June - Respiratory Care

Transcription

JUNE
1
998
VOLUME 43
NUMBER 6
ISSN 0020-1324-RECACP
RE/PIRATORy
A MONTHLY SCIENCE JOURNAL
YEAR— ESTABLISHED 1956
43RD
CASE REPORTS
Acute Pulmonary Edema following Upper
Airway Obstruction
REVIEWS, OVERVIEWS & UPDATES
Leukotriene Modifiers
in
the Treatment of Asttima
1997 PHILIP KITTREDGE
MEMORIAL LECTURE
Mechanical Ventilation: The Next 50 Years
"Three weeks aqo,
Andrew was struqqlinq to breathe'.
"Thanks to Ohmeda,
resuscitation wasn't a stinjqqle for us."
Ki'Uy
^:._,
Hendmm.
R.N.,
St^ Nmye/NlC. U.
Hetrhey Medical Caiter/Pmn State Geisinger Health Systmi
tei^
In the often-hectic
environment of a
I
typical
resuscitation, the last thing
you need
are scattered
components to deal with.
why
That's
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Infant Resuscitation System
combines
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of the
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one
.„,,,,„
Ohmeda miant
module.
eas\'-to-use
The Ohmeda
.""
.
Infant
Resuscitanon
tie
ResuSCltatlOn System Can
System combines everything imo
one compact,
versatile imit.
be used on
all
incubators
and warmers.
For even more
versatility,
die unit
can be driven from wall vacuum or
cyhnders.
Making die Ohmeda
Infant Resuscitation System the
one product
'
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'
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that's
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a
Call us today
'
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ng
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little
easier.
on reader service card
i « «
tkissnnMtr!
T
^
c
i-
Each year respiratory
therapists face
'
t*
new
challenges and
opportunities due to the
ever-changing health care industry.
This meeting will present the answers
and attitudes responsible for
The program
is
success.
approved by the American
Association for Respiratory Care for continuing
respiratory care education credits. Participants are
invited to attend the education,
\.
general sessions
in
management, and
any combination to meet their
professional education
and personal needs. For
more information
visit
our
web
site at
www.aarc.org.
»-.
"pp^^^^^
^^^H
You'd be surprised what new EasiVent" will hold.
And
so will your patients.
Any
holding chamber will hold a dose of respiratory
Chamber
Or any
medication. But only the EasiVent'" Valved Holding
is
designed to hold the complete
MDI
kit inside.
other personal treasure of modest size.
'
Physicians, respiratory therapists,
,
and patients indicate a preference
for the
unique design of EasiVent™.* Since EasiVent'" improves the portability of asthma
treatment,
it
encourages patient compliance.
NAEPP
a
guidelines also
recommend
that
holding chamber to maximize dose delivery.
all
patients using corticosteroids use
Which
is
exactly
what
EasiVent'"
is
designed to do.
EasiVent'"
instructions
improves medication delivery and simplifies patient
advanced features such as a dual, low-resistance
printed on the unit, and built-in coaching signal.
valve, universal
MDI
EasiVent'" Valved Holding Chamber.
advanced design also helps the patient
•Data on
medication. And that's no fish story.
training, with
port,
graphic
Help your patients with compliance. Specify the
It
not only holds the complete
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benefit from their
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Circle 102
l*M-755-55(iO
©1998 DEY
All righls reserved,
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iew
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ASSOCIATE EDITORS
D
RichartJ
Branson
RRT
R
Dean
PhD RRT
Hess
Massachusetts General Hospital
University of Cincinnati
Harvard University
Ohio
Cincinnati.
Boston. Massachusetts
G
MD
MD
University of Virginia
K Stoller
The Cleveland Clinic Foundation
Charlottesville. Virginia
Cleveland, Ohio
Charles
Durbin
Jr
James
EDITORIAL BOARD
A
Thomas
EdD RRT
Barnes
Leonard
D
Hudson
MD
Northeastern University
Seattle,
Michael
J
MD
Bishop
Robert
M
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Kacmarek PhD
RRT
Washington
PhD RRT
Joseph L Rau
Massachusetts General Hospital
University of Wasliinglon
Seattle.
C Mishoe PhD RRT
Shelley
Medical College of Georgia
Washington
Georgia State University
Harx'ard University
Atlanta, Georgia
Bartolome
Tiifis
R
Celli
MD
Toshihiko Koga
University
Catherine
MD
SH
Sassoon
Long Beach.
Kurume. Japan
California
L Chatbum RRT
Robert
H
MD
Arthur S Slutsky
University Hospitals of Cleveland
Marin
Case Western Resen'e University
Washington University
University of Toronto
St Louis. Missouri
Toronto. Ontario,
Cleveland. Ohio
Luciano Gattinoni
MD
Kollef
Patrick Leger
MD
Martin
University of Milan
Clinique Medicale Edouard Rist
Milan. Italy
Paris.
E
John
Heffner
MD
Neil
J
Mavwood.
Maclntyre
MD
Canada
MD
Tobin
Loyola University
France
R
MD
University of California In'ine
Koga Hospital
Boston. Mas.âchusetts
Illinois
MD
Duke University
Durham. North Carolina
University of Arizona
Phoenix. Arizona
STATISTICAL CONSULTANT
Mark
MD
J Heulitt
John
University of Arkansas
Little
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Ward MEd RKT
Abstracts
Summaries of Pertinent
Articles in Other Journals
Commentaries,
Editorials,
& Reviews To Note
Gastric Rupture after Inadvertent Esophageal Intubation with a Jet Ventilation Catheter
—
TB. Aneslhesiology 1998;88(2):537-538.
Gilbert
—Clarke M, Chalmers
Meta-Analyses, Multivariate Analyses, and Coping with the Play of Chance
Lancet 1998;351(9108):I062-1063.
I.
PEEP: More than Just Support?
1998:24(1):
I
— Femandez-Mondejar
E,
Vazquez-Mata G. Intensive Care
Med
-2.
Ethics Review and Clinical Trials— Madder H. Myles P.
McRae
R. Lancet
1
998:35 1(9 08): 10651
1066.
Use of the Breathing Reserve To Interpret Submaximal Exercise Responses
— Mahler DA. Chest
1998:1 13(4):858-859.
Ventilator-Induced
Am J
Saumon G.
Lung Injury: Lessons from Experimental
Med I998:I57( ):294-323.
Respir Crit Care
— Dreyfuss D,
Studies (Review)
I
The Health Care Costs of Smoking (Letter)— Fries JF. N Engl J Med I998:338(7):470-47L The
Health Care Costs of Smoking (Letter)— Hodgson TA. N Engl J Med 1998:338(7):470. Women,
Smoking, and Lung Cancer (Editorial)— Stover DE. Chest 1998:1 13(
1-2.
1
Vena Caval
J
Med
Pulmonary Embolism
Filters for the Prevention of
(
Editorial )
N Engl J Med
Protective Ventilation for Patients with Acute Respiratory Distress
N
son LD.
Engl
J
Med
1
Skin Vasomotor Reflex Predicts Circulatory
SVmR amplitude had decreased to < 0.
Responses to Laryngoscopy and Intubation
control group (n
—
Sakamoto M. Terasaki H.
Anesthesiology 1998:88(2):297.
=
15), intubation
regardless of changes in the
In
Study
reactivity
may
to intubation.
evaluation of autonomic
help to predict circulatory responses
The
relation
between the magnitude
of the skin vasomotor reflex
(SVmR)
immediately
before laryngoscopy and the circulatory respon.ses
to intubation
was examined.
METHODS:
Forty-
MAC (n = 9) or
SVmR
was
and heart
rate
nificantly (p
lanyl
11)
were
fen-
and thiamylal and maintained with nitrous
oxide and sevoflurane. The
by an electroslimulus
SVmR
was evoked
to the ulnar nerve,
and de-
In [he
SVmR amplitude.
was maintained
at
Study
1,
inten-
the blood pressure
of the control group increased sig)
after laryngoscopy.
The blood
SVmR amplitude and the systolic blood pres-
lation (p
<
showed
0.(X)l
).
In
a significant linear corre-
Study
2, the relation
the electric intensity and Ihe
showed
0.01
)
a
weak
in the
I
between
SVmR amplitude
but significant correlation (p
<
MAC group. CONCLUSION: The
SVmR
Helium Versus Oxygen for Tracheal Gas
sufflation
zov R, Oppenheim A, Eidelman LA, Weiss
Spmng CL, Cotev S. Crit Care Med
ferent physical properties,
in patients
with respiratory
intensive care unit in a tertiary university medical center.
PATIENTS: Seven
etiologies. All patients
446
14),
were studied.
In the
monitored group
laryngoscopy was perlormed when Ihe
vidual palienls.
in indi-
in the vol-
mode (Vx 5-7 mL/kg). Inclusion criwere Pacch of > 50 torr (> 6.7 kPa), together
teria
cm HiO and respiratory rate
INTERVENTIONS: All pa-
lienls
=
were ventilated
ume-control
depth for laryngoscopy and intubation
patients
sedated and par-
alyzed patients with respiratory failure of various
of > 14 breaths/min.
(n
DESIGN: Prx>
SETTING: General
failure.
spective, intervention study.
mation lor determining the optimal anesthetic
(if
helium and oxygen, as
an adjunct to conventional mechanical ventilation
iaser-Doppler flow meter. In Study
provides useful infor-
the effect
of tracheal gas insufflation using 2 gases with dif-
evaluation of the
2 groups
Pi-
YG,
1998:26(2): 290.
OBJECTTVE: To evaluate and compare
creases in skin blood flow were detected using a
I,
In-
—
during Mechanical Ventilation
I
pressure of the monitored group did not increase.
sure changes
or
1 .
was performed
by changing the elecuic
In
< O.OI
The
I
998:35 1(9098):277-282.
MAC (n = 6) for 5 min. The
.3
tested
four adult patients (classified as American Soci-
was induced with
1
RESULTS:
sity.
ety of Anesthesiok)gists physical stanis
studied. General anesthesia
—Hud-
induction, the end-tidal con-
2. after
centration of sevoflurane
BACKGROUND: An
l998:338(4):239-247.
Syndrome (Editorial)
1998:338(6):385-387.
Cystic Fibrosis (Review)— Rosenstein BJ, Zeitlin PL. Lancet
Ikula Y,
—Haire WD. N Engl
1998:338(7):463-464.
Respiratory Function of Hemoglobin (Review)— Hsia CC.
Shimoda O,
):
wilh Pimax of > 35
that
were intubated with an endotracheal tube
had an additional lumen opening
RESPIRATORY CARE
•
at its dis-
JUNE 1998 VOL 43 NO 6
IIRIENTHTION HNO
COMPETENCY flSSURHNCE MflMUHL EOR RESPIRRTOfiY CflRll
Garner some applause of your own!
With the Orientation and Competency Assurance Manual for Respiratory
Care, you can ensure that your staff receives a structured orientation and
that
competence
is
periodically assessed
and documented. The Manual
provides you with a resource and examples to create a customized orien-
and competency assurance system
tation
And,
to
it
for respiratory care services.
provides the information, assessment tools, and models necessary
demonstrate that the competence of employees
according to
JCAHO
documented
is
requirements.
"The Clinical Performance Evaluations in the manual
were a great way to get all my staff working at the
same performance level, regardless of where they
went to school. Consistency of care are key words in
health care today, and everything I needed to develop a staff-leveling program was right there."
- John
H. R/ggs,
PhD,
RRT
The Only Orientation and
Competency Assurance Manual
that Gives You All This.
. .
'
team for meetm
Initial
Assessment and Document
Employee
of
Experience, Education, and Credentials
'
Competency
Validation
in Critical
Organizational
Competency Checklists
•
Construction of Clinical
•
Improvement of Competency Assessment Congruency
•
Reporting of Competence Patterns and Trends
System Safety Practices
• Integration of
'
Competency Assessments with
Departmental Orientation
In-Services and Continuing Education
mJ/exceeMnj
'
Orientation and
Competency
Validation for General
•
Respiratory, Adult Critical, Neonatal/Pediatric
mtmmzuJts"
•
'
Orientee Progress Evaluations
'
Preceptor Training and Competency Validation
>
System
•
for the Selection,
Ongoing Assessment,
PhD,
RRT
Appendix-Self-Learning Module
for Critical
Appendix-Orientation and Competency Validation
for Multi-Skilling
and Cross-Training
in
Perinatal Care
Skills,
•
and Competency
H. Riggs,
Linkage of Job Description, Competency
Organizational System Safety Practices
Maintenance, Improvement of
John
for
Annual Performance Evaluation,
and Performance Improvement
and Age-Specific Patient Populations
tkeir
System
Level,
Respiratory Care, Diagnostic Testing,
Appendix-Sample Performance Evaluation Instrument
By Daniel Grady, MEd, RRT; Valerie Lawrence, RRT; Tammy Caliri, RRT;
and Mitzi Johnson, RNC, MSN. 258 Pages, Binder. 1997
$65
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Abstracts
tal
end. through which tracheal gas insufflation
was administered. The
tracheal gas insufflation
was applied continuously throughout
the respi-
and 6 L/niin) with
ratory cycle at 3 flow rates (2. 4.
2 gases, oxygen and helium, while the ventilatory
.sellings
MEASURE-
were maintained constant.
MENTS & RESULTS:
In
addiuon
airway pres-
lo
have demonstrated significant improvements
outcomes
patient
ical ventilation,
(eg. shorter durations
in
of mechan-
lower incidence of ventilator-asso-
ciated pneumonia, fewer patient complications)
as a result of implementing formal
Our hope
tocols.
is
weaning pro-
tha[ these data will assist other
own
hospitals in developing their
systematic guide-
and protocols for weaning patients from
sures and arterial hlood gases, the relative effi-
lines
cacy of tracheal gas insufflation with each gas was
mechanical ventilation.
as the
change
Paco^/Pinm) compared
in
with baseline measurements. Tracheal gas insufflation with both gases
< 0.05)
decreased Paco; signifi-
flow
rates.
This effect was
accompanied by an increase
in Pa„,
with both ga.ses
cantly (p
at all
(o.xygen and helium). However, at flow rates of
6 L/min. tracheal gas
insufflation with
helium
re-
sulted in lower Pi„,a, than with oxygen. Tracheal
gas insufflation with helium was more effective
(as estimated
by the coeftlcieni of efficiency) than
with oxygen at
SION:
all
tilated patients
CONCLU-
flow rates (p < 0.05 ).
In volume-controlled,
mechanically ven-
with respiratory failure, tracheal
were measured
during acute
in 15 patients
respiratory failure, within 24 hours of the institution of mechanical ventilation,
when
during recovery,
and
in
ume
[fk/Vx]); rapid shallow breathing-occlusion
(ROP =
P,,
x fR^r; Pi
i
Questions
Crucial
the
1998:1
— Fein
AM.
Chest
Suppl):277S.
1.3(4
spiratory time
(n
=
1
Patients
[t|]).
who
failed to
had a similar ROP.fRA'r and Pu
1 )
significandy reduced Po i/VtAi, the value of which
Emphysema and other forms of chronic obstructive pulmonary diseazse (COPD) are not only
common, but also have a poor prognosis. Mortality with severe COPD may be as high as 60%
at 5 years
and
associated with a significant
is
degree of disability and cost to the health care sys-
Dr Otto Brantigan's experience
when multiple-wedge resections of
tem. Building on
1950s,
in the
emphysematous lung were performed
to decrease
failed to
who weaned
who
wean was similar to that of patients who
weaned
successfully.
was comparable
successfully (n
of patients
to that
= 38). The
Pimax of patients
We conclude that patients
who failed to wean had a breathing
lar to that
pattern simi-
during acute respiratory failure, despite
a reduced mechanical load on the respiratory muscles
and a relatively adequate inspiratory mus-
cle strength. This suggests that strategies that
enhance respiratory muscle endurance
itate
lizing
L,
Brock
WA. New
Horst.
HM.
Prang
mon
is
one of the most com-
medical therapies administered within ICUs.
Similarly, the
"weaning" or "liberation" of patients
from mechanical ventilation
is
a
common and
extremely important task performed
in
ICUs and
emphysema
to treat
There a Better Right-Sided Tube for OneLung Ventilation? A Comparison of the RightSided Double-Lumen Tube with the Single-
lo the treat-
known
as lung vol-
reduction surgery (LVRS), pneumectomy.
Is
Lumen Tube
— Campos JH.
Anesth Analg 1998:86 (4):696.
for a 20 to 30% reduction in lung volume and
may be performed by stapler or laser resec-
aim
tion, or both.
The mechanisms of benefit have
enhanced
Anatomic
between tracheal carina and
variation
the take-off of the right upper bronchus often
makes
the use of a right-sided
(R-DLT)
rection
ness to be liberated from mechanical ventilation
improved efficiency of respiratory musculature,
vent) undesirable. This study
and for conducting the weaning process. Clini-
and improved
with the
ICUs frequently develop
(heir
that
to
of ventilation
remain
elastic recoil, cor-
perfusion
mismatch,
right ventricular filling. Questions
to
be answered include duration of
benefits, safety,
and cost of LVRS. The National
double-lumen tube
or a single-lumen tube with right-sided
ious methods exist for assessing a patient's readi-
personal preferences regarding the best
Massa EC.
and reduction pneumoplasty. These operations
been attributed
own
Enclosed
Right-Sided
with
Bronchial Blocker
specialized ventilator units within hospitals. Var-
cians working in
facil-
include excision of large bullae (bul-
ment of emphysema. The operations used
ume
may
weaning.
improved surgical and anesthetic technique,
have redeveloped a surgical approach
tous lung and are variously
Mechanical ventilation
uti-
lectomy) and resection of diffusely emphysema-
Horiz 1998:6:52.
wean
|/Pin,ax
to those with acute respiratory failure despite a
reducing hyperinflation, recent investigators,
Care Unit— Kollef MH.
i/Pimax);
and effective inspiratory impedance (Pu i/Vj/in-
Lung Volume Reduction Surgery: Answering
lung volume, thereby improving airflow and
sive
fol-
breathing index (respiratory frequency/tidal vol-
as an alternative to oxygen.
Reducing the Duration of Mechanical VentiThree Examples of Change in the Inten-
patients
The
lowing indices were calculated: rapid shallow
gas insufflation with helium might be suggested
lation:
49
they were ready for discon-
tinuation from mechanical ventilation.
pressure index
estimated using a "coefficient of efficiency" (which
we defined
(Pimax)
enclosed bronchial blocker tube
R-UBB
to
(R-UBB) (Uni-
compared
the
R-DLT
determine whether there was
any advantage of one over the other during anesthesia with one-lung ventilation
(OLV)
for right-
approach to weaning patients from ventilatory sup-
Heart. Lung, and Blood Institute and the Health
sided thoracic surgeries. Forty patients requiring
of wean-
Care Financing Administration have responded
right lung deflation
port. Therefore, variability in the practice
ing patients from mechanical ventilation
is fre-
to the
demand
quently demonstrated, even within a single ICU.
tion about
Recently, several randomized clinical
registry
trials
have
more access
for
LVRS
to
and informa-
by organizing both a national
and conffolled
clinical trial of these pro-
produced conflicting results regarding the best
cedures over a 7-year period. This multicenter
technique for carrying out the weaning process
trial
(eg.
spontaneous breathing
mandatory
lation).
intermittent
trials,
ventilation, pressure-support venti-
Such conflicting findings have
trated the
the difficulties in identifying the "besf medical
"
practices for carrying out this endeavor.
However,
other investigations have suggested that the selec-
weaning
employing
a systematic
approach
lo this
medical process. Prolocol-guided weaning of
mechanical ventilation
in the
ICU
setting, often
perfomied by non-physicians, has gained
in
tance as a result of these invesligalions.
scribe Ihc recent experience of three
448
LVRS
to
to
compare methods of
bilateral
maximal medical therapy.
accep-
Wc de-
ICUs which
to
one of two groups. Twenty patients received a
right-sided
BronchoCalh double-lumen
tube,
and
20 received a Univent tube with a bronchial blocker placed in the right
mainstem bronchus. The
lowing were studied:
(
1
)
tion each tube until satisfactory
achieved; (2)
fol-
time required to posi-
number of times
placement was
that fiberoptic
bron-
choscopy was required (including one with the
Breathing Pattern during Acute Respiratory
Failure
and Recovery
— Del Rosario N. Sassoon
CS. Chctty KG. Gruer SE. Mahutte CK. Eur
RespirJ iy97;l()(
1
1
patient supine and one in lateral decubitus position);
(.3)
number of malpositions
of tubes per case.
The objccfive of
(his
study was to compare the
breathing pattern of patients
from mechanical ventilation
ing acute respiratory failure.
who
failed to
wean
to the pattern dur-
We hypothesized that
a similar breathing pattern occurs under both conditions. Breathing pattern,
sure
(Pii |),
and
mouth occlusion
maximum
after initial con-
fimiation of tube placement; (4) time required until
lung collapse; (5) surgical exposure: and (6) cost
):2.560.
patients
from mechanical ventilation may not be as important as
emphysema
further illus-
complexity of the weaning process and
tion of an individual technique for
intends to enroll patients with end-stage
were randomly assigned
No dil lercnccs were
any of these variables except
sition overall
the
was
R-DLT. No
served
in the
radiograph
in
tliat
greater for the
right
found with
the cost of acqui-
R-UBB
than for
upper lobe collapse was ob-
postoperative period in the chest
any of the patients studied.
We con-
pres-
clude that either tube can be used safely and effec-
inspiratory pressure
tively for right-sided thoracic surgeries that requins
RHSPIRATORY CARE
•
JUNE 1998 VOL 43 NO
6
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all
the best links to other
slated
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They're there, on our website, at
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ost-effectiveness of
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4
Abstracts
OLV.
anesthesia for
Implications: In this study,
right-sided double-lumen tubes were
compared
with the Univent with right-sided bronchial blockers.
The results
indicate that either tube
can be used
Oxide Production
during Sepsis Docs Not Prevent Lung Inflam-
— Aaron
mation
Mullen JB,
.SD,
Valenza
Volgyesi G.
F.
AS, Stewart TE.
Slut.sky
was
worse
significantly
Crit
Med
Care
L-NAME did
not.
in rats that
from
to originate
the lungs of rats after .septic lung injury.
The aim
of this study was to investigate whether treatment
NO synthase inhibitor N-nitro-L-arginine
(L-NAME) would prevent
methyl ester
lipopoly-
saccharide (LPS)-induced increases in exhaled
and whether
L-NAME had more in-
would have an
this
lung inflammation.
DESIGN:
effect
on septic
Prospective, ran-
SUBJECTS:
SETTING:
University laboratory.
Male, anesthetized, paralyzed, and
mechanically ventilated Sprague-Dawley
=
27).
INTERVENTIONS:
Rats were mechan-
40 breaths/min, Vt 3 mL,
(expiratory rate
tive end-expiratory pressure 0. Fio, 0.21
were then randomized
jections of either
=
1
1 )
=
10).
of saline 5 min
was collected
in
later.
1
NO from the lungs
exhaled
but that this inhibition does not
rats,
may worsen
Thereafter, exhaled gas
polyethylene bags for measure-
ments of NO concentration. After 4 hours, the
were
killed
amined
To examine the effect of
and LPS on mean arterial blood pres-
histologically.
L-NAME
sure,
rats
and the lungs were preserved and ex-
6 additional
rats
underwent the same ven-
Preventable Adverse Drug Events in Hospi-
A Comparative Study of Inten-
Care and General Care Units
Sweitzer BJ, Bates
DW.
A, Leape LL. Crit Care
with
Upper Respiratory Tract
in
Children
Infections:
A
—
Comparison with Endotracheal Intubation
AR, Pandit UA. Voepel-Lewis T. Munro HM,
Anesth Analg 1998;86(4):706.
S.
DJ,
Med
1997;25(8):I289.
it.
Tait
Malviya
—Cullen
Burdick E, Edmondson
OBJECTIVES: To compare
Use of the Laryngeal Mask Airway
a suitable alter-
native to the endotracheal tube.
sive
hibit the increase in
proceed with anesthesia for the
mask airway provides
laryngeal
talized Patients:
that
the frequency
and
preventability of adverse drug events and potential
adverse drug events
in intensive
care units
(ICUs) and non-ICUs.To evaluate systems factors involving the individual caregivers, care unit-
teams, and patients involved
each adverse drug
in
event by comparing ICUs with non-ICUs and
Several studies suggest
tracheal tube
(
ETT)
piratory infection
plications.
laryngeal
placement of an endo-
tliat
a child with an upper res-
in
(URl) increases the
However,
risk
of com-
development of the
the
mask airway (LMA) has provided
thesiologists with an alternative
to
1
to
compare
it
The study
(3
mo
for elective surgery
with a URI. Patients with URIs were randomly
LMA (n = 41
)
ETT
= 41 or
(n
)
a
and were followed for the appear-
ance and severity of any perioperative complications.
The two groups were
to age, gender, anesthesia
ber of attempts
ing
at
adult admissions to a stratified,
1
1
all
random sam-
medical and surgical units
in
2 tertiary
ical
and 2 surgical general care
Two tertiary care
hospitals:
1
units.
gical units, including 2 medical
and 3 surgical
PATIENTS: Adult admissions
ICUs.
INTERVENTIONS:
None.
SETTING:
medical and sur-
1
(n
= 4,03
1 ).
MEASUREMENTS
& MAIN RESULTS: Rate of preventable adverse
drug events and potential adverse drug events,
length of stay, charges, costs, and measures of the
were detected by
unit's environment. Incidents
similar with respect
stimulated self-report by nurses and pharmacists
and surgery times, num-
and by daily review of all charts by nurse inves-
lube placement, and present-
URl symptoms. There were no
between groups
1
ple of
cluded 2 medical and 3 surgical ICUs and 4 med-
with the ETT.
allocated to receive either an
4,03
care hospitals over a 6-month period. Units in-
LMA in children with
6 yr of age) who presented
Pros-
anes-
management. This study was therefore designed
to evaluate the u.se of the
DESIGN:
medical ICUs with surgical ICUs.
pective cohort study. Participants included
means of airway
sample consisted of 82 pediatric patients
dose) or an equal vol-
to
L-NAME can in-
conclude
URIs and
LPS (Salmonella
made
is
CLUSION: We
posi-
mg/kg/h x 4 h)
sion
child with an upper respiratory infection, then the
L-NAME. CON-
They
Both groups were again
to receive either
typhosa: 20 mg/kg I.V. x
ume
).
to receive intravenous in-
L-NAME (25
or saline (n
randomized
NO
with air filtered to remove
ically ventilated
(n
rats (n
piratory infections. Results suggest that if the deci-
treated rats that did not receive
NO
domized, placebo-controlled animal laboratory
investigation.
LPS-
did not receive LPS; however,
Increases in exhaled nitric oxide
(NO) have been demonstrated
with the
that did
not cause lung inflammation
reduce lung inflammation, and
OBJECTIVES:
2 groups of rats
flammatory interstitial infiltrate (p < 0.05) and a
trend toward worse lung injury than did LPS-
of septic
1998:26(2):309.
in the
which received LPS compared with the 2
treated rats that received
for right-sided thoracic surgery.
Inhibition of Exhaled Nitric
tion
differences
tigators. Incidents
were subsequently classified
by 2 independent reviewers as
whether they
to
incidence of cough, breath-
represented adverse drug events or potential ad-
holding, excessive secretions, or arrhythmias.
verse drug events and as to severity and preventa-
in the
Although one patient
ETT group required
in the
bility.
Those individuals involved
in the
prevent-
inter-
a muscle relaxant for laryngospasm, the overall
able adverse drug event and potential adverse drug
nal carotid artery so that systemic arterial pressures
incidence of laryngospasm was similar between
event underwent detailed interviews by peer case-
tilation protocol
with cannulation of the right
could be measured.
SULTS: Exhaled
ments of
NO
MEASUREMENTS & RE-
gas was collected and measure-
concentrations were
made using
chemilumine.scence every 20 min for 240 min during ventilation.
A total lung injury score was cal-
culated by determining the extent of cellular infiltrate,
exudate and hemorrhage.
pressure
was recorded every 5 min
Mean
for
arterial
20 min and
then at 20-min periods for 120 min. Exhaled
concentrations increased in
that did not receive
all
the LPS-treated rats
L-NAME by
was reached by 190 min
teau
LPS
(p
< 0.(K)1
L-NAME and LPS
exhaled
NO.
).
20 min;
1
that
mately 4 times greater than control
with
rats not treated
show an
Administration of
pressure in 2 rats treated with
by LPS. This increase
in
with
increase
in
L-NAME induced
a lO-min nonsustained increa.se in
was
a pla-
was approxi-
In contrast, rats treated
did not
NO
mean
arterial
L-NAME followed
mean
arterial
pressure
not seen in 2 placebo and 2 LPS-treated rats
thai did not receive
i50
L-NAME. Lung
intlamma-
the
two groups. There was, however, a
bronchospasm
greater incidence of mild
ETT group compared with
significantly
the
LMA group
in the
(
1
2.2%
investigators.
was 19 events/ 10(X)
0%, p < 0.05). The incidence of major arterial
oxygen desaturation events (SpOj < 90%) during
rate of
placement of the airway device was also
(p
vs
signif-
ETT group (12.5% vs 0%,
icantly increased in the
p < 0.05). Furthermore, the
total
number of
episodes of respiratory complications,
ie,
all
breath-
holding, laryngospasm, bronchospasm, and major
oxygen desaturation, was
the
all
ETT group (35
vs
1
9.
non-ICUs
(25 events/
events/
1
000
in the
easily
managed,
LMA offers a suitable alterin
children with URIs.
compares the use
ol the
ICU
rate
(
1
for the
previous 24 hours
ICUs and non-ICUs.
ferences in rates between
ICU
were
rate
significantly
When adjusted
verse drug event were greater
this,
controversial, results from this
ETT for use
surgical
p < 0.05). Despite
mask airway with the endotracheal tube
for airway management in children with upper reslaryngeal
patient days).
number of drugs used
acuity, length of stay,
and severity of the adin
ICUs than non-
ICUs, but there were no differences between med-
ICU and
interviews
Implications: This study
000 patient days) was
or ordered since admission, there were no dif-
ical
native to the
The medical ICU
)
risks associated with anesthetizing a child with
study suggest that the
(p 0.01
).
significantly greater in
respiratory complications
URl remain
1
ICUs
patient days, nearly twice that
< 0.05 higher than the
and there were no adverse sequelae. Although the
an
The rate of preventable adverse drug
events and potential adverse drug events in
surgical
indicated
ICU
patients. Structured
almost
between ICUs and non-ICUs
teristics
many
charac-
of the patient, patient care team, systems,
and individual caregivers.
rate
no differences
for
CONCLUSIONS: The
of preventable and potential adverse drug
events was twice as high in
ICUs compared with
non-ICUs. However, when adjusted for the num-
RESPIRATORY CARE
•
JUNE 1998 VOL 43 NO
6
Abstracts
A detailed understanding
ber of drugs ordered, there was no greater like-
comparability of studies.
lihood for preventable adverse drug events and
of the methods and limitations of economic anal-
potential adverse drug events to occur in
ICUs
yses
is
essential to clinicians challenged
by a grow-
number of articles and manufacturers' claims
than in non-ICUs. Preventable adverse drug events
ing
and potential adverse drug events occurred
regarding the cost-effectiveness of critical care.
that functioned
who
in units
cumstances, not
at the
stress, or a difficult
cir-
extremes of workload,
Elevation of Peak Expiratory Flow by a "Spitting"
Maneuver: Measured with Five Peak
Flowmeters
environment.
— Strayhom V. Leeper K, Tolley
Self T. Chest 1998;l 13(4):
Horiz I998;6:33.
The ICU, perhaps more than any other
modem
area
medicine, brings the conflicting issues of
high cost and live-saving technology into stark
relief Cost-effectiveness analysis offers a quantitative
method
for selecting
among
treatments to
optimize outcomes for any given financial outlay.
Impediments
to
developing and using cost-
using incorrect
68.2% above the PEF with
the subject using correct technique.
SION: Each of the
five
had a significant elevation
ters
was
CONCLU-
marketed peak flowmein
PEF when
a "spit-
used. Clinicians need to instruct
patients carefully regarding correct technique
when
using peak flowmeters.
Physical Therapy on Expectoration in Patients
OBJECTIVE: To
flow (PEE)
in
2.4 to
Chest Wall Oscillation and Conventional Chest
Cost-EfTectiveness Considerations in Critical
Care— Rubenfeld CD. New
1
E,
134.
1
PEF
for elevation in
technique was
ling action"
normally and involved caregivers
were working under reasonably normal
The range
determine
if
peak expiratory
is higher using incorrect technique ver-
with Stable Cy.stic Hbrosis
dun
J,
—Scherer TA, Baran-
Martinez E, Wanner A, Rubin
sus correct technique with five marketed peak
1998; 113(4):1019.
DESIGN: Randomized, nonblinded
SETTING: University pulmonary medicine
clinic. PATIENTS: Twenty adults with clinically
OBJECTIVE: To compare
EM. Chest
flowmeters.
study.
stable asthma.
INTERVENTIONS:
After inhal-
ing 2 puffs of albuterol via a valved aerosol hold-
ing
chamber (Aerochamber),
patients
min
were
in-
and
quency
chest wall oscillation,
ical
tum, pulmonary function, and oxygen saturation
with stable cystic fibrosis (CF).
structed over the next 15
sions include the lack of accurate estimates or
incorrect (a "spitting" action) technique
treatment effectiveness and reliable cost measures;
peak flowmeters. Order of use of five peak flow-
Pediattic
variations in assumptions used in different cost-
meters and correct vs incorrect technique was ran-
ter.
