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APRIL 1999 VOLUME 44 NUMBER 4 ISSN 0020-1324-RECACP A MONTHLY SCIENCE JOURNAL 44TH Call for EDITORIAL 1999 Open Forum Abstracts Can We YEAR— ESTABLISHED 1956 Rehabilitate the Chest Wall? Deadline June 11,1999 ORIGINAL CONTRIBUTIONS Effects of Respiratory Wall in Muscle Stretch Gymnastics on the Chest COPD Long-Term Tracheostomy and Weaning Work of Breathing with PSV + in Severe COPD PEEP vs CPAP during Prolonged Weaning Effects of Continuous vs Expiratory Tracheal Gas Insufflation on Total PEEP CASE REPORT Unrecognized Motor Neuron Disease as a Cause of Ventilator Dependency in the ICU Just as ancient institutions relied on the Azt^ calendar for vital measurennents of time, today's leading medical institutions rely on ASTECH Peak Flow Meters for vital patient measurements* Because more accurate information leads to more effective therapy. Entrust the health of your patients to the flow meter trusted by hospitals for some peak of the leading medical pulmonary medicine. The ASTECH Peak Flow Meter. A precision instru- ment with and reproducibility a record of accuracy that has stood the test of time in the most demanding environments. 800-527-4278 today Call mation about for really accurate infor- a really accurate peak flow meter. ASTECH^ PEAK FLOW METER ©1999 DEY. Ail rights reserved, 09-733-00 1/99 ZENITH JWk. AWARD WSW ' National Jewish Medical arni Researcit Center (ranked #1 for pulmonary diseases b\ U.S. We^vs and July Circle 133 1998} and other thought leaders use the Astech Peak on reader service card Flov/ Wid Report. Meter exclusively. Ill CPG 1 u^ Spirometry, 1996 Update CPG 2 Oxygen Therapy CPG 3 Nasotracheal Suctioning CPG 4 Patient- Ventilator CPG 5 Directed CPG 6 In-Vitro in L^l^LL^L- Li $1 Acute Care Hospital $1 • $1 • System Checl<s Cough $1 pH and Blood Gas • $1 • Lung Volumes CP627 Static CPG2B Surfactant Replacement Therapy • $1 Changes $1 • CPG29 Ventilator Circuit CP630 Metabolic Measurement using Indirect • $1 Calorimetry during Mechanical Ventilation • Hemoximetry LilLLLLli-LLLLL-^ Analysis and CP631 Transcutaneous Blood Gas Monitoring for Body Plethysmography $1 Capillary Blood Gas Sampling Neonatal $1 & Pediatric Patients $1 • $1 CPG 7 Use of Positive Airway Pressure Adjuncts to CP632 Bronchial Hygiene Therapy CPG33 CPG B Sampling CPG 9 Endotracheal Suctioning of Mechanically CPG34 Defibrillation Ventilated Adults and Children with CPG35 Infant/Toddler Pulmonary Function Tests CPG3G Management CPG37 Assessing Response to Bronchodilator Therapy at CPG38 Discharge Planning for the Respiratory Care CPG39 Long-Term for Arterial Airways $1 • Blood Gas Analysis Incentive Spirometry CPG 11 Postural Drainage CPG 12 Bronchial Provocation CPG 13 Selection of Aerosol Delivery Device CPG 14 Pulse Oximetry CPG 15 Single-Breath CPG IB Oxygen Therapy • • $1 Therapy • Point of Care $1 $1 Patient $1 • $1 Home Carbon Monoxide Diffusing 1999 Update Capacity, CPG 17 Artificial $1 CPG 10 Facility in $1 Home the $1 and/or Desaturation • Humidification during Mechanical Ventilation CPG 19 Transport of the Mechanically Ventilated • during Resuscitation of Airway • Invasive Mechanical Ventilation in the $1 CPG41 Selection of an Aerosol Delivery Device for CPG42 Polysomnography CPG43 Selection of an Ventilation • $1 • $1 $1 Oxygen Delivery Device for $1 CPQ44 Selection of a Device for Delivery of Aerosol to CPG45 Training the Health-Care Professional for the Role the Lung Parenchyma CPG20 Resuscitation in Acute Care Hospitals CPG21 Bland Aerosol Administration CPG22 Fiberoptic Bronchoscopy Assisting CPG23 Intermittent Positive Pressure Breathing CPG4G Providing Patient and Caregiver Training (IPPB) CPG47 Removal CPG48 Suctioning of the Patient CPG49 Selection of Device, Administration of CPG24 • • $1 $1 of Patient $1 $1 Application of CPAP to Neonates Via Nasal Prongs or Nasopharyngeal Tube • $1 Upper Airway CPG25 Delivery of Aerosols to the CPG26 Neonatal Time-Triggered, Pressure-Limited, Time-Cycled Mechanical Ventilation • • $1 $1 $1 Neonatal and Pediatric Patients $1 & $1 • Emergencies Neonatal and Pediatric Patients $1 Neonatal Capnography/Capnometry during Mechanical Hypoxemia $1 CPG 18 for $1 $1 • • • CPG40 or Extended Care Exercise Testing for Evaluation of Patient Pediatric Patients $1 • • • $1 and Caregiver Educator of the Endotracheal in Tube the $1 • • • $1 $1 Home • $1 Bronchodilator, and Evaluation of Response to $1 Therapy in Mechanically Ventilated Patients • $1 $1 CPG99 - Complete Set in Binder • $35 ($60AARCnonmembers) (+$7.00 for Shipping and Handling) American Association for Respiratory Care 1 1 030 Abies Ln., Dallas, TX 75229-4593 Call (972) 243-2272 or fax to (972) with MasterCard, Visa, or Purcfiase Order Texas customers onlv. olease add 8.25% sales tax fincludina shiDoina charaes). 484-2720 Number Texas customers that are exempt from sales tax must attach an exemption certificate. 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A Dillard—Tacoma, Washington 407 by Thomas for Respiratory Care 11030 Abies Ln Daiias TX 75229-4593 (972) 243-2272 ORIGINAL CONTRIBUTIONS Fax (972) 484-2720 • littp://www. aarc.org Preliminary Report on the Effects of Respiratory Muscle Stretch Gymnastics on Chest Wall Mobility in Patients with Therapist Registration or Chronic Obstructive Pulmonary Disease Technician Certification by Fujiyasu Kakizaki, Tsutomii Yamazaki. Hajime Suzuki— Yokohama. Japan, and Masato Shihuya. Minehiko Yamada. and Ikuo Homma— Tokyo. Japan Nationai Board for Respiratory 409 Care Long-Term Tracheostomy in Severe from Mechanical Ventilation 8310Nieman Rd LenexaKS 66214 (913) 599-4200 Fax (913) 541-0156 • hv Enrico Clini. Michele Vitacca. Luca Bianchi. Roberto Porta, http://www.nbrc.org and Nicolino Ambrosino Accreditation of Education Work Programs Committee on Accreditation for COPD Patients Weaned — Gus.sago. 415 Italy of Breathing during Weaning from Ventilation: Does Extending Weaning with Continuous Positive Airway Pressure Confer Any Advantage? by Rajesh G Patel, Many F Petrini. and Terry M Dwyer—Jackson, Mississippi 421 Continuous and Expiratory Tracheal Gas Insufflation Produce Equal Levels of Total PEEP by Edgar Delgado. Adelaida M Miro, Leslie A Hojfinan. Frederick J Tasota, and Michael R Pinsky— Pittsburgh, Pennsylvania 428 Respiratory Care W Euiess Bivd, Suite 300 1701 Euless TX 76040 (817) 283-2835 Fax (817) 354-8519 • http://www.coarc.com Grants, Scholarships, Community Projects CASE REPORT American Respiratory Care Foundation 11 Unrecognized Motor Neuron Disease: 030 Abies Ln TX 75229-4593 Daiias Cheryl State West Aflaiis MHA Government 434 — (703-548-8506) Affairs TEST YOUR RADIOLOGIC SKILL — A Eicher IMPA (703-548-8538) Jiil of — (972) 243-2272 • Fax (972) 484-2720 Government An Uncommon Cause Ventilator Dependency in the Intensive Care Unit by Rodrigo Morales and Jorge E Mendizabal Mobile, Alabama b\ Second Fioor 1225 King St, Alexandria VA 22314 60- Year-Old Woman with Dyspnea on Exertion AH Emad— Shiraz, Iran 437 Fax (703) 548-8499 PFT Measurement of FEV| using RE/PIRATORy h\ James C&RE RESPIRATORY CaRE {ISSN 0020-1324. USPS NUGGETS K Stotler, the Modified Spirometry Technique McCarthy— Cleveland, Ohio Daniel Laskowski, and Kevin 441 A Patient with Dyspnea and Acid Maltase Deficiency by Salim Kathawalla— Minneapolis, Minnesota, and Muzaffar Ahmad— Cleveland, Ohio 443 0489- is published monthly by Daedalus Enterprises Inc, at 1030 Abies Lane, Dallas TX 75229-4593. for the Amer- 190) 1 ican Association for Respiratory Care. One volume is published per year beginning each January. Subscription rates are S75 per year in the US: S90 in all other countries (for airmail, add S94). The contents of LETTERS TO THE EDITOR Lung Protective Ventilatory Strategies for Haynes— Nashua, New Hampshire by Jeffrey ARDS M 445 the Journal are indexed in Hospital and Health Administration Index, Cumulative Index to Nursing and Allied Health Literature. ica, EMBASEyExerpta Med- and RNdex Library Edition. Abridged versions of Respiratory Care are also published in French, and Japanese, with permission from Daedalus En- Physiological Basis of Ventilatory Support reviewed by H Thomas Robertson Seattle, Washington — terprises Inc. Periodicals postage paid at Dallas mailing offices. TX and at additional i 446 POSTMASTER: Send address changes to Respiratory Care, Membership Office. Daedalus Enterprises Inc. BOOKS, FILMS, TAPES, & SOFTWARE Italian. 1030 Abies Lane, Dallas TX 75229-4593. Printed in the United Stales of America Copyright © 1999. by Daedalus Enterprises Inc. Mechanical Ventilation Manual reviewed by Steven Holels —Rochester. Minnesota 447 nEW! Orientation & Competency Manual DEW! Uniform Reporting Manual for Subacute Care The Orientation and Competency Assurance Manual for Respiratory Care provides the information, assessment tools, and models necessary to demonstrate that the competence of employees is documented according to JCAHO requirements. Item BK55 $65 ($qo nonmembers) The Uniform Reporting Manual for Subacute Care is a determine productivity, track trends in the utilization of respiratory care services, assist in determining personnel requirements, measure demand for and intensity of services, and meet the requirements of prospective payment systems. (PPS). tool to Item BK2 $75 ($115 nonmembers) «SS«^" 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 Item BK3 S80 ($150 and practitioner. nonmembers) nEW! I.V. 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. Sample Curriculum struction in l.V.-line placement and management. Contains everything needed to establish a complete l.V.-line course: lesson outlines, checklists and references. Item BK18 $25 ($35 nonmembers) how to order Call the American Association for Respiratory Care at (472)243-2272 Here's for your Continuing Education needs ALSO IN THIS ISSUE AARC Membership 453 392 Application ^ o J J Let Our Vision^^ Of The Present Help You Realize ^ Your Vision Of The Future. N^ Introducing The BiPAP*Vision™System. The Future Of Noninvasive Ventilatory Care. Designed with ttie user and the patient mind, the BiPAP Vision System Higher Performance Capabilities provide in you with higher flow and a wider pressure help will improve the way you treat your patients range to meet the challenging needs of who patients with high breathing require noninvasive ventilation. versatile and simple, it's a dream So come automatic breath-by-breath response to providers. the patient's breathing patterns and circuit Integrated Display Screen with real-time leaks, providing graphics, patient and system data, and every breath. alarm options provides complete To see a Vision patient monitoring. O2 administration (from 21-100%) despite mask leaks. reliable BiPAP Visron System fof optimum support with Irak Pittsburgh, Pennsylvania Customer Service: for yourself or for Corp: 1-800-345-6443 more out how the Vision Local: System advances 1-800-669-9234 www.respironics.com respiratory care. ©1998 m is assist ventilator intended to augment the ventilation of a spontaneously breathing patient. Refer to the BiPAP Vision System complete infofmation on applications. Caution: U.S. federal law restricts this device to sale by or on the order of a physician. BiPAP. Vision and Auto Irak Sensitivity are trademaflts of Respironics, Inc. Circle 125 Global Headquarters 1501 Ardmore Boulevard USA • 15221-4401 information, call 1-800-345-6443. Find Adjustable Oxygen Control allows <:AfM;d. Ttie RESPIRONICS Auto-Trak Sensitivity™ ensures an true for hospital and alternate care Warning: demand. on reader service card clinical manual Respironics, Inc. EDITORIAL OFFICE EDITOR 600 Ninth Avenue, Suite 702 David J Pierson Harhorview Medical Center University of Washington Seattle. Washington Seattle CHIEF IN MD WA 98104 (206) 223-0558 Fax (206) 223-0563 www.rcjoumal.com ASSOCIATE EDITORS MANAGING EDITOR Ray Masferrer D Richard RRT Branson RRT R Dean Hess PhD RRT FAARC Massachusetts General Hospital University of Cincinnati Cincinnati, Ohio Harvard University Boston, Massachusetts Charles Katherine Kreilkamp G Durbin Jr MD James K Stoller MD The Cleveland Clinic Foundation Cleveland, Ohio University of Virginia Charlottesville, Virginia EDITORIAL BOARD Linda Barcus D MD Thomas A Barnes EdD RRT Leonard Northeastern University University of Washington Boston, Massachusetts Seattle. Hudson FAARC Washington Medical College of Georgia Augusta. Georgia COPY EDITOR Matthew Mero Bishop MD Michael J University' of Washington Seattle, M Kacmarek PhD RRT Robert Washington FAARC Joseph Massachusetts General Hospital Georgia State University Harvard University Bartolome Kelly Piotrowski R Celli Atlanta, Georgia Tufts University Toshihiko Koga Koga Hospital MBA RRT Rick Catherine MD SH Sassoon MD University of California lr\'ine Long Beach, California Kurume. Japan RRT Robert L Chatbum L Rau PhD RRT Boston, Massachusetts MD Boston, Massachusetts Sam P Giordano C Mishoe PhD RRT Shelley FAARC Arthur S Slutsky HKollefMD University Hospitals of Cleveland Marin Case Western Reserve University Washington University Cleveland. Ohio St Louis. Missouri MD University of Toronto Toronto, Ontario, Canada Owen Director of Marketing Luciano Gattinoni Tim Goldsbury Director, Advertising Sales MD Patrick Leger MD Martin University of Milan Clinique Medicate Edouard Rist Milan, Italy Paris. J Tobin MD Loyola University Maywood, France Illinois Beth Binkley Advertising Assistant E John Heffner MD Neil MD FAARC R Maclntyre Duke University Durham. North Carolina Medical University of South Carolina Charleston. South Carolina STATISTICAL CONSULTANT Mark J Heuiitt MD John Little A Monthly Science Established J Marini MD Gordon Rock. Arkansas St Paul. D Rubenfeld University of Washington University of Minnesota University of Arkansas Minnesota Seattle, Washington Journal in 1956 The Official Journal of the American Association for Respiratory Care SECTION EDITORS Hugh S Mathewson MD L Rau PhD RRT Drug Capsule Charles G Irvin Gregg L Ruppel Joseph PhD Richard MEd RRT RPFT FAARC PFT Comer Jon Nilsestuen Ken Hargelt PhD RRT FAARC RRT Graphics Corner D Branson Robert S Campbell Kittredge 'j Patricia Ann Doorley Charles G Durbin Jr Comer MS RRT MD Test Your Radiologic Skill RRT RRT MD Abstracts Summaries of Pertinent Articles in Other Journals Commentaries, and Reviews to Note Editorials, Newer Asthma Therapies (editorial)— Smith LJ. Ann Med Intern 1999;130(6);531-532. Prevalence of Acute Respiratory Distress Syndrome after Cardiac Surgery G, Taylor Is KM. Smith PL. Ratnatunga CP. J — Asimakopoulos Thorac Cardiovasc Surg 1999;1I7(3):620-621. Informed Consent Always Necessary for Randomized, Controlled Trials? Robinson W. Randolph A. Morris A. N Engl J Med —Truog RD. 1999;340(10):804-807. Economic Implications of the Diagnosis of Obstructive Sleep Apnea 1. Ann Intern Med 1999;130(6):533-534, (editorial) — Pack Al, Gurubhagavatula Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Re- duce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures. A American Society of Anesthesiologist Task Force on Preop- report by the erative Fasting-Anesthesiology 1999;90(3):896-905. Preventing Complications during Percutaneous Tracheostomy Anesthesiology 1 999;9()( 3 ):9 1 8-9 1 — Bouvette M, Fuhrman TM. 9. The Cuffed Oropharyngeal Airway and Management of the Difficult — Airway Pate! A, Pearce A. Anesthesiology l999;90(3):924-925. The WuScope Technique for Endotracheal Tube Exchange Mabey MF. Siegel JB. Anesthesiology 1999;9()(3):929-930. Infection Control in Long-Term Care: News from the Front — Andrews SR, Norcross SD, — Strausbaugh LJ. Am Infect J Control 1999;27(l):l-3. Team Approach and Control in the Nursing Home Setting Quay DRP. Am J Infect Control 1999;27(l):64-70. to Infection Prevention brecht H, Shearen C, Degelau J, DS underwent SBTs Large Scale Implementation of a Respira- the tory Therapist-Driven Protocol for Ventila- the implementation process (p tor Weaning — Ely EW, Bennett PA, Bowton year progressed. increased throughout RCPs more < 0.001 ). As the often considered DS (p < 0.00 priately — Ahl- perform and interpret 95% of the time, SBTs exist. Through DS S BTs once patients had passed a Am J and physicians ordered more SBTs (46 versus ticipants in ventilator manageinent, prospectively investigated the large-scale 65%, p = 0.004). Overall. SBTs were ordered more often on the medicine than on the surgical compliance with We Respir Crit Care Med 1999;I59(2):439. implementation of a respiratory-therapist-driven (TDP) .services (81 versus 63%. p = ), more a staged implementation DL. Murphy SM, Florance AM, Haponik EF. 1 data but significant barriers to than process, using periodic reinforcement of this large-scale all par- improved weaning protocol can be achieved. 0.001). likely 117 respiratory reflecting medical intensivists' prior use of this Nicotine Nasal Spray with Nicotine Patch for managing 1.067 pa- protocol. Important barriers to protocol compli- with respiratory failure over 9.048 patient ance were identified through a questionnaire Smoking Cessation: Randomised Trial with Blondal T. GudmundsSix Year Follow Up days of mechanical ventilation. During a 12-mo (89 respondents, 76%), and included: Physician son LJ. Olafsdottir protocol that included care practitioners (RCPs) tients period, we reintroduced a previously validated protocol that included a daily screen (DS) cou- pled with spontaneous breathing and physician prompt, as a input from a physician or TDP without daily "weaning team." With graded, staged educational interventions intervals, a 95% RCPs had a 97% completion at 2-mo rate and correct interpretation rate for the DS. The frequency with which 392 (SBTs) trials patients who passed RCP inconsisan SBT from the unfamiliarity with the protocol, tency in seeking an order for physician, .specific reasons cited by the physician for not advancing the patient to a SBT, and lack of .stationary unit assignments by performing the protocol. We conclude RCPs that implementation of a validated weaning strategy feasible as a a is TDP without daily supervision froin weaning physician or team. RCPs can appro- — BMJ Gustavsson G, We.stin A. 1999;318(7179):285. Objective: To evaluate the efficacy of using a nicotine patch for 5 sal 1, spray for 1 months with a nicotine na- year. Design: Placebo controlled, double blind trial. Setting: Reykjavik health centre. Subjects: 237 smokers aged living in or 22-66 years around Reykjavik. Interventions: Nicotine patch for 5 months with nicotine nasal Respiratory Care • April 1 999 Vol 44 No 4 ' Expand Your Vision with a Complete Family of Solutions For Lung Simulation Hands-on Instruction Advanced Research Applications Neonatal to Adult and Passive Active Lung Models Join us in Phoenix, AZ, July 16-18, 1999 IngMar Medical ... Expanding the Care Vision of Respiratory; Tel: AMhKlCAN ASSOC I.VIION tm Rl SPIRATORY CARE 800-583-9910 Fax; 412-683-8404 http://www.ingmarmed.com Internet: 1 ['>72] 14:->-2272 nformation Email: in the April ! [email protected] W9 issue oi AARC Circle 124 spray for year (n= 1 placebo spray (n= included 15 mg 1 1 18) or nicotine patch with Treatment with patches 19). of nicotine for 3 months. 10 month, and 5 for the fourth month, whereas nicotine available for up to 1 —Campos C, Naguib SS, Khalil SN. Anesth Analg 1999;88(2):268. spray was Both groups received Main outcome measure: than the peak inflation pressure at the endotracheal position (P < instantaneous the endobronchial position. at 0.0001). The increase Monitoring peak inflation pressure while for the fifth in the nasal year. supportive treatment. mg mg Pediatric Patients Chuang AZ, Lemak NA, on reader service card was insert- determine whether endo- ing an endotracheal tube and during anesthesia bronchial intubation always causes an immedi- can help to diagnose endobronchial intubation. Our purpose was ate increase in to peak inflation pressure and. if Implications: Monitoring peak inflation pres- Sustained abstinence from smoking. Results: so, the chil- sure while inserting an endotracheal tube and The dren scheduled for central line placement for during anesthesia can help to diagno.se endo- prolonged antibiotic administration comprised bronchial intubation. log rank lest for 6 years (X-=8.5. shows a significant as.sociation P=0.004) between abstinence from smoking and type of treatment. Sustained abstinence rates for the patch and nasal spray group and patch only group were 51*^ v 35% after 6 weeks (P=0.01 dence interval (X"), 3.32%), to 95% confi37% v 25% months (P=0.045, 1.017c after 3 31%v 16% after 27% 4.50%), 1.50% 17% 1. 1 to V 1 3.08%), to 6 months (P=0.005, 1.27% 1%) after 12 6.14%), and 16% to months (P=0.001. v 9% rates show the study group. After routine premedication and induction of anesthesia (halothane gen), an endotracheal tube position was was inserted, in oxy- and verified by auscultation and fluoroscopy. Children were mechanically ventilated using a preset volume pressure-limited ventilator with a 5-L fresh gas flow. All children re- tidal volume using a similar circuit, similar tubing, and a similar compres- ceived a constant sion volume. The lowest peak that the sure to deliver a tidal inflation pres- volume of 15 mL/kg was combination of using a nicotine patch for 5 months with a nicotine nasal spray a more effective u.sed. for than using a patch only. few relapses during gest that it is year is The low percentage of participants using the nasal spray at the 1 method of stopping smoking 1 year, and the second year, sug- not cost effective to use a nasal spray for longer than 7 months after stopping a patch. Endobronchial Intubation Causes an Immediate Increase in Peak Inflation Pressure in tidal How Does Home Management of Asthma Ex- its acerbations by Parents of Inner-City Chil- 6 years after (P=0. 077, 0.93% to4.72%). Conclusions: Short and long term abstinence magnitude of the increase. Fourteen After adjusting the respiratory rate (end- CO, 30 mm Hg) and anesthetic level (halothane end-tidal 1.2%), the peak inflation pres- dren Differ from mendations? McCourt MP, NHLBI Guideline Recom- — Warman Stein REK. KL, Silver Pediatrics EJ, 1999; 103(2):422. Objectives. ity, I ) To describe the asthma morbid- primary care practices, and asthma management of ma: 2) to home inner-city children with asth- determine the responses of parental caretakers to asthma exacerbations in theirchild: and 3) to compare these responses to the rec- was recorded. ommendations of the National Heart. Lung, and The endotracheal tube was advanced into a bron- Blood Institute (NHLBI) asthma guidelines for home management of acute exacerbations of sure at this endotracheal position chus, the position was verified as above, and peak inflation pressure was recorded. The en- asthma. Design and Methods. dobronchial tube was then pulled back into the phone survey was administered between July trachea, and placement of the central ceeded. The peak line pro- inflation pressure at the endobronchial position was significantly greater Respiratory Care • April 1999 Vol 44 No 4 1996 and June 1997 of 2- to 1 to 220 2-year-old children pitalized with asthma at A 64-item tele- parental caretakers who had been hos- an inner-city medical 393 en 0' AND PHYSICIANS THF.RAPISTS want The 740 technological sophistication. is designed to provide you with a lower cost of ownership. Hospital administrators and financial officers want With no need to cut costs. Is it for a compressor, possible hospital wall air or to get both high performance and oxygen blender, the 740 can offer longer scheduled service affordability in one ventilator? It is now. intervals The 740 treats pediatric patients in both and lower maintenance ICU and subacute Combine this with built-in diagnostics and automated settings. The new, simple-to-operate 740" Ventilator from Nellcor Puritan Bennett combines costs. and adult why the 740 self tests and you will see is so affordable to operate. An upgradable platform that will easily also safeguards your investment over the long haul. The 740 to is flexible any caregiving The enough to adapt situation. specially designed EasyCart' enables the 740 to be docked to a patented frictionless piston a accept future enhancements with standard flow triggering to provide wheelchair. This, together with the precise, responsive breath delivery. Tidal ventilator's internal, 2 volumes up to as low as 40 mL and peak flows 300 L/min enable you to pediatric and adult patients -hour battery, allows caregivers to easily maneuver patients within their facility without treat changing ventilators. The optional in a variety external battery offers an additional of clinical situations, from intensive care to subacute. '/: The option of wall mounting the 740 valuable poor space in the ICV. frees up seven hours of battery backup. comes to shove, simply gives you more for your money. >'. nit. duci e 740 Ventilator. Simplicity outside. Sophistication inside. The 740 in is many configured to communicate different ways. See the The standard communications panel on the 740 allows number it to interface with a of external devices including stand-alone remote alarms, nurse systems, central stations call new 740 for To arrange a demonstration of the new 740, call you 1-800-NELLCOR and ©1998 show around. But please, no pushing or shoving. and information NELLCOR PURITAN BENNETT. Circle 108 and we'll a ventilator that really gets systems, such as CliniVision" 740, EasyCart yourself. on reader service card CliniVision are trademarks of Nellcor Puritan Bennett Inc. Nellcor Puritan Bennett Inc. All rights reserved. www.nellcorpb.com A-FRM282-00 Rev. A (1/98) Abstracts center from January. 1995 to February, 1996. years (range 1-21 years) had a sensor placed. Sociodemographics. primary care practices. Sensors were asthma morbidity, and asthma home manage- hours. Eighteen patients underwent continuous ment were assessed. Parents were asked what they would do if their child "began wheezing monitoring for and breathing measures indicated bidity ± average of 2.5 asthma visits for in the 18.1 ± were an that there emergency department 4.5 la.st 6 months, hospitalizations for a.sthma in the last and Mor- faster than usual." Results, 1 1 ± .6 17.9 asthma-related school absences previous school year. Most, but not in the 2.2 2 months, all. of in place for a plications. A Controlled Trial of Exercise Rehabilita- of blood gas samples obtained. The gawa JA, Leaf DA, Lee N, Gleeson MP, Liu H, sion for mm 6.3 pH was pH ings and the blood gases were < PO, 0.813 (P 0.01 for plications Hg. The mm BACKGROUND: In patients who have received a cardiac transplant, the denervated donor heart < 70 mm Hg responds abnormally to exercise and exercise Hg. There were no com- (51%) reported having been given a written asthma action plan. Only 30% of families with blood gas monitoring allowed immediate rec- children age 5 years and older had peak flow continuous The ognition of clinical changes. Conclusion. blood gas sensor is capable tolerance reduced. The role of physical ex- is undergone cardiac transplantation has not been We determined. assessed the effects of training on the capacity for exercise early METHODS: transplantation. had equipment for inhalation of P-agonists, Only This technology provides the clinician with im- tients 39% mediate data that can allow rapid interventions after receiving a heart transplant of the 181 children with persistent symptoms were receiving daily antiinflammatory recommended agents as NHLBI. in the in who were discharged within two weeks assigned to participate unstable patients. guidelines of the after cardiac Twenty-seven pa- of clinically accurate blood gas measurements. families who have ercise in the treatment of patients (97%) all I999;340(4): 272. The values). from sensor placement. Continuous arterial MA, et al. N Engl J Med Hamilton PCO, 960, 0. all and precision for PO, levels bias mm between the sensor read- correlation (r value) 0,927, bia.s/preci- 0.005/0.030; for PCO,, -1.8/ Hg; and for PO,, 1.2/24 had phone access meters. In contra.st, almost — Kobashi- tion after Heart Transplantation 1 were 0.057/9.34 them. Half of the families no until who were at high risk of intubation-related com- longer clinically necessary. There were 4 4 pairs the families had primary care providers and most to ±62 101 24 hours or least at mean of cardiac-rehabilitation in a were randomly six-month structured program (exercise group, of an acute Noninvasive Ventilation for the Treatment 14 patients) or to undergo unstructured therapy exacerbation of asthma, no one mentioned that of Acute Respiratory Failure in Patients with at they would refer to a written plan, only Hematologic Malignancies: taker In response to the scenario 1 care- would measure peak flow and 36% would give /3-agonists. Two steroids initially, and percent would give oral additional person 1 would wheezing continued 40 minutes do so if Only 4% responded that they their clinician. Reports would contact dif- more in aerobic training under the guidance of a phys- Med 1998;24(I2):1283. OBJECTIVE: To evaluate treatment with non- mask invasive ventilation (NIV) by nasal as an home are not af- respiratory failure to decrease the risk of DESIGN: Pro.spective clinical study. SETTING: Hematologic and general intensive care unit (ICU), University of Rome "La Sapi- PATIENTS: 6 consecutive patients with enza". 1 was delivered BiPAP INTERVENTIONS: NIV mask by means of a USA); we eval- via nasal ventilator (Respironics, uated the effects on blood gases, respiratory rate, and hemodynamics along with tolerance, combination of opto-chemical and fiber-optic de- MENTS AND RESULTS: showed gases and respiratory rate within the blood first 24 h temperature on a continuous basis via a sensor P^q/F,,,, (fractional inspired oxygen) ratio, and To evaluate this patients who would nor- pling. Design. which the A arterial blood gas sam- criterion standard study results of arterial in blood gas samples measured by the laboratory analyzer were compared with the sensor readings. Setting. A pe- oxygen saturation significantly im- arterial proved after 1 h of treatment (43± 10 vs 88 ±37 mmHg; 87±22 vs the ICU charged from the center. Patients. Children with severe respira- a who required frequent arterial blood who had a 20-gaugc arterial gas sampling and line in either a radial or femoral site. Results. Twenty-four patients with a mean age of 6.4 396 ±9 vs 95±4%, mean charged < 0.01 failure, ICU Five patients died in while 1 1 were days and were good condition from dis- dis- the hospital. by nasal mask proved be feasible and appropriate for the treatment of respiratory failure in mL per kilogram per minute [18 percent]; P=0.01) and workload (mean [59 percent] 12 v.s. W and a greater reduction [1 1 W P=0.01) in the ventilatory equiv- (mean decrease, 13 [20 alent for carbon dioxide percent] vs. 6 increase. 35 ]18 percent]; percent!; P=0.02). The mean dose of prednisone, the number of patients taking antihypertensive medications, the average number of episodes of rejection tion during the study period, and of infec- and weight gain diac tran.splantation, exercise training increases the capacity for physical work. Improvements in Lung Function, Exercise, and Quality of Life in Hypercapnic COPD Patients after gery Lung Volume Reduction SurS, Kuzma AM, —O'Brien GM, Furukawa Cordova F, Criner GJ. Chest 1999; 1 15(l):75. in in stable condition after stay of 4.3 ±2.4 CONCLUSIONS: NIV to ). following complications independent of the respiratory diatric intensive care unit of a tertiary referral tory failure I75±64; 81 respectively) and continued to improve in the following 24 h (p per kilogram CONCLUSIONS: When initiated early after car- in of treatment. Arterial oxygen tension (Pao,). placed in an artery. Objective. mL of body weight per minute |49 percent] vs. 1.9 did not differ significantly between the groups. improvement a significant peak oxygen con- MEASURE- measure pH, PCOj, PO,, and in pediatric sig- later. 15 of the 16 patients complications, and outcome. Context. Continuous arterial blood gas monithe tol- acute respiratory failure complicating hemato- and caretaker practices. mally require frequent had sumption (mean increase, 4.4 Use of Continuous Arterial Blood technology with hem- Gas Monitoring in the Pediatric Intensive Care Unit— Weiss IK. Fink S, Harrison R, Feldman JD, Brill JE. Pediatrics 1999;103(2):440. tectors that can and RESULTS: As compared nificantly greater increa.ses in guidelines for the new technology based on months base line (with- after heart transplantation) the control group, the exercise group logic malignancies. a one month at hematologic malignancies complicated by acute being followed. Interventions are needed to is in Cardiopulmonary training. was performed ventional mechanical ventilation in patients with management of asthma exacerbations toring stress testing in erance. Clinical whereas control patients received ical therapist, no formal exercise 6 months response to the sce- indi- Lappa A, Rosa G, Gasparetto A. Intensive Care ously hospitalized inner-city children with fect both clinician group underwent an vidualized program of muscular-strength and orrhagic complications and increase clinical NHLBI Each pa- (control group, 13 patients). Conti G, Marino P, Cogliati A, Dell'Utri D, nario. Conclusion. In this population of previ- asthma, the home tient in the exercise six people began /3-agonists and oral steroids than said they would — alternative to endotracheal intubation and con- fered from the scenario responses in that in the past Study Pilot later. of actual practice response to an exacerbation A hematologic patients STUDY OBJECTIVE: To determine the impact of preoperative resting hypercapnia on patient tion outcome after bilateral lung surgery (LVRS). volume reduc- METHODS: We prospectively examined morbidity, mortality, quality of life (QOL), and physiologic outcome, including spirometry, gas exchange, and exercise performance in 15 patients with severe Respiratory Care • April 1999 Vol 44 em- No 4 , Abstracts physema and (group 1 from 3 > of mm 45 < patients with a Paco, "f 1 (group a resting P„co, Hg and compared the results with those ). RESULTS: 2). QOL ologic and mm 45 Hg All preoperative physi- indices were more impaired in the hypercapnic patients than in the eucapnic The hypercapnic did not have access to the results of the baseline when making evaluations their severity as.sess- SETTING AND PARTICIPANTS: ments. mem- Study participants were 193 asthmatic bers (age range, 6 to 55 years) of a large health who underwent maintenance organization a 77±9 hypopnea) of MEASURE- events/h. MENTS AND RESULTS: The was assessed by administering quality of life a Medical Out- comes Study Short Form-36 questionnaire before and after 8 weeks of nCPAP therapy in polysomnographically documented OSA. All di- patients exhibited a baseline evaluation as part of a separate longi- mensions of the quality of lower preoperative FEV,, a lower diffusing ca- tudinal study. This evaluation consisted of spi- cantly impaired pacity of the lung for carbon monoxide, a lower rometry, skin prick testing, and a survey that and gender-matched population, expressed as a symptoms and medica- percentage of normative data: physical func- participants in the ancillary study 86 of 75%; vitality, 41%: role functioning 54%; emotional, 61%; social. 66%); general health. 88%: and mental health. 76%. nCPAP therapy significantly improved the had mild disease, 90 sleep-disordered breathing and sleep fragmen- patients. of ?„„, 'o the fraction of inspired oxygen, ratio included questions on The a lower 6-min walk distance, and higher oxy- tion use. gen requirements. However, were selected, based on after surgery both groups exhibited improvements < 0.0 1 group 1 , p 1, p=0.04; group : 2, 2, pacity (TLC; group 0.001 residual ), group p 2, < 0.001), p=0.03; group RVATLC 2, 2, at p=0.02; group 2, p 2, < < 0.001). 1 time p=0.02), and the 1, However, be- the spirometry, lung vol- disease, and 17 (9%) had correlated highly (p £ NAEP- 0.013) with based indices of severity based on oral glu- tioning, (physical, tation. The nCPAP 9.4±0.7 cm H,0. apy improved tude of improvement predicted, and 80% was related to the degree impairment prior to treatment, mea- rather than to the severity of disease as sured by the RDI and asthma symptoms CLUSIONS: All aspects of the quality of (S once/week, A to life <60% predicted). It did not, however, correlate with current (p=0.87). 