Sample Weak Supplemental Essay for Duke University

What should you avoid when writing a supplemental essay for college admission? Duke Universitys Trinity College offers applicants the opportunity to write a supplemental essay that answers the question: Please discuss why you consider Duke a good match for you. Is there something in particular at Duke that attracts you? Please limit your response to one or two paragraphs. The question is typical of many supplemental essays. Essentially, the admissions folks want to know why their school is of particular interest to you. Such questions often generate remarkably bland essays that make common  supplemental essay mistakes. The example below is one example of what not to do. Read the short essay, and then a critique highlighting some of the mistakes made by the author. Example of ​aWeak Supplemental Essay I believe the Trinity College of Arts and Sciences at Duke is an excellent match for me. I believe college should not be merely a gateway to the work force; it should educate the student in a variety of subjects and prepare him or her for the range of challenges and opportunities that lie ahead in life. I have always been a curious person and enjoy reading all kinds of literature and nonfiction. In high school I excelled in history, English, AP psychology, and other liberal arts subjects. I have not yet decided on a major, but when I do, it will almost certainly be in the liberal arts, such as history or political science. I know that Trinity College is very strong in these areas. But regardless of my major, I want to receive a broad education that spans a variety of areas in the liberal arts, so that I will graduate as not only a viable job prospect, but also as a well-rounded and learned adult who can make diverse and valuable contributions to my community. I believe Duke’s Trinity College will help me grow and become that kind of person. Critique of the Duke Supplemental Essay The sample supplemental essay for  Duke  is typical of what an admissions office frequently encounters. At first glance, the essay may seem just fine. The grammar and mechanics are solid, and the writer clearly wants to expand his or her education and become a well-rounded person. But think about what the prompt is actually asking: discuss why you consider Duke a good match for you. Is there something  in particular at Duke  that attracts you? The assignment here is not to describe why you want to go to college. The admissions office is asking you to explain why you want to go to Duke. A good response, then, must discuss specific aspects of Duke that appeal to the applicant. Unlike a  strong supplemental essay, the sample essay above fails to do so. Think about what the student says about Duke: the school will educate the student in a variety of subjects and present a range of challenges and opportunities. The applicant wants a broad education that spans a variety of areas. The student wants to be well-rounded and to grow. These are all worthwhile goals, but they dont say anything that is unique to Duke. Any comprehensive university offers a variety of subjects and helps students to grow. Also, by talking about the student and using phrases such as him or her, the author makes clear that the essay is presenting generalities rather than creating a clear and specific relationship between Duke and the applicant. A successful supplemental essay must clearly articulate what specific features of the school make it the right match for your personality, passions, and professional goals. The admissions folks need to see a clear and sensible reason for your desire to transfer. Is Your Supplemental Essay Specific Enough? As you write your supplemental essay, take the global replace test. If you can take your essay and substitute the name of one school for another, then you have failed to address the essay prompt adequately. Here, for example, we could replace Dukes Trinity College with the University of Maryland or Stanford or Ohio State. Nothing in the essay is actually about Duke. In short, the essay is filled with vague, generic language. The author demonstrates no specific knowledge of Duke and no clear desire actually to attend Duke. The student who wrote this supplemental essay probably hurt his or her application more than helped it.

What Courses Do Chemical Engineering Students Take

Are you interested in studying chemical engineering? Heres a look at some of the courses chemical engineering students are expected to take in college. The actual courses you would take depend on which institution you attend, but expect to take a lot of math, chemistry, and engineering courses. Youll also study environmental sciences and materials. Many engineers take classes in economics and ethics, too. BiologyCalculusComputer ScienceDifferential EquationsElectronicsEngineeringEnvironmental EngineeringGeneral ChemistryGeometryMaterialsMechanicsOrganic ChemistryPhysical ChemistryPhysicsReactor DesignReactor KineticsStatisticsThermodynamics Typical Course Requirements Chemical engineering usually is a four-year degree, requiring 36 hours of coursework. The specific requirements vary from one institution to another, so here are some examples: Princetons School of Engineering and Applied Science requires: 9 engineering courses4 math courses2 physics courses1 general chemistry course1 computer class1 general biology courseDifferential equations (math)Organic chemistryAdvanced chemistryElectives in science and the humanities What Makes It Special? Studying chemical engineering opens opportunities not only for engineering, but also for biomechanical science, modeling, and simulations. Courses specific to chemical engineering can include: Polymer scienceBioengineeringSustainable energyExperimental biologyBiomechanicsAtmospheric physicsElectrochemistryDrug developmentProtein folding Examples of areas of chemical engineering specialization include: BioengineeringBiotechnologyMicroelectronicsEnvironmental engineeringEngineering mechanicsMaterials scienceNanotechnologyProcess dynamicsThermal engineering Now that you know what courses a chemistry major takes, you may be wondering why you should consider a career in engineering. There are several good reasons to study engineering.

