Respiratory care : the official journal of the American Association for

Transcription

April
Volume
38,
1993
Number 4
ISSN 009891 42-RECACP
RESPIRATORy
A MONTHLY SCIENCE JOURNAL
38TH YEAR— ESTABLISHED 1956
Multipatient
Call for Abstracts
Use
of Prefilled
Humidifiers
1993 Open Forum
Error
in Intrinsic
PEEP Measurement
Upper Airway Trauma and Obstruction:
A Review
Symposium Papers: New Therapies
Respiratory Care
Surfactant Therapy
in
ARDS
Permissive Hypercapnia
Thoracoscopic Surgery
in
SIEMENS
Now
even the tiniest
engine can generate airspeed,
When
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even the
little
patient
makes
In
addition to flow triggering,
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etfort,
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the Servo Ventilator 300 are
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applicable to neonatal, pediatric,
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An advantage that tew
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American Association
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Care • 11030 Abies Lane
• Dallas,
Texas 75229-4593
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INC.
RE/PIRATORy CARE
A
Monthly Science Journal. Established 1956.
11030 Abies Lane
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EDITOR
343
ADJUNCT EDITOR
Philip Kittredge
April 1993
Volume
D Golar, LLA
by Sandra
348
Error
in
Sutherland,
F
Weygert
G
— Rotterdam,
Management
by Anthony L Kovac Kansas
More from "New Horizons
MD
MD
Two New
MD
MD
365
MD
MD
373
M Ayres MD
M Cherniack MD
M Civetta MD
Downs MD
Donald F Egan MD
388
by Douglas
MD
MD
John E Hodgkin
William F Miller
Elian J Nelson RN
Thomas L
MD
398
Seattle,
E Wood—Seattle,
by George Burton
RRT
Syndrome
Washington
Washington
Practitioner's Guide, edited
K Stoller— Cleveland,
Ohio
Normal and Abnormal Swallowing: Imaging
400
MD
MD
A
MD and Judith Tietsort RN RRT
reviewed by James
MD
MD
W
—
Therapist-Driven Protocols (TDPs):
Petty
Alan K Pierce
Henning Pontoppidan
Severinghaus
John
Barry A Shapiro
Steinberg
BOOKS, FILMS, TAPES, & SOFTWARE
MD
MD
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P
Joseph
John B
RRT
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by Robert M Kacmarek— Boston, Massachusetts, and Keith G Hickling
— Christchurch, New Zealand
JOURNAL ASSOCIATES
Reuben
Seattle,
Surgery, and
Ward MEd RRT
Stephen
—
A New Era in Thoracic
in ARDS
VIII":
Therapy
to
Surfactant Therapy in the Adult Respiratory Distress
by Kenneth
MBA
Gareth B Gish MS
George Gregory
Ake Grenvik
Approaches
by David J Pierson
Charles G Irvin PhD
MS Jastremski
Hugh S Mathewson
Michael McPeck BS RRT
Richard R Richard BS RRT
John Shigeoka
R Brian Smith
Jack Wanger
RPFT RRT
H
Kansas
City,
SYMPOSIUM PAPERS
362
MS RRT
Jr
Ronald B George
James M Hurst
Jeffrey J
Review of Causes,
MD
MD
Fluck
—
A
BS RRT
Birenbaum
Burford
PEEP: Cause and Remedy
The Netherlands
Evaluation, and
Bob Demers BS RRT
Donald R Ellon MD
R
Alberta,
REVIEWS, OVERVIEWS, AND UPDATES
351
CONSULTING EDITORS
Robert
Up To
Grootendorst, Gerard Lugtigheid, and Ernst Jan van der
J
John
GT Ford— Calgary,
and
Ventilator Measurements of Intrinsic
by Albert
MD
David Pierson MD
James K Stoller MD
J
for
Canada
R Maclntyre
Howard
Number 4
30 Days: Patient Safety and Cost Analysis
EDITORIAL BOARD
Dean Hess MEd RRT. Chairman
Thomas A Barnes EdD RRT
Richard D Branson RRT
Robert L Chatburn RRT
Charles G Durbin Jr MD
Thomas D East PhD
Robert M Kacmarek PhD RRT
Frank E Biondo
38,
Oxygen Humidifiers
Multipatient Use of Prefilled Disposable
RRT
EDITORIAL COORDINATOR
Donna Stephens BBA
Neil
for Respiratory Care.
ORIGINAL CONTRIBUTIONS
RRT
Brougher
CONTENTS
EDITORIAL OFFICE
Pal
Official Journal of the
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FRACP FRCR
reviewed by Nancy Conway
in
and Martin
—Milwaukee,
Diagnosis and Therapy, edited
W Donner MD
Wisconsin
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LETTERS
Donna Knauf
405
Decreased Paw -peak Does Not Equate to "Improvement"
Jeannie Marchant
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— Cleveland, Ohio: with response by William
Howard— Boston, Massachusetts
Respiratory Care (ISSN 00989142)
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• APRIL '93 Vol 38 No 4
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327
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407
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California
Inappropriate Device for Aerosol Studies?
MB Dolovich —Hamilton,
Ontario, Canada; with response by Jerry Ebert,
Alexander
B Adams, and Beth Green-Eide— St
Prediction
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• APRIL 93 Vol 38
No
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329
—
Abstracts
Summaries of
Pertinent Articles in Other Journals
and Commentaries To Note
Editorials
The Health
GD
et al
A
Benefits of Exercise:
Curfman.
N
Engl
Med
J
Critical Reappraisal (editorial)
1993;328(8):574. (Pertains to Paffenbarger
paper abstracted on Page 333.)
Control of Tuberculosis
sues in
—The Law and the Public's Health
medicine)—GJ Annas.
585-588. (Pertains to Frieden
N Engl J Med
et al
Directly
Observed Treatment of Tuberculosis:
To Try
It
Engl
J
(sounding board)
Med
(legal is-
1993;328(8):(Feb 25. 1993)
—MD
Iseman,
DL
We Can't Afford Not
Cohn, JA Sbarbaro. N
1993;328(8):(Feb 25, 1993)576-578. (Pertains to Goble
et al
A
Removing the Incentive To Sell Kids Tobacco:
mentary)— SA Glantz. JAMA 1993;269:793-794.
Proposal (com-
Sleeping Prone and the Risk of
out exception,
studies demonstrat-
these reports so that physicians can
Sudden Infant Death Syndrome
WG Guntheroth, PS Spiers. JAMA
ed an increased risk for SIDS asso-
assess the evidence and advise par-
ciated with the prone sleeping posi-
ents accordingly.
1992;267:2359.
tion.
—
all
The published
(relative risk or
OBJECTIVE: To
reports that
analyze
critically
show a
relationship be-
tween sudden infant death syndrome
(SIDS) and the prone sleeping position
in
infants.
Peer-reviewed
ters,
DATA SOURCES:
articles,
published
book chapters, and
tional
health
local
statistics
let-
and na-
were
used,
likelihood ratios
odds
ratio) for
SIDS
in the
prone position compared with
SIDS
in
from 3.5
any other position ranged
to 9.3 in
has been associated with re-
duction of
SIDS by 20%
to
67%.
paralleling the reduction in use of the
prone position, with no increase
in
without time or language restrictions.
deaths from aspiration or in other di-
These studies represented three rac-
agnostic categories.
es, four continents,
tries;
and seven coun-
none was published
America.
in
North
STUDY SELECTION: No
We
CONCLUSIONS:
recommend avoidance of
the
prone sleeping position for infants
the
6 months of
first
life
in
unless there
studies were ignored, but only those
is
with case controls were reviewed
Reports from the Netherlands, Great
detail;
we regarded
in
a recent cohort
a specific medical indication for
Britain, Australia,
ease
—MF
singa.
WM
Prummel.
JAMA
Dis-
Wier-
1993:269:479.
seven studies. Pub-
against the use of the prone po-
licity
sition
Smoking and Risk of Graves'
and
New
it.
Zealand
OBJECTIVE: To
is
and.
if so,
assess
to ascertain
smoking
confounding
disease
whether
this
when
controlling
factors.
DESIGN:
association persists
for
if
with Graves'
associated
Consecutive entry case-control study
with two age- and sex-matched control subjects
from two
different pop-
SETTING:
PATIENTS: Five
ulations per case patient.
University hospital.
groups
were
studied:
(1)
Graves'
ophthalmopathy and Graves' hyperthyroidism (n = 100: divided
in four
analytic (prospective) study as par-
indicate that avoiding the prone posi-
subgroups according to the severity
ticularly strong, in addition to six be-
tion for infants in the first 6
months
of the eye disease); (2) Graves' hy-
fore-and-after
of
(intervention)
DATA EXTRACTION:
teria for decision
330
Hill's
cri-
making were used
to assess the quality
the data.
trials.
and validity of
DATA SYNTHESIS:
With-
life
could reduce the number of
perthyroidism
without
clinical
eye
50%. Un-
involvement (n = 100); (3) sporadic
fortunately
these findings have re-
nontoxic goiter (n = 100); (4) auto-
ceived
attention in North
SIDS deaths by
ica.
little
We
as
much
offer here
as
Amer-
an analysis of
immune hypothyroidism
and
(5) toxic
RESPIRATORY CARE
(n
=
75):
nodular «oiter (n = 75).
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Technology
for Life.
ABSTRACTS
The study comprised 200
from
200 from
and
group
served
study to find out whether a tapering
stopping
course of oral prednisolone has any
avoiding obesity
population-based
advantage over an abruptly terminat-
gevity.
control
subjects.
ed course of prednisolone for an epi-
lifestyles
MEASURE:
sode of acute asthma requiring hos-
and the associations of these changes
a
as
and
subjects
population,
hospital-based
a
MAIN
OUTCOME
Smoking
status
was determined from
We
admission.
pital
studied 35 pa-
with
smoking,
cigarette
We
may
increase lon-
analyzed changes
in the
of Harvard College alumni
METHODS: Men
mortality.
a questionnaire at the time of onset
tients
of the disease to exclude any effect
asthma; their mean peak expiratory
who were 45 to 84 years of age in
1977 and who had reported no life-
on smoking. RE-
flow rate (PEFR) on admission was
threatening disease on questionnaires
greatly increased
173 L/min and their
of the disease
itself
SULTS: Smoking
ophthalmopathy
the risk for Graves'
(odds
ratio, 7.7;
95%
confidence in-
admitted to hospital with acute
32 years (range 18-55);
inhaled
ing
(mean dose 908
Graves' hyperthyroidism alone were
tient
more often smokers than control
subjects (odds ratio,
fidence interval,
95%
1.9;
Smoking
1.1 to 3.2).
was not associated with
con-
other
the
thyroid diseases studied. Essentially
similar results
were obtained
adjustment for differences
after
educa-
in
tion
between case patients and con-
trol
subjects.
Among
patients
the
with Graves' ophthalmopathy, smok-
had more severe eye disease than
mg
us-
completed
in
changes
Each pa-
between the
enteric-coated
1962 or 1966 and again
in
1977 were classified according
discharge
daily).
/.ig
received 40
were
all
on
steroids
terval, 4.3 to 13.7), but patients with
also
mean age was
tionnaires.
first
We
and second ques-
analyzed changes in
prednisolone daily for 10 days fol-
their level of physical activity, cigar-
lowed by a tapering course of either
ette
mg
smoking, blood pressure, and
tablets (active ta-
body
weight,
per) or identical placebo tablets (pla-
these
factors
prednisolone 5
cebo
taper), reducing
on Day
1
to
1
no
from 7
tablets
tablets
by Day
18.
The primary outcome measure was
PEFR on
the
waking. Both groups
responded well
to treatment
10 (mean morning
PEFR:
by Day
active ta-
and the
between
RESULTS: Of
1977 and 1985.
(which
riod
of
years
Beginning
moderately vigorous sports activity
(at
an intensity of 4.5 or more meta-
was
group 391 L/min). There was no
with a 23%' lower risk of death
found between the number of cigar-
ther significant change in
smoked per day
or the duration
either
equivalents)
associated
confidence interval, 4 to 42%; p -
group during the 7 days of ac-
0.015) than not taking up moderately
tive or
ophthalmopathy. However, there was
following
a significant increase in the odds ra-
ures analysis of variance, active vs
lower risk (95% confidence
placebo, p = 0.82).
20
with more severe eye
tios in patients
is
CONCLUSIONS: Smoking
associated with Graves'
and
it
for the
disease,
placebo tapering or during the
10 days (repeated meas-
The groups were
also similar in terms of secondary
outcome measures
—symptom
especially increases the risk
PEFR
development of more severe
treatment, evening
after
PEFR, and
ge-
in acute
pering
Pickering,
Asthma
Acute
in
O'Driscoll, S Kalra,
KB
with
plan
AA
a
reserve
may be more
Wood-
cock. Lancet 1993:341:324.
customary
oral
acute
steroids
to tail off the
after
exacerbation
main reason
of asthma:
for this
avoid rebound asthma.
ried out a
dose of
treatment of an
practice
We
the
is
have car-
RESPIRATORY CARE «APRIL
er
Jr,
DL
RT
Hyde,
AL
Wing, I-M Lee,
Jung, JB Kampert.
N
Engl
J
Med
1993:328:538.
con-
23%
higher
risk
non-
constant
than
Men
smoking.
with recently diag-
hypertension (relative
95%
risk, 0.75;
confidence interval, 0.55 to 1.02; p
0.057), as did
men
normal blood pressure
95%
=
with consistently
(relative risk,
confidence interval, 0.40
lean
< 0.001). Maintenance of
body mass was associated with
a
lower mortality
rate
than
long-
term, recent, or previous obesity.
The
associations between changes in
life-
style
and mortality were independent
and were largely undiminished by
age.
Our
findings on death from cor-
onary heart disease mirrored those
to
randomized double-blind
than
smoking, but with a
to
to 0.68; p
The Association of Changes in
Physical-Activity Level and Other
Lifestyle Characteristics with Mortality Among Men
RS Paffenbarg-
—
It is
57%; p = 0.001)
tinuing
0.52;
appropriate.
— BR
M Wilson. CAC
Carroll,
unnecessary
is
course of prednisolone
Double-Blind Trial of Steroid Ta-
41%
interval,
nosed hypertension had a lower risk
asthma; a personal asthma
management
netically predisposed individuals.
cigarette
of death than those with long-term
that steroid tapering
in
Quitting
sports.
smoking was associated with a
treat-
pears to be one of the multiple fac-
failures.
vigorous
This study suggests
ment
inducing Graves' disease
scores,
morning bronchodilator
ophthalmopathy. Thus, smoking ap-
tors
(95%
in
PEFR
of smoking and the severity of the
disease.
man-
90,650
totaled
observation).
nonsmokers, but no association was
ettes
the
10,269 men, 476 died during this pe-
bolic
fur-
of
relation
mortality
to
per group 396 L/min, placebo taper
ers
to
characteristics
lifestyle
in
BACKGROUND:
ward
'93 Vol 38
increasing
No
4
Recent trends
physical
to-
exercise,
on death from
all
causes.
CONCLU-
SIONS: Beginning moderately
vigor-
333
ABSTRACTS
ous sports activity, quitting cigarette
responding relative risks for Quar-
smoking, maintaining normal blood
tiles
pressure, and avoiding obesity were
Quartile
separately associated with lower rates
dence
of death from
causes and from
all
among mid-
coronary heart disease
3
and 2 (as compared with
1) were 0.45 (95% confi-
terval.
(95<7<
0.28 to
dle-aged and older men.
spectively.
Physical Fitness as a Predictor of
dependent,
among
Healthy, Middle-
—
Aged Norwegian Men L Sandvik,
Erikssen, E Thaulow. G Erikssen,
R Mundal, K Rodahl. N Engl J Med
J
p = 0.15). rePhysical
1.22:
CONCLUSIONS:
fitness appears to
Mortality
p =
confidence in-
0.22 to 0.92:
interval,
0.026) and 0.59
be a graded,
long-term
in-
of
predictor
mortality from cardiovascular causes
in healthy,
A
middle-aged men.
was
level of fitness
high
also associated
with lower mortality from any cause.
1993;328:533.
BACKGROUND:
many
Despite
studies suggesting that poor physical
is
an independent risk factor
for death
from cardiovascular causes,
fitness
matter
the
We
versial.
contro-
studied this question in a
follow-up
16-year
Norwegian men
METHODS:
1
remained
has
investigation
Our
,960 healthy
began
that
1972.
in
included
study
men 40
of
59 years of
to
age (84% of those invited to partic-
of Drug-Resistant
Tuberculosis in
New York
TR
T
Frieden,
Mendez, JO Kilburn.
GM
SW
J
N
Dooley.
coronary
were
asfit-
at baseline,
fitness
BACKGROUND:
work
doubled
RESULTS:
New York
in
men had
died,
53%
After an aver-
of them from car-
The
relative risk
of death from any cause
4
Quartile
1
(95% confidence
0.89: p
age,
= 0.015)
smoking
as
0.32
interval,
capacity,
to
after adjustment for
status,
serum
blood pressure, resting heart
tal
fitness
in
compared
(lowest) was 0.54
(highest)
with Quartile
lipids,
rate, vi-
body-mass index,
level
of physical activity, and glucose
erance. Total mortality
was
tol-
similar
among
the subjects in fitness Quar-
tiles
2,
1,
and 3 when the data were
adjusted for these
The adjusted
same
lected information
was
0.41
losis
where
ceptibility testing
Support
1991. Drug-sus-
was performed
RESULTS: Of
Prevention.
the
patients with positive cultures,
at
Your Association
and
518
466
and Tour Profession.
isolates available for test-
33%
ing. Overall,
had isolates
of these patients
resistant to
antituberculosis drugs,
lates
resistant to at
and
19% had
one or more
26%
least
isolates
had
iso-
isoniazid,
resistant
to
Of
the
both isoniazid and rifampin.
Use the
239 patients who had received antituberculosis therapy, 44% had isolates resistant to one or more drugs
and 30% had isolates resistant to
both isoniazid and rifampin. Among
the patients who had never been
the
sistance
to
interval,
on every patient
the Centers for Disease Control
(90%) had
Their
col-
Mycobacterium tubercu-
treated,
(95% confidence
We
City with a positive
during April
of death
0.20 to 0.84; p = 0.013). The cor-
334
New York
variables.
relative risk
from cardiovascular causes in fitness
Quartile 4 as compared with Quartile
1
decade
City,
METHODS:
culture for
age follow-up time of 16 years. 271
diovascular disease.
In the past
there have been recent nosocomial
per-
formed on a bicycle ergometer during a symptom-limited exercise-toletest.
1993;
creased nationwide and more than
in
ness measured as the total
rance
Cauthcn.
Med
the incidence of tuberculosis has in-
risk
with physical
and physical
sessed
Pablos-
328:521.
berculosis.
factors
Engl
—
City
A
Sterling,
outbreaks of multidrug-resistant tu-
Conventional
ipate).
The Emergence
proportion
with
one or more drugs
creased from
10%
in
Reader Service Card
rein-
1982 through
23% in 1991 (p = 0.003). Pawho had never been treated
and who were infected with the hu1984
to
tients
RESPIRATORY CARE
Standard
T
We not only meet all NAEP standards -
^
we've
set
a few of our own.
Our patented flow-sampling technology,
for example, that reduces wear and delivers
superior accuracy and reproducibility. 12
Our easy-to-use, easy-to-read, easy-to-clean
(but hard-to-wear-out) design, for another.
Our meticulous quality-control testing of
every unit.
And our unmatched program of professional
and patient support-including the industry's
only comprehensive peak flow monitoring
system.
All of which helps explain why physicians
have made us the standard - America's #1 peak
flow meter in the hospital, office, and home.
Let us show you how we can meet your
tough standards. Call us toll-free at
•800-962-1266.
&
Peak Flow
Meter
STANDARD RANGE
60
to
LOW RANGE
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880 L/min
Setting the standard for
HealthScan Products
References:
1.
Data on
file,
HealthScan Products
Inc.
2.
Shapiro S, Hendler
J, Ogirala R, et al.:
An
390 L/min
peak flow monitoring.
908 Pompton Avenue, Cedar Grove, NJ 07009-1292
evaluation of the accuracy ot Assess and MiniWright peak flowmeters. Chest 99:358-362. 1991.
'ASSESS Standard and Low Range meters meet National Asthma Education Program Technical Standards
Circle 136
Inc.,
to
lor
Peak Flow Meters, January,
1991.
AA710002-0
5/92
3
ABSTRACTS
man immunodeficiency
or reported injection-drug use were
Treatment of 171 Patients with
Pulmonary Tuberculosis Resistant
more
to Isoniazid
have
likely to
Among
virus
(HIV)
resistant isolates.
with the acquired
patients
immunodeficiency syndrome, those
with
likely
to
were
isolates
resistant
through January 1992 (80% vs 47%,
p = 0.02).
A
culosis therapy
the strongest pre-
p < 0.001).
ratio, 2.7;
There has been
a
in drug-resistant tu-
New York
patients,
City. Pre-
those
in-
HIV, and injection-drug
users are at increased risk for drug
resistance.
prevent
BACKGROUND:
Measures
to control
drug-resistant
and
tuberculosis
are urgently needed.
creasing.
with
We
courses of
patients
monary disease due
sis resistant to
who were
to
clinical
with pul-
M tuberculo-
rifampin and isoniazid
referred to our hospital be-
tween 1973 and 1983. The
patients'
records were analyzed retrospectively.
Their regimens were selected
dividually
and preferably
which
bacilli that were resistant to a
median of six drugs. Thus, their regimens were frequently not optimal.
patients with sufficient fol-
87 (65%) responded to
chemotherapy (as indicated by negdata,
ative
sputum cultures
three
consecutive months); 47 pa-
for
least
at
(35%) had no response, as
shown by continually positive cultures. The median stay in the hospital
was more than 7 months. In a multitients
variate analysis, an unfavorable re-
with a greater number of drugs re-
ceived before the current course of
therapy (odds ratio, 4.0;
95%
fidence
9.9;
interval,
1.6
to
0.001) and with male sex (odds
Delivers Oxygen
with
Every Breath!
re-
sponse was significantly associated
included
to
(median
in-
three medications that they had not
been given previously and
patients
shed
low-up
in-
171
46 years) had previously
age,
Of 134
is
RE-
fully susceptible.
ceived a median of six drugs and
The frequency of
reviewed the
171
SULTS: The
multidrug-resistant
Mycobacterium tuberculosis
treated
fected with
Engl
was
marked increase
viously
N
— M Go-
LA Madsen, D
L Ackerson, CR Horsburgh.
J Med 1993;328:527.
infection
CONCLUSIONS:
berculosis in
Waite.
and Rifampin
Iseman,
history of antituber-
dictor of the presence of resistant or-
ganisms (odds
MD
follow-up
during
die
more
ble,
was
the strain
2.5;
95%
confidence interval,
con-
p
<
ratio,
1.1
to
p < 0.03). Twelve of the patients
with responses subsequently had re-
6.2;
The
lapses.
56%
over
overall response rate
a
was
mean period of 51
Of the 171 patients, 63
(37%) died, and 37 of these deaths
were attributed to tuberculosis. CONmonths.
CLUSIONS: For
patients with pul-
monary tuberculosis
to rifampin
that is resistant
and isoniazid, even the
best available treatment
successful.
is
often un-
Only about half of such
eventually have negative
sputum cultures despite carefully se-
patients
oxygen conservation device, the POMS 20/50,
automatically delivers the prescribed amount of
oxygen during exercise and rest without
adjustment! Approved for sleep.
Configurations available for any oxygen source
Pulsair's
lected regimens administered for ex-
tended periods. Failure to control
resistant infection
is
this
associated with
high mortality and ominous implications for the public health.
and 50 psi) including hospital outlets.
Provides up to 300% more use time.
(20 psi
Call, write or fax for
more
The
information.
Effects of Ventilator
Working
Pressure during Pressure Support
Ventilation— IL Cohen, Z Bilen, S
Krishnamurthy. Chest 1993:103:588.
The
Pulsair Building
P.O.
Box 2609
FL 34954
Ft. Pierce,
US 1-800-327-031
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336
The purpose of
this study was to examine the consequences of altering
ventilator working pressure on airway pressure and flow characteristics
RESPIRATORY CARE
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ABSTRACTS
during pressure support ventilation
(PSV).
A
ventilator (Siemens Servo
900C) and single-lung simulator were
used, and graphic readouts, in
cate,
were taken
binations of
at a variety
PSV, working
tripli-
of compressure,
lung compliance, and airway resistance.
The graphic readouts were
number of "de-
then analyzed for a
pendent variables," and multiple
re-
gression analyses were performed using
PSV
working pressure,
level,
compliance, and resistance as "inde-
pendent variables." The results show
impact of working
that the relative
pressure on airway pressure and flow
and airway
will vary with other lung
'±T>3 =f
easy to see how the ACE®
Aerosol Cloud Enhancer will
It's
characteristics; also, excessive
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The patented design features a unique shape that matches the aerosol
plume. This shape allows the ACE to better capture and deliver the
When
medication.
the inhaler
are suspended in the
ACE
is
actuated, respirable aerosol particles
for delivery to
respirable particles can deposit in the
mouth and
your
Larger, non-
patient.
chamber instead
of the patient's
throat.
ACE
include:
Chambe r lets you feel confident the inhaler worked
and the prescribed dose is available for delivery.
One -W ay Va lve
until
of inspiratory flow and
at
after onset
maximum
flow, greater ringing or overshoot in
the circuit, reduced tidal
volume and
and reduced area
time,
inspiratory
conclusion,
Clear Holding
chamber
40 ms
greater flowrates at
under the airway pressure curve. In
Other features of the
correctly,
work-
ing pressure results in significantly
rjaai»MWi«»i»i»»agisr.jig[«asi
in
the mouthpiece protects the aerosol dose
significantly
affect lung-ventilator interaction in a
quantifiable
findings
Coaching Whistle helps to maintain the slow inspiratory flowrate
recommended for optimum aerosol particle delivery,
in
will
the
in
inhalation begins.
Highly Versatile Design allows the ACE to also be used
with an incentive spirometer, or in conjunction with an
ventilator
adjusting
working pressure
a vent
that
circuit,
fashion.
support
these
Further,
clinical
evidence
working pressure and/or
initial
flow rate need to be individualized to
ensure optimal airway flow and pres-
endotracheal airway or resuscitation bag.
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"1
Qf\C\
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Circle 131
(315)
697-2221
and Treatment
Pneumonia in Ven-
of Nosocomial
DIEMOLDING HEALTHCARE DIVISION
NY 13032 USA Phone
Evaluation of Clinical Judgment in
the Identification
©DHD
Canastota.
sure characteristics.
Fax (315) 697-8083
—J-Y Fagon,
tilated Patients
Y
J
Chas-
tre,
AJ Hance,
let,
C
To
evaluate the accuracy of clinical
Domart, J-L Trouil-
Gibert. Chest 1993:103:547.
diagnosis and treat-
TAKE CARE
judgment
OFYOUR LUNGS.
ventilated patients,
in the
ment of nosocomial pneumonia
THEY'RE ONLY HUMAN.
tients
we
suspected of having nosocomi-
pneumonia because of
sence of a new pulmonary
al
pre-
the
infiltrate
and purulent tracheal secretions.
AMERICAN
338
We
prospectively evaluated the accuracy
LUNG ASSOCIATION
The Chnstrtt^s Seal People
in
studied 84 pa-
of diagnostic predictions and thera-
"
RESPIRATORY CARE
• APRIL '93 Vol 38
No
4
ABSTRACTS
±
peutic plans independently formulat-
function, growth, daily caloric con-
vs
ed by a team of physicians aware of
sumption, blood pressure, blood sug-
munoglobulins also significantly
all clinical,
radiologic, and laboratory
Gram-
data, including the results of
stained bronchial aspirates. Definite
(n
= 51) or probable
(n
= 33) diag-
noses could be established
by
tients
strict
in all pa-
histopathologic and/or
Only 27/84 pa-
bacteriologic criteria.
were diagnosed as having pneu-
tients
Organisms
monia.
pneumonias were
titative cultures
responsible
for
by quan-
identified
of samples obtained
using a protected specimen brush or
Four hundred
pleural fluid cultures.
made
eight predictions were
84 studied
for the
Clinical
patients.
diag-
noses for patients subsequently diag-
nosed
as
pneumonia were
having
accurate in 81/131 cases (62%). Fur-
(33%)
thermore, only 43/131
ther-
blood
ar,
immuno-
and
gases,
DeVilbiss nebulizer. Acute
BEC
monary
ment,
function. During
glucocorticoid
oral
was decreased
in all infants,
4 infants within
the other 3
Within
1
BEC
of
effectively
to
di-
highly resistant
treat
organisms (21 plans), and failure to
treat all
organisms
microbial
therapy
months and
3
infants
in
in
25%
of
tidal
volume
to
peak flow
increased
effects noted in this small
group of
the
patients. In conclusion, inhaled
growth and weight
in-
was
rate of linear
ra-
more than predicted by
intersession variability. In no infant
did pulmonary function decline after
BEC. nor were any apparent adverse
tio
BEC
effective in decreasing oral glu-
creased markedly (2.2 ± 1.8 vs 6.4 ±
2.4 cm/month - mean ± SD and 9.3
cocorticoid therapy and in modifying
±
pression in a very small, highly se-
±
6.5
vs
18.2
7.4
g/day.
change
in
re-
average
± 16
glucocorticoid-induced growth
lect
sup-
group of infants with broncho-
pulmonary dysplasia.
For your convenience, and direct access, the advertisers in this issue and
phone numbers are listed below. Please use this directory for requesting
ten material or for any question you may have.
their
writ-
cases of poly-
pneumonia
without
in
4-5 months.
resistance decreased and the flow at
month of inhaled BEC.
(14
HELP LINES
plans).
Therapeutic plans formulated for patients
in-
(I t.G lT„ian
inappropriate
failure
agnose pneumonia (50 plans), failure
to
treat-
stopped
spectively, without
included
in-
halation produced no change in pul-
daily caloric consumption (1 13
causes
therapy
curred, although respiratory system
j/g/kg/day
apeutic plans proposed for these pa-
treatment
BEC
divided
(25
tients represented effective therapy.
Common
creased during
Im-
cal/kg/day).
delivered by Pulmoaide with a
propionate
in
15
246 ± 74 vs 463 ±111 mg/dL). Pulmonary function revealed moderate
obstructive pulmonary disease before
BEC. After 3 months of BEC inhalation, no significant change oc-
were monitored for 3
months before (control period) and 3
months after (intervention period) instituting inhaled beclomethasone di-
globulins
tid)
110
pneumonia included
the unnecessary use of antibiotics in
45/277 cases (16%). These findings
AARC
indicate that the use of clinical cri-
Bear Medical Systems
800-232-7633
Bird Products Corp
800-328-4139
teria
alone does not permit the accu-
rate diagnosis
monia
in
commonly
inadequate
of nosocomial pneu-
ventilated
patients,
and
results in inappropriate or
therapy
antibiotic
for
Nebulized
Therapy
Steroid
Bronchopulmonary
MM
Cloutier.
N
effect
in
Dysplasia
—
McLellan. Pediatr
Pulmonol 1993:15:1
The
11.
of inhaled beclometha-
sone dipropionate (BEC) was studied
in 7 infants
between 7 and
1
8
months
of age with glucocorticoid-dependent
bronchopulmonary
glucocorticoid
Biochem
dysplasia.
therapy,
Oral
International Inc
Burroughs Wellcome
Co
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Drager
these patients.
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Information
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HealthScan Products
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800-262-3654
MSA Medical
800-851-4500
Newport Medical
800-451-3111
Pulsairlnc
800-327-0313
Puritan-Bennett
800-255-6773
Ross Laboratories
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Siemens Medical Systems
800-944-9046
Sherwood Medical
800-325-7472
3M
612-733-7853
Pharmaceuticals
pulmonarv
RESPIRATORY CARE »APRIL
'93 Vol 38
No 4
339
—
SURVANTA
beractant
intratracheal suspension
bovine pulmonary surfactant
8
mL Single C
HOC 0074-1040-08
SURVANTA
intratracheal
suspension
Sterile
Suspension
For Intratracheal
Administration Only
Not For Injection
00 NOT SHAKE
STORE AT
to VC
PROTECT f ROM UGHT
r
From Ross Laboratories
Helping Premature Babies Survive
Please see adjacent column
for Brief
Summary
B401/2980
Uj
992 Ross Laboratories
.1
Circle 125
of prescribing information.
7
SURVANTA®
(1040)
beractant
Intratracheal
Sterile
suspension
Suspension/For Intratracheal Use Only
INDICATIONS AND USAGE
is indicated tor prevention and
treatment ("rescue") of Respiratory Distress
Syndrome (RDS) (hyaline membrane disease)
SURVANTA
premature infants. SURVANTA significantly
reduces the incidence of RDS, mortality due lo
RDS and air leak complications.
in
Prevention
In premature infants less than 1250 g birth
weight or with evidence of surfactant deficiency, give SURVANTA as soon as possible,
preferably within 15 minutes of birth.
Rescue
To treat infants with RDS confirmed by x-ray
and requiring mechanical ventilation, give
SURVANTA as soon as possible, preferably by
8 hours of age.
CONTRAINDICATIONS
None known.
WARNINGS
SURVANTA
is
intended lor intratracheal use only.
SURVANTA CAN RAPIDLY AFFECT OXYGENATION AND LUNG COMPLIANCE. Thereuse should be restricted to a highly
supervised clinical setting with immediate
availability ol clinicians experienced with intubation, ventilator management, and general
care ol premature intants Infants receiving
SURVANTA should be frequently monitored
with arterial or transcutaneous measurement
ol systemic oxygen and carbon dioxide
fore, its
DURING THE DOSING PROCEDURE,
TRANSIENT EPISODES OF BRADYCARDIA
AND DECREASED OXYGEN SATURATION
these occur, stop
HAVE BEEN REPORTED
If
the dosing procedure and initiate appropriate
measures to alleviate the condition. After stabilization,
resume the dosing procedure.
PRECAUTIONS
General
Rales and moist breath sounds can occur
transiently after administration. Endotracheal
suctioning or other remedial action is not
necessary unless clear-cut signs of airway
obstruction are present.
Increased probability ol post-treatment
nosocomial sepsis in SURVANTA treated
infants was observed in the controlled clinical
trials (Table 3). The increased risk for sepsis
among SURVANTA-treated infants was not
associated with increased mortality among
these infants. The causative organisms were
similar in treated and control infants. There
significant difference between groups
the rate of post-treatment infections other
was no
in
than sepsis.
Use of SURVANTA in infants less than 600 g
1750 g birth
weight has not been evaluated in controlled
trials There is no controlled experience with
use of SURVANTA in conjunction with experimental therapies lor RDS (eg, high-frequency
birth weight or greater than
ventilation or extracorporeal membrane
oxygenation).
No information is available on the effects of
doses other than 100 mg phospholipids kg.
four doses, dosing more frequently
than every 6 hours, or administration after
48 hours of age
more than
Carcinogenesis, Mutagenesis,
Impairment
of Fertility
Reproduction studies in animals have not been
completed. Mutagenicity studies were negaCarcinogenicity studies have not been
performed with SURVANTA.
tive.
ADVERSE REACTIONS
The most commonly reported adverse experiences were associated with the dosing procedure In the multiple-dose controlled
clinical trials, transient bradycardia occurred
with 11.9% of doses Oxygen desaturation
occurred with 9.8% of doses.
Other reactions during the dosing procedure occurred with fewer than 1% of doses
and included endotracheal tube reflux, pallor,
vasoconstriction, hypotension, endotracheal
tube blockage, hypertension, hypocarbia.
hypercarbia, and apnea No deaths occurred
during the dosing procedure, and all reactions resolved with symptomatic treatment
The occurrence of concurrent illnesses
common in premature infants was evaluated
in the controlled trials. The rates in all controlled studies are in Table 3
TABLE 3
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MOTHERS OF ASTHMATICS,
INC
.
Original Contributions
Oxygen
Multipatient Use of Prefilled Disposable
Humidifiers For Up to 30 Days:
Patient Safety
Sandra
D
Golar RRT,
BACKGROUND:
and Cost Analysis
MD
LLA Sutherland RRT, and GT Ford
oxygen humidification units have been shown
contamination when compared to reusable oxygen humidification units. However, prefilled disposable humidifiers are expensive when used
for single patients, especially in areas of high turnover, and it is not known whether
Prefilled disposable
to decrease the likelihood of
these units need to be routinely changed before they are empty.
tients safely using a prefilled disposable
viously reported work.
Are
The number of pa-
humidifer has not been documented
patients at risk of nosocomial infections
due
in pre-
to cross-
contamination when prefilled disposable oxygen humidifiers are applied to multipatient use?
What
are the cost benefits of multiple patient use of prefilled disposable
When local practice or physician preference dictates the use of
oxygen humidifiers?
METHODS
humidification for low-flow oxygen, these questions need to be answered.
& MATERIALS: Data were collected over two time periods to address changes due
to seasonal variations
and include area of
use,
number
of patients, and quantitative
Each disposable humidifimonth or until only 1 inch of water remained.
Costs of using reusable humidifiers and prefilled humidifiers and therapist/nurse time
cultures for aerobic microorganisms (including Legionella).
er was monitored for a period of
1
therapy with both units were compared. During
to initiate
midifiers were also cultured for aerobic microorganisms
We
We
this period,
and
60 reusable hu-
Legionella.
RESULTS:
report results on 1,311 of the 1,315 disposable prefilled oxygen humidifiers used.
saw no significant growth in any of the prefilled disposable humidifiers for pe-
riods of
up
to
30 days, with > 100 humidifiers having been used by > 20 patients.
results show that prefilled disposable oxygen humidifiers can
CONCLUSIONS: Our
be used without cross-contamination, on multiple patients, for a period of 1 month.
The use of prefilled humidifiers in this way represents a substantial cost saving when
compared
to reusable humidifiers. (Respir Care 1993:38:343-347.)
necessary,
Introduction
Although
it
has been suggested that humidifi-
cation of low-flow
oxygen (1-4 L/min) may not be
1
"
4
the practice
is
a standard procedure in
our hospital, appears to be standard practice in Canadian hospitals, and persists
in part
because of the
extremely low relative humidity encountered during cold weather.
The authors
are associated with Calgary
General Hospital,
Bow Valley Centre and Peter Lougheed Centre, Calgary, Alberta, Canada. The reported study was a joint effort of the Respiratory
Therapy and Infection Control Departments.
