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JANUARY 1999 VOLUME 44 NUMBER

ISSN 0020-1324-RECACP

A MONTHLY SCIENCE JOURNAL 44TH YEAR ESTABLISHED 1956

EDITORIALS
Global Respiratory Care:

Common

Interests,

Not

Common

Credentials

Aerosol Therapy

in

Respiratory Care:

Technology

at the

Bedside
to

The Strong Ion Difference Approach


Understanding Acid-Base Balance

ORIGINAL CONTRIBUTIONS
A New Method
in

for

Assessing Nursing

Work Load

a Respiratory Intermediate Intensive Care Unit


of Large- vs

Performance

Small-Volume Holding
Different Propellents

Chambers with MDIs Using

REVIEWS
Stewart's Strong Ion Difference Approach to

Acid-Base Analysis
Bronchodilator Therapy
in

Mechanically Ventilated Patients

SPECIAL ARTICLE
Quantitating Caregiver

Work Load

in

the ICU

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JANUARY 1999
FOR INFORMATION,
CONTACT:
AARC Membership
Services
or Other

VOLUME

44

NUMBER

AARC

EDITORIALS
Global Respiratory Care:

American Association
Respiratory Care

for

A Case of Common
Ohio,

Interests,

Not

Common

11030 Abies Ln Dallas TX 75229-4593


(972) 243-2272 Fax (972) 484-2720

by Jerome

M Sullivan Toledo,

Credentials

and Tetsuo Miyagawa

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

R Swenson Seattle, Washington

26

8310Nieman Rd LenexaKS 66214


(913) 599-4200

Fax (913) 541-0156

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,

Programs Committee on Accreditation


Respiratory Care

for

by Enrico

Michele Vitacca, and Nicolino Ambrosino

Gussago,

Italy

29

1701

W Euless Blvd, Suite 300


TX 76040

Euless

(817) 283-2835

Fax (817) 354-8519

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

American Respiratory Care


Foundation

REVIEWS, OVERVIEWS & UPDATES


Stewart's Strong Ion Difference Approach to Acid-Base Analysis
by Joseph Morfei

11030 Abies Ln Dallas TX 75229-4593


(972) 243-2272 Fax (972) 484-2720

Syracuse, New York

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

Eicher

MPA
St,

(703-548-8538)

1225 King
Alexandria

Second Floor

VA 22314

The Therapeutic

Fax (703) 548-8499

70

RE/PIRATORy

PFT
A New

NUGGETS
Feature for the Journal: Introducing

C&RE
RESPIRATORY CARE {ISSN
190)
1

by Mani S Kavuru and James

K Stoller Cleveland,

PFT Nuggets
Ohio

73 74
76

0020-1324,

USPS 0489at

Borderline Normal?
by Albert Rafanan and Mani S Kavuru

is

published monthly by Daedalus Enterprises Inc,

1030 Abies Lane, Dallas

TX

75229-4593, for the Amer-

Cleveland, Ohio

ican Association for Respiratory Care.

One volume

is

published per year beginning each January. Subscription


rates are

(for airmail,

$75 per year in the US; S90 add S94).

in all other countries

56- Year-Old

Smoker with Dyspnea

by Naresh Mansharamani and Mani S Kavuru

Cleveland, Ohio

The contents of

the Journal are indexed in Hospital and

Health Administration Index, Cumulative Index to Nursing and Allied Health Literature,
ica,

EMBASE/Exerpta Medpublished
in

and RNdex Library Edition. Abridged versions of


are

DRUG CAPSULE
by Thomas

Respiratory Care
terprises Inc.

also

Italian.

French, and Japanese, with permission from Daedalus En-

Opioids and Respiratory Depression A Davis and Hugh S Mathewson

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TX and at additional Send address changes to RESPIRATORY CARE, Membership Office, Daedalus En1030 Abies Lane, Dallas TX 75229-4593. terprises Inc,
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POSTMASTER:

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1999, by Daedalus Enterprises Inc.

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CONTINUED,

ALSO
IN THIS

ISSUE

AARC Membership

117

Application

nEW! Orientation & Competency Manual


The Orientation and Competency Assurance Manual for Respiratory Care provides the information, assessment tools, and models necessary to demonstrate that the competence of employees is documented according to JCAHO
requirements.

nEW! Uniform Reporting Manual for Subacute Care


The Uniform Reporting Manual for Subacute Care is a tool to determine productivity, track trends in the
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how to order Call the American Association for Respiratory Care at (472)243-2272
Here's for your Continuing Education

needs

EDITORIAL OFFICE
600 Ninth Avenue,
Seattle

EDITOR

IN

CHIEF

Suite

702

WA 98 104

(206) 223-0558

Fax (206) 223-0563


www.rcjounial.com

David J Pierson Harborview Medical Center University of Washington Seattle, Washington

MD

MANAGING EDITOR
Ray Masferrer

ASSOCIATE EDITORS
Richard

RRT

D Branson RRT

Dean

Hess

PhD RRT FAARC

University of Cincinnati Cincinnati, Ohio

Massachusetts General Hospital

Harvard University
Boston, Massachusetts

ASSISTANT EDITOR
Katherine Kreilkamp

Charles

Durbin Jr University of Virginia Charlottesville, Virginia

MD

James

Stoller

MD

The Cleveland Clinic Foundation Cleveland, Ohio

EDITORIAL

EDITORIAL BOARD
Thomas

ASSISTANT
Linda Barcus

Barnes

EdD RRT

Leonard
Seattle,

Hudson

MD

Shelley

C Mishoe PhD RRT

Northeastern University
Boston, Massachusetts

University of Washington

FAARC
Medical College of Georgia
Augusta, Georgia

Washington

PRODUCTION
Kelly Piotrowski

Michael
Seattle,

Bishop

MD

Robert

M Kacmarek PhD RRT


Joseph

University of Washington

FAARC
Massachusetts General Hospital

L Rau PhD RRT

Washington

Georgia Slate University


Atlanta, Georgia

Harvard University

Bartolome

Celli

MD

Boston, Massachusetts

PUBLISHER
Sam P Giordano

Tufts University

MBA RRT

Boston, Massachusetts

Toshihiko Koga
Koga Hospital
Kurume, Japan

MD

Catherine
Long Beach,

SH

Sassoon

MD

University of California Irvine California

Robert

L Chatbum RRT

MARKETING
Rick

FAARC
University Hospitals of Cleveland

Marin

Kollef

MD

Arthur S Slutsky
University of Toronto

MD

Owen

Case Western Reserve University


Cleveland, Ohio

Washington University
St Louis, Missouri

Director of Marketing

Toronto, Ontario,

Canada

Tim Goldsbury
Director, Advertising Sales

Luciano Gattinoni
University of Milan

MD

Patrick Leger
Paris,

MD

Martin

Tobin
Illinois

MD

Ctinique Medicate Edouard Rist

Loyola University

Beth Binkley
Advertising Assistant

Milan, Italy

France

Maywood,

John

Heffner

MD

Neil

Maclntyre

MD FAARC
STATISTICAL CONSULTANT

Medical University of South Carolina

Duke

University

RE/PIRATORy

Charleston, South Carolina

Durham, North Carolina

Q\RE
A Monthly
Science Journal
in

Mark
Little

J Heulitt

MD

John

Marini

MD

Gordon
Seattle,

Rubenfeld

MD

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University of Minnesota
St Paul,

University of Washington

Rock, Arkansas

Minnesota

Washington

Established

1956

SECTION EDITORS
Hugh S Mathewson MD L Rau PhD RRT Drug Capsule
Joseph
Charles

The Otficial Journal of the American Association for


Respiratory Care

Irvin

PhD

Richard

Branson

Gregg L Ruppel

MEd RRT RPFT FAARC

Robert S Campbell
Kittredge 's Corner

RRT RRT

PFT Comer
Jon Nilsestuen

PhD RRT FAARC

Patricia

Ann Dooriey

MS RRT

Ken

Hargett

RRT

Charles

Durbin

Jr

MD

Graphics

Comer

Test Your Radiologic Skill

Abstracts

Summaries of

Pertinent Articles in Other Journals

Editorials,

Commentaries, and Reviews To Note


1998;89(5): 1047-1049.

Emergency Informed Consent Pearson KS. Anesthesiology

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-

Spontaneous Recovery after Discontinuation of Intraoperative Cardiopulmonary Resuscitation:

Case Report Frolich MA. Ane.slhesiology 1998;89(5):12.S2-I253.

Massive Pyramidal Tract Signs after Endotracheal Intubation:


loepiphyseal Dysplasia Congenita

Case Report of Spondy-

Rcdl G. Anesthesiology

1998;89(5):1262-1264.

Reducing Ongoing Transmission of Tuberculosis Barnes PF.


1703.

JAMA

1998;280(I9):1702-

"Conventional" and "Unconventional" Medicine: Can They Be Integrated?


Intern

Dalen
1

JE.

Arch

Med

I998;158(20):2I79-2181.

Interpreting the Anion

Gap Reilly

RF. Anderson RJ. Grit Care

Med

998;26( 1

):

77 1- 772.
1

Quantification of Organ Dysfunction: Seeliing Standardization


1998;26{ 11): 1767-1768.

Bernard GR.
Med

Grit Care

Med

Breathing: Does Regular


1774.

Mean Normal? Brochard

L. Crit

Care

1998;26(l l):l773-

Can

Futility

Be Defined Numerically?

Rapoport

J.

Teres D,

Lemeshow

S. Crit

Care

Med

1998:26(11): 178 1-1782.

Practical Use of a Bronchial Blocker in

TubeCapdeville

M,

Hall D,

Combination with a Double-Lumen Endotracheal Koch CG. Anesth Analg 1998;87(6): 1239-1241.

Medical Technology Assessment:


Analg 1998;87(6):1271-1282.

An Overview

Fleisher LA, Mantha

S,

Roizen MF. Anesth

Simple, Quantifiable, and Accurate


JF, Carstens E.

Method

for Applying a Noxious Mechanical Stimu-

lus Antognini

Anesth Analg 1998:87(6): 1446-1449.

Force, Speed, and Oxygen Consumption in Thoroughbred and Draft Horses Polard USB, Leith DE, Fedde MR. J Appl Physiol

TB

could exert the same draft forces as

DH

Arou.sal

and Ventilatory Responses during


J,

and, at each force,

TB

achieved about twice the

Sleep in Children with Obstructive Sleep Ap-

speed, twice the external power, and twice the

nea
O.

Marcus CL. Lutz

Carroll JL,

Bamford

1998:84(6):2052.

O2 consumption
the

as

DH;

thus the 2 breeds had

Appl Physiol 1998:84(6): 1926.


central regulation of upper airway

same gross

efficiencies.

We also found maxto be

Thoroughbred (TB) and

draft horses

(DH) have

imal

O2 consumption of TB

about twice
'

Abnormal
muscles

long been selected for tasks of very different


intensities

that of

DH

(134 vs 72

mL

kg

min

',

may

contribute to the pathophysiology

and force-speed relationships. To

respectively), suggesting adaptations to highintensity exercise.


at

of the childhood obstructive sleep apnea syn-

study their adaptations,

we measured O,
in 3

con-

Peak efficiency was reached

drome (OS AS).

We

hypothesized that

this

was

sumption and related variables

TB

and 4

lower speeds

in

DH

than in

TB, suggesting

.secondary to global abnormalities of ventilatory control during sleep.

DH

during progressive exercise tests on a level

adaptations to high-force low-speed exercise.

We

therefore

com-

treadmill.
5, 10, 15,

The horses exerted


or

a draft force of 0,
at

These differences between


peak efficiency

TB

and

DH in
in

force-

pared the response to chemical stimuli during


sleep between prepubertal children with

20%

of their body weight


ni/s

speeds

speed and aerobic capacities and

speed for

OSAS
at a

that increased

by 2

every 3 min until they

likely reflect different contrac-

and controls. Patients with


higher Pcu2 (58

OSAS

aroused

could not maintain that speed.

We

found

that

tion velocities in

locomotor muscles.

2 vs 60

5 torr, p

<

0.05);

Respiratory Care January 1999 Vol 44

No

those with the highest apnea index had the highest arousal threshold (r

0.52, p

<

0.05).

The

hypercapnic arousal threshold decreased after


treatment. For
all

Opportunities in sleep medicine


Crosstrainfor success and earn college credits at home.
Now you
credits, all

subjects,

hypoxia was a poor

stimulus to arousal, whereas hypercapnia and,


particularly,

hypoxic hypercapnia were potent

can take advantage of the fast-growing number

( il

professional opportunities in sleep medicine

stimuli to arousal.

Hypercapnia resulted

and earn

collegi'

in

de-

without attending on-c-ampus

da.s.ses.

crea.sed airway ob.struction in

OSAS.

Ventila-

For over 20 years, California College for Health .Sciences ha^

tory responses

were similar between patients

been the choice of thou.sands of bu.sy healthcare professionals

with
size

OSAS
was

and controls; however, the sample

small.

We conclude
However,

who wanted to achieve success through distance education. Find out why call now! Accredited Member, DETC.
-

that children with

Kespimtory Programs accredited hy CAAHhP.

OSAS
tory

have slightly blunted arousal responses


the overall ventilain chil-

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wwwcch.sedu

to hypercapnia.

and arousal responses are normal

1-800-961-6409 eXt 1744 Aa^*""'


Call lociiiy or setui this

dren with

OSAS,

indicating that a global deficit


is

coupon
St.,

to:

in respiratory

drive

not a major factor in the

California College for Health Sciences


Dept. 1744,

etiology of childhood
tle

OSAS.

Nevertheless, sub-

222 West 24th

National

City,

CA 91950

abnormalities in ventilatory control

may

exist.

cthsinfo@ccii,s.eciu (619) 477-4360 U7 IJ L/ Li" f *^"*J for ^ ^^^^ catalog and no obligation information about X^ JVCiXL* advancing your career through distance education from CCHS,

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#:

Choose
Bronchoalveolar I^avage Fluid Characteristics

ONE of the following accredited programs:


Master of Science in Health Services
concentrations
in:

School of Health Sciences


Associate of Science

of Early Intermediate and Late Phases


Alterations in Leukocytes, Pro-

of

ARDS:

Respinilor>' Theraplsi

School of Business Bachelor of Science in Business


majors
in:

teins,

PAF and

Surfactant Components
I,

Nakos G,

Kitsiouli EI. Tsangaris

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.

CertiUcate Programs for College Credit


Gen)ntol(>gy

D D D D D

.\tcoiinting

Finance

D D

Marketing Business

Management
Master of Business Administration in Healthcare

Managenienl
Respiraton' Care

Community Health Hdueaiion


Health Psychology
Healthcare Ethics

OBJECTIVE: To

determine the concentration

of proteins and phospholipids, markers of in-

D D

Career Diploma Programs


HKG Technology
IX'ntal Assisting

Master of Science in Healthcare Administnttion

Home
Health Aide

Business Essentials

llammatory reaction such as platelet-activating


factor (PAF),

Polysomnography

D D

Medical

Assi,sting

and

cell alterations in

bronchoal-

Name

veolar lavage

(BAL)

fluid during the evolution

Address
City /State

_Apl.

of the acute respiratory distress syndrome

-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

iMlififmia OtUefte for Heaith Sciences

lHvisiim ofHarcourt Brace

& Compemv

ing hospital.

PATIENTS:

19 mechanically ven-

tilated patients,

9 patients with

ARDS

and 10

Circle 115

on reader service card

patients without cardiopulmonary disease (controls),

were

eligible for this study.

INTERVENthe early,

TIONS:

BAL

was performed during

intermediate, and late phases of

ARDS. MEAfactant phospholipids, surfactant components,


tion.

SUREMENTS & RESULTS:


lipids

Total phospho-

INTERVENTIONS:

Esophageal Doppler

and individual phospholipid classes of

and inflammatory markers such as PAF,

cells,

the surfactant, proteins,

PAF, and

cells

were
in

and proteins were affected

in

patients with

CO measurements were performed by the same operator, whereas TD CO measurements were


carried out by other independent operators.
training period involving the
first

measured. High levels of PAF, an increase

ARDS. These

factors,

undergoing quantitative

neutrophils and proteins, and quantitative as well


as qualitative alterations in phospholipids in

alterations during the course of

ARDS,

could

12 patients

have a significant role


evolution of

in the

pathogenesis and

made

the operator self-confident. In the remain-

BAL fluid were observed in ARDS patients compared to the control group. PAF, proteins, and
neutrophils were higher in early

ARDS.
Required
to

ing patients, the reliability of

ED

was assessed

(evaluation period), using correlation coeffi-

ARDS

than in

Training
ability of

Is

Improve the
III

Reli-

cients

and the Bland and Altman diagram. Beand


limits of agreement

intermediate or late

ARDS. The

surfactant pool

Esophageal Doppler To Measure


in Critically

increased in the early phase and decreased in


the intermediate or late phase of the

Cardiac Output

Patients

tween training and evaluation periods, correlation coefficients, biases,

syndrome.

Lefrant JY, Bruelle P,

Aya AG,

Saissi
JJ.

G, Dauzat
Intensive

were compared.

MEASUREMENTS &
training

REperi-

The
tant

qualitative alterations of surfactant consist


in the surfac-

M, de La Coussaye
Care

JE, Eledjam

SULTS: During
ods, 107 and

and evaluation

of reduced phospholipid content


structures with

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

moreover, there was a considerable decrease


the percentage of pho.sphatidylcholine

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

phatidylglycerol, followed by an increase in

(ED) versus thermodilution (TD)


output (CO) measurement.
tive study.

38 out of 49 patients during training and

phosphatidylethanolamine, phosphatidylserine,
phosphatidylinositol, and sphingomyelin in
three phases of
all

ARDS

compared

to the control

university
critically

DESIGN: ProspecSETTING: Intensive care unit of a hospital. PATIENTS: 64 consecutive


patients requiring a

evaluation periods, respectively. Between the

two periods,
from 0.53 from
limits of

correlation coefficients increased

to 0.89 (p

<

O.(X)I), bias
'

decreased

group. Lysophosphatidylcholine was detectable

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-

tery catheter, sedation,

and mechanical

ventila-

agreement decreased from 3.2

Respiratory Care

January 1999 Vol 44

No

Abstracts

L X min^'
patients
ity
is

(p

<

0.001).

CONCLUSION: A
more than
1

without a clear explanation. The American-Eu-

case-control study

was performed on

patients

period of training involving no

ropean Consensus Committee on

ARDS

was

admitted to a government hospital in Johannesburg, South Africa, used as a referral center for
patients with

probably required to ensure

reliabil-

formed

to re-evaluate the standards for the

ICU

of

CO

measurement by ED.

care of patients with acute lung injury (ALI),

TB. Eighty

patients admitted with

with regard to ventilatory strategies, the more

TB who

died during hospitalization were

Care Researcii and Pre-Emptivc Informed Consent: A Practical Approach Used in Chris Hani Baragwanath ICU Finder M,
Critical

promising pharmacologic agents, and the definition

matched with 80 similar patients with

TB who

and quantification of pathological

feafelt

survived hospitalization. Clinical, demographic,

tures of

ALI

that require resolution.

It

was

and radiological characteristics of each group

T.shukutsoane S. Scribante

J.

Piccolo R. Lip-

that the definition

of strategies for the clinical

were compared.
ties

RESULTS:

In-hospital fatali-

man

J.

Intensive Care

Med

I998:24(4):353.

design and coordination of studies between centers

were

a.s.sociated

with female sex (p=0.01),

and continents was becoming increasingly

lower admission hemoglobin level (p<0.01),

OBJECTIVES:
to obtain

(1)

To

establish a protocol

important to facilitate the study of various


therapies for

new

and weight (p<0.01), and a trend

to

more ex-

within international and local ethical guidelines

ARDS.

tensive infiltrative patterns on chest radiographs.

informed consent for

critical

care re-

Multidrug resistance, extrapulmonary disease,

search,

overcoming constraints previously de-

Quality-Of-Life Assessment in Children and

and HIV infection were unexpectedly not


lated to in-hospital mortality.

rein

scribed and (2)

To

evaluate eventual recruit-

Adolescents with Asthma


486.

Rutishauser
1

C,

High mortality

ment using

this protocol.

descriptive study.

DESIGN: Prospective SETTING: Multidisciplinary

Sawyer SM, Bowes G. Eur Respir J 998;


;

2(2):

the first

weeks of admission suggested

that late

presentation
death.

was

a major factor for in-hospital

ICU

in a

community-based university teaching

hospital.

lowing approval by the University Ethics


mittee and Hospital

PATIENTS & PARTICIPANTS: FolComReview Board,


patients ad-

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

of health outcome measurement


it

chronic disorders. However,

only

re-

on chest radiographs, but much


1

mitted between January and

May

1996 were

cently that health professionals have focused on


quality-of-life assessment in children

less cavitation

and fibrosis (p<0.0

).

CONCLU-

assessed on weekdays for potential enrollment


into exi.sting clinical trials. Discussion with potential

and adoasthma-

SIONS:
from

Clinical predictors of early mortality

lescents. Several generic, as well as the


.specific quality-of-life

TB

included anemia, low body weight,


infiltrates,

candidates and/or next-of-kin occurred

instruments specifically

and extensive
tance and

while multidrug resis-

at the earliest

opportunity and informed consent

designed for use

in

children and adolescents are

HIV

infection

were not significant

was obtained pre-emptively. Next-of-kin was


notified if enrollment subsequently occurred.

reviewed

in this article

with particular regard to

factors. Previous

exposure to

TB

and delayed

the conceptual the measures


studies.

and methodological features of


their applicability in clinical

presentation

may have

influenced our findings.


late in their illness, ag-

We
the

evaluated the number of patients screened,

and

Since patients present

number of
for

potential study candidates, the

The

recently published Child Health


is

gressive case finding would be important in controlling

number

whom

con.sent

was obtained or

re-

Questionnaire

a useful generic instrument to


life, in

TB

in this

population.

fused and the

number subsequently
None.

enrolled.

comprehensively assess quality of


ticular

par-

INTERVENTIONS:
inclusion criteria.

RESULTS: Of 249
the
potential study can-

patients screened, 149

(60%) did not meet

Of 100

when comparing young people with difThe Pediatric Asthma Quality-of-life Questionnaire has shown responferent chronic disorders.

Association of Physical Activity and

Human
7):
1

Sleep Disorders

Shcrrill

DL, Kotchou K,
998; 1 58(1
894.