Parole Officers And The Prison System - 843 Words

The world we live is constantly changing whether we are on the streets or in the prison system. Society doesn’t understand that being in the prison is the almost the same as being on the streets. For instance, there are inmates that sell drugs and rob and kill people and cover it up just as if they were on the streets. There are correctional officers that work there, but they can’t observe everything that goes on in the prison system. This is one of the reasons that being a parole officer would be a good job to have. The streets are already bad enough so taking some of the bad guys off the streets can help get the community back under control. Parole officer not only help in the streets the help in the court house. Parole officers can help the judge make decisions on what the inmate should be given whether its freedom or jail time. Parole officers have allot of offenders to keep in contact with when they have not had contact with the offender this becomes a violation and their parole can be revoked. (https://pap.georgia.gov/parole-violations-revocations) In the past few years I have seem allot of inmates in back in prison because they could not follow the guidelines for parole and they were sent back to prison to finish their sentence. When an offender applies for parole a form filled and sent to his counselor which sends it on to parole. When the parole board looks at an inmate, they look at everything especially his disciplinary history this isShow MoreRelatedProbation Parole And Probation Case Essay1348 Words   |  6 Pages History of Parole and Probation Jindarat Innuan Student #0913685 CCJ 1020 Hillsborough Community College Prof. Leonardo Cadogan November 26th, 2014 The purpose of this research paper is to discuss about Parole and Probation in America. 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In recent years, the correctional administrationRead MoreCorrectional Facilities and Environments1166 Words   |  5 Pagescriminal justice system as many individuals who are convicted of offenses are normally placed on probation rather than being sent to prison. In other cases, convicted criminals who have served their jail terms are usually released on parole. In addition to meeting other requirements, criminals are required to stay out of trouble during parole and probation periods. In order to prevent offenders from committing new offenses; probation, parole, and correctional treatments officers and specialists areRead MoreProbation Is A Sentence That Is Given To Offenders Instead920 Words   |  4 PagesWhen given probation you must meet with an assigned probation officer on a regular basis. Probation dates back to English common law. The first probation officer was recognized by the Supreme Court in 1841. Before parole and probation punishments were very harsh, and often lead to death. Over time we have developed these two systems to punish individuals, but at the same time help them learn how to live in the current society. Parole eventually came in 1888. A few years later we began an earlyRead MoreRace, Ethnicity And Gender1660 Words   |  7 Pagesoffenders are discriminated because their race in parole decision making process. Parole is permanently or temporarily release from prison or from offender’s sentence. There are three types of parole releases: discretionary release, mandatory and unconditional release. The primary focus will be on discretionary release and what factors come to play when board members make a decision for a parole. There is no definite evidence that there is racism in parole because the results of the studies are complexRead MoreRehabilitation Paper1578 Words   |  7 Pagesprevious form. 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Population Reduction Measures Even though the state is expected to obtain savings once this policy is in full effectRead MoreProbation Orientation Meetings And The Criminal Justice Field865 Words   |  4 PagesOrientation Meetings are held on a monthly basis at the District Office as apart to help reentry initiatives. While in an informal setting, a probation officer and the sentencing judge explains the conditions, requirements and answer question. This assist the offender in understanding what is required to successfully complete probation. Probation and Parole is apart of community policing that deals with ethics, integrity, values. This promotes and supports organization strategies to address the causeRead MoreUnited States Parole Program Compared To Australia And1546 Words   |  7 Pages United States Parole Program Compared to Australia and Canada Angela K. Varner University of Cincinnati School of Criminal Justice Seminar in Community Corrections April 19, 2017 â€Æ' Abstract Each country across the globe has its unique ways to deal with criminals. Most of their criminal justice systems include some form of parole for individuals who have completed their sentences, in order to maintain some form of control over them while they readjust to life outside prison. This article willRead MoreReentry and the American Prison System1613 Words   |  6 Pages With the dramatic increase in the prison population since the 1970’s, the number of people released from prison has also seen a steady increase. In 2009, almost 730,000 people were released from state and federal prisons, an increase of more than 20 percent since 2000. Those newly released are often condemned by their time in prison and usually have to deal with a loss of social standing. The transitioning process can present various challenges for them including but not limited to reconnecting

Identification of Bloodstain Patterns Free Essays

The analysis of bloodstain patterns can be a decisive part of a forensic investigation. The patterns of bloodstains may concur with or challenge the sworn statements of witnesses, victims, and suspects. Such bloodstain patterns simply identify the source of the blood and the direction of the blood’s flight path, but during the process, the events of the crime can be reconstructed with reasonable accuracy. We will write a custom essay sample on Identification of Bloodstain Patterns or any similar topic only for you Order Now Unfortunately, the old method of analyzing bloodstain patterns, which uses strings, requires much time and effort. It is also subject to human error. To reduce human error, mathematical calculations are used instead, along with a computer software program known as Back Track. Yet, a three-dimensional representation of the results of bloodstain analysis will be more convincing in any court representation. Therefore, in an effort to revolutionize this aspect of forensic investigation, a concerted effort by four researchers from three agencies, Ottawa Police Service, Carleton University and Royal Canadian Mounted Police, was conducted using the AutoCAD software. The researchers were Kevin Maloney, A. L. Carter, Scott Jory, and Brian Yamashita. The results of their studies were reported in an article published by the Journal of Forensic Investigation, in 2005, volume 55, issue 6, and pages 711 to 725. The article attempts to demonstrate how the combined use of AutoCAD and Back Track programs can create three-dimensional representations of a bloodstain analysis. Summary and Critique The overall purpose of Maloney, Carter, Jory, and Yamashita is to explore the possibility of creating a three-dimensional representation of an analysis of bloodstain patterns. They utilize