This paper reports data also published
in a
paper entitled "Pro-
Humidifier Bottles: Are They Safe and
Cost?" Henderson E, Ledgerwood D.
How Much Do They
Hume
K. Krulicki
W,
Ford GT, Golar SD, Sutherland LLA, Louie TJ, Infection Control
and Hospital Epidemiology
Reprints: Sandra Golar
(in press).
RRT, Calgary General Hospital, Bow
Ave E, Calgary, Alberta. Canada
Valley Centre, 841 Centre
T2E OA
RESPIRATORY CARE
5"7
from the
bubble humidifiers pose
little threat.
However,
simple bubble humidifiers have been shown
bench study
to
in a
produce microaerosols capable of
transmitting contagion
s
and a more recent report
has implicated such devices.
1
'
We
sought to de-
termine the safety of prolonged multipatient use of
prefilled
humidifiers,
rates of prefilled
compare
1
of studies
inated nebulizers are likely to spread infection but
that
longed and Multi-Patient Use of Pre-Filled Disposable Oxygen
A number
1960s and 70s suggest that aerosols from contam-
to
establish
contamination
and reusable humidifiers, and to
costs of using the
two types of device.
343
LENGTH OF HUMIDIFIER USE
Methods and Materials
purpose of
this part
contamination
Areas of the hospital selected to take part
study were the
Room, and
piratory
in the
Emergency Department, Recovery
four Medical Units (including a res-
unit).
Excluded were
patients
Monitoring
and
of
the
disposable
Au-
and February through May, 1991. Re-
usable humidifiers were cultured during
Quantitative cultures were done on both pre-
November
disposable and reusable humidifiers for aero-
filled
bic microorganisms, including Legionella. Residual
in the humidifiers was swirled and asepticalremoved using a tuberculin syringe and a 2510
Blood agar, chocolate agar, and
gauge needle.
water
Prefilled Humidifiers
buffered
charcoal
yeast
extract
mL
oculated by spreading 0.1
monitoring sheet was attached to each humidi-
was placed in service. The dates mat the
humidifier was opened and removed from service,
unit and bed number, and the number of patients
using the humidifer were to be noted. Personnel on
nursing units were informed of the study, and inservice training was provided for the nursing staff
it
on use of the monitoring sheet and the prefilled humidifier (Aquapak,
Hudson RCI, Temecula CA).
Each humidifier was kept
of 30 days or until only
the humidifier.
When
in place for a
the prefilled humidifier
removed, both the flowmeter
ifier
outlet
maximum
inch of water remained in
1
inlet
to the mi-
Culture Procedure
ly
A
occurred
The humidifiers
were collected weekly and transported
1991.
fier as
humidifiers
use.
in
crobiology laboratory.
took
humidifiers
place over two periods of time: April through
gust, 1990,
with methods currently
res-
in
(AFB) isolation and
immunocompromised patients.
piratory or acid-fast bacillus
neutropenic
of the study was to see whether
of reusable
was
plates
were
in-
of water uniformly
over the agar surface. Media were preincubated for
24 hours
to
70%
and
HEPA
exclude environmental contamination,
of the samples were processed using a
(NuAire Bio-
biosafety cabinet
filtration
Model
logical Safety Cabinet,
NM)
Aire Inc, Plymouth
3
NU4 10-400,
Disease Research Laboratory. All plates were
cubated in
5% C0
2
at
37°C and read
hours. Legionella plates were read at
at
7-10 days.
A
Nu-
located in the Infectious
record was
colony forming units per
made of
mL
in-
24 and 48
72 hours and
at
the
number of
(cfu/mL) per plate
and the different morphotypes."
and the humid-
were aseptically sealed with
Results
sterile
gauze and tape and the humidifier was transported
microbiology laboratory.
to the
On
the first
Monday
of each study month, hu-
were connected
midifiers
to
flowmeters and placed
A
total
of 1,315 prefilled disposable humidifiers
were collected; of
these, 1,31
1
had completed data
forms and sufficient water for culturing. In the
with the monitoring sheets above the patient beds.
months of April through August 1990, 636 dispos-
A
check was made midmonth, and any humidifiers
able humidifiers were cultured, and in the months
inch of water or less remaining were taken
of February through May, 1991, 675 disposable hu-
At the beginning of the next
midifiers were cultured. Sixty reusable humidifiers
were cultured during November 1991. During the
with
to
1
the
laboratory.
month,
all
aseptically
remaining humidifiers were removed
and replaced by the same procedure.
first
ers
Reusable Humidifiers
monitoring period, 4/636 disposable humidifi-
had from 10
nificant
to
30 cfu/mL bacterial growth. Sig-
growth was considered
to
be greater than
may have
100 cfu/mL." These four humidifiers
For a
1
-month period, reusable oxygen humidifi-
been suspect due
to
environmental contamination
were used according
to standard hospital prac-
of water samples during planting.
tice as outlined. Hospital
procedure dictated single-
tion biosafety cabinet
ers
changed every
However, adherence to this procedure was
not monitored or enforced by our team because the
A HEPA
was then acquired
filtra-
to prevent
contamination. All of the 675 dis-
patient use, with sterile water being
this inadvertent
8 hours.
posable humidifiers were culture negative during
344
the second monitoring period.
RESPIRATORY CARE
Of
the
60 reusable
Table
1.
Culture
Results
Humidifiers
Humidifier Type
from
Disposable
and
Reusable
Table
2.
Multipatient Use of Disposable Prefilled Humidifiers
during the Study Period
able
prefilled
(Tables 3
&
4).
humidifiers
than reusable devices
Guidelines for use of prefilled dis-
posable humidifiers are sketchy and inconclusive.
CDC
(Centers for Disease Control)
issue
by
22
stating that disposable units
addresses the
may
use for a period longer than 24 hours but
known whether
"when used
sterile
"it is
un-
these need to be routinely changed
before they are empty."
state
be safe to
The Canadian Guidelines
same patient, prefilled
for the
disposable units
may be
left in
place in ac-
cordance with the manufacturer's time limit recommendations."
filled
23
Single-patient usage of these pre-
disposable humidifiers
is
very expensive 10
($2.08 per patient, Canadian dollars), especially in
areas of high patient turnover where humidifiers
might be used for only a few hours. Manufacturers
of disposable oxygen units label their units "single
use," and the time frame for use of the unit
addressed.
Table
4.
Reusable Humidifer Cost per Patient
is
not
)
5.
Reinarz JA, Pierce
ocomial
AK, Mays BB, Sanford
JP.
The po-
of inhalation therapy equipment
role
tential
pulmonary
infection.
Invest
Clin
J
Henderson
nos-
in
1965;
Pierce
AK. Sanford
JP.
&
Nebulization equipment: a potential source of infection
in
and how much do they cost? Infect Control
are they safe
Edmondson EB. Reinarz JA.
gram-negative pneumonias.
Am
Hosp Epidemiol
Stoler
BS.
(in press).
Sterility
Dis Child 1966:
J
Prolonged and multi-patient
et al.
use of pre-filled disposable oxygen humidifier bottles:
44:831-839.
6.
Ledgerwood D. Hume K, Krulicki W,
E,
Ford GT, Golar SD,
ification system.
of a disposable oxygen
humid-
RespirCare 1972;17:572-573.
111:357-360.
7.
CV
Sanders
Jr.
Luby
JP,
WG,
Johanson
Tafuro P. Gurevich
Barnett JA,
lation therapy medications:
Intern
8.
nosocomial outbreak.
Med 1970;73:15-21.
EW, Chapel JF, Dorn GL. Pseudomonas
Koss
vices.
Seigel D,
RespirCare 1977;22:383-385.
A, Pasarino G, Marforio
legionellosis associated with use of
P.
J
Nosocomial
Hosp
Patte F, et
al.
midification.
1
1.
Coyle
MB,
J
Magnan
Evaluation of closed
Hosp
ton:
American Society
Rhame
J.
B. Extended use of prefilled humidifier
Sterility
in
oxygen humidifiers. Respir
Yuen K, Lam W. Evaluating
W. Ching
ility
of disposable wall oxygen humidifiers, during and
T,
between use on
&
patients. Infect Control
the ster-
Hosp Epi-
Jr.
Shadomy
In:
Daschner
Sterile
Joopens D.
it
McComb
C, Boyle
Kappstein
necessary?
et al.
I,
Schuster F, Scholz R, Bauer E,
Influence of disposable
ventilation
22.
pneumonia.
J
Hosp
Infect
1
988;
1
1:161-168.
Centers for Disease Control. National nosocomial infections study report. Atlanta:
M. Bubbling
Control 1986;7:403-407.
"Conchapak'
(
and reusable humidifying systems on the incidence of
water used for humidis
F,
HJ,
Washing-
humidifiers produce microaerosols which can carry bac-
RESPIRATORY CARE
humidifiers and
1979;8:1 117-1121.
Seto
F,
hu-
1990;18:13-17.
FS, Streifel A,
teria. Infect
Meehan TP.
for Microbiology, 1985:143-412.
low-flow oxygen therapy:
Am J Infect Control
13
WJ
clinical microbiology, 4th ed.
CK, Heath
Romo
Lung
demiol 1990;11:604-605.
Manual of
ification in
sterile, prefilled
Infect 1991;17:53-59.
eds.
Cahill
Rigondeau
Morello JA, Smith PB. Aerobic bacteria.
Lennette EH, Balows A, Hausler
12
J,
sterile prefilled
Infect
Technology 1977;14:14-22.
20.
Castel O, Agius G, Grignon B,
Hosp
Care 1990;35:806-810.
Infect
1987;10:47-50.
10.
J
reservoirs and the likelihood of contamination. Respir
oxygen bubble hu-
midifiers and underwater chest drains.
of safe use.
Conine T, Eitzen H, LoSasso A. Bacterial con-
nebulizer reservoirs. Heart
Moiraghi A, Castellani Pastoris M. Barral C, Carle F,
Sciacovelli
J,
tamination potential of
ae-
ruginosa infection potential of oxygen humidifier de-
9.
Cunha BA. Disposable oxygen
1982;3:293-297.
Ann
Ahlgren
I,
bottles: a cost-effective period
Sanford JP. Serralia marcescens infections from inha-
CDC,
1983 (6-month sum-
maries).
23.
Infection Control Guidelines, Health and Welfare.
Can-
ada: Ottawa, 1988.
347
Error in Ventilator Measurements of Intrinsic PEEP:
Cause and Remedy
Albert F Grootendorst
MD, Gerard
Lugtigheid, and Ernst Jan van der Weygert
MD
BACKGROUND:
Observation of discrepancies between values of intrinsic PEEP
(PEEPi) as measured by conventional methods and by the Siemens 300 ventilator
led us to investigate the basis for the differences.
METHOD: We observed
the ven-
method of determining PEEPj and compared ventilator-determined values
to conventionally determined values. RESULTS: Comparison allowed quantitation
and prediction of errors in ventilator PEEPi. CONCLUSION: PEEPi can be seriously underestimated by ventilator-generated measurements that fail to correct
tilator
for the effect of patient-system compliance. (Respir Care 1993;38:348-350.)
Background
to a
manometer and measuring
the pressure increase
immediately after the end of the expiratory phase
Our repeated
finding of serious discrepancies be-
tween values of
pressure, or
(Fig. 2).
intrinsic positive end-expiratory
PEEP P measured by
conventional tech-
niques and those indicated by the Siemens 300 ven-
prompted our research to find the cause.
PEEP, is defined as the pressure remaining in
tilator
airways after the expiratory valve
In contrast to extrinsic
PEEP,
it
closed (Fig.
is
is
the
Intrinsic
not detected by
Time
observing airway pressure on the ventilator manometer. The clinical relevance of PEEPj
on
its
crease
ability to contribute to
work
of
breathing
is
based
barotrauma and to
in-
Fig. 1. Intrinsic
PEEP
from volume trapped
valve
during
is
is
in
the pressure increase resulting
the airways after the expiratory
closed.
spontaneous
breaths via the ventilator. 12 Conventionally,
is
PEEP
1).
PEEP,
determined by connecting the endotracheal tube
Dr Grootendorst and Dr van der Weygert
the
Department of Intensive Care, and
are associated with
Mr
Lugtigheid
is
as-
sociated with the Department of Medical Technology. St Clara
Hospital, Rotterdam,
The Netherlands.
The authors have no
financial interest in the products
men-
tioned or in competing products.
Fig. 2. A.
Reprints: Albert
F Grootendorst MD, St Clara Hospital, OlymHT Rotterdam. The Netherlands.
piaweg 350, 3078
348
Conventional method of determining
PEEP. B. Method used
Siemens 300.
for
determining
RESPIRATORY CARE
intrinsic
intrinsic
PEEP
in
ERROR
IN INTRINSIC PEEP
1
Method
MEASUREMENT
we
results in a value that
call false
PEEP,.
Its
value
is
We
determined from inspection and analysis of
C!ysIem ),
False PEEP, = V,/(C p llle „ +
.
1
the ventilator system that the discrepancies appear
from the way
to result
by
this ventilator.
in
The
which PEEP,
is
tween the tubing-ventilator system and the patient
is
ignored
In the
when
where
measured
The
end of an expiration and then meas-
at the
PEEP
error in intrinsic
PEEP, measurement is made.
Siemens 300, PEEP; is measured by si-
can be described as
the
PEEP,.
true
uring the pressure increase in the system (Fig.
PEEP, -
V/Cpatieni
multaneously closing the inspiratory and expiratory
valves
the system compliance.
is
Csystem
effect of the interaction be-
PEEP, =
false
- V,/(C p;il „„, +
Csysttm
).
This can be rewritten as
2).
PEEP, em)r =
+
(VjXCpatiem
C sy ,,,,,,)/(Cp.,,,,,,)(C P
(Vj)(Cpatient)'^-patienl ((-patient
+
a,,e,,,
+ C iyslem ) -
(-system)-
This can be rearranged to
PEEPj-eno,
As
= (V,)(Cs y s,em)/(Cp a ,,en, : + (C p a„e„
)
1
)(C,vs,em).
V; can be substituted for by (C palienl )(true PEEP,),
this
can be written as
PEEP,
(C pal
,
cn ,)(tmePEEP,)(C, ysu.
+ CsyaeJ.
m )/(Cpa„en,)(Cp,
Thus,
True PEEP, 10
7.5
5
False
15
12.5
Intrinsic
20
17.5
PEEP, =
false
22.5
(true PEEP,)(C,vs,em)/(C sv „ cm
+
C,,„ ICI „).
PEEP (cm H 2 0)
This can be rearranged to
Fig. 3.
300) vs
PEEP,).
1:2,
PEEP (as measured by Siemens
error in intrinsic PEEP (ie, true PEEP, - false
= 1:1, =
The ratios of C system to C pa tiem are
False
•=
1:4,
intrinsic
- =
1:6, 4
=
This leads to an error
ed.
The volume
1:8,
in
=
1:10,
PEEP,
that
patient after the expiratory valve
is
(false
1:15, * = 1:20.
=
can be calculat-
that is trapped in the
True PEEP, =
airways of the
closed (intrinsic
PEEP,)(C sy s,e„, +
C pa „ c „,)/C P a„em.
Results
The
results of
our calculations and the values
generated by the ventilator are shown
and allow one
in
Figure 3
PEEP, from
indicated by the Siemens
to establish the error in
PEEP,
that
is
the false
PEEP,. The relationship between V, and PEEP,
is
300, provided that the compliances of the system
volume, V,) leads to a pressure increase
that is
and the patient are known. To calculate true PEEP,,
described by
this error
should be added to the value of the false
PEEP,. Actual measurements and calculations
PEEP; = V,/C p a„en„
five patients are
where
CP
ai,ent
is
shown
in
Table
1
in
.
the patient's compliance.
Discussion
This
the
is
the true intrinsic
Siemens 300
ter the V,
tient
is
ventilator,
PEEP
PEEP,
(true PEEP,). In
is
measured
af-
distributed over the airways of the pa-
and the tubing-ventilator system
RESPIRATORY CARE
(Fig. 2). This
As can be seen
in
Figure
3, intrinsic
PEEP
can
be seriously underestimated by the Siemens 300.
This error would be intrinsic to any system that
349
ERROR IN INTRINSIC PEEP MEASUREMENT
Table
1
.
Comparison of Results of Measurements and Calculations in 5 Patients
Reviews, Overviews,
& Updates
A Review of Causes, Evaluation, and Management
Anthony L Kovac
Background
Causes of Airway Trauma
I.
II.
&
Trauma
Sites of
III.
MD
&
Obstruction
Obstruction
A. Effects of Skull Fracture
B.
Effects of
Other
Insults
Trauma
IV. Evaluation of Patient with Maxillofacial
Management
V.
of Airway
Trauma
Action
A.
Initial
B.
Nonsurgical Methods
C.
Assuring Proper
D.
Surgical Methods
&
Devices
ET Tube Placement
&
Devices
VI. In Conclusion
Background
trauma
itself that
causes death but the associated
5
airway problems. The respiratory care practitioner
Accidents are the leading cause of death in
Americans under the age of 40 years
1
-
2
(including
children') and the fourth leading cause of death in
Americans of
ages.
all
4
Deaths from
accidents
all
United States during
1984 were 39 per
100,000 population. In adults,
traffic accidents ac-
in
the
counted for
drowning,
50%
fires
of the
total,
(burns and
sonings, and choking.
2
followed by
smoke
needs to hold a high index of suspicion of airway
obstruction in the evaluation of the trauma patient
and
to
maintain
her proficiency
es-
in
proper diagnosis and
treat-
ment, needless deaths associated with airway trau-
ma
1
and obstruction can be prevented.'
Common
causes of airway trauma and/or ob-
falls,
struction
are
fights,
falls,
and
motorized
non-
motorized vehicle accidents, pedestrian accidents,
Although trauma
to the air-
industrial
common
itself is
tion
and respiratory compromise can play a role
many
By
inhalation), poi-
way
not a
or
his
tablishing an airway.
event, airway obstruc-
accidental deaths because
it is
in
often not the
and farm accidents, and
creational activities.
1
" 3,6
motor vehicle accidents,
the
most
common
athletic
and
re-
In the pediatric age group,
falls,
and child abuse are
causes of maxillofacial trauma,
7
and thus of the possible sequelae of airway trauma
or obstruction.
Dr Kovac
is
Associate
Professor,
Department
of
Anes-
thesiology, and Medical Director. Respiratory Therapy Services, University of
Kansas Medical Center, Kansas City, Kan-
It
has been recognized for decades that traffic
accidents account for a large percentage of deaths
from maxillofacial and upper airway trauma,
sas.
es-
pecially in subjects riding without seat belts, be-
The author has no
financial
interest in
any of the products
cause frequently the head, face, neck (or
mentioned.
are injured
Reprints:
Anthony
L Kovac MD.
Department
of
Anes-
thesiology. University of Kansas Medical Center, 3901 Rain-
bow
Blvd. Kansas City
KS
RESPIRATORY CARE
66160-7415.
all
three)
on impact with the steering wheel, dash-
board, or windshield
at
deceleration
18
'
9
(Fig.
a 1956 report of auto accidents, the head
1
).
was
In
in-
volved 70.9% of the time, the driver's side of the
351
UPPER AIRWAY TRAUMA & OBSTRUCTION
was involved 45% of the
vehicle
26%
front passenger's side
time, and the right
of the time.
10
A
1972
study reported head trauma to be the most frequent
(51.3%) and dangerous type of injury
in auto acci-
dents."
determining the etiology of airway obstruc-
In
tion, a differential diagnosis
should consider
(in ad-
dition to blunt or penetrating trauma) an altered
level of consciousness, vascular injuries, foreign
bodies, inflammation, and allergic reactions. 516
Blunt or penetrating trauma to the head, face,
neck, or rib cage can cause airway problems. Trau-
ma
to the maxilla
and mandible may cause airway
obstruction from edema, fractures, or the tongue's
posteriorly onto the pharynx.
falling
1718
Foreign
bodies cause direct obstruction. Allergic reactions,
burn trauma, congenital anomalies, inflammatory
and vascular
neoplasms,
diseases,
may
pecially in the neck)
ondary
rhage.
to
injuries
(es-
cause obstruction sec-
airway compression by edema or hemor-
51618
Aspiration of blood and gastric and pharyngeal
secretions in combination with hypoxia
Fig.
1
.
Traffic accident victim riding without seat belt, with
resultant head, face, neck,
and chest deceleration
injury.
and mortality
Use of
12
juries
state
seat
and shoulder
belts
and child safety
has decreased the number of deaths and
from
traffic accidents.
of Virginia
13
A
1991 study from the
reported that since the institution
of the Virginia seat belt law
January 1988, front
in
seat occupants are less likely to require
treatment following a crash.
juries
is
in-
medical
The reduction of
in-
greater for passengers in the right front
seat than for drivers,
and for
for other types of crashes.
frontal crashes than
The authors of
this
study
believed that the reduction in injuries was due pri-
marily to fewer head and face injuries, particularly
from contact with the windshield and instrument
Use of
panel.
mary
bags as supplements to the
and shoulder
restraints of seat
further decrease morbidity
ma,
usually caused by a combination of head in-
is
jury and massive blood aspiration, rather than
way
However,
the role that aspiration
airways play
A
from displaced jaw
obstruction
21
found
fatalities
20
analyzing 158 consecutive
that,
20%
although
of the
victims dying at the scene or within 24 hours after
the accident had a significant
amount of blood
in
the airways, aspiration did not alter the final fatal
outcome because
victims except one had in-
all
The
study's authors con-
belts should
cluded that aspiration was rarely the cause of death
among
traffic fatalities.
Conversely,
&
and obstructed
in traffic fatalities is controversial.
retrospective study
traffic
air-
fractures.
pri-
and mortality. 1415
Causes of Airway Trauma
A
that hypoxia,
the principal cause of death after maxillofacial trau-
juries precluding survival.
air
consid-
the early post-trauma phase.
in
1986 study from Europe 19 suggests
seats
is
ered an important factor contributing to morbidity
Obstruction
Symposium, 22
in
it
World Health Organization
a
was estimated
that
15% of road
accident fatalities were due to respiratory obstruc-
Other studies 623 found that from 2 1
to
24%
of
with airway injuries died in the
first
2
American College of Surgeons, 5
early deaths following trauma are frequently due to
mismanagement of airway obstruction. This may
tion.
occur because the rescuer, overwhelmed by multi-
the necessity for
According
ple signs
to the
and symptoms,
fails to
recognize signs of
airway obstruction or exercises faulty judgment in
selecting
niques.
352
5
the
proper
airway
management
tech-
patients
hours after admission to the hospital, emphasizing
immediate recognition and
treat-
ment of
the injury. Preventable deaths have been
found
occur
to
in
up
10% of patients
to
with airway
trauma and are most
likely in patients
juries are undiagnosed.
6
RESPIRATORY CARE
whose
in-
Trauma & Obstruction
Sites of
Airway trauma may involve the upper airway
and structures above the larynx) and/or
(the larynx
lower airway (the trachea and tracheobronchial tree
below the larynx). The laryngotracheal airway is
susceptible to injury at the levels of the glottis, sub-
and upper cervical trachea
glottis,
the first three tracheal rings).
1
(at the level
of
The most common
area at the level of the true cords
site is the glottic
(Fig. 2).
Fig. 3.
LeFort
suits in
tilting
I
fracture: fracture through the maxilla.
an open-mouth attitude caused by posterior
of the whole midfacial bony segment. Ce-
rebrospinal fluid rhinorrhea and circumorbital ec7
chymosis also may be present.
'
26
Cartilage
Fig.
Thyroid and cricoid cartilages with cricothyroid
2.
membrane and upper
cervical trachea.
The
glottis
com-
prises the vocal cords (attached to the thyroid cartilage)
and the space between the cords.
Fig. 4.
LeFort
cartilaginous
The LeFort
bones from
1900s,
the LeFort
Rene LeFort of France de-
vised a classification describing fractures of the
skull that
can be useful in predicting possible
14
way
obstruction.-
air-
(LeFort dropped cannon balls on
the faces of cadavers and studied the severity of the
I
fracture,
single detached segment,
which often produces a
a horizontal fracture of
is
fracture
ture
may
their cranial
III
is
bony and
nasal septum.
called craniofacial dis-
attachment occurs.
25
With
fracture (Fig. 5), a basilar skull frac-
be present
2026
the fracture line. There
and the nose
may
is
involved in
also be a break in the
cribriform plate of the ethmoid bone, with tearing
of the dura mater and cerebrospinal
fluid
rhi-
norrhea. Thus, the ethmoid air cells are disrupted
and exposed
resulting injury and lines of fracture.)
The LeFort
III
of the
junction because complete separation of the facial
Effects of Skull Fracture
In the early
fracture: fracture involving the
II
components
to infection.
The LeFort
III
fracture
is
caused by significant force and often results in
widespread facial edema and a widened and flat-
the maxilla at the level of the nasal floor, often ex-
tending above the level of dentition and displacing
the maxilla posteriorly, laterally, rotated about a
vertical axis, or
Fort
I
any combination of these.
25
The Le-
fracture (Fig. 3) often results in the maxilla's
being
tilted superiorly
posteriorly,
resulting
at the front
in
and displaced
malocclusion
mature contact of the molar
teeth.
and pre-
:a26
The LeFort II fracture (Fig. 4) involves the bony
and cartilaginous components of the nasal septum a fracture of midfacial structures and the
—
25
base of the skull. The LeFort
RESPIRATORY CARE
II
fracture often re-
• APRIL "93 Vol 38
No
4
Fig. 5.
LeFort
III
fracture: fracture through orbits
riform plate of the
the fracture
ethmoid bone; the nose
is
and
crib-
involved
in
line.
353
tened interorbital area. Because of the loss of sup-
above the clavicle or a head injury resulting
porting facial structure, these patients often require
consciousness should be suspected of having an as-
early aggressive airway intervention
—with
a cri-
sociated cervical-spine injury.
un-
in
6,23
cothyrotomy or tracheotomy.
LeFort
II
and
III
may
fractures
Evaluation of Patient
cause airway ob-
with Maxillofacial
secondary to bleeding, increased tissue
struction
edema, and secretions.
Trauma
The evaluation of maxillofacial trauma
is
an ex-
tension of the art of physical examination, with in-
Other
Effects of
Insults
spection, palpation, auscultation, and determination
of the loss of normal function.
In addition to the possible effects
on the upper
airway of LeFort-type injuries to the maxilla, man-
and nasal septum, nasal obstruction can refrom nasal fractures, septal hematomas, and
2728
Traumatic causes of oral obforeign bodies.
dible,
sult
struction include foreign bodies, swelling associat-
ed with severe
facial injuries,
and fractures of the
facial bones or mandible, with consequent swelling.
28 29
may
'
Traumatic causes of pharyngeal obstruction
include a posteriorly displaced tongue in facial
A
ing.
and blood or vomitus following facial and/or
20 28 29
Both internal and external in1
'
'-
juries can cause laryngeal or tracheal obstruction.
may
result
from gases (especially
smoke of flash
fires), liquids
(such as
minor laryngeal
may
injury
A
when swallowing
patient with
with
or speak-
major laryngeal injury may
open
contusions,
sub-
lacerations,
cutaneous emphysema, loss of voice, abnormal
la-
ryngeal contour, and progressive airway obstruction.
15 29
'
'
311
the
In
evaluation
laryngotracheal
for
airway
trauma, close attention to anatomic landmarks
An
530
Adam's
One should
configuration of
men
is vi-
alteration in the position of the prominentia
laryngea, or
tant.'
the steam and
-
-
'
Internal injuries
5 29
present
tal.
alkali,
with
only moderate pain
trauma (most common), caustic burns with acids or
oral injuries.
patient
present with a hoarse voice without stridor and
apple,
is
particularly impor-
note that the laryngotracheal
women
is
different
from
that
of
(Fig. 6).
ingestion of acid or alkali), or solid foreign bodies
28 31
"
(such as food or bones).
External injuries
may
from penetrating stab wounds caused by
result
knives, bullets, glass, or shrapnel. Nonpenetrating
blunt trauma such as that inflicted by an auto accident, club, or baseball bat can cause
hemorrhage
or edema, thereby compromising the airway.
Trauma
to the cervical spine
secondary
cause
and neck
may
also
Mech-
obstruction.
respiratory
3032
anisms of respiratory obstruction with neck trauma
include laryngeal and tracheal injury, edema, as-
emphy-
piration of blood or vomitus, subcutaneous
sema, and hematoma formation. 5 Stab and gunshot
wounds, explosions, and power
may
tool ejections also
cause penetrating injuries. Blunt injuries to the
cervical trachea are often caused by
accidents
sports
ey ). 5
-
(steering
activities
wheel
and
(especially
motor vehicle
and
dashboard)
baseball
and
hock-
6 29
-
Sudden hyperextension of
the neck
the cervical spine and
may cause whiplash
injuries.
Any
injury
produced by high-speed vehicles should arouse suspicion of a concomitant vertebral or spinal cord injury.'-
354
623
Also,
all
patients
sustaining
an
injury
Fig. 6.
woman
Laryngotracheal configuration
in
man
(lower)
and
(upper).
RESPIRATORY CARE
• APRIL "93 Vol 38 No 4
The length of
Supraglottic and glottic in-
1
jury secondary to blunt trauma tend to occur in patients
with long necks. This type of trauma
is
often
associated with fractures of the thyroid cartilage
3334
29,30
Signs characterizing the
and hyoid bone.'
early onset of airway obstruction may include
wheezing, dyspnea, hoarseness, subcutaneous em'
physema, and/or marked difficulty in swallowing.
Loss of the normal prominence of the thyroid notch
may
also
be noted on palpation.
and
Infraglottic
in patients
31
'
and cricoid
breathing
ma
narrows the airway.
not
commonly
1
when
later
5 35
'
1,5 ' 33 " 35
cartilage.
subglottic ede-
This type of trauma
'
is
associated with an early swallowing
U4,35
Common
to
features of infraglottic and
trauma are paroxysmal coughing, hemoptyprogressive subcutaneous emphysema, and in-
be able
determine whether an airway obstruction exists.
No
airflow occurs
if
there
is
struction. Partial obstruction
may
complete airway obproduces sounds
sounds or inspiratory
Snoring
tion.
wheezes or
piratory
stridor
may be
present with
lower airway obstruction. Both inspiratory
and expiratory stridor and/or wheezes can occur in
partial
upper and
lower airway
should be noted that
ventilate.
'' 5 -
28
As
many trauma
step
a final
in
obstruction.
the
movement of
for
feel
piratory effort
1
'
5,32
with the patient's ex-
air
and determine whether accessory
muscles are being used for expiration.
Burn
patients,
upon
arrival in the
emergency de-
partment, must be evaluated and observed for signs
burn patient
cartilage
may
res-
initial
piratory assessment, the potential rescuer should
sis,
1,5 ' 36
It
patients hyper-
of pulmonary and respiratory involvement.
Infraglottic injury
are
stridor
present with partial upper airway obstruction. Ex-
glottic
creasing respiratory distress.
that
indicate the degree and location of the obstruc-
partial
common
nearly normal, with difficulty
is
developing several hours
disability.
517
with short necks, often occurring with
fractures of the thyroid
Initially,
1 -
trauma are more
glottic
may
Next, by listening to the patient, one
the patient's neck can affect the
of airway trauma.
site
may
initially
38
The
present with few signs of
airway distress because the subglottic airway
and fractures of the cricoid
be associated with trauma of the cer-
protected from direct thermal injury by the
ynx.
5
'
38
However, the upper airway
is
is
lar-
extremely
vical trachea. Laryngotracheal disruption or separa-
susceptible to obstruction as a result of exposure to
between the upper tracheal cartilage and larynx may occur. Cervical subcutaneous emphysema
occurs with tracheal tears. Pneumothorax and associated injuries of the cervical esophagus also
ma. 5,39 Clinical signs of inhalation injury include
facial burns, singeing of eyebrows and nasal hair,
tion
may
result.
6 33 36
-
-
In evaluating the patient with airway trauma or
obstruction, an important point to consider
is
the
most important
question to ask is, "How are you?" or "Are you
okay?" 537 The patient's failure to respond implies
super-heated air with subsequent upper airway ede-
carbonaceous sputum, carbon deposits and acute
inflammatory changes in the oropharynx, and a history of impaired mentation and/or confinement in a
burning environment.
538
conduct of the patient. Initially, the
Management
of
Airway Trauma
Action
Initial
an altered level of consciousness or inability to
speak because of head injury or complete airway
obstruction.
that
An
appropriate oral response indicates
the victim has a patent airway
with intact
5
and adequate brain perfusion.
According to the American Heart Association's
ventilation
Adult Basic Life Support Guidelines (BLS),
important to simultaneously look,
listen,
and
37
it
is
feel in
the initial assessment of the patient, to expedite artificial
ventilation
if
is
it
needed.
The rescuer
should determine whether accessory muscles of
respiration are being used.
An
gests the presence of hypoxia.
suggests hypercarbia.'-
RESPIRATORY CARE
It
important in the
is
that the severity of injury
ity for
initial
approach to man-
triage of the airway
agement and
trauma patient
and the consequent
prior-
establishing the airway be determined: ur-
gent or immediate; emergent, or within minutes;
and
(a)
elective.
1
5
Basic management objectives are to
maintain an intact airway; (b) protect the airway
in jeopardy; (c)
available;
injury.
1,5,40
and
provide an airway
when none
is
(d) rule out potential cervical-spine
Priorities in stabilization are the
ABCs
support. After Airway, Breathing, Cir-
agitated patient sug-
of basic
An obtunded
culation and hemorrhage control, one should assess
patient
5 29
-
life
for associated local injury.
1
'
5,37
355
The
principal cause of death
injuries
tongue
from maxillofacial
6
and the
obstruction of the upper airway,
is
common
most
the
is
airway obstruction
A
the unconscious or semiconscious patient.
may
tured mandibular arch
collapse, thereby al-
lowing the base of the tongue to obstruct the
way
air-
1,6.9.28
the preferred
method
move
to
lift
jaw
or
37 40
'
Digital or tactile orotracheal intubation
technique that can be accomplished
ful
laryngoscopy cannot be used, as
a use-
is
when
in patients
direct
with se-
vere maxillofacial trauma and in patients with short
spine in a neutral position.
adjuncts
useful
ever-present, a bite block should be used as a pre-
is
the tongue anteriorly,
10 41
'
if
5 37
-
caution. Tactile intubation
flaccid
comatose
patient. '-
is
1
bite risk is
best performed on the
44,45
Oral or nasal airways
In tactile intubation, the intubator, standing at
man-
the side of the patient, places his or her left index
the
in
Because
tubation in a confined space.
thrust
opening the airway and maintaining the cervical
inserted
-
Cardiac
to the guidelines for Basic
Life Support (BCLS), the chin
agement.
immobilization
cervical-spine
'' 5
necks, for trapped victims (prehospital), and for in-
According
are
should be used.
in
frac-
manual
pected,
airway
initial
However, nasal airways should not be
one suspects a basal
skull fracture (as in
and middle fingers
mouth
in the right side of the patient's
(Fig. 7), depresses the
tongue and slides the
a patient with cerebrospinal fluid rhinorrhea and/or
blood
in the ear canals).
In general, the in-hospital rescuer should
100% oxygen
ventilate with
fore
via bag and
and prolonged attempts
intubation,
always
mask
at
bein-
5,37
tubation without ventilation should be avoided.
Intubation attempts should not take longer than 30
seconds.
A
good
rule:
breath,
most
A
rule
When
breath
is
equipment should be
the rescuer's
rescuer needs to take a
needs a breath! 5
likely the patient also
apparatus
suction
follow
to
the
15 37
and other resuscitation
-
hand.
at
Fig. 7. Digital orotracheal intubation. Frontal
Nonsurgical Methods
&
537
In addition to positioning
041
ple nasal and oral airways,'
oral
endotracheal
tracheal
tubation;
129 44 45
ryngeal
-
'
airway (EOA);
'' 5
-
23 42 43
'
use of the
airway;
4647
45 48 49
-
initially
15 2341
intubation;
intubation;
-
and the use of sim-
nonsurgical methods
of establishing the airway
'
used include
-
Berman
of
oral
left
per-
fingers along the surface of the tongue until the epiglottis
and arytenoid cartilage are palpated
(Fig. 8).
The endotracheal tube (ETT) is introduced into the
mouth anterior to the intubator' s left index finger
in-
intubating pha-
esophageal
the
endo-
nasal
digital
fhe laryngeal
view
hand guiding endotracheal tube. (Reprinted, with
mission, from Reference 44.)
Devices
obturator
mask airway; 505
'
and the Augustine Guide. 52 After intubation, ventilation
should be accomplished using positive pres-
sure with a bag-valve device or a volume- or pressure-limited
ventilator.
The
rescuer
must
vigilant to recognize intrathoracic pressure
secondary
to
be
changes
pneumothorax or intubation of a
main-stem bronchus. 5
-
Fig. 8. Digital orotracheal intubation. Left
palpating arytenoid cartilage and
left
3.
(Reprinted, with
(3)
between 2 and
permission, from Reference 44.)
palpating epiglottis. Endotracheal tube
37
index finger (2)
middle finger
is
Endotracheal intubation can be accomplished via
either the oral or nasal route (provided
basilar skull fracture exists).
is
to
356
be avoided.
53
no nasal or
Neck hyperextension
If cervical-spine
injury
is
sus-
and along the
left
middle finger. The
ETT
with both fingers through the glottis (Fig.
the
ETT
has passed the vocal cords,
RESPIRATORY CARE • APRIL
it
is
is
guided
9).
Once
advanced
'93 Vol 38
No 4
Endotracheal tube
guided with both fingers through the glottis.
(Reprinted, with permission, from Reference 44.)
Fig. 9. Digital orotracheal intubation.
(shaded)
to
is
proper depth, and the lungs are auscultated to
its
ensure proper placement.
1
'
4445
NY)
a divided oral airway with a longer tip
is
than the usual oropharyngeal airway.
The
tip is de-
signed to be advanced into the vallecula. This device can be used as an oral airway and
tubation
deemed
is
an
necessary,
when
ETT
in-
can be
4647
advanced through the center of the airway.
has fallen into disfavor.
impression that the
of the
54 " 57
is still
However,
used
in
The
laryngeal
is
mask airway
(Intavent
oropharyngeal
an
ETT. 50 51
'
Its
airway
and
tracheal
50
my
—
a benefit to patients with suspected cer-
vical-spine injury
can be used on
—
—supine,
it
also
patients
lateral, sitting upright,
in other positions
makes access to the
The EDD stylet is inserted through an ETT, which is in turn inserted
into the Augustine Guide handle. After placement
into the oropharynx as with the Berman airway, the
or trapped in a position that
difficult.