PATIENTS:
effectiveness analyses; and lack of an ethical or
dom.
MEASUREMENTS & RESULTS: PEF
ble
CF
regulatory construct to ensure that the decisions
(percentage of personal best
will be carried out fairly. Recently, standards for
of three attempts with correct and incorrect tech-
performing cost-effectiveness analyses have been
nique.
proposed which should enhance the quality and
nificant elevation in
)
when using
was recorded
Each peak flowmeter had a
PEF with
for best
statisfically sig-
incorrect technique.
^
and conventional chest phys-
therapy (CPT) on weight of expectorated spu-
effectiveness analysis to guide medical care deci-
in correct
the effect of high-fre-
oral airway oscillation, high-frequency
in outpatients
SIGN: Prospective randomized
pulmonary division of a
1
:
recruited from the
tertiary care cen-
CF
center.
ratio 9:
1
2:
airway oscillation
frequency 14 Hz; I;E
of chest wall oscillation
(1:
sta-
INTER-
frequency 8 Hz; inspiratory to expiratory
;
DE-
SETTING:
Fourteen outpatients with
VENTIONS: Two modes of oral
(
Uial.
8:
1 ),
|I:E]
two modes
frequency 3 Hz; I:E
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RESPIRATORY CARE
•
JUNE 1998 VOL 43 NO
6
Circle
96 on reader service card
451
Abstracts
16Hz;I:E
4:1; 2: frequency
frequency
1
Hz, 1:E
.5
6: 1),
1
1
:
alternating with
between processes of care and 30-day mortality
should be instructed to continue taking inhaled
CPT
were determined with
steroids
.
and
(clapping,
and encouraged
vibration, postural drainage,
coughing) were applied during the
first
20 min
MEASUREMENTS &
of 4 consecutive hours.
RESULTS: Sputum was collected on
an hourly
basis for a total of 6 consecutive hours. During
the
first
and the
last
hour, patients collected spu-
tum without having any treatment and underwent
pulmonary function
was measured
ration
ing hours
ond
at
Oxygen
(PFTs).
first
To
Hours 2
to
care performance were antibiotic administration
within 8 hours of hospital arrival,
75.5% (95% con-
fidence interval (CI), 73.1-77.9); blood cultures
57.3% (95% CI,
before antibiotics,
(95%
and
initial
54.5-60.
68.7% (95%
when
Used
doses.
ini-
1 );
CI. 66.2-
Dissemination in Japanese Hospitals of Strains
of Staphylococcus Aureus Heterogeneously
CI, 87.5-90.9).
Lower 30-day
mortality
was
Resistant to
95% CI. 0.75-0.96) and blood culture collection
within 24 hours of arrival (OR, 0.90; 95% CI, 0.81-
(9092): 1670.
first
1
.00). State
and
territory
varied from 49.0%' to
performance estimates
89.7%
for antibiotics given
45.6%
within 8 hours and from
drawn within 24 hours.
to
82.6%
for blood
CONCLUSIONS:
cultures
mean sputum dry and wet weights ranged between
122% and 185% of baseline. There was no sta-
Administering antibiotics within 8 hours of hos-
among
pital arrival
and collecting blood cultures within
Fukuchi Y, Kobayashi
BACKGROUND: Since the discovery of the vanMu50 (minimum
strain
[MIC| 8 mg/L),
ment modalities. As measured by sputum wet
The fact that states varied widely in the performance of these measures suggests that opportu-
and
dry weight, oral
an I:E of
9:
1
=
As measured by
(p
airway oscillation at 8 Hz with
and
0.15).
CPT tended
to
ble
= 0.57).
treatment modalities had an effect on
PFTs and oxygen
erated.
saturation
CONCLUSION:
CF, high-frequency
and
tients
improve hospital care of elderiy pa-
all
were well
tol-
oscillation applied via the
CPT have
Long-Acting Inhaled
/3-2
Agonists in
Therapy— Moore RH, Khan A,
1998:1
1
Asthma
Dickey BE. Chest
3(4): 1095.
OBJECTIVE: To review
long-acting inhaled
the
pharmacology of the
/3-2 agonists,
salmeterol and
sputum weight without changing PFTs or oxygen
als,
oral
tri-
evaluate their safety records, and discuss
their roles in the treatment
of asthma.
DATA
airway and chest wall oscillations are self-admin-
SOURCES:
istered, thereby containing health-care expenses.
ing salmeterol or formoterol were identified by
a
Quality of Care, Process, and Outcomes in
Elderly Patients with
Mockalis JT,
Fine JM.
— Meehan TP,
Pneumonia
HM,
DH,
Weber GF, Petrillo MK, Houck PM,
Fine MJ, Krumholz
JAMA
Scinto JD, Galusha
CONTEXT: Pneumonia is a frequent cause of hospitalization
and death among elderly
the relationships
quality
patients, but
between processes of care
pneumonia and outcomes
are uncertain,
for
making
improvement a challenge. OBJECTIVES:
To assess quality of care
pitalized with
for
Medicare patients hos-
pneumonia and
to
process of care performance
lower 30-day mortality.
determine whether
associated with
is
DESIGN:
Multicenler
ret-
rospective cohort study with medical record review.
SETTING: A
pitals
throughout the United Slates.
A
total
total
of 4,(J69 patients
1
of 3,555 acute care hos-
at least
PATIENTS:
65 years old
ho.s-
MAIN OUTCOME
and
Preclinical
MEDLINE
search,
erature updates, and
SYNTHESIS:
clinical studies involv-
weekly computerized
lit-
manual searches. Studies of
were chosen for review.
satisfactory quality
DATA
Salmeterol and formoterol are
potent and selective /J-2-adrenoceptor agonists with
durations of action
I997;278(23):2080.
is
the prevalence of
>
1
2 hours. Their major dif-
VRSA,
re-
METHODS: The vancomycin sus-
of 3 methicillin-resistant
strains
(Mu50. Mu3, and HI
S.
)
aureus
and the
aureus type strain
FDA209P were compared by MIC determinations
Mu3 (MIC 3 mg/L) was
and population analysis.
monia
formoterol, summarize results of their clinical
CPT, high-frequency
sistance occur.
ceptibilities
from the sputum of a patient with pneu-
isolated
comparable augmenting effects on expectorated
saturation. In contrast to
important questions need to
what
( 1 )
methicillin-susceptible S.
In outpatients with sta-
airway opening or via the chest wall and
been concern about the
by what mechanism does vancomycin
(2)
(MRSA)
with pneumonia.
be more effec-
tive than the other treatment modalities (p
None of the
nities exist to
there has
Two
anese hospitals.
be answered:
CPT
(VRSA)
inhibitory concentration
potential spread of such strains throughout Jap-
24 hours were associated with improved survival.
oscillatory devices tended to be less
Hosoda Y, Hori
Lancet 1997:350
I.
comycin-resistant Staphylococcus aureus
the treat-
all
— Hiramatsu K, Ari-
one of the
hour (baseline). For the 5 treatment modalities.
weight,
Vancomycin
S,
6 was averaged and expressed as per-
effective than
properiy, they are effective and safe
adjunctive agents in the treatment of asthma.
8 hours of hospital arrival (odds ratio [OR], 0.85;
centage of the weight expectorated during the
to not take long-
acting /3-2 agonists between regularly scheduled
sec-
assess the effect of the interven-
tisfically significant difference
long-acting /J-2 agonists are admin-
on a regular schedule and
oxygenation assessment, 89.3%
Ual blood culture collection.
71.2);
istered
taka N. Hanaki H, Kawasaki S.
weight of expectorated sputum during
tion, the
National estimates of process-of-
associated with antibiotic administration within
20 min of the
to the fifth hour, patients received
treatments.
satu-
30-minute intervals dur-
For the
to 6.
1
tests
RESULTS:
sis.
logistic regression analy-
after surgery
H (MIC 2
therapy.
1
who had
failed
mg/L), which
sponded favourably
clones of
Mu3
to
with increased resistance against
vancomycin and
their
mined. The prevalence of
strains in
re-
vancomycin therapy. Sub-
vancomycin were selected with
serial
concentra-
MICs were deter-
VRSA
and Mu3-like
Japanese hospitals was estimated by pop-
ulation analysis from 1,149 clinical
lates
a represent-
from a patient with pneumonia who
isolated
tions of
vancomycin
is
MRSA strain, was
ative vancomycin-susceptible
MRSA iso-
obtained from 203 hospitals throughout Japan.
The genetic
traits
of the
Mu3
and
Mu50 strains
were compared with clonolypes of MRSA from
Mu3
Mu50
ferences are that formoterol has a rapid onset of
around the worid. FINDINGS:
action and
had an identical pulsed-field gel electrophoresis
is
a
partial agonist
of high
intrinsic effi-
cacy, whereas salmeterol has a delayed onset and
is
a partial agonist of low intrinsic efficacy. Twice
daily use of either drug results in
symptoms, and a
function, reduced
ity
of
life.
improved lung
better qual-
These agents protect against exercise-
banding
ium,
pattern.
Mu3
and
When grown in a drug-free med-
produced subpopulation of cells with
varying degrees of vancomycin resistance, thus
demonstrating natural heterogeneity, or variability,
vancomycin.
in susceptibility to
Mu3
In the presence
induced asthma for 12 hours and eliminate night-
of vancomycin,
time awakening
resistance roughly proportional to the concentra-
in
most
patients.
Limited tolerance
develops, especially to their bronchoprotective
effects, but their
is
sustained.
improvement of lung function
CONCLUSIONS:
Regular use of sal-
tions of
8
mg/L
vancomycin used. Selection of Mu3 with
more of vancomycin gave
or
rise to
sub-
clones with vancomycin resistance equal to that
Mu50 (MIC
meterol or formoterol provides subjective and
of
objective amelioration of asthma in patients expe-
1,()0(),(KH).
symptoms or physiologic im-
produced subclones with
no
8
mg/lj
at
a frequency of
During screening of Japanese
1/
MRSA
VRSA additional to Mu50 was
pitalized with
pneumonia.
MEASURES:
Four processes of care: time from
pairment despite the regular administration of low
hospital arrival to initial antibiotic administration:
doses of inhaled corticosteroids (equivalent to ap-
The prevalence of MRSA isolates heterogeneously resistant to vancomycin was 20% in
blood culture collection before
proximately 500 //g/d of beclomethasone). Inter-
Juntendo University Hospital, 9.3%
biotics;
initial
hospital anti-
blood culture collection within 24 hours
riencing excessive
mittent use of either long-acting
^2 agonist can
sfrains,
strain
of
found.
of hospital arrival; and oxygenation assessment
provide prolonged protection against exercise-
sity ho.spitals
within 24 hours of hospital arrival. Associations
induced asthma or nighttime symptoms. Patients
erogeneously resistant
4.52
in the
other
7 university hospitals, and 1.3% in non-univer-
RESPIRATORY CARE
or clinics.
•
INTERPRETATION:
Het-
VRSA is a preliminary stage
ABSTRACTS
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have been developed and are cur-
long-term oxygen therapy supplementation pro-
one
longs survival in hypoxemic patients. With only
sure to vancomycin. Heterogeneously resistant
thesis inhibitors
VRSA was found in fiospitals throughout Japan.
rently
This finding could explain,
leukouiene receptor antagonist (zafirlukast) and
limited data
quent therapeutic failure of MRS A infection with
one 5-lipoxygenase inhibitor zileuton were
the objectives of hospitalization, the published
vancomycin
cently approved by the United States
at least partly, the fre-
in Japan.
showing promise
(
Drug Administration
New Approaches
to
apy for Asthma
in clinical trials;
)
re-
Food and
for the treaunent of asthma.
SB.
Am
J
Med
Standards for the Optimal Management of
COPD:
1998:104 (3):287.
admission and
criteria for hospital
standards on the
management of COPD include
an expert consensus statement on these aspects
of hospital care. Surgery, special considerations
Anti-Inflammatory Ther-
— Wenzel
on
a
summary—Celli BR. Chest
1998:1 13
such as sleep, nutrition, and
ical issues are
air travel,
and
eth-
discussed.
(4Suppl):283S.
Tuberculosis Control Policies in Major Met-
Currently, corticosteroids are the therapy of choice
for the
inflammatory component of asthma. This
class of drug provides powerful anti-inflammatory effects in
most
patients;
are not specific and in
some cases may
serious side effects. Also,
ficulty
however, these effects
many
result in
have
patients
dif-
adhering to therapy with inhaled forms of
Tobacco smoking
obstructive
is
the
main cause of chronic
pulmonary disease (COPD), and en-
couragement and support
is
the best
The
way
in
States. VI.
Standard of Practice
smoking cessation
DR. Leff AR.
COPD.
156(5):1487.
to help the patient
three major goals of
ropolitan Health Departments in the United
COPD
with
in
1996—Leff
Am J Respir Crit Care Med
1997;
management
are to lessen airflow limitation, to prevent
and
secondary medical complications, and to
Since 1980.
we have surveyed
at
4-year intervals
the metropolitan health departments iniually re-
these drugs, which are administered by metered
treat
dose inhalers up to several times per day. There
porting
are several other therapies that provide potential
decrease respiratory symptoms and improve
quality of life. Outpatient pharmacotherapy
anti-inflammatory effects, but they are of low
effi-
should be organized in a stepwise manner accord-
control and the factors affecting formulation of
definitive anti-inflammatory effect.
ing to the severity of disease, the aims being to
treatment policies. Between 1992 and 1996, use
induce bronchodilation. reduce inflammation, and
of supervised short-course (6 to 9
cacy, with
While
little
efforts are
currenUy under
way
to
improve
although the role of anti-
> 250 cases of tuberculosis
tent therapy with multiple
facilitate expectoration,
development of targeted anti-inflammatory agents.
inflammatory and mucolytic treatment of COPD
niazid, ethambutol, pyrazinamide,
For example, the leukotrienes, a family of inflam-
has not been clearly established. Pafients whose
increased from
have been shown to enhance
conditions are not well controlled with opfimal
Pyrazinamide use for
mucus
pharmacotherapy are candidates for enrollment
has increased substantially and
that
bronchoconstriction and airway
secretion,
have been the focus of numerous investigations.
RESPIRATORY CARE
•
in a
pulmonary
JUNE 1998 VOL 43 NO
6
rehabilitation program. Correc-
mo)
intermit-
drugs including iso-
corticosteroid therapy, other directions include the
matory mediators
to determine
the perceived standard of practice for mberculosis
and rifampin
43% to 4695- of all new patients.
(74.2% of pafients
initial
in
treatment for children
now predominates
1996 vs 48.1% of patients
453
,
Abstracts
mo
1
+
Duration of treatment, which was 20
in 1992).
2.
in
980.
1
now
is
8.00
±
2.29
mo
in
1
996.
The incidence of human immunodeficiency virusassociated tuberculosis, which was virtually unrecognized
in 1984, has
remained the same be-
tween 1992 and 1996 (18.0%). As
was
years, there
departments
incidence
and an
over a 20-min period before and after the applicafionof NPPV (inspiratory pressure of 10 to 12
and quality of life, but the routine use of PFM
cm HiO and expiratory pressure of 4 to 6 cm HiO).
RESULTS: NPPV increased saturation from 88
± 2% to 90 ± 1% (p < 0.05) and decreased tcco2
trol
that education, regular follow-up.
guide interventions
to
is
way
not the only
to
accomplish these objectives.
among health
(< 5% to > 40%) of
B7-CD28/CTLA-4 Costimulatory Pathways
Are Required
for the
Development of T Helper
HIV-associated tuberculosis. After years of fund-
Cell 2-Mediated Allergic
Inhaled Antigens
Linsley PS,
mean budget
1997;158(5):2042.
Chen
Airway Responses
to
— Keane-Myers A. Cause WC.
ing decreases, there has been an impressive in-
crease in resources in the past 4 years. In 1988.
allocation for health departments
SJ,
Wills-Karp M.
J
Immunol
We have previously demonstrated that the devel-
allocation after inflation versus 1988. In 1996,
opment of allergen-induced airway hyperrespon-
change
overall
in
T cell
however, funds for treatment increased by 84 ±
siveness in a murine model
is
33%. This increase
dent. In the present study,
we examined
in
funding has been translated
expanded use of supervised
into the greatly
inter-
mittent therapy and aggressive screening programs.
which
likely
have resulted
in the
decreased inci-
dence of tuberculosis since the prior
of the
CD4-I-
depen-
the role
B7/CD28-(7rLA4 costimulatory T cell
acti-
vation pathway in the pathogenesis of allergen-
induced airway hyperresponsiveness in
murine
this
model. Sensifized A/J mice develop significant
.survey.
(p
±
2 to
ventilation decreased
± 0.6 L/min
(p
=
± 5%
1
8
±
1
(p < 0.01
).
34
to
± 5%, p =
in
NS). In two
was
a decrease in pressure
cm H2O to -1 ± 2 cm HjO and -14
cm H:0 to -7 ± cm HiO. CONCLUSIONS;
1
1
1
1
In patients with stable, severe cystic fibrosis,
)
to 4.6
There was no change
esophageal pressure measurements were
from -2 1 ±
1
Minute
from 5.3 ± 0.8 L/min
0.08).
also recorded. There
(
mL
not significant |NS]) and respiratory rate
decreased from 24
+
+ 20 mL to 256 ± 37
increased from 2 1 9
=
patients,
budget
was no
Vt
duty cycle (32
decreased by 7.9% versus the prior 4 years and,
in 1992, there
mm Hg to 50 ± 2 mm Hg (p < 0.05).
from51 ± 3
previous
in
a wide variance
in the
show
action plan are effective in improving asthma con-
NPPV
acutely improves gas exchange, (2) decreases
minute ventilation, suggesfing either a reduction
in
CO2 production or an
increase in alveolar ven-
and (3) reduces work of breathing.
nlation,
increases in airway responsiveness, bronchoal-
A Randomized
Comparing Peak Expi-
veolar lavage eosinophils, serum IgE levels, and
Symptom Self-Management
Th2-associated cytokine production following as-
Asthma Attending a Pri-
OVA. Administrafion of
CTLA4-Ig either before Ag sensitization or before
pulmonary Ag challenge abolished Ag-induced
Teaching and Community Hospitals. The
Southwestern Ontario Critical Care Research
airway hyperresponsiveness and pulmonary eosin-
Esmail R. Inman KJ, Sibbald WJ. Crit Care
Trial
ratory Flow and
Plans for Patients nith
mary Care
nett
Clinic
—Turner MO. Taylor D. Ben-
R, Fitzgerald JM.
1998;157(2):540.
piration challenge with
ophilia.
Great emphasis
ics to
placed on educating asthmat-
is
use action plans to achieve better control
of symptoms. The use of peak flow meters
has been
recommended
self-management plans.
(PFM)
as an important part of
We studied 92 (47 female)
adult patients with asthma in a primary care setting to
compare
the effectiveness of action plans
symptoms
using either peak flow monitoring or
self-management. Each patient was
to guide
in-
structed in the use of the action plan in the context
of a 6-month asthma education program taught
by a nurse. Patients were already using inhaled
in the
Examination of cytokine protein levels
Withdrawal and Withholding of Life Support
in the Intensive Care Unit: A Comparison of
Network— Keenan
SP, Busche
KD, Chen LM,
Med
1998;26(2):245.
bronchoalveolar lavage showed a signif-
icant decrease in the level of the
IL-4, after
CTLA4-Ig
change
cytokine,
with no significant
concentration of the Thl cytokine,
in the
IFN-gamma.
Th2
treatment either before sen-
sitization or before challenge,
Further, the Ag-specific
IgG and IgE were
1
Ab isotypes
significantly decreased in ani-
OBJECTIVK: To compare the incidence of withlife support (WD/
drawal or withholding of
WHLS), and
to identify similarities
and differen-
ces in the process of the withdrawal of
port
(WDLS) between
teaching and
sup-
life
community
hospitals' intensive care units (ICUs).
DESIGN:
mals treated with CTLA4-Ig before challenge,
Prospective cohort study, with
while there was no significant change
in the
by retrospective chart review. SETTING; The
Ab
that
isotype.
These data demonstrate
isQ^tion of CTLA4-lg
is
IgG2a
admin-
effective in ablating aller-
gen-induced airway dysfunction concomitant with
Th2 response. We
B7/CD28-CTLA-4 cosfimulation
for the development of many of the
ICUs of 3 teaching
pitals.
hospitals
some data obtained
and 6 community hos-
PATIENTS: All patients who died in these
a 6-mo penod. INTERVENTIONS;
9 ICUs over
MEASUREMENTS & RESULTS:
corticosteroids or were newly prescribed corti-
a significant reduction in the
None.
costeroids by their family physician. Forty-four
conclude that
on admitting diagnosis, cause of death, mode of
were randomized
patients
48
to the
to the
PFM
group and
symptoms group. Spirometry, symptom
.scores, quality
of
life,
medication use, and mea-
sures of health care utilization and morbidity
(emergency department
visits, hospitalizations,
uascheduled doctor
and days
visits,
lost
from work
or school) were recorded at baseline and throughout the study period.
sured
at
the
symptoms
of
and
PC20 methacholine was meaat the final visits.
There were
improvements within groups
significant
ity
first
score,
PC20
for
FEV
significant shift
/J-agonists (p
from higher
< 0.008
to
A
lower daily use of
for both groups)
and
sig-
nificant shifts to higher daily do.ses of inhaled
steroids (p
< 0.(X)1 occurred
)
in
each group. Adher-
ence to the self-management plans wa.s only
symptoms
in the PI-TVl
group antl .52%
Outcomes
for health care utilization
lar
in the
65%
group.
were simi-
except for fewer patients making unscheduled
doctor
454
visits
within the
required
immunologic and physiologic
features of asthma,
PFM group. Our findings
these initiating and involved in
support withdrawn were gathered for
possibly by promoting a pathologic type 2-asso-
ities
patients dying in the
of
life
hundred
The Acute
Effects of Nasal Positive Pressure
Ventilation in Patients with
Fibrosis— Granton
Advanced Cystic
JT, Keslen S. Chest 1998;
292
in
community
hospitals
and
teaching hospitals died in their respective
ICUs over
ence
ICU over a 6-mo period. One
sixty patients in
6-mo
the
period.
in the distribution
community
113(4):1013.
WD/WHLS),
WDLS, and modal-
death (death despite active treatment
ciated response.
hospitals
of
We found a differ-
mode
of death between
and teaching
hospitals, result-
ing from a greater proportion of patients dying as
i
methacholine. and qual-
but no between-group differences.
life,
is
Data
OBJECTIVE: To evaluate
the acute effects of non-
invasive positive pressure vennlanon
(NPPV)
in
patients with .stable chronic respiratory failure sec-
ondary to cystic
fibrosis.
PATIENTS:
Eight pa-
± 5 years of age) with severe airtlow
limitation (mean FEV|, 24 ± 3% predicted) and
chronic re.spiratory failure (PaOj = 67 ± 15 mm Hg
and P.,co2 = 50 ± 4 mm Hg) were evaluated.
tients
(29
METHODS:
Tidal
volume (Vt),
respiratory rate,
minute ventilafion, oxygen saturation, and transcutaneous
COi (tcco;) measurements were made
a result of withholding
hospitals
p
(
1
1
life
support in
.9% vs 3.8% withheld,
community
respectively,
= 0.004). Among the 6 community hospitals and
we found a difference in the
3 teaching hospitals,
proportion of patients dying despite active treat-
ment compared with those dying as a result of
(p = 0.042 and p = 0.044. respec-
WD/WHLS
tively). Initiation
more frequent
at
of
WDLS
by physicians was
teaching hospitals
(81% vs61%,
p = 0.0005). while families more commonly
fiated
WDLS
rfspiratory Care
•
at
community
hospitals
ini-
(34%
June 1998 vol 43 No
vs
6
Abstracts
19%, p = 0.005).
in
A
the quality
was a trend
for
hospitals (0.74
=
+
1
fewer
into
WDAVHLS
hospitals
and teaching hospitals; however, with-
holding of life support was more
The need
for
more cosmetically
oxygen
in the
home,
remain challenges.
ogy,
of Definitions, Epidemiol-
and Factors Influencing
Rennard
SI.
Its
—
Development
Chest 1998:1 13(4 Suppl):235S.
in the
— Kollef MH. New
outcomes of critically
amined
ill
in a systematic
care practitioners on the
patients has not
manner. This
been ex-
is in
contrast
which have demons&ated
ical
care physicians and nurses
in the
a
ICU
method
setting.
on
patient
Outcomes research
outcomes
represents
for the formal evaluation of various
health care provider staffing patterns within the
(COPD)
ICU. Specific patient outcomes including hospital
a heterogeneous collection of conditions that
mortality, respiratory complications, lengths of
Chronic obstructive pulmonary disease
is
can affect various sUTictures within the lung
in
a
number of different ways. These various processes
COPD—Petty TL.Chest
can
1998;113(4Suppl):256S.
If
all
result in limitation of expiratory airflow.
severe enough, this physiologic abnormality
defines
in
The impact of respiratory
to clinical investigations
common in com-
ing hospitals.
Supportive therapy
Care Unit Setting
Horiz 1998:6:91.
the beneficial influence of specially trained crit-
COPD: Overview
community
between community hospitals and teach-
Supportive Therapy in
Intensive
as a Tool for Defining the
COPD through patient
funjre directions in providing
munity hospitals. The process of WDLS appears
to differ
coping with advanced
pleasing oxygen delivery systems to the nose, and
inci-
dence of
similar in
patients with
+ 0.79 [SD]
CONCLUSIONS: The
was
life in
patients with oxygen gain insight
support groups.
compared with teaching
.38 days vs 0.27
0.0028).
and length of
COPD. Many
hospitals and teaching hospitals,
community hospitals to have vasopressors withdrawn (56% vs 70%, p = 0.082). The
time to death after WDLS had begun was longer
days, p
this condition.
Role of Respiratory Care Practitioners
patients in
hospitals
from
Outcomes Researcli
respectively), while there
community
tients suffering
of
trials
vided an effective therapy which improved both
vasopressors
mechanical ventilation withdrawn (68% and 74%,
in
960s and
the 1970s, along with additional advances, pro-
WDLS.
community
1
(76%
(99% vs 89%) and
65%)
before
LTOT dating to the early
bolstered by excellent controlled clinical
Similar proportions had
ventilation
vs
rich history of
greater proportion of patients
teaching hospitals were receiving mechanical
COPD. The
lead to this
chronic obstructive pul-
various conditions that can
syndrome
are prevalent and often
stay,
mine
and medical care costs can be used
the optimal
ICU
to deter-
staffing strategy for res-
piratory care practitioners. Until recently,
we have
lacked good outcomes data for assessing the role
of respiratory practitioners in the ICU. Several barriers
have contributed to
this
deficiency of data
monary disease (COPD) includes long-term oxy-
relentlessly progressive. In aggregate, they rep-
including a lack of funding, absence of a national
gen therapy (LTOT) and patient support groups
resent an important public health problem. This
research initiative aimed at this specific issue, and
comprehensive program
supplement outlines diagnostic and therapeutic
the paucity of clinical investigators in this area
as
two cornerstones
of care
known
as
in a
pulmonary
rehabilitation.
You need
it
The
strategies
by which the practitioner can
assist pa-
of study.
Good outcomes
research requires appro-
now.
19
9 8
LITERARY
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RESPIRATORY CARE
•
JUNE 1998 VOL 43 NO
6
$333 & ARCF
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455
Abstracts
increased intrapulmonary pressures, total pulmonresistance,
;iry
Keep abreast of the
We inves-
and airway abnormalities.
tigated the hypothesis that inhalation of nitric oxide
(NO) could
latest research in
maximum exercise capac-
and excessive ventilatory response
ity
in
influence the
CHF.
Fifteen patients in
to exercise
CHF (mean age 48 +
NO inhala-
12 years) underwent a control and a
RE/PIRATORy
30 ppni.
tion progressive treadmill exercise test with
We determined the maximum oxygen consump-
CARE
CO:
tion (peak Vo;).
pulmonary
ventilation (Ve). respiratory rate, tidal
volume (Vj),
(
production (Vco;), minute
oxygen
ventilatory equivalent for
Ve/Vq:), ventilatory equivalent for carbon diox-
ide (Vg/Vco:). estimated physiologic
tidal
volume
rate,
systemic
slope,
dead space/
(Vi/Vt). Vg/Vco: slope, heart
ratio
arterial pressure.
Vg/exercise time
and Vy/exercise time slope during every
incremental exercise.
Mean maxunum exercise
val-
ues of heart rate, systolic systemic arterial pressure, diastolic
lODM!
systemic
respiratory rate,
peak Vq;. Voj/heart
rate.
Vg/CO:.
maximum exercise time were unchanged by
and
inhalation of nitric oxide. There
was
a strong trend
toward reduction of Vj/ Vq; from 53 ±
Make checks payable
ViVVt.
arterial pressure,
1
5 to 47
= 0.05 1 and in maximum Ve from 58 ±
2 to 48 ± 17 L min-' (p = 0.059). Maximum Vt
decreased from 1639 ± 556 to 1406 ± 479 mL (p
= 0.04). The Ve/Vco: slope was reduced from 43
± 2 to 35 ± 8 (p = 0.01 8). Two patients had signs
±
to
1
2 (p
(see last page for rates),
^
1
subscription officejt
1L030 Abies Lane
Dallas. Texas 75229-4593
priate levels of funding, adequately trained
Vj
in
response to exercise
and
during exercise
in
in
CHF. The
pathway may be involved
mechanisms contributing
to hyperventilation
CHF.
impact on patient
in the
13(4): 1028.
area
ratory lung
volume (EELV) and mean
methods of outcomes research can be employed
and limitations of
in
normal subjects and patients
with severe chronic obstructive pulmonary disease
(COPD). DESIGN: Comparative
TING: Pulmonary
practices.
oscillated
during high-frequency chest com-
(HFCC)
study.
Oxide Inhalation Reduces Pulmonary
TICIPANTS:
Tidal
Volume during Exercise
female) and 6 patients with clinically stable
in
Severe
— Bocchi EA. Auler JO
Guimaraes GV. Carmona MJ. Wajngarten M,
997; .M(4):737.
I
(5
male;
1
female) with hypercapnia.
I
the effectiveness of
mucus from
in
during
COPD
HFCC-i-PEEP
HFCC in clear-
the lungs of patients with airway
disease.
Preoperative Smoking Habits and Postoper-
—
Pulmonary Complications Bluman LG,
Mosca L. Newman N. Simon DG. Chest 1998;
ative
I13(4):883.
the effect of preop-
smoking behavior on postoperative pul-
SETTING: The Veterans AdminPAR-
Medical Center. Syracuse NY.
TICIPANTS:
Patients scheduled for noncardiac
= 410). MEASUREMENTS
& RESULTS: Smoking status was determined by
elective surgery (n
pulmonary complica-
self-report. Postoperative
were determined by systematic extraction
complications occurred in 31 of 141 (22.0%) current smokers.
24 of 187 (12.8%) past smokers, and
cuit spirometer
of
HFCC-
that
was
5.5
(OR)
smokers versus never smok-
(95% confidence
interval [CI], 1.9 to
16.2)
and 4.2 (95% CI.
ment
for type of surgery, type of anesthesia,
1.2 to 14.8) after adjust-
abnormal chest radiograph, chronic cough,
tory of
pulmonary disease,
ease, history of chronic obstructive
disease, education level,
body mass index, and
his-
history of cardiac dis-
pulmonary
pulmonary function,
age. Current
smokers who
reported reducing cigarette consumption prior
to surgery
were more likely to develop a com-
COPD
plication
compared with those who did not
(adjusted
OR = 6.7. 95% CI,
system permitted measurement
and PEEP-induced changes
ers
ratio
pulmonary com-
INTER-
VENTIONS: A pneumatic vest system was operated at 10 Hz with a mean chest wall pressure of
16 cm HiO to provide the HFCC. A closed-cir-
plain the hyperventilation and the limited exercise
including
PAR-
Six normal subjects (5 male;
Multiple mechanisms have been proposed to ex-
(CHF)
SET-
function and lung mechanics
laboratory. University of Alberta Hospitals.
Nitric
capacity in congestive heart failure
ing
plication for current
the effects of pos-
end-expiratory pressure (PEEP) on end-expi-
pression
relates to the role
1
may improve
for developing a postoperative
piratory care practitioners in the ICU. Similarly,
4,56
on
these research goals.
Am Heart J
patients. This higher Vos,. during
RL. Chest 1998;!
(Vos^.)
BeUotti G, Pileggi F.
prevents the
VOSC
and increases
4 of 82 (4.9%) never smokers. The odds
flow rate
Jr.
EELV
in
both phases of spontaneous breathing
tions
—
of res-
Chronic Heart Failure
HFCC
amount of PEEP during
decrease
Flow Rate during High-Frequency
Chest Compression Perry RJ. Man GC. Jones
itive
ICU
COPD
both inspi-
of medical record data. Postoperative pulmonary
OBJECTIVE: To investigate
other
PEEP increased V^sc during
(30.5%) and expiration (57.0%) (both, p
< O.OI ). CONCLUSIONS: Addition of a modest
ration
istration
and organized and dedicated approach must be
to better define the benefits
during inspiration (5.1% increase). In the
patients,
<
on V^sc
Vt.
developed based upon strong research proposals.
the
significant effect
Vg and
minor increase
Inhalation of nitric oxide attenuated the excessive
interest in res-
made
was no
monary complications. DESIGN: Prospective
Oscillated
it
but there
).
cohort study.
medical sciences), and the support of both local
of outcomes research as
expiration to increase 14.6% (p
Vosc during
0.01
sta-
Effects of Positive End-Expiratory Pressure
This will allow advances to be
1
slope during incremental exercise were reduced
disciplines (eg. statistics, epidemiology, general
To accomplish
).
by inhalation of nitric oxide, demonstrating a
experienced clinical investigators from various
outcomes.
