April - Respiratory Care

Transcription

APRIL 1999
VOLUME 44
NUMBER 4
ISSN 0020-1324-RECACP
A MONTHLY SCIENCE JOURNAL
44TH
Call for
EDITORIAL
1999 Open Forum Abstracts
Can
We
YEAR— ESTABLISHED
1956
Rehabilitate the Chest Wall?
Deadline June 11,1999
ORIGINAL CONTRIBUTIONS
Effects of Respiratory
Wall
in
Muscle Stretch Gymnastics on the Chest
COPD
Long-Term Tracheostomy and Weaning
Work
of Breathing with
PSV
+
in
Severe
COPD
PEEP vs CPAP during
Prolonged Weaning
Effects of
Continuous vs Expiratory Tracheal Gas Insufflation
on Total PEEP
CASE REPORT
Unrecognized Motor Neuron Disease as a Cause of Ventilator
Dependency
in
the ICU
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u^
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Directed
CPG 6
In-Vitro
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Use of Positive Airway Pressure Adjuncts to
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CPG33
CPG B
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Endotracheal Suctioning of Mechanically
CPG34
Defibrillation
Ventilated Adults and Children with
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Infant/Toddler Pulmonary Function Tests
CPG3G
Management
CPG37
Assessing Response to Bronchodilator Therapy at
CPG38
Discharge Planning for the Respiratory Care
CPG39
Long-Term
for Arterial
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•
Blood Gas Analysis
Incentive Spirometry
CPG 11
Postural Drainage
CPG 12
Bronchial Provocation
CPG 13
Selection of Aerosol Delivery Device
CPG 14
Pulse Oximetry
CPG 15
Single-Breath
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Oxygen Therapy
•
•
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Therapy
•
Point of Care
$1
$1
Patient
$1
•
$1
Home
Carbon Monoxide Diffusing
1999 Update
Capacity,
CPG 17
Artificial
$1
CPG 10
Facility
in
$1
Home
the
$1
and/or Desaturation
•
Humidification during Mechanical Ventilation
CPG 19
Transport of the Mechanically Ventilated
•
during Resuscitation
of Airway
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Invasive Mechanical Ventilation in the
$1
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Selection of an Aerosol Delivery Device for
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Polysomnography
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Selection of an
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•
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•
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Selection of a Device for Delivery of Aerosol to
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Training the Health-Care Professional for the Role
the Lung Parenchyma
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Resuscitation in Acute Care Hospitals
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Bland Aerosol Administration
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Fiberoptic Bronchoscopy Assisting
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Intermittent Positive Pressure Breathing
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Providing Patient and Caregiver Training
(IPPB)
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Removal
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Suctioning of the Patient
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Selection of Device, Administration of
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•
•
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$1
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$1
$1
Application of
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•
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Upper Airway
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Delivery of Aerosols to the
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Neonatal Time-Triggered, Pressure-Limited,
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•
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&
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•
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for
$1
$1
•
•
•
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or Extended Care
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Pediatric Patients
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•
•
•
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and Caregiver Educator
of the Endotracheal
in
Tube
the
$1
•
•
•
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•
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in
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I
APRIL 1999
/
VOLUME
44
/
NUMBER
4
FOR INFORMATION,
CONTACT:
AARC Membership
or Other
EDITORIALS
AARC
Can
Services
American Association
We
A Dillard—Tacoma, Washington
407
by Thomas
for
Respiratory Care
11030 Abies Ln
Daiias TX 75229-4593
(972) 243-2272
ORIGINAL CONTRIBUTIONS
Fax (972) 484-2720
•
littp://www. aarc.org
Preliminary Report on the Effects of Respiratory Muscle
Stretch Gymnastics on Chest Wall Mobility in Patients with
Therapist Registration or
Chronic Obstructive Pulmonary Disease
Technician Certification
by Fujiyasu Kakizaki, Tsutomii Yamazaki. Hajime Suzuki— Yokohama. Japan, and
Masato Shihuya. Minehiko Yamada. and Ikuo Homma— Tokyo. Japan
Nationai Board for Respiratory
409
Care
Long-Term Tracheostomy in Severe
from Mechanical Ventilation
8310Nieman Rd
LenexaKS 66214
(913) 599-4200
Fax (913) 541-0156
•
hv Enrico
Clini.
Michele Vitacca. Luca Bianchi. Roberto Porta,
http://www.nbrc.org
and Nicolino Ambrosino
Accreditation of Education
Work
Programs
Committee on Accreditation
for
COPD Patients Weaned
— Gus.sago.
415
Italy
of Breathing during Weaning from Ventilation: Does Extending
Weaning with Continuous Positive Airway Pressure Confer Any Advantage?
by Rajesh G Patel, Many F Petrini. and Terry M Dwyer—Jackson, Mississippi
421
Continuous and Expiratory Tracheal Gas Insufflation Produce
Equal Levels of Total PEEP
by Edgar Delgado. Adelaida M Miro, Leslie A Hojfinan. Frederick J Tasota,
and Michael R Pinsky— Pittsburgh, Pennsylvania
428
Respiratory Care
W Euiess Bivd, Suite 300
1701
Euless
TX 76040
(817) 283-2835
Fax (817) 354-8519
•
http://www.coarc.com
Grants, Scholarships,
Community
Projects
CASE REPORT
American Respiratory Care
Foundation
11
Unrecognized Motor Neuron Disease:
030 Abies Ln
TX 75229-4593
Daiias
Cheryl
State
West
Aflaiis
MHA
Government
434
—
(703-548-8506)
Affairs
TEST YOUR RADIOLOGIC SKILL
—
A
Eicher IMPA (703-548-8538)
Jiil
of
—
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Government
An Uncommon Cause
Ventilator Dependency in the Intensive Care Unit
by Rodrigo Morales and Jorge E Mendizabal Mobile, Alabama
b\
Second Fioor
1225 King
St,
Alexandria
VA 22314
60- Year-Old Woman with Dyspnea on Exertion
AH Emad— Shiraz, Iran
437
Fax (703) 548-8499
PFT
Measurement of FEV| using
RE/PIRATORy
h\ James
C&RE
RESPIRATORY CaRE {ISSN
0020-1324.
USPS
NUGGETS
K Stotler,
the Modified Spirometry Technique
McCarthy— Cleveland, Ohio
Daniel Laskowski, and Kevin
441
A
Patient with Dyspnea and Acid Maltase Deficiency
by Salim Kathawalla— Minneapolis, Minnesota, and Muzaffar Ahmad— Cleveland, Ohio
443
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Lung
Protective Ventilatory Strategies for
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ARDS
M
445
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447
nEW! Orientation &
Competency Manual
DEW! Uniform Reporting
Manual for Subacute Care
The Orientation and Competency Assurance
Manual for Respiratory Care provides the
information, assessment tools, and models
necessary to demonstrate that the competence
of employees is documented according to JCAHO
requirements.
Item BK55
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determine productivity, track trends in the
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tool to
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The new Respiratory Home Care Procedure Manual
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struction in l.V.-line placement and management.
Contains everything needed to establish a complete
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ASSOCIATE EDITORS
MANAGING EDITOR
Ray Masferrer
D
Richard
RRT
Branson
RRT
R
Dean
Hess PhD
RRT FAARC
Massachusetts General Hospital
University of Cincinnati
Cincinnati, Ohio
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Boston, Massachusetts
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Katherine Kreilkamp
G
Durbin
Jr
MD
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K
Stoller
MD
The Cleveland Clinic Foundation
Cleveland, Ohio
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Charlottesville, Virginia
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D
MD
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Michael
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University'
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R
Celli
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Koga Hospital
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University of California lr\'ine
Long Beach, California
Kurume. Japan
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MD
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Shelley
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University Hospitals of Cleveland
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A Monthly Science
Established
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Rubenfeld
University of Minnesota
University of Arkansas
Minnesota
Seattle,
Washington
Journal
in
1956
The Official Journal of the
American Association for
Respiratory Care
SECTION EDITORS
Hugh S Mathewson MD
L Rau PhD RRT
Drug Capsule
Charles
G
Irvin
Gregg L Ruppel
Joseph
PhD
Richard
MEd RRT RPFT FAARC
PFT Comer
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PhD RRT FAARC
RRT
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Branson
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Patricia
Ann Doorley
Charles
G
Durbin
Jr
Comer
MS RRT
MD
Test Your Radiologic Skill
RRT
RRT
MD
Abstracts
Summaries of
Pertinent Articles in Other Journals
Commentaries, and Reviews to Note
Editorials,
Newer Asthma Therapies
(editorial)— Smith LJ.
Ann
Med
Intern
1999;130(6);531-532.
Prevalence of Acute Respiratory Distress Syndrome after Cardiac Surgery
G, Taylor
Is
KM. Smith
PL. Ratnatunga CP.
J
— Asimakopoulos
Thorac Cardiovasc Surg 1999;1I7(3):620-621.
Informed Consent Always Necessary for Randomized, Controlled Trials?
Robinson W. Randolph A. Morris A.
N
Engl
J
Med
—Truog
RD.
1999;340(10):804-807.
Economic Implications of the Diagnosis of Obstructive Sleep Apnea
1. Ann Intern Med 1999;130(6):533-534,
(editorial)
— Pack Al,
Gurubhagavatula
Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Re-
duce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective
Procedures.
A
American Society of Anesthesiologist Task Force on Preop-
report by the
erative Fasting-Anesthesiology 1999;90(3):896-905.
Preventing Complications during Percutaneous Tracheostomy
Anesthesiology
1
999;9()( 3 ):9
1
8-9
1
— Bouvette M, Fuhrman TM.
9.
The Cuffed Oropharyngeal Airway and Management of
the Difficult
—
Airway
Pate! A,
Pearce A. Anesthesiology l999;90(3):924-925.
The WuScope Technique for Endotracheal Tube Exchange
Mabey MF. Siegel JB. Anesthesiology 1999;9()(3):929-930.
Infection Control in
Long-Term Care: News from the Front
— Andrews
SR, Norcross SD,
— Strausbaugh
LJ.
Am
Infect
J
Control 1999;27(l):l-3.
Team Approach
and Control in the Nursing Home Setting
Quay DRP. Am J Infect Control 1999;27(l):64-70.
to Infection Prevention
brecht H, Shearen C, Degelau
J,
DS underwent SBTs
Large Scale Implementation of a Respira-
the
tory Therapist-Driven Protocol for Ventila-
the implementation process (p
tor
Weaning
— Ely
EW,
Bennett PA, Bowton
year progressed.
increased throughout
RCPs more
<
0.001
).
As
the
often considered
DS (p < 0.00
priately
— Ahl-
perform and interpret
95% of the time,
SBTs exist. Through
DS
S BTs once patients had passed a
Am
J
and physicians ordered more SBTs (46 versus
ticipants in ventilator manageinent,
prospectively investigated the large-scale
65%, p = 0.004). Overall. SBTs were ordered
more often on the medicine than on the surgical
compliance with
We
Respir Crit Care
Med
1999;I59(2):439.
implementation of a respiratory-therapist-driven
(TDP)
.services (81
versus
63%. p =
),
more
a staged implementation
DL. Murphy SM, Florance AM, Haponik EF.
1
data
but significant barriers to
than
process, using periodic reinforcement of
this large-scale
all
par-
improved
weaning pro-
tocol can be achieved.
0.001). likely
117 respiratory
reflecting medical intensivists' prior use of this
Nicotine Nasal Spray with Nicotine Patch for
managing 1.067 pa-
protocol. Important barriers to protocol compli-
with respiratory failure over 9.048 patient
ance were identified through a questionnaire
Smoking Cessation: Randomised Trial with
Blondal T. GudmundsSix Year Follow Up
days of mechanical ventilation. During a 12-mo
(89 respondents, 76%), and included: Physician
son LJ. Olafsdottir
protocol
that included
care practitioners (RCPs)
tients
period,
we
reintroduced a previously validated
protocol that included a daily screen (DS) cou-
pled with spontaneous breathing
and physician prompt, as a
input from a physician or
TDP
without daily
"weaning team." With
graded, staged educational interventions
intervals,
a
95%
RCPs had
a
97% completion
at
2-mo
rate
and
correct interpretation rate for the DS.
The frequency with which
392
(SBTs)
trials
patients
who
passed
RCP inconsisan SBT from the
unfamiliarity with the protocol,
tency
in
seeking an order for
physician, .specific reasons cited by the physician for not advancing the patient to a
SBT, and
lack of .stationary unit assignments by
performing the protocol.
We
conclude
RCPs
that
im-
plementation of a validated weaning strategy
feasible as a
a
is
TDP without daily supervision froin
weaning physician or team. RCPs can appro-
—
BMJ
Gustavsson G, We.stin A.
1999;318(7179):285.
Objective:
To
evaluate the efficacy of using a
nicotine patch for 5
sal
1,
spray for
1
months with a nicotine na-
year. Design: Placebo controlled,
double blind trial. Setting: Reykjavik health centre.
Subjects: 237 smokers aged
living in or
22-66 years
around Reykjavik. Interventions:
Nicotine patch for 5 months with nicotine nasal
Respiratory Care
•
April
1
999 Vol 44
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W9 issue oi AARC
Circle 124
spray for
year (n=
1
placebo spray (n=
included 15
mg
1
1
18) or nicotine patch with
Treatment with patches
19).
of nicotine for 3 months. 10
month, and 5
for the fourth
month, whereas nicotine
available for
up
to
1
—Campos
C, Naguib SS,
Khalil SN. Anesth
Analg 1999;88(2):268.
spray was
Both groups received
Main outcome measure:
than the peak inflation pressure
at the
endotra-
cheal position (P
<
instantaneous
the endobronchial position.
at
0.0001).
The
increase
Monitoring peak inflation pressure while
for the fifth
in the nasal
year.
supportive treatment.
mg
mg
Pediatric Patients
Chuang AZ, Lemak NA,
was
insert-
determine whether endo-
ing an endotracheal tube and during anesthesia
bronchial intubation always causes an immedi-
can help to diagnose endobronchial intubation.
Our purpose was
ate increase in
to
peak inflation pressure and.
if
Implications: Monitoring peak inflation pres-
Sustained abstinence from smoking. Results:
so, the
chil-
sure while inserting an endotracheal tube and
The
dren scheduled for central line placement for
during anesthesia can help to diagno.se endo-
prolonged antibiotic administration comprised
bronchial intubation.
log rank lest for 6 years (X-=8.5.
shows a
significant as.sociation
P=0.004)
between
absti-
nence from smoking and type of treatment. Sustained abstinence rates for the patch and nasal
spray group and patch only group were 51*^ v
35%
after
6 weeks (P=0.01
dence interval
(X"),
3.32%),
to
95% confi37% v 25%
months (P=0.045, 1.017c
after 3
31%v 16%
after
27%
4.50%),
1.50%
17%
1.
1
to
V
1
3.08%),
to
6 months (P=0.005, 1.27%
1%) after 12
6.14%), and
16%
to
months (P=0.001.
v
9%
rates
show
the study group. After routine premedication
and induction of anesthesia (halothane
gen), an endotracheal tube
position
was
was
inserted,
in
oxy-
and
verified
by auscultation and
fluo-
roscopy. Children were mechanically ventilated
using a preset volume pressure-limited ventilator with a
5-L fresh gas flow. All children
re-
tidal
volume using a similar
circuit, similar tubing,
and a similar compres-
ceived a constant
sion volume.
The lowest peak
that the
sure to deliver a tidal
inflation pres-
volume of 15 mL/kg was
combination of using a nicotine patch for 5
months with a nicotine nasal spray
a
more
effective
u.sed.
for
than using a patch only.
few relapses during
gest that
it
is
year
is
The low percentage of
participants using the nasal spray at
the
1
method of stopping smoking
1
year,
and
the second year, sug-
not cost effective to use a nasal
spray for longer than 7 months after stopping a
patch.
Endobronchial Intubation Causes an Immediate Increase in
Peak
Inflation Pressure in
tidal
How Does Home Management of Asthma Ex-
its
acerbations by Parents of Inner-City Chil-
6 years
after
(P=0. 077, 0.93% to4.72%). Conclusions: Short
and long term abstinence
magnitude of the increase. Fourteen
After adjusting the respiratory rate (end-
CO, 30 mm Hg) and anesthetic
level (halo-
thane end-tidal 1.2%), the peak inflation pres-
dren Differ from
mendations?
McCourt MP,
NHLBI
Guideline Recom-
— Warman
Stein
REK.
KL,
Silver
Pediatrics
EJ,
1999;
103(2):422.
Objectives.
ity,
I
)
To
describe the asthma morbid-
primary care practices, and asthma
management of
ma: 2)
to
home
inner-city children with asth-
determine the responses of parental
caretakers to asthma exacerbations in theirchild:
and
3) to
compare these responses
to the rec-
was recorded.
ommendations of the National Heart. Lung, and
The endotracheal tube was advanced into a bron-
Blood Institute (NHLBI) asthma guidelines for
home management of acute exacerbations of
sure at this endotracheal position
chus, the position
was
verified as above,
and
peak inflation pressure was recorded. The en-
asthma. Design and Methods.
dobronchial tube was then pulled back into the
phone survey was administered between July
trachea,
and placement of the central
ceeded.
The peak
line pro-
inflation pressure at the en-
dobronchial position was significantly greater
Respiratory Care • April 1999 Vol 44
No 4
1996 and June 1997
of 2- to
1
to
220
2-year-old children
pitalized with
asthma
at
A
64-item
tele-
parental caretakers
who had been
hos-
an inner-city medical
393
en
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www.nellcorpb.com
A-FRM282-00
Rev.
A
(1/98)
Abstracts
center from January. 1995 to February, 1996.
years (range 1-21 years) had a sensor placed.
Sociodemographics. primary care practices.
Sensors were
asthma morbidity, and asthma home manage-
hours. Eighteen patients underwent continuous
ment were assessed. Parents were asked what
they would do if their child "began wheezing
monitoring for
and breathing
measures indicated
bidity
±
average of 2.5
asthma
visits for
in the
18.1
±
were an
that there
emergency department
4.5
la.st
6 months,
hospitalizations for a.sthma in the last
and
Mor-
faster than usual." Results,
1
1
±
.6
17.9 asthma-related school absences
previous school year. Most, but not
in the
2.2
2 months,
all.
of
in place for a
plications.
A
Controlled Trial of Exercise Rehabilita-
of blood gas samples obtained. The
gawa JA, Leaf DA, Lee N, Gleeson MP, Liu H,
sion for
mm
6.3
pH was
pH
ings and the blood gases were
<
PO, 0.813 (P
0.01 for
plications
Hg. The
mm
BACKGROUND: In patients who have received
a cardiac transplant, the denervated donor heart
<
70
mm Hg
responds abnormally to exercise and exercise
Hg. There were no com-
(51%) reported having been given a written
asthma action plan. Only 30% of families with
blood gas monitoring allowed immediate rec-
children age 5 years and older had peak flow
continuous
The
ognition of clinical changes. Conclusion.
blood gas sensor
is
capable
tolerance
reduced. The role of physical ex-
is
undergone cardiac transplantation has not been
We
determined.
assessed the effects of training
on the capacity for exercise early
METHODS:
transplantation.
had equipment for inhalation of P-agonists, Only
This technology provides the clinician with im-
tients
39%
mediate data that can allow rapid interventions
after receiving a heart transplant
of the 181 children with persistent symp-
toms were receiving daily antiinflammatory
recommended
agents as
NHLBI.
in the
in
who were
discharged within two weeks
assigned to participate
unstable patients.
guidelines of the
after cardiac
Twenty-seven pa-
of clinically accurate blood gas measurements.
families
who have
ercise in the treatment of patients
(97%)
all
I999;340(4):
272.
The
values).
from sensor placement. Continuous
arterial
MA, et al. N Engl J Med
Hamilton
PCO,
960,
0.
all
and precision for PO, levels
bias
mm
between the sensor read-
correlation (r value)
0,927,
bia.s/preci-
0.005/0.030; for PCO,, -1.8/
Hg; and for PO,, 1.2/24
had phone access
meters. In contra.st, almost
— Kobashi-
tion after Heart Transplantation
1
were 0.057/9.34
them. Half of the families
no
until
who were at high risk of intubation-related com-
longer clinically necessary. There were 4 4 pairs
the families had primary care providers and most
to
±62
101
24 hours or
least
at
mean of
cardiac-rehabilitation
in a
were randomly
six-month structured
program (exercise group,
of an acute
Noninvasive Ventilation for the Treatment
14 patients) or to undergo unstructured therapy
exacerbation of asthma, no one mentioned that
of Acute Respiratory Failure in Patients with
at
they would refer to a written plan, only
Hematologic Malignancies:
taker
In response to the scenario
1
care-
would measure peak flow and 36% would
give /3-agonists.
Two
steroids initially,
and
percent would give oral
additional person
1
would
wheezing continued 40 minutes
do so
if
Only
4%
responded
that they
their clinician. Reports
would contact
dif-
more
in
aerobic training under the guidance of a phys-
Med
1998;24(I2):1283.
OBJECTIVE: To
evaluate treatment with non-
mask
invasive ventilation (NIV) by nasal
as an
home
are not
af-
respiratory failure to decrease the risk of
DESIGN: Pro.spective clinical study.
SETTING: Hematologic and general intensive
care unit (ICU), University of
Rome "La
Sapi-
PATIENTS: 6 consecutive patients with
enza".
1
was delivered
BiPAP
INTERVENTIONS: NIV
mask by means of a
USA); we eval-
via nasal
ventilator (Respironics,
uated the effects on blood gases, respiratory
rate,
and hemodynamics along with tolerance,
com-
bination of opto-chemical and fiber-optic de-
MENTS AND RESULTS:
showed
gases and respiratory rate within the
blood
first
24 h
temperature on a continuous basis via a sensor
P^q/F,,,, (fractional inspired oxygen) ratio, and
To evaluate this
patients who would nor-
pling.
Design.
which the
A
arterial
blood gas sam-
criterion standard study
results of arterial
in
blood gas samples
measured by the laboratory analyzer were compared with the sensor readings. Setting.
A
pe-
oxygen saturation significantly im-
arterial
proved
after
1
h of treatment (43± 10 vs 88 ±37
mmHg; 87±22
vs
the
ICU
charged from the
center. Patients. Children with severe respira-
a
who required frequent arterial blood
who had a 20-gaugc arterial
gas sampling and
line in either a radial or
femoral
site.
Results.
Twenty-four patients with a mean age of 6.4
396
±9
vs
95±4%,
mean
charged
<
0.01
failure,
ICU
Five patients died
in
while
1
1
were
days and were
good condition from
dis-
dis-
the hospital.
by nasal mask proved
be feasible and appropriate for the treatment
of respiratory failure
in
mL
per kilogram per minute [18 percent];
P=0.01) and workload (mean
[59 percent]
12
v.s.
W
and a greater reduction
[1
1
W
P=0.01)
in the ventilatory
equiv-
(mean decrease,
13 [20
alent for carbon dioxide
percent] vs. 6
increase. 35
]18 percent];
percent!; P=0.02).
The mean
dose of prednisone, the number of patients taking antihypertensive medications, the average
number of episodes of
rejection
tion during the study period,
and of infec-
and weight gain
diac tran.splantation, exercise training increases
the capacity for physical work.
Improvements in Lung Function, Exercise,
and Quality of Life in Hypercapnic COPD
Patients after
gery
Lung Volume Reduction SurS, Kuzma AM,
—O'Brien GM, Furukawa
Cordova
F,
Criner GJ. Chest 1999;
1
15(l):75.
in
in stable condition after
stay of 4.3 ±2.4
CONCLUSIONS: NIV
to
).
following complications independent
of the respiratory
diatric intensive care unit of a tertiary referral
tory failure
I75±64; 81
respectively) and continued to improve in the
following 24 h (p
per kilogram
CONCLUSIONS: When initiated early after car-
in
of treatment. Arterial oxygen tension (Pao,).
placed in an artery. Objective.
mL
of body weight per minute |49 percent] vs. 1.9
did not differ significantly between the groups.
improvement
a significant
peak oxygen con-
MEASURE-
measure pH, PCOj, PO,, and
in pediatric
sig-
later.
15 of the 16 patients
complications, and outcome.
Context. Continuous arterial blood gas monithe
tol-
acute respiratory failure complicating hemato-
and caretaker practices.
mally require frequent
had
sumption (mean increase, 4.4
Use of Continuous Arterial Blood
technology
with
hem-
Gas Monitoring in the Pediatric Intensive
Care Unit— Weiss IK. Fink S, Harrison R, Feldman JD, Brill JE. Pediatrics 1999;103(2):440.
tectors that can
and
RESULTS: As compared
nificantly greater increa.ses in
guidelines for the
new technology based on
months
base line (with-
after heart transplantation)
the control group, the exercise group
logic malignancies.
a
one month
at
hematologic malignancies complicated by acute
being followed. Interventions are needed to
is
in
Cardiopulmonary
training.
was performed
ventional mechanical ventilation in patients with
management of asthma exacerbations
toring
stress testing
in
erance.
Clinical
whereas control patients received
ical therapist,
no formal exercise
6 months
response to the sce-
indi-
Lappa A, Rosa G, Gasparetto A. Intensive Care
ously hospitalized inner-city children with
fect both clinician
group underwent an
vidualized program of muscular-strength and
orrhagic complications and increase clinical
NHLBI
Each pa-
(control group, 13 patients).
Conti G, Marino P, Cogliati A, Dell'Utri D,
nario. Conclusion. In this population of previ-
asthma, the
home
tient in the exercise
six
people began /3-agonists and oral steroids
than said they would
—
alternative to endotracheal intubation and con-
fered from the scenario responses in that
in the past
Study
Pilot
later.
of actual practice
response to an exacerbation
A
hematologic patients
STUDY OBJECTIVE: To
determine the im-
pact of preoperative resting hypercapnia on patient
tion
outcome
after bilateral lung
surgery
(LVRS).
volume reduc-
METHODS: We
prospectively examined morbidity, mortality,
quality of
life
(QOL), and physiologic outcome,
including spirometry, gas exchange, and exercise
performance
in 15 patients with severe
em-
No 4
,
Abstracts
physema and
(group
1
from 3
>
of
mm
45
<
patients with a Paco, "f
1
(group
a resting P„co,
Hg
and compared the results with those
).
RESULTS:
2).
QOL
ologic and
mm
45
Hg
All preoperative physi-
indices were
more impaired
in
the hypercapnic patients than in the eucapnic
The hypercapnic
did not have access to the results of the baseline
when making
evaluations
their severity as.sess-
SETTING AND PARTICIPANTS:
ments.
mem-
Study participants were 193 asthmatic
bers (age range, 6 to 55 years) of a large health
who underwent
maintenance organization
a
77±9
hypopnea) of
MEASURE-
events/h.
MENTS AND RESULTS:
The
was assessed by administering
quality of life
a Medical Out-
comes Study Short Form-36 questionnaire before and after 8 weeks of nCPAP therapy in
polysomnographically documented OSA. All di-
patients exhibited a
baseline evaluation as part of a separate longi-
mensions of the quality of
lower preoperative FEV,, a lower diffusing ca-
tudinal study. This evaluation consisted of spi-
cantly impaired
pacity of the lung for carbon monoxide, a lower
rometry, skin prick testing, and a survey that
and gender-matched population, expressed as a
symptoms and medica-
percentage of normative data: physical func-
participants in the ancillary study
86 of
75%; vitality, 41%: role functioning
54%; emotional, 61%; social. 66%);
general health. 88%: and mental health. 76%.
nCPAP therapy significantly improved the
had mild disease, 90
sleep-disordered breathing and sleep fragmen-
patients.
of ?„„, 'o the fraction of inspired oxygen,
ratio
included questions on
The
a lower 6-min walk distance, and higher oxy-
tion use.
gen requirements. However,
were selected, based on
after surgery both
groups exhibited improvements
<
0.0 1
group
1 ,
p
1,
p=0.04; group
:
2,
2,
pacity
(TLC; group
0.001
residual
),
group
p
2,
<
0.001),
p=0.03; group
RVATLC
2,
2,
at
p=0.02; group
2,
p
2,
<
<
0.001).
1
time
p=0.02), and the
1,
However, be-
the spirometry, lung vol-
disease, and 17
(9%) had
correlated highly (p
£
NAEP-
0.013) with
based indices of severity based on oral glu-
tioning,
(physical,
tation.
The nCPAP
9.4±0.7
cm H,0.
apy improved
tude of improvement
predicted, and
80%
was
related to the degree
impairment prior
to treatment,
mea-
rather than to the severity of disease as
sured by the
RDI and
asthma symptoms
CLUSIONS:
All aspects of the quality of
(S once/week,
A
to
life
<60% predicted). It did not, how-
ever, correlate with current
(p=0.87).
60
ther-
(90%), and mental health (96%). The magni-
of quality of
predicted,
group was
nCPAP
(75%), social functioning
vitality
frequently for attacks, and daily use) and on
> 80%
for the
level
Eight weeks of
cocorticoid use (never, infrequently for attacks,
spirometry (FEV,
signifi-
2 to 6 times/week, daily)
composite severity score based on
spirometry and the glucocorticoid use data
still
provided an overall agreement of 63%, with a
arousal indices.
from physical and emotional health
CON-
OSA.
functioning, are markedly impaired by
nCPAP
life,
to social
therapy improved those aspects related
and mental
to vitality, social functioning,
health.
CONCLUSIONS:
weighted kappa of 0.40.
sig-
While current symptoms are the most important
Noninvasive Positive Pressure Ventilation:
in the
hypercapnic
concern of patients with asthma, they reflect
Successful
There was no difference
in mortality
the current level of asthma control
umes, and 6-min walk distance remained
nificantly lower
patients.
(45%) had moderate
ity
I,
both groups, and the hypercapnic group
ilar in
the chart review,
the study subjects (45*^)
(group
cause the magnitude of improvement was sim-
was more impaired,
broad range of asthma severity.
RESULTS: Based on
severe disease. This physician-assessed sever-
scores (group
0.001).
tion, to reflect a
p=0.002;
total exercise
QOL
p
2,
1 .
peak exercise (group
p=0.02),
perceived overall
p=0.001: group
(group
,
ratio
p = 0.005; group
I.
p=0.02; group
I,
).
< 0.001), ?,„,, (group I,
p=0.02), 6-min walk dis-
p
2,
oxygen consumption
(group
1
volume (RV; group
p=0.002; group
tance (group
FVC
in
< 0.00 FEV (group
p < 0.001). total lung ca1, p=0.02; group 2. p <
p
their baseline evalua-
were
life
when compared with an age-
post-LVRS
between the groups (p=0.9).
