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ISSN 0020-1324-RECACP
EDITORIALS
Global Respiratory Care:
Common
Interests,
Not
Common
Credentials
Aerosol Therapy
in
Respiratory Care:
Technology
at the
Bedside
to
ORIGINAL CONTRIBUTIONS
A New Method
in
for
Assessing Nursing
Work Load
Performance
Small-Volume Holding
Different Propellents
REVIEWS
Stewart's Strong Ion Difference Approach to
Acid-Base Analysis
Bronchodilator Therapy
in
SPECIAL ARTICLE
Quantitating Caregiver
Work Load
in
the ICU
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FOR INFORMATION,
CONTACT:
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Services
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VOLUME
44
NUMBER
AARC
EDITORIALS
Global Respiratory Care:
American Association
Respiratory Care
for
A Case of Common
Ohio,
Interests,
Not
Common
by Jerome
M Sullivan Toledo,
Credentials
Kanagawa, Japan
Care
11
http://www.aarc.org
Technology at the Bedside: Aerosol Therapy by James B Fink and Rajiv Dhand Mines, Illinois
in Respiratory
24
Case Be
Therapist Registration or
Technician Certification
National Board for Respiratory
The Strong Ion Difference Approach: Can Made for Its Use in Acid-Base Analysis?
by Eric
a Strong
Care
26
ORIGINAL CONTRIBUTIONS
the Effect of Nursing
fittp://www.nbrc.org
Accreditation of Education
Dependence Nursing Scale (DNS): A New Method to Assess Work Load in a Respiratory Intermediate
Intensive Care Unit
Clini,
for
by Enrico
Gussago,
Italy
29
1701
Euless
(817) 283-2835
http://www.coarc.com
Performance of Large- Volume versus Small- Volume Holding Chambers with Chlorofluorocarbon- Albuterol and Hydrofluoroalkane-Albuterol Sulfate by Jolyon P Mitchell, Mark W Nagel Toronto, Ontario, Canada, and Joseph L Rau Atlanta, Georgia
38
Grants, Scholarships,
Community
Projects
45
Government
Cheryl
Affairs
Affairs
West
MHA
by James
Bronchodilator Therapy in Mechanically Ventilated Patients B Fink, Martin J Tobin, and Rajiv Dhand Mines, Illinois
(703-548-8506)
53
State
Jill
Government
SPECIAL ARTICLE
Quantitating Caregiver Work Load in the ICU: Intervention Scoring System by Dinis Reis Miranda Gronigen, Netherlands
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The Therapeutic
70
RE/PIRATORy
PFT
A New
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Feature for the Journal: Introducing
C&RE
RESPIRATORY CARE {ISSN
190)
1
K Stoller Cleveland,
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The contents of
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Abstracts
Summaries of
Editorials,
Tension Pneumothorax during Apnea Testing for the Determination of Brain Death
Joseph G. Bar-Lavic Y. Zonis Z. Anesthesiology 1998;89(5):1250-125l.
Bar-
Rcdl G. Anesthesiology
1998;89(5):1262-1264.
JAMA
1998;280(I9):1702-
Dalen
1
JE.
Arch
Med
I998;158(20):2I79-2181.
Gap Reilly
Med
998;26( 1
):
77 1- 772.
1
Bernard GR.
Med
Grit Care
Med
L. Crit
Care
1998;26(l l):l773-
Can
Futility
Be Defined Numerically?
Rapoport
J.
Teres D,
Lemeshow
S. Crit
Care
Med
TubeCapdeville
M,
Hall D,
Combination with a Double-Lumen Endotracheal Koch CG. Anesth Analg 1998;87(6): 1239-1241.
An Overview
S,
Method
lus Antognini
Force, Speed, and Oxygen Consumption in Thoroughbred and Draft Horses Polard USB, Leith DE, Fedde MR. J Appl Physiol
TB
DH
Arou.sal
TB
nea
O.
Carroll JL,
Bamford
1998:84(6):2052.
O2 consumption
the
as
DH;
same gross
efficiencies.
draft horses
(DH) have
imal
O2 consumption of TB
about twice
'
Abnormal
muscles
that of
DH
(134 vs 72
mL
kg
min
',
may
we measured O,
in 3
con-
We
hypothesized that
this
was
TB
and 4
lower speeds
in
DH
than in
TB, suggesting
DH
We
therefore
com-
treadmill.
5, 10, 15,
a draft force of 0,
at
TB
and
DH in
in
force-
20%
speeds
speed for
OSAS
at a
that increased
by 2
OSAS
aroused
We
found
that
tion velocities in
locomotor muscles.
2 vs 60
5 torr, p
<
0.05);
No
those with the highest apnea index had the highest arousal threshold (r
0.52, p
<
0.05).
The
subjects,
( il
stimuli to arousal.
Hypercapnia resulted
and earn
collegi'
in
de-
da.s.ses.
OSAS.
Ventila-
tory responses
with
size
OSAS
was
small.
We conclude
However,
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Bronchoalveolar I^avage Fluid Characteristics
of
ARDS:
Respinilor>' Theraplsi
teins,
PAF and
Surfactant Components
I,
Nakos G,
Lekka ME.
n D D
Respiralory Technician
FEG
Technologist
Allied Ht-alth
D D D D D D D
Omimunity Health
Wellnes.s I'roniolion
Intensive Care
Med
Bachelor of Science
in Hcaltli Services majors iK
I998;24(4):296.
D D D D D
.\tcoiinting
Finance
D D
Marketing Business
Management
Master of Business Administration in Healthcare
Managenienl
Respiraton' Care
OBJECTIVE: To
D D
Home
Health Aide
Business Essentials
Polysomnography
D D
Medical
Assi,sting
and
cell alterations in
bronchoal-
Name
veolar lavage
(BAL)
Address
City /State
_Apl.
-Zip
(
.
(ARDS). DESIGN: Prospective controlled study. SETTING: 14-bed medical-surgical intensive care unit in a 750-bed university teach-
Home Phone
Hospital/Facility
_Phone
A
& Compemv
ing hospital.
PATIENTS:
19 mechanically ven-
tilated patients,
9 patients with
ARDS
and 10
Circle 115
were
INTERVENthe early,
TIONS:
BAL
Total phospho-
INTERVENTIONS:
Esophageal Doppler
cells,
PAF, and
cells
were
in
in
patients with
ARDS. These
factors,
undergoing quantitative
ARDS,
could
12 patients
in the
pathogenesis and
made
BAL fluid were observed in ARDS patients compared to the control group. PAF, proteins, and
neutrophils were higher in early
ARDS.
Required
to
ED
was assessed
ARDS
than in
Training
ability of
Is
Improve the
III
Reli-
cients
intermediate or late
ARDS. The
surfactant pool
Cardiac Output
Patients
syndrome.
Aya AG,
Saissi
JJ.
G, Dauzat
Intensive
were compared.
MEASUREMENTS &
training
REperi-
The
tant
M, de La Coussaye
Care
JE, Eledjam
SULTS: During
ods, 107 and
and evaluation
Med
I998;24(4):347.
320
CO
1
measurements were
per-
good surface
properties;
in
formed
in
out of
2 patients and in
49 out of
OBJECTIVES: Assessment
training
of and effect of
.52 patients,
respectively. Continuous
in
CO
monand
and phos-
on
reliability
of esophageal Doppler
for cardiac
itoring
in
was achieved
6 out of
patients
phosphatidylethanolamine, phosphatidylserine,
phosphatidylinositol, and sphingomyelin in
three phases of
all
ARDS
compared
to the control
university
critically
two periods,
from 0.53 from
limits of
to 0.89 (p
<
O.(X)I), bias
'
decreased
ill
pulmonary
ar-
1.2 to 0.1
L x min
(p
<
0.001). and
to 2.2
only in
late
ARDS. CONCLUSION:
Total sur-
and mechanical
ventila-
Respiratory Care
No
Abstracts
L X min^'
patients
ity
is
(p
<
0.001).
CONCLUSION: A
more than
1
case-control study
was performed on
patients
ARDS
was
admitted to a government hospital in Johannesburg, South Africa, used as a referral center for
patients with
reliabil-
formed
ICU
of
CO
measurement by ED.
TB. Eighty
TB who
Care Researcii and Pre-Emptivc Informed Consent: A Practical Approach Used in Chris Hani Baragwanath ICU Finder M,
Critical
TB who
feafelt
tures of
ALI
It
was
T.shukutsoane S. Scribante
J.
Piccolo R. Lip-
were compared.
ties
RESULTS:
In-hospital fatali-
man
J.
Intensive Care
Med
I998:24(4):353.
were
a.s.sociated
OBJECTIVES:
to obtain
(1)
To
establish a protocol
new
to
more ex-
ARDS.
critical
care re-
search,
rein
To
Rutishauser
1
C,
High mortality
ment using
this protocol.
descriptive study.
2(2):
the first
that late
presentation
death.
was
ICU
in a
hospital.
Health-related quality of
es.sential part
in
life
has
become an
is
The HIV-infected participants in the study showed less drug resistance than HIV-negative
patients (p=0.07), equivalent extents of infiltrative patterns
only
re-
May
1996 were
less cavitation
).
CONCLU-
and adoasthma-
SIONS:
from
TB
instruments specifically
and extensive
tance and
at the earliest
in
HIV
infection
reviewed
in this article
factors. Previous
exposure to
TB
and delayed
presentation
may have
We
the
and
number of
for
The
number
whom
con.sent
was obtained or
re-
Questionnaire
TB
in this
population.
number subsequently
None.
enrolled.
par-
INTERVENTIONS:
inclusion criteria.
RESULTS: Of 249
the
potential study can-
Of 100
when comparing young people with difThe Pediatric Asthma Quality-of-life Questionnaire has shown responferent chronic disorders.
Human
7):
1
Sleep Disorders
Shcrrill
DL, Kotchou K,
998; 1 58(1
894.
Quan
Med
is
(40% of all patients screened), we failed to make contact with the next-of-kin in 29 cases (12% of all patients screened). Thus 71 patients or next-of-kin were counselled (28% of all padidates
tients screened). In all,
it
lacks age-
BACKGROUND:
It
and comprehensiveness of quality-of-life assessment. In contrast, the Childhood Asthma Questionnaire provides three different versions for
different target ages.
is
30 patients (12% of
all
patients screened)
into a study.
However,
its
generic part
CONCLUSIONS: A
tus.
come some of
enced
in
OBJECTIVE:
enrollment
To
on self-reported sleep
this
recommended and
further research
disorders
among
study.
tion of adults.
Tucson
sessment.
who in the
and
Remodeling
J,
Artigas
Med
Arch
Intern
Med
1998;158(I7):I916.
Intensive Care
BACKGROUND:
(TB) continue
to
human immunodeficiency
virus
(HIV)
infection,
plicated.
costs.
During the
last
10 years
ARDS
mortality
METHODS: A
retrospective
ables.
10
No
M\
[0
cut costs?
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ABSTRACTS
women
showed
included
that
participating
in the analyses. The results more women than men reported in a regular exercise program and
pital
employees may be
.sensitized to latex
even
ventilation.
To
in the
mode
similar to airway
in
main-
more men
one
that
than
women
and hospital staff See the related editorial: Occupational iMlex Allergy: The
compared
its
CMV;
and
walking
at a brisk
End of the
In-
dioxide tension
partial
(PETCO,)
as a monitor of the
reduced
risk of disorders in
maintaining sleep
ogy l998:89(2):287-289.
CPAPI compared
with
in
an exercise pro-
more
ac-
The Sedative and Analgesic Sparing Effect of Music Koch ME, Kain ZN. Ayoub C, Rosenbaum SH. Anesthesiology 1998;89(2):
300.
during
anesthe-
tized, tracheally
baseline
CMV
that
produced a
PETCO,
of ap-
proximately 35
value
mm
Hg and
a pulse oximetry
>90%.
more than 6
blocks.
BACKGROUND: To determine
whether music
alternating trials of
CMV
Among women
CPAPI,
CPAP
for
1
was applied
CONCLUSIONS:
These
trials
I,
moved
s,
and reapplied
a rate equal to
were performed.
METHODS:
In
phase
35
CMV. The
difference
in arterial
may be
a useful therapeutic
in the treatment
PaCOj/minute
ventilation quan-
among Anesthe-
set or to
have no music.
In
phase
43 adults
summarized
as
Asymptomatic Individuals
1998:89(2):292.
Brown
RH,
in-
way
4.6
pressure
(132
vs.
travenous opioid analgesia were randomly assigned to either a music or no-music group. The
effect of
.2
1/min; p
<
0.(X)OI
re-
BACKGROUND:
Occupational exposure to
quirements, recovery
verse outcomes
room
7.92.6
mm
Hg
ing
X 1' X min"';
<
0.(X)01)
phase
1,
patients in the
of latex allergy
among
occupationally exposed
re-
ing
CMV
(6.31.6
vs.
1.70.9
workers
in
group (0 |0-150]
mg
vs.
90
>
3.5
<
0.001). These
was necessary
to
produce a PaCOj
This repre-
among
eli-
surgery (0.3
0.1
mg/min
vs.
1.6
0.4
mg/
comparable
to that during
CMV.
min; p
< 0.001).
METHODS:
working
and
Participants
who
listened to
improved efficiency of
ventilation,
and
Compared with
Department of Anesthesiology
microg
vs.
0.005).
CMV, CPAPI
PETCO2
Critical
Care Medicine.
clinical ques-
as a monitor of
PaCO,.
tionnaire
testing
was
per-
16
mi-
crog/min,
mean SD, p
<
0.001). Duration of
Food
to
anti-
and the
rate
Fujino Y,
I.
NS).
CONCLUSIONS:
in
U.se of intraoper-
Comput
1998;14(4):225.
body
tion)
in
clarifi-
ative
music
awake
OBJECTIVE:
is
latex
in the
symptoms and latex sensitization without clinical symptoms was 2.4% and 10.1%, respectively. The prevalence of irritant or contact dermatitis was 24%. The risk factors identified for latex sensitization
ratio, 14.1;
hypercapnia
di.stress
in patients
syndrome. Due
ume and/orexpiratory resistance, TGI may cause intrinsic PEEP (PEEPi), and may lessen the advantages of permi.ssive hypercapnia. There
is
95%
0.012); his-
Intermittent
lation
of Venti-
no
reliable
method
to
Bratzke E,
95%
.skin
Downs
=
p
89(2):334.
dynamic hyperinflation, we developed a method to measure FRC with TGI flow. METH-
symptoms with
during
95% CI,
.6-
.^.4;
0.(X)6).
CONCLUSIONS:
among
an-
sensitization
trolled
Hos-
dead-space
100% oxygen (O,) previously equilibrated with 10% argon and 90% Oj. To test the accuracy of our system, we measured the volume in a model
12
Respiratory Care
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Abstracts
FRC
its
of the
was
sufficiently
good
to
volume
Response
to Transitions to
The change of FRC (deltaFRC) of the model lung was measured at a flow of 0, 4, 8, and 12
L/min. Then the
in stroke patients.
However, measurements of
stolic pressure
systolic
and
dia-
Eberle B, Hein1998:I4(4):245.
FRC
at
of a bellows-type model
the
same TGI
at
flow.
PEEPi
work on
useful.
calibration of the
a novel closed-
would be
RESULTS: Our FRC measurements were accurate within 10% except for that of 500 mL without TGI (12.7% 1.1%). As inspiratory
time (TI) and/or
ALV
Nocturnal Body Movements and Hypoxemia
in
tomatically to
ics. Its
momentary
at the
respiratory
mechanminimize
goal
is
TGI flow
increa.sed, the
FRC
inal
tilation
(V^) and,
same
time,
the
work of
breathing.
Aims of our
study were
(1) to investigate
changes
in respiratory
me-
0.843, p
<
0.001).
The higher
the
TGI
denpera A. Scheinin H.
1998:14(4):239.
Clin Monit
Comput
was
the
(OLV),
automated
FRC durOBJECTIVE: The aim of this study was to evaluate the feasibility of the static-charge-sensi-
METH-
piratory-phase
ODS: With
went
institutional approval
and informed
kg) under-
66-88
CONCLUSIONS: The
TGI.
sys-
tive-bed
ALV
during
total
intravenous anesthesia
tem developed
in this study
can be used as a
The
method
termine variables which could be used for evaluating the quality of postoperative sleep and
Use of a Neonatal Blood Pressure Cuff To Monitor Blood Pressure in the Adult finger Comparison with a Standard Adult Arm
breathing.
METHODS: The
frequency of body
and
COj
are continuously
measured
at the
movements and
connector.
The
signals
were read
into an
DLT IBM
SCSB
I-Il
and
pa-
compatible
Davenport R,
Lewis
S. J Clin
I4(4):233.
BACKGROUND:
results, the
con-
The
patients
one preoperative and three consecutive postop(or intermittently) for research in adult stroke
patients,
V^
who
are
ill
erative nights.
ac-
METHOD: We tested
in adults
minimum work of breathing. In addiV^. only PEEP and F,o2 settings are at
by plac-
ing
it
We com-
1,0
and
PEEP =
cm HjO.
and
ABG
min
oxycodone.
RESULTS: The
OLV
total
movement
postop-
(1),
20 min
closure
after onset of
(III).
OLV
(II),
and
after chest
first
RESULTS: The
mean blood
mean
movement
p
0.05,
was assumed
at
mm Hg (95% confidence interval (CI) -14.36 to 15.47 mm Hg), and for the arm cuff was 3.31 mm Hg (95% CI -23.33 to 16.71 mm Hg). Measurements made with the arm cuff were shown
to affect
<
0.001, p
<
0.007).
first
RESULTS: 20 min
(
I
OLV
(II),
(95.5%
vs.
94.2%, p
compliance
to
50 (25-70)
No
oxygen desaturation
decrease
in
Spoj
> 5%)
asvs.
Institution of
mean blood pressure readings was 0.03 mm Hg (95% CI -26.07 to 26.14 mm Hg) and agreement was better when the blood pressure was
measured with the finger cuff
the
first
in respiratory
93.6%, p
89.8%).
odic
Vy
in-
significant
RR unaffected.
In order to
rather than
CONCLUSIONS:
arm
cuff.
movement
In
difference in the inean blood pressure recordings both systolic and diastolic blood pressure
cm HjO,
(7.5
movements.
males
thereby increasing
(6.6-9.0)
V^
clo.se
to baseline
(ASA
I-II),
mL/kg
arm and
finger cuff.
CONCLUSION: The
re-
meathe
movement
and
in
B W). The controller was. thus, effective in maintainining V^. The minimum Piq, during phase
II
SCSB was
a valuable tool
was
101
mm
arm
cuff.
The performance of
that
movement
artefacts of Sp02
CON-
compared with
CLUSIONS:
14
No
PROCEDURE MANUAL
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lor Respiratory Care, Inc.
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transition to
and from
in
OLV
are characterized
into opposite
stylets
in-
OBJECTIVES: To
logical
at
which
by marked changes
directions,
R and C
leaving
TC
V^
unaffected.
The
ALV
laryngoscope (without batteries) with only ambient light. Finally, one stylet
controller
fully,
manages these
transitions .succes.s-
was used
for in-
and maintains
and the
utility
of combining
clini-
Vj during OLV
cal, radiological,
in diagnosis.
was found
to
mended
in the literature.
RESULTS:
254
METHODS: We studied the case histories of patients in whom tuberculous pleural effu1.
successful.
However,
Performance of a
stein
J
Dog
Graven-
when direct illumination from a laryngoscope was used than when ambient light was used. One plastic optical fiber stylet
matically better
January
incidence of tuberculosis,
(
to intubate after
having
Clin IVlonit
Comput
1998;14(4):271.
SD)
8.
years,
A partial lens
OBJECTIVE:
We set out
to establish
whether a
was on
left
55.9% of
patients,
pa-
on the
42.5% of
and
enough
CON-
on both sides
in
1.6% of
patients. In
81.5% of
secondary objective
direct illumination
CLUSIONS: A
two
thirds of the
hemithorax
corporated into an
ETT
was
affected. Associated
in
pulmonary lesions
patients, of
stylet
source from a laryngoscope. Lastly, the fragilof the system was tested.
were detected
18.9% of
whom
the ef-
METHODS: An
us-
14.6% exhibited
fusions,
cavitation. In
93.3% of
anesthetized dog
ing a laryngoscope to elevate the tongue and the view of the larynx conducted through the
plastic optical fiber stylet (placed within an en-
ambient
light is used.
withstanding over 20 uses and 40 sharp bendand-straighten cycles before a lens separation
failure occurred.
protein contents,
levels,
cholesterol
dehydroge-
adenosine deaminase
(ADA)
levels,
concentration
Tuberculous Pleurisy:
tients
ADA2
and
each using a Miller 4 blade and direct illumination from the laryngoscope.
P, Valle
Arch
In-
Two
of the four
tern
Med
Respiratory Care
No
15
Abstracts
72.2% 12.5% (mean SD) of total ADA activity. Total ADA activity was significantly correlated with
after quit
day
rate
in the at
cists,
The cessation
tion
ADA2
(r
(r
feron
gamma
approach
to
geriatric clinical
pharma-
ence, 11%;
95%
seous granulomas
ples in
sam-
result-
79.8% of
in
1
patients,
1.
on the
results of bi-
opsy cultures
sia
(20%).
