventilator is the tubing circuit connecting the ventilator to the patient. The next step is the artificial airway allowing access to the patient' s trachea. This is usually an endotracheal tube, but could be a tracheostomy tube as well. The final step is the patients' airway itself, staring from the trachea to mainstem bronchus, left and right bronchi and then to smaller airways.
Each breath requires oxygen to flow from the wall outlet through tubing to the ventilator. The ventilator then will deliver the appropriate volume or pressure over time through the circuit to the endotracheal tube, and ultimately in the patient' s trachea and then smaller airways. Malfunctions can occur at any step along the way, and may include a problem in more than one system.
The initial evaluation and management of a ventilated patient who appears to be in respiratory distress should include a rapid assessment of appearance, vital signs (including pulse oximetry), cardiac rhythm, the patency of the ventilator circuit connections, and the position and condition of the artificial airway, including a check for air leaking from the nose or mouth. If these actions do not identify the cause of patient distress, a chest x-ray, arterial blood gas, and electrocardiogram should be obtained. A chest x-ray is central to the evaluation of respiratory distress in ventilated patients; important findings include the position of the endotracheal tube as well as signs of pneumonia, pulmonary edema, pneumothorax, pleural effusion, or atelectasis. A tension pneumothorax may be treated presumptively prior to obtaining a chest x-ray by needle decompression followed by placement of a thoracostomy tube.
When confronted with the patient with sudden respiratory distress or change in status, the issue may be a ventilator problem or a patient-centered problem. If the issue is a ventilator problem, the patient' s ventilatory status will likely be improved by removal from the ventilator and manual ventilation with 100% oxygen while improper settings and/or leaks are sought and corrected. Any patients who appear unstable should be removed from the ventilator and bagged with 100% oxygen.
If the issue is a patient-centered problem, respiratory distress in mechanically ventilated patients can be classified anatomically as originating in the airway, the pulmonary parenchyma, or outside the lungs. Common causes include endotracheal tube obstruction, heart failure, pneumonia, patient-ventilator asynchrony due to inadequate sedation, and compression of the lungs by pleural fluid or ascites.
Problems related to the endotracheal tube include obstruction (by secretions, blood, kinking, a foreign body, or by the patient biting upon the tube), migration of the ETT, and ETT cuff malfunction. In-line suctioning, administration of bronchodilators, and repositioning and/or replacement of the ETT can alleviate many of these issues. Problems related to the pulmonary parenchyma and vasculature include atelectasis, pneumonia, aspiration of oropharyngeal or gastric contents, pulmonary edema, and pulmonary emboli; these conditions can all cause respiratory distress in patients undergoing mechanical ventilation. With the exception of acute pulmonary embolism, these conditions can usually be differentiated by physical examination and plain chest radiography. Pulmonary embolism is difficult to diagnose. Although CT scans and angiograms are diagnostic, they require transportation that may be difficult in severely ill patients.
If a ventilator system continues to alarm and the patient does not appear to be receiving its intended benefit, take the patient off the ventilator and use manual bag-valve-ETT ventilation. Bagging the patient allows you to feel the compliance of their lungs. A patient that was easy to bag earlier but now is difficult indicates the problem is with either the airway or intrinsic to the patient. If the patient bags easily and oxygenates well, there is a problem with the ventilator and associated tubing, or with the ventilator settings. The ventilator and tubing should be checked. Any problems found should be corrected. If the system is functioning properly, the ventilator settings should be adjusted or the patient may require additional sedation to improve synchrony with the ventilator.
If the patient is difficult to bag, evaluate the patient for pneumothorax. Consider needle thoracostomy if unilaterally decreased breath sounds are noted. Another possibility for difficulty ventilating is high levels of auto-PEEP. This can be improved by disconnecting the patient' s endotracheal tube and allowing a prolonged exhalation. If the patient is easy to bag after a pause, resume ventilation and adjust the ventilator.
In the stable patient, examine the patient and the ventilatory system. Has the ETT become dislodged? Has there been an accidental disconnection within the system? Is the oxygen attached and on? If the patient becomes hypotensive during ventilation, consider causes and corrective actions. Is the hypotension due to decreased preload, to dynamic hyperinflation, to tension pneumothorax, to pulmonary embolism?