a simulated crime scene that is typically used at the Canadian Police College. The choice of this crime scene is to have known bloodstain patterns with which the results of the combination of Back Track and AutoCAD can be compared. Both the impact angles and the glancing angles of the bloodstain trajectories were incorporated into the program. The comparison shows that the computerized calculations of virtual strings created by the Back Track program match the known location of the blood source, with an average error of six centimeters only. These results prove the precision abilities of the said software. However, a major weakness of this study is its unquestionable reliance on the Back Track program. This program has many limitations and it was even pointed out later in 2006 by Andy Maloney (the relationship to one of the researchers is not described). For example, the Back Track is incapable of computing angled surfaces (Maloney, 2006). Yet, despite the limitations, the efficacy of using the program is grounded on established theory and supported by experimental validation (Carter, 2001). There would be expected errors but these are assumed to be insignificant in the overall investigation. At the same time, the software is known to undergo updates and modifications. The greatest strength of this research is the launching of a better interface between the laboratory science of the forensic team and the assessment abilities of the court. The AutoCAD program has a feature that locks the virtual strings and enables any user to view them from different perspectives. The three-dimensional representation of the analysis of bloodstain patterns is, as the researchers concluded, â€Å"extremely useful in court presentation† (Maloney, et. al. , 2005, p. 724). This article, as well as the research study that it describes, can be considered as a milestone towards a revolutionary aspect of bloodstain pattern analysis. Instead of numbers presented in tabular form or in picture graphs, the results of the analysis can be presented in three dimensions. In three dimensions, the court presentation becomes more realistic, more convincing, and more enlightening, such that the jury can make better assessments. But this article, as far as the advances in forensic science in general and in bloodstain pattern analysis in particular go, can be considered somewhat obsolete. There are now new software or computer programs that can be utilized to produce the same three-dimensional results (Kanable, 2006). This means that in conducting an analysis of bloodstain patterns, a forensic investigator has other options, aside from the combined use of the Back Track program and the AutoCAD. But this wider range of technological tools does not detract from the greatest significance of this article. This article, in great detail and with diagrams, shows how the observed and calculated data are translated into three dimensions. Thus, this article is a recommended reading for every forensic science student. Bibliography Carter, A. L. (2001). The directional analysis of bloodstain patterns theory and experimental validation. Canadian Society of Forensic Science, 34 (4), 173-189. Kanable, R. (2006). HemoSpat: New bloodstain pattern analysis software to hit the market. Law Enforcement Technology, August issue. Retrieved September 28, 2007 from the website of Officer. com at http://www. officer. com/publication/article. jsp? pubId=1id=32890 Maloney, K. , Carter, A. L. , Jory, S. , Yamashita, B. (2005). Three-dimensional representation of bloodstain pattern analysis. Journal of Forensic Identification, 55 (6), 711-725. How to cite Identification of Bloodstain Patterns, Papers

Deregul;Ation Of The Electrical Industry Essay Example For Students

Deregul;Ation Of The Electrical Industry Essay Deregulation of the Electrical IndustryThe roots of modern day regulation can be traced all the way back to thelate 1800s and found in the form of antitrust. By the beginning of the 20th century, the U.S. government had formed the interstate Commerce Commission to regulate the railroad industry, and shortly thereafter, many other regulatory commissions were founded in the transportation, communication, and securities fields. The main goal of these regulatory commissions was to create a reasonable rate structure that would be appealing to both producers and consumers. While this system has worked for many years, it has recently come under heavy criticism, with many people pushing for open competition among electric power producers. Although once believed to be an impossible proposal, competition among electric power producers is finally a reality in a few areas. Massachusetts is just one state where legislation implemented to create competition among electric power producers is not only favored by the people of the state, but has also provided significant rate reductions as well. The attempt at regulating price in the electric industry is a troublesome one. The objective is not only to minimize the cost to consumers, but also to create a rate structure that will entice the electric company to remain in the industry. The regulatory commission wants the electric company to have a reason to innovate so that they will be able to provide cheaper power in the future. However, if the commission captures all gains from innovation in the form of lower pric es, then the electric company has no incentive to undertake any type of innovation. Therefore, a compromise must be reached which would provide adequate incentives for firms to undertake cost-reducing actions while at the same time ensuring that the price for consumers is not exorbitant. The term regulation refers to government controlled restrictions on firm decisions over price, quantity, and entry and exit. Each factor of an industry must be regulated for producers and consumers to truly benefit. The control of price does not mean setting one fixed price, but rather entails the creation of a price structure for purchasing electricity during peak and non-peak times. The control of quantity refers to the governments attempt to control the amount produced or in this case the amount of electricity produced. For example, in the electric industry, it does not make sense to have a lot of small power plants produce electricity. However, at the same time one company can not be allowed to monopolize the industry and set prices at its own discretion. Another factor in this problem is the control of entry and exit in the electric industry. By controlling who can enter the industry, the government can control who produces the electricity and how much of it they produce. However, the effectiveness of regulation has begun to be questioned, and created the evolution of a more competitive market. Ever since the Public Utility Act of 1935, which in turn created the Federal Power Commission, the role of electric utility regulation and its effectiveness has been questioned. Since that act was passed into legislation, the question has always remained: has electric regulation made a difference? Major studies done throughout the 20th century found conflicting results. A study published in 1962 and conducted by Stigler and Friedland compared the price of electricity in states with regulation to the price in states without regulation. However, at the time all states had electric re gulation, so Stigler and Friedland had to go back to the 1920s and 1930s to find states without regulationTheir finding was as expected. In 