60 ther- (90%), and mental health (96%). The magni- of quality of predicted, group was nCPAP (75%), social functioning vitality frequently for attacks, and daily use) and on > 80% for the level Eight weeks of cocorticoid use (never, infrequently for attacks, spirometry (FEV, signifi- 2 to 6 times/week, daily) composite severity score based on spirometry and the glucocorticoid use data still provided an overall agreement of 63%, with a arousal indices. from physical and emotional health CON- OSA. functioning, are markedly impaired by nCPAP life, to social therapy improved those aspects related and mental to vitality, social functioning, health. CONCLUSIONS: weighted kappa of 0.40. sig- While current symptoms are the most important Noninvasive Positive Pressure Ventilation: in the hypercapnic concern of patients with asthma, they reflect Successful There was no difference in mortality the current level of asthma control umes, and 6-min walk distance remained nificantly lower patients. (45%) had moderate ity I, both groups, and the hypercapnic group ilar in the chart review, the study subjects (45*^) (group cause the magnitude of improvement was sim- was more impaired, broad range of asthma severity. RESULTS: Based on severe disease. This physician-assessed sever- scores (group 0.001). tion, to reflect a p=0.002; total exercise QOL p 2, 1 . peak exercise (group p=0.02), perceived overall p=0.001: group (group , ratio p = 0.005; group I. p=0.02; group I, ). < 0.001), ?,„,, (group I, p=0.02), 6-min walk dis- p 2, oxygen consumption (group 1 volume (RV; group p=0.002; group tance (group FVC in < 0.00 FEV (group p < 0.001). total lung ca1, p=0.02; group 2. p < p their baseline evalua- were life when compared with an age- post-LVRS between the groups (p=0.9). CONCLUSIONS; underlying disease severity. Investigators must Patients with moderate to severe resting hyper- therefore use caution capnia exhibit significant improvements of patients for in spi- more than whom when comparing groups severity categorization Outcome in Patients with Acute Lung Injury/ARDS Rocker GM, Mackenzie MG, Williams B. Logan PM. Chest 999; 115(1): — 1 173. is QOL. and ex- based largely on symptomatology. This obser- BACKGROUND: LVRS. The for the use of noninvasive positive pressure ven- erative lung function are related to preoperative symptoms alone do not reflect disease severity, becomes even more important as health-care delivery moves closer to protocols/ however, the magnitude of practice guidelines and "best treatment" pro- rometry, gas exchange, perceived performance ercise after bilateral maximal achievable improvements level of function; improvement can be expected in postop- to be similar to patients with lower resting P„co, levels. Patients on the presence of resting hypercapnia. The long-term benefit of LVRS grams that rely heavily on symptoms in hypercapnic patient remains to be determined. II5(1):85. validate three indi- cators of asthma severity as defined in the Na- Asthma Education Program (NAEP) guidelines (ie, frequency of symptoms, degree of airflow obstruction, and frequency of use of oral glucocorticoids), alone and against severity as assessed by cialists data. in combination, pulmonary spe- provided with 24-month medical chart DESIGN: Cross-sectional comparison of increasing support treatment of patients with in the acute respiratory failure. Highest success rates are recorded in patients with exacerbation of COPD, particularly in patients presenting pri- cess has been more limited in patients with acute hypoxemic respiratory failure, and there are Sleep Apnea: Effect of Nasal Continuous Pos- reports of NPPV Airway Pressure: A Prospective Study — T, Mohsenin V. Chest 1999:1 15(1): 123. in (OSA) common a is referral center condition and TERVENTION: a.ssociated with psychological dysfunction. There (range) life tive and its OSA limited ev- response to nasal continuous posi- airway pressure (nCPAP) treatment. STUDY OBJECTIVE: To of is on the quality of nCPAP PA- 29 patients (23 were male and 6 were female) with a mean (±SE) age of mass index 36.3 ±2.0 asthma severity with physician-assessed sever- kg/height m", and a diagnosis of spiratory disturbance index Respiratory Care • April 1999 Vol 44 No 4 OSA with re- (RDI; apnea/ II score was 16 (11 to 29). further assisted ventilation for 72 h) was achieved on six of nine occasions (66%) when ventilation. We studied in patients Success rate (avoidance of intubation and no NPPV was effect in a case-series analysis. TIENTS: NPPV APACHE (acute physiology and chronic patients with life in Provision of health evaluation) Prospective determination of on the quality of OSA, DESIGN: nCPAP determine the effect and university hospital ICU. IN- ALI/ARDS. RESULTS: Group median with excessive daytime sleepiness and neuro- idence on the effect of NPPV. DESIGN: SETTING: Tertiary 10 patients treated with Obstructive sleep apnea is re- outcome of 12 episodes of ALI/ARDS Experiential cohort study. BACKGROUND: few patients with acute lung ARDS. OBJECTIVES: We injury (ALI) or port the in 4.4 ±2.3 years, a body based on chart review. The pulmonologists (NPPV) is marily with hypercarbic respiratory failure. Suc- questionnaire and clinical-based markers of ity tilation There Quality of Life in Patients with Obstructive itive Lack of Correlation of Symptoms with Specialist-Assessed Long-Term Asthma Severity— Osborne ML. Vollmer WM, Pedula KL, Wilkins J, Buist AS, O'Hollaren M. Chest 1999; tional guide subsequent treatinent decisions. D'Ambrosio C, Bowinan STUDY OBJECTIVES: To to LVRS based should not be excluded from solely vation, that used as the It initial mode of assisted failed after three epi.sodes of planned (1) or self (2) extubation. Duration of successful with ICU NPPV was discharge 64.5 h (23.5 to 80.5 h) in the next 24 to 48 h for three of six patients. Unsuccessful episodes lasted 7.3 h (0.1 to 116 h) with need for conventional ventilation for an additional 5 days 397 Abstracts (ICU and (2.7 to 14 days). Survival hospital) CONCLUSIONS: was 70%. for the 10 patients group of hemodynamically stable patients In a with severe ALI, NPPV NPPV had a high success rate. should be considered as a treatment option for patients in stable condition in the early phase of ALI/ARDS. decline in Effect of Heliox on Nebulizer Function — Hess DR. Acosta FL. Rilz RH, Kacmarek RM, Camargo CA Jr. Chest 999; 5{ ): 84. 1 1 1 1 1 OBJECTIVE: To evaluate nebulizer performance when was used METHODS: power to the neb- Conventional and continuous nebulizer designs were evaluated. The conventional nebulizer was used with 5 buterol and flows of 8 L/min liox, 10 and mg 1 1 L/min heliox; and comparably it al- 8 L/min he- air. was mg also used with albuterol and a heliox flow of 8 L/min. L/min heliox; ? was it cotton plug the nebulizer at to trap aerosol during sim- The amount of ulated spontaneous breathing. on the cotton plug was de- of sepsis and 1994, and 1, mus- Weakness was sys- cle biochemistry tematically assessed in reported frequency of 36 and SURES: The HRQL instruments (Medical Form Health .36-ltem Short Form [SF-.36] and George's St Respiratory Questionnaire |SGRQ), respective- RESULTS: Clinically meaningful and statistically significant reductions in = survivors (n HRQL scores 73) were seen in 7 of SF-36 domains and 3 of SGRQ 3 domains compared with inatched controls (P< 0.001 reductions). HRQL The were seen in largest decrements for in the physical function and pulmonary symptoms and limitations. Analysis of = trauma-matched pairs (n icant reductions in 7 of 8 76% reported in lation number of patients with various electrophysiologic findings but insufficiently reported clinical correlations. When powered tribution to weaning inhaled mass of albuterol 46) revealed signif- £ SF-36 domains (P Quality of Survival after Cardiopulmonary vealed significant reductions in 6 of 8 SF-36 < Intern Med 1999:159(3); acteristics before, during, monary outcomes, and to compare results of the quali- rather than less for the air. time, how- 0.001). Increasing the flow of heliox domains (P (P disease-specific domains. BACKGROUND: of life expectancy and quality of TIVES: To determine in Crit- in METHODS: terms OBJEC- life. the impact of patient char- and after CPR on these assessment with published ty-of-life Acquired Neuromuscular Disorders Outcome of cardiopulmonary resuscitation (CPR) can be poor, In a cohort study, we .studies. assessed by Patients: A and inhaled mass Groupe de Refiexion et Neuro- functioning, depression, and level of dependence < myopathies En Reanimation De Jonghe B. Cook D, Sharshar T, Lefaucheur JP, Carlet J, of survivors after inhospital CPR. Follow-up similar to powering the nebulizer with air at the lower flow. Increasing the albuterol concentra- Outin H. Intensive Care increased the particle size (p mass of albuterol (p of particles to 5 1 < 0.05), microm tion in the nebulizer (p < Arch 249. marily noted in physical functioning and pul- the neb- was more than twofold greater with heliox (p — de Vos R, de Haes HC, Koster RJ. con- when The nebulization nebulizer (67%). ever, was (16%) than and long-term difficulties disability are needed. the continuous ) with heliox, the reduction in ventional nebulizer Evaluation of risk factors for these disorders and studies examining their con- £ 0.05) and 3 of 3 SGRQ domains £ 0.002). CONCLUSIONS: Survivors of ARDS have a clinically significant reduction in HRQL that appears to be caused exclusively by ARDS and its sequelae. Reductions were pri- and inhaled mass of albuterol de- was powered with heliox ulizer in patients neuromuscular abnormalities include a small RW, de Haan 0.001 showed compared to those without. CONCLUSIONS: Prospective studies of ICU-acquired Resuscitation < studies ties, 27) re- creased significantly (p Two and a mortality twice as high = SGRQ of cases. with critical illness neuromuscular abnormali- Analysis of sepsis-matched pairs (n particle size more than respectively) in duration of mechanical venti- was determined using an both nebulizer designs, patients. In a population of a clinically important increase (5 and 9 days, Survey, Standard all ICU by generic and pulmonary Outcomes Study ARDS non-selected 0.003). RESULTS: For respectively. 5 days, electrophysiologic abnormalities were disease-specific ly). in s pactor. 70%, patients mechanically ventilated for domains (P -stage cascade im- studies, Electrophysiologic and histologic abnormalities 0.02) and 3 of 3 1 two of the eight concerning patients with severe asthma, with a termined spectrophotometrically. Particle size 1 studies. MAIN OUTCOME MEAHRQL of ARDS survivors and 1996. controls, assessed 2 albuterol and a heliox ARDS trauma admitted between January air, mg ARDS mus- involvement and were frequently reported, even 8 L/min heliox, and trauma center. Seventy-three pairs of clinical risk factors for flows of 2 L/min at I to cle relaxants, or because of participation in consisted of both peripheral nerve and muscle of albuterol over 40 min albuterol deposited or injured controls without ill severe asthma while others failure, or were selected on the basis of exposure sur- mg A survivors organ sis, vivors and severity-matched controls with the of mouthpiece was used un- is there are if ARDS of medical and regional level PATIENTS: set to deliver 10 flow of 2 L/min. or other ARDS. DESIGN: Prospective, matched, parallel cohort study. SETTING: A 41 -bed munic- The continuous nebulizer was also used with 20 HRQL differences in the July 30, ulizer. ARDS 1 Using a Beta-Agonist Bronchodilator heliox caused by is known. OBJECTIVE: To determine ipal The HRQL aspects of the patient's illness or injury 0.05), inhaled 0.05) to levels < 0.05) while maintaining the smaller particle .size produced with SIONS: The use of III Systematic Review. d'Etude sur les — Med 1 998;24( 1 2): 1 242. and using the lower heliox flow increased the inhaled mass of albuterol (p ically clinical studies of CONCLU- in intensive power a nebulizer IDENTIFICATION mass of medication and the size of the aerosol particles. The flow to when power the nebulizer should be increased heliox is ies care unit (ICU) patients. STUDY AND SELECTION: were identified through BASE, the prospective neuromuscular abnormalities that flow. heliox to affects both the inhaled OBJECTIVE: To summarize Stud- MEDLINE, EM- references in primary and review cles, personal files, arti- and contact with authors. Through duplicate independent review, we used. selected prospective cohort studies evaluating Reduced Quality of Life In Survivors of Acute Respiratory Distress Syndrome witli Critically III Compared Control Patients — David- son TA, Caldwell ES, Curtis JR. Hudson LD, Steinberg KP. JAMA we CONTEXT: Health-related quality of life (HRQL) is reduced in patients who survive acute respiratory distress 398 (ARDS), but whether this after discharge from the RESULTS: Of 827 resuscitated patients, 12% (n = 101) survived to follow-up. Of the survivors, 89% participated in the study. dependent in Most survivors were 16% had cognilively impaired, and in- 17% were daily life (75%), depressive symptoms. Multivariate regression analysis showed that quality of life and cognitive func- were determined by 2 factors known be- tion fore CPR-the reason tors during for admission and age. Fac- and after resuscitation, such as nificantly determine the quality of life or cog- tures, the population, clinical 242 months (tertiary care center). prolonged cardiac arrest and coma, did not sig- abstracted key data regarding design fea- SULTS: at least 3 ho.spital DATA and laboratory di- nitive functioning of survivors. life of our CPR survivors The quality of was worse compared RE- with a reference group of elderly individuals, We identified eight studies that enrolled but better than that of a reference group of pa- agnostic tests, and clinical outcomes. 1999;281(4):.\54. was cognitive life, In duplicate, independently, ICU-acquired neuromuscular disorders. ABSTRACTION: formal instruments the quality of patients. Inception cohorts varied; were mechanically ventilated patients some for a 5 days, others were based on a diagnosis of sep- tients with stroke. The quality of life did not importantly differ between the compared studies of CPR Respiratory Care • survivors. CONCLUSIONS: April 1999 Vol 44 Car- No 4 superior aerodol therapy across the care contuuuim MDILog' Electronic monitors for aerosol delivery The device provides to Records date and time tfie ability of each use and evaluates technique monitor compliance and record true delivery and Reduces lengths evaluate patient technique. staff productivity These features make Transmits data for analysis/ of stay and increases devices disease management asthma and COPD it the ideal storage with fast wireless tool for' communications patients. Ideal for use in acute, subacute, rehab, physician's office and pulmonary home settings Circulaire™ Maximizing Designed for inpatient and Optimum at-home lung deposition delivery of use, the Circulaire's aerosol particle size for superior inhaled medications to ttie lungs concentrated drug patented distensible drug Ideal for protocol-based reservoir minimizes waste delivery while Virtual elimination of systemic reaction to it's tailors variable resistor beta stimulators treatment to individual "Biofeedback" gauges encourage pediatric/ adult patient needs. ^ maximum patient effort HEARr" Better at outcomes Nebulizers HEART® — The high-output extended The aerosol respiratory therapy up to 8 hours of therapy IHEART®} system The MiniHEART® low-flow nebulizer lower cost high-output nebulizer through continuous nebulization therapy unsurpassed in is up delivering in inpatient 10 hours of treatment The low-cost and low-flow UniHEARF" continuous nebulization therapy [CNT] to nebulizer and — ideal for Emergency Department use outpatient settings. XKioakmoA A leader in aerosol drug delivery and drug management, providing superior results through productivity gains and patient outcomes across the care continuum. Circle 104 Westmed.lnc. 3351 E. — on reader service card Hemisphere Loop, Tucson, Arizona 85706 1 ahoi Phone: 800-724-2328 PM 7ndRR Rp\/ m Fax: 520-294-6061 www.lungdepot.com Abstracts diopulmonary resuscitation cessful, but good if survival quality of CPR life after is frequently unsuc- achieved, a relatively can be expected. Quality of life is is mostly determined by factors known before CPR. These may be help- findings informing patients about the outcomes of ful in for 48 h spontaneous breathing after a not differ in the and 120-min .30- The 30- and 120-min 9%, and in-hospital mortality respec- and rates (19 CPR. 18%, respectively). Reintubation was required Contaminated Aerosol Recovery from Pulmonary Function Testing Equipment higher mortality (20 of 61, 32.8%) than did (13.5%) in 61 — Hiebert T. Miles Med Care Crit J, Am Okeson GC. Respir J patients 4.6%) who < (p tolerated extubation (18 of 392, measurements of 0.001). Neither pressure, and oxygen saturation during the trial, Clinically, the spread of infectious agents be- nor other functional measurements before the tween subjects undergoing spirometry trial uncommon. There in the is is quite almost no documentation medical literature on We this subject. studied the retrieval of nonpathogenic Escherichia coli after aerosolizing organisms into standard pulmonary function tubing of a type that is who discriminated between patients quired reintubation from those who extubation. In conclusion, after a re- tolerated of first trial end of the arrival of the aerosol at the distal tubing was documented by culture. After delays of 0, 1,5, forcibly and min. respectively, 1 air was withdrawn from the proximal end of the tubing through a special petri plate assembly. The plates after insufflation of 30 and last — Diehl JL, Atrous SE, Touchard D, Le- Med Am Brochard L. niaire F, Respir Crit Care J is widely performed on ventila- on ratory mechanics have not been studied. -min delay, the proximal samples contained only rare organisms. ganisms were recovered from proximal ples after a delay of 5 or 10 tion of organisms. min No air or- sam- after insuftla- The absence of detectable aerosolized E. coli after delays of 5 and 10 min Thus, detecting hypoxemia portance SCD, To in in SCD, we compared 22 surements of oxygen arterial with in adult patients SCD saturation (S.,,,,2 its effects readings only breathing and after (WOB) the procedure, we graphic waves on the oximeter screen. sess of position the also We .shifted + 5 cm (PS-5). After compared the resistive lowed between 0.05). tests. Du- Effect of Spontaneous Breathing Trial Outcome ration on of Attempts to Discon- tinue Mechanical Ventilation Alia 1, Tobin MJ, Gil A, Gordo Am et al. J Respir Crit Care — Esteban Med A, Vallverdu F, 1 I, 999; 159(2): WOB ± after 0.4 to 0.4 and for PS-5 (1.4 ± 0.6 percentage points), but it almost always accurately estimated S.,„, (underestimating age by 1 . 1 was was never enough to classify a PS-B, p ± 92 < to 80 and surements decreased significantly The duration of spontaneous breathing trials before extubation has been set at 2 h in research studies, but the optimal duration is not known. conducted a prospective, multicenter study involving 526 ventilator-supported patients considered ready for weaning, to outcomes for trials compare 270 and 256 clinical of spontaneous breathing with target durations of 30 and trial 0.3 J/L, also observed in ± 56 cm H2O 0.05). Resistive 1 20 min. Of the patients in the 30- and 120-min groups, respectively, 237 (87.8%) and 216 (84.8%), respectively, completed the out distress and were extubated (p = trial with- 0.32); 32 (13.5%) and 29 (13.4%), respectively, of these patients required rcintubalion within percentage of patients 400 who remained 48 h. The extubated PS-5. A significant reduction in mus- s/min for • (PEEP) was tions, with pattern. as long as strong We conclude that, and regular photoplethysmo- at PS-B and occlusion also ob.served for no significant change all pre.s- condi- in breathing Three patients had ineffective breathing efforts before tracheotomy, and all proved synchrony with the ventilator emia or normoxemia in SCD. As-Required Versus Regular Nebulized Salbutamol for the Treatment of Acute Severe — Bradding P, Rushby I. Scullion Morgan MD. Eur Respir J 1999;I3(2):290. Asthma J, work elastic sure and intrinsic positive end-expiratory pressure hypoxemic pa- erroneously as normoxemic or a normox- be relied upon not to misdiagnose either hypox- ± to 0.6 the pressure-time index of the respiratory cles (181 on aver- percentage points). The error in Spo, graphic waves are present, pulse oximeters can -I- significant reduction mm < 0.2 J/L, p p < 0.05), with a near-significant reduction for PS 5 (0.5 ± 0.5 to 0.2 ± 0.1 J/L, p = 0.05). A and right- tracheotomy ± computed from transpulmonary pressure mea- 512. We in significant reduction was observed 0.9 (S.,„, found oxyhemoglobin dissociation curves, with in the A We pH-corrected p50s ranging from 28 to 38 cur during routine pulmonary function testing bench study. PS-B (from as- hemoglobin percentage (by an average of 3.4 levels of pressure cm HjO 5 - respi- emic patient as hypoxemic. for To patients' and venous oxygen saturation (ETTs) and by a new tracheotomy cannula is al- these Svo,) against oxygen tension. an min or more accepted Spo^ and regular photoplethysmo- terized by strong transfer of aerosolized organisms does not oc- in vitro We tracheotomy during at three identical (PS + 5), and PS arte- divided Hg. Pulse oximetry slightly overestimated oxy- support (PS): baseline level (PS-B), PS H,0 drawn they were stable and charac- if tubing supports the hypothesis that a significant as long as an interval of 5 saturation (Sp,,,) and acute vasooc- in eight measured the work of breathing patients before hypoxemia = oxyhemoglobin tient of organisms into spirometry of particular im- pulse oximetric mea- work induced by the patients' endotracheal tubes after insufflation is assess the accuracy of pulse oximetry in the diagnosis of arterial Tracheotomy tor-dependent patients, but I (SCD) and may oxyhemoglobin dissociation curves, we plotted 1999;159(2):383. ing had counts similar to the air sampled at the After a disease in sickle cell exacerbate microvascular occlusive phenomena. measured by co-oximetry. Changes in the Work of Breathing Induced by Tracheotomy in Ventilator-Dependent Patients 999; by oxyhemoglobin plus reduced hemoglobin) 20 min. 1 1 Pulmonary complications and hypoxemia are common rial geted to Med Respir Crit Care 159(2):447. clusive crisis with simultaneously effectively with trials tar- organisms, air withdrawn from the proximal tub- distal end. Am J Benjamin LJ. was achieved equally were cultured and the colonies were counted. Immediately Accuracy of Pulse Oximetry in Sickle Cell Disease— Ortiz FO, Aldrich TK, Nagel RL, spontaneous breathing, successful extubation frequently used by volume-sensing spirometers. The dent patients. and these patients had a patients, respiratory frequency, heart rate, systolic blood 1999;I59(2):610. the mechanical workload of ventilator-depen- 0.43). groups had similar trial within-unit mortality rates (13 and tively) groups = (75.97c versus 73.0%, respectively, p did trial trial Current British guidelines for the administration of (32-agonists in acute severe ommend asthma rec- regular nebulized therapy in hospitalized patients, followed by as-required (p.r.n.) use via hand-held devices after discharge. Since do not possess anti-intlammalory /32-agonists activity in vivo, had im- ence the after the erbation, rate it and are thus unlikely to influ- of recovery from an asthma exac- was hypothesized that patients given procedure. In vitro measurements the short-acting (32-agonist salbutamol on an ETTs removed from as-required basis after admission to hospital the made with patients, with new ETTs, and with the tracheotomy cannula showed that the cannula reduced the resistive work duced by the .sults in- would recover as quickly as those on regular treatment, but with potential reductions in the dose delivered. Forty-six patients with artificial airway. Part of these re- total was explained by a slight, subtle reduction acute severe asthma were randomly assigned to of the inner diameter of used ETTs. We conclude that tracheotomy can substantially reduce either regular prescriptions of nebulized salbutamol or to usage on a Respiratory Care • p.r.n. basis, April 1999 from 24 h Vol 44 No 4 . Asthma Disease State Management a Partnership Establishing Presented by a highly credentialed staff of experts, this directions on within your All four how to create an effective new videotape offers comprehensive asthma disease management program facility. segments* of DSM are addressed: • Diagnosis • Pharmacological Therapy • Environmental Controls • Patient/Family Education Asthma Disease State Management: IT*"' Establishing a Partnei^hip "-— '-1*1 * NAEPP Guidelines are discussed within each! program This is accredited for CRCE Respiratory Therapists and CEU Nursing credits. Varying state licensure laws apply. I Objectives: • Understand the asthma disease process • Know • Classify asthmatic patients using the • Know • Identify potential environmental hazards • Outline the steps in asthma self which procedures are essential to the assessment and diagnosis of asthma new guidelines the various categories of asthma medications and when them to use management Supported by unrestricted educational grants from Monaghan Medical Corporation and the AARC ORDER FORM AARC Member Add $8 shipping SEND ME Price — $79.95 Nonmember Price — $109.95 & handling COPY(IES) CREDIT CARD [] MASTERCARD CARD NO. [ ] IN for THE TOTAL $5 each additional AMOUNT VISA EXPIRATION DATE . . first set, OF set. $ PURCHASE ORDER NO. / . SIGNATURE [REQUIRED] NAME AARC MEMBER NO. COMPANY TITLE STREET ADDRESS [NO P.O. BOX]. STATE CITY TELEPHONE NUMBER COUNTRY ZIP [ ] Mail or fax order form to: Daedalus Enterprises, 1 1030 Abies Lane, Dallas, Texas 75229 Texas customers only, please add exempt from sales tax 8.25% Phone Inc. 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[4/98] CODE: MAV-HA vrnrnrn--?* Abstracts The primary outcome after hospital admission. measures were length of hospital stay, time to admission to first consideration of the diagnosis (suspicion interval), first consideration and treat- recovery, and frequency of salbutamol nebuli- ment zation from 24 h after admission to discharge. sion and treatment initiation (overall Secondary outcome measures were treatment ment and patient side-effects (tremor, palpitations), Length of hospital stay was reduced satisfaction. in those patients allocated to (geometric mean (GM) salbutamol (GM 3.7 days) versus regular same Time taken 4.7 days). expiratory flow to reach the p.m. salbutamol 75% for of recent best was number of times nebulized therapy was delivered to the (GM regular treatment group p=0.003; GMs less 95% (GM 14.0, range 4-57; confidence interval for ratio of 1.29-3.09). In addition, patients reported tremor (p=0.062) and fewer palpitations (p=0.049) in the p.r.n. group. who had the p.r.n. group Of the patients in received regular nebulized therapy on previous admissions all p.r.n. 1-30) compared with the 7.0, range (n= 12), preferred the p.r.n. regimen. Prescribing fi2- agonists on a p.r.n. basis from 24 h after hospital admission amount of drug effects, is associated with reduced delivered, incidence of side- and possibly length of hospital stay. This has implications for the efficient use of 1 kg 1 . in the combined-treatment group (P<0.05). Weight gain at seven weeks was significantly less in the combined-treatment group than in the bu- defined as intervals longer than 24 hours. RE- propion group and the placebo group (P<0.05 SULTS: The for both comparisons). interval) management overall dian. 6 days [5th [95% 68.9% CI, terval (median, 1 1 to 80.9%]). (26.6% 20.5% cations. Seventy-nine subjects stopped treatment The suspicion in- 54 pain to 32.7%]), and the and 51 days]) was prolonged in because of adverse events: 6 in the placebo group 16 in the nicotine-patch group (3.8 percent), 29 (6.6 percent), in the verse events were insomnia and headache. CLUSIONS: Treatment bupropion alone or respectively. smears The 55 24.1%) of to patients with were positive for acid-fast that bacilli had a median treatment interval of 3 days (5th and 33 days); and 95th percentiles, of patients (CI, 45.2% to 71.2%), exceeded 24 hours. than delays CONCLUSIONS: Delays common in the initial suspicion of tubercu- Both types of delays were in ad- CON- with sustained-release combination with a nicotine patch resulted in significantly higher long- term rates of smoking cessation than use of Ab- either the nicotine patch alone or placebo. stinence rates were higher with combination therapy than with bupropion alone, but the dif- was not ference statistically significant. this interval of treatment were more in initiation losis. 58.2% in (1 1.9 common group (11.4 percent). The most management delays of more than 10 and 25 days occurred in 33.5% (CI, 27.0% to 40.0%) and 18.7% (CL 13.3% bupropion group percent), and 28 in the combined-treatment 130 patients (64.0% [CI, 57.4% to 70.6%]). Overall patients, subjects 1 52 patients (74.9% treatment interval (median, 3 days [5th and 95th percentiles, of 31 total (34.8 percent) discontinued one or both medi- 1 day [5th and 95th percentiles, [CI, A and 52 and 16 days]) exceeded 24 hours tients (me- interval and 95th percentiles, days]) exceeded 24 hours in in patients healthcare resources. manage- group, a gain of 1.7 kg in the bupropion group, and a gain of were determined. Delays were There was a highly in both groups. significant reduction in the group peak and admis- initiation (treatment interval), in the nicotine-patch common even Oxygen Treatment on Heart Rate Abdominal Surgery Rosenberg-Adam- Effect of — after sen S, Lie C, Bernhard A, Kehlet H, Rosenberg with disease that was confirmed by J. Anesthesiology 1999;90(2):380. a positive smear. These data illustrate a need Human Lung Volumes and that Set Them— Leith the Mechanisms DE, Brown R. Eur Re- spirJ 1999;13(2):468. Definitions of mechanisms human that .set improved education of physicians about the benefits of early initiation of therapy for tuberculosis. lung volumes and the them are reviewed in the context of pulmonary function testing, with attention to the distinction between functional residual capacity for (FRC) and the static relaxation A BACKGROUND: common may be the respiratory system, circumstances ume in which FRC and propion, a Nicotine Patch, or Both for Smok- — ing Cessation Jorenby DE. Leischow SJ, Nides MA, Rennard SI, Johnston JA, Hughes AR, et al. N Engl J Med after operation cial effect and residual vol- BACKGROUND AND METHODS: Use of nic- mechanisms. Related terms, conventions, and We some common sant bupropion helps people stop smoking. conducted a double-blind, placebo-controlled at- comparison of sustained-release bupropion (244 tention to "gas trapping", "hyperinflation", and subjects), a nicotine patch (244 subjects), bu- semantic and conceptual difficulties, with propion and a nicotine patch (245 subjects), "restriction". and placebo Delays in the Suspicion and Treatment of Among Hospitalized Patients — Rao VK, lademarco EP, Eraser VJ, Kollef MH. Ann Intern Med tion. ( 1 60 subjects) Smokers with bupropion (150 as well as eight Despite increased awareness of tuberculosis, delays in management are com- for smoking cessa- clinical depression were excluded. Treatment consisted of nine weeks of mg a mg days, and then 150 1999;130(5):404. BACKGROUND: METHODS: The saturation and heart rate. oxygen saturation and heart (21 mg mg day for the three first twice daily) or placebo, weeks of nicotine-patch therapy per day during weeks 2 through 7, 14 per day during week 8, and 7 mg per day double blindly allocated to receive after or oxy- and fourth day major abdominal surgery. RESULTS: The median arterial oxygen saturation significantly from and the heart rate 85 beats/min to 8 ing air first gen therapy between the 96% to 99% rate increased (P < 0.0001) decreased significantly from 1 beals/min (P < 0.0001 the lowest rate oxygen saturation or the highest heart values before oxygen supplementation. Overall, tients 73% of this unselected group of pa- responded with decreased heart ing supplemental rate dur- oxygen therapy. No The abstinence percent in the placebo group, as compared with patient.s System, a network of eight community and ter- 16.4 percent in the nicotine-patch group, 30.3 between the postoperative day studied. Mis- percent in the bupropion group (P<0.0OI), and CLUSION: tiary-care facilities serving the St. Louis, All 203 in the cant differences in changes in heart rate after months were 15.6 oxygen supplementation were found between the nicotine patch (P<0.0OI). Bames-Jewish-Christian Health System from jects in the placebo 402 to 1996. MEASUREMENTS: Time from age of 2. 1 kg, as 8. group given bupropion and patients with tuberculosis hospitalized in the 1988 signifi- RESULTS: smoking was usually day 35.5 percent air decrease in heart rate occurred in patients with quitting rates at 12 dur- administered by a binasal catheter. The greatest among hospitalized patients with tuberculosis. DESIGN: Retrospective cohort study. SETTING: The Bames-Jewish-Christian Health delays ) oxygen supplementation compared with during week 9) or placebo. The target day for PATIENTS: 100 rate in consecutive unselected patients randomly and mon. OBJECTIVE: To investigate management souri, metropolitan area. au- oxygen therapy on 1999;340(9):685. otine-replacement therapies and the antidepres- Tuberculosis have shown a possible benefi- of oxygen therapy on arterial oxygen to the by dynamic rather than by issues are addressed, including hypoxemia and tachy- thors studied the effect of static are set associated with cardia. Preliminary studies in high-risk patients Controlled Trial of Sustained-Release Bu- arterial volume of Cardiac complications are during the postoperative period and By week 7, sub- group had gained an aver- compared with a gain of 1 .6 kg with or without an epidural catheter or CON- Postoperative oxygen therapy increa.sed arterial oxygen saturation and decreased heart rate after uncomplicated abdominal surgery tients in a con.secutive who unselected group of pa- received routine postoperative care. Respiratory Care • April 1999 Vol 44 No 4 .M^s^îmtJî M\ to cut costs? Improve productivitij? Need lielp implementing protocols? Ri'siiii'amn/ Introducing the University of California-San Diego Respiratory Care Patient Driven Protocols Piilii'iil lli-ivcn ran* I'riirdciils IUniversiiy ol CakkxrM San Dwgo. Respiratory Services UCSD medical directors AARC Clinical Practice Guidelines Developed by using Provides 24 specific protocols in general and critical care includil '"• management secretions '"• extubation '•' oxygen chest percussion and drainage aerosol therapy volume reduction lung surgery '' '•' "' management This manual defines: • HTRODyCIHG how to document the initial ordering process • how to taper/discontinue treatments • the indications • how and standards of care to apply those criteria Additional Benefits: enhance continuity of care • minimize variation in care • realize cost containment • • improve utilization Written with the bedside practitioner in mind, these protocols saved Start savino todaij! 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PROGRAM 1 ASSESSING THE RESPIRATORY PATIENT VIDEOCONFERENCE: FEBRUARY 23 LIVE AM -1:00PMCT 11:30 PROGRAM 4 THE ROLE OF THE DISEASE MANAGER LIVE VIDEOCONFERENCE: MAY 25 11:30 AM PROGRAM -1:00 PMCT OF THE ART MARCH 16 1 1 :30 AM -12:00 NOON CT TELECONFERENCE: JUNE 29 1 1 :30 AM -12:00 NOON CT SEPTEMBER PROGRAM PROGRAM 2 MANAGING THE DISEASE LIVE VIDEOCONFERENCE: TELECONFERENCE: APRIL 27 1 1 AM :30 -12:00 NOON CT LIVE VIDEOCONFERENCE: JUNE 22 11:30 AM -1:00 OCTOBER PMCT JULY 13 AM LIVE '^ AM - 12:00 NOON CT iSationall} kiioirii /) reset I fe/ s it 'ill -12:00 NOON CT AM I lie opliotidl rideuUipes, 19 -1:00 111(1 1«' il PMCT your NOVEMBER 16 I lie AM topics you're Lire progrotiis. or TELECONFERENCE: :30 focus IN VIDEOCONFERENCE: OCTOBER 1 1 PROGRAM 26 RESPIRATORY DRUGS, MEDICATIONS, AND DELIVERY DEVICES 11:30 :30 PMCT PROGRAM 8 NEW DEVELOPMENTS TELECONFERENCE: 1 1 28 -1:00 oil 5 COPING WITH THE PEDIATRIC RESPIRATORY EMERGENCY MARCH 23 11:30 AM- 1:00 PMCT AM of respiratory diseases TELECONFERENCE: 11:30 ASTHMA: and treatment VIDEOCONFERENCE: 11:30 TELECONFERENCE: 7 PEEP: THE STATE LIVE siioui.D ATTKND: -12:00 easy for sUi/J lo (ic(piire credits tliey iieea NOON CT irliile lecirtiitig 3 VENTILATORS AND THEIR MANAGEMENT PROGRAM 6 THE LATEST WORD IN THE TREATMENT OF COPD PROFESSOR'S ROUNDS is a profexsionallr produced, aboiii the topics they're interested in. educational broadcast LIVE VIDEOCONFERENCE: AM 11:30 LIVE VIDEOCONFERENCE: AUGUST APRIL 20 -1:00 PMCT 11:30 AM scries that presents the topics 24 -1:00 PMCT TELECONFERENCE: TELECONFERENCE: MAY SEPTEMBER 1 1 18 :30 AM -12:00 NOON CT 1 1 :30 21 AM - 1 2:00 NOON CT Approved for Nursing CEUs AND Respiratory Therapist CRCEs! your peers and requested. staff DONTWAIl TO have Henowned experts Ki:cisn:K...ih< have been chosen to speak on each topic. nrouiam hVbriiary 23 liisi O O CRCE APPROVED APPROVED CEU Unrrvl airi .. . . . . . . ^m- 1999 Prdfessdrs Rounds REGISTRATION b register, please complete the following form. number and we )urchase order will Include your invoice you, or you (972) may 243-2272 before or during a broadcast to receive the teleconference option. 