Problems outside the lungs can cause respiratory distress by restricting inspiration or increasing respiratory drive. Thoracic processes that cause restriction include pneumothorax and large pleural effusions. Abdominal problems, such as ascites, ileus, or splinting from abdominal pain, may limit chest wall expansion and lower the compliance of the respiratory system.54 Fever, shock, pain, delirium, and anxiety can all increase respiratory drive and cause apparent respiratory distress and agitation without a change in respiratory mechanics or gas exchange. These are diagnoses of exclusion, however, and life-threatening disorders must always be considered before administering sedatives and analgesics.
Proximal airway pressure waveforms can be useful in identifying the cause of an acute deterioration in respiratory status in a patient receiving IPPV.55 If the peak pressure is increased but the plateau pressure is unchanged, the problem is an increase in airway resistance: consider the presence of obstruction of the tracheal tube or smaller airways by secretions or bronchospasm. If the peak and plateau pressures are both increased, the problem is a decrease in distensibility of the lungs and chest wall: consider the possibility of pneumothorax, lobar atelectasis, acute pulmonary edema, worsening pneumonia or ARDS, increased abdominal pressure, or development of auto-PEEP. If the peak pressure is decreased, the problem many be a systemic air leak: consider manually ventilating the patient and listening for a cuff leak. A flow diagram in Figure 4 shows how changes in peak and plateau pressures can provide a qualitative assessment of lung mechanics at the bedside of a patient receiving IPPV.
Lower than expected airway pressures would indicate a likely leak in the system, allowing air to escape. This could be a true leak in the tubing, or a cap off of one of the ports on the tubing. Significant leaking around the endotracheal tube can also cause this. In general the patient' s inspired and expired minute volumes should be equal in a closed system, such as a ventilator. Unequal volumes indicate a leak in the system. One common benign cause of unequal volumes is the use of nebulized bronchodilators. Since the nebulizer is attached to the tubing, the extra volume is noted on the expired minute volume. But, since the volume was not delivered by the ventilator itself, it is not noted on the inspired volume reported on the ventilator. This will cause a high expired minute volume alarm on most ventilators, but not indicate a true malfunction in the system.
An emergency physician will see and treat many patients with acute respiratory failure; not all of these will require intubation initially, but emergency physicians must be prepared to manage mechanical ventilation of any patient in respiratory distress who does not improve. NIPPV has become the first-line treatment in an attempt to reverse acute respiratory failure in patient populations with COPD, acute pulmonary edema, or immunocompromise. For patients who do undergo intubation and IPPV, whether performed emergently, urgently, delayed, or electively, lung-protective strategies should be incorporated that reduce risk of iatrogenic injury to the patient' s lungs from IPPV; namely, lower tidal volumes, judicious tailoring of respiratory rate to the patient' s underlying pulmonary condition, careful monitoring to avoid damaging PEEP levels, and permissive hypercapnia.
1. Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine. 4th edition. Philadelphia: Elsevier Inc.; 2004: 146-170.
2. Venkataranam ST, Orr RA. Intra-hospital transport of critically ill patients. Crit Care Clin 1992; 8:525-531.
3. Liesching T, Kwok H, Hill NS. Acute applications of noninvasive positive pressure ventilation. Chest 2003;124:699-713.
4. Girou E, Brun-Buisson C, Taille S, et al. Secular trends in nosocomial infections and mortality associated with noninvasive ventilation in patients with exacerbation of COPD and pulmonary edema. JAMA 2003;290:2985-2991.
5. Ram FS, Picot J, Lightowler J, Wedzicha JA. Non-invasive positive pressure ventilation for treatment of respiratory failure due to exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2004; CD004104.
6. Bach JR, Brougher P, Hess DR, et al. Consensus Conference IV Noninvasive positive pressure ventilation. Respir Care 1997;42:364-449.
7. Ram FS, Wellington S, Rowe BH, et al. Non-invasive positive pressure ventilation for treatment of respiratory failure due to severe acute exacerbations of asthma. Cochrane Database Syst Rev 2005; CD004360.