Quan

SF. Arch Intern

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,

siveness to change over time, but

it

lacks age-

specificity with regard to psychosocial issues

BACKGROUND:

It

generally believed that

and comprehensiveness of quality-of-life assessment. In contrast, the Childhood Asthma Questionnaire provides three different versions for
different target ages.
is

exercise exerts a beneficial effect on the quality

of sleep. However, most studies regarding exercise

30 patients (12% of

all

and sleep have been concerned with the and not on

patients screened)
into a study.

were subsequently enrolled


policy of pre-

However,

its

generic part

influence of exercise on sleep architecture and


efficiency,
tion
its

CONCLUSIONS: A

not reflective of the respondent's health sta-

effects in the preven-

emptive informed consent enabled us to over-

tus.

The other asthma-specific instruments have

and treatment of sleep disorders. More-

come some of
enced
in

the problems previously experi-

major conceptual deficiencies when used as a


single mea.sure for quality-of-life assessment.
In the

over, epidemiological evidence of the benefits

our unit with regards to patient


in critical

of exercise on sleep are limited.

OBJECTIVE:

enrollment

care research. Although

absence of a single ideal instrument, the


is is

To

investigate the influence of moderate exer-

overall recruitment remained low, predictions


for future enrollment

use of batteries of quality-of-life instruments


therefore

cise or physical activity

on self-reported sleep

can be made from

this

recommended and

further research

disorders

among

a randomly selected popula-

study.

required to identify the impact that age and de-

tion of adults.

SUBJECTS AND METHODS:


in the

velopmental status have on quality-of-life as-

Study subjects were participants

Tucson

The American-European Consensus Conference on ARDS, Part 2. Ventilatory, Pharmacologic, Supportive

sessment.

Epidemiological Study of Obstructive Airways


Disease

who in the

2th survey completed health

Therapy, Study Design

Factors Related to In-Hospital Deaths in Patients with Tuberculosis


S.

questionnaires that included .several questions

Strategies and Issues Related to Recovery

and

Remodeling
J,

Artigas
Med

Sacks LV, Pendle

on physical exercise and sleep disorders. Sleep


disorders were classified as disorders in maintaining sleep, excessive daily sleepiness, night-

A, Bernard GR, Carlet


et al.

Arch

Intern

Med

1998;158(I7):I916.

Dreyfuss D, Gatlinoni L, Hudson L,


1998;24(4):378.

Intensive Care

BACKGROUND:
(TB) continue
to

Deaths from tuberculosis

mares, and any sleep disorder. Six questions


regarding exercise and physical activity were
asked. Analyses were performed using multivariate logistic regression

occur despite the availability

The acute respiratory distress syndrome (ARDS)


continues as a contributor to the morbidity and
mortality of patients in intensive care units

of effective antimicrobial agents. Multidrug resistance,

human immunodeficiency

virus

(HIV)

models with selected


vari-

infection,
plicated.

and delayed therapy have been imfac-

measures of sleep disorders as dependent

throughout the world, imparting tremendous hu-

OBJECTIVE: To examine clinical

ables and measures of exercise and physical


activity as the independent or predictor vari-

man and financial

costs.

During the

last

10 years

tors associated with in-hospital death in patients

there has been a decline in

ARDS

mortality

with active TB.

METHODS: A

retrospective

ables.

RESULTS: There were 319 men and 403

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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

obtain these advantages for pa-

in the

absence of perceived latex allergy symp-

tients administered general anesthesia, the au-

toms. These data support the need to transform


the health-care

thors (1) designed a

mode

similar to airway

having sleep symptoms of disorders


taining sleep and nightmares and that

in

main-

environment into a latex-safe


to patients

pressure-release ventilation, intermittent contin-

more men

one

that

minimizes latex exposure

uous positive airway pressure (CPAPl), and

than

women

did regular vigorous activity and

and hospital staff See the related editorial: Occupational iMlex Allergy: The

compared

its

efficiency with that of

CMV;

and

walking

at a brisk

pace for more than 6 blocks


significantly

End of the

In-

(2) assessed the

accuracy of end-tidal carbon

per day. Both

men and women had

nocence. Holzman RS, Kalz JD. Anesthesiol-

dioxide tension
partial

(PETCO,)

as a monitor of the

reduced

risk of disorders in

maintaining sleep

ogy l998:89(2):287-289.

pressure of carbon dioxide in arterial

associated with regular activity at least once a

blood (PaCOj) during

CPAPI compared

with

week, participating regularly


gram, and walking
at

in

an exercise pro-

a normal pace for

more
ac-

than 6 blocks per day. Reduced risk of any


sleep disorder
tivity at least

The Sedative and Analgesic Sparing Effect of Music Koch ME, Kain ZN. Ayoub C, Rosenbaum SH. Anesthesiology 1998;89(2):
300.

during

CMV. METHODS: Twenty

anesthe-

tized, tracheally

intubated patients received

baseline

CMV

that

produced a

PETCO,

of ap-

was associated with regular

proximately 35
value

mm

Hg and

a pulse oximetry

once a week, and for men, walk-

>90%.

Patients were assigned to undergo

ing at a bri.sk pace for

more than 6

blocks.

BACKGROUND: To determine

whether music

alternating trials of

CMV

and CPAPI. During


to the airway, reat

Among women

increases in age also reduced

influences intraoperative sedative and analgesic

CPAPI,

CPAP
for
1

was applied

the risk of nightmares.

CONCLUSIONS:

These

requirements, two randomized controlled

trials
I,

moved

s,

and reapplied

a rate equal to

data provide additional evidence that a program

were performed.

METHODS:

In

phase

35

the ventilator rate during

CMV. The

difference
in arterial

of regular exercise modality


disorders.

may be

a useful therapeutic

adults undergoing urologic procedures with spinal anesthesia

between the carbon dioxide tension


calculation of

in the treatment

of patients with sleep

and patient-controlled intrave-

blood and end-tidal gas [P(a-ET)C02l and the

nous propofol sedation were randomly assigned


to hear favorable intraoperative

PaCOj/minute

ventilation quan-

music via head2,

tified the efficiency

of ventilation. Data were


us-

Prevalence of Latex Allergy


siologists:

among Anesthe-

set or to

have no music.

In

phase

43 adults

summarized

as

mean SD and compared


t-test.

Identification of Sensitized but

undergoing lithotripsy treatment of renal or ureteral calculi

ing the Student's

Asymptomatic Individuals
1998:89(2):292.

Brown

RH,

and receiving patient-controlled

in-

way
4.6

pressure

(132

vs.

RESULTS: Peak air235 cm H20; p <


vs.
)

Schauble JF, Hamilton RG. Anesthesiology

travenous opioid analgesia were randomly assigned to either a music or no-music group. The
effect of

0.001) and minute ventilation (3.51


1

.2

1/min; p

<

0.(X)OI

were lower during


value for PaCOj/
vs.

music on sedatives and analgesics

re-

CPAPI than during CMV. The


minute ventilation (11.12.9

BACKGROUND:

Occupational exposure to

quirements, recovery
verse outcomes

room

duration, and adIn

7.92.6

mm

natural rubber latex has led to sensitization of

was assessed. RESULTS:

Hg
ing

X 1' X min"';

<

0.(X)01)

was greater dur-

health-care workers. However, the prevalence

phase

1,

patients in the

music group required

CPAPI. P(a-ET)C02 was always greater dur-

of latex allergy

among

occupationally exposed
re-

significantly less propofol for sedation than patients in the control

ing

CMV

(6.31.6

vs.

1.70.9

workers

in

American hospitals has not been

group (0 |0-150]

mg

vs.

90

0.0001) and was never

>

3.5

mm Hg; p < mm Hg during


less

producibly determined. The objectives of the


current study were to determine the prevalence

[0-240] mg, median[range]; p

<

0.001). These

CPAPI. CONCLUSIONS: During CPAPI,


ventilation

findings persisted after adjusting for duration of

was necessary

to

produce a PaCOj
This repre-

of and risk factors for latex sensitization

among
eli-

surgery (0.3

0.1

mg/min

vs.

1.6

0.4

mg/

comparable

to that during

CMV.

a cohort of highly exposed health-care workers.

min; p

< 0.001).

Similarly, in phase 2, patients

sents a significant reduction in dead-space ventilation,

METHODS:
working
and

Participants

were 168 of 171

who

listened to

music had a significant reduc-

improved efficiency of

ventilation,

and

gible anesthesiologists and nurse anesthetists


in the

tion in alfentanil requirements (1,600 |0-4,250]

a lower value for P(a-ET)C02.

Compared with

Department of Anesthesiology

microg

vs.

3,900 10-7,200] microg; p

0.005).

CMV, CPAPI
PETCO2

also improves the accuracy of

Critical

Care Medicine.

clinical ques-

This persisted after adjusting for duration of


surgery (52

as a monitor of

PaCO,.

tionnaire

was administered, and

testing

was

per-

9 microg/min vs. 119

16

mi-

formed using a characterized nonammoniated


latex reagent for puncture skin testing, a

crog/min,

mean SD, p

<

0.001). Duration of

Functional Residual Capacity Measurement

Food
to
anti-

stay in the postanesthesia care unit

and the

rate

during Tracheal Gas Insufflation


Clin Monit

Fujino Y,
I.

and Drug Administration-approved assay


quantify latex-specific immunoglobulin

of adver.se events was similar in both groups


(p

Nishrmura M, Hirao O, Taenaka N. Yoshiya


J

NS).

CONCLUSIONS:
in

U.se of intraoper-

Comput

1998;14(4):225.

body
tion)

in

serum, and. when required for

clarifi-

ative

music

awake

patients decreases patient-

cation, a validated two-stage (contact-inhala-

controlled sedative and analgesic requirements.


It

OBJECTIVE:
is

Tracheal gas insufflation (TGI)

latex

glove provocation procedure.


allergy with

should be noted, however, that patients

in the

considered an adjunctive method to enhance

RESULTS: The prevalence of latex


clinical

no-music group did not use a headset during


operation. Thus, the decrease in sedative and

carbon dioxide elimination during permi.ssive

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

with acute respiratory


to increasing tidal vol-

analgesic requirements could be caused by elimination of ambient operating

syndrome. Due

room noise and

not by the effects of music.

ume and/orexpiratory resistance, TGI may cause intrinsic PEEP (PEEPi), and may lessen the advantages of permi.ssive hypercapnia. There
is

were atopy (odds

95%

CI, 1.8-1 12.1; p

0.012); his-

Intermittent
lation

CPAP: A New Mode

of Venti-

no

reliable

method

to

measure PEEPi during


to eval-

tory of allergy to selected fruits, such as ba-

during (leneral Anesthesia


JB, Smith

Bratzke E,

TGI. Using an argon washout method


uate

nanas, avocados, or kiwis (odds ratio, 9.8;


CI, 1.6-61.9; p

95%
.skin

Downs

RA. Anesthesiology 1998;

=
p

0.015); and history of

89(2):334.

dynamic hyperinflation, we developed a method to measure FRC with TGI flow. METH-

symptoms with

latex glove use (odds ratio, 4.6;

ODS: We measured FRC

during

95% CI,

.6-

.^.4;

0.(X)6).

CONCLUSIONS:
among
an-

BACKGROUND: Airway pressure-release ventilation

ing out both the ventilator and

TGI by washTGI circuit with

The prevalence of latex


esthesiologists
is

sensitization

provides ventilation comparable to con-

high (12.5%). Ofthe.se, 10.1%


latex allergy.

trolled

mechanical ventilation (CMV), but with


less

had occult (asymptomatic)

Hos-

lower peak airway pressures and

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

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Abstracts

lung composed of two flasks. The

FRC
its

of the

was

sufficiently

good

to

encourage use of the

Adaptive Lung Ventilation ( ALV) during Anesthesia for

model lung was changed by varying

volume

finger cuff in research involving automatic in-

of water, to active 500, 1000, and 1500 mL.

termittent monitoring to observe sequential

Response

to Transitions to

Pulmonary Surgery: Automatic and from One-

The change of FRC (deltaFRC) of the model lung was measured at a flow of 0, 4, 8, and 12
L/min. Then the

blood pressures over time

in stroke patients.

However, measurements of
stolic pressure

systolic

and

dia-

Lung Ventilation Weiler N, richs W.J Clin Monit Comput


Adaptive lung ventilation
is

Eberle B, Hein1998:I4(4):245.

FRC
at

of a bellows-type model

were not the same with the two

lung was measured

the

same TGI
at

flow.

PEEPi

cuffs and further finger cuff

work on
useful.

calibration of the

a novel closed-

of the model lung was also recorded as the


pressure inside the bellows
end-expiration.

would be

loop-controlled ventilation system. Based upon

instantaneous breath-to-breath analyses, the

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

controller adjusts ventilation patterns au-

tomatically to
ics. Its

momentary
at the

respiratory

mechanminimize

Middle-Aged Females after Lower AbdomSurgery under General Anesthesia:

goal

is

to provide a preset alveolar ven-

TGI flow

increa.sed, the

FRC

inal

of the bellows-type model lung increased. PEEPi

Study with the Static-Charge-Sensitive Bed


Tallila T,

tilation

(V^) and,

same

time,

the

work of

breathing.

Aims of our

study were

and deltaFRC .showed a positive correlation


(r

Polo O, Aantaa R, Lepisto M, LahJ

(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

chanics during transition to and from one-lung


ventilation

flow, the greater

was

the

deltaFRC with both

(OLV),

(2) to describe the

automated

continuous and expiratory-phase TGI.


ing continuous

FRC durOBJECTIVE: The aim of this study was to evaluate the feasibility of the static-charge-sensi-

adaptation of the ventilatory pattern.

METH-

piratory-phase

TGI was higher than during exTGI especially during long TI

ODS: With
went

institutional approval

and informed
kg) under-

consent, 9 patients (33-72 y,

66-88

and high TGI flow.

CONCLUSIONS: The
TGI.

sys-

tive-bed

(SCSB) combined with pulse oximetry

ALV

during

total

intravenous anesthesia

tem developed

in this study

can be used as a

(Spo2) for postoperative monitoring and to de-

for pulmonary surgery.

The

ALV controller uses


V^
is

method

to detect air-trapping during

termine variables which could be used for evaluating the quality of postoperative sleep and

a pressure controlled ventilation mode.

preset by the anesthesiologist. Flow, pressure,

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

the perioperative breathing ab-

connector.

The

signals

were read

into an

DLT IBM

Cuff Khan SQ, Wardlaw JM,


Slattery
J,

normalities were assessed using the

SCSB
I-Il

and
pa-

compatible

PC and processed using a linear oneto calculate

Davenport R,

pulse oximeter in 15 female ASA-class


tients

compartment model of the lung

Lewis

S. J Clin

Monit Comput 1998;

undergoing elective lower abdominal sur-

breath-by-breath resistance (R), compliance (C),


respiratory time constant (TC), serial dead space

I4(4):233.

gery under general anesthesia. Anesthesia and

BACKGROUND:

control of postoperative pain followed standard

(VdS) and V^. Based upon the


troller

results, the

con-

There are few suitable methpractice.

The

patients

were monitored during

optimizes respiratory rate (RR) and tidal


as to achieve the preset

ods for monitoring blood pressure continously

one preoperative and three consecutive postop(or intermittently) for research in adult stroke
patients,

volume (Vy) such


with the
tion to

V^

who

are

ill

but do not justify invasive

erative nights.

Movements were analyzed

ac-

intensive care monitoring.


a neonatal

METHOD: We tested
in adults

cording to their duration and time interval. The


effect of opioids
arterial

minimum work of breathing. In addiV^. only PEEP and F,o2 settings are at

the anesthesiologist's discretion. All patients

arm blood pressure

by plac-

was evaluated by measuring

ing

it

on the forefinger ("finger cuff).

We com-

oxyhemoglobin saturation (SpQj) with

were ventilated using F,o2


3

1,0

and

PEEP =

cm HjO.

Parameters of respiratory mechan-

pared the repeatability of the finger cuff with

pulse oximetry for one hour before and two


ics, ventilation,

and

ABG

wjre recorded during


prior to

blood pressure measured by a standard adult

hours after administration of standard doses of

three 5-min periods: 10

min

arm cuff using

the oscillometric technique in

oxycodone.

RESULTS: The

OLV

total

movement
postop-

(1),

20 min
closure

after onset of
(III).

OLV

(II),

and

after chest

168 ambulatory outpatients attending a cere-

time per hour increased during the


erative night (p

first

brovascular disease clinic.

RESULTS: The
mean blood

Data analyses used nonparametric

0.003). Conversely, periodic

comparisons of paired samples (Wilcoxon,


Friedman) with Bonferroni's correction. Significance

mean

difference between sequential

movement
p

activity decreased significantly dur-

pressure readings with the finger cuff was 0.55

ing the three postoperative nights (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

<

0.05. Values are

0.007).
first

The mean Spo2 depostoperative night

given as medians (range).


after onset of

RESULTS: 20 min
(
I

creased during the

OLV

(II),

resistance had approx),

(95.5%

vs.

94.2%, p

0.002), but returned to

imately doubled compared with

compliance

the preoperative level during the following


nights.

had decreased from 54 (36-81)

to

50 (25-70)

subsequent arm cuff readings


first.

within a few minutes of the

made The mean


arm cuff

No

episodes of apnea with significant


(a

mL/cm H,0. TC remained


2.4) vs. 1.2 (0.9)- 1.6)
s.

stable at 1.4 (0.8-

oxygen desaturation

decrease

in

Spoj

> 5%)
asvs.

Institution of

difference between the finger cuff and

were observed. Opioid administration was


sociated with decreased

followed by a reproducible response of the


controller.

OLV was ALV


in

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

mean Spo2 (94.8%

The sudden changes

in respiratory

93.6%, p
89.8%).
odic

0.02), but did not lead to clinically

mechanics cau.sed a transient reduction


by 42 (8-59)%, with

Vy
in-

significant

hypoxemia (lowest observed Spo2


Postoperative periactivity

RR unaffected.

In order to

rather than

CONCLUSIONS:

reestablish the preset

V^, the controller

arm

cuff.

However, although there was no

movement
In

was suppressed, but


body
fe-

creased inspiratory pressure in a stepwise fashion from 18 (14-23) to 27 (19-39)

difference in the inean blood pressure recordings both systolic and diastolic blood pressure

sleep remained fragmented with frequent

cm HjO,
(7.5

movements.
males

our middle-aged non-obese

thereby increasing
(6.6-9.0)

V^

clo.se

to baseline

measurements differed systematically between

(ASA

I-II),

no severe po.stoperative hythe three-nights

mL/kg

BW vs. 7.9 (5.4-1 1.7) mL/kg

arm and

finger cuff.

CONCLUSION: The

re-

poxemia was observed during


monitoring with the
in rejecting

producibility of sequential blood pressure

meathe

postoperative survey. Perioperative

movement
and
in

B W). The controller was. thus, effective in maintainining V^. The minimum Piq, during phase
II

surements made with the finger cuff was better


than with the
finger cuff

SCSB was

a valuable tool

was

101

mm

Hg. After chest closure, respi-

arm

cuff.

The performance of
that

movement

artefacts of Sp02

ratory mechanics had returned to baseline.

CON-

compared with

of the arm cuff

evaluating general sleep quality.

CLUSIONS:

Respiratory mechanics during

14

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No

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Pnces subiect to change without

transition to

and from
in

OLV

are characterized
into opposite

stylets

were reused during an additional 10

in-

OBJECTIVES: To
logical

determine the age

at

which

by marked changes
directions,

R and C

tubation attempts using a Miller 4 blade and

tuberculous pleural effusions occur, the radio-

leaving

TC
V^

unaffected.

The

ALV

laryngoscope (without batteries) with only ambient light. Finally, one stylet

and biochemical characteristics of the

controller
fully,

manages these

transitions .succes.s-

was used

for in-

effusions, the sensitivities of the various diagnostic tests,

and maintains

reliably without inter-

tubation after 10, 20, 30, 40 and 50 sharp 90

and the

utility

of combining

clini-

vention by the anesthesiologist.

Vj during OLV

degree bend-and-straighten cycles using a Miller

cal, radiological,

and analytic data

in diagnosis.

was found

to

be consistently lower than recom-

4 blade and laryngoscope for direct illumination.

mended

in the literature.

RESULTS:

All attempted intubations were


the

254

METHODS: We studied the case histories of patients in whom tuberculous pleural effu1.

successful.

However,

image quality was dra-

sions were diagnosed with certainty between

Performance of a
stein
J

Plastic Optical Fiber Stylet

for Tracheal Intubation of a

Dog

Graven-

when direct illumination from a laryngoscope was used than when ambient light was used. One plastic optical fiber stylet
matically better

January

1989. and June 30, 1997, in a Span-

ish university hospital in a region with a high

D, Lampotang S. Melker R, Doviak R.

incidence of tuberculosis,
(

RESULTS: The mean


1

was successfully used

to intubate after

having

Clin IVlonit

Comput

1998;14(4):271.

SD)

age of the patients was 34.

8.

years,

been used for 20 intubations and 50 sharp 90


degree bend-and-straighten cycles.

and 62.2% were younger than 35 years. The


effusion
tients,

A partial lens

OBJECTIVE:

We set out

to establish

whether a

was on
left

the right side in


side in

55.9% of
patients,

pa-

separation occurred between the 41st and 50th

novel plastic optical fiber incorporated into an


endotracheal tube (ETT) stylet could be used
for intubation of a dog.

on the

42.5% of

and

bend cycle but the image remained adequate

enough

to successfully intubate again.

CON-

on both sides

in

1.6% of

patients. In

81.5% of

secondary objective
direct illumination

CLUSIONS: A

patients, less than

two

thirds of the

hemithorax

novel plastic optical fiber in-

examined the need for a


ity

corporated into an

ETT

was

affected. Associated
in

pulmonary lesions
patients, of

stylet

can be used with

source from a laryngoscope. Lastly, the fragilof the system was tested.

were detected

18.9% of

a laryngoscope for intubation of a dog. Direct

whom
the ef-

METHODS: An
us-

illumination from a laryngoscope provides a better television

14.6% exhibited
fusions,

cavitation. In

93.3% of

anesthetized dog

was repeatedly intubated

monitor image than when only

more than 50% of leukocytes were lymall

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.