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Dzachowski, PhD, director of education 106-4681 Each session has been approved by the credit hour per program. at the AARC, at (972) By subscribing to the entire series, each viewer can earn a total continuing education credit hours. Whether viewed live, or teleconference (on videotape), participant evaluations and attendance logs must be returned to the AARC no later than 30 days after the given broadcast/teleconference in order of eight to receive credit. AARC for one CRCE Abstracts Endotracheal Intubation, but Not Laryngeal oximetry and capnography affect the outcome Nineteen volunteers yielded 222 matched sam- Mask Airway of anesthetic care. Uncontrollable variables ples. Insertion, Produces Reversible Bronchoconstriction — Kim ES, Bishop MJ. Anesthesiology 1999;90(2):391. clinical studies BACKGROUND: Tracheal intubation frequently results in an increase in respiratory system resistance can be reversed by inhaled that The authors hypothesized that of a laryngeal mask airway would be among and operative procedures by using a patient simulator. patients full-scale We tested the hypothesis that pulse oximetry and capnography shorten the time to diagnosis of insertion ODS: A METH- critical incidents. programmed simulator was to repre- bronchocon- sent a patient undergoing medullary nailing of a insertion of an endotra- fractured femur under general anesthesia and less likely to result in reversible would difficult to generate sta- eliminated the variability bronchodilators. striction than it conclusive data. In the present study, tistically we make in METHODS: Fifty-two (45 men, 7 suffering either malignant hyperthermia, a pneu- women) patients were randomized to receive a 7.5-mm (women) or 8-mm (men) endotracheal mothorax, a pulmonary embolism or an anoxic tube or a No. 4 (women) or No. 5 (men) laryn- siologists mask airway. Anesthesia was induced with 2 microg/kg fentanyl and 5 mg/kg thiopental, and airway placement was facilitated with mg/kg succinylcholine. When a seal to more two groups of equal cheal tube. geal 1 cm than 20 water was verified, respiratory system resistance was measured immediately after airway placement. Inhalation anesthesia was begun with isoflurane centration of 1% to achieve an end-tidal con- for 10 min. Respiratory system resistance was measured again during RESULTS: Among identical conditions. mask airways, system resistance was tients receiving laryngeal respiratory tial pa- < 0.05). P s in the ' The decrease s'' group (P change the anoxic oxygen supply scenario 0.019) with pulse oximetry and capnog- No statistical difference in ' for the other three critical incidents. CONCLU- new approaches monitoring technology. How- SIONS: Simulation may to the study of offer endotracheal tube group based research are impediments to wide-spread 8.6±3.6 cm water x system resistance significant ±7 cm in Evaluation of Volunteers of the VIA V-ABG Resistance was present in patients with endotracheal tubes but not in those with way is Medicare laryngeal mask air- a better choice of airway to minimize — enskow DR, Kern SE. J Clin Monit Comput 1998;14(5):339. VIA V-ABG to allow characterization of clinical ac- The VIA ceptability. OBJECTIVE: To evaluate the VIA V-ABG (VIA Medical Corp.) point-of-care bloodgas and chemistry monitor in healthy human volunteers, with particular emphasis on the measurement ditions vices. Comparison between Some of these instruments, including the V-ABG may device, bedside. gas and chemistry measurements remains an issue that not adequately studied. is KD. Pediatr Pulmonol 1999;27(1):27. There is is common a METHODS: with asthma. in children Good ML, Kubilis P, Westhorpe Comput 1998;14(5):313. OBJECTIVE; Many R. J Clin Monit studies (outcome, epide- miological) have tested the hypothesis that pulse 406 device were compared with paired 2 agonist therapy observed that sal- matic symptoms as demonstrated by increases in -I- J3 We butamol inhalation significantly improved asth- peak expiratory flow (PEF: I22.37±75.38 Experimental con- PETCO2 = 50±2 mmHg, ETPO, = side effect in adult 2 adrenergic therapy. relation to the clinical responses its 152.59 ±80.29; P ygen < 58.I6±2.31; P P< 1 < 0.001) and venous ox- (Pv,02: tension 40.84±2.67 S, WL, /3 limited information in regard to hypo- VIA V-ABG — Lampotang Gravenstein JS, Euliano TY, van Meurs VIA serve quite well as point- Whether or not any of these devices spiratory rate (RR; Full-Scale Patient Simulator etc.). can substitute for traditional laboratory blood I30±5 mmHg) or isocapnic hypoxia (PETCO, = 42±2, PETO2 45±2 mmHg) in addition to room air breathing. Measurements by the Study Using a due of-care devices to perform certain tests at the tidal Pilot difficult comparison device, population studied, phy on Time A is to several factors (range of values measured, were varied by intermittently subjecting (ET), different studies in- vestigating point-of-care devices Influence of Pulse Oximetry and Capnograto Diagnosis of Critical Inci- device appears to have been published for other point-of-care de- kalemia and volunteers to either isocapnic hypercapnia (end- dents in Anesthesia: V-ABG perform well compared with the results which vs. airway reaction. proficiency were also met device for Na, K, and Hct following administration of of blood gases. CLIA measurements but the range of values was too asthmatic patients on potent bronchodilator, suggesting that revers- A utilizing current Hypokalemia < 0.01). CONCLUSIONS: mask airways. device were clinically acceptable and met minimal performance criteria James SW, Cluff ML, Wells DT, Orr JA, West- tracheal tubes after they received isoflurane, a laryngeal VIA V-ABG by the mask airway decreased rapidly only in patients with endo- the range of blood gas values assessed, blood gas measurements compared with water and for Hct was 2.0 and 0.2, Automated Bedside Blood Gas, Chemistry, and Hematocrit Monitor Bailey PL, Mc- in the laryngeal ible bronchoconstriction and Hypokalemia and Salbutamol Therapy in Asthma— Hung CH, Chu DM, Wang CL, Yang use of this tool. mask airway group. in respiratory was highly the lack of s) for s vs. the resources required to perform simulator- the endotracheal tube group of 4.7 X r' X = (median of 432 cm in the laryngeal ' >480 (p of 91 of the subjects, time to diagnosis significantly shorter ever, the limitations of current simulators and but remained unchanged at 9.1 ±3.3 r' X s critical in- Each anesthetic procedure was videotaped. The time to correct diagnosis was measured and analyzed. RESULTS: Based on was .0 0.1 CONCLUSIONS: Over 5.4. narrow cidents. analy,sis 1 was fur- After 10 min of isoflurane, the resistance decreased to water x 1' x one of the four to K for by the time to diagnosis was obtained between groups ' X 1' X s'; Each anesthesiologist was randomized PO2 was to signifi- 1 ter ther (±2 sd) for pH was PCOj was 0.4 and 4.8, for and 17.0, for Na was -0.3 and 5.2, Bias and precision ocrit. 0.01 and 0.04, for one of raphy than without. than less to one with access pulse oximetry and capnography data and the other without. 134-141 mmol/1 for Na, 3.1- for PO,, mmol/l for K, and 30.0-50.4% for hemat- 4.1 standards. Performance criteria were randomly assigned size, mmHg thirteen anesthe- the ini- among patients with x s endotracheal tubes (9.2 ±3.3 cm water x [mean ± SD] compared with 13.4±9.6 cm wacantly oxygen supply. One hundred The range of values were 7.32-7.61 for mmHg for PCO2, 27.9-184.5 pH, 20.9-51.6 33.24±4.95 36.39±3.78 1 ), and venous vs. 28.62±3. vs. 0.01), clinical scores (CS: .59 ±0.7 vs. 0.001), and decreases in re- 3.59±1.28 12; vs. PCO2 tensions (PvCOj: 34.75±2.31; P < 0.001). Sal- samples and measurements performed by two butamol-induced hypokalemia was correlated ABL with a decrease in RR, and an increase of Radiometers (505 and 500). Analysis of results includes bias and precision plots and and PEF. These findings suggest comparison of results with minimal performance mechanism criteria as established by CLIA. RESULTS: is that the PVO2 same involved in eliciting hypokalemia and bronchodilatation. Respiratory Care • April 1999 Vol 44 No 4 Editorials Can We Rehabilitate the Chest Wall? Thomas A Stedmcm's Medical Dictionary defines "rehabilitation" as restoration of the abihty to function in a normal or near normal manner following disease, noted in a recent rehabilitation larly programs are to relieve dyspnea, improve functional health-related quality of that may life.- benefit patients in grams are emerging, and entific illness, or injury.' As review, the primary goals of pulmonary New symptoms, particu- ability, and enhance modalities of therapy pulmonary rehabilitation pro- this trend reflects increasing sci- knowledge and technology as well as emergence and acceptance of this application MD may techniques benefit patients in The novelty of the report is viewing the chest wall as in may chest wall The well be the source of morbidity for patients with congenital or other deformities such as kyphoscoliosis. Begin et al previously reported reduced compliance of the rib cage in patients with rheumatoid arthritis (com- may pared to normal controls), which contribute to reduced lung volume.-* Can the aging chest wall contribute of rehabili- to morbidity in chronic obstructive of Respiratory Care, Kakizaki on a potentially useful new pulmonary rehabilita- a target of opportunity for pulmonary rehabilitation. The muscles of In this issue pulmonary tion programs. the gradual tation. port Dillard et al's re- rehabilitation pulmonary disease? and diaphragm, and the the chest wall accessory respiratory muscles have for years been an important topic of pulmonary rehabilitation research, so it is modality, "respiratory stretch gymnastics."' This article an intriguing hypothesis that stretching the elastic elements has merit for several reasons, including input from the of the chest wall can improve function and quality of perspective of physical therapists and physiologists as well as rehabilitation and pulmonary clinicians, input international contributor, and, perhaps from an most importantly, suggestion of a novel topic for further study and possibly a clinical breakthrough for pulmonary rehabilitation patients. The tions, report by Kakizaki et al however, and, as the study's considered a preliminary report. life. does have serious limita- I title suggests, should be would classify the report as hypothesis-generating rather than hypothesis-confirming, by which I mean the study does not definitively confirm the hypothesis that the stretching changes the elastic properties of the chest wall. Moreover, the considerable limitations of the See The Original Study on Page 409 present, Kakizaki et al prospectively evaluated the chest circumference, Fletcher's dyspnea classification, and vital capacity methods of study suggest caution in mechanism. At interpreting the results, regardless of the of 22 patients with chronic obstructive pulmonary disease before and after instruction in 5 stretching techniques strongly favor further study instead of immediate I implementation. The design of by randomization the study could be greatly strengthened to a treated or control population, and by blinding the study to both the patients and therapists. Such would minimize the bias of ascertainment, the intended to stretch the rib cage, shoulders, thoracic spine, a design and cervical spine. Patients were instructed to perform stretching 3 times a day for 4 weeks. The main results natural tendency to affirm the question under investiga- include: an increase in upper chest wall expansion and tion. Another suggestion would be in patient measurements and to to establish variability document reduction, and smaller changes in the lower chest wall; several weeks before beginning 12 of 22 patients; and in- remove the possibility of recruiting patients improved dyspnea rating creased vital capacity. pnea ratings appeared in The to patients with the greatest dys- be the most likely to respond. These findings, and the proposed mechanism of improvement, pose a serious and interesting question for further study, and the results might help determine the appropriate sample size for future studies. If properly studied and validated in the future, implementation of these stretching Respiratory Care • April 1999 Vol 44 No 4 stability interventions. This who over would are in the improving phase after an exacerbation. Measurements should certainly be obtained close to the intervention this population, Kakizaki in noted for frequent exacerbations. et al objectively assessed patient adherence to the training regimen one time only, by observing how well the patients could perform the stretching techniques after the intended 4-week training period. This approach ap- 407 We Can pears sound, but I would favor Rehabilitate the Chest earlier or serial objective monitoring, review of a patient diary or other log, by hav- some of ing the patients come stretching. a bit disappointing that 12 patients It is to the clinic for the sets of after involving lung volume reduction surgery.^ It be will interesting to learn if stretch techniques produce an improvement were rated as having poor performance of the stretch techniques Wall? chest wall elastance. in may It be that the stretch techniques increase the range of motion, or maximal extent of displacement, without an AP/AV. This would manifest as an maximal pressure at total lung capacity along with an increase in vital capacity. Looking for this effect would also require an estimate of esophageal presassociated change in 4 weeks. The measured parameters could also be improved. The Fletcher dyspnea scale measures dyspnea status with 5 possible discrete choices. Perhaps a more continuous and increase in the To fully evaluate the physiologic effects less discrete scale, such as a visual analog scale or other sure. scale with more choices, would allow detection of subtler changes. Evaluating change in dyspnea or dyspnea during a fixed challenge, in addition to current dyspnea status, stretching, might be more convincing. cerning dyspnea is A further consideration con- it also seems appropriate to of repeated measure respiratory muscle strength by maximal mouth pressures, by transdiaphragmatic pressure, yet, to or, better determine whether frequent stretching affects strength. In conclusion, the report herein the possible effect of the stretching by Kakizaki et al pre- and an opportunity techniques to increase upper extremity strength or fitness. sents excellent food for thought Patients with severe chronic obstructive pulmonary dis- review current concepts of respiratory mechanics and dys- ease report a marked increase in the sensation of dyspnea pnea. with unsupported arm elevation.'^ Because of testing and advancing the stretching regimen involves upper extremity maneuvers, dyspnea may have improved due to training of the upper extremities. A measure of upper quantitative might be necessary A The authors and readers should take up the challenge this and quality of extremity strength or fitness A of dyspnea patients. Pulmonary and on the topic of dyspnea involves the role of chest wall afferent nerve firing. life Thomas A to control for this possibility. final consideration hypothesis in pursuit of more dyspnea and improving the func- effective treatment of tional capacity to Critical MD Dillard Care Service Madigan Army Medical Center Tacoma, Washington previous study using in-phase chest wall vibration suggested that on respiratory sensation are mediated by afferent It would effects REFERENCES information from chest wall respiratory muscles.^ be very interesting to find out whether stretching the chest wall could change afferent information, and might how however, such an experiment might require last; animal preparations to be conclusive. anoreceptor mechanism is at 1. long this this mechmechanism 2. Mahler DA. Pulmonary 3. not require a change in chest wall mechanics to ben- Kakizaki may techniques 4. 5. Confirming this hypothesis would be worthwhile, ance. That of the total the reciprocal of compli- and chest wall Breslin rib cage of rheumatoid patients. Lung 1988:166(3):141-148. EH. Dyspnea-limited response in chronic obstructive pulmo- 7(1): 12-20. Sibuya M. Yamada M, Kanamaru A. Tanaka K. Suzuki H. Noguchi E. et al. Effect of chest wall vibration on dyspnea in patients with chronic respiratory disease. Am J Respir Crit Care Med 1994:149(5): is all of us from monitoring ventilated patients. obtain a measurement of chest wall elastance requires partitioning of the total respiratory system elastance into pulmonary disease. Respir Care 1999: 44(4):409-414. Begin R, Radoux V. Cantin A, Menard HA. Stiffness of the 1 6. elastance represents "stiffness." Compliance respiratory system, lung, Homma 1235-1240. familiar to To is, is Shibuya M, Yamazaki T. Yaniada M, Suzuki H, nary disease: reduced unsupported arm activities. Rehabil Nurs 1992; but difficult. Elastance, defined as pressure change over volume change (E = AP/AV) F, in a subset decrease elastance (increase compliance) of the chest wall. 1998:113(4 Preliminary report on the effects of respiratory muscle stretch tive et al speculate that the stretching rehabilitation (review). Chest gymna.stics on chest wall mobility in patients with chronic obstruc- efit the patient. Kakizaki Wilkins. Balti- Suppl):263S-268S. 1. may & more: I972;p 1086. If the afferent work, then Stedman'.s Medical Dictionary 22nd ed. Williams its 2 components: lung and chest wall. To do this in 7. Jubran A. Laghi F. Mazur M, Parthasarathy S. Garrity PJ. and ER Jr. Fahey Tobin MJ. Partitioning of lung and chest-wall mechanics before after lung-volume-reduction surgery. 1998: 58(0:306-3 1 Am J Respir Crit Care Med 10. mechanically ventilated or spontaneously breathing patients requires obtaining an estimate of pleural pressure, such as esophageal pressure. Fortunately, the techniques for measuring lung mechanics, including static and dynamic chest wall elastance, have recently been reinvigorated by studies 408 The views expressed herein reflect only the views of the author and are not the official views of the Department of the Army or the Department of Defense. Respiratory Care • April 1999 Vol 44 No 4 Original Contributions Preliminary Report on the Effects of Respiratory Muscle Stretch Gymnastics on Chest Wall Mobility in Patients With Chronic Obstructive Pulmonary Disease MD PhD, Tsutomu Yamazaki PT PhD, Suzuki MD PhD, and Ikuo Homma MD PhD Fujiyasu Kakizaki PT, Masato Shibuya Minehiko Yamada MD PhD, Hajime gymnastics (RMSG) on chest wall pulmonary function, and dyspnea in daily living in patients with chronic obstructive pulmonary disease (COPD). PATIENTS AND METHOD: The subjects were 22 consecutive COPD patients who were regularly treated in the outpatient clinic of a medical university rehabilitation hospital. The patients did not have severe limitations in the range of movement in the shoulders, and were unfamiliar with RMSG. Chest wall mobility (difference between chest circumference during deep expiration and deep inspiration), pulmonary function test (forced expiratory volume in 1 s [FEV,] and vital capacity), and dyspnea in daily living (Fletcher's rating) were measured before and after 4 weeks of RMSG. Four RMSG patterns were demonstrated to each patient to ensure that they could perform the gymnastics without assistance. The patients were instructed to perform each pattern four times during each session (3 sessions per day) for 4 weeks, at which time, the patients were asked to return for re-evaluation. RESULTS: Chest wall expansion and reduction increased at both the upper (0.8 ±0.2 and 1.3 ± 0.2 cm, respectively) and lower (0.4 ± 0.2 and 0.7 ± 0.2 cm, respectively) chest walls. Vital capacity increased 119 ± 43 mL, while FEV, remained unchanged. Fletcher's rating improved in 12 patients and remained unchanged in 10; it did not worsen in any of the 22 patients. CONCLUSION: RMSG increases chest wall mobility, possibly by reducing chest wall elastance in patients with COPD. [Respir Care 1999;44(4):409-414] Key words: Chronic ob- OBJECTIVE: To examine the effect of respiratory muscle stretch mobility, structive pulmonary disease, COPD, respiratory muscles, pulmonary function, pulmonary rehabilitation, dyspnea. ing treatment of anxiety or depression, smoking cessation, Background nutrition intervention, At present, respiratory rehabilitation programs may include education, lower and upper extremity exercise training, and other modalities.' The goals of improved health- rehabilitation include relief of dyspnea, related quality of life, and increased functional capacity. and psychosocial and behavioral components, includ- See The Related Editorial on Page 407 Mr Kakizaki and Dr Yamazaki are affiliated with the Department of Rehabilitation. Fujigaoka Rehabilitation Hospital, and Drs Suzuki Yamada are affiliated with the Fujigaoka Hospital. Japan. Mr Showa and Department of Respiratory Medicine. University School of Medicine. Yokohama, Kakizaki and Drs Shibuya. Yamada. and Homma are affiliated Showa University School of with the Second Department of Physiology. Medicine. Tokyo. Japan. Mr Kakizaki the Department of Rehabilitation, is However, respiratory rehabilitation of patients with chronic obstructive pulmonary disease (COPD) is evolving, partly because the pathology of COPD, especially the dyspnea, is not fully understood. Afferent activity from the chest wall also currently affiliated with Toyosu Hospital, Showa University, Tokyo. Japan. Correspondence: Grant support: Pollution-Related Health Damage Compensation and vention Association, Japan. Respiratory Care • April 1 999 Vol 44 No 4 Pre- Mr Fujiyasu Kakizaki. Second Department of Physiol- Showa University School of Medicine. l-.'>-8 Hatanodai. gawa-ku. Tokyo 142-8555, Japan. E-mail: Ka596.^@'tt. rim.or.jp. ogy. Shina- 409 9 Respiratory Muscle Stretch Gymnastics may respiratory muscles pneic sensation.2 which elastance,"^ may * Measurements increased often observed in clinical practice, is an increase elicit play a role in modifying the dys- A stiff chest wall or one with in muscle spindle from the firing noncontracting intercostal muscles*' and could be responsible, in part, for the dyspneic sensation.^ Chest wall expansion and reduction were measured according to the standard method." In brief, a was asked patient A new component of respiratory rehabilitation programs, called respiratory muscle stretch gymnastics (RMSG),^"^ the patient for the An immediate increase in forced vital capacity (VC) (from 1807 ± 141 to 1923 ± 145 mL) in 34 patients^ and a decrease in functional residual capacity (from 4. 19 ± 1.27 to 3.88 ± 1.03 L) in 12 patients after 4 weeks" have been reported as a result of RMSG. Other clinical benefits patient dyspnea at rest quality of life, and after a RMSG tape was was drawn much as possible while and chest circumfer- taut ence was measured (El); then the tape was released, and the chest wall muscles, and to decrease chest wall elas- of short-term^ and long-term" to breathe out as the measuring tape has been designed to stretch the respiratory muscles, mainly tance. flat placed around the patient's chest, and with arms down, the the was asked to breathe in as deeply as possible next measurement (I; ie, deep inspiration). The was again asked to breathe out as far as possible for final measurement (E2). Measurements were done at and the xiphisternum the axillary level (upper chest wall) include decreased Each measurement was repeated twice, and the average value was used. All patients also underwent spirometry before and after 4 weeks of RMSG. improved Testing and quality control followed standard and recom- 6-min walking test, prolonged 6-min walking distance, and de- level (lower chest wall). mended procedures.'^ creased residual volume, total lung capacity, and residual volume/total lung capacity. Protocol has been suggested that reduced chest wall mobility It is associated with a decrease in lung function and exercise endurance.'" It is possible that RMSG increases VC and Chest wall mobility was measured before rometric values obtained when the patients RMSG. were Spi- in a stable exercise endurance by reducing chest wall elastance, caus- condition during routine clinical follow-up within a few ing increased chest wall mobility. Chest wall expansion months before RMSG were used as the pre-RMSG values. Dyspnea was rated according to Fletcher's classification'"* before RMSG. The 4 RMSG patterns^ were demonstrated and reduction have been used by physical therapists to measure chest wall mobility." Herein, we report our pre- RMSG liminary clinical experience with from a physical therapist's point of view, with particular reference to the effect on chest wall mobility, dyspnea, and spirometry. to each patient to ensure that they could perform the gymThe exercises, described below, nastics without assistance. were each done 4 times in a specified order. Patients Methods 4 weeks of Subjects — RMSG, an independent evaluator observed each patient to determine their The The subjects (Table ) were 22 consecutive patients ( men, 3 women; mean age, 73.4 ± 1.0 years [range, 621 1 81]) with COPD but without severe movement in the shoulders. treated as outpatients at habilitation Hospital. The Showa COPD were — one in do 3 sessions of exercises per day for 4 weeks. After the morning, afternoon, and evening instructed to limitations in range of subjects were regularly University Fujigaoka Re- was diagnosed and results of this evaluation perform RMSG. were not revealed until all ability to other measurements and ratings (ie, chest wall mobility, We inquired as RMSG but did not spirometry, and dyspnea) were completed. to the patient's compliance to perform ask for quantitative ratings. All patients stated that they had high compliance. rehabili- was indicated according to standard criteria.'- All were in stable condition while receiving standard medical treatment prior to RMSG. Theophylline was used tation Respiratory Muscle Stretch Gymnastics patients agent was used in 12, and steroid was used in 8 patients. 1. Elevating and Pulling Back the Shoulders and Stretching the Upper Chest. Slowly breathe in through There was no change the nose while gradually elevating in 20, a j3-2 period. The stimulant was used in in 1 1 , an anticholinergic medication during the observation patients did not have any other significant disease, such as unstable cardiac disease or acute infec- Pattern and pulling back both shoulders. After taking a deep breath, slowly breathe out through the mouth, lower the shoulders, and relax. tious disease; all patients willfully participated in the re- program and gave informed consent. The pawere unfamiliar with the effect of RMSG on dyspnea. habilitation tients The protocol was approved by ics Committee. 410 the Showa University Eth- Pattern 2. Pulling Down and Stretching the Upper Chest. Place both hands on the upper chest. Pull back elbows and pull down chest while lifting the chin and inhaling deeply through the nose. Expire slowly through the mouth and relax. Respiratory Care • April 1999 Vol 44 No 4 Respiratory Muscle Stretch Gymnastics Table 1. Patient Patient Profiles for 22 Patients with Chronic Obstructive Pulmonary Disease Respiratory Muscle Stretch Gymnastics V.T- B x: Ml'*: c E Respiratory Muscle Stretch Gymnastics O to D g before after of good performance (n=10) RMSG 4 weeks RMSG poor performance (n=12) Mean ± SE of the expansion in upper chest wall before and 4 weeks of respiratory muscle stretch gymnastics (RMSG) in patients with good and patients with poor RMSG performance. Fig. 3. after VC 4 - FEVi Respiratory Muscle Stretch Gymnastics ACKNOWLEDGMENTS and limited chest expansion. Bull Eur Physiopathol Respir 1985; 21(4);36.3-368. We thank Drs Arata Kanamaru (Second Department of Physiology, Showa 1 University School of Medicine) and Toyosu Hospital. Internal Medicine, icine) for their helpful comments. 1. Kazumasa Tanaka (Department of Showa University School of Med- We also thank Ms Wakako Anderson JM. Assessment of chest function by the physiotherapist. In; Downie PA, Innocenti DM. Jackson SE, editors. Cash's textbook of chest, heart and vascular disorders for physiotherapists. Philadel- Ihara for JB phia; her help in the preparation of this manuscript. 12. Lippincott; 1987:318-324. American Thoracic Society. Standards patients with chronic obstructive REFERENCES 1. Mahler DA. Pulmonary Chest 1998:113(4 Suppl): rehabilitation. 1 3. 3. Homma I, Obata T. Sibuya M, Uchida M. Gate mechanism in breathJ Appl Physiol Manning HL, Basner R, Ringler J, Rand C, Fencl V, Weinberger SE, 15. PC, Fairbairn AS, Appl Physiol 1991;71(1):175-181. Wood CH. The significance 16. Effect of chest wall vibration on dyspnea in patients with Cherniack Am J Re.spir Crit Care Med A, Compliance of the chest wall emphysema. bronchitis and J in chronic (Lond) 1988:400:101-1 I. 11. A, Tanaka K, Suzuki H, Altose Showa Univ Kanamaru A, Sibuya M, Nagai J T, Inoue K, Med I, Stretch up, massage, J, GillquLst J. Effects of and stretching on range of motion and muscle Am J Sports Med 1983;1 1(4):249- Randomized cross-over comparison between respiratory mu.scle stretch gymnastics and inspiratory muscle training (abstract). Am gym- Kaneko M, editor. Fitness worker. Champaign, IL: Human recommendations. Fujinaga H, Miyagawa T, Kokubu F. Respiratory Muscle Conditioning Group. Sci 1996:8:63-71. Homma ATS 252. Benefits of respiratory muscle stretch gymnastics in chronic respiratory disease. Wiktorsson-Moller M, Oberg B, Ekstrand strength in the lower extremity. 18. MD, Homma Appl Rev Respir Dis 1981:123(6);659-664. warming Appl Physiol 1963:18:707-711. Yamada M, Shibuya M, Kanamaru J Crapo RO. Morris AH, Gardner RM. Reference spirometric values Am Edin BB. Vallbo AB. Stretch sensitization of human muscle spindles. J Physiol De Troyer A. Rib cage and diaphragm- humans: effects of age and posture. using techniques and equipment that meet 1994; 149(5): 17. RM, Hodson in in a 1959:2:257-266. J Physiol 1985;59(6):I842-1848. Sibuya M. Yamada M, Kanamaru A, Tanaka K, Suzuki H, Noguchi al. Med Estenne M, Yernault JC. abdomen compliance Effect of chest wall vibration on breathlessness in normal 123.5-1240. 8. Amer- working population. Br chronic respiratory disea.se. 7. CM, Elmes Fletcher J Rev Respir Dis 1987;136(5);1285-1298. I984;56(l):8-n. E, et 6. Am of respiratory symptoms and the diagnosis of chronic bronchitis subjects. J 5. Standardization of spirometry; 1987 update. Statement of the lessness caused by chest wall vibration in humans. et al. 4. 14. Am 1995:152(5 Pt 2):S77-S120. ican Thoracic Society. 26.3S-268S. 2. Med Respir Crit Care and care of for the diagnosis pulmonary disease (review). 19. J Respir Crit Care Killian KJ. Med 1997;155:A45I. Gandevia SC. Summers E. Campbell EJM. Effect of nastic training in asthmatic children. In: for the aged, disabled, and industrial increased lung volume on perception of breathlessness. effort, and tension. Kinetics: 1990:178-181. 9. Yamada M, K, Kakizaki F, Shibuya M, Nakayama H. Tsuzura Y, Tanaka et al. [Clinical effects gymnastics in patients in 10. RM. 414 CG. Hill in with chronic obstructive pulmonary disease.] 21. TR, Adams TE, Crapo RO, Nietrzeba RM. Gardner Exercise performance of subjects with ankylosing spondylitis Hagglund JV. Nordin M. Wallin EU. Thixotropic spindle and reflex responses to stretch. J Physiol (Lond) 1985; 368:323-342. (Article Japanese.) Elliott Appl Physiol 1984:57(3):686-691. behaviour of human finger flexor muscles with accompanying changes of four weeks of respiratory muscle stretch Nippon Kyobu Shikkan Gakkai Zasshi 1996:34(6):646-652. J 20. Hagbarth K-E. Ribot-Ciscar E, Tardy-Gervet tion changes sensitivity. in human MF, Vedel JP, Roll JP. Post-contrac- mu.scle spindle resting discharge and stretch Exp Brain Res 1991;86(3):673-678. Respiratory Care • April 1999 Vol 44 No 4 Severe COPD Patients Mechanical Ventilation Long-Term Tracheostomy MD, Enrico Clini in MD, Luca Bianchi and Nicolino Ambrosino Michele Vitacca MD, Weaned from MD, Roberto Porta MD BACKGROUND: Chronic obstructive pulmonary disease (COPD) patients wiio suffer from acute respiratory failure (ARF) requiring meclianical ventilation are at risk of relapse. It is unknown whether spontaneously breathing patients benefit from retaining a tracheostomy after discharge from the intensive care unit. We studied the effects of long-term (6 months) tracheostomy in severe COPD patients weaned from mechanical ventilation. METHODS: Twenty tracheostomized COPD patients recovering from ARF and weaned from mechanical ventilation were randomly allocated into 2 groups: 10 patients were maintained on tracheal cannula; 10 patients had the tracheal cannula removed (cutaneous fistula spontaneously closed). Breathing pattern, forced lung volumes, 1, 3, and 6 and number of new exacerbations re- respiratory muscle force, and arterial blood gases were evaluated at discharge and at months after discharge. Hospitalized days, mortality rate, quiring antibiotics were recorded. Maximal expiratory pressure (but not other lung function parameters) significantly improved in both groups. In both groups, 2 out of 10 patients died due to respiratory causes after 5.0 ± 0.8 months after discharge. During the follow-up period, exacerbations were significantly greater in the tracheostomized patients than in those whose tracheostomies had been removed before discharge, though there was no significant difference in hospitalized days between the 2 groups. CONCLUSION: Chronic tracheostomy in severe COPD patients is associated with a higher frequency of exacerbations requiring antibiotic treatment. Unless there are absolute indications for tracheostomy, COPD patients weaned from mechanical ventilation should undergo early decannulation. structive pulmonary [Respir Care 1999;44(4):415-420] A'n' words: respiratory failure, chronic ob- disease, meclianical ventilation, airway infection, weaning, decannulation. tracheostomy-related inadequate airway humidification^ Introduction may Prolonged mechanical ventilation is through a tracheostomy.' Although an usually delivered artificial airway is often maintained in place because of swallowing dysfunction, inability to clear secretions, or continuous need for mechanical ventilation,'- the appropriate time for tracheostomy removal latter conditions weaning and in the absence of the debated.^ Tracheostomized patients can after is adversely affect cough reflex and mucociliary clearance. This problem is even more complex in patients with chronic obstructive pulmonary disease (COPD), and patients suffering acute respiratory failure mechanical ventilation are at risk (ARF) requiring of relapse.*'' Therefore, despite the aforementioned potential complications of long- term tracheostomy, tracheostomy in it is conceivable that maintaining a spontaneously breathing patients after dis- from chronic infections and increased secretions charge from the intensive care unit (ICU) can avoid re- such that they frequently need suction. Patients on long- peated tracheostomies and perhaps improve convalescence. suffer term ventilation can be at increased risk of infection," and We conducted a prospective, randomized, controlled study to evaluate the effect (on both course and outcome) of maintaining a tracheal cannula in discharged spontaneEnrico Clini MD, Michele Vitacca MD, Luca Bianchi MD, ously breathing severe COPD patients. Roberto Porta MD are affiliated with the Fondazione S MD. and Nicolino Ambrosino Maugeri IRCCS Lung Function and Respiratory Intermediate Intensive Care Units, Medical Centre of Gussago, Gussago (BS), Correspondence: Enrico Clini Pinidolo, 23; 1-25064 MD, Fondazione S Maugeri IRCCS, Via Gussago (BS), The study was approved by the Ethical the Medical Center of Gussago, S Italy. Respiratory Care • April 1999 Vol 44 Methods Italy. No 4 Committee of Maugeri Foundation 41.'^ . Long-Term Tracheostomy Table 1 . in Severe COPD Demographic. Anthropometric and Last Stable Functional RIICU Characteristics of Patient Population an uncuffed tracheal cannula with an expiratory valve that Group Parameter 1 Group 2 p-value + ns admission, after which patients breathed through allowed them to speak and cough efficiently.* The study inclusion Age, years Sex, ±6 71 M/F ± 6 ± 210 25 mL 737 mL FVC, 40± 27 155 TLC, %pred 144 MIP, %pred 38 MEP, %pred 50 ± ± ± ± (mm Hg) (on oxygen) R,o,. {mm Hg) (on oxygen) Pao,/Fio, (mm Hg) 51 ±6 Paco;- 1154 41 153 ± ± 61 ± 57 ± 76 ± 2,53 ± 146 31 36 7 23 70 ± 7 2.54 % ± 0.27 40 ARF. Previous ns 11 RV, %pred LTOT, ± 15 ±415 ± 19 ± 30 no./year* 0.5 ± spon(2) no of infection (leukocytosis, fever, or radiographically-identifiable pulmonary infiltrates), (3) gens ns less than 2 X imen obtained via ns 10"^ by tracheal bacterial patho- cfu-mL"' on a culture strain (spec- fiberoptic tracheobronchoscopy), (4) no ns current need for antibiotics, and (5) no change in drugs or 36 ns in 6 ns oxygen requirement during Study exclusion the last 7 days. criteria were: (1) conditions indicating 13 ns an absolute need for maintaining tracheostomy, such as 9 ns swallowing or vocal cord dysfunction, obstructive tracheal 12 ns 0.40 ns lesions (granuloma or stenosis, as assessed by fiberoptic tracheobronchoscopy), or inability to spontaneously clear <0.01 ± 0.8 48 consecutive hours, ab.sence of infection as defined 70 0.7 criteria were: (1) unassisted at least clinical or laboratory sign ns ns 24 ± 413 1271 FVC, %pred ± 4 22 taneous breathing for ns 557 ± 225 30 ± 10 FEV|, %pred 8 8/2 8/2 BMI FEV,, 67 secretions, (2) systemic diseases, (3) cancer, and (4) inad- ns 1.1 equate self-care or familial assistance. Group 1: cannula retained. Group forced expiratory volume TLC = total in = = FVC - BMI - body mass inspiratory pressure; oxygen: LTOT = arterial long term oxygen therapy; percent of predicted value. *Previous ARF FEV, = index; RV = forced vital capacity: carbon dioxide tension; Pyo, - arterial fraction of inspired failure: >? pred cannula removed. MIP = maximal lung capacity: pressure: P;,cni 2: one second: residual volume: MEP Measurements - maximal expiratory oxygen tension; F|o, - ARF = Breathing pattern acute respiratory data calculated on the 2 years (tidal volume [V-p|, respiratory rate and minute ventilation [V^]), and forced lung volumes (forced expiratory volume in second [FEV,] and forced [f], preceding the study. 1 capacity [FVC]) were measured with a portable spi- vital rometer and compared with the values predicted by Quan- IRCCS, and was conducted according to the Declaration of Helsinki. Patients gave their informed consent to participate in the study. The jer." was assessed by measuring maximal inspiratory pressure (MIP) and max- (MEP) imal expiratory pressure module system, spiratory Patient Population measurements were considered best values of 5 for analysis. Respiratory muscle strength tional residual capacity (in We studied 20 patients with severe by the American Thoracic Society recovering from termediate ARF COPD (as defined who were guidelines**) and admitted to our respiratory ICU (RIICU) incomplete the weaning process to from prolonged mechanical Demographic, an- ventilation. described by Black and Hyatt.'- 1 All of the patients were severely obstructed and hyperinflated. Their regular medical treatment consisted of inhaled bronchodilators. Eleven patients were on long-term oxygen therapy, none were on domiciliary mechanical ventilation, but 12 of the 20 patients had experienced noninvasive positive pressure ventilation for acute exacerbations of their disease before the study. All of them had been transferred from ICUs of other hospitals, had undergone a percutaneous tracheostomy invasive mechanical ventilation days. Causes of in 54% and 46% tients ARF 1 5 ± 3 days, was prolonged for 25 a et al.'