8. Antonelli M, Conti G, Esquinas A, et al. A multiple-center survey on the use in clinical practice of noninvasive ventilation as a first-line intervention for acute respiratory distress syndrome. Crit Care Med 2007;35:388-390.
9. International Consensus Conference In Intensive Care Medicine. Noninvasive positive pressure ventilation in acute respiratory failure. Am J Respir Crit Care Med 2001;163:283-291.
10. Squadrone E, Frigerio P, Fogliati C, et al. Noninvasive vs invasive ventilation in COPD patients with severe acute respiratory failure deemed to required ventilatory assistance. Intensive Care Med 2004;30:1303-1310.
11. Wang SH, Wei TS. The outcome of early pressure-controlled inverse ratio ventilation on patients with severe respiratory distress syndrome in surgical intensive care unit. Am J Surg 2002;183:151-155.
12. Pinhu L, Whitehead T, Evans T, et al. Ventilator-associated lung injury. Lancet 2003;361:332-340.
13. Broussarsar M, Thierry G Jaber S, et al. Relationship between ventilatory settings and barotrauma in the acute respiratory distress syndrome. Intensive Care Med 2002;28:406-413.
14. Kirby RR, Perry JC, Calderwood HW, et al. Cardiorespiratory effects of high positive end-expiratory pressure. Anesthesiology 1975;43:533-539.
15. Kollef MH, Ahrens TS, Shannon W. Clinical predictors and outcomes for patients requiring tracheostomy in the intensive care unit. Crit Care Med 1999;27:1714-1720.
16. Cunnion KM, Weber DJ, Broadhead WE, et al. Risk factors for nosocomial pneumonia: Comparing adult crucial-care populations. Am J Respir Crit Care Med 1996;153:158-162.
17. American Thoracic Society: Hospital acquired pneumonia in adults: Diagnosis, assessment of severity, initial antimicrobial therapy, and preventative strategies. Am J Respir Crit Care Med 1996;153:1711-1725.
18. Thiel M, Chouker A, Ohta A, et al. Oxygenation inhibits the physiological tissue-protecting mechanism and thereby exacerbates acute inflammatory lung injury. PLoS Biology 2005; 3:e174.
19. Tremblay NJ, Slutsky AS. Ventilator-induced injury: from barotraumas to biotrauma. Proc Assoc Am Physicians 1998;110:482-488.
20. Plotz FB, Slutsky AS, Van Vught AJ, et al. Ventilator-induced lung injury and multiple system organ failure: a critical review of facts and hypotheses. Intensive Care Med 2004;30:1865-1872.
21. Lionetti V, Recchia FA, Ranieri MV. Overview of ventilator-induced lung injury mechanisms. Curr Opin Crit Care 2005;11:82-86.
22. Tittley JG, Fremes SE, Weisel RD et al. Hemodynamic and myocardial metabolic consequences of PEEP. Chest 1985;88:496-502.
23. Biondi JW, Schulman DS, Soufer R, et al. The effect of incremental positive end-expiratory pressure on right ventricular hemodynamics and ejection fraction. Anesthesia and Analgesia 1988;67:144-151.
24. Gammon RB, Shin MS, Buchalter SE. Pulmonary barotraumas in mechanical ventilation. Patterns and risk factors. Chest 1992;102:568-572.
25. Rouby JJ, Lherm T, Martin De Lassale E, et al. Histologic aspects of pulmonary barotraumas in critically ill patients with acute respiratory failure. Intensive Care Med 1993;19:383-389.
26. Pierson DJ. Alveolar rupture during mechanical ventilation: Role of PEEP, peak airway pressure, and distending volume. Respir Care 1988:33:472.
27. Beilin B, Shulman DL, Weiss AT, et al. Pneumoperitoneum as the presenting sign of pulmonary barotraumas during artificial ventilation. Intensive Care Med 1986;12:49-51.
28. Dreyfuss D, Saumon G. Barotrauma is volutrauma, but which volume is the one responsible? Intensive Care Med 1992;18:139-141.
29. Dreyfuss D, Saumon G. Role of tidal volume, FRC, and end-inspiratory volume in the development of pulmonary edema following mechanical ventilation. Am Rev Respir Dis 1993;148:1194-1203.