CONCLUSIONS;
underlying disease severity. Investigators must
Patients with moderate to severe resting hyper-
therefore use caution
capnia exhibit significant improvements
of patients for
in spi-
more than
whom
when comparing groups
severity categorization
Outcome in Patients with Acute
Lung Injury/ARDS Rocker GM, Mackenzie
MG, Williams B. Logan PM. Chest 999; 115(1):
—
1
173.
is
QOL. and ex-
based largely on symptomatology. This obser-
BACKGROUND:
LVRS. The
for the use of noninvasive positive pressure ven-
erative lung function are related to preoperative
symptoms alone do not reflect disease severity, becomes even more important as
health-care delivery moves closer to protocols/
however, the magnitude of
practice guidelines and "best treatment" pro-
rometry, gas exchange, perceived
performance
ercise
after bilateral
maximal achievable improvements
level of function;
improvement can be expected
in
postop-
to be similar to
patients with lower resting P„co, levels. Patients
on the presence of resting hypercapnia.
The long-term
benefit of
LVRS
grams
that rely heavily
on symptoms
in
hypercapnic
patient remains to be determined.
II5(1):85.
validate three indi-
cators of asthma severity as defined in the Na-
Asthma Education Program (NAEP)
guidelines
(ie,
frequency of symptoms, degree
of airflow obstruction, and frequency of use of
oral glucocorticoids), alone
and
against severity as assessed by
cialists
data.
in
combination,
pulmonary spe-
provided with 24-month medical chart
DESIGN:
Cross-sectional comparison of
increasing support
treatment of patients with
in the
acute respiratory failure. Highest success rates
are recorded in patients with exacerbation of
COPD,
particularly in patients presenting pri-
cess has been
more limited
in patients
with acute
hypoxemic
respiratory failure, and there are
Sleep Apnea: Effect of Nasal Continuous Pos-
reports of
NPPV
Airway Pressure:
A Prospective Study —
T,
Mohsenin V. Chest
1999:1 15(1): 123.
in
(OSA)
common
a
is
referral center
condition and
TERVENTION:
a.ssociated
with
psychological dysfunction. There
(range)
life
tive
and
its
OSA
limited ev-
response to nasal continuous posi-
airway pressure (nCPAP) treatment.
STUDY OBJECTIVE: To
of
is
on the quality of
nCPAP
PA-
29 patients (23 were male
and 6 were female) with a mean (±SE) age of
mass index 36.3 ±2.0
asthma severity with physician-assessed sever-
kg/height m", and a diagnosis of
spiratory disturbance index
No 4
OSA
with re-
(RDI; apnea/
II
score
was 16
(11 to 29).
further assisted ventilation for 72 h)
was
achieved on six of nine occasions (66%) when
ventilation.
We studied
in patients
Success rate (avoidance of intubation and no
NPPV was
effect in a case-series analysis.
TIENTS:
NPPV
APACHE (acute physiology and chronic
patients with
life in
Provision of
health evaluation)
Prospective determination of
on the quality of
OSA, DESIGN:
nCPAP
determine the effect
and university hospital ICU. IN-
ALI/ARDS. RESULTS: Group median
with excessive daytime sleepiness and neuro-
idence on the effect of
NPPV. DESIGN:
SETTING: Tertiary
10 patients treated with
Obstructive sleep apnea
is
re-
outcome of 12 episodes of ALI/ARDS
Experiential cohort study.
BACKGROUND:
few
patients with acute lung
ARDS. OBJECTIVES: We
injury (ALI) or
port the
in
4.4 ±2.3 years, a body
based on chart review. The pulmonologists
(NPPV)
is
marily with hypercarbic respiratory failure. Suc-
questionnaire and clinical-based markers of
ity
tilation
There
Quality of Life in Patients with Obstructive
itive
Lack of Correlation of Symptoms with Specialist-Assessed Long-Term Asthma Severity— Osborne ML. Vollmer WM, Pedula KL,
Wilkins J, Buist AS, O'Hollaren M. Chest 1999;
tional
guide
subsequent treatinent decisions.
D'Ambrosio C, Bowinan
STUDY OBJECTIVES: To
to
LVRS based
should not be excluded from
solely
vation, that
used as the
It
initial
mode of
assisted
failed after three epi.sodes of
planned (1) or self (2) extubation. Duration of
successful
with
ICU
NPPV was
discharge
64.5 h (23.5 to 80.5 h)
in the
next 24 to 48 h for
three of six patients. Unsuccessful episodes
lasted 7.3 h (0.1 to 116 h) with
need for con-
ventional ventilation for an additional 5 days
397
Abstracts
(ICU and
(2.7 to 14 days). Survival
hospital)
CONCLUSIONS:
was 70%.
for the 10 patients
group of hemodynamically stable patients
In a
with severe ALI,
NPPV
NPPV
had a high success
rate.
should be considered as a treatment op-
tion for patients in stable condition in the early
phase of ALI/ARDS.
decline in
Effect of Heliox on Nebulizer Function
— Hess
DR. Acosta FL. Rilz RH, Kacmarek RM, Camargo CA Jr. Chest 999; 5{ ): 84.
1
1
1
1
1
OBJECTIVE: To
evaluate nebulizer perfor-
mance when
was used
METHODS:
power
to
the neb-
Conventional and continu-
ous nebulizer designs were evaluated. The
conventional nebulizer was used with 5
buterol and flows of 8 L/min
liox,
10
and
mg
1
1
L/min heliox;
and comparably
it
al-
8 L/min he-
air.
was
mg
also used with
albuterol and a heliox flow of 8 L/min.
L/min heliox;
?
was
it
cotton plug
the nebulizer
at
to trap aerosol during sim-
The amount of
ulated spontaneous breathing.
on the cotton plug was de-
of sepsis and
1994, and
1,
mus-
Weakness was
sys-
cle biochemistry
tematically assessed in
reported frequency of 36 and
SURES: The
HRQL
instruments (Medical
Form Health
.36-ltem Short
Form
[SF-.36]
and
George's
St
Respiratory Questionnaire |SGRQ), respective-
RESULTS:
Clinically meaningful and sta-
tistically significant
reductions in
=
survivors (n
HRQL
scores
73) were seen in 7 of
SF-36 domains and 3 of
SGRQ
3
domains
compared with inatched controls (P< 0.001
reductions).
HRQL
The
were seen
in
largest
decrements
for
in the
physical function and pul-
monary symptoms and
limitations. Analysis of
=
trauma-matched pairs (n
icant reductions in 7 of 8
76%
reported in
lation
number of
patients with various electrophysi-
ologic findings but insufficiently reported clinical correlations.
When powered
tribution to
weaning
inhaled mass of albuterol
46) revealed signif-
£
SF-36 domains (P
Quality of Survival after Cardiopulmonary
vealed significant reductions
in
6 of 8 SF-36
<
Intern
Med
1999:159(3);
acteristics before, during,
monary
outcomes, and to compare results of the quali-
rather than
less for the
air.
time,
how-
0.001). Increasing the flow of heliox
domains (P
(P
disease-specific domains.
BACKGROUND:
of
life
expectancy and quality of
TIVES: To determine
in Crit-
in
METHODS:
terms
OBJEC-
life.
the impact of patient char-
and
after
CPR on these
assessment with published
ty-of-life
Acquired Neuromuscular Disorders
Outcome of cardiopulmo-
nary resuscitation (CPR) can be poor,
In a cohort study,
we
.studies.
assessed by
Patients:
A
and inhaled mass
Groupe de Refiexion
et
Neuro-
functioning, depression, and level of dependence
<
myopathies En Reanimation De Jonghe B.
Cook D, Sharshar T, Lefaucheur JP, Carlet J,
of survivors after inhospital CPR. Follow-up
similar to powering the nebulizer with air at the
lower flow. Increasing the albuterol concentra-
Outin H. Intensive Care
increased the particle size (p
mass of
albuterol (p
of particles
to 5
1
<
0.05),
microm
tion in the nebulizer
(p
<
Arch
249.
marily noted in physical functioning and pul-
the neb-
was more than twofold greater with he-
liox (p
— de Vos R, de Haes HC, Koster
RJ.
con-
when
The nebulization
nebulizer (67%).
ever,
was
(16%) than
and long-term
difficulties
disability are needed.
the continuous
)
with heliox, the reduction in
ventional nebulizer
Evaluation of risk factors for
these disorders and studies examining their con-
£ 0.05) and 3 of 3 SGRQ domains
£ 0.002). CONCLUSIONS: Survivors of
ARDS have a clinically significant reduction in
HRQL that appears to be caused exclusively by
ARDS and its sequelae. Reductions were pri-
and inhaled mass of albuterol de-
was powered with heliox
ulizer
in patients
neuromuscular abnormalities include a small
RW, de Haan
0.001
showed
compared to those without. CONCLUSIONS: Prospective studies of ICU-acquired
Resuscitation
<
studies
ties,
27) re-
creased significantly (p
Two
and a mortality twice as high
=
SGRQ
of cases.
with critical illness neuromuscular abnormali-
Analysis of sepsis-matched pairs (n
particle size
more than
respectively) in duration of mechanical venti-
was determined using an
both nebulizer designs,
patients. In a population of
a clinically important increase (5 and 9 days,
Survey, Standard
all
ICU
by generic and pulmonary
Outcomes Study
ARDS
non-selected
0.003).
RESULTS: For
respectively.
5 days, electrophysiologic abnormalities were
disease-specific
ly).
in
s
pactor.
70%,
patients mechanically ventilated for
domains (P
-stage cascade im-
studies,
Electrophysiologic and histologic abnormalities
0.02) and 3 of 3
1
two of the eight
concerning patients with severe asthma, with a
termined spectrophotometrically. Particle size
1
studies.
MAIN OUTCOME MEAHRQL of ARDS survivors and
1996.
controls, assessed
2
albuterol and a heliox
ARDS
trauma admitted between January
air,
mg
ARDS
mus-
involvement and were frequently reported, even
8
L/min heliox, and
trauma center.
Seventy-three pairs of
clinical risk factors for
flows of 2 L/min
at
I
to
cle relaxants, or because of participation in
consisted of both peripheral nerve and muscle
of albuterol over 40 min
albuterol deposited
or injured controls without
ill
severe asthma while others
failure, or
were selected on the basis of exposure
sur-
mg
A
survivors
organ
sis,
vivors and severity-matched controls with the
of
mouthpiece was used
un-
is
there are
if
ARDS
of
medical and regional level
PATIENTS:
set to deliver 10
flow of 2 L/min.
or other
ARDS. DESIGN: Prospective, matched, parallel cohort study. SETTING: A 41
-bed munic-
The continuous nebulizer was
also used with 20
HRQL
differences in the
July 30,
ulizer.
ARDS
1
Using a Beta-Agonist Bronchodilator
heliox
caused by
is
known. OBJECTIVE: To determine
ipal
The
HRQL
aspects of the patient's illness or injury
0.05), inhaled
0.05) to levels
<
0.05) while maintaining the smaller par-
ticle .size
produced with
SIONS: The use of
III
Systematic Review.
d'Etude sur
les
—
Med
1
998;24(
1
2):
1
242.
and using the lower heliox
flow increased the inhaled mass of albuterol
(p
ically
clinical studies of
CONCLU-
in intensive
power
a nebulizer
IDENTIFICATION
mass of medication and
the size of the aerosol particles.
The flow to
when
power
the nebulizer should be increased
heliox
is
ies
care unit (ICU) patients.
STUDY
AND SELECTION:
were identified through
BASE,
the prospective
neuromuscular abnormalities
that flow.
heliox to
affects both the inhaled
OBJECTIVE: To summarize
Stud-
MEDLINE, EM-
references in primary and review
cles, personal files,
arti-
and contact with authors.
Through duplicate independent review, we
used.
se-
lected prospective cohort studies evaluating
Reduced Quality of Life In Survivors of Acute
Respiratory Distress Syndrome
witli Critically
III
Compared
Control Patients
— David-
son TA, Caldwell ES, Curtis JR. Hudson LD,
Steinberg KP.
JAMA
we
CONTEXT:
Health-related quality of
life
(HRQL) is reduced in patients who survive acute
respiratory distress
398
(ARDS),
but whether this
after discharge
from the
RESULTS: Of
827 resuscitated patients, 12% (n = 101) survived to follow-up. Of the survivors, 89% participated in the study.
dependent
in
Most survivors were
16% had
cognilively impaired, and
in-
17% were
daily life (75%),
depressive
symptoms. Multivariate regression analysis
showed
that quality
of
life
and cognitive func-
were determined by 2 factors known be-
tion
fore
CPR-the reason
tors during
for admission
and age. Fac-
and after resuscitation, such as
nificantly determine the quality of life or cog-
tures, the population, clinical
242
months
(tertiary care center).
prolonged cardiac arrest and coma, did not sig-
abstracted key data regarding design fea-
SULTS:
at least 3
ho.spital
DATA
and laboratory
di-
nitive functioning of survivors.
life
of our
CPR
survivors
The
quality of
was worse compared
RE-
with a reference group of elderly individuals,
We identified eight studies that enrolled
but better than that of a reference group of pa-
agnostic tests, and clinical outcomes.
1999;281(4):.\54.
was
cognitive
life,
In duplicate, independently,
ICU-acquired neuromuscular disorders.
ABSTRACTION:
formal instruments the quality of
patients.
Inception cohorts varied;
were mechanically ventilated patients
some
for
a
5
days, others were based on a diagnosis of sep-
tients with stroke.
The
quality of
life
did not
importantly differ between the compared studies
of
CPR
Respiratory Care
•
survivors.
CONCLUSIONS:
April 1999 Vol 44
Car-
No
4
superior aerodol therapy across
the care
contuuuim
MDILog'
Electronic
monitors for
aerosol delivery
The device provides
to
Records date and time
tfie ability
of
each use and
evaluates technique
monitor compliance and
record true delivery and
Reduces lengths
evaluate patient technique.
staff productivity
These features make
Transmits data for analysis/
of stay
and increases
devices
disease
management
asthma and COPD
it
the ideal
storage with fast wireless
tool for'
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patients.
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in
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delivery of
use, the Circulaire's
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inhaled
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ttie
lungs
concentrated drug
patented distensible drug
Ideal for protocol-based
reservoir minimizes waste
delivery
while
Virtual elimination of systemic reaction to
it's
tailors
variable resistor
beta stimulators
treatment to individual
"Biofeedback" gauges encourage
pediatric/ adult patient needs.
^
maximum
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Abstracts
diopulmonary resuscitation
cessful, but
good
if
survival
quality of
CPR
life after
is
frequently unsuc-
achieved, a relatively
can be expected. Quality of
life
is
is
mostly determined by factors
known before CPR. These
may be help-
findings
informing patients about the outcomes of
ful in
for
48 h
spontaneous breathing
after a
not differ in the
and 120-min
.30-
The 30- and 120-min
9%,
and in-hospital mortality
respec-
and
rates (19
CPR.
18%, respectively). Reintubation was required
Contaminated Aerosol Recovery from Pulmonary Function Testing Equipment
higher mortality (20 of 61, 32.8%) than did
(13.5%)
in 61
—
Hiebert T. Miles
Med
Care
Crit
J,
Am
Okeson GC.
Respir
J
patients
4.6%)
who
<
(p
tolerated extubation (18 of 392,
measurements of
0.001). Neither
pressure, and
oxygen
saturation during the
trial,
Clinically, the spread of infectious agents be-
nor other functional measurements before the
tween subjects undergoing spirometry
trial
uncommon. There
in the
is
is
quite
almost no documentation
medical literature on
We
this subject.
studied the retrieval of nonpathogenic Escherichia coli after aerosolizing
organisms into stan-
dard pulmonary function tubing of a type that
is
who
discriminated between patients
quired reintubation from those
who
extubation. In conclusion, after a
re-
tolerated
of
first trial
end of the
arrival of the aerosol at the distal
tubing was documented by culture. After delays of 0, 1,5,
forcibly
and
min. respectively,
1
air
was
withdrawn from the proximal end of
the tubing through a special petri plate assembly.
The
plates
after insufflation of
30 and
last
— Diehl JL, Atrous SE, Touchard D, Le-
Med
Am
Brochard L.
niaire F,
Respir Crit Care
J
is
widely performed on ventila-
on
ratory mechanics have not been studied.
-min delay, the proximal
samples contained only rare organisms.
ganisms were recovered from proximal
ples after a delay of 5 or 10
tion of organisms.
min
No
air
or-
sam-
after insuftla-
The absence of
detectable
aerosolized E. coli after delays of 5 and 10 min
Thus, detecting hypoxemia
portance
SCD, To
in
in
SCD, we compared 22
surements of
oxygen
arterial
with
in adult patients
SCD
saturation
(S.,,,,2
its
effects
readings only
breathing
and
after
(WOB)
the procedure,
we
graphic waves on the oximeter screen.
sess
of
position
the
also
We
.shifted
+
5
cm
(PS-5). After
compared
the resistive
lowed between
0.05).
tests.
Du-
Effect of Spontaneous Breathing Trial
Outcome
ration on
of Attempts to Discon-
tinue Mechanical Ventilation
Alia
1,
Tobin MJ, Gil A, Gordo
Am
et al.
J
Respir Crit Care
— Esteban
Med
A,
Vallverdu
F,
1
I,
999; 159(2):
WOB
±
after
0.4 to 0.4
and for PS-5 (1.4 ± 0.6
percentage points), but
it
almost always accu-
rately estimated S.,„, (underestimating
age by
1
.
1
was
was never enough
to classify a
PS-B, p
± 92
<
to
80
and
surements decreased significantly
The duration of spontaneous breathing
trials
be-
fore extubation has been set at 2 h in research
studies, but the optimal duration
is
not known.
conducted a prospective, multicenter study
involving 526 ventilator-supported patients considered ready for weaning, to
outcomes for
trials
compare
270 and 256
clinical
of spontaneous breathing
with target durations of 30 and
trial
0.3 J/L,
also observed in
± 56 cm H2O
0.05). Resistive
1
20 min. Of the
patients in the 30-
and 120-min
groups, respectively, 237 (87.8%) and 216
(84.8%), respectively, completed the
out distress and were extubated (p
=
trial
with-
0.32); 32
(13.5%) and 29 (13.4%), respectively, of these
patients required rcintubalion within
percentage of patients
400
who remained
48
h.
The
extubated
PS-5.
A significant reduction
in
mus-
s/min for
•
(PEEP) was
tions, with
pattern.
as long as strong
We
conclude
that,
and regular photoplethysmo-
at
PS-B and
occlusion
also ob.served for
no significant change
all
pre.s-
condi-
in breathing
Three patients had ineffective breath-
ing efforts before tracheotomy, and
all
proved synchrony with the ventilator
emia or normoxemia
in
SCD.
As-Required Versus Regular Nebulized Salbutamol for the Treatment of Acute Severe
—
Bradding P, Rushby I. Scullion
Morgan MD. Eur Respir J 1999;I3(2):290.
Asthma
J,
work
elastic
sure and intrinsic positive end-expiratory pressure
hypoxemic pa-
erroneously as normoxemic or a normox-
be relied upon not to misdiagnose either hypox-
±
to 0.6
the pressure-time index of the respiratory
cles (181
on aver-
percentage points). The error in Spo,
graphic waves are present, pulse oximeters can
-I-
significant reduction
mm
<
0.2 J/L, p
p < 0.05), with a near-significant reduction for
PS 5 (0.5 ± 0.5 to 0.2 ± 0.1 J/L, p = 0.05).
A
and
right-
tracheotomy
±
computed from transpulmonary pressure mea-
512.
We
in
significant reduction
was observed
0.9
(S.,„,
found
oxyhemoglobin dissociation curves, with
in the
A
We
pH-corrected p50s ranging from 28 to 38
cur during routine pulmonary function testing
bench study.
PS-B (from
as-
hemoglobin percentage (by an average of 3.4
levels of pressure
cm HjO
5
-
respi-
emic patient as hypoxemic.
for
To
patients'
and venous oxygen saturation
(ETTs) and by a new tracheotomy cannula
is al-
these
Svo,) against oxygen tension.
an
min or more
accepted Spo^
and regular photoplethysmo-
terized by strong
transfer of aerosolized organisms does not oc-
in vitro
We
tracheotomy during
at three identical
(PS + 5), and PS
arte-
divided
Hg. Pulse oximetry slightly overestimated oxy-
support (PS): baseline level (PS-B), PS
H,0
drawn
they were stable and charac-
if
tubing supports the hypothesis that a significant
as long as an interval of 5
saturation (Sp,,,)
and acute vasooc-
in eight
measured the work of breathing
patients before
hypoxemia
= oxyhemoglobin
tient
of organisms into spirometry
of particular im-
pulse oximetric mea-
work induced by the patients' endotracheal tubes
after insufflation
is
assess the accuracy of
pulse oximetry in the diagnosis of
arterial
Tracheotomy
tor-dependent patients, but
I
(SCD) and may
oxyhemoglobin dissociation curves, we plotted
1999;159(2):383.
ing had counts similar to the air sampled at the
After a
disease
in sickle cell
exacerbate microvascular occlusive phenomena.
measured by co-oximetry.
Changes in the Work of Breathing Induced
by Tracheotomy in Ventilator-Dependent Patients
999;
by oxyhemoglobin plus reduced hemoglobin)
20 min.
1
1
Pulmonary complications and hypoxemia are
common
rial
geted to
Med
Respir Crit Care
159(2):447.
clusive crisis with simultaneously
effectively with trials tar-
organisms, air withdrawn from the proximal tub-
distal end.
Am J
Benjamin LJ.
was achieved equally
were cultured and the colonies
were counted. Immediately
Accuracy of Pulse Oximetry in Sickle Cell
Disease— Ortiz FO, Aldrich TK, Nagel RL,
spontaneous breathing, successful extubation
frequently used by volume-sensing spirometers.
The
dent patients.
and these patients had a
patients,
respiratory frequency, heart rate, systolic blood
1999;I59(2):610.
the mechanical workload of ventilator-depen-
0.43).
groups had similar
trial
within-unit mortality rates (13 and
tively)
groups
=
(75.97c versus 73.0%, respectively, p
did
trial
trial
Current British guidelines for the administration of (32-agonists in acute severe
ommend
asthma rec-
regular nebulized therapy in hospital-
ized patients, followed by as-required (p.r.n.)
use via hand-held devices after discharge. Since
do not possess anti-intlammalory
/32-agonists
activity in vivo,
had im-
ence the
after the
erbation,
rate
it
and are thus unlikely
to influ-
of recovery from an asthma exac-
was hypothesized
that patients
given
procedure. In vitro measurements
the short-acting (32-agonist salbutamol on an
ETTs removed from
as-required basis after admission to hospital
the
made with
patients, with new
ETTs, and with the tracheotomy cannula showed
that the
cannula reduced the resistive work
duced by the
.sults
in-
would recover
as quickly as those
on regular
treatment, but with potential reductions in the
dose delivered. Forty-six patients with
artificial
airway. Part of these re-
total
was explained by
a slight, subtle reduction
acute severe asthma were randomly assigned to
of the inner diameter of used ETTs.
We
con-
clude that tracheotomy can substantially reduce
either regular prescriptions of nebulized salbu-
tamol or to usage on a
Respiratory Care
•
p.r.n. basis,
April 1999
from 24 h
Vol 44 No 4
.
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Abstracts
The primary outcome
after hospital admission.
measures were length of hospital
stay,
time to
admission to
first
consideration of the diagnosis
(suspicion interval),
first
consideration and treat-
recovery, and frequency of salbutamol nebuli-
ment
zation from 24 h after admission to discharge.
sion and treatment initiation (overall
Secondary outcome measures were treatment
ment
and patient
side-effects (tremor, palpitations),
Length of hospital stay was reduced
satisfaction.
in those patients allocated to
(geometric
mean (GM)
salbutamol
(GM
3.7 days) versus regular
same
Time taken
4.7 days).
expiratory flow to reach
the
p.m. salbutamol
75%
for
of recent best was
number of times
nebulized therapy was delivered to the
(GM
regular treatment group
p=0.003;
GMs
less
95%
(GM
14.0,
range 4-57;
confidence interval for ratio of
1.29-3.09). In addition, patients reported
tremor (p=0.062) and fewer palpitations
(p=0.049)
in the p.r.n. group.
who had
the p.r.n. group
Of the
patients in
received regular neb-
ulized therapy on previous admissions
all
p.r.n.
1-30) compared with the
7.0, range
(n=
12),
preferred the p.r.n. regimen. Prescribing fi2-
agonists on a p.r.n. basis from 24 h after hospital
admission
amount of drug
effects,
is
associated with reduced
delivered, incidence of side-
and possibly length of hospital
stay.
This has implications for the efficient use of
1
kg
1
.
in the
combined-treatment group (P<0.05). Weight
gain
at
seven weeks was significantly less
in
the combined-treatment group than in the bu-
defined as intervals longer than 24 hours. RE-
propion group and the placebo group (P<0.05
SULTS: The
for both comparisons).
interval)
management
overall
dian. 6 days [5th
[95%
68.9%
CI,
terval (median,
1
1
to 80.9%]).
(26.6%
20.5%
cations. Seventy-nine subjects stopped treatment
The suspicion
in-
54 pa-
in
to 32.7%]),
and the
and 51 days]) was prolonged
in
because of adverse events: 6 in the placebo group
16 in the nicotine-patch group
(3.8 percent),
29
(6.6 percent),
in the
verse events were insomnia and headache.
CLUSIONS: Treatment
bupropion alone or
respectively.
smears
The 55
24.1%) of
to
patients with
were positive for acid-fast
that
bacilli
had a median treatment interval of 3 days (5th
and 33 days);
and 95th percentiles,
of patients (CI, 45.2% to 71.2%),
exceeded 24 hours.
than delays
CONCLUSIONS: Delays
common
in the initial
suspicion of tubercu-
Both types of delays were
in
ad-
CON-
with sustained-release
combination with a nic-
otine patch resulted in significantly higher long-
term rates of smoking cessation than use of
Ab-
either the nicotine patch alone or placebo.
stinence rates were higher with combination
therapy than with bupropion alone, but the dif-
was not
ference
statistically significant.
this interval
of treatment were more
in initiation
losis.
58.2%
in
(1 1.9
common
group (11.4 percent). The most
management delays of more than 10
and 25 days occurred in 33.5% (CI, 27.0% to
40.0%) and 18.7% (CL 13.3%
bupropion group
percent), and 28 in the combined-treatment
130 patients (64.0% [CI, 57.4% to 70.6%]).
Overall
patients,
subjects
1
52 patients (74.9%
treatment interval (median, 3 days [5th and 95th
percentiles,
of 31
total
(34.8 percent) discontinued one or both medi-
1
day [5th and 95th percentiles,
[CI,
A
and 52
and 16 days]) exceeded 24 hours
tients
(me-
interval
and 95th percentiles,
days]) exceeded 24 hours in
in patients
healthcare resources.
manage-
group, a gain of 1.7 kg in
the bupropion group, and a gain of
were determined. Delays were
There was a highly
in both groups.
significant reduction in the
group
peak
and admis-
initiation (treatment interval),
in the nicotine-patch
common
even
Oxygen Treatment on Heart Rate
Abdominal Surgery Rosenberg-Adam-
Effect of
—
after
sen S, Lie C, Bernhard A, Kehlet H, Rosenberg
with disease that was confirmed by
J.
Anesthesiology 1999;90(2):380.
a positive smear. These data illustrate a need
Human Lung Volumes and
that Set
Them— Leith
the
Mechanisms
DE, Brown R. Eur Re-
spirJ 1999;13(2):468.
Definitions of
mechanisms
human
that
.set
improved education of physicians about the
benefits of early initiation of therapy for tuberculosis.
lung volumes and the
them
are reviewed in the
context of pulmonary function testing, with
at-
tention to the distinction between functional residual capacity
for
(FRC) and
the static relaxation
A
BACKGROUND:
common
may be
the respiratory system,
circumstances
ume
in
which
FRC
and
propion, a Nicotine Patch, or Both for
Smok-
—
ing Cessation
Jorenby DE. Leischow SJ,
Nides MA, Rennard SI, Johnston JA, Hughes
AR,
et al.
N
Engl
J
Med
after operation
cial effect
and residual vol-
BACKGROUND AND METHODS:
Use of nic-
mechanisms. Related terms, conventions, and
We
some common
sant bupropion helps people stop smoking.
conducted a double-blind, placebo-controlled
at-
comparison of sustained-release bupropion (244
tention to "gas trapping", "hyperinflation", and
subjects), a nicotine patch (244 subjects), bu-
semantic and conceptual difficulties, with
propion and a nicotine patch (245 subjects),
"restriction".
and placebo
Delays in the Suspicion and Treatment of
Among Hospitalized Patients
—
Rao VK, lademarco EP, Eraser VJ, Kollef MH.
Ann
Intern
Med
tion.
(
1
60 subjects)
Smokers with
bupropion (150
as well as eight
Despite increased awareness
of tuberculosis, delays in
management
are
com-
for
smoking cessa-
clinical depression
were ex-
cluded. Treatment consisted of nine weeks of
mg a
mg
days, and then 150
1999;130(5):404.
BACKGROUND:
METHODS: The
saturation and heart rate.
oxygen saturation and heart
(21
mg
mg
day for the
three
first
twice daily) or placebo,
weeks of nicotine-patch therapy
per day during weeks 2 through 7, 14
per day during
week
8,
and 7
mg
per day
double blindly allocated to receive
after
or oxy-
and fourth day
major abdominal surgery.
RESULTS: The
median
arterial
oxygen saturation
significantly
from
and the heart
rate
85 beats/min to 8
ing
air
first
gen therapy between the
96%
to
99%
rate increased
(P
<
0.0001)
decreased significantly from
1
beals/min (P
<
0.0001
the lowest
rate
oxygen
saturation or the highest heart
values before oxygen supplementation.
Overall,
tients
73%
of this unselected group of pa-
responded with decreased heart
ing supplemental
rate dur-
oxygen therapy. No
The abstinence
percent in the placebo group, as compared with
patient.s
System, a network of eight community and
ter-
16.4 percent in the nicotine-patch group, 30.3
between the postoperative day studied.
Mis-
percent in the bupropion group (P<0.0OI), and
CLUSION:
tiary-care facilities serving the St. Louis,
All 203
in the
cant differences in changes in heart rate after
months were 15.6
oxygen supplementation were found between
the nicotine patch (P<0.0OI).
Bames-Jewish-Christian Health System from
jects in the placebo
402
to 1996.
MEASUREMENTS: Time
from
age of 2.
1
kg, as
8.
group given bupropion and
patients with tuberculosis hospitalized in the
1988
signifi-
RESULTS:
smoking was usually day
35.5 percent
air
decrease in heart rate occurred in patients with
quitting
rates at 12
dur-
administered by a binasal catheter. The greatest
among hospitalized patients with tuberculosis. DESIGN: Retrospective cohort study.