The system was durable,

phocytes, and almost


acteristics

had the biologic chartotal

withstanding over 20 uses and 40 sharp bendand-straighten cycles before a lens separation
failure occurred.

of exudates (98.8% had high

protein contents,
levels,

94.9% had high


lactate

cholesterol

dotracheal tube) and displayed on a television

and 82.3% had high


1

dehydroge-

monitor. Four prototype identical stylets were


tested.

nase levels). All but

effusion (99.6%) had an

Repeated intubations were attempted

adenosine deaminase

(ADA)
levels,

concentration

with each stylet and graded as either successful


or failed. All four stylets were tested 10 times

Tuberculous Pleurisy:
tients

Study of 254 Pa-

higher than 47 U/L, 96.8% (123/127) of the


effusions had high

aides L, Alvarez D. San Jose E. Penela


et al.

ADA2

and

each using a Miller 4 blade and direct illumination from the laryngoscope.

P, Valle

JM, Garcia-Pazos JM,


1998;158(18):2017.

Arch

In-

82) of the effusions had high interferon


levels.

89% (7.3/ gamma

Two

of the four

tern

Med

Adenosine deaminase 2 contributed

Respiratory Care

January 1999 Vol 44

No

15


Abstracts

72.2% 12.5% (mean SD) of total ADA activity. Total ADA activity was significantly correlated with

and impatience by day 8


nortriptyline group.

after quit

day
rate

in the at

cists,

and physicians, our large-scale interven-

The cessation

tion

improved prescribing patterns and quality


advance

ADA2
(r

(r

0.83) and with inter-

months was 15 (14%) of 108 and 3 (3%) of


106, respectively (p

of care and thus provides a population-based

feron

gamma

0.30) levels. Definitive

.003; absolute differ-

approach

to

geriatric clinical

pharma-

diagnosis was based on the ob.servation of ca-

ence, 11%;

95%

confidence interval, -18% to


ef-

cology. Future research should focus on the demonstration of

seous granulomas
ples in

in pleural biop.sy tissue

sam-

-4%). Nortriptyline cau.sed frequent adverse


fects,

improved health outcomes

result-

79.8% of
in
1

patients,
1.

on the

results of bi-

including dry mouth (64%) and dysgeu-

ing from improved prescribing choices for the


elderiy.

opsy cultures

7% of patients, and on pleural


8.5% of pa-

sia

(20%).

CONCLUSIONS: We

conclude

that

effusion cultures in the remaining


tients.

nortriptyline led to an increased short-term ces-

Results of the tuberculin skin test were

sation rate

compared with placebo.

In addition,

Gastrointestinal Motility

and Gastric Tube

positive in only 66.57f of patients.

CONCLU-

there

were

significant, but relatively small, re-

Feeding
tients

SIONS:
at a

In these patients,

lymphocyte-rich ex-

ductions in withdrawal symptoms. Nortriptyline to

Mechanically Ventilated PaBosscha K, Nieuwenhuijs VB, Vos A,


in
Crit

udative pleural effusions occurred, on average,

may

represent a

new

therapeutic approach

young age, with no preference

for either the

smoking

cessation.

Samsom M, Roelofs JM, Akkermans LM. Care Med 1998 ;26(9):15I0.


OBJECTIVE: To

right or the left side;

normally affected no more

than two thirds of the hemithorax; and were


generally unaccompanied by pulmonary
trates.
infil-

Improving Prescribing Patterns for the


derly through an Online

El-

determine the fasted and fed

Drug Utilization Re-

gastrointestinal motility characteristics that are

High

ADA

concentration was a highly

view Intervention:
sician,

A System Linking the Phy-

possibly responsible for ga.stric retention in chanically ventilated patients.


spective, case series.

mePro-

sensitive diagnostic sign


rise in

and was caused by a

Pharmacist, and Computer

Monane
JAMA

DESIGN:

ADA2 concentration.

The most

sensitive

M, Matthias DM, Nagle BA, Kelly MA.


1998:280(1 4): 249.
1

SETTING:
patients

Surgical inten-

criterion based

on pleural biopsy was the ob-

sive

care

unit

of a

university

hospital.

servation of caseous granulomas, and culture of

PATIENTS: Seven

who

required me-

biopsy material further increa.sed overall sensitivity.

CONTEXT:
outcomes

Pharmacotherapy
to

is

among

the

chanical ventilation for thoracic or combined

Negative skin

test results

were no guar-

most powerful interventions


in the elderly.

improve health

thoracic-neurologic injuries and nine healthy


volunteers.

antee of the effusion being nontuberculous. This,


together with the low

However, since some


improving phar-

INTERVENTIONS:

None.

MEA-

mean age of

the patients

medications are less appropriate for older patients,

SUREMENTS AND MAIN RESULTS:


Antroduodenal manometry was performed during fasting and gastric feeding with a polymeric
diet in patients during

and the low frequency of associated pulmonary


lesions, suggests that tuberculous pleural effu-

systems approaches
care

to

macy

may

be an effective

sion

is

a primary form of tuberculosis in this

inappropriate medication use.

way to reduce OBJECTIVE: To


utili-

mechanical ventilation,

region.

determine whether a computerized drug


zation review

weaning, and after detubation. Gastric retention

(DUR)

database linked to a tele-

volumes were determined during


feeding. Motility data were

gastric tube
re-

A Randomized

Trial of Nortriptyline for

pharmacy intervention can improve suboptimal


medication use
in the elderiy.

compared with

Smoliing Ces.sation

Prochazka AV,
Licari

Weaver

DESIGN: Popu1,

cordings from nine healthy volunteers. During


the fasting state, under sedation and morphine, the migrating
significantly (p
vs.

MJ, Keller RT, Fryer GE,

PA, Lofaso D.

lation-based cohort design, April

1996,

Arch

Intern

Med

1998;158(18):2035.

through March 31, 1997.


tory care.

SETTING: Ambulatotal

motor complex

in patients

was

PATIENTS: A

of 23,269 pa-

<
in

.001) shortened: median 32.0

BACKGROUND: Smoking cessation rates with


current therapy are suboptimal.

tients

aged 65 years and older throughout the

101.0 mins

healthy volunteers. During

One

class of

United States receiving prescription drug benefits

gastric tube feeding, the motility pattern did not

drugs that
clics.

may improve cessation is the tricyOBJECTIVE: To add nortriptyline hyto

from a large pharmaceutical benefits man-

convert to a normal postprandial pattern until

ager during a 12-month period.

INTERVENprescribing
database

morphine was discontinued.

An

interdigestive

drochloride to a behavioral smoking cessation

TION: Evaluation of provider


through a computerized online

or mixed interdigestive-postprandial pattern

was

program

enhance cessation

rates

and reduce

DUR

seen during gastric tube feeding


tients

in

most pa-

withdrawal symptoms.

SUBJECTS AND
a randomized, doutrial

using explicit criteria to identify potentially inappropriate drug use in the elderiy.
alerts triggered

during morphine administration. Most


activity fronts during gastric feed-

METHODS: We conducted

Computer
whereby
dis-

(94%) of the

ble-blind, placebo-controlled

at

an

affili-

telephone calls to physicians by


in geriatrics,

ing started in the

duodenum. Gastric

retention

ated Department of Veterans Affairs Medical

pharmacists with training


principles of geriatric

percentages during gastric tube feeding were


negatively correlated (r^=.44; p
antral

Center and an

Army

Medical Center. Subjects

pharmacology were

<

.01) with

were aged 18 through 70 years, smoked 10 or

cussed along with therapeutic substitution options.

motor

activity.

CONCLUSIONS:

These

more
rent

cigarettes per day,

and were without curstarted at 25

MAIN OUTCOME MEASURES:


RESULTS: A

Conof

data suggest that morphine administration affects antroduodenal motility in

major depression. Nortriptyline hydrochlo-

tact rate

with physicians and change rate to


total

mechanically

ride or

matched placebo was


to the

mg

suggested drug regimen.


43,(X)7 alerts

ventilated patients.

The

gastrointestinal

motor

before bed 10 days prior to quit day and titrated


to 75 mg/d or The behavioral

were triggered. From


calls

a total of

pattern involved in impaired gastric


in

emptying

maximal

tolerated dose.

43,007 telepharmacy
alerts,

generated by the

morphine-treated patients

is

characterized by

intervention consisted of 2 group

we were

able to reach 19,368 physicians

antral hypomotility
tivity fronts

and persisting duodenal ac-

sessions and

12 individual follow-up visits.

regarding 24 266 alerts (56%). Rate of change


to a

during continuous intragastric feedmotility patterns suggest that

Withdrawal symptoms were measured using a


daily diary, and

more appropriate

therapeutic agent

was 24%

ing.

The observed

smoking cessation was defined

(5860), but ranged from

40%
to

for long half-life for drugs that


patients'

early administration of enteral feeding might be

as self-reported abstinence, expired carbon

mon-

benzodiazepines to
theoretically

2%

7%

more

effective into the

duodenum

or jejunum

oxide of 9

ppm

or less, and a 6-month urine


le.ss

were contraindicated by

than into the stomach of mechanically ventilated patients.

cotinine level of

than 50 ng/mL.

RESULTS:

self-reported history. Except for rate of change

A total

of 214 patients were randomized (108 to

of beta-blockers
structive

in patients

with chronic oball rates

nortriptyline

and 106

to placebo).
in

There was a withdrawal

pulmonary disease,

of change

Ventilatory Care in a Selection of Ontario


Hospitals: Bigger Is Not Necessarily Better!
Critical

significant reduction

several

were significantly greater than the expected


baseline

symptoms including
tability,

anxious/tense, anger/irri-

2%

rate of

change.

CONCLUSIONS:

Care Research Network (CCR-net)


J.

difficulty concentrating, restlessness.

Using a system integrating computers, pharma-

Keenan SP. Montgomery

Chen LM, Esmail

16

Respiratory Care January 1999 Vol 44

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

& Associates, Inc. specializes in recruitment of


United Arab Emirates and Beijing, China.

healthcare staff for international locations including

Saudi Arabia,

the

DRINK

UP.

coordinating

all

activities of the

Service and developing

partnerships with attending physicians. Applicants must have


a Bachelor's degree in Respiratory Care,

be a Registered

Respiratory Therapist with the National Board of Registry

Care, and be eligible for a license as a Respiratory Care


Practitioner in the State of Texas. Master's degree preferred.
to: Human Resources, Code PDRC, M.D. Arderson Cancer Center, 1S15 Holcombe Blvd., Box 205, Houston, TX 77030; or fax to (713) 745-0064; or email to job$@mdanderson.org (no attachments please). Employment office is located at 1100 Holcombe Blvd., Suite 1.150. Equal Employment Opportunity Employer/

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Email: hza@hziegler.com Web: www.hziegler.com

Circle 105

on reader service card

Circle 135

on reader service card


was performed during each

R,

Inman KJ, Sibbald WJ. Intensive Care Med

CONCLUSIONS: The

structure

and process of

Indirect calorimetry

I998;24(9):946.

ventilatory care in this sample of Southwestern

ventilatory

mode

for a period of 30 mins.

Ox-

Ontario ICUs was found to be variable. Not

all

ygen consumption, energy expenditure,

CO,

OBJECTIVE: To

determine whether there

is

this variability
pital size,

could be accounted for by hos-

production, and respiratory quotient did not differ significantly

vaiiability in the structure

and process of ven(ICUs) of

suggesting a potential for improveFurther study

between the two ventilatory


patients'

tilatory care in intensive care units

ment
is

in overall ventilatory care.

modes, regardless of the


tion.

randomiza-

the hospitals of Southwestern Ontario.

DESIGN:

required before any specific

recommenda-

There were no

statistically significant dif-

Self-administered questionnaire-based survey.

tions can be considered.

ferences with regard to respiratory rate, minute

SETTING: ICUs of

selected

community and

volume, and blood gas analysis. All patients


tolerated both ventilatory

teaching hospitals of Southwestern Ontario.

modes without any


Pressure
are both used
venti-

PARTICIPANTS: Head
tals

of respiratory therapy

Comparison of Oxygen Cost

of Breathing

signs of discomfort.

CONCLUSIONS:
BIPAP

service of respective hospitals: in those hospi-

with Pressure-Support Ventilation and Biphasic Intermittent Positive Airway Pressure

support ventilation and


for

without respiratory therapists, the

ICU

nurse

INTERVENTION: Self-administered questionnaire. OUTCOME MEASURE(S): The


manager.
availability of different

Ventilation
gla
Crit

Staudinger T.
P.

weaning patients gradually from the

Kordova H. Roget al.

lator.

BIPAP may
is

be advantageous

in patients

M. Tcsinsky
Care

Locker GJ, Laczika K,

not breathing sufficiently with


patient effort
tilatory

PSV.

since no

Med

I998;26(9):1518.

models of ventilators

necessary with use of this ven-

and respiratory therapist and physician coverage were assessed.


In addition, the use of clin-

mode.

OBJECTIVE: To
tion

assess the oxygen cost of

breathing with either pressure-support ventila-

ical practice guidelines, respiratory therapists,

(PSV) or biphasic

intermittent positive air-

and the nursing role


determined.

in ventilatory care

were

way

pressure ventilation (BIPAP).

DESIGN:
SETsta-

Oxygen Uptake during Peritoneal Ventilation in a Porcine Model of Hypoxemia Gif-

RESULTS:
modes of

In general, the struc-

Prospective, randomized, crossover study.

fin

DM, Gow KW.


Crit

Warriner CB. Walley KR.

ture of ventilatory care, including availability

TING: Medical
sity hospital.

intensive care unit of a univer-

Phang PT.

Care

Med

1998:26(9): 1.564.

of different

ventilation,

and coverage

PATIENTS: Twenty clinically

by respiratory therapists and physicians was

ble

and spontaneously breathing patients

after

OBJECTIVES:

Peritoneal ventilation

(PV) can

more comprehensive
lation varied
tals

in larger hospitals.

Howventi-

long-term mechanical ventilation.

INTERVENto start

greatly increase P^(,, in

hypoxemic

rabbits.

We

ever, the availability of

some modes of

TIONS:
either

Patients

were randomized

on

tested the hypothesis that the peritoneum can

more than expected among hospiin

PSV

or

BIPAP, and measurements were


an adaptation period of 30 mins.
the ventilatory
after,

provide a gas exchange surface for oxygen uptake in larger animals that, like humans, have a

of comparable size. Similarly, variability

performed

after

the process of ventilatory care, defined by the


availability of clinical practice guidelines

Immediately

mode was

smaller relative peritoneal surface area and cor-

and

changed and
period, the

after another

30-min adaptation

responding blood flow.

DESIGN:

Prospective,

the roles of respiratory therapists varied both

same measurements were performed.

randomized, controlled animal study. SET-

within and

among

hospitals of different size.

MEASUREMENTS AND MAIN RESULTS:

TING:

University research laboratory.

INTER-

Respiratory Care

January 1999 Vol 44 No

17

Abstracts

VENTIONS:

In six anesthetized pigs, a

modi-

of the Pio2 monitoring data suggested that the


likelihood of death increased with increasing

who
ity

received

fied endotracheal tube (9.0-inner diameter)

was
peri-

course.

ECLS as a part of their hospital INTERVENTIONS: Predicted monalthe Pediatric Respirasur-

inserted into the peritoneal cavity,

and the

duration of time at or below a Pi,io2 of '5 torr


(2.0 kPa) or with the occurrence of

was calculated using

toneal cavity

was

ventilated with

oxygen

in he-

any Pbio2

tory Failure score

and was compared with

lium in gas phase. Measurements of peritoneal

values of

<

torr

0.8 kPa).

vival at the time of hospital discharge. Hospital

oxygen uptake and mixed venous oxygen


uration were

sat-

charges were used as a proxy for resource

uti-

made over iO mins


PV;

of: a)

baseline
c) F,,

Cardiovascular Complications Adversely Affect Survival

lization.

Cost-per-life-year-saved calculations
life

F|o2 0.20, no
0.20,

b) F,o2 0.20.

PV;

during Extracorporeal

Mem-

were performed based on a normal


ancy for survivors.

expect-

PV. dopamine 5 microg/kg/inin;


no PV;
e) F,o2 0.15.

d) basef)

brane Oxygenation
Martin OR. Crit Care

Becker
1

JA. Short BL.

MEASUREMENTS AND
Twenty
patients

line F|02 0.15.

PV; and

Med

998 Sep;26(9): 1582.

MAIN RESULTS:
tified.

were iden-

F,o2 0.15, PV, dopamine 5 microg/kg/min.

MEASUREMENTS AND MAIN RESULTS:


Mixed venous oxygen
.saturation

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)

has been used in the man-

the baseline F|q2 of 0.20

and

33%

an F|02 of

agement of infants with cardiorespiratory


ure.

entire hospital length of stay.


tality rate for

ICU and 23.5 days for the^ The observed morwas 20%. Median

0.15 and did not increaise significantly froin


baseline with

ECMO causes a decrease in load-dependent


that

these patients

PV

or with dopamine

at

either

measures of cardiac performance


been demonstrated

have not
outcome,

predicted mortality rate based on the Pediatric

F,o2- Peritoneal

oxygen uptake, measured with

to affect patient

Respiratory Failure score calculation was 83%.

a water.seal .spirometer,

was

9.1

3.1 (SD) and

while other cardiovascular complications occur

The
was
life

hospital charges incurred by these patients

11.93.0 mL/min when lung F|02 was 0.20

which may

affect

outcome. The purpose of

this

median of $199,096. Based on a normal


this results in a

and 0.15, respectively, and 9.72.8 and


1

study was to describe the cardiovascular complications associated with

expectancy for survivors,

2.2 2.7

mL/min when

F,o2

was 0.20 and

0.

ECMO,

and

to deter-

cost of $4,190/life-year.

CONCLUSIONS:

and dopamine was infused, respectively.

CON-

mine

their relationship to survival.

DESIGN:

ECLS
done
ably

for the pediatric patient with


at

AHRF

is

CLUSION:
alter

Peritoneal ventilation does not re-

Data were obtained, retrospectively, from the


medical records of 500 consecutive newborns
treated with

a considerable cost.

However,

ECLS

sult in clinically significant

oxygen uptake or

affects survival favorably,

and compares favor-

mixed venous oxygen

saturation in a por-

ECMO at our institution since

984.

cine model of hypoxemia.

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.,

Relationship of Brain Tissue

POj To Out-

complication, requiring medical intervention

liquid ventilation, nitric oxide).

These

come after Severe Head Injury


CS. Crit Care

Valadka AB,

192 infants. Myocardial stun, the near-total absence of systolic function during
curred in 59 infants.

data also provide a framework for cost-based

Gopinath SP, Contant CF, Uzura M, Robertson

ECMO.

oc-

analyses

at

other

ECLS

institutions.

Med

1998;26(9):1576.

Rhythm

abnormalities, in-

cluding noncannulation-related bradycardia,

Precision and Accuracy of Self-Measured

OBJECTIVE: To determine
tissue

thresholds of brain

occurred

in

43

infants, cardiac arrest,

and

peri-

PO2

(Pbio2) that are critical for survival

cardial effusion in 17 infants,

and noninfective
infant re-

structive

after severe

head

data collection.

DESIGN: Prospective SETTING: Neurosurgical ininjury.

thrombosis

in

infants.

Only one

Peak Expiratory Flow Rates in Chronic ObPulmonary Disease Murata GH, Lium DJ. Busby HK, Kapsner CO. South Med

quired ligation of a patent ductus arteriosus during

I998;91(10):919.

tensive care unit of

Ben Taub General

Hospital,

ECMO.

Infants with at least one cardiovas-

a comprehensive academic neurosurgical facility

cular complication had a lower survival rate,

BACKGROUND:

The

precision and accuracy

and Level

trauma center. PATIENTS: For-

compared with those


cation. Survival rates

infants without a compli-

of self-measured peak expiratory flow rates

ty-three severely head-injured patients

not obeying

who were commands on presentation or whose

were decreased

in infants

with myocardial stun, arrhythmia, and cardiac


arrest.

(PEER) have not been determined for patients with chronic obstructive pulmonary disease
(COPD).
and

condition deteriorated to this level shortly after

Hypertension and pericardial effusion

METHODS:

Twenty-eight male vettwice daily, before

admission.

placement

INTERVENTIONS: Intracerebral of Licox (n = 39) or Paratrend (n=4)


or in the inten-

were not associated with decrea.sed survival.

erans recorded their

PEER

CONCLUSION:

These findings suggest

that

after bronchodilators, for 6


in the

months. Spi-

PO2 probes during craniotomy


sive care unit.

MEASUREMENTS AND MAIN


monitoring continued for an
hrs.

RESULTS:

Pi,io2

some cardiovascular complications during ECMO are more common than previously thought, and cardiovascular complications may
adversely impact outcome.

rometry was also done


tion laboratory

pulmonary func-

up

to

times per patient during

the observation period.

4-week "baseline"
for

average of 84.641.8

The probes were

cal-

was
in Pe-

identified for each patient. Baseline coef-

ibrated before insertion according to the

manCost of Extracorporeal Life Support


diatric Patients witii

ficients of variation

(CV) were calculated


after

ufacturer's specifications. After removal, probes

the

morning (AM) and evening (PM) PEFR.

were tested

in

room

air

and

in

blood gas stan-

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.

AMPRE, AMPOST. PMPRE

and

PMPOST

was below

the values of 20, 15, 10, 8, 6, 4, and

were 14.96.9%. !2.65.6%, 14.94.8%, and

2 torr (2.7, 2.0, 1.3, 1.0, 0.8, 0.5, and 0.3 kPa,

OBJECTIVES: To
tracorporeal
life

determine the impact of ex-

1I.26.0%, respectively. There were strong


correlations between self-measured

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

(ECLS) on mortality with acute hypoxemic reat

PEFR

and

values obtained in the pulmonary function laboratory on the

spiratory failure

(AHRF)

our institution; and

same day.

CONCLUSIONS:
COPD.

Self-

ods was

utilized.

Both Licox and Paratrend


air

to calculate the ho.spital charges associated with

measured PFFRs are reasonably precise and accurate in patients with

probes functioned well in room

and

in the

the use of

ECLS. DESIGN: Retrospective


Pediatric intensive care unit

re-

Level

control.

However,

in the

zero-oxygen

view of medical records and hospital charges.

solution, the Paratrend probes

gave an average

SETTING:

(ICU)

Pulmonary Gangrene: Radiological and


Pathologic Correlation

reading of 7.01.4 torr (0.90.2 kPa), com-

of a university-affiliated children's hospital. PA-

Curry CA, Fishman


J

pared with 0.30.3 torr (0.040.04 kPa) for


the Licox probes.