For the normal sub-
)
erative
in
their
RESULTS:
HFCC caused a significant decrease in EELV
to 82.0% of FRC (p < 0.01 and the addition of
4.8 ± 0.5 cm H2O of PEEP during HFCC increased
EELV to 97.5% FRC. In the COPD pauents,
HFCC decreased EELV to 92.3% of FRC (p <
0.01
and the addition of 3.7 ± .0 cm H:0 of
PEEP increased EELV to 98.4% FRC. For the normal subjects, increasing EELV to near FRC caused
The VE/exercise time slope and Vj/exercise time
L-arginine-nitric oxide
and
surement of Vosc
OBJECTIVE: To examine
increase in
piratory care sendees
chamber
jects.
the recovery period with inhalation of nitric oxide.
tistically significant
and national organizations with an
isothermic
of pulmonary congestion during peak exercise or
aad mail to the
^
(FRO. An
connected near the mouthpiece permitted mea-
)
1
Respiratory Care
residual capacity
in
EELV
were expressed as percent baseline functional
2.6 to
1
CLUSIONS: Current smoking was
with
a
7.
1 ).
CON-
associated
nearly 6-fold increase in risk for a
postoperative pulmonary complication. Reduction in
smoking within
1
month of surgery was
not associated with a decreased risk of postoperative
pulmonary complications.
RESPIRATORY CARE
•
JUNE 1998 VOL 43 NO
6
Abstracts
—
]]lJIJJilJiJiJ
Circle 115
Volume Therapy
in the Critically
— Boldt
111:
Is
There
function were analyzed from arterial blood sam-
MuUer M. Mentges D,
Papsdorf M, Hempelmann G. Intensive Care Med
ples
1998;24(1):28.
line" value)
a Difference?
J.
on the day of admission
to the
ICU and on
the day of sepsis diagnosis, respectively ("base-
and daily over the following 5 days.
Mortality during and after the study did not dif-
OBJECTIVE: There
are
still
several concerns
fer significantly
There were also no differences between the
oxyethylstarch solution (HES) in critically
dence of pulmonary,
patients.
The
effects of
volume replacement with
the
inci-
renal, or hepatic failure in
two subgroups. Mean
arterial pressure, heart
PCWP were similar in both subgroups,
HES
over 5 days on hemodynamics, laboratory
rate,
data,
and organ function were compared with vol-
whereas cardiac index, oxygen delivery index, oxy-
and
ume therapy using human albumin (HA).
DESIGN: Prospective, randomized study. SET-
gen consumption index, and the
TING:
fractional inspired
Clinical investigations
sive care unit
on a surgical
inten-
(ICU) of a university hospital.
PATIENTS: 150 traumatized patients (injury
severity score > 15) and 150 postoperative patients
partial pressure
ratio
between the
of oxygen in arterial blood and
oxygen were higher
in the
HES-
than in the HA-treated groups. Standard coagulation parameters did not differ,
albumin con-
centration increased significantly in both
HA
INTERVENTIONS:
Either 10% low-molecular weight HES (HEStrauma, n = 75; HES-sepsis, n = 75) or 20% HA
groups, and lactate concentrations decreased only
(HA-trauma, n = 75; HA-sepsis, n = 75) was given
min was
with sepsis were analyzed.
for 5
days to maintain the pulmonary capillary
wedge pressure (PCWP) between 12 and 15
torr.
The entire management of therapy of the patients
was performed by physicians who were not
smdy and blinded
involved
in the
regimen.
MEASUREMENTS & RESULTS: In
to the infusion
in
the HES-sepsis patients (from 2.8 ± 0.5
to 1.5
+ 0.4 mg/dL). Volume replacement using albusignificantly (p
< 0.001 more
)
costly than
therapy with
HES. CONCLUSIONS: Volume
therapy with
10% HES
for 5 days in the
ICU
Mahul
Viale JP, Duperret S.
P,
Delpuech C, Weismann D, Arinat G.
Crit
Med
Care
—
Delafosse B,
Am J Respir
1998;157(2):428.
Inspiratory muscle unloading decreases ventilatory drive. In this study,
course of this effect
modes of ventilatory
receiving
support: pressure support
ventilation (PSV), during
assisted,
the time
with chronic ob-
(COPD)
pulmonary disease
structive
2
we examined
in patients
which each cycle was
and biphasic positive airway pressure
(BIPAP),
set
up
in
such a manner that
sponta-
1
neous breath took place between 2 consecutive
pressure-assisted breaths.
the switch
The
associated with an increase
and a drop
(mean
per
Pj,)
liter
first
breath following
from spontaneous breathing
in tidal
PSV was
to
volume (Vy)
mean ttansdiaphragmatic pressure
and inspiratory work (Wi) performed
in
but with unchanged values of esophageal
occlusion pressure
at
1
00 ms
(Pes 0.
1 ),
diaphrag-
matic electrical activity (EMGdi), and
WI
per-
formed by breath. The same phenomena were
HES may
pared with the preceding spontaneous breath. Dur-
replacement using
even be associated
with improved hemodynamics.
HES
appears to
be a valuable and significantly cheaper alterna-
several routine laboratory parameters for assess-
tive to
ing pulmonary, renal, hepatic, and coagulation
apy
•
of Ventilatory Re-
sponses to Inspiratory Unloading in Patients
showed no disadvantages compared with
an infusion regimen using 20% albumin. Volume
patient
addition to extensive cardiorespiratory monitoring,
RESPIRATORY CARE
Time Course Evolution
between the infusion groups.
about the extensive and prolonged use of hydrill
—even
albumin
in the critically
JUNE 1998 VOL 43 NO
6
for
ill
prolonged volume ther-
patient.
observed for the assisted breath of
BIPAP as
ing the subsequent breaths of PSV, Pes
0.
1
,
com-
EMGd,,
Wi performed per breath decreased progressively up to the sixth to eighth breaths, and Vt re-
and
turned to pre-PSV values.
We conclude that in pa-
457
Abstracts
with
tienLs
COPD the decrease in ventilatory drive
PSV
associated with
takes place from the
first
breath onwards but requires 6 to 8 breaths to be
During BIPAP. as a consequence
fully achieved.
We analysed data for all patients listed for
ODS:
USA
transplantation in the
tic fibrosis,
on the waiting
of ventilatory drive, assisted breaths following
ing,
emphysema, cys-
pulmonary
or interstitial
fibrosis in
The numbers of patients entered
the years 1992-94.
of the kinetics of the PSV-induced down regulation
for
list,
post-transplantation, died wait-
and currenUy waiting were: emphysema group
spontaneous breaths are characterized by an en-
1,274, 843, 143, and 165; cystic fibrosis group
hanced
664, 318. 193, and 59;
inspiratory efficiency.
First
Decade of Continuous Monitoring
FINDINGS: The
group.
sis
The
on
the waiting
list.
from
of transplantation com-
relative risks
pared with waiting were 0.87, 0.61. and 0.61
1
month. 6 months, and
= 0.008),
year (p
I
pulmonary
at
respec-
with cerebral perfusion pressure versus outcome
tively.
responding relative risks were 2.09, 0.71, and 0.67
agement of cerebral perfusion pressure alone
(p
in
=
For
interstiti;il
0.09).
No
the
of 178 patients underwent continuous monitor-
ing 2 years of follow-up.
1
and management of cerebral extraction of oxy-
ing
gen and cerebral perfusion pressure, while a con-
group of 175 patients underwent monitoring
trol
and management of cerebral perfusion pressure only.
INTERVENTIONS:
emergency procedures.
RESULTS: The
Routine neuro-
MEASUREMENTS &
2 groups of patients
emphysema group. The
relative to waiting
1
fibrosis, the cor-
was apparent
survival benefit
DESIGN: Prospective,
interventional study. SETTING: Intensive care
unit of a university hospital. PATIENTS: Adults
(n = 353 w ith severe acute brain tauma. A group
I
1.12,
at
year, respectively,
and
below
1
.
.0 dur-
1
INTERPRETATION:
that lung transplantation
does not confer a survival benefit
end-stage
and
1
the relative risk did not decrease to
These findings suggest
in
of transplantation
risks
were 2.76,
month, 6 months, and
emphysema by
with
in patients
2 years of follow-up.
Other benefits not accounted for
such as improved quality of
in this analysis
may
however,
life,
were matched
Coma Scale
vention: Characteristics of Participants
hematomas and brain
swelling, pupillary
Non-Participants
—
and
Abdulwadud O. Abramson
abnormalities, early hypotensive events (before
M. Forbes A. James A, Light
intensive care monitoring), as well as
RespirMedl997;9I(9):524.
els
initial lev-
Thien F.
L,
et al.
Outcome
nificantly better (p
at
6 months postinjury was
< 0.00005)
in the
sig-
178 patients
undergoing monitoring and management of cerebral extraction of
oxygen along with cerebral
per-
fusion pressure, than in the control group of 175
patients undergoing monitoring
and management
of cerebral perfusion pressure alone.
CLUSION:
CON-
In patients with severe acute brain
As
part of an evaluation of the patient education
tal,
in
1994/95
clinic of
at the
The Alfred Hospi-
a tertiary referral hospital in Melbourne, Aus-
The objective of the study was
tralia.
Effect of Diagnosis
cere-
on Survival Benefit of Lung
—
Limg Disease
Bennett LE. Keck BM. Edwards
Transplantation for End-Stage
Hosenpud JD.
EB. Novick RJ. Lancet 1997:351 (9095 ):24.
full
A
total
foniis of end-
stage lung disea.se are debilitating, whether the
a.ssocialed mortality rate
tation
is
unclear.
exceeds
that
of transplan-
a.ss
of COPD can be attributed to bacterial infection,
and antibiotic therapy has been demonstrated
improve
outcomes and hasten
clinical
clinical
to
and
physiologic recovery. The major pathogen con-
Haemophilus influenzae, and
tinues to be
resis-
tance to /J-lactam antibiotics such as ampicillin
can be expected in 20 to
40% of isolated strains.
whom the cost of clin-
Certain high-risk patients, in
ical
treatment failure
simple clinical
is
high, can be identified
criteria. Patients
by
with significant
cardiopulmonary comorbidity, frequent purulent
ministration, long duration of COPD,
underlying lung function tend to
fail
and severe
therapy with
older drugs, such as ampicillin, and early relapse
can be expected. Treatment directed toward
resis-
may
pathogens with potent bactericidal drugs
to lead to
and overall lower
improved
clinical
outcomes
costs, particularly if hospital
mine
if
new
therapies have significant clinical,
and economic advantages over
quality-of-life,
older agents.
asthma edu-
in the pro-
Lung Volume Reduction Surgery: An Analysis of Hospital
Klontz B,
Costs
Wan^n WH,
—Elpem EH, Behner KG,
Szidon JP, Kesten
S.
Chest
1998; 113(4):896.
to immediate, rather than
OBJECTIVE: Lung volume
nificant predictors of attendance. Subjects ran-
were approximately
(LVRS) represents a potential breakthrough in the
management of advanced emphysema, although
likely to attend than conU'ol sub-
questions remain about clinical and economic
domized
to the intervention
three times
more
jects (odds ratio
|OR| = 3.3, 95%
val |CI| 1.5-7.3).
(OR =
confidence
6.6,
inter-
Asthmatics over 60 years old
95% CI
likely to attend
2.2- 19.8) than the age
group
16-30 years. The increasing trend in attendance
across age categories
0.001
liance
METH-
at
compliance with the programme
was 43.2%. Allocation
of lung transplantation for
various types of end-stage lung disease.
vis-
Approximately one half of all exacerbations
delayed, education and age were the only sig-
We undertook analysis to clar-
ify the survival benefit
to investi-
of 125 asthmatics aged
were approximately 6 times more
BACKGROUND: Although certain
its.
gate which demographic and clinical characteristics
gramme, and
alone.
primary care
for a significant proportion of all
otics should enroll these high-risk patients to deter-
was conducted
asthma and allergy
oxygen
managed
and acute respiratory infections account
outpatient
cation
over 16 years agreed to participate
outcome than when
(COPD)
the fifth leading cause of death in the United
States,
vented. Future studies examining the role of antibi-
trial
were associated with attendance
in better
is
admissions and respiratory failure can be pre-
randomized, controlled
cational session.
bral perfusion pressure is
Chronic obsUTictive pulmonary disease
of asthma edu-
plan, a
monitoring and managing cerebral extraction of
pressure result
Suppl):249S.
component of the Australian Asthma Management
with compromised cerebrospinal fluid spaces.
conjunction with cerebral perfusion
of Antibiotics and the
be expected
trauma and intracranial hypertension associated
in
at
Outcomes of
Therapy in Exacerbations of
COPD—Grossman RF. Chest 1998:113(4
tant
of intracranial pressure and cerebral perfusion
pressure.
required to improve par-
debility, malnutrition, chronic corticosteroid ad-
Attendance at an Asthma Educational Inter-
nial
is
by young and employed asthmatics
hospital-based asthma education programs.
exacerbations of COPD. advanced age. generalized
justify lung transplantation for these patients.
with regard to age. postresuscitation Glasgow
scores, rates of acute surgical intracra-
Over
inter-
in the cystic fibro-
of patients undergoing monitoring and man-
severe acute brain trauma.
ticipation
poor.
time-depen-
clearest survival benefit
lung transplantation occurred
comparatively assess outcome
alternative strategy
Antibiotic
tion relative to that for patients
OBJECTIVE: To
An
was
who had expressed
attend for their educational sessions.
est, failed to
The Value
Management Strategies and Clinical Outcome—Cruz J. Crit Care Med 1998;26(2):344.
in attending sessions
half of the asthmatics,
of mortality after transplanta-
to assess the risk
agement of cerebral extraction of oxygen along
fibro-
compliance
dent nonproportional hazard analysis was used
of Jugular Bulb Oxyhemoglobin Saturation:
of patients undergoing monitoring and man-
A
group 481, 230, 160, and 48.
sis
The
pulmonary
interstitial
Despite offering incentives and conducting the education sessions at subjects" preferred times, their
).
was highly
significant (p
There was no relationship between
<
atten-
and gender, medication, atopy, smoking
sta-
tus or the physical accessibility of the hospital.
reduction surgery
implications of widespread application of
we
In this report,
ing physicians' fees, for
pital
LVRS.
describe hospital costs, exclud-
LVRS. DESIGN: Hos-
charges were obtained from billing records
and converted
to costs
by applying multiple cost-
SETTING: A large, urban academic medical center. PATIENTS: Fifty-two consecutive patients who received bilateral LVRS
to-charge ratios.
through a median sternotomy between April
RESPIRATORY CARE
•
1
995
nEW! Orientation &
Competency Manual
The Orientation and Competency Assurance
Manual for Respiratory Care provides the
information, assessment tools, and models
necessary to demonstrate that the competence
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requirements.
Item BK55
S65 ($40
nonmembers)
nEW! Respiratory Home Care
Procedure Manual
The new Respiratory Home Care Procedure Manual
is especially designed for the home care setting.
And, it is easily adaptable to any alternate care
site from subacute to home medical equipment
companies and nursing agencies. The manual
features five sections of information, forms, and
checklists for the patient and practitioner.
Item BK3
$80 ($150
nonmembers)
nEW! Uniform Reporting
Manual for Subacute Care
The Uniform Reporting Manual for Subacute Care is
tool to determine productivity, track trends in the
a
care services, assist in
determining personnel requirements, measure demand for and intensity of services, and meet the requirements of prospective payment systems. (PPS).
utilization of respiratory
Item BK2
nEW!
$75 ($115
I.V.
nonmembers)
Sample Curriculum
Sample Curriculum
is designed for use by
respiratory care educational programs in conjunction with their clinical affiliates. A course following
this curriculum will augment training programs for
respiratory care practitioners with thorough in-
The
I.V.
struction
in I.V. -line
placement and management.
Contains everything needed to establish a complete
I.V. -line course: lesson outlines, checklists and references.
Item BK18
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how to order Call the American Association
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Here's
for your Continuing Education
needs
44th
-^ ¥ y,
:^";W
A^^r
I
sociation for
o r y Care
Managers and educators
from
will
all
across the country
gather to exchange
more about
many
ideas and learn
meeting the
challenges
in
health care.
A
vast array of educational
opportunities especially
designed to help them
compete
in
an increasingly
aggressive and business-
oriented health industry
will
be
AARC
available. Join
the
and your respiratory
care colleagues
in
Atlanta
for a relaxing vacation and
learning experience.
at Atlanta, Georgia
Nov. 7-10, 1998
)
Abstracts
and August 1996.
was
RESULTS: Median hospital stay
14.8 ± 12.8 days; range =
= 6 ± 9.2
(mean =
10 days
3 to 48 days), including 2 days (mean
=
days; range
unit
(ICU
One
).
35 days)
to
1
in the intensive care
hospital death occurred. Hospital
costs per case ranged from $11,712 to $121 .829.
mean costs of $30,976 and median
with
Costs were related significantly to dura-
$19,77
1 .
tion of
ICU
who
tients
costs of
and length of hospitalization. Pa-
stay
accrued the highest costs were sig-
remainder of the sample
nificantly older than the
(69.3 years vs 62.4 years).
LVRS
CONCLUSIONS:
Hos-
(HlyA). an important virulence factor
NO liberation in isolated endothe-
stimulator of
lial cells,
eration
and
and
in extrain-
was found to be a potent
testinal E. coli infections,
that
it
also causes thrombtixane gen-
related va.soconstriction in rabbit lungs.
We investigated the effect of different concentfations of HlyA on pulmonary NO synthesis in buffer-perfused rabbit lungs. NO release into the alveolar as well as the intravascular
compartment was
NO and by measurement of (per-
tion of expired
oxy-)nitrite/nitrate release into the perfusate.
HlyA
induced a pressor respKinse and an immediate dose-
lated directly to hospital stay. Identification of fac-
dependent increase of exhalative and intravascular
of
tors associated with
vary significantly but are
prolonged stays can be used
in assessing benefits
LVRS
and risks of
against
of health-care dollars.
utilization
DNase I Acutely Increases Cystic Fibrosis Sputum Elastase Activity and Its Potential To
Induce Lung Hemorrhage in Mice Cantin
—
Am J RespirCritCareMed
AM.
1998;157(2):464.
NO liberation, further enhanced by the addition
sis
potential of
sputum
evaluated.
tle
in
I
to increase cystic fibro-
and lung damage was
Sputum from CF patients
lung hemorrhage
C57BL/6
when
±
.56 vs 3.9 1
1
lit-
instilled inlranasally
1
mg/mL bovine DNase
showed increased neutrophil
(7.97
induced
mice. However, sputum treated in
by the addition of
vitro
I
DNase
elasta,se activity
elastase activity
± 0.62 /iM. p < 0.0
1 )
and
in-
NOS
These
).
I
alone
bolism. Intravascular gas was documented within
travascular compartments.
bition of
in-
Enhancement of NO
NO
(L-NMMA)
synthesis
amplified
greatly, the HlyA-elicited vasoconstrictor response.
Inhibition of the pressor response by a
that
marked
NO formation. We conclude
( 1
NO biosynthesis occurs in this model
of the septic lung, 2 that the signal transduction
(
in
response to
)
HlyA proceeds
changes
in
when
that
hour of treat-
sep-
were highest, induced lung hemorrhage
DNase
I
We conclude
therapy of patients with
CF
can
acutely increase the elastase activity of sputum
and also
its
potential to induce
hemorrhage
in the
murine lung.
and not
shear stress, and (3) that
approaches using
NOS
in
an Kndotoxin-
of Gastric Insufflation
and the Risk
Position
— Latorre
F,
Eberle B,
Weiler N. Mienert R. Stanek A. Goedecke R.
W. Anesth Analg
Heinrichs
1998;86(4):867.
mask airway
an incomplete mask seal causing gas-
is
insufflation or oropharyngeal air leakage.
tric
objective of the present study
incidence of
LMA
was
gastric insufflation
age.
to assess the
malpositions by fiberoptic
and oropharyngeal
One hundred eight
placement
tidal
sure exceeded
Schultc
Mayer K, GesslerT. Ruhl M. .SchlaudraH
et al.
Am
J
Med
1
J.
998;
patients
were
air leak-
.studied after
any surgical
mask
is
(NO)
is
an important vasodilator that
produced by constitutive (cNOS) as well as
inducible
(INOS) isoforms of nitric oxide synthase.
The pore-forming hemolysin of Escherichia
162
40 cm HiO. or air leakage from
prevented further increases
culi
incidence of
in
Wj.
erative
smoking behavior on postoperative
SETTING: The
pul-
the
and
in
90%
(
istration
in
= 4 0). MEASUREMENTS
1
self-report. Postoperative
tions
pulmonary complica-
rent smokers,
24 of 87
1
( 1
1
of 141 (22.0%) cur-
2.8%) past smokers, and
was
5.5
(95% confidence
16.2) and 4.2
ment
(95%
(OR)
ers
ratio
pulmonary com-
interval [CI], 1.9 to
CI. 1.2 to 14.8) after adjust-
for type of surgery, type of anesthesia abnor-
mal chest radiograph, chronic cough, history of
pulmonary disease, history of cardiac disease,
tory of chronic obstructive
pulmonary
cation level, pulmonary function,
and age. Current smokers
who
his-
disease, edu-
body mass index,
reported reducing
were more
cigarette
consumption prior
likely to
develop a complication compared with
was
The over-
in
19%
19 of 21) of these patients,
42% and was
PAR-
the
LMA was malpositioned. Oropharyngeal air
leakage occurred
Veterans Admin-
LMA
LMA malpositions was 40% (43
of 108). Gastric air insufllation occurred
(21 of 108),
step-
stomach, airway pres-
position in relation to the laryngeal entrance
all
Nitric oxide
.seal
LMA
volumes (Vx) were increased
until air entered the
verified using a fiexiblc bronchoscope.
I57(2):498.
The
laryngoscopy, and to determine their influence on
Impact on Pulmonary Hemodynamics
Burger H,
complications occurred in 3
potential risk of the laryngeal
wise
Rcspir Cril Care
1998:1 13(4):883.
elective surgery (n
Mask Airway
Laryngeal
Induced Septic Lung Model: Role oi'cNOS and
H.
—
Pulmonary Complications Bluman LG,
Mosca L, Newman N, Simon DG. Chest
TICIPANTS:
inhibitors in sepsis.
the induction of anesthesia, before
Oxide Biosynthesis
Preoperative Smoking Habits and Postoperative
via activation of
manipulations. After clinically satisfactory
Nitric
gas embolism as a complication of
arterial
mechanical ventilation.
have important implications for therapeutic
which elastase
instilled intranasally in mice.
arterial cir-
aware of venous
human
(LMA)
levels
em-
rhDNase on 4
in
pulmonary
culations. Clinicians need to be
gas
cohort study.
Spumm collected
after
the cerebral, coronary, and
and
The next
fatal cerebral arterial
pulmonary vasoconstriction. These findings may
A
hour
end-expiratory pressure. She sustained an
itive
thrombox-
ane receptor antagonist did not interfere with the
exotoxin-elicited
therapy levels 24 hours after aerosol treatment.
1
We report a 53-year-old woman with ARDS who
NO liberation into both the alveolar and the
ment. Elastase levels returned to pre-rhDNase
from 2 of 6 patients
Morris A. Chest 1998:1 13(4):l 132.
phos-
(MeOSAAPV-CMK). In vivo administration of
2.5 mg aerosolized recombinant human DNase
I to patients with CF resulted in a 2.2-fold increase
arate days
—Weaver LK,
with Positive Pressure Ventilation
day she sustained a
alanyl-alanyl-prolyl-valine-chloromethylketone
I
Venous and Arterial Gas Embolism Associated
effects
neutrophil elastase inhibitor methoxysuccinyl-
of sputum elastase activity within
gastric air insufflation.
this vasodilator release mitigates the HlyA-induced
in
phate buffer and were suppressed by the
of cases. Such mal-
positioning considerably increased the risk of
dourea-dihydrobromide. blocked the HlyA-evoked
to .secondary
were not observed with DNase
position revealed sub-
40%
ciated with cardiovascular instability.
cNOS directly related to exotoxin activity
vs 44.5
mask
acute right ventricular myocardial infarction asso-
= 92.8 + 40.7
1
verification of
optimal placement in
aminoguanidine and 2-(2-aminoethyll-2-thiopseu-
mice (broncho-
12.0 /Jg/mL. p < 0.01
tic
required positive pressure ventilation with pos-
in
+
not require laryngoscopy. In our study, fiberop-
NOS inhibitor N(G)-monomethyl-L-arginine (LNMMA), but not the iNOS selective inhibitors
substrate L-arginine.
alveolar lavage fluid hemoglobin
duced marked lung hemorrhage
placement of laryngeal mask airways does
tine
The nonspecific
of the
formation (L-arginine) slightly reduced, and inhi-
The
Rou-
factor for gastric air insufflation. Implications:
monitored on-line by chemiluminescence detec-
re-
pital costs
LMA position. We conclude that clinically unrecognized LMA malposition is a significant risk
independent of
those
who
2.6 to 17.
was
1
).
OR = 6.7, 95% CI,
CONCLUSIONS:
Current smoking
associated with a nearly 6-fold increase in risk
for a postoperative
Reduction
was
to surgery
did not (adjusted
in
pulmonary complication.
smoking within
I
month of surgery
not as.sociated with a decreased risk of post-
operative pulmonary complications.
RESPIRATORY CARE
•
ABSTRACTS
Automatic Actuation of a Dry Powder Inhaler
—Bisgaard H. Am
a Nonelectrostatic Spacer
into
J
Respir Crit Care
Med
Reduction
in
smoking within
was not associated with
month of surgery
1
a decreased risk of post-
operative pulmonary complications.
1998;157(2):5I8.
TB
CONCLUSIONS:
CI. 1.9-9.9) were independent predictors of
diagnosed
in
San Francisco.
Timely, adequate medical evaluation and follow-
up care of immigranLs and refugees has a relatively
This article describes a
new
'"automatic spacer"
device, which has been developed to improve the
delivery of inhaled medication to
In the device, a dry
powder
young
inhaler (DPI)
children.
Ventilator-Associated Pneumonia: Clinical Significance
and Implications
Pneumonia
producing an aerosol cloud of fine drug particles
comial infection
(aerodynamic diameter. < 4.7/jm) with a long
The new device combines
half-
the principal advan-
tages of the conventional spacer and the DPI.
It
den Brande
(ll):26.50.
coordination or forced inhalation, and
it
is
exposure of the patient
and pro-
show
— Hansson
gency and Life-Saving Procedure
F.
Eyskens E. Eur Respir J I997;I0
pneumonia (VAP) occurs
in a pa-
with mechanical ventilation, and
Lung volume
reduction surgery
for rigorously selected patients with severe debil-
it
is
a serious problem
— with
signifi-
cant morbidity and mortality rates. Aspiration of
bacteria
from the oropharynx, leakage of contam-
A5
emphysema.
itating
eralized
1
mothoraces during his
first
high repeatability of drug delivery owing to the
piratory
mechanical nature of the actuation (relative stan-
important factors
dard deviation, 12%). and a prolonged residence
Nurses caring for patients treated with mechan-
bronchopneumonia and
time of the fine particle aerosol (half-life of the
ical ventilation
must recognize
transferred to Belgium.
and cros.s-contamination from
res-
equipment and health care providers are
in the
development of VAP.
and
risk factors
-year-old
emphysema developed
inated secretions around the endotracheal tube,
should prove advantageous
emerg-
neither present nor developing at the time of
intubation;
patient position,
s).
is
ing as a promising and unique therapeutic option
(mass median aerodynamic diameter. 2.8 fim). a
82
(LVRS)
it
a high yield of fine drug particles in the aerosol
fallout of the fine particles.
B.
W. van
Jorens PG, van Schil P. van Kerckhoven
Intubation and mechanical ventilation greatly in-
tient treated
halers. Studies with the prototype device
United States and the lead-
ing cause of death from nosocomial infections.
tor-as.sociated
pellants used in pressurized metered dose in-
noso-
crease the risk of bacterial pneumonia. Ventila-
lung dose and pharyngeal dose, without need for
avoids
in the
common
most
the second
is
has the potential to provide a high ratio between
to the additives
TB
prevention and control programs.
Lung Volume Reduction Surgery as an Emer-
mech-
is
high yield and should be a high priority for
MJ. Munro CL. Heari Lung 1997;26(6):419.
anically actuated into a nonelectrostatic spacer,
life.
—Grap
for Nursing
man
pneu-
holiday abroad.
to respiratory insufficiency, intubation
anical ventilation
with gen-
bilateral
were necessary. In
Due
and mech-
total.
6 chest
tubes were inserted but massive air leak persisted
and his respiratory condition deteriorated due
sepsis.
As
The
patient
to
was
a last resort, bilateral
These features
include strategies for reducing these factors as part
LVRS was performed through a median
treatment of
of their nursing care. This article summarizes the
omy. The most diseased areas of the upper lobes
in the
young children with inhaled medication.
VAP:
sternot-
incidence, associ-
containing the air leak were resected bilaterally
ated factors, diagnosis, and current therapies, with
and a pleurectomy was associated. Three months
an emphasis on nursing implications in the care
after operation, there
Pulmonary Complications Bluman LG.
Mosca L, Newman N. Simon DG. Chest
of these patients.
ment
1998:1 13(4):883.
Tuberculosis
literature related to
Preoperative Smoking Habits and Postoper-
—
ative
erative
smoking behavior on postoperative
SETTING: The Veterans AdminPAR-
cohort study.
istration
TICIPANTS:
elective surgery (n
= 410).
MEASUREMENTS
self-report. Postoperative pulmonary complica-
tions
K. Chin DP. Schecter GF.
Reingold AL. Arch Intern
Med
1998: I58(7):753.
ers
was
(OR)
5.5 (95%' confidence interval [CI], 1.9 to
and 4.2 (95% CI.
16.2)
ment
ratio
pulmonary com-
1.2 to 14.8) after adjust-
for type of surgery, type of anesthesia, abnor-
(TB) or who
foreign-bom individuals after their arrival
United States.
METHODS:
cation level, pulmonary function,
body mass index,
after a follow-
dramatic case, lung vol-
reduction surgery proved to be effective and
a life saving procedure.
United States from July
December
1.
who arrived
1992. through
San
31. 1993. with a destination of
Francisco. California, and a referral for further
medical evaluation.
URES: Time
ment
MAIN OUTCOME MEAS-
to report to the local health depart-
after arrival
and the yield of active and pre-
ventable cases of
evaluations.
TB
from follow-up medical
RESULTS: Median
United States
to
Effects of the Prone Position
—
Mascheroni
Pelosi P. Tubiolo D.
D. Vicardi P. Crotti S. Valenza F, Gattinoni L.
J
Respir Crit Care
Med
Am
1998;157(2):387.
in the
Retrospective cohort
We
studied 16 patients with acute lung injury
receiving volume-controlled ventilation to assess
the relationships
between gas exchange and
res-
piratory mechanics before, during, and after 2
hours
in the
prone position.
expiratory lung
We measured the end-
volume (EELV. helium
the total respiratory system
(Csi,rs),
dilution),
the lung (Cj^l)
and the thoracoabdominal cage (Cslw) compliances
(end-inspiratory occlusion technique and esoph-
time from arrival
ageal balloon), the hemodynamics, and gas ex-
seeking care in San Fran-
change. In the prone position, PaO: increased from
in the
disease, edu-
relies
on further medical evaluation and follow-up of
cisco was 9 days (range. 1-920 days).
pulmonary
this
Lung Injury
are at high risk for tuberculosis
mal chest radiograph, chronic cough, history of
tory of chronic obstructive
ume
second of almost
who
have active TB. The system's effectiveness
pulmonary disease, history of cardiac disease,
his-
up of 8 months. In
1
1
were sustained
on Respiratory
Mechanics and Gas Exchange during Acute
in the
of 141 (22.0%)cur-
results
United States identifies foreign-bom individuals
grants and refugees applying for a visa to the
complications occurred in
.3 1
100%. The
Overseas screening of immi-
study of 893 immigrants and refugees
24 of 187 (12.8%) past smokers, and
was a remarkable improve-
spirometric values with an increase in
was even
BACKGROUND:
rent smokers.
and
Immigrants
pul-
in
forced expiratory volume in
among
Refugees— DeRiemer
its
immigrants and refugees (83.4%)
ther medical evaluation, 5
1
who
Of 745
sought fur-
(6.9%) had active
TB
103.2 ± 23.8 to 129.3
±
32.9
mm Hg (p < 0.05)
without significant changes of Csi.rs and
EELV.
+
97.4 to
However.
Cs,,w
decreased from 204.8
cigarette
consumption prior
likely to
develop a complication compared with
dictor of failure to seek further medical evalua-
± 52.5 mL/cm HiO (p < 0.01 and the dewas correlated with the oxygenation increase (r = 0.62. p < 0.05). Furthermore, the greater
OR = 6.7, 95% CI,
tion in the United States. Class B-1 disease sta-
the baseline supine Csi.w, the greater
and age. Current smokers
those
2.6 to
who
1
who
did not (adjusted
7. 1).
reported reducing
to surgery
CONCLUSIONS:
was associated with
were more
Current smoking
a nearly 6-fold increa.se in risk
for a postoperative
pulmonary complication.