SETTING: The Bames-Jewish-Christian Health
delays
)
oxygen supplementation compared with
during week 9) or placebo. The target day for
PATIENTS:
100
rate in
consecutive unselected patients randomly and
mon. OBJECTIVE: To investigate management
souri, metropolitan area.
au-
oxygen therapy on
1999;340(9):685.
otine-replacement therapies and the antidepres-
Tuberculosis
have shown a possible benefi-
of oxygen therapy on arterial oxygen
to the
by dynamic rather than by
issues are addressed, including
hypoxemia and tachy-
thors studied the effect of
static
are set
associated with
cardia. Preliminary studies in high-risk patients
Controlled Trial of Sustained-Release Bu-
arterial
volume of
Cardiac complications are
during the postoperative period and
By week
7,
sub-
group had gained an aver-
compared with a gain of
1
.6
kg
with or without an epidural catheter or
CON-
Postoperative oxygen therapy in-
crea.sed arterial
oxygen saturation and decreased
heart rate after uncomplicated abdominal sur-
gery
tients
in a con.secutive
who
unselected group of pa-
received routine postoperative care.
No
4
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Abstracts
Endotracheal Intubation, but Not Laryngeal
oximetry and capnography affect the outcome
Nineteen volunteers yielded 222 matched sam-
Mask Airway
of anesthetic care. Uncontrollable variables
ples.
Insertion, Produces Reversible
Bronchoconstriction
— Kim
ES, Bishop MJ.
Anesthesiology 1999;90(2):391.
clinical studies
BACKGROUND:
Tracheal intubation fre-
quently results in an increase in respiratory sys-
tem resistance
can be reversed by inhaled
that
The authors hypothesized that
of a laryngeal mask airway would be
among
and operative procedures by using a
patient simulator.
patients
full-scale
We tested the hypothesis that
pulse oximetry and capnography shorten the
time to diagnosis of
insertion
ODS:
A
METH-
critical incidents.
programmed
simulator was
to repre-
bronchocon-
sent a patient undergoing medullary nailing of a
insertion of an endotra-
fractured femur under general anesthesia and
less likely to result in reversible
would
difficult to generate sta-
eliminated the variability
bronchodilators.
striction than
it
conclusive data. In the present study,
tistically
we
make
in
METHODS:
Fifty-two (45 men, 7
suffering either malignant hyperthermia, a pneu-
women) patients were randomized to receive a
7.5-mm (women) or 8-mm (men) endotracheal
mothorax, a pulmonary embolism or an anoxic
tube or a No. 4 (women) or No. 5 (men) laryn-
siologists
mask airway. Anesthesia was induced with
2 microg/kg fentanyl and 5 mg/kg thiopental,
and airway placement was facilitated with
mg/kg succinylcholine. When a seal to more
two groups of equal
cheal tube.
geal
1
cm
than 20
water was verified, respiratory sys-
tem resistance was measured immediately after
airway placement. Inhalation anesthesia was begun with isoflurane
centration of
1%
to achieve
an end-tidal con-
for 10 min. Respiratory sys-
tem resistance was measured again during
RESULTS: Among
identical conditions.
mask airways,
system resistance was
tients receiving laryngeal
respiratory
tial
pa-
< 0.05).
P
s
in the
'
The decrease
s''
group (P
change
the anoxic
oxygen supply scenario
0.019) with pulse oximetry and capnog-
No
statistical difference in
'
for the other three critical incidents.
CONCLU-
new approaches
monitoring technology. How-
SIONS: Simulation may
to the study of
offer
endotracheal tube group
based research are impediments to wide-spread
8.6±3.6
cm
water x
system resistance
significant
±7 cm
in
Evaluation of Volunteers of the
VIA V-ABG
Resistance
was present
in patients
with endotracheal tubes but not in those with
way
is
Medicare
laryngeal
mask
air-
a better choice of airway to minimize
—
enskow DR, Kern SE.
J
Clin Monit
Comput
1998;14(5):339.
VIA V-ABG
to
allow characterization of clinical ac-
The VIA
ceptability.
OBJECTIVE: To
evaluate the
VIA V-ABG
(VIA Medical Corp.) point-of-care bloodgas and
chemistry monitor in healthy human volunteers,
with particular emphasis on the measurement
ditions
vices.
Comparison between
Some
of these instruments, including the
V-ABG
may
device,
bedside.
gas and chemistry measurements remains an
issue that
not adequately studied.
is
KD.
Pediatr Pulmonol 1999;27(1):27.
There
is
is
common
a
METHODS:
with asthma.
in children
Good ML, Kubilis P, Westhorpe
Comput 1998;14(5):313.
OBJECTIVE; Many
R. J Clin Monit
studies (outcome, epide-
miological) have tested the hypothesis that pulse
406
device were compared with paired
2 agonist therapy
observed
that sal-
matic symptoms as demonstrated by increases
in
-I-
J3
We
butamol inhalation significantly improved asth-
peak expiratory flow (PEF: I22.37±75.38
Experimental con-
PETCO2 = 50±2 mmHg, ETPO, =
side effect in adult
2 adrenergic therapy.
relation to the clinical responses
its
152.59 ±80.29; P
ygen
<
58.I6±2.31; P
P<
1
<
0.001) and venous ox-
(Pv,02:
tension
40.84±2.67
S,
WL,
/3
limited information in regard to hypo-
VIA V-ABG
— Lampotang
Gravenstein JS, Euliano TY, van Meurs
VIA
serve quite well as point-
Whether or not any of these devices
spiratory rate (RR;
Full-Scale Patient Simulator
etc.).
can substitute for traditional laboratory blood
I30±5 mmHg) or isocapnic hypoxia (PETCO,
= 42±2, PETO2
45±2 mmHg) in addition
to room air breathing. Measurements by the
Study Using a
due
of-care devices to perform certain tests at the
tidal
Pilot
difficult
comparison device, population studied,
phy on Time
A
is
to several factors (range of values measured,
were varied by intermittently subjecting
(ET),
different studies in-
vestigating point-of-care devices
Influence of Pulse Oximetry and Capnograto Diagnosis of Critical Inci-
device appears to
have been published for other point-of-care de-
kalemia and
volunteers to either isocapnic hypercapnia (end-
dents in Anesthesia:
V-ABG
perform well compared with the results which
vs.
airway reaction.
proficiency
were also met
device for Na, K, and Hct
following administration of
of blood gases.
CLIA
measurements but the range of values was too
asthmatic patients on
potent bronchodilator, suggesting that revers-
A
utilizing current
Hypokalemia
< 0.01). CONCLUSIONS:
mask airways.
device were clinically ac-
ceptable and met minimal performance criteria
James SW, Cluff ML, Wells DT, Orr JA, West-
tracheal tubes after they received isoflurane, a
laryngeal
VIA V-ABG
by the
mask airway
decreased rapidly only in patients with endo-
the range of blood
gas values assessed, blood gas measurements
compared with
water
and for Hct was 2.0 and
0.2,
Automated Bedside Blood Gas, Chemistry,
and Hematocrit Monitor Bailey PL, Mc-
in the laryngeal
ible bronchoconstriction
and
Hypokalemia and Salbutamol Therapy in
Asthma— Hung CH, Chu DM, Wang CL, Yang
use of this tool.
mask airway group.
in respiratory
was highly
the lack of
s) for
s vs.
the resources required to perform simulator-
the endotracheal tube group of 4.7
X r' X
=
(median of 432
cm
in the laryngeal
'
>480
(p
of 91 of the subjects, time to diagnosis
significantly shorter
ever, the limitations of current simulators and
but remained unchanged at 9.1 ±3.3
r' X s
critical in-
Each anesthetic procedure was videotaped. The time to correct diagnosis was
measured and analyzed. RESULTS: Based on
was
.0
0.1
CONCLUSIONS: Over
5.4.
narrow
cidents.
analy,sis
1
was
fur-
After 10 min of isoflu-
rane, the resistance decreased to
water x 1' x
one of the four
to
K
for
by the
time to diagnosis was obtained between groups
'
X 1' X s';
Each anesthesiologist was
randomized
PO2 was
to
signifi-
1
ter
ther
(±2 sd) for pH was
PCOj was 0.4 and 4.8, for
and 17.0, for Na was -0.3 and 5.2,
Bias and precision
ocrit.
0.01 and 0.04, for
one of
raphy than without.
than
less
to
one with access
pulse oximetry and capnography data and the
other without.
134-141 mmol/1 for Na, 3.1-
for PO,,
mmol/l for K, and 30.0-50.4% for hemat-
4.1
standards. Performance criteria
were randomly assigned
size,
mmHg
thirteen anesthe-
the ini-
among patients with
x s
endotracheal tubes (9.2 ±3.3 cm water x
[mean ± SD] compared with 13.4±9.6 cm wacantly
oxygen supply. One hundred
The range of values were 7.32-7.61 for
mmHg for PCO2, 27.9-184.5
pH, 20.9-51.6
33.24±4.95
36.39±3.78
1
),
and venous
vs.
28.62±3.
vs.
0.01), clinical scores (CS:
.59 ±0.7
vs.
0.001), and decreases in re-
3.59±1.28
12;
vs.
PCO2 tensions (PvCOj:
34.75±2.31; P
<
0.001). Sal-
samples and measurements performed by two
butamol-induced hypokalemia was correlated
ABL
with a decrease in RR, and an increase of
Radiometers (505 and 500). Analysis of
results includes bias and precision plots and
and PEF. These findings suggest
comparison of results with minimal performance
mechanism
criteria as established
by CLIA.
RESULTS:
is
that the
PVO2
same
involved in eliciting hypokale-
mia and bronchodilatation.
Respiratory Care
•
April 1999
Vol 44 No 4
Editorials
Can
We
Thomas
A
Stedmcm's Medical Dictionary defines "rehabilitation"
as restoration of the abihty to function in a normal or near
normal manner following disease,
noted
in a recent
rehabilitation
larly
programs are
to relieve
dyspnea, improve functional
health-related quality of
that
may
life.-
benefit patients in
grams are emerging, and
entific
illness, or injury.'
As
review, the primary goals of pulmonary
New
symptoms, particu-
ability,
and enhance
modalities of therapy
pulmonary
rehabilitation pro-
this trend reflects increasing sci-
knowledge and technology as well as
emergence and acceptance of
this application
MD
may
techniques
benefit patients in
The novelty of the
report
is
viewing the chest wall as
in
may
chest wall
The
well be the source of morbidity for patients
with congenital or other deformities such as kyphoscoliosis.
Begin
et al
previously reported reduced compliance of
the rib cage in patients with rheumatoid arthritis (com-
may
pared to normal controls), which
contribute to re-
duced lung volume.-* Can the aging chest wall contribute
of rehabili-
to morbidity in chronic obstructive
of Respiratory Care, Kakizaki
on a potentially useful new pulmonary
rehabilita-
a target of opportunity for pulmonary rehabilitation.
The muscles of
In this issue
pulmonary
tion programs.
the gradual
tation.
port
Dillard
et al's re-
rehabilitation
pulmonary disease?
and diaphragm, and the
the chest wall
accessory respiratory muscles have for years been an important topic of pulmonary rehabilitation research, so
it
is
modality, "respiratory stretch gymnastics."' This article
an intriguing hypothesis that stretching the elastic elements
has merit for several reasons, including input from the
of the chest wall can improve function and quality of
perspective of physical therapists and physiologists as well
as rehabilitation
and pulmonary
clinicians, input
international contributor, and, perhaps
from an
most importantly,
suggestion of a novel topic for further study and possibly
a clinical breakthrough for
pulmonary
rehabilitation pa-
tients.
The
tions,
report
by Kakizaki
et al
however, and, as the study's
considered a preliminary report.
life.
does have serious limita-
I
title
suggests, should be
would
classify the report
as hypothesis-generating rather than hypothesis-confirming,
by which
I
mean
the study does not definitively con-
firm the hypothesis that the stretching changes the elastic
properties of the chest wall. Moreover, the considerable
limitations of the
See The Original Study on Page 409
present,
Kakizaki
et al
prospectively evaluated the chest circum-
ference, Fletcher's dyspnea classification, and vital capacity
methods of study suggest caution in
mechanism. At
interpreting the results, regardless of the
of 22 patients with chronic obstructive pulmonary dis-
ease before and after instruction in 5 stretching techniques
strongly favor further study instead of immediate
I
implementation.
The design of
by randomization
the study could be greatly strengthened
to a treated or control population,
and by
blinding the study to both the patients and therapists. Such
would minimize
the bias of ascertainment, the
intended to stretch the rib cage, shoulders, thoracic spine,
a design
and cervical spine. Patients were instructed to perform
stretching 3 times a day for 4 weeks. The main results
natural tendency to affirm the question under investiga-
include: an increase in upper chest wall expansion
and
tion.
Another suggestion would be
in patient
measurements and
to
to establish variability
document
reduction, and smaller changes in the lower chest wall;
several
weeks before beginning
12 of 22 patients; and in-
remove
the possibility of recruiting patients
improved dyspnea rating
creased
vital capacity.
pnea ratings appeared
in
The
to
patients with the greatest dys-
be the most likely to respond.
These findings, and the proposed mechanism of improvement, pose a serious and interesting question for further
study,
and the
results
might help determine the appropriate
sample size for future studies.
If
properly studied and val-
idated in the future, implementation of these stretching
No
4
stability
interventions. This
who
over
would
are in the
improving phase after an exacerbation. Measurements
should certainly be obtained close to the intervention
this population,
Kakizaki
in
noted for frequent exacerbations.
et al objectively
assessed patient adherence to
the training regimen one time only,
by observing how well
the patients could perform the stretching techniques after
the intended
4-week
training period. This approach ap-
407
We
Can
pears sound, but
I
would favor
Rehabilitate the Chest
earlier or serial objective
monitoring, review of a patient diary or other log, by hav-
some of
ing the patients
come
stretching.
a bit disappointing that 12 patients
It is
to the clinic for
the sets of
after
involving lung volume reduction surgery.^
It
be
will
in-
teresting to learn if stretch techniques produce an improve-
ment
were
rated as having poor performance of the stretch techniques
Wall?
chest wall elastance.
in
may
It
be that the stretch techniques increase the range
of motion, or maximal extent of displacement, without an
AP/AV. This would manifest as an
maximal pressure at total lung capacity
along with an increase in vital capacity. Looking for this
effect would also require an estimate of esophageal presassociated change in
4 weeks.
The measured parameters could also be improved. The
Fletcher dyspnea scale measures dyspnea status with 5
possible discrete choices. Perhaps a
more continuous and
increase in the
To
fully evaluate the physiologic effects
less discrete scale, such as a visual analog scale or other
sure.
scale with more choices, would allow detection of subtler
changes. Evaluating change in dyspnea or dyspnea during
a fixed challenge, in addition to current dyspnea status,
stretching,
might be more convincing.
cerning dyspnea
is
A
further consideration con-
it
also
seems appropriate
to
of repeated
measure respiratory
muscle strength by maximal mouth pressures,
by transdiaphragmatic pressure,
yet,
to
or, better
determine whether
frequent stretching affects strength.
In conclusion, the report herein
the possible effect of the stretching
by Kakizaki
et al pre-
and an opportunity
techniques to increase upper extremity strength or fitness.
sents excellent food for thought
Patients with severe chronic obstructive pulmonary dis-
review current concepts of respiratory mechanics and dys-
ease report a marked increase in the sensation of dyspnea
pnea.
with unsupported arm elevation.'^ Because
of testing and advancing
the stretching
regimen involves upper extremity maneuvers, dyspnea may
have improved due to training of the upper extremities. A
measure of upper
quantitative
might be necessary
A
The authors and
readers should take up the challenge
this
and quality of
extremity strength or fitness
A
of dyspnea patients.
Pulmonary and
on the topic of dyspnea involves
the role of chest wall afferent nerve firing.
life
Thomas A
to control for this possibility.
final consideration
hypothesis in pursuit of more
dyspnea and improving the func-
effective treatment of
tional capacity
to
Critical
MD
Dillard
Care Service
Madigan Army Medical Center
Tacoma, Washington
previous
study using in-phase chest wall vibration suggested that
on respiratory sensation are mediated by afferent
It would
effects
REFERENCES
information from chest wall respiratory muscles.^
be very interesting to find out whether stretching the chest
wall could change afferent information, and
might
how
however, such an experiment might require
last;
animal preparations to be conclusive.
anoreceptor mechanism
is at
1.
long this
this
mechmechanism
2.
Mahler DA. Pulmonary
3.
not require a change in chest wall mechanics to ben-
Kakizaki
may
techniques
4.
5.
Confirming
this
hypothesis would be worthwhile,
ance. That
of the
total
the reciprocal of compli-
and chest wall
Breslin
rib
cage
of rheumatoid patients. Lung 1988:166(3):141-148.
EH. Dyspnea-limited response
in
chronic obstructive pulmo-
7(1): 12-20.
Sibuya M. Yamada M, Kanamaru A. Tanaka K. Suzuki H. Noguchi
E. et
al.
Effect of chest wall vibration on dyspnea in patients with
chronic respiratory disease.
Am J
Respir Crit Care
Med
1994:149(5):
is
all
of us from monitoring ventilated patients.
obtain a measurement of chest wall elastance re-
quires partitioning of the total respiratory system elastance
into
pulmonary disease. Respir Care 1999: 44(4):409-414.
Begin R, Radoux V. Cantin A, Menard HA. Stiffness of the
1
6.
elastance represents "stiffness." Compliance
respiratory system, lung,
Homma
1235-1240.
familiar to
To
is,
is
Shibuya M, Yamazaki T. Yaniada M, Suzuki H,
nary disease: reduced unsupported arm activities. Rehabil Nurs 1992;
but difficult. Elastance, defined as pressure change over
volume change (E = AP/AV)
F,
in a subset
decrease elastance (increase compliance) of the chest
wall.
1998:113(4
Preliminary report on the effects of respiratory muscle stretch
tive
et al speculate that the stretching
rehabilitation (review). Chest
gymna.stics on chest wall mobility in patients with chronic obstruc-
efit the patient.
Kakizaki
Wilkins. Balti-
Suppl):263S-268S.
1.
may
&
more: I972;p 1086.
If the afferent
work, then
Stedman'.s Medical Dictionary 22nd ed. Williams
its
2 components: lung and chest wall.
To do
this in
7.
Jubran A. Laghi F. Mazur M, Parthasarathy S. Garrity
PJ.
and
ER
Jr.
Fahey
Tobin MJ. Partitioning of lung and chest-wall mechanics before
after
lung-volume-reduction surgery.
1998: 58(0:306-3
1
Am J Respir Crit Care Med
10.
mechanically ventilated or spontaneously breathing patients
requires obtaining an estimate of pleural pressure, such as
esophageal pressure. Fortunately, the techniques for measuring lung mechanics, including static and
dynamic chest
wall elastance, have recently been reinvigorated by studies
408
The views expressed herein
reflect
only the views of the author and are
not the official views of the Department of the
Army
or the Department
of Defense.
No
4
Original Contributions
Preliminary Report on the Effects of Respiratory Muscle Stretch
Gymnastics on Chest Wall Mobility in Patients With Chronic
Obstructive Pulmonary Disease
MD PhD, Tsutomu Yamazaki PT PhD,
Suzuki MD PhD, and Ikuo Homma MD PhD
Fujiyasu Kakizaki PT, Masato Shibuya
Minehiko Yamada
MD
PhD, Hajime
gymnastics (RMSG) on chest wall
pulmonary function, and dyspnea in daily living in patients with chronic obstructive
pulmonary disease (COPD). PATIENTS AND METHOD: The subjects were 22 consecutive COPD
patients who were regularly treated in the outpatient clinic of a medical university rehabilitation
hospital. The patients did not have severe limitations in the range of movement in the shoulders, and
were unfamiliar with RMSG. Chest wall mobility (difference between chest circumference during
deep expiration and deep inspiration), pulmonary function test (forced expiratory volume in 1 s
[FEV,] and vital capacity), and dyspnea in daily living (Fletcher's rating) were measured before
and after 4 weeks of RMSG. Four RMSG patterns were demonstrated to each patient to ensure that
they could perform the gymnastics without assistance. The patients were instructed to perform each
pattern four times during each session (3 sessions per day) for 4 weeks, at which time, the patients
were asked to return for re-evaluation. RESULTS: Chest wall expansion and reduction increased
at both the upper (0.8 ±0.2 and 1.3 ± 0.2 cm, respectively) and lower (0.4 ± 0.2 and 0.7 ± 0.2 cm,
respectively) chest walls. Vital capacity increased 119 ± 43 mL, while FEV, remained unchanged.
Fletcher's rating improved in 12 patients and remained unchanged in 10; it did not worsen in any
of the 22 patients. CONCLUSION: RMSG increases chest wall mobility, possibly by reducing chest
wall elastance in patients with COPD. [Respir Care 1999;44(4):409-414] Key words: Chronic ob-
OBJECTIVE: To examine the effect of respiratory muscle stretch
mobility,
structive
pulmonary
disease,
COPD,
respiratory muscles,
pulmonary function, pulmonary
rehabilitation,
dyspnea.
ing treatment of anxiety or depression, smoking cessation,
Background
nutrition intervention,
At present, respiratory rehabilitation programs may
in-
clude education, lower and upper extremity exercise training,
and other modalities.' The goals of
improved health-
rehabilitation include relief of dyspnea,
related quality of
life,
and increased functional capacity.
and psychosocial and behavioral components, includ-
See The Related Editorial on Page 407
Mr
Kakizaki and Dr Yamazaki are affiliated with the Department of
Rehabilitation. Fujigaoka Rehabilitation Hospital, and Drs Suzuki
Yamada
are affiliated with the
Fujigaoka Hospital.
Japan.
Mr
Showa
and
Department of Respiratory Medicine.
University School of Medicine.
Yokohama,
Kakizaki and Drs Shibuya. Yamada. and
Homma are affiliated
Showa
University School of
with the Second Department of Physiology.
Medicine. Tokyo. Japan.
Mr
Kakizaki
the Department of Rehabilitation,
is
However, respiratory
rehabilitation of patients with chronic
obstructive pulmonary disease
(COPD)
is
evolving, partly
because the pathology of COPD, especially the dyspnea,
is
not fully understood. Afferent activity from the chest wall
also currently affiliated with
Toyosu Hospital, Showa University,
Tokyo. Japan.
Correspondence:
Grant support: Pollution-Related Health
Damage Compensation and
vention Association, Japan.
Respiratory Care
•
April
1
999 Vol 44
No
4
Pre-
Mr
Fujiyasu Kakizaki. Second Department of Physiol-
Showa University School of Medicine. l-.'>-8 Hatanodai.
gawa-ku. Tokyo 142-8555, Japan. E-mail: Ka596.^@'tt. rim.or.jp.
ogy.
Shina-
409
9
Respiratory Muscle Stretch Gymnastics
may
respiratory muscles
pneic sensation.2
which
elastance,"^
may
*
Measurements
increased
often observed in clinical practice,
is
an increase
elicit
play a role in modifying the dys-
A stiff chest wall or one with
in
muscle spindle
from the
firing
noncontracting intercostal muscles*' and could be responsible, in part, for the
dyspneic sensation.^
Chest wall expansion and reduction were measured according to the standard method." In brief, a
was asked
patient
A new component of respiratory rehabilitation programs,
called respiratory muscle stretch gymnastics
(RMSG),^"^
the patient
for the
An immediate increase in forced vital capacity (VC)
(from 1807 ± 141 to 1923 ± 145 mL) in 34 patients^ and
a decrease in functional residual capacity (from 4. 19 ±
1.27 to 3.88 ± 1.03 L) in 12 patients after 4 weeks" have
been reported as a result of RMSG. Other clinical benefits
patient
dyspnea
at rest
quality of
life,
and
after a
RMSG
tape
was
was drawn
much
as possible while
and chest circumfer-
taut
ence was measured (El); then the tape was released, and
the chest wall muscles, and to decrease chest wall elas-
of short-term^ and long-term"
to breathe out as
the measuring tape
has been designed to stretch the respiratory muscles, mainly
tance.
flat
placed around the patient's chest, and with arms down, the
the
was asked to breathe in as deeply as possible
next measurement (I; ie, deep inspiration). The
was again asked to breathe out as far as possible for
final measurement (E2). Measurements were done at
and the xiphisternum
the axillary level (upper chest wall)
include decreased
Each measurement was repeated
twice, and the average value was used. All patients also
underwent spirometry before and after 4 weeks of RMSG.
improved
Testing and quality control followed standard and recom-
6-min walking
test,
prolonged 6-min walking distance, and de-
level (lower chest wall).
mended
procedures.'^
creased residual volume, total lung capacity, and residual
volume/total lung capacity.
Protocol
has been suggested that reduced chest wall mobility
It
is
associated with a decrease in lung function and exercise
endurance.'"
It is
possible that
RMSG
increases
VC
and
Chest wall mobility was measured before
rometric values obtained
when
the patients
RMSG.
were
Spi-
in a stable
exercise endurance by reducing chest wall elastance, caus-
condition during routine clinical follow-up within a few
ing increased chest wall mobility. Chest wall expansion
months before RMSG were used as the pre-RMSG values.
Dyspnea was rated according to Fletcher's classification'"*
before RMSG. The 4 RMSG patterns^ were demonstrated
and reduction have been used by physical therapists to
measure chest wall mobility." Herein, we report our pre-
RMSG
liminary clinical experience with
from a physical
therapist's point of view, with particular reference to the
effect
on chest wall mobility, dyspnea, and spirometry.
to
each patient to ensure that they could perform the gymThe exercises, described below,
nastics without assistance.
were each done 4 times
in a specified order. Patients
Methods
4 weeks of
Subjects
—
RMSG,
an independent evaluator observed
each patient to determine their
The
The subjects (Table ) were 22 consecutive patients (
men, 3 women; mean age, 73.4 ± 1.0 years [range, 621
1
81]) with
COPD but without severe
movement
in the shoulders.
treated as outpatients at
habilitation Hospital.
The
Showa
COPD
were
—
one in
do 3 sessions of exercises per day
for 4 weeks. After
the morning, afternoon, and evening
instructed to
limitations in range of
subjects
were regularly
University Fujigaoka Re-
was diagnosed and
results of this evaluation
perform
RMSG.
were not revealed
until all
ability to
other measurements and ratings
(ie,
chest wall mobility,
We inquired as
RMSG but did not
spirometry, and dyspnea) were completed.
to the patient's
compliance
to
perform
ask for quantitative ratings. All patients stated that they
had high compliance.
rehabili-
was indicated according to standard criteria.'- All
were in stable condition while receiving standard
medical treatment prior to RMSG. Theophylline was used
tation
patients
agent was used in 12, and steroid was used in 8 patients.
1. Elevating and Pulling Back the Shoulders
and Stretching the Upper Chest. Slowly breathe in through
There was no change
the nose while gradually elevating
in 20, a j3-2
period.
The
stimulant
was used
in
in
1
1
,
an anticholinergic
medication during the observation
patients did not have any other significant
disease, such as unstable cardiac disease or acute infec-
Pattern
and pulling back both
shoulders. After taking a deep breath, slowly breathe out
through the mouth, lower the shoulders, and relax.
tious disease; all patients willfully participated in the re-
program and gave informed consent. The pawere unfamiliar with the effect of RMSG on dyspnea.
habilitation
tients
The protocol was approved by
ics
Committee.
410
the
Showa
University Eth-
Pattern 2. Pulling Down and Stretching the Upper Chest.
Place both hands on the upper chest. Pull back elbows and
pull
down
chest while lifting the chin and inhaling deeply
through the nose. Expire slowly through the mouth and relax.
Respiratory Care
•
April 1999
Vol 44 No 4
Table
1.
Patient
Patient Profiles for
22 Patients with Chronic Obstructive Pulmonary Disease
V.T-
B
x:
Ml'*:
c E
O
to
D
g
before
after
of
good
performance
(n=10)
RMSG
4 weeks
RMSG
poor
performance
(n=12)
Mean ± SE of the expansion in upper chest wall before and
4 weeks of respiratory muscle stretch gymnastics (RMSG) in
patients with good and patients with poor RMSG performance.
Fig. 3.
after
VC
4
-
FEVi
ACKNOWLEDGMENTS
and limited chest expansion. Bull Eur Physiopathol Respir 1985;
21(4);36.3-368.
We thank Drs Arata Kanamaru (Second Department of Physiology, Showa
1
University School of Medicine) and
Toyosu Hospital.
Internal Medicine,
icine) for their helpful
comments.
1.
Kazumasa Tanaka (Department of
Showa University School of Med-
We
also thank
Ms Wakako
Anderson JM. Assessment of chest function by the physiotherapist.
In;
Downie PA,
Innocenti
DM.
Jackson SE, editors. Cash's textbook
of chest, heart and vascular disorders for physiotherapists. Philadel-
Ihara for
JB
phia;
her help in the preparation of this manuscript.
12.
Lippincott; 1987:318-324.
American Thoracic Society. Standards
patients with chronic obstructive
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Respiratory Care
•
April 1999 Vol 44
No 4
Severe COPD Patients
Mechanical Ventilation
Long-Term Tracheostomy
MD,
Enrico Clini
in
MD, Luca Bianchi
and Nicolino Ambrosino
Michele Vitacca
MD,
Weaned from
MD,
Roberto Porta
MD
BACKGROUND:
Chronic obstructive pulmonary disease (COPD) patients wiio suffer from acute
respiratory failure
(ARF) requiring meclianical
ventilation are at risk of relapse. It
is
unknown
whether spontaneously breathing patients benefit from retaining a tracheostomy after discharge
from the intensive care unit. We studied the effects of long-term (6 months) tracheostomy in severe
COPD patients weaned from mechanical ventilation. METHODS: Twenty tracheostomized COPD
patients recovering from ARF and weaned from mechanical ventilation were randomly allocated
into 2 groups: 10 patients were maintained on tracheal cannula; 10 patients had the tracheal
cannula removed (cutaneous
fistula
spontaneously closed). Breathing pattern, forced lung volumes,
1, 3, and 6
and number of new exacerbations re-
respiratory muscle force, and arterial blood gases were evaluated at discharge and at
months
after discharge. Hospitalized days, mortality rate,
quiring antibiotics were recorded.