CONCLUSIONS:

Analysis

TIENTS: Twenty patients admitted diatric ICU between 1991 and 1995

to the pe-

EK, Buckley JA. South Med


957.

1998;9I(10):

for

AHRF

18

Respiratory Care

January 1999 Vol 44

No

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Abstracts

Although frequently referred


gangrene

to as

pulmonary prompt

(p

0.02).

The nurse case management


in

inter-

brane disease, with and without synthetic surfactant replacement. Tracheal aspirates

abscess or necrotizing pneumonia, pulmonary


is

vention was not associated with statistically significant

were

a distinct entity, requiring

changes

medication type or dose,


lipids or

collected prior to and for


tiation of a

96-108

hr after initrial

medical and often surgical management. Radiographically.


it

body weight, blood pressure, or


adverse events.

with

randomized double-blind

of

begins as a lobar consolida-

CONCLUSIONS: A

nurse case

synthetic surfactant

(EXOSURF

Neonatal) or

tion, usually in the

upper lobes, develops

lu-

manager with considerable management responsibility can,


in

air-treated control patients.

Using the captive


sur-

cencies. and coalesces to form a cavity.

"mass
be

association with primary care

bubble technique,

we measured minimum
first

within a mass" or air crescent sign


present.

may

physicians and an endocrinologist, help improve

face tension (initial adsorption,

quasi-static

A vasculitis ensues, devitalizing parenthat

glycemic control

in diabetic patients in a

group-

compression, dynamic cycling

at .30

cpm,

sec-

chyma

must be drained surgically or ex-

pectorated through a patent bronchus. Serious

More Than a Case Manager. Wagner EH. Ann Inmodel


See the related editorial:
tern

HMO.

ond

quasi-static

compression and 5 min after

quasi-static compressions) in 39 surfactanttreated

complications of pulmonary gangrene that often lead to death are detected on

Med

I99H:l29(fi):654-656.

and 44 control babies.

We

also

comone

computed

to-

pared

minimum

surface tension with the respi-

mography (CT) before

these changes are appar-

Multicenter, Open-Label Study of Recombi-

ratory support provided.

Twelve hours

after

ent on chest radiographs.

Specifically, a

nant

Human DNase

in Cystic Fibrosis
Di.sease.

Pa-

dose of synthetic surfactant,


tension on
first

minimum

surface

narrowed or obliterated bronchus impedes drainage of necrotic parenchyma and thrombosis of


large vessels prevents the delivery of antimi-

tients with

Moderate Lung

DNa.se

quasistatic compression de-

International Study

Group

Harms HK, MaPulmonol 1998;

creased
17.6
1.3

significantly

from

20.91.4

to

touk E, Toumier G, von der Hardt H, Weller

mN/m compared to air-treated babies,

crobial therapy.

We

review the

literature

and

PH, Romano L,
26(3): 155.

et al. Pediatr

report this case to


in the early

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

compression and during dy-

monary gangrene.

Cystic fibrosis

is

characterized by the accu-

namic cycling over 48-60 hr occurred more


rapidly in surfactant-treated babies. Ventilator

mulation of thick viscous purulent secretions.

Nurse Case Management To Improve Glycemic Control in Diabetic Patients in a Health

Recombinant human deoxyribonuclease


(rhDNase) breaks down extracellular
which contributes
sputum.
to the increased viscosity

support did not correlate with


cheal aspirate surface tension.

minimum

tra-

DNA,
of

We conclude that
surface ten-

Maintenance Organization:
Controlled Trial

Aubert

RE, Herman

A Randomized, WH,
et

treatment of babies with synthetic surfactant im-

multinational, open-label study


in

was

proved tracheal aspirate


sion within
1

minimum
first

Waters
al.

J,

Moore W, Sutton D. Peterson BL.

conducted

974

cystic fibrosis patients with


vital

2 hr of the

dose and for the

Ann

Intern

Med

1998;I29(8):605.

moderate lung disease [forced

capacity

next

48-60

hr.

(FVC) 40-70% of predicted

values] to

examine

BACKGROUND: Control of hyperglycemia delays or prevents complications of diabetes, but

the safety and efficacy of aerosolized rhDNase,


2.5

Hydatid Disease
tive Analysis of

in

Childhood:

Retrospec-

mg. once

daily over a period of at least

376 Cases

Anadol D, Goc-

many

persons with diabetes do not achieve op-

weeks. Patients were assessed under conditions reflecting routine clinical practice.

men A, Kiper N. Ozcelik


1998;26(3):190.

U. Pediatr Pulmonol

timal control.

OBJECTIVE: To compare

dia-

During

betes control in patients receiving nurse case

rhDNase
ics

therapy, at least one respiratory tract

management and

patients receiving usual care.

infection (RTI) requiring intravenous antibiot-

During a 20-year period, 376 children with hydatid disease


sity

DESIGN: Randomized,
TING: Primary

controlled

trial.

SET-

was experienced by 29.5% of patients. Forced


1

were treated

at

Hacettepe Univer-

care clinics in a group-model

expiratory volume in

second (FEV,, and

FVC

Ihsan Dogramaci Children's Hospital. There

health maintenance organization

(HMO). PAdiabetes mel-

were significantly improved from baseline by a

were 223 males and 153 females with a mean


age of 8.90.
1

TIENTS:
lilus

17 patients with type

mean of 10.5% and 7.2%.


alteration

respectively.

Voice
fre-

years. Hydatid cysts

were

lo-

and 121 patients with type 2 diabetes mel-

and pharyngitis were the most

calized in the lungs in 222 patients, in the liver


in

litus.

INTERVENTION: The
written

nurse case
algo-

quent rhDNase-related adverse events, but only

56

patients,

and

in

other organs in the refever,

manager followed

management
in

2% of all
ilar to

patients discontinued treatment

due

to

maining

patients.

Cough,

and abdominal

rithms under the direction of a family physician

adverse events. The results obtained were sima subanalysis of data from the
first

pain were the most

common symptoms. One

and an endocrinologist. Changes

therapy were

hundred eight patients had medical, 182 patients

communicated

to

primary care physicians. All


their pri-

months of a placebo-controlled U.S. study. The


patients in the present study had a similar fre-

had surgical, 73 patients had medical and and 4 patients had medical and percuinitial

patients received

ongoing care through

surgical,

mary care physicians.


value,

MEASUREMENTS: The
at

quency of RTIs and improvement

in

pulmonary

taneous drainage treatment as the


apy.

ther-

primary outcome, hemoglobin Ale (HbAlc)

function, and reported fewer rhDNase-related

When

evaluating the results of therapy, the

was measured

baseline and

at

12

and cystic fibrosis-related adverse events than


patients in the U.S. study.

relapse rate
tients than

was higher

in surgically treated

pa-

months. Fasting blood glucose levels, medication type

We
is

conclude

thai

medically treated patients.

We

con-

and dose, body weight, blood pres-

administration of
ated,

rhDNase

safe, well toler-

clude that medical treatment of childhood hy-

sure, lipid levels, patient-perceived health status,

and effective under conditions reflecting

datidosis

is

best,

except

in

cases

with

episodes of severe hypoglycemia, and


hospital admissions

routine clinical practice in patients with cystic


fibrosis

complications such as infection, parenchymal

emergency department and


were also assessed.

and moderate lung disease. Babies

compression or obstruction of airways,


or viscera;
all

bile duct

RESULTS: 72%
in the

of patients
nurse case
1

of these are indications for sur-

completed follow-up. Patients

Tracheal Aspirate Surface Tension


with Hyaline

in

gical therapy.

management group had mean decreases of


percentage points
in

.7

Membrane

Disease: Effects of

HbAlc
in fasting

values and 43

Synthetic Surfactant Replacement


lan

McMilS. Pe.
.

Hypoxia and Chest Pain due


stipation:

to

Acute Con-

mg/dL

(2.38

mmol/L)

glucose levels;

DD,

Singhal N, Shukla

AK, Schurch

An Underdiagnosed Condition?

patients in the usual care group

had decreases
values and

diatr

Pulmonol 1998;26(3):173.
objective

Luder AS, Segal D, Saba N. Pediatr Pulmonol


1998;26(3):222.

of 0.6 percentage points


15

in

HbAlc

mg/dL

(0.83

mmol/L)

in fasting

glucose lev-

Our

was

to

determine changes

in surfirst

els (p

<

0.01). Self-reported health status im-

face tension of tracheal aspirate over the

An

obese, previously healthy, 10-year-old boy

proved

in

the nurse case

management group

4-5 days of

life in

babies with hyaline

mem-

presented with acute respiratory distress, chest.

20

Respiratory Care January 1999 Vol 44

No

Abstracts

and abdominal pain. He was hypoxic and dyspneic in Itie emergency room. Tiie abdomen

cation
J

Approach

Fries JF,

McShane

D. West

disabling injury than most other workers. Trau-

Med

I998;I69(4):20I.

matic injury

commonly occurs from working


to

was distended and tender, and the rectum was


full

with machinery or animals. Respiratory illness

of hard stool. Following catharsis, he


all

made
clin-

We undertook this study to identify persons with


high medical use to target them for health pro-

and health problems from exposures

farm

a complete recovery with resolution of


ical signs.

chemicals are major concerns, and dermatoses,


hearing loss, certain cancers, and zoonotic
in-

A review of the

literature reveals that

motion and .self-management interventions specific to their

acute constipation as a cause of

hypoxia and

problems.

We

compared

the re-

fections are important problems. Innovative

respiratory distress has been recognized, but has


rarely

ductions in cost and health risk of a health

means of encouraging
all

safe

work

practices arc
to reach

been reported.

We

believe that this

is

education program aimed


with a similar
levels.

at high-risk

persons

being developed. Efforts are being made

common phenomenon but probably infrequently


recognized.

program addressed

to all risk

groups of farmworkers, including migrant

We compared health risk and use in 2,586


of employee (N =

and seasonal workers, farm youth, and older


farmers.

high-risk persons with those

Approach

to the Diagnosis of Pulmonary Dis-

50,576) and .senior (N

= 39,076) groups and


Higher So2 '" Chronic Neonatal Lung DisFitzgerald D, ease: Does It Improve Sleep?

ease in Patients Infected with the

Human

Im-

munodeficiency Virus

Haramati

contrasted results in specific high-risk disease


or behavior categories (modules)-arlhritis, back
pain, high blood pressure, diabetes mellitus,

LB, Jenny-

Avital ER. J Thorac Imaging I998;l.^(4):247.

Van Asperen

P, Leslie

G, Arnold

J,

Sullivan C.

Patients infected with the

human immunodetV
infectious and

heart disease, smoking, and obesity-against each


other, using validated self-report measures, over

Pediatr Pulmonol I998;26(4):235.

ciency virus are predisposed to develop a variety of

common and uncommon


stratify the risk

6-month period. Interventions were a

stan-

Sleep fragmentation, decreased rapid eye move-

neoplastic pulmonary diseases. Clinical infor-

dard generic health education program and a


similar program directed at high risk individuals (Healthtrac).

mation that can

of occurrence
I

ment (REM) sleep time, and poxemia have been reported


chronic neonatal lung disease

REM
in

sleep hy-

infants with
in early

of these pulmonary conditions includes:


cell

CD4

Health risk scores improved


high-risk group

(CNLD)

count-the most important determinant; 2)

by 11%

in the overall

com-

infancy despite an awake hemoglobin oxygen


saturation (S,,2)

concurrent antimicrobial therapy; 3) prior travel


history; 4)
activate:

pared with

9%

in the

employee group and


u.se

6%

>93%.

Interestingly, higher

known

latent infections that

may

re-

in the senior

group. Physician

decreased by

inspired

Oj

concentrations have been

demon-

and 5) underlying respiratory disease.

0.8 visits per 6

months

in the high-risk
1

group

strated to reduce

REM

sleep fragmentation in

Specific pulmonary diseases are discussed including: bacterial pneumonia, bronchitis,

compared with 0.05 and 0. 5 vi.sits, respectively,


per 6 months in the employee and senior groups.

CNLD

patients in middle infancy.


S,,,,,

However,

my-

the effect of increased


ture in infants with

on sleep architecnear the time of

cobacterial and fungal infections, Pneumocystis


carinii

Hospital stays decreased by 0.2 days per 6

CNLD

pneumonia, toxoplasmosis, cytomegalodifferential diagnosis

months

in the high-risk

group compared with

discharge from neonatal intensive care has not

virus,
cer.

Kaposi sarcoma, lymphoma, and lung cancan be generated

0.05 days in the comparison groups. The duration of illness or

been reported.

We

performed paired overnight


in a

confinement

to

home decreased
in the

polysomnography
infants with

sleep laboratory on 16

based on the chest radiographic pattern. Focal


or multifocal areas of consolidation usually represent conventional bacterial pneumonia or, less

by 0.9 days per 6 months in the high-risk group


and
0.
1

CNLD

(4

weeks median corrected

5 and 0.25, respectively,

employee
1

age)

in air

or their usual inspired oxygen (So2

commonly,

tuberculosis. In severely

immuno-

and senior groups. Using imputed costs of $ 30 per physician visit, $ ,000 per hospital day, and
1

>93%)

and again when receiving 0.25 L/min

higher than baseline inspired oxygen via nasal


catheters
(S.,,,,

compromised
ing:

patients, unusual diseases caus-

$200 per
$1,138

sick day, previous year costs were

>97%).

A control group of seven


was
similarly studied.

ing consolidation should be considered includ-

in direct costs for the high-risk


in the

groups

healthy preterm infants

Rhodococcus

infection,

nocardiosis,

compared with $352 and $995


direct costs
risk

employee

For

CNLD

infants

on supplemented O,, sleep

cryptococcosis, aspergillosis, and

lymphoma.

and senior groups, respectively. At 6 months,

duration decreased by

15% (42266 min

vs.

Nodules can be present in tuberculosis, histoplasmosis, cryptococcosis, and Kaposi sar-

were reduced by $304

in the

highin the

359 89 min;

p<
by

0.005), and sleep efficiency

decreased

group compared with $57 and $70

coma.

Interstitial

opacities are common

in

Pneu-

comparison groups. Total costs were reduced

66.4 14.0%; p

mocystis carinii pneumonia, histoplasmosis, and

$484
$87

in
in

the high-risk groups the

compared with
in the

cytomegalovirus pneumonia. Cavitation and


cysts are features of Pneumocystis carinii pneu-

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.

employee group and $120

I3.44.3 min; p=0.420),


( 1

senior group.

The

return on investment

was

monia, tuberculosis, aspergillosis, and lung


cancer. Disease of the airways
is

and

REM arousal index

8.66.5

vs.

8.8 7.2;

increasingly

about

6:

in the high-risk

group compared with

p=().990) were not significantly affected. Conversely, higher

recognized in those with acquired immunodeficiency syndrome.

4:1 in the

comparison groups. Effective health


in larger

O, did not

alter sleep architec-

Lymphadenopathy

is

most

education programs can result


in

changes
in

ture in the control group.

The mean non-REM

common

in

mycobacterial infection, but can be

use and costs

in high-risk

persons than

(NREM)
p=0.003;
creased (p

respiratory rate decreased


controls: p=0.02),

(CNLD:
So2
in-

a feature of fungal infection,


posi sarcoma,

lymphoma, Ka-

unscreened persons, justifying more intensive


educational interventions
in high-risk

NREM
mean

and lung cancer. The combined

groups.

<

0.05), although the

transcu-

use of clinical information, knowledge of typical

taneous

CO, was
in

unaltered in both

CNLD

and

conditions associated with the

human imHealth and Safety Risks


riculture
J

control groups. This study confirmed low


in

munodeficiency syndrome, and radiographic


patterns offers a useful approach to the diagnosis

Production Ag-

Von Essen SG, McCurdy SA. West


is

REM%

CNLD

infants in early infancy

and
af-

demonstrated

that a higher

S^q, adversely

of pulmonary disease

in the patient

with the

Med

1998;169(4):214.

fected .sleep time but did not influence

REM
target

human immunodeficiency

virus.

sleep duration or arousal frequency.

Production agriculture

associated with a va-

S2

Reducing Need and Demand for Medical Services in High-Risk Persons. A Health Edu-

riety

of occupational illnesses and injuries. Ag-

Sa02

>93% >97%

is,

therefore, as efficacious as an

in

optimizing sleep architecture

in

ricultural

workers are

at

higher risk of death or

CNLD

infants.

Respiratory Care

January 1999 Vol 44

No

21

Editorials

Global Respiratory Care:

Case of

Common

Interests,

Not
In

Common

Credentials

most countries of the world, the care of

patients with

sponsibility of existing categories of health care providers.

respiratory conditions
nurses, or

may be provided by physicians, physiotherapists. The care may be provided, in


by the combined
efforts of these profes-

Thus, medical assistants

in

Malaysia

may

fulfill

the role of

the respiratory therapist, while nurses or physicians ac-

some

instances,

complish

this task (in addition to others) in


is

many Euro-

sionals or even by

some

other category of health care


is

pean countries. Respiratory care

provided to patients by

worker. In most areas of the world, there


"health care profession

no

distinct

physiotherapists in France and Spain and to a large extent


in Brazil.

whose

practitioners are dedicated

Of interest,

in Japan, respiratory care is

provided

and specifically trained


circumstance
ica,

to deal with all aspects

of the care

by physiotherapists,

clinical engineers,

and nurses. The

of patients with respiratory problems."' The more global


is

practitioners in Japan
clinical experience,

must have a minimum of 3 years


in re-

the opposite of
is

what

exists in

North Amer-

where respiratory care

and they must also participate

established as a discrete health

The North American model has been in Taiwan and the Philippines and in some areas of Central America. Clearly,
care profession.

spiratory care training seminars.


Interest in establishing a distinct respiratory care pro-

adopted to a greater or lesser degree

fession

is

gaining

momentum

in a

number of

countries.
link-

the care of respiratory patients around the world

Only
is

pro-

recently, respiratory care education

programs or

vided by caregivers with disparate credentials.

ages with American programs have been established in

Turkey and

India. Serious discussions regarding the estab-

lishment of such programs are underway in Argentina and

Common

Interests,

Not Credentials

Venezuela, and Costa Rica has an established baccalaureate

program
is

in respiratory care. in

Outside of the United States and Canada, other health


care professionals
therapist.
fulfill

projects

underway

One of the more ambitious Mexico and involves the estab-

the function of the respiratory

lishment of respiratory care schools with a standardized

The

role of the respiratory therapist in various

curriculum throughout the country.

countries

may be

carried out by nurses, physiotherapists,

physicians, or other specialized technicians or clinical engineers. Despite the group performing the respiratory service,
it is

the

"common

International Fellows Present Diverse Credentials

interest," not the credentials, that

unite the different disciplines in providing for the pulmo-

nary needs of the patient. Regardless of location, the com-

The

International Fellowship Project sponsored


for Respiratory
is

by the

mon

interest is at the heart of efforts to analyze

and

es-

American Association
that
tials

Care and the Amer-

tablish the

most appropriate high-quality care of patients

ican Respiratory Care Foundation

instructive of the point

with respiratory conditions.

many

individuals with various professional creden-

provide respiratory care around the world. The project,


in 1990,

See The Original Study on Page 29

&

which was established


nity for
to visit the
is

has provided the opportu-

The Special Article on Page 70


The
level of education

69 health care professionals from other countries


United States and observe respiratory care as
it

practiced here.-

The

diversity of the professional creis illustrative

and training required of those

dentials of the International Fellows

of the

providing respiratory care differs extensively from country


to country, as

many

different types of professionals providing respira-

does the scope of practice. In addition, the

tory care.

The occupational

titles

of the fellows include

model followed for the provision of respiratory care varies dramatically from one region of the world to another. In

exercise physiologists, pulmonary function technologists,

physicians (anesthesiologists, cardiologists, intensivists, internists,

many

countries, the provision of selected respiratory

mo-

pulmonologists, and surgeons), respiratory thera-

dalities is

added on

to or incorporated as part

of the re-

pists, nurses,

medical assistants, physiotherapists, and clin-

22

Respiratory Care January 1999 Vol 44

No

Global Respiratory Care

ica!

engineers.

As

diverse as this

list

is,

individuals in

requiring respiratory care will benefit from the sharing of


ideas representing an integrated global view.

these specialties provide

some form of

respiratory patient

care in their respective countries.

Jerome M SuHivan MS RRT Community and Technical College


University of Toledo
President, International Council for Respiratory Care

Sharing the Best Practices

The

rapid international expansion of respiratory care

Toledo, Ohio

has been coupled with a tremendous need for formal education and training in the clinical practice and theoretical
basis of the profession.

Tetsuo Miyagawa PhD RPT RCET RRT Department of Physical Therapeutics


College of Medical Sciences

The

globalization of respiratory

care should not be thought of as an extension of the North

Showa

University

American model.

On

the contrary,

it

must be viewed from

Kanagawa, Japan

a global perspective in a context that values the rich diversity of care providers.

Viewing the global continuum of care

for patients with

REFERENCES
L Pierson DJ. What
43(1):17-19.
2.
is

respiratory problems leads us to conclude that, while there


are vast differences in the quality of care and while
different disciplines deliver respiratory care,

respiratory care? (editorial) Respir Care 1998;

many
all

we can

American Respiratory Care Foundation,

International Fellowship Pro-

gram: Executive Summary, Dallas, Texas. Oct, 1998.

learn

from one another. Practitioners providing respiratory

care will find an increasing need to collaborate and share


the "best practices," and this need will

become

greater as
in-

Correspondence: Jerome

Sullivan

MS

RRT.

Professor and Interim

medical technology develops and as the exchange of

Dean, Community and Technical College, University of Toledo, 2801


Bancroft. Toledo,

formation on the Internet increases. Ultimately, patients

OH

4.3606. jerome.sullivan@utoledo.edu.

Respiratory Care January 1999 Vol 44

No

23

Technology
Aerosols are most

at the

Bedside: Aerosol Therapy in Respiratory Care


members of

commonly used
tract.

for delivery of
is

medi-

the health care

team so

that therapeutic op-

cation to the respiratory

Aerosol delivery

attractive

tions can be better utilized as evidence of their effective-

because
to the

it

provides relatively direct application of medication

ness becomes available in the literature.

upper and lower airways, allowing for a high thera-

Over

the years, Rbspiratory

Care has been

at the fore-

peutic index with low systemic drug levels and related side
effects.

front in providing respiratory care professionals information to develop

However, aerosol delivery

is

highly device and techin the

and maintain expertise

in their field.