RESPIRATORY CARE
•
and 296 (39.7%) were candidates for preventive
therapy. Being a refugee
tus
based on overseas
[OR], 3.5;
was an independent
TB
95% confidence
NO 6
135.9
)
crease
prone posifion
=
<
its
decrease
Con-
screening (odds ratio
in the
interval (CI), 2.0-6.2)
sequently, the oxygenation changes in the prone
95%
position were predictable from baseline supine
and being from mainland China (OR, 4.4;
JUNE 1998 VOL 43
pre-
(r
0.82, p
0.01).
46?
m
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iratory Care
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1
9
Abstracts
Csi.w (r
= 0.80, p < 0.01
Returning to the supine
).
compared with basehne
position, CsLrs increased
(42.3
±
14.4 vs 38.4
±
mUcni HjO; p < 0.01
13.7
),
mainly because of the lung component (57.5 ±
25.1 vs 52.4
( 1 )
in
baseline
+ 23.3
mUcm H2O; p < 0.01
d.^ and
its
may
changes
).
Thus,
play a role
determining the oxygenation response in the
prospective study during a 2-month period in 1993
FVC, and peak expiratory flow
with a pulse oximeter available and a compari-
paradoxical bronchoconsuiction.
son with the same period
device delivered significantly more fenoterol to
SETTING; An
imeter
residents ordered
their discretion.
resumed.
PATIENTS;
All patients
who underwent ABG or SpO: measurements.
INTERVENTIONS; During the prospective study,
Csu-, and Cstx when
is
EDof auni-
adult medical
vereity hospital in France.
prone position; (2) the prone position improves
the supine position
1992 without the ox-
in
ABG or SpO; measurements at
The reasons
Breathing Reserve at the Lactate Threshold
a Pulmonary Mechanical from
to Differentiate
— Medoff BD,
Cardiovascular Limit to Exercise
DM.
Oelberg DA, Kanarek DJ. Systrom
Chest
mined whether
Criteria used to define the respec-
of pulmonary mechanics and cardio-
vascular disea.se in limiting exercise performance
are usually obtained at peak exercise, but are de-
pendent on maximal patient
tiate heart
effort.
To
from lung disease during a
differen-
less effort-
dependent domain of exercise, the predictive value
of the breathing reserve index (BRI
[Vpl/maximal
tilation
= minute
voluntary
ven-
ventilation
[MVV]) at the lactate threshold (LT) was evaluated. DESIGN: Thirty-two patients with chronic
obstructive pulmonary disease (COPD) and a pulmonary mechanical limit (PML) to exercise de-
maximum oxygen
fined by classic criteria at
uptake (Vo:max) were compared with 29 patients
(CVL) and
with a cardiovascular limit
mal control
subjects. Expired gases
and
Vg were
available metabolic cart (Model 2001:
Med-
Graphics Corp: St Paul MN). Arterial blood gases,
lactate
were sampled each minute dur-
ing exercise, and cardiac output (Q)
by
tem 77: Baird Corp; Bedford
RESULTS;
lactate threshold
at
was measured
first-pass radionuclide ventriculography (Sy.s-
exercise.
For
MA) at
rest
ABG measurements in
MEASUREMENTS & RESULTS; The
patients
who had
BRI
at
(r
=
< 0.0001 The
(0.73 + 0.03, mean
0.85, p
).
BRIlt was higher for PML
± SEM) vs CVL (0.27 ± 0.02, p < 0.0001 ), and
vs control subjects (0.24 ± 0.03, p < 0.0001
A
BRIlt ^ 0.42 predicted a PML at maximum exer).
with a sensitivity of 96.9%, a specificity of
95.1%, a positive predictive value of 93.9%, and
a negative predictive value of 97.5%.
SIONS; The BRI]
ing the
T, a variable
CONCLU-
measured dur-
submaximal realm of exercise, can
tinguish a
PML
dis-
from CVL.
Oximeter in an Adult Emergency
Department: Impact on the Number of Arterial Blood Gas Analyses Ordered
Le BourLIse of a Pulse
—
delles G, Estagnasie P, Lenoir F,
Brun
P,
Drey-
fussD. Chest 1998:1 1.3(4):1042.
OBJECTIVES; To assess
ABG levels
tients.
of arterial blood gas
the impact of pulse ox-
(ABG)
were measured
The use of SpO; did not
in
1
19 pa-
result in the order-
ABG determinations. One hunABG measurements were
justified. There were fewer unjustified ABG detering of fewer useful
minations in 1993 when the pulse oximeter was
available than in
vs 54 of 184: p
1
992 when
< 0.001
)
it
was not
( 1
4 of
1
1
mainly because fewer
ABG determinations were ordered for miscellaneous nonrespiratory indications
< 0.01
of 1 84: p
).
(1
3 of
1
1
of a pulse oximeter did not affect the ordering of
ABG
useful
measurements but allowed a
nificant reduction of unjustified
levels ordered in an
emergency department (ED). DESIGN;
A
Aerochamber (39.2% vs
The
any
RESPIMAT
alone or an
MDl
with
9.9% of
11.0%- and
metered dose, respectively: p < 0.01). Oropharyngeal deposition of fenoterol from the
< 0.0
vs 7 .7%, respectively: p
1
1 ).
new
MDl (37. %
device was lower than that from the
1
The
RESPIMAT
device deposited significantly more fiunisolide
lungs compared with
in the
MDl
(44.6%' vs 26.4%, respectively: p
plus spacer
< 0.01
),
while
resulting in similar oropharyngeal deposition
(26.2% vs 31.2%, respectively). Introduction of
a baffie into the
RESPIMAT system reduced lung
deposition of flunisolide to 29.5%, and oropha-
<
ryngeal deposition to 7.8% (p
0.01).
CON-
CLUSION; The RESPIMAT device may prove
to be an effective alternative to MDIs for the
administration of inhaled bronchodilators and corticosteroids.
The high lung deposifion and low
may lead to improved
oropharyngeal deposition
efficacy and tolerability of inhaled medications,
especially corticosteroids.
9 vs 43
CONCLUSION; The availabiUty
sig-
ABG measure-
Compliance with Peak Expiratory Flow Monitoring in
J,
Home Management of Asthma
Cartier A,
Malo
JL, Rouleau
—Cote
M. Boulet LP.
Chest 1998:1 13(4);968.
ments. Substantial cost savings could be achieved
by using SpO:
in
BACKGROLTVD: The recent consensus reports
an ED.
on asthma management emphasize the importance
Lung Deposition
of Eenoterol and Flunisolide
of using peak flowmeters to accurately assess the
Delivered Using a Novel Device for Inhaled
degree of airflow obstruction. However, the opti-
Medicines: Comparison of
RESPIMAT with
Conventional Metered-Dose Inhalers with and
without Spacer Devices
J,
— Newman SP, Brown
Steed KP, Reader SJ. Kladders H. Chest
1998:1 13(4);957.
mal way
to use those devices has not yet
termined.
with peak expiratory flow (PEF) measurements
in the
long-term management of asthma and to
compliance.
OBJECTIVES; To compare
fenoterol or
lung deposition of
f unisolide administered from a
novel,
SETTING;
tertiary-care hospitals.
and
prospective
'\sthma clinics from three
DESIGN; A
PATIENTS; Twenty-six
(RESPIMAT: Boehringer Ingelheim Ltd:
Bracknell, UK) or from conventional metered dose
inhalers (MDls) with and without spacers. DE-
to .severe
Patients
were asked
Two randomized, three-way crossover stud-
evening
PEF
droplets
ter
INTERVENTIONS;
device.
In
one
.study,
radiolabeled
RESPIMAT device
MDl with or without an
asthma taking
I
descriptive
-year
duration.
patients with
moderate
an asthma education
part in
MAIN OUTCOME MEASURES;
program.
ies. SETTING: Clinical research laboratory. PARTICIPANTS; Healthy, nonsmoking volunteers.
of
study
multidose inhalation device delivering liquid
SIGN;
been de-
OBJECTIVES: To assess compliance
identify the characteristics of patients with poor
measure morning and
to
using an electronic peak flowme-
with a 3-month memory: they were unaware
that
PEF values were being recorded by this
RESULTS; Compliance with PEF mea-
aerosols of fenoterol from the
surements was relatively good during the
and from a conventional
month (63% of the measurements done)
Aerochamber spacer (Tnidell Medical: London,
with regular reinforcement,
Ontario, Canada). In the second study, radiola-
and to
33%
beled aerosols of fluni.solide from a
RESPIMAT
ning, 8 of
RESPIMAT device
modified by
(<
device, from a
inclusion of a baffie/impaclor in the mouthpiece,
and from
a conventional
MDl
with an Inhacort
spacer (Boehringer Ingelheim: Ingelheim, Ger-
imetry (SpO;) on the indications and the number
466
study
dred and five (88%)
many).
adult
1992.
and peak
patients, the
all
(BRI lt) correlated with the BRI
Vojmax (BRImax)
cise,
The data
12 nor-
measured breath by breath using a commercially
pH, and
choice was justified.
were compared with those for 184 consecutive
patients:
tive roles
who deter-
included 152 patients. Spo. alone was u.sed in 33
1998:1 13(4):913.
OBJECTIVES:
their
were
for their ordering
reviewed by two independent experts
MDl
the lungs than either an
rate) to detect
MEASUREMENTS & RESULTS;
Assessment of the deposition of fenoterol or
nisolide in the lung and
scintigraphy.
oropharynx using
flu-
gamma
Safety was as.sessed based on
reported adverse effects and spirometry (FEV|,
at 12
fell
to
first
but even
50% at 6 months
months. Right from the begin-
26 subjects (30%) never or almost never
5% of the readings done) measured PEF, with
seven of these subjects writing fabricated results
in their diaries
60%
most of
the lime.
At
of the subjects were measuring
1
2 months,
PEF < 25%
of the time, and most of them continued writing
fabricated
PEF values in
their diaries.
None of the
subjects' characteristics helped us to identify those
who had poor compliance
ments.
CONCLUSIONS;
RESPIRATORY CARE
•
with these measure-
While short-temi com-
1
Abstracts
pliance with
PEF measurements
not interested in measuring
is
good,
asthma are
PEF twice
daily over
a prolonged period. In the current
of a.sthma.
fairly
to severe
most patients with moderate
management
PEF measurement devices
can be sug-
gested to those showing a strong personal interest in
using them, but should be limited to short
periods of time. Furthermore, this study outlines
the usefulness of electronic
peak flowmeters when
doing clinical research where
is
PEF improvement
an important outcome.
both
VAIs and their caregivers. INTERVENTION:
None.
sis
ANALYSIS:
Confirmatory factor analy-
with principal components extraction.
lique (oblimin) solution
the factor matrices.
tors
needed
was used
An ob-
for rotation of
The number of common
to obtain the best
fit
fac-
of the factor model
on chronic daily therapy. Total and regional deposition were correlated with breathing pattern,
pulmonary function, demographic
factors,
patient's
tion
measured lung dose on pulmonary func-
was estimated by stopping
the drug and ob-
was determined with use of maximum-likelihood
serving changes in spirometry over a 2-week fol-
estimation. Confirmatory factor analysis with
low-up period. After discontinuance of the drug,
ear structural equation modeling
formed.
sis
RESULTS:
was
lin-
also per-
Confirmatory factor analy-
did not fully replicate the factor structure
proposed by Lawton
et al.
CONCLUSIONS: The
all
patients reported worsening of
dyspnea and
producing sputum. There was a
difficulty
model proposed by Lawton
giving Appraisal Scale for Caregivers of Home-
ful
foundation for examining the appraisal of fam-
patients, as
much
as
ily
caregivers of home-based VAIs. Additional
was found
in the
pharynx (range 0.0
—
MA,
Sereika S,
Hoffman LA, Matthews
Sevick
JT,
Chen
development work
is
et al
provides a use-
— Diot
the underlying
dimen-
tors in Cystic Fibrosis
sions of the Caregiving Appraisal Scale
(CAS)
Smaldone A, DeCelie-Germana
with use of data collected ftom caregivers of home-
Smaldone GC.
based ventilator-assisted individuals (VAIs). DE-
156(5): 1662.
SAMPLE: Two
hundred seventy-seven primary family caregivers
of VAIs.
MEASURES:
developed by Lawton
Twenty-eight-item
et al
48% of the deposited
to
0.029), and pharyngeal depo-
CAS
(1989), and an inves-
= -0.696. p < 0.006) and age
(r
volume
(r
= -0.743, p <
Palmer LB.
0.(X)5).
Grimson R,
0.16mgand0.78mgofthe 2.5 mg nebulizer dose
(mean 0.47 + O.Ot mg) and correlated negatively
with FEV % predicted, r = -0.6 1 1 p = 0.0 52
1997:
For the lungs, deposition ranged between
,
However,
To
aerosol
0.30 mg,
J,
(
1
,
).
the spirometric decrements following
identify factors influencing lung dose of aero-
cessation of therapy did not correlate with the lung
human deoxyribonuclease
dose of the drug. Analysis of regional deposition
solized recombinant
(rhDNase
I),
we used gamma camera and
filter
techniques to measure deposition in 15 clinically
tigator-developed instrument to assess physical
stable patients with cystic fibrosis
health and sociodemographic characteristics of
and 10 females, age 6- .31
RESP
paUents completed the study. In some
P,
SIGN: Cross-sectional survey. SETTING: Residences of home-based VAIs.
all
sition correlated negatively with fidal
rhDNase I Aerosol Deposition and Related Fac-
OBJECTIVE: To confirm
but
mean 0.089 mg ±
needed for the CAS.
GJ. Heart Lung 1997;26(6):430.
sig-
FEV| {9c predicted, mean ±
SE, 86.9% ± 5.57 to 77.8% ± 5.73. p < 0.005),
nificant decrease in
A Confirmatory Factor Analysis of the CareBased Ventilator-Assisted Individuals
and
disease severity. In addition, the effects of each
yr.
mean
(CF) (5 males
16.9)
who wen?
within the lungs indicated a wide range of distribution
between central and peripheral zones.
In conclusion, the deposition pattern of
I
aerosols in patients with
CF is largely
rhDNase
influenced
Abstracts
by respiratory physiology, which
itself
depends
upon age and severity of lung disease. As the
patients grow there is a decrease in upper airway
deposition and
more
particles are presented to the
more airways
lungs where those patients with
dis-
ical
conditions that suggested the possibility of
INTERVENTIONS:
inadequate preload.
administered rapidly until the Ppa„ rose by
one
airway deposition of rhDNase
days and for different
younger
patients,
I
is
significant, espe-
may be related
and
to
in stroke
and Altered Lung Func-
to Physical Inactivity
tion in
COPD Patients—Semes
I,
Gautier V. Var-
ray A. Prefaut C. Chest 1998;1 13(4):900.
mine
tive
( 1 )
pulmonary disease (COPD)
skeletal
were to deter-
whether patients with chronic obstruc-
muscle performance
(ie.
have impaired
maximal strength
and endurance) compared with healthy subjects,
and
whether the
(2)
level
of physical
body
activity,
14.2
+ 3.6
mm Hg; p = 0.001
to baseline
RVEDVI
mL/m-; p =
0.22).
in
SV
(r
= 0.44);
in
RVEDVI exceeded
poor response
dict a
was not a
fluid.
Seventeen
COPD patients and eight healthy
age-matched control subjects performed
voluntary contraction
and an endurance
test
(MVC)
20%
of
MVC
an imposed regular pace until exhaustion. The
endurance
test
duration determined the muscle
"limit time" (Tum).
(PA
± 33
between
= 0.58
).
and
Pp;,,,
A positive
As
A
score of physical activity
score)
was obtained using an adapted phys-
ical activity
questionnaire for the elderly, and body
4 of 9 cases
CONCLUSION:
RESULTS: The results showed that T|,m
test.
and
PA
Comparison of Drug Delivery from Conventional versus "Venturi" Nebulizers
son SG, Everard
— Devada-
ML. Linto JM. Le Souef PN. Eur
RespirJ1997;IO(lI):2479.
Attempts to improve drug delivery from conventional jet nebulizers
have included the use of stor-
age systems to reduce drug wastage during exhaVenturi nebulizers enhance drug delivery
lation.
during inhalation, reducing treatment times and
ulizer (Acorn) used both with
and without a
(Ventstream and Pari LC). Filters were
ulizers
RVEDVI.
to
is
an
In
indi-
best assessed
by an empiric fluid challenge.
salbutamol. and 18 children with cystic fibrosis
(
3-
6 yr^ inhaled through these devices. The quan-
1
tity
)
of drug collected on the
filter
was assessed
using ultraviolet spectrophotometry.
Diaphragm
Cellular Adaptations in the
Chronic Obstructive Pulmonary
vine S. Kaiser L. Leferovich
Med
stor-
age chamber (Mizer), compared to 2 Venturi neb-
attached to the 4 nebulizer systems, containing
J.
in
— Le-
Disea.se
N
Tikunov B.
Engl
cle size distribution
ulizer
The
parti-
of the aerosol from each neb-
system was measured using laser diffrac-
tion. Inspiratory filter
was lower than
1997;337(25):I799.
the
deposition using the Acorn
Acorn with Mizer. and both
Venturi nebulizers. Filter deposition using the
BACKGROUND:
In patients with severe chronic
phragm undergoes physiologic adaptations
COPD patients
diaphragm, an adap-
reliable predictor of the re-
obstructive pulmonary disease
in
in the
tation that increases resistance to fatigue.
a predictor of fluid respon-
impedance method. Symptom-limited oxygen
using a maximal incremental exercise
of the muscle fibers
of age on inhaled dose from a conventional jet neb-
vidual patient, adequacy of preload
J
Severe
drug wastage. This study investigated the effect
in
composition was measured by the bioelectrical
uptake (Vo,s|) was also assessed
CONCLUSIONS:
COPD increases the slow-twitch characteristics
in
to fluid.
was superior
siveness. Ppa,
forms of these proteins.
138 mL/m-, a thresh-
consisting of dynamic con-
tractions of the quadriceps against
at
maximum
of the quadriceps
dif-
3.4 vs
old value that has been suggested to reliably pre-
RVEDVI
ODS;
r
was observed
sponse to
in
(
controls had higher percentages of the fast iso-
but not with respect
the relationship
COPD patients. METH-
muscle performance
±
(105 + 31 vs 119
S V was suonger
respon.se to fluid
which
10.0
(
RVEDVI and fluid-induced change
between
change
).
SV)
There was a moderate corre-
composition, and lung function are related to skeletal
increase in
fered with respect to baseline Ppa„
lation
OBJECnVE: The aims of this work
Responders (n = 20;
volume [SV]) and non-
10%
chains, troponins, and tropomyosin, whereas the
MEAS-
clinical indications.
UREMENTS & RESULTS:
responders (n = 16; <
Impaired Skeletal Muscle Endurance Related
at least
were given on separate
fluid challenge, these
> 10% increase
laryngeal side effects.
was
mm Hg. When a patient underwent more than
3
ease have enhanced pulmonary deposition. Upper
cially in
Thirty-
six fluid challenges. Fluid (saline or colloid)
acterized
by an
increa.se in
(COPD).
the dia-
char-
Acorn with Mizer was lower than
trend with age. height, or weight
any nebulizer. Aerosol
LC.
die Pari
No
was noted using
particle size using the
Vent-
energy expenditure and
stream was lower than the other nebulizer sy.stems.
We hypothesized that
Drug output from both Venturi nebulizers was
relative resistance to fatigue.
these physiologic characteristics
would be asso-
more
efficient than
from the jet nebulizer, used
COPD
ciated with structural adaptations consisting of an
with and without the storage chamber, during in-
patients (p<0.05). Significant positive correla-
increased proportion of less-fatigable slow-twitch
halation by children with cystic fibrosis.
muscle
haled dose did not change with the patient's age
score were significantly decreased in
tions
were found
and the
0.52; p
same
and
PA
in the
score
< 0.05). and
results
Vcfesi (r
p < 0.05).
COPD group between Ti.n,
(r =
(r = 0.60; p < 0.05), FEV,
P^ (r = 0.63; p < 0.05). The
were found between the
= 0.57; p < 0.05) and FEV,
CONCLUSION:
cate impaired skeletal
PA
score
= 0.63;
patients related to altered lung function
volume
[
± standard
error] forced expira-
and asso-
of the various isoforms of myosin heavy chains,
indi-
tory
myosin
Volume as a
Hemodynamic Response
Predictor of the
METHODS: We obtained biopsy spec-
to a
— Wagner JO. Leatherman JW.
Fluid Challenge
Chest 1998;I13(4):I048.
in
1
second. 33
venuicular end-dia.stolic volume index
(RVEDVI)
and pulmonary artery occlusion pressure
as predictors of the
right
(Pp;n,)
hemodynamic response
to a
DESIGN: Pro.spective cohort
SETTING: Medical ICU of a university-
in-
or size using both types of nebulizer.
and tropomyosin
light chains, froponin.
Pulmonary Function
Tests:
Comparison of 95th
Percentile-Based and Conventional Criteria of
Normality
WR
Jr.
— Margolis ML. Monloya
South
Med J
BACKGROUND:
FJ.
Palma
1997;90(12):1 187.
Although 95th peiv;entile-based
were determined by sodium dodecyl sulfate-poly-
normal limits are recommended instead of con-
acrylamide-gel elecQ-ophoresis.
We also used im-
ventional criteria of nonnality to guide pulmonary
munocytochemical techniques
to
determine the
we have found no
how the choice of normight influence PFT interpretation.
function test (PFT) readings,
proportions of the various types of muscle fibers.
objective assessment of
RESULTS: The diaphragm-biopsy specimens
mal limits
from the patients had higher percentages of slow
OBJECTIVE: To compare thermodilution
The
imens of the diaphragm from 6 patients with severe
COPD (mean
COPD
in
ciated physical inactivity.
Right Ventricular End-Dlastolic
proteins.
and slow isoforms of myofibrillar
± 4 of the predicted
value; residual volume. 259 ± 25 of the predicted
value) and 10 control subjects. The proportions
(r
These findings
muscle endurance
fibers
myosin heavy chain
I
(64
±
3 vs
45 ±
2,
p<
0.(X)1
).
METHODS: We did a retrospective comparison
of
PFT readings
referenced to conventional cri-
and lower percentages of fast myosin heavy chains
teria
lla(29±3vs39±2.p = 0.01)andllb(8±
ments influenced by 95th percentile-based nor-
1
7
+
1 .
1
vs
p < 0.00 1 ) than the diaphragms of the con-
Similar differences were noted
when im-
of normality versus independent repeat
asse.ss-
We also conducted a
nationwide telephone survey of VA Hospital PFT
mal
limits in 166 veterans.
fiuid challenge.
trols.
study.
munohistcK-hemical techniques were used to com-
laboratories.
ICU
pare the percentages of these fiber types in the 2
curred in only 7.2% of 616 individual PFTs; how-
of a community hospital.
PATIENTS: Twentywho had one or more clin-
groups. In addition, the patients had higher per-
ever, these discrepancies could potentially influ-
five critically
centages of the slow isoforms of myosin light
ence
affiliated
408
county hospital and medical-surgical
ill
patients
at least
RESPIRATORY CARE
RESULTS:
Discordant readings oc-
PFT
1
component of
•
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in the Practice of Patient Assessment
A.
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Appreciate the cost of care
Understand the scope and limitations of the
practitioners role in patient assessment
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be
a
Abstracts
26.5% of our subjects. The 95th
percent! le-based
normal hmits were used by only
40%
laboratories, without relationship to
or hospital
size.
CONCLUSIONS:
of
terial
V A PFT
56% [95% confidence
geography
Discrepancies
and 95th percentile-based
ings,
in the
majority of
used
VA PFT laboratories.
A New Bronchoscopic Technique for the DiagPneumonia in HIV-Positive
Sauleda J, Maimo A. Riera M. Ramirez
—
Togores B. Pons
S, et al. Respir
Med
commensals, such as nontypable Haemophilus
with-
was
influenzae, cause most bronchial infections by
37-75%] and
exploiting deficiencies in the host defenses.
37-75%) and 94% (CI. 86-100%) for mpBAL.
When both techniques were assessed together, sensitivity increased to 70% (CI, 53-87%'). The use
equilibrium in which the numbers of bacteria are
of a single catheter reduced the cost of the orig-
When an
these figures were
pBAL
contained by the host defenses but not eliminated.
procedure by approxi-
an inflammatory response. Neutrophil products
mpBAL can improve
can further impair the mucosal defenses, favor-
TPC
bacterial
followed by a
pneumonia and reduces
its
ing the bacteria, but
symptoms
cost.
sists,
Infection in
COPD—Wilson
R.
Chest 1998:1 13(4 Suppl):242S.
to evaluate in
HIV-positive patients with bacterial pneumonia,
the diagnostic value of a
new endoscopic
nique that uses a single catheter to perform a
scopic plugged catheter
ified protected
(TPC followed by
)
a
obstructive pulmonary disease
tele-
mod-
ficult
and
were included
mpBAL
in the study.
diffuse
sponse both
Samples from
were cultured quantitatively.
According
symptoms
that
can vary sponta-
overcome,
the infection per-
may
cause lung dam-
About half of exacerbanons involve bacteinfection, but these patients are not easy to
from those who are uninfected, which
that antibiotics
is strictly
have to be given more often
necessary. Further research
whom
to characterize those patients in
infection has a
in the short
more important
needed
is
bacterial
role.
Lung Transplantation for COPD
and long term. The role
of bacterial infection, and thus use of antibiotics,
in
shows
to
In appropriately selected patients with chronic
that bacterial infection has a significant role
in
were classified
gression
group (27 with bac-
—Trulock EP.
Chest 1998:1 13(4 Suppl);269S.
COPD is controversial. The available evidence
the clinical and microbiological results, patients
in the study
chronic inflammation
is
if
rial
than
are dif-
the infection
neously, and difficulties in defining clinical re-
Standard bronchoalveolar lavage was performed
to rule out opportunistic infections.
(COPD)
if
However,
age.
means
because of the heterogeneous nature of
COPD,
bronchoalveolar lavage (mpBAL).
Fifty-eight HIV-positive patients with respiratory
infection
resolve.
differentiate
Clinical studies of acute exacerbations of chronic
tech-
is
mately 50%. The use of a single catheter to per-
The Role of
The aim of the present study was
exacerbation occurs, this equilibrium
upset and bacterial numbers increa.se, which incites
91(9):530.
Trc
between exacerbations, which represents an
teria
the diagnostic yield in FTrV-positive patients with
1997;
Some
COPD patients are chronically colonized by bac-
form a
nosis of Bacterial
Patients
intervals (CI)
was 100%:
specificity
inally described
J.
1
(CI,
PFT read-
criteria are not
(3
56%
its
between 95th percentile-based and conventional
normal limits can potentially influence
pneumonia) or the control group
out bacterial pneumonia). Sensitivity of TPC
acute exacerbations, but
is
less certain.
its
obstructive
role in disease pro-
Upper
pulmonary disease (COPD) and a-l-
antitrypsin deficiency
respiratory tract
emphysema, lung
trans-
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AT 535/^75
AT 535/^75
AT ^30/^70
AT =30/570
MASTERCARD
2
1
fore investigated prospectively the evolution of
a Pressurized Metered-Dose Inhaler Formu-
Body weight decreased (from 85 ± 42
LS. Systolic and mean pulmonary arterial pressure decreased in LS and SS.
Airway Ob-
Right ventricular ejection fraction increased in LS.
treated with
1
ABSTRACTS
Differences in Bronchodilating Potency of
Salbutamol
in
Turbuhaler as Compared with
lation in Patients with Reversible
struction
— Lofdahl CG, Andersson
son E, Carlsson LG, Friberg K, Hedner
J
1997:10(1
to 8
±40 kg) during
1
lishing the
via Turbuhaler
cluded.
nasal
CPAP was 64 ± 6 months. Most of the pa-
tients
(77%) were smokers
were increased on admission, whereas plasma
ment.
):2474.
1
re-
mal.
We
suggest that in these patients,
oedema
and via a pressurized metered-
sterone-vasopressin and with a normal cardiac out-
ratio for salbutamol
put.
ble-blind, randomized design. Outpatients with
lowed a confection of blood gases, associated with
mild-to-moderate chronic reversible airway ob-
the resolution of
were given single doses of salbutamol
pMDI.
Effi-
Noninvasive positive pressure ventilation
oedema, a decrease
and an increase
arterial pressures
in
al-
pulmonary
in right
ven-
after
each dose. The
including
1
first
study
2 padenLs.
The salbutamol doses given were: 50, 100 and
2x 1 00 /^ via Turbuhaler and 2x 1 00 /Jg via pMDI
(Ventolin). The study showed that 2x 100 ;jg of
salbutamol inhaled via Turbuhaler
is
that
via a
2x100
study.
study including 50
was a placebo-controlled 5-way
Two
is at
salbutamol inhaled
/Jg
pMDI. The second
patients
pMDl,
100 /ig salbutamol via Turbuhaler
least as potent as
crossover,
doses of salbutamol via Turbuhaler,
50 and 2x 1 00 /Jg, and via pMDI, 00 and 2x200
1
/Jg,
were given. There was a dose-dependent
response
(FEV|)
in
forced expiratory volume in
for both inhalers.
in baseline
FEVi
second
1
Adjusted for differences
values, the estimated nslative dose
potency for Turbuhaler versus
A 30 Year Epi-
Respiratory Health Status:
demiological Study of Workers in Paris
mann
F,
Annesi
Chwalow
I,
J.
—Kauff-
Eur Respir J 1997;
10(11):2508.
pMDI was
1
.98:
The
validity of scales used for subjective assess-
ment of health,
is
particularly transitional indices,
under discussion. The aim of the present study
was
ity
and predictive valid-
to assess the concurrent
30
smdy of 9
1
5 workers
was conducted over
years, with both retrospective self-assessment
assessment of the reason for death during the
M, Favre H, Kyle
Chevrolet JC. Eur Respir
Jolliet P,
J
1997;
assessment of respiratory deterioration over
tional lung function values
was
(FEVi
after
to investigate the hae-
modynamic and endocrinological
effects of non-
also related to the
same
FEVi (smoking,
risk factors as de-
occupational exposure).
significantly predictive of death
were measured
at
study |LS1).
of
To
NIPPV and
and water handling hormones
admission and discharge (long
discriminate between the action
from
all
was
causes,
1
.5
(Paco2) for the group as a
whole increased slighUy,
but significantly, from 5.2
mm
± 0.7 kPa (39 ± 5
to 5.4 ± 0.5 kPa (4 ± 4 mm Hg) (p < 0.05).
Mean pulmonary artery pressure (Ppa) at rest did
not change 16 ± 5 mm Hg vs 17 ± 5 mm Hg; not
Hg)
1
patients with
was 24 ±
t5
(NS).
of
FEV
5
pulmonary hypertension
mm Hg at
to
versus 20
±
7
at to,
1
Ppa
mm Hg at
We conclude that the significant decrease
I
after 5-year
follow-up was related to a
and pulmonary artery pressure remained
an unselected series of 65
OSA
stable in
patients treated
which increased by a small, but
significant,
amount
Propofol for Sedation in the Intensive Care
Unit: Essentials for the Clinician
MA.
Respir
Med
— Marinella
1997;91(9):505.
Propofol
is
a short-acting intravenous anesthetic
commonly utilized
in the intensive care unit
(ICU)
for sedation of mechanically ventilated patients.
The
it
rapid onset and termination of action
make
an attractive drug for use in the ICU. The safety
However,
there are potential adverse reactions associated
long-term variability (objective and subjective)
with the drug. This review discusses the phar-
self-
assessment of respiratory health deterioration was
significantly related to
FEV|. Subjective assess-
macology, administration and adverse effects
associated with propofol with which clinicians
who
administer propofol should be familiar.
in respiratory health
Five- Year Effects of Nasal Continuous Positive
Airway Pressure in Obstructive Sleep ApChaouat A, Weitzenblum E,
—
noea Syndrome
Kessler R,
Oswald M, Sforza
E,
Liegeon
MN,
KriegerJ. Eur Respir J 1997;10(1 1):2578.
other treatments, measurements
4 hours with-
There have been very few studies assessing the
out NIPPV and 4 hours with NIPPV (short study
[SS]). NIPPV entailed a correction of Paco; and
an increase of Pao.. in LS and SS. Oedema dis-
long-term physiological effects of nasal contin-
were performed on the fourth day,
474
±
However, Pao. increased in the subgroup of
patients with hypoxaemia at to (n = 23), from 7.8
Hgj).
res-
were included. ESchocardi-
ography, cardiac radionuclide assessment, blood
salt
(PaO:) for
stable (9.4
respiratory causes. Asthmatics exhibited greater
provides valid information.
catecholamines,
oxygen tension
whole remained
with the highest (but nonsignificant) rate ratio for
ment of long-term changes
and hypoxaemic worsening of a chronic
Arterial
mm Hg] vs 9.4 ± 1.2 kPa [71 ±9 mm
profile of propofol is well established.
invasive positive pressure ventilation (NIPPV).
piratory insufficiency
1 1
decline), an association
adjustment for FEV] level.
Eleven patients with oedema and recent hypercapnic
1
and longitudinal lung
than nonasthmatics. Independent of dyspnoea,
The aim of this study was
[71
±
%
subsequent 20 years was performed. Subjective
Self-evaluation of respiratory deterioration
10(11):2553.
< 0.01 ).
1
follow-up evaluation
pressure, unlike arterial carbon dioxide tension,
An
2 years apart.
of Noninvasive Mechanical Ventilation in Res-
U,
(p
kPa
second
for 5 years with nasal continuous positive airway
1
cline in
nard C, Righetti A, Vallotton
(tj)
the group as a
at the
1
76 ± 2
to
surements of spirometric values
Haemodynamic and Endocrinological Effects
M, Rey-
of the predicted value
in
(to)
of respiratory health changes and objective mea-
which remained
JB, Ritz
% at baseUne
study population. Daytime arterial oxygen tension
tudinal
It
—Thorens
80 ± 2 1
high percentage of smokers and exsmokers in the
function changes
piratory Failure
fixjm
A longi-
assessment of respiratory health changes.
en via a conventional pressurized metered-dose
given via Turbuhaler.