Maximal expiratory pressure
(but not other lung function pa-
rameters) significantly improved in both groups. In both groups, 2 out of 10 patients died due to
respiratory causes after 5.0 ± 0.8 months after discharge. During the follow-up period, exacerbations
were significantly greater
in the
tracheostomized patients than in those whose tracheostomies
had been removed before discharge, though there was no
significant difference in hospitalized days
between the 2 groups. CONCLUSION: Chronic tracheostomy in severe COPD patients is associated
with a higher frequency of exacerbations requiring antibiotic treatment. Unless there are absolute
indications for tracheostomy, COPD patients weaned from mechanical ventilation should undergo
early decannulation.
structive
pulmonary
[Respir Care 1999;44(4):415-420] A'n' words: respiratory failure, chronic ob-
disease, meclianical ventilation, airway infection, weaning, decannulation.
tracheostomy-related inadequate airway humidification^
Introduction
may
Prolonged mechanical ventilation
is
through a tracheostomy.' Although an
usually delivered
artificial
airway
is
often maintained in place because of swallowing dysfunction, inability to clear secretions, or
continuous need for
mechanical ventilation,'- the appropriate time for trache-
ostomy removal
latter
conditions
weaning and in the absence of the
debated.^ Tracheostomized patients can
after
is
adversely affect cough reflex and mucociliary clear-
ance. This problem
is
even more complex
in patients
with
chronic obstructive pulmonary disease (COPD), and patients suffering acute respiratory failure
mechanical ventilation are
at risk
(ARF)
requiring
of relapse.*'' Therefore,
despite the aforementioned potential complications of long-
term tracheostomy,
tracheostomy
in
it
is
conceivable that maintaining a
spontaneously breathing patients after dis-
from chronic infections and increased secretions
charge from the intensive care unit (ICU) can avoid re-
such that they frequently need suction. Patients on long-
peated tracheostomies and perhaps improve convalescence.
suffer
term ventilation can be
at
increased risk of infection," and
We
conducted a prospective, randomized, controlled
study to evaluate the effect (on both course and outcome)
of maintaining a tracheal cannula in discharged spontaneEnrico Clini
MD,
Michele Vitacca
MD, Luca
Bianchi
MD,
ously breathing severe
COPD
patients.
Roberto Porta
MD
are affiliated with the Fondazione S
MD. and Nicolino Ambrosino
Maugeri IRCCS Lung Function and Respiratory Intermediate Intensive
Care Units, Medical Centre of Gussago, Gussago (BS),
Correspondence: Enrico Clini
Pinidolo, 23; 1-25064
MD,
Fondazione S Maugeri IRCCS, Via
Gussago (BS),
The study was approved by
the Ethical
the Medical Center of Gussago, S
Italy.
Methods
Italy.
No
4
Committee of
Maugeri Foundation
41.'^
.
Table
1
.
in
Severe
COPD
Demographic. Anthropometric and Last Stable Functional
RIICU
Characteristics of Patient Population
an uncuffed tracheal cannula with an expiratory valve that
Group
Parameter
1
Group 2
p-value
+
ns
admission, after which patients breathed through
allowed them to speak and cough efficiently.*
The study inclusion
Age, years
Sex,
±6
71
M/F
± 6
± 210
25
mL
737
mL
FVC,
40±
27
155
TLC, %pred
144
MIP, %pred
38
MEP, %pred
50
±
±
±
±
(mm Hg) (on oxygen)
R,o,. {mm Hg) (on oxygen)
Pao,/Fio, (mm Hg)
51
±6
Paco;-
1154
41
153
±
±
61 ±
57 ±
76 ±
2,53 ±
146
31
36
7
23
70 ± 7
2.54
%
±
0.27
40
ARF.
Previous
ns
11
RV, %pred
LTOT,
± 15
±415
± 19
± 30
no./year*
0.5
±
spon(2)
no
of infection (leukocytosis, fever,
or radiographically-identifiable pulmonary infiltrates), (3)
gens
ns
less than
2
X
imen obtained via
ns
10"^
by tracheal
bacterial patho-
cfu-mL"' on a culture strain (spec-
fiberoptic tracheobronchoscopy), (4)
no
ns
current need for antibiotics, and (5) no change in drugs or
36
ns
in
6
ns
oxygen requirement during
Study exclusion
the last 7 days.
criteria were: (1) conditions indicating
13
ns
an absolute need for maintaining tracheostomy, such as
9
ns
swallowing or vocal cord dysfunction, obstructive tracheal
12
ns
0.40
ns
lesions (granuloma or stenosis, as assessed
by fiberoptic
tracheobronchoscopy), or inability to spontaneously clear
<0.01
±
0.8
48 consecutive hours,
ab.sence of infection as defined
70
0.7
criteria were: (1) unassisted
at least
clinical or laboratory sign
ns
ns
24
± 413
1271
FVC, %pred
± 4
22
taneous breathing for
ns
557 ± 225
30 ± 10
FEV|, %pred
8
8/2
8/2
BMI
FEV,,
67
secretions, (2) systemic diseases, (3) cancer,
and
(4) inad-
ns
1.1
equate self-care or familial assistance.
Group
1:
cannula retained. Group
forced expiratory volume
TLC =
total
in
=
=
FVC -
BMI - body mass
inspiratory pressure;
oxygen:
LTOT =
arterial
long term oxygen therapy;
percent of predicted value. *Previous
ARF
FEV, =
index;
RV =
forced vital capacity:
carbon dioxide tension; Pyo, -
arterial
fraction of inspired
failure: >? pred
cannula removed.
MIP = maximal
lung capacity:
pressure: P;,cni
2:
one second:
residual volume:
MEP
Measurements
- maximal expiratory
oxygen tension; F|o, -
ARF =
Breathing pattern
acute respiratory
data calculated on the 2 years
(tidal
volume
[V-p|,
respiratory rate
and minute ventilation [V^]), and forced lung volumes
(forced expiratory volume in
second [FEV,] and forced
[f],
preceding the study.
1
capacity [FVC]) were measured with a portable spi-
vital
rometer and compared with the values predicted by Quan-
IRCCS, and was conducted according
to the Declaration
of Helsinki. Patients gave their informed consent to participate in the study.
The
jer."
was assessed by
measuring maximal inspiratory pressure (MIP) and max-
(MEP)
imal expiratory pressure
module system,
spiratory
Patient Population
measurements were considered
best values of 5
for analysis. Respiratory muscle strength
tional residual capacity (in
We
studied 20 patients with severe
by the American Thoracic Society
recovering from
termediate
ARF
COPD
(as defined
who were
guidelines**)
and admitted to our respiratory
ICU (RIICU)
in-
complete the weaning process
to
from prolonged mechanical
Demographic, an-
ventilation.
described by Black and Hyatt.'-
1
All of the patients were severely obstructed and hyperinflated.
Their regular medical treatment consisted of
in-
haled bronchodilators. Eleven patients were on long-term
oxygen therapy, none were on domiciliary mechanical ventilation, but 12
of the 20 patients had experienced nonin-
vasive positive pressure ventilation for acute exacerbations of their disease before the study. All of
them had
been transferred from ICUs of other hospitals, had under-
gone a percutaneous tracheostomy
invasive mechanical ventilation
days. Causes of
in
54% and 46%
tients
ARF
1
5
±
3 days,
was prolonged
for
25
a
et al.'^ Patients
1
performed consecutive maneuvers
minute interval between efforts)
able values differing by
< 5%
until 2 accept-
were obtained. The best
value was recorded. Spirometry and respiratory muscle
function were measured through a mouthpiece while the
cannula was closed with a cap. Arterial blood was sampled
at the radial artery
with the patient
in the sitting position
and while breathing a fraction of inspired oxygen (F|qJ
that maintained arterial oxygen saturation at s 90% for
s
1
hour. Arterial
oxygen tension
(Pj.o,), arterial
carbon
pH were measured
with a
and
dioxide tension (Paco,)' ^^^
±
Ciba Corning 840 analyzer. Pao/Fio,
5
method
ratio
was measured
were exacerbation'^ and pneumonia
of cases respectively. At admission, pa-
needed ventilatory assistance for 14
±
3 hours per
was obtained 9
±
5 days after
day. Successful weaning'"
416
after
to the
visual on-line spiro-
the starting level of the maneuver. MEP and MIP
measurements were compared with the predicted values of
(with
Table
A
trol
Bruschi
in
a re-
graphic control during tidal breathing allowed us to con-
when
shown
mouth using
from the level of funcmeasuring MIP) and total lung
MEP), according
capacity (in measuring
thropometric, and functional characteristics of the patients
in their last stable condition are
at the
starting
* Suppliers of
commercial products are identified
section
end of the
at
the
in the
Product Sources
text.
Respiratory Care
•
April 1999
Vol 44 No 4
in
COPD
Severe
while patients were receiving oxygen via nasal prongs, and
ber of exacerbations requiring use of antibiotics. Mortality
F,„, was calculated with the following conversion factor:
was assessed by percentage rate. Analysis of variance was
used to test differences between and within groups. When-
F|(,^
tal
=
+
21
(3
X oxygen
flow
in
L/min of supplemen-
ever necessary, a post hoc
oxygen).'''
with Bonferroni correction
test
This procedure was deemed acceptable because the tracheal cannula (with the valve inserted) allowed normal
was used to evaluate the contrast between and within groups.
oxygen delivery from the nose through the tracheostomy.
microbiology before randomization were tested by means
During the follow-up, the cumulative number of days
spent in hospital due to respiratory causes, the number of
of an additional Fisher's exact
Differences in frequency distribution of exacerbations and
test.
A
p value
<
0.05 was
considered statistically significant.
exacerbations requiring antibiotic use, and mortality were
recorded from the hospital registers and interviews with
the patients' general practitioners. Exacerbation of
was defined by worsening of symptoms,
Results
COPD
fever, increased
purulent sputum requiring changes to normal treatment,
short courses of antibiotics, oral steroids, and other bron-
Decisions regarding treatment of exacerbation
chodilators.''^
and hospital admission were made by the general
ner,
who was
practitio-
not aware of the purpose of the study.
Demographic, anthropometric and functional character-
when in their last stable condition are
The groups differed only in the use of
long-term oxygen therapy, which was more frequent in the
patients of Group 2. Mean duration of RIICU stay was not
16 ± 8 days; Group
different between the groups (Group
istics
of patients
shown
Table
in
1
.
1
Microbiology
19
2:
scopic protected specimen brush in both groups, processed
with the methods described
in Bartlett et al.'^
We
used
±
10 days).
The course of breathing
Cultures were performed on specimens from broncho-
respiratory muscle strength,
in
Table
2.
No
the groups at any time.
was performed in the
following agar media: Trypticase soy + 5% Mutton Blood,
over time
Chocolate
II
-I-
Isovitalex, Mannitol salt,
McConkey
II,
Sabouraud dextrose. All cultures were incubated at 37° C
under aerobic and anaerobic conditions and in carbon dioxide-enriched atmosphere. Cultures were evaluated for
growth
after
24 hours and 48 hours, and,
if
negative, dis-
carded after 5 days. Bacterial agent colonization was defined as the isolation of a potential pathogen in
culture, in the
absence of signs or symptoms of lower
respiratory tract infection."*'''
within
1
hour
sputum
Samples were transferred
to the laboratory. All the potential isolated
in
patterns, forced lung
Only
both groups (p
over time did not change
<
Pac^Fio, ratio also
2).
Table 3 shows the bacteria species present
in the air-
ways before randomization. No significant differences were
seen between the groups. The total bacterial growth was
similar between groups, the value ranging from 2 X 10^ to
X lO"^ cfu-mL~'.
One subject of Group 2 had to be restarted on mechanical ventilation with a new tracheostomy because of severe
2
exacerbation 18 days after discharge.
died in hospital.
Two
charge due to
of
ARF
patient
ARF
requiring
were pneumonia
2).
the patients
±
ICU
0.8
months
after dis-
admission. The causes
(2 patients
from Group
1
and
1
and severe exacerbation (I patient
One patient from Group underwent ac-
from Group
from Group
None of
out of 10 patients (20%) in both
groups died after a mean of 5.0
domly assigned to 2 groups: Group
Oxygen requirement
in either group:
remained unchanged (see Table
improved
significantly
0.005).
oratory methods.-"
After inclusion criteria were verified, patients were ran-
were observed between
MEP
pathogen micro-organisms were identified by standard lab-
Study Design
volumes,
and arterial blood gases are shown
significant differences
N-acetylcysteine to homogenize the sputum specimen.'''
Inoculation of homogenized sample
:
2)
1
(cannula retained)
cidental self-decannulation during the follow-up at the 5th
and Group 2 (cannula removed and cutaneous fistula spontaneously closed). The retained cannulae were fitted with
month; the cannula was not replaced and the fistula closed
spontaneously. At the end of the follow-up all the surviv-
a valve that facilitates speaking and coughing. Measure-
ing patients
ments were
at
at
I
performed at the time of randomization (TR),
the time of discharge (TO), and during the follow-up
1, 3, and 6 months after discharge (Tl, T3, and T6,
respectively).
from Group
1
were decannulated.
The cumulative number of days spent in hospital during
the follow-up was not significantly different (Group I:
10.2 ± 9.7 days per patient; Group 2: 4.5 ± 2.7 days per
patient).
The frequency
ing use of antibiotics
is
distribution of exacerbations requir-
shown
Figure
in
1
.
All the patients
Statistics
from Group
Results are
mean ± SD. Frequencies were
microbiological variables and the num-
shown
used to describe the
Respiratory Care
as
•
April 1999
Vol 44 No 4
1
suffered at least
1
exacerbation during the
follow-up, whereas only 5 of the 10 patients in
required antibiotic therapy for exacerbations (p
<
Group 2
0.005).
417
Table
2.
Time Course of Respiratory Functional Parameters
Variable
in
Severe
COPD
in
COPD
Severe
hypothesis. Before entering the randomization, the
Group 1
D Group 2
of patients with sputum
number
positive for potential infectious
agents was not significantly different between the groups
6^
(see Table 3).
Airway
bacterial colonization is
common
in
stable patients with chronic lung disease, as well as in
patients with long-term tracheostomy.'**" Bacterial distri-
bution in our sample of patients showed a prevalence of
Gram-negative
ill
4
3
cumulative number of patients suffering exacerbation. X-axis:
<
value
fre-
distribution of exacerbations requiring antibiotics, p
0.005 for differences tested by Fisher's x^ analysis.
quency
et
al,^'*
prevalence of Pseudomonas
a significant
aureus are well-known contaminants of the hospital environment, and colonizing species during mechanical venti-
Exacerbations during the 6 months of follow-up. Y-axis;
1.
de Latorre
aeruginosa. Pseudomonas aeruginosa and Staphylococcus
Exacerbations requiring antibiotic use
Fig.
has been reported in chronically
patients.2^ In contrast to the report of
we observed
12
strains, as
Contamination could easily have been
introduced by routine suctioning or humidification, ambi-
lation in the ICU.^"'
ent air during the
weaning
trial,
a nasal sinus infection, the
ventilator circuit, or the tracheostomy cuff.
In
49
sets
of cultures on 15 subjects with long-term
tracheostomy, Niederman et aF^ found that patients with
All the patients
showed a severe impairment in respirano differences between the 2 groups
tory function, with
FEV|/FVC
despite a slight but not significant difference in
mostly due to the small sample
ratio
size.
Follow-up mea-
persistent tracheobronchial colonization
were more
ill
and
developed tracheobronchitis more often than those without
persistent tracheobronchial colonization. A limitation of
our study
is
that there
was no microbiological evaluation
2 groups because
during the follow-up period. This aspect of data collection
However,
between
was not possible in this case for technical reasons the
same bronchoscopic technique used to sample bronchial
the 2 groups, taken at discharge after randomization (par-
secretions could not be easily applied in the ambulatory
surements were taken differently
in the
of the presence of the tracheostomy in Group
was no difference
there
available data not presented).
tial
(60%, equally distributed
episodes of
tilation
1
.
in spirometric function
Most of
in the 2 groups)
the patients
had experienced
ARF treated with noninvasive mechanical ven-
during the 2 years prior to the study (see Table
The only
significant difference
the previous use of long-term
1
).
between the 2 groups was
oxygen therapy, which was
higher in Group 2 (tracheostomy removed). This might constitute
Group (tracheostomy retained).
were discharged with an uncuffed
a bias that favored
Patients of
Group
1
1
tracheal cannula with an expiratory valve, but without a
humidification system. In a previous study,-'
significant short-term improvements
tion
and
in tracheal secretions
we found
in respiratory func-
over 10 days by applying a
hygroscopic condenser humidifier.
It is
unknown whether
the use of a humidifier might have resulted in
improved
—
and sputum sample is not as reliable a means of
sample collection as bronchial brush or bronchoalveolar
setting,
lavage, a
more appropriate means
Thus, there was no
logical data
and
way
clinical
to identify pathogens.^^
to correlate bronchial microbio-
outcome
in
terms of
bations during the follow-up. In our study,
from Group
1
experienced
at least
all
new
exacer-
the patients
one exacerbation
quiring antibiotic use, but only 4 patients from
re-
Group 2
experienced an exacerbation requiring antibiotic use. This
suggests that prolonged tracheostomy plays an adverse
role in the
management of
COPD
patients.
However, the
lack of standardization of antibiotic use and the small population of this study should
make
us very cautious in in-
terpreting this interesting result. Moreover, the causes of
the increased tracheobronchial infection rate in
Group
1
mainly on lung hyperinflation and mechanics,^'' MEP better reflects the patient's fitness and is directly related to the
unknown. Coughing is an important aspect of effective
mucus clearance,^'' and decannulation could have favored
a more effective cough reflex and thereby reduced the
probability of exacerbation in Group 2. Furthermore, de-
improvement of peak cough flows and spontaneous cough
cannulation could also have reduced the risk of aspiration
respiratory function in Group 1. Both groups showed a
significant improvement in MEP. Whereas MIP depends
reflex."
From
a pathophysiological point of view, retain-
are
and related exacerbation or pneumonia.^"
ing a tracheostomy might reduce the dead space ventilation
and the work of breathing, though these 2 aspects
were not assessed
in the present study.
We
considered whether the presence of a tracheostomy
valve in Group 1 created a favourable bias, and concluded
that the bacterial exacerbation results do not support that
;
Conclusion
No
4
Although the number of days spent in hospital due to
respiratory causes was not different between the 2 groups,
our study suggests that chronic tracheostomy might ad-
419
COPD
versely affect the course of severe
from mechanical
risk
pear to affect short-term survival
power of
statistical
COPD patients.
severe
in
ited
by the small patient population, our
that
COPD
patients
was
the present study
11.
of ex-
However, long-term tracheostomy does not ap-
acerbation.
While the
weaned
patients
by increasing the
ventilation,
12.
13.
lim-
ventilation
Severe
COPD
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Pony
Am
Peters
Jr,
cet 1998:352(91
Cannula:
Rev Respir Dis 1969:99(5):696-702.
Fanfulla F, Fiorentini
1988:1976-2016.
ders;
15.
MC.
Reference values of maximal respiratory mouth pressures: a pop-
editors.
lute indications for retaining the tracheostomy.
Am
sex.
Zoia
1,
ulation-based study.
14.
should undergo early decannulation unless there are abso-
PRODUCT SOURCES
and
Bruschi C. Cerveri
al.
results suggest
weaned from mechanical
in
1994;7(9): 1645-1652.
Kirkpatrick
MB,
1
Bass JB. Quantitative bacterial cultures of bron-
choalveolar lavage fluids and protected specimens from nonnal subjects.
29.
Am
Bennett
Rev Respir Dis 1989:l39(2):546-648.
WD. Zeman
cough clearance.
30. Devita
MA,
J
KL. Effect of enhanced suprainaximal flows on
Appl Physiol 1994:77(4): 577- 1583.
1
Spierer-Rundback L. Swallowing disorders
in patients
with prolonged orotracheal intubation or tracheostomy tubes. Crit
Care
Med
1990;18(12):1328-1330.
Respiratory Care • April
1
999 Vol 44
No 4
Work
of Breathing during Weaning from Ventilation: Does Extending
Weaning with Continuous Positive Airway Pressure
Any Advantage?
Confer
Rajesh
G
BACKGROUND:
Patel
MD, Marcy F
Petrini
PhD, and Terry
M
Dwyer
MD
PhD
(CPAP) during
weaning from meclianical ventilation is unproven. METHODS: Forty-two patients were weaned
witli pressure support ventilation (PSV) following prolonged mechanical ventilation. The 20 patients in Group A were removed directly from PSV after at least 24 hours of PSVj+s (5 cm HjO of
PSV plus 5 cm HjO of positive end-expiratory pressure). The 22 patients in Group B were weaned
for an additional 24 hours on CPAP. Weaning outcome was compared between the 2 groups by }^.
RESULTS: The work of breathing was lower with PSVj+j versus CPAP, (5 cm H2O of CPAP)
when all 42 patients were taken together, in the 36 patients who succeeded weaning, and in 6
patients who failed. The work of breathing was not different between Groups A and B for either
ventilatory
The advantage
mode. There were no
CONCLUSION: The work
of using continuous positive airway pressure
between the failure rates
statistical differences
in the 2
modes.
PSVj+s was lower than during CPAP,. The work
of breathing and the weaning outcome were the same in PSV5+5 and CPAP5. Extending weaning
with CPAPj following PSVj+s offered no benefit, but instead imposed an additional load on the
of breathing during
ventilatory musculature. (Respir Care 1999;44(4):421-427] Key words: work of breathing, pressure
support ventilation, continuous positive airway pressure, bi-level airway pressure, weaning, mechanical
ventilation.
flow resistance from the tracheal tube, breathing
Introduction
and ventilator
Gradual weaning with pressure support ventilation (PSV)
circuit.^
piratory pressure
The
"^
(PEEP)
to
circuit,
addition of positive end-ex-
PSV
results in bi-level
airway
in
pressure,
PEEP
mechanically ventilated patients recovering from prolonged
from the
loss of glottic function
acute respiratory failure.'-^ This weaning consists of grad-
airway,' overcomes the loss of end-expiratory lung vol-
improves respiratory muscle strength and endurance
ually lowering the inspiratory pressure to a
low
level,-
ume
that occurs
improves pulmonary mechanics impaired
when
caused by the
artificial
patients are supine or semi-upright,*
optionally followed by continuous positive airway pres-
prevents dynamic airway closure in patients with airway
sure (CPAP).
diseases,''
PSV
is
CPAP
a form of partial ventilatory support that delivers
a pre-selected
amount of positive pressure
in
response to a
effort. An inspiratory airway prescm HjO can reduce the inspiratory
and improves gas exchange.**
is
a spontaneous
mode of ventilatory
When
spontaneous inspiratory
ing cycle.
sure between 3 and 14
than the patient's inspiratory flow,
work load by overcoming
the
imposed work due
to air-
support that
delivers a positive airway pressure throughout the breaththe gas flow during inspiration
is
higher
CPAP delivering a con-
tinuous flow can overcome the air-flow resistance from
the tracheal tube
and the breathing
circuit,^
and can im-
prove pulmonary mechanics'-^'" and offset the intrinsic
Rajesh
G
Patel
MD, Marcy F
are affilialed with the
and
Critical
Petrini
PhD. and Terry
M
Dwyer
MD PhD
PEEP
ual
weaning with PSV, some physicians discontinue me-
chanical ventilation directly, without additional
Jackson, Mississippi.
Correspondence: Rajesh
PEEP),^
Following prolonged mechanical ventilation and grad-
Department of Medicine. Division of Pulmonary
Care Medicine. University of Mississippi Medical Center,
(or auto
G
Medical Center. 1500 East
Patel MD, Department of Veterans
Woodrow Wilson Drive. Jackson MS
Affairs
.^9216.
No 4
However,
it is
modes of
possible that the level of inspira-
tory airway pressure during
to
E-mail: [email protected].
support.
PSV
is
greater than necessary
simply overcome the imposed work,"* thus relieving the
421
Work
from a portion of the physiologic work of breathing
patient
(WOB), and
For
as a consequence the patient can fail weaning.
'2
However, the inspiratory airway pressure dur-
CPAP may
may
some physicians extend weaning with
reason,
this
CPAP."
ing
of Breathing during Weaning from Ventilation
also be inappropriate
—
for instance,
CPAP
be inadequate to overcome the imposed work,'^ re-
work load and,
sulting in additional
therefore, unnecessary
plastic tube, a nonreservoir-humidified circuit,
PEEP
ternal
CPAP,
from
valve. Either
extubation or decannulation
is
the next step in our
CPAP
algorithm. Intermittent face-mask
24 hours
in
those patients
who
All our patients entered the study after they were grad-
weaned and when they were ready
CPAP
with an inspiratory pressure level of 5
drawbacks and there may be no
extending weaning with CPAP.
overall advantage in
WOB
The
important in assessing the performance of
is
and
the respiratory muscle activity
weaning success."'''-'*
tilatory support
working during
patient
is
If the
may be
is
a reliable predictor of
WOB
is
'''
If the
Comparing
the
study
when
of 5
cm HjO.
Patients
and an
were included
in the
(1) the process that led to the patient's respi-
ratory failure had improved; (2) the patient
was hemody-
namically stable and there was no further need for vaso-
from
active agents; (3) the patient had adequate gas exchange
WOB
is
working harder than he would be
decannulated.'-*
PEEP
external
be supported
to
cm HjO
too low, the ven-
high, relieving the patient
breathing.''
weaning
used for up to
are extubated or decannu-
ually
its
is
from PSV5+5.
lated
respiratory muscle fatigue. Thus, the possible benefits of
can be offset by
and an ex-
or from PSV5+5,
measured
lished results aids in the determination of
if
too high, the
(as indicated
extubated or
and
WOB
when
to
pub-
the patient
can be extubated or decannulated."'"'-"'
by an
arterial
fraction of inspired
oxygen tension
oxygen
<
S:
60
mm of Hg
0.40); (4) the patient
could tolerate pressure support levels between 5 and 10
HjO;
(5) the patient
pressure
^ -20 cm
cm
could inspire with a peak negative
HjO;
was judged by
(6) the patient
his
or her attending physician to be able to continue the wean-
Objectives
ing.
The University of Mississippi
Board exempted
The goal of
this
study was to determine whether ex-
CPAP
tending weaning with
removing patients
directly
determined whether the
the
same
as during
confers an advantage over
from
PSV
and PEEP.
CPAP
this earlier
we
studied
removal from mechanical ventilation
resulted in a higher failure rate than extended
with
we
and appropriate for successful
removal from mechanical ventilation. Second,
whether
First,
WOB during PSV with PEEP was
weaning
CPAP.
Two
Investigation
Review
study from review.
modes, PSV5+5 and CPAP5, were compared
in all
the patients, after they were rested overnight on assist-
control
mode. The Siemens Servo 900C was used for testDowns Flow Generator was used for
ing PSV5^.5, and the
CPAP5. Each patient was stable for a period of
20-30 minutes during the new ventilatory mode before
data were collected. Modes were tested by pseudorandom
order (by computer-generated numbers). The patients were
testing
rested
Methods
this
on
assist-control ventilation for
30 minutes between
modes. Inspired gas was maintained
at
30-40%
and humidified by a pass-over heater
in
both modes. Peak
oxygen,
negative pressures were measured prior to data collection,
and Protocol
Patients
and
arterial
blood gases were obtained on each mode im-
mediately following the data collection.
We
studied 42 patients being
weaned from mechanical
ventilation. In our intensive care unit, the
prolonged mechanical ventilation (> 72
weaning
after
hours)
as follows: gradual lowering of
is
sequence of
PSV
during the
daytime, with overnight rest on assist control ventilation
PSV, we rouemploy 5 cm HjO of PEEP, and set trigger sensitivity at -2 cm HjO. This weaning process may take several days, until the pre-set inspiratory pressure level on
using a Siemens Servo 900C.* While on
tinely
PSV decreases to 5 cm HjO (PSV5+5, 5 cm HjO PSV plus
5 cm HjO of PEEP). At this point, some physicians choose
to prolong weaning with 5 cm HjO of CPAP (CPAP5) for
at least
justable
24 additional hours.
Downs Flow
CPAP
is
provided by an ad-
Generator, a disposable corrugated
was weaned from PSVj^^j or CPAPj at the
who was not aware of
study results. At our institution, some physicians always
wean directly from PSV5+5 while others extend weaning
with CPAP5. Even though the assignment to the 2 groups
in our study was not random, the treatment of any given
patient depended solely on the patient's physician, whose
call schedule was determined months in advance, and was
Each
patient
discretion of his or her physician,
independent of the patient population present
in the inten-
sive care unit at the time of the study.
All patients were
mately 24 hours,
at
were removed from
patients,
15
weaned from PSV<;_^5 for approxipoint, 20 patients (Group A)
which
full ventilatory support.
Of
these 20
were extubated, 2 underwent decannulation
with a tracheal button, and 3 had permanent tracheosto-
mies (due
to obstructive sleep apnea).
Following extuba-
face-mask
* Suppliers of commercial products are identified in the Product Sources
tion or decannulation, intermittent
section at the end of the text.
employed. Twenty-two patients (Group B) had
422
CPAP, was
their
wean-
No
4
Work
Table
Difference in
1.
Work
of Breathing between
PSV,+, and CPAP,
Group
All Patients (n
CPAP5
=
0.67
42)
(n
failure (n
= 36)
= 6)
0.64
0.90
±
±
±
0.96
±
0.53 (0.08)
< 0.0001
0.53 (0.09)
0.95
±
0.52 (0.09)
<0.000I
0.61 (0.25)
1.03
±0.65(0.26)
0.0022
1.01
±
±
(/!
=
18)
0.76 ±0.62(0.15)
Group B
(n
=
18)
0.51
PSV5+5 and CPAP5
PSV5«5 =
test.
values are
means ± standard
pressure support ventilation of
±0.41
deviation, reponed in joules per
cm H2O
.'>
p value
0.54 (0.08)
A
Group
42 Patients
PSV,,^,,
Weaning success
Weaning
in
0.89
(0.10)
liter,
with the standarxl error of the estimate shown
with an external positive end-expiratory pressure of 5
cm H2O; CPAP5 =
0.0097
0.57(0.14)
<
0.47(0.11)
in parentheses.
The p values were
0.0001
calculated using the paired
/
continuous positive airway pressure of 5 ctn H2O.
at
normal; however, the chest wall compliance would have
were extubated, 4
been the same during the 2 modes because they were
underwent decannulation with a tracheal button, and 5 had
tested sequentially in each patient. Thus, differences in the
ing extended for an additional 24 hours with
which point
Group B
3 of the
1
permanent tracheostomies
apnea,
I
patient
had tracheal
patients
CPAP,.
had obstructive sleep
(3 patients
had a cerebrovascular accident,
stenosis). All patients
patient
1
were followed for 48
PSV5+5 and CPAP,.
Weaning from mechanical ventilation was considered suchours after the discontinuation of
cessful
if
a patient did not require full
mechanical venti-
WOB would have been due to differences in the work
done by the lung. Data were analyzed using a Gaussianbreath-elimination method that we developed in order to
omit breaths with artifactual changes
The WOB
in joules
per minute (J/min) was calculated breath-by-breath in our
ume by
WOB
esophageal pres-
in
sure due to nonrespiratory maneuvers, 22
data analysis program by multiplying
48 hours.
latory support within these
total
WOB
per unit vol-
the minute ventilation.