The

nique dependent, with a large range of variability


delivered to the desired
site

dose

Journal publishes tools to change clinical practice based

of action. There

is

currently an

on available

evidence.''^'* In that tradition, this

month's

exponential growth in aerosol technology development, ranging from the development of alternatives to the chlorofluo-

issue provides a wealth of fine examples:

rocarbon (CFC)-based metered-dose inhaler (MDI) to the administration of aerosols for systemic effects.
clinical practice

The common

See The Original Study on Page 38

of aerosol administration has not kept pace

&

The Review on Page 53


comparison of the old (CFC) and

with this rapidly evolving knowledge of aerosol devices and


delivery techniques, resulting in lost opportunities to provide
the best care at the lowest possible cost.
First, in their in vitro

new (hydrofluoroalkane [HFA]) formulations of MDIs used


to deliver albuterol, Mitchell et al'" provide a clear

Most textbooks used

to train respiratory care practitio-

exam-

ners (RCPs) and physicians have a paucity of information

ple of

how changes

in aerosol

technology require us to
years, the adage "bigin the

on device selection and application. RCPs may spend upwards of

rethink past assumptions. For

many
to

60%- 80%

of their clinical time administering

ger

is

better" has been

shown

be true

performance

aerosols in a wide variety of clinical settings. Although


aerosol therapy comprises a relatively large percentage of
the

of holding chambers used with MDIs. Since 1978, re-

RCP's

clinical practice,
initial

it

does not occupy a similar

proportion of either

didactic training or continuing

education, as evidenced by the fact that

< 3% of the pages in

commonly used

respiratory care textbooks are devoted to the


''

topic of aerosols.'

review of standard medical textbooks

used by physicians during their training revealed virtually no


discussion of criteria for device selection or directions for

proper use of various aerosol-generating devices.

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

do physicians and RCPs


sol therapy at the

learn about aerosol therapy?

nominal dose as the


able to a patient

CFC MDI,

the respirable drug avail-

In medical school, the clinical practice of ordering aero-

was increased by

40% when
is

the

HFA

bedside or in the clinic

is

largely based

MDI was

used with the smaller-volume holding chamber.


that not only

on the student's observation of ordering patterns by the


attending physicians at the bedside. attending physicians
is

These findings suggest


sarily better with the

bigger not neces-

The

practice of the

HFA MDI,

but the patient using the

often based on their

own

observa-

small-volume holding chamber


dose of albuterol with the

tions during training. This

method of

training perpetuates

may receive a 40% greater new combination than is available


is

practice patterns that are traditional rather than based


scientific evidence.

on

from using the


apy and

MDI

alone. This

key information for the

Such

clinical practice often

ignores

clinician in selecting various devices for bronchodilator therin establishing

innovations that could improve care and reduce costs.

dosing strategies for their patients.

To change
an expert
relative term.
ability

these patterns of practice, the

RCP

must be
the

Second, Selection of Device, Administration of Bronchodilator,

in aerosol therapy.

Expertise

is,

of course, a
is

and Evaluation of Response


is

to

Therapy

in

Me-chani-

One of
to

the joys of respiratory care

ccdly Ventilated Patients

the latest in a series of

AARC

and luxury

develop and maintain a good knowlin a

(American Association for Respiratory Care) Clinical Practice

edge base (expertise)


other

few

relatively limited areas (such

Guidelines providing an evidence-referenced guide to

as aerosol therapy) that are not

common knowledge among

support the rational use of aerosol therapy.'^ These guidelines

share relevant

members of the health care team. The RCP must new information and perspectives with other

provide potent tools to support the


of-the-art aerosol therapy, but

RCP

in

promoting

state-

of necessity, their format assumes

24

Respiratory Care January 1999 Vol 44

No

Aerosol Therapy

in

Respiratory Care

considerable working knowledge and expertise, requiring the


reader to
fill

REFERENCES
1.

in the

blanks between guidelines and practice.

Third, this

month Respiratory Care inaugurates a new


It

Comprehensive

re.spiratory care.

Dantzker DR. Matlntyre NR,


Saunders, 1995.

quarterly feature exploring aerosol therapy in medicine.


is

Backow ED,
2.

eds. Philadelphia:

WB

designed to help respiratory care practitioners, physi-

Respiratory care: a guide lo clinical practice, 4"^ cd. Burton

GC,

Hodgkin JE, Ward


cians,
area.

JJ, eds.

Philadelphia: Lippincott Raven, 1997.


7"' ed.

and others develop and maintain expertise


series will incorporate

in this
-3.

Egan's fundamentals of respiratory care,

Scanlan CL, Wilkins

The

segment formats, includ4.

RL,

Stoller JK, eds. St Louis:

Mosby, 1999.

ing one on the clinical practice of aerosol medicine, which


will provide evidence-based reviews offering a

Respiratory care equipment. Branson


eds. Philadelphia:

RD, Hess DR. Chatburn RL,


consensus

commonin in
6. 5.

JB

Lippincott, 1995.
for Respiratory Care. Aerosol
state-

sense approach to clinical practice.


this issue

We

begin the series

American Association

of the Journal with "Bronchodilator Therapy


Patients,"''*

ment 1991. RespirCare

I991;.^6(9):916-921.

Mechanically Ventilated

which

fills

the

gap

AARC
AARC.

Clinical Practice Guideline. Selection of aerosol delivery

device. RespirCare l992;37(8):89l-897.

between understanding the key elements of the


practice guidelines and applying

clinical
7.

Clinical Practice Guideline. Delivery of aerosols to the upper

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

airway. RespirCare 1994;39(8):803-807.


8.

AARC Clinical
of aerosol

Practice Guideline. Selection of a device for delivery

to the lung

parenchyma, Respir Care l996;41(7):647-653.

9.

AARC

Clinical Practice Guideline. Selection of an aerosol delivery

of aerosol medicine that are likely to shape future of aerosols for systemic ther10.

device for neonatal and pediatric patients, Respir Care I995;40(I2):

clinical practice, (eg, the use

1325-1335.
Mitchell JP, Nagel

MW,

Rau JR. Performance of

large versus small


albuterol.

apy

is

rapidly expanding, with 3 corporations actively de-

volume holding chambers with CFC- and HFA-formulated


RespirCare 1999:44(1
1

veloping systems for administration of inhaled insulin).


Last, the series will include a

):38-44.

segment on basic aerosol

1.

Moren

F.

Drug deposition of pressurized

inhalation aerosols.

I.

In-

methods, which will provide a guided exploration of aerosol physics, devices,

fluence of actuator tube design. Int J Pharm; 1:205-212.


12.

and

testing techniques designed to

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

RCP and physician gain a better understanding of the


underlying successful aerosol therapy.
13.

scientific principles
It is

our hope to provide a dynamic and current forum for


facets of aerosol therapy

AARC

Clinical Practice Guideline. Selection of device, administra-

tion of bronchodilator,

and evaluation of response

to therapy

in

the

many

and the implications for

mechanically ventilated patients. RespirCare 1999;44(1):I05-1


14.

13.

the practice of respiratory care.

As

the series evolves,

we

will

Fink JB, Tobin MJ. Dhand R. Bronchodilator therapy


cally ventilated patients. Respir

in

mechani-

be soliciting ideas and submissions from you the readers.


Please contact us through the editorial office of Respiratory

Care 1999;44(l):53-69.

Care with your comments,

criticisms,

and suggesfions.

James B Fink
Rajiv

MS RRT

Dhand

MD
&
MS
Jr

Division of Pulmonary and Critical Care Medicine

Edward Hines

Jr

Veterans Affairs Hospital


Correspondence
Reprints:

Loyola University of Chicago


Stritch School of

James B Fink

RRT, Dept

of Pulmonary

Medicine

and Critical Care Medicine, Edward Hines

Veterans Affairs Hospital,

Hines, Illinois

Medical Service (111), Hines, IL 60141-5000. james.nnk@med.va.gov.

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

provide insight into the particular

one of considerable progress but also of increas-

acid-base processes contributing to a specific pathophysiologic circumstance.''


'"

ing complexity (and confusion) in concepts and terms, as

This approach has borne

inter-

ably narrated in the review of the strong ion difference

esting fruit and

some controversy

in the appreciation that


alter solution

(SID) approach to acid-base analysis by Morfei


issue.'

in this

hypo- and hyperproteinemia can

pH and
in pro-

This concept, which was


in 1981,^

first

advanced by Peter

HCO3"."
tein

This has forced a revision of our interpretation

Stewart

has been embraced by

some

in the acid-

of the magnitude of anion gap changes.'- Changes

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

not readily predicted by either


that a normal, singlelike the

vocate that

we abandon

older frameworks of acid-base

HCO3

or classic gauges of metabolic deviations.'''

physiology, not only for lack of precision but also because


these former paradigms lead us astray in thinking about

Schlichtig,'''

however, has suggested


not exist, and

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

approach to diagnosis, treatment and understanding of


acid-base disorders?
In

his study of critically

ill

patients in intensive care units.

one sense, Stewart's term (SID)

is

really not so

new

but rather a

new

twist to the old buffer base term of Singer

See The Review on Page 45

and Hastings.^ Under normal conditions, SID and buffer


base are both roughly 40 mEq/L. Likewise, the discerning
reader will note a parallel similarity with
classic anion gap,
It

must, however, be recognized that what can happen in


test solutions

which are just


the

offset

SID and the by about 25 mEq/L,

simple

and be predicted
to strict

in certain clinical

situations

by adherence

mathematical principles of

which

is

the

sum of

HCO3"

concentration and the

dependent and independent variables does not necessarily


reveal the truth of normal and abnormal physiology.

difference between the other normally circulating strong


ions (Ca^"^, Mg"^"^, lactate, urate, sulfate) that are not

The

pathways by which acid-base equivalents move


of
cells, different

in

and out

included

in the

anion gap calculation. Therefore, a SID

compartments, and the body via the kid-

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

concentrations of ions and acid-base variables in complex


situations, such as that presented

by a

critically

ill it

patient,

methanol and

salicylates).

can inform us only of the

final state, not

how

was

at-

nonrespiratory, normal

SID

acidosis suggests a hyperchlo-

tained. Stewart's advocates extend the sophistication of


their

remic acidosis from loss of alkaline equivalents, and a SID lower than 40
surfeit
is

approach

to

claim that because


in

HCO,"

and

H^

are

consistent with a metabolic alkalosis or a

dependent variables
though there

their

Weltanschauung, the body


but rather only SID. Alrole of Pf-o, as a sensed
status,
it

of unmeasured cations (as in cationic paraproteine-

does not sense or regulate


is

pH

mias or ingestion of cations, such as

Mg^

and Ba^^).
heuristic

no quarrel with the

The
value.

great virtue of the Stewart approach

is its

parameter and determinant of acid-base


cult to see

is diffi-

By

rigorous quantitation,

it

forces us to consider

and quantify the significant and important contribution


that strong cations

A^-ot (the other two independent variables) are monitored, especially considering that they
are

how SID and

and anions, as well as weak acids (SID

summations of multiple individual


that

entities (strong ions

and

A,, in the Stewart lexicon),

may

play in determining

and weak acids)


ferent tissues

may

not always be the

same

in dif-

nonrespiratory acid-base changes. Several studies have

and compartments, or over time.

shown

that the

mean pH

calculated for multiple subjects

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-

sider the case for

*^

or pH), but

we must remain some-

Careful analysis of strong ion or weak acid changes

what humble

at this stage in

our knowledge of acid-base

26

Respiratory Care January 1999 Vol 44

No

Strong Ion Difference and Approach to Acid-Base Analysis

workings.
lated

We

are not even certain of

what

is

being regu-

hardly any better than a more traditional base excess or

protein conformation or the charge on certain

amino

anion gap analysis

in

estimating the metabolic acid-base

acids with

pKs

in the

range of physiologic pH.


cell

We know

disturbance or the presence of pathologic unmeasured anions.'*'^


tion of

now
allel
is

that there are

numerous

membrane

transporters

There are a number of factors


or
its

in the

determina-

and ion channels

that tightly

couple the exchange or parstrong ions, so


it

SID

calculation by the Stewart equation that


its

movement of H^ and HCO," with


other.

conspire to reduce

utility

and precision. To measure

not possible to say which determines the distribution

SID

and concentration of the


level, they

At the

cell

and membrane

aspires, the additional

may

be inextricably linked. Until

we have

better understanding of the biophysical functioning of trans-

porters and channels,

we

cannot say whether only strong

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,

depending upon the precision

ions are transported to create a

H^

secondarily being formed or


to

new SID, with HCOj" and consumed in the new


of water

very precision that this approach seeks, especially


difficult cases

in

more
cal-

of extreme acidosis or alkalosis.''"^

To

compartment (due

changes

in the dissociation

culate

SID

(or

pH) an average pK

for total protein

and

dictated by the requirement of electroneutrality), or whether

phosphates must be incorporated into the equation. These

H^

and

HCO," move
is

directly

from one compartment

to

may

not always apply to a particular patient in

whom

another. This

the crux of the matter for those

who might
us totally
it

temperature, osmolality, pH, Pco,' and albumin-to-globulin ratios

abandon the
ignore

pH

meter for a "SID-ometer."


a

may

differ significantly
it

The advocates of

SID approach would have

Given the foregoing,


remain a powerful tool

from normal. would be premature at present


it

to

HCO^"

in thinking

and measuring since

is

propound the SID approach. Although


in

certainly will

dependent variable. Certain acid-base disorders are provided as examples of the power of SID. Thus, while
true that
it is

acid-base research, for clinical

management
ment of
warrant

it

is

more cumbersome, possibly more ex-

one can achieve correction of a nonanion gap


(ie,

pensive, and not sufficiently better than a critical assessthe base excess, anion gap, or pH/P(^Q^
its

metabolic acidosis by treatment with neutral fluids


those with

maps
one

to

SID of

0) such as saline or

KCl (potassium
it

widespread adoption.''^ Interpretation of acidart,

chloride) in a contraction metabolic alkalosis,

does not
little

base disorders will always remain partly an

that

necessarily follow that the problem then


chloride. In this specific case,
lular

is

one of too

combines an

intelligent synthesis of the clinical history,

it is a problem of extracelvolume contraction with preceding enhanced Na re-

physical examination, and other ancillary laboratory data

taken together
the nature

in the

context of the individual patient and


his or her disease.

absorption and acid excretion.


a strong cation, such as
utilize

By providing

chloride with

and temporal course of

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

Veterans Affairs Puget Sound Health Care System


University of Washington
Seattle,

HCO3"

concentration (and thus SID) without

a Pco, change, one must necessarily have a cation, such as

Washington

Na^

or

K^, accompany
It is

it

or have an anion, such as

CP,
REFERENCES
1

leave the system.

simplistic to say that a

nonanion gap

metabolic acidosis

is

merely an inability of the body to

maintain normal Na"^ and


ple, the

CP

concentrations. For
that

examMorfei
ysis.
J.

nonanion gap metabolic acidosis

develops

Stewart's strong ion difference approach to acid-base anal-

RespirCare 1999;44(l):45-52.

with carbonic anhydrase inhibition occurs because the spe2.

Stewart PA.

How to understand acid-base. New York:


human

Elsevier,

98

cific

mechanism of Na'^/H"^ exchange


is

in the

brush border
at

3.

Singer RB. Hastings AB. Improved clinical method for estimation of


disturbances of acid-ba.se balance of
blood. Medicine 1948;

of the proximal tubule

unable to operate

a speed not a
4.

sufficient to reclaim all the filtered bicarbonate.

It is

27:223-242.
Constable PD.
ria:

problem of too much chloride reabsorption because chloride


is

simplified strong ion


J

model

for acid-base equilib1.

application to horse plasma.

Appl Physiol 1997;83(1):297-31

also lost.
5.

Lindinger MI, Heigenhauser GJF, McKelvie RS. Jones NL. Blood


ion regulation during repeated

Putting aside the uncertainties and subtleties of molecular acid-base transport


art

maximal exercise and recovery


LJ,

in

mechanisms in cells, does the Stewin the day-to-day


6.

humans.
Pieschl

Am

Physiol 1992;262(1 Pt 2):R126-R136.

approach offer any striking advantage


realm? The case to date
is

RL, Toll PW, Leith DE, Peterson


in the

Fedde MR. Acid-base


J

clinical

not convincing.

Two
SID
7.

changes

running greyhound: contributing variables.

Appl

Physiol 1992;73(6):2297-2304.
Javaheri S. Corbett

recent papers demonstrate that an approach using a

W, Wagner

K,

Adams JM.

Quantitative cerebro-

gap determination (SID directly measured minus SID

cal-

spinal fluid acid-base balance in acute respiratory alkalosis.

Am

culated from the Stewart equation) performed well, but

Respir Crit Care

Med

1994;l50(l):78-82.

Respiratory Care

January 1999 Vol 44

No

27

Strong Ion Difference and Approach to Acid-Base Analysis

8.

Ohtake

PJ. Jennings

DB.

Ventilation

is

stimulated by small reducJ

16.

Gilfix

BM, Bique M, Magder

S.

physical chemical approach to the


J

tions in arterial pressure in the

awake dog.

Appl Physiol 1992;

analysis of acid-ba.se balance in the clinical setting.

Crit

Care

73(4):1549-1557.
9.

1993;8(4):I87-197.

Alf'aro V, Palacios L.
rats

Acute mild hypothermia


J

in

awake unrestrained

17.

Kellum JA, Kramer DJ, Pinsky MR. Strong


for exploring unexplained anions. J Crit

ion gap: a

methodology

induces a mixed acid-base disorder.

Appl Physiol 1996;80(6):


18.

Care 1995;IO(2):5l-55.
regulation: a

2143-2150.
10.

Kowalchuk JM, Scheuermann BW. Acid-base


ison of quantitative methods.

compar-

Kellum J A, Bellamo R, Kramer DJ, Pinsky MR. Hepatic anion


during acute endotoxemia.
J

flux

Can

Physiol Pharmacol 1994;72(7):

Appl Physiol 1995;78(6):2212-22I7.


19.

818-826.
Siggaard-Andersen O, Fogh-Andersen N. Base excess or buffer
ba.se

Rossing TH. Maffeo N, Fcncl V. Acid-base effects of altering plasma


protein concentration in

human blood

in vitro. J

Appl Physiol 1986;

(strong ion difference) as measure of a non-respiratory acid-base

6l(6):2260-2265.
12.

Figge

J,

Rossing TH. Fend V. The role of serum proteins


J

disturbance. Acta Aneasth Scand SuppI 1995;107:123-128.


in acid-

base equilibria.
13.

Lab Clin Med 1991;1 17(6):453^67.


1986;81(l):86-90.
is

McAuliffc
losis.

JJ,

Lind LJ, Leith DE, Fencl V. Hypoproteinemic alka-

Am J Med

14.

Schlichtig R. Base excess vs strong ion difference: which


useful? In: Nemato.

more
Correspondence: Erik
100/4D-139,
bian

LaManna.

editors.

Oxygen

transport to tissue

XVIII.
15.

New
P.

York: Plenum Press. 1997:91-95.

R Swenson MD,

Associate Professor of Medicine,

Wilkes

Hypoproteinemia, strong ion difference, and acid-base


ill

VA

Pugel Sound Health Care System. 1660 South Colum-

.status in critically

patients. J

Appl Physiol

998;84(5): 1740-1748.

Way,

Seattle

WA

98108. eswenson@u. washington.edu.

28

Respiratory Care January 1999 Vol 44

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,

and Nicolino Ambrosino

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

score with accepted scores of illness severity, nursing

work

load,

and

clinical

outcome.

METHODS: The

study was conducted in a 6-bed adult

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-

spiratory pressure) were recorded.

Mortality rate and days spent in the

The DNS score was determined at admission and at discharge. RIICU were also recorded. The DNS describes the dependence of
commitment, which
staff.
1

patients needing increasing levels of nursing

is

determined by scoring 13 tasks


is

according to the amount of time spent on them by nursing


a

Scoring

done by use of a

scale with

minimum

of

(no dependence) and increasing by

to a

activities for

each task. Total score for the

DNS

ranges from

maximum according to the number of to 45. RESULTS: At admission, the DNS


and

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

score was significantly better correlated with the

NEMS

(r

11 at discharge).

At admission, the

DNS

0.70) than with the

APACHE

II score,

maximal inspiratory pressure, or


with scores for clinical
the dependence level of patients
to
1

the

number of days spent

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

nursing scale, acute respiratory failure,

mechanical

ventilation, respiratory care, tracheotomy,

weaning.

Background

See The Related Editorial on Page 22

&
Up
to to one-fourth
all
-

The Special Article on Page 70


hospital budlittle is

of acute-care hospital costs and close

10% of

health care costs are

consumed

in critical

still

consume an important proportion of a


Despite this well-known
fact,

care units.'

In the U.S., this results in expenditures

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)

known about temporal

trends of patient conditions, patient


in the

outcome, and nursing work load

ICU. Nursing ac-

Drs Clini, Vitacca, and Ambrosino are

affiliated

with Fondazione S

Correspondence

&

Reprints: Enrico Clini

MD.

Fondazione S Maugeri
(BS).
Italy.

Maugeri IRCCS, Respiratory Intermediate Intensive Care Unit. Depart-

IRCCS.

Via

Pinidolo,

23.

1-25064

Gussago

ment of Pneumology, Medical Center of Gussago, Gussago (BS),

Italy.

fsm.g2 @ numerica.it.

Respiratory Care

January 1999 Vol 44

No

29

Assessing Nursing

Work Load

in

a Respiratory Care Intermediate

ICU

tivities

have been widely studied

in the higher-risk

ICUs.

Estimates of nursing work load in the

ICU

include the

Therapeutic Intervention Scoring System (TISS)'' and de-

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

neurologic status, acute

severe worsening of hypercapnia, acute decrease in values

pH (<

7.35), tachypnea, or

abdominal paradox. Con-

ditions

commonly considered as contraindications to NPPV


of
exclusion.'-''

with chronic diseases, such as chronic heart failure and


chronic obstructive pulmonary disease, and iatrogenic side
effects of aggressive care in the
in chronically unstable patients

were

criteria

Success and failure of nonin'

vasive mechanical ventilation and need for endotracheal


intubation were defined according to Brochard et al.
patients
''

ICU setting have resulted who need multidisciplinary


been growing
interest in

Seven

care.