(FEVi )
volume
of a simple estimate of long-term subjective
years was significantly related to both cross-sec-
is
significant, de-
crease in forced expiratory
significant [NS]) nor did exercising Ppa. In the
(95% confidence interval 12-3.2). These studies
showed that the same bronchodilating effect can
be achieved when half the dose of salbutamol givinhaler
baseline assess-
(
more potent
than 2x 100 /jg salbutamol inhaled via a
and
Validity of Subjective Assessment of Changes
in
at the
We observed a small, but
± 0.7 kPa (59 + 5 mm Hg) to 8.9 ± 1.2 kPa (67
± 9 mm Hg). Arterial carbon dioxide tension
tricular ejection fraction.
cacy and safety variables were measured before
was a 4-way crossover study
The mean duration of home treatment with
Left ventricular ejection fraction did not change.
decreased. Natriuretic peptides and catecholamines
can occur independently of renin-angiotensin-aldo-
and during 6 hours
with this syndrome
Sixty-five patients were in-
Cardiac index was normal on admission and then
S,
with the aim of estab-
administered via Turbuhaler and via
CPAP.
Bondes-
dose inhaler (pMDI). Both studies were of a dou-
struction
blood gases, and pulmonary
in patients
Homblad
given
dose potency
arterial
haemodynamics
J.
nin activity, aldosterone, and vasopressin were nor-
Two studies are presented,
lung function,
L.
Y, Jemsby P. Kallen A, Ullman A. Werner
Svedmyr N. Eur Respir
appeared.
for
uous positive airway pressure (CPAP) for the obstructive sleep
apnoea syndrome (OSA).
We there-
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Case Reports
Acute Pulmonary Edema following Upper Airway Obstruction:
Case Reports and Brief Review
M
Richard H Kallet MS RRT, Brian
Daniel RRT,
Michael Cropper MD, and Michael A Matthay MD
INTRODUCTION: Postobstructive pulmonary edema is generally characterized by fulminant pulmonary
edema that becomes apparent within seconds or minutes after the relief of severe upper airway obstruction. The development of postobstructive pulmonary edema is believed to result from the generation
of extremely high negative intrathoracic pressures against an occluded airway. However, the mechanism responsible for the development of acute pulmonary edema in this setting is uncertain. Measurement
of the ratio of total protein concentration between pulmonary edema fluid and plasma is an established,
accurate method for distinguishing hydrostatic from increased-permeability pulmonary edema. CASE
SUMMARIES: We report 3 cases of severe postobstructive pulmonary edema. The pulmonary edema
fluid to
plasma
total protein concentration ratio
was measured immediately following relief of the obstruc-
The ratio of the pulmonary edema fluid protein concentration to plasma total protein concentration
was 0.42(0.10) mean (± standard deviation). Ratios < 0.65 are characteristic of hydrostatic pulmonary
edema, whereas patients with increased-permeability pulmonary edema, as seen in acute lung injury,
have a ratio between 0.75 and 1.0. Pulmonary edema in all 3 cases resolved within 24 hours. IN CONCLUSION: These data indicate that postobstructive pulmonary edema may result from a primary hydrostatic mechanism. These cases also illustrate the value of measuring the ratio of pulmonary edema fluid
to plasma total protein concentration to determine the mechanism of pulmonary edema. [Respir Care
1998;43(6):476-480] Key words: Postobstructive pulmonary edema, pulmonary edema, pulmonary edema
tion.
fluid,
upper airway obstruction.
and croup,' airway compression by tumors,'' poststrangula-
Introduction
and hanging/ laryngospasm,'' foreign body aspiration,*
tion
Postobstructive pulmonary
edema has been described
as
an infrequent complication following severe upper airway
obstruction'- from a variety of causes including epiglottitis
and endotracheal tube obstruction.' Postobstructive pulmonary
edema is generally
edema that becomes
characterized by fulminant pulmonary
clinically apparent within
utes after the obstruction
Richard
H
Kallet
eral Hospital;
MS RRT; Respiratory Care Services,
University of California, San Francisco. Brian
tute;
San Francisco Gen-
Department of Anesthesia; Cardiovascular Research
M
Daniel
RRT;
Insti-
Car-
diovascular Research Institute; University of California, San Francisco.
Michael Cropper
nia,
MD;
Department of Anesthesia; University of Califor-
San Francisco. Michael
A
Matthay
MD;
Departments of Medicine and
Anesthesia; Cardiova.scular Research Institute; University of California,
arterial
relieved.'*"'
wedge pressure measurements have been
cleared.'''"" In
edema
in part
by the National Institutes of Health,
NIH
51856.
Correspondence
hours.'-'-''-'''""
The development of postobstructive pulmonary edema may
result from an acute alteration in lung vascular and interstipressures generated by extremely high negative intratho-
theory
is
that the
prolonged mechanical
''•*''
stress
An alternative
may alter the
permeability of the pulmonary microvascular and alveolar
&
Reprints: Richard
H
Kallet
MS
RRT.
Respiratory
Care Services, San Francisco General Hospital, NH: GA-2, 1001 Potrero
Ave, San Francisco
476
reported,
most instances, postobstructive pulmonary
resolves rapidly within 24 to 48
racic pressures against an occluded airway.'
This paper was supported
seconds or min-
Normal pulmonary
but always well after the airway obstruction has been
tial
San Francisco, San Francisco, California.
is
CA 941
10; e-mail:
Rich_Kallet@quickmail.ucsf.edu.
epithelial
membrane, thus favoring increased permeability
as
mechanism in the development of pulmonary
edema.''""'- A number of other factors, such as hypoxia,'
the primary
RESPIRATORY CARE
•
ACUTE PULMONARY EDEMA FOLLOWING UPPER AIRWAY OBSTRUCTION
massive central nervous system sympathetic discharge,' and
ous amounts of frothy pulmonary edema tluid projected from
release of vasoactive substances such as histamine, serotonin,
the endotracheal tube.
and
kinins,'*
postulated
may
be contributory. The exact interplay of these
mechanisms
in the
iologic complexity, postobstructive
represent pulmonary
edema
An arterial
pathogenesis of postobstruc-
pulmonary edema remains uncertain. Because of its phys-
tive
Samples of this pulmonary edema
were obtained as described below.
pulmonary edema may
primarily caused by increased
after a patent
85
torr,
PaO:
blood gas analysis with F102
a few minutes
1
airway was established revealed
296
torr,
with a base deficit
ventilated in a volume-control
mode
5.1.
with
fluid
pH
The
PEEP
7. 12,
Paco:
was
patient
10
cm HiO
hydrostatic forces, increased permeability, or a combination
because of persistent respiratory acidosis (pH 7.23 with Paco:
ofboth.'-5»"'-
69
The ratio of the total protein concentration in pulmonary
edema fluid to that in plasma is an established, accurate method
for distinguishing hydrostatic
pulmonary edema."'''
from increased-permeability
In this article,
we
report the results of
3 well-documented cases of postobstructive
One
case
is
pulmonary edema.
reported in detail.
torr) and hypoxemia (PaO: 74 torr on Fio: .0). The patient
was then given 10 mg of intravenous furosemide. Urine out1
put
was 2.2 L over
steadily
was
3 hours. During this time, oxygenation
improved with PaOi 94
edema
was successonset of pulmonary edema
taken 10 hours after the development of pulmonary
revealed mild bibasilar
fully extubated
Case Summaries
on Fio: 0.70. The patient
The chest radiograph
torr
transferred to the intensive care unit.
1
The
infiltrates.
7 hours after the
patient
and was then discharged from the intensive care unit shortly
thereafter. Hospital discharge occurred
The first patient, a previously healthy 25-year-old Asian
American man, was involved in a high speed motor vehicle
accident and suffered only facial injuries.
A
computerized
tomography (CT) examination revealed a large
orbital floor
defect with both zygomatic arch and maxillary fractures.
days
later,
the patient
was taken
to the operating
room
Two
for repair
of his facial fractures. Preoperatively, the chest was clear by
auscultation and radiographic exam.
The
operative course
complicated by bleeding. The patient received
products and 7.3
of
1
L and
.5
L of crystalloid with
a urine output of
1
.5
the patient's overall fluid balance
1.3
was
L of blood
an estimated blood loss
At the end of surgery,
was -1-5.6 L. Both gas exL.
4 days
later.
Two subsequent cases of postobstructive pulmonary edema
were
identified in
which pulmonary edema
samples were obtained immediately
monary edema. The second
patient
without a history of cardiac disease
way
after
fluid
and plasma
development of pul-
was
a 24-year-old
who developed
man
upper
air-
obstruction from an aspirated foreign body following a
drug overdose. Immediately following endotracheal intubation,
moderate quantities of pulmonary edema
fluid
were
collected.
pulmonary edema resolved within 12 hours.
In the third patient, a 1 3-year-old boy developed severe laryngospasm and oxygen desaturation following laser treatment
Clinically, the
of laryngeal papillomas. There was no history of cardiac
dis-
change and pulmonary mechanics during surgery were nor-
ease or volume overload. After endotracheal intubation, copi-
mal with a Pa02îO: of 470 torr and effective
tem compliance of 47 mL/cm H2O.
ous quantities of pulmonary edema fluid were suctioned and
The
respiratory sys-
room
intubated and breathing spontaneously on a T-piece with an
F|o, of 0.40. Shortly thereafter, the patient
and
bit
down on
became agitated
was attempt-
the endotracheal tube while he
ing to ventilate, thereby occluding the airway.
was not
in
place because the endotracheal tube had been
hypertension (205/95
arterial
sure of 132
mm
He developed sysHg with a mean pres-
mm Hg), tachycardia of 132 beats/min and hypox-
emia with a pulse oximeter saturation of 85%. Manual
ventilation with an F102 of 1 .0 was attempted with little success because the patient continued to bite
patient
Pulmonary Edema Fluid Collection
down on
the endo-
The patient intermittently opened his mouth
and some ventilation was achieved. However, there
The following procedure was
tion catheter
alleviated.
trap
Edema tluid was
(Sherwood Medical,
ples
inspi-
lasted several minutes. Therefore, the
was given 100-mg succinlycholine, 2-mg midazolam,
7.5-mg droperidol. and 5-mg morphine sulfate intravenously
to stop him from occluding the endotracheal tube and to make
patient
it
possible to deliver adequate ventilation and oxygenation.
Immediately
after the patient
RESPIRATORY CARE
•
was sedated and
JUNE 1998 VOL 43
relaxed, copi-
NO 6
was suctioned with
a
diately after the obstruction of the endotracheal tube
slightly
which
was cleared. The endowedged 14 French suc(Baxter Health Care Corp, Deerfield ID imme-
tracheal tube
total protein
were 2 episodes of total occlusion and negative pressure
carried out in each of the
3 patients just after the obstruction
tracheal tube.
ratory efforts
& Measurement
A bite block
inserted only for the surgical procedure.
temic
showed bilateral pulmonary edema. The
was extubated the next morning with resolution of the
pulmonary edema within 12 hours.
the chest radiograph
patient arrived in the postanesthetic recovery
St Louis
MO). Measurement of the
on the pulmonary edema
was done by
was
collected in a standard specimen
fluid
and plasma sam-
the biuret and the bromcresol green dye-
binding technique.'"' This method provides a good reflection
of alveolar
edema fluid. '^ Measurement of total protein conedema fluid and plasma correctly charactype of pulmonary edema that results from either
centration in the
terizes the
hydrostatic or increased permeability.'at the
same time
in
'^
Blood was drawn
order to measure the corresponding plasma
total protein concentration.
477
The mean (± standard deviation) ratio of pulmonary edema
plasma total protein concentration was 0.42 (0.10).
All 3 patients had ratios of < 0.65 (Table ), which are charfluid to
1
acteristic
of hydrostatic pulmonary edema, whereas patients
with increased-permeabihty pulmonary edema, as seen in acute
lung injury, have ratios between 0.75 and 1.0."
Table
1
.
Pulmonary Edema Fluid and Plasma Total Protein
Concentration Measurements
Postobsuiictive Pulmonary
Patient
in 3 Patients
Edema
with
ing pulmonary venous pressure and Pmv even farther. Hypoxia
pulmonary engorgement and hypertension, an
can increase both pre- and postcapillary vasomotor tone,--
result in direct
which would cause a further increase
poxia, hypercapnia, and acidosis
tractility,
may
in
Pmv
pulmonary venous pressure and Pmv^''^
further raising
Therefore, the fact that a patient
may be
free of cardiac dis-
ease or have a normal pulmonary capillary
measurement
In addition, hy-
depress myocardial con-
wedge pressure
after relief of the obstruction-*'"
does not pre-
clude the possibility of acute, transient myocardial dysfunction
during the
relief of
is
Chest radiographs taken prior to and just after
crisis.
upper airway obstruction have shown that the heart
some
slightly enlarged in
we
In the introduction,
patients.'"
stated that postobstructive pul-
may
directly
ability.-'' If
the
pulmonary edema
pulmonary edema
the ratio of
tration
would have been
studies of re-expansion
or minutes after the obstruction
al*
were the
first to
was
relieved."'" Galvis et
recognize that active expiration during
acute upper airway obstruction acts as a modified Valsalva
maneuver and,
therefore, provides functional positive end-
expiratory pressure (PEEP). These investigators reasoned
that the cardiovascular abnormalities described
PEEP
be counterbalanced by
resulting in a
compensated
relieved and the
PEEP effect
above would
during the expiratory phase,
state."
When
is lost,
pulmonary edema would
the obstruction
is
develop. However, the gross manifestation of pulmonary
edema following
relief of the obstruction
may be
mislead-
plasma protein concen-
comes from
pulmonary edema and some of the
on neurogenic pulmonary edema."'-"
However, application of these theories to account for the
mechanism of pulmonary edema formation in postobstruc-
early reports
tive
pulmonary edema
is
stress
case studies described the onset as occurring within seconds
fluid to
to support the increased permeability hypothesis
edema during upper airway
uncertain. Early
in the first patient resulted
higher.-' In general, the evidence cited
to the alveolar-capillary
is
might
from both volume overload and increased permeability, then
monary edema becomes 'clinically apparent' soon after the
obstruction is relieved. The exact time of onset of pulmonary
obstruction
effect that
damage to the pulmonary capillaries,' or hypoxia
alter pulmonary capillary endothelial perme-
pulmonary edema may
when
as well as
result
is
from an oxidative injury from
change
re-expansion
suddenly reinflated,
reperfusion.-'"''-
Shear
lung volume. During the obstruc-
in
tion, functional residual capacity is
like effect
in
both from the application of shear
a completely collapsed lung
stress requires a
damage
not convincing. First, the
membrane observed
supported by the
PEEP-
caused by active expiration against a partially or
fully obstructed
relief of the
airway."" Chest radiographs taken prior to
upper airway obstruction have been reported
show marked pulmonary
to
hyperinflation.'" Therefore, inspi-
ratory efforts during the obstruction
volumetric pressure swings
at
most
likely
occur as iso-
an elevated lung volume. This
argues against stress-related lung injury as an important factor in postobstructive
pulmonary edema. Second, a recent study
reported that neurogenic pulmonary
edema was
associated
pulmonary edema
with a hydrostatic mechanism in the majority of their cases.''
may form prior to relief of the obstruction, and that the PEEP
may prevent alveolar flooding and mask radiographic
Therefore, the proposed similarities between postobstructive
ing.
It
has been suggested that
interstitial
effect
Leatherman and Schwartz-'' have documented
evidence.'"-''"'^
diffuse alveolar infiltrates on the chest radiograph prior to
relief
of the obstruction.
These cases occurred
in
young
patients without evidence
it
(-t-
5.6 L) in the
possible (although unlikely) that
in this case. Stalcup
makes
development of pul-
and Mellins^" observed
pulmonary edema
development of pulmonary edema
pulmonary edema.
Only one other case
edema has measured
total protein ratio to
report'"*
the
mechanism
in postobstructive
of postobstructive pulmonary
pulmonary edema
fluid to
plasma
describe the pathogenesis of pulmonary
edema following acute airway obstruction. In that report, a
pulmonary edema to plasma total protein ratio of 0.83 was
that
can occur
reported following emergency airway obstruction in the oper-
asthma may be potentiated by aggressive
fluid ther-
ating room.''*
that the negative pressure
in severe
patient
volume overload with a
rise in left atrial pressure contributed to
monary edema
first
at the
and possible cerebral hypoxia) do
sive adrenergic discharge
not necessarily support an increased-permeabihty
for the
of cardiac disease. However, the positive fluid balance
onset of the obstruction
pulmonary edema and neurogenic pulmonary edema (mas-
apy, leading to both increased hydrostatic forces and decreased
colloid osmotic pressures.
tein concentration (6.8
fluid overload
However, the normal plasma pro-
g/dL) in the
first
patient argues against
because dilution of the plasma protein would
have been expected.
The hypothesis that
that case
was complicated by prolonged
arterial pressure
piratory distress syndrome.
It
does not appear from that report
pulmonary edema fluid to plasma total protein ratio
was measured at the time pulmonary edema first occurred,
that the
postobstructive pulmonary
edema may
be a form of increased-permeability pulmonary edema
on two theories.
However,
< 50 mm Hg with a pulmonary
capillary wedge pressure = 9 mm Hg) and extensive cerebral
infarction.''* The patient went on to develop severe acute resshock (mean
First,
is
based
subjecting the pulmonary microcir-
culation and alveolar epithelium to prolonged mechanical stress
from repeated high negative
intrathoracic pressure swings
disrupt the alveolar-capillary
membrane."^"
'-
Second, the
intense adrenergic response to hypoxia and acidosis
RESPIRATORY CARE
•
may
may cause
but was measured hours later in the intensive care
hydrostatic pulmonary
fluid to
edema resolves,
plasma total protein
had 3 confounding factors
the
unit.'"*
As
pulmonary edema
ratio rises." Therefore, that patient
—
the timing of the measurement,
shock, and the neurologic insult
increased ratio of pulmonary
—
that
edema
may account
fluid to
for the
plasma protein
479
...
Acute Pulmonary Edema following Upper Airway Obstruction
concentration. '* In our review of the literature,
3 individual cases of patients
who developed
we found
relief
only
9.
syndrome
piratory distress
edema.''*''*
after postobstructive
pulmonary
interesting that each of those cases
It is
was com-
plicated by the presence of shock (systolic blood pressure
80
10.
<
measurements of pulmonary edema
tein ratio are indicative
fluid to
plasma
2.
total pro-
of a primary hydrostatic mechanism.
1
3
pulmonary edema appear to be
to
upper airway obstruc-
Joucken K. Collard E, Mayne A. Pulmonary edema
fol-
edema occurs by
mechanism.
fluid to
plasma
Frank LP, Schreiber GC. Pulmonary edema following acute upper
(letter).
16.
for determining the
mechanism of pulmonary
formation. Because of the availability of respiratory
care clinicians in the intensive care unit,
Am J Med
1
979;67(
1
):32-38.
MA,
Eschenbacher WL, Goetzl EJ. Elevated concentrations
D4 in pulmonary edema fluid of patients with the adult
MA,
Matthay
Matthay
J
Immunol 1984:4{6):479-483.
Clin
Wiener-Kronish JP.
Intact epithelial barrier function
for the resolution of alveolar
MA.
1):
edema
humans.
in
Am Rev
1250- 1 257.
Pathophysiology of pulmonary edema. Clin Chest
Med
I985;6(3):301-314.
17.
Wise RA.
Effect of circulatory mechanics
ducing pulmonary edema.
emergency depart-
ment, and postanesthetic recovery setting, these practition-
JF, Staub
of leukotriene
Matthay
RespirDis 1990;l42(6Pt
non-
Murray
Pitts L,
value of edema fluid protein measurement in patients with
is critical
measuring
total protein ratio as a
Anesthesiology 1986;65(1 ):106.
Fein A, Grossman RF, Jones JG, Overland E.
respiratory distress syndrome.
15.
In addition, this report illustrates the value of
pulmonary edema
Weissman C. Damask MC, Yang J. Noncardiogenic pulmonary edema
pulmonary edema.
self-limited with res-
hypothesis that postobstructive pulmonary
method
P,
NC. The
14.
invasive
Randour
airway obstruction
olution within 12-24 hours"* provides further support to the
edema
Willms D, Shure D. Pulmonary edema due
following laryngeal obstruction. Anesthesiology 1984;60(2):163-165.
1
most reported cases of uncomplicated postob-
a hydrostatic
Otol Rhinol Laryngol
(3):225-231.
1
insight into the pathogenesis
of postobstructive pulmonary edema. The results of our early
structive
Ann
124- 128.
lowing acute upper airway obsUuction. Acta Anaesthiol Belg 1986;37
1
fact that
1):
tion in adults. Chest 1988;94(5): 1090- 1092.
mm Hg).'-"'-*
These three case reports provide
The
of acute upper airway obstruction.
1980;89(2Pt
the acute res-
1
8.
obstruction.
ers are ideally suited to carry out this procedure.
19.
J Crit
on hydrostatic forces pro-
Care 1986:1:247-256.
AG. Pulmonary edema complicating
Galvis
Am J
Einerg
Med
upper airway
relief of
1987:5(4):294-297.
Brower R. Wise RA, Hassapoyannes C, Bromberger-Bamea B, PerS. Effect of lung inflation on lung blood volume and pulmonary
mutt
In Conclusion
venous flow.
in
which
protein ratio
edema
the
pulmonary edema
fluid to
plasma
Effect of alterations of pleural pressure on cardiac output.
Southern
Med
2
Lang SA, Duncan PG, Shepard DA, Ha HC. Pulmonary oedema asso-
fluid to
plasma
total protein ratio
obstructive pulmonary
hydrostatic form of
edema
0.42
(0.
10)
edema suggest
1
22.
and the
that post-
plasma
high altitude: review, patho-
Med
1985;6(3):491-507.
Barin ES, Stevenson IF, Donnelly GL. Pulmonary oedema follow-
(l):54-57.
at
25.
total protein ratio.
Lorch DG. Sahn SA. Post-extubation pulmonary edema following
anesthesia induced by upper airway obstruction: are certain patients
these case reports also illustrate the clinical value of measuring
fluid to
Anaesth 1990:37(2):210-218.
J
at
ing acute upper airway obsUuction. Anaesth Intensive Care 1986; 14
to providing
mechanism of postobstmctive pulmonary edema,
pulmonary edema
Can
Schoene RB. Pulmonary edema
physiology and update. Clin Chest
23.
24.
insight into the
1985;78(4):423-428.
ciated with airway obstruction.
represents a high-pressure or
pulmonary edema. In addition
J
total
was measured. The low values of pulmonary
rapid resolution of the pulmonary
Appl Physiol 1985:58(31:954-963.
Wise RA.
We report three cases of severe, postobstructive pulmonary
edema
J
20.
increased risk? Chest 1986;90{6):802-805.
Sofer S, Bar-Ziv
J,
Scharf SM. Pulmonary edema following relief
of upper airway obstruction. Chest 1984:86(3):401-403.
26.
Scherer R, Dreyer P. Jorch G. Pulmonary edema due to partial upper
27.
Leatherman JW, Schwartz
airway obstruction
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Tami TA, Chu
F,
Wildes TO. Kaplan M. Pulmonary edema and acute
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Am J
ID,
MG. Pulmonary edema
JAMA
1
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Physiol 1981;51(4):887-894.
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JJ.
Gerblich
AA. Upper airway
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J.
edema
fusion of ischemic
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Smith
Am Rev
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dog lung
results in fever, leukopenia,
WS, Matthay MA. Evidence
for a hydrostatic
human neurogenic pulmonary edema. Chest
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Kollef
MH,
Pluss
and lung
Respir Dis 1986;l34(4):752-756.
J.
1997;1
1
1
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(5):
in
1326- 1333.
Noncardiogenic pulmonary edema following up-
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CD. Pulmonary edema following
in rabbits.
Robin ED. Pathogenesis of neurogenic pulmonary oedema.
Bishop MJ, Boatman ES, Ivey TD, Jordan JP, Cheny FW. Reperedema.
Nishizawa M, Chaffee TL, Goto H. Pulmonary edema induced by
(5):479-48l.
Increased pulmonary vascular
Lancet 1975:2(7938): 749-751.
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obstruction due to inhala-
endotracheal tube obstruction: a case report. RespirCare 1993;38
ML, Cheney FW.
RespirDis 1981:124(4):422-427.
1
pulmonary edema. Chest 1992; 102
(2):644-645.
Pavlin DJ, Nessly
permeability as a cause of re-e,\pansion
7):
3
of a tracheal T-tube resulting
upper airway
1983:76(8): 1058-1060.
J
edema in acute asthma. New Engl J Med 1977:297( 1):592-596.
Ohkuda K, Nakahara K, Binder A, Staub NC. Venous air emboli in
Jackson FN, Rowland V, Corssen G. Laryngospasm-induced pul-
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1
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sheep: reversible increase in lung microvascular permeability. J Appl
1833-1835.
Zulueta
988; 4(6)66 1 -662.
29.
Dis Child 1984;138(4):356-358.
complication of acute airway obstruction.
1
Stalcup SA, Mellins RB. Mechanical forces producing pulmonary
Shannon DC. Pulmonary edema associated
with croup and epiglottitis. Pediatrics 1977;59(.5):695-698.
Oswalt CE, Gates GA, Holmstrom
Med
1
Kanter RK, Watchko JF. Pulmonary edema associated with upper
airway obstruction.
Med
Care
Pulmonary edema due
28.
airway obstruction. Laryngoscope l986;96(5):506-509.
Travis
S.
literature.
Medicine
(Baltimore) 1991;70(2):91-98.
RESPIRATORY CARE
•
& Updates
Reviews, Overviews,
Leukotriene Modifiers in the Treatment of Asthma
David
A Stenipel MD
Introduction
Pathophysiology of Asthma
Mechanism of Inflammation
& Biopsy Findings
Bronchoalveolar Lavage
Remodeling
Role of Inflammatory Mediators
Effects of Leukotrienes
Pharmacodynamics of Leukotriene Modifiers
Drug-Drug Interactions
Adverse Effects
Clinical Trials
Zaflrlukast
Zileuton
Leukotriene Modifiers in Exercise-Induced Asthma
Leukotriene-Modifying Agents
& Aspirin-Induced Asthma
Using Leukotriene Modifiers in Asthma Therapy
In
Summary
[RespirCare 1998;43(6):481-489] Key words: Asthma, leukotriene modifiers,
pharmacodynamics.
Introduction
of their high potency for inducing bronchoconstriction
in vitro
(1,000 times greater than histamine or prostaglandin)."*
Asthma is an inflammatory condition, resulting from comamong various inflammatory mediators, cells,
plex interactions
and other tissues
in the airways.' Detailed analyses
of bronchial
mucosal biopsies of the proximal large airways of asthmatic
individuals have revealed a cellular infdtrate typically
com-
posed of eosinophils and lymphocytes, along with epithelial
Several mediators, including histamines, cysteinyl leuko-
and kinins, as well as products of eosinophils, such
as eosinophilic cationic protein,
have also been found
in the
asthmatic airway.-' These mediators interact with receptor cells
in the
airways to evoke bronchoconstriction, bronchial hyper-
reactivity,
mucous
obstruction,
have been developed
process, either
first
new
class of
20 years. These drugs
an effort to inhibit the inflammatory
by blocking the leukotriene receptor
(eg, zafir-
by interfering
with the binding of arachidonic acid to 5-lipoxygenase (5(eg, zileuton).' Leukotriene-receptor blockers
be capable of attenuating the early and
late
appear to
phase bron-
choconstriction response and the increase in nonspecific
bronchial reactivity following challenge with inhaled allergens;'-^ leukotriene-synthesis inhibitors
may
be less effec-
tive in this regard.^
edema, and microvascular leak-
age. Cysteinyl leukotrienes are of particular interest because
in
in the last
lukast) or antagonizing leukotriene synthesis
LO)
damage and desquamation.trienes,
Oral leukotriene modifiers represent the
asthma therapy introduced
In addition to these drugs,
which
are currently
approved
for clinical use, several other leukotriene-modifying drugs are
in various stages
of development. These include three other
leukotriene-receptor antagonists, montelukast.** pranlukast,'
and verlukast,'"
David
A Stempel MD;
Mason Medical
Department of Allergy and Immunology, Virginia
ing
sites.
all
inhibit the binding
Correspondence: David
Avenue, Seattle
A
Stempel
MD,
Virginia
Mason
Clinic, 11 00 9th
WA 98101.
RESPIRATORY CARE
of which block high affinity LTD4-bind-
Two investigational drugs, MK-0591
Center, University of Washington, Seattle, Washington.
of 5-LO to
JUNE 1998 VOL 43 NO
6
and Bayx-1005,
activating protein
(FLAP)."
Published clinical studies of asthma patients taking leukotriene modifiers are few.
•
its
It
appetus that
this
new
class of asthma
481
LEUKOTRIENE MODIFIERS
medications
As
matics.
is
no marker
for these patients. In
revised Guidelines for the Diagnosis
Institute
primary therapy
will
11
and Management of
of the National Heart, Lung,
recommends inhaled
in adults
corticosteroids as
and children age 12 or older with
Mediators of acute inflammation produce bronchoconexudation of plasma, edema, and hypersecretion of
striction,
mucus,
of which act to narrow the airway and result in
all
wheezing, dyspnea, and other symptoms of asthma. Airway
inflammation
review the mechanisms of action, pharmacology,
ical effects,
Role of Inflammatory Mediators
its
mild persistent asthma.'
I
THE TREATMENT OF ASTHMA
effective in only a select population of asth-
yet, there is
Asthnui, the Expert Panel Repiort
and Blood
IN
clin-
and safety of the currently available leukotriene
is
the primary factor underlying the airway hyper-
responsiveness characteristic of asthma.
An abundance of in-
flammatory mediators have now been associated with
asth-
matic inflammation. These include histamine, prostaglandins,
modifiers.
lipid
Pathophysiology of Asthma
mediators (eg, the cysteinyl leukotrienes), platelet-acti-
vating factor (PAF), bradykinin, adenosine, anaphylatoxins,
substance P, thromboxane, serotonin, oxygen radicals, com-
Mechanism
plement fragments, and neurokin A. The wide range of medi-
of Inflammation
ators involved in the inflammation process
It is
recognized that individuals
who die because
of asthma
have grossly inflamed airways, marked by edema, mucus
plugging, infiltration of the airway wall by eosinophils, mast
cells, epithelial cells, fibroblasts,
T cells.- By
secreting preformed
ators that act either directly
macrophages, and activated
and newly synthesized medi-
on the airway or
indirectly through
neural mechanisms, these cells can adversely affect airway
function.'
Airway inflammation can be
acute, subacute, or
chronic.
Bronchoalveolar Lavage and Biopsy Findings
asthma
in all patients.'-''
airway hyperreactivity
in
is
ade of histamine, which
has
little
effect
demonstrated by the
is
assumed
fact that block-
to play a role in asthma,
on asthma symptoms. '* Although
PAF has been
specifically associated with eosinophilic inflammation,
it
may
not be a major factor in the pathophysiology of asthma because
even potent
PAF antagonists
on bronchial
challenges.'^ Bradykinin, however,
have failed
to
have an impact
an activator of sensitized sensory nerves
producing tightness
presence of inflammatory changes even
unlikely
it
The complexity of the inflammatory response underlying
tant as
Only recently have bronchial biopsies and bronchoalveolar lavage (BAL) in living patients clearly documented the
makes
one of these will control the symptoms of
that altering only
in the
chest and coughing.'^
many other mediators
these and
may be
is
impor-
in the airways,
The
role of
a subject of ongoing research.
Effects of Leukotrienes
those with mild
asthma.- Eosinophils, in particular, are thought to contribute
to the
development of asthma, because they contain several
The immediate response by
patients with
asthma
to a spe-
may damage the airway epithelium. Sensory nerve
endings may then become exposed, leading to activation of
cific allergen is
neurogenic inflammatory pathways that cause the release of
leukotrienes,
potent inflammatory mediators, or spasmogens, into the air-
gered mast cells in the airways." Leukotrienes have gener-
way
ated attention because they are far
proteins that
tissue.'-'-'
ators such as prostaglandin D2, histamine,
in their
Remodeling
produced largely through the action of medi-
and the cysteinyl
which derive from Immunoglobulin
E (IgE)-trig-
more potent than histamine
bronchoconstricting effect.-"
Leukotrienes are synthesized from arachidonic acid
in the
phospholipid bi-layer. Activation of 5-LO converts arachidonic
The airway smooth muscle
found
to
with asthma
is
often
acid to an unstable intermediate. 5-hydroxyperoxyeicosate-
be hypertrophied. Inflammatory remodeling
is
char-
traenoic acid,
acterized by
new
vessel formation, increased
epithelial goblet cells,
stitial
in patients
mucosal edema, and deposition of inter-
coUagens beneath the epithelium
manent changes
numbers of
to the airway.
shape of the airway and
may
that
may
result in per-
Inflammation may
alter the
contribute to the development
(LTA4).
which
LTA4 is the
is
converted to epoxide leukotriene A4
intermediate product from which
all
the
other leukotrienes are synthesized. Ultimately, the action of
5-LO on
arachidonic acid results
leukotrienes:
in
the formation of 5
LTA4. LTB4, LTC4, LTD4. and LTE4
(Fig. 1).^
Leukotrienes C4, D4. and E4 each contain a cysteine residue
of persistent bronchial hyperresponsiveness and irreversible
and
bronchial obstruction. Clinical sUidies have indicated that short-
Leukotrienes are rapidly metabolized and eliminated from the
term treatment with inhaled corticosteroids can modify the
circulation.
intensity of
inflammatory remodeling and even reverse base-
ment membrane
that
alter
482
thickening.'''