1922, the average price of electricity was 2.44 cents per kilowatt-hour in states with regulation. However, in states without regulation, the average price increased to 3.87 cents per kilowatt-hour. While many would say that prices could vary for reasons other than regulation, Stigler and Friedland controlled the analysis of other variables and found that no significant difference in price existed. Other critics felt that this study was done in a time when regulation was just getting started, and that regulators in the present day are more effective. Two other studies which found different results were those conducted by Meyer and Leland and another done by Greene and Smiley. In their study, which used data from 1969 and 1974, Meyer and Leland utilized econometric estimates of demand and costs to find hypothetical unregulated prices. Their concl usion was that the regulated prices were significantly lower, but that even lower prices were demanded. In a similar study conducted by Greene and Smiley, they found that unregulated prices were 20-50% higher than actual regulated prices. Although these studies seem to reach conclusions that support regulation, the alternative finding by Leland and Meyer that even lower prices were demanded seems to be an indication towards open competition among electric producers. Soon thereafter, the trend toward competition between electric producers began to emerge. Life And Times Of Alexander The Great EssayHowever, even though the law seems to have many more benefits than it does negatives, it has come under recent criticism. Many opponents of the law feel it is not doing its designed purpose, and consumer backlash was so great that Issue 4 asking whether or not the law should be repealed. An organization called The Campaign for Fair Electric Rates, backed by failed congressional candidate John OConnor and consumer advocate Ralph Nader, led the effort to repeal the law, calling it the biggest consumer rip-off in Massachusetts history. The big issue involved in the attempted repeal was lawmaker reneging on their promise to protect consumers by allowing utilities to recover 100% of their bad investments. Because deregulation will cause some utilities to lose money on investments in power plants or on contracts they made when they expected to keep selling power at a regulated price, the question becomes do they deserve compensation for these st randed costs, which may approach $200 billion nationally? For instance, utilities spent more than $5 billion building the Seabrook nuclear plant in New Hampshire, which produces 1,150 megawatts. In contrast, private developers have proposed more than 50 new plants, which combined would produce 30,000 megawatts, and the cost of these projects is estimated at slightly more than $15 billion. The utilities argue that public regulators approved those expenses and that the state can not back out on them now, stating that many plants have already begun to implement the new law, including selling most of their power plants. Repealing the law now, they argue, would create utter chaos. Therefore, a provision was written into the law allowing for utilities to recover all of their stranded costs over a 10-year transition period. While proponents of the law were hoping for a 30% rate reduction, of which two-thirds would have come from consumers not having to pay for most of the utilities strande d investments, they will now have to settle for a guaranteed 15% rate cut, hopefully with more to come through competition. The question now on everyones mind is: has the law served its purpose and reduced electric rates? In a study done by Standard and Poors DRI entitled Economic and Environmental Analysis of the New Massachusetts Electricity Law, and released on September 2, 1998, it found that the new has triggered substantial economic and environmental benefits. According to the study, electric rates will decline by almost 28% by the year 2010 as a direct result of retail competition and industry restructuring. The DRI, a conservative report when compared to others, predicts that consumers will save $470 million in 1998 alone, and increases that estimate to at least $550 million per year in future years as a result of the new law. Also, the study predicts the Commonwealth to achieve higher economic output and employment growth triggered by the estimated $10 billion consumers and businesses will save on electricity costs. By 2010, there will be over 60,000 more jobs, a $19.6 billion gain in consumers cumulative real discretionary income, and lower price inflation. All of this forecasting appears to put the law in a favorable light, but many want to know how its working now. According to the Massachusetts Electric Company, its 970,000 customers have saved a total of $67 million on their electricity bills in the first six months of the new electricity law. On September 1, savings for the companys customers increased to more than 15%, or a total savings of $25 million per month, one full year ahead of the required rate cut. This was due to the companys affiliates selling their power plants. SummaryBy examining the early results of the Massachusetts Electricity Law, along with projections such as the ones provided by Standard and Poor, one can determine that the deregulation of the electric industry has been long overdue. The deregulation of the electrical industry proves that any industry can and should be deregulated. It also proves that competition of the utility companys is in the best interest of society as a whole and that no industry should be allowed to exist without it. Economics Essays

Tori Amos - Strange Little Girls free essay sample

ToriAmos is known for writing songs about everything from religion to rape, but shedecided to do something different for her sixth album, Strange LittleGirls. On it, Tori covers 12 songs written by men mostly for or aboutwomen in which she sings from the perspective of the women. She has taken songsby Depeche Mode, Neil Young, The Beatles and even Eminem and turned them intoher own. For each, Amos has imagined a different woman. At times shes acharacter straight from the lyrics, at other times, she may be entirely a Toricreation. For each song, on the liner notes, there is a coinciding imageof Amos dressed as the songs character. She also worked with Neil Gaiman toinvent a group of short stories about each character. For example, the cover ofEminems ? Bonnie Clyde is told from the point of view of themother who is about to be dumped off a bridge by her own husband anddaughter. We will write a custom essay sample on Tori Amos Strange Little Girls or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page For Tori Amos fans, Strange Little Girls is achange, but I think it features the same old Tori. She still gives her inspiringbeam of womanhood and individuality. Her voice still captivates and amazes thosewho listen to her. If you dont already own Strange LittleGirls because youre leery about what it will be like, I suggest you getit. Tori Amos doesnt disappoint.

Assisted Ventilation in Status Asthmaticus Essays