^ Patients 1 performed consecutive maneuvers minute interval between efforts) able values differing by < 5% until 2 accept- were obtained. The best value was recorded. Spirometry and respiratory muscle function were measured through a mouthpiece while the cannula was closed with a cap. Arterial blood was sampled at the radial artery with the patient in the sitting position and while breathing a fraction of inspired oxygen (F|qJ that maintained arterial oxygen saturation at s 90% for s 1 hour. Arterial oxygen tension (Pj.o,), arterial carbon pH were measured with a and dioxide tension (Paco,)' ^^^ ± Ciba Corning 840 analyzer. Pao/Fio, 5 method ratio was measured were exacerbation'^ and pneumonia of cases respectively. At admission, pa- needed ventilatory assistance for 14 ± 3 hours per was obtained 9 ± 5 days after day. Successful weaning'" 416 after to the visual on-line spiro- the starting level of the maneuver. MEP and MIP measurements were compared with the predicted values of (with Table A trol Bruschi in a re- graphic control during tidal breathing allowed us to con- when shown mouth using from the level of funcmeasuring MIP) and total lung MEP), according capacity (in measuring thropometric, and functional characteristics of the patients in their last stable condition are at the starting * Suppliers of commercial products are identified section end of the at the in the Product Sources text. Respiratory Care • April 1999 Vol 44 No 4 Long-Term Tracheostomy in COPD Severe while patients were receiving oxygen via nasal prongs, and ber of exacerbations requiring use of antibiotics. Mortality F,„, was calculated with the following conversion factor: was assessed by percentage rate. Analysis of variance was used to test differences between and within groups. When- F|(,^ tal = + 21 (3 X oxygen flow in L/min of supplemen- ever necessary, a post hoc oxygen).''' with Bonferroni correction test This procedure was deemed acceptable because the tracheal cannula (with the valve inserted) allowed normal was used to evaluate the contrast between and within groups. oxygen delivery from the nose through the tracheostomy. microbiology before randomization were tested by means During the follow-up, the cumulative number of days spent in hospital due to respiratory causes, the number of of an additional Fisher's exact Differences in frequency distribution of exacerbations and test. A p value < 0.05 was considered statistically significant. exacerbations requiring antibiotic use, and mortality were recorded from the hospital registers and interviews with the patients' general practitioners. Exacerbation of was defined by worsening of symptoms, Results COPD fever, increased purulent sputum requiring changes to normal treatment, short courses of antibiotics, oral steroids, and other bron- Decisions regarding treatment of exacerbation chodilators.''^ and hospital admission were made by the general ner, who was practitio- not aware of the purpose of the study. Demographic, anthropometric and functional character- when in their last stable condition are The groups differed only in the use of long-term oxygen therapy, which was more frequent in the patients of Group 2. Mean duration of RIICU stay was not 16 ± 8 days; Group different between the groups (Group istics of patients shown Table in 1 . 1 Microbiology 19 2: scopic protected specimen brush in both groups, processed with the methods described in Bartlett et al.'^ We used ± 10 days). The course of breathing Cultures were performed on specimens from broncho- respiratory muscle strength, in Table 2. No the groups at any time. was performed in the following agar media: Trypticase soy + 5% Mutton Blood, over time Chocolate II -I- Isovitalex, Mannitol salt, McConkey II, Sabouraud dextrose. All cultures were incubated at 37° C under aerobic and anaerobic conditions and in carbon dioxide-enriched atmosphere. Cultures were evaluated for growth after 24 hours and 48 hours, and, if negative, dis- carded after 5 days. Bacterial agent colonization was defined as the isolation of a potential pathogen in culture, in the absence of signs or symptoms of lower respiratory tract infection."*''' within 1 hour sputum Samples were transferred to the laboratory. All the potential isolated in patterns, forced lung Only both groups (p over time did not change < Pac^Fio, ratio also 2). Table 3 shows the bacteria species present in the airways before randomization. No significant differences were seen between the groups. The total bacterial growth was similar between groups, the value ranging from 2 X 10^ to X lO"^ cfu-mL~'. One subject of Group 2 had to be restarted on mechanical ventilation with a new tracheostomy because of severe 2 exacerbation 18 days after discharge. died in hospital. Two charge due to of ARF patient ARF requiring were pneumonia 2). the patients ± ICU 0.8 months after dis- admission. The causes (2 patients from Group 1 and 1 and severe exacerbation (I patient One patient from Group underwent ac- from Group from Group None of out of 10 patients (20%) in both groups died after a mean of 5.0 domly assigned to 2 groups: Group Oxygen requirement in either group: remained unchanged (see Table improved significantly 0.005). oratory methods.-" After inclusion criteria were verified, patients were ran- were observed between MEP pathogen micro-organisms were identified by standard lab- Study Design volumes, and arterial blood gases are shown significant differences N-acetylcysteine to homogenize the sputum specimen.''' Inoculation of homogenized sample : 2) 1 (cannula retained) cidental self-decannulation during the follow-up at the 5th and Group 2 (cannula removed and cutaneous fistula spontaneously closed). The retained cannulae were fitted with month; the cannula was not replaced and the fistula closed spontaneously. At the end of the follow-up all the surviv- a valve that facilitates speaking and coughing. Measure- ing patients ments were at at I performed at the time of randomization (TR), the time of discharge (TO), and during the follow-up 1, 3, and 6 months after discharge (Tl, T3, and T6, respectively). from Group 1 were decannulated. The cumulative number of days spent in hospital during the follow-up was not significantly different (Group I: 10.2 ± 9.7 days per patient; Group 2: 4.5 ± 2.7 days per patient). The frequency ing use of antibiotics is distribution of exacerbations requir- shown Figure in 1 . All the patients Statistics from Group Results are mean ± SD. Frequencies were microbiological variables and the num- shown used to describe the Respiratory Care as • April 1999 Vol 44 No 4 1 suffered at least 1 exacerbation during the follow-up, whereas only 5 of the 10 patients in required antibiotic therapy for exacerbations (p < Group 2 0.005). 417 Long-Term Tracheostomy Table 2. Time Course of Respiratory Functional Parameters Variable in Severe COPD Long-Term Tracheostomy in COPD Severe hypothesis. Before entering the randomization, the Group 1 D Group 2 of patients with sputum number positive for potential infectious agents was not significantly different between the groups 6^ (see Table 3). Airway bacterial colonization is common in stable patients with chronic lung disease, as well as in patients with long-term tracheostomy.'**" Bacterial distribution in our sample of patients showed a prevalence of Gram-negative ill 4 3 cumulative number of patients suffering exacerbation. X-axis: < value fre- distribution of exacerbations requiring antibiotics, p 0.005 for differences tested by Fisher's x^ analysis. quency et al,^'* prevalence of Pseudomonas a significant aureus are well-known contaminants of the hospital environment, and colonizing species during mechanical venti- Exacerbations during the 6 months of follow-up. Y-axis; 1. de Latorre aeruginosa. Pseudomonas aeruginosa and Staphylococcus Exacerbations requiring antibiotic use Fig. has been reported in chronically patients.2^ In contrast to the report of we observed 12 strains, as Contamination could easily have been introduced by routine suctioning or humidification, ambi- lation in the ICU.^"' ent air during the weaning trial, a nasal sinus infection, the ventilator circuit, or the tracheostomy cuff. In 49 sets of cultures on 15 subjects with long-term tracheostomy, Niederman et aF^ found that patients with All the patients showed a severe impairment in respirano differences between the 2 groups tory function, with FEV|/FVC despite a slight but not significant difference in mostly due to the small sample ratio size. Follow-up mea- persistent tracheobronchial colonization were more ill and developed tracheobronchitis more often than those without persistent tracheobronchial colonization. A limitation of our study is that there was no microbiological evaluation 2 groups because during the follow-up period. This aspect of data collection However, between was not possible in this case for technical reasons the same bronchoscopic technique used to sample bronchial the 2 groups, taken at discharge after randomization (par- secretions could not be easily applied in the ambulatory surements were taken differently in the of the presence of the tracheostomy in Group was no difference there available data not presented). tial (60%, equally distributed episodes of tilation 1 . in spirometric function Most of in the 2 groups) the patients had experienced ARF treated with noninvasive mechanical ven- during the 2 years prior to the study (see Table The only significant difference the previous use of long-term 1 ). between the 2 groups was oxygen therapy, which was higher in Group 2 (tracheostomy removed). This might constitute Group (tracheostomy retained). were discharged with an uncuffed a bias that favored Patients of Group 1 1 tracheal cannula with an expiratory valve, but without a humidification system. In a previous study,-' significant short-term improvements tion and in tracheal secretions we found in respiratory func- over 10 days by applying a hygroscopic condenser humidifier. It is unknown whether the use of a humidifier might have resulted in improved — and sputum sample is not as reliable a means of sample collection as bronchial brush or bronchoalveolar setting, lavage, a more appropriate means Thus, there was no logical data and way clinical to identify pathogens.^^ to correlate bronchial microbio- outcome in terms of bations during the follow-up. In our study, from Group 1 experienced at least all new exacer- the patients one exacerbation quiring antibiotic use, but only 4 patients from re- Group 2 experienced an exacerbation requiring antibiotic use. This suggests that prolonged tracheostomy plays an adverse role in the management of COPD patients. However, the lack of standardization of antibiotic use and the small population of this study should make us very cautious in interpreting this interesting result. Moreover, the causes of the increased tracheobronchial infection rate in Group 1 mainly on lung hyperinflation and mechanics,^'' MEP better reflects the patient's fitness and is directly related to the unknown. Coughing is an important aspect of effective mucus clearance,^'' and decannulation could have favored a more effective cough reflex and thereby reduced the probability of exacerbation in Group 2. Furthermore, de- improvement of peak cough flows and spontaneous cough cannulation could also have reduced the risk of aspiration respiratory function in Group 1. Both groups showed a significant improvement in MEP. Whereas MIP depends reflex." From a pathophysiological point of view, retain- are and related exacerbation or pneumonia.^" ing a tracheostomy might reduce the dead space ventilation and the work of breathing, though these 2 aspects were not assessed in the present study. We considered whether the presence of a tracheostomy valve in Group 1 created a favourable bias, and concluded that the bacterial exacerbation results do not support that ; Conclusion Respiratory Care • April 1999 Vol 44 No 4 Although the number of days spent in hospital due to respiratory causes was not different between the 2 groups, our study suggests that chronic tracheostomy might ad- 419 Long-Term Tracheostomy COPD versely affect the course of severe from mechanical risk pear to affect short-term survival power of statistical COPD patients. severe in ited by the small patient population, our that COPD patients was the present study 11. of ex- However, long-term tracheostomy does not ap- acerbation. While the weaned patients by increasing the ventilation, 12. 13. lim- ventilation Severe COPD Quanjer PH. Working Party on "Standardization of lung function tests." Bull Eur Physiopathol Respir 1983:19(Suppl 5):7-10. Black LF, Hyatt RE. Maximal respiratory pressures: normal values and relationship to age Johansen WG 16. Germany 17. Italy 18. Am 19. MA Tobin MJ New ventilation. et al. Bacterial Tobin MJ. A New York: McGraw-Hill: An evolving consensus (ed- Br AF 1 99.5:274(23): 9. et al. JE. Knaus P, et al. 1 Respir Crit Care in Am Med J Respir pulmonary Nava S, pulmonary dis- SUPPORT Cril Care Med 1 Investiga- NM, Vermeire NB, for 420 more than COPD 21 days. in clinical microbi- editors. Clinical anaes- breath spontaneously. Eur Respir J W. de Rocha O, Lowenberg la S. J RD, Zeigler A, J, Paloinar M. Planas M. J Nava S. Foglio K, in severe Ambrosino N. chronic obstructive lung disease and acute respiratory failure: short- and long-tenn prog- 26. 27. Care Cook CD, Mead J, Med I996:22(2):94-100. Orzalesi MM. Static volume-pressure character- of the respiratory system during maximal efforts. Bach JR, Saporito LR. Criteria for extubation removal for patients with ventilatory American Thoracic Society. Gibson Reynolds HY. 1995;152(3):1028-10.33. Clini E, Rubini F. 1983:19:1016-1022. Paoletti P, WW, Merril Gram-negative tracheobronchial colonization. Med I997:I55(J):386. failure. J Appl Physiol and tracheostomy lube A different approach to weaning. Chest 1996:1 0(6): 1566- 57 1. 1 J, Howard M. patients requiring mechanical ventilation Eur Respir Ferranti istics Rubini F. Zanotti E. Ambrosino N, Bruschi C, Vitacca in M. nosis. Intensive 28. Optimal assessment and management of chronic obstructive weaning Niederman MS, 25. Vitacca 1995:152(5 Pt 2):S77-S120. P. Pride who JH. Barnhart K. Rowlett ):956-967. Published Fracchia C, Rampulla C. Survival and prediction of successful ventilator H. Essentials Non-invasive mechanical ventilation 1996:154(4 Pt disea,se (review). Med Law Respir Crit Care 852- 1857. pulmonary disease (COPD). The Eurpoean Respiratory Task Force. Eur Respir J 1995:8(8):I398-142(). 10. Van Saene S, Pattern of tracheal colonization during mechanical ventilation. Ain WA. Harrel FE Jr, Desbiens N. Outcomes following acute exacerbation of se- Respir Crit Care Siafakas J Chest 1984:85(l):.^9-44. intubated Standards for the diagnosis and care of patients with chronic ob- J Am 1 Soutenbeck CP, Van Saene HK, In: home. in patients living at Respiratory infection complicating long-term tracheostomy. The im- Dawson NV, Thomas C, Jr, erratum appears Am AB. 1996: 154(1): 24- 129. 24. de Latorre F, Pont T. Ferrer A, Rt)s.sello Zimmerman RP. vere chronic obstructive pulmonary disease. The Am J 23. -year survival of patients admitted to intensive care I JAMA structive Murray A, Mostafa plication of persistent in the Anaesth 1974:46(l):29-34. J Fulkerson WJ, 8. Ortqvist term tracheostomy. Chest 1993:104(l):136-138. units with acute exacerbation of chronic obstructive tors. J, Increased frequer.cy of obstructive airway abnormalities with long- and practice of mechanical ventila- editor. Principles MG. Wagner DP, Wagner Connors Bellacasa 1994:7(10:2026-2032. York: McGraw-Hill:1994:775-792. Hospital and 7. CG, Jorbeck HJ, Frostell one-year study Med tracheostomized patients Forbes AR. Temperature, humidity and mucus flow ea.se. la colonization of distal airways in healthy RH, Andersson G, editor. Principles Pingleton SK. Complications associated with mechanical ventilation. Seneff York: Raven Press: 1994:55-72. M, Clini E, Foglio K, Scalvini S, Marangoni S, Quadri A, Ambrosino N. Hygroscopic condenser humidifiers in chronically Chest 1989:96(4):712-7I3. trachea. 6. New thesiology. Philadelphia: Bailliere's; 1991:5:1-23. 22. Bishop MJ. The timing of tracheotomy. tion. 5. lower respi- 21. Vitacca 1994:749-774. In: diagno.stic techniques for in the intensive care management. Chest 1986:90(2): indications, technique, and practice of mechanical 4. to transtracheal 1997;10(5):1 137-1 144. Harlid ology. Heffner JE, Casey K. Hoffman C. Care of the mechanically venti- itorial). Bacteriology of expectorated sputum with wash technique compared Cabello H. Torres A. Cells R. El-Ebiary M, Puig de tracheostomy. 20. Heffner JE, Miller KS, Sahn SA. Tracheostomy lated patient with a tracheostomy. In: 3. disease. Lan- Respiratory tract colonization and infection in patients with chronic 269-274. 2. SM. Washington JA. Noninvasive J REFERENCES 1: Saun- Rev Respir Dis 1978:1 17(6):1019-1()27. Respir Crit Care unit. Part WB subjects and chronic lung disease: a bronchoscopic study. Eur Respir MN System, Medical Graphic Corp, St Paul Blood Gas Analyzer: Ciba Coming 840, Ciba Coming, Medfield 1. JF, Nadel JA. 26):467^73. Bartlelt JG, Finegold Xaubet A, Respiratory Module System: RPM Murray Critical care. In: Madison JM, Irwin RS. Chronic obstructive pulmonary diagnosis and management. Type B, Cosmed, Rome, 1 et ratory infections. In: Pennington JE, editor. Respiratory infections: Portable Spirometer: class Casali L, Rev Respir Dis 1992;146(3):790-793. JI. quantitative culture and Biesalsky-type cannula, Biesalsky, Rusch, M. Textbook of respiratory medicine. Philadelphia: a.spirates. Pony Am Peters Jr, cet 1998:352(91 Cannula: Rev Respir Dis 1969:99(5):696-702. Fanfulla F, Fiorentini 1988:1976-2016. ders; 15. MC. Reference values of maximal respiratory mouth pressures: a pop- editors. lute indications for retaining the tracheostomy. Am sex. Zoia 1, ulation-based study. 14. should undergo early decannulation unless there are abso- PRODUCT SOURCES and Bruschi C. Cerveri al. results suggest weaned from mechanical in 1994;7(9): 1645-1652. Kirkpatrick MB, 1 Bass JB. Quantitative bacterial cultures of bronchoalveolar lavage fluids and protected specimens from nonnal subjects. 29. Am Bennett Rev Respir Dis 1989:l39(2):546-648. WD. Zeman cough clearance. 30. Devita MA, J KL. Effect of enhanced suprainaximal flows on Appl Physiol 1994:77(4): 577- 1583. 1 Spierer-Rundback L. Swallowing disorders in patients with prolonged orotracheal intubation or tracheostomy tubes. Crit Care Med 1990;18(12):1328-1330. Respiratory Care • April 1 999 Vol 44 No 4 Work of Breathing during Weaning from Ventilation: Does Extending Weaning with Continuous Positive Airway Pressure Any Advantage? Confer Rajesh G BACKGROUND: Patel MD, Marcy F Petrini PhD, and Terry M Dwyer MD PhD (CPAP) during weaning from meclianical ventilation is unproven. METHODS: Forty-two patients were weaned witli pressure support ventilation (PSV) following prolonged mechanical ventilation. The 20 patients in Group A were removed directly from PSV after at least 24 hours of PSVj+s (5 cm HjO of PSV plus 5 cm HjO of positive end-expiratory pressure). The 22 patients in Group B were weaned for an additional 24 hours on CPAP. Weaning outcome was compared between the 2 groups by }^. RESULTS: The work of breathing was lower with PSVj+j versus CPAP, (5 cm H2O of CPAP) when all 42 patients were taken together, in the 36 patients who succeeded weaning, and in 6 patients who failed. The work of breathing was not different between Groups A and B for either ventilatory The advantage mode. There were no CONCLUSION: The work of using continuous positive airway pressure between the failure rates statistical differences in the 2 modes. PSVj+s was lower than during CPAP,. The work of breathing and the weaning outcome were the same in PSV5+5 and CPAP5. Extending weaning with CPAPj following PSVj+s offered no benefit, but instead imposed an additional load on the of breathing during ventilatory musculature. (Respir Care 1999;44(4):421-427] Key words: work of breathing, pressure support ventilation, continuous positive airway pressure, bi-level airway pressure, weaning, mechanical ventilation. flow resistance from the tracheal tube, breathing Introduction and ventilator Gradual weaning with pressure support ventilation (PSV) circuit.^ piratory pressure The "^ (PEEP) to circuit, addition of positive end-ex- PSV results in bi-level airway in pressure, PEEP mechanically ventilated patients recovering from prolonged from the loss of glottic function acute respiratory failure.'-^ This weaning consists of grad- airway,' overcomes the loss of end-expiratory lung vol- improves respiratory muscle strength and endurance ually lowering the inspiratory pressure to a low level,- ume that occurs improves pulmonary mechanics impaired when caused by the artificial patients are supine or semi-upright,* optionally followed by continuous positive airway pres- prevents dynamic airway closure in patients with airway sure (CPAP). diseases,'' PSV is CPAP a form of partial ventilatory support that delivers a pre-selected amount of positive pressure in response to a effort. An inspiratory airway prescm HjO can reduce the inspiratory and improves gas exchange.** is a spontaneous mode of ventilatory When spontaneous inspiratory ing cycle. sure between 3 and 14 than the patient's inspiratory flow, work load by overcoming the imposed work due to air- support that delivers a positive airway pressure throughout the breaththe gas flow during inspiration is higher CPAP delivering a continuous flow can overcome the air-flow resistance from the tracheal tube and the breathing circuit,^ and can improve pulmonary mechanics'-^'" and offset the intrinsic Rajesh G Patel MD, Marcy F are affilialed with the and Critical Petrini PhD. and Terry M Dwyer MD PhD PEEP ual weaning with PSV, some physicians discontinue mechanical ventilation directly, without additional Jackson, Mississippi. Correspondence: Rajesh PEEP),^ Following prolonged mechanical ventilation and grad- Department of Medicine. Division of Pulmonary Care Medicine. University of Mississippi Medical Center, (or auto G Medical Center. 1500 East Patel MD, Department of Veterans Woodrow Wilson Drive. Jackson MS Affairs .^9216. No 4 However, it is modes of possible that the level of inspiratory airway pressure during to E-mail: [email protected]. Respiratory Care • April 1999 Vol 44 support. PSV is greater than necessary simply overcome the imposed work,"* thus relieving the 421 Work from a portion of the physiologic work of breathing patient (WOB), and For as a consequence the patient can fail weaning. '2 However, the inspiratory airway pressure dur- CPAP may may some physicians extend weaning with reason, this CPAP." ing of Breathing during Weaning from Ventilation also be inappropriate — for instance, CPAP be inadequate to overcome the imposed work,'^ re- work load and, sulting in additional therefore, unnecessary plastic tube, a nonreservoir-humidified circuit, PEEP ternal CPAP, from valve. Either extubation or decannulation is the next step in our CPAP algorithm. Intermittent face-mask 24 hours in those patients who All our patients entered the study after they were grad- weaned and when they were ready CPAP with an inspiratory pressure level of 5 drawbacks and there may be no extending weaning with CPAP. overall advantage in WOB The important in assessing the performance of is and the respiratory muscle activity weaning success."'''-'* tilatory support working during patient is If the may be is a reliable predictor of WOB is ''' If the Comparing the study when of 5 cm HjO. Patients and an were included in the (1) the process that led to the patient's respiratory failure had improved; (2) the patient was hemodynamically stable and there was no further need for vaso- from active agents; (3) the patient had adequate gas exchange WOB is working harder than he would be decannulated.'-* PEEP external be supported to cm HjO too low, the ven- high, relieving the patient breathing.'' weaning used for up to are extubated or decannu- ually its is from PSV5+5. lated respiratory muscle fatigue. Thus, the possible benefits of can be offset by and an ex- or from PSV5+5, measured lished results aids in the determination of if too high, the (as indicated extubated or and WOB when to pub- the patient can be extubated or decannulated."'"'-"' by an arterial fraction of inspired oxygen tension oxygen < S: 60 mm of Hg 0.40); (4) the patient could tolerate pressure support levels between 5 and 10 HjO; (5) the patient pressure ^ -20 cm cm could inspire with a peak negative HjO; was judged by (6) the patient his or her attending physician to be able to continue the wean- Objectives ing. The University of Mississippi Board exempted The goal of this study was to determine whether ex- CPAP tending weaning with removing patients directly determined whether the the same as during confers an advantage over from PSV and PEEP. CPAP this earlier we studied removal from mechanical ventilation resulted in a higher failure rate than extended with we and appropriate for successful removal from mechanical ventilation. Second, whether First, WOB during PSV with PEEP was weaning CPAP. Two Investigation Review study from review. modes, PSV5+5 and CPAP5, were compared in all the patients, after they were rested overnight on assist- control mode. The Siemens Servo 900C was used for testDowns Flow Generator was used for ing PSV5^.5, and the CPAP5. Each patient was stable for a period of 20-30 minutes during the new ventilatory mode before data were collected. Modes were tested by pseudorandom order (by computer-generated numbers). The patients were testing rested Methods this on assist-control ventilation for 30 minutes between modes. Inspired gas was maintained at 30-40% and humidified by a pass-over heater in both modes. Peak oxygen, negative pressures were measured prior to data collection, and Protocol Patients and arterial blood gases were obtained on each mode immediately following the data collection. We studied 42 patients being weaned from mechanical ventilation. In our intensive care unit, the prolonged mechanical ventilation (> 72 weaning after hours) as follows: gradual lowering of is sequence of PSV during the daytime, with overnight rest on assist control ventilation PSV, we rouemploy 5 cm HjO of PEEP, and set trigger sensitivity at -2 cm HjO. This weaning process may take several days, until the pre-set inspiratory pressure level on using a Siemens Servo 900C.* While on tinely PSV decreases to 5 cm HjO (PSV5+5, 5 cm HjO PSV plus 5 cm HjO of PEEP). At this point, some physicians choose to prolong weaning with 5 cm HjO of CPAP (CPAP5) for at least justable 24 additional hours. Downs Flow CPAP is provided by an ad- Generator, a disposable corrugated was weaned from PSVj^^j or CPAPj at the who was not aware of study results. At our institution, some physicians always wean directly from PSV5+5 while others extend weaning with CPAP5. Even though the assignment to the 2 groups in our study was not random, the treatment of any given patient depended solely on the patient's physician, whose call schedule was determined months in advance, and was Each patient discretion of his or her physician, independent of the patient population present in the intensive care unit at the time of the study. All patients were mately 24 hours, at were removed from patients, 15 weaned from PSV<;_^5 for approxipoint, 20 patients (Group A) which full ventilatory support. Of these 20 were extubated, 2 underwent decannulation with a tracheal button, and 3 had permanent tracheostomies (due to obstructive sleep apnea). Following extuba- face-mask * Suppliers of commercial products are identified in the Product Sources tion or decannulation, intermittent section at the end of the text. employed. Twenty-two patients (Group B) had 422 CPAP, was their Respiratory Care • April 1999 Vol 44 wean- No 4 Work Table Difference in 1. Work of Breathing during Weaning from Ventilation of Breathing between PSV,+, and CPAP, Group All Patients (n CPAP5 = 0.67 42) (n failure (n = 36) = 6) 0.64 0.90 ± ± ± 0.96 ± 0.53 (0.08) < 0.0001 0.53 (0.09) 0.95 ± 0.52 (0.09) <0.000I 0.61 (0.25) 1.03 ±0.65(0.26) 0.0022 1.01 ± ± (/! = 18) 0.76 ±0.62(0.15) Group B (n = 18) 0.51 PSV5+5 and CPAP5 PSV5«5 = test. values are means ± standard pressure support ventilation of ±0.41 deviation, reponed in joules per cm H2O .'> p value 0.54 (0.08) A Group 42 Patients PSV,,^,, Weaning success Weaning in 0.89 (0.10) liter, with the standarxl error of the estimate shown with an external positive end-expiratory pressure of 5 cm H2O; CPAP5 = 0.0097 0.57(0.14) < 0.47(0.11) in parentheses. The p values were 0.0001 calculated using the paired / continuous positive airway pressure of 5 ctn H2O. at normal; however, the chest wall compliance would have were extubated, 4 been the same during the 2 modes because they were underwent decannulation with a tracheal button, and 5 had tested sequentially in each patient. Thus, differences in the ing extended for an additional 24 hours with which point Group B 3 of the 1 permanent tracheostomies apnea, I patient had tracheal patients CPAP,. had obstructive sleep (3 patients had a cerebrovascular accident, stenosis). All patients patient 1 were followed for 48 PSV5+5 and CPAP,. Weaning from mechanical ventilation was considered suchours after the discontinuation of cessful if a patient did not require full mechanical venti- WOB would have been due to differences in the work done by the lung. Data were analyzed using a Gaussianbreath-elimination method that we developed in order to omit breaths with artifactual changes The WOB in joules per minute (J/min) was calculated breath-by-breath in our ume by WOB esophageal pres- in sure due to nonrespiratory maneuvers, 22 data analysis program by multiplying 48 hours. latory support within these total WOB per unit vol- the minute ventilation. Data Collection and Analysis Statistics Measurements were made determine the to WOB stages of weaning. the WOB A at a fixed point before the final report would change at the beginning of PSV5+5 Petrini et al suggested that by little between this point tubation or decannulation; in that report the a low but constant level of 1 and 24 hours prior PSV was and ex- WOB during not different between to extubation in patients gradually weaned with PSV following prolonged mechanical ventilation.'" The WOB Prior to the beginning of the study, the quired sample size was calculated to minimum re- be approximately 20 patients in order to detect a difference of 30% between the 2 modes t < ing p in each group, using the paired 0.05, a statistical variability of 40%, as we test, and assum- power of 80%, and a usually found WOB our patients. in Data are reported as means, plus or minus the standard deviation (SD), with the standard error of the estimate per unit volume in joules per liter (J/L) was measured using a CP-100 Pulmonary Monitor. The flow transducer used for continual measurements of airway flow and airway pressure was placed at the proximal end of the endotracheal or tracheostomy tube. Esophageal pressure (SEE) in parentheses. The SEE was used to estimate the accuracy of the determination of the mean. The used to describe the distribution of the values Comparisons between each mode were made by the t test. Between-group comparisons were made by paired each patient by performing the airway occlusion test." groups was compared using the chi-square Each data collection period was 5 minutes. Data were from the CP-100 Pulmonary Monitor to an IBMcompatible computer via a serial port and stored in the computer using software provided by BiCore. This pulmonary monitor in the test population, 2^ was measured with an esophageal balloon incorporated into a nasogastric tube. Balloon placement was checked in sent SD was the unpaired sults t test. Frequency of observations were considered significant with a p in the test i)^). < 2 Re- 0,05 for all tests. Results reliably provides a breath-by-breath, real- time display of the measured and calculated weaning parameters, including WOB.ô (Its use is described in a report The pulmonary monitor assumes a normal chest wall compliance of 0,2 L/cm HjO in the calculation of WOB. The value of the chest wall compliby Nilsestuen et al,^') ance for individual patients may have been different Respiratory Care • April 1999 Vol 44 No 4 from The mean WOB was less during PSV5+5 than during 42 patients were taken together (p < 0.0001), as well as when the 36 patients who succeeded and the 6 patients who failed were considered as separate CPAP, when all groups (Table 1). The WOB measured in J/min was also 423 Work Table 2. Respiratory Parameters Parameter in of Breathing during Weaning from Ventilation PSV,^, and CPAP, Mode Work PSV5+5 2 groups: Group in the J/L versus Group B = unpaired test. t ± 0.51 of Breathing during Weaning from Ventilation A = Similarly, there were WOB nificant differences in the 0.76 ± 0.62 (0.15) = 0.41 (0.10) J/L, p no 0.17, CPAP, 1 test. A A successfully. and 4 patients of 6 patients (2 patients total in each group were weaned in Group B) failed weaning in (ie, Group A required mechanical ventilation within 48 hours). There were no statistical differences modes p = (2 of 20 in between the Group A failure rates in the 2 Group versus 4 of 22 in B, x^- 0.75). WOB than with PSV,^,. This finding was higher with CPAP, may be due levels of airway pressure delivered to the different by these 2 modes. PS V a form of partial ventilatory support that delivers a se- amount of positive pressure in response to a spontaneous inspiratory effort, while ventilatory mode where CPAP is positive pressure a spontaneous is maintained throughout the breathing cycle. With PSV5^_,, the mandatory ventilation 10 cm H2O, PEEP was < in these 22 and patients, work was the physiologic total Two other factors have been reported to contribute to the WOB. First, while the presence of auto-PEEP can increase the WOB,^-* in this study Table cm H2O I auto-PEEP was approx- PSV,,, than in CPAP, (see that difference is too small to explain the and 2), less in observed difference in WOB. Second, the ventilatory cir- PSV^s and CPAP'^^s can impose different amounts of inspiratory work. However, we have previously shown that the circuitry used in this study re- cuits for providing sults in similar pressure. WOB when providing The pulmonary monitor assumes compliance (C^J of 0.2 L/cm HjO WOB. similar levels of 2'' a normal chest wall in the calculation Patients with respiratory failure could have a C,.^^, of as L/cm HjO. Although it is not likely that our had such a low chest wall compliance (since they had recovered from the respiratory failure and were being low as 0.1 patients weaned), C^.„ we calculate that, in our patients, a halving of L/cm HÔ, which would double the work), would only increase the total WOB by (from 0.2 chest wall to 0.1 Respiratory Care • April 1999 Vol 44 No 4 WOB > was These 21 patients were subsequently extubated. while the remaining patient 28 patients, and > imposed work level of physiologic 30 breaths/minute in the 21 The patients. observed in the present study were < respiratory rates 30 breaths/minute, despite WOB and and we did not observe any signs of 2), > values 0.8 J/L with was most spiratory muscle activity (see Tables distress. 1 Since different, the re- likely adequate to over- work additional increase in CPAP, was not the failure rate in the 2 groups come any in tachypnea was attributed to the this that the CPAP, might have imposed. Two previous studies failed to establish a significant WOB (in joules versus it but one they found that 0.8 J/L. CPAP5. In addition, the greater inspiratory pressure during PSV5+5 can result in the increased tidal volume seen with PSV5+5 versus CPAP, (see Table 2). 10 PSV < 6 patients the In in all < obstructive pulmonary disease. at intermit- breaths/minute, HÔ). greater inspiratory airway pressure provided by PSV^^., maintained 20 minutes (ie, They measured imposed work and physiologic 0.8 J/L. work cm of 5 difference in is for 0.8 J/L, while in the remaining 22 patients cm HjO, whereas during CPAP5 the inspiratory pressure is 5 cm H2O. In both modes the expiratory airway pressure is 5 cm H2O. Thus, the higher WOB during CPAP, may reflect the inspiratory airway pressure imately CPAP, of 0-2 im- WOB in 28 patients from minimal mechanical ventilatory support work. The respiratory rates were group of 42 mechanically ventilated patients judged ready to be weaned, the lected to increase the studied the et al'^ were placed on after the patients all is shown has been Kirton was not extubated, because of the high Discussion In a WOB. posed tent of 18 patients total CPAP, Recently statistically sig- measured during .01 ± 0.57 (0. 14) J/L versus in the 2 groups: Group A = Group B = 0.89 ± 0.47 (0.11) J/L, p = 0.52, unpaired / no more than 20%, a value well within the variability of the measurement. sures provided WOB uated who had versus by between similar bilevel airway pres- PSV CPAP. versus who respiratory failure but per CPAP,. liter) was not in 8 patients did not have chronic They found different that the WOB between PSV,^^, Similarly, Sassoon et aP"* reported that in 9 patients with chronic obstructive pulmonary disease covering from respiratory failure, the joules per liter) during with 8 Petros et al" eval- using the Hamilton Ventilator WOB re- (measured in PSV, (using a Puritan Bennett 7200a) cm HjO CPAP (demand valve system with Puritan Bennett 7200a) was not different from that measured during 8 cm H2O CPAP (flow-by with Puritan Bennett 7200a or continuous flow system with CPAP system). The absence of Emerson water column significant difference observed in the studies by Petros and Sassoon result of the different types of CPAP may be the mechanical ventilators and systems used, the different patient groups studied, or a lack of statistical power due to small sample size. There are several strategies for weaning from mechanical ventilation.