Data Collection and Analysis
Statistics
Measurements were made
determine the
to
WOB
stages of weaning.
the
WOB
A
at a fixed point before the final
report
would change
at
the beginning of PSV5+5
Petrini et al suggested that
by
little
between
this point
tubation or decannulation; in that report the
a low but constant level of
1
and 24 hours prior
PSV was
and ex-
WOB
during
not different between
to extubation in patients gradually
weaned with PSV following prolonged mechanical
venti-
lation.'"
The
WOB
Prior to the beginning of the study, the
quired sample size was calculated
to
minimum
re-
be approximately 20
patients in order to detect a difference of
30% between the
2 modes
t
<
ing p
in each group, using the paired
0.05, a statistical
variability of
40%,
as
we
test,
and assum-
power of 80%, and a
usually found
WOB
our patients.
in
Data are reported as means, plus or minus the standard
deviation (SD), with the standard error of the estimate
per unit volume in joules per
liter (J/L)
was
measured using a CP-100 Pulmonary Monitor. The flow
transducer used for continual measurements of airway flow
and airway pressure was placed
at the
proximal end of the
endotracheal or tracheostomy tube. Esophageal pressure
(SEE)
in parentheses.
The SEE was used
to estimate the
accuracy of the determination of the mean. The
used to describe the distribution of the values
Comparisons between each mode were made by the
t test. Between-group comparisons were made by
paired
each patient by performing the airway occlusion test."
groups was compared using the chi-square
Each data collection period was 5 minutes. Data were
from the CP-100 Pulmonary Monitor to an IBMcompatible computer via a serial port and stored in the
computer using software provided by BiCore. This pul-
monary monitor
in the test
population, 2^
was measured with an esophageal balloon incorporated
into a nasogastric tube. Balloon placement was checked in
sent
SD was
the unpaired
sults
t
test.
Frequency of observations
were considered significant with a p
in the
test i)^).
<
2
Re-
0,05 for
all
tests.
Results
reliably provides a breath-by-breath, real-
time display of the measured and calculated weaning parameters, including
WOB.ô
(Its
use
is
described in a report
The pulmonary monitor assumes a
normal chest wall compliance of 0,2 L/cm HjO in the
calculation of WOB. The value of the chest wall compliby Nilsestuen
et al,^')
ance for individual patients
may have been
different
No 4
from
The mean
WOB
was
less during
PSV5+5 than during
42 patients were taken together (p <
0.0001), as well as when the 36 patients who succeeded
and the 6 patients who failed were considered as separate
CPAP, when
all
groups (Table
1).
The
WOB
measured
in
J/min was also
423
Work
Table
2.
Respiratory Parameters
Parameter
in
PSV,^, and CPAP, Mode
Work
PSV5+5
2 groups: Group
in the
J/L versus
Group B =
unpaired
test.
t
±
0.51
A =
Similarly, there were
WOB
nificant differences in the
0.76
±
0.62 (0.15)
=
0.41 (0.10) J/L, p
no
0.17,
CPAP,
1
test.
A
A
successfully.
and 4 patients
of 6 patients (2 patients
total
in
each group were weaned
in
Group B)
failed
weaning
in
(ie,
Group
A
required
mechanical ventilation within 48 hours). There were no
statistical differences
modes
p
=
(2 of
20
in
between the
Group
A
failure rates in the 2
Group
versus 4 of 22 in
B, x^-
0.75).
WOB
than with PSV,^,. This finding
was higher with CPAP,
may be due
levels of airway pressure delivered
to the different
by these 2 modes. PS V
a form of partial ventilatory support that delivers a se-
amount of
positive pressure in response to a spon-
taneous inspiratory effort, while
ventilatory
mode where
CPAP
is
positive pressure
a spontaneous
is
maintained
throughout the breathing cycle. With PSV5^_,, the
mandatory ventilation
10
cm H2O, PEEP
was
<
in these
22
and
patients,
work was
the physiologic
total
Two other factors have been reported to contribute to
the WOB. First, while the presence of auto-PEEP can
increase the WOB,^-* in this study
Table
cm H2O
I
auto-PEEP was approx-
PSV,,,
than in
CPAP,
(see
that difference is too small to explain the
and
2),
less in
observed difference
in
WOB.
Second, the ventilatory
cir-
PSV^s and CPAP'^^s can impose different amounts of inspiratory work. However, we have
previously shown that the circuitry used in this study re-
cuits for providing
sults in similar
pressure.
WOB
when providing
The pulmonary monitor assumes
compliance (C^J of 0.2 L/cm HjO
WOB.
similar levels of
2''
a normal chest wall
in the calculation
Patients with respiratory failure could have a
C,.^^,
of
as
L/cm HjO. Although it is not likely that our
had such a low chest wall compliance (since they
had recovered from the respiratory failure and were being
low as
0.1
patients
weaned),
C^.„
we
calculate that, in our patients, a halving of
L/cm HÔ, which would double the
work), would only increase the total WOB by
(from 0.2
chest wall
to 0.1
No 4
WOB
>
was
These 21 patients
were subsequently extubated. while the remaining patient
28 patients, and
>
imposed work
level of physiologic
30 breaths/minute
in the 21
The
patients.
observed in the present study were
<
respiratory rates
30 breaths/minute,
despite
WOB
and
and we did not observe any signs of
2),
>
values
0.8 J/L with
was most
spiratory muscle activity
(see Tables
distress.
1
Since
different, the re-
likely adequate to over-
work
additional increase in
CPAP,
was not
the failure rate in the 2 groups
come any
in
tachypnea was attributed to the
this
that the
CPAP, might
have imposed.
Two
previous studies failed to establish a significant
WOB
(in joules
versus
it
but one they found that
0.8 J/L.
CPAP5. In addition, the greater inspiratory pressure
during PSV5+5 can result in the increased tidal volume
seen with PSV5+5 versus CPAP, (see Table 2).
10
PSV <
6 patients the
In
in all
<
obstructive pulmonary disease.
at
intermit-
breaths/minute,
HÔ).
greater inspiratory airway pressure provided by PSV^^.,
maintained
20 minutes
(ie,
They measured imposed work and physiologic
0.8 J/L.
work
cm
of 5
difference in
is
for
0.8 J/L, while in the remaining 22 patients
cm HjO,
whereas during CPAP5 the inspiratory pressure is 5 cm
H2O. In both modes the expiratory airway pressure is 5 cm
H2O. Thus, the higher WOB during CPAP, may reflect the
inspiratory airway pressure
imately
CPAP,
of 0-2
im-
WOB in 28 patients
from minimal mechanical ventilatory support
work. The respiratory rates were
group of 42 mechanically ventilated patients judged
ready to be weaned, the
lected
to increase the
studied the
et al'^
were placed on
after the patients
all
is
shown
has been
Kirton
was not extubated, because of the high
Discussion
In a
WOB.
posed
tent
of 18 patients
total
CPAP,
Recently
statistically sig-
measured during
.01 ± 0.57 (0. 14) J/L versus
in the 2 groups: Group A =
Group B = 0.89 ± 0.47 (0.11) J/L, p = 0.52, unpaired
/
no more than 20%, a value well within the variability of
the measurement.
sures provided
WOB
uated
who had
versus
by
between similar bilevel airway pres-
PSV
CPAP.
versus
who
respiratory failure but
per
CPAP,.
liter)
was not
in
8 patients
did not have chronic
They found
different
that the
WOB
between PSV,^^,
Similarly, Sassoon et aP"* reported that in 9
pulmonary disease
covering from respiratory failure, the
joules per liter) during
with 8
Petros et al" eval-
using the Hamilton Ventilator
WOB
re-
(measured
in
PSV, (using a Puritan Bennett 7200a)
cm HjO CPAP (demand
valve system with Puritan
Bennett 7200a) was not different from that measured during 8
cm H2O CPAP
(flow-by with Puritan Bennett 7200a
or continuous flow system with
CPAP
system).
The absence of
Emerson water column
significant difference ob-
served in the studies by Petros and Sassoon
result of the different types of
CPAP
may be
the
mechanical ventilators and
systems used, the different patient groups studied,
or a lack of statistical
power due
to small
sample
size.
There are several strategies for weaning from mechanical ventilation.*'
We try
to maintain a balance
between the
beneficial effects of a period of total rest for the respiratory muscles recovering
from fatigue
curred during respiratory
failure-''
that
may have
oc-
and the harmful effects
of prolonged inactivity that result in muscle weakness and
atrophy.''' In
full
our intensive care unit patients are rested on
mechanical support
until they
have started
to recover
425
Work
illness. Weaning with gradual PSV
hemodynamics are stable, there is ade-
from the underlying
begins
when
the
quate gas exchange, and the patient
ventilator.
Conclusion
Our
able to trigger the
is
Because the primary process leading
me-
to
show
results
that the
WOB
PSV5+5 was
during
lower than during CPAP5, and the weaning outcome was
com-
same in patients weaned from PSV,^, as in patients
whose weaning was extended with CPAP5. Extending
weaning with CPAP5 offered no benefit in these patients,
pared directly with those studies that employ a switch
but instead imposed an additional load on the ventilatory-
chanical ventilation has not completely resolved prior to
the institution of weaning,
we cannot
substitute
CPAP,
a T-piece in one step. Thus, our results cannot be
from
full ventilatory
who can
to separate patients
from mechanical
support to
CPAPj
or T-piece in order
immediate weaning
tolerate
ventilation''"'"
or
from those who
will re-
the
musculature. Thus, during gradual weaning with
lowing prolonged mechanical ventilation,
ventilatory support can be
removed
full
directly
PSV
fol-
mechanical
from PSV, +5.
quire gradual weaning from prolonged mechanical venti-
PRODUCT SOURCES
lation.
There were no differences
WOB
in
during
PSV5+5 and
Group A, in whom
full mechanical ventilatory support was removed from
PSV5+5, and the patients of Group B, in whom weaning
was extended for an additional 24 hours (see Table 1). The
during
CPAP5 between
Ventilator:
the patients of
Servo 900C, Siemens-Elma AB, Sweden
CPAP
CPAP,
did not improve the
outcome. Thus, the present study supports the idea
External
that,
Downs Flow
Generator, #9250, Vital Signs
Totowa NJ
Inc,
2 groups were otherwise similar (see Table 3). Further-
more, extending weaning with
System:
Adjustable
PEEP
Valve:
#9005, Vital Signs Inc, Totowa
NJ
following gradual weaning with PSV, further use of CPAP5
offers
no additional
benefit,
and that patients can be ex-
tubated or decannulated directly from
PS V5+5. This
shorter
protocol saves a day of weaning by eliminating the use
of
CPAP.
The present study has 2
assignment of patients to the
dom. The decision
The first
2 groups was not
limitations.
Esophageal Balloon Catheter:
Smart Cath, BiCore Monitoring Systems,
or extended with
removed
truly ran-
directly
CPAP5 was made
VarFlex, BiCore Monitoring System, Irvine
from
CA
advance and were independent
CA
Humidifler:
by the phy-
RCI Conchatherm
some physicians always extubate from PSV5+5, while others deem it safer to extend
the weaning with CPAPj. However, the assignment to a
particular group was the result of call schedules that had
in
Irvine
Pneumotachometer:
sician caring for that patient;
been determined months
CA
Irvine
that the
as to whether a patient's mechanical
ventilatory support should be
PSV5+5
is
Pulmonary Mechanics Monitor:
Model CP-100, BiCore Monitoring Systems,
111,
Respiratory Care Inc, Arlington
Heights IL
ACKNOWLEDGMENTS
The authors would
like lo
thank the respiratory therapists and intensive
care nursing staff for their cooperation during this study.
of the patients
time of the
in the intensive care unit at the
study. Thus, the bias that
may have
entered into the study
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A
second limitation
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is
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that
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427
Continuous and Expiratory Tracheal Gas Insufflation Produce Equal
Levels of Total PEEP
M Miro MD,
Edgar Delgado RRT, Adelaida
Frederick J Tasota
RN MSN,
Leslie
and Micliael
A
R
Hoffman
RN
PhD,
MD
Pinsky
BACKGROUND:
Tracheal gas insufflation (TGI) used in conjunction with mechanical ventilation
can increase total positive end-expiratory pressure (total PEEP). We tested the theory that TGI
delivered throughout the entire respiratory cycle (c-TGI) increases total PEEP more than expiratory phase TGI (e-TGI). We also studied whether a pressure relief valve in the ventilator circuit
could prevent increase in total PEEP during TGI. METHODS: Using an artificial lung model and
pressure control ventilation, we studied the effect of c-TGI and e-TGI, with and without a pressure
and with and without maintenance of a constant minute ventilation (Vj), at 3 different
RESULTS: Under constant V^ conditions, the increase in total PEEP
was equivalent with c-TGI and e-TGI. Without adjustments to maintain V^ constant, Vp. increased
during c-TGI and decreased during e-TGI. Under all conditions increasing the inspiratory-expiratory ratio increased total PEEP. CONCLUSION: When Ve is maintained constant, c-TGI and
relief valve,
inspiratory-expiratory ratios.
e-TGI produce equivalent
TGI
levels of total
PEEP. Failure
to adjust the ventilator settings
creates changes in ventilatory parameters that are unique to each delivery system.
Care 1999;44(4):428-433] Key words: tracheal gas
insufflation,
mechanical
ventilation,
during
[Respir
barotrauma,
ventilatory support.
gas then insufflates the airway with an oxygen mixture
Introduction
.
equivalent to that delivered by the mechanical ventilator.
Tracheal gas insufflation (TGI) was developed to aid in
the reduction of alveolar distending pressures and yet main-
adequate gas exchange when treating patients with
tain
acute lung injury.
When
chanical ventilation,
utilized in conjunction with
me-
TGI can enhance carbon dioxide (COj)
elimination for a constant minute ventilation (V^), potentially
reducing ventilatory requirements.'
TGI
^
cm above
CO2 washout from
the carina.
A
flow of
the anatomic
distal
elimination,
it is
M
Miro
TGI
Vp
Vg and peak airway presCO2
constant while increasing
TGI
is
delivery have been proposed.
to deliver
TGI continuously
TGI can also be
throughout the respiratory cycle (c-TGI).
is
affiliated with the
Department of Respiratory
Care, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
Adelaida
high
2-''*'''
The simplest method
RRT
at
the efficiency of
possible either to reduce mechanical
sure (Ppeak)' or to l^sep
elimination.
to
mechanism is enhanced
TGI improves
by decreasing
Several methods of
Edgar Delgado
believed to be
gas mixing due to the turbulence created
catheter flow. '^''-i 2 Since
CO2
is
dead space proximal
the catheter tip.^"* Another possible
ventilatory support
involves an intratracheal catheter advanced to a
position approximately 2
The major mechanism of CO2 elimination
MD and
Michael
R
Pinsky
MD are
affiliated with the
gated (using solenoid valves) to deliver gas during specified phases of the respiratory cycle.
Regardless of the
Department of Anesthesiology and Critical Care Medicine, School of
delivery method, adverse effects have been observed with
Medicine, University of Pittsburgh Medical Center, University of
TGI, including increases
burgh, Pittsburgh, Pennsylvania. Leslie
erick
J
Tasota RN,
MSN
A
Hoffman
RN PhD
Pitts-
and Fred-
are affiliated with the University of Pittsburgh
in Ppâk
and end-expiratory lung
volume. The increase in end-expiratory lung volume
dynamic form of hyperinflation, and
is
re-
often re-
Medical Center, and the Department of Acute/Tertiary Care. School of
flects a
Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania.
ferred to as auto-positive end-expiratory pressure (auto-
Correspondence: Edgar Delgado RRT, Department of Respiratory Care,
University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh
PA
15213. E-mail: [email protected].
428
It has been postulated that increases in Ppg^^
and end-expiratory lung volume are greater during c-TGI
because gas is delivered throughout the respiratory
PEEP).'*-"'
No 4
Continuous and Expiratory Tracheal Gas Insufflation Produce Equal Levels of Total PEEP
Pneumotach
Internal pressure transducer
signal
TGI
catheter
Pressure relief valve
Inspiratory limb
Compliance spring
To TGI
gas source
Proximal airway pressure port
Fig.
1
Experimental apparatus. TGI = tracheal gas Insufflation; pneumotach
.
cycle. **•''•"' Thus, a potential reason for the observed in-
PEEP
crease in auto-PEEP and consequent increase in total
(set
PEEP + auto-PEEP)
with c-TGI
because the ventilator-delivered
tidal
is
an increase
V^,
in
volume (Vj) was not
proportionally reduced (volume control ventilation) or the
ventilator circuit
TGI volume
(pressure control ventilation).
There are several reports
teractions
to vent excess
was not properly adapted
'*''
that describe a variety
constant during
= pneumotachometer.
PCV,
using either c-TGI or
total
PEEP
used a single compartment
test this
artificial
sure end-expiratory lung pressures.
total
PEEP
levels during
would be
levels
e-TGl. To
the
same
we
hypothesis,
lung model to mea-
We
then compared
c-TGI with those produced dur-
Vg
ing e-TGI, with and without adjustments to maintain
constant.
of
between TGI and mechanical ventilation
in-
Methods
that
influence ventilatory parameters such as Vj; and total
1^'^
When c-TGI is used with PCV, the ventilator
compensates for the increased flow from the catheter by decreasing ventilator-derived Vj. However, this
PEEP.'^
Equipment, Calibration, and
Initial
Conditions
initially
compensation ends
ventilator flow ceases. In this situ-
if
The apparatus consisted of a single-compartment artifiTGI catheter device, pneumotach-
cial lung, linear resister,
Vg measurement,
adjustable pressure relief
ation with c-TGI, gas continues to flow into the lung dur-
ometer for
between cessation of ventilator flow and
the beginning of expiration, which results in an increased
valve, and mechanical ventilator (Fig. 1).*
ing the interval
volume of
insufflated gas and, therefore, an increase in
peak inspiratory pressure because the ventilator does not
recognize the excess volume. This situation can be avoided
by the insertion of a pressure
lator circuit,
which allows the excess gas
the atmosphere.'-*
Ve
is
an increase in pressure
TGI (e-TGI)
relief valve into the venti-
is
during
be vented into
catheter (1.67
artificial
trachea (73
transducer,
et al'** recently
found
TGI
artificial
the
length including pneumotach-
catheter swivel).
was placed within
(ventilator
Vp (compared to no TGI).
cm total
of the
The
mode with
inner diameter) inserted into the
pneumotachometer, connected
avoided. Use of expiratory phase
decreases
mm
ometer, resister, and
distal to the tip
avoids this problem because gas flows only
PCV, e-TGI
TGI
thereby maintained constant and
during expiration. However, Imanaka
that,
to
lung model was operated in the single-lung
TGI
A
calibrated
to a differential pressure
the artificial airway 14.5
catheter to record total
cm
V^
-I- TGI) entering the lung. Volume calibration
measurements were performed by injection of a known
volume (0.750 L) using a calibration syringe. Volume calibration measurements were repeated until a s 3% varia-
Both c-TGI and e-TGI produce back pressure during
PCV
and, thus, similarly increase expiratory resistance.
But the effect of either TGI method on
is
unclear.
We
V^ and total PEEP
Vg was kept
hypothesized that as long as
Respiratory Care
•
April 1999
Vol 44 No 4
* Suppliers
of commercial products are identified
in the
Product Sources
section at the end of the text.
429
Table
1.
Continuous Tracheal Gas Insuftlalion versus Expiratory Tracheal Gas Insufflation with and without Adjustments
Minute Ventilation
to
Maintain Constant
.
Vg. These changes in Vp led to a greater total PEEP during
c-TGI than during e-TGI, particularly at an I:E ratio of 2:
Further, these changes in Vp corresponded to changes in
IBTotal-PEEP
-- Minute
Ventilation
T
15
1
t15
between
the pressure gradient
Table
O
X
10
10
and
Pj^^t,
PEEP
total
(see
1).
s
s
Discussion
p
0.
1
>
-5
5
i
Tracheal gas insufflation can be an effective tool to
CO^
promote
in
elimination from the anatomical dead space
both spontaneously breathing subjects'** and during me-
chanical ventilation.-"'
-0
However, a problem limiting the
successful application of
Continuous TGI
Fig. 3. Total
Expiratory
without Pressure
witliout Driving
Relief Valve
Pressure Adjusted
PEEP and minute
made
PEEP =
to
TGI
pressurization of the airways
hyperinflation. Continuous
an inspiratory-expira-
ventilation at
tory ratio of 1:1 without adjustments
lation constant.
TGI
keep minute
venti-
positive end-expiratory pressure; TGI
the potential for over-
TGI poses
eter during inspiration.'-*"*
when Vg
strates that
is
However, our study demon-
maintained constant, both c-TGI
and e-TGI produce equivalent levels of total PEEP. Furthermore, failure to
make adjustments
system during TGI creates changes
Results
1
and Figures 2 and 3 summarize the
results of
V^
ventilation.
could be maintained constant
between e-TGl and c-TGI. and when compared
to control,
but maintaining constant S/^ required different maneuvers
c-TGI and e-TGI. Vg increased during c-TGl (10.2
L/min
1:1;
at
an I:E ratio of
and 11.2 L/min
at
1:2;
1
1.5
an I:E
L/min
at
an I:E ratio of
of 2:1), but could be
ratio
held constant by the insertion of a pressure relief valve
Vg
into the ventilator circuit. Conversely,
decreased dur-
ing e-TGl (9.6 L/min at an 1:E ratio of 1:2; 10.2 L/min at
an I:E ratio of
1
:
1
;
param-
interest in the clinical application
of TGI has
spurred debate regarding the optimal means to deliver this
to both
for
in ventilatory
therapy. There are potential advantages and disadvantages
our measurements.
Minute
to the ventilator
unique to each delivery system.
eters
Continued
Table
a greater risk of
over-pressurization due to gas flow from the tracheal cath-
=
tracheal gas insufflation.
is
and production of dynamic
and
9.
1
L/min
at
an I:E ratio of
2:
1
),
but
c-TGI and e-TGl with regard
and ease of
to efficacy, safety,
use,-' -^^ but both techniques require
standing of the unique interactions between
ventilator system,
rameters.
We
an under-
TGI and
the
and of TGI's effects on ventilatory pa-
designed our study to examine and describe
the ventilator adjustments necessary to maintain constant
Vp
during
PCV
with TGI, and to document changes in
ventilatory parameters
when adjustments
are not incorpo-
rated.
auto-PEEP development
Prior research has evaluated
PCV
with c-TGI during
and volume control ventilation
PCV
could be held constant by proportionally increasing the
(VCV),'^ and the use of a pressure
ventilator driving pressure.
with c-TGI to keep
When V^ was held constant, the amount of
TGI-induced total PEEP above control was equivalent for
auto-PEEP development with e-TGI during PCV and VCV,
as well as volume-adjusted c-TGI during VCV."* However, the difference in effect between c-TGI and e-TGI on
total PEEP during PCV when minute volume is allowed to
Total
PEEP.
c-TGl and e-TGI:
7.5
8.5
cm HnO
cm HjO
versus 7.5
versus 8.5
cm HjO
cm HjO
cm HjO
versus 12.6
mained constant when
total
PEEP
increased under
all
held constant has not been described.
1:2;
vary or
an I:E ratio of
1:1;
Our data confirm that during PCV, both c-TGI and eTGI increase total PEEP. As previously demonstrated by
at
an I:E ratio of 2:1.
PEEP
re-
held constant, reflecting a
As
I:E ratio increased,
conditions (see Table
1
).
is
our group and others, the increase in
Interactions between the ventilator system
If
no modifications were made
Respiratory Care
•
and
TGI
to the ventilator system,
control, while
April 1999
e-TGI decreased
Vol 44 No 4
total
PEEP
is
due
to
a combination of an increase in airway pressure, limiting
expiration, and delivery of a larger
Using
V-p.'-''*'-'''*
c-
TGl
without volume adjustment increased Vp,
Ppp.,^,
total
PEEP when
(I:E ratios
expiratory time
of l:land 2:1). However,
c-TGI increased V^ above
et al studied
an I:E ratio of
cm HjO
Vg was
Imanaka
at
Pressure gradients between Ppeak and total
constant compliance in the system.
relief valve during
constant.'^
at
and
12.2
Vp
shortened,
Vp and
when
was shortened
the inspiratory time
and
was
Pp^^k "i'd not increase (as seen with an
I;E ratio of 1:2). Using
e-TGI without volume adjustment
maintained Ppeak but increased
total
PEEP. The
resulting
431
decrease in the pressure gradient between
PEEP
Vg
decreased
Pp^^j^
and
because, during
at all I:E ratios,
volume delivered depends on the pressure gradient
the
between the proximal airway and the end-expiratory
in-
trapulmonary pressure, which the ventilator does not meapressure gradient between proximal airway
If the
sure.
PEEP decreases
pressure and total
V-j.
Conclusion
total
PCV,
during e-TGI, delivered
decreases (as demonstrated by our data). Note, how-
would be
ever, that the V-y decrease
neither linear nor
Our study demonstrates
that
when Vg
maintained
is
constant both c-TGI and e-TGI produce equivalent levels
of total PEEP.
It is
necessary to adjust ventilator settings
Vg constant
to maintain
during both c-TGI and e-TGI, and
failure to adjust the ventilator
system causes changes to
De-
ventilatory parameters unique to each delivery system.
spite recent
advances
in
our knowledge of TGI, the chal-
predictable from measures of inspiratory flow, peak in-
lenges related to the monitoring of end-expiratory lung
spiratory pressure, or ventilator inspiratory pressure set-
pressures, adequate humidification, and a pressure relief
need
ting. Further, the
to increase the inspiratory pressure
and
setting to maintain the pressure gradient
obvious from measurement of
intuitively
PEEP
Increase in total
easily addressed. In
delivered
(ventilator
PEEP
total
Vg
the
ventilator-derived
livered
TGI)
-I-
product sources
more
is
in total
Vg.
results in increased
total
Vj causes
Lung 26001, Michigan Instruments
Grand Rapids MI
an increase
TGI
Inc,
Keene
inspiration. --2' After reducing ven-
PEEP
total
levels with
c-TGI during
Our data
demonstrate that if inspired Vg is kept constant by a pressure relief valve during c-TGI, or by increasing driving
pressure during e-TGI, total
PEEP
NH
Pneuniotachometer:
No. 2 Fleisch, Lausanne, Switzerland
Linear Resistor:
112275 7100R20, Hans Rudolph, Kansas City
levels are also equiva-
PCV.
Catheter Device:
Portex let Ventilator Adapter #600 101, Concord/Portex,
an amount equivalent to that de-
are equivalent to those seen with e-TGI."*
lent during
Lung Model:
Training Test
greater than that caused by e-TGI.
Vj by
Vy,
to address total endotracheal tube occlusion
are yet to be resolved.
alone.
VCV
increase associated with c-TGI, reduce
by TGI during
tilator-derived
VCV
mechanism
Artificial
Vy
and
in Ppeak
not
is
c-TGI with VCV, the increase
This c-TGI-induced increase in
To avoid
Pp^..,t-
during c-TGI with
Vj
MO
Adjustable Pressure Relief Valve:
Other factors can also increase auto-PEEP. Increased
#042301, Bird Products Corp, Palm Springs
CA
resistance due to the decrease in cross-sectional area of the
endotracheal tube from the
TGI
catheter can increase auto-
PEEP. Also, the expiratory time is inversely related to the
amount of total PEEP formation, regardless of the mode of
TGI
Mechanical Ventilator:
Puritan-Bennett 720()ae, Mallinckrodt, Pleasanton
Differential Pressure Transducer:
delivery (as demonstrated by our comparisons at I:E
ratios of 1:2 versus
crease in total
PEEP may
result in increased alveolar
anatomic dead space and
perative to consider these
CO,
washout).
phenomena when
utilizing
itations.
We
remotely different from the complex animal or
this
model permitted us
measure true end-expiratory lung pressure
which may be impossible
are currently
in the
no techniques
may
human
to clinically
not match
Vp
the alveolar level in the absence of
limitation holds true for both
and
432
MO
200, Allied
MO
human
ACKNOWLEDGEMENTS
to accurately
(total
PEEP),
We
thank
Tom McCormick
for his exceptional biomedical skills that
enabled us to develop the expiratory tracheal gas insufflation technique
lung. Since there
measure true
al-
utilized in the study. This research
tute for
Nursing Research, NIH,
was supported by
US
the National Insti-
Public Health Service (Grant No.
ROl NR01086-08).
conditions present at
TGI
REFERENCES
conditions. This
c-TGI and e-TGI, and,
there-
of method should be based on individual
institutional experience
RT
Health Care Products Inc, St Louis
5540, Hans Rudolph, Kansas City
1.
fore, the choice
North-
is
veolar pressures, titrating the ventilator system to proximal
airway pressure
Corporation,
Calibration Syringe:
in this study presents certain lim-
used a single compartment model, which
model. However,
Engineering
Timeter Calibration Analyzer, Series
TGI
with inverse ratio ventilation.
The lung model used
Validyne
CA
Independent Flow Calibrating Device:
im-
is
It
ridge
dead
space ventilation, which offsets TGI's benefits (the reduction in
MP45,
versus 2:1). Clinically, this in-
1:1
CA
and preference.
Nahum
A, Burke
WC,
Crooke PS, Marini
JJ.
Ravenscraft SA. Marcy TW, Adams AB,
Lung mechanics and gas exchange during
pres.sure-controI ventilation in dogs.
Augmentation of
CO,
elimina-
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4
by an intratracheal catheter.
tion
Am
O, (TRIO)
Rev Respir Dis I992;146(4):
2.
WC, Nahum
Ravenscraft SA, Burke
TW,
Marini
JJ.
A,
Adams AB, Nakos G. Marcy
CO, clearance
Am
S,
tained constant. Intensive Care
AM, Hoffman LA,
MR. Transtracheal
Am
5.
Med
is
main-
1994;20(6):407-4I3.
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Rev Respir Dis I991;144(6):I229-1233.
Bergofsky EH, Hurewitz AN. Airway insufflation: physiologic effects on acute and chronic gas exchange in humans. Am Rev Respir
Nahum
JJ.
Burke
TW,
Marini
JJ.
J
Adams AB. Burke WC. Marini
CO, removal during tracheal
18,
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Comparison of
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Kamm
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R, Slutsky AS. Effect
11.
Slutsky AS,
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Slut.sky
AS, Watson
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in the central
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Effect of
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Appl Physiol 1987:62(2):513-519.