' '

In recent years, there has

(21%) in whom NPPV failed and endotracheal intubation was performed underwent a short period of invasive mechanical ventilation, early extubation (within

the use of intermediate


patients.
'2

ICUs

for the treatment of these

Scores of the patient's severity of illness and nursing

work load
proposed
cation scores

in the first

24-48 h

after

admission have been


care.'
'''^

to predict the

need for aggressive

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

chanical ventilation. In those ICUs, the patients had un-

dergone

at least

2 unsuccessful T-piece

trials.

The time

fulfilling the patient's

elapsed from intubation to tracheotomy ranged from 2 to

dence. Furthermore, the relationship between the patient's

24 days, while the time

to

admission to our RIICU ranged

dependence
less studied.

level

and the nursing commitment for chron-

ically unstable patients in the intermediate

ICUs has been

from 3 to 45 days. In our RIICU, mechanical ventilation was delivered through a tracheotomy maintaining the modalities

To

take into account

all

components of the

of ventilation (usually either pressure support ven-

nursing work load in our respiratory intermediate

ICU

tilation or

continuous positive airway pressure or both)


in the

(RIICU),

we developed a new

scale, the

ing Scale (DNS), to evaluate the level

Dependence Nursof dependence for

performed
tocol

ICUs of provenience. The weaning


failure

pro-

and the definition of success and


et al.'^
trials:

were those
failed the

RIICU

patients.
this study

of

Nava

Of

the 33 patients, 5

(15%)

The aims of
the

were

to evaluate patients' levels

weaning

2 died in the RIICU, and 3 were discharged


ventilation.

of dependence by scoring nursing activities by means of

with invasive

home mechanical

DNS

and

to

compare the

DNS

score with accepted


load,

Group

3 patients

were continuously monitored for

carfail-

scores of illness severity, nursing

work

and

clinical

diac and respiratory functions because an impending

outcome.

ure of their underlying cardiac and/or respiratory disease

required a low-risk intensive care environment.'^

Methods
Patients

Measurements
Clinical conditions were evaluated by use of the

APACHE
One-hundred-eleven patients,
admitted to our

II

score.

'-^

Nursing work load was evaluated by


al.**

who were

consecutively

use of the

NEMS proposed by Reis-Miranda et


(minimum work
arterial

NEMS
oxy-

RIICU between

July 1996 and June 1997,

ranges from

load) to 63. Arterial oxyarterial

were divided

into 3 groups according to the reason for

gen tension,

carbon dioxide tension,

admission: acute respiratory failure requiring noninvasive

gen saturation
gen,

(S^q,),

and

mechanical ventilation (Group

1),

prolonged weaning from


2), or cardiorespi-

an automated analyzer

pH were measured by means of (ABL 500; Radiometer, Copenha-

invasive mechanical ventilation (Group

ratory monitoring for impending failure of the underlying

disease (Group 3).

Demographic and anthropometric


blood gases
at in

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.

clinical characteristics, arterial

admission,

fractional inspired concentration that could maintain S^q,

and chronic diseases of patients are shown


failure

Table

1.

above

92%

independently of the breathing modality (spon-

Cardiac patients included subjects with acute respiratory

taneous or assisted ventilation). The inspiratory muscle


strength

(pulmonary edema or embolism), difficulty

in

wean-

was assessed by measuring maximum

inspiratory

ing from mechanical ventilation after surgery, and decom-

pressure (Pjmax) ^^ 'he level of functional residual capacity,

pensated chronic heart failure.

according to the method of Black and Hyatt '^ and by use

30

Respiratory Care

January 1999 Vol 44 No

Assessing Nursing

Work Load
Admission

in

a Respiratory Care Intermediate

ICU

Table

Characteristics of the Study Population

at

in a

Respiratory Intermediate Intensive Care Unit

Assessing Nursing

Work Load

in

a Respiratory Care Intermediate

ICU

Table

2.

Clinical Severity. Nursing

Work Load,

Level of Dependency, and Outcome

in the

Study Population as Determined by Different Scoring

Methods
Total
(n

Group
(n

Group 2
(1

Group
(n

111)

33)

33)

45)

p (Anova)

APACHE

II*

Assessing Nursing

Work Load

in

a Respiratory Care Intermediate

ICU

Table

3.

Spearman's Correlation Coefficients between Dependence


Nursing Scale (DNS) and Nine Equivalent Manpower
Scale

DNS, may

describe impairment or disability

when

the pa-

tient is in a stable condition.-''

(NEMS)

at

Hospital Admission with Indices of

Patients in our sample

were admitted

to the hospital for

Clinical Severity. Respiratory

Muscle Strength, and Length

of Hospital Stay

monitoring of cardiopulmonary parameters (Group 3) or


for treatment of respiratory insufficiency

(Groups

and 2)
val-

NEMS
DNS
p
0.71

APACHE
0.41

II

MIP
-0.43
p

HS
0.43

complicating an underlying chronic disease. The


ues of the

mean

APACHE

II,

NEMS,

and

DNS

at

admission

<

0.00

< <

0.01

<

0.005

< <

0.005

describe the whole group of patients treated in our RIICU.

NEMS
p

0.44

-0.15

0.33

DNS and NEMS but not APACHE II


in the 3

significantly differed

0.005

NS
MiP = maximal

0.01

groups (see Table

2),

suggesting that similar levels

of clinical severity
APACHE =
pressure:

may

reflect different levels


It

of patient

Acute Ptiysioiogy and Chronic Health Evaluation;


hospital stay;

inspiratory

HS =

NS =

dependence and nursing work load.


in a

has been proposed


that

not signit~icant.

sample of about 1000 patients

NEMS
at

sets a

quantitative analysis of nursing

work load

in a general

ICU,' showing a mean value of 26


tients

admission,

admitted to an RIICU.

Thi.s score

correlates with the global nursing

more significantly work load than do scores


for an imlittle
is

which

is

similar to the value recorded in the total group of

patients cared for in our

RIICU

(28

8). In particular,

the

of patient's clinical severity


In the U.S.

at

admission.

DNS scores and NEMSs were significantly higher in Group


2 patients, confirming that this category of patients necessitates

and Europe, acute care accounts

portant proportion of hospital costs;

however,

higher costs in terms of

human

resources and time.

known about
tient's

the relationship between the acute care pain the in

RIICU

nursing-staff assistance per patient

may

differ

outcome and nursing work load

ICU.'

''

Fur-

according to time spent assisting with mechanical ventilation (either invasive or noninvasive)-** or

thermore, age, improvement of survival


eases, the

chronic disin

because of the

and iatrogenic side effects from aggressive care


setting (sedation, steroids, prolonged stay,

patient's severity of

symptoms, neurologic condition, pharself-care, or ability to

ICU

me-

macologic therapies,
cific function.-"

perform a spe-

chanical ventilation associated pneumonia, infections, poly-

Nursing work load devoted to noninvasive

neuropathies and physical deconditioning, delayed rehabilitation, malnutrition,

mechanical ventilation, a modality specifically performed


in the

acquired immunodeficiency, and

RIICU

(ie,

mask

preparation, education, assistance

an increasing number of surgical techniques) have resulted


in patients

procedures during pauses of noninvasive ventilation) takes

who may

be defined as "chronically unstable"

no more time than standard medical no more than


differ

therapies.-'*

It

requires

and who require multidisciplinary care." Intensive care


units with a
itation

20%

of the

total shift

time and does not


first

from nursing work load within the

48 h of

lower level of nursing assistance and rehabil-

invasive mechanical ventilation.'" At admission, our patients

could lead such patients to a high level of depen-

with acute respiratory failure treated by means of

dence. --

noninvasive mechanical ventilation had


is

DNS

scores sig-

There

increased interest in the use of intermediate

nificantly lower than those for patients needing prolonged

ICUs
the

as an adequate environment for treating patients re-

weaning from mechanical ventilation (see Table


longed invasive mechanical
difficult

2).

Pro-

quiring high levels of nursing assistance.'-'** According to

ventilation (as occurs during

American Thoracic Society guidelines, chronic


most
is

respi-

weaning)

is

associated with a high level of imin

ratory illnesses per se are the


ability.-'

common

cause of dis-

mediate and long-term mortality

chronic obstructive

However, information

lacking about the role of

pulmonary
to

disease.'^ In multiple chronic pathologies, pro-

nursing work load in improving patient disability following a severe exacerbation of chronic disease. In particular,
there
is

longed weaning from mechanical ventilation consumes up

50%

of the total nursing time from 24 to 48 h after

no mention about the association between the kind


the first

patient admission

(computed by measuring minutes of each

of nursing activities and the level of patient dependence.

task activity; authors' unpublished data).

DNS

results for

Our study

is

aimed

at elucidating this

problem by

Group 2

patients confirm a higher necessity for nursing

proposing a score (DNS) as a


define the role
light, the

new means to qualitatively work load in an RllCU. In this of nursing

assistance, thus suggesting the requirement for a higher

nurse-to-patient ratio.

The Group

3 patients

who were
1

ad-

DNS

could add

new

information on the effect of


the patient's

mitted to our

RIICU

for monitoring of cardiopulmonary

specific nursing

work load on
is

dependence

in

parameters had lower

DNS

scores than

Group
fact

and 2

an ICU. This score


to

different

from those commonly used

patients despite a similar level of clinical severity as as-

measure daily living

activities in chronic diseases (eg,

sessed by

APACHE

II

and mortality. This


is

confirms

the Activities of Daily Living

and the Physical Perforthose indexes, unlike the

that the level

of patient dependence

not necessarily re-

mance Test

scales).-'' -* In fact,

lated to the clinical severity or

outcome.

Respiratory Care January 1999 Vol 44

No

33

Assessing Nursing

Work Load

in

a Respiratory Care Intermediate ICU

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;

for C, S, SI, SP,


total

SL
admission and discharge. Letter abbreviations are see the

and

Dependence Nursing Scale scores determined

Appendix

for definitions.

As shown

in

Figure

correlates better with the

1, the DNS score at admission NEMS than with the APACHE II

tance. '' Furthermore, the evaluation of P]n,ax has

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

going mechanical ventilation for various causes both in a


medical ICU'-* and an RIICU. '^

admitted to an

RIICU

(ie,

patients

patients admitted to a general

who differ from "acute" ICU and evaluated by


II

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).

score did not differ

DNS

tasks (except tracheotomy care)


patients'

showed a
stays

the 3 groups, including those admitted only for

significant

improvement during the

RIICU

monitoring purposes (see Table


the information

DNS

seems

to increase

(see Figure 2).

from

NEMS;

however,

NEMS

takes into

account only 3 of the 13 dependence items described by

DNS

that are typical of chronically unstable patients

who
Study Limitations

have a high need for multidisciplinary care. In the study


population, the length of hospital stay correlated better

with the

DNS

score than the

APACHE

II

score; however,

DNS

correlates poorly with Pj^.^^ at admission, thus con-

In this study with a small sample size,

DNS

was comits

firming the different significance of

DNS

and parameters

pared with

NEMS

only.^

comparison with other acderivais

evaluating a patient's respiratory condition on admission.


In chronic obstructive pulmonary disease patients, inspiratory muscle strength
is

cepted work load scales, such as TISS-^ and


tives,*''

would have been expected. However,

NEMS

considered an index of the ability

derived from the TISS 28.*

NEMS has also been validated


at the

of the respiratory system to handle the mechanical load:''


a reduced inspiratory muscle strength

with the TISS 28 and indicated for multicentric use in

may be
due
to

associated

ICUs, for evaluation and comparison of work loads

with a fatigued breathing pattern in humans.-'^ Moreover,


patients needing mechanical ventilation

same

level,

and for prediction and planning of nursing

an exacer-

staff allocation at the individual patient level.'*"'

bation of their disease

may have lower

levels of Pj^ax ^t

We

did not do a formal study of

DNS

reliability.

Nev-

admission than patients not needing mechanical assis-

ertheless, the scale

had been defined on the basis of op-

34

Respiratory Care

January 1999 Vol 44

No

Assessing Nursing

Work Load

in

a Respiratory Care Intermediate

ICU

Fig. 3.

Frequency distribution of

partial

and

total

Dependence Nursing Scale scores determined


Appendix
for definitions,

at

admission (white bars) and


all

at

discharge

(black bars). Letter abbreviations are tasks; see the


of

<

0.001 between times for

items except C, TC, SP.

No

obs = number

of observations.

erator consen.sus; therefore,


rely

we

are confident that

we can

Conclusion

on

it.

Ail patients admitted to our

period were included in the study.

RIICU during the study The 3 groups of patients

In conclusion, this preliminary study


tients admitted to an

shows

that in pa-

RIICU

for different reasons,

DNS can

represent the pathology/indications for admission to our

describe different levels of patient


reflects nursing clinical illness

dependence and better


the severity of the

RIICU. Therefore, we cannot draw any conclusion about


the generalized u,se of

work load than does

DNS

in patients

with other indica-

and inspiratory muscle function. The


admission
in

DNS

tions for hospitalization.

score should be determined at

order to pre-

Respiratory Care

January 1999 Vol 44 No

35

Assessing Nursing

Work Load

in

a Respiratory Care Intermediate

ICU

diet the nursing woric load.

To confirm our

data, multi-

with respiratory failure due to chronic obstructive pulmonary disease: a randomized, controlled
trial.

centric validation studies

on larger samples should be en17.

Ann

Intern

Med

1998:128(9):

couraged.

721-728.

Nava
et al.

S,

Rubini

F, Zanotti E,

Ambrosino N, Bruschi C, Vitacca M,


in

ACKNOWLEDGMENTS
We
thank the respiratory nursing staff
at

Survival and prediction of successful ventilator weaning


patients requiring mechanical ventilation for

COPD
namely Mirella
Baratti, Tiziana
18.

more than 21

our

in.stitution,

days. Eur Respir J 1994;7(9):1645-I652.

Piacentini, Giuliano Assoni, Sabrina Baccanelli,

Doriana

Zimmerman

JE,

Wagner DP, Knaus WA, Williams

JF. Kolakow.ski

Cola. Lucia Marchina, Emanuele Mottinelli, Pierangela Picotti, Miriam


Pintossi, Luigia Popolo.

D, Draper EA. The use of risk predictions to identify candidates for


intermediate care units. Implications for intensive care utilization

and Simonetta Stefanini.


19.

and

cost.

Chest 1995;108(2):490-499.

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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

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Am Geriatr Soc
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27. Rozzini R, Frisoni
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Italian Multicenter

Group of ICU Research (GIRTl). Time Oriented


for

GB,

Bianchetti A, Zanetti O, Trabucchi

Score System (TOSS): a method for direct and quantitative assess-

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Am

Geriatr Soc 1993;

Reis-Miranda D, Moreno R, lapichino G. Nine equivalents of nursing

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Reis-Miranda D. The therapeutic intervention scoring system: one


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Meharg

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Cece RD,
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Intensive Care

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S, Evangelisti F.

Rampulla C, Campagnoni ML, Fracchia C,

725-738.
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Rubini

Human

and financial costs of noninvasive mechanical

Elpern EH, Silver

MR, Rosen RL, Bone RC. The

noninvasive re-

ventilation in patients affected by


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COPD

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spiratory care unit: pattern of use

and financial implications. Chest

Chest I997;II1(6):163I-I638.

I991;99(l):205-208.
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31. Begin P, Grassino A. Inspiratory muscle dysfunction

and chronic

Knaus

WA,

Draper EA, Wagner DP, Zimmerman JE.

APACHE
Med

II:

hypercapnia

in

chronic obstructive pulmonary di.sease.

Am

Rev ReJ

a severity of disease classification system. Crit Care

1985;

spir Dis 1991:143(5 pt 1):905-9I2.

l3(IO):818-829.
14.

32. Rou.s.sos
ventilation in acute respira-

CS, Macklem PT. Diaphragmatic fatigue

in

man.

AppI

Ambrosino N. Noninvasive mechanical


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Physiol 1977:43(7): 189-197.


33. Vitacca

Eur Respir
J.

1996;9(4):795-807.
F, Conti

M,

Clini E, Porta R, Foglio K,

Ambrosino N. Acute exac-

15.

Brochard L, Mancebo
al.

Wysocki M, Lofaso

G, Rauss A,

et

erbations in patients with


ventilation.

COPD:

predictors of need for mechanical

Noninvasive ventilation for acute exacerbations of chronic ob-

Eur Respir

1996:9(7): I487-I493.

structive
16.

pulmonary disease.

Engl

Med

1995;333(13):817-822.
et

34.

Yang KL, Tobin MJ.


outcome of
J
trials

prospective study of indexes predicting the

Nava
al.

S,

Ambrosino N,

Clini E, Prato

M, Orlando G, Vitacca M,
in the

of weaning from mechanical ventilation.

Engl

Noninvasive mechanical ventilation

weaning of patients

Med

199I;324(2I):I445-1450.

36

Respiratory Care January 1999 Vol 44

No

Assessing Nursing

Work Load

in

a Respiratory Care Intermediate ICU

APPENDIX

Dependence Nursing Scale

Performance of Large- Volume versus Small- Volume Holding Chambers with Chlorofluorocarbon-Albuterol and Hydrofluoroalkane- Albuterol Sulfate
Jolyon P Mitchell

PhD C Chem, Mark

W Nagel H BSc, and Joseph L Rau PhD RRT

BACKGROUND:The

recent development of non-chlorofluorocarbon propellant formulations for

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-

tered dose inhalers.

Background
Pressurized metered-dose inhalers (pMDIs), which were

the delivery of inhaled aerosolized medications.' Previously,

pMDIs have

utilized chlorofluorocarbon

(CFC) prode-

pellants for the generation of aerosol drug particles. In

introduced

in the late

950s, offer a convenient method for

1987, the United Nations Environmental

Programme

veloped the Montreal Protocol on Substances that Deplete


the
Jolyon P Mitchell

Ozone Layer, which

initially called for a

50%

reduc-

tion in

CFC

production, which was

to be followed by an

PhD C Chem and Mark


affiliated

W Nagel H BSc are affiliated

eventual ban by 1996.


facturers have been

As

a result, pharmaceutical

manu-

with Trudell Medical International, London, Ontario, Canada, and Joseph

L Rau PhD RRT

forced to seek alternatives to

CFC-

is

with Cardiopulmonary Care Sciences, Geor-

gia State University, Atlanta, Georgia.

Supported by Trudell Medical International.

See The Related Editorial on Page 24


Director, Medical

Correspondence

&

Reprints: Jolyon

P Mitchell PhD.

Aerosol Laboratory, Trudell Medical International, 725 Third Street, London, Ontario, Canada,

NSV

5G4. jmilchell@lrudellmed.com.
li.sted

based propellants for use

in

pMDIs. Hydrofluoroalkanes

*Suppliers of commercial products are


section at the end of the text.

in

the Product Sources

(HFAs) share many of

the attractive properties of

CFCs

without the propensity for damaging the atmospheric ozone

38

Respiratory Care

January

999 Vol 44

No

Effects of

MDI

Propellant on Holding Chamber Performance

pMDI

(Airomir''^

<c

Airomir^^

Volumatic

28.3
Fig. 1
.

0.5

L/min
metered-dose Inhalers (pMDI) alone or with either Aero-

Equipment configuration

for testing of pressurized

Chamber

or Volumatic holding chambers.

layer.

albuterol sulfate, incorporates the

A new formulation of the adrenergic bronchodilator, HFA propellant 134a


first

Methods
Large-volume holding chambers were represented by
the

and was

released outside the U.S. as Airomir* in 1995

and subsequently as Proventil


Kenilworth, NJ).
It

HFA (Key
CFC

Pharmaceuticals,

Volumatic HC, and small-volume devices were repre-

sented by the

AeroChamber HC.

has been well established with

formulations that

Both AeroChamber and Volumatic


to

HCs were washed

in

larger-volume holding chambers (HCs; eg, those with a

mild detergent and allowed to dry naturally prior to testing

700- to 1000-mL capacity) deliver significantly more drug


than smaller-volume HCs.^"* However, preliminary

minimize interference from

electrostatic effects.**

Each

work

device was then connected in turn to the United States

by us

and Barry and O'Callaghan* suggest


to

that the

change

Pharmacopeia induction port


pactor operated at 28.3

(throat) of the cascade im-

from

CFC

HFA

propellants

may

decrease the impor-

0.5

L/min

(Fig.

1).

rubber

tance of

HC

volume on dose

delivery.

The purpose of this

coupling piece was used between the


induction port to ensure a leak-tight
fit.

HC

and impactor

study was to investigate the performance of 2 representative large-

Prior to testing the

and small-volume

HCs

with CFC-formulated
sulfate

device with drug,

we measured

the flow through the im-

albuterol (Ventolin)

and HFA-formulated albuterol

pactor by coupling a calibrated Timeter

RT200

reference
actuator.

flow meter to the chamber

in place

of the

pMDI

(Airomir), both of which deliver a nominal unit dose of 90


jLig

One measurement was made

using each of 3

HCs
test,

of

albuterol

from the mouthpiece of the manufacturer's


to study the influence

each type with Ventolin, actuating the


doses were dispensed

pMDI

canister 3

actuator.

Our objective was

of cham-

times to waste immediately before use. In each


at

ber capacity on both total dose and fine-particle dose. In


this study, fine particles

30-s intervals into the

HC, with
canister

have been defined as having an

the impactor operating continuously.

The pMDl

aerodynamic diameter of

<

4.7 jitm (based on the cut point

was
all
it

left in

place for at least 20

s after

actuation to permit

of the impactor stage closest to the 5-ju-m aerodynamic

of the drug to reach the device and impactor, and then

diameter limit associated with improved penetration be-

yond

the upper respiratory

tract).''

was shaken and reinserted into the manufacturer's actuator. The HC was then removed from the impactor, and

Respiratory Care January 1999 Vol 44

No

39

Effects of

MDI

Propellant on Holding Chamber Performance

100
1

(D

N
80

CO
TJ

S (0
0)

c
CD

60
a>

40
(0

0)

>
20

Effects of

MDI

Propellant on Holding Chamber Performance

100
(D

N
80

CO

o B
TO

W
c
CD

^
(/> (/>

60

Q)

40
CD

0)

_>
TO

20

Effects of

MDI

Propellant on Holding Chamber Performance

vitro studies

by Dolovich'^ with a CFC-formulated placebo


total unit dose. In

results

were much closer

to those obtained in the present

containing fluorescent particles to be an important influ-

study with the Volumatic


tolin;

HC

(63.8

2.3

ju,g

with Ven-

ence on both fine-particle and


vich's study, the

Dolo-

67.9

2.5

;u.g

with Airomir), which had been pre-

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

minimize the influence of

electrostatic charge in accoret


al.**

dance with the recommendations of Wildhaber


In another in vitro study,

Wildhaber

et al'"

examined

to

5-^im aerodynamic diameter) continued to increase

to-

HFA-albuterol delivery

in pediatric ventilator circuits, in-

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

cluding the AeroChamber-M V and the Nebuhaler HC.