*' We try to maintain a balance between the beneficial effects of a period of total rest for the respiratory muscles recovering from fatigue curred during respiratory failure-'' that may have oc- and the harmful effects of prolonged inactivity that result in muscle weakness and atrophy.''' In full our intensive care unit patients are rested on mechanical support until they have started to recover 425 Work of Breathing during Weaning from Ventilation illness. Weaning with gradual PSV hemodynamics are stable, there is ade- from the underlying begins when the quate gas exchange, and the patient ventilator. Conclusion Our able to trigger the is Because the primary process leading me- to show results that the WOB PSV5+5 was during lower than during CPAP5, and the weaning outcome was com- same in patients weaned from PSV,^, as in patients whose weaning was extended with CPAP5. Extending weaning with CPAP5 offered no benefit in these patients, pared directly with those studies that employ a switch but instead imposed an additional load on the ventilatory- chanical ventilation has not completely resolved prior to the institution of weaning, we cannot substitute CPAP, a T-piece in one step. Thus, our results cannot be from full ventilatory who can to separate patients from mechanical support to CPAPj or T-piece in order immediate weaning tolerate ventilation''"'" or from those who will re- the musculature. Thus, during gradual weaning with lowing prolonged mechanical ventilation, ventilatory support can be removed full directly PSV fol- mechanical from PSV, +5. quire gradual weaning from prolonged mechanical venti- PRODUCT SOURCES lation. There were no differences WOB in during PSV5+5 and Group A, in whom full mechanical ventilatory support was removed from PSV5+5, and the patients of Group B, in whom weaning was extended for an additional 24 hours (see Table 1). The during CPAP5 between Ventilator: the patients of Servo 900C, Siemens-Elma AB, Sweden CPAP CPAP, did not improve the outcome. Thus, the present study supports the idea External that, Downs Flow Generator, #9250, Vital Signs Totowa NJ Inc, 2 groups were otherwise similar (see Table 3). Further- more, extending weaning with System: Adjustable PEEP Valve: #9005, Vital Signs Inc, Totowa NJ following gradual weaning with PSV, further use of CPAP5 offers no additional benefit, and that patients can be extubated or decannulated directly from PS V5+5. This shorter protocol saves a day of weaning by eliminating the use of CPAP. The present study has 2 assignment of patients to the dom. The decision The first 2 groups was not limitations. Esophageal Balloon Catheter: Smart Cath, BiCore Monitoring Systems, or extended with removed truly ran- directly CPAP5 was made VarFlex, BiCore Monitoring System, Irvine from CA advance and were independent CA Humidifler: by the phy- RCI Conchatherm some physicians always extubate from PSV5+5, while others deem it safer to extend the weaning with CPAPj. However, the assignment to a particular group was the result of call schedules that had in Irvine Pneumotachometer: sician caring for that patient; been determined months CA Irvine that the as to whether a patient's mechanical ventilatory support should be PSV5+5 is Pulmonary Mechanics Monitor: Model CP-100, BiCore Monitoring Systems, 111, Respiratory Care Inc, Arlington Heights IL ACKNOWLEDGMENTS The authors would like lo thank the respiratory therapists and intensive care nursing staff for their cooperation during this study. of the patients time of the in the intensive care unit at the study. Thus, the bias that may have entered into the study REFERENCES from the group assignment should be minimal. Table 3 shows that the 2 groups were very similar parameters in all 1. measured, so the 2 groups were well matched. A second limitation may have been tent face-mask is assisted CPAP that weaning success by the fact that in we used Group A 2. following extubation or decannula- 3. tending weaning with direct PSV, + ,, and the AM. Koerner SK, Belman MJ. Prediction of Chest 1993;I03(4):I2I5-I2I9. Brochard L, Rua F, Lorino H, Lemaire F, Harf A. Inspiratory pressure support compensates for the additional whether ex- work of breathing caused by the endotracheal tube. Anesthesiology l99l;75(5):739-745. 5. 6. Smith RA. Physiologic PEEP. Respir Care l988;33(7):620-626 Marini JJ. Weaning techniques and protocols. Re.spir Care 1995; 40(3):233-238. postextubation or postdecannu- does not reduce the benefit of an earlier extubation or decannulation. 426 CPAP at Nathan SD, Ishaaya tion. How- offered any advantage over removal from ventilator support need for face-mask lation CPAP to assess Care I988;.'?.1(2);99-120. minimal pressure support during weaning from mechanical ventila- 4. was Re.spir Maclntryre NR. Weaning from mechanical ventilatory support: vol- breath. Respir Care I988;33(2):I21-124. from PSV5 + , in the 17 patients. Face-mask CPAP has been shown to reduce the incidence of reintubation following extubation from mechanical ventilation. ''^ role of pressure support ventilation in reducing work of breathing. ume-assisting intermittent breaths versus pressure-assisting every intermit- tion ever, the purpose of this study Kacmarek RM. The clinical 7. Petrof BJ. Legare M, Goldberg P, Milic-Emili J, Gottfried SB. Con- tinuous positive airway pressure reduces work of breathing and dyspnea during weaning from mechanical ventilation in severe chronic Respiratory Care • April 1999 Vol 44 No 4 . Work obstructive pulmonary disease. Am of Breathing during Weaning from Ventilation Rev Respir Dis 1990;14I(2): 8. Quan SF, Falltrick TR, Schlobohm RM. Extubation from ambient or expiratory positive airway pressure in adults. Anesthesiology 1981; Gherini S, Peters spir RM. Virgilio RW. Mechanical work on the lungs J A, Marks JD. Petros AJ, A Inspiratory work with and without continuous Lamond CT, Bennett D. The Bicore pulmonary monitor. 24. device to assess the work of breathing while weaning from me- Hormann C, Baum M, Luz G. Putensen 1 in the early stage of C. Putz G. Tidal volume, weaning in Med 1992; OC, DeHaven BC. Morgan PJ, Windsor vated imposed work of breathing masquerading J. Fiastro JF. Civetta JM. Ele- as ventilator Shikora SA. Bistrian BR. Borlase BC, Blackburn GL. Stone Med CK. MD, work of breathing cal ventilation. MF, 1 in 30. Petrini know about MF, Norman JR. Work Patel weaning from mechani- hour and 24 hours on bi-level airway pressure prior Am J Respir Crit Care WA. RW, J. A Rev Respir Dis 1982;126(5):788-791. Respiratory Care • April 1999 Vol 44 No 4 Mahutte muscle work of breathing during flow-by, de- NMT. Faulkner J. Am in patients simple with chronic Rev Respir Dis 1992; 145(5): Hughes RL, Roussos C, Sahgal V. When Brochard L, Rauss A. Benito Care Med S, Conti G. 1 983 ;84( 1)76-84. Mancebo J. Rekik N. Tobin MJ. Alia I. ventilation. 32. Med Am J Respir Solsona JF. Valverdu A comparison of four methods of weaning J et al. ventilatory 1994;l50(4):896-903. 31. Esteban. A. Frutos F, to Med 1998;A308 Jaeger M. Milic-Emili the venti- of breathing and pressure- CS, Lodia R, Rheeman CH. Kuei JH, Light Inspiratory Braun Crit pressure sup- for assessing the validity of the esophageal balloon tech- Am to Comparison of three methods of gradual withdrawal from Rev Respir Dis 1989;139(2):515-521. RG. Comparison of work of breathing (WOB) 19. Baydur A. Behrakis PK. Zin nique. Appl Physiol 1988; should respiratory mu.scles be exercised? Chest Am extubation (abstract). method J support during weaning from mechanical ventilation. F. Inspiratory port prevents diaphragmatic fatigue during between lung mechanics and work 1219-1222. 29. I990;18(2):157-162. Brochard L. Harf A. Lorino H. Lemaire Petrini PEEP on breathing. Respir Care I987;32(6):431^*41. obstructive pulmonary disease. 1338-1344. 18. Impact of mand-flow, and continuous-tlow systems patients receiving pressure support ventilation. Chest I995;108(5): 17. JJ. severe airflow obstruction. in stan- Banner MJ, Kirby RR, Kirton OC, DeHaven BC. Blanch PB. Breathing frequency and pattern are poor predictors of Med- airway pressure, and T-piece. Respir Care 1996;41(1 1):10I3-1019. of breathing: reliable predictor of weaning and extubation. Crit Care 16. Oxford: Oxford statistics. CS. Mahutte CK. What you need RG, 28. Sassoon mechanically ventilated patients. Chest I988;94(2):232-238. Work medical time product on pressure support ventilation, continuous positive wean- Habib MP, Shon BY. Campbell SC. Comparison of Benotti PN. to weaning. Respir Care I995;40(3):249-256. work of dard weaning parameters and the mechanical work of breathing in 15. to Banner MJ. Expiratory positive-pressure valves: flow resistance and 27. Patel ing intolerance. Chest 1995;108(4):1021-1025. 14. Smith TC. Marini lator in 26. Kirton M. An introduction 25. Sassoon patients without 18(4):226-230. 13. method 65(4): 1488-1499. breathing frequency, and oxygen consumption at different pressure support levels A Gaussian JR. Publications; 1995. of breathing ):985-988. chronic obstructive pulmonary disease. Intensive Care MF, Evans JN. Wall MA. Norman 1995;29(l):55-62. 23. Bland ical chanical ventilation. Anaesthesia 1993;48(1 12. the patient-ventilator .system Corner. Respir Care 1996,41(I2):1 105-1 122. Anesthesiology 1985;63(6):598-607. 1 Managing improve work of breathing calculations, Biomed lustrum Technol positive airway pressure in patients with acute respiratory failure. 1 Care 1994;39(9):897-905. 22. Petrini continuous positive airway pressure. Chest 1979;76(3);25 1-256. Katz respiratory monitor that enables breathing: a validation study. Re- using graphic analysis: an overview and introduction to Graphics and work of breathing with positive end-expiratory pressure and 10. A new work of 21. Nilsestuen JO. Hargett K. 55(l):53-56. 9. PB. Banner MJ. accurate measurement of 20. Blanch 281-289. patients I. etal. from mechanical Spanish Lung Failure Collaborative Group. N Engl 1995;332(6):345-350. Meduri UG. Turner RE, Abou-Shala N. Wunderink R. Tolley Noninvasive positive pressure ventilation via face mask. intervention in patients with acute hypercapnic and E. First-line hypoxemic respiratory failure. Chest 1996;109(I):179-193. 427 Continuous and Expiratory Tracheal Gas Insufflation Produce Equal Levels of Total PEEP M Miro MD, Edgar Delgado RRT, Adelaida Frederick J Tasota RN MSN, Leslie and Micliael A R Hoffman RN PhD, MD Pinsky BACKGROUND: Tracheal gas insufflation (TGI) used in conjunction with mechanical ventilation can increase total positive end-expiratory pressure (total PEEP). We tested the theory that TGI delivered throughout the entire respiratory cycle (c-TGI) increases total PEEP more than expiratory phase TGI (e-TGI). We also studied whether a pressure relief valve in the ventilator circuit could prevent increase in total PEEP during TGI. METHODS: Using an artificial lung model and pressure control ventilation, we studied the effect of c-TGI and e-TGI, with and without a pressure and with and without maintenance of a constant minute ventilation (Vj), at 3 different RESULTS: Under constant V^ conditions, the increase in total PEEP was equivalent with c-TGI and e-TGI. Without adjustments to maintain V^ constant, Vp. increased during c-TGI and decreased during e-TGI. Under all conditions increasing the inspiratory-expiratory ratio increased total PEEP. CONCLUSION: When Ve is maintained constant, c-TGI and relief valve, inspiratory-expiratory ratios. e-TGI produce equivalent TGI levels of total PEEP. Failure to adjust the ventilator settings creates changes in ventilatory parameters that are unique to each delivery system. Care 1999;44(4):428-433] Key words: tracheal gas insufflation, mechanical ventilation, during [Respir barotrauma, ventilatory support. gas then insufflates the airway with an oxygen mixture Introduction . equivalent to that delivered by the mechanical ventilator. Tracheal gas insufflation (TGI) was developed to aid in the reduction of alveolar distending pressures and yet main- adequate gas exchange when treating patients with tain acute lung injury. When chanical ventilation, utilized in conjunction with me- TGI can enhance carbon dioxide (COj) elimination for a constant minute ventilation (V^), potentially reducing ventilatory requirements.' TGI ^ cm above CO2 washout from the carina. A flow of the anatomic distal elimination, it is M Miro TGI Vp Vg and peak airway presCO2 constant while increasing TGI is delivery have been proposed. to deliver TGI continuously TGI can also be throughout the respiratory cycle (c-TGI). is affiliated with the Department of Respiratory Care, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania. Adelaida high 2-''*''' The simplest method RRT at the efficiency of possible either to reduce mechanical sure (Ppeak)' or to l^sep elimination. to mechanism is enhanced TGI improves by decreasing Several methods of Edgar Delgado believed to be gas mixing due to the turbulence created catheter flow. '^''-i 2 Since CO2 is dead space proximal the catheter tip.^"* Another possible ventilatory support involves an intratracheal catheter advanced to a position approximately 2 The major mechanism of CO2 elimination MD and Michael R Pinsky MD are affiliated with the gated (using solenoid valves) to deliver gas during specified phases of the respiratory cycle. Regardless of the Department of Anesthesiology and Critical Care Medicine, School of delivery method, adverse effects have been observed with Medicine, University of Pittsburgh Medical Center, University of TGI, including increases burgh, Pittsburgh, Pennsylvania. Leslie erick J Tasota RN, MSN A Hoffman RN PhD Pitts- and Fred- are affiliated with the University of Pittsburgh in Ppâk and end-expiratory lung volume. The increase in end-expiratory lung volume dynamic form of hyperinflation, and is re- often re- Medical Center, and the Department of Acute/Tertiary Care. School of flects a Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania. ferred to as auto-positive end-expiratory pressure (auto- Correspondence: Edgar Delgado RRT, Department of Respiratory Care, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh PA 15213. E-mail: [email protected]. 428 It has been postulated that increases in Ppg^^ and end-expiratory lung volume are greater during c-TGI because gas is delivered throughout the respiratory PEEP).'*-"' Respiratory Care • April 1999 Vol 44 No 4 Continuous and Expiratory Tracheal Gas Insufflation Produce Equal Levels of Total PEEP Pneumotach Internal pressure transducer signal TGI catheter Pressure relief valve Inspiratory limb Compliance spring To TGI gas source Proximal airway pressure port Fig. 1 Experimental apparatus. TGI = tracheal gas Insufflation; pneumotach . cycle. **•''•"' Thus, a potential reason for the observed in- PEEP crease in auto-PEEP and consequent increase in total (set PEEP + auto-PEEP) with c-TGI because the ventilator-delivered tidal is an increase V^, in volume (Vj) was not proportionally reduced (volume control ventilation) or the ventilator circuit TGI volume (pressure control ventilation). There are several reports teractions to vent excess was not properly adapted '*'' that describe a variety constant during = pneumotachometer. PCV, using either c-TGI or total PEEP used a single compartment test this artificial sure end-expiratory lung pressures. total PEEP levels during would be levels e-TGl. To the same we hypothesis, lung model to mea- We then compared c-TGI with those produced dur- Vg ing e-TGI, with and without adjustments to maintain constant. of between TGI and mechanical ventilation in- Methods that influence ventilatory parameters such as Vj; and total 1^'^ When c-TGI is used with PCV, the ventilator compensates for the increased flow from the catheter by decreasing ventilator-derived Vj. However, this PEEP.'^ Equipment, Calibration, and Initial Conditions initially compensation ends ventilator flow ceases. In this situ- if The apparatus consisted of a single-compartment artifiTGI catheter device, pneumotach- cial lung, linear resister, Vg measurement, adjustable pressure relief ation with c-TGI, gas continues to flow into the lung dur- ometer for between cessation of ventilator flow and the beginning of expiration, which results in an increased valve, and mechanical ventilator (Fig. 1).* ing the interval volume of insufflated gas and, therefore, an increase in peak inspiratory pressure because the ventilator does not recognize the excess volume. This situation can be avoided by the insertion of a pressure lator circuit, which allows the excess gas the atmosphere.'-* Ve is an increase in pressure TGI (e-TGI) relief valve into the venti- is during be vented into catheter (1.67 artificial trachea (73 transducer, et al'** recently found TGI artificial the length including pneumotach- catheter swivel). was placed within (ventilator Vp (compared to no TGI). cm total of the The mode with inner diameter) inserted into the pneumotachometer, connected avoided. Use of expiratory phase decreases mm ometer, resister, and distal to the tip avoids this problem because gas flows only PCV, e-TGI TGI thereby maintained constant and during expiration. However, Imanaka that, to lung model was operated in the single-lung TGI A calibrated to a differential pressure the artificial airway 14.5 catheter to record total cm V^ -I- TGI) entering the lung. Volume calibration measurements were performed by injection of a known volume (0.750 L) using a calibration syringe. Volume calibration measurements were repeated until a s 3% varia- Both c-TGI and e-TGI produce back pressure during PCV and, thus, similarly increase expiratory resistance. But the effect of either TGI method on is unclear. We V^ and total PEEP Vg was kept hypothesized that as long as Respiratory Care • April 1999 Vol 44 No 4 * Suppliers of commercial products are identified in the Product Sources section at the end of the text. 429 Continuous and Expiratory Tracheal Gas Insufflation Produce Equal Levels of Total PEEP Table 1. Continuous Tracheal Gas Insuftlalion versus Expiratory Tracheal Gas Insufflation with and without Adjustments Minute Ventilation to Maintain Constant . Continuous and Expiratory Tracheal Gas Insufflation Produce Equal Levels of Total PEEP Vg. These changes in Vp led to a greater total PEEP during c-TGI than during e-TGI, particularly at an I:E ratio of 2: Further, these changes in Vp corresponded to changes in IBTotal-PEEP -- Minute Ventilation T 15 1 t15 between the pressure gradient Table O X 10 10 and Pj^^t, PEEP total (see 1). s s Discussion p 0. 1 > -5 5 i Tracheal gas insufflation can be an effective tool to CO^ promote in elimination from the anatomical dead space both spontaneously breathing subjects'** and during mechanical ventilation.-"' -0 However, a problem limiting the successful application of Continuous TGI Fig. 3. Total Expiratory without Pressure witliout Driving Relief Valve Pressure Adjusted PEEP and minute made PEEP = to TGI pressurization of the airways hyperinflation. Continuous an inspiratory-expira- ventilation at tory ratio of 1:1 without adjustments lation constant. TGI keep minute venti- positive end-expiratory pressure; TGI the potential for over- TGI poses eter during inspiration.'-*"* when Vg strates that is However, our study demon- maintained constant, both c-TGI and e-TGI produce equivalent levels of total PEEP. Furthermore, failure to make adjustments system during TGI creates changes Results 1 and Figures 2 and 3 summarize the results of V^ ventilation. could be maintained constant between e-TGl and c-TGI. and when compared to control, but maintaining constant S/^ required different maneuvers c-TGI and e-TGI. Vg increased during c-TGl (10.2 L/min 1:1; at an I:E ratio of and 11.2 L/min at 1:2; 1 1.5 an I:E L/min at an I:E ratio of of 2:1), but could be ratio held constant by the insertion of a pressure relief valve Vg into the ventilator circuit. Conversely, decreased during e-TGl (9.6 L/min at an 1:E ratio of 1:2; 10.2 L/min at an I:E ratio of 1 : 1 ; param- interest in the clinical application of TGI has spurred debate regarding the optimal means to deliver this to both for in ventilatory therapy. There are potential advantages and disadvantages our measurements. Minute to the ventilator unique to each delivery system. eters Continued Table a greater risk of over-pressurization due to gas flow from the tracheal cath- = tracheal gas insufflation. is and production of dynamic and 9. 1 L/min at an I:E ratio of 2: 1 ), but c-TGI and e-TGl with regard and ease of to efficacy, safety, use,-' -^^ but both techniques require standing of the unique interactions between ventilator system, rameters. We an under- TGI and the and of TGI's effects on ventilatory pa- designed our study to examine and describe the ventilator adjustments necessary to maintain constant Vp during PCV with TGI, and to document changes in ventilatory parameters when adjustments are not incorporated. auto-PEEP development Prior research has evaluated PCV with c-TGI during and volume control ventilation PCV could be held constant by proportionally increasing the (VCV),'^ and the use of a pressure ventilator driving pressure. with c-TGI to keep When V^ was held constant, the amount of TGI-induced total PEEP above control was equivalent for auto-PEEP development with e-TGI during PCV and VCV, as well as volume-adjusted c-TGI during VCV."* However, the difference in effect between c-TGI and e-TGI on total PEEP during PCV when minute volume is allowed to Total PEEP. c-TGl and e-TGI: 7.5 8.5 cm HnO cm HjO versus 7.5 versus 8.5 cm HjO cm HjO cm HjO versus 12.6 mained constant when total PEEP increased under all held constant has not been described. 1:2; vary or an I:E ratio of 1:1; Our data confirm that during PCV, both c-TGI and eTGI increase total PEEP. As previously demonstrated by at an I:E ratio of 2:1. PEEP re- held constant, reflecting a As I:E ratio increased, conditions (see Table 1 ). is our group and others, the increase in Interactions between the ventilator system If no modifications were made Respiratory Care • and TGI to the ventilator system, control, while April 1999 e-TGI decreased Vol 44 No 4 total PEEP is due to a combination of an increase in airway pressure, limiting expiration, and delivery of a larger Using V-p.'-''*'-'''* c- TGl without volume adjustment increased Vp, Ppp.,^, total PEEP when (I:E ratios expiratory time of l:land 2:1). However, c-TGI increased V^ above et al studied an I:E ratio of cm HjO Vg was Imanaka at Pressure gradients between Ppeak and total constant compliance in the system. relief valve during constant.'^ at and 12.2 Vp shortened, Vp and when was shortened the inspiratory time and was Pp^^k "i'd not increase (as seen with an I;E ratio of 1:2). Using e-TGI without volume adjustment maintained Ppeak but increased total PEEP. The resulting 431 Continuous and Expiratory Tracheal Gas Insufflation Produce Equal Levels of Total PEEP decrease in the pressure gradient between PEEP Vg decreased Pp^^j^ and because, during at all I:E ratios, volume delivered depends on the pressure gradient the between the proximal airway and the end-expiratory in- trapulmonary pressure, which the ventilator does not meapressure gradient between proximal airway If the sure. PEEP decreases pressure and total V-j. Conclusion total PCV, during e-TGI, delivered decreases (as demonstrated by our data). Note, how- would be ever, that the V-y decrease neither linear nor Our study demonstrates that when Vg maintained is constant both c-TGI and e-TGI produce equivalent levels of total PEEP. It is necessary to adjust ventilator settings Vg constant to maintain during both c-TGI and e-TGI, and failure to adjust the ventilator system causes changes to De- ventilatory parameters unique to each delivery system. spite recent advances in our knowledge of TGI, the chal- predictable from measures of inspiratory flow, peak in- lenges related to the monitoring of end-expiratory lung spiratory pressure, or ventilator inspiratory pressure set- pressures, adequate humidification, and a pressure relief need ting. Further, the to increase the inspiratory pressure and setting to maintain the pressure gradient obvious from measurement of intuitively PEEP Increase in total easily addressed. In delivered (ventilator PEEP total Vg the ventilator-derived livered TGI) -I- product sources more is in total Vg. results in increased total Vj causes Lung 26001, Michigan Instruments Grand Rapids MI an increase TGI Inc, Keene inspiration. --2' After reducing ven- PEEP total levels with c-TGI during Our data demonstrate that if inspired Vg is kept constant by a pressure relief valve during c-TGI, or by increasing driving pressure during e-TGI, total PEEP NH Pneuniotachometer: No. 2 Fleisch, Lausanne, Switzerland Linear Resistor: 112275 7100R20, Hans Rudolph, Kansas City levels are also equiva- PCV. Catheter Device: Portex let Ventilator Adapter #600 101, Concord/Portex, an amount equivalent to that de- are equivalent to those seen with e-TGI."* lent during Lung Model: Training Test greater than that caused by e-TGI. Vj by Vy, to address total endotracheal tube occlusion are yet to be resolved. alone. VCV increase associated with c-TGI, reduce by TGI during tilator-derived VCV mechanism Artificial Vy and in Ppeak not is c-TGI with VCV, the increase This c-TGI-induced increase in To avoid Pp^..,t- during c-TGI with Vj MO Adjustable Pressure Relief Valve: Other factors can also increase auto-PEEP. Increased #042301, Bird Products Corp, Palm Springs CA resistance due to the decrease in cross-sectional area of the endotracheal tube from the TGI catheter can increase auto- PEEP. Also, the expiratory time is inversely related to the amount of total PEEP formation, regardless of the mode of TGI Mechanical Ventilator: Puritan-Bennett 720()ae, Mallinckrodt, Pleasanton Differential Pressure Transducer: delivery (as demonstrated by our comparisons at I:E ratios of 1:2 versus crease in total PEEP may result in increased alveolar anatomic dead space and perative to consider these CO, washout). phenomena when utilizing itations. We remotely different from the complex animal or this model permitted us measure true end-expiratory lung pressure which may be impossible are currently in the no techniques may human to clinically not match Vp the alveolar level in the absence of limitation holds true for both and 432 MO 200, Allied MO human ACKNOWLEDGEMENTS to accurately (total PEEP), We thank Tom McCormick for his exceptional biomedical skills that enabled us to develop the expiratory tracheal gas insufflation technique lung. Since there measure true al- utilized in the study. This research tute for Nursing Research, NIH, was supported by US the National Insti- Public Health Service (Grant No. ROl NR01086-08). conditions present at TGI REFERENCES conditions. This c-TGI and e-TGI, and, there- of method should be based on individual institutional experience RT Health Care Products Inc, St Louis 5540, Hans Rudolph, Kansas City 1. fore, the choice North- is veolar pressures, titrating the ventilator system to proximal airway pressure Corporation, Calibration Syringe: in this study presents certain lim- used a single compartment model, which model. However, Engineering Timeter Calibration Analyzer, Series TGI with inverse ratio ventilation. The lung model used Validyne CA Independent Flow Calibrating Device: im- is It ridge dead space ventilation, which offsets TGI's benefits (the reduction in MP45, versus 2:1). Clinically, this in- 1:1 CA and preference. Nahum A, Burke WC, Crooke PS, Marini JJ. Ravenscraft SA. Marcy TW, Adams AB, Lung mechanics and gas exchange during pres.sure-controI ventilation in dogs. Augmentation of CO, Respiratory Care • April 1999 Vol 44 elimina- No 4 Continuous and Expiratory Tracheal Gas Insufflation Produce Equal Levels of Total PEEP by an intratracheal catheter. tion Am O, (TRIO) Rev Respir Dis I992;146(4): 2. WC, Nahum Ravenscraft SA, Burke TW, Marini JJ. A, Adams AB, Nakos G. Marcy CO, clearance Am S, tained constant. Intensive Care AM, Hoffman LA, MR. Transtracheal Am 5. Med is main- 1994;20(6):407-4I3. 15 16 6. Am Rev Respir Dis I991;144(6):I229-1233. Bergofsky EH, Hurewitz AN. Airway insufflation: physiologic effects on acute and chronic gas exchange in humans. Am Rev Respir Nahum JJ. Burke TW, Marini JJ. J Adams AB. Burke WC. Marini CO, removal during tracheal 18, in 19, Comparison of normal dogs. Kamm Am Am Rev R, Slutsky AS. Effect 11. Slutsky AS, Menon Slut.sky AS, Watson Am J Respir Crit Care Med between tracheal gas F. Pin.sky insufflation, ARDS in JJ. airways 1995:15I:A427. Miro A, Hoffman L. Tasota E, in the central MR. Effect of mechanical ventilation (abstract). Respir Care 1997; J Appl Physiol 1987:62(2):513-519. Leith Imanaka H, Kacmarek RM. Riggi V, Ritz R. Hess D. Expiratory phase and volume-adjusted tracheal gas insufflation: a lung model Med l998;26(5):939-946. Nakos G, Lachana A, Prekates A, Pneumatikos J. Guillaume M, DE, Brown R. Tracheal Respiratory Care • April 1999 Vol 44 insufflation of No 4 Kalfon P, Rao GS, Gallart L, Puybasset L, Coriat P, Rouby JJ. ogy I997;87(l):6-17, discussion 25A-26A. 21 Gowski DT, Miro AM. New tory failure. Crit Care AS. Catheter position and blood gases during J. Med 1996:153(3):1019-I024. Nahum A, Adams AB, Marini Permissive hypercapnia with and without expiratory washout in patients with severe acute respiratory distress syndrome. Anesthesiol- dogs. Appl Physiol 1982:53(2):483-^89. constant-flow ventilation. 12. in 20 Rev Respir Dis 1986;I33(4):626-629. J 1997:25(1): Pappas K, Tsagaris H. Respiratory effects of tracheal gas insufflation in spontaneously breathing COPD patients. Intensive Care Med 1995; Lehnerl BE, Oberdorster G, Slutsky AS. Constant-flow ventilation of apneic dogs. Med 2I(I1):904-912. RD, Brown of flow rate on blood gases during constant flow ventilation 10. Delgado and total-PEEP on PaCO, Respir Dis 1993;l48(3):562-568. Watson JW, Burwen DR, Respir Crit Care study. Crit Care Adams AB, Marcy tracheal gas insufflation: continuous and phase-specific gas injection 9. Am J Shapiro RS, Ravenscraft SA, interaction Appl Physiol I993;75(3):I238-1246. A, Ravenscraft SA, Nakos G, Modes of Care 42(11): 1063. A, Ravenscraft SA, Nakos G. WC, Nahum 1995;23(2):348-356. Imanaka H. Kacmarek RM. Ritz R, Hess D. Tracheal gas insufflavolume control ventilation. A lung model (abstract). 17. Effect of catheter flow direction on gas insufflation in dogs. 8. Med Tasota FJ, Hoffman LA, Pinsky Tracheal gas insufflation cools and dries gas Dis 1989:140(4):885-890. 7. AM, insufflation. In- creasing flow rates progressively reduce dead space in respiratory failure. Miro Tracheal gas insufflation during pressure-control ventilation: study. Airway Marini tion-pressure control versus flow augments gas exchange efficiency (abstract). E. Adams AB, 145-152. Blair L. Wesmiller S, Ondulick B, Pinsky AN. Bergofsky EH, Vomero E, effect of using a pressure relief valve. Crit Rev Respir Dis 1993:147: A892. Hurewitz Gowski DT, Delgado MR. Kotanidou A, Tsagaris H, Roussos C. Tra- cheal gas insufflation reduces the tidal volume while P„co, Ravenscraft SA, Effect of tracheal gas insufflation on gas exchange in canine oleic acid-induced lung injury. Crit Care 14 Nakos G, Zakinthinos Miro Ancsth rates sustains life for several hours. low flow Nahum A, Chandra A, Niknam J, JJ. Rev Respir Dis 1993:148(2): 345-351. 4. 13 Tracheal gas insufflation augments during mechanical ventilation. 3. at 1985;63(3):278-286. 965-973. 22. Adams AB. Nurs ventilatory strategies in acute respira- Q 1996:19(3):l-22. Tracheal gas insufflation (TGI). Respir Care I996;41(4): 285-291. 433 Case Reports Unrecognized Motor Neuron Disease: Ventilator Dependency Rodrigo Morales A previously healthy woman MD An Uncommon Cause in the Intensive and Jorge of Care Unit E Mendizabal MD We ruled developed ventilatory failure leading to ventilatory support. out primary cardiovascular and pulmonary etiologies for the ventilatory failure. Multiple attempts wean ventilatory support were unsuccessful. Eventually, findings consistent with upper and lower motor neuron involvement were discovered, as well as paradoxical movement of the abdominal wall during inspiration. Nerve conduction studies and needle electromyographic examination showed signs of motor neuron degeneration such as those seen in amyotrophic lateral sclerosis (ALS). ALS to should be considered a possible diagnosis in patients with otherwise unexplained ventilator dependence and paradoxical movements of the abdominal wall. [Respir Care 1999;44(4):434-436] Key words: motor neuron disease, amyotrophic ventilatory dependency, lateral sclerosis, mechanical ventilation. Introduction ache and noted "twisting" of her mouth. Within minutes, while in the transferring Neurological disease is occasionally responsible for acute ventilatory failure requiring prolonged assisted ventilation in the intensive care unit (ICU). specifically amyotrophic Motor neuron disease (MND), lateral sclerosis sents with acute ventilatory failure respiratory musculature. is usually due (ALS) to rarely pre- weakness of the The diagnosis of ALS in these cases made retrospectively and by eliminating other more common neurogenic or myogenic causes of ventilatory weakness. to We MND, facility, she became diaphoretic and progressed from mild dyspnea to frank ventilatory failure. After orotracheal intubation she was transported by emergency medical personnel to our hospital. Her medical history was unremarkable and she was a nonsmoker. Physical examination revealed an alert and well nourished woman who was able to follow instructions while receiving assisted ventilation. She was afebrile, her vital signs were stable, and her initial cardiac and respiratory present a case of ventilator dependence secondary examinations provided no clues as to the cause of her and review the pertinent respiratory arrest. literature. Her neurological examination revealed mild generalized limb muscle weakness (strength 4/5), brisk Case Report deep tendon reflexes with unsustained bilateral ankle clo- nus and bilateral extensor plantar response. A 70 year-old woman was transferred to our institution for ventilatory support after suffering a respiratory arrest. patient had been complaining of "frequent sive dysphonia for these symptoms falls" The and progres- week, but had noticed worsening of 1 in the 2 days prior to presentation. She denied dysphagia, sensory symptoms, muscle twitching, or cramps. On the day of presentation she complained of a head- MD and Jorge E Mendizabal MD are affiliated with the Alabama Medical Correspondence: Rodrigo Morales Fillingim Street, usouthal.edu. 434 Mobile AL Center, Mobile, Alabama. MD, 4th floor, 36617-2293. MSTN, E-mail: Suite L, 2451 nnorales@jaguarl. A noncontrast computed tomography of the head (performed at the transferring facility) showed no acute findings, but revealed an incidental small right parietal convexity mass with the radiologic appearance of a dural based meningioma. 24 hours University of South muscular sory examination was unremarkable, and anal sphincter tone was normal. vealing. Rodrigo Morale.s No atrophy or limb or tongue fasciculations were noted, sen- On Maximum A chest radiograph inspiratory pressure (MIP), after admission, was -8 cm HjO was unremeasured [-0.784 kPaJ. 4 we set the ventilator to presmode and recorded an MIP of -10 cm H20 [-0.980 kPa]. Over the following 24 hours we gradually hospitalization day sure support decreased the pressure support; then the patient was extubated and placed on face mask. However, within 10 min- Respiratory Care • April 1999 Vol 44 No 4 " Unrecognized Motor Neuron Disease: Ventilator Dependency ICU The most common utes of extubation her oxygen saturation dropped and she lator became bradycardic. We neurological causes of respiratory muscle weakness in the began noninvasive ventilation with pressure support of 8 cm HÔ positive end-expiratory pressure 0.784 kPa] and a 1 (PEEP) of 8 cm HÔ [0.784 kPa]. After several minutes the patient appeared exhausted and an 113 a arterial blood sample showed a mm Hg [15.1 CO2 kPa). Pq, of 106 content of 24 mmol/L. We ICU of 6.95, Pô, of [14.1 kPa], and ventilation. Her course involved further unsuccessful attempts to dis- in the setting.' are acute demyelinating polyradiculoneuropathy (Landry-Guillain-Barre syndrome), myasthenia gravis, crit- polyneuropathy, acute intermittent porphyria, ical illness Lambert-Eaton myasthenic syndrome, and neuromuscular blockade.' ALS reintubated the patient and again placed her on mechanical in the pH mm Hg ICU dependence belongs to a group of degenerative diseases col- lectively known MND,^ which as include a spectrum of mo- idiopathic degenerative diseases primarily affecting the MND can primarily affect the upper motor continue mechanical ventilation, eventually leading to a tor neurons. tracheostomy. During the course of her hospitalization the neuron (primary patient developed a nosocomial urinary tract infection, (progressive spinal muscular atrophy), or both (ALS).^ which was effectively treated with intravenous We antibiotics. movements of eventually noted paradoxical the abdominal wall during spontaneous inspiration, and a time fluoroscopically-guided sniff test real- revealed reduced but symmetrical diaphragmatic excursion. At that time MIP was -10 cm HÔ [-0.981 kPa], with volume of 300 mL. tidal A a spontaneous consulting neurology team noticed mild facial diple- gia and generalized weakness with interossei, hyperreflexia, sponse. Their exam and distal About 25% of cases present did not note fasciculations in the limbs lower motor neuron initially with bulbar symptoms characterized by the gradual onset of dysphagia, dysand dysphonia (primary bulbar arthria, ratory muscle weakness, later in the course of when ALS sclerosis). "* Respi- occurs, tends to present it or primary bulbar forms of MND. However, the majority of patients with MND suffer an insidious onset, with vague complaints of clum2-* siness, muscle twitching, cramping, and mild weakness.