CONCLUSIONS: We
conclude
that
sation rate
In addition,
Gastrointestinal Motility
CONCLU-
there
were
Feeding
tients
SIONS:
at a
In these patients,
lymphocyte-rich ex-
may
represent a
new
therapeutic approach
smoking
cessation.
El-
High
ADA
view Intervention:
sician,
mePro-
Monane
JAMA
DESIGN:
ADA2 concentration.
The most
sensitive
SETTING:
patients
Surgical inten-
criterion based
sive
care
unit
of a
university
hospital.
PATIENTS: Seven
who
required me-
CONTEXT:
outcomes
Pharmacotherapy
to
is
among
the
Negative skin
test results
were no guar-
improve health
INTERVENTIONS:
None.
MEA-
mean age of
the patients
systems approaches
care
to
macy
may
be an effective
sion
is
mechanical ventilation,
region.
(DUR)
gastric tube
re-
A Randomized
compared with
Smoliing Ces.sation
Prochazka AV,
Licari
Weaver
DESIGN: Popu1,
PA, Lofaso D.
1996,
Arch
Intern
Med
1998;158(18):2035.
SETTING: Ambulatotal
motor complex
in patients
was
PATIENTS: A
of 23,269 pa-
<
in
tients
101.0 mins
One
class of
drugs that
clics.
INTERVENprescribing
database
An
interdigestive
was
program
enhance cessation
rates
and reduce
DUR
in
most pa-
withdrawal symptoms.
SUBJECTS AND
a randomized, doutrial
using explicit criteria to identify potentially inappropriate drug use in the elderiy.
alerts triggered
METHODS: We conducted
Computer
whereby
dis-
(94%) of the
ble-blind, placebo-controlled
at
an
affili-
duodenum. Gastric
retention
Center and an
Army
pharmacology were
<
.01) with
motor
activity.
CONCLUSIONS:
These
more
rent
Conof
tact rate
mechanically
ride or
mg
ventilated patients.
The
gastrointestinal
motor
a total of
emptying
maximal
tolerated dose.
43,007 telepharmacy
alerts,
generated by the
morphine-treated patients
is
characterized by
we were
antral hypomotility
tivity fronts
sessions and
more appropriate
therapeutic agent
was 24%
ing.
The observed
40%
to
mon-
benzodiazepines to
theoretically
2%
7%
more
duodenum
or jejunum
oxide of 9
ppm
were contraindicated by
cotinine level of
than 50 ng/mL.
RESULTS:
A total
of beta-blockers
structive
in patients
nortriptyline
and 106
to placebo).
in
pulmonary disease,
of change
significant reduction
several
symptoms including
tability,
anxious/tense, anger/irri-
2%
rate of
change.
CONCLUSIONS:
16
No
Program Director
Respiratory Care Services
The University of Texas M.D. Anderson Cancer Center, Division of Anesthesiology and Critical Care, has an opening for an individual as the Program Director of Respiratory Care Services. The incumbent will be responsible for the professional and technical guidance and leadership of the
Service, including the planning, organizing,
directing,
Helen Ziegler
Saudi Arabia,
the
DRINK
UP.
coordinating
all
activities of the
be a Registered
Smoke-free environment.
HE LNIVERSnY ^T TEX^S
MD ANDERSON
CANCER CENTER
Helen Ziegler
Suite 2403, 180 Dundas St. West, Toronto, ON, 1Z8 Canada Tel: (416) 977-6941 or 800-387-4616 Fax: (416) 977-6128
Circle 105
Circle 135
R,
CONCLUSIONS: The
structure
and process of
Indirect calorimetry
I998;24(9):946.
ventilatory
mode
Ox-
all
CO,
OBJECTIVE: To
is
this variability
pital size,
ment
is
randomiza-
DESIGN:
recommenda-
There were no
SETTING: ICUs of
selected
community and
PARTICIPANTS: Head
tals
of respiratory therapy
of Breathing
signs of discomfort.
CONCLUSIONS:
BIPAP
ICU
nurse
Ventilation
gla
Crit
Staudinger T.
P.
lator.
BIPAP may
is
be advantageous
in patients
M. Tcsinsky
Care
PSV.
since no
Med
I998;26(9):1518.
models of ventilators
mode.
OBJECTIVE: To
tion
(PSV) or biphasic
in ventilatory care
were
way
DESIGN:
SETsta-
RESULTS:
modes of
fin
TING: Medical
sity hospital.
Phang PT.
Care
Med
1998:26(9): 1.564.
of different
ventilation,
and coverage
ble
after
OBJECTIVES:
Peritoneal ventilation
(PV) can
more comprehensive
lation varied
tals
in larger hospitals.
Howventi-
INTERVENto start
hypoxemic
rabbits.
We
some modes of
TIONS:
either
Patients
were randomized
on
PSV
or
provide a gas exchange surface for oxygen uptake in larger animals that, like humans, have a
performed
after
Immediately
mode was
and
changed and
period, the
after another
30-min adaptation
DESIGN:
Prospective,
within and
among
TING:
INTER-
Respiratory Care
17
Abstracts
VENTIONS:
modi-
who
ity
received
was
peri-
course.
and the
toneal cavity
was
ventilated with
oxygen
in he-
any Pbio2
values of
<
torr
0.8 kPa).
sat-
uti-
of: a)
baseline
c) F,,
lization.
Cost-per-life-year-saved calculations
life
F|o2 0.20, no
0.20,
b) F,o2 0.20.
PV;
during Extracorporeal
Mem-
expect-
d) basef)
brane Oxygenation
Martin OR. Crit Care
Becker
1
MEASUREMENTS AND
Twenty
patients
PV; and
Med
MAIN RESULTS:
tified.
were iden-
OBJECTIVES:
genation
Extracorporeal
membrane oxyfail-
The median age was 4.83 yrs. The median duration of ECLS was 9 days, with 19.5
days
in the pediatric
was 61%
at
at
(ECMO)
and
33%
an F|02 of
ICU and 23.5 days for the^ The observed morwas 20%. Median
these patients
PV
or with dopamine
at
either
have not
outcome,
F,o2- Peritoneal
to affect patient
a water.seal .spirometer,
was
9.1
The
was
life
which may
affect
this
2.2 2.7
mL/min when
F,o2
0.
ECMO,
and
to deter-
cost of $4,190/life-year.
CONCLUSIONS:
CON-
mine
DESIGN:
ECLS
done
ably
AHRF
is
CLUSION:
alter
a considerable cost.
However,
ECLS
oxygen uptake or
saturation in a por-
984.
sure of
RESULTS: Hypertension (mean arterial pres>65 mm Hg) was the most common
in
when considering cost/life-year calculations. The data presented in this .study may serve as a benchmark for comparison with newer therapies
(i.e.,
POj To Out-
These
Valadka AB,
192 infants. Myocardial stun, the near-total absence of systolic function during
curred in 59 infants.
ECMO.
oc-
analyses
at
other
ECLS
institutions.
Med
1998;26(9):1576.
Rhythm
abnormalities, in-
OBJECTIVE: To determine
tissue
thresholds of brain
occurred
in
43
and
peri-
PO2
and noninfective
infant re-
structive
after severe
head
data collection.
thrombosis
in
infants.
Only one
Peak Expiratory Flow Rates in Chronic ObPulmonary Disease Murata GH, Lium DJ. Busby HK, Kapsner CO. South Med
I998;91(10):919.
Hospital,
ECMO.
BACKGROUND:
The
and Level
not obeying
were decreased
in infants
(PEER) have not been determined for patients with chronic obstructive pulmonary disease
(COPD).
and
METHODS:
admission.
placement
PEER
CONCLUSION:
that
months. Spi-
RESULTS:
Pi,io2
some cardiovascular complications during ECMO are more common than previously thought, and cardiovascular complications may
adversely impact outcome.
pulmonary func-
up
to
4-week "baseline"
for
average of 84.641.8
cal-
was
in Pe-
ficients of variation
the
were tested
in
room
air
and
in
Acute Respiratory
FailJ.
before
dilators.
(PRE)
and
(POST)
baseline
broncho-
dard calibration solutions. Pio2 data were analyzed by comparing the average time that Pio2
ure
Vats A. Pettignano
Care
R, Culler S, Wright
RESULTS: The
CVs
for
Crit
Med
1998:26(9): 1587.
and
PMPOST
was below
2 torr (2.7, 2.0, 1.3, 1.0, 0.8, 0.5, and 0.3 kPa,
OBJECTIVES: To
tracorporeal
life
who were living 3 mos after injury vs. those who died. A Tobit regression analysis using maximum likelihood methrespectively) in patients
support
in pediatric patients
PEFR
and
spiratory failure
(AHRF)
same day.
CONCLUSIONS:
COPD.
Self-
ods was
utilized.
and
in the
the use of
re-
Level
control.
However,
in the
zero-oxygen
gave an average
SETTING:
(ICU)
CONCLUSIONS:
Analysis
TIENTS: Twenty patients admitted diatric ICU between 1991 and 1995
to the pe-
1998;9I(10):
for
AHRF
18
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No
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broadcast/teleconference
in
Abstracts
to as
pulmonary prompt
(p
0.02).
inter-
brane disease, with and without synthetic surfactant replacement. Tracheal aspirates
were
changes
96-108
hr after initrial
with
randomized double-blind
of
CONCLUSIONS: A
nurse case
synthetic surfactant
(EXOSURF
Neonatal) or
lu-
"mass
be
bubble technique,
we measured minimum
first
may
quasi-static
glycemic control
in diabetic patients in a
group-
at .30
cpm,
sec-
chyma
HMO.
ond
quasi-static
Med
I99H:l29(fi):654-656.
We
also
comone
computed
to-
pared
minimum
Twelve hours
after
Specifically, a
nant
Human DNase
in Cystic Fibrosis
Di.sease.
Pa-
minimum
surface
tients with
Moderate Lung
DNa.se
International Study
Group
creased
17.6
1.3
significantly
from
20.91.4
to
crobial therapy.
We
review the
literature
and
PH, Romano L,
26(3): 155.
et al. Pediatr
show
the importance of
CT
pul-
who did not show any change. Reduction in minimum tracheal aspirate surface tension on
first
detection and
management of
quasi-static
monary gangrene.
Cystic fibrosis
is
minimum
tra-
DNA,
of
We conclude that
surface ten-
Maintenance Organization:
Controlled Trial
Aubert
RE, Herman
A Randomized, WH,
et
was
minimum
first
Waters
al.
J,
conducted
974
2 hr of the
Ann
Intern
Med
1998;I29(8):605.
capacity
next
48-60
hr.
values] to
examine
Hydatid Disease
tive Analysis of
in
Childhood:
Retrospec-
mg. once
376 Cases
Anadol D, Goc-
many
weeks. Patients were assessed under conditions reflecting routine clinical practice.
U. Pediatr Pulmonol
timal control.
OBJECTIVE: To compare
dia-
During
rhDNase
ics
management and
DESIGN: Randomized,
TING: Primary
controlled
trial.
SET-
were treated
at
Hacettepe Univer-
expiratory volume in
FVC
TIENTS:
lilus
respectively.
Voice
fre-
were
lo-
litus.
INTERVENTION: The
written
nurse case
algo-
56
patients,
and
in
manager followed
management
in
2% of all
ilar to
due
to
maining
patients.
Cough,
and abdominal
adverse events. The results obtained were sima subanalysis of data from the
first
therapy were
communicated
to
had surgical, 73 patients had medical and and 4 patients had medical and percuinitial
patients received
surgical,
MEASUREMENTS: The
at
in
pulmonary
ther-
When
was measured
baseline and
at
12
relapse rate
tients than
was higher
in surgically treated
pa-
We
is
conclude
thai
We
con-
administration of
ated,
rhDNase
datidosis
is
best,
except
in
cases
with
bile duct
RESULTS: 72%
in the
of patients
nurse case
1
in
gical therapy.
.7
Membrane
Disease: Effects of
HbAlc
in fasting
values and 43
McMilS. Pe.
.
to
Acute Con-
mg/dL
(2.38
mmol/L)
glucose levels;
DD,
Singhal N, Shukla
AK, Schurch
An Underdiagnosed Condition?
had decreases
values and
diatr
Pulmonol 1998;26(3):173.
objective
in
HbAlc
mg/dL
(0.83
mmol/L)
in fasting
glucose lev-
Our
was
to
determine changes
in surfirst
els (p
<
An
proved
in
management group
4-5 days of
life in
mem-
20
No
Abstracts
and abdominal pain. He was hypoxic and dyspneic in Itie emergency room. Tiie abdomen
cation
J
Approach
Fries JF,
McShane
D. West
Med
I998;I69(4):20I.
matic injury
made
clin-
farm
A review of the
hypoxia and
problems.
We
compared
the re-
means of encouraging
all
safe
work
practices arc
to reach
been reported.
We
is
at high-risk
persons
program addressed
to all risk
Approach
Human
Im-
munodeficiency Virus
Haramati
LB, Jenny-
Van Asperen
P, Leslie
G, Arnold
J,
Sullivan C.
human immunodetV
infectious and
stan-
of occurrence
I
REM
in
sleep hy-
infants with
in early
CD4
(CNLD)
by 11%
in the overall
com-
pared with
9%
in the
6%
>93%.
Interestingly, higher
known
may
re-
in the senior
group. Physician
decreased by
inspired
Oj
demon-
months
in the high-risk
1
group
strated to reduce
REM
sleep fragmentation in
CNLD
However,
my-
CNLD
months
in the high-risk
virus,
cer.
been reported.
We
confinement
to
home decreased
in the
polysomnography
infants with
sleep laboratory on 16
CNLD
(4
employee
1
age)
in air
commonly,
tuberculosis. In severely
immuno-
and senior groups. Using imputed costs of $ 30 per physician visit, $ ,000 per hospital day, and
1
>93%)
compromised
ing:
$200 per
$1,138
>97%).
groups
Rhodococcus
infection,
nocardiosis,
employee
For
CNLD
infants
lymphoma.
duration decreased by
vs.
in the
highin the
359 89 min;
p<
by
decreased
coma.
Interstitial
in
Pneu-
66.4 14.0%; p
$484
$87
in
in
compared with
in the
7% (73. 2 10.6% vs. < 0.005) but percentage of time in REM sleep (REM%) (31.58.9% vs. 29.88.6%; p=0.560), REM epoch duration
(I2.42.8 min
vs.
senior group.
The
return on investment
was
and
8.66.5
vs.
8.8 7.2;
increasingly
about
6:
in the high-risk
4:1 in the
O, did not
Lymphadenopathy
is
most
changes
in
common
in
in high-risk
persons than
(NREM)
p=0.003;
creased (p
(CNLD:
So2
in-
lymphoma, Ka-
NREM
mean
groups.
<
transcu-
taneous
CO, was
in
unaltered in both
CNLD
and
Production Ag-
REM%
CNLD
and
af-
demonstrated
that a higher
S^q, adversely
of pulmonary disease
in the patient
with the
Med
1998;169(4):214.
REM
target
human immunodeficiency
virus.
Production agriculture
S2
Reducing Need and Demand for Medical Services in High-Risk Persons. A Health Edu-
riety
Sa02
>93% >97%
is,
therefore, as efficacious as an
in
in
ricultural
workers are
at
CNLD
infants.
Respiratory Care
No
21
Editorials
Case of
Common
Interests,
Not
In
Common
Credentials
patients with
respiratory conditions
nurses, or
in
Malaysia
may
fulfill
the role of
some
instances,
complish
many Euro-
sionals or even by
some
provided to patients by
no
distinct
whose
Of interest,
provided
of the care
by physiotherapists,
clinical engineers,
practitioners in Japan
clinical experience,
the opposite of
is
what
exists in
North Amer-
The North American model has been in Taiwan and the Philippines and in some areas of Central America. Clearly,
care profession.
fession
is
gaining
momentum
in a
number of
countries.
link-
Only
is
pro-
programs or
Turkey and
Common
Interests,
Not Credentials
program
is
in respiratory care. in
projects
underway
The
countries
may be
physicians, or other specialized technicians or clinical engineers. Despite the group performing the respiratory service,
it is
the
"common
The
by the
mon
and
es-
American Association
that
tials
tablish the
many
&
practiced here.-
The
of the
many
tory care.
The occupational
titles
model followed for the provision of respiratory care varies dramatically from one region of the world to another. In
many
mo-
dalities is
added on
to or incorporated as part
of the re-
pists, nurses,
22
No
ica!
engineers.
As
diverse as this
list
is,
individuals in
some form of
respiratory patient
The
Toledo, Ohio
has been coupled with a tremendous need for formal education and training in the clinical practice and theoretical
basis of the profession.
The
globalization of respiratory
Showa
University
American model.
On
the contrary,
it
Kanagawa, Japan
a global perspective in a context that values the rich diversity of care providers.
REFERENCES
L Pierson DJ. What
43(1):17-19.
2.
is
many
all
we can
learn
become
greater as
in-
Correspondence: Jerome
Sullivan
MS
RRT.
OH
4.3606. jerome.sullivan@utoledo.edu.
No
23
Technology
Aerosols are most
at the
commonly used
tract.
for delivery of
is
medi-
team so
Aerosol delivery
attractive
because
to the
it
Over
at the fore-
peutic index with low systemic drug levels and related side
effects.
is
in their field.
The
dose
of action. There
is
currently an
on available
month's
exponential growth in aerosol technology development, ranging from the development of alternatives to the chlorofluo-
rocarbon (CFC)-based metered-dose inhaler (MDI) to the administration of aerosols for systemic effects.
clinical practice
The common
&
exam-
ple of
how changes
in aerosol
technology require us to
years, the adage "bigin the
many
to
60%- 80%
ger
is
shown
be true
performance
RCP's
clinical practice,
initial
it
proportion of either
commonly used
topic of aerosols.'
How
then
shown that larger-volume spacers allow plume development and thus a greater percentage of drug available to the patient. "'^ These early observations, which are confirmed in the present report'" in the initial comparison of the large- and small-volume chambers with the CFC MDIs, were not consistent with use of the new HFA MDIs, which were developed to meet U.S. Food and Drug Administration requirements. While the new environmentally friendly HFA MDI provided the same
searchers have
greater
CFC MDI,
was increased by
40% when
is
the
HFA
is
largely based
MDI was
The
practice of the
HFA MDI,
own
observa-
method of
training perpetuates
on
MDI
alone. This
Such
ignores
To change
an expert
relative term.
ability
RCP
must be
the
in aerosol therapy.
Expertise
is,
of course, a
is
to
Therapy
in
Me-chani-
One of
to
AARC
and luxury
few
share relevant
members of the health care team. The RCP must new information and perspectives with other
RCP
in
promoting
state-
24
No
Aerosol Therapy
in
Respiratory Care
REFERENCES
1.
in the
Third, this
Comprehensive
re.spiratory care.
Backow ED,
2.
eds. Philadelphia:
WB
GC,
JJ, eds.
in this
-3.
The
RL,
Mosby, 1999.
commonin in
6. 5.
JB
Lippincott, 1995.
for Respiratory Care. Aerosol
state-
We
American Association
I991;.^6(9):916-921.
Mechanically Ventilated
which
fills
the
gap
AARC
AARC.
clinical
7.
them to clinical practice. The series will also include a segment on new frontiers in aerosols. The purpose of this segment will be to discuss
emerging technologies and other recent advances
field
in the
AARC Clinical
of aerosol
to the lung
9.
AARC
of aerosol medicine that are likely to shape future of aerosols for systemic ther10.
1325-1335.
Mitchell JP, Nagel
MW,
apy
is
):38-44.
1.
Moren
F.
inhalation aerosols.
I.
In-
and
Corr D, Dolovich M, McCormack R. Ruffin R. Obminski G. Newhouse M. Design and characteristics of a portable breath actuated,
particle size selective aerosol inhaler. J Aerosol Sci 1982;13(l):l-7.
help the
scientific principles
It is
AARC
tion of bronchodilator,
to therapy
in
the
many
13.
As
we
will
in
mechani-
Care 1999;44(l):53-69.
criticisms,
and suggesfions.
James B Fink
Rajiv
MS RRT
Dhand
MD
&
MS
Jr
Edward Hines
Jr
James B Fink
RRT, Dept
of Pulmonary
Medicine
Hines, Illinois
Respiratory Care
January
999 Vol 44
No
25
The Strong Ion Difference Approach: Can a Strong Case Be Made Its Use in Acid-Base Analysis?