EDD stylet is advanced. Easy syringe aspiration of
35 mL of air indicates that the EDD stylet is in the
Inter-
trachea. (Resistance to aspiration indicates esoph-
an
oral
intubation
However,
its
use
was
in patients in
difficult
may have
or
im-
ageal placement of the
then advanced over the
chea
(Fig.
1
EDD stylet.) The ETT is
EDD stylet and into the tra-
1).
bleeding.
The Augustine Guide® (Augustine Medical Inc,
Eden Prairie MN, Fig. 10) is a simple device that
incorporates the concepts of a Berman airway, an
intubating stylet, and a modification of the esoph-
ageal detector device
Wee 58
(EDD) concept
and used
in
Europe.
Assuring Proper Endotracheal
Tube Placement
limitations in
patients with nasal, pharyngeal, or upper airway
scribed by
sition
successful use has been reported in
spontaneously breathing patients and
possible.
Although the guide is designed for use on
whose head and neck are in a neutral po-
the patient
areas
SA, England), a new device used in Euintermediate in design and function be-
is
tween
whom
it
some
USA.
national
rope,
EOA
patients.
head and airway
Because of complications (such as esophageal
trauma and inadvertent tracheal intubation), the
EOA
Augustine Intubation Guide components. (Figure
Inc, Eden Prairie MN.)
Fig. 10.
courtesy of Augustine Medical
The Berman Intubating Pharyngeal Airway®
(Hudson Oxygen Therapy Saber Co, New York
City
Positioning Blade
originally de59
This device
A traumatized airway is often a difficult airway.
Traumatic conditions that may present a difficult
airway include severe facial fractures and lacerations,
burns of the mouth and airways, and foreign
body
aspiration.
The
difficult
airway
may
also in-
volve major hazards such as laryngospasm.
in-
stomach, regurgitation and aspiration,
or obstruction. Intubation may be impossible or
flation of the
may
44 53 60
-
'
Anatomic
was developed for use in the prehospital phase of
52
emergency care and for the difficult airway, to
esophageal intubation
perform rapid, blind, orotracheal intubation on
adult patients. The guide may be used on conscious
with traumatic causes and have been discussed in a
or unconscious, apneic or spontaneously breathing
RESPIRATORY CARE
result.
causes of airway difficulty may, of course, coexist
review by Wilson
of.
in this journal
57
and by Benum-
61
357
If
mL
30
of
intubation
air
can be easily withdrawn, tracheal
When marked
confirmed.
is
resistance to
withdrawal of the plunger occurs and the plunger
rebounds to
its
on release, the
original position
EDD
esophagus has been intubated. 59 The
found effective
years; however, in children under
EDD
has been
and children older than 5
in adults
year of age, the
1
has been found to be unreliable. 67
Surgical
&
Methods
Devices
The prime indication for using a surgical airway
emergency situation is inability to intubate
in the
the trachea.
1668
oropharyngeal
ryngospasm,
11.
Fig.
mL
35
Augustine Intubation Guide. Easy aspiration of
of air with the syringe indicates
EDD
stylet is in
trachea. Resistance to aspiration indicates esophageal
placement
Medical
EDD
of
Inc,
Eden
stylet.
Prairie
A
fractures,
may
be nec-
maxillofacial
trauma,
surgical airway
because of severe
essary
obstruction
hemorrhage,
or
cervical-spine
injuries,
or any
indication to oral or nasal intubation. '• 5
an intubation attempt
If
(Figure courtesy of Augustine
fails, it is
have a game plan or decision
MN.)
la-
edema, laryngeal trauma or
glottic
tree
-
contra-
29 68 69
-
-
important to
4461
(Fig.
12).
Such plans include invasive surgical methods such
Inadvertent
esophagus
placement
of the
ETT
into
the
an ever-present danger. Confirmation
is
of proper endotracheal tube placement includes di-
observation of bilateral
as percutaneous tracheotomy with transtracheal jet
(PTTJV), 45 6170
ventilation
72
-
'
cricothyroidotomy,
and conventional tracheotomy. 15
-
2945
73 " 75
Percutaneous
chest
dilational tracheotomy, a modification of the con-
wall movement, auscultation of breath sounds over
ventional tracheotomy procedure that uses no cut-
the lungs, absence of breath sounds over the stom-
ting except for a small skin incision, has gained at-
ach, compliance of the resuscitation bag, condensa-
tention for
rect
visualization,
vapor
tion of water
in the
ETT
lumen, visualization
by fiberoptic bronchoscopy, adequate or improving
saturation by pulse oximetry, adequate
C0
try is
role
its
recommended
for
elective cases but
in
is
not
emergency access. 76 77 Rapid en'
an advantage of the surgical airway. Disad-
excre-
vantages include possible complications such as
tion
by capnography, colorimetric detection of end-
hemorrhage, esophageal perforation, subcutaneous
tidal
carbon dioxide (etCOi), and use of the esoph-
ageal detector device. However, Brunei et
2
al
62
have
suggested that clinical signs of tube location can be
dj
unreliable.
Methods
such
as
fiberoptic
nography may not be readily available for emergency use. A colorimetric end-tidal C0 2 detector
(EasyCap* Nellcor, Chula Vista CA)
portable device that
are not available.
is
useful
when
is
Q
Not Anticipated
I
bron-
choscopy, pulse oximetry, radiography, and cap-
a simple,
Sedation/Anesthesia
Mask
± Paralysis
Ventilatior
z
Choose ETT Technique:
Oral, blind nasal,
F=r
or special (retrograde
fiberoptic)
|
Laryngoscopy
|
other monitors
63 " 66
[
The esophageal detector device (EDD) is pop58,5y
Use of the device involves draw-
Tracheotomy!
I
Success
j
Cricothyrotomy
I
[
Success
]
Tracheotomyl
ular in Europe.
ing back on the plunger of a
50-mL
syringe con-
Fig. 12.
Management
of the difficult airway.
ETT = endo-
nected with airtight fittings to the endotracheal tube
tracheal tube. (Adapted, with permission, from Reference
connector, with the endotracheal tube cuff deflated.
44.)
358
RESPIRATORY CARE
No
4
or mediastinal
emphysema,
tracheal stenosis or ob-
struction, cellulitis of the neck,
and abscess forma-
tion.1,5,68.69
The cricothyroid membrane
to
be the easiest and safest
is
site
believed by
''
gain airway entry in an emergency.
gical cricothyroidotomy can be
make
scalpel blade to
some
through which to
A
5 - 68,69
sur-
performed with a
#1
the incision and the blunt
handle to enlarge the opening, allowing passage of
anETT(Fig.
13).
Thyroid
Cartilage
Cricoid
Fig.
14.
Technique
percutaneous transtracheal
for
cothyroidotomy using intravenous catheter
Technique
cri-
penetrate
membrane.
cricothyroid
Fig. 13.
to
for surgical cricothyroidotomy.
proper diagnosis and treatment, deaths associated
PTTJV
ilar to
ever,
has advantages and complications sim-
How-
those of a surgical cricothyrotomy.
PTTJV
is
of
PTTJV
membrane 5
'
7 "- 78,79
(Fig.
1.
and obstruction of the cath57 "' 7
'
A
ves-
2.
has been adapted (Cook Critical Care,
Bloomington IN)
ducer that
Drawbacks
14).
REFERENCES
cri-
is
to
pliable
allow passage of a larger intro-
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80
A
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361
Symposium Papers
More from "New Horizons VIII ":
A New Era in Thoracic Surgery,
and Two New Approaches
David J Pierson
Last month's issue of the Journal featured the
first
three papers
Horizons" symposium
Meeting,'"
1
pages that follow
ments
4 6
that
A ARC
1992
at the
Annual
which focused on emerging techniques
and therapeutic approaches
the series,
"New
from the eighth annual
in respiratory care. In the
this introduction,
we complete
presenting overviews of three develop-
may
disorders in the
radically
ICU and
change the way
clinic are
common
approached. Ex-
panded technical capabilities and new
clinical ap-
plications for the thoracoscope are already chang-
Therapy
to
MD
have the opportunity
is
to try
in
premature infants
respiratory
stories of
quarter century
that
is
factant to very premature babies,
ARDS.
jury have led to therapeutic strategies that,
ticle
as
it
If this is so,
why
known
young overdose
vic-
so
new
logic
this
one must await more formal study
results
and
government approval before most clinicians can
be
preventing and treating
in
ARDS. 4
After reviewing the na-
and function of surfactant, he de-
products that are currently under study
therapy could be just around the corner, although
to
shouldn't sur-
beginning on Page 365, Kenneth P Steinberg
use of surfactant in
tim described in the following scenario, another
patients like the
be de-
addresses this question and others pertaining to the
summarizes the data
ARDS
to
7
commercial
scribes the various natural and synthetic
For
prevented
neonatal counterpart? In the ar-
in its
is
ture, production,
Surfactant Therapy
in the last
and even mortality
Surfactant function has long been
ARDS
syndrome (ARDS).
now be
creased through the use of this agent.
factant be as effective
change the management of the adult
can
from the full-blown syndrome appears
understanding of the pathogenesis of acute lung in-
will radically
medical progress
RDS
by the prophylactic administration of exogenous sur-
pathologic conditions. Recent developments in our
respiratory distress
absence
syndrome (RDS). One of the
distress
most dramatic
Its
main cause of neonatal
the
is
defective in
prov-
that decreases alveolar
surface tension and prevents atelectasis.
ing the face of invasive pulmonary diagnosis and
if
in practice. Surfactant
it
endogenous substance
the
the surgical approach to treatment in a variety of
en to be as efficacious as their proponents contend,
ARDS
in
far.
Evidence
that
in
may be
ing; yet there
sible reduction
ARDS
and
have been made available
that surfactant
derangements
in
ARDS
improves the physiois
not very convinc-
other effects, including a pos-
in overall
mortality that
is
neither
theoretically nor statistically explained at this point.
Much more
still
is
to be learned about surfactant
therapy, and, as with the other modalities discussed
Dr Pierson
versity of
is
Professor of Medicine. School of Medicine, Uni-
Washington, and Medical Director of Respiratory
Care, Harborview Medical Center
the Lifecare
Respiratory Care:
New Therapies
Reprints:
David
J
Pierson
Seattle,
in
much more
in the
information will surely
near future.
Washington. He
in
Respiratory Care."
MD, ZA-62, Harborview
Center, 325 Ninth Ave, Seattle
362
—
Symposium "New Horizons
was Chairman of
in these articles,
be forthcoming
WA 98104.
Medical
Consider a
common
clinical scenario in the
ICU:
In a suicide gesture, a 20-year-old student takes an
RESPIRATORY CARE
—
1
NEW HORIZONS
overdose of tricyclic antidepressant
tablets,
becomes
tilation
unconscious, vomits, and aspirates prior to rescue.
which
Over
that
24 hours, the patient develops severe
the next
hypoxemia, diffuse pulmonary
pulmonary
artery
occlusion
—
Five — or
ished lung-thorax compliance
ARDS.
ical criteria for
normal
infiltrates, a
and dimin-
pressure,
the defining clin-
all
even two
—years
ago, ventilator settings and monitoring data on the
day of
third
have looked
this
patient's
might typically
illness
deliberately create
• Ventilator mode:
synchronized
intermittent
mandatory ventilation
mL
for
70
• Arterial blood gas values:
H
total
PEEP
(ap-
pH
7.40,
H
the high tidal volumes, minute
tomed
ing
ARDS
A
will
mL/kg
• Inspiration-expiration
(eg,
400
ratio:
1
mL for 70 kg
patients are actually iatrogenic
if
have
to
we apply lower
and can be
pressures and less ven-
order to accomplish
be allowed to
rise
and
pH
this,
to fall,
Pco 2
some-
times to values well beyond what most clinicians
would regard
if
as physiologically acceptable
they are, will they improve survival in
are the challenges that
many of the
:
• Rate: 15 breaths/min
• Minute ventilation: 6 L/min
• Total PEEP: 15 cm H 2 (applied
—
thus,
damage nor
PEEP
15
cm
cm H 2
total
PEEP): 30
• Arterial blood gas values:
pH
or
were posed
to
Kacmarek and
As usual,
article.
in,
and, in
existence of ventilator-related lung
the clinical benefit of permissive hyper-
capnia has been demonstrated by a prospective, controlled clinical
trial.
However,
clinicians aspiring to
stay current in respiratory care need to be
this
• Transpulmonary (ventilating) pressure (alveo-
ARDS,
be cost-effective? These
important answers are not yet
fact, neither the
H 2 0; no auto-PEEP)
• Peak and end-inspiratory (alveolar) pressure:
important
new
therapeutic
watch for additional developments
aware of
approach and
in the
months
to
to
cm H 2
7.28, Pccb
80
HCO-T 30 mEq/L
According to all the books and bedside teachers
from which nearly everyone currently practicing reslearned ventilator management, this
primary goal of mechanical ven-
RESPIRATORY CARE
major hypothesis
ventilator
Hickling as they prepared their
A
first
Are these things reasonable? Are they safe? Even
patient)
wrong.
was
patients like
management is that
complications seen so commonly in
'new'
result in less morbidity, or
piratory care
ARDS
among
"permissive hypercapnia."
tion
torr,
are accus-
50-60% or
One of the most common complications durmanagement has been barotrauma, often mani-
tilation to the lung. In
below.
minus
we
to using.
ac-
• Ventilator mode: pressure-controlled ventila-
all
M Kacmarek and Keith G Hick-
may be caused by
prevented
and laboratory data could be very
lar pressure
that.
in detail in
to avoid further lung injury that
these and other
2
Pco 2 40
same case were being managed
• Tidal volume: 6
an approach to
is
behind the
missive hypercapnia," several aspects of these ven-
looks
by Robert
fested by bronchopleural fistula.
2
cording to the rapidly spreading philosophy of "per-
45
is
does precisely
primary goals, as described
(Page 373), 5
alone to
higher.
HCOf 24 mEq/L
different, as seen
let
the one sketched here has remained at
+ auto-PEEP): 25 cm
settings
that
described and named, mortality
• Peak inspiratory pressure: 80 cm H :
• End-inspiratory hold pressure: 70 cm
tilator
its
ARDS
—
be anathema to what
During the quarter century since
ratio: 1:2.5
• Minute ventilation: 22 L/min
• Applied PEEP: 20 cm H 2 0;
if this
management of
One of
kg patient)
• Inspiration-expiration
• Rate: 24 breaths/min
Today,
go uncorrected
— would
volumes, and ventilating pressures
• Tidal volume: 12 mL/kg (eg, 850
torr,
it
most of us were taught. Yet here
the
in
that aspect of respiratory
and make things normal. To allow a severe
respiratory acidosis to
the paper
like this:
to restore acid-base status to normal
one advantage of ventilatory support,
one can 'take over'
failure
ling
plied
is
is
Consider a second common clinical scenario: An
asymptomatic middle-aged smoker is found to have
a peripheral pulmonary nodule that was not present
on a chest radiograph taken 2 years previously. Can-
363
NEW HORIZONS
cer has to be the leading diagnostic possibility, al-
though
could well turn out to be a granuloma or
it
other benign process. If preliminary general medical
evaluation and a chest
CT
scan do not suggest meta-
static disease, the lesion will
out in order to
make
—
probably have to
come
the diagnosis with certainty.
—
monary nodule hypothesized above. These include
pneumothorax or
unresolving empyema, and even esophageal pro-
definitive treatment for recurrent
cedures and mediastinal staging
though thoracoscopy
greatly
is
lung cancer. Al-
in
not new,
from the rapid advances
it
in
has benefited
television and
years ago, this would have
or even two
meant a conventional thoracotomy, much incisional
other surgery-related technology, and this proced-
pain, 2-3 days of postoperative chest-tube drainage,
effects
special attention to the prevention of postoperative
ment, and postoperative respiratory care. In the
ar-
E Wood
re-
Five
atelectasis
days
and pneumonia, and a
minimum
of 5-7
Even if the mass proved to be
would face 3-6 weeks away from
in the hospital.
benign, the patient
ure's expanding utilization
ticle
is
sure to have profound
on pulmonary diagnosis, surgical manage-
beginning on Page 388, Douglas
views the history of thoracoscopy and the spectrum
of
its
current and future uses.
6
work and other usual activity.
Today this patient would likely experience something quite different. If the nodule were within a few
centimeters
'wedged
of the
pleural
surface,
it
out' using an automatic stapling device via
video-directed
thoracoscopy,
performed
through
two small (2-3 cm) chest-wall incisions rather than a
conventional lateral thoracotomy, and if the lesion
proved benign on frozen
The
section,
the
procedure
would return directly
to his room instead of to an ICU; incisional pain
would be minimal; the chest tube would come out
the next day; total hospitalization would be about 3
days; and the patient would probably be back at
work within a week.
would be
finished.
patient
Today, thoracoscopic surgery
many
364
is
REFERENCES
would be
being used
in
other clinical settings besides the solitary pul-
Jenkinson SG. Lung transplantation
— an update. Respir
Care 1993;38:278-281.
Hardy KA. Advances
in
our understanding and care of
patients with cystic fibrosis. Respir
Care 1993:38:282-
289.
Rennard
SI,
Daughton D. Transdermal nicotine
for
smok-
ing cessation. Respir Care 1993:38:290-294.
Steinberg KP. Surfactant therapy in the adult respiratory
distress
syndrome. Respir Care 1993:38:365-372.
Kacmarek RM. Hickling GK. Permissive hypercapnia.
Respir Care 1993;38:373-387.
Wood DE.
Thoracoscopic surgery. Respir Care 1993:
38:388-397.
Avery ME. Twenty-five years of progress
membrane
disease. Respir
RESPIRATORY CARE
in
hyaline
Care 1991:36:283-287.
Surfactant Therapy in the
Adult Respiratory Distress Syndrome
Kenneth P Steinberg
MD
Introduction
What
Surfactant,
Is
Anyway?
A. Chemical Composition
B.
Metabolism
C.
Function
D.
Commercial Surfactants
Neonatal Respiratory Distress Syndrome
III.
IV. Adult Respiratory Distress
(HMD)
Syndrome
A. Surfactant Abnormalities in ARDS
B. Mechanisms for Surfactant Dysfunction
Surfactant Therapy for
ARDS
A. Animal Models
B.
Human Studies
C.
Dosing Considerations
Summary
VI.
Introduction
identified
12 patients with tachypnea, respiratory
distress, severe
Lungs of
all
mammals
contain a potent surface-
active material (surfactant),
which
is
essential for
normal pulmonary function. In 1959, Avery and
Mead' made
the
important observation
lungs of premature infants
membrane
disease
who
the
died of hyaline
respiratory
(neonatal
syndrome) were deficient
that
in surfactant.
distress
The
adult
syndrome (ARDS) was sub-
respiratory distress
sequently described by Ashbaugh, Bigelow, Petty,
and Levine
in 1967.
:
In their
landmark
pliance,
diograph
who were
infiltrates
refractory to
on chest
ra-
oxygen therapy.
Seven of those patients died and postmortem examination of their lungs revealed atelectasis, vascular congestion, hemorrhage, pulmonary edema,
and hyaline membranes.
and colleagues noted a
In that article,
Ashbaugh
striking similarity
between
ARDS
on
to
and hyaline membrane disease. They went
postulate that surfactant deficiency might also
play a role in the pathophysiology of
they
article,
hypoxemia, decreased thoracic com-
and diffuse alveolar
Since 1967,
ARDS
has
ARDS.
become widely recog-
nized as a form of acute respiratory failure that
fol-
lows sepsis, multiple trauma, and other well-desDr Steinberg is Acting Instructor of Medicine. Division of Pulmonary and Critical Care Medicine, Harborview Medical Center.
University of Washington School of Medicine, and Medical
Director. Respiratory Care Program, Seattle Central
ity
College
—
Seattle.
Commun-
Washington.
held
in
1992
AARC
Annual Meeting
ARDS
is
an acute process rec-
emia, bilateral
— severe hypox-
on chest radiograph, ab-
infiltrates
compliance' (Table
ARDS
in the
1).
In
1972, the incidence of
United States was reported to be ap-
6
proximately 150,000 cases per year, although more
recent studies suggest a significantly
San Antonio, Texas.
RESPIRATORY CARE
3 4
ognized by a constellation of signs
sence of congestive heart failure, and decreased lung
A version of this paper was presented by Dr Steinberg as part
of the Lifecare New Horizons Symposium "New Therapies in
Respiratory Care," during the
cribed risk factors.
No
4
lower
inci-
365
SURFACTANT THERAPY
Table
1
ARDS
Diagnostic Criteria for
.
IN
ARDS
the other important phospholipids include phospha-
tidylglycerol
^
Pa02/Fi02
150, or
< 200 on >
5
PEEP
cm H :
Diffuse parenchymal infiltrates on chest radiograph
Pulmonary
clinical
No
artery
wedge
pressure
(if
<
available)
factant with regard to reduction of surface tension.
18 torr or no
evidence of congestive heart failure
Table
other obvious explanation for these findings
7
dence.
Regardless of the exact incidence,
ARDS
is
a very severe form of acute respiratory failure with a
case fatality rate that continues to be greater than
50%. 5 8 Unfortunately,
'
largely
this
figure
has remained
unchanged over the years despite many
inter-
ventional trials and experimental protocols, and the
ARDS
optimal treatment strategy for
remains con-
troversial.
The exact
etiology and pathogenesis of
also remains unclear, though
ARDS
likely results
it
from
activation of a multifaceted cascade of inflammatory
mediators that can lead to acute lung injury.
estingly,
Ashbaugh and
Petty's
since been substantiated, and
it
is
early
now
9
Inter-
theory has
generally ac-
cepted that abnormalities of endogenous surfactant
contribute to the severe lung dysfunction seen in patients
with
ARDS. 10
Given the frequency and severity of ARDS,
it
has been appropriate to continue to search for a successful treatment.
With
the early and sustained suc-
cess of surfactant replacement as a therapy for neo-
RDS, many clinicians and investigators
now wondering if surfactant replacement will
natal
that
are
be
"magic bullet"?
What
Is
Surfactant,
Anyway?
Chemical Composition
Surfactant
Type
It is
II
cells
is
made and
complex mixture of phospho-
a
neutral lipids,
proteins (Table 2).
and several surfactant-related
The various phospholipids
count for approximately
surfactant."
secreted by the alveolar
onto the alveolar surfaces of the lung.
composed of
lipids,
85%
ac-
of the composition of
Most of the phospholipids
are saturated
phosphatidylcholines (PCs) with the most prevalent
and probably most active being dipalmitoylphospha-
(DPPC, lecithin). DPPC accounts for
50-60% of pulmonary surfactant. Some of
tidylcholine
nearly
(PG) and sphingomyelin (SM). The
phospholipids are the most active component of sur-
2.
Chemical Composition of
Human
Surfactant
SURFACTANT THERAPY
other primary components.
moved by way of
bodies,
factant.
The phospholipids
are
Table
IN
ARDS
3.
Functions of Surfactant
the Golgi apparatus to lamellar
'packets'
of sur-
These lamellar bodies are secreted
into the
which are
intracellular
Lowers alveolar surface tension
Prevents alveolar collapse (atelectasis), especially
alveolar space where the surfactant 'unfolds,' forms
Helps prevent alveolar edema
tubular myelin, and then spreads along the surface
Increases lung compliance
of the alveolus, forming a very thin layer on top of a
Decreases work of breathing
on the surface of alveolar
thin layer of water also
ing cells.
13
Surfactant
is
constantly being degraded
and replaced. Functional surfactant
into small vesicles that can be taken
II cells,
lin-
although some surfactant
is
is
cells
The
also lost via the
vesicles that are taken up by the
Type
II
can fuse with lamellar bodies and be reutilized
by the Type
II
cells to
50%
estimated that nearly
adult lungs
is
form new
surfactant.
of surfactant
recycled in this way.
May improve host defense mechanisms
May reduce alveolar inflammation
broken down
up by the Type
airways and lymphatics or scavenged by macrophages.
low lung
at
volumes
in
14
It is
normal
13
anisms against pulmonary infections
15
and moder-
ating the inflammatory response within the lung.
While
the phospholipids, especially
DPPC,
primarily responsible for these functions,
coming
The
are
be-
addition of specific sur-
apoproteins can greatly
ciency of phospholipids
sion.
is
clear that the surfactant proteins are inte-
grally involved as well.
factant
it
16
in
increase
the
effi-
reducing surface ten-
17
Function
Commercial Surfactants
Surfactant
a highly surface-active material that
is
lines the alveolar surfaces of the lung,
forms most of
its
of surfactant
to
is
functions.
where
per-
it
The primary function
reduce the surface tension within
low
alveoli, thereby preventing alveolar collapse at
lung volumes. Surface tension can be thought of as
the collapsing pressure within an alveolus.
face of an alveolus
The
sur-
lined by an extremely thin
is
layer of water. This water layer has a tendency to
bead up, pulling
lapsing
it.
The
tempting to do
The higher
that
walls of the alveolus and col-
in the
force generated by the water's atthis is referred to as surface tension.
the surface tension, the
more
likely
it is
an alveolus will collapse. Conversely, the lower
the surface tension, the less likely
lus will collapse
for gas
and the more
exchange
an alveo-
it
is
that
likely
it
will stay
to occur. Surfactant acts
open
by form-
Several surfactants are
now
available for clinical
or research purposes (Table 4).
Some
They contain
either
are purely artificial:
spreading
artificial
(Exosurf,®
agents
surfactants
DPPC
Wellcome, Research Triangle Park NC) or
with
human recombinant
proteins.
with
Burroughs
DPPC
Other surfactant
products are derived from animal sources and contain various
amounts of
DPPC
and surfactant-asso-
ciated protein. Curosurf® (Chiesi Farmaceutici)
produced from pig lungs and
is
is
used more ex-
tensively in Europe than in the United States. Sur-
Columbus OH)
vanta® (Ross Laboratories,
is
de-
rived from calf lungs. Both Exosurf and Survanta
have been approved
in the
premature infants with or
RDS. Human
United States for use
at
in
high risk for neonatal
surfactant obtained from
amniotic
ing a film over the water that lines an alveolus, like
oil
floating
on water, and helps prevent
the water
Table
Surfactant Products Available for Clinical or Re-
4.
search Purposes
film from beading up, thereby decreasing the surface tension (or collapsing pressure) within that al-
Artificial surfactant
veolus.
at
By
helping to keep alveoli open, especially
low lung volumes during exhalation, surfactant
helps prevent atelectasis,
improve ventilation-per-
fusion matching, improve lung compliance, and decrease the inspiratory
work of breathing (Table
Other functions of surfactant
ly
that
have yet
3).
to be ful-
Phospholipid (Exosurf)
Phospholipid + recombinant protein
Natural, modified surfactant
Bovine (Survanta. beractant)
Porcine (Curosurf)
Human
surfactant
Amniotic
fluid
elucidated include improving host defense mech-
RESPIRATORY CARE
367
SURFACTANT THERAPY
fluid has
been used experimentally, but
Surfactant Abnormalities in
poses.
There are theoretical
risks
and benefits
various
which
contain surfactant-associated proteins, have
been shown experimentally
ically active in
to
be more physiolog-
reducing surface tension than
which contains no
protein.
1718
Ex-
is
Although
anti-
genicity in infants has not been a problem, Survanta
and Curosurf contain animal protein, and adults
may have an increased potential for adverse immune responses because of their well-developed immune systems and the need for repeated dosing.
Unfortunately, no human studies have directly compared any one of these products to another;
difficult
to
know which
ficacious and safest in
product
Abnormalities
and Curosurf,
Survanta
products.
is
the
so,
it
most
is
ef-
humans. Theoretically, the
would be one that contains recombinant human proteins: This would provide the add-
monary
in
ed benefit of the surfactant-associated proteins while
fortunately, such a product
immune
is
not available (1992)
commercial or human research
for
response. Un-
use.
lung
Ashbaugh and
years, with
Petty
and pul-
recoil
elastic
surfactant have been noted in
ARDS
for
making some of
the earliest observations. In their original description
of
ARDS, 2
they measured the surface tension in
lung homogenates from autopsy specimens in 2 of
Both patients had a minimum
their 12 patients.
face tension of
> 20 dynes/cnv (normal
dynes/cm : ). Since
is
sur-
< 10
time, several investigators
that
have studied surfactant abnormalities in patients
with ARDS as well as in animal models of acute
lung injury. 23
26
"
Probably the most complete de-
ARDS
scription of surfactant abnormalities in
27
published by Gregory and colleagues.
was
In a study
using bronchoalveolar lavage in normal subjects, pa-
best product
reducing the risk of any
ARDS
to using
these
osurf,
Adult Respiratory Distress Syndrome
too dif-
is
it
to obtain for clinical pur-
and too expensive
ficult
ARDS
IN
tients at risk for
ARDS, and
patients with
ARDS,
they documented both quantitative and qualitative
abnormalities of surfactant in patients with
They found not only
tent was reduced but
factant was altered
ARDS.
that the total phospholipid conthat the
as
composition of the sur-
well.
They described
de-
creases in the relative amounts of phosphatidyl-
Neonatal Respiratory Distress Syndrome
(Hyaline
Membrane
choline,
Disease)
DPPC, and
phosphatidylglycerol and in-
creases in the fractions of other phospholipids in-
cluding sphingomyelin, which resulted
A
the
primary deficiency of pulmonary surfactant
major etiology of
ies available
RDS
in neonates.
19
The
is
stud-
demonstrating that the use of exog-
enous surfactant improves gas exchange and lung
mechanics and reduces the mortality of newborns
with
RDS
have been subjected
to meta-analysis.
in the
DPPC
They
also
in
a decrease
(lecithin-sphingomyelin, or L-S) ratio.
demonstrated reduced protein content,
with a reduction in both
SP-A and SP-B.
All of
these abnormalities were present in the patients at
risk for
20
tients
ARDS
who
but were
already had
more pronounced
in the pa-
ARDS.
Some of the studies suggest that surfactant therapy
may also reduce complications of RDS, such as bar-
normalities in the functional activity of the surfactant
21
otrauma and bronchopulmonary dysplasia. On the
other hand, surfactant therapy probably does not af-
jects, the
fect other complications of prematurity,
tracranial
such as
21
hemorrhage, sepsis, and retinopathy.
less clear that prophylactic surfactant therapy
in-
It is
adds
any benefit compared to rescue therapy except per-
Gregory and colleagues also found significant abin these patients.
high in patients
tant
quire mechanical ventilation and supplemental oxy-
5).
gen for
RDS
368
their respiratory failure.
at
risk for
ARDS
with
normal sub-
was twice as
but was four
ARDS. Other
dysfunction with the severity of respiratory
RDS. 22 Nevertheless, exogenous surfactant has become the standard of care for premature infants with
RDS, and for some at high risk for RDS who re-
very premature infants
at
to that in
surface tension
in-
vestigators have correlated the degree of surfactant
lire.
in
Compared
times higher in patients
very high risk for
haps
27
minimum
Ample evidence appears
to link
fail-
abnormal surfac-
composition and function to the pathophysiologic abnormalities in patients with ARDS (Table
However, unlike the neonatal situation, in which
is caused by an underproduction of surfactant
'93 Vol 38
No
4
SURFACTANT THERAPY
IN
ARDS
Reasons
by immature lungs, surfactant dysfunction is only a
part of the problem in ARDS and is a result, not the
Table
cause, of acute lung injury.
Altered production
6.
Damage
Table
Surfactant Abnormalities
5.
Documented
in
ARDS
Pa-
to
II
ARDS
cells
Inactivation of existing surfactant
Proteolytic
tients
Type
for Surfactant Abnormalities in
enzymes
Toxic oxygen radicals
Reduced
total
Reduced
total protein
Inhibition of surfactant activity
phospholipid content
Plasma proteins
content
PG
SM
Increased PI, PE,
Decreased L-S
therapy improved lung compliance,
ratio
30
decreased pul-
monary edema, and improved oxygenation. 31
Altered biophysical activity
Increased surface tension
factant-deficient guinea pigs,
In sur-
treatment with exog-
enous surfactant markedly improved oxygenation
*See text or Table 2 for meaning of abbreviations.
(PaCb)
els
Mechanisms
alveolar space
Alveolar edema
Altered phospholipid composition
Decreased PC, DPPC,
in the
Dilution of existing surfactant
Decreased SP-A, SP-B*
for Surfactant Dysfunction
compared
to control animals.
32
Animal mod-
of hyperoxic lung injury have also been used. In
these models, surfactant replacement decreased al-
veolar permeability, decreased shunt, improved oxy-
Many
different
mechanisms
alter surfactant
and
genation, and improved overall survival.
33
surfactant function in the setting of acute lung injury
(Table
cells
probable that damage to the Type
6). It is
from the inflammatory changes
ARDS
that
II
results in decreased production of surfactant
ARDS. Inactivation or destruction of existing surfactant may occur. Activated neutrophils present in
in
the lungs during
ARDS
enzymes and
olytic
release a myriad of prote-
toxic
oxygen
probably inactivate surfactant and
is
also
known
that the presence
radicals that can
its
components.
It
of plasma proteins
can interfere with or inhibit the function of normal
surfactant.
membrane
Human Studies
occur in
With damage to the alveolocapillary
in ARDS, albumin and other plasma
Currently, there
1987,
Lachmann
with surfactant function. Finally, with the flooding
of alveoli from pulmonary edema, surfactant can be
diluted or
many
washed away. For
of which are probably
time, surfactant composition
inpatients with
all
at
of these reasons,
work
at the
same
and function are altered
little
in
clinical experience
with
humans with ARDS.
In
instilled a natural surfactant prepa-
ration into the trachea of a terminally
patient with sepsis
and severe
ill
4-year-old
ARDS. 34 Within
4
hours of that treatment, the patient had a dramatic
in P a o: (from 19 to 240 torr) and
marked improvements in his chest radiographs. In
1989, Richman and colleagues reported giving Cu-
improvement
rosurf
proteins can leak into the alveolar space and interfere
is
exogenous surfactant
via
bronchoscope
ARDS. 35 One
patient
improvement
in
patients
to
three
patients
with
had a significant and sustained
oxygenation, while the other two
had smaller, transient increases
in arterial
oxygenation. Finally, Nosaka and colleagues
36
re-
ported in 1990 on the use of a bovine lung surfactant (surfactant-TA, Survanta) in 2 patients with
ARDS. 10
ARDS. Both
Surfactant Therapy for
patients
were given multiple doses of
surfactant intratracheally over several days and both
ARDS
had encouraging improvements
in
oxygenation; nei-
ther patient developed antibodies to the preparation.
Animal Models
All of these studies are anecdotal reports using large
Several animal studies have been published that
show
that surfactant
replacement
is
beneficial in ex-
perimental models of acute lung injury. In a model
of acid-aspiration lung injury in rabbits, surfactant
RESPIRATORY CARE
No 4
boluses of surfactant given through an endotracheal
tube or a bronchoscope.
Recently, the efficacy of surfactant replacement
has been studied in adults with
ARDS
in
two pros-
369
SURFACTANT THERAPY
pective,
placebo-controlled
trials
is
a
an
using
solized, artificial surfactant (Exosurf).
37 38
'
aero-
Exosurf
completely synthetic, protein-free
surfactant
DPPC, hexadecanol, and
tyloxapol.
consisting of
Preliminary results from
multicenter
tients
trial
with
Weg
37
and colleagues of a
of aerosolized Exosurf
sepsis-induced
ARDS
in
52 pa-
demonstrated
trends towards improved physiology, with a de-
creased
shunt
fraction
and improved
piratory compliance in the treated patients.
static
They
found a trend toward a decreased mortality:
the control group died versus
treatment groups (Table
7).
37%
in the
res-
also
47%
of
combined
This trend did not reach
statistical significance. In that study,
Exosurf or pla-
was aerosolized for either 12
or 24 hours per day for up to 5 days using an in-line
cebo (normal
saline)
nebulizer that aerosolized only during inspiration.
Both Exosurf and the saline seemed to be welltolerated, with only one pneumothorax occurring
due
to
Table
7.
plugging of an exhalation
filter
by Exosurf.
Early Results of Trials of Exosurf in Sepsis-Induced
ARDS*
IN
ARDS
.
SURFACTANT THERAPY
and function of surfactant
in
ARDS. Animal
data
12.
sults
of two
trials
sonably safe
with
in patients
ARDS
and
that
is
rea-
it
may
14.
proved
work
be answered before
to
—not
in
therapy
this
ap-
is
treatment of
in the
itially
ARDS,
many
van Iwaarden
Welmers
F,
lungs.
into la-
Appl Physiol
J
B, Verhoef
J,
Haagsman HP,
Am J
a dis-
Respir Cell
Mol
Biol 1990;2(
):91-98.
1
Synthetic surfactant (Exosurf) inhibits
endotoxin-stimulated cytokine secretion by
promising interventions.
enhances
Thomassen MJ, Meeker DP, Antal JM, Connors MJ,
Wiedemann HP.
other in-
A
mechanism of rat alveolar macrophages.
the host-defense
16.
an important role
Uptake of lung surfactant subtractions
van Golde LM. Pulmonary surfactant protein
proves to be Yes, surfactant replacement will play
ease that has been refractory to so
1987;35:426-444.
Wright JR. Wager RE, Hamilton RL, Huang M. Clem-
1986;60:817-825.
15.
which is, Does it really
the answer to this question
If
Metabolism and turnover of
J A.
Am Rev Respir Dis
mellar bodies of adult rabbit
the least of
ARDS?
Wright JR. Clements
ents JA.
reduce mortality. However, several major questions
remain
(SP-D), a collagenous surfactant-associated pro-
Biochemistry 1989;28:6361-6367.
surfactant.
using aerosolized Exosurf are ex-
W,
and biochemical characterization
E. Purification
preliminary re-
suggesting that surfactant replacement
citing,
CP4
tein.
13.
ARDS. The
with
Persson A, Chang D, Rust K, Moxley M, Longmore
of
reasonable to prospectively study surfactant replacein patients
ARDS
Crouch
and early anecdotal reports of the treatment of
ARDS patients with surfactant suggested that it was
ment
IN
lar
macrophages.
Am
Respir Cell
J
Mol
human
alveo-
Biol 1992:7(3):
257-260.
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(abstract).
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Ikegami M, Tabor B. Jobe A. Absolom D. Aer-
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Appl Physiol 1987;62:756-761.
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Vincent JL, ed.
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Gas exchange and lung morphology after
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Anaesthesiol Scand 1986;30:321-328.
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1990;336:947-948.
