No abstract

Humidification of inhaled gases has been standard of care in mechanical ventilation for a long period of time. More than a century ago, a variety of reports described important airway damage by applying dry gases during artificial ventilation. Consequently, respiratory care providers have been utilizing external humidifiers to compensate for the lack of natural humidification mechanisms when the upper airway is bypassed. Particularly, active and passive humidification devices have rapidly evolved. Sophisticated systems composed of reservoirs, wires, heating devices, and other elements have become part of our usual armamentarium in the intensive care unit. Therefore, basic knowledge of the mechanisms of action of each of these devices, as well as their advantages and disadvantages, becomes a necessity for the respiratory care and intensive care practitioner. In this paper, we review current methods of airway humidification during invasive mechanical ventilation of adult patients. We describe a variety of devices and describe the eventual applications according to specific clinical conditions.

The current and projected deficit in the physician workforce in the US is a challenge for primary care and specialty medical settings. Foreign medical graduates (FMGs) represent an important component of the US graduate medical education (GME) training pathway and can help to address the US physician workforce deficit. Availability of FMGs is particularly important to the internal medicine community, as recent data demonstrate that internal medicine is the specialty with the highest number of FMGs. System-based and logistical inefficiencies in the current US visa system represent significant obstacles to FMG trainees and have important psychological, emotional, and logistical consequences to FMG engagement and participation in US GME training and in the posttraining workforce. In this article, we review the contemporary structure, process, and challenges of obtaining a visa for GME training. The H1B and J1 visa programs are compared and contrasted, with an emphasis on logistical specifics for FMG GME trainees and training programs. The process of and options for J1 visa waivers are reviewed. These considerations are specifically reviewed in the context of recent policy decisions by the Trump administration, with emphasis on the effects of these decisions on FMGs in medical training and practice.

IntroductionDue to hospital crowding, mechanically ventilated patients are increasingly spending hours boarding in emergency departments (ED) before intensive care unit (ICU) admission. This study aims to evaluate the association between time ventilated in the ED and in-hospital mortality, duration of mechanical ventilation, ICU and hospital length of stay (LOS).MethodsThis was a multi-center, prospective, observational study of patients ventilated in the ED, conducted at three academic Level I Trauma Centers from July 2011 to March 2013. All consecutive adult patients on invasive mechanical ventilation were eligible for enrollment. We performed a Cox regression to assess for a mortality effect for mechanically ventilated patients with each hour of increasing LOS in the ED and multivariable regression analyses to assess for independently significant contributors to in-hospital mortality. Our primary outcome was in-hospital mortality, with secondary outcomes of ventilator days, ICU LOS and hospital LOS. We further commented on use of lung protective ventilation and frequency of ventilator changes made in this cohort.ResultsWe enrolled 535 patients, of whom 525 met all inclusion criteria. Altered mental status without respiratory pathology was the most common reason for intubation, followed by trauma and respiratory failure. Using iterated Cox regression, a mortality effect occurred at ED time of mechanical ventilation > 7 hours, and the longer ED stay was also associated with a longer total duration of intubation. However, adjusted multivariable regression analysis demonstrated only older age and admission to the neurosciences ICU as independently associated with increased mortality. Of interest, only 23.8% of patients ventilated in the ED for over seven hours had changes made to their ventilator.ConclusionIn a prospective observational study of patients mechanically ventilated in the ED, there was a significant mortality benefit to expedited transfer of patients into an appropriate ICU setting.