^ Previous reports describe ventilatory failure as the atrophy of the bilateral extensor plantar re- lateral sclerosis), the presentation of tial MND.' ** ini- In all the reported cases, previously healthy individuals develop ventilatory failure lead- The becomes or lingual musculature. Intravenous administration of 10 ing to mechanical ventilation. mg of edrophonium chloride (Tensilon) increased MIP by 5 cm H2O [0.490 kPa]; the neurological team considered ventilator-dependent because of profound neurogenic the test inconclusive. An assay for antibodies against the acetylcholine receptor in the muscle returned negative. trial of physostigmine produced no improvement of her weakness, and it A appeared to we Muscle fasciculations occurred tially attributed to at this time and were ini- anticholinergic toxicity from the physostigmine. Nerve conduction studies revealed small plitude of the compound muscle am- action potential of the median, ulnar, and peroneal nerves, with preservation of the conduction velocity. tials Her sensory nerve action poten- were normal, and repetitive nerve stimulation did not show a decremental response. Needle electromyography (EMG) weakness of the respiratory apparatus. Paradoxical movements of the abdominal wall detected diffuse limb muscle denervation and neurogenic motor unit recruitment pattern. The findings were consistent with a diffuse motor neuronopathy such as that seen in ALS. The combination of upper and lower motor neuron disease identified in the physical examination and noted in our patient) are (as a sign of diaphragmatic weakness, Retrospectively, the history of our patient suggested possible involvement of the lower motor neuron bulbar mus- Chen culature. Similarly, et observed signs of upper al'' motor neuron involvement prior a series of ure. MND to recognition of do not describe signs of upper motor neuron volvement upon initial presentation.''^ muscle weakness variable in these series, but note that is the in months preceding the onset of overt respiratory failure.' Nerve conduction duced amplitude of testing in the MND ventilator- tivity consistent EMG of involved mus- groups shows evidence of spontaneous motor unit acwith neurogenic denervation and reduced muscle unit recruitment patterns.- The diagnosis confirmed if similar findings are recorded is usually from 3 or more muscle groups from different limbs or the tongue. ^ Direct Discussion needle is occasionally identified as the sole cause of ventilatory failure and/or venti- April 1999 action potential, with a normal latency and conduction velocity in the absence of focal conduction block. ^ • usually reveals re- compound motor cle Respiratory Care in- The presence of '^ signs of mild respiratory impairment are often reported ventilatory primary neurological etiology in Other reports of ALS as a primary cause of ventilatory failure ALS. The patient remained on support and was eventually discharged to a skilled nursing home facility. A ALS patients presenting with ventilatory fail- the results of the electrophysiological studies led to the diagnosis of and are suggestive of MND.'tos discontinued the physostigmine because induce abdominal cramping and diarrhea. patient Vol 44 No 4 EMG study of the diaphragm is feasible in the ICU The technique for electrophysiological testing of phrenic nerve and diaphragm is presented in detail by setting.'" the 435 Unrecognized Motor Neuron Disease: Ventilator Dependency ALS, Bolton.'" In phragm EMG REFERENCES needle examination of the dia- reveals spontaneous motor unit activity, with a decreased number of relatively normal-sized motor unit potentials.'" The choice among long term ALS alternatives for patients depends sentation of the ventilatory failure." In on the ALS rol patients pre- the is patients, failure, most who likely long-term option. suffer more ' ' Chronic ALS of ALS carries invariably fatal rol Sci Chen profound legal and ethical implications for ALS patients, sisted suicide at some 56% tor point in their disease. support and counseling services their feelings may Psycholog- help to alleviate amyotrophic F, Evangelista T, Pinto A, Luis Ramsey DA, Bolton CF, Mo- neuron disease presenting as acute respiratory failure: a clinical Neurol Neurosurg Psychiatry 1996;60(4): J sclerosis and respiratory failure. Acta Anaesthesiol Scand 1993;33(6):628-630, Annane D, Korach JM, Templier Summary et al. F, Durand MC, Dinet-Busso N, Le Diaphragmatic paralysis preceding amyotrophic eral sclerosis (letter). Meyrignac C, Poirier lat- Lancet 1993;342(8877):990-991. J, Degos JD, Amyotrophic lateral sclerosis presenting with respiratory insufficiency as the primary complaint, medical or neurological etiologies cannot be established as primary causes of ventilatory ure or ventilator dependence, MND. The signs of upper and lower we recommend fail- Eur Neurol 1985;24(2):1 15-120, 10. considering presence of bulbar symptoms, movements ing inspiration should prompt consideration of MND, Can Escarabill J Med 12. J, Estopa R, Farrero E, Monasterio C, Manresa F, Longin amyotrophic lateral sclerosis, Respir 1998;92(3):438^41, Ganzini L, Johnston MA, in the intensive care Neurol Sci I994;21(2):S28-S34, term mechanical ventilation dur- and Bolton CF, Assessment of respiratory function unit. motor neuron degeneration, or the occurrence of paradoxical abdominal WS, Bentson H, McFarland BH, Telle SW, Lee Attitudes of patients with amyotrophic lateral sclerosis and their neurophysiological studies should be obtained in these caregivers toward assisted suicide, cases. 967-973, 436 in 1994;15(4):675-681, 1996;139(Aug Suppl):l 17-122, Carre A, the diagnosis of Med 455^58, Kuisma MJ, Saarine KV, Teirmaa HT, Undiagnosed amyotrophic of hopelessness. '^ When more common Head Neck 1989;1 l(l):51-59, R, Grand'Maison F, Strong MJ, lateral ical Neu- disease presenting with respiratory failure, J Neu- and pathological study, admitted to considering as'^ Clin Chest ML, Motor neuron outcome J Miller R. Bulbar amyotrophic lateral sclerosis: patterns of de Carvalho M, Matias T, Coelho the patients and their caregivers. In a recent large-scale survey of AD, lateral sclerosis. vasive mechanical ventilation, thereby reducing the need ill Neurosurg Psychiatry 1994;57(8):886-896. Kaplan LN, Hollander D. Respiratory dysfunction insidious onset of ventilatory The in critically Neurology and General Medicine. progression and clinical management. can be managed with negative pressure or nonin- for specialized resources." editor. York: Churchill Livingstone; 1995:859-878. Hillel senting with acute onset of ventilatory failure, tracheostomy Aminnoff MJ, Leigh PN, Ray-Chaudhuri K. Motor neuron disease (review), pre- initial Young GB. Neurological complications New management ventilatory Bolton CF. patients. In: ... Respiratory Care N Engl J : • April 1999 Med I998;339(I4): . Vol 44 No 4 Patricia A A Doorley MS RRT and Charles 60- Year-Old G Durbin Woman Ali Jr MD, Section Editors with Dyspnea on Exertion Emad MD Case Summary A 60-year-old woman of a gradual increase weight chills, fever, in loss, How sought medical attention because dyspnea on exertion. She denied abdominal symptoms, chest pain, cough, expectoration, or other cardiopulmonary symptoms. Her medical history was negative for hypertension, diabetes, or trauma. The patient Test Your Radiologic Skill What What mgs What would you answer these questions? are the major findings in the radiographs and differential diagnosis is suggested CT? by these find- .' treatment is indicated? Answers had no prior hospitalizations or recent medical evaluations. Physical examination revealed woman who was an obese afebrile, with a heart rate of 109 beats/min, a respiratory rate of 20 breaths/min, and blood pressure 110/70 mm Hg. Examination of the chest vealed bowel sounds in the lower portion of the thorax. Heart sounds gallops. left re- hemi- were normal, without murmurs or as was the neurologic The abdomen was normal, Radiographs and CT. The left hemidiaphragm is markThe mediastinum and heart are pushed to edly elevated. the opposite site, suggesting the presence of extrinsic pressure on these structures. hemidiaphragm is line (arrow). All gas shows the posteroanterior and lateral chest radiographs. Arterial blood gas analysis showed pH 7.33, the left 1 mm carbon dioxide tension (Paco^) 33 Hg, arterial oxygen tension (Pao^) 61 Hg, and oxyhemoglobin arterial mm saturation 91% while the patient breathed room Shiraz, Iran, elevation 1,600 metric pressure 690 mm m [5,000 at air (in normal baro- Hg). Chest fluoroscopy showed motion of the significantly restricted ft], left The shadows are located under the leaf of hemidiaphragm. CT reveals intra-abdominal contents, including hol- low-viscous structures and part of the spleen within the left hemithorax. There are no mediastinal, pulmonary, or diaphragmatic masses. The heart and mediastinum have been partly displaced to the collapsed. The right. showed mild narrowing of the left Differential Diagnosis. vation of the left pression, and no evidence of endobronchial lesions. Cyto- and distended abdominal viscera. '^ and microbiologic studies were negative. An esopha- scess, diaphragmatic hernia, eventration Phrenic nerve palsy is of the diaphragm, suggested by the presence of: elevation of the diaphragm; diminished, absent, or para- in normal shows a section from a computerized doxical motion of the diaphragm on inspiration; medias- showed tomogram (CT) of the middle part of the chest. Abdominal sonography was normal. Barium enema showed displacement of the transverse colon into the left chest beneath the left is the gastrointestinal series esophagus and fundus of the stomach to be position. Figure 2 lower lobe Differential diagnoses for ele- palsy, atelectasis, logic left hemidiaphragm include: phrenic nerve subpulmonic effusion, subpulmonic ab- main bronchus and moderate to severe narrowing of the left upper and lower lobe bronchi due to extrinsic com- gogram and upper The right lung is well aerated. hemidiaphragm, but no paradoxical motion on sniffing or coughing. Fiberoptic bronchoscopy are also visible. In completely visible and has a continuous examination. Figure Gas shadows the lateral chest radiograph, the leaf of the elevated left tinal shift on inspiration; paradoxical motion of the diasniffing or coughing during fluoroscopy,'-'* phragm upon and prolonged phrenic nerve conduction time detected by electrophrenic stimulation. ^ In this case, the absence of paradoxical motion of the hemidiaphragm. left hemidiaphragm upon sniffmakes the diagnosis of ing or coughing during fluoroscopy phrenic nerve palsy unlikely. Ali Emad MD is affiliated with the Division of Respiratory Diseases, Department of Internal Medicine, Shiraz University of Medical Sciences. Shiraz, Iran. Correspondence: Ali PO Box Collapse of the the left left lower lobe can cause elevation of hemidiaphragm. However, there was no evidence of chronic pneumonitis, tuberculosis, or endobronchial Emad MD, 71345-1674, Shiraz, Respiratory Care • Shiraz University of Medical Sciences, Iran. E-mail: [email protected]. April 1999 Vol 44 No 4 lesion as the cause of atelectasis in this patient. Negative examinations of sputum, bronchial washing, and bronchial 437 A 60- Year-Old Woman with Dyspnea on Exertion Fig. 2. I Computed tomography (CT) image through the mid-portion of the patient's chest. Eventration Hernia t w Diagram showing the difference between diaphragmatic and eventration. In diaphragmatic hernia the leaf of the diaphragm is seen as a broken line on the chest radiograph, while in eventration of the diaphragm it is seen as a smooth, unbroken Fig. 3. herniation I Fig. 1. line. Radiographs of a 60-year-old tress. A. Posteroanterior woman witln respiratory dis- chest radiograph. B. Lateral chest radio- though the diagnosis of diaphragmatic eventration can be graph. confirmed in fluoroscopy, left lower lobe is aphragmatic hernia, especially a hernia "sac." Figure 3 hemidiaphragm rather shows the difference between diaphragmatic eventration brushing suggest that the collapse of the secondary to the elevation of the left than to intrinsic pulmonary disease. In the absence of symptoms and and diaphragmatic hernia with regard signs referable to an abdominal process, and with a normal abdominal sonography, subpulmonic or subdiaphragmatic abscess or effusion can be excluded. extrinsic pressure The CT on the lung verifies the presence of tissue placed abdominal contents into the The remaining 2 caused by the left dis- hemithorax. differential diagnoses are congenital diaphragmatic eventration and diaphragmatic hernia. Al- 438 most cases by routine chest radiograph and can be difficult to differentiate from a di- it to the position and condition of the diaphragm. A history of trauma to the lower chest or abdomen,'' or the presence of a defect in the contour of the diaphragm on the chest radiograph'-'' suggests diaphragmatic hernia, this and diagnosis might be confirmed by an upper gastrointestinal series or barium enema, since either the stomach or the colon can protrude through the diaphragmatic Induction of a pneumoperitoneum is hernia.-'' a safe and accurate Respiratory Care • April 1999 Vol 44 No 4 A 60- Year-Old Woman with Dyspnea on Exertion The muscular element of the diaphragm formed diagnostic procedure for differentiating a diaphragmatic cavities. hernia from a paralyzed or eventrated diaphragm. In diaphragmatic hernia, the injected air will enter from the from the cervical myotomes.--'* Congenital eventration peritoneum into the pleural cavity.* Sonography, radionuclide liver CT of the chest* may and spleen scanning,^ and is re- from incomplete or absent muscularization of the pleuroperitoneal membrane.'' Early return of the midgut to sults the abdominal cavity may be an important factor in the normal diaphragm development. '-^^ '" The phrenic be necessary for diagnosis of hernia in occasional cases. failure of The diagnosis of severe eventration in this case was based on (1) the presence of an intact leaf of the left nerve hemidiaphragm, best seen on the lateral chest radiograph abnormalities, such as aplasia of the lung, hypoplasia of as an the unbroken line, (2) the lack of paradoxical motion of diaphragm on fluoroscopy, and (3) the normal barium examination. is normal. may be Eventration the aorta, transposition of the of the sternum, ribs or The most common In neonates diaphragm tion of the because the condition all, is is and infants, complete eventra- generally corrected surgically potentially life-threatening.* Over- symptomatic adult patients should primarily be managed with oxygen therapy and upright posture, though antibiotics may be necessary for infection control. patient responds well to supportive is required.* In pa- with modest diaphragmatic elevation, and in those who demonstrate dition, surgery little functional impairment from the con- can be postponed. Surgery ficult to differentiate it it not indicated is for treatment of partial eventration, except when the management, surgery might be avoided. Otherwise, surgery tients If from a mass lesion when in the is treatment if radiograph as mass that is ium esophagogram, tissue require surgical they develop dyspnea. If significant lung atelectasis is associated with eventration, surgery should be soft continuous with the diaphragm." Bargastrointestinal series, echocardiogra- nance imaging, and CT of the chest may be required to exclude other causes.'* The majority of these patients are asymptomatic.'" Total or complete congenital eventration on the Many left side. is usually found patients with this condition remain was offered to was declined. Unfortunately she missed subsequent appointments and no follow-up examinations this patient, but arise from the abdomen, the respiratory system, or the heart. Abdominal symptoms, including nausea, vomiting, belching, some patients. and abdominal pain, are present in Volvulus of the stomach'^ and of the co- can occur and are occasionally life-threatening. Cough, respiratory distress, cyanosis, and chest pain can occur due to compression of the lung or mediastinum. lon'** considered."'- Because of her respiratory symptoms and It is important to note that the motion of the eventrated diaphragm may be normal, adoxical motion eventration. is restricted, or absent. True par- not present in congenital (nonparalytic) "* Acquired (paralytic) diaphragmatic eventration follows or other data are available. injury to the phrenic nerve or its roots, which can be caused by trauma, childbirth (especially with breech pre- Discussion sentation), or Eventration of the diaphragm, which is seen on the chest phy, radionuclide liver scan, sonography, magnetic reso- Symptoms can the collapse of the lung, surgical treatment it is a homogeneous, smoothly marginated infants because of shifting of the labile mediastinum.'" more commonly indicated in the pein adults. Asymptomatic patients may the anteromedial portion of the right hemidiaphragm.'-'* Characteristically, asymptomatic.'" Prominent symptoms are usually seen in age group than should have regular follow up," and is vertebrae.''-'" location for the partial diaphrag- is dif- Surgical intervention for correction of complete con- diatric matic eventration cleft lip, bony abnormali- lung or it causes pronounced symptoms.'" genital eventration abdominal contents, cleft palate, puliiionary sequestration, or ties Treatment. associated with other congenital is a rare condition, broadly defined as an abnormally high position of part major abdominal surgery.'* Central neurological disease, myopathies, levels and changes in diaphragmatic caused by neighboring lesions can also produce the occurs as a result of paralysis, acquired form of eventration. Acquired diaphragmatic aplasia, or atrophy to varying degree of the diaphragmatic eventration can be associated with aneurysm of the aorta, or all of the diaphragm. muscle fibers.'" It There are 2 distinct etiologic types of eventration, congenital (nonparalytic) and acquired (paralytic).'"''' subdiaphragmatic hydatid cyst, pericarditis, alcoholic neuritis, spondylitis, and poliomyelitis. '*-2" Anatomically, the congenital eventrations are further divided into 3 forms: partial, complete, and bilat- REFERENCES eral. '^-'s During weeks 8 to 10 of fetal life, the membranous diaphragm develops by fusion of the septum transversum and the dorsal mesentery of the foregut, and thereafter divides the coelomic cavity into the pleural and peritoneal Respiratory Care • April 1999 Vol 44 No 4 1. Wilcox PG. Pardy RL. Diaphragmatic weakness and paralysis. Lung 1989;167(6):323-341. 2. Bellemare F. Evaluation of human diaphragm function. Monaldi Arch Chest Dis 1993;48(l):92-93. 439 A 3. Woman 60- Year-Old with Dyspnea on Exertion Shackleton KL, Stewart ET, Taylor AJ. Traumatic diaphragmatic 12. Tarver RD, Conces DJ and 5. disorders. J its 6. 7. Jr, Cory DA, Vix VA. Imaging the diaphragm 13. S, 14. Mearns AJ, Choudhury AK. Traumatic rup- Ann Thorac Surg 1995;60(5):1444-I449. Oh KS, Newman B, Bender TM, Bowen A. Radiologic evaluation Obara H, Hoshina H, Iwai H, Hisano K. Eventration of the 1988;26(2):355-364. and children. Acta Paediatr Scand I987;76(4): Wang SM, imaging trauma: pulmonary, tracho17. bronchial, and diaphragmatic injuries. Semin Ultrasound CT MR. Commare MC, 10. 1 1 cases. Pediatr Ribert in children. J M, Linder R Eur the dia- 19. Coll Surg Edinb 1991;36(4):222-224. J 1 15-1 138. Pediatr 1990;57(1): 125-127. J CH, Lin YJ, Yang HB, Wu MH. Congenital J bilateral Pediatr 1997;156(7): in the diagnosis S. MR of partial eventration of the diaphragm Chest 1993;104(I):328. Llaneza PP, Salt WB 2d. Gastric volvulus. Med More common then pre- l986;80(5):279-283, 287-288. Tsunoda A, Shibusawa M, Koike T. Volvulus of the sigmoid colon (letter). Am J Gaster- oenterol 1992;87(1 1):I682-1683. Singh G, Bose SM. Agenesis of hemidiaphragm Aust JL. Plication of the diaphragm for unilateral eventration or paralysis. 1985;65(5):1 associated with eventration of the diaphragm Pulmonol 1994;18{3):187-I93. Jawad AJ, al-Sammarai AY, al-Rabeeah A. Eventration of phragm II 18. Kurstjens SP, Barois A. Diaphragmatic paralysis in children: a review of Lin viously thought? Postgrad 1996;17(2):114-118. 9. Philippart AI. Congenital diaphragmatic her- Am Yamashita K, Minemori K, Matsuda H, Ohishi T, Matsunobe (letter). in blunt chest MD, Dalvi R, Chari G, Fernandez AR. Congenital eventration of dia- 654-658. Kang EY, Muller NL. CT Klein 572-574. 16. 8. Pediatr Surg 1993;28(1): agenesis of diaphragm: report of a case. Eur Am S, Ito 15. of the diaphragm. Radiol Clin North in infants ML, Surg Clin North phragm. Indian diaphragm. diaphragm Cullen nia. Thorac Imaging 1989;4(1):1-18. Shah R, Sabanathan ture of J 42^t4. 18(I);49-59. 4. Hicsonmez A, Buyukpamukcu N. The long Kizilcan F, Tanyel PC, term results of diaphragmatic plication. spectrum of radiographic findings. Radiographics 1998; injuries: 20. Cardiothorac Surg I992;6(7):357-360. NZ J Gibson GJ. Diaphragmatic tures, in adults (review). Surg 1993;63(4):327-328. paresis: pathophysiology, clinical fea- and investigation (review). Thorax 1989;44(1 1):960-970. eaas 4 5^" International Respiratory Conbri^ss Oecem ber 1 3- IJS ,_J-^ 99 Las VEOASd Nevada 1999 440 Respiratory Care • April 1999 Vol 44 No 4 Mani S Kavuru MD and James K Measurement of FEVj Using K James Stoller MD, Table chronic obstructive lung disease presented with the com- was obtained using 2 different methods A spirometry test for coaching ex- shows the Spirometry piratory effort. Table 1 shows What would account for the differences in the results ure 1 results. Fig- volume-time tracings for Spirograms 1 and 2. of these tests? Discussion Based on the decreased FEV|/FVC ratio volume in 1 second to forced expiratory (ratio of forced vital capacity), both spirograms indicate severe obstructive lung disease characterized as stage III Series Editors PFT Nuggets Daniel Laskowski RPFT, and Kevin McCarthy 72-year-old white male ex-smoker with a history of plaint of increasing shortness of breath. MD, the Modified Spirometry Technique Case Summary A Stoller chronic obstructive pulmonary 1. Spirometry Results RCPT Measurement of FEV, using the Modified Spirometry Technique 2. have good back extrapolated volume whichever is < FVC 5% of peak flow of starts (time to less than 1 patients with severe obstructive lung disease greater, and to better achieve adequate expiratory duration isfy end-of-test criteria, a and have a satisfactory exhalation time and meet 3. To allow 20 ms) or or 0.15 L, for spirometry testing has to sat- modified expiratory maneuver been described by Stoller et al.' end-of-test criteria (6 seconds of exhalation, a plateau in Specifically, the modified expiratory maneuver consists of the volume-time curve, or if the subject cannot or should a maximally forceful not continue to exhale). expiratory effort begun on the technician's prompting at The start-of-test criteria are best assessed on a flowvolume curve, whereas the end-of-test criteria are best assessed on a volume-time curve. After 3 acceptable spi- approximately 3 seconds rograms have been obtained, the following reproducibility teria criteria largest should be applied: The 2 largest FEV, should be L within 0.2 and reproducibility the acceptability FVC and the 2 of each other. If both criteria are not met, continue testing with additional spirograms until either (1) the criteria are met, (2) a total of 8 tests have been per- higher FVC effort.'' The is satisfies the end-of-test criteria, Spirogram 1 raise the issue of concomitant restrictive lung disease, because the low the lower in the second limit of set FVC is normal for our laboratory. The of results is be- FVC FEV, is of the FEV,/ normal. Though the similar in both spirograms, the higher value FVC and the because of a more sustained expiratory results of ratio in the first effort results COPD by patients with from the lower Satisfying end-of-test criteria for spirometry COPD slows lung emptying. As a because result, air nique was examined the technician encourages (ie, is modified expiratory technique. In ical purposes and is < p difficult (58% vs 19%, 0.001). This improved rate of satisfying end-of-test was achieved without significant lessening of FEV, On the basis of these advantages, as well as improved comfort and patient preference, the modified expiratory technique has gained popularity and dard technique used at The Cleveland in the is the stan- Pulmonary Function Laboratory Clinic Foundation. REFERENCES 1. Crapo RO, Morris AH, Gardner RM. Reference spirometric values using techniques and equipment that meet Am 2. paramount for clinfirst 3. values in clinical and epidemiologic studies requires American Thoracic Society. Standards Med recommendations. for the diagnosis 5. Am J 1995;152(5 Pt 2):S77-S120. American Thoracic Society. Lung function spir Dis 4. and care of pulmonary disease (review). testing: selection erence values and interpretative strategies (guideline). Am of ref- Rev Re- 1991;144(5):1202-1218. Standardization of spirometry: 1994 update (guideline). American Thoracic Society. assuring adequate lung emptying or, in conditions of ex- ATS Rev Respir Dis 1981;123(6):659-664. Respir Crit second of expiration, comparison of FEV, /FVC ratios or FVC use of the this study, values. is unaffected by events after the is forceful criteria flow limitation an expiratory plateau FEV, maximum modified technique was associated with a significantly a patient maintains an expiratory effort for 15 seconds. Although measuring the crossover in a blowing for the entire duration of expiration) versus the patients with chronic obstructive if the expiratory flow FVC infrequently achieved, and end-of-test criteria are satisfied only when which 48 subjects used a standard expiratory tech- trial in value caused by early termination of the expiratory effort. for patients with severe (ie, below 200 mL/s). The impact of this modified expiratory maneuver on the rate of achieving end-of-test crifalls higher rate of achieving end-of-test criteria formed, or (3) the patient cannot continue. Spirogram 2 followed by a relaxed initial effort, Stoller JK. Am Basheda J S. Respir Crit Care Med 199.');152(3):1 107-36. Laskowski D. Goormastic M, McCarthy K. piratory flow limitation, a standardized duration of expi- Trial of standard versus modified expiration to achieve end-of-test ratory effort. criteria. 442 Am Rev Respir Dis 1993;148(2):275-280. Respiratory Care • April 1999 Vol 44 No 4 . A Patient with Dyspnea and Acid Maltase Deficiency Salim Kathawalla MD Case Summary Ahmad and Muzaffar nary fibrosis. VC muscle weakness A 39-year-old male with known by is MD itself as a measure of respiratory nonspecific and nondiagnostic. Also, history of acid maltase in longstanding respiratory muscle weakness, the decrease deficiency complained of chronic and progressive exer- in VC may The dyspnea was worse tional dyspnea. in the supine po- and relieved by the upright posture. The sition results of be due to more than muscle weakness alone because of decreased chest wall and lung compliance, which is associated with microatelectasis.' Thus, VC by itself is physical examination and chest radiography were normal. not useful in monitoring patients with respiratory muscle Spirometry results are shown weakness. The most widely applied clinical findings went another diagnostic 1 2. Table in and spirometric 1 . Based on the results, the patient under- test. What do the spirometric results show? What was the additional diagnostic test the cause of this patient's static maxiat the and expiratory muscle strength are mouth (MIP and MEP). MIP values that clarified dyspnea? HjO exclude clinically The spirometry results indicate severe restrictive pulmonary impairment. Since the diffusing lung capacity is normal, a restrictive parenchymal lung process such as With the and diaphragm VC upon assuming is a large decrease in patient's history jects there is caused by a However, even a reduction in shift with a consequent reduction and a change known to in resting cause respiratory muscle weakness, the spirometric findings suggest diaphragmatic weakness. The diagnostic sitting test performed was a spirometry in and the supine position, which demonstrated a decrease in position. A the 50% capacity (VC) on assuming the supine vital diagnosis of diaphragm paralysis was made and the patient was treated with a nocturnal rocking bed. The characteristic abnormality of inspiratory muscle weakness is a low VC with a reduced total lung capacity and preserved residual volume. Carbon monoxide ing capacity is reduced, but is diffus- normal or raised when adjusted for volume.- This feature is useful to distinguish muscle weakness from alveolar disorders such as pulmo- Salim Kathawalla Critical MD Ahmad Minnesota. Muzaffar Pulmonary and tion, is affiliated with the Department of Pulmonary. Care and Sleep Medicine, Park Nicollet Clinic. Minneapolis. Critical MD is affiliated with the Department of Care Medicine, The Cleveland Clinic Founda- Cleveland. Ohio. Correspondence: Muzaffar Critical Ahmad MD. Department of Pulmonary and Care Medicine, Cleveland Clinic Foundation, 9500 Euclid Av- enue, Cleveland OH 44195-5038. Table I . VC in normal young sub- in the supine position, of blood to the pulmonary circulation, of dyspnea in the supine position and of acid maltase deficiency, cm In patients with neuromuscular disease weakness, there the supine position. fibrosis is unlikely. greater than 80 important respiratory muscle weakness. Discussion pulmonary tests for global in- mal inspiratory and expiratory pressure measured spiratory Spirometry Results in intrathoracic gas volume, diaphragmatic position when su- A pine.''-^ Patient with Dyspnea and Acid Maltase Deficiency Further, in patients with restrictive and obstructive lung disease without diaphragmatic weakness, there VC ease and diaphragmatic involvement, strictive pulmonary impairment and 55% (mean In a study of 46%) upon assuming by Allen et al, a VC all VC subjects in Am had re- 2. the supine position. > 25% obstructive defect, 35% J, Green M. AssessRev Respir Dis 1988; 137(4): Gibson GJ, Pride NB, Davis JN, Loh LC. Pulmonary mechanics muscle weakness. Am Rev in Respir Dis 1977; Hurtado A. Fray WW. Studies on total pulmonary capacity. J Clin Invest 1933;12:825-832. with an Wade OL, Gibson ment and was very suggestive of diaphragmatic vital JC. The effect of posture on diaphragmatic move- capacity in normal subjects with a note on spirometry as an aid in determining radiological lung volumes. weakness.* Thorax I951;6: 103-126. 6. Allen S. Hunt B. Green M. Fall in vital capacity with posture. Br J Dis Chest I985;79(3):267-271. REFERENCES 7. 1 . Moxham Am ll5(3):389-395. 4. conjunction with a re- on lung function of over Mier-Jedrzejowica A, Brophy C, patients with respiratory 5. strictive defect recommendations. 877-83. 3. '^ upon ATS Rev Respir Dis l981:123(6):659-664. ment of diaphragm weakness. decreased by 37- decrease of assuming the supine position, using techniques and equipment that meet also upon assuming the supine In a study of patients with neuromuscular dis- a substantial decrease in position.* is Crapo RO, Morris AH, Gardner RM. Reference spirometric values Newsom-Davis Rev Respir Dis J. The diaphragm and neuromuscular 1979;! 19(2 Pt 2): 1 disease. Am 15-1 17. Respiratory Care Open Forum The AARC and its science journal, Respiratory Care, nvjie submission of brief abstracts related to any ajpPpbf cardiorespiratory care. i The abstracts will be reviewed, and selected authors be invited to present posters at this year's Open Forum dmjtig the AARC International Respiratory Congress^KLas Vegas, NV, Dec. 13-16. Accepted abstracts will ai.ô be published in the November 1999 issue of^nwiRAXORY Care. will accepted abstracts are automatically considered American Respiratory Care Foundation research grants, so don't miss this opportunity to share your research efforts with your colleagues and vie for ARCF's financial awards! All for — Act today final submission deadline is June 11. More information is available in the latest issue of Respiratory Care under "Call for Open Forum Abstracts," or call Linda Barcus at (972) 243-2272. You can also submit your ab^tact electronically at http://www.rcjournal.com. Membership in the AARC is not required for participation. 444 Respiratory Care • April 1999 Vol 44 No 4 Letters addressing topics of current interest or material in RESPIRATORY CARE decline a letter or edit without changing the author's views. pretation of information No anonymous reply in print. Care. 600 — not standard letters The content of can be published. Type may simply reflect the author's letter double-spaced, mark it "For Publication," and mail ARDS end-expiratory pressure (PEEP) than ARDS potentiated by extrapulmonary illness, which may by Kacmarek and Chiche concern- increased nonpulmonary thoracic elastance. ing the use of lung protective ventilatory strategies it be composed of more PEEP-responsive alveolar flooding and collapse, and perhaps (LPVS) to for the acute respiratory syndrome (ARDS) published It may be ironic, therefore, that in the lor ventilator settings to REFERENCES 1. those patients with better, mechanics say "great interest" because I hold great enthusiasm for, and consider myself aproponentof LPVS in I am less enthusiastic ARDS. However and rather skeptical about the ability of LPVS to improve mortality in patients is with founded on the ARDS My skepticism ARDS. fact that the majority of nonsurvivors do not die from respiratory failure,- and despite my shared concerns with the authors that injurious ventilation may in fact potentiate translocation (eg, 1998;43(9):724-727. we may tai- Suchyta more responsive vival and modifying 3. Gattinoni L, Pelosi P, Suter tory distress utilization of LPVS for ever these benefits ifested may more by a reduction ferent ARDS may prove beneficial in the treatment of syndromes? likely in ventilator be man- and inten- 4. Amato MB, Barbas CS, Medeiros DM, Magaldi RB, Schettimo GP, Lorenzi-FUho G, strategy attribute the premature to addition, that work by Gattinoni ARDS insult in overall survival. Jeffrey M Haynes RRT CPFT potentiated from a pulmonary soUdation that is less of a protective- ventilation on mortality in the acute respira- N Engl J Med 1998;338(6):347-354. Staff Respiratory Therapist et al' suggests may have more parenchymal et al. Effect tory distress syndrome. absence of worsening multiple organ function to a ventilation strategy. In disease. Dif- Am J Respir Crit Care Medl998;158(l):3-ll. improvement is PM, Pedoto ARDS, how- from the lung, it 1992; syndrome caused by pul- remain optimistic that sive care unit days rather than a significant feel Chest factors. monary and extrapulmonary I CG, A, Vercesi P, Lissoni A. Acute respira- in sur- between the study and control groups at hospital discharge. Elliott 101(4):1074-1079. of proinflammatory cytokines and bacteria I TP, tory distress syndrome: a report of survival may more frequently die.' In terms of the Amato LPVS trial,* it is true that the LPVS study group had a better survival rate after MR, Clemmer Ontie JF Jr, Weaver LK. The adult respira- ARDS triggered by sepsis) 28 days, but there was no difference pro- ARDS: the data are convincing! Respir Care lung mechanics with September 1998 issue of RESPIRATORY Kacmarek RM, Chiche JD. Lung tective ventilatory strategies for the intention of improving survival, but Care.' I inter- RESPIRATORY 2. distress accept or Letters read with great interest the point-of-view article may opinion or WA 98104. Response to Lung Protective I be considered for publication. The Editors published practice or the Journal's recommendation. Authors of criticized material will have the opportunity to 9th Avenue, Suite 702, Seattle Ventilatory Strategies for will letters as St Joseph Hospital Nashua, con- New Hampshire (received October 27, 1998) responsive to positive Respiratory Conbrcss D E C E M B^R _1 3- 1 S , J^ g 9 Las Vegas, Nevada 1999 Respiratory Care • April 1999 Vol 44 No 4 445 Listing and Reviews of Books and Other Media. Note and software films, tapes, Physiological Basis of Ventilatory Support, John Slutsky MD Marini J MD. and Arthur (Lung Biology Editors. Health and Disea.se. Volume 1 1 8. 