Assisted Ventilation in Status Asthmaticus Essays Assisted Ventilation in Status Asthmaticus Paper Assisted Ventilation in Status Asthmaticus Paper Assisted Ventilation in Status Asthmaticus Background When a patient is admitted in the Intensive Care Unit (ICU) with a diagnosis of status asthmaticus, it means that the asthma attack is extremely severe and critical.   In this situation, the patient does not respond to high doses of steroids and inhaled bronchodilators.   According to Groth, this resistance to medication is most likely the consequence of three things that make it extremely hard to get air in and lout of the lungs.   These three factors are as follows:  ·Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Bronchospasm, which is a condition of an extreme spasm of the airways.  ·Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Edema, which is a condition when the lining of the airways is swelling.  ·Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Thick mucus secretions in the airways. Normally, when an individual breathe in, the airways are pulled open when the chest wall becomes larger; however, when the individual breathe out, the airways have a tendency to collapse, locking in air in the chest. However, when a person is an asthmatic, emptying the lungs takes a long time for the reason that the airways are restricted. An asthmatic person cannot totally empty the lungs prior to having to take one more breath. When a person is severely asthmatic, he/she experiences shorter breathing so he/she tries to breathe faster and he/she has little time to exhale. When this happens, the lungs keep hold of, or â€Å"trap,† lots of air, which is called hyperinflation or air-trapping. Moreover, this procedure makes it more difficult to take another breath in, and the breathing muscles have to try harder and make more effort to take in any air. Groth said that a young or if not a healthy asthmatic can more often than not surmount this complexity, but at the expense of a c onsiderable strain on the breathing muscles. Then, when this demand is continued for too long, for instance due to resistance to medicine, the asthmatic person’s breathing muscles can get exhausted and he/she will acquire respiratory failure. Furthermore, according to Corbridge and Hall (1995), status asthmaticus is a life threatening type of asthma described as a situation in which an increasingly worsening attack is impassive or not responsive to the customary proper treatment with adrenergic drugs and that causes pulmonary insufficiency. The most important mechanical occurrence in status asthmaticus is a progressive rise in airflow resistance. In addition, mucosal edema or inflammation and mucous plugging are the primary causes for the late recovery in status asthmaticus. Ibsen added that the combination of acidosis, hypercapia, and hypoxia together with the mechanical consequences of increased lung volumes might bring about or cardiovascular arrest or cardiovascular depression. Indications for ICU Admission   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Schwarz and Lubinsky (1997) asserts that a person with status asthmaticus should be admitted to ICU when he/she feels the following:  ·Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Exhaustion  ·Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Altered sensorium  ·Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Presence of high-risk factors  ·Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Use of continuous inhaled beta-agonist therapy  ·Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Failure to improve in spite of adequate therapy  ·Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Increasing PCO2 ins spite of treatment  ·Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Markedly decreased air entry Due to difficulty in breathing, a person with status asthmaticus admitted in then ICU is ventilated through assisted or mechanical ventilation. Groth said that a mechanical ventilator takes over the function of breathing in the course of status asthmaticus; however, it does nothing to overturn airway inflammation or bronchospasm. The main function of a mechanical ventilator is to sustain breathing for the exhausted muscles until such a time when a variety of medications become helpful and effective. For a patient in the ICU to obtain mechanical ventilation, he/she needs an endotracheal tube, which is a plastic tube that is inserted by means of the nose or mouth into the windpipe or trachea and is linked to the ventilator. Moreover, the patient must likewise be sedated with an opioid-like morphine called fentanyl and medically paralyzed so as to let the ventilator function effectively and to make the patient comfortable. Mechanical Ventilation   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   If the patient has already undergone rapid extubation but still suffers difficulty of breathing, there is probably a failure in extubation.   Werner (2001) says that extubation is a major complication of translaryngeal intubation, but its impact on mortality, duration of mechanical ventilation (MV), length of intensive care unit (ICU) and hospital stay, and need for ongoing hospital care has not been adequately defined.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Hence, in the case of extubation failure, the patient in the ICU should be intubated. Epstein et al., (2000) said that as many as 20% of extubated patients require reintubation (specifically extubation failure) within 72 hours of extubation, with the exact prevalence depending on numerous factors. The pathophysiologic basis of extubation failure is often different from the cause of weaning failure. Extubation failure substantially prolongs the duration of mechanical ventilation, intensive care unit stay, and hospital stay, and substantially increases hospital mortality. Therefore, prediction of extubation outcome and prevention of extubation failure may be critically important. Unfortunately, standard weaning tests have not proven sufficiently accurate in predicting extubation outcome. New semi-objective measurements of cough strength and secretion volume can help recognize patients at increased danger for extubation failure. It is signifi cant to observe that mortality increases with reintubation delay, which illustrates that clinical worsening might occur during the period without ventilatory support. As a result, better result possibly will come from rapid detection of patients at increased danger, followed by quick reinstitution of ventilatory support when extubation failure happens. Schwarz and Lubinsky (1997) also said that the patient in the ICU should be intubated and mechanically ventilated he/she suffers the following:  ·Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Diminishing level of consciousness  ·Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Significant hypoxemia that is poorly responsive or unresponsive to supplemental oxygen therapy alone  ·Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Apnea or respiratory arrest  ·Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Impending respiratory failure marked by significantly rising PCO2  with fatigue, decreased air movement, and altered level of consciousness The choice to intubate an asthmatic should be done with tremendous concern. According to Cox, Barker and Bohn (1991), positive pressure ventilation in an asthmatic person is made difficult by acute air trapping and airway obstruction that causes hyperinflated lungs, which might refuse to accept further inflation and puts the patient at high danger of barotrauma. As a result, mechanical ventilation must be carried out just in the face of constant deterioration regardless of maximal bronchodilatory therapy. Moreover, Werner (2001) agrees that the assessment and choice to intubate an asthmatic should not be taken without due consideration, and intubation must be prevented if possible. Tracheal intubation may aggravate bronchospasm (O’Rourke Crone, 1982) and positive pressure ventilation will significantly boost the danger of circulatory depression and barotraumas (Williams et al., 1992). According to Corbridge and Hall (1995), ventilator management can be challenging to a certain extent. For this reason, the following principles should be applied in taking care of a patient with status asthmaticus in the ICU:   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   1.Do not attempt to regulate or normalize the pCO2. Tolerate hypercapnia, and make use of pharmacologic buffering agents if needed to raise the pH to 7.2. How high a pCO2 you could do with to endure is determined by the pressures required to ventilate the patient.