37.
surfactant replacement in experimental adult respiratory
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pulmonary surfactant
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Pison U. Buchhorn R, Obertacke U. Joka T.
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Lachmann
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activity in acute respiratory distress
W, Buchhom
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pathogenesis and therapy of
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Obertacke U,
IN
is
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in-
Am
Rev Respir Dis 1992; 145(4,
RESPIRATORY CARE
jury model (abstract).
Part2):A184.
M Kacmarek PhD RRT and Keith G Hickling MD
Robert
Introduction
The Rationale
for the
Technique
A.
ARDS
B.
Acute Severe Asthma
C.
Ventilator-Induced
D. Ventilator-Induced
Effects
III.
&
Lung
Lung
Injury:
Animal Data
Injury:
Human
Data
Applications of Hypercapnia
A. Physiologic Effects
Clinical Applications
B.
What
Summary
C. pH:
IV. In
Is
Unacceptable?
Permissive hypercapnia can best be defined as a
Introduction
deliberate limitation of ventilatory support to avoid
In the past, mechanical ventilation for the
agement of acute respiratory
failure has
nipulated to ensure that the arterial Pco:
(35-45
torr).
was normal
This frequently required that
umes be maintained
10-15
in the
Recently, not only the need but the
man-
been ma-
mL/kg
wisdom
tidal vol12
regional or global overdistention, thus allowing the
PaC02 to
torr).
rise to levels greater than
Permissive hypercapnia
vent or reduce the severity of ventilator-induced
range.
lung injury. The two settings in which (because of
of main-
high airway pressure and localized overdistention)
P a co2 during mechanical ventilawhen high tidal volume (Vt) and minute ven-
taining a normal
ventilator-induced lung injury
tion
are adult respiratory distress
tilation (\fe)
and high airway pressures are required,
has been challenged.
310
The term "permissive hy-
percapnia," popularized by one of us (Hickling),
mechanical ventilation
in
which high airway pres-
sure and overdistention are avoided at the cost of
an increase
in
Dr Kacmarek
is
P a co2- 3 5 7
'
we
Director,
version of this paper
New
Respiratory Care"
most patients requiring mechanical ventilatory support,
although hypercapnia
is
contraindicated in the
presence of raised intracranial pressure and
cause adverse effects
in patients
for the
may
with some forms
Technique
Department of Intensive Care, Christ-
New
Zealand.
was presented by Dr Kacmarek during
Horizons Symposium
at the
M
ARDS
— Boston, Massachusetts.
"New
Therapies
1992 Annual Meeting of the
AARC
in
in
San Antonio, Texas.
Reprints: Robert
strat-
discuss ideally should be applied to
Director, Respiratory Care, Massachusetts
church Hospital, Christchurch,
the Lifecare
occur
of severe cardiovascular disease.
esthesiology, Harvard Medical School
A
likely to
"
General Hospital, and Assistant Professor, Department of An-
is
most
acute severe asthma. However, the ventilatory
egies that
The Rationale
Dr Hickling
is
syndrome (ARDS) and
3
has been used as a conceptualization of an approach
to
normal (> 50-100
maintained to pre-
is
Kacmarek PhD RRT, Respiratory Care,
The
earliest definitions
of
ARDS
described a
syndrome characterized by widespread generalized
pulmonary infiltrates on chest roentgenogram associated with decreased pulmonary compliance and
hypoxemia." The general clinical impression was
that ARDS was a generalized homogeneous process.
Recent data 12
l4
have demonstrated
that this is
Ellison 4, Massachusetts General Hospital, Fruit Street. Boston
not true. Computerized tomographic (CT) scans of
MA 021 14.
the chest have clearly demonstrated the
RESPIRATORY CARE
hetero-
373
PERMISSIVE HYPERCAPNIA
geneous nature of the disease. 13 Consolidation, nor-
mal lung
and markedly overdistended
tissue,
gions have been defined,
13
distribution of infiltrates.
distribution,
and areas
to
tinoni et al
with
1516
of the lung for gas exchange. Gat-
'/:
14
ARDS
have referred
emphasize
to
that ap-
proaches to ventilation should focus on the fact that
the reduced lung compliance
due largely
is
to a re-
duction in the volume of aerated lung available for
compliance of the aerated
ventilation; the specific
ventilation (square flow
matically in late-stage
(ie.
waveform) and
the pres-
ARDS. The
inflection point
typically gone, hysteresis
is
is
de-
creased, and, generally, the compliance curve
shifted
to the lungs of patients
"baby lungs"
as
by the inflection point
ence of marked hysteresis. This picture changes dra-
on the P-V curve
alterations result in the availability of only
'/3
identified
sure-volume (P-V) curve during volume-targeted
supported by mul-
is
of normal ventilation-to-perfusion matching.
about
is
which the slope of the compliance curve
changes as a result of lung recruitment) on a pres-
and low ventilation-perfusion
These
This
the point at
This heterogeneous dis-
gas studies identifying areas of both high
tiple inert
ARDS.
as well as a gravitational
i:
ARDS
tribution of pathology in
re-
more
to the right.
In light of the above, ventilating with
15 mL/kg), and large
\fe,
is
1819
Vts of
10-
regardless of system pres-
sure developed, favors the delivery of the majority
of the
Vt
to those lung units with
normal or
in-
creased pulmonary compliance. The effect that this
may have on
localized lung injury
is
discussed below.
lung appears to be relatively normal in most patients. In addition, the
mechanical properties of the
lung differ during early
ARDS. As
1),
illustrated
ARDS.
compared
by Benito and Lemaire
lung volume
recruitable
as
present
is
Acute Severe Asthma
to late
17
The other
(Fig.
early
in
setting
most commonly associated
with high peak airway pressures and overdistention,
if
normal Vjs are applied,
is
acute severe asthma.
20
bronchospasm and increased secretion volume and viscosity result in some areas of
lung that are markedly overdistended with auto-PEEP
In these patients,
and other areas
that are consolidated.
line overdistention
PEEP
caused by
air
21
The base-
trapping and auto-
increases the probability of hypotension, al-
veolar rupture, pneumothorax, and related forms of
barotrauma. The degree of hyperinflation
by Vt,
tory time (I:E), and
Ventilator-Induced
20
30
40
50
10
20
TRANSPULMONARY PRESSURE
30
40
Many
(cm HjO)
pressure-volume curves of the respiratory
two patients at 0, 10, and 20 cm H 2
PEEP.
for
The curves on the
chest radiograph
little
hysteresis,
left
are from a patient with a normal
who was
and the
intubated for coma. There
FRC
is
the right are from a patient early
Without
PEEP
normal.
in
the course of
ARDS.
applied, the pressure-volume curve
on the
highest level of
lost
PEEP
inflation
(20
limb (arrow,
cm H 2 0),
is
The curves on
dem-
onstrates marked hysteresis (arrowheads) and an
flection point
right).
in-
At the
the inflection point
is
and the pressure-volume curve assumes a monoP-V slope (compliance) similar to that
normal lungs. (Adapted, with permission,
from Reference 17.)
374
this topic,
22
Lung
Injury:
Animal Data
animal studies have been designed to eval-
uate the effect of various ventilatory strategies on the
inducement or proliferation of lung
injury.
These
data point to the development of a form of acute
lung injury histologically similar to
ARDS when
animals are ventilated with high airway pressure and
either localized or generalized overdistention occurs.
A
number of
cently.
these studies have been reviewed re-
45723,24
Table
sentative studies.
The
effects of
tonic profile with a
of patients with
affected
50
Fig. 1. Static
system
For a review of
\fe.
see Smith and Marini.
10
is
ventilator rate, ratio of inspiratory-to-expira-
sure (PIP)
Dreyfuss
at
et al.
1
lists
a
few of the more repre-
25 " 31
cm H
peak inspiratory prescm H
PEEP were studied by
45
:
:
25
They compared
RESPIRATORY CARE
the effects of high
1
So.
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9
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<
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—
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^
.5
«
BJ
0-
BO
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2
§"
00
o.'
E
5 W
>
«5 O pj
00
C
.So'cu a
—.
—
tS x>
.a
5-
5-
4-
3-
O
2-
.6
.5
.7
between
4
2
.8
Dry lung weight (g/kg
FAU (%
BW)
6
per unit
Na + space)
water (Qwl) and dry lung weight, and (B) fractional albumin uptake by
and animals ventilated at 45 cm H 2 PIP (HIPPV). Open circles = control; closed circles = 5 min HIPPV; closed squares = 10 min HIPPV; and closed triangles = 20 min HIPPV. (Reprinted, with
Fig. 2. Correlation
PIP
(A) extravascular lung
Na + space (FAU)
lung interstitium per unit
cm H 2
crovascular permeability
control
group
in healthy adult rats to a control
ed with lower PIP (7
in
ventilat-
PIP/0 PEEP), on mi-
over
5-,
and 20-
10-,
minute periods of ventilation. As noted
Figure
in
both extravascular lung water and fractional
bumin uptake by
Both high-PIP groups demonstrated deP a o 2 and most animals
electasis.
creases in compliance and
.
died within the 48-hour study period. All of these
2,
al-
the lung interstitium increased
with time in the treatment groups. The effect of 20
minutes of 45
is
cm FLO
displayed in Figure
PIP on the alveolar capillary
3.
Hyaline membranes, fibrin
formation, cell debris, and denudement of the base-
ment membrane
Kolobow
are illustrated.
et al
26
have reported on the effects of
prolonged application of 50
cm H
:
PIP
in pre-
viously healthy adult sheep. Control animals were
volume control with a Vt of 10 mL/kg
PIP. High-PIP animals were di2
two groups, both ventilated with pressure
ventilated in
at
15-20
cm H
vided into
control at pressure settings of 50
of 50-70 mL/kg.
One group was
cm FLO
ventilated at a rate
of 3/min, the other group was ventilated
with the addition of 3.8%
ed
at
10
C0 2
.
and Vjs
at
12/min
All animals ventilat-
mL/kg had normal
blood-gas,
hemo-
Fig. 3.
Alveolar septum with three capillaries of an adult
rat after
20 minutes
of ventilation at
right side, the epithelial lining is
basement membrane
composed
45
(arrows). Hyaline
of cell debris
and
cm H2O.
At the
destroyed, denuding the
fibrin
(f)
membranes (HM)
are present.
Two
endothelial cells (En) of another capillary are visible
side the interstitium
(In).
At the lower
left
side, a
in-
mono-
dynamic, and lung-compliance values after 48 hours
cyte
of ventilation. At autopsy, lungs were pink and well
blood-air barrier. (Reprinted, with permission, from Refer-
aerated, with only small-to-moderate areas of at-
ence
376
fills
the lumen of a third capillary with a normal
25.)
RESPIRATORY CARE
animals
at
autopsy had highly abnormal lungs, dem-
onstrating gross atelectasis and markedly elevated
surface tensions, although the animals receiving
C0
3.8%
who
2
were not as severely impaired as those
did not inspire
Tsuno
et al
32
C0
2.
more
In a
recent study,
reported on the effects of ventilating
normal sheep for 48 hours with a PIP of only 30
cm H
2
0. With
this
management
protocol,
an-
all
imals survived the study period but marked lung
jury
was
in-
present at autopsy. These results are
still
similar to the effects noted by others
31
during me-
chanical ventilation of healthy adult dogs.
The
effects of high
els in previously
and low Vjs and
induced lung injury
studied by Corbridge et
mals, they applied
PEEP, and
at
in the other
dogs) with 12
As one would
duced
Vt
in the
al.
2s
In
in
PEEP
one group of ani-
30 mL/kg with 3
mL/kg
15
cm FLO PEEP
1
(small
hour
cm H
Vj for
Vt
:
after injury.
expect, the shunt fraction
high PEEP/low
lev-
dogs were
was
re-
group. However,
PEEP, 34
volume was highest
contrary to data on the effects of
overall
extravascular
in
fluid
group with a low
PEEP and
the
high Vj. Both wet- and
dry-lung-weight to body-weight ratios were elevat-
ed
in the
the high
high Vj group. In
Vt groups showed
addition,
and marked hysteresis, compared
group
(Fig. 4).
80
P-V loops
in
a clear inflection point
to the
low Vt
changes noted. 29 Animals ventilated
at
showed
14/0
no difference from control animals, whereas animals ventilated
45/0 demonstrated dramatic de-
at
Other studies have also demonstrated
injury.
pulmonary edema
7 28
'
Many
creases in compliance and were cyanotic. All of
these animals died with gross
that
PEEP
appears to protect against ventilator-induced lung
'
30
animal studies have thus clearly shown
that lung overdistention as a result
Vt and
of ventilation
prior to the completion of the 60-minute period of
with high
mechanical ventilation. Their lungs were dark red
histologically similar to
with marked perivascular and alveolar hemorrhage
vented or reduced in severity by the addition of
cm FLO PEEP
and edema. The application of 10
PEEP
high PIP causes acute lung injury
ARDS.
with PIP maintained
may
This can be pre-
at the
same
(45/10 group) dramatically altered the extent of this
pattern of ventilation
injury.
Compliance was only slightly decreased. No
edema or hemorrhage was noted, although interstitial edema was present and wet-lung weights
lung injury
gross
pear to have been adequately explored.
were greater than control. Animals ventilated
Ventilator-Induced
and 30/10 were similar
at
30/
to those at 45/10,
al-
though the level of perivascular edema was
Dreyfuss
et
30
injury in
humans.
domized
studies
Vt
(achieved by ex-
airway pressure
cm H 2 0, V T 19 mL/kg). with those at high
high airway pressure (PIP 45 cm H : 0, Vt
40 mL/kg), ambient airway pressure with negative
extrathoracic pressure using an iron lung (external
negative pressure
-44 cm
H
(PIP 7
mL/kg,
Vt 40 mL/kg), and
PEEP (PIP 45 cm H 2 0,
2
0,
cm H 2
PEEP 10 cm H 2 0)
the effects of 10
V T 25
Lung
this issue
Injury:
does not ap-
Human
Data
direct data are available linking high
obtained similar results, also
ternal thoracic strapping) at high
Vt and
any Vt, 35 but
model. They compared the effects
al
rat
of ventilation with normal
(PIP 45
little
The
peak alveolar pressures and ventilator-induced lung
the 30/10 group.
with an adult
Very
less in
at
level.
also affect the extent of
cm H 2 0, V T
13 mL/kg).
negative pressure
Vt
(PIP 45
-44 cm
H
controlled, prospective, ran-
been performed with these concerns
mind. Yet,
in
there are abundant data suggesting that ventilatory
strategies that limit
peak pressures and overdis-
tention favorably affect outcome.
A
decrease in
mortality over conventional neonatal mechanical
ventilation has
been demonstrated with extracor-
poreal gas exchange incorporating mechanical ventilation limited to a
cm H 2 0)
few periodic breaths
at
low PIP
and moderate levels of PEEP. 36
to control
animals
(< 30
The most
striking
This study has been criticized. 37 however, because
findings were the similarity of injury in the two
groups with high
No
of ventilator management have
cm H
2
of
its
'play the winner' randomization strategy that
0, and external
biased the odds for subsequent randomization, ac-
0). All of these an-
cording to the outcomes of patients already treated.
imals had gross and perivascular edema. Increases
This methodology resulted in only one neonate's
were noted
being randomized to the control group. Such rando-
in
2
both dry- and wet-lung weight. Ex-
amination by electron microscopy in these two
mized prospective data are not available
groups (high Vt) showed detachment of endo-
however, Gattinoni
from
thelial cells
their
basement membranes, with
occasional intracapillary blebs and
rupted
Type
I
cells.
damaged
The group with
the
or dis-
normal
Vt
(19 mL/kg) as a result of chest strapping was similar
to
controls in
PEEP and
a lower
The addition of
all
respects.
Vt
modified the effect of the
edema was
However, perivascular edema was present
high pressure. In this group no gross
noted.
along with rare blebs affecting endothelial
and epilethial
cells
were
intact.
cells;
Chest-wall
re-
et al
38
creases in mortality with extracorporeal
(ECC0 2 R)
and low
using low PIP (< 40
rate ventilation
the multicenter
trial.
39
pressure. In the multicenter
cm H 2 0)
at
trial,
rapid rates with large
kg were used. The validity of
PIP ventilation has also been shown
that the patient populations
378
:
removal
in
in
pulmonary management in Gattinoni et al's se38
ries,
as compared to the multicentered adult
ECMO trial of the 1970s, 39 was the limitation of
been challenged because
lung injury that otherwise occurred in rabbits. 31
CO
cm H 2 0), PEEP,
when compared to that
The major difference
striction to prevent lung overdistention with high
to prevent the
in adults;
have shown marked de-
er aspects of
it
is
39
high PIPs (> 60
Vts of 10-15 mL/
this
comparison has
difficult to
were
be certain
identical,
and oth-
management may have changed.
RESPIRATORY CARE
More
recently, retrospective data of Hickling et
improvement in mortality when
compared to Apache II prediction data if a maximum PIP (< 40 cm H 2 0) is specified. In this group
of 50 patients with a lung injury score of > 2.5 according to the scoring system proposed by Murray
40
actual mortality was 16% compared to
et al,
39.6% predicted. In an unpublished prospective series of 64 patients ventilated with PIP of < 40 cm
H 2 and Vr < 7 mL/kg, Hickling indicates a mortality of 26%. A subpopulation of 53 of these pa40
extients, all with a lung injury score of > 2.5,
al
3
indicate
an
perienced a 26.4% mortality compared to Apache
53.3% mortality. The lung injury
was 3.1, while that of non-
prediction of
II
in
animals or humans.
25-30.33-35.4
Lung
Ventilator-Induced
was
3.2 (difference not significant).
None
of these 53 patients developed pneumothorax dur-
The
ing mechanical ventilation.
results of such un-
controlled studies, using a comparison with
II
Apache
predicted mortality, must be interpreted cautious-
ly,
From
Injury:
and human data
become obvious.
the animal
number of
facts
(
studies,
Barotrauma during mechanical ventilation has
also been associated with the combination of high
41 42
airway pressures and overdistention.
In addition
forms of barotrauma (pneumothorax,
pneumomediastinum, pneumoperitoneum, and subto the classic
cutaneous
emphysema 41
tension cyst formation,
emphysema, 44
and systemic gas embointerstitial
),
45
46
have been associated with classic approaches
to ventilator management in ARDS. Table 2 lists
lism
available, a
develops.
overdistention
(2)
In
1 )
and of
in
animal
itself in-
ARDS when
duces an acute lung injury similar to
Although high PIP
consistently results in lung injury in animal models,
because of differences
modes used
in
(pressure-
and volume-targeted), and the evidence regarding
lung-sparing
the
effects
of
PEEP and
thoracic
strapping and the equivalent effect of high negative
extrathoracic pressure ventilation, the peak trans-
pulmonary pressure appears
to
be the single pres-
sure most associated with injury. (3)
ment of
however.
i-m
Clinical Implications
score of survivors
survivors
documented
the injuries by mechanical ventilation
injury
overdistention. (4)
ARDS)
is
A minimum
level of
PEEP
(in
necessary to raise lung volume above the
on the P-V curve.
inflection point
there are
The develop-
always associated with local
is
no data
to
(5)
Although
demonstrate that similar ven-
tilator-induced lung injury occurs in patients,
believe that
it
agement on the assumption
finitive trials are
we
reasonable to base clinical man-
is
that
it
does, while de-
conducted. (6) The extent of lung
overdistention resulting from any given level of
PIP depends on lung- and chest-wall compliance,
Table
2.
The Spectrum of Lung
Injury by Mechanical
Ven-
tilation
"
The pressures
29 32 47 49
'
'
-
'
'
-
-
'
-
Severe hypoxemia
'
'
From
-
26,28,32,33
interstitial
resulting in injury in animal studies
are therefore not directly translatable to
edema 25 28 29 32 35 47 48
Gross pulmonary edema 27 29 32 47
Interstitial
this information, a
25,27
be formulated (Table
measure
26,32,33
3).
Alveolar neutrophil infiltration 32
tilation, these
Type II pneumocyte proliferation 32
Emphysematous changes 32
local overdistention is
lymphocyte
infiltration
-
Detachment of endothelial cells 2 3249
Denuding of basement membrane 25 32
"
1
-
-
Intracapillary blebs
"
is
cause PIP, particularly
tion, is not
43
and the lev-
minimized. In addition, bein
volume-control ventila-
only a reflection of lung-thorax compli-
ance, but also airway- and ventilator-system (circuit
47
impossible to
guidelines are designed to ensure that
3"
Alveolar macrophage accumulation
Pneumothorax 41
it
of local overdistention during mechanical ven-
el
32 47
Because
local transpulmonary pressure
Alveolar hemorrhage 29,32
Interstitial
humans.
number of guidelines
regarding limits during mechanical ventilation can
albumin levels 25,28,48
Hyaline membrane formation
Atelectasis
to pro-
duce lung injury may show interspecies variation.
Decreased compliance 26
Increased
and the degree of overdistention required
and
artificial
airway) resistance,
tory plateau pressure
may
9
end-inspira-
be a better parameter to
a reflection of
peak alveolar
Subcutaneous emphysema 44
target because
Tension cyst formation 45
pressure.
Systemic gas embolism 46
inspiratory plateau) preferably should be
RESPIRATORY CARE
50,51
it
is
Maximum
peak alveolar pressure (end-
< 35
cm
379
H
H
:
minimum
0. Because a
PEEP
level of
(5-15
cm
0) is necessary to recruit available lung tissue and
improve oxygenation in ARDS, 5,6 917 the maximum
2
-
available ventilating pressure
H
2
0. Localized
air
cm
about 20-30
is
trapping (auto-PEEP) should be
C0
Experimental data on extracorporeal
(ECC0 2 R) 38 56 58
-
adjuncts to
may
lines
re-
2
and tracheal flushing 59 60 as
the above mechanical ventilatory guide-
moval
'
allow us not only to minimize ventilator-
C0
induced injury but also to maintain a normal
2.
avoided because preliminary data indicate auto-
However, these techniques
PEEP
or not universally available, whereas permissive
PEEP and FRC,
enhances maldistribution of
favoring overdistention of lung units with high and
normal compliance. 52 Respiratory
hypercapnia
of us.
all
by
rate is limited
inspiratory time and I:E.
Table
available to
is
are either experimental
&
Effects
Applications of Hypercapnia
Guidelines for Provision of Mechanical Ventilation
3.
Physiologic Effects
PAP* < 35 cm H :
Vj appropriate to
maintain PAP, frequently 5-7
mL/kg
PEEP
cm H 2
10-15
Eliminate inflection point on P-V curve
Avoid
air
< 20-25;
by development of auto-
limit set
PEEP
Inspiratory time limit set by development of
I:E generally
<
1:1;
may be
many
patients
and
transport.
(Fl02>
livery,
Vt
-
1
FI02) ,
R
trapping
where PB
Limits on inspiratory time, I:E,
in
impedance
range
< 35 cm
H 2 0.
is
dicated, Hickling et al
3
already
as
Vts
also demonstrated that a
(compared
al-
may
in
in-
have demonstrated a lower
mortality than predicted using
53
this
contrary to accepted teaching regarding
management. However,
ventilator
et al
ARDS
In
Vrs of 5-7 mL/kg. The use of Vrs
necessitate
Lee
to gas de-
should be selected to maintain peak
veolar pressure
exchange
barometric pressure and
is
R
is
the respiratory
ratio,
in this range.
Vj
of 6
mL/kg
mL/kg) had no untoward effect on
(SICU) patients, while
reducing PIP and tending to shorten
to 12
increases in
is
P aco 2
and
P acc>2
limits the
thus
is
Pao 2 becomes much
have been reported by Kiiski
man
et al.
If
et al
34
and Leather-
55
at
these limits on the application of mechanical
we must
accept higher
P a co 2
it
is
levels.
concept of permissive hypercapnia
is
suming R =
would be 3
1
1
0.8)
and PB of 760
.5 torr,
whereas
in
conclusion to the above dilemma.
torr,
the
P aco 2 of 100
returns the Pac>2 to 311
respect to
PA o 2
torr,
torr.
oxygen content
is
oxyhemoglobin dissociation curve
a result of elevated P a co 2 However,
hyperdynamic circulation during hy-
the shift in the
to the right as
.
percarbia. any decrease in
That
creased cardiac output'
the
a
at
Pao 2 would be 244 torr. Although the increase
P a co 2 decreased the Paot by 60 torr, an increase
offset
is,
For ex-
the
obvious that
the only log-
oxygen
an Fio 2 of 0.50, a P aco 2 of 40 torr (as-
because of the
ventilation are to be maintained,
breathed
torr if
less important.
,
ample,
More important with
stay. Similar data
100
to about
-
air is
to
in the Fio 2 to 0.65
SICU
when room
be adequate. However, as Fio 2 is increased, the effect of elevated P a co 2 on Pac>2> and
content
significantly
duration of intubation and
Pao 2 This
result in decreases in
of great importance
surgical intensive care unit
380
- (PaCO:) (FlO: +
rate
ence of a global increase
ical
al-
their lung dis-
predicted by the alveolar gas equation
Pao 2 = (Pb - Ph,o)
much above 20-25/min should
air
fact,
normally,
tem, cardiovascular system, acid-base balance, and
As
must be established individually with the
goal of avoiding auto-PEEP. Finally, in the pres-
this
relatively
P aco 2 levels chronically above 60 torr.
The physiologic effects of elevated P aco 2 of central
oxygen
be avoided because of the likelihood of
and auto-PEEP.
function
in pa-
In
ease, with
•"PAP = peak alveolar pressure.
9
uncommon
not
with chronic pulmonary disease.
concern are associated with the central nervous sys-
auto-PEEP
greater but limited by the develop-
ment of auto-PEEP
Generally, rates
is
tients
though compromised as a result of
trapping and auto-PEEP
Respiratory rate
Chronic hypercapnia
in
ARDS
2
by enhanced transport of
1
'
content
2
is
normally
as a result of in-
and the oxyhemoglobin
dissociation curve's rightward shift, facilitating ox-
ygen unloading
to tissue.
RESPIRATORY CARE
,
Figure 6 summarizes the complex effects of CO :
on the myocardium and circulatory system. As noted, the effects of elevated C0 2 are mediated
PCO2 of > 60 torr caused a 2-14% increase in systolic
blood pressure with mixed effects over time on sys-
through a direct effect on each circulatory bed and
Generally, hypercarbia has a mild vasoconstricting
an indirect effect resulting from stimulation of both
effect
the sympathetic
and parasympathetic branches of
the autonomic nervous system.
muscle
(rat)
62
Isolated cardiac
responds to acute hypercarbia by a de-
w
crease in contractility
but heart rate and cardiac
output increase as a result of increased endogenous
adrenergic activity.
contractility
hour.
65
64
In at least one study, cardiac
spontaneously
recovered
within
1
The administration of blocking drugs aug-
ments the reduction of contractility and cardiac output does not
Capellier
rise.
et al
66
64
In a series of
ARDS
patients,
noted a mild increase in cardiac
index with an elevation of P a cc>2 (> 60
torr).
sidering the multitude of factors affecting the
cardium
in critically
ill
Conmyo-
patients, the effects of hy-
percarbia must be evaluated on an individual basis.
It
is
our experience that hypercarbia
well tolerated, especially
ly
over
1
when
it
generally
is
develops gradual-
temic vascular resistance (-19% to
7%
66
change).
66
on pulmonary vasculature. 68 Capellier et al
7-21%
in
systolic
pulmonary
arnoted a
increase
terial pressure and a 5-52% increase in pulmonary
vascular resistance over a 2-week period. In our
clinical experience,
dynamic
when
it
we have found
effects of hypercarbia
hemo-
that the
have been minimal
develops gradually over 12-48 hours.
Carbon dioxide has an anesthetic effect on the
central nervous system. It was the first gas used by
Hickman in 1824 for surgical anesthesia. 61 Anesthesia (hypercarbic narcosis) occurs as a result of
the acute effect of
and
intracellular
P a co: on cerebrospinal
An
pH.
pH
intracellular
pH
fluid
of about
6.7 results in anesthesia; this requires an arterial
202
Pcc>2 of about
to
95
torr
torr.
69
However, Paco?
have been found not
of halothane
required
maintain
to
up
levels
amount
to affect the
anesthesia.
Hypercarbic narcosis in animals (PaCOz 200
67
torr) is
associated with marked ventilatory and circulatory
to 2 days.
stimulation, increased muscle tone, and cortical sei-
zure activity:
due
The CNS-depressant
and the inhibitory effects of
The
effect of
upon
CO
:
on
intracellular
buffering
pH
2 is
pH
is
Intra-
capabilities.
occurs
67
dependent
much more
rapid-
than adjustment of cerebral spinal fluid (CSF)
pH. Intracellular
pH
is
within 15 minutes and
as
C0
transmission
intracellular acidosis.
intracellular
cellular adjustment of
ly
effect of
to direct inhibition of synaptic
CSF pH
capacity.
buffered to
90%
60%
of capacity
within 3 hours, where-
requires 24 hours to buffer to
60%
of
70
Severe acute hypercarbia
blood flow and glomerular
may
also reduce renal
filtration.
62
It
may
in-
crease the leakage of potassium from cells, primarily in the liver,
Fig. 6. This diagram shows the complexity of the mechanisms by which carbon dioxide can influence the cir-
culatory system.
See
text for details.
and may
affect the action of various
pharmacologic agents by altering their distribution,
by ionization, and by affecting their solubility and
protein binding capacity.
62
Most of
fects of acute hypercarbia appear to
resulting intracellular acidosis,
Carbon dioxide has a direct depressant effect on
peripheral vascular smooth muscle, resulting in a
decrease
in peripheral
vascular resistance,
67
while
sympathetic stimulation has a vasoconstricting effect.
62
In Capellier' s series of
RESPIRATORY CARE
the adverse ef-
(Reprinted, with
ARDS
patients,
No
4
a
which
be due to the
is
rapidly re-
stored toward normal (particularly in the brain and
myocardium), making functional disturbances shortlived.
The key
to the successful application of per-
missive hypercapnia
is
the gradual increase in
Pco 2
over time. This usually requires a commitment to
381
approach to mechanical ventilation from the
this
onset of ventilatory support.
approach that emphasizes limited peak alveolar
pressure (< 35 cm H 2 0), avoidance of hyperinflation
Clinical
Of
the studies evaluating the use of permissive
3 567175
the series of severe
4),
hypercapnia (Table
-
acute asthma patients presented by Darioli and Perret
72
most impressive. Of the 26 patients venfor 34 episodes of severe acute asthma, none
the
is
tilated
The successful
died.
in severe acute
application of this technique
asthma
is
even more striking when
compared to other similar published series (Table
5^72,76-84 j^g rjaj-joij
an(j perret series is the only
one with no mortality. Similar, although
already discussed, Hickling et
lished
tients,
tality
3
al,
and an unpublished series of
in a
ated in critically
short-term
patients.
ill
Even extremes of
hypercapnia
severe
occurring
intentionally in children, as reported
et al
89
(Pco 2 range 155-269
un-
by Goldstein
of 35
torr for periods
minutes to 2 days), have been well tolerated with
no neurologic or cognitive sequelae. However, the
overriding question in the
missive hypercapnia
is
how
management of permanage the resultant
to
respiratory acidosis.
pH: What
Is
ARDS
pa-
showed significant reductions in actual morwhen compared to predictions by Apache II
where PIP was kept at < 40 cm H 2 0, none of the
patients developed pneumothorax during mechanical ventilation,
and
in a
subgroup of 53 patients
with lung injury scores equal to or greater than 2.5,
39 survived (73.6%), with an average lung injury
score of 3.1. Scores over 2.5 are classified as se-
vere
ARDS.
39
Lewandowski
series of
2.5
38
et al
ARDS
Unacceptable?
Some
and others inhaled
12 of the
mortality in a
18
oxide.
ECC0 R
Twenty
and
ECCO R
:
patients
all
survived,
receiving
ECC0 R
2
patients
body-
frequent
patients received
nitric
were managed without
while
and
2
(66%) also survived.
Although none of these are controlled and randomized studies, it is difficult not to take notice of
their success in terms of
outcome
pH due
limit of
can be tolerated and
to respiratory acidosis
is
associated with sub-
sequent recovery has not been clearly defined,
though Prys-Roberts 67 estimates
it
(survival).
As
in-
to
PaCO: of 500
torr.
Neither of us proposes this as the
pH; however, we find
limit of unacceptable
stating
an overall specific level impossible without evaluating the cardiopulmonary response to a given
Most would agree
almost
the
pH
all
a
pH >
7.25
is
mechanically ventilated patients.
It is
the effects of the
acidosis against the effects of elevated levels of
ventilation.
Whether
to treat
an acidosis with bicarbonate
is
an abundance of evidence 90
"
95
to suggest that the
use of bicarbonate infusion in metabolic acidosis
increases intracellular acidosis and does not im-
prove tissue oxygenation, hemodynamics, or out-
come. In
fact, there is
evidence that extracellular
ATP-
acidosis delays the onset of cell death in
depleted hepatocytes.
96
ically addressing the use
However, no data
of bicarbonate
specif-
sistently
reported
35%, while
above 50-60%, "' 8588 although
variations in patient population and underlying dis-
make such comparisons in studies of
From these data it is
argue against a ventilatory management
hypercapnia
is still
commencement
ARDS
ideally, a gradual increase in
difficult to
avail-
open to debate. As
indicated earlier, pressure limitation and permissive
hypercapnia should probably be initiated from the
requires further study and
ease process
difficult to interpret.
man-
in the
able. Its use associated with permissive
to
has been con-
in-
fusion presents another area of great debate. There
acute asthma series varies from
9.5%
in
We
range < 7.25 that answers are elusive.
agement of respiratory acidosis are currently
ARDS
pH.
well tolerated in
dicated in Table 4, the mortality in other severe
the published mortality in
al-
be about 6.5
a pure respiratory acidosis associated with a
in
pressure-controlled ventilation,
hypercapnia,
position changes.
that
would thus recommend weighing
16%
report a
patients with a lung injury score
managed with
permissive
74
The lower
pub-
(see Table 4). In the unpublished prospective series
382
(no
71
As
>
air trapping
com-
less
by Menitove and Gold-
pelling, data are presented
ring.
(Vt < 10 mL/kg) and
auto-PEEP), and permissive hypercapnia. As noted,
the effects of elevated C0 2 are usually well toler-
Use
of mechanical ventilation so
that,
P a co 2 occurs with
its
concomitant compensation of pH.
RESPIRATORY CARE
•
E
-a
-§
8
a W
JH
—
S 8
.2
"a
-a
o oj
> u
o
5 I
oeS
§
3
"5
E
3
a"
"5b -a
3=
at
Z a
—
(0
00
oo
ojo
in
3 I
iJ5
M
b
.2,
?
.—
E n
==
-a
9- 0-
°
~"
Table
5.
Survival of Patients in Status Asthmaticus Requiring
Mechanical Ventilation*
Am
ventilated patients with acute severe asthma.
Rev
22.
Smith TC, Marini
ics
J
23.
study. Pediatrics 1985;76:479-487.
Impact of
JJ.
and work of breathing
in
PEEP
on lung mechan-
37.
severe airflow obstruction.
ARDS:
Inverse
JJ.
ratio
ventilation
in
38.
Parker JC. Hernandez LA, Peevy KJ. Mechanics of ven-
Med
Dreyfuss D, Basset G, Soler
P,
Saumon G.
Intermittent
hyperventilation with high
inflation
Am Rev RespirDis 1985;132:880-884.
Kolobow T, Moretti MP, Fumagalli R, Mascheroni D,
Prato P, Chen V, et al. Severe impairment in lung func-
rats.
Am
Rev
T.
peak airway pressures.
T, Sznajder
JI.
ume and low PEEP
prospective
Am
due
42.
Crawford GP, Chudoba MJ,
Am
Rev
43.
inflation
Am
ventilation
Rev Respir Dis
1
974;
1
44.
Am Rev Respir Dis
Maunder
Dreyfuss D, Soler P, Basset G,
Saumon G. High
pulmonary edema: respective
Am
in-
45.
1988;138:720-723.
Hudson LD. Subcutaneous
RJ, Pierson DJ,
pathophysiology,
management. Arch
Intern
Med
diag-
1984:144:
of PEEP, peak airway pressure, and distending
Pierson DJ. Complications of mechanical ventilation.
Pierson DJ,
Kacmarek RM,
care.
New
York:
Woodring JH. Pulmonary
respiratory
Foundations of
eds.
Churchill
Livingstone,
emphysema
in the
syndrome. Crit Care
Med
interstitial
distress
rabbits. J
Appl Physiol 1989,66:2364-
Gefter
WB,
Kelley
Kolobow
at
T.
Marini
distress
47.
JJ,
moderately high airway pres-
Greenfield LJ, Ebert PA, Benson
pressure
ventilation
DW.
48.
Ann
Intern
Hedley-Whyte
rabbits:
effect
Carlton DP,
10:699-703.
to
thoracotomy and lung over
Cummings
JJ,
Scheerer RG, Poulain FR.
Med
Dil-
JB. Extracorporeal circulation
in
young lambs.
J
Nilsson R, Grossman G. Robertson B. Pathogenesis of
Marini
artificial
ventilation:
JJ,
Ravenscraft SA.
Mean airway
pressure: phys-
importance
—
Part
I.
Physiologic determinants and measurements. Crit Care
Med
RH, Roloff DW, Cornell RG, Andrews AF,
RESPIRATORY CARE
1
Appl Physiol 1972;33:14-21.
iologic determinants and clinical
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of ventilation pattern. Crit Care
PW, Zwischenberger
989;
1980:40:218-225.
50.
1990;18:634-637.
Bartlett
1
evidence against the role of barotrauma. Respiration
Appl Physiol 1975;39:672-679.
Peevy KJ, Hernandez LA, Moise AA, Parker JC. Baroin
Med
Macrophage accumulation
neonatal lung lesions induced by
(CPPV) on edema forma-
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lung. J
Am
J.
microvascular protein permeability
Effect of positive
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dog
Mill-
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on surface tension properties of
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Woo SW,
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1982;127:360-365.
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46.
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radiographic, and pathologic significance.
volume and positive
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wall restriction limits high airway pressure-induced lung
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Albelda
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1985;13:786-791.
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with
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33.
ran-
1979:242:2193-
definition of the adult respiratory distress syn-
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565.
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31.
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Yanos
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1989;87:5-6.
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Extracellular acidosis delays
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1990:18:166-168.
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patients
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489.