1 .S in Claude Lenfant, Executive Editor) Hardcover, lustrated, il- .464 pages. Marcel Dekker Inc, New York NY; makes a persuasive case sentence from the preface establishes the rationale for this exceptional volume: our view that broad-based and "It is inti- mate knowledge of the physiology underpinning ventilatory support is indispensable to optimal care of difficult patients who for the benefits of does not cover specifics about the technique. the physiologic con.sequences of endotracheal Among the other excellent contributions in use of diagrams in the Loring this part, the chapter on mechanics of lungs and chest and the Sassoon and Mahutte chapter ful to readers are particularly help- reviewing those physics-based The work of breathing chapter concepts. also includes a useful discussion of the various approaches to the estimation of of breathing by The gas exchange chapter tients. work mechanically ventilated pais disappointing only because the authors have pre- Drs Marini and Slutsky have viously written in-depth discussions of the this belief, believe to be the best sin- topic at a higher level of sophistication, gle source on the science of ventilatory sup- which would have been more appropriate The contributing authors include a compiled what port. I nearly complete assembly of the most prom- The inent clinician-scientists in this field. range of topics covered comprehensive, is The for this book. by Russell ter final section of the chap- a scholarly critique of the is practice of pharmacological maximization of oxygen delivery as a primary goal dressed their assigned topics patients. ticipated, there is an- all the tervention. it is those Part not truly redunits Two, on the consequences of chanical ventilation, is me- comments on the ac- ments themselves. The chapter on ventilatory support focuses primarily plications of pressure control is full on ap- modes, which appropriate for the general advanced level of the book. In addition, it provides a concise perspective on sedation and paralysis that is superior to the earlier chapter devoted to that topic. The companion chapter on tilatory support partial ven- again discusses the issues of patient- ventilator dyssynchrony. good overview of and includes the merits of proportional assist ventilation to address this prob- sure in severe air flow obstruction, the use of nitric a of mechanical ventilation, implementing synchrony with ventilatory support, and specific problems tory modes. in ventilation. review by Tremblay of patient-ventilator dys- full di-scussion all is It of the standard ventila- followed by a scholarly et al both of animal The studies and of clinical investigations of ven- majority of the chapters are addressed to tilator-induced lung injury. That informa- experienced clinicians with a well-estab- tion not a book for beginners. lated patient, including curacy and interpretations of the measure- more approachable The lead-off chapter by Maclntyre provides is of the all can be taken on a venti- ing applications of positive end-expiratory lying ventilatory support, the consequences This that pressure and continuous positive airway pres- arranged in 4 parts: the physiology under- The 38 measurements believers in this infor full-time clinicians than the first part. assigned focus. itoring the mechanically ventilated patient has compiled a very useful review of other ventilatory support techniques, includ- chapters are own anatomic complications. The chapter on mon- should be required reading for who remain As could be dant, because each chapter maintains on the lem. Part Three includes chapters discussing It some overlap among chapters, but generally have logically earlier chapter in the care of acute respiratory distress syndrome cated and critical manner. which might more intubation, been paired with the a and the majority of the authors have adin a .sophisti- on implementing ventilatory support, begins with an excellent chapter on require ventilatory assistance." In support of Part Three, it wall, 1998. $295.00. 98104. proportional assist ventilation, although on work of breathing A WA Respiratory Care. 600 Ninth Avenue. Suite 702, Seattle to Books, Films, Tapes, & Software Send review copies of books, to publishers: is helpful background for interpreting which volumes may oxide and other pharmacological approaches, noninvasive positive pressure ventilation, high-frequency ventilation, liquid ventilation, and extracorporeal support. These chapters recall the wide range of solutions that have been explored toward the goal of improving outcomes of patients with respiratory failure. Part Four, on special problems tion, includes in ventila- an extensive review of baro- lished understanding of respiratory physi- the debate over ology. For teachers and investigators in the be too high or which lung inflation vol- the barotrauma umes may be too low for acutely injured CC Macklin. This chapter discu.sses tidal vol- chapter covering the anatomic ume-related lung injury unrelated to baro- of ventilator support of patients with field respiratory failure, this book is a well-com- By lungs. The tidal trauma that features a complete discussion of mechanism first proposed by their consequences of endotracheal intubation is trauma, and addresses the more controversial choices of authors and topics, the editors complete and exceptionally well done. It issue as to have clearly succeeded goal to pro- reminds even experienced clinicians of the injury can produce systemic effects. vide "a resource that will serve as a firm substantial range of anatomic complications parative evaluation of ventilator piled summary of current basis from ally which to opinion. in their advance our continu- Part One, on the physiology of ventilatory support, represents both the best and most challenging plified by the first that can arise as a consequence of estab- part of the book, exem- chapter, by Younes and is The one Two was the chap- tings. While on sedation, which includes a cookbook- egies is iirtificial disappointment of Part ter strategies airway. lishment of an evolving knowledge." whether ventilator-induced lung style critical to difficult aspects critical illness set- the obvious goal of these strat- optimize recovery, the variability u.sed, of clinical conditions leading to ventilatory assessment of the goals failure ordinarily force the choice of a sur- naming of agents without a one of the most of the care of patients in Com- management that could be may not necessarily be Georgopoulos, on the neurophysiology of and complications of sedation of a mechan- rogate end point that patient-ventilator interactions. This chapter ically ventilated patient. linked to the quality of the eventual outcome. 446 Respiratory Care • April 1999 Vol 44 No 4 Books, Films, Tapes, The chapter by Morris and final Cook on mechanical ventilation clinical trials in reminder of the posed on "How can we can we best what we should do?" to a over 1.400 pages long not likely to be welcome, proportional is nutritional support addresses the line This soft-cover book is in format and divided into 3 sections. Part I, "Why between ventilatory and ox- ygenation failure, the pathophysiologic dications, and special required. is objectives of mechanical ventilation are defined according to 1992 American Asso- unique, its application requires a ciation for Respiratory Care and 1 993 Amer- ican College of Chest Physicians ical believe it promises to be the most it is discussed 2 of the chapters, proportional assist vendeserves a chapter of volume devoted its own in a to the physiologic basis of It is the a pleasure to encounter a well-edited critically written volume intended most physiologically-oriented of ratory practitioners. Again, this is some of for beginners. Indeed, for respi- not a book the initial chapters on the physiology of ventilatory support presume a higher level of physiologic sophistication than that possessed by most board-certified critical care physicians. Subsequent chapters on the clinical application of ventilatory support assume famil- iarity with all of the ventilatory support ap- modem intensive care unit proaches used by practitioners, and hence will be difficult go- Part II, "How To sus transport ventilators, and volume- modes of targeted versus pressure-targeted Ventilator Set-Up," the authors review a selection of appropriate tidal volumes, oxy- The spiratory flow. on inspiratory flows Care Medicine Department of Medicine University of Washington Seattle, Washington tors. MD and Faroque A Khan MB. Soft-cover, illustrated adelphia, 1 Edi- 88 pages. Phil- PA: American College of Physi- cians-American Society of Internal Respiratory Care • April 1999 may preparing for boards find useful. These include guidelines on the parameters used need for and initial institution commonly used during mechanical tion, several ventila- compliance measurement ex- and a 38-question quiz. Also ercises, included are 5 case studies covering several conditions clinical — including asthma, chronic obstructive pulmonary disease, acute respiratory distress syndrome, pulmo- and ysis of waveforms). Several figures in this of insuf- 56, mentioned earlier, and Figure 50, in spontaneously which the inspiratory pressure versus time ficient inspiratory breathing patient flow is illustration in the given; the authors point The baseline changes without explanation). out that this can be detected by observing a waveform downward deflection of the ventilator airway manometer needle. Unfortunately, the computer-generated and do not meet the authors do not complete the lesson by uti- Graphics this Though waveform graphics to document same phenomenon. An example 2, is provided Figure 56); however, the di- show wave is marginal, and it fails to the "scalloping out" of the pressure that is pathognomonic of this event. Newer modes and techniques of mechanventilation are each described in this section. They include airway pressure section illustrations appear to be standards of quality that are found in the Comer of Respiratory Care. they do convey the basic points, actual ventilator-generated better serve the authors This examples would and readers. final section also includes a glossary of terms and definitions that coincide with the 1993 ventilator consensus termi- nology and classification. The manual's chapters are not referenced. However, the re- annotated bibliography lists major contrib- lease ventilation; proportional-assist venti- utors to the mechanical ventilator literature. lation and permissive hypercapnia; noninvasive positive pressure ventilation in acute respiratory failure; ing, and the monitoring dur- weaning from, and withdrawal of ven- References are current to 1997. The manu- form may not be as enjoyable to read as other books that use a narrative. A al's outline condensed or a pocket-size version may be tilatory support. III. The better appreciated. Despite a ical errors and manual does contain much of the this namic compromise, nosocomial pneumonia, sential information and oxygen toxicity. to deal with special A chapter included problems encountered in specific clinical conditions. is is An algorithm presented to aid trouble-shooting during Vol 44 No 4 may benefit few typograph- less than ideal illustrations, problems include volutrauma, hemody- mechanical ventilation, which Medicine, 1998. $40.00. tions that the respiratory care practitioner representations (which also offers an anal- inspiratory time cal ventilation are outlined in Part Raoof a valuable sec- effects of different and Complications associated with mechani- Mechanical Ventilation Manual, Suhail is An flow are addressed. ical Critical Part IV, the Appendix, tion of the manual, containing several sec- section are poor examples (including Figure teacher working in the field of respiratory care. Division of Pulmonary and energy ex- the problems associated with inappropriate the bookshelves of every investigator and H Thomas Robertson MD to read "resting" penditure. nary edema, and a chapter of diagrammatic rates, is- volume merits a prominent place on be corrected in- gen concentrations, ventilator agram's quality sues, this reference to Ventilate," discusses Regardless, because of the high level of presentation covering a broad range of A of ventilatory support, a section of formulae pressure ventilators, intensive care unit ver- (Appendix ests. its to assess the Mechan- differences between positive and negative lizing ing for a physiologist with medical inter- The Ventilator Consensus conferences.'-^ ventilation. In the chapter, "Basics of Initial ventilatory support. and problem of the "resisting" energy expenditure should to assess the significant innovation in ventilator supfwrt of the past 2 decades. While tilation The merits. Its physiologic it strong grasp of individual patient physiol- in in- clinical conditions where ventilatory support how importance, and clinical patient's nutritional status. Ventilate?", briefly outlines ogy, and I an out- does not receive the depth assist ventilation of coverage that rationale tilation. the difference While any suggestion for an addition that is already the inexf)erienced practitioner. authors describe causes of malnutrition, a book filled with things that is A section on Raoof and Khan designed to be a practitioners interested in mechanical ven- ter for book is strategies for ven- a fitting final chap- do, asking the question, manual malnutrition in the ventilated patient. management. It is In the preface, editors state that their quick reference source for interns or other tilator investigate a Software in obtain- difficulties ing interpretable data is & ventilated patient. es- needed for care of the Its use of graphs and gorithms helps convey concepts in al- simple understandable terms. The Mechanical Ventilation Manual does fill the requirements of residents or students of respiratory 447 . & Books, Films, Tapes, care looking for basic reference material that quick and easy to is interpret. Software binemia, given that both of these hemoglo- tionality binopathies can affect pulse oximetry. good. Similarly, the chapter on accuracy and Chapter 3 provides an overview of blood Steven Holets AS RRT RCP Clinical Specialist Department of Respiratory Care Mayo Medical Center Rochester, Minnesota oxygen measurement. The discussion of the Clark electrode Missing ful. electrode is too superficial to be use- discussion of is how the Clark incorporated into the blood gas is analyzer and issues such as calibration and The quality control. discussion of spectro- photometers and carbon monoxide-oxime- REFERENCES ters, however, is good. Mention of indwell- ing blood gas probes American Association 1 for Respiratory Care. Consensus conference on the essentials of mechanical ventilators. Respir Care 1992; view). American College of Chest Physi- Consensus Conference. Chest 1993; 104(6):1833-1859. based on Beer's law. Beer's law is used to ef- Nonetheless, Beer's law provides a model to describe the principles of pulse oximetry. Chapter 4 provides a su- Editor. (Medical Science Series) Hardcover, perb discussion of Beer's law as Phil- measurement of oxygen to the Chapters adelphia PA: Institute of Physics Publish- 5. 6, This book emphasizes the design of pulse is applies one of the Medical Science erful enough light source that pow- is to International Organization for Medical As to fabricate the pulse try as well as the equations, oxime- methods, and light that passes The book into 1 is consists of 3 chapters. A 244 pages divided glossary is included at end of the book. Each chapter includes is the beginning of the chapter. all The editor at and of the chapter contributors are from the Department of Electrical and Computer Engineering at the University of Wisconsin. may be very important information for engineers responsible for designing pulse oximeters, it has limited usefulness for clinicians. The more is The probe packages clin- the light- emitting diodes and photosensor so it can be attached to the patient. Clinicians must regularly choose an appropriate pulse oximetry probe errors and troubleshoot issues related to due to probes and their placement. Chapter 8 covers electronic control of 2 chapters of the book cover pulse oximetry and Chapter 9 covers signal normal oxygen transport and the motivation processing algorithms. These chapters are The first for pulse oximetry. I suspect that many clinicians will find these chapters too superficial to this be useful. Noticeably absent from chapter oxygen. I is a discussion of mixed venous also expected some discussion of carboxyhemoglobinemia and methemoglo- 448 may find interesting the discussions of graphical displays, numerical displays, and alarm controls. The final chapter of the book (Chapter 13) describes clinical applications of pulse oximetry. There are interesting dis- monitoring tissue blood supply and organ viability (such as dental pulp blood supply), use of pulse oximetry during ground and air and fetal monitoring during child- Noticeably absent from this chapter is a discussion of the use of pulse oximetry in many parts of the book, reflects the fact that ;ire engineers and not clinicians. strength of this book its is a emitting diodes and photosensors are dis- ically useful. end of the saturation pulse oximetry. In that respect, the book has chapter on probes (Chapter 6) the oxygen light. Issues related to light- Cu- at the true proportional to the intensity Ob- found if detailed coverage of the technical aspects of relevant, but not exhaustive, references. chapter rather than the usual placement the 85% 85%. less than The major The photodetector produces todetector. jectives are included with each chapter. riously, these are if greater than produce an inaccurately high ox- will ygen saturation is is measured by a pho- cussed in extensive detail. Although this providers. the through tissue from the light-emitted diode of the incident and health care it sat- produce an inaccu- will it low oxygen saturation reading the authors current that neers, medical physicists, 85%. Because the intensive care unit. This chapter, like software required for effective functioning. written for biomedical engi- the tfue oxy- if light-emitting diodes (Chapter 5). discussed in Chapter 6. the amount of The book is 85%, oxygen saturation birth. met by ware required uration of and has a narrow Medical and Biological Engineering and the includes the hardware and soft- less than is methemoglobin causes a puLse oximetry to penetrate tissue, is small into a probe, fit emission spectrum. These requirements are It only correct is gen saturation transport, enough Series of the International Federation for Physics. globin. This cussions of pulse oximetry applications in and 7 cover light-emitting oximetry requires a oximeters and it saturation. diodes, photodetectors, and probes. Pulse ing; 1997. $90.(X). oxy- presence of methemo- in the Chapter 12 describes issues related to the theoretical UK and gen saturation user interface for pulse oximeters. Clinicians Design of Pulse Oximeters, JG Webster, Bristol stated globin solutions, but does not apply for whole blood because of the scattering 244 pages. It is that pulse oximeters overestimate the and is an im- determine the oxygen saturation of hemo- fects. illustrated, curacies due to methemoglobin. true testing. has 1 1 ) is portant error in this chapter related to inac- rately Light absorbance in pulse oximetry However, there clinical relevance. nous oxygen saturation catheters. There is is particularly errors of pulse oximeters (Chapter without discussion of optodes or mixed ve- Slutsky AS. Mechanical ventilation (re- cians' nearly absent, no analysis of point-of-care 37(9):999-1130. 2. is of pulse oximeters achieved is primary its However, intent. this clinical relevance in expense of at the many places throughout the book. Because of strong engineering approach, mathe- its matical relationships are presented throughout the text that clinicians might find intimidating. anyone would recommend I who this book for wishes to learn more about the technical aspects of pulse oximetry what happens inside the probe and the display. — ie, box between the Due to its relatively steep cost ($90) and limited clinical usefulness, this is not a book onto the shelves of pists and that will find many its way respiratory thera- critical care physicians. very technical and thus might be of limited Dean usefulness to clinicians. R Hess PhD RRT FAARC to cal- Department of Respiratory Care ibration of pulse oximeters. Clinicians will Massachusetts General Hospital Chapter 10 analyzes issues related find this information useful. the chapter on simulators to of Harvard Medical School check the func- Boston, Massachusetts The .section Respiratory Care • April 1 999 Vol 44 No 4 & Books, Films, Tapes, Human Immunodeficiency Virus and the Lung, Mark Beck MD, MD Rosen J Editors. (Lung Biology and Disease, Volume 1 19, New in Healtii Claude Lenfant, Executive Editor) Hardcover, 584 pages. M and James illustrated, moral considerations, such as the when gay situation raised immunodeficiency syndrome (AIDS) epidemic knowledge on is which the rapidity at aspects of all human immu- rus the pathophysiology and natural itself, history of HIV infection, and the syndromes associated with HIV-induced immunosup- knowledge pression. Furthermore, this seems to be in a status of continuous change. These changes occur on many fronts, ranging from the epidemiology of HlV-infection and AIDS to the therapeutic approaches available for AIDS-related complications. most current Centers for Disease Concase definition of to act as surro- gates. (although Two Part discusses aspects of the cell The section is that quite appropriately divided into chapters dedi- HIV and cated to infection of lung cells. HIV and of to clinical aspects the lungs. Pulmonary Dis- Part Three, "Diagnosis of orders." includes excellent chapters on bronchoscopy and on noninvasive diagnostic tests. The chapter on bronchoscopy includes useful diagnostic algorithms to approach fo- HIV disease. the chapter on noninvasive tests includes a useful table on the radiographic patterns of abnormalities in HIV infection. vide excellent clinical descriptions of the and its complete fash- knowledge on HIV infection pulmonary complications and se- The book tions. Part is divided into 6 different sec- One provides an overview of HIV infection, which, in addition to epidemiology, includes a chapter on tion HIV and intensive care for patients with tion. injec- drug users and a chapter dedicated to I found portant. the.se While the HIV infec- chapters particularly iminitial spread of the AIDS epidemic occurred mostly within the gay community, the HIV is currently spreading these entities ter is rapidly evolving. marizes the experience in tions of HIV in this particular group as well as the challenges confronting prevention and infection control strategies nous drug users. among some important Respiratory Care • HIV 1 sible format." In general, the book is easy to read. The index and and well written and well organized is facilitates the rapid location Numerous tables support The and complement the of references list ,500), but of specific figures, photographs, is text. extensive (over few cover papers published after at least at San Francisco In This book will be of interest for all health HIV-infected patients. The target audience includes pulmonary and critical care physicians, respiratory therapists, and intensive care nurses. Respiratory therapists and summary, in addition to providing an excellent review of both the infectious and noninfectious pulmonary complications of HIV. care providers involved in the treatment of one occasion a missing word ob- scures the meaning of a sentence (Page 73). the book also addresses general aspects of the epidemiology and pathogenesis of HIV infection, aspects of cell and molecular biology of particular relevance to the lungs, and specific issues related to the care of the HIV patient with pulmonary disHIV patient in the intensive ease or to the find particularly interesting the care unit. Health care providers involved in chapters related to invasive and noninva- the care of HIV-infected patients will find sive diagnostic procedures, as well as the particularly useful the chapters dedicated to nurses may The most which the difficult field problem faced by any is difficult for the authors to printed. The pulmonary complications of disease. it extremely Gustavo Matute-Bello by the time the book is problem MD Senior Fellow provide truly up- editors recognize this and HIV that the rapidity at evolves makes to-date information the different book. Division of Pulmonary and Critical Care Medicine Department of Medicine infec- clude the most comprehensive and current University of Washington and information available, emphasizing that ethical April and syn- state their efforts to "in- The chapter dedicated intensive care for patients with tions includes intrave- The chap- for the diagnosis of this condition. book on HIV disease injection drug us- many of a very useful algorithm The chapter on HIV and ers addresses both the specific complica- pulmonary [the infection] thesize disparate information into an acces- on Pneumocystis carinii pneumonia sum- clinical sections of the a faster rate HIV complications of meet compre- high number of typographical errors, and in among intravenous drug users and members of nongay ininority groups. at overall the authors compendium of hensive the evo- pulmonary complica- should be noted that it the treatment (and prevention) of General Hospital quelae. However, (HAART) on pulmonary syndromes associated with HIV. although in a concise, yet more 1996. Unfortunately, there are an unusually different ion the current liked to see their stated goal of "providing a 1 by some of the most important authorities summarize tions. contents. complications of HIV. These chapters pro- the field, represents a major effort to HIV. as co-receptors for would have I The remain- field ciency Virus and the Lung, co-authored in CXCR5, lution of HIV-related and diffuse pulmonary disease, while cal Human Immunodefi- and bewildered when approaching the of Also, make of chemokine receptors, ticularly the role such as findings failed to into the pages of the book, par- antiretroviral therapy and Five are dedicated Piuls Three, Four, ing clinical sections (Four and Five) include it way not included is discussion on the impact of highly active descriptions of infectious and noninfectious change makes some important new their AIDS referenced). Unfortunately, is HIV and lung lymphocyte function, and HIV easy a rapid pace of it and alveolar macrophage function. for the non-HIV-specialist to feel confused Such by the time the published." Perhaps for this reason trol nodeficiency virus (HIV) infection has evolved, including knowledge about the vi- unlikely to change is is the are relevant to the lungs. the acquired which book members, and molecular biology of HIV infection most impressive features of the difficult patients prefer their lovers or partners, rather than their biological family York: Marcel Dekker Inc; 1998. $195.00. One of Software to in the preface 999 Vol 44 No 4 Seattle, Washington 449 News There to releases about no charge is new products and for these listings. RESPIRATORY CARE, New New Products services will be considered for publication in this section. Send descriptive release and glossy black and white photographs Products & Services Dept, 1030 Abies Lane, Dallas 1 The Reader Service Card can be found Drug Administration (FDA) TX market to Xopenex'"(levalbuterol HCl). According to the company, the inhalation solution two dosage strengths available in & Services 75229-4593. back of the Journal. at the is send your request elec- this issue, or tronically via "Advertisers Online" at http://www.aarc.org/buyers_guide/ for use with a nebulizer for the treatment and prevention of bronchospasm. Sepracor says the new drug the therapeutically active is (R)-isomer of racemic albuterol. A company spokesperson describes racemic albuterol as an equal mixture of (R) and (S) isomers drug is and explains that although the the world's leading brochodilator for asthma, they found that removing the (S) isomers increased effectiveness of the (R) isomer. For Sepracor, circle more information from number 192 on the reader service card in this issue, or send your request electronically via "Advertisers Online" http://www.aarc.org/buy- at ers_guide/ System Software for Exercise System. Spacelabs Burdick Inc announces the release of version 2.1 software for the Quest* Exercise Stress System. According to a company press release, the updated version includes several new features: graphical Nasal and tabular trends (both Wash recently on display and printed components of the in-stage and final reports); test trended and allergy ST level way cially available NIBP to BP mesurements and take sufferers. A company now be to help relieve the pain press and pressure associated with congested nasal or sinus commer- passages. programmed RinoFlow interfaced with three different RinoFlow™ its Sinus System for sinus release says the device provides a gentle and slope measurements during the exercise stress test; the system can available Wash and Nasal heart rate, blood pressure, and System. Respironics has made incorporate them sisting Respironics as portable describes and easy the to use, con- of a small compressor unit the size of a tissue box (weighing about 5 lbs) and into final reports; "freeze screen" func- Vital Signs Monitor. a hand-held misting ond, 12-lead printouts; and a Digital Base- has introduced BCI International new vital signs mon- connect to the compressor. For more infor- line Stabilization Filter eliminates baseline itor, com- mation from Respironics, circle number wander pany, the tion allows user to print artifact. and save 10-sec- For more information from Spacelabs Burdick, circle number its the Advisor™. According to the new monitor offers all of the basic parameters for vital signs moni- ECG (3/5 NIBP, 191 on the reader service card in this issue, toring, with or send your request electronically via respiration, invasive pressures, "Advertisers Online" peratures. at http://www.aarc. org/buyers_guide/ BCI lead), Sp02, and tem- chamber and tube 194 on the reader service card that in this issue, or send your request electronically via "Advertisers Online" at http://www.aarc. org/buyers_guide/ says a recorder and battery option are available and that a PC card allows for field upgrades. For more infor- Bronchodilator. Sepracor Inc has received final 450 approval from the U.S. Food and mation from number 193 on BCI International, circle the reader service card in RESPIRATORY CARE • APRIL 1 999 VOL 44 NO 4 . Form Approved: VOLUNTARY For reporting by health professionals of adverse events and prcxluct problems MEi:)JfccH THF FDA MEDICAL PRODUCTS REPORTINC PROGRAM Page . Patient identifier 2 Age at 3 Sex 4. Triage unit sequence « Suspect medication(s) C. time 0910-0291 Eicplrm: 4/30/96 statament on revsfM OMB Care) of A. Patient information 1 OMB No S*« FDA Use Only (Resp Weight 1 Name . & (give labeled strength mfr/labeler, if known) of event: or I I female I I male #1 .lbs Date In of birth: confidence 1. Q 2 Outcomes Adverse event (check all and/or | | Product problefti attributed to adverse event I death 'I I I I I Therapy dates #1 defects/malfunctions) initial or prolonged I LJ Diagnosis for use Q »1 Dyes Dno #2 Dyes #2 other: 4 Date of this report event Event abated after use stopped or dose reduced 5 (indication) #1 required intervention to prevent Lot # 6. 3 Date of (if known) Exp. date 7. #1 #1 #2 #2 (if known) n no nggPPy"'' Dgg^Py"'' Event reappeared after 8 imoday.yr) 5. unknown, give duration) #2 #2 4 congenital anomaly permanent impairment/damage - (if #1 I life-threatening hospitalization (e.g.. — | I 3. Irom'lo (or best estimate) disability that apply) Dose, frequency & route used 2 Adverse event or product problem B. #2 kgs reintroduction Describe event or problem »^\Jyes\Juo NDC 9. # (for Dyes #2 n n&'' no Concomitant medical products and therapy dates (exclude treatment 10. D^g^Py"'' product problems only) of event) Suspect medical device D. 1 Brand name 2 Type 3. Manufacturer of device name & address Operator of device 4 I I I I health professional lay user/patient other: Expiration date 5. (mo/day/yr) 6, model # _ 6. Relevant tests/laboratory data, including dates 7. If catalog # serial # implanted, give date (mo/day/yr) _ 8. If lot# explanted, give date (mo/day/yr) other # 9. Device available for evaluation? I 1 7 Other relevant history, including preexisting medical conditions (eg. race, pregnancy, smoking and alcohol use. hepatic/renal dysfunction, etc.) I yes LJ no LJ 2 5600 Fishers Lane Rockvllle, MD 20852-9787 DA Form 3500 1/96) or FAX of event) allergies, Reporter (see confidentiality section on back) Name & address MEDWaTCH FDA) to Concomitant medical products and therapy dates (exclude treatment 0, E. Mail to: (Do not send returned to manufacturer on Health professional? yes to: 1-800-FDA-0178 5 If phone # 3. Occupation no you do NOT want your identity disclosed to the manufacturer, place an Submission of a report does not constitute an admission that medical personnel or " tfie X " in this Also reported to 4 box. Q I 1 I I I I manufacturer user facility distributor product caused or contributed to the event. ADVICE ABOUT VOLUNTARY REPORTING How to Report experiences with: • medications (drugs or biologies) • medical devices (including • special nutritional products (dietary in-vitro diagnostics) other products regulated by • use section FDA SERIOUS adverse events. An event serious when the patient outcome is: • death • life-threatening (real risk of dying) • hospitalization • disability (significant, persistent or • congenital anomaly • required intervention to prevent permanent impairment or Report even (initial in fill C for all products except or prolonged) permanent) if needed each patient • attach additional blank pages • use a separate form • Report is the sections that apply to your report just medical devices supplements, medical foods, infant formulas) • report: • FDA report either to for or the manufacturer (or both) Important numbers: • 1-800-FDA-0178 • 1-800-FDA-7737 • 1-800-FDA-1088 to FAX report modem to report by to report by phone or for more information 1 -800-822-7967 for for damage a VAERS form vaccines If your report involves a serious adverse event with a device and occurred in a facility outside a doc- if: it • you're not certain the product caused the may be legally required to report to and/or the manufacturer. Please notify the person in that facility who would handle such reporting. tor's office, that facility event • FDA you don't have all the details Report product problems - quality, performance Confidentiality: The patient's FDA and protected or safety concerns such as: confidence by • suspected contamination • questionable • defective stability the law. components poor packaging or labeling • therapeutic failures The public reporting burden for tills collection of information iias been estimated to average 30 minutes per response, including tiie time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden held in strict reporter's identity, including the identity of a may be shared DHHS Reports Clearance Office Paperworlc Reduction Project (0910-0291) Hubert H. Humphrey Building. Room 531-H 200 Independence Avenue. S.W. Washington, DC 20201 "An agency may not conduct or sponsor, and a person is not required to respond to, Please do a collection of intormation uniess it displays control number." a currently valid OMB to: U.S. Pleasc UsG Addrcss Provided Below - Just Fold DEPARTMENT OF HEALTH AND HUMAN SERVICES In Thirds, Tape • Food and Drug Administration and IVIail Department of Health and Human Services NO POSTAGE NECESSARY MAILED THE UNITED STATES OR APO/FPO IF Public Health Service Food and Drug Administration Rockville, Official MD IN 20857 Business Penalty for Private Use $300 NOT return this form to either of these addresses. Public Health Service FDA Form 3500-back is with the manufacturer unless requested otherwise. However, FDA will not disclose the reporter's identity in response to a request from the public, pursuant to the Freedom of Information Act. self-reporter, »i • The identity to the fullest extent of BUSINESS REPLY MAIL FIRST CLASS MAIL PERMIT NO. 946 ROCKVILLE, MD POSTAGE WILL BE PAID BY FOOD AND DRUG ADMINISTRATION ME[:)i)&^CH The FDA Medical Products Reporting Program Food and Drug Administration 5600 Fishers Lane Rockville, MD 20852-9787 I,,I.III...I.iI.iI.Ii..IiII.Ii.Ii.iIIiiIiIiiiImMI . . . . American Association for Respiratory Care JJ. Please read the eligibility requirements for each of the classifications in the right-hand column, then complete the applicable section. All information requested below must be provided, except where indicated as optional. See other side for For office use only more information and fee schedule. Please sign and date and type or print clearly. Processing of applica- application on reverse side tion takes approximately 15 days. D Active Associate n D Foreign Physician Industrial D n Lost Name Special FOK ACTIVE MEMBER Student An individual is eligible if he/she lives in the U.S. or its territories or was an Active Member of the following criteria: (1 ) is prior to moving outside its borders or territories and meets legally credenlialed as a respiratory core professional if employed in a state that mandates such, (21 is a groduote or an occredited educational program in respiratory care, [3] holds a credential issued by the NBRC. An individuol who is an AARC Active Member in good ONE OR OR _ standing on December 8, 1994, good standing. First Name will continue as such provided his/her membership remoins PLEASE USE THE ADDRESS OF THE LOCATION WHERE YOU PERFORM YOUR JOB, THE CORPORATE HEADQUARTERS IF IT IS LOCATED ELSEWHERE. Social Security in NOT Place of Employment No. Address Home Address City_ .Zip State City Phone No. .Zip State Phone No. MEMBER OR SPECIAL FOR ASSOCIATE do who not meet the requirements of hold a position related to respiratory care but be Associate Members. They have all the rights and benefits of the Assostanding committee. The following subciation except to hold office, vote, or serve as choir of a classes of Associate Membership are available: Foreign, Physician, and Industrial [individuals manufacture, sole, or distribuwhose primary occupation is directly or indirectly devoted to the tion of respiratory care equipment or supplies). Special Members are those not working in a respiratory care-related field. Active Technical Director Assistant Technical Director Pulmonary Function Specialist Member shall PLEASE USE THE ADDRESS OF THE LOCATION WHERE YOU PERFORM YOUR JOB, THE CORPORATE HEADQUARTERS IF IT IS LOCATED ELSEWHERE. Instructor/Educator Place of Employment Staff Therapist Address Technician Rehabilitation/Home Care City_ Medical Director .Zip State Sales Phone No. Student Other, specify FOR STUDENT MEMBER Members Typo of BusinosM D Hospital D Skilled Nursing Facility D DME/HME n Home Health Agency n Educational Institution D Manufacturer or supplier Individuals will be in U.S. Citizen? — Student Members do not receive Continuing Respiratory Core Education SPECIAL NOTICE (CRCE) transcripts. Upon completion of your respiratory care education, continuing education may be pursued upon your reclassification to Active or Associate Member. credits Scfiool/RC Program Address City_ _ Yes in the process of seeking accreditation from, .Zip State Birth (optional) if they meet all the requirements for Associate an educational program in respiratory care accredited by, or an AARC-recognized agency. classified as Student Membership and are enrolled Other, specify Dote of Sex (optional) Phone No. length of program n year n 2 years No 1 Have you ever