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

aerodynamic diameter) drug output

when

tested with

CFC-formulated sodium cromoglycate,

inal unit

dose from the pMDI. With the elimination of

but significant increases in available drug were also evi-

electrostatic charge, the

AeroChamber-MV and

the larger

dent with increasing spacer volume beyond 500

mL. The

Nebuhaler delivered

63%

and 72%, respectively, of the

present study therefore focused on the behavior of 2


that represent small-capacity (145

HCs

dose as particles finer than 6.8-^im aerodynamic diameter.

mL) and

large-capacity

These data are


Airomir

(750
or

mL) devices

with albuterol delivered with either


It is

HFA

CFC

as propellant.

likely that the exact relationship

between

HC or spacer volume and drug output depends on


that results in a particular

the precise formulation (eg, propellant type, metered vol-

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

ume, drug and excipient content)


aerosol

4.7 /Lim aerodynamic diameter). Therefore, both studies

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

support the conclusion that increases in chamber volume

between 140 and 750

mL have little if any impact on the


from these
albuterol.

mass of
devices
In

albuterol delivered as fine particles

HC

or spacer.

when using HFA-formulated


is

In vitro studies characterizing aerosol delivery with

what

probably the closest comparison with the

pMDIs
appear

formulated using
in the literature.

HFA propellants are beginning to


produced from the CFCa higher velocity from the

present study, Schulz et al" compared, using (as

we

did)

Barry and O'Callaghan^' and others

an Andersen cascade impactor, the in vitro delivery of

have observed

that the aerosol


at

formulated Ventolin emerges

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

manufacturer's actuator mouthpiece than does that from

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

were, in most cases, comparable with those found

present study. For example, their fine-particle doses for


the small-volume

ms and 60 ms

and 64.5
of 45.4
for the

pMDI

discharge. In addition, the analysis revealed

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

reported fine-particle doses of 72.3


terol)

2.2 /ng (CFC-albu-

and 77.7

2.7 ixg (HFA-albuterol),

which are

slightly

Barry and O'Callaghan* also compared the delivery of


Ventolin and Airomir via AeroChamber with that from a

greater than the doses obtained with the Volumatic


the present study (63.8
2.5
jU,g

HC

in

2.3 pig for Ventolin

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

for Airomir). Nevertheless, both investigations

show

that the difference in

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

reasonable to speculate that


the

if

from 24.6

jug (Ventolin) to 42.

(Airomir): These doses were

much lower than the equiv-

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

alent values obtained in the present study with the Volu-

matic HC, which had a similar capacity (750 mL).


ever,

Howwas

when

the influence of electrostatic charge

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

the Nebuhaler, the fine-particle dose in/x.g

(Ventolin) and 74.8

/Lig

(Airomir). These

plume velocity and smaller

42

Respiratory Care January 1999 Vol 44

No

Effects of

MDI

Propellant on Holding Chamber Performance

volume occupied by

the aerosol

from the

HFA formulation
In the larger

dose-response relationship to HFA-formulated albuterol

would

be expected to result in reduced particle-wall inter-

when

inhaled with a small-volume

HC.

actions within the smaller-volume


the walls are further

HC.

HC.
Conclusions

from the axis of plume generation and

therefore less involved with the inertial deposition process.

The

safety of inhaled

HFA- 134a

propellant on a shortet al.'-

term basis has been demonstrated by Donnell


subjects to cumulative doses of
tions of either

They

Preliminary investigation of HFA-formulated albuterol


sulfate delivery

investigated the acute patient response in 12 healthy male


1,

by a large- and small-volume

HC

using

2, 4, 8,

and 16 inhala-

cascade impaction testing of particle sizes revealed that


both

34a propellant without drug and CFCpropelled albuterol (salbutamol). Their study found no dif-

HP A-

HCs

almost eliminate particles larger than 4.7-iam


fine-particle unit doses

aerodynamic diameter. Total and

ferences

in

(heart rate

pulmonary function, cardiovascular performance and blood pressure), tremor, or serum potassium

were increased for both

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

formulation. In addition, there was no significant differ-

on patient response and

the safety profile for

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

The equivalence of bronchodilator effects between HFAformulated albuterol and the

dose compared with the larger HC.

CFC

formulation has also

been established

in

preliminary studies. For instance,


the bioequivalence of

Nogami-Itoh

et al'^

compared

HFAanes-

PRODUCT SOURCES

formulated albuterol with the

CFC

formulation for the


in the

prevention of histamine-induced bronchospasm


thetized dog.

Holding Chambers (HCs):

They concluded

that both formulations pro-

AeroChamber valved

HC

with

FLOWSIGnal, Mon-

vided equivalent dose-related inhibitory effects. In another


study with 20 asthmatic subjects with exercise-induced

aghan Medical Corp., Pittsburgh

NY

Volumatic HC, Allen

& Hanburys Ltd., Stockley Park

bronchospasm, Dockhorn
in

et al'-*
1

found equivalent changes


s

UK
Drugs:
Ventolin, GlaxoWellcome (Canada)
Inc.,

forced expiratory volume

after exercise challenge

with either Proventil-HFA or Ventolin. Side effects, which

Mississauga

were monitored through changes


sure,

in heart rate,

blood pressimilar.

Ontario Canada

and electrocardiographic
et al'^

QT

intervals,

were
1

Airomir,

3M

HealthCare, Loughborough

UK

Kleerup

found

that

HFA- 134a and CFC-

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:

Model RT200. Timeter Instrument Corp,

Louis

MO

Drug Assay:
Star HPLC System, Varian Associates Inc,

Walnut Creek

The improved

delivery seen with the typical small-vol-

ume

HC

(represented by

AeroChamber

HC

in

both our

CA
Statistical Software:

study and that of Schulz et al")


clinical

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

samples of AeroChamber that were


increase in

REFERENCES
Riker Laboratories Inc. Self-propelling, powder-dispensing compositions.
2.

we found an average

representing a

37%

increase in dose

mass of 6.6 compared with


1

/u,g,

that

from CFC-formulated
to

albuterol. If in fact the dose-response


is

HFA-formulated albuterol

equivalent to that for the

Barry

US Patent 837465. 1960. PW, O'Callaghan C. The optimum


J

size

and shape of spacer


l99.'>;8(3):.3()3-30.').
I.

devices for inhalational therapy.


3.

Aerosol

Med

CFC
ment

formulation, as indicated in the preliminary stud-

Moren

F.

Drug deposition of pressurized


J

inhalation aerosols.

In-

ies,'^''' this increase

may
is

allow for fewer doses per treat4.

fluence of actuator tube design. Int

Pharni 1978; 1:20.5-2 12.

in either acute or

maintenance conditions. Further


therefore needed
to quantify the

Corr D. Dolovich M. McCormack R. Ruffin R. Obminski G. Newhouse M. Design and characteristics of


a portable breath actuated.

clinical investigation

Respiratory Care

January 1999 Vol 44 No

43

Effects of

MDI

Propellant on Holding Chamber Performance

particle size selective medical aerosol inhaler.


13(1): 1-7.
5.

Aerosol Sci 1982;

Schulz D, Carlson S, Ross D.

In vitro

pertbrmance characteristics of

two CFC-free metered dose

inhalers

(MDIs) with

large

and small BP, Coper

Rau

JL. Mitchell JP, Nagel

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.

Donnell D, Harrison LI,

Ward

NM, Ekholm
J

KM,
amount of
13.

et al.

Acute safety of the CFC-free propellant HFA-I34a from

Barry

PW. O'Callaghan

C. In vitro comparison of the

a pressurized metered dose inhaler.

Eur

Clin Pharmacol

1995;

salbutamol available for inhalation from different formulations used


with different spacer devices. Eur Respir
7.
J

48(6):473^77.
Nogami-Itoh M, Yakuo
I,

1997;I0(6):1345-I348.
retention,

Hamnierbeck

DM,
1

Miller RL,

Takeyama

Lippmann M. Ycates DB, Albert RE. Deposition,


clearance of inhaled particles (review). Br J Ind

and

K. The equivalent bronchodilator effects of .salbutamol formulated in

Med

I980;37(4):

chlorofluorocarbon and hydrotluoroalkane- 34a metered dose inhalers

337-362.
8.

on the histamine-induced pulmonary response

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

charge on a plastic spacer device influences

Dockhom

RJ,

Wagner DE, Burgess GL, Hafner KB, Letoumeau

the delivery of salbutamol.

Eur Respir

I996;9(9):1943-I946.

Colice GL. Klinger

NM.

Proventil

HFA

provides protection from

Dolovich

MB. Lung

dose, distribution, and clinical response to ther-

exerci.se-induced bronchoconstriction comparable to Proventil and

apeutic aerosols. Aerosol Sci Technol 1993;18:230-240.


10.

Ventolin.
1.5.

Ann

Allergy

Asthma Immunol l997;79(l):85-88.


propellant

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

34a salbutamol sulfate


1

an

in vitro study.

Chest

metered-dose inhaler

in patients

with asthma. Chest

996; 109(3);

1998;113(1):I86-191.

702-707.

44

Respiratory Care January 1999 Vol 44

No

Reviews, Overviews,

&

Updates

Stewart's Strong Ion Difference Approach to Acid-Base Analysis


Joseph Morfei

MS RRT

Background
History
Alkali Reserve

Whole Blood Buffer Base


Standard Bicarbonate

The Great Trans-Atlantic Acid-Base Debate


Base Excess Standard Base Excess

Anion Gap
Stewart's Approach

Application of Stewart's Approach


Nonvolatile

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-

generally acknowledged to be controlled


is

been

by the kidney and


ventional

traditionally quantified through the

terms of the balance between the respiratory

plasma bicarbonate ion concentration [HCO3 " ]p. This con-

and nonrespiratory (metabolic) systems. The term "acidbase balance" refers to the maintenance of the free hydro-

method of expressing

the influence of the respiis

ratory and metabolic systems

on [H^]

expressed through

gen ion concentration


concentration
is is

in the

body. The free hydrogen ion


in

the Henderson-Hasselbalch equation

(ie,
is

pH = pK

-I-

log

normally expressed

terms of pH, which

[HCO3

]/[C02(d)]).'-'

The equation

derived from the

equal to the negative log of the hydrogen ion concen-

dissociation equilibrium for carbonic acid.

However, an

tration (ie,
to

pH = log

[H"^]).

The

respiratory system helps

examination of the hydrolysis reaction shows that there are

normalize the free hydrogen ion concentration by reg-

some problems with using


pH. In order for [HC03~]

the Henderson-Hasselbalch

ulating dissolved carbon dioxide


affects free

(COt
-I-

[d]),

which

in turn

equation to express the effects of

hydrogen ion through the hydrolysis reaction:


H"^.

to influence

CO2 and bicarbonate on pH as expressed in


it

C02(d)

-f-

HjO^HjCOj^ HC03^

the Henderson-Hasselbalch equation,

would have

to vary

independently of [COj ].The hydrolysis reaction clearly


"states,"

however,

that

[CO2] and [HCO3


fact,

do not vary

See The Related Editorial on Page 26

independently of each other. In


]

both [H"^] and

[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

with the Department of Cardiorespiratory

to expressing

changes

in the

metabolic component of acid-

Sciences, State University of


cuse,

New York

Health Science Center, Syra-

base balance and the effect that those changes have on pH.

New

York.

Standard bicarbonate concentration, buffer base, and base


excess have
all

Correspondence: Joseph Morfei, Department of Cardiorespiratory Sciences, Silverman Hall,


Street,

been professed

to

be the most accurate

SUNY

Health Science Center, 750 East

Adams

expression of this acid-base component. Stewart's "equation,"

Syracuse

NY

13210. morfeij@vax.cs.hscsyr.edu.

however, shows that none of the traditional meta-

Respiratory Care

January 1999 Vol 44

No

45

Strong Ion Difference

in

Acid-Base Balance

bolic indices have any effect

on body pH. This paper is a review of the various forms of expressing the metabohc

[HCO3
the

dard bicarbonate

component of acid-base balance and

the independent vari-

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

ables in Stewart's approach as an alternative

mechanism

therefore does not take into account any in vivo increase in

for predicting the cause and correction for metabolic acid-

bicarbonate ion that has resulted from a hypercarbia by

base disturbances.

way of
History
Thus,
in

the hydrolysis reaction

and

that has

moved
is

into

interstitial fluid in

response to a concentration gradient.

cases of hypercarbia,
it

when

the P^o,

corrected

In 1916,

Hasselbalch

made

the first blood

pH

measurethat

to

40

mm Hg in vitro,

will result in a false


is

low [HCO3"]

ments (with a hydrogen electrode) and suggested


blood pH.

met-

because the bicarbonate

unable to re-equilibrate from

abolic acid-base disturbances be identified as the "reduced"

the interstitial fluid to the in vitro plasma.


In 1960,

He

also suggested that this

measurement be

Astrup

et

aP showed

that

because the carbon

made

after partial pressure to

of carbon dioxide (Pco,) had

dioxide-bicarbonate system only accounts for

~75%
a

of

been adjusted

40

mm

Hg.''

the buffering against fixed acids or bases, a correction factor should be used that

would then produce

more

Alkali Reserve

accurate measure of what he referred to as "base excess"


or deficit. In order to express the base excess, he proposed

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

multiplying the deviation of the standard bicarbonate from


the

mean by

1.2.

Astrup** believed that the use of the

quantity base excess


it

was preferable
acid).'

to buffer base
it

because

was more
In I960,

easily understood (ie,

expressed in

mEq/L

the surplus

amount of fixed

Siggaard-Anderson and Engel'" reported on an


that they

HCO3"
He

(which he referred to as

BHCO3)

at

pH

of 7.4.

acid-base

nomogram

had developed through a

also introduced the term "alkali reserve" to refer to

series of titrations

on normal blood. The blood was equil-

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

hemoglobin concentrations with the

point of intersection at a

pH

of 7.4 and a P^o, of 40


this point

mm

Hg

being labeled zero. Deviations from

were

Whole Blood Buffer Base


"In 1948, Singer and Hastings* introduced the concept

identified as base excess. This

nomogram

eliminated the

need

to

apply the correction factor that had previously

been proposed by Astrup. Siggaard-Anderson and Engel


of whole blood buffer base as a parameter for the measurement of metabolic disturbances of acid-base equilibrium. This term was defined by the authors as the
the concentrations of buffer anions (in
in

had also included a buffer base curve on


that illustrated the
lines with

their

nomogram

changing slopes of the equilibration


to either

sum of

changes

hemoglobin concentration or

mEq/L) contained

base excess, but they proposed that base excess be used as


the index of metabolic acid-base balance.'"
In 1963,

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

(plasma) have been


Pco,-" (Note, in the
stands for base ex-

of such buffer anions in normal blood, as


titration

observed during primary changes


previous and following quotation,
cess.)

determined by

of whole blood with strong acid,


all

is

BE

about 45 to 50 mEq/L; nearly

this buffer capacity is

He

further stated, as had several previous authors

contributed by hemoglobin and bicarbonate."'

(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

(plasma) as indicators of nonrespiratory acid-base

disturbances and probably the choice will depend on the

The term standard bicarbonate was


1957 by Jorgensen and
Astrup.**
It

first

introduced

in

easiest available analytical


fact that

method."" This referred


and

to the

represents the bicarin fully

HCO3"

diffuses into interstitial fluid in response


that

bonate concentration of the plasma

oxygenated

to a concentration gradient

[HC03~]

is

affected

blood that has been equilibrated to a

P(-o,

of 40

mm Hg.

It

by Pco, through the hydrolysis


sample
a false
after this diffusion

reaction. Therefore, in con-

was

their feeling that standard bicarbonate

was

the best

ditions of hypercarbia, the withdrawal of an arterial blood

indicator of nonrespiratory acid-base disturbances because

had taken place would

result in

by adjusting the Pco,

to

40

mm

Hg,

its

influence on

low base excess reading.

46

Respiratory Care January 1999 Vol 44

No

Strong Ion Difference

in

Acid-Base Balance

The Great Trans-Atlantic Acid-Base Debate


Base Excess
In 1963,

Standard Base Excess

Schwartz and Relman^ took issue with the use

of base excess and base deficit as descriptors for metabolic


complications to acid-base balance. They believed that

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

the value of the buffer base after

P^o
is

had been restored


value
is

40

mm Hg.

This in vivo base excess

magnitude of the base excess or


his use

deficit

does not always

now

referred to as "standard base excess" and

predict the severity of the acid-base condition.

representative of the equilibration of the extracellular fluid

The work of Astrup and

of the base excess as the

compartments with COj.^"^^

measure of metabolic acid-base disturbance became a topic


of international discussion and was labeled as "The Great
Trans- Atlantic Acid-Base Debate" by the editors of Anesthesiology''* (the debate referred to articles published in

It is a calculated value and assumes a 5 g percentage hemoglobin concentration to

allow for the decreased protein concentration


lular fluid.

in extracel-

of Medicine, "> and involved the work of Siggaard-Anderson et al'^


the Lancet'^
in Copenhagen and the work of Schwartz and Relman^ from Boston). The "Boston school" (Schwartz and Rel-

and the

New England Journal

Anion Gap

Neither
icit

[HCO3

by

itself,

nor base excess or base defall

man) objected
".
.

to the use

of the term base excess because


in the

by themselves can indicate

the possible causes of

blood

in

vivo does not behave

blood

in vitro."'"

same manner as As was previously mentioned, this was


of hypercarbia, the bicarbonate
in the

nonrespiratory acid-base disturbances.


tification process,

To

aid in this iden-

due

to the fact that in cases


is

ion that
into the
fluid.

produced
editorial

red blood cells not only diffuses


into the surrounding interstitial
to say that "First, clearly, the
in

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
.

plasma but also

electroneutrality

(ie,

the total anion concentration in the


total cation concentration. If the total
is

The

went on

body

is

equal to the

titration

curve for bicarbonate and P^o,

vivo differs

anion concentration

taken to be comprised of [Cl~]

-I-

from

that obtained in vitro. Secondly,

any calculation of

[HCO3

4-

other unmeasured anions, then using the re-

metabolic parameters based upon in vitro titrations does


not apply to the in vivo situation. Buffer base, standard bicarbonate, and base excess accordingly have no quantitative validity."'''

lationship expressed by

Emmet and
which
is

Narins allows one to


representative of the

calculate the anion gap,

concentration of fixed acids in the blood.


the anion

An

increase in
in the

gap

is

an indication of an increase

con-

In 1976, Severinghaus'**

proposed a "detente" between

centration of fixed acids in the blood and a metabolic


acidosis. Furthermore,

the Boston and a 3 g

Copenhagen schools of thought by adding


line to the
1).'''

hemoglobin
(Fig.

Siggaard-Anderson alignment

CP
if
(ie,

by monitoring whether HCO3" and have increased or decreased allows one to determine

nomogram
in

Although Siggaard-Anderson had

the acidosis

already proposed using 5 g hemoglobin as a buffer line for

a loss of base

was due to a gain of acid or a loss of base would be electrically balanced by a gain
fol-

vivo extracellular fluid base excess, Severinghaus

felt

of chloride with a normal anion gap [a hyperchloremic metabolic acidosis], whereas a gain of acid would be

that the use

of 3 g hemoglobin would better accommodate


better at the
adults. This

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

the gained acid and a high anion


It

gap due

to the gain

of

corrected for the fact that as P(;q^ rose acutely in vivo, the

has been shown, however, that the anion gap

bicarbonate that was generated through the hydrolysis reaction diffused into the interstitial fluid.
size of the interstitial

influenced by the concentration of plasma proteins,


is

Depending on

the

namely albumin, and therefore

not always an accurate

compartment, only one-third

to oneto
in

indicator of the magnitude of change in the metabolic

fourth of the

be measured

newly formed bicarbonate would remain in whole blood. "The buffering of COj
its

component of acid-base balance. ^''-^'^

vivo was like that of blood diluted by

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

This allowed one to estimate the extracellular fluid base


excess as a true indicator of the metabolic component of
acid-base balance without interference from acute changes
in Pf^o

base disturbances, they are based on approximations and


simplifications.

They do not allow


ill

for the incorporation or

consideration of other physiologic data that

may be

useful

when

dealing with critically

patients.^*

Respiratory Care

January 1999 Vol 44 No

47

Strong Ion Difference

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

Strong Ion Difference

in

Acid-Base Balance

Stewart's Approach

weak

acids, [AjotI-

and Pco,. The [SID]

is

the difference

between the sum of the concentrations of


in

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

and the sum of


[K^]

all

[Ca^']

strong anions. That is, -f[Mg + ']) - ([Cr]


total

SID = ([Na^]

[other strong
all

art.27-28

anions]).-"

[Ajot] represents the

concentrations of

ance

one

that

makes

a distinction

between

the nonvolatile
tion being

weak

acids present in the particular soluIn

independent variables (Pco,- net strong ion charge [SID],

examined.

and

weak acid [A-^qj]) and dependent variables ([HCO/ ], [HA] (weak acid), [A~] (anion), [CO,""],
total

inorganic phosphate, [Pjtot]

plasma, [AjotI = [PO4' ]

'^

composed of
]

[H2FO4I +

[H3PO4]; serum proteins

+ [HPO4([PrTox] = [Pr~
its

-t-

[0H~], and [H^]).

In vivo, the

independent variables can

[HPr]); and albumin."

CO2

is

produced through normal


resultant partial

be changed independently of the others, whereas none of


the dependent variables can be

metabolism via the Krebs cycle and


pressure, Pco,'s

changed primarily or
that Stewart

in-

determined by Dalton's law.

dependently. Most significant


the

is

showed
is

that

hydrogen ion concentration can only be affected by


".
. .

Application of Stewart's Approach


Since Pco,' [SID], and [Ajqj] are the only variables can alter pH, then it follows that a reexamination of

independent variables. Therefore.

since [H^]

a de-

pendent variable,

movements

into or out of a solution

do not provide quantitative explanations


[H"^].