The saga of acid-base pathophysiology over
century
is
for
the past
in
such studies
may
inter-
some controversy
in this
pH and
in pro-
first
advanced by Peter
HCO3"."
tein
Stewart
some
in the acid-
base field as the reference standard for describing, diagnosing, and investigating acid-base perturbations.
concentration
may account
for
some
ventilation
They
ad-
responses and
Ppo,.
pH
vocate that
we abandon
HCO3
Schlichtig,'''
value
SID does
much
anion gap,
it
how
body defends against and corrects acid-base disturbances. How revolutionary and compelling is the SID
the
too must be altered up or down, depending upon the protein concentration, a finding corroborated
by Wilkes"
in
ill
is
really not so
new
but rather a
new
offset
simple
and be predicted
to strict
in certain clinical
situations
by adherence
mathematical principles of
which
is
the
sum of
HCO3"
The
in
and out
included
in the
40 suggests a possible metabolic acidosis of either endogenous organic acid overproduction or underclearance (lactic acid or ketoacid), intake of exogenous
greater than
acid, or acid precursors (eg,
neys, gut, skin, and other iatrogenic routes are many. Plasma
by a
critically
ill it
patient,
methanol and
salicylates).
how
was
at-
nonrespiratory, normal
SID
remic acidosis from loss of alkaline equivalents, and a SID lower than 40
surfeit
is
approach
to
HCO,"
and
H^
are
dependent variables
though there
their
pH
Mg^
and Ba^^).
heuristic
The
value.
is its
is diffi-
By
rigorous quantitation,
it
forces us to consider
A^-ot (the other two independent variables) are monitored, especially considering that they
are
and
may
play in determining
may
same
in dif-
shown
that the
mean pH
This
is
by use of the Stewart analysis quite accurately predicts the mean measured pH under a variety of acid-base extremes,
but that in individual cases there
ation.''-''
other intracellular
regulate
SID cannot act upon proteins and compounds and transduce signals that ventilation or renal function (much like we connot to say that
may be
significant devi-
*^
or pH), but
what humble
at this stage in
26
No
workings.
lated
We
what
is
being regu-
amino
in
acids with
pKs
in the
We know
now
allel
is
numerous
membrane
transporters
in the
determina-
that tightly
SID
conspire to reduce
utility
SID
At the
cell
and membrane
may
we have
we
to which one measurement of Ca^^, Mg^^, sulfate, urate, and lactate with their attendant costs. The problem of cumulative random assay error with so many measured parameters is not trivial and may compromise the
requires,
H^
in
more
cal-
To
compartment (due
changes
in the dissociation
culate
SID
(or
pH) an average pK
and
H^
and
HCO," move
is
directly
to
may
whom
another. This
who might
us totally
it
abandon the
ignore
pH
may
differ significantly
it
The advocates of
to
HCO^"
in thinking
is
certainly will
dependent variable. Certain acid-base disorders are provided as examples of the power of SID. Thus, while
true that
it is
management
ment of
warrant
it
is
pensive, and not sufficiently better than a critical assessthe base excess, anion gap, or pH/P(^Q^
its
maps
one
to
SID of
0) such as saline or
KCl (potassium
it
does not
little
that
is
one of too
combines an
taken together
the nature
in the
By providing
chloride with
some of
the
Na^, one permits the kidney to cation to accompany the excess bicarwithout violating electroneutrality or
fluid
Erik
Swenson
MD
bonate
in the urine
Pulmonary and
Critical
Care Section
compromising extracellular
a change in
volume
status.
To
obtain
HCO3"
Washington
Na^
or
K^, accompany
It is
it
CP,
REFERENCES
1
nonanion gap
metabolic acidosis
is
CP
concentrations. For
that
examMorfei
ysis.
J.
develops
RespirCare 1999;44(l):45-52.
Stewart PA.
Elsevier,
98
cific
in the
brush border
at
3.
unable to operate
a speed not a
4.
It is
27:223-242.
Constable PD.
ria:
model
also lost.
5.
in
humans.
Pieschl
Am
clinical
not convincing.
Two
SID
7.
changes
Appl
Physiol 1992;73(6):2297-2304.
Javaheri S. Corbett
W, Wagner
K,
Adams JM.
Quantitative cerebro-
cal-
Am
Med
1994;l50(l):78-82.
Respiratory Care
No
27
8.
Ohtake
PJ. Jennings
DB.
Ventilation
is
16.
Gilfix
S.
awake dog.
Crit
Care
73(4):1549-1557.
9.
1993;8(4):I87-197.
Alf'aro V, Palacios L.
rats
in
awake unrestrained
17.
ion gap: a
methodology
Care 1995;IO(2):5l-55.
regulation: a
2143-2150.
10.
compar-
flux
Can
818-826.
Siggaard-Andersen O, Fogh-Andersen N. Base excess or buffer
ba.se
human blood
in vitro. J
6l(6):2260-2265.
12.
Figge
J,
base equilibria.
13.
McAuliffc
losis.
JJ,
Am J Med
14.
more
Correspondence: Erik
100/4D-139,
bian
LaManna.
editors.
Oxygen
transport to tissue
XVIII.
15.
New
P.
R Swenson MD,
Wilkes
VA
.status in critically
patients. J
Appl Physiol
998;84(5): 1740-1748.
Way,
Seattle
WA
28
No
Original Contributions
Dependence Nursing Scale: A New Method To Assess the Effect of Nursing Work Load in a Respiratory Intermediate Intensive Care Unit
Enrico Clini
MD,
Michele Vitacca
MD,
MD
BACKGROUND:
sive care units
In recent years, there has been increased interest in respiratory intermediate inten(RIICUs) as suitable environments when treating patients needing respiratory assistance. The aims of this study were to evaluate the dependence level of patients by use of a new scale, the Dependence Nursing Scale (DNS), for scoring the work activities of nurses and to compare the DNS
work
load,
and
clinical
outcome.
METHODS: The
RIICU in an Italian respiratory rehabilitation department. Over 1 year. 111 consecutively admitted patients who required mechanical ventilation for acute on chronic respiratory failure (33 patients. Group 1), prolonged weaning from mechanical ventilation (33 patients. Group 2), or cardiopulmonary monitoring (45 patients. Group 3) were admitted to the study. At
admission, demographic and anthropometric data, severity of disease (as determined by Acute Physiology and Chronic Health Evaluation
Equivalents of Nursing
Manpower Use
[APACHE] II), nursing work load (as measured by the Nine Score, NEMS), and inspiratory muscle strength (maximal in-
The DNS score was determined at admission and at discharge. RIICU were also recorded. The DNS describes the dependence of
commitment, which
staff.
1
is
Scoring
done by use of a
scale with
minimum
of
to a
activities for
DNS
ranges from
score
3.
and the
NEMS were significantly higher for patients in Group 2 than for patients in Groups 1
all
All tasks except tracheotomy care significantly improved, resulting in a significant decrease in the
DNS
score for
patients (from 18
10 at admission to 10
NEMS
(r
11 at discharge).
At admission, the
DNS
APACHE
II score,
the
illness severity
in the RIICU. CONCLUSIONS: Compared and inspiratory muscle function, the DNS score can better predict
and better reflect the nursing work load required for patients admitted an RIICU. [Respir Care 999;44( ):29-37] Key words: nursing work load, severity of illness, dependence
I
mechanical
weaning.
Background
&
Up
to to one-fourth
all
-
10% of
consumed
in critical
still
care units.'
up
to
get.-*
astonishingly
1% of the gross national product.'' The costs of critical care may be less in Europe, where intensive care units (ICUs)
affiliated
with Fondazione S
Correspondence
&
MD.
Fondazione S Maugeri
(BS).
Italy.
IRCCS.
Via
Pinidolo,
23.
1-25064
Gussago
Italy.
fsm.g2 @ numerica.it.
Respiratory Care
No
29
Assessing Nursing
Work Load
in
ICU
tivities
in the higher-risk
ICUs.
ICU
include the
Group 1 patients, noninvasive positive pressure ven(NPPV) by the nasal route or face mask was prescribed when patients met the following criteria:"* severe
In
tilation
Time Oriented Score System (TOSS),** and more recently, the Nine Equivalents Of Nursing Manpower Use Score (NEMS)."-'" Older patient age, improvement in survival of patients
rivatives,*-^ the
dyspnea
of
at rest, deterioration in
pH (<
7.35), tachypnea, or
ditions
were
criteria
Seven
care.
' '
(21%) in whom NPPV failed and endotracheal intubation was performed underwent a short period of invasive mechanical ventilation, early extubation (within
ICUs
work load
proposed
cation scores
in the first
24-48 h
after
to predict the
Pre-
dictions of nursing
work load and planning of staff allohave been based on these scores. However, these do not completely describe the work load aimed at
needs related to the level of depen-
24-36 h), and noninvasive pressure support ventilation by mask until weaning. '^ Group 2 patients were transferred to our RIICU after tracheotomy had been performed in ICUs of other hospitals due to difficult weaning and need of prolonged meface
dergone
at least
2 unsuccessful T-piece
trials.
The time
to
dependence
less studied.
level
from 3 to 45 days. In our RIICU, mechanical ventilation was delivered through a tracheotomy maintaining the modalities
To
all
components of the
ICU
tilation or
(RIICU),
we developed a new
scale, the
performed
tocol
pro-
were those
failed the
RIICU
patients.
this study
of
Nava
Of
the 33 patients, 5
(15%)
The aims of
the
were
weaning
with invasive
home mechanical
DNS
and
to
compare the
DNS
Group
3 patients
carfail-
work
and
clinical
outcome.
Methods
Patients
Measurements
Clinical conditions were evaluated by use of the
APACHE
One-hundred-eleven patients,
admitted to our
II
score.
'-^
who were
consecutively
use of the
NEMS
oxy-
RIICU between
ranges from
were divided
gen tension,
gen saturation
gen,
(S^q,),
and
1),
an automated analyzer
data,
Denmark) on arterial blood samples from the radial Samples were obtained within the first 24 h after admission. When necessary, oxygen was delivered at a
artery.
admission,
Table
1.
above
92%
in
wean-
inspiratory
30
Respiratory Care
Assessing Nursing
Work Load
Admission
in
ICU
Table
at
in a
Assessing Nursing
Work Load
in
ICU
Table
2.
Work Load,
in the
Methods
Total
(n
Group
(n
Group 2
(1
Group
(n
111)
33)
33)
45)
p (Anova)
APACHE
II*
Assessing Nursing
Work Load
in
ICU
Table
3.
DNS, may
when
the pa-
(NEMS)
at
were admitted
of Hospital Stay
(Groups
and 2)
val-
NEMS
DNS
p
0.71
APACHE
0.41
II
MIP
-0.43
p
HS
0.43
mean
APACHE
II,
NEMS,
and
DNS
at
admission
<
0.00
< <
0.01
<
0.005
< <
0.005
NEMS
p
0.44
-0.15
0.33
significantly differed
0.005
NS
MiP = maximal
0.01
2),
of clinical severity
APACHE =
pressure:
may
of patient
inspiratory
HS =
NS =
not signit~icant.
NEMS
at
sets a
work load
in a general
admission,
admitted to an RIICU.
Thi.s score
which
is
RIICU
(28
8). In particular,
the
at
admission.
however,
human
known about
tient's
RIICU
may
differ
ICU.'
''
Fur-
according to time spent assisting with mechanical ventilation (either invasive or noninvasive)-** or
chronic disin
because of the
patient's severity of
ICU
me-
macologic therapies,
cific function.-"
perform a spe-
RIICU
(ie,
mask
who may
therapies.-'*
It
requires
20%
of the
total shift
48 h of
dence. --
DNS
scores sig-
There
ICUs
the
2).
Pro-
respi-
weaning)
is
common
cause of dis-
chronic obstructive
However, information
pulmonary
to
nursing work load in improving patient disability following a severe exacerbation of chronic disease. In particular,
there
is
50%
patient admission
DNS
results for
Our study
is
aimed
at elucidating this
problem by
Group 2
nurse-to-patient ratio.
The Group
3 patients
who were
1
ad-
DNS
could add
new
mitted to our
RIICU
specific nursing
work load on
is
dependence
in
DNS
scores than
Group
fact
and 2
different
sessed by
APACHE
II
confirms
of patient dependence
mance Test
scales).-'' -* In fact,
outcome.
No
33
Assessing Nursing
Work Load
in
5-1
El
ADMISSION
DISCHARGE
TOTAL
p<0.0001
p<0.01
Fig. 2. Partial
for B, H, F,
M,
E, D,
MO
at
p<0.0001
for
TOTAL
tasl<s;
SL
admission and discharge. Letter abbreviations are see the
and
Appendix
for definitions.
As shown
in
Figure
been conunder-
sidered as a
means
to predict
weaning
in patients
score or the Pi^ax- This may be due to the fact that the DNS reflects the pathophysiologic condition of patients
admitted to an
RIICU
(ie,
patients
Unlike
changes
of the
APACHE
II
and
NEMS, DNS
in
can monitor
our study,
all
in a patient's
dependence. Indeed,
APACHE II).
among
Indeed, the
APACHE
2).
DNS
showed a
stays
significant
RIICU
DNS
seems
to increase
from
NEMS;
however,
NEMS
takes into
DNS
who
Study Limitations
with the
DNS
APACHE
II
score; however,
DNS
DNS
was comits
DNS
and parameters
pared with
NEMS
only.^
NEMS
may be
due
to
associated
same
level,
an exacer-
levels of Pj^ax ^t
We
DNS
reliability.
Nev-
34
Respiratory Care
No
Assessing Nursing
Work Load
in
ICU
Fig. 3.
Frequency distribution of
partial
and
total
at
at
discharge
<
No
obs = number
of observations.
we
we can
Conclusion
on
it.
shows
that in pa-
RIICU
DNS can
DNS
in patients
DNS
order to pre-
Respiratory Care
35
Assessing Nursing
Work Load
in
ICU
To confirm our
data, multi-
with respiratory failure due to chronic obstructive pulmonary disease: a randomized, controlled
trial.
Ann
Intern
Med
1998:128(9):
couraged.
721-728.
Nava
et al.
S,
Rubini
F, Zanotti E,
ACKNOWLEDGMENTS
We
thank the respiratory nursing staff
at
COPD
namely Mirella
Baratti, Tiziana
18.
more than 21
our
in.stitution,
Doriana
Zimmerman
JE,
JF. Kolakow.ski
and
cost.
Chest 1995;108(2):490-499.
REFERENCES
1.
Black LF, Hyatt RE. Maximal respiratory pressures: normal values and relationship to age and sex. Am Rev Respir Dis 1969;99(5):
management
(review).
696-702.
20. Bruschi C, Cerveri
I,
Zoia
MC,
Fanfulla F, Fiorentini
M,
Casali L, et
2.
al.
Am
Med
1997; 156(4 pt
ulation-based study.
21. Byrick RJ,
1282-1301.
3.
Am Rev Respir Dis 1992;146(3):790-793. Mazer CD, Caskennette GM. Closure of an intermediate
Helpern NA,
icine:
Wang
Med
1994:22(12):2008-2012.
De
Lisa
JA
(ed). Rehabilitation
Takala
J,
Ruokonen
E. Costs
and resource
utilization in intensive
care. In:
ondary
951.
American Thoracic Society. Evaluation of impairment/disability secto respiratory disease. Am Rev Respir Dis 1982;I26(5):945-
inter-
24. Katz S,
Care
Med
1974;2(2):57-60.
Ford AB, Moskowitz RV, et al. Studies of illness in the aged. The index of ADL: a standardized measure of biological and psychological function.
AM.
Intermediate TISS: a
new
JAMA
1963;185:914-919.
non-lCU
patients. Crit
25. Katz S,
Care
7.
Med
1994;22(9): 1406-141
1.
inter-
26.
Downs TD, Cash HR, Grotz RC. Progress in development of the index of ADL. Gerontologist 1970;I0(l):20-30. Reuben DB, Siu AL. An objective measure of physical function of
Am Geriatr Soc
M. Phys-
Med
1996;24(l):64-73.
8.
Italian Multicenter
GB,
performance
test
and
ICU
patients.
Intensive Care
Med
28.
people. J
Am
for rehabilitative
manpower use
score
(NEMS).
Intensive Care
Med
I997;23(7):
760-765.
10.
50(4):293-318.
29.
Kramer N, Meyer
prospective
trial
TJ,
Meharg
J,
Cece RD,
Care
Hill
NS. Randomized,
in acute
management?
11.
Intensive Care
Med
I997;23(6):615-617.
in intensive
In:
respiratory failure.
Am
I,
J Re.spir Crit
Med
1995:151(6): 1799-
P
30.
1806.
New York:
Marcel-Dekker, 1996:
Nava
S, Evangelisti F.
725-738.
12.
Rubini
Human
noninvasive re-
COPD
fail-
Chest I997;II1(6):163I-I638.
I991;99(l):205-208.
13.
and chronic
Knaus
WA,
APACHE
Med
II:
hypercapnia
in
Am
Rev ReJ
1985;
l3(IO):818-829.
14.
32. Rou.s.sos
ventilation in acute respira-
in
man.
AppI
Eur Respir
J.
1996;9(4):795-807.
F, Conti
M,
15.
Brochard L, Mancebo
al.
Wysocki M, Lofaso
G, Rauss A,
et
COPD:
Eur Respir
1996:9(7): I487-I493.
structive
16.
pulmonary disease.
Engl
Med
1995;333(13):817-822.
et
34.
Nava
al.
S,
Ambrosino N,
Clini E, Prato
M, Orlando G, Vitacca M,
in the
Engl
weaning of patients
Med
199I;324(2I):I445-1450.
36
No
Assessing Nursing
Work Load
in
APPENDIX
Performance of Large- Volume versus Small- Volume Holding Chambers with Chlorofluorocarbon-Albuterol and Hydrofluoroalkane- Albuterol Sulfate
Jolyon P Mitchell
BACKGROUND:The
pressurized metered-dose inhalers prompts the need for the comparative evaluation of dose delivery by small- versus large-volume holding chambers (HCs). The performance of 2 representative large-
and small-volume HCs has been investigated with chlorofluorocarbon-formulated albuterol (Ventolin) and hydrofluoroalkane-formulated albuterol sulfate (Airomir) with the objective of studying the influence of chamber capacity on so-called "fine-particle" dose and total dose. Three AeroChamber and a similar number of Volumatic HCs were tested with each formulation. METHODS: An 8-stage Andersen cascade impactor was used to determine mass-weighted size distributions of drug delivered at the mouthpiece of each HC. The mass of albuterol (Ventolin) or albuterol sulfate (Airomir) collected in the impactor was assayed by high performance liquid chromatography with ultraviolet detection in order to measure both fine-particle dose (< 4.1 -fim aerodynamic diameter) and total dose. RESULTS: For Ventolin, the fine-particle and total doses were 45.4 0.3 fig and 47.2 0.1 fig, respectively, for the AeroChamber HC and 63.8 2.3 /xg and 66.1 3.0 ftg, respectively, for the Volumatic HC. For Airomir, the fine-particle and total doses expressed as albuterol base equivalent were 62.0 2.9 fig and 64.2 3.0 /u.g, respectively, for the Aei^oChamber HC and 67.9 2.5 jug and 69.7 3.4 fig, respecfively, for the Volumatic HC. CONCLUSIONS: There was a significant difference in both fine-particle and total dose between large- and smallvolume HCs with Ventolin (unpaired t test, p < 0.001). However, both HCs performed similarly with Airomir (p = 0.056). In all cases, the available dose from the HCs comprised > 95% of fine particles. [Respir Care 1999;44(l):38-44] Key words: Aerosol propelkmts, albuterol, hronchodilalor
aerosols, chlorofluorocarbon, hydrofluoroalkane, drug delivery, holding chambers, in vitro studies,
me-
Background
Pressurized metered-dose inhalers (pMDIs), which were
pMDIs have
utilized chlorofluorocarbon
(CFC) prode-
introduced
in the late
Programme
50%
reduc-
tion in
CFC
to be followed by an
As
a result, pharmaceutical
manu-
CFC-
is
Correspondence
&
Reprints: Jolyon
P Mitchell PhD.
Aerosol Laboratory, Trudell Medical International, 725 Third Street, London, Ontario, Canada,
NSV
5G4. jmilchell@lrudellmed.com.
li.sted
in
pMDIs. Hydrofluoroalkanes
in
CFCs
38
Respiratory Care
January
999 Vol 44
No
Effects of
MDI
pMDI
(Airomir''^
<c
Airomir^^
Volumatic
28.3
Fig. 1
.
0.5
L/min
metered-dose Inhalers (pMDI) alone or with either Aero-
Equipment configuration
Chamber
layer.
Methods
Large-volume holding chambers were represented by
the
and was
HFA (Key
CFC
Pharmaceuticals,
sented by the
AeroChamber HC.
formulations that
in
electrostatic effects.**
Each
work
by us
that the
change
from
CFC
HFA
propellants
may
0.5
L/min
(Fig.
1).
rubber
tance of
HC
volume on dose
delivery.