'^
There are no data
demonstrate leukotriene modifiers have
remodeling.
at
present
this ability to
are, therefore, referred to as the cysteinyl leukotrienes.
LTE4
is
a urinary metabolite that can be used to
gauge the production of leukotrienes
Among the
iind
in
humans.'
leukotrienes, the cy.steinyl leukotrienes C4, D4,
E4 are the most potent bronchoconstrictors.
When
injected
intradermally, the cysteinyl leukotrienes cause a wheal-and-
RESPIRATORY CARE
•
LEUKOTRIENE MODIHERS
IN
THE TREATMENT OF ASTHMA
Arachidonic Acid
FLAP
-
I
ft
5-HPETE
5-LO
Zileuton
5-LO
\
LTA4
LTC4
LTB4
i
LTD4
Zafirlukast
J'
LTE4
Fig. 1. Leukotriene production pathway. 5-LO = 5-lipoxygenase; 5-HPETE = 5-hydroxyperoxyeicosatetraenoic acid; FLAP = 5-lipoxygenase activating protein; LTA4 =
leukotriene A4; LTB4 = leukotriene B4; LTC4 = leukotriene C4; LTD4 = leukotriene D4;
LTE4 = leukotriene
E4.
flare reaction.^' Cysteinyl leukotrienes constrict
both the large
and small airways of normal and asthmatic subjects
in
vivo."
ment of asthma
in adults
and children age 12 years or
After oral ingestion, zafirlukast
is
gastrointestinal tract
and reaches peak concentrations
tor response to leukotriene challenge.-^
blood roughly 3 hours
later.
The airways of asthmatic patients are more responsive to
LTC4, LTD4, and LTE4 than are the airways of people with-
is
out asthma, but the degree of hyperresponsiveness
apeutic effect of zafirlukast
However, individuals vary widely
same order as
the
The reason
is
in their bronchoconstric-
is
not of
seen with histamine or methacholine."
for this finding is unclear
and requires more study.
In addition to their constricting effects
reduced
in the
Because bioavailability of the drug
40% when taken with food, it is necessary to take
zafirlukast
ity to
older.
absorbed rapidly from the
1
hour before or 2 hours
after meals.-'
The
derived primarily from
is
ther-
its abil-
attenuate bronchoconstriction mediated by cysteinyl
leukotrienes.-*
Liver microsomes that metabolize zafirlukast are formed
on smooth muscle, the
2C9 (CYP2C9) enzyme pathways.
human liver microsomes have demon-
cysteinyl leukotrienes inhibit mucociliary function, increase
via the cytochrome P450,
the production of mucus, and facilitate microvascular per-
In vitro studies with
-^"^'
meability and the formation of edema.
strated that zafirlukast inhibits
CYP2C9 and cytochrome P450,
3A4 (CYP3A4) isoenzymes
at
All of these are currently accepted as pathophysiology of
asthma. The magnitude of response to blocking or removing
only leukotrienes
is
not clear, because
it is
matory changes caused by other mediators
abated. This fact
likely that inflam-
may continue un-
may have important implications for the effi-
plasma concentrations close
to those
achieved clinically.-' Because the clearance of zafir-
lukast
reduced
is
ble those found in
cacy of leukotriene-modifying drugs.
Zileuton
is
maximum compliance
AUC) are approximately dou-
in elderly patients, its
(Cmax) and area under the curve
younger
(
adults.-'
an inhibitor of 5-LO, the enzyme
that catalyzes
the formation of leukotrienes from arachidonic acid. Like
Pharmacodynamics of Leukotriene Modifiers
zafirlukast, zileuton
it
LTD4 antagonists and 5-LO
rate
inhibitors appear to amelio-
asthma symptoms to some degree.-* Zafirlukast
is
a potent,
selective,
and long-acting leukotriene LTD4-receptor antag-
onist that
is
indicated for the prophylaxis and chronic treat-
RESPIRATORY CARE
•
is
clinically effective to the degree that
limits bronchoconstriction
mediated by cysteinyl leuko-
trienes.-^'
Both zileuton and
its
N-dehydroxylated metabolite can also
be oxidatively metabolized by the cytochrome P450 isoen-
zymes CYPl A2, CYP2C9, and CYP3A4. Zileuton
is indi-
483
in
the Treatment of Asthma
cated for the prophylaxis and chronic treatment of asthma in
Reports of Churg-Strauss syndrome, a sometimes
fatal vas-
adults and children 12 years of age and older. Unlike zafir-
culitis,
lukast. zileuton's bioavailability is not significantly affected
The syndrome may
by the presence of food
toms, such as fever, weight loss, and muscle aches and pains.
in the
stomach.'"
have been associated with zafirlukast and zileuton.
first
appear as generalized flu-like symp-
Eosinophilia, vasculitic rash, worsening pulmonary
Drug-Drug Interactions
symp-
toms, cardiac complications, and/or neuropathy have also been
reported.-'
Due
to
its
inhibition of the
The
P450 isoenzyme pathways, con-
overall annual incidence of Churg-Strauss
syndrome
current administration of zafirlukast with other drugs metab-
in the general
olized via these pathways can cause drug-drug interactions;
confirmed cases of Churg-Strauss syndrome'- and over a
dozen reported cases of hypereosinophilia have been reported
these other medications are
shown
in
a
Table
36%
1
.
Among the most
increase in the elim-
important of these interactions
is
ination half-life of S-warfarin,
which prolongs prothrombin
in the
far.
population
250,000 patients
is
2.4 per million." At least eight
who have
received zafirlukast thus
The incidence of Churg-Strauss syndrome
for the eight
time by 35%. Patients should have their prothrombin times
confirmed cases would, therefore, be 25 per million, a 10-
closely monitored and medication dose adjusted accordingly.
fold increase
Other drugs
should be used with caution when co-admin-
that
above the incidence
in the
general population.
In the majority of these reports, patients
were being tapered
when
istered with zafirlukast include tolbutamide, phenytoin, car-
off oral steroids
bamazepine. dihyropyridine blockers, cyclosporine, cisapride,
one confirmed case of Churg-Strauss syndrome has been
and astemizole.-'
reported in a patient taking zileuton. This patient
Zileuton can interfere with the metabolism of warfarin,
fenadine. and propranolol.
It is
most important
73%
a
increase in
its
Cmax- and a
who have
tak-
Liver toxicity has been observed in some subjects receiv-
to note that zileu-
shown to decrease the clearance of theophylline
by approximately 50%. This has resulted in a twofold increase
AUC,
was not
ing oral steroids."
ter-
ton has been
in theophylline's
the Churg-Strauss developed. At least
ing leukotriene modifiers. In placebo-controlled
vations in alanine aminotransferase
24%
to 3 times the
(ALT)
upper limit of normal
(
trials, ele-
greater than or equal
ULN
)
occurred in
1
.9%
received both
of patients treated with zileuton, compared with 0.2% of
zileuton and theophylline have experienced an increase in the
placebo-treated patients. In patients treated with zileuton for
prolongation of
its
half-life. Patients
frequency of theophylline-related adverse events,
ie,
up
compared
ton and warfarin resulted in a
and a 15% decrease
22%
in the clearance
increase in the
mean
AUC
months, 4.6% developed elevated
these elevations occurred during the
of R- warfarin, but no effect
risk of elevated
prothrombin times.*
first
then once a
month
transferase activity
first
mild headache, and increased amino-
However, symptomatic
dental injury, dyspepsia, nausea, and myalgia."'
had no other attributable cause were diagnosed
Effects of
Drug-Drug
Interactions. Zafirlukast
Warfarin
Zafirlukast
Prolonged
Decreased
prothrombin time
and
--
484
maximum
Cn^
AUC of
Erythromycin
Decrease
in
mean
Theophylline
Decrease
in
mean
Increase
in
that
one patient
mean
plasma levels of
plasma levels of
plasma levels of
zafirlukast
zafirlukast
zafirlukast
Decreased clearance
2 X increase
prothrombin time
of terfenadine
theophylline levels
AUC = area under the
in
Propranolol
Aspirin
Prolonged
compliance;
and hyperbilirubinemia
hepatitis
and Zileuton
Terfenadine
zafirlukast
Zileuton
enzyme
recommended dosage.
headache, unspecified pain, abdominal pain, asthenia, acci-
.
times the
the
Hepatic transaminase levels have not been found to be elevated in patients taking zafirlukast at the
1
liver
levels return to normal.'"
with zafirlukast.-' The most
Drug
increased
year, and peri-
frequent adverse effects associated with zileuton have been
Table
at
ALT elevations greater than 5
ULN occur, zileuton should be discontinued until
be generally well tolerated. Gas-
may occur
of
months of treatment, every
for the first 3
odically thereafter. If
trointestinal disuirbances,
61%
months of treat-
ALTs. The manufacturer recommends
2 to 3 months for the remainder of the
to
2
function monitoring prior to the initiation of treatment and
Adverse Effects
Both drugs appear
ALT, compaied
ment. Females over the age of 65 years appear to be
on S-warfarin. These changes were associated with a clinically
significant increase in
to 12
with 1.1% of patients receiving only their usual care;
with those taking theophylline alone. Co-administration of zileu-
in
X mcrease m
AUC of proprant)lol
serum
1
t
RESPIRATORY CARE
•
JUNE 1998 VOL 43 NO
6
3
Leukotriene Modihers
who had
to
received zafirlukast
recommended dose)
the
for
at
in
a dose of 40 mg/day (twice
100 days. Liver enzymes returned
normal within 3 months of stopping zafirlukast
treatment.-^'
the Treatment of asthma
4 weeks, airway function and symptoms were found
improved
was seen
L,
in
g group, with an increase in FEVj of 0.32
baseline. This response was
in the 2.4
1
hour of drug administration.
In another study with a similar design,
400 or 600
Most clinical
als
have
trials
using zafirlukast have been conducted
with mild to moderate asthma. These clinical
determined the effects of zafirlukast
first
protocols with antigens, cold
Spector et
al-''
air,
tri-
in challenge
mg of zileuton or placebo four times a day for
weeks. Eight
(6.
1
%)
evaluated the efficacy of oral zafirlukast in
controlled, dose-ranging study in patients with moderate
required concomitant corticosteroid treatment, compared with
21 (15.6%) of the patients receiving placebo. At the time of
in those patients receiving zileuton,
improvement
in the
cacy
in
A total of 276 subjects were ran-
may
not respond at
domized
to receive zafirlukast at a
dose of either
5, 10,
or 20
compared with
a
7.7%
placebo group.""
Although the leukotriene modifiers have demonstrated
who had been treated with âgonists alone or in com-
bination with theophylline.
in a
asthma
2-month
patients,
all
it is
also apparent that
to these drugs. This
clinical trial
of zileuton
in
many
effi-
patients
was demonstrated
which half the
patients
mg twice daily or placebo. Compared with placebo, only the
improved, while the other half showed no improvement.
40-mg dose was
no improvement
awakenings,
first
significantly effective in reducing nighttime
morning asthma symptoms, daytime asthma
and /3-agonist
score,
use. This
dose also significantly increased
evening peak expiratory flows (PEFR) and forced expiratory
volume
lukast
after
40
1
second (FEV|). Compared with baseline,
by
1
1%.
zafir-
mg twice daily decreased awakenings by 46%, fi-
agonist use by
30%, daytime symptoms by 26%, and FEVi
A small (n =
which
10) double-blind study in
received either zafirlukast 40
patients
mg or placebo in random order
week apart also found a significant increase
The onset of action in patients with
asthma has been reported to occur within the first week of therapy.''* Zafirlukast was found to be similar in effectiveness to
sodium cromolyn in patients with self-assessed mild to modon 2 days
in
at least
FEVi with
erate
is
noted after a 6- to 8-week
rent studies suggest continuing therapy.''^
trial,
The reasons
for this
As noted
earlier,
large difference in response are not clear.
leukotriene modifiers are effective against only one of
mediators of airway inflammation. In
If
no cur-
many
many
patients, factors
may be dominant. There may also be
One recent study, for example, has
other than leukotrienes
genetic factors at work.
suggested that only certain people with a particular genotype
respond to inhibition of S-LC"
a
zafirlukast.^^
asthma."
Although the
1
of the patients receiving the 600-mg dose
peak drug concentration, the average FEVi improved 15.7%
exercise, and aspirin.
a 6-week, multicenter, double-blind, randomized, placebo-
asthma,
401 patients with
mild to moderate asthma were randomized to receive either
Zaflrlukast
in patients
be
which was 1 3.4% greater than
apparent within
Clinical Trials
to
both zileuton groups. The largest improvement
Leukotriene ModiHers in Exercise-Induced Asthma
There
modifiers
is
some
may
early evidence to indicate that leukotriene
be useful in ameliorating symptoms in some
patients with exercise-induced
results
of these studies are generally encour-
aging, close evaluation often reveals a rather modest effect.
27%
decrease from baseline
may be involved
in the
asthma (EIA)." Leukotrienes
development of EIA, although
this is
unclear. Initial studies failed to demonstrate a rise in
still
in the
leukotriene levels in the lavage or urine of asthmatic subjects
to only
following exercise challenge,''" although such a rise has been
0.24 difference from placebo on a 3-point scale.'" While dif-
noted in lavage specimens from patients with asthma after an
For example, a reported
daytime asthma score
at the
end of one study amounted
ferences between drug-treated and placebo subjects
statistically significant, their clinical
In this
same
importance
study, the clinical difference
is
may
be
questionable.
amounted
to
one
moming without asthma symptoms every week, one fewer
puffs of âgonist/day, an FEV| improvement of only 0.23
less
L and
a
moming PEFR improvement
of only
1
5 L/min.
allergen challenge."'
A study using improved methodology,
however, has found an increased urinary concentration of LTE4
after
an exercise challenge in asthmatic children."*
Studies demonstrating the efficacy of leukotriene modifiers in
preventing
EIA
also provided important support for
the role of leukotrienes in the etiology of EIA.
Improvements
have been reported following treatment with orally adminZileuton
istered zafirlukasr"^""'
and zileuton.'"
In another study testing inhaled zafirlukast, 9 patients with
been asso-
EIA were challenged with exercise on a cycle ergometer." Drug
improved peak flows and spirometry (FEVi),
administration resulted in significant, though variable, inhibition
In controlled clinical trials, oral zileuton has
ciated with
reduced symptoms, and less need for /3-agonist
In
rescue.'^""'
one multicenter, double-blind, placebo-controlled study,'*
of EIA. Three subjects experienced almost complete inhibition;
three others
showed partial
jects experienced
to receive either zileuton 1.6 or 2.4 g/day or placebo. After
interindividual variation
Respiratory Care
•
June 1998 Vol 43 No
6
little
inhibition.
or no effect.
139 patients with mild to moderate asthma were randomized
The remaining three sub-
A considerable degree of
was noted in
all
of these studies.
485
in
Leukotriene-Modifying Agents
zileuton. Identification of responders
and Aspirin-Induced Asthma
standing of a genetic marker, which
may require the
is
under-
yet to be determined.
In addition, in three trials comparing the efficacy of leukotriene
Aspirin-induced asthma
is
poody understood.
greatest risk appear to be individuals
who have
asthma and
to
host
rhinosinusitis.'-
may be
According
TTiose at
underlying
one hypothesis, the
overresponsive to products of the lipoxygenase
pathway. Alternatively, there
may
be abnormal cellular
re-
modifiers to inhaled corticosteroids, the inhaled corticosteroid
performed
better.^'-^*
were compared
trial,
fluticasone offered significantly greater protection than
improvement in PEFR. Another
compared pranlukast and inhaled beclometha417 patients with asthma. The increase in FEVj was
clinical trial
leading to the removal of a helpful substance or to the cre-
sone in
Patients with aspirin-sensitive
some
inhaled fluticasone and zafirlukast
zafirlukast as well as greater
sponses to aspirin and/or different arachidonic metabolites
ation of an inflammatory substance of
When
in a histamine bronchial hyperresponsiveness
significantly greater for inhaled
kind.-""^
asthma have a dramatic
level
lukast. Finally,
beclomethasone and not pran-
when beclomethasone was compared to zafir-
48 1 mild
moderate asthmatics, beclomethasone
of intolerance to aspirin as well as to other nonsteroidal anti-
lukast in
inflammatory agents. Patients with aspirin-sensitive asthma
demonstrated significanfly superior outcomes (p < 0.01) for
morning PEFR and clinical FEV].''
have been shown to release leukotrienes when challenged with
acetylsalicylic acid,
and these
patients also demonstrate a higher
basal production of leukotrienes than other asthmatics.
Given these findings,
it
is
kotriene modifiers have been
-''•'^'
perhaps not surprising that leu-
shown
to
have a significant impact
on aspirin-sensitive asthma. For example, 8 aspirin-sensitive
who participated in
In patients
to
whose asthma is incompletely controlled with
inhaled steroids, the question
is
whether to increase the dose
of this medication or add a long-acting bronchodilator or
leukotriene modifier. Currently, there
is
support for the addi-
tion of a long-acfing /?-agonist^*' rather than increasing the
a double-blind, placebo-
dose of inhaled steroids, but there are no data demonstrating
showed marked improvement over baseline following administration of MK-0679,
an investigational leukotriene antagonist. Bronchodilation was
induced for at least 9 hours after oral administration. The average peak improvement in FEVi was 18% above the predrug
comparable effect with the addition of zileuton or zafirlukast
asthmatic patients
controlled, two-period crossover study
However, the bronchodilator response varied between
baseline.
5% and 34%
and was found
asthma and aspirin
to correlate with the severity
of
to inhaled steroids.
it
ticosteroids as first-hne therapy, except in
may
II'
views inhaled corticosteroids
effective anti-inflammatory medication
recommend
currently available and continues to
these drugs
as first-line therapy for the long-term control of mild persistent
to severe
asthma
Although leukotriene modifiers
may
some patients, their precise role has not yet
defined. The Guidelines for the Diagnosis and
be efficacious
been clearly
(Fig. 2).
in
Management ofAstlwm^
sible alternatives to
This
new
who have mild
in patients
persistent
1
2 years
asthma (Step
2).
class of medication has the limitation of poten-
who
prescribe these drugs need
to follow liver function studies in all patients
on zileuton as
well as for patients on higher dosages of zafirlukast.
should also be aware that these two
new
agents
may
They
be asso-
find that the use of an oral preparation
to factor into their decision preliminary
486
a specific instance
where
appropriate, but comparative
studies are necessary to demonstrate whether these drugs are
in
EIA,
but, again, clinical trials
do not
work
indicate that they have
greater efficacy than inhaled short-acting /J-2 agonists. For
EIA, the use of a short-acting inhaled
is still
)3-2
agonist probably
the best choice.
In
Summary
about half of asthma patients
Leukotriene modifiers are a
new
therapeutic class repre-
senting a generation of research about the underlying
anism of asthma. They demonstrate
that,
mech-
once researchers
understand the pathways of the disease pathogenesis, they can
then proceed to develop medications to interfere with these
processes. Zafirlukast and zileuton are the
first
of these
new
medications; others are certain to follow. Their development
suggests that the future holds further advances for the treat-
Although inunguing, these new medications do not appear
is
appealing as an alternative to inhaled steroids, but they need
that only
is
ment of asthma.
ciated with Churg-Strauss syndrome.
may
may be
class of medication
suggest zafirlukast or zileuton as pos-
liver toxicity. Physicians
Physicians
reduce the risk of hospitalization for asthma.*^*^
truly superior to the other agents. Leukotriene modifiers
molyn, nedocromil, or sustained-release theophylline for long-
tial
to
new
is
low doses of inhaled corticosteroids, cro-
term control and prevention of symptoms
of age and older
who
improved patient outcomes, and recently has been
Aspirin-induced asthma
this
most potent and
children,
corticosteroids in conformity with established guidelines
shown
The Expert Panel Report
young
be started on cromolyn or nedocromil. Use of inhaled
vital for
sensitivity.-''*
Using Leukotriene Modifiers in Asthma Therapy
as the
more experience is gained with leukotriene modiwould seem prudent to continue to use inhaled cor-
Until
fiers,
to
be as effective as inhaled corticosteroids or more effective
evidence suggesting
than cromolyn or nedocromil.
may respond
drugs
at all to
may
be effective
A recent review states that these
in aspirin-sensitive asthma,**- but their
RESPIRATORY CARE
•
JUNE 1998 VOL 43 NO
6
in
...
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Eur Respir
J
A. Comparative efficacy of
in asthmatics
on
pm /3-2
agonists
1997:10:P2716.
Woolcock A, Lundback,
effect of inhaled fluticasone propionate
00 /Jg bd compared with
•
oral zafirlukast
Greening AP, Ind
B, Ringdal N, Jacques
LA. Comparison
1996; 1 53(5):
PW,
Northfield
M, Shaw G. Added
salmeterol ver-
symptoms on
& Hanburys Limited UK Study
20
mg bd on bronchial
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6
Donahue JG, Weiss ST, Livingston JM. Goetsch MA, Greineder DK,
Piatt R. Inhaled steroids
JAMA
63.
Pasma HR. The
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(abstract).
Group. Lancet 1994:.^44(8917):219-224.
MK-0679 on
function in aspirin sensitive asthmatic subjects. Thorax 1993;48(12):
Westbroek
Med
Laitinen
asthma
existing inhaled corticosteroid. Allen
):1025-I029.
Dahlen B, Margolskee DJ, Zetterstrom O, Dahlen S-E. Effect of the
leukotriene receptor antagonist
57.
Kerwin E, Silvers W, Faiferman
sus higher-dose corticosteroid in asthma patients with
Urinary leukotriene E4 concentrations increase after
Dis 1991:143(5 Part
56.
P,
patients with
1481-1488.
Christie PE, Tagari P, Ford-Hutchinson
a.spirin
Chervinsky
trial in
dose of inhaled steroids.
1992:146(1 ):96-103.
Arm JP, Lee TH.
S,
of addition of salmeterol to inhaled steroids with doubling of the
response to bronchial provocations with allergen, aspirin, leu-
kotriene D4. and histamine in asthmatics.
55.
mild to moderate asthmatics (abstract). Eur
Oral pranlukast (Ultair) vs inhaled beclomethasone; results of a
12-week
Immunopharmacologic update. Course summary. Naples.
'90:
Wenzel
J.
ence 1995:1429-1439.
53.
in
RespirJ 1997;I0:P1554.
1413-1418.
and the
risk of hospitalization for asthma.
1997:277(1 1):887-891.
Buchner DA, Carlson
AM, Stempel DA.
Patterns of anti-inflammatory
therapy in the post-guidelines era: a retrospective claims analysis
of managed care members.
Am J Managed Care
1997;3:87-93.
489
1997 Philip Kittredge Memorial Lecture
Neil
Mechanical Ventilation
in
R Maclntyre MD
1997
The outcome of mechanical
ventilation
dent upon the underlying disease
Mechanical ventilators are devices or systems
that are
designed to provide oxygen to and clear carbon dioxide from
pulmonary
capillary blood.
While positive pressure gas deUv-
state.
is
obviously depen-
Generally, patients with
rapidly reversing lung diseases and underlying
(eg, asthma,
good health
drug overdose, anesthesia recovery) can expect
mortality rates of less than
5%. On
the other hand, acute res-
mechanical ventilation, sys-
syndrome (ARDS) and chronic obstructive
pulmonary disease (COPD) may have mortalities approach-
tems using positive pressure masks, negative extrathoracic
ing 40 to 50%. Moreover, patients on mechanical ventilators
pressure, and devices implanted into the vasculature to pro-
who have severe multi-organ failure and the sepsis syndrome
may have mortality rates approaching 100%.
ery to the lungs through an artificial airway
common way
most
to provide
is
probably the
vide either intra- or extracorporeal gas exchange would also
meet
this definition
I
will be discussing
the issue of positive pressure ventilation applied through an
worldwide; approximately half of them are in
use in North America. Based on diagnosis-related-group data,
it is
also estimated that approximately
1
.5
million patients in
that are occurring in the
use of positive pressure mechanical ventilation in 1997.
the
number of patients being
the
Duke
is
rising.
The experience of
University Respiratory Care Service shows
despite a falling bed census, the
has steadily increased over the
two reasons
last
decade. There are
at least
for this. First, the aging population presents the
medical system with more chronic disease and more acute
operating rooms and recovery rooms each year. Given these
of those chronic diseases.
80%
that,
number of ventilator hours
the United States receive mechanical ventilation outside of
numbers and assuming approximately
First,
intubated and requiring positive
pressure mechanical ventilation
airway.
In 1997, an estimated 100,000 positive pressure ventilators are in use
There are two important trends
of mechanical ventilation. For the pur-
poses of our discussion here, however,
artificial
piratory distress
As we
flares
take better care of this aging
can
population, their need for subsequent medical care obviously
be calculated that the average length of stay on a ventilator
increases. Indeed, every successful extubation and hospital
is in
the neighborhood of
1
to
1
.5
utilization,
it
weeks. The average cost
of a mechanical ventilator runs anywhere between $10,000
and $30,000 U.S.
dollars. Increasing costs are associated with
discharge means there will be
sion.
at least
one subsequent admis-
A second reason is the delivery of more aggressive med-
ical care. Specifically,
aggressive surgeries are being carried
more
increasing capabilities such as graphic displays, sophisticated
out on older and more seriously
monitors, microprocessor-control systems, and automated
aggressive chemotherapies are being given to patients with
record keeping.
The
life
span of a mechanical ventilator
10 to 15 years. Using these estimates,
is
about
we can see that the world-
wide yearly market for mechanical ventilation
the hun-
is in
ill
patients. Similarly,
more immunocompromised
patients
and thus a higher incidence of sepsis and respiratory
failure.
malignancies resulting
in
For the same reason, the
AIDS
(acquired immunodeficiency
syndrome) population has also impacted the need
dreds of millions of dollars.
for
mechan-
ical ventilation.
A second major trend in mechanical
is
Neil
R
Maclntyre
cal Center;
MD;
that as patients resolve the acute
Department of Medicine; Duke University Medi-
tory failure, they often enter a
Durham. North Carohna.
tilator
Dr Maclntyre presented
the Phillip Kittredge
the 43rd International Respiratory Congress,
New Orleans,
tory Care Services,
Durham
490
NC 27710;
P
R
more
Memorial Lecture during
them
December
step-down
6-9.
1997. in
Louisiana.
Coirespondence: Neil
dependence, resulting
to
O
MD.
Professor of Medicine, Respira-
Box 3111, Duke
e-mail:
University Medical Center,
macin001@mc.duke.edu.
more chronic phase of ven-
in increasing pressure to
cost effective venues of care. This
units, subacute hospitals,
lator facilities are
Maclntyre
ventilation in 1997
phase of their respira-
growing
in
move
means
that
and long-term venti-
number and in the complexity
mean that the need
of services provided. Both of these trends
for mechanical ventilation will only increase over the fore-
seeable future.
RESPIRATORY CARE
•
JUNE 1998 VOL 43 NO
6
.
MECHANICAL VENTILATION: THE NEXT 50 YEARS
This can lead to a delay in the weaning process and
Goals of Mechanical Ventilation
withdrawing the patient from the
There are both
realistic
major injury
third
and unrealistic goals for mechan-
ventilator.
The
and being on
that intubation
is
a ventilator increase the risk of infection. Indeed,
Certainly a realistic goal
ical ventilation.
that
is
pulmonary
ventilation should be able to provide
mechanical
with appropriate levels of Pq; and Pco:- Moreover,
be done without injuring the patient's lungs
nosocomial pneumonia
capillary blood
this
is
one of the most serious
complications that can occur in a patient on mechan-
should
and
ical ventilation
in the process.
significantly lengthens the
it
ventilator length of stay.
Reducing infections could
It is
unfortunate that clinicians sometimes also have unreal-
be one of the major goals of an improved mechan-
istic
goals for mechanical ventilation. For instance, a mechan-
ical ventilation
ical ventilator is
that
might contribute
3.
of lung injury. Certainly,
to resolution
may
may impact
for ventilator
the duration of respiratory
ical ventilator is a
part, a
mechan-
support (not a therapeutic) device that
injury.
own
These
consider
ICU
costs.
is
Advances on the Immediate Horizon
designed to 'buy time" while other therapies, including the
patient's
This
Taken together, the cost per day
management can run $ 1 ,000/day or
more, a substantial fraction of
and mortality. However, for the most
failure
cost.
operational costs.
contribute to disease resolution so that a
mechanical ventilator
Mechanical ventilation carries a high
includes not only capital costs but also supply and
adequate gas exchange, alveolar recruitment, and minimal atro-
genic harm
system.
sometimes considered a therapeutic device
(5 to 10 years)
defense system, effect resolution of the lung
realistic
and unrealistic goals are important
when designing
There are a number of developments
to
new mechanical
studies looking at
to 10 years
Lung
ventilation technologies.
may
over the next 5
that
address the three limitations noted above.
protective ventilator strategies that supply adequate
gas exchange while protecting the lung will be a major focus
Limitations to Mechanical Ventilation in 1997
of research. Spiecifically, strategies that adequately recruit lung
volume but
There are three major problems with mechanical ventilation
in
—
1997
why we
three reasons
are not attaining our goals.
yet
do not overdistend
more common. To
this end,
the lung are likely to
become
pressure-volume plots looking
and overdistention will be increas-
for alveolar recruitment
ingly important in setting ventilator parameters. High-frequency
1
mechanical ventilators
In the sickest patients,
may
not be able to supply adequate gas exchange. Patients
dying from gas exchange impairment are cer-
tainly in the minority (ie,
< 15% of ARDS
is
maximal alveolar
strategy. This
seems
to
show
the
same thing
as
new
are important adjuncts that
future systems.
exchange while reducing
2.
it is
Positive pressure mechanical ventilation can cause
The
three types of iatrogenic injuries.
first is
direct
is
injury can be the result of excessive levels of sup-
clinical trials. Surfactant
plemental oxygen (oxygen toxicity) or can be the
are used as "liquid
ticularly important
and
from the
results
tissue (particularly the healthier regions
fact that lung
available.
There
and Fio,
injury. Nitric
oxide
improves ventilation-perfu-
Whether
this
replacement and fluorocarbons that
PEEP" may
also help recruit appropriate
lung volumes and improve ventilation perfusion matching.
Another promising technique
of the lungs)
flation
can be damaged when overdistended by mechan-
stretch
become
also help us improve gas
outcome, however, awaits the results of
translates into better
seems par-
may
it
populations at
sion matching and reduces the need for Fio:-
lung injury from the mechanical ventilator. This
result of stretch injury. Stretch injury
in pediatric
likely that adult studies will
devices
certainly promising in that
volumes and limited
the ultimate lung protection
be clear
and
risk for stretch injury
ill
a problem that must be addressed with
may be
stretch
deaths),
but suboptimal gas exchange in those very
patients
ventilation with properly recruited lung
is
the use of tracheal gas insuf-
(TGI) to flush the endotracheal tube during exhala-
and thereby reduce effective dead space. Because tidal
volume can be reduced, TGI may reduce the need for high
tion
ical ventilation strategies
recruit
and
designed to aggressively
ventilate the sicker regions of the lung.
This injury seems potentiated
recruitment of alveoli
is
when inadequate
also present
ventilation pressures.
To improve
A second major
patient-ventilator synchrony, there are a
injury
from positive pressure mechanical
ventila-
ber of possible advances on the immediate horizon.
tion
ventilatory muscle overload
from
patient-
processor technology
is
in patients
and cycling
significant
criteria
receiving partial ven-
response. Pressure rise time adjusters and computerized feed-
a
on the
flow deliv-
ventilator
can cause
imposed load and discomfort
to the
back systems
match
ventilator delivery to patient effort are
improve synchrony. Placing ventilator sens-
ing sites for patient activity closer to the ventilatory muscles
is
•
to
likely to further
patient that results in substantial needs for sedation.
RESPIRATORY CARE
getting increasingly better at detect-
ing patient activity and producing an appropriate ventilator
is
tilatory support. Inappropriate triggering,
ery,
is
that
ventilator dyssynchrony. This
occurs primarily
phenomenon
num-
First, itiicro
also likely to occur. Sites such as the distal endotracheal
491
tube, the pleural space, or
that has
tilator
Better monitors, particularly of the function of cen-
may all come
even the phrenic nerve
tral
by the end of the next decade. Another technique
to fruition
promise
gauge
its
improving synchrony
to
have the ven-
response to a flow signal in a
mode known
in
is
nervous system (the most sensitive organ to
impairments
in
gas exchange) and respiratory mus-
cle function (critical in determining patient
wean-
ing capabilities) will be developed. Finally, closely
as proportional assist ventilation
(PAV).
linked ventilator functions and patient
Reducing infections may come from a variety of
areas.
markedly enhance the ventilator's
Circuits less prone to contamination, techniques to keep the
vide partial support.
upper airway free of pharyngeal and gastrointestinal con-
practitioners will be critical in
ways of sterilizing
tamination, and perhaps
still
may
in the future. Ironically,
hand washing tech-
the simplest and, perhaps,
most effective way
be useful adjuncts
niques are
the pharynx
compliance with
to reduce infections, but
this practice is
will
More advanced nonphysician
managing these
sophisticated devices.
2.
It is
may finally begin
An obvious ap-
possible that the ventilator
to function as a therapeutic device.
no-
proach would be to use a ventilator as a system to
where near 100%.