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   2.Make an effort to keep plateau (alveolar) pressures 30-35 cm H20. Peak pressures might be higher than this because of increased airways resistance.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   3.Small tidal volumes are typically required because of propensity and high resistance for air trapping. 5-7 cc/kg is a logical and practical place to begin.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   4.Rate must be low and expiratory time long, inspiratory time somewhat short. The plan is to leave as much time as possible for expiration, without causing the inspiratory pressure to be extremely high since you are attempting to get the gas in over too short a period. Rates of 10-14 and I:E ratios of 1:4 to 1:6 are usual.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   5. Pressure cycled or volume cycled ventilation can be employed. If employing volume-cycled ventilation, be certain to look at the pressures generated cautiously. If employing pressure cycled, the ventilator will typically not arrive at â€Å"plateau† or no flow, and you have to look at the volumes delivered. Regular reassessment is vital.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   6.If you come across problem with oxygenation or just cannot move the chest, manually bag the patient and re-examine therapy and ventilator strategy.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   7.Case series and some anecdotes show that there has been certain success with the use of pressure support ventilation in the sedated, but not paralysed, intubated asthmatic. Its regular use has not been subjected to controlled trials.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   8.The patient should be well sedated and generally paralyzed during mechanical ventilation. Constant infusions or doses scheduled on a regular basis must be used.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   9.Premedicate with lidocaine and extra sedation prior to suctioning to lessen the bronchoconstriction in reaction to stimulation.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   10.Go on with insistent bronchodilator therapy-aerosols or MDIs, atrovent, intravenous terbutaline, and steroids. Take into account â€Å"kitchen sink† therapies like ketamine, magnesium, isoflurane, and helium. Respiratory Acidosis, Metabolic Acidosis and Permissive Hypercapnea as a Lung Protective Strategy According to (Rebuck and Read, 1971), the customary regulation that respiratory acidosis determines or affects intubation has become outdated. With the start of more insistent utilization of inhaled b-agonist therapy, 1% of asthmatic children confined in the hospital (Cox, Barker and Bohn, 1991) and around 5 to 10% of asthmatic patients confined in   pediatric intensive care (Pirie et al., 1998) need intubation. Rebuck and Read (1971) maintains that asthma is a sickness of airway obstruction, specifically, increased airway resistance, causing persistence of the time constant or the time required for lung units to fill and empty. Hence, slow ventilator rates are typically required. Tuxen and Lane (1987) also claims that during high peak airway pressures, the rule of mechanical ventilation of patients with status asthmaticus is controlled hypoventilation, putting up with higher levels of PCO2  so as to peak inspiratory pressures and reduce tidal volume. The incidence of respiratory acidosis goes after that of hypercarbia (Nowak, 1983). In addition to acute airflow limitation, metabolic acidosis might also happen (McFadden and Lyons, 1968). Numerous instruments are possibly included. Then, according to Roncoroni et al. (1976), if cardiac output is compromised, hypoxia of the peripheral tissues might trigger lactic acidosis to build up or worsen. Furthermore, increased oxygen consumption by the respiratory muscles might be a factor as well. Also, it might likewise be generated with the aggressive administration of nonselective sympathomimetics (Appel et al, 1983). Darioli and Perret (1984) established the idea of controlled hypoventilation with lower-than-traditional respiratory rates and tidal volumes in asthmatic adult patients, and discovered a significantly reduced frequency of barotrauma and death measured up to to historical control subjects. Meanwhile, this idea has been broadly accepted and realized to develop outcomes in asthmatic adult patients. Moreover, this concept, which is called permissive hypercapnia has also been reported in asthmatic children patients. Dworkin and Kattan (1989) dispensed mechanical ventilation to 10 children with the purpose of keeping peak inspiratory pressure , 60 cm H2O and arterial pH . 7.10;   Paco2 ranged from 40 to 90 mm Hg; then, they did not detect air leak following intubation, and all of the 10 children survived. In addition, Cox et al (1991) said that when asthmatic children being given mechanical ventilation with initial tidal volumes of 10 to 12 mL/kg at rates of 8 to 12 breaths/min, inspirat ory time was set at 1 to 1.5 s (considering an expiratory time of approximately 5 s), and tidal volumes were modified to keep peak inspiratory pressures at 45 cm H2O, just two postintubation pneumothoraces were observed, and all children survived without sequelae in spite of considerable hypercarbia throughout mechanical ventilation. Werner (2001) said that permissive hypercapnia could be endured provided that the patient continues to be sufficiently oxygenated. A longer I:E ratio, frequently more than 1:3-4, helps tolerate slow but total emptying of the lungs during exhalation, helping and assisting ventilation and preventing unnecessary further air-trapping (auto-PEEP). The utilization of positive end-expiratory pressure (PEEP) is contentious (Werner, 2001). A person with status asthmaticus in respiratory failure on mechanical ventilation frequently has a considerable amount of air trapping that causes intrinsic PEEP, which possibly will be worsened by means of continuing PEEP during exhalation. Nevertheless, a number of patients may perhaps gain by the addition of PEEP, maybe by way of preserving airway patency during exhalation. Therefore, in a patient in the ICU who continues to be refractory to the initial ventilatory settings with no or very low PEEP, carefully escalating the PEEP may possibly demonstrate to be beneficial. Werner (2001) added that customarily, slow controlled ventilation with heavy sedation and with or without muscle relaxation is the strategy employed to ventilate patients with status asthmaticus. However, warning is necessitated, because the use of muscle relaxants with high-dose