L,
patients with lactic acidosis:
Cooper DJ, Walley KR, Wiggs BR, Russell JA. Bicarbonate does not improve hemodynamics in critically
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with the adult respiratory
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in
1991;19:1352-1356.
93.
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Montgomery AB, Stager MA, Carrico CJ, Hudson LD.
in patients
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89.
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Chatterjee K, Arieff AI. Metabolic and
Effects of bicarbonate therapy on
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Bersin
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Hyers
87.
effects of so-
lactic acidosis in dogs.
1989;87:7-14.
92.
AM, Lippmann M, Holtzman
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administration in patients with heart disease.
in se-
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85.
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hemodynamic
Rodriguez-Roisin R.
Mechanical ventilation
vere exacerbation of asthma. Eur
Graf H, Leach W, Arieff AI. Metabolic
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170.
84.
90.
20 cases and
No
4
387
Douglas E
I.
Wood
MD
THORACOSCOPIC SURGERY
almost exclusively for the
lysis
of pleural adhe-
empyemas and
sions in tuberculous
the production
uations and resections that often must be converted
to
open thoracotomies. Any thoracic surgery has
of therapeutic pneumothorax for tuberculosis. With
the potential for pulmonary, vascular, cardiac, tra-
the introduction of anti-tuberculosis drugs and the
cheobronchial, or esophageal complications. Fur-
development of techniques of pulmonary
resection, the treatment of cavitary tuberculosis by
thermore,
pneumothorax became obsolete.
derline
Since that time, thoracic surgeons have used thoracoscopy primarily for the evaluation of pleural
sistance, a thoracoscopic operation
further
effusions, pleural biopsies,
and small lung biopsies.
Thoracoscopy became more popular for the diagnosis of pleural disease with improvement in endo-
The appearance of
scopic instrumentation.
number of publications
many
relating
a large
experiences
of
authors in diagnostic and minor therapeutic
thoracoscopy culminated
in the First International
Symposium on Thoracoscopy
held in Marseilles in
many
patients referred for thoracoscopic
techniques are critically
ill
and may have bor-
pulmonary function.
Except for the additional technology of video asstandard
procedure.
operative
team requires a surgeon and
is
similar to a
The thoracoscopy
assistant,
an anesthesi-
ologist, a scrub nurse, a circulating nurse,
and occa-
sionally a second surgical assistant. Nearly
tients are
unilateral lung ventilation. Patients are fully posi-
tioned and prepared for a major thoracotomy
if
becomes necessary
dis-
for reasons of
unexpected
1980. Atlases of diagnostic thoracoscopy and tho-
ease, technical considerations, or control of
racoscopy techniques for simple procedures have
plications (Fig.
subsequently been published.
pa-
all
operated on under general anesthesia with
it
com-
1).
34
The modern era of thoracoscopic surgery
emerged in the late 1980s following descriptions of
the thoracoscopic treatment of spontaneous pneumothorax and pleural effusions.
56
Clinical experience
reported in the literature has included lung biopsy,
7 " 10
lung resections,""
pulmonary
section,
15 " 17
and
blebs
resection or ablation of
bullae,
14
esophageal myotomy,
mediastinal masses,
sympathectomy, 24
lothorax.
13
"
20 " 22
26
esophageal
1819
pericardiectomy,
and
re-
resection of
23
treatment
thoracic
of
chy-
27
Operating room setup for thoracoscopy, showing
surgeon and two surgical assistants, cardiothoracic anesthesia, and video equipment. The patient is in a full lateral position and is prepared for a full
Fig. 1.
General Operative Procedures
position of
Modern thoracoscopic procedures are not minor
They are major thoracic operations conducted through minimally invasive access. Though
the visible scars seem minor to the patient and the
thoracotomy
physician, thoracoscopic procedures are potentially
geon and the operating team. Rigid and
and complex than are open thoracic
surgical procedures. Thoracic surgeons must assess
the relative safety and efficacy of open versus tho-
thoracoscopic telescopes are inserted through 2- to
if
one becomes necessary.
operations.
more
difficult
Videomonitors are
set
up on both sides of the
operating table for easy visualization by the surflexible
racoscopic techniques for major lung, esophageal,
3-cm intercostal incisions and attached to a videocamera for visual examination of the pleural space.
Ventilatory isolation and collapse of the ipsilateral
and cardiac procedures.
lung are necessary for adequate inspection of the
A
fully
equipped cardiothoracic operating room
pleural space.
One
3-cm
in-
in appropriate points
on
to four additional 2- to
made
and surgical intensive care unit is just as important
for patients undergoing thoracoscopy as it is for pa-
cisions can then be
tients undergoing other cardiothoracic operations.
These patients are undergoing major thoracic eval-
struments for grasping, cutting, or coagulating. Endoscopic stapling devices have also been produced
RESPIRATORY CARE
the chest wall for introduction of endoscopic in-
389
can be introduced through these small in-
that
cisions. Larger incisions
can also be made (without
spreading the ribs) to improve exposure for difdissections,
ficult
to
standard
introduce
in-
struments, or to allow removal of large specimens.
At the completion of the thoracoscopic prois placed through one
cedure, a thoracostomy tube
of the thoracoscopic ports. Each of the incisions
is
manward and
closed, and otherwise healthy patients can be
aged
in the
room and on
recovery
the
have
rarely require the intensive care unit. Patients
significantly less pain after a thoracoscopic pro-
cedure than after a more standard thoracotomy with
chest-muscle division and rib retraction. Patients
are ambulatory
on the operative day and have mini-
problems
mal
monary
Many
toilet
maintaining
with
pul-
excellent
2. Chest radiograph of a 49-year-old man with a
heavy smoking history and a new right-lower-lobe nod-
Fig.
ule.
because they experience less pain.
of these patients can be discharged within 24
hours of their chest tube removal and most are back
to full preoperative activities within a
week of
sur-
gery.
Indications
Lung
Although biopsies of the lung with small-cup
bi-
opsy forceps have been performed by thoracoscopy
many
for
years, open-lung biopsy has
finitive standard for the diagnosis
been the de-
of diffuse lung
immuThe main disadvantage of
disorders or pulmonary infiltrates in the
nocompromised
patient.
open-lung biopsies has been the need for a formal
thoracotomy, which can be a major undertaking for
a ventilated intensive care unit patient.
The
intro-
duction
of endoscopic
made
it
possible to staple and excise a
lung,
allowing more substantial biopsies via the
stapling
instruments
has
wedge of
910
With thoracoscopic aswedge biopsies of the lung can now be
thoracoscopic route.
sistance,
accomplished
both ambulatory and intensive
in
Fig. 3. Computed tomography scan of 49-year-old man
whose radiograph is shown in Figure 2.
racoscopic visualization,
pling device or the
provides
create a
undiagnosed pulmonary nodules
common
diagnostic dilemma. Bronchos-
copy and transthoracic needle biopsy may be unrevealing,
leaving
the
clinician
with
an
un-
diagnosed benign or malignant nodule (Figs. 2
&
These patients have previously required a thoracotomy for biopsy and resection. With tho3).
390
of these peripheral
adequate
Nd:YAG
diagnostic
sta-
laser (Fig. 4). This
material
for
de-
termining whether the thoracoscopic procedure
definitive or
whether
care unit patients.
Patients with
many
nodules can be identified and excised with a
or open resection."'
Wakabayashi
of thoracoscopy
it
requires a
is
more extensive
2829
et al
614
with
sistance for ablation of
have championed the use
carbon
dioxide
laser
pulmonary blebs or
Patients with recurrent spontaneous
as-
bullae.
pneumothorax
and apical or superior segment blebs can have these
blebs resected thoracoscopically with the stapler or
RESPIRATORY CARE
lymph nodes,
mediastinal
pleural metastases, and
associated pleural effusions.
some
save
my
In
opinion, ac-
staging by thoracoscopic techniques
curate
from
patients
inappropriate
acotomies, allow other patients
may
thor-
undergo ap-
to
propriate neoadjuvant therapies with chemotherapy
more accurate pre-resection
or radiation, and allow
operative planning.
The
role of thoracoscopy for resection of bron-
chogenic carcinoma
is
less
however. On-
clear,
cologic principles in lung resections should not be
nodule with an endoscopic sta-
Fig. 4. Right-lower-lobe
pling instrument being applied to perform a
wedge
ly,
pulmonary
resection of the undiagnosed nodule. Fortunate-
this patient
had a benign inflammatory process
that
was completely resected thoracoscopically. The patient
was saved the pain and disability of a thoracotomy.
ablated with the
Nd:YAG
laser (Fig. 5).
A
pleu-
rectomy or pleurodesis for the creation of pleural
adhesions helps to prevent recurrence of a pneumothorax.
with
Patients
physema may have
advanced bullous empulmonary com-
significant
promise by compression of normal lung by large
bullae.
ically
sacrificed in order to convert the resection to a tho-
racoscopic procedure. Standards of safety
bronchi should not be sacrificed by thoracoscopic
electrical coagulation or
ablation, resulting
in
Nd:YAG
laser
improved pulmonary func-
proved instrumentation, several surgeons have
re-
ported major pulmonary resections with video thoracoscopic assistance.
1213
more surgeons
Certainly
perform lobectomies and even pneumonec-
will
tomies as experience accumulates and clear standards are established for the role of thoracoscopic
resections in bronchogenic carcinoma.
Pulmonary metastatic disease from head and
neck squamous
cell
carcinoma,
renal
car-
cell
cinoma, or gastrointestinal adenocarcinoma can be
with
resected
tion.
With increasing experience and im-
techniques.
These may also be ablated thoracoscopby
in deal-
ing with the pulmonary arteries and veins and the
struments.
30 31
-
thoracoscopic
stapling
in-
pulmonary me-
If there are isolated
tastases without other evidence of distant meta-
disease,
static
this
patients disease-free
may
render
some of
these
and provide prolonged
sur-
At this time (1993), thoracoscopic resection
of pulmonary nodules necessitates a peripheral lovival.
cation abutting the visceral pleura.
improve,
As techniques
techniques
localization
for
intra-
parenchymal nodules and safe resection techniques
should
make
nearly
all
peripheral
nodules
re-
sectable by thoracoscopy.
Fig. 5.
Right-upper-lobe apical bleb being excised by an
endoscopic stapling instrument in a 16-year-old
with recurrent spontaneous pneumothorax.
Lung cancer remains
cancer death
in
both
the
most
common
men and women.
woman
cause of
Accurate
Pleura
Examination of the pleura is important for determining the etiology of a pleural effusion. The pleural
space can be completely inspected, pleural fluid
determining
evacuated and examined, and pleura-based nodules
optimal lung cancer therapy. Thoracoscopy can be
biopsied under direct vision. Both malignant and
used to assess the primary tumor with
benign effusions can be well palliated during tho-
staging of lung cancer
is
critical for
its
local ex-
tension into mediastinal structures, aorta, or chest
wall.
It
can also assist in assessing hilar and
RESPIRATORY CARE
No
4
racoscopy. Under direct vision,
sure
complete evacuation
it is
of the
possible to aspleural
fluid.
391
which can be followed by talc poudrage, mechanical pleural abrasion, or even parietal pleurectomy
to create pleural adhesions. Talc poudrage and
pleurectomy are particularly effective means for
32
palliating a malignant effusion.
problems,
many
thoracotomy and decortication
to
uate the infected pleural space.
dif-
empyema
of an
33
complete evacuation.
(Fig.
A
by mediastinoscopy or mediastinotomy, but
others require a median sternotomy or thoracotomy
in-
and assure
hemothorax
is
its
also dif-
tho-
have reported using thoracoscopy for the diagnosis
and excision of bronchogenic cysts, esophageal
2021
The use of thoand Stage-I thymoma.
cysts,
racoscopy for mediastinal masses
fancy.
lead to a fibrothorax, resulting in significant res-
stay;
direct vision, all liquefied
piratory
Though
racoscopy has not yet been reported for excision of
malignant mediastinal masses, several surgeons
and clotted blood
can be removed. Such material, if left in place, can
Under
in-
are access-
for adequate diagnosis or excision.
evacuate by a simple tube thoracostomy.
ficult to
Many masses
times requiring a
With minimally
6)
accessibility for biopsy.
completely evac-
vasive techniques, thoracoscopy can lyse the adhesions
cause diagnostic dilemmas because of their
ible
Chronic and acute empyemas often create
ficult therapeutic
node metastases, thymoma, teratoma, and bronchogenic or esophageal cysts. These masses often
It
is
is
in its in-
still
clear that these patients benefit
from
minimal postoperative pain and shortened hospital
however, the efficacy of thoracoscopy for be-
nign cysts and benign thymomas has yet to be
compromise.
proven. Follow-up of these patients
assure that there
cysts or
essential to
is
no recurrence of enterogenous
is
thymomas,
if
thoracoscopic results are to
be compared to established open techniques.
Certainly, thoracoscopy has
agnosis of mediastinal masses.
much
It is
to offer in di-
also likely that
an increasing number of diagnoses will be adequately treated by thoracoscopic resection. Masses
in the posterior
mediastinum are commonly neuro-
genic tumors that are well circumscribed and benign.
Fig. 6.
Pleural adhesions being divided by endoscopic
Many
discrete
of these tumors are pleura-based and
and do not involve any
vital
structures.
Therefore, they seem well suited to resection by
scissors.
thoracoscopic surgery. However, some of these tu-
Pleura-based masses, particularly
if
benign, can
be resected using thoracoscopic techniques. These
are often neurogenic or pleural masses that have
few major attachments and can be fairly easily circumscribed under thoracoscopic visualization. Malignant pleural masses need to be biopsied for diagnosis,
and
coscopy.
It is
this
can
rare that
but occasionally
be
facilitated
mesothelioma
a parietal
is
by
are closely applied to vital structures or in-
sinuate into the neural foramen. Others
may be ma-
and are more appropriately resected by
open procedures to assure complete removal of malignant tissue and safe control of the nerves and
lignant
vessels of the neural foramen.
thora-
resectable,
pleurectomy
mors
is
Esophagus
per-
The esophagus
lies in the posterior
mediastinum
formed for palliation. Thoracoscopy can be used
for pleurectomy in cases of mesothelioma, ma-
and
lignant or benign pleural effusions, or recurrent
esophageal reflux, and benign and malignant neo-
pneumothorax.
plasms and
Mediastinum
such as diffuse esophageal spasm and achalasia,
have mostly been managed by medical therapy and
is
the
site
of
motility
cysts. Disorders of
disorders,
esophageal motility,
hydrostatic dilatation. Esophageal
Common
mediastinal masses presenting for di-
agnosis and excision are
392
lymphoma and lymph
myotomy
effective treatment for both disorders but
utilized
gastro-
is
is
an
rarely
because of the morbidity associated with a
RESPIRATORY CARE
thoracotomy to access the intrathoracic esophagus.
Esophageal myotomies by thoracoscopy with good
have been reported. l8,19
results
If
other surgeons
can reproduce
this success, patients
thoracoscopic
myotomy
a
to
may
prefer a
med-
of
lifetime
and the variable success of
ications or the risks
esophageal dilatation.
therapy
surgical
Effective
pericardium or pericardial effusion, a thoracoscopy
may
and allow a pericardial biopsy. For
direct
treatment of a large pericardial effusion with tam-
ponade, a pericardial
is
intra-
or pericardiectomy
37
Other cardiac procedures have been proposed,
another prob-
requires
window
can be performed relatively easily with thoracoscopic techniques.
Gastroesophageal reflux disease
lem.
phoid abdominal approach. For cases of thickened
but no others have been reported to date
may
— though
be possible for minimally invas-
abdominal or intrathoracic anti-reflux procedures;
thoracoscopy
however, these are major operations with
ive treatment of the patent ductus arteriosus and
sig-
Improved medical therapy has
placement
allowed many patients to be adequately controlled
fibrillators
nificant morbidity.
on a medical regimen. To
date, there are
of
automatic
cardiac
internal
de-
and patches and epicardial pacemakers.
no reports
of thoracoscopic anti-reflux procedures. However,
Other
Nissen fundoplications and Hill's anti-reflux procedure have been performed by laparoscopy. The
reports of these procedures
initial
sults,
but longer term
yet to be established.
results
some
re-
and comparisons have
34
is
commonly
indicated for
with limited esophageal cancer and for
patients with benign stricture or motility dis-
orders.
The
vocated as
transhiatal
a
Miscellaneous indications for thoracoscopic approaches include cervicodorsal sympathectomy,
the assessment
and the
Esophageal resection
patients
show good
esophagectomy has been ad-
technique for removing the
total
thorax.
The
role of thoracoscopy in the evaluation
and treatment of thoracic trauma
there
is
2(1
of the thoracic duct for chylo-
ligation
27
24
and repair of diaphragmatic hernia,
is
unknown, but
a significant potential for thoracoscopy to
better define the
management of trauma
patients
with significant hemothorax.
esophagus via a neck and abdominal approach,
without requiring a thoracotomy.
sons for this approach
is to
thoracotomy, but one of
its
One of
Patient Selection
the rea-
avoid the morbidity of a
limitations
is
Patients considered for thoracoscopic procedures
poor oper-
ative visualization of the intrathoracic esophagus.
should have one of the diagnostic or therapeutic
Thoracoscopy allows visualization of the intra7
5
This is
thoracic esophagus during this procedure.'
likely to produce an important advantage, permitting a safer dissection and a direct view for an
dications elucidated earlier.
adequate en-bloc cancer resection for esophageal
nical considerations). In general, patients should be
"'
to thoracoscopic techniques (ie, inadequate
Leiomyoma of
the esophagus
is
a benign extra-
mucosal mass of the esophageal wall that often produces swallowing difficulties and requires resection by thoracotomy. Thoracoscopy is ideally
suited for excising these benign extramucosal le-
sions of the esophagus, though experience
is
mucosa during
the procedure.
13,16
thoracotomy
vasive thoracoscopy can provide definitive therapy
in a patient
who
cannot tolerate a thoracotomy.
Contraindications to thoracoscopy include pleural
symphisis, pulmonary hypertension, bleeding
disorders, inability to tolerate single-lung ventilation,
and honeycomb lung. With dense pleural ad-
hesions
Pericardium
if
becomes necessary for adequate completion of the
procedure or for management of a complication.
However, there are exceptions if minimally in-
nec-
essary to perform this safely without perforation of
tumor
resection, inadequate nodal staging, or unsafe tech-
able to tolerate a full thoracotomy
carcinoma.
the esophageal
agement should not
in-
The principles of manbe compromised by converting
it
is
difficult to access the pleural
space ad-
equately to perform a thoracoscopic procedure. In
Thoracoscopy
is
ideally suited for approaches to
patients
done via
monary
the pericardium that have previously been
a
median sternotomy, thoracotomy, or
RESPIRATORY CARE
a
subxy-
with pulmonary hypertension, any pulresection with manipulation of the hilum
associated with a high risk for exsanguinating
is
hem-
393
orrhage, and these patients
may
not tolerate one-
age to the vagus, phrenic, or recurrent laryngeal
lung anesthesia. Disorders of bleeding are relative
nerves; or recurrence of tumor in inadequately re-
contraindications for any technique that does not
sected malignancies. Bleeding
provide wide exposure for evaluation and control of
minor from
even minor bleeding.
vessels in the lung
this
Advantages
is
usually relatively
from small
parenchyma or pleura. Most of
bleeding can be controlled by direct suture,
intercostal blood vessels or
more aggressive and major procedures
In
my
experience, patients undergoing thoraco-
scopic procedures generally have shorter hospitalization,
diminished pain, less disability, and a more
rapid return to work.
As
a result, the overall cost of
thoracoscopic procedures
is
when
ventional thoracotomy
patient's hospitalization
less than that of con-
consideration of the
and length of
disability are
considered. For
many
patients, the small
inch
used
for
incisions
thoracoscopy
1- to 2-
are
cos-
more acceptable than the incisions used
for median sternotomies and thoracotomies. The
most significant improvement, however, seems to
be the minimized postoperative pain and return of
site for as
monary
and veins
arteries
is
and needs
substantial
be considered by every thoracic surgeon performing major pulmonary resections. Bleeding
from the pulmonary
arteries or veins
can cause ex-
sanguination in minutes. Procedures on the right
hemothorax can also damage the azygous vein or
the superior vena cava and procedures on the left
can damage the descending aorta or
artery.
left
subclavian
Procedures on or within the pericardium can
result in bleeding
from coronary
arteries,
cardiac chambers, or the epicardium.
any of the
It is
important
undergo these operations
in a fully
equipped cardiothoracic operating room because
may
bleeding from these sites
require immediate
conversion to an open thoracotomy for control unless the bleeding is
long as a year.
per-
to
that all patients
most of these patients to full activity within 1 to 2
weeks. Patients undergoing traditional posterolateral thoracotomy are often out of work for 4-10
weeks and may have persistent pain at their thor-
are
formed, the potential for injury to the central pul-
metically
acotomy
As
vascular clip application, or laser coagulation.
very minimal.
Procedures on the lung parenchyma can result in
an
Disadvantages
air leak or a
bronchopleural
fistula.
Endoscopic
stapling instruments have been developed for use
most thoracoscopic procedures require a longer operating time than traditional open
procedures. Much of this is probably due to the relCurrently,
ative lack of experience with thoracoscopic tech-
niques, and
the
it
operative
is
likely that with
added experience
time for thoracoscopic procedures
open procedures. Operating room costs for the thoracoscopy equipment
and for the longer operating time are currently
will be similar to that for
during thoracoscopy. Although these staplers
need improvement,
if
they
appropriate pressure
before
to
apply
in-
adequate experience
applied.
Un-
when pulmonary resections are performed or during mobilization of the esophagus for
an
esophageal
procedure.
With
multiple
tho-
emphysema can decommonly an important prob-
racoscopic ports, subcutaneous
velop, but this
physicians
adequately
are possible
lem.
referring
are
recognized injuries to the trachea or major bronchi
Excitement about new, minimally invasive, hightechnology surgical procedures may cause many
and
still
believe that they provide no
increased risk of air leak over standard open pro-
cedures
higher than for open-thorax surgical procedures.
patients
I
is
not
Esophageal perforation can occur during mobilization of the esophagus, resection of
the esophageal wall, or esophageal
tumors
in
myotomy.
If
with a given technique has been gained or the tech-
recognized and managed immediately, perforation
nique has been established as safe and effective.
is
not usually a source of important morbidity;
however,
Complications
if
unrecognized
at the
time of procedure,
an esophageal perforation has significant risk of
both serious morbidity and mortality.
Thoracoscopy can
result in bleeding; air leak;
esophageal perforation; thoracic duct injury; dam-
394
A
thoracic duct injury
is
possible during proced-
ures in the posterior mediastinum or during
RESPIRATORY CARE
mo-
• APRIL 93 Vol 38 No 4
bilization of the esophagus.
Injury to either the
monary nodule by preoperative needle
localization
possible
or marking with methylene blue dye (similar to the
during esophageal procedures or patent ductus ar-
preoperative needle localization technique in non-
teriosus ligation. Phrenic nerve injury
palpable breast nodules),
right or left recurrent laryngeal nerve
is
possible
is
during any of the pericardial or cardiac procedures
marking are limited
because the phrenic nerve courses over the peri-
logic imaging.
It
will
3839
but localization and
to nodules apparent
on radio-
be more important to develop
cardium. Both the phrenic and vagus nerves can be
techniques for reliably identifying nodules intra-
injured in the superior mediastinum.
operative^ and defining the margins of known
Any
surgical procedure involves the risk of ineither
fection,
by contamination of the surgical
nodules to assist
field or a
secondary infection such as pneumonia
would
resulting
from a poor cough
work
and post-
effort
One
section.
be
in
their safe
and complete
re-
possible technology to be developed
thoracoscopic
which may
ultrasound,
effectively in identifying lesions within the
operative atelectasis due to pain. These risks should
collapsed lung. Thoracoscopic ultrasound remains
be no higher with thoracoscopic procedures than
completely untested and requires the development
with open-thorax surgical procedures. In
plications of atelectasis and
to
be
fact,
com-
pneumonia may prove
less after thoracoscopic
procedures than after
try to
likely if surgeons
apply thoracoscopy to malignant indications
without continuing to adhere to previously defined
surgical oncology principles.
The
inability to pal-
pate nodules manually during the resection could
result in a
experience in
missed second or third tumor elsewhere
The inability to palpate
combined with the limitations of tho-
its
is
—and
interpretation.
Though laparoscopic and thoracoscopic
mentation
thoracotomies, but this remains to be proven.
Oncologic complications are
of instrumentation to be used within the chest
advancing exponentially,
it
mains relatively crude when compared
instrure-
still
to the in-
struments that are used for open procedures. The
engineering
difficulties
producing
in
instru-
mentation that can dissect meticulously or grasp
firmly at a distance of 30-35
cm from
the surgeon's
hands are daunting, but a number of companies are
improving
As
technology.
the
within the pleural space.
rapidly
the nodule
strumentation improves, especially the endoscopic
racoscopic
exposure
and
may
instrumentation
cause surgeons to perform inadequate local re-
tumor behind or providing inadequate margins of normal tissections, leaving microscopic or gross
sue.
The
risk for local recurrence in these cases is
certainly high
if
precision that
is
These
fully
they are not resected with the
used
in
same
open thoracic procedures.
risks of inadequate resection
considered before the
need
to
be care-
planning of a tho-
racoscopic procedure for malignant disease.
this
and endoscopic stapling de-
technique
suturing
vices, the surgical procedures will
An
in-
important limiting factor
improve as well.
is
the lack of ex-
perience in most surgeons' hands as thoracoscopic
A
applications develop at a rapid rate.
learning and experience
is
period of
necessary for practicing
surgeons to be able to convert their previous open
techniques
to
thoracoscopic
video-assisted
tech-
niques. General surgery and cardiothoracic surgery
residents in training are
now
finding that laparo-
scopy and thoracoscopy are important parts of their
Problems and Future Directions
surgical training as they carry these
into practice.
In the past, the thoracic surgeon utilized a
com-
The
new
techniques
effectiveness and safety of tho-
racoscopic procedures have yet to be proven in
bination of palpation and inspection to identify the
many
nodules within the lung. Thoracoscopy can allow
stitutions
thorough inspection of the surface of the lung,
pare traditional thoracic surgery procedures to
though
in a limited
and sometimes distorted
al-
field.
However, thoracoscopy does not routinely permit
manual palpation of the lung parenchyma to aid in
finding pulmonary nodules that are not on the visceral pleural surface. Techniques have been developed
to
allow the surgeon to locate a
RESPIRATORY CARE
known
No 4
pul-
cases. This will require study in several in-
and possibly
in
thoracoscopic techniques.
these
multicenter
It
procedures critically
is
trials to
new
important to study
and prospectively
evaluate their safety and effectiveness.
We
also systematically
examine the benefits of
racoscopy because
we assume them
stantial
com-
to
to
must
tho-
be sub-
because of the diminished postoperative
395
.
.
may
pain, but the true effects
when compared
not be as important
median sternotomy or muscle-sparing
like a
7.
to stable, well-tolerated incisions
Marchandiese FX, Vandenplas O, Wallon
J.
Thoracoscopic lung biopsy
lung disease.
8.
McKeown
PP. Conant P, Hubbell DS. Thoracoscopic
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9.
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Ann Thorac Surg
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cations. Aust
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now
is
10.
al-
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other
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DR. Open lung
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GE. Special
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yttrium-aluminum garnet laser-assisted pulmonary
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28.
Med 99
Hill repair. J Gastrointestinal
Takabe K. Thoracoscopic diagnosis
and treatment of chylothorax
Intern
Ridley PD, Braimbridge
ment and
M, Chevalier JM. Transthoracic endos-
copy for upper thoracic chemical sympathectomy. Ann
27.
Aelony Y, King R, Boutin C. Thoracoscopic
drage leurodesis for chronic recurrent pleural effusions.
Surg 1992,35(5,
No
4
397
Books, Films,
Tapes & Software
and Reviews of Books and Other Media
Listing
Note
to publishers:
Send
RLSPIRATORY CARt.
re\ ie» copies of
books, films, tapes, and software to
1
TX
75229-4543.
Therapist-Driven Protocols (TDPs):
tual studies
A
Practitioner's Guide, by George
despite the tremendous appeal and
G Burton MD and Judy A Tietsort
RN RRT. Spiral-bound. 270 pages.
rationale for protocols, there remains
aerosolized medications and volume
a great need for careful study and re-
expansion therapy,
finement. The editors' statement that
(Pages 175 and 202).
Academy
CA:
Torrance
Medical
Systems, 1993. $155.00.
reminds the reader
that
our hope that these ruminations
"It is
will serve as a basis for
Therapist-driven protocols (alternately
known
as 'treat-and-evaluate' pro-
own TDP
velop your
tingly recognizes this
need for
includes the rapid shallow-breathing
fur-
Consult Service) are a popular and
medicolegal considerations (Chapter
promising strategy
4) and implementation details (Chap-
optimize de-
to
livery of respiratory care.
Although a
number of protocols and algorithms
and
ters 5
6). the
book then
the
Care
for Res-
for various respiratory care activities
piratory
Guidelines
few of these have been subjected
originally in the
December 1991 and
August
volumes
to
scrutiny to assure enhanced
critical
efficacy of respiratory care. Another
challenge to implementing therapistdriven protocols has been the lack of
a single collection of protocols that
could serve as a source document
from which available protocols could
be selected
menting
—
ideally, both for imple-
1992
senting
that
protocols.
many
in this
piratory care services (eg,
dyspnea
sessing
mechanical
While recognizing
are "still tentative
and
preliminary,"
the editors have assembled an extensive collection of
many
respiratory care
A
organized
Protocols
Practitioner's
into
18
Guide
chapters,
ginning with a discussion of the
is
bera-
tionale for therapist-driven protocols
(Introduction
and Background, and
Advantages of the Therapist-Driven
Protocol Program).
The
editors then
fail
ing precisely,
to
mak-
so that others can
ie,
easily reproduce the logic of the protocol.
tive
For example, the "post-opera-
open heart
weaning"
ventilator
protocol states: "After evaluating the
following parameters, switch patient
heated aerosol via T-tube." The
ified criteria
be met?
9 spec-
all
some be met? What
must just
If not,
exactly
is
meant
insti-
The format of
other instinot pre-
some
In
made
of the protocols
by "evaluating the parameters?"
own
published.
heavily upon articles
available
spiral-bound
has permitted
book
the
its
is
a large
volume, which
single
rapid
availability
and timeliness. In a few pages,
rectly
di-
copying some of the source
un-
materials (eg. Pages 121, 122, 227)
published survey of available proto-
has impaired the legibility of the ma-
cols.
terial,
Dr
from
To
Therapist-Driven
been
Some
3.
specify the criteria for decision
as-
and which
at
J
ing criterion.
reader wonders: "Must
from
some of which has
Yang and Tobin (N Engl
1991;324:1445-1450) as a wean-
res-
weaning from
ventilation)
index of
Med
to
instances, the editors' protocols call
services.
(TDPs):
to
and from work
tutions
viously
protocols for
themselves,
protocol
of the protocols presented
book
protocols
the
which cover a wide array of
tutions,
these
RES-
of
PIRATORY Care. The remaining 150
pages of the book are devoted to pre-
studying
critically
Practice
published
derive from the editors'
therapist-driven
programs and for
Clinical
pages),
ing protocols (Pages 208 and 215)
reprints
have been proposed and published,
(66
of the protocols agree.
all
For example, only one of the wean-
ther study. After a brief discussion of
as a Respiratory
Not
2.
presented twice
is
you to deprogram" fit-
Therapy
grams or
same nomogram for vital capacity,
which is a part of protocols for both
Burton's
extensive
the extent that this
book
pre-
sents a large collection of protocols
in
it
one volume,
a
is
its
major value
is
—
a 'smorgasbord'
from which protocol planners can
pick.
On
the other hand, to the extent
few protocols have been evalu-
that
could not be read
text
in the
in the
review copy.
Overall, "Therapist-Driven Res-
that
complete 'one stop' source of
available protocols
and some of the
busiest flow diagrams (eg. Page 225)
piratory Protocols (TDP):
Guide"
titioner's
is
A
Prac-
a unique and
very important collection of protocols that presents the state of the art
in
a field that remains in
its
infancy.
ated in controlled studies and that the
Institutional
review the evidence for their efficacy
book
individual readers seeking a single
by presenting 12 collected abstracts
have examined the impact of
existing problems within the field of
cols and reprints of
therapist-driven
therapist-driven protocols,
documents
will
the material presented
individual
purchasers
As an example,
these
that
piratory care.
tion
protocols
Although
of available
on
this
literature
res-
collec-
398
sources, the text reflects
from various
some of
which
the
in-
clude:
appears
complete, the relative paucity of ac-
collects protocols
1
is
.
Some of
redundant.
the
inclusive
libraries,
schools,
and
volume containing proto-
some key source
this a muchneeded purchase. At the same time,
find
must
weigh
features of completeness and
RESPIRATORY CARE
.
THE BEAR
1000
VENTILATOR.
REDEFINING
THE SHAPE OF
THERAPY.
.
'
Bear
.
Bear Medical Systems, Inc.
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Phone 800-232-7633 909-788-2460
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is
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Bear Medical Systems,
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©1992 Bear Medical Systems,
Inc.
BOOKS, FILMS, TAPES. AND SOFTWARE
convenience
against
the
price tag for a spiral-bound
$155.00
Chapter
1.
volume
"Radiation
in
which 79 of the 270 pages are
available free (ie, by reviewing the
in
jour-
in the original
source material
the
The authors explain how
posure.
measured, the
are
effects
and how
The Cleveland
—
ator
who
typically have not
Medical Director
pathologists
Respiratory Care
had formal education
Clinic Foundation
Chapter
Cleveland, Ohio
ner. Jones,
2,
in this subject.
by Cunningham. Don-
and Point, provides an an-
atomic and physiologic overview of
the act of swallowing. Detailed sche-
and Abnormal Swallowing: Imaging in Diagnosis and
Therapy, edited by Bronwyn Jones
DonFRACP FRCR and Martin
Normal
W
MD. Hardcover, 235 pages, illusNew York: Springer Verlag,
ner
matic drawings and charts assist in
comprehensive explanation of
their
the three phases involved
in the
swal-
lowing process, with a brief discussion of the coordination between res-
trated.
piration
1991. $125.00.
who
eofluorography will benefit from
Normal and Abnormal Swallowing
Chapter
who have
professionals
a basic un-
derstanding of general anatomy and
who
It is
by Jones and Donner,
clear that this chapter
pose of completing the videofluoro-
structures associated with the swal-
scopic
lowing mechanism. This book
place
The
examination.
emphasis on
authors
"tailoring"
the
tended to familiarize the reader with
procedure to the patient by obtaining
imaging of the pharynx and the spec-
a brief, relevant history to guide the
trum of swallowing disorders. Jones
examination; however,
and Donner
a
be a helpful guide rather
text is to
clear
that
they
in
pha-
discussing
ryngeal structure and function. Each
is
reference
followed by an extensive
list
The
text
schematic
is
well
on the top-
supported by
illustrations, static
images
of the swallowing mechanism, and
easily read charts.
The
editors
of the 12 contributors of
are
radiologists,
the
and 10
this
book
2
con-
other
tributors are speech pathologists.
400
normal
An
to different stimuli.
ex-
example describes those individuals who can voluntarily open
cellent
and control the cricopharyngeus for
the purpose of producing esophageal
speech, guzzling beer, or swallowing
swords! Compensation and decompensation are well defined and brok-
en
down
into five distinct phases, in-
dicating site and deficiency of the an-
atomic reference point.
Chapter 6 describes the interreof the pharynx and the
lationship
discusses the potential
It
be
The im-
helpful.
that reflux
can cause to the pharynx.
larynx, lung, and heart.
Chapter 7 reviews
tural lesions of the
common
struc-
pharynx, larynx,
and esophagus, with excellent, detailed descriptions of webs, pouches,
and tumors in the pharynx and an explanation of the effects
of radiation on the pharynx. Reladiverticuli.
tionships
among
and pharynx
in
the trachea, larynx,
neck
injuries to the
and foreign-body ingestion are well
described.
Chapter
8.
by Barbara Sonies. ex-
problem and/or the patient's normal
plains the use of ultrasound imaging
of intake needs to be em-
as a noninvasive evaluation tool to
phasized because the patient's per-
investigate the soft-tissue structures
pattern
formance
is
therapeutic
the basis for providing
intervention to enhance
safe swallowing.
Chapter
that helps the reader to
locate further information
ic.
to
stances that produce the swallowing
The book contains 14 chapters
chapter
believe that
portance of reproducing the circum-
it
and includes a 1-page glossary of baterms used
asked would be
I
questions
is
and
text,
their objective.
sic
of specific
list
have accomplished
an exhaustive
than
purpose of the
state the
the patient's air-
swallow
was
knowledge of the pharynx and other
is in-
if
threatened.
esophageal reflux and the damage
3,
focuses on "The Tailored Examination."
is
conditions that can arise from gastro-
written by radiologists for the pur-
lack
how
this
intimate
physiology but
However,
indicate
not
aspiration can be safely toler-
esophagus.
information.
directed toward health care
is
determining
the adjustment process of the
and swallowing. Any reader
has had experience viewing vid-
to
Chapter 5 defines adaptation as
and the oper-
helpful information for speech
do
ated or what to do
way
the timing of as-
interventions.
authors
much
why
critical
is
ation of the basics of radiation ex-
to protect the patient
K Stoller MD
piration
therapeutic
risks of radiation exposure,
James
understanding
roscopy," provides a detailed explan-
radiation
nals).
by Beck and Gayler,
Video-Recorded Fluo-
by Jones and Don-
ner, logically follows with informa-
tion
on
tional or
the
"Interpreting
is
to
the
Study."
compare func-
motion abnormalities with
normal dynamic swallow, and
structural
abnormalities by analysis
of structure. Emphasis
defining
when
in
swallowing. Ultrasound
extended periods of time without risk
4, also
Their approach
involved
can be performed repeatedly or for
is
placed on
aspiration occurs and
of future tissue changes related to
diation
ra-
exposure. While ultrasound
imaging has many applications
in the
analysis of the oral-pharyngeal phase,
it
is
unable to specifically define the
occurrence of aspiration. Sonies
is
quick to point out the benefits as
well
as
the
disadvantages
of
this
technique.