HC
and impactor
and small-volume
HCs
with CFC-formulated
sulfate
we measured
albuterol (Ventolin)
RT200
reference
actuator.
in place
of the
pMDI
using each of 3
HCs
test,
of
albuterol
pMDI
canister 3
actuator.
of cham-
HC, with
canister
The pMDl
aerodynamic diameter of
<
was
all
it
left in
s after
actuation to permit
yond
tract).''
was shaken and reinserted into the manufacturer's actuator. The HC was then removed from the impactor, and
No
39
Effects of
MDI
100
1
(D
N
80
CO
TJ
S (0
0)
c
CD
60
a>
40
(0
0)
>
20
Effects of
MDI
100
(D
N
80
CO
o B
TO
W
c
CD
^
(/> (/>
60
Q)
40
CD
0)
_>
TO
20
Effects of
MDI
vitro studies
results
HC
(63.8
2.3
ju,g
with Ven-
Dolo-
67.9
2.5
;u.g
amount of available drug increased with volume to ~140 mL, but little further increase was measured with greater chamber volume. However, the fine-particle fraction (mass contained in the range from increasing
1
washed with
ionic detergent
and dried
in
ambient
air to
Wildhaber
et al'"
examined
to
to-
HFA-albuterol delivery
ward 100% of the total dose with HC volumes in excess of ~ 400 mL. Barry and O'Callaghan^ also noted a similar correlation between the volume of cylindrical spacers and
fine-particle
Mea-
surements were made before and after the removal of eleccharge on the delivery devices, and drug amounts from each device were reported as percentages of the nomtrostatic
(<
5-/i,m
when
tested with
inal unit
AeroChamber-MV and
the larger
mL. The
Nebuhaler delivered
63%
HCs
mL) and
large-capacity
(750
or
mL) devices
HFA
CFC
as propellant.
between
good agreement with findings with which the AeroChamber and Volumatic HCs delivered 69% and 75%, respectively, of the nominal dose leaving the mouthpiece of the manufacturer's actuator (90 /u-g) (based on particles finer than
in in the present study, in
plume geometry following actuation. It is therefore recognized that the findings from this study may not be applicable beyond the formulations examined or with other
designs of
mass of
devices
In
HC
or spacer.
what
pMDIs
appear
formulated using
in the literature.
we
did)
have observed
HFA- and CFC-formulated albuterol via small- and largevolume HCs (unspecified). They reported fine-particle
(< 4.7-^im aerodynamic
diameter) and total doses that
in the
HFA-formulated Airomir. Their high-speed video analysis of the aerosol plume showed that the leading edge of the Airomir aerosol had a velocity approximately one-half
the
that of the Ventolin aerosol cloud at both 10
after
ms and 60 ms
and 64.5
of 45.4
for the
pMDI
HC (50.3 2.8 fig for CFC-albuterol 1.1 /Ltg for HFA-albuterol) compare with doses 0.3 ^ig (Ventolin) and 62.0 2.9 jug (Airomir)
for the larger
volume occupied by the Airomir aerosol was 25 cm^ on average, compared with 695 cm^ for the Ventolin
that the
aerosol.''
AeroChamber. However,
HC,
they
and 77.7
which are
slightly
HC
in
and 67.9
700-mL, large-volume HC (Nebuhaler), which had a capacity comparable to that of the Volumatic HC. Measurements were obtained for new, unwashed HCs and for the
Nebuhaler
after coating the interior surfaces
show
of the
HC
performance between large- and smallvolume HCs (based on fine-particle dose) was markedly smaller with the HFA-formulated albuterol. On the basis
it
with antistatic paint. The fine-particle doses from the untreated Nebuhaler ranged
jLtg
of this comparison,
particles in the
is
if
from 24.6
CFC formulation have greater velocities at the time of pMDI actuation, they would
plume from
be more likely to impact on the walls of a smaller-volume
Howwas
when
HC than on a chamber of larger capacity. The walls of the smaller HC are closer to the axis of plume generation,
where particle-wall interactions would be expected
crease. In contrast, the slower
to in-
removed from
creased to 68.5
/Lig
(Airomir). These
42
No
Effects of
MDI
volume occupied by
the aerosol
from the
HFA formulation
In the larger
would
when
HC.
HC.
HC.
Conclusions
The
safety of inhaled
HFA- 134a
They
HC
using
2, 4, 8,
and 16 inhala-
34a propellant without drug and CFCpropelled albuterol (salbutamol). Their study found no dif-
HP A-
HCs
ferences
in
(heart rate
pulmonary function, cardiovascular performance and blood pressure), tremor, or serum potassium
large-
and small-volume
HCs
the
with
HFA-formulated albuterol
ence
sulfate
compared with
CFC
following each incremental dose. Longer-term clinical experience with the CFC-free propellant should provide additional data
HFA-propellant use.
dose delivery of HFA-formulated albuterol between the large- and small-volume HCs, allowing use of the more convenient smaller-volume HC with no loss of
in
CFC
been established
in
Nogami-Itoh
et al'^
compared
HFAanes-
PRODUCT SOURCES
CFC
They concluded
AeroChamber valved
HC
with
FLOWSIGnal, Mon-
NY
bronchospasm, Dockhorn
in
et al'-*
1
UK
Drugs:
Ventolin, GlaxoWellcome (Canada)
Inc.,
Mississauga
in heart rate,
blood pressimilar.
Ontario Canada
and electrocardiographic
et al'^
QT
intervals,
were
1
Airomir,
3M
HealthCare, Loughborough
UK
Kleerup
found
that
1/12 sal-
Cascade Impactor:
1
butamol (albuterol) sulfate produced clinically and statistically similar airway responses and side effects in a ran-
ACFM (Mk-II) nonviable ambient particle sizing sampler, Graseby Andersen, Smyrna GA
St.
domized crossover study with 24 stable, mild-to-moderate asthmatic subjects. However, none of these in vivo stud'''''^ indicated that a spacer or HC had been used in the ies
administration of the aerosol.
Reference Flowmeter:
Louis
MO
Drug Assay:
Star HPLC System, Varian Associates Inc,
Walnut Creek
The improved
ume
HC
(represented by
AeroChamber
HC
in
both our
CA
Statistical Software:
may have
implications for
dosing with HFA-formulated albuterol, requiring further dose-response investigations in subjects who use HCs for bronchodilator administration. In association with
fine particles in the 3
tested,
SigmaStat,
SPSS
Inc,
Chicago IL
REFERENCES
Riker Laboratories Inc. Self-propelling, powder-dispensing compositions.
2.
we found an average
representing a
37%
increase in dose
/u,g,
that
from CFC-formulated
to
HFA-formulated albuterol
Barry
size
Aerosol
Med
CFC
ment
Moren
F.
inhalation aerosols.
In-
may
is
in either acute or
clinical investigation
Respiratory Care
43
Effects of
MDI
In vitro
pertbrmance characteristics of
inhalers
(MDIs) with
large
Rau
MW,
Coppolo D. Assessment of
large
1
volume
2.
spacers.
Eur Resp
I996,9(S23):255.
S, Klinger
and small volume holding chamber performance with HFA-formulated albuterol (abstract). Chesl 1996;! 10(4 Suppl):82S.
6.
Ward
NM, Ekholm
J
KM,
amount of
13.
et al.
Barry
PW. O'Callaghan
Eur
Clin Pharmacol
1995;
48(6):473^77.
Nogami-Itoh M, Yakuo
I,
1997;I0(6):1345-I348.
retention,
Hamnierbeck
DM,
1
Miller RL,
Takeyama
and
Med
I980;37(4):
337-362.
8.
in
dogs.
Pharm
K,-
Wildhaber JH, Devadason SG, Hayden MJ, James R, Dufty AP, Fox
Res 1997;I4(2):208-2I2.
14.
RA,
9.
et al. Electrostatic
Dockhom
RJ,
Eur Respir
I996;9(9):1943-I946.
NM.
Proventil
HFA
Dolovich
MB. Lung
Ventolin.
1.5.
Ann
Allergy
Wildhaber JH, Hayden MJ, Dore ND. Devadason SG, LeSouef PN.
Salbutamol delivery from a hydrotluoroalkane pressurized metereddose inhaler
in pediatric ventilator circuits:
Kleerup EC, Tashkin DP, Cline AC, Ekholm BP. Cumulative doseresponse study of
non-CFC
HFA
an
in vitro study.
Chest
metered-dose inhaler
in patients
996; 109(3);
1998;113(1):I86-191.
702-707.
44
No
Reviews, Overviews,
&
Updates
MS RRT
Background
History
Alkali Reserve
Anion Gap
Stewart's Approach
Weak
Acids
Conclusions
[Respir Care 1999;44(l):45-52] Key words: Acid-base balance, anion gap, base
excess, bicarbonate, buffers, physiology, Stewart's equation, strong ion difference.
Background
The concept of acid-base balance has
expressed
in
The "nonrespiratory"
base balance
historically
is
or metabolic
component of
acid-
been
and nonrespiratory (metabolic) systems. The term "acidbase balance" refers to the maintenance of the free hydro-
method of expressing
on [H^]
expressed through
in the
(ie,
is
pH = pK
-I-
log
normally expressed
[HCO3
]/[C02(d)]).'-'
The equation
However, an
tration (ie,
to
pH = log
[H"^]).
The
the Henderson-Hasselbalch
(COt
-I-
[d]),
which
in turn
to influence
C02(d)
-f-
HjO^HjCOj^ HC03^
would have
to vary
however,
that
do not vary
[HCO3 vary with [COj], and it is this dependence of [HC03~] on [COj], particularly in blood plasma, that has resulted in some controversy and confusion when it comes
Joseph Morfei
MS RRT
is
to expressing
changes
in the
New York
base balance and the effect that those changes have on pH.
New
York.
been professed
to
SUNY
Adams
Syracuse
NY
13210. morfeij@vax.cs.hscsyr.edu.
Respiratory Care
No
45
in
Acid-Base Balance
on body pH. This paper is a review of the various forms of expressing the metabohc
[HCO3
the
dard bicarbonate
The problem with stan40 mm Hg after blood sample has been removed from the patient. It
]
would be
is
eliminated.'*
that
P^o,
is
adjusted to
mechanism
base disturbances.
way of
History
Thus,
in
and
that has
moved
is
into
interstitial fluid in
cases of hypercarbia,
it
when
the P^o,
corrected
In 1916,
Hasselbalch
made
pH
measurethat
to
40
mm Hg in vitro,
low [HCO3"]
met-
He
measurement be
Astrup
et
aP showed
that
made
~75%
a
of
been adjusted
40
mm
Hg.''
the buffering against fixed acids or bases, a correction factor should be used that
more
Alkali Reserve
VanSlyke (1883-1971) was the pioneer of acid-base theory and methods. Over the course of some 50 years, he and his associates, through research and publication, developed methods and equipment that were the precursors to today's blood gas measurement and interpretation.*^ It was VanSlyke who proposed to determine
Donald
mean by
1.2.
was preferable
acid).'
to buffer base
it
because
was more
In I960,
expressed in
mEq/L
the surplus
amount of fixed
HCO3"
He
(which he referred to as
BHCO3)
at
pH
of 7.4.
acid-base
nomogram
series of titrations
HCO,".'* Van Slyke and his associates introduced the terms alkali deficit and alkali excess as substitutes for metabolic
acidosis and metabolic alkalosis.'
ibrated at 3 different
point of intersection at a
pH
mm
Hg
were
nomogram
eliminated the
need
to
their
nomogram
sum of
changes
hemoglobin concentration or
mEq/L) contained
whole blood. These buffer anions are as follows: the bicarbonate in plasma and in red cells; hemoglobin; plasma proteins; and the phosphate in plasma and red cells. The
total quantity
Siggaard-Anderson" reported
both
that
".
small
changes
in
BE
(blood) and
BE
in
determined by
is
BE
He
(Shaw and Messer'^ and Hickman et al'^), that "at present it seems that no preference can be given either BE (blood)
or
Standard Bicarbonate
BE
first
introduced
in
to the
HCO3"
oxygenated
to a concentration gradient
[HC03~]
is
affected
P(-o,
of 40
mm Hg.
It
was
was
the best
result in
to
40
mm
Hg,
its
influence on
46
No
in
Acid-Base Balance
Roos and Thomas^' developed theoretical equawhich allowed for base excess and standard bicarbonate to be corrected for in vivo behavior. They proposed
In 1967,
tions
to identify this corrected value as the standard
blood buffer
normal compensatory responses were being interpreted as primary metabolic disorders. They also pointed out that
the
base. This
would be
to
P^o
is
40
mm Hg.
deficit
now
in extracel-
and the
Anion Gap
Neither
icit
[HCO3
by
itself,
man) objected
".
.
to the use
blood
in
blood
in vitro."'"
To
due
ion that
into the
fluid.
produced
editorial
Emmet and Narins^^ proposed the "anion gap": anion gap = [Na^] - ([CF] + [TCOj]), where TCO2 is total CO2 This concept is based on the law of
.
electroneutrality
(ie,
The
went on
body
is
equal to the
titration
vivo differs
anion concentration
-I-
from
any calculation of
[HCO3
4-
lationship expressed by
Emmet and
which
is
An
increase in
in the
gap
is
an indication of an increase
con-
In 1976, Severinghaus'**
hemoglobin
(Fig.
Siggaard-Anderson alignment
CP
if
(ie,
by monitoring whether HCO3" and have increased or decreased allows one to determine
nomogram
in
the acidosis
a loss of base
was due to a gain of acid or a loss of base would be electrically balanced by a gain
fol-
felt
of chloride with a normal anion gap [a hyperchloremic metabolic acidosis], whereas a gain of acid would be
infants and
anemic subjects and that 5 g was 14-18 hemoglobin range normally seen in
lowed by a
fixed acid).
is
loss of
HC03^
due
to increased buffering
of
gap due
to the gain
of
corrected for the fact that as P(;q^ rose acutely in vivo, the
bicarbonate that was generated through the hydrolysis reaction diffused into the interstitial fluid.
size of the interstitial
Depending on
the
to oneto
in
fourth of the
be measured
newly formed bicarbonate would remain in whole blood. "The buffering of COj
its
interstitial fluid to
One can see that although these traditional methods of measuring the metabolic component of acid-base balance
are reliable and useful in the interpretation of simple acid-
about one-third
actual
hemoglobin concentration."2o
may be
useful
when
patients.^*
Respiratory Care
47
in
Acid-Base Balance
TCOi
in
plasma
60
HC05
In
plasma
(mmol/l)
(mmol/l)
(
pCOi
Of blood
in
blood
= 37"C
(kPa)
(mm Hgl
r 10
Patient identification
in
Acid-Base Balance
Stewart's Approach
weak
acids, [AjotI-
is
the difference
all
strong cations
-I-
The concept of strong ion difference [SID] and its role maintaining homeostasis was proposed by Peter A StewStewart's approach to understanding acid-base bala quantitative
is
all
[Ca^']
SID = ([Na^]
[other strong
all
art.27-28
anions]).-"
concentrations of
ance
one
that
makes
a distinction
between
the nonvolatile
tion being
weak
examined.
and
weak acid [A-^qj]) and dependent variables ([HCO/ ], [HA] (weak acid), [A~] (anion), [CO,""],
total
'^
composed of
]
[H2FO4I +
+ [HPO4([PrTox] = [Pr~
its
-t-
In vivo, the
CO2
is
changed primarily or
that Stewart
in-
is
showed
is
that
since [H^]
a de-
pendent variable,
movements
for
changes
in
that
changing [H^
changes
They may contribute part of the mechanism for in some situations, but they do not deter]
the
way
that
we
classify
and
on
pH
is
confirmed by
others.-''"'
in biologic [H"^] require
and accepted. Since Pco, is an independent variable, it can directly effect changes in pH
through the hydrolysis reaction:
HCO,"
4-
is
de-
will
result
in
an
in-
all
H^
[Ajoj] and [SID] are independent variables and thus cannot be adjusted by Pco,-
2.
According
equilibrium: [H^]
metabolic
X [A^] =
[A
]
3.
-I-
=
X
4.
normal protein
state, the
SID
is
it
[HCO3
is
[HCO,
5.
]
K, X
Pco,;
measured [SID]
if
normal [SID]
(140
-F
base
6.
Carbonate ion formation equilibrium: fH"^] X = K, X [HCO, ]; [CO,- [HCO,] Electrical neutrality: [SID] + [H + - [CO,^-] - [OH] = 0. [A]
]
+ [K + ])-[Cr] =
the
8,
4)
-104 =
if
40),
and
the
in
showing
system
that
is its
".
each of the
by changing the
in
dependent variables
tion of,
in this
own
all
specific func-
which SID
in
is
and
is
three indepen-
(ie, [SID], [Ajoj], and Pco,)- The exact .solution for [H + ] follows: [H^]-* + ([SID] + K^) X - K' - K, X Pco,) X [H + ]-' + (Ka X [SID] -
dent variables
SID =
0.
The
resultant
change
the ion
is
[AtotD
is
removed.
Pco,)
K, X K, X P^o,)
0.2S
tells
Ppo, = equation
us that in any
a
to the
CO2, and
weak
acid,
Second,
if
SID would be to correct the water imbalance. sodium concentration is normal, altering the
[H^]
is
Respiratory Care
No
49
in
Acid-Base Balance
albumin (3.5-4.5
as any strong acid
g/dL).""*
act
in
[CP]
will result
would on
the directional
change of pH.
decrease in
SID and
The
is
pH
accompanied by a
loss of
Hypophosphatemia,
represents only
will
[COjCd)
tate,
HCO,]).^
If
normal [Pitot]
is
only
~1 mM, which
have shown
distinguished
that [A-pQ-p]
mainly
albumin
will
follows that
if
then a decrease in
[CP]
common
patients
that ".
equivit,
removing from
lactic,
The kidney, which is normally identified with controlling the metabolic component of acid-base balance, does not try to regulate [HC03~] in response to a metabolic
acid-base disturbance, but
it
mmol
.
ke-
.."
and
[CI ~]. ^2. 35.36 xhus, if the kidneys are to raise the
plasma
alkalosis.''44o.4i
this,
C\
must be
present, in
only Pco,- [AjotI' or [SID] can change [H"^] in any body fluid compartment) allows us to more clearly focus
not to say
kidney cannot
move H^
or
HCO3"
directly across
more
easily
it.
P^q
membrane: Various
it is
but
final
[SID]
the
is
[OH"], [HCO3 ], and [CO3values, not the amounts of these ions which may have been moved."-** To correct a hypochloremic alkalosis, C\ must be replaced, which will have the effect of reducing plasma SID. There are a number of ways to accomplish this without
[H""],
inorganic phos2).^^
serum
proteins,
[Ajqt]
'S
same way
It
is
paradoxical hyperventilation.''-
pH
are
P^o,- ^ID,
way
The attempt
to restore
is
in
which
it
homeostasis
in the
presence of an
acid-base disturbance
to the metabolic
when
it
comes
'^
clearly understood in
Weak
Acids
terms of
its
pH
is
much
As previously mentioned,
AjoT' found
with
in
the nonvolatile
weak
acids,
whole blood
~60%
50
No
in
Acid-Base Balance
LUNGS
in
Acid-Base Balance
the
[H^]
in
body
fluids
is
19.
of strong ions between these compartments and the resultant effect on [SID] within that compartment.
CMn Lab
Invest 1963;15:211-217.
One would
plasma
20. Severinghaus
is
Clin
Lab
Roos A, Thomas LJ
siology
Jr.
The
in-vitro
body and
pH would
967 ;28(6)
048- 063
1
22. Severinghaus
for standard-
attempted.
23.
Monit 1991;7(3):276-277.
Clinical u,se of the anion gap. Medicine
(Baltimore) 1977;56(l):38-54.
REFERENCES
1.
24. Figge
in acid-
base equilibria.
25. Figge
J,
Am
Physiol 1908;21:427.
Mydosh
Fend V. Serum
2.
Hasselbalch
Blutes aus
26.
Lab Clin Med 1992;I20(5):713-719. Fencl V, Rossing TH. Acid-ba.se disorders in critical care medicine (review). Annu Rev Med 1989;40:17-29.
ria:
a follow-up. J
27. Stewart
ga.ses:
PA.
How
to
New
York/Oxford:
WB
pH
PA.
Modem quantitative
acid-base chemistry.
Can
Physiol
J Clin
Pharmacol 1983;6I(12):1444-1461.
29. Weinstein Y,
Studies of acidosis.
its
I.
significance and
its
Med
measure of acidosis.
6.
Biol
Chem
1917;30:289-346.
ion
in hu-
human
mans.
Am
J Phy.siol
I992;262(l Pt 2):R126-R136.
quantitative acid-base chemistry: ap-
27:223-242.
7.
Schwartz
DE. Stewart's
B,
Relman AS.
New Eng
its
Med
1963;268:138232.
91(1);1-16.
Eicker
SW. An
Jorgensen K, Astrup
a
P.
Standard
HCO,"
clinical significance
and
33.
new method
for
its
9:122.
9.
Food Anim Pract 1990;6(1);45^9. Garella S, Chang BS, Kahn SI. Dilution acidosis and contraction alkalosis: review of a concept. Kidney Int 1975;8(5);279-283.
Clin North
Am
34.
10.
Siggaard-Anderson O, Engel K.
alka-
Care
Med
1980;8(12):725-728.
in
data.
1 1
improved method for the calculation of the relevant blood acid-base Scand J Clin Lab Invest 1960;12:177-186.
Siggaard-Anderson O. Acute experimental acid base disturbances
in
Hoffmann
E,
volume and
pH
36.
Rev I989;69(2):
315-382.
Intracellular
pH
(review). Physiol
Rev 1981;
critical
in
Clin
Lab
Invest 1963;66;l-20.
transfer of bicarbonate between the blood and tissues caused by alterations of carbon dioxide concentration in
man.
Am
J
Physiol 1932;100:122-136.
Am J Med
38.
13.
Hickman
B, Wilson
WP,
Human
physiology.
New
York: Springer-
Clin
39.
Wang
F, Butler T,
Bunker
J.
The
1965;26(5);591-594.
15. 16. 17.
phatemia
.
to
Engl
Med
1986;
More acid^ase
A.strup P.
315(25):1591-1595.
40. McAuliffe JJ, Lind LJ, Leith
losis.
New Eng
Med
1963;269;817.
P.
alka-
micro
41
Am J Med
1986;8l(l):86-90.
method
for determination of
and standard
Severinghaus
HC03"
J.
in capillary blood.
Scand
Clin
Lab
Invest
human blood
in vitro. J
1960;12:172-176.
18.
61(6):2260-2265.
Acid-base balance
nomogram
a Boston-Copenha-
42. Rossing
hypoprotdnemia.
TH, Boixeda D, Maffeo N, Fencl V. Hyperventilation with J Lab Clin Med 1988;1 12(5):553-559.