steroids has been linked with the growth of prolonged paralysis. On the other hand, a number of practitioners give an account of ventilating children with status asthmaticus with pressure support alone, enabling the patient to set his or her own respiratory rate as identified by his or her own physiologic time stable at the same time helping ventilation by means of relieving the fatigue caused by considerable work of breathing. Noninvasive positive pressure ventilation (NPPV), for instance, continuous positive airway pressure (CPAP) or bimodal positive airway pressure (BiPAP) delivered by way of a facemask, has been utilized for support of status asthmaticus. NPPV has been demonstrated to splint the airways, letting better exhalation and emptying (Werner 2001). Tuxen and Lane (1987) asserted that patients necessitate monitoring and supportive measures during mechanical ventilation. They also said that patients might be uneasy and air hungry while ventilated with low respiratory rates, and hypercapnia as a result of an approach of controlled hypoventilation. Preferably, flow-volume loops should be monitored to determine if sufficient time is given for exhalation to evade breath stacking, which happens if the next breath is delivered prior to exhalation is finished. Moreover, monitoring auto–positive end-expiratory pressure (auto-PEEP) and exhaled tidal volume is vital as well. Pirie et al. (1998) said that electrolytes and fluids must be monitored. Prior to arrival in the hospital, children with status asthmaticus have frequently had reduced oral intake and might have been vomiting as a consequence of respiratory difficulty or adversative effects from their medications. This causes decreased intravascular volume status that might be potentiated by the outcomes of positive pressure ventilation. Furthermore, cardiac output might be reduced as a consequence of lessened preload that are caused by auto-PEEP and air trapping. This decreased cardiac output and intravascular volume might perhaps be complemented by metabolic acidosis. Intravascular fluid expansion is necessary to cure hypotension, hypoperfusion, or metabolic acidosis. Moreover, diastolic hypotension might irregularly develop from high doses of beta-agonists. A vasoconstrictor (specifically, phenylephrine or norepinephrine,) might be taken into account if considerable diastolic hypotension in the face of sufficient intravascular volume persists. Monitor serum electrolyte levels, as medications used to treat asthma can result in significant kaliuresis (Tuxen and Lane, 1987). Meanwhile, Nowak et al. (19833) said that placement of indwelling arterial catheters offers nonstop blood pressure monitoring in addition to arterial blood gas sampling. They also maintained that blood gases must be monitored to evaluate response or reaction to therapy in mechanically ventilated patients.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Meanwhile, mechanical ventilation utilizing unsuitable settings can generate acute inflammatory response in the lund and acute parenchymal lung injury. The related release of cytokines into alveoli and the systemic circulation (Ranieri et al., 1999) might be a factor to multiple organ dysfunction (Slutsky and Tremblay, 1998) and mortality in acute respiratory distress syndrome (ARDS). â€Å"Lung-protective† ventilation strategies try to evade these outcomes by means of restraining peak lung distension and evading end-expiratory collapse, tolerating the hypercapnia that frequently results; such strategies decreased mortality rate in ARDS in two randomized trials (Slutsky and Tremblay, 1998). Hypercapnia is normally considered as an adverse result of limiting alveolar stress, but in a series of studies, Laffey, Engelberts and Kavanagh (2000) have asked whether hypercapnic acidosis per se might be a factor to the advantages of lung-protective ventilation. They demonstrated that in isolated perfused rabbit lungs, respiratory acidosis protected the lung from ischemia–reperfusion injury, while respiratory alkalosis potentiated the damage. The protective result of respiratory acidosis was linked with inhibition of xanthine oxidase, and was prohibited by means of buffering the acidosis; specifically, the protection was because of the acidosis instead of hypercapnia.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Acidosis restrains the cytokine expression and respiratory burst in macrophages (Roncoroni et al., 1976). Then, Laffey, Engelberts and Kavanagh (2000) have talked about other studies recommending cytoprotection by hypercapnic acidosis. Hence, even though it appears that it is impossible that all of the evident advantage of lung protective ventilation is a direct result of hypercapnia, the hypothesis tackled by Laffey, Engelberts and Kavanagh (2000) is a significant and sensible one. If â€Å"lung-protective ventilation† in ARDS does decrease pulmonary and systemic inflammation, and possibly multiple organ dysfunction, hypercapnic acidosis as such could possibly be somewhat responsible, maybe by downregulating inflammatory cells, and perhaps other mechanisms in addition to inhibition of xanthine oxidase. Therapy and Care in the ICU ICU therapy begins in step-wise fashion and escalates to a â€Å"kitchen sink† approach. This is because there is fairly little data which points to one combination of therapies being superior to others, and because an asthmatic deteriorating despite â€Å"usual† therapy is in significant danger. Standard therapy includes steroids (solumedrol) and beta-agonists (intermittent aerosols, continuous aerosols, or intravenous terbutaline). â€Å"Adjunctive† therapy includes anticholinergic agents (Atrovent). Chest physiotherapy and/or IPV (intermittent percussive ventilation) may be helpful and/or necessary for some patients.â€Å"Kitchen sink† therapies include magnesium, helium, ketamine, antibiotics, inhalational anesthetics, aerosolized lasix.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Based on the literature of Groth, the patient in the ICU must be prescribed continuous nebulization of albuterol for the first eighteen hours after the patient’s admission to the Intensive Care Unit and then switch to intermittent albuterol every two hours. Inhaled ipratropium could also be added every 6 hours. Ipratropium is an anticholinergic bronchodilator, and reduces bronchoconstriction through a different means. Then the patient will continue to be treated with a high dose of intravenous corticosteroids. He/she will also be given antibiotics if he/she has a fever, a high white blood cell count, and increased cough and mucus indicating that he/she has an infection.