RESPIRATORY CARE
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ALLINCKRODT
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BOOKS. FILMS, TAPES, AND SOFTWARE
Chapter
by Point, Bryan. Zin-
9,
and Cunningham, leads us into
reich,
approach
grated
of an
analysis
'high-tech'
a
inte-
cross-sectional
to
swallowing secondary
Ta-
to aging.
ble 12.4 outlines the neurodegener-
and vascular disorders associat-
ative
ed with dysphagia prevalent
compares
the
in
the type of dis-
In conclusion. Normal and Abnormal Swallowing provides an ex-
cellent source of information as
imaging, although
lates to
much more emphasis on
it
re-
places
it
the role of
imaging for dysphagia. The authors
elderly and
describe the appearance of gross ana-
order to the radiologic observation
diagnostic imaging than on the use of
tomic structures and the anatomy
made. Overall the format
imaging
re-
lated to the neural control of swal-
lowing using computed tomography
(CT) and magnetic resonance imag-
The importance of
ing (MRI).
sectional imaging
to
is
(
1
cross-
confirm
)
and/or stage a mass located in or
near the upper aerodigestive
and
(2)
tract,
diagnose a lesion of the pe-
ripheral or central nervous
system
re-
sponsible for a physiologic swallowing disorder. This information
be
may
a level that only radiologists or
at
physicians with experience reading
CT
and
can understand.
M
Balfe,
by Dennis
discusses imaging of the pharynx after surgery. His approach to exam-
Chapter
10.
ination techniques and the effects of
radiation therapy to the patient with
head and/or neck cancer
static
is
easy to
excellent
Balfe's
understand.
grams and
dia-
image pictures
as-
sist
the reader in understanding the
text
and visualizing motion from the
static
view.
in children.
1
1
.
Kramer takes
the reader
through an excellent description of
radiologic
the
examination
tech-
nique, documenting that the examin-
must
er
13,
by Susan
D
HIV
and late-stage
early-
try
ynx that reveal opportunistic tumors
and infections that interrupt the function of the swallowing mechanism.
to
circum-
reproduce
also the
author to em-
first
phasize to the reader that additional
personnel
care of the patient
pertinent
purposes.
is
clearly
how-
the preferred diagnostic tool;
ever, the
overview of CT, MRI, and
ultrasound
is
helpful.
I
believe that
Chapter 14 should be entitled "The
Multidisciplinary
Approach To Pro-
viding Diagnostic and Rehabilitative
Swallowing
Services"
have been Chapter
1
and
to
should
allow
all
health care professionals insight into
a holistic team approach to meet the
needs of the patient. This would give
to include,
because
or nothing
is
in
my
experience
available.
Swallowing," focuses on dysphagia
rehabilitation. In
my
greater incentive for health care professionals
14, by Palmer, DuChane,
and Donner, entitled the "Role of Radiology in the Rehabilitation of
Chapter
who
all
other chapters in this book because
demonstrates that the individual
it
who
are not radiologists to
read the book, given the cost.
Nancy
A Conway MS CCC
Speech-Language Pathologist
opinion, this in-
formation should have preceded
Program Coordinator of
Speech and Audiology Services
Sinai Samaritan Medical Center
Milwaukee, Wisconsin
presents with a swallowing disorder
requires not only an accurate patho-
physiologic diagnosis but a holistic
and social impacts of func-
logical
tion as well.
proach
is
A
multidisciplinary ap-
outlined with team
may need
12. again
mem-
bers defined as the attending phy-
speech pathologist, occupa-
sician,
nurse,
and radiologist. Individualiis recom-
patient.
only
meet the needs of each
This can be accomplished
if all
team members are familiar
a report ensures accurate intervention
to
promote a safe and
low for the
ies
patient.
The case
histor-
provided give opportunity to un-
impact
derstand the importance of the role
of clinical evaluation incorporating
thors provide a nice review of the
the past medical history and the
prevalence of swallowing dysfunc-
ponents of behavior, communication,
and the changes
that
its
occur
in
Abstracts
Final Deadline
June 7
efficient swal-
on the swallowing function. The au-
and neurologic disease and
Open Forum
to
to get
by Donner and
Call for
tional therapist, respiratory therapist,
with the process. Joint production of
Jones, looks at the process of aging
402
therapeutic
therapeutic
into
insight
the
to
involved for the study.
tion
for
Videorecorded fluoroscopy
techniques would have been helpful
Additional
mended
Chapter
patients.
She provides computed tomography
images and static views of the phar-
within limits of safety and judgment.
special
in-
rence of swallowing difficulties in
zation of each procedure
is
Wall,
forms the reader about the occur-
stances that cause feeding difficulty
She
easy to
approach that considers the psycho-
by Sandra S Kramer,
provides an overview of swallowing
Chapter
Chapter
little
MRI
is
read and use as an educational guide.
com-
See Page 426
for abstract
submission form,
cognition, and psychosocial functions.
RESPIRATORY CARE
RDS SURVIVALREDUCE RISKS
*mm^&
In
controlled clinical triaiPfith
more
4400 preterm infants, protein-free
EXOSURF Neonatal reduced RDS
than
morbidity and improved survival without
increasing the risks of IVH, BPD, sepsis,
and other complications*
IVH was actually reduced by
by
48%
tively) in
1237
22%
and BPD
(P= 0.036 and 0.021, respeca placebo-controlled
infants
> 1250 g
trial
involving
birth weight.
1
No other surfactant has been so extensively studied or used, worldwide,
none has proved safer or more
than
EXOSURF
and
effective
Neonatal.
_K)SUrf"NEONAffir
)lfosceril
Palmitate, Cetyl Alcohol,
ipOlJFor
Intratracheal Suspension/10-mLvial
Circle 112
3
ExGSUrfNEONATAi;
(Colfosccril Palmitate, Cetyl Alcohol,
TylOXapoO For Intratracheal Suspension/10-mL vial
INCREASE RDS SURVIVAL...
REDUCE RISKS
PLEASE CONSULT FULL PRODUCT INFORMATION BEFORE PRESCRIBING
INDICATIONS
AND USAGE:
Exosurf Neonatal
indicated for
is
1
Prophylactic
birth weights of less than 1350 grams who are at risk of
PRECAUTIONS), 2. Prophylactic treatment of infants with
who have evidence of pulmonary immatunRescue treatment of infants who have developed RDS.
treatment of infants with
developing
ty,
RDS
(see
weights greater than 1350 grams
birth
and
3.
CONTRAINDICATIONS: There
are no
known
contraindications to treatment with
other adverse events were significantly reduced in the Exosurl Neonatal group,
particularly vanous forms of pulmonary air leak and use of pancuronium. Reflux:
Reflux of Exosurf Neonatal into the endotracheal tube
observed and
Intratracheal Administration Only: Exosurl Neonatal should be
administered only by
instillation into
the trachea (see
DOSAGE AND
ADMINIS-
>20% Drop
TRATION). General: The use of Exosurf Neonatal requires expert clinical care by
experienced neonatologists and other clinicians who are accomplished at neonatal intubation and ventilatory management Adequate personnel, lacilities, equipment, and medications are required to optimize pennatal outcome in premature
infants. Vigilant clinical attention should be given to all infants pnor to. during, and
if
rapidly affect oxygenation
sures should be reduced immediately, without waiting
for confirmation of respira-
improvement by blood gas assessment. Failure to reduce inspiratory ventilain such instances can result in lung overdistention and fatal
the mfanl becomes pink and transcutaneous
air leak
Hyperoxia:
oxygen saturation is in excess of 95%, FiO? should be reduced in small but
tory
pressures rapidly
tor
pulmonary
II
repeated steps
saturation
(until
is
90
to
95%)
without waiting for confirmation of
Failure to reduce Fi0 2 in
elevated artenal pO? by blood gas assessment.
instances can result
Hypocarbia:
hyperoxia
in
measurements are <30
torr,
arterial or
If
such
transcutaneous CO?
the ventilator rate should be reduced at once. Failure
reduce ventilator rates in such instances can result in marked hypocarbia,
is known to reduce brain blood flow. Pulmonary Hemorrhage: In the single study conducted in infants weighing <700 grams at birth, the incidence of pulmonary hemorrhage (10% vs 2% in the placebo group) was significantly increased
to
which
in
the Exosurf Neonatal group.
None
of the five studies involving infants with birth
weights >700 grams showed a significant increase in pulmonary hemorrhage in
the Exosurf Neonatal group. In a cross-study analysis of these live studies, fatal
pulmonary hemorrhage occurred in three infants, two in the Exosurf Neonatal
group and one in the placebo group. Mortality from all causes among infants who
developed pulmonary hemorrhage was 43% in the placebo group and 37% in the
Exosurl Neonatal group Pulmonary hemorrhage in both Exosurf Neonatal and
placebo infants was more frequenl
who had
in
a patent ductus artenosus
infants who were younger, smaller, male, or
Pulmonary hemorrhage typically occurred in
Mucous Plugs: Infants whose
in both treatment groups
ventilation becomes markedly impaired dunng or shortly after dosing may have
mucous plugging of the endotracheal tube, particularly if pulmonary secretions
were prominent pnor to drug administration. Suctioning of all infants pnor to dos-
the
first
2 days of
ing
may
lessen the chance of
life
mucous plugs
obstructing the endotracheal tube.
be replaced immediately.
in
If
oxygen saturation declines dunng dosing, drug administration should be halted
and,
necessary, peak inspiratory pressure on the ventilator should be increased
by 4 to 5 cm H s O for 1 to 2 minutes. In addition, increases of FiO? may be required
if
for
to
1
2 minutes.
DOSAGE AND ADMINISTRATION:
Preparation of Suspension: Exosurl
it does not contain
However, the reconstituted suspension is chemically
r
and physically stable when stored at 2 to 30X (36 to 86°F) for up to 12 hours
Neonatal
is
best reconstiluted immediately before use because
antibaclenal preservatives
:
the controlled clinical studies, infants
known prena-
or postnatally to have major congenital anomalies, or who were suspecled of
having congenital infection, were excluded from entry However, these disorders
cannot be recognized early in life in all cases, and a few infants with these conditally
tions
were entered. The
benefits of Exosurf Neonatal in the affected infants
who
received drug appeared to be simitar to the benefits observed in infants without
anomalies or occult infection Prophylactic Treatment—Infants <700 Grams: In
infants weighing 500 to 700 grams, a single prophylactic dose of Exosurf Neonatal
significantly improved FiO? and ventilator settings, reduced pneumothorax, and
reduced death from RDS, but increased pulmonary hemorrhage (see WARNINGS). Overall mortality did not differ significantly between the placebo and
Exosurf Neonatal groups Data on multiple doses in infants in this weight class are
Rescue Treatment—Number of Doses: A small number of
have received more than two doses of Exosurl Neonatal as reson the safety and efficacy of these additional doses
available
Carcinogenesis, Mutagenesis, Impairment of Fertility:
are not
Exosurl Neonatal at concentrations up to 10,000 ug/plate was not mutagenic in
the Ames Salmonella assay Long-term studies have not been performed in aninot yet available
infants with
to
be used
evaluate the carcinogenic potential of Exosurf Neonatal. The effects of
Exosurl Neonatal on
General: Premature
fertility
have not been studied.
Exosurf Neonatal,
Each vial of Exosurf Neonatal should be reconstituted only with 8 mL of the
accompanying diluent (preservative-free Sterile Water for Injection). Dosage:
Accurate determination of weight at birth is the key to accurate dosing.
Prophylactic Treatment: The first dose of Exosurf Neonatal should be administered as a single 5 mlAg dose as soon as possible after birth. Second and third
doses should be administered approximately 12 and 24 hours later to all infants
who remain on mechanical ventilation at those times Rescue Treatment:
Exosurf Neonatal should be administered in two 5 mL/kg doses. The initial dose
should be administered as soon as possible after the diagnosis of RDS is confirmed. The second dose should be administered approximately 12 hours following the first dose, provided the infant remains on mechanical ventilation. Use of
Special Endotracheal
Tube Adapter: With each
vial of
Exosurf Neonatal for
each
The adapters are clean
Intratracheal Suspension, five different sized endotracheal tube adapters
with a special nght angle Luer*-lock sideport are supplied
but not stenle. Administration:
Exosurf Neonatal
tration of
sideport
The
infant
should be suctioned pnor to adminisis administered via the
Exosurl Neonatal suspension
on the special endotracheal tube adapter
MECHANICAL VENTILATION. Each
WITHOUT INTERRUPTING
Exosurf Neonatal dose
is
administered
in
two 2.5 mL/kg half-doses. Each half-dose is instilled slowly over 1 to 2 minutes
(30 to 50 mechanical breaths) in small bursts timed with inspiration. After the first
2.5 mL/kg half-dose is administered in the midline position, the infant's head and
torso are turned 45° to the right for 30 seconds while mechanical ventilation is
is returned to the midline position, the second 2.5
mL/kg half-dose is given in an identical fashion over another 1 to 2 minutes. The
infant's head and torso are then turned 45° to the left for 30 seconds while
mechanical ventilation is continued, and the infant is then turned back to the midline position. These maneuvers allow gravity to assist in the distribution of Exosurf
continued. After the infant
in the lungs. During dosing, heart rate, color, chest expansion, facial
expressions, the oximeter, and the endotracheal tube patency and position should
be monitored. Suctioning should not be performed for two hours after
Neonatal
is
administered, except
when
dictated by clinical neces-
sity.
HOW
Suspension is supplied in a
Exosurf Neonatal for Intratracheal
of Stenle Water for Injection, and five endotracheal
tube adapters (2.5, 3.0, 3.5, 4.0, and 4.5 mm ID) (NDC 0081-0207-01) Store
Exosurl Neonatal for Intratracheal Suspension at 15" lo 30°C (59° to Q&T) in a
SUPPLIED: Exosurf Neonatal
carton containing one 10
Suspension, one 10 mL vial
mL
for Intratracheal
vial of
dry place.
EDUCATIONAL MATERIAL: A
videotape on dosing is available Irom your
Burroughs Wellcome Co. representative. This videotape demonstrates techniques
safe administration of Exosurf Neonatal and should be viewed by health care
for
professionals
who
will
administer the drug.
Licensed under U.S. Patent Nos. 4312860 and 4826821
500009
August 1990
birth is
some
1. Long W, Corbet A, Cotton R, et al. A controlled trial of synthetic
in infants weighing 1250 g or more with respiratory distress synN Engl J Med 1991;325:1696-1703. 2. Corbet A, 8ucciarel!i R, Goldman S.
Decreased mortality rate among small premature infants treated at birth
with a single dose of synthetic surfactant: a multicenter controlled trial J Pediatr
1991,118:277-284 3. Long W, Thompson T, Sundell H. et al. Effects of two
rescue doses of a synthetic surfactant on mortality rate and survival without
bronchopulmonary dysplasia in 700- to 1350-gram infants with respiratory distress syndrome J Pediatr. 1991,118:595-605 4. Stevenson D. WaltherF, Long W,
References:
surfactant
et al
associated with a high incidence of morbidity and
infants
who
received Exosurf Neonatal developed severe
complications and either survived with permanenl handicaps or died In controlled
clinical studies evaluating the safety and efficacy of Exosurf Neonatal, numerous
assessments were made In infants receiving Exosurf Neonatal, pulmonary
hemorrhage, apnea and use of methylxanthines were increased. A number of
safety
.
et
al
Controlled
•Increased apnea was noted in three trials but proved to be a marker for survival.
Increased pulmonary hemorrhage was noted in one trial with infants 500-699 g."
ft
Burroughs Wellcome Co.
.
Wellcome Research Triangle Park. NC 27709
.
1993 Burroughs Wellcome Co.
All rights
reserved.
EX-Y04781
trial
dose of synthetic surfactant at birth
699 grams J Pediatr. 1992,120:S3-S12.
of a single
mature infants weighing 500
1
<B
Bacteriostatic Water for Injection, USP.
drome.
mortality. Despite significant reduclions in overall mortality associated with
.
Do Not Use
Definitive data
ADVERSE REACTIONS:
Copr
'
Solutions containing buffers or preservatives should not
for reconstitution
RDS
cue treatment.
mals
following reconstitution.
Exosurf Neonatal
In
reflux occurs,
to 5
If
endotracheal tube obstruction from such plugs is suspected, and suctioning is
unsuccessful in removing the obstruction, the blocked endotracheal tube should
PRECAUTIONS: General:
If
necessary, peak inspiratory pressure
cm H ? until the endotracheal tube
transcutaneous
Transcutaneous Oxygen Saturation:
be increased by 4
'
Acute Effects: Exosurf Neonatal can
and lung compliance Lung Compliance: If chest
expansion improves substantially after dosing, peak ventilator inspiratory presExosurf Neonatal
after administration of
dunng dosing has been
associated with rapid drug administration
ventilator should
on the
clears.
Exosurl Neonatal.
WARNINGS:
may be
drug administration should be halted and,
to
in pre-
Advertising
NATIONWIDE
NATIONWIDE
Guidelines
RESPIRATORY THERAPIST
To place recruitment advertising, contact Valley
Forge
Press at (800) 220-4979.
ARE YOU INTERESTED IN
Ads
.
.
.
•
Providing care that makes a difference?
•
Having
•
Having your
a voice in building superior quality care
and
service?
efforts recognized?
can be faxed to (215) 935-
JOIN ONE OF THE FASTEST GROWING HEALTH CARE COMPANIES IN THE
UNITED STATES'
8208 or mailed to Respira-
Due to rapid growth, we are accepting resumes for Respiratory Therapists in the states of
INDIANA, WASHINGTON, PENNSYLVANIA, WISCONSIN, & OHIO. The qualified
tory Care, 1288 Valley Forge
Road, Suite
50,
Box
P.O.
candidates will be Registered, Credentialed, or Credentialed-Eligible.
WE OFFER AN EXCELLENT SALARY AND BENEFIT PACKAGE!
Please send your resume in confidence
to:
ADVANCED LIFELINE SERVICES,
Valley
1135,
PA
Forge,
10507 Timberwood
Louisville,
19482.
INC.
106
Circle, Suite
KY 40223
ATTN: Linda Meier
No
phone
calls, please.
MAINE
PSG-TECH
NATIONWIDE
Respiratory Therapist with 2 yrs. polysomnography
experience. Needed for busy 2 bed certified
Computerized Nicolet System (PROSOM).
35K
+
sleep lab.
NATIONWIDE
FulJ time:
benefits.
Sherrill Barks
Neuroscience Institute
Business Partnership Opportunity
930 Congress Sr.
ME 04102
(207) 772-0740
for Licensed Respiratory Therapists
Portland,
Pulmocare, Inc.
EARN CONTINUING
RESPIRATORY CARE
EDUCATION CREDIT
WITH AARC
VIDEOCONFERENCES
Provides:
Management, Marketing Systems, and Financing.
You build your own business and financial security.
For more information contact:
1-800-25-PULMO
2425 West Loop Soutn, Suite 1038
CALL Q14) 830-0061
RESPIRATORY CARE
• APRIL 93 Vol 38
•
Houston, Texas 77027
(713) 439-7578
No
4
NEW YORK
Technical Director
of Respiratory
PENNSYLVANIA
MARYLAND
RESPIRATORY CARE
RESPIRATORY
THERAPISTS & TECHNICIANS
Therapy
Brooklyn
Voluntary
hospital
seeks
degreed, M.S. degree
employment of experienced professionals
in our progressive Respiratory Care
Registered
Service.
B.S.
in
Respiratory
to
head dept. Well
versed in all aspects of Respiratory
Therapy
including
state
regulations, JCAHO, and Quality
Assurance studies.
Supervisory
exp. required. Excellent salary
and benefits package.
preferred
Therapist
We
have
full
time and part-time positions
available for Respiratory Therapists and
Respiratory Care Technicians. Previous
Open
We
Heart/Critical Care skills preferred.
are a
289 bed acute care hospital
and Washington,
City,
nights per week,
9PM to 7AM and
PRN RRT tates
is
a
DC.
the
modern
Send
and excellent benefits.
able; $22.00, $23-00, $24.00. Great op-
portunity to use your knowledge and
the
practice
of Respiratory
Resumes may be faxed
ST.
what you
ly at
find professionally
and personal-
Dorchester General Hospital.
lent starting salary
JOESEPH HOSPIITAL
uman
12th
&
resources
phone
and good working con-
(410) 228-551
1,
a
ext
friendly
420
or write
PA 19603
Human
Resources Dept.,
300 Byrn
(215)378-2490
Fax (215) 378-2706
to the Personnel
call at
a
shift, excel-
We would welcome
ditions.
Com-
which includes
Walnut Streets
Reading,
in
skills
Care,
transpott.
plete benefits package
to:
Jim Churchill
2525 Kings Highway
Brooklyn, New York 1 1 229
718 377-7900 Ext. 283
avail-
ICU/ER, Neonatal
member of
offer a competitive salary,
resume or apply
Inc.
three
12 hour day rotate.
generous premium for night
Brooklyn,
confidence
.Toeseph Hospital
facilities
of
full
Stabilization, and
ABG's and implementation of
various therapy protocols. You will like
We
Community Hospital
two
lias
time positions available immediately. Four
New York
Franciscan Health System.
to:
RRT
in
resumes
confidence
OR
CRTT
14 Red Acute Care Hospital
located within 2 hours of Philadelphia,
St.
in
PRACTITIONER
1
Please contact Personnel or send
Personnel Director
CARE
Our expansion into an Open Heart
Program allows opportunities for
Street
Cambridge,
eoe
Director 718-252-4851
EOE
MD
21613
DORCHESTER GENERAL HOSPITAL
Your neighbor! taking core of you
Please
RESPIRATORY CARE
PROFESSIONALS
Arden
165-bed acute care
Hill Hospital, a
Hudson
facility in the beautiful
opportunities
excellent
RCP
Registered
professional
environment.
7:00a.m.-3:30p.m.
Located
just
competitive
benefit
TDAs
Please
One
life
a
or
position
is
is
split
ski
New
resorts,
we
offer
includes
health,
pension
insurance,
plan,
and tuition reimbursement.
contact:
Dchorah
Carr,
Human
Resources, (914) 294-5441, Ext.4282.
ARDEN HILL HOSPITAL
Human
Care
12 hour shifts
The Union Memorial Hospital,
Resource Department
Harriman Drive
Goshen,
NY
Advertisers.
a
comprehensive
and
which
York City
MARYLAND
Respiratory Care Opportunities
Full-time/Part-time/PRN
friendly,
The other
shift.
salary
program
and
in
hour north of
1
Valley, has
Certified
shifts!
and south of the
dental
work
to
evening and night
a
for
Support
Respiratory
Their
Advertising Dollars
Support
Your Association
and Your Profession.
a 419 bed
currently
has
positions available in our respiratory
care department. We offer a competitive
salary and comprehensive benefits
package. To discuss these positions
please call 410-554-2028 or send resume
and cover letter to:
teaching
hospital
The Union Memorial Hospital
Dept. of
Human Resources
201 E. University Pkwy
Baltimore, MD 21218
Use the
Reader Service Card
for Information on
Advertised Products.
10924
RESPIRATORY CARE
• APRIL
'93
Vol 38
No
4
WASHINGTON, D.C.
VIRGINIA
WASHINGTON, D.C
RESPIRATORY CARE
THH 1AM1LV U.ALIH CkNlbR
JOHNSTON -WILMS HOSPITAL
I
I
I
|
NEONATAL
SPECIALISTS
Come to work now and be
here for the September opening of our exciting
We are seeking experienced neonatal
to work full-time 12-hour nights. This is
specialists, RRT's and CRTT's
state-of-the-art
equipment, HFOV and HFJV.
with
your chance to work
Georgetown University Hospital is a nationally-recognized universitybased teaching hospital. In exchange for your skills and experience, we
offer an outstanding benefits package which includes choice of medical
insurance, tuition assistance to Georgetown University for you and your
children, fully-paid retirement plan, generous leave, and much, much
more.
For consideration, send resume to:
new Neonatal
Holds Exceptional
Opportunity
The
new
,
Family Health Center at
Johnston-Willis Hospital represents
an
exciting health services breakthrough
for the Richmond area. Due to open in
July
it
will
offer
a 24-bed
single
room
Maternity Care Unit, a 9-bed Neonatal
Special Care Unit and a 10-bed Pediatric Unit with a 4-bed PICU. It will also offer
an exceptional environment
Intensive Care Unit!
>»X«* GEORGETOWN UNIVERSITY MEDICAL CENTER
j
....
for a:
'IIP
Ml'
P.O.
Box 32-233
ATTN: Recruitment Office
Job "ASRESP
Washington, DC 20007
eoe/aae
Neonatal/Pediatric
Respiratory Therapy
Supervisor - This groundfloor
opportunity will have a broad impact
and offers the ability to be a 'working"
supervisor. Responsibility will
GEORGIA
GEORGIA
encompass
scheduling, overseeing departmental operations, coordinating and
directly delivering respiratory care/
We seek the VA state
treatments.
certified or registered therapist with at
staffing,
m
H
peds or neonatal
experience including one year in a supervisory role. We will begin active re-
HOMECflRE RESPIRATORY THERAPIST
least three years of
cruiting for Staff Respiratory Therapists at
end of March. To learn what a
medical leader— and an unsurpassed
setting—can do for your career please
Barbara Starr,
direct your resume to:
Recruitment Retention Manager,
1401
HOSPITAL,
JOHNSTON-WILLIS
Johnston-Willis Dr., Richmond, VA 23235,
EOE No agencies,
(804) 330-2076.
the
MARKETING MANAGER
Well established J.C.A.H.O. accredited company
Objective:
An
"Grow
a
home oxygen and
• is
capable of working unsupervised and independently
• is
a skilled
• is
aggressive, yet friendly and polite
has "people skills"
industrious and efficient
• is
resourceful and intelligent
•
Top
has good trouble-shooting skills
good
at
follow through
salary, profit sharing,
to
optimal completion
m
APRIL
93 Vol 38
No
4
If you fit the above description of
job both financially rewarding and
and generous paid time off
an acceptable candidate you will find
emotionally satisfying Send Resume to:
•
an already very
problem solver
• is
• is
RESPIRATORY CARE
respiratory business in
acceptable candidate for this excellent opportunity
•
CALL o.\&
Georgia seeks a highly motivated
competitive area"
please.
ESS."-*
in
R.R.T. or C.R.T.T. with well rounded clinical experience and managerial skills
this
RESPIRATORY MANAGER
P.O. BOX 568
ALBANY. GA 31702
GEORGIA
GEORGIA
GEORGIA
REGISTERED RESPIRATORY THERAPIST
HCA
PULMONARY LAB
SUPERVISOR
Piedmont Hospital,
a
in central Georgia,
is
for the 3 p.m.
p.m.
As an
500-b»d acute
HCA
- 1 1
seeking a
accredited
CRTT, RRT
or registry eligible Respiratory Therapist
shift.
facility,
Fairview Park Hospital offers competitive salaries and
an excellent benefits package, including education and childcare assistance.
For consideration please contact the
located 4 miles north of
Atlanta, is currently seeking
a Pulmonary Lab supervisor.
care
Fairview Park Hospital, a modern, 190-bed, general acute care facility located
facility
Human
Resources Department.
downtown
Requirements for this position include
RPFT. and a minimum of 3 years
experience in the areas of pulmonary
function testing, arterial blood gas
sampling,
bronchoscopies
and
pulmonary rehabilitation. Also, at least
2 years of supervisory experience in a
full function pulmonary lab is required.
The qualified candidate should have
extensive
experience
in
quality
assurance methods and in successfully
meeting regulatory and accrediting
agency standards.
Piedmont Hospital offers a pleasant
working
environment
and
an
outstanding
benefits
package. For
immediate
consideration,
please
forward your resume to:
PIEDMONT HOSPITAL
Personnel Dept.
1968 Peachtree Rd.,
Atlanta,
NW
GA 30309
HCA
P.O.
Fairview Park
Hospital
Box 1408, Dublin,
GA 31040
(912) 275-2000 Extension 2125
h
OHIO
FLORIDA
RESPIRATORY
PRACTITIONERS
RESPIRATORY
Summa
THERAPISTS
Venice Hospital, a 342-bed non-profit
acute care facility located on the
Gulf Coast of Florida;: has excellent
opportunities for Respiratory Therapists.
RRT or CRTT, Florida license required.
Critical
care experience
(ventilator
mgmt. .arterial lines, intubation, etc.)
preferred. Day, evening and night
Health System, an 81 1-bed system
dedicated to excellence in patient care,
medical education and research has a full
time 1 lpm-7:.30am and a part time evenings
and nights position available on the Akron
City Hospital campus. If you are a certified
registered or registry eligible and licensed
shifts
are available.
We offer highly competitive salaries
and benefits plusanoutstanding work
fessional
team
Here you
will
VENICE
HOSPITAL
Inrouchwuhtechiiology. In touch with your
RESPIRATORY
THERAPIST
Head
Hilton
seeking
a
Hospital
is
currently
Respiratory
certified
Employment Services
654 S. famiami Trail Venice,
,
Equal Opportunity Employer.
FL
34285
ICU,
pulmonary
our
for
Two
Dept.
Experience required.
Cardio-
Summa
work with
join the pro-
Health System.
a leading respira-
CCU, PICU, SCV1CU. We offer:
•
Competitive salary
•
Comprehensive benefits
•
Tuition reimbursement
•
Monthly CRCEs
The Akron
area offers relaxing country side
major metropolitan excitement plus an advantageous cost of living, attractive housing
market, and an area rich
tional
educa-
in cultural,
and recreational advantages.
Interested candidates please submit
or contact
Department
of
Human
resume
Resources,
AKRON CITY
St.,
Therapist
at
tory provider that staffs 4 Critical Care Units
-
environment. Interested individuals
call (800) 368-3442 or send resume to:
SOUTH CAROLINA
come
Respiratory Practitioner,
is
HOSPITAL, 525 E. Market
Akron, Ohio 44309, 21 6-375-3255. Equal
Opportunity Employer.
yrs.
Please send
resume with salary history to Larry
Zimmel, V.P., Support Services.
J.
HILTON HEAD
HOSPITAL
P.O.
Box 21
Head
29925
Hilton
1
17
Island
SC
Summa
Health System
Member Hospital?.
Mi-im City Hospital
An Equal Oppty Employer
RESPIRATORY CARE
St.
Vmiuv Medical Center
•
APRIL
'93
Vol 38
No
4
TEXAS
INDIANA
II
$1,000 Sign-On Bonus
llll
RESPIRATORY TECHNICIAN/
THERAPIST
Our
(
hospital hos o
10PM-6AM|,
lull
be
must
lime position on
certified
weekend
includes every other
experience, excellent benefit
or
3rd
shift
regisl
Salory bo
package
plus
$
I
000
sign-on bonus.
Apply or send resume with cover
letter to:
Jackson County
Schneck
Memorial Hospital
200
S.
Walnut
Seymour, IN
St.
47274
EOE^^^
$1,000 Sign-On Bonus
CERTIFIED
RESPIRATORY
TECHNICIAN
Our
has
hospital
full
time positions
Respiratory Technicians on 2nd
and 3rd
for
shifts,
including every other weekend. Salary based
on experience, excellent benefit package plus
$1 ,000 sign-on bonus.
Apply or send resume with cover
Human
letter to:
Resources Dept.
*W
A^^VW
Jackson Counfy
V
Schneck
Memorial Hospital
200
Walnut SI.
Seymour, IN 47274
S.
WISCONSIN
TEXAS
TEXAS
ARIZONA
10KING
YOUR WEEKEND
DIRECTOR OF
CARDIOPULMONARY
SERVICES
Zdle Lipshy University' Hospital, in Dallas,
is
facility for the University of Texas
Southwestern Medical Center at Dallas. Continuing in
the tradition of patient-focused care, we are seeking a
director to develop our
ideal candidate will have a Bachelor's degree in Respirator)'
Therapy. Biological or Health Science or the equivalent of
work experience. Individual must
also be a registered
Respiratory Therapist and have 4-5 years of managerial
experience in a related
clinical area A Master's degree in
Business Administration, Hospital Administration or
Health Services Management is preferred.
otter an excellent benefits package. If you're
interested in
Manager,
Human
a contribution in an
to high quality patient care
art service,
resume
making
please
call
Amy
and
Harkins,
atmosphere
state-of-the-
Employment
collect at (214) 590-3150, or forward
vour
Zale Lipshy University Hospital, Attn:
Resources. 5151 Harrv Hines Blvd.. Dallas
to:
Texas 75235. EOE,
for the
Respiratory Care
Therapist in Flagstaff,
The Director will be responsible for managing the
operational, financial, personnel activities and clinical
aspects of the Respiratory Care and EKG Services. Our
committed
Techniques
a Respiratory
new Cardiopulmonary
Services Department.
We
Intervention
You won't have to
leave home to get
away from it all as
the teaching
and research
new
•CESSATION
GETAWAY COULD BE
AS CLOSE AS YOUR
BACKDOOR.
Member UHt
Practitioner
Arizona. Tail
pines, beautiful
mountains and
crystal blue skies are right outside the
door. And you'll find lots to do, from
downhill and cross country skiing in
winter to hiking, camping, rock climbing
and
fishing in
dining, our
summer. Plus
own symphony and
fine
a
respected university.
As a
regional medical center, FlagMedical Center also provides a fastpaced environment and great opportunities for career growth with flexible
scheduling and competitive benefits.
staff
Currently, we're looking for a Respiratory Therapist that must be CRTT
by the state of AZ and
of two years experience with critical care and emergency
or RRT, licensed
Covers four major
aspects of smoking
cessation
— the impact
smoking on
and mortality,
of
behavioral
components, current
cessation programs,
have a
minimum
and
ZaleDpshy
areas.
University Hospital
N1CU or willingness to fly fixed
intervention.
wing
III
At Southwestern Medical Center
air
effective
A one
ambulance preferred.
Call or write us at 1-800-446-2324,
Personnel Dept., Flagstaff Medical Cen-
GET THE
illness
ter, 1200 N. Beaver Street, Flagstaff, AZ
86001 We can give you the kind of challenge you want. Plus a great place to
.
hour videotape lecture
by Kathleen A. Smalky,
MD, MPH.
spend your weekends.
Item VT35
243-2272
For a Membership
Application
— $40 Ea
(AARC Member
Call (214)
FLAGSTAFF MEDICAL CENTER
An Equal Opportunity Employer
$35),
add $4.50 for shipping
and handling.
To Order
Promoting
Respiratory Care
Decisions
This
dynamic eight-page booklet
adults
make
is
designed especially
respiratory care their career decision. Each
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young
help
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presents
information on the practice of respiratory care, the skills used, patients,
working conditions, job prospects, qualifications, and training. This
exciting color booklet will fill classrooms with eager young adults on their
way to a challenging career. Item PR12. $20, Pkg 50 (Member $10)
"Hello, I'm Your Respiratory
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It's
a greeting that says what
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brochure does best: introduces you and
respiratory care. This six-page brochure not only introduces you, but
describes what you do
— from diagnosis,
to treatment, to
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Packed with information to provide to your patients or other
hospital staff. Item PR1 1. $20, Pkg 50 (Member $10)
to training.
Transitions
your respiratory care program with those wanting a change
rewarding job with this eight-page booklet. Its full-color pictures
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the compassion, challenge,
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of a career
in
Fax
to |214)
AARC Order
credit cards or P
484-2720.
If
Department,
O
numbers may
1030 Abies Lane,
Allow One Day for Order Processing
Addresses outside the continental U S
and contact
Order
$15
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or less
for
call (2
1
4]
2432272,
ordering by mail, send coupon
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or
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many
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Item PR 13. $20, Pkg
Orders wilh
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Form Approved;
OMB
No. 0910-0143
DATE RECEIVED
Medloi/ Device 'w /M\
& Laboratory \<Z)
Product Problem ^5TJ
Reporting Program
1.
PRODUCT
Name of
Lot Number(s)
IDENTIFICATION:
(Include sizes or other identifying characteristics and attach labeling,
if
Manufacturer's
Number(s)
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Manufacturer's City, State, Zip
2.
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Dr. Joseph G. Valentino
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Attention:
I
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IN
THE CONTINENTAL UNITED STATES
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and 4:30 PM
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commenting on
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RESPIRATORY CARE,
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letters as
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criticized material will
"For Publication," and mail
it
The
it
to
ventilation
Equate to "Improvement"
ventilation
Howard's excellent study of
pressure-controlled ventilation (PCV)
volume-controlled
ventilation
RESPIRATORY CARE
REFERENCES
pressure-controlled
to
peak
lower
a
at
in-
findings
regarding
peak inspiratory pressure
(Paw-peak).
Mr Howard
of barotrauma
".
is
the likelihood
.
.
reduced because
of the ability to ventilate
when using
Paw-peak"
lower
at
pressure-con-
trolled vs volume-controlled ventilation.
Mr Howard's
show
study did indeed
Paw -peak
a reduction in
VCV
from
transition
to
summary he concludes
the
at
PCV
In his
that this
an
is
"improvement." However, the persis-
effect
but
supported,
it
not only un-
the
In
is
first
cm H 2
creased
but
tidal
45%! Thus,
PCV, each of
trauma," or more
in
trauma,
2
the result of increasing
is
volume beyond
the lung
volu-
limit. In the
elastic
its
second place, P aw
-
P eak
is
a poor indicator of peak lung vol-
ume, especially
one mode of ventilation
(eg,
from
from
after the switch
VCV
to
to another
PCV). Note
that
the lung does not necessarily have to
rupture to suffer
damage from
over-
distention; disturbance of the surfactant
system can lead to alveoli of
smaller diameter and alveolar collapse,
promoting intra-alveolar lung
edema. 3
with a reduction
was not associated
in
pulmonary baro-
trauma (the study was not designed
Elsewhere
Paw-peak
I
have discussed the
basis for expecting that
should be decreased
changing from
emphasized
VCV
to
that this decrease
have pointed out
happen
switched
from
Reduction
mean
in
pressure (mean airway pressure
went up or stayed the same in 64%
of the patients, which may or may
be
not
Paw-peak
a
Reduction
benefit).
in
was not associated with a
re-
duction in peak inspiratory alveolar
pressure
—
a
more appropriate index
—because
of pulmonary barotrauma
peak alveolar pressure (P a iv- P eak)
proportional
Paiv-peak
=
to
tidal
tidal
volume
is
(ie,
volume/compliance).
These are important
details,
and
res-
piratory care professionals cannot retain their status as experts in
nize
basic
mechan-
they cannot recog-
concepts of respiratory
system mechanics.
I
RRT
Director
is irrel-
Respiratory Care Department
&
is
Childrens Hospital
volume-controlled
Cleveland, Ohio
that
a
fact,
patient
'93 Vol 38
Open
B.
No 4
Med
1992;
and
lung
the
1992;18:319-321.
Chatbum RL. Some
possible mis-
conceptions
peak
about
airway
Respir Care 1991;
(letter).