52
Respiratory Care
No
Bronchodilator Therapy
James B Fink
in
MS
RRT, Martin
Tobin
MD,
MD
Introduction
Basic Concepts of Aerosol Therapy
Inertia!
Impaction
Gravitational Sedimentation
Diffusion
The Airway The Environment The Assessment Evaluation of Lower Respiratory Tract Aerosol Delivery with Bench Models of Mechanical Ventilation
Aerosol-Generating Devices
Nebulizers
Position
in the
Ventilator Circuit
Mode and
Settings
Methods
to Assess
In Vivo
Radionuclide Studies
Estimation of Plasma Levels Technique of Aerosol Administration Care of Spacers and Nebulizers EfUcacy of Bronchodilator Administration during Mechanical Ventilation
Bronchodilator Efficacy
Bronchodilator Dose
Drug
Toxicity
Conclusion
[Respir Care 1999;44(l):53-69]
pulmonary
James B Fink
MS
Jr
RRT. Martin
Tobin
MD.
MD
are
Correspondence
&
Reprints:
James B Fink
(111),
MS
RRT, Division of
Jr
Pul-
Pulmonary and
Care Medicine.
monary and
Hospital,
Critical
Veterans Affairs
Edward Hines
Medical
Service
Hines,
IL
60141-5000.
james.fink@med.va.gov.
Respiratory Care
No
53
Bronchodilator Therapy
in
Introduction
is
the ratio of
median
at
The
tic
An
aerosol with a
GSD
of
< .2 MMAD,
1
by several decades of research. The advantages of aerosol therapy include efficacy with a smaller dose (compared
with that for systemic administration of the drug) and a
rapid onset of action.' Inhaled drugs are delivered directly
to the respiratory tract, their systemic absorption
ited,
is
median
GSD,
Inertia!
Impaction
impaction
is
limInertial
the primary
mechanism
for depo-
bronchodilators are routinely used with mechanically ventilated patients in the intensive care unit, yet
sition
of particles 5
;u,m or larger
that
motion
to
remain
The
delivery of inhaled
motion
in a straight line.
The
greater the
mass and
drugs
in
in
ambulatory patients
are
Nebulizers and
When
a particle
is
traveling in a stream
MDIs
commonly used
of gas that
is
on the
namic diameter
(MMAD)
between
and 5
^im.""
Whereas
The
greater the
mass of the
MDIs
tility
tendency for the particle to impact with the surface, depositing on the airway, rather than continuing to travel
biotics, surfactant,
and
Traditionally, nebulizers have been used for bronchodilator therapy in patients receiving mechanical ventilation;
which increases
to
When MDIs
>
particles that
These condiventi-
aerosol given by
MDI
mg
techniques inhaled drugs can be administered safely, conveniently, and effectively in mechanically ventilated
patients.
Gravitational Sedimentation
and they
settle
due to
it
when the aerosol parmovement on a trajectory slows, gravity. The greater the mass of the
and
affects particles as small as
1
To
tients,
better understand
how
4-10
s
is
we
allowed for
ambulatory
patient.''
The
particle size of
an aerosol
is
been reported.
is
com-
Diffusion
monly represented by
the
particle mass,
the log
is
normal distribution,
in
which
Diffusion, or
aerodynamic diameter
Brownian movement,
particles
is
the primary
mech-
MMAD
is
the
<
apex of
that bell
As gas reaches
region of the
curve or
at
50%
reduced to zero.
same
mass of
particles in the
aerosol are less than and half are greater than the
MMAD.
54
No
Bronchodilator Therapy
in
and peripheral
airways.** In
partiin-
due
to evaporation as the
<
3 ju,m in diameter
is
is
believed to occur
when
away from
tions,
the nozzle.'^
spiratory flow
<
40 L/min.
in the respirable
plume of particles moves Due to the velocity and dispersion from the MDI, under ambulatory condi-
Aerosol droplets
(MM AD,
1-5
80%
when
the canister
is
A particle's depth
<
1
Dolovich
tree
1
is
down
to
when
the
MDI
is
placed 4
cm from
an
/xm. Particles
MDI
actuation into a
exhaled.
chamber-style spacer decreases impaction losses by reducing the velocity of the aerosol jet,'- allowing time for
The Nebulizer
For ambulatory patients, a nebulizer
liver
is
with the
MDI
is
much
> 50%
of
its
total
dose of aerosol
ume, gas flow, density, operating pressure, and nebulizer model. '0" During mechanical ventilation, nebulizers producing aerosols with
MMADs
of 1-3
/i,m are
more
likely
was thought
to significantly
lower respiratory
circuit
tract since
lower respiratory
on the ventilator
and endo-
was
tracheal tube.'' Within the limits of the design of the nebulizer, the
mechan-
that that in
Howsize may
bulatory patients.
""
To
amcomplex array
more time to deliver a standard dose of medication. Ambient humidity and temperature also
require considerably
affect the particle size
),''
a comparison of differ-
in
mechanically ventilated
re-
is
discussed below.
maining
in the nebulizer.
aerosol to as
much
as 5
The
Ventilator-Patient Interface
The
ventilator circuit
is
is
MDI
The
MDI
MDI
Use of a generic
respirable
1%
is
of the
total
amount of
mixture
may
MDI
formulations."*
Breath Conflgurations
During controlled mechanical ventilation (CMV), the
pattern and rate of inspiratory gas flow, as well as the rate
20 msec.
the metered dose canister begins as the propellants vaporize or "flash," leaving the actuator in a
differ
from
The
MDI
is
15
m/s, falling by
50%
within 0.
as a cloud develops
may
actuator orifice.'-
The
particles
As
in the
Respiratory Care
No
55
Bronchodilator Therapy
in
Ventilator
Rdatfd
Deoice Relatt-d-MDI
Dru^ Related
Dose
Aerosol particle size Duration of achon
Mode
Tidal
of ventilation
volume
Respiratory rate
Timing of
MDI
actuation
Duty cycle
Inspiratory
waveform
Device Related-NehuUrpr
in
metered
dose
inhaler. (Modified
from Reference
4,
with permission.)
using an aerosol
in a hot,
high-humidity climate
in
may
well
delivered dose.
The Airway
Although the endotracheal tube (ETT)
The Assessment
The common method
flow
rates.
is
commonly con-
chodilator administration
through changes
in expiratory
During mechanical ventilation, forced expiratory maneuvers are often impractical and rarely performed.
Most
in
on changes
in the inspira-
nar-
wye
to the
ETT), which
that are not
result in points of
impacair-
tion
and turbulence
found
in the
normal
Evaluation of Lower Respiratory Tract Aerosol Delivery with Bench Models of Mechanical
Ventilation
view,
we
much
aerosol
from the
MDI
ETT
during
CMV.'^
nism
The Environment
Ventilator circuits are typically designed to provide heat
to
42%
and humidity
an increase
to inspired gas to
from 0.3%
to
97.5%
Humidity has been shown to relate to particle size and reduced deposition during
is
models simulated
The use of a
facilitate
CMV,
unique
The ambulatory
patient
56
No
Bronchodilator Therapy
in
Nebulizers
100
MDIs
100
Q)
80
80
>
T3
<U CO
60
60
O
"O
"to
c E o
40
40
20
I
^#
.$i^'
20
^*^
f' ^*^
^,0^ O^
<#
Fig. 2.
Range
of values reported
in
bench models
range
is
generated by nebulizers (open bars) and metered dose inhalers (MDIs; solid signaled by the upper and lower limits of bars. Depending on the technique of
administration,
Delivery
between
was
greatest
and 97.5% of the nominal dose was delivered to the lower respiratory tract. when an MDI was actuated into a catheter^^ because the drug was released
Fuller,''^
O'Riordan.^^Thomas,^' O'Doherty.^"
Rau,22 Taylor,23
Diot,^'' Fink.^^
Position
tlie
Aerosol Gen-
When
erator in
Ventilator Circuit.
Placement of a nebis
tion of the
tract
lower respiratory
ulizer at a distance of
30
cm from
MDIs
similar
(~15%
with
more
efficient than
and
each
Aerosol-Generating Devices
Nebulizers.
highly
tions. "-"-''2*'
The
sol delivery.-'*
among
uous aerosol generation, a nebulizer unit powered by pressurized gas from a piped (wall) system, cylinder, or
Metered Dose
Inlialers.
com-
MDI
can-
pressor
is
connected
power
MDIs
limb of the
ventilator circuit.
The
latter
include
as cylindrical spacers
is
more
Howto
ber devices (Fig. 4). Both in vitro and in vivo studies have
by most ventilators
found
that the
combination of an
MDI
and a chamber
the nebulizer
(<
15 psi)
is
by compressed
in the hospital
air
or oxygen sources
psi).-''
MDI
(> 50
driving
MDI
into an
air
flow
to the
lower respira-
This observation
may
Respiratory Care
No
57
Bronchodilator Therapy
in
MDI
Medianlcal Breath Generator
Spacer
Endotracheal Tube
VenUUtor 2
test aerosol deposition in mechanically ventilated patients. generated machine-delivered breaths. The metered dose inhaler (MDI) was actuated into a cylindrical spacer placed in the inspiratory limb of the ventilator circuit. The ventilator circuit was connected to an endotracheal tube with an elbow connector. The endotracheal tube with balloon inflated was positioned
Fig.
3.
Ventilator
inside a model of the trachea and mainstem bronchi. The aerosol deposited on filters placed at the ends of each bronchus. Ventilator 2 was used to simulate patient respiratory effort (spontaneous breathing) by inflating section Y of the test lung, which produced corresponding displacement in section X because of a metal bar connecting the 2 sections. The negative pressure produced in section X triggered ventilator 1. A filter placed in the expiratory limb of the ventilator circuit trapped any aerosol that bypassed the endotracheal tube. (Modified from Reference 25, with permission.)
mg
of
Aerosol impaction
in the
en-
effi-
tients.
The
when
(internal diameter of 3 or
mm)
sol
6 However,
(MMAD
lower respiratory
lower respiratory
The
MDIs
40%,
''24.25,34
'
particles of
<
some
fier
When
actuation of the
MDI
into a spacer
was
cation
may
MDI;
this
to
MMAD
35 min to com-
of
likely to be
more
which
is
MMAD
of 1-3 ixm.
risk
of ventilator-associated pneu-
58
No
Bronchodilator Therapy
in
re-
sulted in
Aerosol
if
modes of ventilation
was up
to
the
found
23%
higher in
equivalent
Vj Vy
(Table
1).
the
tracheal tube.
Vj
volume of the ventilator tubing and endoof > 500 mL in adults are associated
1),'''-'^
but the
Vj can be
directly cor-
used to connect the metered dose inhaler (MDI) canister to the elbow adapters; C, collapsible cylindrical spacer chamber that can be fitted in the inspiratory
limb of the ventilator circuit; D, noncollapsible cylindrical holding
volume and
MDIs produce
aerosol
over a
finite portion
chamber; E, aerosol cloud enhancer spacer, w/ith which the MDI flume is directed away from the patient. (Modified from Reference
4, with permission.)
and ventilator tubing are swept off the walls and entrained
dry
ad-
Approximately
may
when
administered by an
tilated patients,-^^
dose of albuterol
mechanically ven-
DNase)
to reduce the
whereas
< 1%
'
amount of medication
treatment,
ventilator circuit.
we recommend
in
mechanically venti-
MDIs. but
there
is
variation,
74%). '
depends
with a
helium-oxygen
The
on the extent
vivo situation.
may improve
We
model
and reproducible
results.
The
when
comparing the
and
in cor-
50%
MDI
during
CMV
when
breathing heliox
compared
oxygen."
ventilator
Methods
to Assess
Deposition In Vivo
Ventilator
Mode and
Settings.
The
mode
Radionuclide Studies
Imaging of radiolabeled aerosols has
traditionally
of an
MDI
been
in
MDI
employed
to assess total
No
59
Bronchodilator Therapy
in
>
"3
o
(A
2
0) re
o c O
UJ
Fink,
Fig. 5. Effect of
96
humidity on aerosol delivery. The efficiency of aerosol delivery to the lower respiratory
tract
is
shown
p
for
bench models
and humidified
ventilator circuits.
The
reduced by
humidified.
*,
<
0.05;
<
0.01; *", p
<
permission.)
30
25
20
CO
Bronchodilator Therapy
in
Table
Effect of Tidal
Volume
(V-^)
and Ventilatory
Mode on
Aerosol Delivery
Bronchodilator Therapy
in
D
1
MDI (n=7)
SVN
8
(n=9)
c
_o
o
Q.
}
6
a
c
SS
4
2
4
1
Fig. 7.
PUFF
(MDI)
min (SVN)
Aerosol deposition to the lungs (expressed as a percentage of the dose delivered to patients
dose inhaler (MDI) or small-volume nebulizer (SVN). The cumulative dose delivered to the patient is expressed as the number of puffs for the MDI and as the time for the SVN. With the MDI (n = 7), 5.65% 1.09% of the dose deposited in the lungs compared with 1.22% 0.35% with the SVN (n = 9). (Modified from Reference 15, with permission.)
receiving radiolabeled fenoterol) with a metered
20 r
Nebulizers
MDIs
^
15
'.4'
g w o
10
Q.
Q)
T
J~
'^
vVl'
I
..o^^'
^^o^^'
^^""^
.o\^ ^*
,^^'
^^^'
<<^'
#
and
al,^^
Fig. 8.
radiolabeled aerosols
2.2%
to
15.3%
with nebulizers
whereas the other studies were conducted in a humidified circuit. Only the data reported by O'Riordan had been corrected for tissue adsorption of radioactivity (reported value x 1 .9).^^ Studies (from left to
right):
^i
Fuller.^i
(From Reference
4, with
permission.)
15%
from 4 puffs of an
MDI
more commonly reported 2% delivery. Thus, 50 /xg of albuterol would be delivered to the lung with a nominal dose of 2500 /nm with a nebulizer. This dose would be similar to the 60 fig of albuterol delivered
conditions and the
aerosol administration
from
that with an
MDI
(Table
3).
62
No
Bronchodilator Therapy
in
1.50
-,
Table
2.
in
Mechanically Ventilated
1.25
fill
2.
at least
30
cm
1.00
3.
a
0.75
-
4.
volume (a 500
mL
in adults).
Attempt
to use
>
0.3, if possible.
to
5.
compensate
required.
^ o
h V
0.50
5.
ventilator,
remove
0.25
7.
medication
is
nebulized or
when no
more aerosol
conditions.
is
0.00
->
8.
Reconnect ventilator
alarm settings.
circuit
and return
to original ventilator
and
10
15
20
25
30
*The volume of solution associated with maximal
nebulizers and should be
efficieitcy
Time (min)
Fig. 9.
known
Comparison
of
serum
Placement of the nebulizer, placed between the ventilator and the inspiratory limb
efficient for aerosol delivery than
more
trols
holding
patient.
'The nebulizer may be operated continuously or only during inspiration; the been shown
to
method has
chamber with optimal technique and breath hold under ambient conditions) and stable mechanically ventilated patients with chronic
obstructive pulmonary disease using a chamber-style adapter
in
Some
flow to the nebulizer. Continuous gas flow from an external source can also be used
the nebulizer.
power
patients
when
the spacer
is
pulled
open during use. a noncollapsible spacer chamber is used to actuate an MDI, it should be removed from the ventilator circuit between treatments. There is no evidence
that nebulizers placed
When
shown
MDI
during
CMV.
lower respiratory
tract.
is
subject
Mechanical Ventilation
Bronchodilators are
among
the
most commonly
u.sed
The Centers
and Preven-
tion (Atlanta)
at the start
recommend
disassembled,
and
air dried.
Care should
is difficult
to predict
on
be taken
between uses.
been observed
aerosolized
ergic
jS-adrenergic-'--"*-*'^-'''
or anticholin-
become contaminated.
chamber
bronchodilators. ''^''o
spacer used with MDIs remains in the ventilator circuit between treatments and condensate collects inside it. The formation of condensate within the spacer can be reduced
circuits or heat
and mois-
with
Respiratory Care
No
63
Bronchodilator Therapy
in
Table
3.
Technique
for
in
nomena
the lung
1.
Assure
tidal
volume
>
500
mL
airway oc-
(in adults)
during assisted
ventilation.
2.
Aim
>
0.3
pressure, and
its
Ensure
From
tient)
inspiration.
4. 5.
pattern,
Shake the
MDI
vigorously.
in
6.
Actuate
MDI
of inspiration by
the ventilator."
7.
8.
Rrs
max =
Lipeak
air
"plat J
flow
dose
is
delivered.*
*With MDIs
it
is
cireiiil
so that
Rrs min
[Pipeak
MnitJ
air
flow
it
In
MD!
is
recommended
A Rrs =
Rr,
max R min
Tidal
[Pp,
when an
MDI
is
inspiration.
min: however.
delivery.'^
MDI
actuation
20-30
s after
compromise drug
Volume
- PEEP,]
Most mechanically
Bronchodilator Efficacy
COPD
demSince
lowing bronchodilator
administration''**'"-'''-''-'-'''*.
The primary goal of aerosol therapy is to achieve the greatest amount of drug deposition in the lower respiratory tract. However, increased drug deposition in the lower
respiratory tract does not necessarily correlate with greater
our
studies,-'''-'''*
it
therapeutic efficacy.
The response
to bronchodilator ad-
was manifested mainly in the central airways without much apparent effect on visco-elastic behavior or time constant inhomogeneities in the lung. The time conalbuterol
stant (R^-^min
in
our patients
improved
at the
was not
that
Once
been
bedside,
it
is
important to realize
any respiratory
effort
by
measure changes
in
ohmic
Most
dilators
to
determine their
ments of changes
ful
in resistance
may
clinical efficacy.
tilated patients is
Airway
at
with patients
who
rapid
airway occlusions
The occurrence of
to predict in
a bronchodilator response
is
difficult
performed
at end-inspiration
by
mechanically
10).
flow limitation
is
lower
initial
pressure
Moreover, the
influence on the
value of
P|i,
MDI. Early
re-
showed promising
''^
total
or
maximal
into a
flects the
tional
"ohmic" resistance of the airways and an addieffective resistance(AR); AR represents two phe-
Manthous and colleagues-'^ reported no benefit from administration of up to 100 puffs of a bronchodilator aerosol with an MDI and elbow adapter in venMDI.-"
Later,
More
recently,
it
has
64
Respiratory Care
Bronchodilator Therapy
in
50-
P peak
50
40
40
O
Jo
20
init
Pplat
O
xso
/
20
;10
0.
0-1
I
1
PEEP:
0-
Time, sec
Fig. 10.
Time, sec
for monitoring patient
is
determined by difference
the airway pressure
falls
to an
plateau (P
init)
and over 3 s
plat. B,
MDI
for bron-
circuit.
is
The
when
the
MDI
actuation
inspiration.
'^--5''
Bronchodilator Dose
On
markedly lower
latory patients,
in
was ambu-
was recommended
doses of
0.0
2.5 5.0 7.5
10.0
12.5
15.0
Dose
Fig. 11. Effect of albuterol
(albuterol,
mg)
in
on flow-resistive pressure
rapid
fall in
10 me-
mg of albuterol
with a nebulizer
NEB) produced a
flow-resistive pres-
mg
an
sure (21.5
5.7
cm HjO
in
at baseline vs 17.6
)'1
<
0.01).
mg
of albuterol
produced
in
incremental benefit
with values with 2.5
resistive
MDI
(Fig. 12).'-*
The
MDI was
administered to stable
3.6
cm HjO
(p
>
0.05 compared
in
mg
albuterol). In contrast,
no change
flow-
to inspiration, with
of albuterol with a
20-30 s between actuations. Minimal therapeutic advantage was gained by administering higher doses (Fig. 13), whereas the potential for side effects was increased (Fig.
14)
32.54
[fi
lish a rational
tients. In
is
dosing schedule
in ventilator-supported pa-
(}^g
bronchodilators
may be needed
if
in
summary, when the technique of administration carefully executed, most stable mechanically ventilated
airway obstruction or
not optimal.
patients with
COPD
However,
needed
to assess
MDI
or 2.5
mg
No
65
Bronchodilator Therapy
in
22
20
p<0.001
o
q> (0
\ O
E o D E
12
i\
_j
ty
oJ
1
Bronchodilator Therapy
in
100-1
8 *
16 puffs
p<0.05 p<0.01
90-
E
*->
<D
(O
80
Bronchodilator Therapy
in
its
tilated patients:
comparison of dose
to the lungs.
Am
Fahey
PJ,
and
in
We
MDI
18.
Med
1999;159
(in
and spacer
in a
nificant bronchodilatation in
stable
is
Fuller
C,
COPD, and
model.
Aerosol
minimal. The magnitude of the bronchodilator effect obtained with 4 puffs of albuterol
is
Med
1992;5:251-259.
19.
O'Riordan TG, Greco MJ, Perry RJ, Smaldone GC. Nebulizer function during mechanical ventilation.
comparable
to that ob-
I992;I45(5):
1117-1122.
20.
MDI
or nebulizer
O'Doherty MJ, Thomas SHL, Page CJ, Treacher DF, Nunan TO.
Delivery of a nebulized aerosol to a lung model during mechanical
ventilation: effect of ventilator settings
may be
struction.
21.
and volume of
fill.
Am
ACKNOWLEDGMENT
Supported by a Department of Veterans Affairs Research Service
grant (RD).