30. Dreyfuss D, Saumon G. Ventilator-induced lung injury: Lessons from experimental studies. Am J Respir Crit Care Med 1998;157:294-323.
31. Slutsky AS. Lung injury caused by mechanical ventilation. Chest 1999;116:9S-15S.
32. Vlahakis NE, Hubmayr RD. Cellular stress failure in ventilator-injured lungs. Am J Respir Crit Care Med 2005;171:1328-1342.
33. Webb HH, Tierney DF. Experimental pulmonary edema due to intermittent positive pressure ventilation with high inflation pressures. Protection by positive end-expiratory pressure. Am Rev Respir Dis 1974;110:556-565.
34. Parker JC, Hernandez LA, Longenecker GL, et al. Lung edema caused by high peak inspiratory pressures in dogs. Role of increased microvascular filtration pressure and permeability. Am Rev Respir Dis 1990;142:321-328.
35. Parker JC, Hernandez LA, Peevy KJ. Mechanisms of ventilator-induced lung injury. Crit Care Med 1993;21:131-143.
36. Chu EK, Whitehead T, Slutsky AS. Effects of cyclic opening and closing at low- and high-volume ventilation on bronchoalveolar lavage cytokines. Crit Care Med 2004;32:168-174.
37. Belperio JA, Keane MP, Lynch JP 3rd, et al. The role of cytokines during the pathogenesis of ventilator-associated and ventilator-induced lung injury. Semin Respir Crit Care Med 2006;27:350-364.
38. Tutor JD, Mason CM, Dobard E, et al. Loss of compartmentalization of alveolar tumor necrosis factor after lung injury. Am J Respir Crit Care Med 1994;149:1107-1111.
39. Slutsky AS, Tremblay LN. Multiple system organ failure. Is mechanical ventilation a contributing factor? Am J Respir Crit Care Med 1998;157:1721-1725.
40. Borrelli E, Roux-Lombard P, Grau GE, et al. Plasma concentrations of cytokines, their soluble receptors, and antioxidant vitamins can predict the development of multiple organ failure in patients at risk. Crit Care Med 1996;24:392-397.
41. Ranieri VM, Suter PM, Totorella C, et al. Effect of mechanical ventilation on inflammatory mediators in patients with acute respiratory distress syndrome. JAMA 1999;282:54-61.
42. The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 2000;342:1301-1308.
43. Gattinoni L, Pelosi P, Crotti S, Valenza F. Effects of positive end-expiratory pressure on regional distribution of tidal volume and recruitment in adult respiratory distress syndrome. Am J Respir Crit Care Med 1995;151:1807-1814.
44. Malbouisson LM, Muller JC, Constantin JM, et al. Computed tomography assessment of positive end-expiratory pressure-induced alveolar recruitment in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med 2001;163:1444-1450.
45. Brower RB, Lanken PN, MacIntyre N, et al. Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome. N Engl J Med 2004;351:327-336.
46. Connors AF Jr, McCaffree DR, Gray BA. Effect of inspiratory flow rate on gas exchange during mechanical ventilation. Am Rev Respir Dis 1981;124:537-543.
47. Laghi F, Segal J, Choe WK, et al. Effect of imposed inflation time on respiratory frequency and hyperinflation in patient with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2001;163:1365-1370.
48. Tuxen DV. Permissive hypercapnic ventilation. Am J Respir Crit Care Med 1994;150:870-874
49. Darioli R, Perret C. Mechanical controlled hypoventilation in status asthmaticus. Am Rev Respir Dis 1984;129:385-387.
50. Marquette CH, Saulnier F, Leroy O, et al. Long-term prognosis of near-fatal asthma. A 6-year follow-up study of 145 asthmatic patients who underwent mechanical ventilation for a near-fatal attack of asthma. Am Rev Respir Dis 1992;146:76-81.
51. Rodrigo G, Rodrigo C. Assessment of the patient with acute asthma in the emergency department: A factor analytic study. Chest 1993;104:1325-1328.
52. Feihl F, Perret C. Permissive hypercapnia: How permissive should we be? Am J Respir Crit Care Med 1994;150:1722-1737.