Mr
sense that
I
may be
Chatburn
misunderstood as a result of his extracting
from
excerpts
the
PCV
paper and using them out of the originally intended context.
Indeed,
mentioned
I
may
clinicians
that
the text
in
perceive a de-
crease in Paw-peak to be advantageous.
The
es
remains that
fact also
was
significance
in
Paw-peak-
lower
Paw-peak)
"Improvement"
may
would
change(s)"
(ie,
not be the most
perhaps
term;
appropriate
cant
statistical
identified for chang-
"signifi-
be
better.
Please keep in mind the total reported
findings
Paw-peak
— not
just
one variable. The
decrease
when
with the other findings
change
and
in
combined
—
significant
minute ventilation, Cdyn,
P<A-ai02
—may
suggest
that
number of
patients
proved from
their previous status.
a
im-
clinically
agree that reduction in Paw-peak
would mislead one
Robert L Chatburn
but
Rainbow Babies
"In
one responsible? (ed-
the
Mr Howard responds:
I
it
that
Intensive Care
pressures
air-
when
PCV 4
evant with respect to lung damage.
could
way
ical ventilation if
theoretical
4.
an improvement. Reduc-
Paw-peak
is
itorial).
of
reduction
a
that
Baro-
36:872-874.
Whatever else you may conclude
from Mr Howard's study, you must
believe
volume
Med
in-
utrauma than he was on VCV.
Paw-peak is
G.
volutrauma, but which
is
keep the lung open. Intensive Care
theoretically at greater risk of vol-
not
Saumon
D,
trauma
Lachman
3.
was
these patients
Paw-peak did not decrease
accurately
patients.
):32-40 [Cor-
1
18:139-141.
to
volume
"baro-
place,
In
at the transition
mis-
actually
one
dropped from 50
to test this hypothesis).
leading.
Dreyfuss
flow rather than a de-
waveform.)
to
14
in
rection, 38(2):3 17],
2.
VCV
scending-ramp
tent belief that a reduction in Paw-peak
is
in all patients if
patient, Paw-peak
44
and results
Respir Care 1993;38(
had been provided with a constant
tion
reduces barotrauma
Ventilator: application of an algo-
rithm
In
P a w-peak detidal volume increased.
would probably have
Pressure-control ven-
with a Puritan-Bennett 7200a
tilation
(5/14) of patients,
inspiratory
points out that other au-
thors believe the
that.
been observed
concerned that some readers may
his
Mr Ho-
ward's data show exactly
(This
I
Howard WR.
1.
a higher risk of
barotrauma." Sure enough,
creased, but
been lack-
ing in previous studies.' However,
misinterpret
Journal.
Letters
volume and thus
tidal
36%
provides important and de-
tailed information that has
am
inter-
have the opportunity to reply
spiratory pressure but with a higher
Mr
(VCV)
accept
opinion or
75229-4593.
Decreased Paw -peak Does Not
vs
may
Editors
reflect the author's
crease as well.
lowed
I
if
Vt
did not de-
also agree that,
to rise, increasing
Vt
if al-
could be
detrimental. Aside from that, one can
expect to ventilate with a lower
the Paw-peak
is
Vj
if
lowered from an origi-
nal starting point.
405
isw^r?
)BU*»'
"-S5S5
r3?
More Than A Ventiiator •••
We're Ifoe owe company thatpacks a complete system
When
you unpack the 7200®
Series ventilatory system, you'll find
much more than a ventilator.
\bu'll
find a dedication to service, as well
as clinical, educational
cal support.
tilator, it's
Ours
a system.
ventilatory
and techni-
isn't just
a ven-
The 7200 Series
system:
The
Were In It For Life
right
Zl PURITAN
choice, for the right reasons. Call
BENNETT
1-800-255-6773-
Circle 129
LETTERS
Mr Chatbum
isolates one finding,
and takes issue with it He
Piw-poJt,
and
ventilation
control
welcome
I
we
chose
maintain
to
all
William Howard
pa-
CMV-baseline Vt.
Specifically, reported Vt at P-T is a
means of communicating the effect
that PCV has on Wj (as well as the
other reported variables). We, as do
MBA RRT
Director, Respiratory Care
their
at
tients
New England
Medical Center
Boston, Massachusetts
REFERENCES
Patients did not continue
Vt
Mr Chatbum
That
Gentle-Haler
the
complete-
fails to
transfer
Paw -peai
Chatbum
mentions
that
mean
mean
airway pressure or increased
64%
in
of the pa-
one should look at all of
patients in a study and support
tients. First,
the
with
their results
cance, as
call
statistical
did. In fact,
I
signifi-
one will
re-
from the study, there was no
statistically significant difference in
mean airway
eral
pressure. Second, sev-
variables
pressure.
Reduction
sulting in
no
difference in
means
mean airway
affect
in
P.w-peaic
re-
ensured
is
no need
is
for
co-
to
metered dose inhaler (MDI) use by
with inhalation; and (2) there
to
asthmatics cannot be deduced from
1992
issue,
1
De-
because
the
study design was inherently weak.
This
is
because a larger-than-usual
dose of bronchodilator (300 /xg of
al-
was administered to a relasmall group of, on average,
buterol)
tively
moderate asthmatics, which almost
certainly ensured that all of the subjects
using
would
device
either
reduction
10- fold
is
a 7-
throat
the
in
dose, which provides no benefit but
contributes in a major
way
to local
side effects such as hoarseness and
thrush
as
2
or systemic side effects such
sup-
hypothalamic-pituitary-axis
pression and the potential for impaired growth in children
when
er doses of steroids are used.
dynamic
filtering
tance valve in the
3 '5
larg-
Aero-
and the low-resis-
Aerochamber
pro-
vide a relatively foolproof system for
achieve the plateau of the response
accomplishing
curve regardless of the relative
improving patient compliance with
effi-
ciencies of the two devices. Given the
probability
titration
of beta
study
a
error,
using
one,
dose-
two, or
would have
both
benefits,
6
thus
aerosol therapy and clinical benefit
By
2
contrast, the Gentle-Haler re-
duces the throat dose by only 50-
charge
to
be
(in the overall patient
it
would nevertheless allow only
Mr Chatbum should
comment on other find-
one
adjustable
variable,
thank those
questions
the
conclusion that similar bronchodilatation
is
achievable with both deliv-
who
contacted
regarding
RESPIRATORY CARE
•
me
pressure-
APRIL
'93
60% 7
and, as with the standard
and
been shown
inhalation,
to
lem for many
the elderly
which
patients,
particularly
children below 4 years old
fants.
ous ages and handicaps.
number of
In their introduction,
Chipps
et al
MDI
It
has
and disabled, as well as
be used optimally by patients of vari-
12 ' 14
MDI,
be a significant prob-
ery systems, provided that both can
suggested that the advantage of the
P.w-p«k.
with
there
such a study shown bioequivalence,
have
pressure to
ings and improvements and not focus
I
Aerosol delivery
requires coordination of aerosol dis-
pressure
believe that
on
fold: (1)
because
been much more convincing. Had
be maintained
only
latter.
mean airway
population).
I
feature that dis-
three puffs of medication
mean airway
responsibly
main
tinguishes the former from the
statistically significant
that other variables
altered for
Aerochamber spacer
to
either did not affect
airway pressure
actuator
the paper by Chipps et al in the
CMV
from
PCV!
Mr
reduction in aerosol jet
die
ordinate aerosol discharge precisely
to that of the
cember
Piw-peak
is
provides clinical benefit equivalent
decreased 12.5% within 24 hours of
initial
velocity
chambers such as the Aerochamber
and its much larger cousins the
Nebuhaler and Volumatic are two-
In fact, re-
ly explain that the patient's
the
MDI, because
The advantages of valved holding
Aerochamber Questioned
in
Thus, a more ap-
at that.
have been a Gentle-Haler versus an
Gentle-Haler Comparison to
ferring to this specific pediatric patient,
is
Puritan-Bennett
a
Ventilator: application of an
rection, 38(2):3 17].
unless
one case
refers to
which Vt increased 45%.
reduce the forward veloc-
propriate clinical comparison might
it.
Mr Chatbum
to
is
of the spray. However, this
Pressure-control ven-
RespirCare 1993;38(l):32-40 [Cor-
blood gas results and clinical indicators allowed
ity
with a
CMV
from
that differed
PCV
pared,
holding chambers, and a relatively
algorithm and results in 14 patients.
Pawpeak
maintain the Vt used during CMV.
Vt), then
with
tilation
7200a
CMV-baseline
was adjusted to
(from
transition
chambers such as the Aerochamber,
to which the Gentle-Haler was com-
minor one
Howard WR.
1.
dynamics of the unfolding events
the bedside. Second, if Vt changed
the
at
im-
little
This implies that the
.."'
.
only one of the advantages of valved
other responsible clinicians, adjust to
at
.
major advantage of valved holding
ignores two points. First, at transition,
osol with low velocity and
paction
questions from others.
8" 11
was because of
patient-
and
in-
this that
a
and task-specific
accessory devices have been
developed
in recent years
—such
as
does not
Aerochambers and similar devices
require a spacer but produces an aer-
with 7-cm and 8-cm masks and ex-
Gentle-Haler
Vol 38
No 4
is
that
it
".
.
.
407
LETTERS
tremely low-resistance valves for pro-
Until then, studies such as that
viding MDI-generated aerosols to
Chipps
dal-breathing infants and children,
and the Aerochamber with
mask
whom
1214
10-cm
or uncooperative
for elderly
adults to
ti-
MDI-generated aero-
et al
by
Epstein
adult
mask
Michael
T Newhouse
Clinical Professor of Medicine
McMaster University
unwilling to
Director, Barnett Medical Aerosol
close their lips around a mouthpiece.
Research Laboratory
who
departments,
in
are
MV"
" and Aerovent
St Joseph's Hospital
accessory devices have also been de-
Hamilton, Ontario, Canada
Aerochamber
Am
Rev
SC, Prior A. What deter-
Allen
MD MSc
emergency
asthma
com-
pressur-
Respir Dis 1983;128:253-255.
particularly useful for patients with
life-threatening
A
means of
ized aerosol inhaler use.
der these experimental conditions.
is
Parsons JE, Corey PN,
parison of three
was demonstrated un-
must be provided by caregivers.
sols
The Aerochamber with
SW,
(abstract).
1990;141:A18.
Worsley GH, Reilly PAJ.
lence simply because similar bronchodilatation
inhaler
Am Rev Respir Dis
demonstrating clinical equiva-
as
aerosol
surized
should not be construed
1
mines whether an elderly patient
can use a metered dose inhaler correctly?
Br
J
Dis Chest 1986;80:45-
49.
Crompton GK. Problems
patients
have using pressurized aerosol
halers.
Eur
in-
1982;63
Respir Dis
J
(Suppl 119):101-104.
veloped specifically for intubated
in-
bags
hand-operated
by
tilation
mechanical
ventilators.
even been possible
I5lf
'
It
or
has
1.
with
patients
tracheostomy.
17
could
cations
None
be
Aerochamber spacer
of these appli-
means of an unaided MDI
The benefits of
and valved holding cham-
2.
Oropharyngeal candidiasis
tients treated
ber in aerosol therapy were recently
emphasized
in the
conference
dorsed
AARC
statement,
this
18
consensus
which
3.
apy.
While photographs in the Chipps
al paper were apparently provided
demonstrate similar sprays from
1
et
to
it
should be stressed that the
brick A. Spacer device with
dose inhaler alone and with Aero-
attachment
Allergy Clin
J
latter
Brown PH, Blundell G, Greening
AP, Crompton GK. Do large vol-
Russi E. Short-term effect of albu-
ume
terol,
CW,
Kraemer R, Frey U, Sommer
spacer devices reduce the sys-
Thorax
1989;298:160-161.
delivered via a
device, in
1990;45:
wheezy
new
auxilliary
infants.
Am
Rev
Respir Dis 1991;144:347-351.
736-739.
Grigg
J,
Amon
S,
Jones T. Clarke
nocortical suppression utilizing the
peutic aerosols to intubated babies.
rendering meaningless any clin-
Nebuhaler for inhalation of steroid
Arch Dis Child 1991;67:25-30.
comparison.
aerosols. Clin Allergy 1987; 17:393-
Rau
likely that the Gentle-
398.
Evaluation of a reservoir device for
it
is
Haler, like the unaided
and beta-agonist
MDI
4.
actuator
5.
provided by
blind
6.
istics
all
of the
at-
chamber systems, demonstration
in the problem patients
for whom holding chambers were developed must await further research.
trial.
BMJ
a
M. Design and
double
ing
medical aero-
Newman
SP, Weisz A, Clarke
SW.
Bronchodilator delivery from Gentle-Haler, a
new
low-velocity pres-
Groff JL.
Meeker DP, Stelmach K. Modification of the spacer device: use in
the patient with arthritis or an artificial airway.
Chest 1992:102:1243-
1244.
.
Maclntyre NR. Brougher
D,
Newhouse MT, Pierson
nient
1-7.
7.
RJ,
study. Chest 1992;102:924-930.
character-
Aerosol Sci 1982; 13:
Harwood
metered-dose bronchodilator deliv-
of a portable breath actuated,
sol inhaler. J
JL,
ery to intubated adults: an in vitro
treat-
1991;303:163-165.
particle size selective
and benefits of valved hold-
its utility
Growth
Corr D, Dolovich M, McCormack
house
devices. However, because the Gen-
tributes
S.
D, Ruffin R, Obminski G, New-
valved holding chambers or reservoir
tle-Haler lacks virtually
OD, Pedersen
ment with budesonide:
compliance, provide bronchodi-
latation similar to that
Wolthers
of asthmatic children during
canister, will, un-
der optimal conditions of adult pa-
408
Br
Med J
A, Silverman M. Delivery of thera-
Thus,
of
dilators to infants with asthma.
1988;81:424-428.
Prahl P, Jensen T. Decreased adre-
ically relevant
tient
Immunol
mask
broncho-
giving
for
for this demonstra-
was disassembled
tion,
O'Callaghan C, Millner AD, Swar-
temic effects of high dose inhaled
and Aerochamber,
Aero-
nol 1989;6:263-267.
with beclomethasone
corticosteroids?
the Gentle-Haler
pa-
in
and
inhaler
chamber with mask. Pediatr Pulmo-
dipropionate delivered by metered-
chamber.
en-
approach to aerosol ther-
DR.
Pyszczynski
36-
in 6- to
month-old children by means of a
metered dose
GA,
Salzman
Reliable sal-
butamol administration
1422.
or the Gentle-Haler.
MDI
RA, Newhouse MT.
matics. Respir Care 1992;37: 1414-
accom-
readily
Allergy 1988:60:403-
Conner WT, Dolovich MB. Frame
metered
for
Ann
406.
dose inhaler (MDI) use by asth-
plished by
the
children.
Clinical compari-
son of Gentle-Haler actuator and
permanent
a
Wong
Chipps BE, Naumann PF,
GA, Raabe OG.
to adapt the in-
fant device for aerosol delivery for
adult
RM, Barbera JM, Middleton
HB, Eby DM. Delivery of albuterol
aerosol by Aerochamber to young
Sly
REFERENCES
fants or adults requiring assisted ven-
I.
P,
Hess
DJ, Zi-
for
Respiratory Care: aerosol consensus statement
— 1991.
Respir Care
1991;36:916-921.
"93 Vol 38
No 4
LETTERS
Dr Chipps
responds:
puffs
Our study showed
MDI
Haler
that the Gentle-
actuator and the Aero-
chamber spacer with standard
were equally effective
ator
increases
desirable
ting
FVC
and
FEF25-75,
actu-
in elici-
in
FEV|,
30 randomly
in
se-
lected asthmatics during a 6-hour pe-
of about
This
is
important because both
the Gentle-Haler and the
Aerocham-
ber prevent the unpleasant and potendetrimental focused oropharyn-
tially
for our study as typ-
50
1
of albuterol, not 300
/Ltg
choice for our study because
MDI
We
actuators.
Newhouse
do not agree with Dr
our study design was
that
The
inherently weak.
beta error
was not
possibility of
large, as suggested
by Dr Newhouse, considering the
in-
herent consistency of the numerous
measurements
we made
that
with
it
Newman
et al
2
studied the Gentle-
Haler and contrasted
MDI
of a standard
that
its
Because the Gentle-Haler requires
no spacer,
same
it
physically about the
is
size as a conventional actuator.
smaller size
Its
venient than a
makes
more conspacer device. With
it
Aerochamber, undesirably large
the
particles are collected or evaporated
the
in
Tc-99m. They found about
a
60%
the
temporary reservoir for
the inhalable particles pending inhalation
by the
patient.
With
Gen-
the
tle-Haler, formation of larger parti-
cles
is
prevented by vortex action,
and a relatively slow and gentle aerosol is released with
the oral cavity
may
no focused
jet;
serve as a spacer
matics. Respir Care 1992;37: 1414-
oropharyngeal deposition
in
lung
in
when compared
Haler
1422.
Newman
2.
50%
MDI
to results as-
actuator.
drug
less
is
is
more
or
delivered to the lung as with a
MDI
actua-
tor.
should be noted that
it
in
both cases the drug that deposits in
the
throat
distributed,
diffusely
is
one
spot.
MDFs
high-
rather than concentrated at
In contrast, the standard
velocity jet causes a heavy and un-
pleasant deposit of drug
at
SW.
surized
Am
aerosol
low-velocity presinhaler
(abstract).
Rev Respir Dis 1990;141:A18.
by the
released
properly used standard
new
tle-Haler, a
Even though
much drug
Gentle-Haler, as
SP, Weisz A, Clarke
Bronchodilator delivery from Gen-
sociated with use of a properly used
standard
metered
for
dose inhaler (MDI) use by asth-
re-
deposition with use of the Gentle-
Editor's Note:
Dr Newhouse
ed the Aerochamber and
is
invent-
associ-
ated with Trudell Medical of Canada
and
in
Monaghan
subsidiary
U.S.
its
Medical
the
research
and de-
velopment of Aerochamber devices.
Dr Chipps is a consultant to Vortran
Medical
Technology,
manufacturer
of Gentle-Haler.
An
Inappropriate Device for
Aerosol Studies?
the point
of impact on the oropharynx.
Newman
and the spacer be-
spacer,
comes
Clinical compari-
son of Gentle-Haler actuator and
radioactive
ber, but
stat-
GA, Raabe OG.
actuator using
with
Wong
Chipps BE, Nuumann PF,
1.
Aerochamber spacer
tagged
albuterol
Haler would be useful.
low-up period. Of course, as we
REFERENCES
delivery to
ed, additional studies of the Gentle-
fol-
MD
is
The measured oropharyngeal deposition was more than that claimed
by Dr Newhouse for the Aerocham-
each patient during the 6-hour
E Chipps
Sacramento, California
patients.
and about a 10% increase
velocity jet emitted by standard
Bradley
normal usage by asthmatic
typical of
on
with the high-
it
preferable for the typical patient.
was an appropriate
associated dosage
duction
associated
may make
Gentle-Haler
of the
believe that three puffs and this
geal deposition of particles and Freblast
device of choice, but the small size
suggested by Dr Newhouse.
/xg as
We
riod following treatment with albuterol.
we chose
of patient use involved delivery
ical
et al
2
also note that the
The
in-vitro evaluation
and com-
offers several po-
parison of the performance of de-
advantages for inhaler ther-
vices used to deliver medications by
apy: (1) reduction in 'cold Freon' ef-
metered dose inhaler (MDI) to the
Gentle-Haler
tential
fect
".
.
.
on the back of the
throat, a
ma-
lung
should
provide
accurate
and
jor cause of misuse of conventional
useful information to physicians, al-
MDIs,
in
lowing them some measure of con-
oropharynx from corticosteroid
fidence in choosing the best device
the
(2)
aerosols,
fewer local side effects
and
(3)
more time
for the
for their patients.
results obtained
The
validity of the
from these evalua-
volume. Thus, both the Aerochamber
patient to coordinate inhalation with
spacer and the Gentle-Haler actuator
actuation."
require less precise coordination of
similar to those associated with the
systems devised and the proper use
puff and inhalation than does a stan-
dard
MDI
actuator.
As described
in
our report,
1
MDI
only
about
50%
age
delivered by either the Gentle-
is
of the normal
dos-
Haler or the Aerochamber. The three
These advantages are
tions
depends upon the
use of the Aerochamber. Hence, the
of equipment to
Gentle-Haler actuator and the Aero-
ments.
chamber spacer provide similar benefits over the standard MDI. In some
situations, as described by Dr Newhouse, the Aerochamber may be the
by Ebert
'93 Vol 38
No 4
I
urements
make
in-vitro test
the measure-
believe that the recent study
1
et al
illustrates
how meas-
made on equipment
de-
signed for uses other than those in-
tended can produce data that are not
409
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Why use
LETTERS
applicable to the in-vivo clinical
sit-
mulation Atrovent (20 ^g/puff) con-
gave higher values for the
sistently
uation.
Ebert et al's paper describes the
size characteristics of aerosols gener-
ated by
MDIs
with various adapters
than Azmacort
accuracy
in
at
240
counting the fewer par-
or spacers used in the treatment of
ticles present in the
patients receiving mechanical venti-
would be
The equipment measuring the
aerosol was an optical (laser) particle
counter (OPC), and the number dis-
the
tributions of particle diameters for the
tion of the
lation.
various
MDI
drug aerosols were the
primary data obtained. This number
was then
distribution
tain the
cles with diameters
5.0 /im
utilized to ob-
cumulative volume of parti-
(ie,
respirable particles) and a
density of water
OPCs
between 0.67 and
( 1
.0
g/mL).
volume (ARV)
,ug/puff. The
available respirable
greater,
Atrovent sample
particularly
after
sample had been passed through
The use of a diluting
would also cause evapora-
While the
available to the patient.
end
may
results
not be different, the
numbers would be more acThe volumes quoted by Ebert
actual
curate.
et al are 6- to 200-fold higher than
4
for sim-
devices.
Bishop
those given by Bishop et
MDI
ilar
adapter
OPC
used a different
al
sampling
for
the isodiluter.
his aerosols
a
cumulative
airstream
sample of 80 drug doses
to get ad-
CFC
(chlorofluorocarbon)
MDI
propellants present in the
dose,
producing smaller-sized aerosol par-
equate numbers of particles for analysis.
ARV. The
rate
of evaporation varies
between drugs because
tion of the
composition of
a func-
is
it
CFCs
pres-
ent in the formulation.
among
The findings
That
in this
in
OPCs.
various
study are sim-
those of other investigations.
ilar to
is,
from a
56
the dose of aerosol delivered
MDI
used with a spacer tends
be greater than
to
would have been useful
This points out the variability
sensitivity
and. by definition, a greater
ticles
and needed
that
from
in-line
the
connectors and elbow devices. Thus,
an aerosol and classify them accord-
authors had provided data for the
the use of spacers in ventilator cir-
ing to physical diameter, not aerody-
MDIs
cuits
namic diameter (d ae ). However, the
d ae accounts for the density and ir-
to the original aerosol
by the use of these various spacer de-
comparison of the performance of
regular shape of the drug particles
vices in terms of both particle-size
devices
and more accurately predicts the be-
distribution
count the particles within
haviour of the aerosol as
de-
is
it
livered to or inhaled by the patient.
2
It
alone to illustrate the changes
brought about
and drug dose available
inhalation.
for
if
presenta-
Similarly,
number
tion of the primary data (ie,
would have indicated
The aerodynamic diameter can be
distributions)
measured by cascade impacters and
whether surfactant droplets, which
laser-sizing systems (eg. Aerosizer,
comprise approximately
API,
APS
and the
Massachusetts,
MDI
OPC, by
is
to provide
patients.
A
important information for
the user, but the instrument used to
make
one
these measurements should be
that yields data relevant to the
conditions that exist during use of
the product.
of each
num-
MB Dolovich PEng
design,
Assistant Clinical Professor
dose, were included in the
ber distribution. The
3300, TSI Inc. Minnesota).
15%
would be expected
more drug to ventilated
The Hiac/Royco 5250 OPC, used
does not differentiate between sur-
of Medicine
by Ebert and co-workers, operates on
factant-only droplets (no drug) and
McMaster University
by a
those containing drug. Because the
St Joseph's Hospital
the principle that light scattered
particle as
of light
size.
is
it
moves through
proportional to
While the
its
a
beam
physical
sensitivity of
OPCs
has increased with the use of laser
light, the
accuracy of the instrument
as a counter
is
determined
in part
by
the concentration of particles in the
volume of aerosol sampled. Greater
empty droplets
lets
are smaller than drop-
Hamilton, Ontario,
containing drug, the distribution
Canada
would be weighted to the smaller diameters, which would, in turn, influence the ARV calculation. Another
concern surrounds the lack of humidified air in the
sampling
circuit.
would lead
numbers of particles flowing past the
light beam, and, ideally, the volume
derestimation
of
should be diluted sufficiently to en-
medications.
is
obtained with reduced
and hence greater
—hence,
the
incorporation
A
an
OPC) would have allowed
these
plain
why
may
the lower-dose
RESPIRATORY CARE
devices in terms of aerody-
partly ex-
namic-size
MDI
MDI
for-
able
2.
a direct
comparison of drug delivery from
This
Adams AB. Green-Eide
characteristics
aerosols
No
4
and
mass
of
of
the
drug
MDI
B.
spacers and
volume of medication. Respir
Care 1992:37:862-868.
cascade impacter (rather than
50-fold in the test circuit described
et al.
J,
evaluation of
adapters: their effect on the respir-
diameter
of an isodiluter to dilute the aerosol
by Ebert
Ebert
An
to an un-
for all three
.
Swift DL. Aerosol characterization
and generation.
able each individual particle to be
counted 3
particle
ARVs
I
Un-
during pa-
like conditions that exist
tient use, this
accuracy
REFERENCES
In:
Moren
house
MT, Dolovich MB,
osols
in
agnosis
medicine:
F.
New-
eds. Aer-
principles,
di-
and therapy. Amsterdam:
Elsevier Science. 1985:53-76.
3.
Hinds
New
WC.
Aerosol
technology.
York: John Wiley
&
Sons.
1982:315-346.
411
LETTERS
4.
bution generated by MDIs.
to expectations for aerosol deposition
compressed the data
in the clinical setting. In
inhaler aerosol
by the
characteristics are affected
endotracheal tube actuator/adapter
1990;73:
Anesthesiology
used.
1263-1265.
M, Turpie F,
Com-
Posmituck G, Newhouse MT.
parative efficiency of aerosol deposition to the lung
from 4 devices
used with a metered dose inhaler
(MDI)
in
(MV)
patients.
mechanically ventilated
1991;4(Suppl
Rau
6.
made on more devices (which were
categorized)
ARV
de-
were maintained across four
vices
mean
medications, but, additionally,
ARVs
We
OPC,
among
differed
medications.
a device used in
many
settings
pharmaceutical
hospitals,
facilities.
All
an
adults:
in
vitro
have problems with
sizing systems
and accuracy,
sensitivity
1
'
2
but they
investigator of medical aerosol de-
Her comments describe the
operation of optical particle counters
believe
criticize their
that
accuracy
However, we do not
comments
her
detract
from the conclusions of our study.
Our goal was
among
the aerosols delivered via
metered
dose
inhalers
(MDIs)
through
various
devices
(adapters
and spacers) into a mechanical ven-
A number of such
tilation circuit.
de-
made com-
vices have recently been
mercially available, and their design
features could
impede or aid the de-
livery of aerosol particles in the res-
pirable range.
the
Our concern was with
differences
among
in
devices, and
sider the
volume
ARV
as
aerosol
we
generation and
delivery
did not con-
(available respirable
measured by an OPC)
as
terest.
diluter
The sampling with an
may have
introduced
ments by cascade impacters and/or
an aerosol particle sizer might have
could
cause
particle
loss
occurs,
among
it
be
should
similar
devices. Concerning the hu-
Kim
midification of the circuit,
et al
due to drying
humidified
system.
in
knowledged
ARV
that
able from our work.
We
we
outcome variables of the drug
may
devices
ferences and previous studies, but
to
make
a total of
1
we
,620 meas-
urements of aerosol particle
distri-
obligated to report
differences are best
Despite the technical concerns of
Ms
we
Dolovich,
believe our conclu-
Our
sions are sound.
data support the
design
affects
aerosol delivery and that the
number
notions
device
that
of
MDI
actuations
may need
customized according
be
to
to the clinical
we
need of the patient and the device
ac-
use.
Jerry Ebert
Alexander B Adams MPH
Beth Green-Eide MA
could have been
med-
St
in
Ms
RRT
RRT
RRT
Respiratory Care Services
Paul-Ramsey Medical Center
St Paul, Minnesota
Dolovich
REFERENCES
dose/puff differences
Vincent
J.
Aerosol sampling
sci-
ence and practice. Chichester NY:
cautioned
drawn from bench
Our
felt
ARV
vices.
sampling with an isodiluter
speculative.
we
explained by the designs of the de-
be factors.
We
we found such
vices. Nevertheless,
consistent differences in the bench
1.
among
could be surmised from design dif-
effect
through the various de-
after delivery
ication particle difference, or actu-
OPC
more ambitiously,
Perhaps,
suggested
sure differences, actuator style,
that
should
should have measured clinical
due to canister size or canister pres-
suggests
We
not explic-
We
ator-use technique, and
of
all
differences
among medications were
that the differences
an un-
Therefore,
chose not to add humidity.
mean ARVs.
3
MDI
found only a small effect on
particle size
alone.
study that
if
Reporting
study.
have provided data for the MDIs
equally
loss
our
compress our large table
to
of data to
them. The
spectrum, but,
/urn
we chose
iso-
oration of propellants with dilution
ARV
differences
observations with measure-
certain
some
The evap-
error, but that is not clear.
and
412
actually quite ac-
is
curate in the particle-size range of in-
an absolute value to be meaningful.
chose
the
would behave in the human
lung. The OPC, however, can be appropriate for bench studies of aerosol
across the 1-5
to determine, in a
bench study, whether differences exist
how
(d ae ), a better indicator of
Dolovich, an accomplished
in this setting.
were
Repeating
al.
our observations was impractical so
laser-
aerosols
(OPCs) and
4
et
The cascade impacters and
appreciate the insightful letter
livery.
found by Bishop
strengthened
respond:
Ms
ARVs,
particle-count-range data for
Adams, and Green-Eide
We
protocol,
absolute
in
have advantages and disadvantages.
do measure aerodynamic diameter
from
a different
and differences
me-
study. Chest 1992;102:924-930.
Ebert,
previously
spite of the use of
similar results and conclusions
measured the aerosol with an
including
OPC,
another
had
than
been reported. In
aerosol sampling systems, of course,
tered-dose bronchodilator delivery
intubated
among
differences
study, multiple
RJ, Groff JL. Eval-
uation of a reservoir device for
to
our bench
measurements were
egories for the nine devices tested.
companies, and research
1):8.
Harwood
J,
Med
Aerosol
J
to
we found significant differences in
ARV among devices and device catThese
Fuller H, Dolovich
5.
When we
mean ARVs,
Bishop MJ, Larson RP, Buschman
DL. Metered dose
that
conclusions
studies might be
reported
ARV
val-
ues should not be compared directly
Wiley, 1989.
2.
Heitbrink
proach
WA,
aerodynamic
RESPIRATORY CARE
Baron PA.
to evaluating
An
ap-
and correcting
particle sizer
measure -
No
4
LETTERS
Director of
Respiratory Care
Am
Ind
Hyg Assoc
1992;53(7):
J
427-431.
Kim CS,
3.
of metered-dose
aspects
Size
tory Care.
Op't Holt TB, Dunlevy CL. The
1.
MA.
Sackner
Trujillo D,
haler aerosols.
Am
use of preadmission criteria to pre-
in-
Rev Respir Dis
in a
4-year
We
are looking for a strong individual to lead
our dynamic, growing respiratory care department.
The candidate selected will have the opportunity to
create an ideal structure and environment tor con-
respiratory care curriculum. Respir
tinued growth.
Care 1992;37:439-443.
piratory Therapist (RRT). has a Bachelor's degree
The
Bishop MJ, Larson RP, Buschman
Tinto V. Dropout from higher ed-
2.
characteristics are affected
by the
1990:73:
Rev
research.
recent
Res
Educ
1975;45( 11:89-125.
endotracheal tube actuator/adapter
Anesthesiology
a theoretical synthesis of
ucation:
Garrison
3.
a
is
Res-
Registered
a Respiratory Care
in
environment Must
he able to demonstrate a thorough knowledge of
procedures, and equipment.
current techniques,
Excellent verbal and written
communications
skills
required.
DR. Dropout
prediction
within a broad psychosocial con-
1263-1265.
candidate
ideal
(Master's preferred), and has at least 5 years ex-
perience
DL. Metered dose inhaler aerosol
used.
academic success
dict
1985;132:137-142.
4.
Parkland Memorial Hospital, Dallas,
needs an experienced and seasoned Manager for Director of Respira-
Texas,
REFERENCES
ments and phantom count creation.
Our
Clinical facilities include Level
intensive care unit. Level
3 neonatal
trauma center with sepand a regional burn
1
arate adult and pediatric ICUs,
center.
text:
an analysis of Boshier's con-
Q
Educ
Adult
model.
gruence
1987;37(3):212-222.
Prediction Models and
Parkland
Health
the
nowned
School
We
known
las,
Their Application
is
the primary teaching hospital for
Center
Science
University
of
are located
for
its
at
Dallas'
world-re-
Texas Southwest Medical
in
the heart of exciting Dal-
economic growth, world famous
professional sports teams, shimmering glass sky-
Dr Op
't
Holt responds:
scrapers, restaurants of every cuisine, and a
new
Arts District. You'll find great weather, the friend-
read with interest the study by
I
Op't Holt and Dunlevy
would
academic
of
diction
and
success
Discussion
In the
on the pre-
1
we
in
our paper,
1
discussed the issue of our find-
ings' being specific versus being ge-
Are prediction
neralizable and noted that the specif-
models program-specific
(situational)
applied
findings
ic
only
our
to
or are they cross-program applicable
program and validated previous work
(universal)?
done by a faculty member
On
the basis of the literature, ed-
ucators appear divided on this point.
Tinto,
2
for example, takes the posi-
tion of generalization,
whereas Garri-
in
we suggested was
went through
to
most ex-
haustive regarding prediction of stuI
the nursing experience
is
believe that
dent success or failure.
respiratory
care
relevant to
profession be-
cause nursing like respiratory care
pletion.
that
ademic
programs
levels.
My
nursing literature
is
several
at
ac-
We
determine the
to
I
hope
raised
by
this
Mr
of
clarifies
the
issue
Holt
EdD RRT
Respiratory Therapy Division
School of Allied
Medical Professions
The Ohio
Columbus, Ohio
you
proving
"consummate
professional" and that you
are the
provide the best patient
care possible.
Pubic
Relations
REFERENCES
ac-
levels.
1.
begin
Doctoral Candidate
Tampa, Florida
w "><
Op't Holt TB, Dunlevy CL. The
use of preadmission criteria to pre-
James R Black
RESPIRATORY CARE
The best public relations
you can achieve with your peers
State University
replicated in other prodifferent
mi
"""
to
Black.
be
Holt-Dunlevy model can be made
ademic
values
Relation s
comes from
fulness (generalization) for the Op't
if it is
minimum
Tim Op't
claim of professionwide use-
grams of similar and
Public
predictors that assure academic suc-
cross-program applicable.
only
Parkland
cess."
predictive
models have not been found
stated "the procedure de-
programs whose faculty wish
for
analysis of the
that
eoe/aa
we
scribed here could serve as a model
offers levels of credentialing and ed-
ucational
Professional Placement
5201 Harry Hines Boulevard
Dallas, Texas 75235
determine the lowest
needed for successful program com-
erature appears to be the
Respiratory Care Recruiter
Parkland Memorial Hospital
applicable to other
programs was the process
possible entry grade point average
lit-
compensation and benpackage. Qualified candidates should submit
resumes to
offer a competitive
our pro-
In health professions, the nursing
A
efits
in-
tax.
We
gram. The only part of the paper that
son takes the position of specificity.
1
the
come
their
like to raise a question relative
to their conclusion:
people, affordable housing, and no state
liest
dict
academic success
in a
4-year
respiratory care curriculum. Respir
Care 1992;37:439-443.
No 4
American Association for
Respiratory Care
11
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TX 75229-4593
Dallas,
(214)243-2272
413
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TX
1
and mail notices
to
RESPIRATORY CARE
Notices Dept,
The American Respiratory Care Foundation Awards
1.
for 1993
$2,000 for the best original paper (study, evaluation, or case report) accepted for publication from November 1992
through October 1993. This award
is
not limited to papers based on
Open Forum
2 Four awards of $1,000 each for papers accepted for publication from
Forum
any Open
3.
Notices
75229-4593.
presentation (not limited to 1992
presentations.
November 1992 through October 1993 based on
Open Forum).
Five awards of $500 each for the best papers submitted (not necessarily published) by 1993
who have
'never published' in the Journal.
Meeting and must submit
November
Office by
a
Three awards of $333 each are
first
Open Forum
author must present the abstract
paper based on the abstract before the 1993 Annual Meeting (received
1993). Co-authors
1,
The never-published
to
may have
previously published in
at
participants
the
Annual
in the Editorial
RESPIRATORY Care.
be awarded to the authors of the three best features from Test Your Radiologic
Skill,
Blood Gas Corner, Kittredge's Corner, and PFT Corner accepted for publication from November 1992 through October
1993. All three (or none) of the features
may be chosen from
a specific category (eg, all three
may be chosen from Blood
Gas Corner).
All awards will be
made
at the
1993 Annual Meeting. Papers are judged automatically.
Registration
Any 1993 Open FORUM
No
application
is
necessary.
Reimbursement
presenter (or co-author designee), as in the past, will receive complimentary registration for an
adequately prepared paper based on his 1993
OPEN FORUM
abstract, submitted prior to or at the
1993 Annual Meeting.
THE NATIONAL BOARD FOR RESPIRATORY CARE— 1993 Examination and
Fee Schedule
Respiratory
Home
The only
Care
Equipment
single source
ofCGA, NFPA
and DOT
Regulations
Available from Steven McPherson, an acknowledged authority
on
respiratory
equipment, and Daedalus Enterprises. This book's seven chapters provide
all
home
care
equipment from
Coverage on
home
artificial
home
vital
care
information on
airways to ventilators. These chapters feature:
care ventilator patients.
Cleaning, disinfecting, and monitoring procedures to minimize infection.
