to opioid reduction. 9 A service that likely has substantial harms for some, and small benefit for few under the most generous assumptions, should be held to the same standards as other preventive services, regardless of whether it is a laboratory test that leads to an invasive treatment or a series of questions that lead to counseling and referral.Screening for drug use is reasonable to consider in clinical practice, but it is not evidence-based for improving health. These observations should serve as an important call for the development and study of new strategies to identify and address drug use in ways that can reduce related harms of such use.

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In a classic model of ventilator-induced lung injury, high peak pressure (and zero positive end-expiratory pressure) causes respiratory swings (obliteration during inspiration) in right ventricular filling and pulmonary perfusion, ultimately resulting in right ventricular failure and dilation. Pulmonary edema was due to increased permeability, which was augmented by a modest (approximately 40%) increase in hydrostatic pressure. The lung injury and acute cor pulmonale is likely due to pulmonary microvascular injury, the mechanism of which is uncertain, but which may be due to cyclic interruption and exaggeration of pulmonary blood flow.

Abrupt deflation after sustained inflation can cause acute lung injury. It seems to be mediated by acute left ventricular decompensation (caused by increased left ventricular preload and afterload) that elevates pulmonary microvascular pressure; this directly injures the endothelium and causes edema, which is potentiated by the surge in pulmonary perfusion.

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Background: During the COVID-19 pandemic, a need for innovative, inexpensive, and simple ventilator devices for mass use has emerged. The Oxylator is an FDA approved, fist-size, ultra-light, portable ventilation device developed for out-of-hospital emergency ventilation. It has not been tested in conditions of severe lung injury or with added PEEP. Objectives: 1) To assess the performance and reliability of the device in simulated and experimental conditions of severe lung injury, and 2) to derive monitoring methods allowing the delivery of a safe individualized ventilation during situations of surge. Methods: Functioning of the device with added PEEP valve was extensively tested on a bench, mimicking adult patients with various respiratory mechanics during controlled ventilation, spontaneous breathing, and prolonged unstable conditions where mechanics and/or breathing effort was changed at every breath. The device was further tested on a porcine model (n=4) with normal lungs and after inducing lung injury and was compared with conventional ventilation modes. Results: The device was stable and predictable: it delivered a constant flow (30 L/min) and cycled automatically at the inspiratory pressure set (minimum of 20 cmH 2 O) above auto-PEEP. Changes in respiratory mechanics manifested as changes in respiratory timing, allowing prediction of tidal volumes from respiratory rate. Simulating lung injury resulted in relatively low tidal volumes (330 mL with compliance of 20 mL/cmH 2 O). In the porcine model, arterial oxygenation, CO 2 and pH were comparable to conventional modes of ventilation. Conclusion: The Oxylator is a simple device that delivers stable ventilation with tidal volumes within a clinically acceptable range in bench and porcine lung models with low compliance. External monitoring of respiratory timing is advisable, allowing tidal volume estimation and recognition of changes in respiratory mechanics. The device can be an efficient, low-cost practical rescue solution for providing ventilatory support as a temporary bridge but requires a caregiver at bedside.