Nunan TO.
pt 1):872-
Am
22.
Rau
JL,
Harwood
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Newhouse MT. Dolovich MB. Control of asthma by
view). aerosols (re-
RH, Lerman
J,
efficiency
Engl
Med
1986;315(14):870-874.
24. Diot P,
in
a model of
Boucher BA, Kuhl DA. Coffey EC, Fabian TC. Drug use
intensive-care unit.
in
a trauma
Am
1995;152(4pt 1):1391-
Dhand
1394.
25. Fink JB,
delivery
in vitro
9(3):585-595.
Brain JD, Valberg PA. Deposition of aerosol
(review).
in the respiratory tract
an
Am
Med
Am
Effects of nebulizer
mode and
position in a
Tobin MJ,
York:
27.
New
McGraw
Hill,
of mechanical
38(8):887-895.
Yu CP,
Harvey CJ, O'Doherty MJ, Page CJ, Thomas SHL, Nunan TO, and
Treacher DF. Effect of a spacer on pulmonary aerosol deposition
aerosol deposition.
Am
Ind
Hyg Assoc
1979.40(1 1):999-1(X)5.
J
Aero-
from a
Med
50(l):50-53.
29.
Hess D,
Homey
P. Pooler S,
Bishop MJ, Larson RP, Buschman DL. Metered dose inhaler aerosol
characteristics are affected by the endotracheal tube actuator/adapter
Dhand
J
used. Anesthesiology
31. Fuller
13
MT. Optimal
deliv-
comparing four
911-915.
14
32.
Wood LDH.
pt
Metered-dose
Moren
300.
F,
after administration
1
980;|36;29533.
Am
1):1567-1570.
15
Fuller
WW,
Newhouse MT.
68
No
Bronchodilator Therapy
in
34.
Gamer
SS. Wiest
delivery by metered-
52.
Manthous CA, Chatila W, Schmidt GA. Hall JB. Treatment of bronchospasm by metered-dose inhaler
albuterol in mechanically ventilated patients. Che,st I995:107(I):2I0-213.
Pharmacotherapy I994:I4(2):2ia-214.
35.
Svartengren
M, Anderson M,
Philipson K.
in air or in
Camner
P.
Human
lung
53.
Dhand
depo.silion of particles
suspended
helium/o.xygen mixture.
dose inhaler
Am
36.
Med
G..
1995:151(6):I827-1833.
R, Duarte
Philipson K.
in air
Camner
P.
54.
Dhand
or in helium-
MJ. Dose-response
by metered-dose
in-
oxygen.
37.
Am.
Med. I993;l47(3):524-528.
Am
Med
Fink
J,
Dhand
1996;154(2pt l):388-393.
55. Reinoso
albuterol
from a
MDI
MA,
model
38. Fink
J.
(abstract).
Am
Med
I997:I55:A268.
dependency
unit.
Am
Rev
Dhand
RP
Jr,
Smith
RM, Young
Am
Respir
Care
Med
I996;I53;A377.
in
39.
57.
Am
40.
Med
I994;149( I):2I4-2I9.
58. Sprague
DH. Treatment of
intraoperative
Thomas SHL. ODoherty MJ. Fidler HM, Page CJ, Treacher DF. Nunan TO. Pulmonary deposition of a nebulized aerosol during mechanical ventilation. Thorax I993:48(2):154-I59.
59.
JR, Tayyab
Am
41. Maclntyre
NR.
Silver
RM.
Miller
CW.
Schuler
Coleman RE.
60.
Aerosol delivery
in intubated,
Gay PC,
Patel
Gilles B,
Care
42.
Med
1985;13(2):81-84.
SJ.
Determination of salbutamol
human serum by
tilated patients.
61. Bates
JHT, Milic-Emili
The flow
J.
mea-
perometric detection.
43.
Chromatogr I984;3I
l(2):3l 1-317.
plasma
Appl Physiol
salbutamol concentration.
I985:58(6):1840-1848.
63. Jackson
205-211.
44. Duarte
AC, Milhom
HT
Jr,
Norman
JR.
reevaluation of the
J
AG, Dhand
measurement.
Appl
JW. Serum
Physiol I974;36(2):264-268.
64. Pepe PE, Marini JJ. Occult positive end-expiratory pressure in
Am
me-
Med
1996:154(6 pt
):I658-I663.
WR.
cir-
effect.
Am
mechanical ventilator
65. Dollery
Am
Med
l984:77(5):8.34-838.
CT. Williams FM. Draffan GH. Wise G, Sahyoun H, Paterson GW, Walker SR. Arterial blood levels of tluorocarbons in asthmatic patients following use of pressurized aerosols. Clin Pharmacol
46.
MA,
Cadle
RM.
et al.
An
Ther 1974:15(0:59-66.
66. Silverglade A. Cardiac toxicity of aerosol propellants.
JAMA
1972;
Ann
Intern
Med
1995:122(10):
222(7):827-828.
67. Spahr-Schopfer lA,
762-766.
47.
Lerman
J,
Wegener
T,
Wretman
S,
ipra-
under
MDI
in
intubated rabbits.
Am
Med
1994;l50(3):790-794.
48. Bernasconi
M, Brandolese
and
Manzin
E, Rossi A.
Dose-
D. Equivalence of continuous flow nebulizer and inetered-dose inhaler with reservoir bag for treatment of acute airflow obstruction.
oxygen tension
in
mechanically
Chest 1988;93(3):476-48l.
69. Alvine
Med
lators
I990:I6(2):108-114.
GF, Rodgers
P,
Fitzsimmons
Disposable jet
Aragon C, Cerda
E. Bronchodi-
nebulizers:
70. Beaty
how
Ritz
Chest I992;I0I(2):316-319.
in-line nebulizers
CD,
com-
Am
Rev
71.
in
1360-1363.
Summer W,
tion
1994:
care.
Arch Intern
Med
1989;149(3):6I8-
I05(5):15I 1-1515.
51. Fernandez A,
623.
J,
Munoz
de
la
Calle B, Alia
I,
Ezpeleta A, de
la
Cal
in
72.
WM,
Haponik EF.
Sub.stitution of meteredin
MA, Reyes
ventilated
COPD patients.
Med
1994:20(3): 199-202.
Chest I992;10I(2):305-308.
No
69
Special Article
The Therapeutic
MD
Cullen and colleagues developed The Therapeutic Intervention Scoring System (TISS) in 1974' with the double objectives of measuring severity of illness at patient
level
manpower
at the patient
in
suming.
Acute Physiolscores-
development of
and
if
(APACHE)
was
largely based
made
As
of
illness for
way,
that of
measuring severity of
me-
torical objective,
Swan Ganz
ing nursing
last
25 years. As a matter of
worldwide use of
substantially, as
ICU
setting for
mix of groups of
Let
me
illustrate this
management
purposes.-''
&
tivities
It
is
TISS have made their appearance in The important distinction to make here
that the
APACHE
more severely
ill
aim of measuring nursing work load. The nursing profession has been critical of TISS
is
illness.
for not
ICU.
TISS-28
into the
This criticism
that,
by aiming
at scor-
ing
TISS-28, "single
atrium monitoring," 8
MD, Head
points; in
NEMS,
was made
to
exclude
MD,
9700
BR
Groningen,
2 versions
Netherlands, d.reis.miranda@chirc.azg.nl.
70
No
QUANTITATING CAREGIVER
WORK LOAD
IN
THE ICU
It is
mind
that
TISS
is
an
TISS com-
was felt that TISS did not adequately describe local, more specific caregiver activities, hundreds of different TISS versions were developed over the years, such as that by Clini and associates documented in this issue.' The large majority of these remain unpublished, and none of them has been validated in multicenter and
sion, or
because
it
to 10.8
min of
work'')
was
established and validated in multicenter studies. This association (in itself reflecting average values)
was
strength-
is
under care,
say
are very
much
more
My
final
comment concerns
TISS can be
seems
fair to
used for evaluating the match between the number of nursing full-time equivalents (FTEs) staffing a given
the required number of
the
number of
ICU and
becomes.
al''
FTEs
in
One
by Clini
et
is
that
their
some coun-
NEMS.
That 3 of
were identical
in
place,
and some
activities otherwise
performed by
nurse
(eg,
are
in the criticism
is
work
and
key aspect,
but that are not necessarily associated to the listed "therapeutic" items.
in the research
to the In
With
this in
view,
my
colleagues and
are
same professional (and budget) group. the last few years, within the ICU work context,
in
task
some coun-
new
version of
point that
some
activities are
now performed by
from
all
to identify
These separate professional groups usuto the nursing staff (and budget) of the
we
obtained consensus
ally
do not belong
hygiene (eg,
in-
new
many
countries and
may be
seen as complementary to
organ donation), and (5) management and administrative activities (eg, research, coordination with other disciplines).
(including the
these
DNS-score of
do not cover
in the
An
made
new
activities,
cluded
in the
feature of these
is
REFERENCES
1.
(sub)item.
activities will
the study, as
was done
is
Knaus
Care Med 1974;2(2):57-60. WA, Zimmerman JE. Wagner DP. Draper EA.
Lawrence DE.
ation of
work load
ICU.
No
71
QUANTITATING CAREGIVER
WORK LOAD
IN
THE ICU
Med
198I;9(8):
inter-
591-597.
3.
results
from a multi-
Kreling B, Robinson
collection strategies in
Med
1996;24(l):64-73.
SUPPORT.
4.
WT, Lave
JR, Pinsky
MR.
Moreno R, lapichino G. Nine equivalents of nursing manpower use score (NEMS). Intensive Care Med 1997;23(7):760Reis Miranda D,
765.
ICU
13(2):434-442.
scale
(DNS);
Moreno
R. Reis
Miranda D. Nursing
Eu-
rope: the
practice.
Chest 1998;
113(3);752-758.
6.
J,
Moreno
Intermediate TISS: a
new
DW,
Schaufeli
WB,
Fidler
(eds).
Or-
non-ICU
patients. Crit
ganisation and
management of
Care
Med
1994;22(9); 1406-141
72
No
Mani S Kavuru
PFT Nuggets
A New
PFT Nuggets
With
this
new,
"nug-
to
data.
we
call
PFT
Nuggets.
Named
and spirograms) are the province for respiratory care practitioners' expertise.
compact package,
of a number of
installments, each of
which
How
will this
new
pulmonary function
(PFT)
is
re-
PFT
nuggets
in
On
is is
posed
that
clinically
common and
(eg,
flow-volume loops,
reader
challenged to respond.
PFT
results and,
we
this
ically relevant
may accompany
spirometry.
Why
new
feature?
The Editors
valuable
Our purpose
is
to
PFT Nuggets
PFTs
offers several
new and
related cases.
standing of
is critical
As
we
think that
PFT Nuggets
when
To
way
is
sometimes
in clinical
and
is
we hope
of the
this
is
commonly used
new
community.
by simDirector,
by
MD
MD
nical orientation,
who
Stoller
MD.
Director.
Critical
Pulmonary Function
&
OH
44195-
The Cleveland
Clinic Foundation
5038.
Cleveland, Ohio
Respiratory Care
No
73
Borderline Normal?
Albert Rafanan
MD
MD
Man
Case Summary
Table
1 .
A
163
1.
Test
Predicted
Prebronchodilator
Predicted
performed.
He
is
FEV,
(L)
cm
tall
(Table
1).
Is this
spirogram normal?
2.
Why?
Discussion
Strictly speaking,
ciety guidelines
on interpretative
rogram would be considered normal. The forced vital capacity (FVC), forced expiratory volume in 1 second (FEV ),
,
and FEV|/FVC
[(FEV,
limits of
0.0414
X Ht
is
the predicted
mean FEV,
3.34 L.
man
is
0.842
There5"'
percentile
the
3.34
L minus
0.84
the
0.486
0.80).
in
lung
function are due to technical factors (instrument, procedure, posture, ambient conditions) and biologic factors
(within individual, between individuals, and between populations).^ Clinicians are primarily interested in variation
due
to disease
with
all
considered
noise.-*
The
is
typical strategy in
pulmonary funcmeasured
val-
tion interpretation
to
compare
a patient's
Department of Pulmonary
MD.
Director,
Pulmonary Function
Care Medicine,
&
Critical
OH
44195-5038.
r
REFERENCES
American Thoracic Society. Lung function
erence values and interpretative strategies.
Borderline Normal?
3.
Am
4.
144(5):1202-1218.
5.
MR. Concepts of normality applied to the measurement of Am J Med 1986;80(6):1 158-1 164. Pennock BE. Cottrell JJ. Rogers RM. Pulmonary function testing: what is "normal"? Arch Intern Med 1983:143(1 1):2123-2127. Pennock BE. Rogers RM. McCaffree DR. Changes in measBecklake
'""S function.
ATS
recommendations.
is
Am
97-99.
No
75
56- Year-Old
Naresh Mansharamani
MD
and Mani
S.
Kavuru
MD
Case Summary
to express
are:^
40 years) presents with a history of chest tightness and difficulty in breathing with frequent awakenings at night.
commonly used
1
second
first
viral
upper
He
(2)
is
lator/FEV| prebronchodilator
100), (3)
How
do you
interpret the
pulmonary function
agonists
100).
2. Is there a significant 3.
response to albuterol?
j3
is
change as a
is
Do you
indi-
percentage of the
initial
cated?
most dewith
Discussion
seen
in patients
to
an inhaled bron-
many
is
may
offer
what constitutes
significant
appears
what
is
the best
way
to express reversibility,
an FEV, change
less than
10% and
an absolute
FEV,
in-
and what
is
no response
to bron-
chodilators.
The following
are
commonly
offered reasons
Although certain
for performing a postbronchodilator study:- (1) bronchodilator response could help establish a diagnosis (presum-
flow between
of the forced
vital
capacity
may
justify a
more
sponse, there
a great deal
more
sponse
may
dependent on forced
If the
vital
capacity
(FVC) and
a bronchodilator response
may be
helpful prognostically,
FVC
FEF2575
value.
is
Dr Kavuru
this
is
Department of Puhnonary
&
Critical
When
show
is
8%
siveness
identified
by FEF2,75
criteria.''
of Pulmonary
&
Critical
guidelines
recommend
Boston, Massachusetts.
the percent
change
is
is
s 2%
1
MD.
Director.
Critical
Pulmonary Function
&
change
in
FEV,
or
FVC
greater than
OH
44195-
5038.
76
No
A
Table
Man
with Dyspnea
Drug
Hugh S Mathewson
MD and Joseph
Section Editors
Capsule
Davis
CRNA MAE
MD
Nearly
all
pounds
in
that
1.
Table
Many
summoned
is
to the postan-
partial agonists,
to treat the
depression of
to state
been made
exists.
is si-
Monitoring of opioid
oxygenation,
is
effects, especially
on ventilation and
and
is
Another approach
to
the
answer
to this problem'^
the
theme of
this article.
is
dose-related;
howis
The use of aspirin and acetaminophen is common, ularly when combined with codeine and congeners
ti-inflammatory drug
particin oral
quite variable
is
among
it
When
given,
as
important that
its
this
is
purpose
when
other
modes of administration
is
which clonidine
the best
The
based
do not contribute
bert," are
to respiratory depression.'-
on the assumption
The
The opioid receptors, as classified by Atcheson and Lamshown in Table 2. Recent research, both experis
is
me-
become an
established
method of pain
partic-
similarly mediated
is
unclear; there
evidence that
it
6-receptor stimulation
may
be contributory.'-* In humans
/i-
occur.**
Neonates are
may
but not
Opioid com-
is
An
Thomas A Davis CRNA MAE is with Nurse Anesthesia Education and Hugh S Mathewson MD is the Medical Director of Respiratory Care
Education and
versity of
is
No
this
mechanism have
clinical investigation.
MD.
known
bow
KS 66160-7282.
The underlying
postulate
is
that pain
78
No
Table
Agonists
Morphine
Meperidine
Fentanyl
Sufentanil
Alfentanil
Remifentanil
Agonist-antagonists
Pentazocine
Butorphanol
Nalbuphine
Buprenorphine
Dezocine
Antagonists
Naloxone
Naltrexone
Nalniefene
Table
2.
Effect
M-1
5.
13.
Atcheson R, Lambert
DC
(editorial).
Br
14,
6.
involved in
Am
J
Nurs l994;94(4):24-30.
7.
Eur
Anaesthesiol I992:9(6):457^62.
view). Yale
8.
Biol
Med
199h64(4):3.'51-374.
15
(re-
effects of intrathecal
may be mediated by
Can
Anaesth l995:42(10):891-903.
9.
Bruelle P, Ferrer
E,
Eledjam
JJ.
16.
in obstetrics.]
Cah Anes-
Pharm Res 1991:8(2): 196-199. Willette RN, Doorley BM, Sapru HN, Activation of cholinergic mechanisms in the medulla oblongata reverse intravenous opioidinduced respiratory depression. J Pharmacol Exp Ther 1987:240(1):
3.'i2-358.
Egbert
AM.
Postoperative pain
management
Med
1996;12(3):583-599.
Borgbjerg
FM.
Nielsen K. Franks
J.
H,
el al.
a controlled study in
Watson
WA.
Steele
human volunteers. Pain 1996:64(1): 123- 128. MT, Muelleman RL, Rush MD. Opioid toxicity
response to naloxone.
J
1109-1114.
12
Jarvis
recurrence after an
initial
Segal IS.
Maze M.
Ventilatory effects of
col 1998;36(1-2):11-17.
19.
human
volun-
in the
United States:
Anesthesiology 1992;76(6):899-905.
Altern
80
No
Listing
lo publishers:
6(K1 Ninth
WA
98104.
Methods
in
Pulmonary Research.
Stefan
E Taylor,
Editors. Hard-
one
to
in a
This
text is
tist.
new
international multi-authored
at the
Simon
Hillier
MD
Care
aimed primarily
editors,
basic scien-
The
in their
U.
to speed" in
book
who
Department of Anesthesia
Riley Hospital for Children
Indianapolis, Indiana
good
volume
is
of a given technique.
The
Essentials of
Cardiopulmonary Exercise
Testing. Jonathan
illustrated,
is
maand
who
their
man
that
are
\
animal
methods.
How-
methods. The
discussions of clinical
human
The
ilIt
do come in small packages. Cardiopulmonary Exercise Testing by Jonathan N Myers is a diminutive volume measuring only 9X6x3/4
Good
things
Essentials of
research
book
are
is
good
inches, but
tion.
it
is
methods.
lustrations
The book
Of
the
20 primary authors, 7
1
from
is
1
phys-
North America,
rors.
The
monary response
bration of
to exercise, use
and
cali-
and
is
from 1997.
this
It
is
vessels,
chapter on invasive
testing.
exercise
However,
this
that there
was no discussion of
for determination of
"techni-
methods
pulmonary
Both these
how-
ever,
it
is
anyone
test-
The
first
section in the
book
methods have
and disease.
significantly
enhanced our
in
The 2
in rodents,
lung
health
excellent chapter
lung.
ters
on
The chapter on
aerosols contains
some
surement.
is
book
The
section
might be of
on
intravital
summaFor
and
although most of
this
information
in
new ways
that clarify
textbooks.
suspect
that,
in
general, the
first
edema
contains chap-
remainder of
be of limited
summary of physthat
I
workload
seen.
that is
have
working
science
As
I
a physician
who
and
intravital
useful to the
diopulmonary exercise
years,
vessels and
tion
interstitial pressure.
The
sec-
found
this helpful in
and
those
who
fully
type of
summary
is
my
future teaching.
The
some of the
writing style
clear and
more conversational
and
clinical literature.
The The
By
reviewing this
text, the
Journal reader
new
to the field.
chapters on
diology.
lung ultrastructure
and autora"Further
The
stated
aim of
the text
is
to provide a
methods
that
No
81
&
Software
in
ture format.
As
practitioners,
we all
develop
emphasis on gas
Butler
MS
exchange.
in this aim.
RRT RPFT,
and Robert
trated,
Janice
Close
RRT RPFT,
illus-
Davis
own
The ever-changing world of health care makes the education of respiratory care practitioners
book
is
and
eth-
of practice and increasing number of workplace sites require a broad scope of learned
skills.
put
ics,
it
into practice.
The foundation of
pressions of
work
in general in
Chapter
critical
"Cardiopulmonary Responses
clarifies
to Exercise,"
The
may
an area that
is
frequently difficult
for those
new
to the subject.
Chapter 4, "In-
may
a "black
box
" to
many
Home
ventilator
The book is technically well assembled. The type font is easily readable
and the tables and figures are clearly drawn
The student
of
in
derstandable, as techniques in
home
care
and
labelled.
There
is
an index that
is
ap-
and
learn.
We
can
utilize a text
this
vary more from patient to patient and practitioner to practitioner than in hospital practice.
and effective
practice.
While
Ideally, standardized
approaches can
Chapter
5,
"Applications in Cardiovascu-
in the
home
as they
lar
who have
dures for proper metered dose inhaler administration via a ventilator circuit
completed
ucation.
their
own
were cu-
and other
topics in detail.
caught
my
at-
all
are devoted to
"cookbook meth-
tory care.
intro-
duction,
list
diopulmonary exercise
tual discussion
testing.
More
Equipment required
listed, as
tex-
and
clinical
examples need
to
be devoted
to the effects of
pulmonary
Many clin-
Upon
spired
was
in-
procedural information called the Laboratory Report and offers Critical Thinking
tient referred
use of the
would encourage
instruc-
aloud or give
Questions.