Reducing the cost of mechanical
ventilation
deliver drugs into the lung
may come from
several advances. For instance, increasingly sophisticated but
inexpensive microprocessor systems are likely to be devel-
oped
demands
ability to pro-
of care. Protocols are likely to
come
in
One could imagine that
This
ap-
the lung could be
in various anti-inflammatory, infective,
all
provide gas ex-
change without necessarily providing bulk flow positive pressure ventilation.
Will
we
also develop a
'therapeutic' ventilator pattern? Perhaps high-fre-
quency techniques may evolve
also reduce the cost
two
proach.
directly.
may be an immersion
or growth/repair solutions that
much simpler mechanical components. Supply cost
may also come down as manufacturing techniques improve
and nosocomial infections are better controlled. The develered with
opment of management protocols should
as an aerosol or
immersed
mechanical ventilation to be deliv-
that will allow for
parenchyma
may be
into pressure
manip-
ulation strategies that enhance recovery.
areas. First, ad-
vanced-level nonphysician practitioners (eg, advanced res-
ventilators without specific physician orders.
numbers decrease, the need
Technology
3.
piratory care practitioners) will be trained to run mechanical
to replace positive pressure ventilation
delivered through an endotracheal tube
As physician
develop.
is
The most obvious approaches
likely to
are extra-
for these 'physician extenders'
corporeal systems. Closely related to this are intra-
to run these sophisticated
systems independently will become
vascular systems that provide gas exchange through
increasingly important. Similar developments are likely to occur
in other
ICU management areas such as
nutrition, fluid
indwelling catheters in the great veins or pulmonary
man-
artery.
agement, antibiotic selection, and sedation. Second, computer
protocols will be developed to perform similar functions.
Com-
ficial
puter protocols, however, will be slow to replace practitioners
skilled in assessment
ers,
and subjective sensations will
practitioners to
make proper
arti-
lungs or permanently with lungs from cadav-
animals, or synthetic engineering laboratories.
nario where
by
require experienced
still
the use
Indeed, one might envision a "Darth Vader" sce-
and judgment because important input
variables such as patient comfort, respiratory muscle activity,
The most dramatic change could be
of lung transplantation, either temporarily with
all
the respiratory function
a device that
is
provided
one wraps around the chest.
decisions.
How Do We Evaluate New Technology?
Advances on the Distant Horizon (10
to
50 years)
Predicting what will happen over the next 10 to 50 years
obviously involves a
lot
of guesswork. However, these will
be the systems that will ventilate you and
age, and so
come
we hope
in three
it
is
done
right.
I
me
as
we enter old
think that advances will
general areas.
As new devices and techniques come along, it is imperwe have a system designed to evaluate them prop-
ative that
erly.
A
very important consensus conference was sponsored
by the American Association for Respiratory Care and the
American Respiratory Care Foundation looking
involved in evaluating
Care, September
1
.
Traditional positive pressure ventilation with oxy-
gen supplementation strategies
will
be greatly im-
proved. This will occur for several reasons. Techniques to reduce infection and provide better airway
protection are likely to
come from improved ven-
new
technologies
at the issues
(RESPIRATORY
1995). In essence, this group proposed three
levels of evaluation: a simple engineering evaluation, a phys-
iologic
tion.
outcome evaluation, and
a clinical
outcome evalua-
Obviously, the cost of these evaluations rises as they
become more complex.
that devices with
low
It
risk
was
felt
by
this
consensus group
and low cost needed
to
be evalu-
tilator patient interfaces. Surfactants, vasodilators,
and other agents
will
be developed
that
enhance ven-
tilation
perfusion matching and greatly improve the
ability
of the positive pressure ventilator to supply
gas exchange with lower pressures and less harm.
492
ated only on their engineering claims. If the device has
moderate cost or more moderate
using
risk,
some meaningful physiologic
however,
if
it
more
should be evaluated
data.
Most importantly,
a device has significant cost implications or sig-
RESPIRATORY CARE
•
JUNE 1998 VOL 43
NO 6
MECHANICAL VENTILATION: THE NEXT 50 YEARS
nificant risks associated with
trial
to demonstrate
must be kept
in
it, it
improved
mind
should undergo a controlled
outcome. This schema
clinical
we have more and more
as
gies introduced in an increasingly
complex and
technolo-
cost conscious
health care delivery system.
Because
clinical trials are likely to
for expensive
be required, especially
and risky technologies,
it is
important that
develop evaluation systems to perform them. Clinical
networks are going
to
be extraordinarily important to carry
out cost-effective and timely evaluations in clinical
trials
with
As more and more
computerized decision-making systems become implemented
in ICUs around the country, it is conceivable that these could
a randomized, placebo controlled format.
be linked to form clinical
trials
networks.
we
In Conclusion
trials
networks would be an important thing for us to begin devel-
oping now.
An example
Health (NIH)
might be the National
medical centers whose infrastructure
Their charge
Institutes of
ARDS network. This is a consortium of 10 major
is
to
conduct
clinical trials
is
funded by the NIH.
on 400
ARDS patients
a year. Promising therapies are considered by this group and
subject to clinical trials
if
deemed important enough. Other
research networks could include large health care systems (eg,
the Veterans Administration,
RESPIRATORY CARE
•
managed care
groups). These
JUNE 1998 VOL 43 NO
6
It
has been an honor and a pleasure to deliver the 1997 Philip
Kittredge Memorial LecUire. Phil
who contributed
was a colleague and a
friend
an enormous amount to the respiratory care
profession. In considering where mechanical ventilation
going during the next 50 years,
that Phil
it,
and
this
I
would have
invite all of
relished.
you
to
I
I
think there
is
is
an exciting future
am excited to be involved with
become involved with bringing
technology into the 21st century.
493
—
Books, Films,
Tapes, & Software
The Application of Magnetic Resonance
Study of Lung, Antonio
to the
G
Cutillo
607 pages. Armonk
MD, Editor.
Illustrated,
NY: Futura
Publishing Co; 1996. $98.
and Reviews of Books and Other Media. Note
Listing
films, tapes,
and software
The editor has achieved
he
to
RESPIRATORY CARE, 600
the stated goals that
sets out in the Preface; the material is well
Because
book
this
is
the
combined
effort
of a group of physicists, biophysicists, bio-
Magnetic resonance (MR) imaging of the
lung has had
its
share of problems during
its
developmental stages. Imaging problems are
normal lung anatomy and
directly related to
ologists,
it
and pulmonary medicine physicians,
should have a wide audience of very spe-
cialized readers.
of this book
and respiratory motion have Umited the wide
chapters that
lung.
MR
imaging of the
However, continuing research
area has developed
new
in the
techniques that are
beginning to overcome these inherent
ficulties.
To
this end, this
dif-
book presents
a
comprehensive, systematic account of the
theoretical
and experimental data accumu-
lated in both basic
and
MR research.
fundamental MR
clinical
This book discusses the
the
I
MR
in
and
diagnostic thoracic
it
is
certainly
has anything to do
be from a basic
sci-
of pulmonary medicine perspective. This
far the
most comprehensive book today
about the application of
the lung because
book
it
rent
are apt to
is
is
it
MR to the study of
includes both a histor-
and indications for future
While
parts of this
become outdated
fairly rapid-
most up-to-date and cur-
certainly the
comprehensive
text available
MR
on
imaging of the lung, with many in-depth,
monary vasculature and pulmonary embol-
view-style chapters that will transcend time,
ism, lung cancer, and obstmctive sleep apnea.
for at least a
of 57 contributors from
all
over the
re-
few years more.
The book
is
1
legal terms
clear,
The production
reasoning. Despite
simpUfication.
1
ter' s
14 chapters, or 438 pages, are dedicated to
entists
and
acknowledges the
ambiguity of ethical decision making.
He
addition to any medical
endorses neither today's trendy ethical
rel-
clinician scientists
normal lung and
rightly
this
or bad:
first
in Part
contents.
ativism
radi-
Each of the 7 chapters
The author
vidual libraries of those dedicated basic sci-
The
theories of moral
relative brevity (163
contains a set of study questions and ap-
school library and to the departmental or indi-
all.
its
book provides well-developed
pages), the
MR imaging, MR physics,
ology. There are 18 chapters in
in
explanadons and generally avoids over-
These contributors are well-known authors
pulmonary medicine, and pulmonary
and ethical theory. Key
and concepts are explained
two of the primary
trasting
text as a
of
its title.
does a creditable job of comparing and con-
qual-
would highly recommend
welcome
aptly described by
understandable language. The author
Netherlands, Slovenia, Japan, and Germany.
1
is
the reader gains a basic founda-
tion in relevant legal
ity is
superb.
,
plied exercises that relate closely to the chap-
thoroughly referenced and
beautifully illustrated.
This text
In Part
world, including countries such as The
in the fields
ethical
Toward this end, Charles Carroll's Legal
Issues and Ethical Dilemmas in Respiratory Care is a practical resource.
who
with the lung, whether
This book, edited by Dr Cutillo, has a
from
simply good sense
informed about the ethical and
to be well
ence perspective or from a clinical practice
ly,
free
life
now
It is
some-
thing for everybody
imaging, with particular attention to the pul-
total
for on-the-job behavior, they alone cannot
legal issues that affect professional practice.
basic clinical research.
current use of
sense and a professional
pulmonary medicine physician who has
ical perspective
acterization of experimental lung injury,
common
same fime
accountability.
remain generally sound guidelines
or legal conflicts.
recent developments in diagnostic imaging
MR char-
While
attitude
guarantee a working
not be of any interest to
at the
demanding more professional
many
a clinical practice, there
by
greater participation in health care
while there are
may
too,
The public today
decision making, while
charm
is that,
WA 98104.
Consumerism,
effects.
its
think that part of the
properties of normal and diseased lungs,
and quantitative lung imaging,
has exerted
engineers, biochemists, pathologists, radi-
physiology. Magnetic susceptibility effects
clinical acceptance of
to adapt to these factors.
demands
selected and organized.
Send review copies of boolcs,
to publishers:
Ninth Avenue, Suite 702. Seattle
who
study the
MR imaging of the healthy
(ie,
"No
situation
nor yesterday's absolutism
one way
good
to
view each
(ie,
"there
situation").
is
only
The author
avoids the 'cookbook approach': he offers
and diseased lung.
MR properties of normal and diseased lungs,
no pat recipes for
Eric J Stern
quantitative studies of the lung, and lung
is in itself
depends only on your viewpoint")
it
ethical success. Instead,
MD
he presents us with a thoughtful and pragmatic approach to sorting out the relevant
to the hard
Department of Radiology
core pulmonary medicine scientist and physi-
Harborview Medical Center
would
ments from each of the dominant ethical
Washington
viewpoints with elements of pragmatism,
These would be of interest
injury.
cist.
Chapter
1
5
is
the only chapter that
be of particular interest to the clinical pul-
Seattle,
issues of ethical dilemmas.
monologist and radiologist. Chapter 16
scientific
would be of interest only
roll
to those
common
sense, Car-
provides the reader with a helpful
At
apnea. Chap-
Legal Issues and Ethical Dilemmas in Res-
method
piratory Care, Charles Carroll. 163 Pages.
times the process proposed by Carroll seems
ter 17
in clinical respiratory
MR
medicine as
it
relates
imaging, and the potential for
imaging
in the future.
1
8
is
a glos-
sary of terms and abbreviations, which
actually one of the
chapter that has
Philadelphia:
more useful
utility
beyond
FA
Davis Co; 1996. $17.95.
MR
is
chapters, a
this textbook.
for approaching moral problems.
mechanical and somewhat simplistic. But
in general his
With a 1996 copyright,
has the future arrived? Chapter
494
method, and
ele-
discusses the current state of the art
cial interest in obstructive sleep
to
with a spe-
Combining
Litigation, risk
management,
liability,
out-of-court settlements, ethical conflicts
all
of these uncomfortable subjects have had
profound influence on the workplace of
today. Like
all
industries, health care has
had
ful clinician
approach provides the thought-
with a helpful and effective
way
of sifting through the myriad factors involved
in
moral and ethical decision making.
Part 2 of the
book switches from a heavy
emphasis on infomiation
RESPIRATORY CARE
•
to
its
practical appli-
JUNE 1998 VOL 43
NO 6
BOOKS, Films, Tapes,
cation.
Each of the 8 chapters
in Part 2
focuses on a single issue, such as confidentiality or care of the terminally
ill.
ments of each
issue, including relevant legal
considerations.
The reader
is
then presented
with a variety of hypothetical but highly realistic clinical situations,
each of which serves
as a departure point for discussion.
the several simulated
panied by a
list
dilemmas
is
•
wide array of
sion making.
dilemmas from
The information
it
contains
makes Legal
and Ethical Dilemmas in Respiratory Care a worthwhile addition to any
Issues
clinician's library.
However,
prove most effective
book and
this text will
when used
as a springboard for
The
as a
group
dis-
cussion.
accom-
exercises, and discussion points allow the
student
JUNE 1998 VOL 43
—
NO 6
author's well-chosen examples,
or the clinician
—
realistic ethical
Whether one chooses
reason than to
armed,"
I
and moral
the safety of a classroom.
know
to read
that
it
for
no other
"forewarned
is
fore-
book ranks
as impor-
Robert Hirnle
MS RRT
believe this
tant reading.
work-
Each of
of questions that form the
RESPIRATORY CARE
foundation for the readers' analysis and deci-
In this
section, the author briefly presents key ele-
& software
to deal with a
Respiratory Care Program
Highline
Community College
Des Moines, Washington
495
I*
•
Interactive Clinical Skills Software
Computer- Assisted
Hone your
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13
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users with real-life scenarios that require assessment & treatment
decisions. Each simulation
is scored, & the user is provided with the coranswers & rationale for the simulation. Available in 31/2" disk
format. Computer requirements: Windows 3.1 or higher
rect
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-z:::^::-
j
Test Your
Patricia
A
Dooiley
MS RRT and Charles G
Postoperative
Cough
K Kasel MEd
Debra
Durbin
in a
Jr
MD,
Radiologic Skill
Section Editors
Man Exposed
to Tuberculosis
RRT, Rhonda L Kasten CRTT, and Neal J Moser
Case Summary
His social history included
1
20 pack-years of cigarette smok-
ing and a history of alcohol abuse.
A 66-year-old man presented to the emergency room, complaining of abdominal pain. Subsequent evaluation revealed
A post-
a perforated duodenal ulcer, requiring surgical repair.
operative chest radiograph
The
was done
(Fig.
1
and 2-pillow orthopnea. His current medications
at
owned
several
also
went
to
homes of patients with
tuberculosis to collect data for clinical
active
tests.
exertion
admission
included inhaled albuterol and ipratropium bromide for
treat-
COPD. Twenty-seven years prior to admission, the
had a positive tuberculin
patient
He
patient
pulmonary
(COPD) characterized by extreme dyspnea on
ment of his
out using a mask.
The
where he worked with acid fumes with-
).
patient's history revealed chronic obstructive
disease
clinical laboratories
MD
test.
At
that time,
he was pre-
scribed and initially treated with isoniazid and rifampin, iilthough
after
Debra
MD;
month
1
K
Kasel
the patient stopped taking these medications.
MEd RRT;
Rhonda L Kasten CRTT; and Neal
J
Moser
Respiratory Care Program; Northern Kentucky University, Highland
Heights. Kentucky.
Rhonda L Kasten CRTT; Children's Hospital Medical
Ms Kasten was a stu-
Center. Cincinnati. Ohio. At the time of this work,
dent
at
Northern Kentucky University. Highland Heights. Kentucky.
Reprints
&
Correspondence:
Ms
Debra
K
Kasel
MEd RRT.
Respiratory
Care Program, Northern Kentucky University. Highland Heights
How
KY 4 1099.
Fig. 1.
Postoperative chest radiograph.
would you answer these questions?
What
abnormalities can be seen on the chest radiograph?
What
is
What
additional testing
the differential diagnosis?
would be helpful?
Answers
RESPIRATORY CARE
•
JUNE 1998 VOL 43 NO
6
& Discussion on next page
497
Test your Radiologic Skill
Answers
and fever and
symptoms
The chest radiograph
reveals diffuse, prominent interstitial
markings consistent with a chronic process. There
hilar
enlargement with prominent
ating upward. There
is
is
bilateral
postsurgical air seen under the right hemidiaphragm.
pneumonia. These
may reveal loss of breath sounds and vocal
but may also be normal.
fremi-
RML,
RML collapse is often difficult to detect on posterior-anteradiographs because the RML is relatively slim and lies
markings radi-
interstitial
increased density of the right middle
lobe which suggests partial atelectasis or infiltration. There
is
examination
tus in the
chills related to obstructive
often persist despite antibiotic therapy. Physical
rior
obliquely in the superior-inferior plane.
It
may, however,
obscure the right cardiac border and straighten the contour
of the heart shadow. Chest radiograph abnormalities are more
Differential diagnosis includes granulomatous disease,
mon
com-
and endobronchial lesions.
infections, sarcoidosis,
Obstruction could be caused by neoplasia, aspirated foreign
often seen in the lateral view.'
The volume
collapse of the right middle lobe
is
loss resulting
from
seen as a triangle of
increased density between the minor fissure and lower half
body, pulmonary secretions, broncholiths, or allergic bron-
chopulmonary
aspergillosis.
Additional beneficial testing
to clarify the nature
middle lobe process includes a
chest
2),
lateral chest
computed tomographic
of the right
radiograph (Fig.
scan, and bronchoscopy.
Discussion
For
right
from
fer
radiograph demonstrated
this patient, a lateral chest
middle lobe collapse. This patient
right
may
therefore suf-
middle lobe syndrome (RMLS), which
is
defined as a recurrent or chronic collapse of the middle lobe
of the right lung.
Graham and
colleagues' described a con-
dition they attributed to bronchial
compression of the right
(RML) bronchus from peribronchial lymphadenopathy. Although RMLS commonly presents with
middle lobe
pulmonary symptoms, such as cough, hemoptysis, and wheezing
it
can be asymptomatic and detected only by chest
roentgenography.
sexes and
is
It
occurs in children and adults of both
associated with numerous conditions.
RMLS
can be divided pathophysiologically into obstructive and
nonobstructive types.
Obstructive
RMLS may
lesions, extrinsic
be caused by endobronchial
compression of the right middle lobe
bronchus, and granulomatous
adenopathy secondary
infection.-^
compression of the
Additionally,
neoplasm
common cause
of extrin-
has been implicated."*^ The most
sic
"•
to sarcoidosis or metastatic
RML bronchus is enlargement of peri-
choliths, aspirated foreign bodies (particularly in children),
and inspissated secretions associated with cystic
bronchopulmonary
is
most susceptible
is
lateral ventilation present in the right
tributes to
ful in
or the
One
possible expla-
be
the relative lack of col-
tic
to collapse.
nation for this propensity to collapse
the
middle
lobe.**
This con-
poor mucus clearance with peripheral plugging of
the small airways.
The most common symptoms
marked
is
in patients
with
RMLS are
in Fig. 2.
evaluating bronchial patency,
lymph node enlargement
and calcifications, or other causes of extrinsic compression
RML airway.'*'" High-resolution CT scans may also
helpfijl in identifying subtle abnormalities.'* Flexible fiberop-
bronchoscopy
is
required to evaluate the patency of the
RML bronchus.
The treatment of RMLS
is
directed at the underlying cause.
was asymptomatic and
treat-
ment involved bronchodilator therapy, mucous clearance
tech-
In this particular case, our patient
cough, hemoptysis, dyspnea, chest pain, audible wheezing.
498
right
Computerized tomographic (CT) scans of the chest are help-
RML bronchus
However, the RML
RMLS,
patent with no apparent obstruction.
is
of the major fissure. This
fibrosis or
aspergillosis.''-^
In the nonobstructive type of
bronchus
chest radiograph showing the collapse of the
middle lobe.
lymph nodes. Less common causes include bron-
bronchial
allergic
Fig. 2. Lateral
niques and antibiotic therapy.
The
RESPIRATORY CARE
patient
•
had previously under-
JUNE 1998 VOL 43 NO
6
TEST YOUR Radiologic Skill
gone evaluation for
RML collapse, which failed to identify
4.
Lazarus SC. Disorders of intrathoracic airways.
JA,
an obstructive source such as endobronchial lesions or extrinsic
compression of the
for active tuberculosis.
RML bronchus. There was no evidence
The
from the hospital 5 days
patient did well
Poe RH. Middle-lobe
sion.
6.
atelectasis
NY State J Med
due
7.
Med
lobe syndrome. Post-
lobe syndrome.
Ann Thorac Surg
9.
S,
Oda M, Hayashi Y, Ohta Y, Shimizu
Treatment of bronchial stricmre due to endobronchial tuberJ
Surg 1997;21(5):480-487.
RESPIRATORY CARE
Eraser
sis
Wantanabe Y, Murakami
World
J.
Isolated mid-
and treatment of the so-
Thorax 1980:35(6):449-452.
aspergillosis.
CR, Terry PB, Traystman
aller-
Ann Allergy 1980;44<4):217-2I9.
Menkes HA. Collateral ven-
RJ,
and the middle lobe syndrome.
Am
Rev Respir Dis
1978;1 18(2)305-310.
1983;35(6):679-686.
culosis.
bronchopulmonary
Inners
tilation
1948;4:29.
Wagner RB. Johnston MR. Middle
J, et al.
Nadel
Eisenberg RS, Valdesuso C. Middle lobe syndrome secondary to
gic
8.
grad
JF,
W B Saun-
to sarcoidosis with pleural effu-
Bertelsen S, Struve-Christensen E, Aasted A, Sparup
called middle lobe syndrome.
Graham EA, Burford TH, Maver JH. Middle
Murray
1978;78(13):2095-2097.
dle lobe atelectasis: aetiology, pathogenesis,
REFERENCES
In:
Textbook of respiratory medicine. Philadelphia:
ders; 1994:1471-1482.
5.
and was discharged
after surgery.
editors.
•
RG, Pare JA, Pare PD,
Eraser RS, Genereaux GP. Diagno-
of diseases of the chest, 3rd ed. Philadelphia:
W B Saunders;
1988:519-529.
10.
Gudmundsson G, Gross TJ. Middle
lobe syndrome (review).
Am Fam
Physician 1996;53(8):2547-2550.
499
Nonimmune Hydrops Fetalis
Kathy Douglas
Case Summary
RRT
color and
was moving
all
extremities. His blood pressure
was
within normal limits and he was transferred to the newborn
A 37-year-old woman presented to our obstetrics service
The estimated fetal gestation was 34-36 weeks
by dates. This was the woman's fourth pregnancy; she had
three living, healthy children. An ultrasound at 30 weeks of
intensive care unit (NICU).
Soon
in active labor.
no
gestation revealed
fetal
The
anomalies.
had declined
patient
alpha Fetoprotein screening. All prenatal blood work was nor-
mal. Rupture of
membranes occurred 9 hours prior to
meconium stained.
deliv-
male infant presented cyanotic and
delivery, the
admission to the
//g/kg/min was added. Morphine sulfate
for sedation. Bright red blood
therefore, he
of age the baby showed increasing
orally intubated with a 3.5 endotracheal tube (ETT). Breath
sors, the
kg infant was given Apgar scores of 2
at
utes for a heart rate
> 100
beats/min.
The
3.
165
1
and 5 min-
He had no
other spon-
both
at 0.3
became
at
10
mg was given
surfactant.
edema of his
tamine hydrochloride was started
furosemide was given
bilaterally.
again
was suctioned from
was not given exogenous
abdomen were noted to be markedly distended. His extremities were atrophic. He was immediately
floppy. His neck and
sounds with hand ventilation were equal
NICU the infant
the
By
ETT;
10 hours
trunk and neck.
His urine output was lagging behind his fluid intake, so dobu-
ery and the fluid was lightly
Upon
after
hypotensive and a dopamine hydrochloride drip
at
10 jUg/kg/min and
to increase renal perfusion
3-mg
and urine
output. In addition to complete parenteral support with pres-
baby was maintained on mechanical ventilation with
an Fdo: between 0.75 and 1.00. His second chest radiograph,
taken at 12 hours of age,
is
shown
in Fig.
1.
taneous activity or breathing. Cord blood gases were significant:
Pa02 10
mm Hg (1.3 kPa), Paco: 89 mm Hg (1 1.9 kPa). pH
of 7.08, bicarbonate level of 25.3 mEq/L, and a base deficit
of -7.9. The venous cord blood values were: Pq: 28
(3.7 kPa), Pco:
mEq/L, and
By
46
mm
Hg
(6.1 kPa),
pH
7.3,
mm Hg
HCOj
10 minutes of age the infant had slowly improved
color while receiving positive pressure ventilation by
ual resuscitation at an Fdo: of
ities
1
.(X).
He was moving
and showed some respiratory
and venous
lines
were
inserted.
effort.
and glucose. The baby's
mg%,
initial
Coombs
test,
arterial
for blood
blood cul-
blood glucose screen was
necessitating a push of 8-cc
DiqW. A 300-mg dose
of ampicillin was given. The infant's heart rate remained
ble in the
1
in
man-
his extrem-
Umbilical
Blood was drawn
gases, complete blood count, type.
ture,
21.7
a base deficit of -4.2.
sta-
50 beats/min range, and effective ventilation was
provided with a time-cycled, pressure-limited infant ventilator.
SpO: remained above
manate was given
of 32.
for a
90%.
A
bolus of 30
mL of plas-
blood pressure of 40/22 with a mean
By 30 minutes of age
the infant continued to
have good
Kathy Douglas RRT, Departmenl of Respiratory Care. The Toledo Hos
pital,
Toledo. Ohio
Correspondence: Kathy Douglas RRT. Department of Respiratory Care.
The Toledo
500
Hospital,
2142
N Cove
Blvd. Toledo
OH 4.^606.
Fig.
1
.
The
infant's
chest radiograph taken at 12 hours of age.
RESPIRATORY CARE
•
JUNE 1998 VOL 43 NO
6
TEST YOUR Radiologic Skill
How
What
is
shown on
Based on
this chest
this radiograph,
What procedure
is
would you answer these questions?
radiograph?
what might be included
in the differential
diagnosis?
indicated?
Answers
RESPIRATORY CARE
•
JUNE 1998 VOL 43 NO
6
& Discussion on next page
501
Answers
The chest radiograph revealed
that the
ETT is in good posi-
tion at the third thoracic vertebrae. Tips of the umbilical
and
arterial catheters
tions.
can be seen and are
venous
acceptable posi-
There are monitoring devices (electrocardiogram leads)
over the
left
lower quadrant and
are diffuse bilateral
pulmonary
are visible, particularly in the
ble can be seen in the
is
in
left
in the right
upper chest. There
infiltrates.
Air bronchograms
left chest.
The stomach bub-
upper abdominal quadrant. There
a large pleural effusion on the right. (Fig. 2)
Included in the difTerential diagnosis for
this patient
would
be the causative or associated factor(s) for the pleural effusion,
which are respiratory
distress
syndrome, hypoplastic lung,
or pneumonia.
The indicated procedure
the
compressed
right lung.
is
to insert a chest tube to
expand
.
REFERENCES
of acceptable blood gases and acid-base balance. The baby's
initial
hypoglycemia was immediately corrected. Coagulopathy
and hyperbilirubinemia were managed and corrected within
the baby's
first
days of life.
He was extubated and
1
(CPAP) on his fifth
hospital day. On his tenth day of life the baby was weaned
from CPAP. He was given low flow oxygen via nasal cannula. Chest tubes were clamped and then removed at 8 and
1 days of life. He was placed in an open crib on his twelfth
hospital day and discharged by 4 weeks of age.
2.
AE, Bain AD.
3.
4.
pected prior to delivery. Survival
ability
fetalis
may depend on
of a highly skilled resuscitation team
delivery.
Although the
can be sus-
infant's survival
the avail-
is
enhanced by the
ability to
5.
at the infant's
good
out-
setting
and
editors. Diseases in the fetus
P. Gastrointestinal disorders. In:
Core curriculum
phia;
In:
and neonatal physi-
Reed GB, Claireaux
and newborn. St Louis:
WB Saunders;
Beachy
P,
Deacon
J,
edi-
for neonatal intensive care nursing. Philadel-
1993.
Apkon M. Pathophysiology of hydrops
Rejjal
natal
ARA, Rahbeeni Z, al-Zahrani AF.
management
J Perinat
6.
provide expert manage-
ment and intensive support in both the delivery
in the immediate postnatal period.
Fetal
1992.
Blood disorders.
1989.
tors.
fetalis.
Semin
Perinatol
Med
in
Prognostic factors and pre-
non immune hydrops
fetalis are still
a dilemma.
1996;24(5):461-466.
human parvovirus B 19 infection in idiononimmune hydrops fetalis. Am J Obstet Gynecol
Jordan JA. Identification of
pathic
come
Z.
1995;19(6):437-446.
may be determined
primarily by prenatal factors, the likelihood of a
Beachy
and other causes of neonatal edema and
WW, editors.
WB Saunders;
Mahnovski V, Pavlova
CVMosby;
1
most cases, the presence of hydrops
fetali.s
RA, Fox
ology. Philadelphia:
nasal continuous positive airway pressure
In
Phibbs RH. Hydrops
ascites. In: Polin
placed on
1996;174(l):37-42.
7.
Gallagher
8.
Jones DC.
PG.
Seminars
in
perinatology.
Semin
Perinatol
I995;19(6):435-436.
Nonimmune
fetal
hydrops: diagnosis and obstetrical man-
agement. Semin Perinatol 1995;19(6):447-461.
9.
ACKNOWLEDGMENT
I
thank Brian Bradley
RESPIRATORY CARE
MD for reviewing this manuscript.
•
JUNE 1998 VOL 43
NO 6
Maisels MJ. Jaundice.
editors.
In:
Avery GB, Fletcher
MA, MacDonald MG,
Neonatology: pathophysiology and management of the new-
bom, 4th
ed.
JB Lippincott; 1994.
503
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TX
& Services
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advertisers index at the back of the Journal.
Measurement System. The system
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of a patented fiber optic sensor which
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Arterial blood gases are obtained
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According to
system
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this
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suited for critically
patients, including
Solution.
neonates, pediatrics, and adults. For
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III
Designed
Maril Products Inc reports that
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available.
to verify proper solution prepa-
ration of Control
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change color to confirm proper mixing. Control III disinfectant
remains active up
to 14
ill
is
well
more
information from Instrumentation Labora-
number 161 on
tory circle
vice
Card
in this issue, or
the
Reader Ser-
send your request
and control
bacterial,
viral,
it
has received 510(k) marketing clearance
FDA for its Portable BioZ^^' non-
from
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NONINVASIVE Cardiac function
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pathogens on hard surfaces and equipment.
and has been used as an alternative
For more information from Maril Products
invasive monitoring methods for critically
Inc. circle
vice
Card
number 160 on
in this issue,
the
Reader Ser-
ill
patients.
For more information from Car-
dioDynamics
or send your request
International Corporation cir-
number 163 on
electronically via "Advertisers Online" at
cle
in this issue, or
tronically
to the
via
the
Reader Service Card
send your request elec-
Online"
"Advertisers
at
Patient central monitor. MarInhaled Corticosteriod Powder.
quette introduces the Prism suite of network
GlaxoWellcome announces
products and applications designed to
powder form of flu-
Rotadisk®, an inhalation
ticasome propionate,
is
scription in the U. S.
the drug
ment
for
young
is
as
is
that Flovent*
now
available
indicated as a preventive treat-
asthma
in adults
and children as
4 years of age. Flovent Rotadisk
a foil-covered disk containing 4 blisters,
imum
at a variety
to the infor-
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of hardware. The client server PC-
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based system has a 32-bit
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mation Center application. The company says
when
and a dose of medthe patient inhales
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iological waveforms/patient
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to
4 phys-
main
dis-
information from GlaxoWellcome circle
play screen. For more information from
number 162 on
Marquette, circle number 164 on the Reader
Blood Gas measurement System.
in this issue, or
Instrumentation Laboratory announces the
tronically
•
mation
tem. Marquette offers the Clinical Infor-
through the mouthpiece.
RESPIRATORY CARE
applicadons on a single
system while providing access
into a specially designed plas-
ication dispensed
SensiCath Blood Gas
pitals to consolidate
inhalation device called the Diskhaler®,
a blister can be pierced
GEM
resentative says that the system allows hos-
operating system. Designed for the Prism sys-
Once loaded
tic
in-
A company rep-
powder medication.
or compartments, of
launch of the
by pre-
GlaxoWellcome says
crease caregiver efficiency.
the
Reader Service Card
send your request elec-
via "Advertisers Online" at
JUNE 1998 VOL 43
NO 6
Service Card in this issue, or send your
request
Online"
electronically
at
via
"Advertisers
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AARC97-00
AARC97-01
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AARC97-04
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AARC97-08
AARC97-09
50 Years of Respiratory Care, Robert R. Weilacher
Keynote Address, Richard M. Scrushy
Long-Term Acute Care Hospitals, David E. Moseley
Part 1-Meehanics: How the Lungs Work and How
Diseases Affect Them, Kenneth P. Steinberg
How To Implement a Program, Julien M. Roy
How To Write a Business Plan and Market Your
Program, Trina M. Limberg
More Reimbursement, Julien M. Roy
Outcomes, Outcomes, Outcomes, Trina M. Limberg
Competency Assessment - Who Needs It?,
Robert
Hospital Environment, Richard Sheldon
AARC97-36B Ask the Experts!, James
Q
Development of Age-Specific Education Material,
Melva Proudlock
PeerAssessmentCanTakethe"YUK!"Outof
Performance Appraisals,
AARC97-38
Q
Scott Reistad
Assessing the Aging Adult, John E. Carlson
I've Fallen and I Can't Get Up!: Promoting
Q
1
5
Nobody
is
"Moving"
Time?, Jerry
AARC97-16
Ventilation
17
AARC97-47
AARC97-48
"Moves"
-
(Oscillation, Nitric Oxide,
Their Uses in Transport,
Adams
Kathleen
S.