been a member ^ If so, NOT Supervisor Staff n D D D D ) Individuals Primary Job Kesponsiblltty (check one only) n n n n n D ( Medical Director/Medical Sponsor when? From of the AARC? [j 4 years n Other, specify Expoctod Dato oi Graduaflon to Preferred mailing address: (REQUIRED INFORMATION) D Home D Month Business AnJIRPffiSiHii Respiratory Care • 1 1030 Abies Lane • Dallas, TX 75229-4593 Year • [972] 243-2272 • Fax [972] 484-2720 EMBCRSHIP APPUeATION American Association for Respiratory Care Demographic Questions We request that you answer these questions in order to help us design services and programs to meet your needs. Chaclc fhe Highest D D D n n D RC Graduate Technician Associate Degree Bachelor's Degree Master's Degree Doctorate Degree Number D D n Dogree Earned High School of Years in Kesplraiory Care 0-2 years 3-5 years 6-10 years Job Status D D 1 1 1-15 Years 6 years or more — 1999 Respiratory Care Open Forum FORMAT AND TYPING INSTRUCTIONS The American Association for Respiratory Care and its RESPIRATORY Care, invite submission of science journal, brief abstracts related to The any aspect of cardiorespiratory and selected authors abstracts will be reviewed, Open Forum invited to present posters at the AARC be during the International Respiratory Congress in Las Vegas, Nevada, December 13-16, 1999. Accepted abstracts published in the Membership November 1999 in the issue of RESPIRATORY will be Care. AARC is not required for participation. All accepted abstracts are automatically considered for Accepted abstracts care. will ARCF 40%; be photographed and reduced by will therefore, the size of the original text should be at least 10 points. Abstracts should be 400 words or less and have or 1 clear, concise table or figure. Geneva makes A the clearest reproduction. the abstract should be the explain content. Follow title in all title may font like Helvetica The first line of capital letters. Title should with names of all authors (including credentials), institution(s), and location; underline pre- name. Type or electronically print the abstract sinparagraph in the space provided on the abstract blank. Insert only one letter space between sentences. Text submission on diskette is encouraged but must research grants. senter's gle spaced in a single SPECIFICATIONS—READ CAREFULLY! An abstract may report (1) an original study, (2) the evaluation of a method, device or protocol, or (3) a case or case series. Topics may be aspects of adult acute care, con- table form, or a simple figure within the space allotted. fits be attached to the abstract form. Provide tinuing care/rehabilitation, perinatology/pediatrics, cardio- is pulmonary technology, or health care delivery. The abstract may have been presented previously at a local or regional mation requested. but not national —meeting and should previously in a national journal. The not have been published abstract the only evi- is dence by which the reviewers can decide whether the author should be invited to present a poster at the OPEN FORUM. Therefore, the abstract must provide all important data, findings, artd conclusions. Give specific information. Do not write may be submitted in may be included provided it No figure, illustration, or table be accompanied by a hard copy. Data to all author infor- A clear photocopy of the abstract form may may be employed without new or infrequently used abbreviations should out on first use. Any recurring phrase or expres- be used. Standard abbreviations explanafion; be spelled sion may be abbreviated, if it is first explained. Check the grammar, facts, and figof language; and (3) conformance to these abstract for (1) errors in spelling, ures; (2) clarity An specifications. may may staff of RESPIRATORY Care abstract not prepared as requested general statements, such as "Results will be presented" or not be reviewed. Questions about abstract preparation "Significance will be discussed." be telephoned to the editorial at (972) 406-4667. to submit abstracts early. Abstracts postmarked by April ESSENTIAL CONTENT ELEMENTS Early Deadline Allowing Revision. Authors may choose Original study. Abstract must include ( 1 ) Background: statement of research problem, question, or hypothesis; (2) Method: description of research design and conduct in sufficient detail to permit judgment of validity; (3) Results: ment of research findings with tical analysis; (4) state- quantitative data and statis- Conclusions: interpretation of the meaning 1999 will be reviewed and the authors notified by to be mailed by May 7, 1 2, only 999. Rejected abstracts will be accompanied by a written critique that should, in many cases, authors to revise their abstracts and resubmit Deadline (June letter them by enable the Final 11, 1999). of the results. Method, device, or protocol evaluation. Abstract must Final Deadline. The mandatory Final Deadline include (1) Bacicground: identification of the method, device, 1999 (postmark). Authors or protocol and tion its intended function; (2) Method: description of the evaluation in sufficient detail to permit judgment by letter only. will These is June 11, be notified of acceptance or rejec- letters will be mailed by August 25, 1999.' of its objectivity and validity; (3) Results: findings of the evaluation; (4) Experience: summary of the author's practical expe- Mailing Instructions. Mail (do not fax!) 2 clear copies and a rience or a lack of experience; (5) Conclusions: interpreta- of the completed abstract form, diskette tion of the evaluation stamped, self-addressed postcard (for notice of receipt) and experience. Cost comparisons should 1999 Respiratory be included where possible and appropriate. Case report. Abstract must report a case mon or of exceptional educational that is uncom- value and must include (1) Introduction: relevant basic information important to understanding the case. (2) Case details Summary: patient data and response, of interventions. (3) Discussion: content should reflect results of literature review. The author(s) should have been actively involved in the case and a case-managing physician must be a co-author or must approve the report. (if possible), Care Open Forum 11030 Abies Lane TX 75229-4593 Dallas to: . 1999 Respiratory Care Open Forum Abstract Form must be in all upper case (capital) Title 1 letters, authors' full names and text in upper and lowercase. 2. Follow title with all authors' names, including credentials (underline presenter's name), and institution, location. 3. ; Do not justify (ie, leave a 'ragged' right margin). 4. Do not use type size than 10 points. (Do not exceed 400 less words.) 5. All text and the or figure, must table, fit into the rectangle shown. (Use only clear, 1 concise table or figure.) 6. Submit 2 clean copies. This form may be photocopied if multiple abstracts are to be submitted. Mail original & 1 photocopy (along with postage-paid postcard) to 1999 Respiratory Care Open Forum 11030 Abies Lane TX 75229-4593 Dallas, Early Deadline April 2, 1999 is (postmark) Final Deadline June II, is 1999 (postmark) Electronic Submission Is Now Available. Visit www.rcjournal.com to find out more RE/PIRAJORy QiRE Manuscript Preparation Guide General Information A paper expressing personal but substanti- Point-of-View Paper: ated opinions on a pertinent topic. Title Page, Text, References, Tables, Respiratory Care welcomes original manuscripts related to the and Illustrations may be included. science and technology of respiratory care and prepared according to these Instructions and the Uniform Requirements for Special Article: Manuscripts Submitted to Biomedical Journals [Respir Care categories 1 997; 42(6):623-634]. Manuscripts are blinded and reviewed by professionals who are experts in their fields. for all aspects of the manuscript message clear is and it conforms is copyedited so that to the Journal's style. papers are copyrighted by Daedalus Inc and may Published ing. is A paper drawing attention to a pertinent concern; may Editorial: it present an opposing opinion, clarify a position, or bring a problem into focus. not be published A Letter: elsewhere without permission. Editorial consultation as a Special Article. Consult with the Editor before writing or submitting such a paper. Authors are responsible and receive galleys to proofread before publication. Each accepted manuscript its A pertinent paper not fitting one of the foregoing may be acceptable available at any stage of planning or writ- On request, specific guidance is provided for all publication cat- To receive these Instructions and related materials, write Respiratory Care, 600 Ninth Avenue, Suite 702, Seattle WA signed communication, marked "For publication," about prior publications in ics. this Journal or Tables and illustrations 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. Drug Capsule: & Structure A brief, instructive case report involving blood —with Questions, Answers, and A mini-review paper about a drug or class of drugs that includes discussions of Research Article: It A report of an original investigation (a study). includes a Title Page, Abstract, Introduction, Methods, Results, Graphics Comer: A briefcase report incorporating waveforms for monitoring or diagnosis erences, Tables, Appendices, Figures, and Figure Captions. uation of an old or new A description and eval- Comer: Kittredge's care equipment device, method, technique, or modification. rial It pharmacology, pharmacokinetics, and pharmacotherapy. Discussion, Conclusions, Product Sources, Acknowledgments, Ref- Evaluation of Device/MethodyXechnique: Discussion. —with Questions, Answers, and Discussion. 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/MethodATechnique, Evaluation Methods, Evaluation Results, Discussion, Conclusions, Product Sources, Acknowledgments, References, Tables, Appendices, Figures, and Figure Captions. PFT Corner: Like Blood Gas Comer, but involving pulmonary function 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, or is must be associated with the exceptionally instructive. All authors case. A case-managing physician must either be an author or furnish a letter approving the manuscript. Its components are ry, 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 CRI is characterized by figures, March 1996 Issue of RESPIRA- TORY Care for more detail. Case Summa- Discussion, References, Tables, Figures, and Figure Captions. Test Your Radiologic Skill: Like Blood Gas Comer, ing pulmonary medicine radiography and including one or Review Article: and A comprehensive, critical review of the literature state-of-the-art summary of a It the central pertinent topic that has been the 40 published research articles. Title Page, OutIntroduction, Review of the Literature, Summary, Acknowl- graphs; may but involv- more radio- involve imaging techniques other than conventional chest radiography. subject of at least line, edgments, References. Tables, Appendices, and Figures and Captions may be Review of Book, Film, Tape, or Software: A balanced, critical review of a recent release. included. Preparing the Manuscript Overview: A critical review of a pertinent topic that has fewer than 40 published research Print articles. on one side of white with margins of at least Update: been A report of subsequent developments in a topic that has critically reviewed in this Journal or elsewhere. RESPIRATORY CARE Manuscript 1 bond paper, in. (25 8.5 in. x 11 mm) on all in. (216 x 279 sides of the page. mm) Use double-spacing throughout the entire manuscript. Use a standard font (eg. Times, Helvetica, or Courier) at least 10 points in size, and Preparation Guide, Revised 2/98 Manuscript preparation Guide do not use italics Number all pages except for special emphasis. upper-right comers. Indent paragraphs 5 spaces. in Paper accepted but not yet published: Do notjustify. Do 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 DeRemee RA. Clinical profiles of diffuse Page, Abstract, Text, Product Sources List, Acknowledgments, References, each Table, and each Appendix. the first person 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 reviewer inspection. Cite references text with superscript numerals. erences are in first cited. On Assign numbers the reference page, in the list in the order that ref- the cited works numerical order. Follow the Journal's style for references. Abbre- viate journal names Chapter in book with AK. Acute Harwood RJ. 1977. editor(s): respiratory failure. In: Guenter CA, Welch MH, edi- Pulmonary medicine. Philadelphia: JB Lippincott; 1977:26-42. tors. Tables. Use consecutively numbered tables to display information. Start each table on a separate page. Number and including all nonstandard abbreviations and symbols. notes with conventional designations (*, them sufwrscript t, t, §, H, 1, Key the foot- **, tf) in con- body. Do not use Do not submit tables as phoin the table tographs, reduced in size, or on oversize paper. Comparison of nebulizer delivery methods the table and 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, AMA drug eval- CO: Publishing Sciences Group; horizontal or vertical rules or borders. Rau dis- be cited as references: desig- nate the accepting journal, followed by (in press), and provide 3 copies article for pulmonary in cap- References. Cite only published works as references. Manuscripts of the in-press interstitial 76-85. p. American Medical Association Department of Dnigs. Methods, Results, Discus- Pierce accepted but not yet published York: Futura; 1990. Corporate author book: letters (eg. Introduction, Begin subheadings ease. in and active voice. Center main section headings on the page and type them ital possible.) Use the same type- face as in the text. through a neonatal endotracheal tube: a bench study. Respir Care Illustrations. Graphs, line drawings, photographs, 1992;37(I1):123.V1240. are figures. Article in a publication that Page numbers each issue beginning with Use only illustrations that clarify Number them consecutively as Fig. I, 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 1991 ;15(Mar):6 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 1, 62,64. publication must be of professional quality. Data for the original Corporate author journal article: American Association graphs should be available to the Editor upon request. for Respiratory Care. Criteria for establish- If color is essen- consult the Editor for more information. In reports of animal ing units for chronic ventilator-dependent patients in hospitals. Respir experiments, use schematic drawings, not photographs. Care 1988;33(1 1):I044-1046. 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 titles and detailed explanations on figures; put this 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):139S-143S. ic Abstract in journal: (Abstracts citations are to be avoided. Those more Stevens DP. Scavenging ribavirin from an oxygen hood to reduce envi(abstract). Respir Care 1990;35(1 1): 1087-1088. Enright P. may be given Can we 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 obstiiictive 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;148(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.) ronmental exposure Drugs. Identify precisely end of the when text, available are mentioned, list city, do not any comfirst and list time state or any man- them on a Product Sources page before the References. Provide model and manufacturer's suggested num- price, if the study has cost implications. ease (editorial). Lancet 1992;340(8833): 1440- 1441. Ethics. Letter in journal: When reporting experiments on that procedures Aelony Y. Ethnic norms for pulmonary function tests (letter). Chest were conducted in human subjects, indicate accordance with the ethical standards of the World Medical Association Declaration of Helsinki [Respir Care 1997;42(6):635-636] or of the institution's committee 1991;99(4):1051. RESPIRATORY CARE Manuscript Preparation Guide, Revised 2/98 Manuscript Preparation Guide on human experimentation. State that informed consent was Do not obtained. use patient's names, or illustrations. in text initials, or hospital numbers When reporting experiments on animals, acknowledged. Computer Dislcettes. Authors are encouraged to submit electron- indi- ic versions of manuscripts as well as printed copies (3.5 on in Macintosh or cate that the institution's policy, a national guideline, or a law the care and use of laboratory animals will be was followed. author's name; IBM-DOS name and version of word-processing program used; and filename(s). Software used Do to produce graphics and tables should not write on diskette labels except with Statistics. Identify the statistical tests used in analyzing the data, be similarly identified. and give the prospectively determined level of significance in the felt-tipped pen. If revision of a manuscript Methods section. Report actual book and published p values article references to Cite only text- in Results. support choices of tests. Iden- diskettes in. format). Label each diskette with date; 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- tify Work ing manufacturers and their locations. These should be listed on the Prior and Duplicate Publication. product-sources page. or accepted elsewhere should not be submitted. In special instances, that has been published the Editor may consider such material, provided that permission to Units of Measurement. Express measurements of length, height, publish given by the author and original publisher. Please con- weight, and volume in metric units appropriately abbreviated; tem- sult the Editor is before submitting such work. peratures in degrees Celsius; and blood pressures in millimeters of mercury (mm Hg). surements in Show units. Report hematologic and clinical-chemistry mea- conventional metric and in SI (Systeme Internationale) gas pressures (including blood gas tensions) List SI equivalent values, SI when ed in the repwrted RESPIRATORY CARE all must should be able to A paper with corporate authorship must specify the key persons responsible for the [0.981 kPa]." For conarticle. Authorship is not justified solely on the basis of sohcitation I988;33(10):861-873 (Oct and 1997;42(6):639-640 (June of fiinding, collection or analysis of data, provision of advice, or similar services. Conflict of Interest Authors are asked to disclose any liaison or finan- arrangement they have with a manufacturer or distributor whose part of the submitted manuscript or with the manufacturer or distributor of a competing product. (Such arrangements do not disqualify a paper all in torr. may is should have participat- shaping of the manuscript; publicly discuss and defend the paper's content. 1988), 1989;34(2):145 (Feb 1989), product in the have proofread the submitted manuscript; and 1997). cial listed as authors work and jwssible, in brackets following non- values—for example, "PEEP, 10 cm H2O version to SI, see Authorship. All persons from consideration and are not disclosed to review- Persons who provide such ancillary services exclusively be recognized in an Acknowledgments section. Permissions. 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Please use the following forms: cm H2O (not cniH20), f (not bpm), L (not 1), IVmin (not LPM, l/min, or 1pm), mL (not ml), mm Hg (not mmHg), pH (not Ph or PH), p > O.OOI (not p>0.001 ), s (not sec), SpO: (pulse-oximetry saturation). See RESPIRATORY CARE: Standard Abbreviations and Symbols [RespirCare I997;42(6):637642]. Editorial Office: RESPIRATORY CARE Submitting the Manuscript Mail three copies [1 copy with author(s) name(s), 600 Ninth Avenue, Suite 702 Seattle 98104 script, figures, and 1 diskette, and the Cover Letter WA affiliation(s), 2 copies without name(s) and affiliation(s) for reviewers] of the manu- & Checklist to RESPIRATORY CARE, 600 Ninth Avenue, Suite 702, Seattle WA 98104. Do not fax manuscripts. Protect figures with cardboard. Keep a copy of the manuscript and figures. Receipt of your manuscript RESPIRATORY CARE Manuscript address- you con- on the topic of your paper. Your manuscript may be sent one or more of them for blind peer review. viation only if the term occurs several times in the paper. Write out the full term the whom (206) 223-0558 (voice) (206) 223-0563 (fax) e-inail: [email protected] [email protected] Preparation Guide, Revised 2/98 , COVER LETTER & CHECKLIST A copy of this Title of completed form must accompany all manuscripts submitted for publication. Paper: Publication Category: FAX: _Phone: Corresponding Author: Mailing Address: Yes Reprints: No E-mail Address: _ "We, the undersigned, have all participated in the work reported, proofread the accompanying manuscript, and approve mission for publication." Please print and include credentials, title, institution, academic appointments, city and state. than 4 authors, please use another copy of this form.* its If sub- more *First Author: Author Signature/Date. *Second Author: Author Signature/Date. *Third Author: Author Signature/Date. •Fourth Author: Author Signature/Date. 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Have authors' names been omitted from text and figure labels? Have copies of 'in press' references been provided? Has the manuscript been proofread by all the authors? Have the manufacturers and their locations been provided for all devices and equipment used? ' ' ' ' ' Respiratory care Manuscript ' Preparation Guide, Revised 2/98 — — Not-for-profit organizations are offered a free advertisement of up to eight lines to appear, on a space-available Calendar of Events basis, in an insertion order. DeadUne is Submit copy and insertion orders to AARC & AFFILIATES April 27 RESPIRATORY CARE. Ads Calendar of Events, RESPIRATORY CARE, '99 — Teleconference for other meetings are priced at $5.50 per line month two months preceding the AARC s 1999 the 1 month in which you wish 1030 Abies Lane, Dallas — "Confidence in Tomorrow" at Foxwoods Resort and Casino. The keynote speaker After viewing a tape of the second installment of the in the 20th of the Calendar of Events and require the ad to run. TX 75229-4593. — June 16-18 Oakbrook, Illinois The 1999 ISRC annual convention Richard and exhibition Blumenthal, Connecticut Attorney will be held at Drury Lane Theatre and Conference Center General; and featured speaker in the is Dr. is Chicagoland area. Topics will Henry Lee, renowned forensic include "Asthma: Managing the Disease," scientist. with opportunities under PPS, participate in a live telephone Contact: John Evenwell question-and-answer session (203) 688-2201 for more information. Rounds" "Professor's (11:30-12 noon one series, CDT) and receive CRCE credit hour. Contact: The May AARC at —Edinboro, Pennsylvania The Northwest District of the PSRC host its will 18th Aimual Education Seminar and Equipment Exhibition at Ramada Inn Edinboro. Featured speaker is Thomas Petty, MD, presenting equipment Pulmonary Medicine: Looking Ahead to Contact: Steve Easly 30-May — 2 AARC Patient Other Meetings May 6-8 (915)577-6563. May — 19-21 Virginia Beach, Virginia VSRC announces its 22nd annual Las Vegas, Nevada The American Lung Association of Nevada is sponsoring the 14th annual Respiratory Health Conference Tropicana Resort and Casino. Sea," at the "Symposium by the Ramada Tower at the Oceanfront. Sam Giordano more information. is the Assessment Course for respiratory therapists at the Westin May 20-21 Suites Philadelphia Airport. Each The for Aerosols at the physical assessment, and include ER trauma, in — International Society Medicine 2th International Congress at the Austria Center in Vienna, Austria. MSRC presents "The Maine Event" 6 hours of 1 —Rockport, Maine attendee will receive a pocket guide to at the Contact: Call (702) 431-6333 for June 12-16, 1999 at (757) 468-0702. be conducting the 1 [email protected]. at Contact: Dolly Saunders will at (618) 234-2120, ext. 1287, or e-mail keynote speaker. Philadelphia, Pennsylvania The Contact: Mike Lawrence to spring seminar, (814)866-3555. April and up will be featured, Contact: Bertha Butler The at regulation update, and CO-oximetry. CE hours are available. "Excerpts from the Evolution of the Solution of COPD." Breakout sessions include mechanical ventilation, blood gas speakers and state-of-the-art 12 the survival techniques for respiratory care. The Southwest Region of TSRC is sponsoring its 28th Annual Seminar at the El Paso Community College, Transmountain Campus. Outstanding (972) 243-2272. April 30 maximizing career potential and at —El Paso, Texas 19-21 management and subacute, Topics include aerosol drug Samoset Resort. Topics delivery, aerosol deposition neonatal and clearance, cellular and molecular CRCE credit are available as well as a waveforms, pulmonary rehab, the interactions, environmental certificate of course completion. tobacco settlement, and aerosols, standardization, aerosol Preregistration Contact: The is HMOs/managed required. AARC at (972) 243-2272. May diagnostics, and aerosol therapy. care. Contact: Bobbi Shirley (207) 797-0793 for more information. —San Antonio, Texas The Respiratory Care Society of The University of Texas Health Washington announces the 26th Science Center Annual Pacific Northwest Regional conjunction with the Respiratory Care Conference and District) Meydenbauer Center. San Antonio, at A- 1090 Vienna, Riverwalk Respiratory Care AARC neonatal/p)ediatrics section chair Katie Sabato, and AARC spokesperson Cheryl West. CRCE Symposium credit available. respiratory care in the year 2(X)5, Contact: Ellen Perry at (425) 899-3361 Respiratory Care • April 1999 Sheraton Four — August 19-20 Cleveland, Ohio The Cleveland Clinic Foundation program include disease management, which has been approved neonatal update, managing cystic fibrosis, and critical care transport. CRCE credits provided. Contact: UTHSCSA, Respiratory Care Vol 44 No 4 at Department of is sponsoring a continuing education Points Hotel Riverwalk North. Topics Six May 4-5 Hartford, Connecticut The CSRC present their Symposium e-mail [email protected]. and Wilford Hall Medical at the 4, Phone fax (-1-43/1)405 13 83-23, TSRC (Alamo Center, announce the 4th Annual Henry Lee, Austria. (-f43/l)405 13 83-22, in Speakers include forensics expert Dr. ore-mail [email protected]. Postgraduate Medical Education and Research. Alser Strasse May 28 2-4^Bellevue, Washington exhibit at the Contact: Vienna Academy of at 1 titled "Respiratory Therapy," accreditation. Omni It for Category will be held at the International Hotel. Contact: For more information, Laurie Martel at call (216) 444-5696 or (800)862-8173. (210) 567-8850. 46! Notices of competitions, scholarships, fellowships, examination dates, and the Notices like will be before the desired listed here free new educational programs, of charge. Items for the Notices section must reach the Journal 60 days month of publication {January pertinent information and mail notices to 1 for the March RESPIRATORY CARE issue, February Notices Dept, 1 1 for the April issue, etc). Include 1030 Abies Lane. Dallas ISa Helpful TX all 75229-4593. LUeb. Sites American Association for Respiratory Care http://www.aarc.org — Current job — American Respiratory Care Foundation eaao listings — Clinical Practice Guidelines National Board for Respiratory Care http://www.nbrc.org 45^" International lespiratory c o n 13 r e s s / .._ & awards fellowships, grants, RESPIRATORY CARE online ! http://www.rcjournal.com DEC EM.B E R 1 3|- 1(5 r — 997 Subject and Author Indexes — Contact the editorial \j\^ 9 9 1 r staff Las Vegas] Nevada Astlima Management Model System http://www.nhlbi.nih.gov The National Board for Respiratory Examination Care — 1999 Examination Dates and Fees Examination Date CRT Examination Examination Fee $120 (new applicant) July 10, 1999 Application Deadline: RRT Examination May 1, 80 1999 December 4, 1999 120 Application Deadline: August 1, 80 1999 (reapplicant) written only 130 CSE only 250 Both (new applicants) 210 Both For information about other services or 8310 Nieman Road, Lenexa 462 KS 66214, or call fees, write to the National (913) 599-4200, FAX (new applicant) written only (reapplicant) (all applicants) (reapplicants) Board for Respiratory Care, (913) 541-0156,or e-mail: [email protected] RESPIRATORY CARE • APRIL 1999 VOL 44 NO 4 Y NOTICES New Additions to AARC Web Site Make Communication Easy WATCH FOR The AARC's web SPECIAL ISSUES OF R E S P ATO CARE I R site (www.aarc.org) make communication AARC Executive Office and among other AARC memmuch more direct and accessible. Recent additions to the with the bers site include: R — Chat AARC members can chat on specific topics will be planned — Do you have Just Ask in real time. Organized chats in the future. a question about AARC policies or on issues? Do you need help in interpreting reimbursement and government policies? Do you want to know what the AARC is doing about legislative advocacy? You can positions post a question in this area for possible posting. ARTIFICIAL AIRWAYS — Hotline to the President Do you want immediate action from the top? Click on the "red phone" hotline to President Dianne Kimball. An E-mail will be sent directly to her. — Help Line Do you have a clinical or professional question you want answered? Post it on the help line and other AARC members will respond. — Specialty Section Mailing Lists If you are a member of one of the nine specialty sections, you have instant networking capabilities through the electronic mailing lists of each group. Patient Assessment Course for Respiratoiy Therapists JUNE 1999 Due overwhelming demand, the patient assessment course for is being offered twice this year. The first test date has passed, and the remaining test will be conducted in Phoenix, Arizona from July 18-20 (immediately following Summer Forum). Space is at a premium and preregistration is required. JULY 1999 to respiratory therapists Successful completion of the course will earn participants 16 hours of CRCE credit and a certificate of course completion. Each attendee will be given a pocket guide to physical assessment, to help them on the job. Following the last class, participants will take a 100-item test developed by the NBRC. Tests will be graded on-site for those wishing to obtain their scores immediately. For more information and to register, visit the AARC web site at www.aarc.org. AARC, Affiliates Set Conference Sciiedules Q//^ this issue 1999 "^dl The AARC and many of the affiliates have set their schedules 1999 conferences and seminars. Foremost among AARC's offerings are its Summer Forum (July 16-18) and Annual International Respiratory Congress (Dec. 13-16). Check out the AARC's website at www.aarc.org for all meeting for registration materials and a list of affiliate conferences. Videoconference Program Set; Nursing CEUs Offered A series of eight videoconferences are scheduled for 1999 through the AARC Professor's Rounds series, which are now approved for nursing CEUs as well as CRCE credit. Topics are: respiratory assessment, asthma management, ventilator management, disease management, pediatric emergencies, COPD, PEEP, and respiratory pharmacology. (B^bstxacts CRCE Online Debuts Now you can earn continuing education on the Internet from the AARC through its new CRCE Online website. After you pay number of continuing education units you wish to attempt (by submitting your credit card number on a secure server site), you are given access to the list of courses. Read the material, take the test, and then print out a certificate showing you passed. Your participation will also be noted on your CRCE record with the AARC. Log on to the AARC's website at www.aarc.org and look for CRCE Online. for the RESPIRATORY CARE • APRIL 1999 VOL 44 NO 4 463 1 Authors in This Issue Kathawalla, Salim 443 415 415 415 428 407 42 437 445 448 428 447 409 409 443 Laskowski, Daniel 441 Matute-Bello, Gustavo 449 Ahmad, Muzaffar Ambrosino, Nicolino Bianchi, Luca Clini, Enrico Delgado, Edgar Dillard, A Thomas M Dwyer, Terry Emad, Ali Haynes, Jeffrey M Dean R Hess, Hoffman, Leslie A Holets, Steven Homma, Ikuo Kakizaki, Fujiyasu To Advertisers at Owen Call (877) 3 Circle Reader Service No. 124 Call (800) 583-9910 393 Copyright Information. 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RESPIRATORY CARE, at FL 33469 For recruitment/ (972) 243-2272, RESPIRATORY CARE. 394-395 Mallinckrodt Inc 1 08 Call (800) NELLCOR 390 Respironics Inc Call (800) 345-6443 386 Sims Portex Inc Call (800) 258-5361 Westmed 399 Inc Call (800) 724-2328 made payable 1 to RESPIRATORY CARE and sent to the 1030 Abies Lane, Dallas TX subscription office at 75229-4593. prohibited. Permission to photocopies and copies for commercial purposes must be requested in writing, via e-mail 421 R Pinsky, Michael Circle Reader Service No. 104 noncommercial purposes of article in this Journal for scientific or educational 421 Circle Reader Service No. 147 IngMar Medical in G Marcy F Circle Reader Service No. 125 Cover 4 Call (800) 847-8000 Reproduction Rajesh Petrini, Call (800) 527-4278 12 Inc. Patel, Circle Reader Service No. DHD Healthcare photocopy a single the Cover 2 1 434 428 434 M Morales, Rodrigo TRG-TRAC Laboratories Daedalus Enterprises is Cover . 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Reprints for commercial use terprises Inc. may be purchased from Daedalus En- For more information and prices call (972) 243-2272. CHANGE OF Address. Notify the AARC at (972) 243-2272 as soon as possible of any change in address. Note the subscription number (from the mailing label) and your name, old address, and DISCLAIMER. The opinions expressed in any article or editorial are those of the author and do not necessarily reflect the views of the Editors, the American Association for Respiratory prises Inc. Neither are the Editors, the for the consequences of the Care (AARC), or Daedalus Enter- AARC, weeks use of any methods or de- sues, requests Manuscripts. The year. $ 1 in the 464 $9 US and Puerto 75 for 2 years, and $260 for 3 years countries (add $94 per year for air mail). Single copies $7; add Journal publishes clinical studies, method/device evaluations, reviews, and other materials related to cardiopulmonary Individual subscription rates are $75 per year (12 issues), $145 for 2 years, and $215 for 3 years $90 per Allow 6 countries. icine Rico. Rates are address. or the Publisher responsible clinical applications or vices described in any article or advertisement. SUBSCRIPTION Rates. new To avoid charges for replacement copies of missed ismust be made within 60 days in the US and 90 days in other for the change. when for air mail postage to overseas countries. in all other and research. Manuscripts PIRATORY Care, 600 may Ninth Avenue, Suite 702, Seattle structions for authors are printed in every issue. the Instructions is available med- be submitted to the Editorial Office, RES- from the WA 98104. An expanded In- version of editorial office. available cost Checks should be :• Copyright © RESPIRATORY CARE 1999, by Daedalus Enterprises Inc. • APRIL 1999 VOL 44 NO 4 A/a fê: Respiratory Car£ is the most highly regarded peer-reviewed scientific publication for the Clinician participating in the evaluation and care of patients vîth cardiopulmonary problems. Please print; Incomplete forms Respiratory Cute Subscription U.S. 1 YR 02bsiics) 2VIB (Mhsus) 3YIIS «06 Issues) Signature will Form SubscHptlons a»75 D'145 a '215 not be processed. For faster service, fax to Subscriptions OutsMe "-^ •90 a '175 D»260 ' (972)484-2720 Is a check the amount of Enclosed In Charge to my: D n D Mastercard Visa Bill Me "ttCLHissim 1 Authors in This Issue Ahmad, Muzaffar 443 415 415 415 428 407 42 437 445 448 428 447 Ambrosino, Nicolino Bianchi, Luca Clini, Enrico Delgado, Edgar Dillard, Dwyer, Terry Emad, Ali M Haynes, Jeffrey Hess, A Thomas M Dean R Hoffman, Leslie A Holets, Steven Homma, McCarthy, Kevin Mendizabal, Jorge Miro, Adelaida 441 E 434 428 434 M Morales, Rodrigo Patel, Rajesh Petrini, G 421 Marcy F 421 R Pinsky, Michael Shibuya, Masato 428 415 446 409 K 441 Porta, Roberto Robertson, Stoller, H Thomas James Suzuki, Hajime 409 Ikuo Kakizaki, Fujiyasu. . . Kathawalla, Salim . . . Laskowski, Daniel. . . NO POSTAGE NECESSARY Matute-Bello, Gustavc IF MAILED IN THE UNITED STATES Advertij BUSINESS REPLY MAIL in This Is FIRST-CLASS MAIL Bird Products Corpon POSTAGE WILL BE PAID BY ADDRESSEE Laboratories . . 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The f AARC Publications PO BOX 11605 Riverton NJ 08076-7205 yi $7; add $9 for air mail 464 l...l,.l.ll...l.,.l.ll..l...l..l.lll....l.l..l.l.l % "^^T&Z.^ '^te- •''^^t^ y^~ ^£VlO^ ^ /l^ ^ ^ ^-l-^y /^ t^ To W Pilhec/ W, riting a part is of patients _I ^^^JP/SL^ nome quickly becoming a the patient care more made caring for of challenge than a some necessary. Until •^ Vr/,'SO. continuum. Unfortunately, equipment limitations have ^^-^ •^-^-i^^ prescription for care ventilation routine TZi^j «te: ^^filU Combine the vMBBBB" Pressure Support with othefT^Srarcs families. Introducing the TBird Legacy, the only homecare ventilator delivering Pressure Support. Research has like flow and integrated alarms and the result is a great homecare The Legacy's and their simplified patient with all interface even reduces the substantial To learn more about effective homecare ventilation, contact Thermo Respiratory Alternate Qjre at (877) fatigued by the ventilator can concentiate the TBird Legacy's on getting well sooner, continuing the help -not hinder- the decision. Write weaning process even a prescription for TBird Legacy ® Pressure Support's ability to home. capabilities will and give BIRD PRODUCTS CORPORA TION Thermo Respiratory Group Tlicniio Kcsiiiriilorv Alleninlc liOO 1 . BiMllson. R-D,. RRT & TRG-TRAC (874-8722). demon- While numerous factors enter into your decision to send a patient home, of the comforts d'fTiome" burden placed on family members. reduce work of breathing.' Patients less at your patients hospii triggering ventilator for your patients Now. strated *^ D.lv:s, K., .MP PEEP and slmuLilcd p.nicn; demand. I -i^'.si. 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