Guides
for educating staff on
equipment, therapy, patient assessment, and
safety.
Procedures for gas administration and monitoring devices, humidifiers and nebulizers,
artificial
airways and resuscitators, respirators, and ventilators.
Hardcover, 192 pages, Item BK7, $18.00
(AARC Members
— $15.00)
plus
$3.00 shipping for each book.
/ need Respiratory
Send me
U
d
[Zl
Payment, plus $3.00 shipping
Bill
me,
Charge
Home
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copy(ies).
my purchase
to
my
order
Visa
for
each book,
number
is
enclosed
in
the
amount
of
$
is
MasterCard
Card Number
X
Name
Address
AARC Member Number
(necessary
for
AARC member price)
Mail to: Daedalus Enterprises, P.O. Box 29686. Dallas, TX 75229-9998
item
bk7
Not-for-profit organizations are offered a free advertisement of up to eight lines
in
RESPIRATORY CARE. Ads
two months preceding
CARE,
1
the
for other meetings are priced at $7.00 per line
month
which you wish the ad
in
TX
and
t<
re
Submit copy
to run.
|
,
.
on a space-available
include pediatric
topics
mental
environ-
pulmonary
update,
monitoring, asthma update.. For information, call Kelvin
MacDonald BS RCP RRT(213) 667-6635.
AARC Videoconference. The AARC, in
VHA Satellite Network, presents the
Topics include neonatal/pediatric/adult ICU topics, ther-
May
apist-driven protocols, research in respiratory care, and
conjunction with
HHN vs MDI controversy.
third
Call (701
)
224-7870.
13
13-15 in Catlinburg, Tennessee. The
its
TSRC
Annual Convention and Exhibition, "Walk
on the Wild Side,"
at the
River Terrace Resort. Sched-
MEd RRT, Tommy
uled speakers are John Hiser
MEd RRT, Sam
Giordano
MBA
Rounds
RRT, John Walton
MD,
RRT, Robert Kac-
MBA MHA
MEd
Dunne
Patrick
entation,
in
"Therapist-Driven
Care," features George
G
RRT, and Damon Law-
May
nostic
presents
its
22nd Annual Conference, "Diag-
and Application Update '93,"
management. For
ventilation,
and
at
exhibits, call
Candy
(615)
384-1569.
Camino Real
N
Memorial Hospital, 2001
TX 79902.
(915) 542-6563.
line
registration information, call Colleen
Schabacker
the
protocols,
therapist-driven
neonatal
at
Paso Del Norte Hotel. Contact Stephanie Echols, Respiratory Care, Providence
CPT,
Respiratory
in
MD and Sam Giordano
19-21 in El Paso, Texas. The Southwest Region,
TSRC,
Oregon, El Paso
infections,
"Pro-
MBA RRT. Call (214) 830-0061.
tions in health care, professionalism, mechanical ventila-
augmented
Protocols
Burton
son RRT. Topics include test-taking techniques, transi-
nosocomial
titled
Respiratory Care." The third pres-
Rust
marek PhD RRT, Jim Fink RRT, Beth Roark RRT,
Larry Gentilello, Brian Carlin
is
of a 6-part videoconference series
fessor's
tion,
interpretation,
ECMO
mechanics, cardiac disease and treatment, non-invasive
EdD RRT. Dean Hess MEd RRT, Robert Kacmarek
PhD RRT, George Burton MD, and Beth Roark RRT.
presents
x-ray
concerns,
health
NDSRC
len
April
Calendar
of Events
month
Annual Convention and features Deborah Cul-
April 12-14 in Bismarck, North Dakota. The
its
Calendar of Events
the 25th of the
is
Calendar of Events, RESPIRATORY
75229-4593.
AARC & AFFILIATES
hosts
basis, in
insertion order. Deadline
rtion orders to
on
For information
May
19-21 in Jekyll Island, Georgia. The Georgia/
Carolina
South
committee
VI
Region
Annual Conference and Assembly
Partee at (615) 443-6816.
at the
presents
its
Holiday Inn.
Topics include analgesia, sedation, and paralysis; emerApril 13-16 in Cincinnati, Ohio. The Ohio, Kentucky,
and Indiana Societies host the 20th Annual Region
Respiratory Care Meeting, "Going Platinum!"
for
II
at
the
B Sabin Convention Center and Hyatt Regency
Hotel. Contact Dave Dunlap, Chair, at (606) 292 4271
(Monday and Friday) or (606) 344-2058 (Tuesday,
Albert
gency airway care; resonant ventilation of the lungs;
lung transplantation; controversies surrounding circuit
changes; and advances
antimicrobial therapy. Contact
Barber, Spartanburg Regional Medical Center, 101
East
Wood
May
Wednesday, Thursday).
in
Bob
St,
SC
Spartanburg
29303. (803) 591-6524.
22-25 in Spokane, Washington. The Respiratory
Care Society of Washington presents the 20th Annual
April 26-28 in Philadelphia, Pennsylvania. The
presents
the
its
Adam's Mark
Hotel. This year's
theme
piratory All-Stars: Building Pride through
The Pennsylvania
tured.
PSRC
28th Annual Conference and Exhibition
State
Sputum Bowl
Contact Betsy Schneck
Kathy Yandle
at
at
is
at
"Res-
Teamwork."
Finals are fea-
(215)
829-3578 or
(215) 453-4517.
Pacific Northwest Regional
ence
at
Cavanaugh's Inn
at
Respiratory Care Conferthe Park. Specialty sections
focusing on pediatrics, management, pulmonary functions, critical care,
and computers are planned.
A
post-
graduate pulmonary physiology course, panel discussion
on hospital restructuring, special moonlight
statewide
Sputum Bowl
finals are scheduled.
and
cruise,
This
is
the
largest respiratory care conference in a 5-state region.
May 4-5 in Industry Hills, California. Chapter 4 of the
CSRC and Kaiser Permanente host the 3rd Annual Neonatal
Pediatric
Tournament
Pulmonary Care Conference and Golf
at the
Sheraton Hotel and Resort. Featured
RESPIRATORY CARE
For more information and
Bob Bonner.
to receive a brochure, contact
Respiratory Care Program. Highline
munity College,
PO Box
98000,
Des Moines
Com-
WA
98198.(206)783-6845.
417
CALENDAR
KRCS
May
26-28 in Salina, Kansas. The
16th
Annual Educational Seminar, "Clinical and Legal
Issues:
presents
its
The Future of Respiratory Care." Scheduled
speakers include Jack
K
Clausen
MD;
Frank Stennek
A Hoffman JD
RRT: Cheryl Brown MHA: and Larry Buney JD. Topics
PhD: John Goodman BS RRT; David
pulmonary diagnostics and exercise
include
testing,
and
transtracheal ventilation, therapist-driven protocols,
medical,
and licensure
legal,
issues.
information, contact Cindy Fazell
RRT
1234 or Russ Babb
at
mation on exhibits, contact
For registration
CRTT
at
(913) 243-
April 22-23 in Napa, California. The California Soci-
Pulmonary Rehabilitation hosts
ety for
Conference, "Rising
To
Valley. Contact Gerilynn Connors
Morris
May
Napa
or Kathleen
14-15 in Las Vegas, Nevada. The American Lung
piratory
Health
Conference
Casino. Topics include
at
Eileen Ruiz, American
Harrah's
nutritional
ARDS, and
dependent neonates,
and
Hotel
assessment,
drug-
sleep disorders. Contact
Lung Association of Nevada,
NV
4100 Boulder Hwy, Las Vegas
823-4245.
BS RRT,
Association of Nevada presents the 8th Annual Res-
(913) 826-6191. For infor(913)
4th Annual
RN MS RRT at (707) 963-6588.
Don Hedden RRT
at
its
the Future," at the Inn of
89121. (702) 454-
2500.
August 11-13
Albuquerque,
in
Mexico Society
for Respiratory
convention
the
at
Albuquerque
Highlights include lectures by
Lewis and Thomas
New
Mexico. The
Care presents
Convention
AARC
Petty, Robert
its
New
annual
President Diane
Kacmarek. and Louise
Nett. Contact Schuyler Michael. Pulmonary Rehab,
Box 26666, Albuquerque
NM
87125-6666.
May
16-19 in San Francisco, California. The Amer-
ican
Lung Association and American Thoracic Society
Center.
PO
(505) 841-
host an International Conference. Vital information on
the prevention and control of lung disease
a variety of
J
New York NY
June 11-13
in
10019-4374.
Memphis, Tennessee.
and Health Centers presents
Care Symposium, designed
April 20-21
in
Little
Rock, Arkansas. Respiratory
CRTT
Care Services of Arkansas Children's Hospital presents
ren,
its
Annual Pediatric/Neonatal Cardiopulmonary Care
presented in
O'Donnell, American Lung Association, 1740 Broad-
way,
1741.
OTHER MEETINGS
is
symposia and workshops. Contact Maureen
its
St
Joseph Hospital
13th Annual Respiratory
to prepare candidates for the
exam. Contact Dot Younginer or Konnye War-
St Joseph
Hospital,
220 Overton, Memphis
TN
38105.(901)577-2780.
Conference. Special sessions focus on current and future
trends
asthma treatment and education, metabolic
in
monitoring
in
in the
ICU. primary pulmonary hypertension
newborns, and other issues. The meeting also features
poster
sessions
Mike Anders
and roundtable
RRT
or Shelley
discussions.
Dedman RRT,
Contact
Respiratory
Care Services, Arkansas Children's Hospital. 800 Marshall St, Little
418
Rock
AR 72202.
(501) 320-3535.
October 24-29
in Jerusalem, Israel.
Congress of Asthmalogy convenes
The XlVth World
in Jerusalem.
Topics
presented include molecular biology in lung disease,
cells involved in asthma,
and the house-dust mite and
asthma. Abstracts are currently being accepted. Contact
Gil-Kenes, Suite 946, 1617
JFK
Blvd, Philadelphia
PA
19103.(800)223-3855.
RESPIRATORY CARE
RE/PIRATORy QVRE
Manuscript-Preparation Instructions for
Authors and Typists
General Information
advisable to consult the F.ditor before writing or submitting
such a paper.
Rfspiratory Care welcomes
original manuscripts related to
respiratory care and prepared according to these Instructions.
Perfection
not required, but efforts in that direction are
is
Computer
appreciated.
may
paper drawing attention to a pertinent concern;
problem into focus.
Letter:
A
signed communication about prior publications in
this journal, or
in these Instructions.
tions
Editorial consultation
available by telephone or letter
is
any stage of planning or writing. Specific guidance
at
(in printed
may
Blood Gas Corner:
respiratory
a case report, an evaluation, a review, overview, or update or a
cussion.
book review:
PFT
for converting to
name
of journal
is
TX
and for
in-
model manuscript,
list
units;
abbreviations, and copy of these Instructions
available. Write to
Dallas
and from SI
typists, a
Respiratory Care.
75229-4593, or
call
1030 Abies Lane.
1
(214) 243-2272
ble-blind manner. Accepted manuscripts
for clarity
and
in a
dou-
may be copyedited
authors receive galleys to proofread
style:
illustra-
care
A
brief, instructive
blood data
— with
title,
case report involving
questions,
answers, dis-
Corner: Like Blood Gas Corner, but involving
monary function tests.
Test
Your Radiologic
Skill:
pul-
Like Blood Gas Comer, but
involving pulmonary medicine radiography and including one
or
Manuscripts are reviewed by authoritative referees
about other pertinent topics Tables and
be included. Type double-spaced, supply a
mark "For publication."
form) will be provided on request for writing a research paper,
house manuscript review. For
it
present an opposing opinion, clarify a position, or bring a
diskette submissions are encouraged
and may reduce processing and review time. See requirements
A
Editorial:
more radiographs, may involve imaging techniques other
than conventional chest radiography.
Review of Book, Film, Tape, or Software:
ical
review of
A
balanced,
crit-
a recent release.
before publication. Published papers are copyrighted by the
publisher and
may
not be published elsewhere without per-
Considerations
mission.
Prior and Duplicate Puhlication:
Publication Categories
Research Article:
A
Work
that
has been pub-
lished or accepted elsewhere usually should not be submitted.
report of an original
investigation (a
instances, the F.ditor
In special
may
provided that permission to publish
study).
is
consider such material,
given by the author and
other publisher. Please consult the Editor before submitting
Evaluation of Device/Method/Technique:
evaluation of an old or
new
A
description and
modification.
Case Report:
was treated in
Authorship: All persons
A
report of a clinical case that
a
new way,
or
is
is
uncommon,
managing physician must
or
exceptionally instructive. All
authors must have been associated with the case.
A
case-
either be an author or furnish a letter
Article:
A
comprehensive,
critical
summary of
erature and state-of-the-art
has been the subject of
ticipated in the reported
not
critical
at least
A
A
paper with collective (corporate) authorship must
is
review of the
40 published research
not justified solely on the basis of solicitation of funding,
lit-
a pertinent topic that
collection or analysis of data, provision of advice, or similar
services. Persons performing such ancillary services
articles
in the
Acknowledgments
may
be
section.
review of a pertinent topic about which
enough has been published
Update:
manu-
should be able to publicly discuss and defend the paper's
content.
recognized
Overview: A
should have par-
the shaping of the
should have proofread the submitted manuscript; and
script; all
all
listed as authors
work and
specify the key persons responsible for the article. Authorship
approving the manuscript.
Review
such work.
device, method, technique, or
to merit a
Review
Conflict of Interest: Authors of research or evaluation papers,
Article.
report of subsequent developments in a topic that
points of view, or editorial are asked to disclose on the
script's title
has been critically reviewed
Point of View Paper:
A
in this
A
going categories
may be
may have
paper expressing personal but sub-
stantiated opinions on a pertinent
Special Article:
journal or elsewhere.
and controversial
topic.
RESPIRATORY CARE
•
APRIL
'93 Vol 38
No
4
with a manufacturer or distributor whose product
figures in the submitted manuscript or with the manufacturer
or distributor of a competing product. (Such arrangements will
pertinent paper not fitting one of the fore-
acceptable as a Special Article.
manu-
page any liaison or financial arrangement they
It
is
not disqualify a paper from consideration and will not be dis-
closed to reviewers.)
419
INSTRUCTIONS FOR AUTHORS & TYPISTS
Details about Sections:
Preparation of the Manuscript
addition to reading these Instructions, authors and
Note:
in
typists
can benefit from inspecting papers recently published
Respiratory Care and using them
in
Make
Title:
as
as models.
Title Page: List (a)
and
titles,
11 in.) with
bond paper, 216 x 279 mm (8 in. x
least 25 mm (1 in.) on all sides of the
side of white
margins of
at
page. Double-space the entire manuscript (three lines per vertical
Number
inch).
pages
all
paragraphs 5 spaces.
Do
headings, or other words.
identification
in
upper-right corners. Indent
not justify.
Do
Do
not underline
titles,
not type authors' names or other
anywhere except on the
title
page. Repeat
title
only (no authors) on the abstract page. Begin each of the fol-
lowing on a new page:
sources
list,
appendix,
the
first
page, abstract, text, product-
title
acknowledgments, reference
list
each
table,
of figure legends. Use standard English.
person and active voice (eg,
fly") rather than the 'obscure person'
is
list,
believed that pigs can fly")
"We
believe that pigs can
(eg, "It
the latter obscures the
and type them
in capital
section headings on the page
and small
letters (eg.
Introduction,
Methods, Results, Discussion). Begin subheadings
margin and type them
Equipment,
and small
in capital
Statistical Analysis).
Do
at the left
letters (eg. Patients,
not underline or darken
and address for reprint requests;
sources of support such as
and date of any meeting
tion, location,
(f)
name
of organiza-
at
which
a version of
the paper has been presented; (g) disclosure of financial relations of
any author with commercial products or
interests con-
—
or with competing products or inter-
nected with the paper
ests; (h)
name,
any; and
(i)
and
title,
disclaimers,
affiliation of statistical consultant, if
if
any.
Abstract: (required only for research articles and evaluations
of devices/ methods/techniques). The abstract must summarize
what was studied; why and how
drawn from
must also appear
the abstract.
it
was
studied; the results,
the results. All information in the abstract
in the
The
paper
itself.
Do
not cite references in
abstract for a research article should include
the following headings (in
all
capital letters), appropriately
placed within the abstract and followed by colons:
BACK-
GROUND, METHODS, RESULTS, CONCLUSIONS.
should
for
a
include
The
paper evaluating a device/method/technique
BACKGROUND,
following headings:
the
DESCRIPTION OF DEVICE, EVALUATION METHODS, EVALUATION RESULTS, CONCLUSIONS. The
Manuscript Structure
Most kinds of papers have standard parts in a standard order,
as shown hereafter. However, papers can vary individually,
all
(e)
and supplies;
grants, equipment, drugs,
abstract
section headings or subheadings.
and not
name, address (include
room number for courier service), telephone
number, and Fax number of corresponding author; (d) name
building and/or
clusions
main
in Text: Center
all
professional
including important data and statistical significance; and con-
identity of the responsible party (the believer).
Headings
institutional affiliations; (c)
names of
full
letters,
Employ
and passive voice
— because
each
of the paper; (b)
title
with academic and credential
authors,
General Specifications
Type on one
and yet as short
the paper's title as specific, clear,
you can.
papers will have
all
abstract should be
case
the parts listed here.
all
one paragraph, not indented, and not
longer than 250 words. Center
letters,
title,
typed in capital and lower
over abstract.
Introduction: Briefly describe the background of the work or
Research Article:
ods,
Title Page, Abstract, Introduction,
Discussion,
Results,
Conclusions,
Product
Meth-
Sources,
Acknowledgments, References, Tables, Appendices, Figure
Legends.
the paper. Cite only pertinent references,
subject extensively.
the
work reported
Do
in
and do not review the
not include data or conclusions from
your paper. In a research paper, end
this
section with a clear statement of the research question(s) or
hypothesis(es).
Evaluation of Device/Method/Technique: Title Page, Abstract, Introduction,
Description of Device/Method/Technique,
Evaluation Methods, Evaluation Results, Discussion, Conclusions,
Product
Sources,
Acknowledgments,
References,
Tables, Appendices, Figure Legends.
Methods Section
(in a research paper):
Describe the selection
of patients, controls, or laboratory animals. Give details about
randomization. Describe methods for blinding of observations.
Give numbers of observations. Report losses
(eg, dropouts or disqualified subjects), listing
Case Report:
Title Page, Introduction,
Case Summary, Dis-
jects or data sets lost,
when
lost,
and why
to observation
numbers of sub-
lost.
Describe meth-
cussion. References, Tables, Figure Legends.
ods
Review Article: Title Page, Table of Contents, Introduction,
Review of the Literature, State -of-the-Art Summary, Acknowl-
ences and brief descriptions for methods that have been pub-
edgments, References. Tables, appendices, and
modified methods, give reasons for using them, and evaluate
in sufficient detail to
allow other workers to replicate your
work. Give references to established methods; provide refer-
may
be included. Other formats
may be
illustrations
suitable.
Point of View Paper: Title Page, Text, References. Tables
and
420
illustrations
may be
included.
lished but are not well
their limitations.
Drugs
—
known; describe new or
substantially
Report calibration of measuring devices.
Identify precisely
all
drugs and chemicals used, giving
generic names, doses, and routes of administration.
If
desired.
'93 Vol 38
No 4
brand names
may be
given
in
parentheses after generic names.
—
Commercial Products Identify any
(including model number if applicable)
—
parentheses in the
in
mentioned, do not
them on
list
the first time
name,
tioned, giving the manufacturer's
try
commercial
city,
it
men-
is
state or
coun-
product,
list
name and model number,
or country. Manshould be included when the study
the generic term, brand
name,
manufacturer's
and
city,
ufacturer's suggested price
state
or evaluation has cost implications. For example;
four or more products are
text. If
any manufacturers
list
and
product
in the text; instead,
a Product Sources page at the
end of the
before the References. Provide model numbers
and manufacturer's suggested price
if
when
text
available
Manual
Resuscitators:
BagEasy, Respironics
Code
PA, S20.50
Inc. Murrysville
Totowa NJ, $19.85
Blue, Vital Signs Inc.
the study has cost impli-
Ventilators:
cations.
Ethics
— When reporting experiments on human
subjects, indi-
cate that procedures were in accordance with the ethical stan-
dards
of
committee
institution's
the
human
on
experi-
mentation. State that informed consent was obtained after the
nature of the procedure!
When
tions.
Do
had been explained.
s)
patient's names, initials, or hospital
numbers
in text
not use
or illustra-
7200, Puritan-Bennett Corp. Overland Park
KS
Bear Cub. Bear Medical Systems. Riverside
CA
Acknowledgments Page: On this page you may recognize the
services of persons who made ancillary contributions to the
work or the manuscript. Such services might be advice about
methodology; data collection;
on the
was followed.
and other services. Each acknowledgment must specify the
vice rendered.
—
advice or analysis;
manuscript preparation; in-house review;
patient, or subject;
the institution's or any national guide or national law
care and use of laboratory animals
Statistics
statistical
equipment selection or operation; cooperation as caregiver,
reporting experiments on animals, indicate that
Named
ser-
persons must provide written agreement
(accompanying submitted manuscript)
to
be so recognized.
paragraph of the Methods section, iden-
In the last
used
tify the statistical tests
in
analyzing the data, and give the
References
prospectively determined level of significance. Cite references
of
to support choices
cles, not
(Cite textbooks or published arti-
tests.
handbooks of commercial software.) Identify any gen-
eral-use or commercial computer programs used,
naming man-
Use of References: References
Be
to further information.
careful to
reason for a specific citation
ufacturers and their locations.
are used to support statements
of fact, to indicate sources of information, or to guide readers
(ie,
make
clear in the text the
do not imply support of
a
statement of fact by citing a reference that simply addresses
Results Section: Present results
Tables and illustrations
the text
may
in logical
sequence
also present data.
summarize only important observations and
report
all
Do
and evaluated by the authors. Cite only published or accepted
Be
sure to
for the Dis-
not discuss the findings in the Results sec-
Exact p values are preferred
when
the issue). Cite only sources that have actually been consulted
not repeat in
emphasize or
trends.
do not save some of them
the results;
cussion section.
tion.
Do
the data in the tables or illustrations:
all
in the text.
cases but are essential
in all
values are not statistically significant.
Do
not report orig-
merely as nonsignificant or NS.
inal results
material.
review
Cite
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in
more than 3 years old and make every
mine whether an
citing
Avoid
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abstract has been subsequently published as a
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When
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Reference
original
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numerals.
is
Do
first
2. etc.
number
if
reference you cite
After the
you
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cite
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Type
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not
list
references double-spaced, using the styles of the
8.
and books, capitalize only
with
nebulised
pentamidine
(letter).
Lancet 1988;2:905.
words and
first
Smith DE, Herd D, Gazzard BG. Reversible bronchoconstriction
List all authors (do not use "et al").
examples given hereafter.
In titles of articles
Letter in journal:
cit" or
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Spell out in full the
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torial,
or
item's
title.
Do
letter, identify
it
Provide both
item
is
or nonindexed
and
last
Obtain authors' names,
article
9.
Hess D.
New
therapies for asthma. Respir Care (year, in
press).
complete page numbers.
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and book
titles,
dates,
and
volume and page numbers from the original cited articles and
books, not from other articles' reference lists, which often are
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Paper accepted but not yet published:
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bers.
known
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If the cited
Examples of correct reference listings follow (these
must be double -spaced in a manu-
Personal author book: (Specific pages should be cited whenever possible.)
10.
Nunn
JF.
Applied respiratory physiology.
New
York:
Appleton-Century Crofts. 1969.
are single-spaced here but
script).
Note:
To
specify pages in a book, place a colon after the year
Article in a journal carrying pagination throughout
and then
volume:
1969:85-95 (series of contiguous pages), 1969:85,95 (separ-
list
the
Examples:
page(s).
1969:85 (one page).
ated pages).
1.
Shepherd KE, Johnson DE. Bronchodilator
testing:
analysis of paradoxical responses. Respir Care
an
1988;
33:667-671.
Article in publication that
numbers every
Corporate author book: (Specific pages should be
whenever possible.)
issue beginning
11.
with Page
2.
1:
American Medical Association Department of Drugs.
AMA drug evaluations. 3rd ed.
Bunch D. Establishing a national database
care. AARC Times 1991;15(Mar):61,62,64.
for
3.
article:
establishing
units
12.
chronic
patients in hospitals. Respir
ventilator-dependent
ods of numbering and identifying supplements. Supply suf-
Chapter
interstitial
pulmonary
fibrosis.
Chest 1986:89(3. Suppl):139s-143s.
Abstract in journal: (Abstracts are not strong references.
Abstracts more than 3 years old should not be cited.
cited, abstracts
should be identified as such.)
reduce environmental
exposure (abstract).
whenever
AK. Acute respiratory failure. In: Guenter CA.
Welch MH. editors. Pulmonary medicine. Phildelphia:
JB Lippincott, 1977:171-223.
Pierce
Newspaper
14.
article:
CFCs may
Rensberger B, Specter B.
be destroyed by
The Washington Post 1988 Aug 7:Sect
A:2(Col5).
Respir
Care 1990;35:1087-1088.
Dictionary or similar reference:
Editorial in journal:
15.
6.
Pulmonary medicine.
When
Stevens DP. Scavenging ribavirin from an oxygen hood
to
editors.
in book: (Specific pages should be cited
natural process.
5.
MH.
JB Lippincott, 1977.
possible.)
allow retrieval.)
Reynolds HY. Idiopathic
Guenter CA, Welch
Philadelphia:
13.
4.
when-
editor(s): (Specific pages should be cited
Care 1988:33:1044-1046.
Article in journal supplement: (Journals differ in their meth-
ficient information to
CO: Publishing
ever possible.)
for Respiratory Care. Criteria for
for
Littleton
Sciences Group, 1977.
home
Book with
Corporate author journal
cited
Rochester DF. Does respiratory muscle
fatigue or incipient fatigue? (editorial).
Am
rest
Pneumohemopericardium. Dorland's
dictionary, 26th ed. Philadelphia:
relieve
medical
illustrated
WB
Saunders. 1981:
1038.
Rev Respir
Dis 1988;138:516-517.
Tables: Use tables to display information, compare data, or
show
Editorial with no author given:
7.
High frequency
1
422
:706-708.
ventilation
(editorial).
Lancet
1991;
trends. Start each table
struct a table with
on
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Do
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fewer than four lines (rows) of data (instead,
columns
put the data in the text). Avoid
more than
8
RESPIRATORY CARE
• APRIL
'9.3
across.
Vol 38
No
4
Number
Table
tables as
order of their
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1,
mention
first
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2, etc,
in the text.
Place the
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all
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tions (asterisk, dagger, double dagger, etc) in consistent order,
Type
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1,
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If a figure
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its
in
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to
course).
placing them superscript in the table body.
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Supply the name
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weight, and volume
Give temperatures
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Hg). Report hematologic and clin-
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Show
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pressures (including blood gas tensions) in
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SI equiv-
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when possible, in brackets following non-SI values—for example. "PEEP, 10 cm H:0 [0.981 kPa]." For conversion to SI, see Respiratory Care 1988;33:861-873 (Oct
alent values,
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Number them
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I,
1988) and 1989;34:145 (Feb 1989).
double-spaced throughout.
it
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with final figures to be prepared after review. Figures
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izontal
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x 4
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and unusual abbreviations
Use an abbreviation only
if
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33%.
first
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Standard units of measurement can be abbreviated without
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many
great
spaced
is
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inches will be
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the term occurs several times in the
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is
Abbreviations and Symbols: Use standard abbreviations and
viations in the
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Accuracy
common!
errors are
must be of professional qual-
may accompany
but rough sketches
script,
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mitting the paper.
list
torr, 2.3
employ a
kPa). If you
abbreviations and symbols, provide a double-
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sult the
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No 4
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423
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it.
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1.
Use
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sure the manuscript
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to
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not Fax manuscripts. Protect figures with cardboard
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A
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in
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that
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Keep
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Is
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You
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all
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Has
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11.
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Have
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ticipated in the
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424
its
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RESPIRATORY CARE
all
authors?
—
1993 Call for Abstracts
Respiratory Care
The American Association
for Respiratory
Care and
its sci-
•
Open Forum
Abstract Format and Typing Instructions
ence journal. Respiratory Care, invite submission of brief
and selected authors
abstracts will be reviewed,
will be invited
Open Forum during the AARC Annual
Meeting in Nashville, Tennessee, December 11-14, 1993. Accepted abstracts will be published in the November 1993 issue
to present
papers
at the
Membership
of Respiratory Care.
in the
AARC
is
Accepted abstracts
The
abstracts related to any aspect of cardiorespiratory care.
not nec-
should be the
stract
will be photographed. First line of ab-
title in all
plain content. Follow
capital letters. Title should ex-
with names of
title
authors (including
all
and location. Underline presenter's
credentials), institution(s).
name. Type or electronically
print the abstract single
spaced
space between sentences. Text submission on diskette
essary for participation.
in
the space provided on the abstract blank. Insert only one letter
is
en-
couraged but must be accompanied by a hard copy. Identifiers
Specifications— READ
masked (blinded)
will be
CAREFULLY!
paragraph. Data
An
abstract
may
report
1)
(
an original study, (2) the eval-
uation of a method or device, or (3) a case or case series.
Topics
may
habilitation,
be aspects of adult acute care, continuing care/ reperinatology/pediatrics,
cardiopulmonary
management of
nology, health occupations education, or
sonnel and health-care delivery.
presented previously
at a local
The
tech-
abstract
or regional
—but not
national
meeting and should not have been published previously
national journal.
which
per-
may have been
the reviewers can decide
by
whether the author should be
invited to present a paper at the Open Forum. Therefore, the
abstract must provide all important data, findings, and conclusions.
Give
specific information.
Do
lotted.
not write such general
Make
the abstract all
in table
one
form and simple
may be included provided they fit within the space alNo figures, illustrations, or tables are to be attached to
the abstract. Provide all author information requested in right
column of
A
abstract form.
photocopy of the abstract
clear
form may be used. Standard abbreviations may be employed
without explanation.
A new
or infrequently used abbreviation
should be preceded by the spelled-out term the
used.
in a
abstract will be the only evidence
The
figures
for review.
may be submitted
if
Any
first
is
it
explained.
grammar,
spelling,
(3)
recurring phrase or expression
conformance
Check
facts,
first
may be
time
it
is
abbreviated
the abstract for (1) errors in
and figures;
(2) clarity
to these specifications.
An
of language;
abstract not pre-
may not be reviewed. Questions about abmay be telephoned to the editorial staff of
Respiratory Care at (214) 243-2272.
pared as requested
stract preparation
statements as "Results will be presented" or "Significance will
Deadlines
be discussed."
The mandatory
Essential Content Elements
thors will be
An
original study abstract must include
(
1 )
Introduction: state-
ment of research problem, question, or hypothesis;
(2)
Method:
description of research design and conduct in sufficient detail
to
permit judgment of validity; (3) Results: statement of re-
search findings with quantitative data and statistical analysis;
(4) Conclusions: interpretation
of the meaning of the results.
method/device evaluation abstract must include
duction: identification of the
method or device and
(1)
its
A
—
only
to
Final Deadline
is
notified of acceptance
be mailed by August
15.
June 7 (postmark). Auor rejection by letter
Authors may choose to sub-
mit abstracts early. Abstracts received by March 19 will be re-
viewed and the authors notified by April
will be
accompanied by
24. Rejected abstracts
a written critique that should in
many
cases enable authors to revise their abstracts and resubmit
them by
the final deadline (June 7).
Intro-
intended
Mailing Instructions
function; (2) Method: description of the evaluation in sufficient detail to permit
(3) Results: findings
mary of
judgment of
its
objectivity and validity;
of the evaluation; (4) Experience: sum-
the author's practical experience or a notation of lack
Mail (Do not fax!) 2 clear copies of the completed abstract
form and a stamped, self-addressed postcard
(for notice of re-
ceipt) to:
of experience; (5) Conclusions: interpretation of the evaluation
and experience. Cost comparisons should be included where
possible and appropriate.
case that
is
uncommon
A
case report abstract must report a
or of exceptional teaching/learning val-
ue and must include: (1) case
summary and
Respiratory Care Open Forum
11030 Abies Lane
Dallas
TX
75229-4593
(2) significance of
case. 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.
RESPIRATORY CARE
425
J
.
Open Forum
1993 Respiratory Care
Abstract
Form
1
Title
must be
thors'
2.
in all
names and
Follow
title
upper ease (eapital)
text in
letters,
au-
upper and lower case.
with all authors' names including cre-
dentials (underline presenter's name), institution,
and location.
3.
4.
5.
Do
Do
not justify
(ie.
leave 'ragged' right margin).
not use type size less than 9 points.
must
All text, tables, and figures
fit
into the rec-
tangle shown.
6.
Submit 2 clear copies. This form may be photocopied
7.
if
For more
multiple abstracts are to be submitted.
details, see
accompanying examples and
editorial.
Presenter's
Name &
Credentials
Presenter's Mailing Address
Presenter's Voiee
Phone
Corresponding Author's
&
Fax
Name &
Credentials
Corresponding Author's Mailing Address
&
Corresponding Author's Voice Phone
Mail original
&
Fax
photocopy
1
(along with postage-paid postcard)
to:
Respiratory Care Open Forum
11030 Abies Lane
Dallas
Early deadline
is
March
TX
75229
19. 1
99
(abstract received)
Final deadline
is
June
7,
1993
(abstract postmarked)
8.1
426
cm
or 3.2"
RESPIRATORY CARE
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out
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interrupting
be
to
home
with-
activities.
Patients undergo the ambulatory test
after a trained clinician provides a
brief
program on how
to operate the
The following morning
recorder.
test is retrieved
and the
the
results are
forwarded to the physician for diagnosis;
OSA
those
are
who
positive
test
for
then referred to a sleep
NMC
treatment.
laboratory
for
Homecare,
Reservoir
1601
Place,
Trapelo Rd, Waltham
MA
02154.
(617)466-9850.
STRESS TEST MONITOR.
AARC SUMMER FORUM
Ac-
Vail, Colorado, July 16-18. 1993
cording to the manufacturer, Quinton's
Q4500
stress test
monitor pro-
vides system flexibility never before
possible in a stress test system: faster
NEON-COLORED NEBULIZERS.
and
Schuco's new Neon Nebulizers (30
editing, unlimited storage, in-test
final
custom
reports,
tionary digital
filtering
system
random noise without
reduces
stricting
Q4500
and a revolu-
the
that
re-
range of signals. The
provides narrative and tabular
summaries, trend graphs, averaged-
RESPIRATORY CARE
psi
as
AC
units in
Day Glo
colors such
neon blue and neon pink) mark
the beginning of a
new
trend in
home
care equipment that will help keep
patients
spirited.
manufacturer,
According
these
to
the
nebulizers
are
AARC ANNUAL CONVENTION
SITES & DATES
1993 Nashville, Tennessee
December 11-14
1994 Las Vegas, Nevada
December 10-13
1995 Orlando, Florida
December
2-5
1996 San Diego. California
November
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427
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409
Howard. William
413
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Chatburn, Robert
405
Kovac, Anthony L
Chipps, Bradley
407
Lugtigheid, Gerard
400
409
Newhouse, Michael
409
Pierson. David J
343
Steinberg, Kenneth
343
Stoller,
409
Sutherland,
348
van der Weygert, Ernst Jan
348
373
Wood, Douglas E
388
Bear Medical Systems
399
MSA
410
BCI
331
Newport Medical
328
Pulsair Inc
Adams. Alexander B
Black, James R
L
E
Conway, Nancy
Dolovich,
MB
Ebert, Jerry
Ford,
GT
Golar, Sandra
D
Green-Eide, Beth
Grootendorst, Albert
Hickling, Keith
F
G
405
373
M
351
348
T
407
413
Op't Holt, Tim
362
365
P
K
LLA
398
James
343
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International Inc
Bird Products Corp
Burroughs Wellcome
DHD
403, 404
Co
Medical
326
336
406
Puritan-Bennett
337,
340. 341
338
Ross Laboratories
Drager Critical Care Systems
332
Siemens Medical Systems
HealthScan Products
335
Sherwood Medical
Cover 2
Cover 4
Mallinckrodt Sensor Systems
401
3M
Cover 3
Medical
Pharmaceuticals
Employment:
404A
See Career Opportunities
Parkland Memorial Hospital, Dallas
428
TX
...
413
RESPIRATORY CARE
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110 Bird Products Corp
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135 BCI International
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112
Burroughs Wellcome
Exosurf
131
DHD
Medical
Aerosol Cloud Enhancer
101
(ACE)
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Critical
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136 HealthScan Products
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140 Mall inckrodt Sensor
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Portable Blood
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Medical Products
Electrolyte
122
MSA
MiniOx Monitor
115 Newport Medical
Wave
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102
Pulsairlnc
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98 Puritan-Bennett
PB3300 Intra-Arterial
Blood Gas Monitoring
System
129 Puritan-Bennett
7200 Ventilator Series
125 Ross Laboratories
Survanta
103 Siemens Medical
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155
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130
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issue.
Current beta2
aerosol inhalers:
For most
patients,
a juggling
act.
Specialists don't have to be told that traditional aerosol
inhalers are a problem. They
know the
difficulty
most
patients
have coordinating pressing and breathing.
Soon there will be an answer from
3M Pharmaceuticals.
Coming soon.
The
in
3M
3M
first significant advance
aerosol technology in 35 years.
Pharmaceuticals
Health Care
St. Paul,
Minnesota 55144-1000
Circle 130
VOLDYNE
Wy
Volumetric Incentive Deep-Breathing Exerciser
The accuracy
patients
Voldyne 2500
A
of Voldyne, in a new size, matched to geriatric
and patients with smaller lung capacities.
...
smaller, lighter flow
cup reduces the work of breathing, thus
improving patient performance and progress.
Every
unit
reliability
is
individually tested
and superior accuracy
and calibrated
for
performance,
of inhaled lung volume.
Volume incentive spirometry improves assessment of patient
progress by eliminating the guesswork associated with spirometers
that only measure flow.
Graduations printed on both sides of the unit allow the therapist to
conveniently observe volumes while instructing and encouraging
the patient.
For further information, contact your Sherwood
Representative or call
OR. /Critical Care
_ _
...»
on
1-800-325-7472
(outside Missouri)
1-800-392-7318
(in
Missouri)
A Sherwood
^^
MEDICRL
©1991 Sherwood Medical Company
Circle 155
®

Respiratory care : the official journal of the American Association for

Transcription

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