53. Bidani A, Tzouanakis AE, Cardenas VJ, et al. Permissive hypercapnia in acute respiratory failure. JAMA 1994;272:957-962.
54. Gilroy RJ Jr, Lavietes MH, Loring SH, et al. Respiratory mechanical effects of abdominal distension. J Appl Physiol 1985;58:1997-2003.
55. Marino PL. The ICU Book. 2nd edition. Baltimore: Lippincott Williams & Wilkins; 1997: 428-430.


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It can really feel awkward to go over STD screening, yet it is essential. Speaking about obtaining checked shows you appreciate your partner and also can even make you more detailed What Does Std Testing Include
Should I Obtain Examined For Sexually Transmitted Diseases? What Does Std Testing Include
The majority of the moment, Sexually transmitted diseases have no signs and symptoms. Checking is the only way to recognize for sure if you have a STD. So if you’ve had any type of sort of sex-related get in touch with that can spread out STDs like vaginal, rectal, or foreplay talk with a doctor or registered nurse concerning obtaining tested.
The Relevance of Routine STD Checking
Did you recognize that people can send over 25 various conditions via sex? With that several conditions, it’s critical to guarantee that you are regularly examining for Sexually transmitted diseases. Nevertheless, around 50% of sexually energetic individuals will certainly get a Sexually Transmitted Disease by the age of 25, as well as STDs among older adults get on the increase also. If you are nervous or uncertain of just how to start, right here’s a summary of what you need to learn about Sexually Transmitted Disease screening.
How Does Sexually Transmitted Disease Evaluating Work?
The type of diagnostic testing relies on the STD in question. For some Sexually transmitted diseases, such as gonorrhea, a pee sample is all that experts need. Meanwhile, for various other STDs, such as HIV and also syphilis, they could call for a blood sample. Particular STDs call for a physical exam or a swabbing of your genital areas for identification. A trusted medical care center or urgent care facility will help you really feel secure as well as comfortable during any type of testing. What Does Std Testing Include
At-home STI Testing
At-home examination kits for certain STIs, such as HIV, chlamydia and gonorrhea, have actually been gaining acceptance and appeal. For residence STI testing, you accumulate an urine example or an oral or genital swab and then send it to a lab for analysis.
Some examinations call for more than one sample. The advantage of house screening is that you have the ability to gather the sample in the privacy of your home without the need for a pelvic exam or workplace go to.
However, examines done on examples you accumulate yourself might have a greater rate of false-positive results, meaning that the examination suggests you have an STI that you truly don’t have. If you test positive from a home test, contact your physician or a public health center to verify the test results. If your house test outcomes are adverse, however you’re experiencing signs, contact your physician or a public health clinic to verify the outcomes.
Sexually Transmitted Disease Testing: What’s Right For You? What Does Std Testing Include
Sexually transmitted diseases are common, however the kinds of Sexually Transmitted Disease testing you need may vary by your danger elements. Find out what’s recommended for you.
If you’re sexually active, especially with multiple partners, you’ve probably listened to the adhering to advice sometimes: Make use of defense and get checked.
This is important since an individual can have a sexually transmitted disease (STD) without recognizing it. In a lot of cases, there aren’t any kind of signs or signs and symptoms. As a matter of fact, that’s why many professionals prefer the term sexually transferred infections (STIs) due to the fact that you can have an infection without illness symptoms.
However what kinds of STI testing do you require? As well as exactly how often should you be evaluated? The answers depend on your age, your sexual behaviors as well as various other danger aspects. What Does Std Testing Include
Do not presume that you’re obtaining STI screening whenever you have a gynecologic exam or Pap test. If you believe that you require STI screening, request it from your doctor. Speak to your doctor concerning your issues and what tests you ‘d like or require.
Sexually Transmitted Disease Tests Can Stop Long-Term Wellness Issues
While Sexually Transmitted Disease testing will not avoid you from getting a disease, it will help you prevent complications related to Sexually transmitted diseases, along with maintain you from spreading it to future sexual partners. Neglected Sexually transmitted diseases can have serious health and wellness repercussions, and sometimes waiting too long to get checked means that the damage from the untreated infection might currently be irreversible. Some health and wellness issues that could be dealt with by without treatment STDs consist of infertility, pelvic inflammatory condition, cervical cancer cells, liver illness or liver failing, and also heart and also capillary damage. For females that are expecting, an untreated STD causes a higher risk for ectopic maternities, miscarriages, and also premature delivery, together with the possibility of passing the Sexually Transmitted Disease to their child.