Leith
Imanaka H, Kacmarek RM. Riggi V, Ritz R. Hess D. Expiratory
phase and volume-adjusted tracheal gas insufflation: a lung model
Med
l998;26(5):939-946.
Nakos G, Lachana A, Prekates A, Pneumatikos
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Guillaume M,
DE, Brown R. Tracheal
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Rao GS,
Gallart L, Puybasset L, Coriat P,
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JJ.
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AS. Catheter position and blood gases during
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Med 1996:153(3):1019-I024.
Nahum A, Adams AB, Marini
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of flow rate on blood gases during constant flow ventilation
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Delgado
and total-PEEP on PaCO,
Respir Dis 1993;l48(3):562-568.
Watson JW, Burwen DR,
Respir Crit Care
study. Crit Care
Adams AB, Marcy
tracheal gas insufflation:
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Am J
Shapiro RS, Ravenscraft SA,
interaction
Appl Physiol I993;75(3):I238-1246.
A, Ravenscraft SA, Nakos G,
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WC, Nahum
1995;23(2):348-356.
Imanaka H. Kacmarek RM. Ritz R, Hess D. Tracheal gas insufflavolume control ventilation. A lung model
(abstract).
17.
Effect of catheter flow direction on
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Tasota FJ, Hoffman LA, Pinsky
Tracheal gas insufflation cools and dries gas
Dis 1989:140(4):885-890.
7.
AM,
insufflation. In-
creasing flow rates progressively reduce dead space in respiratory
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Miro
Tracheal gas insufflation during pressure-control ventilation:
study.
Airway
Marini
tion-pressure control versus
flow augments gas exchange efficiency (abstract).
E.
Adams AB,
145-152.
Blair L. Wesmiller S, Ondulick B, Pinsky
AN. Bergofsky EH, Vomero
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Hurewitz
Gowski DT, Delgado
MR.
Kotanidou A, Tsagaris H, Roussos C. Tra-
cheal gas insufflation reduces the tidal volume while P„co,
Ravenscraft SA,
Effect of tracheal gas insufflation on gas exchange in canine oleic
acid-induced lung injury. Crit Care
14
Nakos G, Zakinthinos
Miro
Ancsth
rates sustains life for several hours.
low flow
Nahum A, Chandra A, Niknam J,
JJ.
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345-351.
4.
13
Tracheal gas insufflation augments
during mechanical ventilation.
3.
at
1985;63(3):278-286.
965-973.
22.
Adams AB.
Nurs
ventilatory strategies in acute respira-
Q
1996:19(3):l-22.
Tracheal gas insufflation (TGI). Respir Care I996;41(4):
285-291.
433
Case Reports
Unrecognized Motor Neuron Disease:
Ventilator
Dependency
Rodrigo Morales
A
previously healthy
woman
MD
An Uncommon Cause
in the Intensive
and Jorge
of
Care Unit
E Mendizabal
MD
We ruled
developed ventilatory failure leading to ventilatory support.
out primary cardiovascular and pulmonary etiologies for the ventilatory failure. Multiple attempts
wean ventilatory support were unsuccessful. Eventually, findings consistent with upper and lower
motor neuron involvement were discovered, as well as paradoxical movement of the abdominal wall
during inspiration. Nerve conduction studies and needle electromyographic examination showed
signs of motor neuron degeneration such as those seen in amyotrophic lateral sclerosis (ALS). ALS
to
should be considered a possible diagnosis in patients with otherwise unexplained ventilator dependence and paradoxical movements of the abdominal wall. [Respir Care 1999;44(4):434-436]
Key words:
motor neuron disease, amyotrophic
ventilatory dependency,
lateral sclerosis,
mechanical
ventilation.
Introduction
ache and noted "twisting" of her mouth. Within minutes,
while in the transferring
Neurological disease
is
occasionally responsible for acute
ventilatory failure requiring prolonged assisted ventilation in
the intensive care unit (ICU).
specifically
amyotrophic
Motor neuron disease (MND),
lateral sclerosis
sents with acute ventilatory failure
respiratory musculature.
is
usually
due
(ALS)
to
rarely pre-
weakness of the
The diagnosis of ALS
in these cases
made retrospectively and by eliminating other more
common neurogenic or myogenic causes of ventilatory weakness.
to
We
MND,
facility,
she
became
diaphoretic and
progressed from mild dyspnea to frank ventilatory
failure.
After orotracheal intubation she was transported by emer-
gency medical personnel
to
our hospital. Her medical history
was unremarkable and she was a nonsmoker.
Physical examination revealed an alert and well nourished
woman who was
able to follow instructions while
receiving assisted ventilation. She
was
afebrile, her vital
signs were stable, and her initial cardiac and respiratory
present a case of ventilator dependence secondary
examinations provided no clues as to the cause of her
and review the pertinent
respiratory arrest.
literature.
Her neurological examination revealed
mild generalized limb muscle weakness (strength 4/5), brisk
Case Report
deep tendon reflexes with unsustained
bilateral ankle clo-
nus and bilateral extensor plantar response.
A 70 year-old woman was transferred to our institution for
ventilatory support after suffering a respiratory arrest.
patient
had been complaining of "frequent
sive dysphonia for
these
symptoms
falls"
The
and progres-
week, but had noticed worsening of
1
in the
2 days prior to presentation. She de-
nied dysphagia, sensory symptoms, muscle twitching, or
cramps.
On the day of presentation she complained of a head-
MD and Jorge E Mendizabal MD are affiliated with the
Alabama Medical
Correspondence: Rodrigo Morales
Fillingim
Street,
usouthal.edu.
434
Mobile
AL
Center, Mobile, Alabama.
MD,
4th floor,
36617-2293.
MSTN,
E-mail:
Suite L, 2451
nnorales@jaguarl.
A
noncontrast computed tomography of
the head (performed at the transferring facility)
showed no
acute findings, but revealed an incidental small right parietal
convexity mass with the radiologic appearance of a
dural based meningioma.
24 hours
University of South
muscular
sory examination was unremarkable, and anal sphincter
tone was normal.
vealing.
Rodrigo Morale.s
No
atrophy or limb or tongue fasciculations were noted, sen-
On
Maximum
A
chest radiograph
inspiratory pressure (MIP),
after admission,
was -8
cm HjO
was unremeasured
[-0.784 kPaJ.
4 we set the ventilator to presmode and recorded an MIP of -10 cm H20
[-0.980 kPa]. Over the following 24 hours we gradually
hospitalization day
sure support
decreased the pressure support; then the patient was extubated and placed on face mask. However, within 10 min-
No
4
"
Unrecognized Motor Neuron Disease: Ventilator Dependency
ICU
The most common
utes of extubation her
oxygen saturation dropped and she
lator
became bradycardic.
We
neurological causes of respiratory muscle weakness in the
began noninvasive ventilation
with pressure support of 8
cm HÔ
positive end-expiratory pressure
0.784 kPa] and a
1
(PEEP) of 8 cm HÔ [0.784
kPa]. After several minutes the patient appeared exhausted
and an
113
a
arterial
blood sample showed a
mm Hg [15.1
CO2
kPa). Pq, of 106
content of 24 mmol/L.
We
ICU
of 6.95, Pô, of
[14.1 kPa],
and
ventilation.
Her course
involved further unsuccessful attempts to dis-
in the
setting.'
are acute demyelinating polyradiculoneuropathy
(Landry-Guillain-Barre syndrome), myasthenia gravis,
crit-
polyneuropathy, acute intermittent porphyria,
ical illness
Lambert-Eaton myasthenic syndrome, and neuromuscular
blockade.'
ALS
reintubated the patient
and again placed her on mechanical
in the
pH
mm Hg
ICU
dependence
belongs to a group of degenerative diseases col-
lectively
known
MND,^ which
as
include a spectrum of
mo-
idiopathic degenerative diseases primarily affecting the
MND
can primarily affect the upper motor
continue mechanical ventilation, eventually leading to a
tor neurons.
tracheostomy. During the course of her hospitalization the
neuron (primary
patient developed a nosocomial urinary tract infection,
(progressive spinal muscular atrophy), or both (ALS).^
which was effectively treated with intravenous
We
antibiotics.
movements of
eventually noted paradoxical
the ab-
dominal wall during spontaneous inspiration, and a
time fluoroscopically-guided sniff
test
real-
revealed reduced
but symmetrical diaphragmatic excursion. At that time
MIP
was -10 cm HÔ [-0.981 kPa], with
volume of 300 mL.
tidal
A
a spontaneous
consulting neurology team noticed mild facial diple-
gia and generalized
weakness with
interossei, hyperreflexia,
sponse. Their
exam
and
distal
About 25% of cases present
did not note fasciculations in the limbs
lower motor neuron
initially
with bulbar symp-
toms characterized by the gradual onset of dysphagia, dysand dysphonia (primary bulbar
arthria,
ratory muscle weakness,
later in the
course of
when
ALS
sclerosis).
"*
Respi-
occurs, tends to present
it
or primary bulbar forms of
MND. However, the majority of patients with MND
suffer an insidious onset, with vague complaints of clum2-*
siness,
muscle twitching, cramping, and mild weakness.^
Previous reports describe ventilatory failure as the
atrophy of the
bilateral extensor plantar re-
lateral sclerosis), the
presentation of
tial
MND.'
**
ini-
In all the reported cases, pre-
viously healthy individuals develop ventilatory failure lead-
The
becomes
or lingual musculature. Intravenous administration of 10
ing to mechanical ventilation.
mg of edrophonium chloride (Tensilon) increased MIP by
5 cm H2O [0.490 kPa]; the neurological team considered
ventilator-dependent because of profound neurogenic
the test inconclusive.
An
assay for antibodies against the
acetylcholine receptor in the muscle returned negative.
trial
of physostigmine produced no improvement of her
weakness, and
it
A
appeared
to
we
Muscle fasciculations occurred
tially attributed to
at this
time and were
ini-
anticholinergic toxicity from the phy-
sostigmine. Nerve conduction studies revealed small
plitude of the
compound muscle
am-
action potential of the
median, ulnar, and peroneal nerves, with preservation of
the conduction velocity.
tials
Her sensory nerve action poten-
were normal, and repetitive nerve stimulation did not
show a decremental response. Needle electromyography
(EMG)
weakness of the respiratory apparatus. Paradoxical movements of the abdominal wall
detected diffuse limb muscle denervation and neu-
rogenic motor unit recruitment pattern. The findings were
consistent with a diffuse motor neuronopathy such as that
seen in ALS. The combination of upper and lower motor
neuron disease identified
in the physical
examination and
noted in our patient) are
(as
a sign of diaphragmatic weakness,
Retrospectively, the history of our patient suggested possible
involvement of the lower motor neuron bulbar mus-
Chen
culature. Similarly,
et
observed signs of upper
al''
motor neuron involvement prior
a series of
ure.
MND
to recognition of
do not describe signs of upper motor neuron
volvement upon
initial presentation.''^
muscle weakness
variable in these series, but note that
is
the
in
months preceding the onset of overt respiratory
failure.'
Nerve conduction
duced amplitude of
testing in
the
MND
ventilator-
tivity consistent
EMG
of involved mus-
groups shows evidence of spontaneous motor unit acwith neurogenic denervation and reduced
muscle unit recruitment patterns.- The diagnosis
confirmed
if
similar findings are recorded
is
usually
from 3 or more
muscle groups from different limbs or the tongue. ^ Direct
Discussion
needle
is
occasionally identi-
fied as the sole cause of ventilatory failure and/or venti-
April 1999
action potential,
with a normal latency and conduction velocity in the absence of focal conduction block. ^
•
usually reveals re-
compound motor
cle
Respiratory Care
in-
The presence of
'^
signs of mild respiratory impairment are often reported
ventilatory
primary neurological etiology
in
Other reports of ALS as a primary cause of ventilatory
failure
ALS. The patient remained on
support and was eventually discharged to a
skilled nursing home facility.
A
ALS
patients presenting with ventilatory fail-
the results of the electrophysiological studies led to the
diagnosis of
and are suggestive of
MND.'tos
discontinued the physostigmine because
induce abdominal cramping and diarrhea.
patient
Vol 44 No 4
EMG study of the diaphragm
is
feasible in the
ICU
The technique for electrophysiological testing of
phrenic nerve and diaphragm is presented in detail by
setting.'"
the
435
Unrecognized Motor Neuron Disease: Ventilator Dependency
ALS,
Bolton.'" In
phragm
EMG
REFERENCES
needle examination of the dia-
reveals spontaneous motor unit activity, with a
decreased number of relatively normal-sized motor unit
potentials.'"
The choice among long term
ALS
alternatives for
patients depends
sentation of the ventilatory failure." In
on the
ALS
rol
patients pre-
the
is
patients,
failure,
most
who
likely long-term option.
suffer
more
'
'
Chronic
ALS
of
ALS
carries
invariably fatal
rol Sci
Chen
profound legal and ethical implications for
ALS
patients,
sisted suicide at
some
56%
tor
point in their disease.
support and counseling services
their feelings
may
Psycholog-
help to alleviate
amyotrophic
F, Evangelista T, Pinto
A, Luis
Ramsey DA, Bolton CF, Mo-
neuron disease presenting as acute respiratory
failure: a clinical
Neurol Neurosurg Psychiatry 1996;60(4):
J
sclerosis
and respiratory
failure.
Acta Anaesthesiol Scand
1993;33(6):628-630,
Annane D, Korach JM, Templier
Summary
et al.
F,
Durand MC, Dinet-Busso N, Le
Diaphragmatic paralysis preceding amyotrophic
eral sclerosis (letter).
Meyrignac C, Poirier
lat-
Lancet 1993;342(8877):990-991.
J,
Degos JD, Amyotrophic
lateral
sclerosis
presenting with respiratory insufficiency as the primary complaint,
medical or neurological etiologies
cannot be established as primary causes of ventilatory
ure or ventilator dependence,
MND. The
signs of upper and lower
we recommend
fail-
Eur Neurol 1985;24(2):1 15-120,
10.
considering
presence of bulbar symptoms,
movements
ing inspiration should prompt consideration of
MND,
Can
Escarabill
J
Med
12.
J,
Estopa R, Farrero E, Monasterio C, Manresa F, Longin
amyotrophic
lateral sclerosis,
Respir
1998;92(3):438^41,
Ganzini L, Johnston
MA,
in the intensive care
Neurol Sci I994;21(2):S28-S34,
term mechanical ventilation
dur-
and
Bolton CF, Assessment of respiratory function
unit.
motor neuron degeneration, or
the occurrence of paradoxical abdominal
WS, Bentson H, McFarland BH,
Telle
SW, Lee
Attitudes of patients with amyotrophic lateral sclerosis and their
neurophysiological studies should be obtained in these
caregivers toward assisted suicide,
cases.
967-973,
436
in
1994;15(4):675-681,
1996;139(Aug Suppl):l 17-122,
Carre A,
the diagnosis of
Med
455^58,
Kuisma MJ, Saarine KV, Teirmaa HT, Undiagnosed amyotrophic
of hopelessness. '^
When more common
Head Neck 1989;1 l(l):51-59,
R, Grand'Maison F, Strong MJ,
lateral
ical
Neu-
disease presenting with respiratory failure, J Neu-
and pathological study,
admitted to considering as'^
Clin Chest
ML, Motor neuron
outcome
J
Miller R. Bulbar amyotrophic lateral sclerosis: patterns of
de Carvalho M, Matias T, Coelho
the patients and their caregivers. In a recent large-scale
survey of
AD,
lateral sclerosis.
vasive mechanical ventilation, thereby reducing the need
ill
Neurosurg Psychiatry 1994;57(8):886-896.
Kaplan LN, Hollander D. Respiratory dysfunction
insidious onset of ventilatory
The
in critically
Neurology and General Medicine.
progression and clinical management.
can be managed with negative pressure or nonin-
for specialized resources."
editor.
York: Churchill Livingstone; 1995:859-878.
Hillel
senting with acute onset of ventilatory failure, tracheos-
tomy
Aminnoff MJ,
Leigh PN, Ray-Chaudhuri K. Motor neuron disease (review),
pre-
initial
Young GB. Neurological complications
New
management
ventilatory
Bolton CF.
patients. In:
...
Respiratory Care
N
Engl
J
:
•
April 1999
Med
I998;339(I4):
.
Vol 44 No 4
Patricia
A
A
Doorley
MS RRT
and Charles
60- Year-Old
G
Durbin
Woman
Ali
Jr
MD,
Section Editors
with Dyspnea on Exertion
Emad
MD
Case Summary
A
60-year-old
woman
of a gradual increase
weight
chills, fever,
in
loss,
How
sought medical attention because
dyspnea on exertion. She denied
abdominal symptoms, chest pain,
cough, expectoration, or other cardiopulmonary symptoms.
Her medical history was negative for hypertension, diabetes,
or trauma.
The
patient
Test Your
Radiologic Skill
What
What
mgs
What
would you answer these questions?
are the major findings in the radiographs and
differential diagnosis is suggested
CT?
by these find-
.'
treatment
is
indicated?
Answers
had no prior hospitalizations or
recent medical evaluations. Physical examination revealed
woman who was
an obese
afebrile, with a heart rate
of 109
beats/min, a respiratory rate of 20 breaths/min, and blood
pressure 110/70
mm
Hg. Examination of the chest
vealed bowel sounds in the lower portion of the
thorax. Heart sounds
gallops.
left
re-
hemi-
were normal, without murmurs or
as was the neurologic
The abdomen was normal,
Radiographs and CT. The left hemidiaphragm is markThe mediastinum and heart are pushed to
edly elevated.
the opposite
site,
suggesting the presence of extrinsic pres-
sure on these structures.
hemidiaphragm
is
line (arrow). All gas
shows the posteroanterior and lateral chest radiographs. Arterial blood gas analysis showed pH 7.33,
the left
1
mm
carbon dioxide tension (Paco^) 33
Hg, arterial
oxygen tension (Pao^) 61
Hg, and oxyhemoglobin
arterial
mm
saturation
91%
while the patient breathed room
Shiraz, Iran, elevation 1,600
metric pressure 690
mm
m
[5,000
at
air (in
normal baro-
Hg). Chest fluoroscopy showed
motion of the
significantly restricted
ft],
left
The
shadows
are located under the leaf of
hemidiaphragm.
CT reveals intra-abdominal
contents, including hol-
low-viscous structures and part of the spleen within the
left hemithorax. There are no mediastinal, pulmonary, or
diaphragmatic masses. The heart and mediastinum have
been partly displaced to the
collapsed.
The
right.
showed mild narrowing of
the left
Differential Diagnosis.
vation of the
left
pression, and no evidence of endobronchial lesions. Cyto-
and distended abdominal viscera. '^
and microbiologic studies were negative.
An
esopha-
scess, diaphragmatic hernia, eventration
Phrenic nerve palsy
is
of the diaphragm,
suggested by the presence
of:
elevation of the diaphragm; diminished, absent, or para-
in normal
shows a section from a computerized
doxical motion of the diaphragm on inspiration; medias-
showed
tomogram (CT) of the middle part of the chest. Abdominal
sonography was normal. Barium enema showed displacement of the transverse colon into the left chest beneath the
left
is
the
gastrointestinal series
esophagus and fundus of the stomach to be
position. Figure 2
lower lobe
Differential diagnoses for ele-
palsy, atelectasis,
logic
left
hemidiaphragm include: phrenic nerve
subpulmonic effusion, subpulmonic ab-
main bronchus and moderate to severe narrowing of the
left upper and lower lobe bronchi due to extrinsic com-
gogram and upper
The
right lung is well aerated.
hemidiaphragm,
but no paradoxical motion on sniffing or coughing. Fiberoptic bronchoscopy
are also visible. In
completely visible and has a continuous
examination.
Figure
Gas shadows
the lateral chest radiograph, the leaf of the elevated left
tinal shift
on inspiration; paradoxical motion of the diasniffing or coughing during fluoroscopy,'-'*
phragm upon
and prolonged phrenic nerve conduction time detected by
electrophrenic stimulation. ^ In this case, the absence of
paradoxical motion of the
hemidiaphragm.
left
hemidiaphragm upon sniffmakes the diagnosis of
ing or coughing during fluoroscopy
phrenic nerve palsy unlikely.
Ali
Emad
MD
is
affiliated with the Division of Respiratory Diseases,
Department of Internal Medicine, Shiraz University of Medical Sciences.
Shiraz, Iran.
Correspondence: Ali
PO Box
Collapse of the
the left
left lower lobe can cause elevation of
hemidiaphragm. However, there was no evidence
of chronic pneumonitis, tuberculosis, or endobronchial
Emad MD,
71345-1674, Shiraz,
Respiratory Care
•
Shiraz University of Medical Sciences,
Iran. E-mail:
[email protected].
April 1999
Vol 44 No 4
le-
sion as the cause of atelectasis in this patient. Negative
examinations of sputum, bronchial washing, and bronchial
437
A
60- Year-Old
Woman
Fig. 2.
I
Computed tomography
(CT)
image through the mid-portion
of the patient's chest.
Eventration
Hernia
t
w
Diagram showing the difference between diaphragmatic
and eventration. In diaphragmatic hernia the leaf of the
diaphragm is seen as a broken line on the chest radiograph, while
in eventration of the diaphragm it is seen as a smooth, unbroken
Fig. 3.
herniation
I
Fig. 1.
line.
Radiographs
of a 60-year-old
tress. A. Posteroanterior
woman
witln
respiratory dis-
chest radiograph. B. Lateral chest radio-
though the diagnosis of diaphragmatic eventration can be
graph.
confirmed
in
fluoroscopy,
left
lower lobe
is
aphragmatic hernia, especially a hernia "sac." Figure 3
hemidiaphragm rather
shows the difference between diaphragmatic eventration
brushing suggest that the collapse of the
secondary to the elevation of the
left
than to intrinsic pulmonary disease.
In the absence of
symptoms and
and diaphragmatic hernia with regard
signs referable to an
abdominal process, and with a normal abdominal sonography, subpulmonic or subdiaphragmatic abscess or effusion can be excluded.
extrinsic pressure
The
CT
on the lung
verifies the presence of
tissue
placed abdominal contents into the
The remaining 2
caused by the
left
dis-
hemithorax.
differential diagnoses are congenital
diaphragmatic eventration and diaphragmatic hernia. Al-
438
most cases by routine chest radiograph and
can be difficult to differentiate from a di-
it
to the position
and
condition of the diaphragm.
A
history of trauma to the lower chest or abdomen,'' or
the presence of a defect in the contour of the
diaphragm on
the chest radiograph'-'' suggests diaphragmatic hernia,
this
and
diagnosis might be confirmed by an upper gastroin-
testinal series or
barium enema, since either the stomach or
the colon can protrude through the diaphragmatic
Induction of a pneumoperitoneum
is
hernia.-''
a safe and accurate
No
4
A
60- Year-Old
Woman
The muscular element of the diaphragm
formed
diagnostic procedure for differentiating a diaphragmatic
cavities.
hernia from a paralyzed or eventrated diaphragm. In diaphragmatic hernia, the injected air will enter from the
from the cervical myotomes.--'* Congenital eventration
peritoneum into the pleural cavity.* Sonography, radionuclide liver
CT of the chest* may
and spleen scanning,^ and
is
re-
from incomplete or absent muscularization of the
pleuroperitoneal membrane.'' Early return of the midgut to
sults
the
abdominal cavity may be an important factor
in the
normal diaphragm development. '-^^ '" The phrenic
be necessary for diagnosis of hernia in occasional cases.
failure of
The diagnosis of severe eventration in this case was
based on (1) the presence of an intact leaf of the left
nerve
hemidiaphragm, best seen on the lateral chest radiograph
abnormalities, such as aplasia of the lung, hypoplasia of
as an
the
unbroken
line, (2) the
lack of paradoxical motion of
diaphragm on fluoroscopy, and
(3)
the normal barium
examination.
is
normal.
may be
Eventration
the aorta, transposition of the
of the sternum, ribs or
The most common
In neonates
diaphragm
tion of the
because the condition
all,
is
is
and
infants,
complete eventra-
generally corrected surgically
potentially life-threatening.* Over-
symptomatic adult patients should primarily be man-
aged with oxygen therapy and upright posture, though
antibiotics
may be
necessary for infection control.
patient responds well to supportive
is
required.* In pa-
with modest diaphragmatic elevation, and in those
who demonstrate
dition, surgery
little
functional impairment from the con-
can be postponed. Surgery
ficult to differentiate
it
it
not indicated
is
for treatment of partial eventration, except
when
the
management, surgery
might be avoided. Otherwise, surgery
tients
If
from a mass lesion
when
in the
is
treatment
if
radiograph as
mass that is
ium esophagogram,
tissue
require surgical
they develop dyspnea. If significant lung
at-
electasis is associated with eventration, surgery should be
soft
continuous with the diaphragm." Bargastrointestinal series, echocardiogra-
nance imaging, and
CT
of the chest
may be
required to
exclude other causes.'* The majority of these patients are
asymptomatic.'"
Total or complete congenital eventration
on the
Many
left side.
is
usually found
patients with this condition remain
was offered
to
was declined. Unfortunately she missed
subsequent appointments and no follow-up examinations
this patient, but
arise
from the abdomen, the respiratory
system, or the heart. Abdominal symptoms, including nausea, vomiting, belching,
some
patients.
and abdominal pain, are present
in
Volvulus of the stomach'^ and of the co-
can occur and are occasionally life-threatening.
Cough, respiratory distress, cyanosis, and chest pain can
occur due to compression of the lung or mediastinum.
lon'**
considered."'- Because of her respiratory symptoms and
It is
important to note that the motion of the eventrated
diaphragm may be normal,
adoxical motion
eventration.
is
restricted, or absent.
True par-
not present in congenital (nonparalytic)
"*
Acquired (paralytic) diaphragmatic eventration follows
or other data are available.
injury to the phrenic nerve or
its
roots,
which can be
caused by trauma, childbirth (especially with breech pre-
Discussion
sentation), or
Eventration of the diaphragm, which
is
seen on the chest
phy, radionuclide liver scan, sonography, magnetic reso-
Symptoms can
the collapse of the lung, surgical treatment
it is
a homogeneous, smoothly marginated
infants because of shifting of the labile mediastinum.'"
more commonly indicated in the pein adults. Asymptomatic patients
may
the anteromedial portion of the right
hemidiaphragm.'-'* Characteristically,
asymptomatic.'" Prominent symptoms are usually seen in
age group than
should have regular follow up," and
is
vertebrae.''-'"
location for the partial diaphrag-
is dif-
Surgical intervention for correction of complete con-
diatric
matic eventration
cleft lip,
bony abnormali-
lung or
it
causes pronounced symptoms.'"
genital eventration
abdominal contents,
cleft palate, puliiionary sequestration, or
ties
Treatment.
associated with other congenital
is
a rare condition,
broadly defined as an abnormally high position of part
major abdominal surgery.'* Central neuro-
logical disease, myopathies,
levels
and changes
in
diaphragmatic
caused by neighboring lesions can also produce the
occurs as a result of paralysis,
acquired form of eventration. Acquired diaphragmatic
aplasia, or atrophy to varying degree of the diaphragmatic
eventration can be associated with aneurysm of the aorta,
or
all
of the diaphragm.
muscle
fibers.'"
It
There are 2
distinct etiologic types of
eventration, congenital (nonparalytic) and acquired (paralytic).'"'''
subdiaphragmatic hydatid cyst, pericarditis, alcoholic neuritis,
spondylitis,
and poliomyelitis. '*-2"
Anatomically, the congenital eventrations are
further divided into 3 forms: partial, complete,
and
bilat-
REFERENCES
eral. '^-'s
During weeks 8 to 10 of fetal life, the membranous
diaphragm develops by fusion of the septum transversum
and the dorsal mesentery of the foregut, and thereafter
divides the coelomic cavity into the pleural and peritoneal
Respiratory Care
•
April 1999
Vol 44 No 4
1.
Wilcox PG. Pardy RL. Diaphragmatic weakness and
paralysis.
Lung
1989;167(6):323-341.
2.
Bellemare
F.
Evaluation of
human diaphragm
function.
Monaldi
Arch Chest Dis 1993;48(l):92-93.
439
A
3.
Woman
60- Year-Old
Shackleton KL, Stewart ET, Taylor AJ. Traumatic diaphragmatic
12.
Tarver RD, Conces DJ
and
5.
disorders. J
its
6.
7.
Jr,
Cory DA, Vix VA. Imaging the diaphragm
13.
S,
14.
Mearns AJ, Choudhury AK. Traumatic rup-
Ann Thorac Surg 1995;60(5):1444-I449.
Oh KS, Newman B, Bender TM, Bowen A. Radiologic evaluation
Obara H, Hoshina H, Iwai
H, Hisano K. Eventration of the
1988;26(2):355-364.
and children. Acta Paediatr Scand I987;76(4):
Wang SM,
imaging
trauma: pulmonary, tracho17.
bronchial, and diaphragmatic injuries.
Semin Ultrasound
CT MR.
Commare MC,
10.
1 1
cases. Pediatr
Ribert
in children. J
M, Linder
R
Eur
the dia-
19.
Coll Surg Edinb 1991;36(4):222-224.
J
1
15-1 138.
Pediatr 1990;57(1): 125-127.
J
CH, Lin YJ, Yang HB,
Wu MH. Congenital
J
bilateral
Pediatr 1997;156(7):
in the diagnosis
S.
MR
of partial eventration of the diaphragm
Chest 1993;104(I):328.
Llaneza PP, Salt
WB
2d. Gastric volvulus.
Med
More common
then pre-
l986;80(5):279-283, 287-288.
Tsunoda A, Shibusawa M, Koike
T. Volvulus of the sigmoid colon
(letter).
Am
J
Gaster-
oenterol 1992;87(1 1):I682-1683.
Singh G, Bose SM. Agenesis of hemidiaphragm
Aust
JL. Plication of the diaphragm for unilateral even-
tration or paralysis.
1985;65(5):1
associated with eventration of the diaphragm
Pulmonol 1994;18{3):187-I93.
Jawad AJ, al-Sammarai AY, al-Rabeeah A. Eventration of
phragm
II
18.
Kurstjens SP, Barois A. Diaphragmatic paralysis in
children: a review of
Lin
viously thought? Postgrad
1996;17(2):114-118.
9.
Philippart AI. Congenital diaphragmatic her-
Am
Yamashita K, Minemori K, Matsuda H, Ohishi T, Matsunobe
(letter).
in blunt chest
MD,
Dalvi R, Chari G, Fernandez AR. Congenital eventration of dia-
654-658.
Kang EY, Muller NL. CT
Klein
572-574.
16.
8.
Pediatr Surg 1993;28(1):
agenesis of diaphragm: report of a case. Eur
Am
S, Ito
15.
of
the diaphragm. Radiol Clin North
in infants
ML,
Surg Clin North
phragm. Indian
diaphragm.
diaphragm
Cullen
nia.