Difficult
"Moves":
Places, Kathleen
AARC97-18 Workshop:
AARC97-46
What Do We Do With Our
A. Focht
Conventional)
AARC97
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S.
Disease
AARC97-45
Home
Safety for the Older Patient, Melaine Giordano
AARC97-
AARC97-42
AARC97-43
AARC97-44
AARC97- 2 Telemedicine in Home Care, Nicholas J. Macmillan
AARC97-13 The Go-Goes, the Slow-Goes, and the Can't-Goes:
AARC97-14
AARC97-49
Difficult
Airways and
Difficult
George G. Burton. Jeanne Pollock. Judy Tietsort
of Measuring Outcomes
in Respiratory Critical Care, William J. Sibbald
AARC97-22 Star Trek Respiratory Care: Going Where No One
Has Gone Before with Telemedicine, Michael W. Runge
AARC97-23 Use of Invasive Monitoring in a Patient in Acute
AARC97-21 The "Whys" and "Wherefores"
Q
Respiratory Failure, Jolm W. Hint. Charles G. Durhin, Jr
AARC97-24 Experiences in Developing, Selling, and Managing
DME Company-Based Asthma Education and
Intervention Program, Joseph
AARC97-25 Competency Documentation
S.
for
AARC97-52 Mechanical
P.
L.
CO2
Steinberg
Post
AARC97-30
Q
a
AARC97-3 Financial Tools for Today's Manager, Kevin L Shrake
AARC97-32 "Partnering" in Health Care, Karen J. Stewart
AARC97-33 Program Overview; Medical Direction of
Patient-Driven Protocols To Help Control
Utilization, Kevin L. Shrake
1
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Inactive Medical Director: What Can Anyone
Do?, George G. Burton
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AARC97-60
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Managed Care
Care
Contracts,
Colleen Bittner. Jeanne M. Pollock
in a Pulmonary Function
Lab: How To Get to the Bottom of Unexplained
Dyspnea, Fernando Martinez. John Wald
Neurologic and Cellular Causes for Dyspnea: A
Neurologist's Viewpoint, John Wald
Case Studies for Unexplained Dyspnea Connected
with Neurologic Disorders, Fernando Martinez
An Approach to Technology Assessment,
David H. Walker
Critical Care is Expensive, ye/f//«vrfH
Standardization of Technology - A Case Study,
AARC97-63 Part 3-Acid-Base Balance: How It Works and
What Can Go Wrong, Robert B. Schoene
AARC97-64 Home Care in Europe; Socialized Medicine;
65
66
2 tapes
Epidemiology of Home Mechanical Ventilation in
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Services in Europe, Patrick U'gcr Susan Sortor Leger
AARC97-69 How Did the Dinosaurs Breathe?, David J. Pierson
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The Next 50 Years,
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Respiratory Care: Past
Infant
Lewarski
Practice of Routine Ventilator Checks,
AARC97-54 Techniques
AARC97-58
AARC97-27 Pulmonary Rehabilitation and the Non-obstructive
Lung Disease Patient, John E. Hodgkin
AARC97-29 Pressure-Controlled Ventilation (PCV): What's
with the Pressure?, Marshall
R.
Home
S.
Ventilation:
AARC97-57 The "Shocking Truth"
Lewarski
Out-Practical Applications, Kenneth
Neal
AARC97-53 The
a
JCAHO and
Performance Improvement, Daniel J. Grady
AARC97-26 Part 2-Gas Exchange: Getting Oxygen In and
Q
of a
Program, Joseph
Management Across the Continuum,
Studies
and How To Decannulate, Mike Harrell
Communication Alternatives for the
Tâcheostomized Patient, Mary Spremulli
Monitoring and Delivery of Inhaled Nitric Oxide,
Robert M. Kacmarek
Use in Adults, Richard D. Branson
Use in Pediatrics, Cardiac Surgery and Sickle Cell
Anemia, Peter Betit
Use in Neonatal Hypoxemic Respiratory Failure,
John E. Thompson
Financial Analysis of Home Care Business
Operations, Patrick J. Duime
Merging Sales and Clinical Skills, Robert W. King
Clinical Products' Development and Marketing,
Patrick J. Dimne
A Success Story in Home Care: Development and
Management
Adams
2 tapes
Q
Blockade: Etiology and Prevention, John W. Hoyt
Introduction: Why, How, When, Types of TXibes,
and Problems, Mike Harrell
Impact IVacheostomy on Quality of Life, Mary Spremulli
AARC97-39
AARC97-40 Weaning and Decannulation: Swallowing
1
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George G. Burton.
AARC97-37 Prolonged Weakness Following Neuromuscular
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K. Stoller.
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AARC97-72 A
Nightingale's Song:
Mechanical Ventilation, John
AARC97-73 Liquid
Ventilation:
From
Q
Q
a
Q
AARC97-95 How Can
My
AARC97-79 Medicare
Denials:
The Provider's
Joseph
Skilled Nursing Facihties,
AARC97-81 Fraud and Abuse
Gary
A.
Gruver
Activities in Post-acute
Q
AARC97-87 Your
Profession:
Agency Updates
-
a
ATS
What They Say
Improves Outcomes, Karen
a
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Is
True?.
J.
Stewart. Robert
M.
Kacmurek, Sharon S. Ehrmeyer Susan B. Blonshine
AARC97-103 The 6-Minute Walk Is Nothing When Compared to a
and 104 Complete Exercise Evaluation/Charting Should Be
Done by Exception Instead of by Conventional
Means, Carl Mottram. Gretchen Lawrence. Patricia
Ann Doorley. Gary W. Kaujfman
AARC97-105 Managed Care Curricula, Shelley C. Mishoe
AARC97-106 Wellness and Disease-Prevention Curricula,
William
Q
Q
Q
F.
Galvin
AARC97-107 Disease Management Curricula, Joseph L. Rau
AARC97-108 Gerontology Curricula, Helen M. Sorenson
AARC97-I09 Smoking Cessation Curricula, Crystal L Dunlevy
Guidelines for the Diagnosis and Management of Asthma:
AARC97The Expert Panel Report II, Allan T. Luskin
Impact on Quality of Life: Recent Advances in
AARC97-1
Asthma Management, Andrew P. Greening
AARC97- 2 Safety and Efficacy of Steroids in Asthma,
1 1
Q
a
1 1
1 1
Allan
AARC97-113A
JRCRTE-NBRC,
a
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and 102
AARC-
Kerry E. George. Carole J. Miller.
Benjamin F. George
AARC97-89 Part 1 -Ventilator-Associated Pneumonia:
Pathogenesis and Risk Factors, Marin H. Kollef
AARC97-90 Part 2-The Prevention of VAP in the Year 2000,
Marin H. Kollef
AARC97-9I The Bronchial Provocation Challenge: Meeting the
I
Rau
AARC97-1(X) What Do I Need To Know about the Lung
Transplant Patient?, Patricia Ann Doorley
AARC97-101 Ventilator Care Should Be Done by Credentialed
Care
and Their Effect on Respiratory Care;
Panel Discussion, Panelists: K. Cornish, T. Carter, G.
Gruver M. Welch
AARC97-82 Five Things I Learned This Year about Lung-Voliuneand 83 Reduction Sm^gery/Five Things I Learned This Year
About Creating Credibility Outside Respiratory
Care, Catherine M. Foss/Barbara L. Butler
AARC97-84 Five Things I Learned This Year about the TVeatment
and 85 of COPD/Five Things I Learned This Year About
Point-of-Care Testing, Dm '«// Pierson/Catherine M. Foss
AARC97-86 Five Things I Learned This Year about Patient
Compliance through Education, Gretchen Lawrence
Settings
L.
Neil R. Maclnryre
Perspective,
of Respiratory Care Services in
Ehrmeyer
AARC97-96 What Do The Numbers Mean?, Cr\stal L. Dunlevy
AARC97-97 Part 4-Exercise: Normal and Abnormal Responses
and How To Use Them, Robert B. Schoene
AARC97-99 Report from the 1996 Consensus Conference,
Tami Carter
AARC97-80 Reimbursement
Pass
Shelley C. Mishoe
McPeck
Baby's Singing the Blues... Jazz Him Up with
Waveforms!, Katie Sabato
AARC97-76 Invasive Bi-Level Pressure Ventilation in Neonates,
Infants, and Children: A Retrospective on Three
Years of Utilization, Curtis J. Bauer
AARC97-77A International Respiratory Care: Around the World
in Four Hours, Jerome M. Sullivan. Suhharee
Suwanjutha, Alan C. Biggs
AARC97-77B international Respiratory Care: Around the World
in Four Hours, Toshihiko Koga, R. Vijai Kumar.
Hector Lôn Garza
AARC97-77C International Respiratory Care: Around the World
in Four Hours, Pierre Emery. Tamotsu Sugimoto,
Airton Stinglein Crespo. Kamarudin Jaulam
AARC97-78 Medicare Denials: The Payer's Perspective,
Melvin A. Welch, Jr
AARC97-75
S.
Meet
to
AARC97-93 Pulmonary Function Testing: What Do You Need
and When Do You Need It?, Charles G. Ir\-in
AARC97-94 How Can I Manage the Information Explosion?,
Delivery Challenges during
Pediatric Mechanical Ventilation, Michael
Gas Labs
(JCAHO, CAP, CLIA) and
Inspections, Sharon
a
W. Salver
the Abyss to the Bedside,
Jeanette Asselin
AARC97-74 Meeting Aerosol
the Regulations
Outcomes of Pediatric
T.
Luskin
A Cost-Effective Program for Children
Hospitalized with Asthma, Timothy R. Myers
AARC97-113B Panel Discussion: Drugs and Medications - What's
Right and What's Wrong, Andrew P. Greening.
Allan T. Luskin. Timothy R. Myers
AARC97- 1 4 Pre-hospital and Inter-hospital Ti'ansport, Jerry A. Focht
AARC97-1 15 Ventilation during Transport and Diagnostic
Studies in Acute Care Hospital, Robert S. Campbell
AARC97- 6 Ventilatory Support in the Operating Room,
1
a
1
Charles G. Durbin. Jr
AARC97-
Guidelines, Charles G. liTin
1
1 1
7
Use of Ventilators
in the
Home, Robert M. Kacmarek
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F R
U
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T S
I
REFORTINt. PRIK.RA
2
Age
at
FOA Use Only (Resp
No. 0910-0291 Expires: 4/30/91
Cai
Page
C.
A. Patient information
Patient identifier
i
reporting
For
by health professionals of adverse
events and product probletns
3 Sex
time
4
Weigtit
Suspect medication(s)
Name
1
(give labeled strength
S
mfr/labeler,
if
known)
of event:
female
I
I
I
I
Date
In
of
confidence
birtti:
male
Adverse event or product problem
B.
Adverse event
1
lJ
2
Outcomes
(cfieck
all
and/or
QJ
Product problem (eg
,
I
I
Diagnosis for use
6
Lot #
Therapy dates
(if
unknown, give duration)
defects/malfunctions)
I
I
I
I
congenital anomaly
I
4
3.
disability
I
life-ttireatening
I
Dose, frequency & route used
attributed to adverse event
that apply)
deatfi
I
2
hospitalization
5
(indication)
-
initial
or prolonged
event
#1
Dyes
#2
Dyes
\_\ othe
(If
known)
Exp. date
(if
4 Date of
ttiis report
3 Date of
Event abated after use
stopped or dose reduced
required intervention to prevent
permanent impairmenfdamage
known)
8
D
D
no
Dfe"''
no
DgggPy"''
Event reappeared after
reintroduction
5
Describe event or problem
NDC
9
10.
D.
6
Relevant tests/laboratory data, including dates
7
Otiier relevant history, including preexisting
race, pregnancy,
medical conditions (eg, allergic
smoking and alcohol use. hepatic/renal dysfunction, etc )
Mail to:
FDA Form 3500
MEdWaTCH
or
5600 Fishers Lane
Rockville, MD 20852-9787
r
1/96)
FAX
1
to:
-800-FDA-01 78
#
(for
#1
Dyes
#2
Dyes
product problems only)
D
n
no
Dfe"'
no
DgggPy"''
Concomitant medical products and therapy dates (exclude treatment
Suspect medical device
of event)
ADVICE ABOUT VOLUNTARY REPORTING
How
Report experiences with:
•
medications (drugs or biologies)
•
medical devices (including
•
special nutritional products (dietary
in-vitro
diagnostics)
other products regulated by
Report
•
use section
FDA
SERIOUS adverse events. An event
when the patient outcome is:
•
death
•
life-threatening (real risk of dying)
•
hospitalization
•
disability (significant, persistent or
•
congenital anomaly
•
required intervention to prevent permanent
(initial
in
C
for
all
products except
attach additional blank
•
use a separate form
•
report either to
or prolonged)
permanent)
FDA
pages needed
each patient
if
for
or the manufacturer
(or both)
Important numbers:
• 1-800-FDA-0178
• 1 -800-FDA-7737
• 1-800-FDA-1088
to
FAX
report
modem
to report
by
to report
by phone or
for
more information
•
1
-800-822-7967
damage
impairment or
Report even
fill
•
serious
is
the sections that apply to your report
just
medical devices
supplements, medical foods, infant formulas)
•
to report:
•
for
for
a VAERS form
vaccines
If your report involves a serious adverse event
with a device and occurred in a facility outside a doc-
if:
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RE/PIRATORy CARE
Manuscript Preparation Guide
A paper expressing personal but substanti-
Point-of-View Paper:
General Information
ated opinions on a pertinent topic. Title Page, Text, References, Tables,
Respiratory Care welcomes original manuscripts related to the
and
Illustrations
may be
included.
science and technology of respiratory care and prepared accordthese Instructions and the Uniform Requirements for
ing to
Special Article:
A pertinent paper not fitting one of the foregoing
Manuscripts Submitted to Biomedical Journals [Respir Care 1997;
categories
42(6):623-634]. Manuscripts are blinded and reviewed by pro-
Editor before writing or submitting such a paper.
fessionals
who are
for all aspects of the manuscript
message
is
and receive galleys
clear and
it
is
to proofread
copyedited so that
conforms to the Journal's
papers are copyrighted by Daedalus Inc and
may
style.
Published
Editorial consultation
On request,
is
is
provided for
it
may
present an opposing opinion, clarify a position, or bring a problem
into focus.
A
Letter:
available at any stage of planning or writ-
specific guidance
A paper drawing attention to a pertinent concern;
Editorial:
not be published
elsewhere without permission.
ing.
be acceptable as a Special Article. Consult with the
experts in their fields. Authors are responsible
before publication. Each accepted manuscript
its
may
all
publication cat-
To receive these Instructions and related materials, write
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signed communication, marked "For publication,"
about prior publications
ics.
in this
Tables and illustrations
Journal or about other pertinent top-
may
be included.
egories.
to
98104,
call
Publication Categories
Blood Gas Comer:
gas values
(206) 223-0558, or fax (206) 223-0563.
A brief, instructive case report involving blood
— with Questions, Answers, and Discussion.
Drug Capsule: A mini-review paper about
& Structure
that includes discussions of
Research Article:
It
A
a drug or class of drugs
pharmacology, pharmacokinetics,
and pharmacotherapy.
report of an original investigation (a study).
includes a Title Page, Abstract, Introduction, Methods, Results,
Discussion, Conclusions, Product Sources, Acknowledgments, Ref-
Graphics Comer:
A brief case report incorporating waveforms for
monitoring or diagnosis
— with Questions, Answers, and Discussion.
erences, Tables, Appendices, Figures, and Figure Captions.
Evaluation of Device/Method/Technique:
uation of an old
It
or new
A description and eval-
Kittredge's
Comer:
care equipment
device, method, technique, or modification.
rial
A brief description of the operation of respiratory
— with information from manufacturers and
comments and
edito-
suggestions.
has a Title Page, Abstract, Introduction, Description of De-
vice/Method/Technique, Evaluation Methods, Evaluation Results,
PFT
Discussion, Conclusions, Product Sources, Acknowledgments, Ref-
function
erences, Tables, Appendices, Figures, and Figure Captions.
Corner: Like Blood Gas Comer, but involving pulmonary
tests.
Com-
parative cost data should be included wherever possible.
Cardiorespiratory Interactions.
interaction
A report of a clinical case that is uncommon, or was
Case Report:
managed
in a
new way,
must be associated with
or
is
exceptionally instructive. All authors
the case.
A case-managing physician must
either be an author or furnish a letter approving the manuscript. Its
components
ry,
are Title Page, Abstract, Introduction,
A case report demonstrating the
between the cardiovascular and respiratory systems.
should be a patient-care scenario; however, the case
theme
—
is
the systems interaction.
equations, and a glossary. See the
TORY Care for more
—
CRI is characterized by figures,
March 1996 Issue of RESPIRA-
detail.
Case Summa-
Discussion, References, Tables, Figures, and Figure Captions.
Test
Your Radiologic Skill:
Like Blood Gas Comer, but involv-
ing pulmonary medicine radiography and including one or
Review
Article:
A comprehensive, critical review of the literature
and state-of-the-art summary of a pertinent topic
subject of at least
line, Introduction,
40 published research
Review of the
that has
articles. Title
Literature,
been the
may
graphs;
may
more
radio-
involve imaging techniques other than conventional
chest radiography.
Page, Out-
Summary, Acknowl-
edgments, References. Tables, Appendices, and Figures and Captions
It
the central
Review of Book, Film, Tape, or Software:
A
balanced, critical
review of a recent release.
be included.
Preparing the Manuscript
Overview:
A critical review of a pertinent topic that has fewer than
40 published research
articles.
Print
Update:
been
A
report of subsequent developments in a topic that has
critically
reviewed
in this Journal or elsewhere.
RESPIRATORY CARE Manuscript
in. x
in. (216 x 279 mm)
mm) on all sides of the page. Use
on one side of white bond paper, 8.5
with margins of
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1
in.
(25
1 1
double-spacing throughout the entire manuscript. Use a standard
font (eg, Times, Helvetica, or Courier) at least 10 points in size,
Preparation Guide, Revised 2/98
and
Manuscript preparation Guide
do not use
italics
Number all pages in
Do not justify. Do
except for special emphasis.
Paper accepted but not yet published:
upper-right comers. Indent paragraphs 5 spaces.
Hess D.
New
therapies for asthma. Respir Care (year, in press).
not put authors' names, institutional affiliations or allusions to
institutional affiliations in the text, or other identification any-
Personal author book: (For any book, specific pages should be cited
where except on the
whenever
the abstract page.
page. Repeat
title
only (no authors) on
title
Begin each of the following on a new page:
Title
Page, Abstract, Text. Product Sources List, Acknowledgments, References, each Table, and each Appendix.
the
first
Use standard English
and small
sion).
ital
and small
at the left
letters (eg, Patients,
New
in
cap-
margin and type them
Equipment,
uations, 3rd ed. Littleton
Statistical Analysis).
may be
reviewer inspection. Cite references
text with superscript numerals.
erences are
in
On
first cited.
Assign numbers
the reference page,
in the
order that ref-
the cited
list
in the
works
numerical order. Follow the Journal's style for references. Abbre-
viate journal
names
Chapter
book with
in
AK. Acute
respiratory failure. In: Guenter
Harwood
RJ.
CA. Welch MH,
edi-
Pulmonary medicine. Philadelphia: JB Lippincott; 1977:26-42.
tors.
Tables. Use consecutively numbered tables to display information.
each table on a separate page.
Start
Number and
including
all
nonstandard abbreviations and symbols.
notes with conventional designations (*,
them superscript
t, |, §, \\.%,
and
Key
the foot-
**, tt) in con-
in the table body. Do not use
Do not submit tables as pho-
tographs, reduced in size, or on oversize paper.
Comparison of nebulizer delivery methods
the table
title
give each column a brief heading. Place explanations in footnotes,
sistent order, placing
as in Index Medicus. List all authors.
Article in a journal carrying pagination throughout volume:
JL.
1977.
editor(s):
horizontal or vertical rules or borders.
Rau
AMA drag eval-
CO: Publishing Sciences Group;
cited as references: desig-
nate the accepting journal, followed by (in press), and provide 3 copies
article for
dis-
in cap-
Pierce
of the in-press
pulmonary
76-85.
p.
American Medical Association Department of Drugs.
Methods, Results, Discus-
References. Cite only published works as references. Manuscripts
accepted but not yet published
Clinical profiles of diffuse interstitial
York: Futura; 1990.
Corporate author book:
letters (eg. Introduction,
Begin subheadings
ease.
in
person and active voice.
Center main section headings on the page and type them
ital
possible.)
DeRemee RA.
Use
the
same type-
face as in the text.
through a neonatal endotracheal tube: a bench study. Respir Care
1992:37(1
1):
1
Illustrations. Graphs, line drawings, photographs,
233- 1 240.
are figures.
Article in a publication that
Page
numbers each
issue beginning with
Use only
Number them
illustrations that clarify
consecutively as Fig.
1
,
and radiographs
and augment the
Fig. 2,
ing to the order by which they are mentioned in the text.
1:
Bunch D.
Establishing a national database for
home care.
AARC Times
all
figures are cited. If any figure
text.
and so forth accord-
Be
sure
was previously published, include
copyright holder's written permission to reproduce. Figures for
l99l;l5(Mar):6l,62,64.
publication must be of professional quality. Data for the original
Corporate author journal
article:
graphs should be available to the Editor upon request.
for Respiratory Care. Criteria for establish-
consult the Editor for
more information.
If color is essen-
In reports of
ing units for chronic ventilator-dependent patients in hospitals. Respir
experiments, use schematic drawings, not photographs.
Care I988;33(l I):I044-I046.
consent must accompany any photograph of a person.
Article in journal supplement: (Journals differ in their
numbering and identifying supplements. Supply
to
tial,
promote
methods of
and detailed explanations on figures; put
titles
this
animal
A letter of
Do not place
information in
figure captions. If possible, submit radiographs as prints and fullsufficient information
size copies of film.
retrieval.)
Reynolds HY. Idiopathic
interstitial
pulmonary
fibrosis.
Chest 1986;
89(3Suppl):l39S-l43S.
ic
Abstract in journal: (Abstracts citations are to be avoided. Those
more
Stevens DP. Scavenging ribavirin from an oxygen hood to reduce envi-
ronmental exposure (abstract). Respir Care 1990:35(11): 1087-1088.
may
Can we
be given
relax during spirometry? (editorial).
Am Rev Respir
drugs and chemicals used, giving gener-
on the product-sources page.
In parentheses in the text, identify
mercial product (including model
is
country. If four or
bers
Negative-pressure ventilation for chronic obstructive pulmonary dis-
number
if
applicable) the
mentioned, giving the manufacturer's name,
at the
no author given:
brand names
If desired,
parentheses after generic names. Drugs should be
more products
ufacturers in the text; instead,
Dis 1993;I48(2):274.
Editorial with
in
Commercial Products.
it
Editorial in journal:
all
names, doses, and routes of administration.
listed
than 3 years old should not be cited.)
Enright P.
Drugs. Identify precisely
end of the
when
text,
are mentioned,
list
do
city,
not
any comfirst
and
list
time
state or
any man-
them on a Product Sources page
before the References. Provide model
available and manufacturer's suggested price,
if
num-
the study
has cost implications.
ease (editorial). Lancet 1992;340(8833):I440-I441.
Ethics.
Letter in journal:
Aelony Y. Ethnic norms
1
When
reporting experiments on
that procedures
99 1:99(4): 05
1
for
pulmonary function
tests (letter).
Chest
were conducted
in
human
subjects, indicate
accordance with the ethical stan-
dards of the World Medical Associatiim Declaration of Helsinki
[Respir Care 1997;42(6):635-636] or of the institution's committee
1.
Preparation Guide, Revised 2/98
Manuscript preparation Guide
on human experimentation. State
Do
obtained.
that
informed consent was
not use patient's names, initials, or hospital
numbers
will be
acknowledged.
Computer Disltettes. Authors
encouraged
are
to
submit electron-
animals, indi-
ic
versions of manuscripts as well as printed copies (3.5
cate that the institution's policy, a national guideline, or a law on
in
Macintosh or
or illustrations.
in text
When reporting experiments on
the care and use of laboratory animals
author's name;
was followed.
IBM-DOS
name and
used
in
analyzing the data,
and give the prospectively determined level of significance
Methods
book and published
tify
in the
section. Report actual p values in Results. Cite only textarticle references to
support choices of tests. Iden-
Do
to
produce graphics and tables should
not write on diskette labels except with
felt-tipped pen. If revision of a manuscript
tion of acceptance for publication,
we
is
required as a condi-
ask that an electronic version
of revision be supplied to facilitate copyediting and production.
any general-use or commercial computer programs used, nam-
ing manufacturers and their locations.
These should be
listed
on the
Units of Measurement. Express measurements of length, height,
weight, and volume in metric units appropriately abbreviated; temperatures in degrees Celsius; and blood pressures in millimeters of
mercury
(mm
surements
units.
in
Show
Hg). Report hematologic and clinical-chemistry mea-
conventional metric and
in
SI (Systeme Internationale)
gas pressures (including blood gas tensions) in
List SI equivalent values,
Prior and Duplicate Publication.
when
that has
been published
the Editor
may
publish
is
given by the author and original publisher. Please con-
sult the
Editor before submitting such work.
Authorship. All persons
ed
in the reported
listed as authors
work and
in the
should have participat-
shaping of the manuscript;
have proofread the submitted manuscript; and
1988;33( 10):861-873 (Oct
1988), 1989;34(2):145(Feb 1989). and 1997;42(6):639-640(June
all
must
should be able to
all
publicly discuss and defend the paper's content.
A paper with
cor-
porate authorship must specify the key persons responsible for the
[0.981 kPa]." For conarticle.
RESPIRATORY CARE
consider such material, provided that permission to
torr.
possible, in brackets following non-
values— for example. "PEEP. 10 cm H2O
version to SI. see
Work
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product-sources page.
Si
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and filename(s). Software used
Statistics. Identify the statistical tests
in.
format). Label each diskette with date;
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of funding, collection or analysis of data, provision of advice, or similar services.
Persons
who
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1997).
may
Conflict of Interest Authors are asked to disclose any liaison or finan-
Permissions. The manuscript must be accompanied by copies of
arrangement they have with a manufacturer or distributor whose
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ers.)
from consideration and
A statement to this effect is
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tables); to use illustrations
edgments
Abbreviations and Symbols. Use standard abbreviations and sym-
Avoid creating new abbreviations. Avoid
and unusual abbreviations
viation only
if
name persons
it
parentheses. Thereafter,
all
abbreviations
in the abstract.
Use an abbre-
sider expert
to
the abbreviation alone.
it.
Never
Standard units of mea-
15 torr. 2.3 kPa).
Please use the following forms; cm HiO (not cmH20). f (not bpm),
L (not 1), L/min (not LPM, l/min, or 1pm), mL (not ml), mm Hg (not
mmHg), pH (not Ph or PH), p > 0.001 (not p>0.001), s (not sec),
SpO; (pulse-oximetry saturation). See RESPIRATORY CARE:
Standard Abbreviations and Symbols [Respir Care 1997;42(6):637-
Editorial Office:
642).
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Manuscript Preparation Guide. Revised 2/98
to)
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No
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I
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D
D
n
Foreign
Physician
Industrial
FOR ACTIVE MEMBER
US
Special
or its territories or was on Active Member
if he/she lives in the
borders or territories, and meets ONE of the following criteria M is
o respirotory core professional if employed in a state that mandates
uch, OR |21 is a groduole of an accredited educational program m_ respiratory care, OR (3]
holds o credential Tssued by the NBRC An individual who is on AARC Active Membei in go
standing on December 8, 1994, will continue as such provided his/her membership r(
An
Student
individual
prior to
eligible
is
moving outside
its
)
legally credentioled as
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Nome
First
Nome
_
good
standing.
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Address
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City_
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State
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State
)
(
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Individuols who hold a position related to respiratory care but do not meet the requirements of
Member shall be Associate Members They hove oil the rights ond benefits of the Association except to hold office, vote, or serve as choir of a standing committee The following subclosses of Associate Membership ore available Foreign, Physicion, and Industrial (individuals
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D Technical Director
D
D
n
n
n
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D
D
D
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Active
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respirotory core-related field
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enrolled
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Institution
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in
credits
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Health
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if they meet oil the requirements for Associate
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classified as Student
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Home
be
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year
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Other, specify
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1
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•
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&
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participate in a live telephone
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fax (215) 923-3212.
aton in Ocean City, Ocean City, Maryland.
Philadelphia,
Pennsylvania.
— Marylaml/
District of Columbia Society
—
Videotape Teleconference
June 16
View Protocols Revisited: 1998. Part 4 of
the AARC's 1998 Professor's Rounds
Series.
AARC at
September 16-18
Thomas
Department of Patient Care SeiTices
2nd Annual Jefferson Ventilator
16 hours are available.
Contact: The
16 hours.
Illinois. Preregistration
required.
Atlanta Airport Marriott Hotel. Atlanta.
CRCE:
June 5 — Jefferson Medical College &
at
June 5-6
—
Joint Commission on
Accreditation of Healthcare Organizations
question-and-answer session.
Subacute Care and Patient Assessment
CRCE:
will also be offered.
for
Contact: Jeanette Ledbetter
City Centre, 'Washington
credit hour.
1
Contact: The
to receive the
AARC
at
(972) 243-2272
& register
90-minute video
for the teleconference.
October 8
June 17-19
SO""
— Illinois Society
Annual Convention and Exhibition
Oakbrook Terrace,
Center.
CRCE:
Illinois.
Credit has been requested.
Contact: Larry Dastych— (847)618-3190.
July 7
— Videotape Teleconference
View Outcomes Measurement: Part 5 of
the AARC's 1998 Professor's Rounds
Series,
&
CRCE:
Contact: The
AARC at (972)
to receive the
90-minute video
243-2272
&
~ AARC
s
November 18-21
AARC
Sam Giordano
MBA
"The RCP: Practice
NYSSRC
will
and
SUNY
in
and a
assessment workshop Oct 9-10
in
— Atlanta. Georgia
The 1998 Medtrade' Exhibition
Conference
will
be held
&
Georgia
1
.200 exhibitors representing 2,500
manufacturers, showcasing more than
250,000 products and services, including
FDA approvals.
the latest in
at the
Contact:(770)641-8181;
fax (770) 641-1499; web:
http://www.semcopro.com.
Manhattan.
register
Contact:(5l6)444-3181
www.nyssrc.org.
1998
December 9-11
An
— Grenoble. France
international conference on the
Diagnosis and Treatment of Sleep
speakers from
for
facility July
AARC at (972)
Oct
1
Contact: Congress Secretariat
CRCE.
ADTSAS,
243-2272
Hopital de
la
Service de Reanimation
for registry information.
— Nevada Society
93 Grande Rue de
la
Atlantis Hotel Casino, Reno, Nevada.
76 55
CRCE:
Patrick. levy @imag.fr.=
10 credits have been requested.
8943L
et d'
Assistance
Croix Rousse, 69317
Lyon Cedex
NV
at
Croix Rousse,
Respiratoire. Hopital de la Croix Rousse.
Annual Conference and Business Meeting,
Contact: John Steinmetz
all
French. Abstracts for presentation are due
19-20;
participants can earn 7 hours of
over the world with
all
sessions translated into either English or
Spirometry Workshop will be conducted
Circle. Sparks
at the
World Congress Center. Featuring nearly
Stony
be hosting a clinical
Cornell Club
will
Capital Hilton.
Contact: (630) 792-5800.
New
workshop on hemodynamic monitoring.
up to 20 hours.
Following the Summer Forum, a
July 20-21
is
York,
Care and Hospice,
at the
Breathing Disorders will feature 50
CRCE: Approved
Contact: The
New
rehabilitation, sleep diagnostics,
Registry Resort, Naples. Florida.
same
Manhattan,
asthma case management, pulmonary
Summer Forum
at the
be held June 4
the 21st Century." Other topics include
for the teleconference.
July 17-19
in
RRT speaking on
Brook
credit hour.
1
ORYX for Home
York. Featured speaker
Also, the
A
DC.
— New York Societ}-
Executive Director
participate in a live telephone
question-and-answer session.
Care and Hospice, Sheraton
preconference program. All About
30th Annual Symposium, Marriott
Marquis
Home
(202) 574-6348.
Southeastern Chapter
Drury Lane Theater and Conference
4th National Conference and Exhibition
at
181 Brooks
i
6,
04, France.
June 12-16, 1999
(702) 331-0721
for Aerosols
for information or a registration brochure.
1
—
August 21
Ohio Society
The Critical Care Committee's annual
Phone 33 (0)4 76
fax 33 (0)4 76 76 56
in
in
7, e-mail:
— Intenuilional
Societ}'
Medicine
2th International Congress
Center
1
at
the Austria
Vienna. Austria.
Contact: The Vienna Academy of
seminar. Holiday Inn Rockside Road,
Postgraduate Medical Education and
Independence, Ohio.
Research, Alser Strasse 4, A- 1090
CRCE:
Vienna, Austria. Phone (-h43/l) 405 13
6 credits are available.
83-22, fax (+43/1) 405 13 83-23, e-mail:
Contact: Nancy Johnson~(330) 929-7166
e-mail:
medacad@via.at.
abbyru@aol.com.
RESPIRATORY CARE
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JUNE 1998 "VOL 43 NO
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•
JUNF. 1998
VOL
43
Inc.
NO
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V)e
To our way of thinking,
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June - Respiratory Care

Transcription

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