I Assume I Have Symptoms Of A Sexually Transmitted Disease. Should I Get Evaluated?
If you’ve had sexual contact with an additional individual as well as discover any indications of a Sexually Transmitted Disease, talk to a doctor or nurse regarding getting checked. STD signs and symptoms can come and go gradually, however that doesn’t mean the Sexually Transmitted Disease is gone. It prevails for STD signs and symptoms to be so light that they never mind you, but you need to still see a doctor or nurse if you see anything that feels off.
Different STDs Have Various Symptoms. Signs Of STDs Include:
Sores or bumps on and around your genital areas, thighs, or butt cheeks weird discharge from your vagina or penis burning when you pee and/or needing to pee a lot irritation, pain, irritation and/or swelling in your penis, vagina, vulva, or rectum flu-like signs like fever, body pains, inflamed glands, and sensation tired. What Does Std Testing Include
All of these symptoms can be triggered by points that aren’t STDs (like pimples, UTIs, or yeast infections ). So obtaining examined is the only means to recognize without a doubt what’s taking place. Your nurse or medical professional will aid you find out what type of screening or therapy you may need. Tell them about:
Your signs and symptoms What sort of sex-related call you’ve had (like genital, rectal, or foreplay, or anything that includes skin-to-skin genital contact or passing sexual liquids) Whether you make use of prophylactic and/or dental dams.
It’s truly crucial to get checked if you assume you have a Sexually Transmitted Disease, because some STDs can trigger severe health issue if you do not treat them. Additionally, having a STD makes you more probable to get various other STDs, like HIV. And also it’s ideal to learn immediately if you have a Sexually Transmitted Disease, so you can avoid giving it to other people.
The suggestion of getting tested may seem frightening, yet attempt to chill out. Most typical Sexually transmitted diseases can be easily treated with medicine. And Sexually transmitted diseases that can not be healed usually have treatments to assist you with signs and also to decrease your chances of providing the Sexually Transmitted Disease to anybody else. So the earlier you understand you have a STD, the quicker you can start dealing with yourself as well as your companion( s).
Testing for All Sexually Transmitted Diseases Might Not Be Essential
If the thought of going through a battery of Sexually Transmitted Disease tests to make sure you’re clear of each and every single Sexually Transmitted Disease seems like way too much to bear, it may be comforting to comprehend that not every single examination may be required. Relying on your way of life you are likely to be more vulnerable to some infections than others, as well as a chat with your healthcare provider can assist pinpoint your threats much more very closely.
When you comprehend your personal danger factor, you can then be checked for that particular STD. What Does Std Testing Include
Sexually active people. Everyone should be screened for HIV eventually, with ladies additionally testing for gonorrhea and chlamydia, as they are more likely than men to have infection without signs. Those in monogamous connections that exercise safe sex can be checked less often.
People Having Unprotected Sex
It’s smart to get STD examinations before you start having sex with a brand-new companion if you don’t intend to make use of a prophylactic. If you assume you might already have been exposed, here are the size s of time after direct exposure when you can get a reputable test:
2 weeks for gonorrhea as well as chlamydia
In between one week as well as 3 months for syphilis
In between six weeks and three months for liver disease C and also B, or HIV
These include those with several sex companions, or who make love with sex employees. These groups go to high threat of HIV infection or liver disease C, gonorrhea, chlamydia or syphilis. This includes all types of sex: dental, rectal or vaginal. What Does Std Testing Include
Child boomers. If you were born in between 1945 and 1965, there is a higher threat of hepatitis C that can cause severe liver conditions and cancer cells. Prior to these dates, there was no knowledge of the virus and absolutely no tests for it.
If the anxiety of getting a positive examination outcome and diagnosis is holding you back, it can aid to remind on your own that obtaining checked is essential for your very own wellness and that of your partner.
Many Sexually transmitted diseases are treatable, as well as the faster you’re examined the earlier you can get ideal therapy.