Thorac Imaging 1989;4(1):1-18.
Shah R, Sabanathan
ture of
J
42^t4.
18(I);49-59.
4.
Hicsonmez A, Buyukpamukcu N. The long
Kizilcan F, Tanyel PC,
term results of diaphragmatic plication.
spectrum of radiographic findings. Radiographics 1998;
injuries:
20.
Cardiothorac Surg I992;6(7):357-360.
NZ
J
Gibson GJ. Diaphragmatic
tures,
in adults (review).
Surg 1993;63(4):327-328.
paresis: pathophysiology, clinical fea-
and investigation (review). Thorax 1989;44(1 1):960-970.
eaas
4 5^" International
Respiratory Conbri^ss
Oecem ber
1
3-
IJS ,_J-^
99
Las VEOASd Nevada
1999
440
No 4
Mani S Kavuru
MD and James K
Measurement of FEVj Using
K
James
Stoller
MD,
Table
chronic obstructive lung disease presented with the com-
was obtained using 2
different
methods
A
spirometry
test
for coaching ex-
shows the Spirometry
piratory effort. Table
1
shows
What would account
for the differences in the results
ure
1
results. Fig-
volume-time tracings for Spirograms
1
and
2.
of
these tests?
Discussion
Based on the decreased FEV|/FVC ratio
volume in 1 second to forced
expiratory
(ratio
of forced
vital capacity),
both spirograms indicate severe obstructive lung disease
characterized as stage
III
Series Editors
PFT Nuggets
Daniel Laskowski RPFT, and Kevin McCarthy
72-year-old white male ex-smoker with a history of
plaint of increasing shortness of breath.
MD,
the Modified Spirometry Technique
Case Summary
A
Stoller
chronic obstructive pulmonary
1.
Spirometry Results
RCPT
Measurement of FEV, using the Modified Spirometry Technique
2.
have good
back extrapolated volume
whichever
is
<
FVC
5% of
peak flow of
starts (time to
less than
1
patients with severe obstructive lung disease
greater,
and
to better achieve adequate expiratory duration
isfy end-of-test criteria, a
and have a satisfactory exhalation time and meet
3.
To allow
20 ms) or
or 0.15 L,
for spirometry testing has
to sat-
modified expiratory maneuver
been described by Stoller
et al.'
end-of-test criteria (6 seconds of exhalation, a plateau in
Specifically, the modified expiratory maneuver consists of
the volume-time curve, or if the subject cannot or should
a maximally forceful
not continue to exhale).
expiratory effort begun on the technician's prompting at
The start-of-test criteria are best assessed on a flowvolume curve, whereas the end-of-test criteria are best
assessed on a volume-time curve. After 3 acceptable spi-
approximately 3 seconds
rograms have been obtained, the following reproducibility
teria
criteria
largest
should be applied: The 2 largest
FEV, should be
L
within 0.2
and reproducibility
the acceptability
FVC
and the 2
of each other.
If
both
criteria are not met,
continue testing with additional spirograms until either (1)
the criteria are met, (2) a total of 8 tests
have been per-
higher
FVC
effort.''
The
is
satisfies the end-of-test criteria,
Spirogram
1
raise the issue of con-
comitant restrictive lung disease, because the
low the lower
in the
second
limit of
set
FVC
is
normal for our laboratory. The
of results
is
be-
FVC
FEV, is
of the FEV,/
normal. Though the
similar in both spirograms, the higher value
FVC
and the
because of a more sustained expiratory
results of
ratio in the first effort results
COPD
by patients with
from the lower
Satisfying end-of-test criteria for spirometry
COPD
slows lung emptying. As a
because
result,
air
nique
was examined
the technician encourages
(ie,
is
modified expiratory technique. In
ical
purposes and
is
<
p
difficult
(58%
vs 19%,
0.001). This improved rate of satisfying end-of-test
was achieved without significant lessening of FEV,
On
the basis of these advantages, as well as im-
proved comfort and patient preference, the modified expiratory technique has gained popularity and
dard technique used
at
The Cleveland
in the
is
the stan-
Pulmonary Function Laboratory
Clinic Foundation.
REFERENCES
1.
Crapo RO, Morris AH, Gardner RM. Reference spirometric values
Am
2.
paramount for
clinfirst
3.
values in clinical and epidemiologic studies requires
American Thoracic Society. Standards
Med
recommendations.
for the diagnosis
5.
Am
J
1995;152(5 Pt 2):S77-S120.
American Thoracic Society. Lung function
spir Dis
4.
and care of
pulmonary disease (review).
testing: selection
erence values and interpretative strategies (guideline).
Am
of
ref-
Rev Re-
1991;144(5):1202-1218.
Standardization of spirometry: 1994 update (guideline). American
Thoracic Society.
assuring adequate lung emptying or, in conditions of ex-
ATS
Rev Respir Dis 1981;123(6):659-664.
Respir Crit
second of expiration, comparison of FEV, /FVC ratios or
FVC
use of the
this study,
values.
is
unaffected by events after the
is
forceful
criteria
flow limitation
an expiratory plateau
FEV,
maximum
modified technique was associated with a significantly
a patient maintains an expiratory effort for 15 sec-
onds. Although measuring the
crossover
in a
blowing for the entire duration of expiration) versus the
if
the expiratory flow
FVC
infrequently achieved, and end-of-test criteria are satisfied
only
when
which 48 subjects used a standard expiratory tech-
trial in
value caused by early termination of the expiratory effort.
for patients with severe
(ie,
below 200 mL/s). The impact of this modified expiratory maneuver on the rate of achieving end-of-test crifalls
higher rate of achieving end-of-test criteria
formed, or (3) the patient cannot continue.
Spirogram 2
followed by a relaxed
initial effort,
Stoller JK.
Am
Basheda
J
S.
Respir Crit Care
Med
199.');152(3):1 107-36.
Laskowski D. Goormastic M, McCarthy K.
piratory flow limitation, a standardized duration of expi-
Trial of standard versus modified expiration to achieve end-of-test
ratory effort.
criteria.
442
Am
Rev Respir Dis 1993;148(2):275-280.
No
4
.
A
Patient with
Dyspnea and Acid Maltase Deficiency
Salim Kathawalla
MD
Case Summary
Ahmad
and Muzaffar
nary fibrosis.
VC
muscle weakness
A
39-year-old male with
known
by
is
MD
itself as
a measure of respiratory
nonspecific and nondiagnostic. Also,
history of acid maltase
in
longstanding respiratory muscle weakness, the decrease
deficiency complained of chronic and progressive exer-
in
VC may
The dyspnea was worse
tional dyspnea.
in the
supine po-
and relieved by the upright posture. The
sition
results of
be due to more than muscle weakness alone
because of decreased chest wall and lung compliance, which
is
associated with microatelectasis.' Thus,
VC
by
itself is
physical examination and chest radiography were normal.
not useful in monitoring patients with respiratory muscle
Spirometry results are shown
weakness. The most widely applied
clinical findings
went another diagnostic
1
2.
Table
in
and spirometric
1
.
Based on the
results, the patient under-
test.
What do the spirometric results show?
What was the additional diagnostic test
the cause of this patient's
static
maxiat the
and expiratory muscle strength are
mouth (MIP and MEP). MIP values
that clarified
dyspnea?
HjO exclude clinically
The spirometry results indicate severe restrictive pulmonary impairment. Since the diffusing lung capacity is
normal, a restrictive parenchymal lung process such as
With the
and diaphragm
VC
upon assuming
is
a large decrease in
patient's history
jects there
is
caused by a
However, even
a reduction in
shift
with a consequent reduction
and a change
known
to
in resting
cause respiratory muscle weakness,
the spirometric findings suggest diaphragmatic weakness.
The diagnostic
sitting
test
performed was a spirometry
in
and the supine position, which demonstrated a
decrease in
position.
A
the
50%
capacity (VC) on assuming the supine
vital
diagnosis of diaphragm paralysis
was made
and the patient was treated with a nocturnal rocking bed.
The characteristic abnormality of inspiratory muscle
weakness
is
a low
VC
with a reduced total lung capacity
and preserved residual volume. Carbon monoxide
ing capacity
is
reduced, but
is
diffus-
normal or raised when ad-
justed for volume.- This feature
is
useful to distinguish
muscle weakness from alveolar disorders such as pulmo-
Salim Kathawalla
Critical
MD
Ahmad
Minnesota. Muzaffar
Pulmonary and
tion,
is affiliated
with the Department of Pulmonary.
Care and Sleep Medicine, Park Nicollet Clinic. Minneapolis.
Critical
MD
is
affiliated with the
Department of
Care Medicine, The Cleveland Clinic Founda-
Cleveland. Ohio.
Correspondence: Muzaffar
Critical
Ahmad MD. Department
of Pulmonary and
Care Medicine, Cleveland Clinic Foundation, 9500 Euclid Av-
enue, Cleveland
OH
44195-5038.
Table
I
.
VC
in
normal young sub-
in the
supine position,
of blood to the pulmonary circulation,
of dyspnea in the supine position and of acid maltase
deficiency,
cm
In patients with neuromuscular disease
weakness, there
the supine position.
fibrosis is unlikely.
greater than 80
important respiratory muscle weak-
ness.
Discussion
pulmonary
tests for global in-
mal inspiratory and expiratory pressure measured
spiratory
Spirometry Results
in intrathoracic
gas volume,
diaphragmatic position when su-
A
pine.''-^
Patient with Dyspnea and Acid Maltase Deficiency
Further, in patients with restrictive and obstructive
lung disease without diaphragmatic weakness, there
VC
ease and diaphragmatic involvement,
strictive
pulmonary impairment and
55% (mean
In a study
of
46%) upon assuming
by Allen
et al,
a
VC
all
VC
subjects
in
Am
had
re-
2.
the supine position.
> 25%
obstructive defect,
35%
J, Green M. AssessRev Respir Dis 1988; 137(4):
Gibson GJ, Pride NB, Davis JN, Loh LC. Pulmonary mechanics
muscle weakness.
Am Rev
in
Respir Dis 1977;
Hurtado A. Fray
WW.
Studies on total pulmonary capacity.
J
Clin
Invest 1933;12:825-832.
with an
Wade OL, Gibson
ment and
was very suggestive of diaphragmatic
vital
JC.
The
effect of posture
on diaphragmatic move-
capacity in normal subjects with a note on spirometry
as an aid in determining radiological lung volumes.
weakness.*
Thorax I951;6:
103-126.
6.
Allen S. Hunt B. Green M. Fall
in vital capacity
with posture. Br
J
Dis Chest I985;79(3):267-271.
REFERENCES
7.
1 .
Moxham
Am
ll5(3):389-395.
4.
conjunction with a re-
on lung function of over
Mier-Jedrzejowica A, Brophy C,
patients with respiratory
5.
strictive defect
recommendations.
877-83.
3.
'^
upon
ATS
Rev Respir Dis l981:123(6):659-664.
ment of diaphragm weakness.
decreased by 37-
decrease of
assuming the supine position,
also
upon assuming the supine
In a study of patients with neuromuscular dis-
a substantial decrease in
position.*
is
Crapo RO, Morris AH, Gardner RM. Reference spirometric values
Newsom-Davis
Rev Respir Dis
J.
The diaphragm and neuromuscular
1979;! 19(2 Pt 2):
1
disease.
Am
15-1 17.
Respiratory Care Open Forum
The AARC and
its science journal, Respiratory Care,
nvjie submission of brief abstracts related to any
ajpPpbf cardiorespiratory care.
i
The
abstracts will be reviewed, and selected authors
be invited to present posters at this year's Open
Forum dmjtig the AARC International Respiratory
Congress^KLas Vegas, NV, Dec. 13-16. Accepted
abstracts will ai.ô be published in the November
1999 issue of^nwiRAXORY Care.
will
accepted abstracts are automatically considered
American Respiratory Care Foundation research
grants, so don't miss this opportunity to share your
research efforts with your colleagues and vie for
ARCF's financial awards!
All
for
—
Act today final submission deadline is June 11.
More information is available in the latest issue of
Respiratory Care under "Call for Open Forum
Abstracts," or call Linda Barcus at (972) 243-2272.
You can also submit your ab^tact electronically at
http://www.rcjournal.com. Membership in the
AARC is not required for participation.
444
Respiratory Care
•
April 1999 Vol 44
No
4
Letters addressing topics of current interest or material in
RESPIRATORY CARE
decline a letter or edit without changing the author's views.
pretation of information
No anonymous
reply in print.
Care. 600
— not standard
letters
The content of
can be published. Type
may simply
reflect the author's
letter
double-spaced, mark
it
"For Publication," and mail
ARDS
end-expiratory pressure (PEEP) than
ARDS
potentiated by extrapulmonary illness,
which
may
by Kacmarek and Chiche concern-
increased nonpulmonary thoracic elastance.
ing the use of lung protective ventilatory
strategies
it
be composed of more PEEP-responsive
alveolar flooding and collapse, and perhaps
(LPVS)
to
for the acute respiratory
syndrome (ARDS) published
It
may be
ironic, therefore, that
in the
lor ventilator settings to
REFERENCES
1.
those patients with better,
mechanics
say "great interest" because
I
hold
great enthusiasm for,
and consider myself
aproponentof LPVS
in
I
am
less enthusiastic
ARDS. However
and rather skeptical
about the ability of LPVS to improve mortality in patients
is
with
founded on the
ARDS
My skepticism
ARDS.
fact that the majority of
nonsurvivors do not die from res-
piratory failure,-
and despite
my shared con-
cerns with the authors that injurious ventilation
may
in fact potentiate translocation
(eg,
1998;43(9):724-727.
we may tai-
Suchyta
more responsive
vival
and modifying
3.
Gattinoni L, Pelosi P, Suter
tory distress
utilization of
LPVS
for
ever these benefits
ifested
may more
by a reduction
ferent
ARDS may prove
beneficial in the treatment of
syndromes?
likely
in ventilator
be man-
and
inten-
4.
Amato MB, Barbas CS, Medeiros DM,
Magaldi RB, Schettimo GP, Lorenzi-FUho
G,
strategy
attribute the
premature to
addition,
that
work by Gattinoni
ARDS
insult
in overall survival.
Jeffrey
M Haynes RRT CPFT
potentiated from a pulmonary
soUdation that
is less
of a protective- ventilation
on mortality
in the acute respira-
N
Engl
J
Med
1998;338(6):347-354.
Staff Respiratory Therapist
et al' suggests
may have more parenchymal
et al. Effect
tory distress syndrome.
absence of worsening multiple
organ function to a ventilation strategy. In
disease. Dif-
Am J Respir Crit Care
Medl998;158(l):3-ll.
improvement
is
PM, Pedoto
ARDS, how-
from the lung,
it
1992;
syndrome caused by pul-
remain optimistic that
sive care unit days rather than a significant
feel
Chest
factors.
monary and extrapulmonary
I
CG,
A, Vercesi P, Lissoni A. Acute respira-
in sur-
between the study and control groups
at hospital discharge.
Elliott
101(4):1074-1079.
of proinflammatory cytokines and bacteria
I
TP,
tory distress syndrome: a report of survival
may more frequently die.' In terms of the
Amato LPVS trial,* it is true that the LPVS
study group had a better survival rate after
MR, Clemmer
Ontie JF Jr, Weaver LK. The adult respira-
ARDS triggered by sepsis)
28 days, but there was no difference
pro-
ARDS:
the data are convincing! Respir Care
lung mechanics with
September 1998 issue of RESPIRATORY
Kacmarek RM, Chiche JD. Lung
tective ventilatory strategies for
the intention of improving survival, but
Care.'
I
inter-
RESPIRATORY
2.
distress
accept or
Letters
read with great interest the point-of-view
article
may
opinion or
WA 98104.
Response to Lung Protective
I
be considered for publication. The Editors
published
practice or the Journal's recommendation. Authors of criticized material will have the opportunity to
9th Avenue, Suite 702, Seattle
Ventilatory Strategies for
will
letters as
St Joseph Hospital
Nashua,
con-
New
Hampshire
(received October 27, 1998)
responsive to positive
Respiratory Conbrcss
D E C E M B^R
_1
3-
1
S
,
J^ g 9
Las Vegas, Nevada
1999
Respiratory Care
•
April 1999 Vol 44
No 4
445
Listing and Reviews of Books and Other Media. Note
and software
films, tapes,
Physiological Basis of Ventilatory Support, John
Slutsky
MD
Marini
J
MD.
and Arthur
(Lung Biology
Editors.
Health and Disea.se.
Volume
1
1
8.
1
.S
in
Claude
Lenfant, Executive Editor) Hardcover,
lustrated,
il-
.464 pages. Marcel Dekker Inc,
New York NY;
makes a persuasive case
sentence from the preface establishes
the rationale for this exceptional volume:
our view that broad-based and
"It is
inti-
mate knowledge of the physiology underpinning ventilatory support
is
indispensable
to optimal care of difficult patients
who
for the benefits of
does not cover specifics about the technique.
the physiologic con.sequences of endotracheal
Among
the other excellent contributions in
use of diagrams in the Loring
this part, the
chapter on mechanics of lungs and chest
and the Sassoon and Mahutte chapter
ful to readers
are particularly help-
reviewing those physics-based
The work of breathing chapter
concepts.
also includes a useful discussion of the var-
ious approaches to the estimation of
of breathing by
The gas exchange chapter
tients.
work
mechanically ventilated pais
disap-
pointing only because the authors have pre-
Drs Marini and Slutsky have
viously written in-depth discussions of the
this belief,
believe to be the best sin-
topic at a higher level of sophistication,
gle source
on the science of ventilatory sup-
which would have been more appropriate
The
contributing authors include a
compiled what
port.
I
nearly complete assembly of the most prom-
The
inent clinician-scientists in this field.
range of topics covered
comprehensive,
is
The
for this book.
by Russell
ter
final section
of the chap-
a scholarly critique of the
is
practice of pharmacological maximization
of oxygen delivery as a primary goal
dressed their assigned topics
patients.
ticipated, there is
an-
all
the
tervention.
it
is
those
Part
not truly redunits
Two, on
the consequences of
chanical ventilation,
is
me-
comments on
the ac-
ments themselves. The chapter on
ventilatory support focuses primarily
plications of pressure control
is
full
on ap-
modes, which
appropriate for the general advanced level
of the book. In addition,
it
provides a concise
perspective on sedation and paralysis that
is
superior to the earlier chapter devoted to that
topic.
The companion chapter on
tilatory support
partial
ven-
again discusses the issues of
patient- ventilator dyssynchrony.
good overview of
and includes
the merits of propor-
tional assist ventilation to address this prob-
sure in severe air flow obstruction, the use of
nitric
a
of mechanical ventilation, implementing
synchrony with
ventilatory support, and specific problems
tory modes.
in ventilation.
review by Tremblay
of patient-ventilator dys-
full di-scussion
all
is
It
of the standard ventila-
followed by a scholarly
et al
both of animal
The
studies and of clinical investigations of ven-
majority of the chapters are addressed to
tilator-induced lung injury. That informa-
experienced clinicians with a well-estab-
tion
not a book for beginners.
lated patient, including
curacy and interpretations of the measure-
more approachable
The lead-off chapter by Maclntyre provides
is
of the
all
can be taken on a venti-
ing applications of positive end-expiratory
lying ventilatory support, the consequences
This
that
pressure and continuous positive airway pres-
arranged in 4 parts: the physiology under-
The 38
measurements
believers in this in-
for full-time clinicians than the first part.
assigned focus.
itoring the mechanically ventilated patient has
compiled a very useful review of
other ventilatory support techniques, includ-
chapters are
own
anatomic complications. The chapter on mon-
should be required reading for
who remain
As could be
dant, because each chapter maintains
on the
lem. Part Three includes chapters discussing
It
some overlap among
chapters, but generally
have
logically
earlier chapter
in the
care of acute respiratory distress syndrome
cated and critical manner.
which might more
intubation,
been paired with the
a
and the majority of the authors have adin a .sophisti-
on implementing ventilatory
support, begins with an excellent chapter on
require ventilatory assistance." In support
of
Part Three,
it
wall,
1998. $295.00.
98104.
proportional assist ventilation, although
on work of breathing
A
WA
Respiratory Care. 600 Ninth Avenue. Suite 702, Seattle
to
Books, Films,
Tapes, & Software
Send review copies of books,
to publishers:
is
helpful
background for interpreting
which
volumes may
oxide and other pharmacological ap-
proaches, noninvasive positive pressure ventilation,
high-frequency ventilation, liquid
ventilation,
and extracorporeal support. These
chapters recall the wide range of solutions
that
have been explored toward the goal of
improving outcomes of patients with respiratory failure.
Part Four,
on special problems
tion, includes
in ventila-
an extensive review of baro-
lished understanding of respiratory physi-
the debate over
ology. For teachers and investigators in the
be too high or which lung inflation vol-
the barotrauma
umes may be
too low for acutely injured
CC Macklin. This chapter discu.sses tidal vol-
chapter covering the anatomic
ume-related lung injury unrelated to baro-
of ventilator support of patients with
field
respiratory failure, this
book
is
a well-com-
By
lungs.
The
tidal
trauma
that features a
complete discussion of
mechanism
first
proposed by
their
consequences of endotracheal intubation
is
trauma, and addresses the more controversial
choices of authors and topics, the editors
complete and exceptionally well done.
It
issue as to
have clearly succeeded
goal to pro-
reminds even experienced clinicians of the
injury can produce systemic effects.
vide "a resource that will serve as a firm
substantial range of anatomic complications
parative evaluation of ventilator
piled
summary of current
basis from
ally
which
to
opinion.
in their
advance our continu-
Part One,
on the physiology of
ventila-
tory support, represents both the best and
most challenging
plified
by the
first
that
can arise as a consequence of estab-
part of the book,
exem-
chapter, by Younes and
is
The one
Two was
the chap-
tings.
While
on sedation, which includes a cookbook-
egies
is
iirtificial
disappointment of Part
ter
strategies
airway.
lishment of an
evolving knowledge."
whether ventilator-induced lung
style
critical
to
difficult aspects
critical illness set-
the obvious goal of these strat-
optimize recovery, the variability
u.sed,
of clinical conditions leading to ventilatory
assessment of the goals
failure ordinarily force the choice of a sur-
naming of agents
without a
one of the most
of the care of patients in
Com-
management
that
could be
may
not necessarily be
Georgopoulos, on the neurophysiology of
and complications of sedation of a mechan-
rogate end point that
patient-ventilator interactions. This chapter
ically ventilated patient.
linked to the quality of the eventual outcome.
446
No 4
Books, Films, Tapes,
The
chapter by Morris and
final
Cook on
mechanical ventilation
clinical trials in
reminder of the
posed
on
"How
can
we can
we best
what we should do?"
to a
over 1.400 pages long
not likely to be welcome, proportional
is
nutritional support addresses the
line
This soft-cover book
is in
format and divided into 3 sections.
Part
I,
"Why
between ventilatory and ox-
ygenation failure, the pathophysiologic
dications,
and special
required.
is
objectives of mechanical ventilation are
defined according to 1992 American Asso-
unique,
its
application requires a
ciation for Respiratory
Care and 1 993 Amer-
ican College of Chest Physicians
ical
believe
it
promises to be the most
it
is
discussed
2 of the chapters, proportional assist vendeserves a chapter of
volume devoted
its
own
in a
to the physiologic basis
of
It is
the
a pleasure to encounter a well-edited
critically written
volume intended
most physiologically-oriented of
ratory practitioners. Again, this
is
some of
for beginners. Indeed,
for
respi-
not a book
the initial
chapters on the physiology of ventilatory
support presume a higher level of physiologic sophistication than that possessed
by
most board-certified critical care physicians.
Subsequent chapters on the
clinical appli-
cation of ventilatory support
assume famil-
iarity
with
all
of the ventilatory support ap-
modem intensive care unit
proaches used by
practitioners,
and hence
will
be
difficult go-
Part
II,
"How To
sus transport ventilators, and volume-
modes of
targeted versus pressure-targeted
Ventilator Set-Up," the authors review a selection of appropriate tidal volumes, oxy-
The
spiratory flow.
on
inspiratory flows
Care Medicine
Department of Medicine
Seattle,
Washington
tors.
MD and Faroque A Khan MB.
Soft-cover, illustrated
adelphia,
1
Edi-
88 pages. Phil-
PA: American College of Physi-
cians-American
Society
of
Internal
Respiratory Care
•
April 1999
may
preparing for boards
find useful.
These
include guidelines on the parameters used
need for and
initial institution
commonly used during mechanical
tion, several
ventila-
compliance measurement ex-
and a 38-question quiz. Also
ercises,
in-
cluded are 5 case studies covering several
conditions
clinical
— including
asthma,
chronic obstructive pulmonary disease,
acute respiratory distress syndrome, pulmo-
and
ysis of
waveforms). Several figures
in this
of insuf-
56, mentioned earlier, and Figure 50, in
spontaneously
which the inspiratory pressure versus time
ficient inspiratory
breathing patient
flow
is
illustration
in the
given; the authors point
The
baseline changes without explanation).
out that this can be detected by observing a
waveform
downward deflection of the ventilator airway manometer needle. Unfortunately, the
computer-generated and do not meet the
authors do not complete the lesson by
uti-
Graphics
this
Though
waveform graphics
to
document
same phenomenon. An example
2,
is
provided
Figure 56); however, the di-
show
wave
is
marginal, and
it
fails to
the "scalloping out" of the pressure
that is
pathognomonic of
this event.
Newer modes and techniques of mechanventilation are each described in this
section.
They include airway pressure
section illustrations appear to be
standards of quality that are found in the
Comer
of Respiratory Care.
they do convey the basic points,
actual ventilator-generated
better serve the authors
This
examples would
and readers.
final section also includes a glos-
sary of terms and definitions that coincide
with the 1993 ventilator consensus termi-
nology and classification. The manual's
chapters are not referenced. However, the
re-
annotated bibliography
lists
major contrib-
lease ventilation; proportional-assist venti-
utors to the mechanical ventilator literature.
lation
and permissive hypercapnia; nonin-
vasive positive pressure ventilation in acute
respiratory failure;
ing,
and the monitoring dur-
weaning from, and withdrawal of ven-
References are current to 1997. The manu-
form may not be as enjoyable
to
read as other books that use a narrative.
A
al's outline
condensed or a pocket-size version may be
tilatory support.
III.
The
better appreciated. Despite a
ical errors
and
manual does contain much of the
this
namic compromise, nosocomial pneumonia,
sential information
and oxygen
toxicity.
to deal with special
A
chapter
included
problems encountered
in specific clinical conditions.
is
is
An
algorithm
presented to aid trouble-shooting during
Vol 44 No 4
may
benefit
few typograph-
less than ideal illustrations,
problems include volutrauma, hemody-
mechanical ventilation, which
Medicine, 1998. $40.00.
tions that the respiratory care practitioner
representations (which also offers an anal-
inspiratory time
cal ventilation are outlined in Part
Raoof
a valuable sec-
effects of different
and
Complications associated with mechani-
Mechanical Ventilation Manual, Suhail
is
An
flow are addressed.
ical
Critical
Part IV, the Appendix,
tion of the manual, containing several sec-
section are poor examples (including Figure
teacher working in the field of respiratory care.
Division of Pulmonary and
energy ex-
the problems associated with inappropriate
the bookshelves of every investigator and
H Thomas Robertson MD
to read "resting"
penditure.
nary edema, and a chapter of diagrammatic
rates,
is-
volume merits a prominent place on
be corrected
in-
gen concentrations, ventilator
agram's quality
sues, this
reference to
Ventilate," discusses
Regardless, because of the high level
of presentation covering a broad range of
A
of ventilatory support, a section of formulae
pressure ventilators, intensive care unit ver-
(Appendix
ests.
its
to assess the
Mechan-
differences between positive and negative
lizing
ing for a physiologist with medical inter-
The
Ventilator Consensus conferences.'-^
ventilation. In the chapter, "Basics of Initial
ventilatory support.
and
problem of
the "resisting" energy expenditure should
to assess the
significant innovation in ventilator supfwrt
of the past 2 decades. While
tilation
The
merits. Its physiologic
it
strong grasp of individual patient physiol-
in
in-
clinical conditions
where ventilatory support
how
importance, and
clinical
patient's nutritional status.
Ventilate?", briefly outlines
ogy, and
I
an out-
does not receive the depth
assist ventilation
of coverage that
rationale
tilation.
the difference
While any suggestion for an addition
that is already
the inexf)erienced practitioner.
authors describe causes of malnutrition,
a book filled with things that
is
A section on
Raoof and Khan
designed to be a
practitioners interested in mechanical ven-
ter for
book
is
strategies for ven-
a fitting final chap-
do, asking the question,
manual
malnutrition in the ventilated patient.
management.
It is
In the preface, editors
state that their
quick reference source for interns or other
tilator
investigate
a
Software
in obtain-
difficulties
ing interpretable data
is
&
ventilated patient.
es-
needed for care of the
Its
use of graphs and
gorithms helps convey concepts
in
al-
simple
understandable terms. The Mechanical
Ventilation
Manual does
fill
the require-
ments of residents or students of respiratory
447
.
&
care looking for basic reference material that
quick and easy to
is
interpret.
Software
binemia, given that both of these hemoglo-
tionality
binopathies can affect pulse oximetry.
good. Similarly, the chapter on accuracy and
Chapter 3 provides an overview of blood
Steven Holets
AS RRT RCP
Clinical Specialist
Department of Respiratory Care
Mayo
Medical Center
Rochester, Minnesota
oxygen measurement. The discussion of the
Clark electrode
Missing
ful.
electrode
is
too superficial to be use-
discussion of
is
how
the Clark
incorporated into the blood gas
is
analyzer and issues such as calibration and
The
quality control.
discussion of spectro-
photometers and carbon monoxide-oxime-
REFERENCES
ters,
however,
is
good. Mention of indwell-
ing blood gas probes
1
for Respiratory Care.
Consensus conference on the essentials of
mechanical ventilators. Respir Care 1992;
view). American College of Chest Physi-
Consensus Conference. Chest 1993;
104(6):1833-1859.
based on Beer's law. Beer's law
is
used to
ef-
Nonetheless, Beer's law provides a
model
to describe the principles
of pulse oximetry. Chapter 4 provides a su-
Editor. (Medical Science Series) Hardcover,
perb discussion of Beer's law as
Phil-
measurement of oxygen
to the
Chapters
adelphia PA: Institute of Physics Publish-
5. 6,
This book emphasizes the design of pulse
is
applies
one of the Medical Science
erful
enough
light
source that
pow-
is
to
International Organization for Medical
As
to fabricate the pulse
try as well as the equations,
oxime-
methods, and
light that passes
The book
into
1
is
consists of
3 chapters.