A deis
start
critically.
monary
allow both students and instructors to clearly understand the evaluation objectives.
on exercise capacity
Aside from
able, clear,
this, I
Guide online
at the
I
Davis
PCEs,
wondered why
and logical
it
approach and
World Wide
this text.
Web
site.
would recommend
cise physiology
as a reference or in-
and
testing.
topics are
I
mance
Criteria
( I
through 5)
at the
end of
an-
appreci-
The
Joshua
Benditt
MD
in the author's
statement
uti-
document procedures,
as nearly
all
stan-
be attempted
"a
skill
PCE
only
when
to
has been
Division of Pulmonary
by
the
the text.
It
would be outside
it
the intent of
& Critical
Care Medicine
may need
be validated as the
subjectivity of this
revisited
Department of Medicine
University of Washington School
quarter progresses.
The
is
lip
when
the
of Medicine
Seattle,
Washington
could be included
or lec-
82
Respiratory Care
&
Software
a larger,
more
criteria-laden,
and possibly
performance sec-
strumentation and sensors, signal processing and the origins of biological signals,
or she sees
fit.
The numerous
cross refer-
tion of
each PCE.
section
As
an instruc-
of proce-
is
there
if
and
dures,
when
it
is
needed
is
able,
of
American
The
Association
for
own
and
chapters. Chapters
on
thera-
increasing use of
electrical safety
body of the book. The numerous appendices cover the standard prefixes and units of
the
on
electrical
The
il-
safety.
Systeme Internationale
(SI),
physical
the
A
phy
was taken
to
make
to
The
variety of
constants, and
common
is
abbreviations.
at the
book
visually appealing.
Good
typogra-
was
While
this
work
aimed squarely
in larger
work
each chap-
be easily read
than opti-
addition.
much of
its
the information
The book
usage;
all
is
contained within
pages
may be of
value
and physi-
tions are
are 3-hole-punched
cians.
Of special
interest will
be the discus-
with
lost
and
electrical safety.
As
found the
tional
The conceptual
level
of the discussion in
all cli-
few typographic or
the
program and
am
considering
it
for
few obvious
nicians, but the technical details in the general instrumentation chapters will
where the diode labeled D, does not connect to the output of the circuit).
Overall.
be of
in-
John
Basile
RRT
and biomedical
plication
and Design
As a biomedical
Washington Washington
Community College
Seattle,
an outstanding
is
success.
The choice of
subjects
is
well
Medical Instrumentation: Application and Design. 3"' ed. John G Webster, Editor.
presented in
The
Hardcover,
illustrated.
691 pages.
New
1998. $87.95.
Matthew
Sailors
BEBME MEBE
Medical Informaticist
and engineering
Cottonwood Hospital
Doctoral Student
tation: Application
origin, acquisition,
the
will find
logical signals
tion of integrated
Murray, Utah
Respiratory Care
No
83
Home
and Evaluation of Response
>
Tube
'
Lung Volumes
Respir Care 1994;39(8):797-836
Parenchyma
>
Caregiver Educator
at
Point of Care
Ventilation in the
Home
Directed
Cough
Artificial
Airways
Analysis and Hemoximetry
In-Vitro
Polysomnography
Single-Breath Carbon Monoxide Diffusing Capacity Use of Positive Airway Pressure Adjuncts to Bronchial
Hygiene Therapy
RespirCare 1993;38(5):495-521
Patient- Ventilator
System Checks
RespirCare 1995;40(7}:744-768
Metabolic Measurement Using Indirect Calorimetry during
Nasotracheal Suctioning
Bronchial Provocation
Exercise Testing for Evaluation of Hypoxemia and/or
Desaturation
Mechanical Ventilation
Capillary Blood
Gas Sampling
for Neonatal
Body Plethysmography
Respir Care 1992:37(8):882-922
Respir Care 1994;39(12): 1170-1 190
Incentive Spirometry
Pulse Oximetry
Ventilator Circuit
Changes
Oxygen Therapy
Spirometry
in the
Mechanical Ventilation
84
No
Guidelines, Recommendations,
& Statements
PROCEDURE
adult, pedi-
arterial
blood oxygenation.
4.1 Patients in
whom
is
may
tempo-
airway.
device removed at the earliest appropriate time. Occasionally, acute airway obstruction of the artificial
manif
artificial air-
way. (This guideline pertains to the decision processes surrounding the removal of an artificial
translaryngeal airway, and the procedure referred to
as extubation.)
exchange
(ie,
surgical airway
management).
is
asso-
ciated with
many complications
-
including but
to extuba-
tive
2.2 Extubation
may
result in
high inspired oxygen fraction to maintain acceptable gas exchange after extubation.
tive reflexes are usually
struction
from laryngospasm,"
Airway protecfol-
depressed immediately
monary edema;-' -' pulmonary aspiration syndrome;^"*" or impaired respiratory gas exchange.
lowing and for some time after extubation and, therefore, measures to prevent aspiration should be
considered.
Hypoxemia
is
after extubation
may
result
from but
not limited to
oxygen
airway;
immediately avail-
monary edema;
6.1.4 bronchospasm;
cheal tube
deemed
to
6.1.5
development of
pulmonary
atelectasis, or lung
collapse;
6.1.6
aspiration;
6.1.7 hypoventilation
Respiratory Care
85
may be
pH
not limited
to:
8.1.3
8.1.4
strength;
work of breathing;
futility is
sure
6.2.4 bronchospasm.
mL/kg
6.3 Death
tube.
ventilation
or after
< 10
L/min.-'
some
interval
< 35
dur-
new disorder. A trial of extubation may be used in some marginal patients with the expectation that the
need for reintubation
is likely.
when determined
by
stethoscope.""
The need
to reinsert
is
an
artificial
airway following
extubation
maintenance and
fail-
ume
ratio)
of
<
ure of reintubation
practice.
may
be an indication of poor
CROP
index
The
failure
and complication
rates of extubation
a modified
RSB
and unsuccessful
extubation.^'"'^)
mL/cm
work of breathing < 0.8 J/L;"""*'^^ 8.1.12 oxygen cost of breathing < 15%
8.1.11
total;^'^"
oxygen
F102
to
<
maintain adequate
arterial
perience suggests
0.40.)
cm
primarily a
research tool.)
8.1.15
maximum
met traditional weaning criteria.-'' Examples of weaning criteria include but are not limited to
8.1.1 the capacity to maintain adequate arterial partial
of respiratory
fail-
may
be assessed by but
not
normal consciousness,'^'
managed
secretions.
86
Respiratory Care
is-
all
patients
anticipated;
with
intubation;''^
flated
breaths;"^'
hemo-
documented knowledge and demonstrated skills specific to patient assessment and airway management, should determine the appropriateness of extubation, be available to assess success, and begin appropriate interventions should immediate
complications occur. Personnel skilled in
endotracheal intubation and the insertion
whenever extubation
is
per-
formed.
lowed by adequate spontaneous ventilation through the natural airway, adequate oxygenation, and no
need for re-intubation.
9.1 Clinical
documented knowledge and demonstrated skill in providing oxygen administration devices and suctioning the airway, may
provide support to Level-II personnel during the extubation procedure.
10.2.3 In the event of acute obstruction of
noninvasive measurements of
values,
blood gas
maintenance
skills
may remove
the endolife.'"
When
Oxygen source
and does not require reintubation, this suggests that planned extubation should have been considered
sooner."'*
RET
12.0
FREQUENCY
manual
ventilation system
The timing of extubation is determined by improvement in the patient's condition that mandated an artificial
10.1.6 Oral and pharyngeal airways 10.1.7 Endotracheal tubes of various sizes
may
occur
treated immediately.
ment (laryngoscope
teries, stylettes)
patients, follow
control of exposure to
CDC
Respiratory Care
87
I99I;3(4):3I4-3I6.
tact agents
in pa-
tients
Wilson
Head Neck Surg I995;l 12(2):235-237. GW, Bircher NG. Acute pulmonary edema
after
devel-
oping
illofac
Oral
Max-
G Durbin Jr MD,
Chairman
Charlottesville
VA
16.
Hartley
Richard
D Branson RRT,
OH Cincinnati OH
extubation.
17.
Anaesth l993;71(4):56l-568.
Elkharrat
laits
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89
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65. Sapijaszko
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1996;24(4):601-607.
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1993;19(6):340-342.
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M.
Viires N, Piquet
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71. Listello D, Sessler
54303. www.cdc.gov
Interested persons
may photocopy
90
Respiratory Care
'
DLCO
ide
1.0
PROCEDURE
monox-
DLCOsb
is
measured
is
also
commonly
report-
(DLCOsb), sometimes referred to as the transfer factor for carbon monoxide (TCO).
VA
vapor (BTPS).
2.3
The
ratio
of
reported as the
American Association
for Respiratory
(AARC)
COsb) Clinical Practice Guideline (CPG) was published in 1993, and was based largely on the American Thoracic Society (ATS) 1987 recommendations.'
3.3 Clinics
ATS
has published
new
re-
AARC CPG
1995 ATS recommendations. Various methods are commercially available to perform DLCOsb- This Guideline can be applied in many (perhaps most) cases and is based on experience and research with the traditional method (10minute breathhold with alveolar sample collection). For non-traditional or newer methods, it is the manufacturer's and the scientific community's responsibility to define the comparability of the newer
methods with the
old.
may be
indicated for
known
as usual interstitial
(BOOP, or crypto-
Diffusing capacity
is
measurement of carbon
monoxide (CO) transfer from inspired gas to pulmonary capillary blood. During the test, the subject inspires a gas containing CO and one or more tracer
gases to
emphysema
and cystic
fibrosis;""
methods of measuring DLCO have been described, the most commonly used technique is the singlebreath maneuver, or
re-
DLCOsb
are referenced.^
Many
of these standards
torr' at standard
(STPD).
2.2
at
which the
Respiratory Care
91
1999
Update
methods used
DLCO include:
7.1.1 DLCO should be corrected for hemoglobin (Hb) level according to the method described by Cotes and co-workers.^"
some
Hb
is
adjust-
monoxide
Hb-adjusted
-t-
oxyhemoglobin
<
15 years of age
and
Hb-adjusted
women
the
Hb
is
adjusted to a
-i-
muscular incoordination preventing the subject from adequately performing the maneuver or inability to obtain or maintain an adequate lip seal on the instrument mouth5.2.1 mental confusion or
piece;
DLCO should be corrected for the effects of COHb present in the subject's blood.' COHb-adjusted DLCO = measured
DLCO(l+[%COHb/100]).
7.1.3
DLCO
test;'
smoking within 24 hours of test administration (smoking may have a direct effect on DLCO independent of the effect ofCOHb'"); 5.2.4 decreased lung volumes that would
not yield valid test results;
5.2.5 devices that are improperly calibrat-
and appropriate correction for the alveolar or inspired oxygen pressures are recommended.' Altitude-adjusted DLCO = measured
titude
120])
Altitude-adjusted
DLCO
= measured
150])
-
47
DLCOsb requires
breathholding
patients
at total
neuvers to allow
gas to be eliminated
capacity (TLC);
some
may perform
normal
from the
7.1.5
lungs.'
ther a Valsalva (higher than normal intrathoracic pressure) or Miiller (lower than
in-
DLCO
varies with
can result
heart and
in alteration
7.1.6
body
been reported
to
be associated with an
in-
to-technologist).
may
also
92
Respiratory Care
1999 Update
influence
DLCO."
(if a
compressed gas
used).
CO2 and
may produce
significantly
H2O)
different results.
should be replaced
frequency rec-
ommended by
the manufacturer,
when
percent-of-predicted DLCO have been observed -*"" and are attributed to variations in testing techniques and computational algorithms and errors in gas analysis. The choice of equipment may also influence the measured DLCO.-'-* 7.3 Choice of reference equations may affect the final interpretation of measured DLCO values.-" 7.4 Validation of the testing technique and equipment may include but is not limited to 7.4.1 Volume accuracy of spirometer should be < 3% over an 8-L volume (ie, meets or exceeds all ATS recommendations-) and must be checked each day that
in
the test
is
sured
DLCO
and
order
(ie,
CO2
H2O
when
how
alveolar gas
is
analyzed.
Normal standard
subjects (biologic
to establish intra-
controls)
may be used
DLCO
8.0
ASSESSMENT OF NEED
(see Sec-
(min-
imum)
7.4.2
syringe. Spirometer
must maintain
.
Gas analyzers should be subjected to each test. Manufacturers should be encouraged to provide software and techniques by which
analyzer linearity
ATS
recommendations.-
may
be easily checked
Gas analyzer
lin-
earity should
be
7.4.2.1 within
full
span, of
commences and determination that the subject is able to follow commands. 9.3 Inspiratory volume exceeding 90% of the largest previously measured vital capacity (FVC or VC), attained in < 2.5 s in healthy subjects
and within 4
s in
duration of the
seconds, with no
1%
7.4.4
The
1.5
dead space (anatomic plus system) and proper collection and analysis of
9.5.1
be <
cm H2O/L/S
flow of 6 L/s.
alveolar gas.
The addition of
mendations.
7.4.5
in-line filters
may
cause
exceed recom-
VC
is
<
0.
ed for when determining entire system dead space as well as discard volume (before alveolar collection).
used,
when
de-
filter
dead
7.4.6
Demand valve
is
sensitivity of
<
10
cm
9.5.3 For alveolar-gas sample-bag systems, the volume of the alveolar gas sam-
H2O
Respiratory Care
93
1999
Update
obtained in < 4
should be av-
II
individual or a physician.
II:
10.2.2 Level
tests
Personnel supervising
have formal educa(as a part of a
Two
or
more acceptable
DLCO
tion
testing should
eraged; the
whichever
that
DLCO
10%
greater.
and training
ducible to within
is
We
mL CO
',
respiratory therapy or
9.7
smoking for 24 hours prior to the test; however, because subjects do not always comply, the time of the last smoking event should be
recorded.
COHb
should be
in-
DLCO
11.0
MONITORING:
performed
is
at altitude
recommended.
If
Hb correction
made, both
values
DLCO
The following should be evaluated during the performance of the DLCO measurement to assess the
validity of the results:
should be reported.
ducibility of
DLCOsb:
be seated for at least 5 minutes prior to testing and should remain seated throughout the
dent on the methodology employed; certified calibration gases for use before each
series of
allow
measurements.
for analysis of total
10.1.3
COoximeter
Hb
and
COHb is
strongly
recommended.
10%
or 3
of the aver-
pulmonary function
testing.
The
calibration), with
documented
training,
dif-
suspect or
if
the equipment
moved
to a dif-
ferent location.
11.3.1
Volume
calibration
performed on a daily
11.3.2
quarterly,
basis,
Gas analyzer
linearity
checked
may be performed by
for either Level
I
persons
II.
or Level
I:
The
technologist perform-
formed
suspect.-
Level
tests
more frequendy
initially to estab-
comparison.
94
Respiratory Care
1999 Update
11.3.4.2
It is
Bio-QC
tervals."
at
in pa-
may be
tested.
11.5 Inspired oxygen concentration: test gas concentration should be 20.93% and at sea
level pressure. Subjects should
must always be performed between patients, and protective gloves must be worn if there are open cuts, or sores, on the technologist's
hands.-
at least 5
performing the
first test.
Technologists should
document
ty to
13.3 Due to the nature of the DLCO maneuvers and the likelihood of coughing when the test is performed by subjects with known or suspected
active infection with
lotted time.
11.6
The
The
final report
about
11.7
test quality.
precautions are:"
final report
DLCO,
and
the corrected
DLCO
COHb,
(ie,
altitude),
the
Hb
The alveolar
The room in which the DLCO test performed should meet or exceed the recommendations of U.S. Public Health Service"" for air changes and ventilation. The ideal situation is to establish an area
13.3.1
is
in the testing
We
strongly
The final report should indicate which method was used to correct the raw DLCO value and for what the DLCO value
es of interpretation.
is
recommend
that, if this is
room
DLCO
(Hb), corr
to 2 hours.
DLCO (CO)].
11.8
DLCOsb
results should
be subject to ongo-
(QA) and/or
ini-
OSHA recommendations,
especial-
and on an ongoing
come
between
It
measurements
patients. If sterilization
is
either
nologist interface.''
may
be used
is
in circuit,
although
their efficacy
cautions for
all pafients,
follow recommendations
However, such
filters
and droplet
DLCO
filter
ma-
used, the
dead-
Respiratory Care
95
1999
Update
Cancer Chemother
15.
& Pharmacol
1993;32:407-409.
16.
RE 2nd. Carbon monoxide diffusing capacity. Clin Chest Med 1989;10(2):187-198. Mitchell DM, Fleming J, Pniching AJ, Harris JR, Moss
FM, Veale D, Shaw
RJ. Pulmonary function in human immunodeficiency virus infection; a prospective 18-
RRT RPFT, Chairman, Rochester MN BS RRT RPFT, Mason MI Robert A Brown BS RRT RPFT, Waunakee WI Gregg L Ruppel MEd RRT RPFT, St Louis MO Jack WangerMBA RRT RPFT, Lenexa KS
Carl Mottmm
Susan Blonshine
17.
month study of serial lung function in 474 patients. Am Rev Respir Dis 1 992; 1 46:745-75 1 Owens GR, Rogers RM, Pennock BE, Levin D. The diffusing capacity as a predictor of arterial oxygen desaturation during exercise in patients with chronic obstructive
pulmonary disease.
N Engl J Med
984;3 1 0: 1 2 1 8- 1 22 1
REFERENCES
1.
18.
Nordenfelt
I,
pacity) as a predictor of
in
American Thoracic Society. Single breath carbon monoxide diffusing capacity (transfer factor): recommendations
for a standard technique.
restrictive
Chn
19.
Physiol 1987;7:423-430.
Am
effect of
ca-
1987;136:1299-1307.
2.
American Thoracic Society. Single breath carbon monoxide diffusing capacity (transfer factor): recommendations
for a standard technique
Crit
1992;146(4):951-
958.
20. Cotes JE.
1995
tests:
update.
Am
Respir
Lung
Care
Med
1995;152;2185-2198.
signifi-
3.
1979:203,329.
J.
21.
4.
WR,
impairment
Am
23.
Chest 1977;4:488-492.
5.
Lawson WH.
ma-
2.
Thorax 1983;38:5-9.
Clinical
24.
testing: a
1972;32:788-794.
6.
Morris
pulmonary function
tory procedures,
effect of
human pregnancy on
monoxide
as
Lake
City: Intermountain
monary
measured
Med
Knudson RJ, Kaltenbom W, Burrows B. Single breath carbon monoxide transfer factor in different forms of
chronic airflow obstruction in a general population sample.
CO
diffusing capacity
(DLCO)
Thorax 1990;45:514-519.
cycle (abstract).
in pa-
Am
8.
Light
Serial
pulmonary function
2):A759.
26. Clausen
J,
Arch Intern
Med
1983;143:429-43.
9.
Am
Rev
Respir Dis
2): A37.
Wanger
J,
Irvin C. Comparability of
in a
pulmonary
results
Am J Med
10.
1977;63:926-932.
in
from 13 laboratories
1991;36:1375-1382.
28.
Am
Intra-individual
11.
Frank ST,
Weg
using
Am
and
Sem
13. Abratt
1986; 134:856.
in pul-
monary function
Am Rev
Ngan HY, Liang RH, Lam WK, Chan TK. Pulmonary toxicity in patients with non-Hodgkins lymphoma treated
96
RESPIRATORY CARE
1999
Update
personnel qualifications.
1986;134(3):623-624.
32.
Am
GA:
Crapo RO,
Irvin
CG,
editors.
1-01-1996. www.cdc.gov
35. Centers for Disease Control
&
OC, Williams
WW,
1985;6:442-444.
34.
Gamer
54303. www.cdc.gov
Appendix Follows
Respiratory Care
97
1999
Update
APPENDIX
Factors that Result in a Decrease in
DLCO
Factor
Deficiency in red blood cells
Anemia
Multiple pulmonary emboli, early collagen-vascular disease, early sarcoidosis, miliary tuberculosis
Emphysema
volume
Parenchymal restrictive processes including pulmonary resection, idiopathic interstitial fibrosis, asbestosis, scleroderma lung disease, histiocytosis-X,
sarcoidosis,
pneumonia
DLCO
Factor
Increase in pulmonary capillary blood volume
de-
return), exercise
Early polycythemia
Specific Abnormalities
Leading
to
an Increase in
DLCO*
Abnormality
Precipitation Condition
Lung compression
Increased airway resistance
excavatum
airway lesions
Asthma, cystic
fibrosis, central
Congestive heart
'Physiologic' leaks
Tympanic
*The
listed
may photocopy
98
'
Home
HCS
cial
1.0
PROCEDURE
artifi-
ryngeal suctioning;''
2.1.1.2 without an endotracheal airway,
whose
vital capacity
and muscle
mechanical aspiration of secretions from the nasopharynx, oropharynx, and trathat involves the
2.1.1.3
whose
chea.
cial (as
The
patient
may
or
may
no adverse reac-
The proce-
dure includes patient preparation, the actual suctioning event, and follow-up care and observation
may be
indicated
in:
of the patient.