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Groth also asserted that several of the treatments of last resort employed in status asthmaticus consist of giving general anesthesia with inhalational anesthetics, which are very effective and powerful bronchodilators. Nevertheless, the help of an anesthesiologist will be needed to give this kind of treatment. Intravenous anesthetics like ketamin, can be useful as well. Recommendations Sin Fai Lam, Mow and Chew (1992) said that a more open-minded use of the ICU for patients with severe asthma has formerly been promoted. Procrastination might bring about a respiratory arrest. The result is at all times worse following a respiratory arrest; Lee, Tan and Lim (1997) gave an account of a merely 50% survival from hypoxic brain damage following a respiratory arrest despite good intensive care treatment. It is not advantageous to wait until the patient is almost dilapidated from CO narcosis to take control of the airway. If active airway intervention is unavoidable, it is preferable to come up with this decision early instead of late. This means that it is better to be pro-active instead of procrastinating. Early endotracheal intubation and mechanical ventilation in the patient with life threatening asthma might be practical procedures that can save life and bring about good clinical outcome. Complete signs for intubation are cardiac and respiratory arrest or considerable alteration in mental state. At other instances, the decision made in the face of increasing exhaustion and progressive deterioration. Based on the various literature discussed in this paper, would like to see more patients who need ventilation be intubated electively instead of as a consequence of a cardiorespiratory arrest. Blood gas abnormalities by itself are not a sign to intubate the patient. Several patients with respiratory acidosis and hypercapnia will respond and react to treatment with bronchodilators and do not need mechanical ventilation. More significant is the development in clinical findings and in the arterial blood gases. Furthermore, procrastination in the instigation of mechanical ventilation when it is certainly necessary is connected to the fear of complications. Definitely, contemplation and reflection should at all times be provided to the possible dangers. Intubation in a dyspnoeic, relentless and anxious patient must be carried out by the most knowledgeable and skilled clinician available. A large endotracheal tube must be chosen because it helps suction and lessens airways resistance. Based on the literature, there are advantages of both oral and nasotracheal intubation, and sedative options in the preparation of the patient differ among people. When endotracheal intubation has been performed, the physician’s priority should be to take control with positive pressure ventilation. This will necessitate the utilization of sufficient sedation and typically paralysis with a muscle relaxant. Paralysis might regularly merely be necessary in the first stages of ventilation, and must be weaned off as soon as possible to lessen the danger of acute myopathy. Ventilation must primarily be in the CMV manner. Ventilatory settings should also be selected to evade extreme lung inflation. This approach will lessen the danger of systemic hypotension or pneumothorax. Lung inflation is lessened by means of permitting a sufficient time for exhalation (TE). Meanwhile, expiratory time may perhaps be prolonged by means of reducing minute ventilation (VE) by either minimizing inspiratory time (TI) or lowering respiratory rate RR or tidal volume (VT). Inspiratory time is lessened through increasing inspiratory flow rate and by means of employing a square flow wave form. Tidal volumes of 8-10 mls/kg with a respiratory rate of 10-14 and inspiratory flow rates of 60 L/min or higher are frequently appropriate (Sin Fai Lam, Mow and Chew, 1992). A suitable peak airway pressure of 50 mm H20 should be aimed for. Furthermore, controlled hypoventilation is a method employed to lessen the danger of hypotension and barotrauma. The goal is to guarantee sufficient oxygenation, stay away from extreme dynamic hyperinflation (DHI) and tolerate a degree of hypoventilation. It is completely tolerable to let the PCO 2to increase so as to evade DHI. One must not try to normalize the PCO2 to the detriment of DHI (Lee, Tan and Lim, 1997). Hypotension might be attributed to too much DHI. A short experiment of apnoea (30-45 seconds) is indicative, as blood pressure rises and venous return increases during the period of apnoea. If this does not occur, other causes of hypotension like fluid depletion, tension pneumothorax, unnecessary sedation or myocardial depression should be taken into account. Lastly, A number of studies have evidently revealed that mechanical ventilation saves lives in life-threatening asthma (Sin Fai Lam, Mow and Chew, 1992). With good ICU management, the period of required ventilation is short, complications can be kept to a minimum, and there is more often than not no problem in weaning the patient off the ventilator. Nevertheless, we should remember that ultimately, the therapy and remedy of acute life-threatening asthma does not merely begin 3 days prior to the attack, but much earlier, as most acute attacks are avoidable with the appropriate use of standard and regular prophylactic medication, the proper education of patients, the avoidance of trigger factors, the appropriate implementation of a co-management plan between the patient and his doctor, the objective measurement of the PEFR, and the accessibility to medical care in times of crisis.# References Appel D, et al. (1983). Lactic acidosis in severe asthma. American Journal of Medicine. Corbridge T, and J. Hall. (1995). The assessment and management of adults with status asthmaticus. American Journal of Respiratory Critical Care Med. Cox R, G. Barker, and D. Bohn. (1991). Efficacy, results, and complications of mechanical ventilation in children with status asthmaticus. Pediatric Pulmonology. Darioli R, and C. Perret. (1984). Mechanical controlled hypoventilation in status asthmaticus. American Review of Respiratory Disorder. Epstein, S. et al. (2000).   Effect of Unplanned Extubation on Outcome of Mechanical Ventilation. American Journal of Respiratory Critical Care Med. Groth, M. Status Asthmaticus.   Retrieved from http://denverpost.healthology.com Laffey J, D. Engelberts, and B. Kavanagh. (2000). Buffering hypercapnic acidosis worsens acute lung injury. American Journal of Respiratory Critical Care Med. Lee K, W. Tan, and T. Lim. (1997). Severe asthma. SMJ. McFadden E. Jr, and H. Lyons. (1968). Arterial-blood gas tension in asthma. N Engl J Med. Nowak R, et al. (1983). Arterial blood gases and pulmonary function testing in acute bronchial asthma: predicting patient outcomes. JAMA. O’Rourke P. and R. Crone. (1982). Halothane in status asthmaticus. Critical Care Med. Pirie J, et al. (1998). Changes in treatment and outcomes of children receiving care in the ICUs for severe acute asthma. Pediatric Emergency Care. Rebuck A, and J. Read. (1971). Assessment and management of severe asthma. American Journal Medicine. Roncoroni A, et al. (1976). Metabolic acidosis in status asthmaticus. Respiration (Herrlisheim). Ranieri V, et al. (1999). Effect of mechanical ventilation on inflammatory mediators in patients with acute respiratory distress syndrome. JAMA. Schwarz A, and P. Lubinsky. (1997). Acute severe asthma. In: Levin DL and Morriss FC, eds. Essentials of Pediatric Intensive Care. 2nd ed. Vol 1. Sin Fai Lam K, B. Mow, and L. Chew. (1992). The profile of ICU admissions for acute severe asthma in a general hospital. SMJ. Slutsky A, and L. Tremblay. (1998). Multiple system organ failure. Is mechanical ventilation a contributing factor? American Journal of Respiratory Critical Care Med. Tuxen D, and S. Lane. (1987). The effects of ventilatory pattern on hyperinflation, airway pressures, and circulation in mechanical ventilation of patients with severe airflow obstruction. American Review of Respiratory Disorder. Werner, H. (2001). Status Asthmaticus in Children : A Review.   CHEST. Williams T. et al. (1992). Risk factors for morbidity in mechanically ventilated patients with acute severe asthma. American Review of Respiratory Disorder.