A
244 pages divided
glossary
is
included at
end of the book. Each chapter includes
is
the beginning of the chapter.
all
The
editor
at
and
of the chapter contributors are from the
Department of Electrical and Computer Engineering at the University of Wisconsin.
may
be very important information for engineers
responsible for designing pulse oximeters,
it
has limited usefulness for clinicians. The
more
is
The probe packages
clin-
the light-
emitting diodes and photosensor so
it
can
be attached to the patient. Clinicians must
regularly choose an appropriate pulse oximetry probe
errors
and troubleshoot issues related to
due
to
probes and their placement.
Chapter 8 covers electronic control of
2 chapters of the book cover
pulse oximetry and Chapter 9 covers signal
normal oxygen transport and the motivation
processing algorithms. These chapters are
The
first
for pulse oximetry.
I
suspect that
many
cli-
nicians will find these chapters too superficial to
this
be useful. Noticeably absent from
chapter
oxygen.
I
is
a discussion of mixed venous
also expected
some discussion of
carboxyhemoglobinemia and methemoglo-
448
may
find interesting the discussions of
graphical displays, numerical displays, and
alarm controls. The
final
chapter of the book
(Chapter 13) describes clinical applications
of pulse oximetry. There are interesting dis-
monitoring tissue blood supply and organ
viability (such as dental
pulp blood supply),
use of pulse oximetry during ground and air
and
fetal
monitoring during child-
Noticeably absent from
this
chapter
is
a discussion of the use of pulse oximetry in
many
parts of the book, reflects the fact that
;ire
engineers and not clinicians.
strength of this
book
its
is
a
emitting diodes and photosensors are dis-
ically useful.
end of the
saturation
pulse oximetry. In that respect, the book has
chapter on probes (Chapter 6)
the
oxygen
light. Issues related to light-
Cu-
at
the true
proportional to the intensity
Ob-
found
if
detailed coverage of the technical aspects of
relevant, but not exhaustive, references.
chapter rather than the usual placement
the
85%
85%.
less than
The major
The photodetector produces
todetector.
jectives are included with each chapter.
riously, these are
if
greater than
produce an inaccurately high ox-
will
ygen saturation
is
is
measured by a pho-
cussed in extensive detail. Although this
providers.
the
through tissue from the
light-emitted diode
of the incident
and health care
it
sat-
produce an inaccu-
will
it
low oxygen saturation reading
the authors
current that
neers, medical physicists,
85%. Because
the intensive care unit. This chapter, like
software required for effective functioning.
written for biomedical engi-
the tfue oxy-
if
light-emitting diodes (Chapter 5).
discussed in Chapter 6. the amount of
The book
is
85%,
oxygen saturation
birth.
met by
ware required
uration of
and has a narrow
Medical and Biological Engineering and the
includes the hardware and soft-
less than
is
methemoglobin causes a puLse oximetry
to penetrate tissue, is small
into a probe,
fit
emission spectrum. These requirements are
It
only correct
is
gen saturation
transport,
enough
Series of the International Federation for
Physics.
globin. This
cussions of pulse oximetry applications in
and 7 cover light-emitting
oximetry requires a
oximeters and
it
saturation.
diodes, photodetectors, and probes. Pulse
ing; 1997. $90.(X).
oxy-
presence of methemo-
in the
Chapter 12 describes issues related to the
theoretical
UK and
gen saturation
user interface for pulse oximeters. Clinicians
Design of Pulse Oximeters, JG Webster,
Bristol
stated
globin solutions, but does not apply for
whole blood because of the scattering
244 pages.
It is
that pulse oximeters overestimate the
and
is
an im-
determine the oxygen saturation of hemo-
fects.
illustrated,
curacies due to methemoglobin.
true
testing.
has
1 1 )
is
portant error in this chapter related to inac-
rately
Light absorbance in pulse oximetry
However, there
clinical relevance.
nous oxygen saturation catheters. There
is
is particularly
errors of pulse oximeters (Chapter
without discussion of optodes or mixed ve-
Slutsky AS. Mechanical ventilation (re-
cians'
nearly absent,
no analysis of point-of-care
37(9):999-1130.
2.
is
of pulse oximeters
achieved
is
primary
its
However,
intent.
this
clinical relevance in
expense of
at the
many
places throughout the book. Because
of
strong engineering approach, mathe-
its
matical relationships are presented through-
out the text that clinicians might find intimidating.
anyone
would recommend
I
who
this
book
for
wishes to learn more about the
technical aspects of pulse oximetry
what happens inside
the
probe and the display.
—
ie,
box between the
Due
to
its
relatively
steep cost ($90) and limited clinical usefulness, this
is
not a
book
onto the shelves of
pists
and
that will find
many
its
way
respiratory thera-
critical care physicians.
very technical and thus might be of limited
Dean
usefulness to clinicians.
R
Hess
PhD RRT FAARC
to cal-
Department of Respiratory Care
ibration of pulse oximeters. Clinicians will
Chapter 10 analyzes issues related
find this information useful.
the chapter
on simulators
to
of
Harvard Medical School
check the func-
The
.section
Respiratory Care
•
April
1
999 Vol 44
No
4
&
Human Immunodeficiency Virus and the
Lung, Mark
Beck
MD,
MD
Rosen
J
Editors.
(Lung Biology
and Disease, Volume
1
19,
New
in Healtii
Claude Lenfant,
Executive Editor) Hardcover,
584 pages.
M
and James
illustrated,
moral considerations, such as the
when gay
situation raised
immunodeficiency syndrome
(AIDS) epidemic
knowledge on
is
which
the rapidity at
aspects of
all
human immu-
rus
the pathophysiology and natural
itself,
history of HIV infection,
and the syndromes
associated with HIV-induced
immunosup-
knowledge
pression. Furthermore, this
seems
to
be
in
a status of continuous change.
These changes occur on many
fronts, rang-
ing from the epidemiology of HlV-infection
and
AIDS to the therapeutic approaches
available for AIDS-related complications.
most current Centers for Disease Concase definition of
to act as surro-
gates.
(although
Two
Part
discusses aspects of the cell
The
section
is
that
quite
appropriately divided into chapters dedi-
HIV and
cated to
infection of lung cells.
HIV and
of
to clinical aspects
the lungs.
Pulmonary Dis-
Part Three, "Diagnosis of
orders." includes excellent chapters
on bron-
choscopy and on noninvasive diagnostic
tests.
The chapter on bronchoscopy
includes
useful diagnostic algorithms to approach fo-
HIV
disease.
the chapter
on noninvasive
tests includes a
useful table on the radiographic patterns of
abnormalities in
HIV
infection.
vide excellent clinical descriptions of the
and
its
complete fash-
knowledge on HIV
infection
pulmonary complications and
se-
The book
tions. Part
is
divided into 6 different sec-
One provides an overview of HIV
infection, which, in addition to epidemiol-
ogy, includes a chapter on
tion
HIV and
intensive care for patients with
tion.
injec-
drug users and a chapter dedicated to
I
found
portant.
the.se
While the
HIV
infec-
chapters particularly iminitial
spread of the
AIDS
epidemic occurred mostly within the gay
community, the
HIV
is
currently spreading
these entities
ter
is
rapidly evolving.
marizes the experience
in
tions of
HIV
in this particular
group as well
as the challenges confronting prevention and
infection control strategies
nous drug
users.
among
some important
Respiratory Care
•
HIV
1
sible format."
In general, the
book
is
easy to read. The index
and
and
well written and
well organized
is
facilitates the rapid location
Numerous
tables support
The
and complement the
of references
list
,500), but
of specific
figures, photographs,
is
text.
extensive (over
few cover papers published
after
at least
at
San Francisco
In
This book will be of interest for
all
health
HIV-infected patients. The target audience
includes pulmonary and critical care physicians, respiratory therapists,
and intensive
care nurses. Respiratory therapists and
summary,
in addition to
providing an
excellent review of both the infectious and
noninfectious pulmonary complications of
HIV.
care providers involved in the treatment of
one occasion a missing word ob-
scures the meaning of a sentence (Page 73).
the
book also addresses general
as-
pects of the epidemiology and pathogenesis
of
HIV
infection, aspects of cell
and mo-
lecular biology of particular relevance to
the lungs, and specific issues related to the
care of the
HIV patient with pulmonary disHIV patient in the intensive
ease or to the
find particularly interesting the
care unit. Health care providers involved in
chapters related to invasive and noninva-
the care of HIV-infected patients will find
sive diagnostic procedures, as well as the
particularly useful the chapters dedicated to
nurses
may
The most
which the
difficult
field
problem faced by any
is
difficult for the authors to
printed.
The
pulmonary complications of
disease.
it
extremely
Gustavo Matute-Bello
by the time the book
is
problem
MD
Senior Fellow
provide truly up-
editors recognize this
and
HIV
that the rapidity at
evolves makes
to-date information
the different
book.
Division of Pulmonary and
Critical
Care Medicine
Department of Medicine
infec-
clude the most comprehensive and current
and
information available, emphasizing that
ethical
April
and syn-
state their efforts to "in-
The chapter dedicated
intensive care for patients with
tions includes
intrave-
The chap-
for the diagnosis of this condition.
book on HIV disease
injection drug us-
many of
a very useful algorithm
The chapter on HIV and
ers addresses both the specific complica-
pulmonary
[the
infection]
thesize disparate information into an acces-
on Pneumocystis carinii pneumonia sum-
clinical sections of the
a faster rate
HIV
complications of
meet
compre-
high number of typographical errors, and in
among intravenous drug users and members of nongay ininority groups.
at
overall the authors
compendium of
hensive
the evo-
pulmonary complica-
should be noted that
it
the treatment (and prevention) of
General Hospital
quelae.
However,
(HAART) on
pulmonary syndromes associated
with HIV. although
in a concise, yet
more
1996. Unfortunately, there are an unusually
different
ion the current
liked to see
their stated goal of "providing a
1
by some of the most important authorities
summarize
tions.
contents.
complications of HIV. These chapters pro-
the field, represents a major effort to
HIV.
as co-receptors for
would have
I
The remain-
field
ciency Virus and the Lung, co-authored
in
CXCR5,
lution of HIV-related
and diffuse pulmonary disease, while
cal
Human Immunodefi-
and bewildered when approaching the
of
Also,
make
of chemokine receptors,
ticularly the role
such as
findings failed to
into the pages of the book, par-
antiretroviral therapy
and Five are dedicated
Piuls Three, Four,
ing clinical sections (Four and Five) include
it
way
not included
is
discussion on the impact of highly active
descriptions of infectious and noninfectious
change makes
some important new
their
AIDS
referenced). Unfortunately,
is
HIV and lung lymphocyte function, and HIV
easy
a rapid pace of
it
and alveolar macrophage function.
for the non-HIV-specialist to feel confused
Such
by the time the
published." Perhaps for this reason
trol
nodeficiency virus (HIV) infection has
evolved, including knowledge about the vi-
unlikely to change
is
is
the
are relevant to the lungs.
the acquired
which
book
members,
and molecular biology of HIV infection
most impressive features of
the
difficult
patients prefer
their lovers or partners, rather than their bi-
ological family
York: Marcel Dekker Inc;
1998. $195.00.
One of
Software
to
in the preface
999 Vol 44
No 4
Seattle,
Washington
449
News
There
to
releases about
no charge
is
new products and
for these listings.
RESPIRATORY CARE, New
New Products
services will be considered for publication in this section.
Send descriptive release and glossy black and white photographs
Products
& Services Dept,
1
The Reader Service Card can be found
Drug Administration (FDA)
TX
market
to
Xopenex'"(levalbuterol HCl). According
to the
company, the inhalation solution
two dosage strengths
available in
& Services
75229-4593.
back of the Journal.
at the
is
send your request elec-
this issue, or
tronically via "Advertisers Online" at
http://www.aarc.org/buyers_guide/
for use
with a nebulizer for the treatment and pre-
vention of bronchospasm. Sepracor says
the
new drug
the therapeutically active
is
(R)-isomer of racemic albuterol.
A com-
pany spokesperson describes racemic
albuterol as an equal mixture of (R) and
(S) isomers
drug
is
and explains
that although the
the world's leading brochodilator
for asthma, they
found that removing the
(S) isomers increased effectiveness of the
(R) isomer. For
Sepracor, circle
more information from
number 192 on
the reader
service card in this issue, or send your
request electronically via "Advertisers
Online"
http://www.aarc.org/buy-
at
ers_guide/
System Software for Exercise System.
Spacelabs Burdick Inc announces the
release of version 2.1 software for the
Quest* Exercise Stress System. According to a
company
press release, the
updated version includes several new features: graphical
Nasal
and tabular trends (both
Wash
recently
on display and printed components of the
in-stage and final reports); test trended
and allergy
ST
level
way
cially available
NIBP to
BP mesurements and
take
sufferers.
A
company
now be
to help relieve the pain
press
and pressure
associated with congested nasal or sinus
commer-
passages.
programmed
RinoFlow
interfaced with three different
RinoFlow™
its
Sinus System for sinus
release says the device provides a gentle
and slope measurements during the exercise stress test; the system can
available
Wash and
Nasal
heart rate, blood pressure, and
System. Respironics has
made
incorporate them
sisting
Respironics
as portable
describes
and easy
the
to use, con-
of a small compressor unit the size
of a tissue box (weighing about 5 lbs) and
into final reports; "freeze screen" func-
Vital Signs Monitor.
a hand-held misting
ond, 12-lead printouts; and a Digital Base-
has introduced
BCI International
new vital signs mon-
connect to the compressor. For more infor-
line Stabilization Filter eliminates baseline
itor,
com-
mation from Respironics, circle number
wander
pany, the
tion allows user to print
artifact.
and save 10-sec-
For more information
from Spacelabs Burdick,
circle
number
its
the Advisor™. According to the
new monitor
offers all of the
basic parameters for vital signs moni-
ECG (3/5
NIBP,
191 on the reader service card in this issue,
toring, with
or send your request electronically via
respiration, invasive pressures,
"Advertisers Online"
peratures.
at
http://www.aarc.
org/buyers_guide/
BCI
lead),
Sp02,
and tem-
chamber and tube
194 on the reader service card
that
in this issue,
or send your request electronically via
"Advertisers Online" at http://www.aarc.
org/buyers_guide/
says a recorder and battery
option are available and that a
PC
card
allows for field upgrades. For more infor-
Bronchodilator. Sepracor Inc has received
final
450
approval from the U.S. Food and
mation from
number 193 on
BCI
International, circle
the reader service card in
RESPIRATORY CARE
•
APRIL
1
999
VOL 44 NO 4
.
Form Approved:
VOLUNTARY
For
reporting
by health professionals of adverse
events and prcxluct problems
MEi:)JfccH
THF FDA MEDICAL PRODUCTS REPORTINC PROGRAM
Page
.
Patient identifier
2
Age
at
3
Sex
4.
Triage unit
sequence
«
Suspect medication(s)
C.
time
0910-0291 Eicplrm: 4/30/96
statament on revsfM
OMB
Care)
of
A. Patient information
1
OMB No
S*«
FDA Use Only (Resp
Weight
1
Name
.
&
(give labeled strength
mfr/labeler,
if
known)
of event:
or
I
I
female
I
I
male
#1
.lbs
Date
In
of birth:
confidence
1.
Q
2
Outcomes
Adverse event
(check
all
and/or
|
|
Product problefti
attributed to adverse event
I
death
'I
I
I
I
I
Therapy dates
#1
defects/malfunctions)
initial
or prolonged
I
LJ
Diagnosis for use
Q
»1
Dyes Dno
#2
Dyes
#2
other:
4 Date of
this report
event
Event abated after use
stopped or dose reduced
5
(indication)
#1
required intervention to prevent
Lot #
6.
3 Date of
(if
known)
Exp. date
7.
#1
#1
#2
#2
(if
known)
n
no
nggPPy"''
Dgg^Py"''
Event reappeared after
8
imoday.yr)
5.
unknown, give duration)
#2
#2
4
congenital anomaly
permanent impairment/damage
-
(if
#1
I
life-threatening
hospitalization
(e.g..
—
|
I
3.
Irom'lo (or best estimate)
disability
that apply)
Dose, frequency & route used
2
Adverse event or product problem
B.
#2
kgs
reintroduction
Describe event or problem
»^\Jyes\Juo
NDC
9.
#
(for
Dyes
#2
n n&''
no
Concomitant medical products and therapy dates (exclude treatment
10.
D^g^Py"''
product problems only)
of event)
Suspect medical device
D.
1
Brand name
2
Type
3.
Manufacturer
of device
name & address
Operator of device
4
I
I
I
I
health professional
lay user/patient
other:
Expiration date
5.
(mo/day/yr)
6,
model # _
6.
Relevant tests/laboratory data, including dates
7.
If
catalog #
serial #
implanted, give date
(mo/day/yr)
_
8.
If
lot#
explanted, give date
(mo/day/yr)
other #
9.
Device available for evaluation?
I
1
7
Other relevant history, including preexisting medical conditions (eg.
race, pregnancy, smoking and alcohol use. hepatic/renal dysfunction, etc.)
I
yes
LJ
no
LJ
2
5600 Fishers Lane
Rockvllle, MD 20852-9787
DA Form 3500
1/96)
or
FAX
of event)
allergies,
Reporter
(see confidentiality section on back)
Name & address
MEDWaTCH
FDA)
to
Concomitant medical products and therapy dates (exclude treatment
0,
E.
Mail to:
(Do not send
returned to manufacturer on
Health professional?
yes
to:
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5
If
phone #
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no
you do NOT want your
identity disclosed to
the manufacturer, place an
Submission of a report does not constitute an admission that medical personnel or
"
tfie
X
" in this
Also reported to
4
box.
Q
I
1
I
I
I
I
manufacturer
user
facility
distributor
product caused or contributed to the event.
ADVICE ABOUT VOLUNTARY REPORTING
How to
Report experiences with:
•
medications (drugs or biologies)
•
medical devices (including
•
special nutritional products (dietary
in-vitro
diagnostics)
other products regulated by
•
use section
FDA
SERIOUS adverse events. An event
serious when the patient outcome is:
•
death
•
life-threatening (real risk of dying)
•
hospitalization
•
disability (significant, persistent or
•
congenital anomaly
•
required intervention to prevent permanent
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Report even
(initial
in
fill
C
for
all
products except
or prolonged)
permanent)
if needed
each patient
•
attach additional blank pages
•
use a separate form
•
Report
is
the sections that apply to your report
just
medical devices
supplements, medical foods, infant formulas)
•
report:
•
FDA
report either to
for
or the manufacturer
(or both)
Important numbers:
• 1-800-FDA-0178
• 1-800-FDA-7737
• 1-800-FDA-1088
to
FAX
report
modem
to report
by
to report
by phone or
for
more information
1
-800-822-7967
for
for
damage
a VAERS form
vaccines
If your report involves a serious adverse event
with a device and occurred in a facility outside a doc-
if:
it
•
you're not certain the product caused the
may be legally required to report to
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tor's office, that facility
event
•
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Report product problems -
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Confidentiality: The patient's
FDA and protected
or safety concerns such as:
confidence by
•
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•
questionable
•
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the law.
components
poor packaging or labeling
•
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The public reporting burden for tills collection of information
iias been estimated to average 30 minutes per response,
including tiie time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed,
and completing and reviewing the collection of information.
Send comments regarding this burden estimate or any other
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held
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Please do
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OMB
to:
U.S.
Pleasc UsG Addrcss Provided Below - Just Fold
DEPARTMENT OF HEALTH AND HUMAN SERVICES
In
Thirds, Tape
•
Food and Drug Administration
and
IVIail
Department of
Health and Human Services
NO POSTAGE
NECESSARY
MAILED
THE
UNITED STATES
OR APO/FPO
IF
Public Health Service
Rockville,
Official
MD
IN
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Business
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Use $300
NOT
return this form
to either of these
addresses.
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is
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self-reporter,
»i
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I,,I.III...I.iI.iI.Ii..IiII.Ii.Ii.iIIiiIiIiiiImMI
.
.
.
.
JJ.
Please read the eligibility requirements for each of the classifications in the
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tion takes
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D
Active
Associate
n
D
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Physician
Industrial
D
n
Lost
Name
Special
FOK ACTIVE MEMBER
Student
An
individual is eligible if he/she lives in the U.S. or its territories or was an Active Member
of the following criteria: (1 ) is
prior to moving outside its borders or territories and meets
legally credenlialed as a respiratory core professional if employed in a state that mandates
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[3]
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ONE
OR
OR
_
standing on December 8, 1994,
good standing.
First
Name
will
continue as such provided his/her membership remoins
PLEASE USE THE ADDRESS OF THE LOCATION WHERE YOU PERFORM YOUR JOB,
THE CORPORATE HEADQUARTERS IF IT IS LOCATED ELSEWHERE.
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OR SPECIAL
FOR ASSOCIATE
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The following subciation except to hold office, vote, or serve as choir of a
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—
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Staff
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)
Individuals
Primary Job Kesponsiblltty (check one only)
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n
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n
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D
(
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D
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n
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1999 Respiratory
Care Open Forum
FORMAT AND TYPING INSTRUCTIONS
The American Association for Respiratory Care and its
RESPIRATORY Care, invite submission of
science journal,
brief abstracts related to
The
any aspect of cardiorespiratory
and selected authors
abstracts will be reviewed,
Open Forum
invited to present posters at the
AARC
be
during the
International Respiratory Congress in Las Vegas,
Nevada, December 13-16, 1999. Accepted abstracts
published in the
Membership
November 1999
in the
issue of RESPIRATORY
will
be
Care.
AARC is not required for participation.
All accepted abstracts are automatically considered for
Accepted abstracts
care.
will
ARCF
40%;
be photographed and reduced by
will
therefore, the size of the original text should be at least
10 points. Abstracts should be 400 words or less and
have
or
1 clear,
concise table or figure.
Geneva makes
A
the clearest reproduction.
the abstract should be the
explain content. Follow
title in all
title
may
font like Helvetica
The
first line
of
capital letters. Title should
with names of all authors (includ-
ing credentials), institution(s), and location; underline pre-
name. Type or electronically print the abstract sinparagraph in the space provided on
the abstract blank. Insert only one letter space between sentences. Text submission on diskette is encouraged but must
research grants.
senter's
gle spaced in a single
SPECIFICATIONS—READ CAREFULLY!
An
abstract
may report
(1)
an original study,
(2)
the eval-
uation of a method, device or protocol, or (3) a case or
case series. Topics may be aspects of adult acute care, con-
table form, or a simple figure
within the space allotted.
fits
be attached to the abstract form. Provide
tinuing care/rehabilitation, perinatology/pediatrics, cardio-
is
pulmonary technology, or health care delivery. The abstract
may have been presented previously at a local or regional
mation requested.
but not national
—meeting and should
previously in a national journal.
The
not have been published
abstract
the only evi-
is
dence by which the reviewers can decide whether the author
should be invited to present a poster
at the
OPEN FORUM.
Therefore, the abstract must provide all important data, findings, artd conclusions.
Give
specific information.
Do
not write
may be submitted in
may be included provided it
No figure, illustration, or table
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to
all
author infor-
A clear photocopy of the abstract form may
may be employed without
new or infrequently used abbreviations should
out on first use. Any recurring phrase or expres-
be used. Standard abbreviations
explanafion;
be spelled
sion
may be
abbreviated,
if it is first
explained.
Check
the
grammar, facts, and figof language; and (3) conformance to these
abstract for (1) errors in spelling,
ures; (2) clarity
An
specifications.
may
may
staff of RESPIRATORY Care
abstract not prepared as requested
general statements, such as "Results will be presented" or
not be reviewed. Questions about abstract preparation
"Significance will be discussed."
be telephoned to the editorial
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to
submit abstracts early. Abstracts postmarked by April
ESSENTIAL CONTENT ELEMENTS
Early Deadline Allowing Revision. Authors may choose
Original study. Abstract must include
( 1 )
Background:
statement of research problem, question, or hypothesis; (2)
Method: description of research design and conduct in sufficient detail to
permit judgment of validity; (3) Results:
ment of research findings with
tical analysis; (4)
state-
quantitative data and statis-
Conclusions: interpretation of the meaning
1999 will be reviewed and the authors notified by
to
be mailed by
May 7,
1
2,
only
999. Rejected abstracts will be accom-
panied by a written critique that should, in
many cases,
authors to revise their abstracts and resubmit
Deadline (June
letter
them by
enable
the Final
11, 1999).
of the results.
Method, device, or protocol evaluation. Abstract must
Final Deadline. The mandatory Final Deadline
include (1) Bacicground: identification of the method, device,
1999 (postmark). Authors
or protocol and
tion
its
intended function; (2) Method: descrip-
tion of the evaluation in sufficient detail to permit judgment
by
letter only.
will
These
is
June
11,
be notified of acceptance or rejec-
letters will
be mailed by August 25,
1999.'
of its objectivity and validity; (3) Results: findings of the evaluation; (4) Experience:
summary of the
author's practical expe-
Mailing Instructions. Mail (do not
fax!) 2 clear copies
and a
rience or a lack of experience; (5) Conclusions: interpreta-
of the completed abstract form, diskette
tion of the evaluation
stamped, self-addressed postcard (for notice of receipt)
and experience. Cost comparisons should
1999 Respiratory
be included where possible and appropriate.
Case report. Abstract must report a case
mon or of exceptional educational
that
is
uncom-
value and must include (1)
Introduction: relevant basic information important to understanding the case. (2) Case
details
Summary:
patient data
and response,
of interventions. (3) Discussion: content should reflect
results of literature review.
The
author(s) should have been
actively involved in the case and a case-managing physician
must be a co-author or must approve the
report.
(if possible),
Care Open Forum
11030 Abies Lane
TX 75229-4593
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to:
.
1999 Respiratory
Care Open Forum Abstract Form
must be in all
upper case (capital)
Title
1
letters,
authors' full
names and
text in
upper
and lowercase.
2.
Follow
title
with
all
authors' names, includ-
ing credentials (underline presenter's
name),
and
institution,
location.
3.
;
Do not justify
(ie,
leave a 'ragged'
right margin).
4.
Do not use type size
than 10 points.
(Do not exceed 400
less
words.)
5. All text
and the
or figure, must
table,
fit
into
the rectangle shown.
(Use only
clear,
1
con-
cise table or figure.)
6.
Submit 2 clean copies.
This form may be photocopied
if
multiple
abstracts are to be
submitted.
Mail original & 1
photocopy (along with
postage-paid postcard) to
1999 Respiratory
Care Open Forum
11030 Abies Lane
TX 75229-4593
Dallas,
Early Deadline
April 2, 1999
is
(postmark)
Final Deadline
June
II,
is
1999 (postmark)
Electronic
Submission
Is
Now
Available. Visit
www.rcjournal.com
to find out
more
RE/PIRAJORy QiRE
Manuscript Preparation Guide
General Information
A paper expressing personal but substanti-
Point-of-View Paper:
ated opinions on a pertinent topic. Title Page, Text, References, Tables,
Respiratory Care welcomes original
manuscripts related to the
and
Illustrations
may
be included.
science and technology of respiratory care and prepared according to these Instructions and the Uniform Requirements for
Special Article:
Manuscripts Submitted to Biomedical Journals [Respir Care
categories
1
997;
42(6):623-634]. Manuscripts are blinded and reviewed by professionals
who are experts
in their fields.
for all aspects of the manuscript
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is
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is
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what the AARC is doing about legislative advocacy? You can
positions
post a question in this area for possible posting.
ARTIFICIAL
AIRWAYS
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Hotline to the President
Do you want immediate action
from the top? Click on the "red phone" hotline to President
Dianne Kimball. An E-mail will be sent directly to her.
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Specialty Section Mailing Lists
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Patient Assessment Course for Respiratoiy Therapists
JUNE 1999
Due
overwhelming demand, the patient assessment course for
is being offered twice this year. The first test
date has passed, and the remaining test will be conducted in
Phoenix, Arizona from July 18-20 (immediately following Summer
Forum). Space is at a premium and preregistration is required.
JULY 1999
to
respiratory therapists
Successful completion of the course will earn participants 16
hours of CRCE credit and a certificate of course completion. Each
attendee will be given a pocket guide to physical assessment, to
help them on the job. Following the last class, participants will
take a 100-item test developed by the
NBRC.
Tests will be graded
on-site for those wishing to obtain their scores immediately. For
more information and
to register, visit the
AARC web
site at
www.aarc.org.
AARC, Affiliates Set Conference Sciiedules
Q//^ this issue
1999 "^dl
The AARC and many
of the affiliates have set their schedules
1999 conferences and seminars. Foremost among AARC's
offerings are its Summer Forum (July 16-18) and Annual
International Respiratory Congress (Dec. 13-16). Check out
the AARC's website at www.aarc.org for all meeting
for
registration materials
and a
list
of affiliate conferences.
Videoconference Program Set; Nursing CEUs
Offered
A series
of eight videoconferences are scheduled for 1999
through the AARC Professor's Rounds series, which are now
approved for nursing CEUs as well as CRCE credit. Topics are:
respiratory assessment, asthma management, ventilator management, disease management, pediatric emergencies, COPD,
PEEP, and respiratory pharmacology.
(B^bstxacts
CRCE Online Debuts
Now you can earn continuing education on the Internet from
the AARC through its new CRCE Online website. After you pay
number of continuing education units you wish to
attempt (by submitting your credit card number on a secure
server site), you are given access to the list of courses. Read
the material, take the test, and then print out a certificate
showing you passed. Your participation will also be noted on
your CRCE record with the AARC. Log on to the AARC's website at www.aarc.org and look for CRCE Online.
for the
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415
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449
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Ambrosino, Nicolino
Bianchi, Luca
Clini, Enrico
Delgado, Edgar
Dillard,
A
Thomas
M
Dwyer, Terry
Emad, Ali
Haynes, Jeffrey
M
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Hess,
Hoffman, Leslie
A
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Homma,
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443
415
415
415
428
407
42
437
445
448
428
447
Ambrosino, Nicolino
Bianchi, Luca
Clini, Enrico
Delgado, Edgar
Dillard,
Dwyer, Terry
Emad, Ali
M
Haynes, Jeffrey
Hess,
A
Thomas
M
Dean R
Hoffman, Leslie
A
Holets, Steven
Homma,
McCarthy, Kevin
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Pinsky, Michael
Shibuya, Masato
428
415
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409
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Porta, Roberto
Robertson,
Stoller,
H Thomas
James
Suzuki, Hajime
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Kathawalla, Salim
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l...l,.l.ll...l.,.l.ll..l...l..l.lll....l.l..l.l.l
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To
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April - Respiratory Care

Transcription

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