2.1 Patient preparation.
2.1.1
Whenever
mented
to experience
2.1.2
Whenever
who
exhibit cardiac
2.1.4.4 patients
who
may
not be
all
patients cared
When preoxygenation
it is
and/or hyper-
recommended
tation
charge summary, and the health care professional establishing the patient in the
thorough instruction
tation bags
use of resusci-
home
should request
this information.
when
is
the
hyperoxygenation or hyperventila-
< 1.5L
volume may be
makes
whom
preoxygenation
may
not be necessary or
Respiratory Care
99
AARC Guideline:
in
the
Home
2.1.6
Normal
be
only
'^
when
specifi-
(for example,
cough"").
event: Actual introduction
2.2
The suctioning
whom pre-procedure
the
tra-
chea via the laryngostoma or artificial airway should be in accordance with existing Clinical
Practice Guidelines.''"
2.2.1
It is
common and
home
care set-
during suctioning
in the
home
environ-
home
care
is
lacking."
used when
endotracheal suctioning
is
per-
cared for at
home
is
by cough. The
way,'^ the risk of cutaneous infection in the caregiver, and transmission of organ-
is
evidenced by:
isms to
essary
cough;
4.2 coarse rhonchi and expiratory wheezing audible to the patient and/or caregiver
performed.
2.2.3
fol-
lowed by the suctioning of air through the device to dry the internal surface and, thus, discourage microbial growth. The outer surface of the device may be wiped
with alcohol or hydrogen peroxide. The
suction catheter or tonsil
sure-cycled ventilation;
4.6 indication by the patient that suctioning
is
necessary;
lowed
to air dry
ner described
may
be reused.
We
recom-
mend
be discarded after
gen saturation
plugging.-^
(as indicated
by pulse mucus
may
indicated,
lost.^"
prove to be more detrimental than potential adverse reactions. Routine or 'scheduled' suctioning, with
no indication of need
is
not recom-
mended.
100
Respiratory Care
AARC Guideline:
in
the Home
count introduced
is
saline
instilled.'-"
of the following:
as indicated by such monitoring has
oxygen desaturation
if
pulse oximetry
by pulse oximetry;
been prescribed;
6.2 trauma to the oral, tracheal, or
bronchial mucosa;
6.3 cardiac arrest; 6.4 respiratory arrest;
6.5 cardiac dysrhythmias;
by
patient;
HCS
10.0
RESOURCES
bronchospasm or bronchoconstriction;
plies to
Equipment: Equipment and supused for suctioning the home care patient may include:
10.1
10.1.1 electrically
powered aspirator
way;
6.10 hypertension;
6.11 hypotension.
battery-powered aspira-
may
who
fail-
leaves the
home
or lives in an environ-
ment subject
ures;
to frequent
power
Open suction systems are used most frequently. (The use of closed
hydration
airway
is
who is not
immunosuppressed'*);
integrity.
by
for suction-
when
itself.
the need does not obviously present For patients on long-term mechanical
when
active in-
system check.-'
present or suspected;
when hyper-
inflation
is
medically indicated;
when preoxy-
medically indicated;
Respiratory Care
101
AARC Guideline:
in
the Home
ed
ability to effectively
when medically
indicated;
and clean,
store
disinfect,
HCS
The
11.0
MONITORING
10.2 Personnel:
As
in:
whenever possible.
patient
is
mem-
including
the presence
or absence of cyanosis,
airway management procedures and patient assessment should be specified as trainers (eg, licensed and credentialed respiratory care practitioners and
registered nurses). These trainers
should also observe, on a regular basis,
when medically
indicated.
HCS
12.0
FREQUENCY
performance of the procedure by the patient and caregivers to determine the need for reinforcement and remediation.^'*
The suctioning procedure should be undertaken only when indications are clearly present (Sections 4, 5,
& 8).
INFECTION CONTROL
home
environ-
HCS
demongood understanding of the pro-
13.0
To
ment and
indicated;
Immunizations recommended by the Centers for Disease Control and Prevention should be current in both caregivers and patient. When
HIV
tion are
known
to
tient's status is
to
com-
known
should be instituted."
With
all
airway;
102
Respiratory Care
AARC Guideline:
in
the Home
as indicated;
13.3 cleaning and disinfection of all equipment and supplies beginning with thorough mechanical cleaning with detergent and water and followed by one of the
AARC Clinical
1992:37r8):898-901.
10.
Naigow D. Powaser
MM.
The
following
13.3.2 a 60-minute soak in a solution of
&
ung
1.
of ventilator-assotranscolo-
>
ciated pneumonia.
Mechanisms of bacterial
should not be
Med
1995;2U4):365-383.
12.
Am J Crit Care
1993; 2:326-330.
saline
13.
Hagler
and suction
13.3.4 glutaraldehyde;-'
Am
13.3.5 boiling
when equipment
with-
Crit
14 Bostick
instillation as part
between use;
15.
Pa02 and amount of secretions. Heart & Lung 1987;16-532-537 Gray JE. Maclntyre NR, Kronenberger WG. The effects of
of the suctioning procedure: effects on
bolus normal-saline instillation in coniunction with endotracheal suctioning. Respir Care 1990:35:785-790
American Association
AARC
Clini-
Respiratory
Home
me-
WA
Beal
Barry J Make
Peggi Rohart Allan
MD, Denver CO
H R,
Bernstein
MA
Saposnick
Centers for Disease Control Prevention. Guidelines for prevention of nosocomial pneumonia. Part
1
:
issues
on pre-
REFERENCES
1.
1994;39(12):1 191-1236.
American Association
AARC Clinical
19.
Committee
II:
in hospitals. Part
American Association
AARC Clinical
20.
recommendations for
Am J
Home cleaning-dis-
American Association
AARC Clinical
2
1
Dis 1986:5:54-58.
Riegel B.
T Eorshee. A
literature
&
Hardy KA.
Lung 1985:14:507-518.
Bach JR. Update and perspectives on noninvasive
tory muscle aids. Part 2.
respira-
The
insufflation-exsufflation:
comparison
23.
Chest 1994:105:1538-1544.
American Association
ventilation in the
AARC
Clini-
1562.
6.
Make
B. Gilmartin
M. Brody
JS,
GL
Snider. Rehabilitation
24.
1320
American Association
training. Respir
AARC
Clini-
concept and
7.
initial
Care 1996:41(7)-658-663.
Gamer
Advisory
&Lung
8.
1990:19:79-83.
Vol 44 No
103
AARC Guideline:
Home
lanta
GA:
1988;3:179-187.
1-01-1996. www.cdc.gov
26.
ment used
808.
in the
27.
S.
A comparison
Care
29.
re-
ammonium compound
1993;1 1:25-33.
Interested persons
may photocopy
104
Respiratory Care
and Evaluation
adult
The reader
is
referred to previ-
venti-
and
MDI
reported 6-
re-
1%'"'* in adults
and 0.9
in infants.-'
mechanical ventilation.
2.1 Devices include metered dose inhaler
selected,'-'""""
its
how
it is
operated,"-'"-'"'-"
placement
or inline
volume nebulizer (SVN) large volume nebulizer (LVN); ultrasonic nebulizer. (Although experience suggests that inhalers that dispense dry
2.3.3 Assessment
necessary to deterfrere-
powder
bench study reports positive results and suggests clinical trials." Such use cannot yet be recommended.) 2.2 Aerosolized bronchodilators have been shown to be effective in adults, children, and incuits, a recent
An
empirical
trial
of
bronchodilator
is
recommended
in
in
any
whom a
fants receiving
mechanical ventilation."-'
'^
'*"
In-
is
reduced, increased
haled beta-adrenergic'
bronchodilators'^
and anticholinergic
may be
initial
can
all
BDMV3.0 SETTING:
Aerosolized bronchodilator therapy via mechanical
ventilator can be provided in a
lation. In ventilator-supported
COPD
patients,
number of
settings
including: hospital,
care facility.
in the
whenever bronis
been shown
to be
reduced in intubated.
Respiratory Care
105
AARC GUIDELINE:
SELECTION OF DEVICE
documented
me-
chanical ventilation:
from a nebulizer may inciease volumes, flows, and peak aiiway pressures,
cuit
be con-
adjustments
at
tramdicated for patients in extremis (eg, prolonged inspiratory pause for patients with high
auto-PEEP).
5.2 Certain medications
in
made
to
accommodate
may be
contraindicated
some
patients.
may
result in the
product-specific contraindications.
patient's
becoming unable
to trigger the
hypoventilation.
may have
6.7 At least one early anecdotal report described cardiac toxicity due to
are unlikely to occur with doses
in clinical practice
CFCs used
as
6.2 Inappropriate device selection or inappropriate use of device and/or technique variables
recommended
life
may
result in underdosing.'
particularly
when
may
reduced
maintained between
may
possibly compromise
circuit.''*""'
successive doses.^"
by an
fects
MDI
or nebulizer
may
cause adverse
ef-
may
mized
to
patients.-"-*"
7.2 Ventilator
position.
modes and settings can affect deLung-model studies suggest that low
may
cause bronchospasm or
*
irritation
of the airway.^'
MDI
can be increased
and increased duty cycle (inspiratory phase) are all associated with improved aerosol deposition.'^''' '""
compared
and pres-
shown
that
tizing inflammation
me-
probably from the topical effect of the oleic acid used for its surfactant property and the
chlorofluorocarbons (CFCs). Such administration
is
not recommended.
The
results of further
condemn
this
may
6.6
technique of operation
sensitivity of the
may
affect ventilator
alter the
chodilator.
It is
106
Respiratory Care
AARC Guideline:
Selection of Device
7.4 Placement of the aerosol device in the ventilator circuit affects the
amount of drug
deliv-
damage
at the
carina in
cm
response to temperature and ingredients (oleic acid) of the aerosol.'" Insufficient data are available to sup-
from the endotracheal tube is more efficient than placing it between the patient Y and the
endotracheal tube because the tubing acts as a
reservoir for accumulation of aerosol between
inspirations.'^""-* If
an
artificial
nose
is in
use,
it
7.6.1.4
MDI
actuation
is
performed
The
volume nebulizer
mechani-
drug de-
An
me-
chanical ventilation
tion of an
MDI
Mass median aerodynamic diameter (MMAD) and time required for treatment may vary with
7.6.2.2
Accessory device adapter design affects aerosol delivery and the amount of drug
available to the lung.'*-'-"
7.6.1.1 Chamber-style adapter.
in vitro that the
and
in vivo
-""'''
7.6.2.3
the pressure
may
combination of an
MDI
and
aerosol over
MDI
actuation into an
change particle size characteristics and drug output.'""' When gas flow driving the nebulizer is from a secondary gas source (other than the ventilator), the volumes, flows, and pressures delivered by the ventilator
to the patient are altered."
showing
fill
volume
and
flow."-""
real-
densate
when
between treatments.
7.6.2.6 Nebulizers are vulnerable to
No
pub-
7.6.1.3
Small-gauge
tracheal
amount of medication
that
is
90%
in vitro), in
Respiratory Care
107
AARC Guideline:
Selection of Device
the expirato-
may
LVN:
from base-
delivered
may
due
^Qj^
to
63-66
and
required.
7.6.4.3
Few
units
meet
MM AD of 1-3
microns."
7.6.4.4 Devices are vulnerable to con-
change
in patient baseline;
tamination.
7.6.5
modify dose;
USN
it
modify therapy;
Although
use of the
USN may
9.1.4.5
apparent
changes
in
comparaevaluation:
bronchial responsiveness.
gle dose
is lacking.''*"
or
more of
the follow-
ing in the mechanically ventilated patient suggests the need for bronchodilator administration:
bronchodilator;
8.1.2 presence of
9.3 Documentation
ed with reduced
ratory time ratio;
rate,
time received
9.3.1.2 Responses
vital signs,
measured including
denced by
8.1.3.1 increased
by changes
peak inspiratory pres-
PEEP
tions.
8.1.3.2
sounds;
8.1.3.3 intercostal and/or sternal retractions;
9.3.1.3
Note observations
relative to
time of administration
manometer and
ca-
pability to
end-expiratory pause.
10.1.1.1
9.1.1
Equipment required
Pneumotachograph
for
mea-
suring auto-PEEP
10.1.1.2
for
moni-
108
Respiratory Care
AARC Guideline:
Selection of Device
volume
es-
changes
at the airway.
when
available
ministering medication;
10.2.2.3 maintain and clean equipment;
10.2 Personnel:'-"
10.2.1 Level
II
personnel
licensed or
documented equivalent training and ability should possess knowledge and skills to: 10.2.1.1 perform initial assessments and care for the unstable patient; 10.2.1.2 assess patient condition and
response to therapy;
10.2.1.3 identify the indications for and
changes
ty of
in
provider or physician.
comply with
Standard Precautions.
10.2.3
When
ability
10.2.1.6 modify dosages and/or frequency according to patient response; 10.2.1.7 use proper technique for administration of aerosols.
10.2.1.8 perform and
accordance with
document
MDI with
spacer,
signs;
SVN, USN);"
10.2.3.3 properly use and clean equip-
or ventilatory
mechan-
ment;
10.2.3.4 modify dosages and/or fre-
Standard Precautions, as set forth by the Centers for Disease Control and
Prevention (CDC).
10.2.1.11 Level
II
and instructed communication and assure appropriate with physician regarding severity of
quency
as prescribed
symptoms.
personnel
who
care
BDMV
11.0
MONITORING:(bronchodilator
response)
11.1 Patient observation
members
tremor
11.1.2
tient-ventilator
licensed or
mented equivalent
and
ability to:
symptoms and vital signs'11.4 Improvement in dyspnea-"' 11.5 Changes in SaO,-" or SpOj
11.3 Patient
'"*
Respiratory Care
109
"
AARC Guideline:
Selection of Device
24-hour intervals with continuous administraand whenever visibly soiled. Nebulizers should not rinsed with tap water between treatments
at
tion''
maximal
inspirato-
research
tool.'"'
in acute
11.9.4
Auto-PEEP reduction
11.12 Changes in
arterial
Synopsis
Recommendations
Ventilator Settings
Caution:
tor is
If
may
af-
and
may be
exam and
sta-
tidal
Ppiat
the rate
may need to be
12.1.4
Recommendations: Consider
not otherwise contraindicated
the following, if
(1)
ously, if available.
Use of a
tidal
mL
The
Pinsp-Ppiat difference
should be
after bronchodilator
spiratory pause or lower flows, which may improve pulmonary deposition of aerosol; however clinical judgment and patient evaluation must assure that the patient's inspiratory flow demands are met (ie,
is
subjec-
sponse to therapy.
and physiologically appropriate and autois not increased);(3) because spontaneous breaths may improve aerosol deliver, spontaneous
PEEP
on
ventilator is affected.
2.
manufacturer recommendation
terol
(ie,
salme-
Humidifier Use
Caution: Use of an external gas source to power
every 12 hours).
the nebulizer
may
13.0
INFECTION CONTROL:
Standard Precautions as
(2)
an
artificial
CDC
CDC
recommendaand droplet
er,
begun.
nuclei.""
much
as
40%,
110
Respiratory Care
2.
American Association
An
may compen3.
American Association
therapy
1307.
at
MDI
is re-
duced significantly by
American Association
AARC Clinical
Respir Care
In vitro assess-
Recommendations:
chamber device;
ration; (3)
(1)
Use an
Everard
ment of drug delivery through an endotracheal tube using a dry powder inhaler delivery system. Thorax
1996:51(l):75-77.
6.
may be
required
when
clini-
inadequate response.
4.
Gross NJ,. Jenne JW, Hess D. Bronchodilator therapy. In: M.J. Tobin, editor. Principles and Practice of Mechanical Ventilation.
Nebulizer Use
Cautions: (1)
McGraw
New York
Do
1994:1077-1123.
(2)
Am
1993;148:1567-1570.
Recommendations: (1) When possible place the nebulizer 30 cm from the proximal end of the endotracheal tube; (2)
in the expiratory
it
Manthous CA, Chatila W, Schmidt GA, Hall JB. Treatment of bronchospasm by metered-dose inhaler albuterol in
mechanically ventilated patients. Chest 1995; 107:210213.
may be
necessary to add a
filter
9.
limb of the circuit to maintain expiratory flow-sensor accuracy when large doses of
aerosol are delivered by nebulizer.
Dhand
metered-dose inhaler
ventilator-supported patients.
1995;151:1827-1833.
Dhand
PJ,
R, Duarte
5.
Patient Monitoring
to therapy with
each
treat1
tients.
1.
996; 1 54:388-393.
For volume ventilation: peak inspiratory pressure and the difference between peak inspirato12.
of bronchodilator responsiveness
mechanically venti-
Gay PC,
Patel
Am. Rev. Respir. Dis 1987;136:880-885. HG, Nelson SB, Gilles B, Hubmayr RD. Me-
volume.
13.
Auto-PEEP
Peak expiratory flow and/or flow-volume loop
Breath sounds
Wegener T, Wretman
fect of ipratropium
S,
tion in
14.
Group
Chairman, Galveston
Jon Nilsestuen
PhD RRT,
TX
monary disease on mechanical ventilation: utilization of metered-dose inhalers. Am Rev Respir Dis
1990;141:164-168.
15. Fresoli
James Fink MS RRT, Mines IL Dean Hess PhD RRT, Boston MA James Volpe III Med RRT, San Diego CA
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RP, Smith
RM, Young
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1.
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AARC Clinical
18.
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Anesthesiology
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111
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position
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Motoyama EK, Fort MD Klesh KW, Mutich RL, Guthrie RD. Early onset of airway reactivity in premature infants with bronchopulmonary dysplasia. Am Rev Respir Dis
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in ventila-
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Pediatr
man.
1992:120:974-979.
Newman
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vier.
In
1990:73:1263-1265.
37.
Dolovich
in
SP,
Ahrens RC, Ries RA, Popendorf W, Wiese JA. The delivery of therapeutic aerosols through endotracheal tubes.
Pediatric Pulmonol. 1986: 2:19-26.
Aerosols
23.
Amsterdam 1993: 375-399. Fuller HD, Dolovich MB, Posmituck G, Wong Newhouse MT. Pressurized aerosol versus jet
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444.
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38.
Gamer
SS, Wiest
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Newhouse MT,
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Thomas SHL, O'Doherty MJ, Fidler HM, Page CJ, Treacher DF, Nunan TO. Pulmonary deposition of a nebulized aerosol during mechanical ventilation. Thorax
1993:48:154-159.
40.
(editorial).
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Rev Respir Dis 1993:148:1444-1446. Wollam PJ, Kasper CL, Bishop MJ, Pierson DJ.
and assessment of bronchodilator response
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Med
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tion.
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45. Alvine
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O'Riordan TG, Greco MJ, Perry RJ, Smaldone GC. Nebulizer function
1990:18:866-870.
47. Beaty
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48. Silverglade A. Cardiac toxicity of aerosol propellants.
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CT, Williams FM, Draffan GH, Wise G, Sahyoun H, Paterson GW, Walker SR. Arterial blood levels of fluorocarbons in asthmatic patients. Clin Pharmacol
112
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AARC Guideline:
Selection of Device
tive
Spahr-Schopfer lA, Lerman J, Cutz E. Newhouse MT, Dolovich M. Proximate delivery of a large experimental
65. Phipps
ers:
PR, Gonda
effects
I.
MDI
le-
on
particle size
Am
Med
Chest 1990;97:1327-1332.
66. Phipps PR,
Gonda
I.
American Association
ventilation. Respir
AARC
Clini-
duced by
on
particle size
and con-
mechanical
Med
Care 1992;37(8):887-890.
1994;7:239-258.
ef-
J,
67. Loffer
DT,
Ikle D,
Nelson HS.
Chest
1
A
1
comparison of commer1
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Assessment of bronchodila-
from an un-
Rau
JL,
Harwood
device for metered-dose bronchodilator delivery to intubated adults: an in vitro study. Chest 1992:102:924-930.
54. Ebert
ers
J,
B.
An
evaluation of spac-
Thomas SHL, O'Doherty MJ, Page CJ, Treacher DF, Nunan TO. Delivery of ultrasonic nebulized aerosols to a lung model during mechanical ventilation. Am Rev
Respir Dis 1993;148(4):872-877.
and adapters:
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DE,
Pilarski
Med
moderate
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to severe
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Kacmarek RM.
1996;77(4):292-297.
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WJ, Greenspan JS, Antunes MJ, Cullen JA, AR, Wiswell TE. Pulmonary response to an
inhaled
O'Doherty M, Turner
S,
Bateman N. Pulmonary deposition of nebulized pentamidine isethionate: effect of nebulizer type, dose and
American Association
AARC
Clini-
59. Kendrick
vol-
ume, residual volume and matching of nebulizer to compressor. Respir Med 1995:89(3): 157-9, 1995 Mar.
60. Nerbrink O,
Re.spirCare 1996;41(7):654-657.
73.
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AARC
Clini-
Why
do medical
74.
and caregiver
Aerosol
Med
1994:7:259-276.
Gamer
Advisory
61.
Goularte TA,
Make
BJ,
in
Mcme-
GA:
Am J Med
62. Hamill RJ,
1984;77:834-838.
1-01-1996. www.cdc.gov.
75. Centers for Disease Control and Prevention. Guidelines for
MA Cadle RM, et
tion
An
outbreak of Burkholderia
(for-
tract coloniza-
and infection associated with nebulized albuterol therapy. Ann Intern Med 1995;122:762-766.
63.
54303. www.cdc.gov.
76. Center for Disease Control
64. Cockroft
DW,
Interested persons
may photocopy
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