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

treat acid-base disorders is

appropriate. Little time will be spent discussing primary


respiratory disturbances since the effect of Pcq,
clearly understood

mine the value of [H^], and by themselves cannot explain


in
it."-'*

on

pH

is

This relationship has subsequently been

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:

Stewart proposed that changes

COt + HjO*-^ HjCO,'^

several interacting mechanisms. Specifically, through a series

HCO,"

4-

H"^. Conditions of hypocarbia will result in a

of complex calculations, Stewart determined that the


all

decrease in [H^] and a primary respiratory alkalosis,

behavior of [H^] and

other dependent variables


is,

is

de-

whereas conditions of hypercarbia


crease in

will

result

in

an

in-

termined by 6 equations. That

[H^] must obey

all

H^

and a primary respiratory acidosis. Both

equations simultaneously as follows:


1.

[Ajoj] and [SID] are independent variables and thus cannot be adjusted by Pco,-

Water dissociation equilibrium: [H^| X [OH^] =

2.

KwWeak acid dissociation Ka X [HA|:

According
equilibrium: [H^]

to Stewart, the nonrespiratory or

metabolic

X [A^] =
[A
]

acid-base disturbances result from deviations of [SID] (the


strong ion difference) or [AjotI (nonvolatile

3.

Conservation of mass for "A": [HA]

-I-

=
X

concentration), not from changes in

4.

[AtotIBicarbonate ion formation equilibrium: [H^J

normal protein

state, the

SID

is
it

weak acid Assuming a ]. normally around 40 mEq/L,

[HCO3

and the difference between


the base excess:

and the measured [SID]

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]
]

excess and ([Na""]


40. For example,

+ [K + ])-[Cr] =
the
8,

4)

-104 =
if

measured [SID] were 48 mEq/L,


(48

then the base excess would be

40),

and

the

Stewart, using a computer, solved these 6 equations

measured [SID] were 35 mEq/L, then would be - 5 (35 - 40).

the base excess

simultaneously, ending up with 4th-order polynomials


the dependent variables,

in

The value of [SID], and

therefore [H"^], can be changed


first
is

showing
system

that
is its

".

each of the

by 2 general mechanisms. The

by changing the
in

dependent variables
tion of,

in this

own
all

specific func-

water concentration of the compartment

which SID
in

is

and

is

uniquely determined by,


."^s
. .

three indepen-

being measured. This can be accomplished with any solution with

(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

concentration will cause a dilutional acidosis as water

[AtotD

added and a concentrational alkalosis as water


These changes are
bance
identified

is

removed.

[H^f - (K^ X {Kj+ K, X X [H+] - Ka X K, X K, X


According
the value for
to Stewart, this

Pco,)

K, X K, X P^o,)
0.2S
tells

by hyponatremia and hyper-

Ppo, = equation

natremia, respectively. -''-'^ Correction of this causal distur-

us that in any
a

to the

solution that contains strong ions.

CO2, and

weak

acid,

Second,

if

SID would be to correct the water imbalance. sodium concentration is normal, altering the

[H^]

is

determined only by the strong ion

concentration of the strong ions will also alter the SID.

difference, [SID], total concentration of the nonvolatile

Potassium, calcium, and magnesium concentrations do not

Respiratory Care

January 1999 Vol 44

No

49

Strong Ion Difference

in

Acid-Base Balance

vary enough to produce any significant changes in SID,


but alterations in chloride do vary enough. If water content

albumin (3.5-4.5
as any strong acid

g/dL).""*

These nonvolatile weak acids

are an independent variable, as are

SID and P^o, and


on [H^] and

act

and thus [Na^] are normal, an increase


in a

in

[CP]

will result

would on

the directional

change of pH.

decrease in

SID and

a resultant acidosis. This hyperis

The
is

effect that inorganic phosphate has

pH

chloremic metabolic acidosis

accompanied by a

loss of

seen in conditions of hyperphosphatemia, a component


failure. 2*

base of the same magnitude as the gain of chloride; thus,


it

of the acidosis seen in renal

Hypophosphatemia,
represents only

will

show a normal anion gap (A" = [Na^] - [Cl~] +

however, cannot produce a detectable alkalosis because

[COjCd)
tate,

HCO,]).^

If

strong organic acids, such as lac-

normal [Pitot]

is

only

~1 mM, which
have shown

formate, or keto acids, accumulate in plasma, then a


is

"true" metabolic acidosis develops. This

distinguished

-5% of [A-rox]-'"' A number of studies


weak

that [A-pQ-p]

mainly

from a hyperchloremic metabolic acidosis by a normal


chloride concentration and an abnormally high anion gap

comprises serum protein, with albumin being the major


acid that contributes to acid-base balance. ^^-^^^b.
in

(due to a decrease in [HCOj"]).-^^''


It

Thus, increases or decreases


directional

albumin

will

have the same

follows that

if

water content and [Na^] are normal,


will result in a higher

change on base excess and [HC03~] as the

then a decrease in

[CP]

alkalosis. This is a very


that in critically
ill

common

patients

SID and an show with an abnormal pH, more


disorder. Studies

addition or removal of any strong acid

would have. Fencl


is

and Rossing-* found


change of
almost 3
toacids)
.

that ".

the acid-base effect of a

g/dL of plasma protein concentration


of a strong acid (hydrochloric,

equivit,

than half had a metabolic alkalosis.^"*

alent to adding to a liter of plasma, or

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-

.."

In other words, hyperproteinemia produces a

base deficit and hypoproteinemia produces a base excess.

does regulate [Na^], [K^],

The independence of serum


sis

protein has been illustrated

and

[CI ~]. ^2. 35.36 xhus, if the kidneys are to raise the

plasma

through hyperproteinemia' s effect on the metabolic acidoseen in


cholera'*''

[H^] for correction of a hypochloremic

alkalosis, they can

and the effect of hypoproteinemia on


to acid-base balance (ie,

only do so by reducing the SID of the extracellular space

alkalosis.''44o.4i

by increasing [Cl~]. To accomplish


reabsorbed
at a faster rate

this,

C\

must be

Accepting Stewart's approach


that

than Na^. This will not take


is

place, however, if dehydration

present, in

which case the


is

only Pco,- [AjotI' or [SID] can change [H"^] in any body fluid compartment) allows us to more clearly focus

conservation of Na"^ takes precedence.-* This


that the
its

not to say

on the primary cause of any acid-base disturbance and


therefore to
alters

kidney cannot

move H^

or

HCO3"

directly across

more

easily

and accurately correct

it.

P^q

membrane: Various
it is

electrolytes will respond to the

[H^] through the hydrolysis reaction and provides


controlled by the gut and the kidney and provides
in Pco,-

specific antiporter systems that allow for their transport,

the compensatory change to primary disturbances in SID.

but

the "final [SID] value

which determines the


]

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""],

compensatory change to primary disturbances


(ie,

[Ajoj] represents fixed acids in plasma


phates,

inorganic phos2).^^

serum

proteins,

and albumin; Fig.

[Ajqt]

'S

not adjusted in the


to chronic

same way

as P^q, and SID. In response


re-

primary hypoproteinemic alkalosis, neither


is

disturbing [Na^]: HCl, KCl, CaClj, or


ministered.
tered,
it is

It

should be noted that


K"*^,

MgClj can be adwhen KCl is adminis-

nal nor respiratory compensation

seen, but there

is

paradoxical hyperventilation.''-

the Cl~, not the

that corrects the metabolic

and AjoT o"

pH

are

The effects of summarized in Table 1


Conclusions

P^o,- ^ID,

alkalosis. ''' This is not to say that

potassium does not play

a role in helping to correct a severe metabolic alkalosis:


Its

reciprocal relationship with hydrogen ion and the

way
The attempt
to restore
is

in

which

it

helps to maintain electroneutrality during re-

homeostasis

in the

presence of an

absorption of sodium in the kidney has been well documented.''**

acid-base disturbance
to the metabolic

not a precise science

when

it

comes

component. Although the respiratory com<

ponent of acid-base balance, P^q


Nonvolatile

'^

clearly understood in

Weak

Acids

terms of

its

production, regulation, and effect on pH, the

metabolic component's regulation and effect on

pH

is

much

As previously mentioned,
AjoT' found
with
in

the nonvolatile

weak

acids,

more complex. Various

indices (alkali reserve,

whole blood

plasma are represented by the concentra-

buffer base, standard bicarbonate, base excess, standard

tions of inorganic phosphate,

serum proteins, and albumin,

base excess, anion gap, and strong ion difference) have

~60%

of the plasma protein being represented as

each been touted as the most accurate indicators.

50

Respiratory Care January 1999 Vol 44

No

Strong Ion Difference

in

Acid-Base Balance

LUNGS

Strong Ion Difference

in

Acid-Base Balance

the

[H^]

in

body

fluids

is

mainly altered by the movement

19.

Siggaard-Andersen O. Blood acid-base alignment nomogram. Scand


J

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

JW. Siggaard-Anderson and


J

the "great trans-atlantic

conclude that electrolyte imbalance


bolic disturbances in the

is

the cause of meta21.

acid-base debate". Scand

Clin

Lab

Invest Supple 1993;214:99-104.

Roos A, Thomas LJ
siology

Jr.

The

in-vitro

body and

and in-vivo carbon dioxide

that the use of

dissociation curves of true plasma: a theoretical analysis. Anesthe.

[SID] to monitor and correct abnormalities of

pH would

967 ;28(6)

048- 063
1

appear to be the most precise identifier of a metabolic


disturbance and should be the focus of any iatrogenic correction that
is

22. Severinghaus

JW. Acid-base balance controversy: case

for standard-

base excess as the measure of nonrespiratory acid-base imbalance.


J Clin

attempted.
23.

Monit 1991;7(3):276-277.
Clinical u,se of the anion gap. Medicine

Emmett M, Narins RG.


J,

(Baltimore) 1977;56(l):38-54.

REFERENCES
1.

24. Figge

Rossing TH, Fend V. The role of serum proteins


J

in acid-

Henderson LJ. The theory of


organism.

neutrality regulation in the animal

base equilibria.
25. Figge
J,

Lab Clin Med 1991;1 17(6):453-467.


T,

Am

Physiol 1908;21:427.

Mydosh

Fend V. Serum

proteins and acid-base equilib-

2.

Hasselbalch

KA. Die Berechnung der Wasserstoffzahl des


als

Blutes aus
26.

der frien gebundenen Kahlensaure desselben, und die Sauerstoff-

bindung des Blutes


1916;78:112.
3.

Funktion der Wasserstoffzahl. Biochem

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

understand acid-base balance, a quantitative

Malley WJ. Clinical blood

invasive and noninvasive tech-

acid-base primer for biology and medicine.


Elsevier, 1981:186.
28. Stewart

New

York/Oxford:

niques and applications. Philadelphia:


4.

WB

Saunders. 1990;1 18-1 19.


II.

Severinghaus JW, Astrup PB. History of blood gas analysis.

pH

PA.

Modem quantitative

acid-base chemistry.

Can

Physiol

and acid-base balance measurements.


277.
5.

J Clin

Monit 1985; 1(4): 259Bicarbonate condetermination as

Pharmacol 1983;6I(12):1444-1461.
29. Weinstein Y,

Magazanik A, Grodjinovsky A, Inbar O, Dlin RA,

Van Slyke DD, Cullen GE.


centration of blood plasma:

Studies of acidosis.
its

I.

Stewart PA. Reexamination of Stewart's quantitative analysis of


acid-base status.

significance and

its

Med

Sci Sports Exerc 1991;23(1 1):I270-1275.

measure of acidosis.
6.

Biol

Chem

1917;30:289-346.

30. Lindinger MI, Heigenhauser GJ,

McKelvie R, Jones NL. Blood

ion

Singer RB, Hastings AB. Improved clinical method for estimation of


disturbances of acid-base balance of

regulation during repeated

maximal exercise and recovery

in hu-

human

blood. Medicine 1948;

mans.

Am

J Phy.siol

I992;262(l Pt 2):R126-R136.
quantitative acid-base chemistry: ap-

27:223-242.
7.

Schwartz

31. Fencl V, Leith

DE. Stewart's

B,

Relman AS.

critique of the parameters used in

plications in biology and medicine (review). Respir Physiol 1993;

evaluation of acid-base disorders.


1388.
8.

New Eng
its

Med

1963;268:138232.

91(1);1-16.

Eicker

SW. An

introduction to strong ion difference (review). Vet

Jorgensen K, Astrup
a

P.

Standard

HCO,"

clinical significance

and
33.

new method

for

its

determination. Scand J Clin Lab Invest 1957;

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

Astrup P, Jorgensen K, Siggaard-Andersen O. Engel K. Acid-base


metabolism:

34.

10.

Siggaard-Anderson O, Engel K.

new approach. Lancet 1960;1:1035-1039. A new acid-base nomogram: an


35.

Hodgkin JE, Soeprono FF, Chan DM. Incidence of metabolic


lemia
in hospitalized patients. Crit

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,

Simonsen LO. Membrane mechanisms

volume and

pH
36.

regulation in vertebrate cells (review). Physiol

Rev I989;69(2):

315-382.

dogs: an investigation of the acid base and electrolyte content of

Roos A, Boron WF.


61(2):296-434.

Intracellular

pH

(review). Physiol

Rev 1981;
critical
in

blood and urine. Scand


12.

Clin

Lab

Invest 1963;66;l-20.

Shaw LA, Messer AC. The


the lungs.

transfer of bicarbonate between the blood and tissues caused by alterations of carbon dioxide concentration in

37. Kassirer JP,

Berkman PM, Lawrenz OR, Schwartz WB. The


hypokalemic alkalosis
1965;38:172-189.

role of chloride in the correction of

man.

Am
J

Physiol 1932;100:122-136.

Am J Med
38.

13.

Hickman

B, Wilson

WP,

Frayser R. Observations on the early


J

Schmidt RF, Thews G.


Verlag, 1983:336, 640.

Human

physiology.

New

York: Springer-

elevation of serum potassium during respiratory alkalosis.


Invest 1956;35;601.
14.

Clin
39.

Wang

F, Butler T,

Rabbani GH, Jones PK. The acidosis of cholera;

Bunker

J.

The

great trans-atlantic acid-base debate. Anesthesiology

contributions of hyperproteinemia, lactic acidemia, and hyperphos-

1965;26(5);591-594.
15. 16. 17.

phatemia
.

to

an increased serum anion gap.

Engl

Med

1986;

More acid^ase
A.strup P.

disturbances (editorial). Lancet 1963;2:1 102.


(letter).

315(25):1591-1595.
40. McAuliffe JJ, Lind LJ, Leith
losis.

Acid base disorders

New Eng

Med

1963;269;817.
P.

DE, Fencl V. Hypoproteinemic

alka-

Siggaard-Anderson O, Engel K, Jorgensen K, Astrup

micro
41

Am J Med

1986;8l(l):86-90.

method

for determination of

pH, carbon dioxide tension, base excess

Rossing TH, Maffeo N, Fencl V. Acid-base effects of altering plasma


protein concentration in

and standard
Severinghaus

HC03"
J.

in capillary blood.

Scand

Clin

Lab

Invest

human blood

in vitro. J

AppI Physiol 1986;

1960;12:172-176.
18.

61(6):2260-2265.

Acid-base balance

nomogram

a Boston-Copenha-

42. Rossing

gen detente. Anesthesiology 1976;45(5):539-54l.

hypoprotdnemia.

TH, Boixeda D, Maffeo N, Fencl V. Hyperventilation with J Lab Clin Med 1988;1 12(5):553-559.

52

Respiratory Care

January 1999 Vol 44

No

Bronchodilator Therapy
James B Fink

in

Mechanically Ventilated Patients


J

MS

RRT, Martin

Tobin

MD,

and Rajiv Dhand

MD

Introduction
Basic Concepts of Aerosol Therapy
Inertia!

Impaction

Gravitational Sedimentation
Diffusion

The Nebulizer The Metered Dose Inhaler


Differences during Mechanical Ventilation

The Ventilator-Patient Interface


Breath Configurations

The Airway The Environment The Assessment Evaluation of Lower Respiratory Tract Aerosol Delivery with Bench Models of Mechanical Ventilation
Aerosol-Generating Devices
Nebulizers
Position

and Method of Connecting the Aerosol Generator

in the

Ventilator Circuit

Metered Dose Inhalers


Aerosol Particle Size
Characteristics of the Ventilator Circuit

Endotracheal Tube Size

Heating and Humidification Density of the Inhaled Gas


Ventilator

Mode and

Settings

Methods

to Assess

Lower Respiratory Tract Aerosol Deposition

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

Choice of Aerosol-Generating Device


Nebulizers

Metered Dose Inhalers versus


nebulizers,

Conclusion
[Respir Care 1999;44(l):53-69]

Key words: Aerosols,

pulmonary

mechanics, bronchodilators, ^-agonists.

James B Fink

MS
Jr

RRT. Martin

Tobin

MD.

and Rajiv Dhand


Critical

MD

are

Correspondence

&

Reprints:

James B Fink
(111),

MS

RRT, Division of
Jr

Pul-

affiliated with the Division of

Pulmonary and

Care Medicine.

monary and
Hospital,

Critical

Care Medicine. Edward Mines

Veterans Affairs

Edward Hines

Veterans Affairs Hospital, and Loyola University ChiIllinois.

Medical

Service

Hines,

IL

60141-5000.

cage Stritch School of Medicine, Hines,

james.fink@med.va.gov.

Respiratory Care

January 1999 Vol 44

No

53

Bronchodilator Therapy

in

Mechanically Ventilated Patients

Introduction

Geometric standard deviation (GSD)


of therapeuviation
is

is

the ratio of

median

diameter to the diameter of particles

at

one standard de-

The
tic

scientific principles underlying the use

from the median.

An

aerosol with a

GSD

of

aerosols in ambulatory patients have been established


'

considered to be monodisperse. The greater the

< .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

the larger the

median

particle size; the greater the

GSD,

the wider the range of particle sizes in the aerosol.

Inertia!

Impaction
impaction
is

limInertial

and systemic side effects are minimized.- Inhaled


information

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

and an important mechju,m. Inertia is the tenis in

anism for particles as small as 2

regarding their efficacy and the optimal technique for their


administration has been limited.^

dency for an object with mass


in

that

motion

to

remain

The

delivery of inhaled

motion

in a straight line.

The

greater the

mass and

drugs
in

in

mechanically ventilated patients differs from that


in several respects. *

velocity of a particle, the greater the inertia keeping that


particle in motion.

ambulatory patients
are

Nebulizers and

When

a particle

is

traveling in a stream

MDIs

commonly used

aerosol generators since they

of gas that

is

diverted by a turn in the airway, the inertia


it

produce respirable particles with a mass median aerody-

of the particle tends to keep


path).

on the

initial trajectory (or

namic diameter

(MMAD)

between

and 5

^im.""

Whereas

The

greater the

mass of the

particle, the greater the

MDIs
tility

are chiefly used to deliver bronchodilators and oc-

tendency for the particle to impact with the surface, depositing on the airway, rather than continuing to travel

casionally corticosteroids, nebulizers have greater versa-

and can be used

to administer bronchodilators, anti'"

with the flow of gas. The higher the inspiratory flow of


gas, the greater the velocity

biotics, surfactant,

mucokinetic agents, and other drugs.

and

inertia of the particles,

Traditionally, nebulizers have been used for bronchodilator therapy in patients receiving mechanical ventilation;

which increases

the tendency for


in large

even smaller particles

to

impact and deposit


flows

airways. Turbulent air flow,

however, metered dose inhalers (MDIs) are equally effective.

convoluted passage, airway bifurcations, and inspiratory

When MDIs

and nebulizers are used optimally, bronor 2.5

>

30 L/min increase the impaction of

particles that

chodilatation occurs with as few as 4 puffs of albuterol

are larger than 2 /u,m in the larger airways.


tions affecting air flow
lation.

These condiventi-

aerosol given by

MDI

mg

by nebulizer. With proper

abound during mechanical

techniques inhaled drugs can be administered safely, conveniently, and effectively in mechanically ventilated
patients.

Gravitational Sedimentation

See The Related Editorial on Page 24


Basic Concepts of Aerosol Therapy

Gravitational sedimentation occurs


ticles lose inertia, their

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

particle, the faster

will settle. Gravitational sedimenta-

tion increases with time

To
tients,

better understand

how

aerosol delivery differs in

fim. If ambulatory patients hold their breath for


after inhaling

4-10

s
is

mechanically ventilated versus spontaneously breathing pa-

an aerosol, residence time for the particles


is

we

begin with a review of the basic definitions of

increased in the lung, and thus extra time

allowed for

aerosol characteristics and their implications for deposition in the

deposition through gravitational sedimentation, especially


in the last

ambulatory

patient.''

6 generations of the airway. The influence of a

The

particle size of

an aerosol

is

the primary factor in


in the

breath hold on aerosol delivery during mechanical ventilation has not

determining deposition efficiency and distribution

been reported.

lung. Since medical aerosols are generally heterodisper.se,

the distribution of particle diameters in the aerosol

is

com-

Diffusion

monly represented by
the
particle mass,

the log
is

normal distribution,

in

which
Diffusion, or

aerodynamic diameter

plotted against frequency of

Brownian movement,
particles

is

the primary

mech-

forming a bell-shaped curve.

MMAD

is

the

anism for deposition of


the lung parenchyma.

<

3 /im in diameter onto


this
is

particle size (expressed in microns) at the

apex of

that bell

As gas reaches

region of the

curve or

at

50%

of the cumulative distribution curve of the

lung, gas flow and inertia for particles

reduced to zero.

same

aerosol. Thus, half of the

mass of

particles in the

Aerosol particles collide with other particles and deposit

aerosol are less than and half are greater than the

MMAD.

upon contact with

the airway surfaces. Particles 1-3 ju,m in

54

Respiratory Care January 1999 Vol 44

No

Bronchodilator Therapy

in

Mechanically Ventilated Patients

size deposit in both central

and peripheral

airways.** In
partiin-

propellants are initially 35 fjun in size and rapidly decrease


in size

ambulatory adult patients, optimal deposition of


cles

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

of the jet fired range

plume of particles moves Due to the velocity and dispersion from the MDI, under ambulatory condi-

Aerosol droplets

(MM AD,

1-5

80%

of the dose leaving the actuator impacts and

ixm) have a better chance than larger or smaller particles to


deposit in the lower respiratory tract of ambulatory patients.'

deposits in the oropharynx, especially


fired

when

the canister

is

from inside the mouth. '''''


et al'^

A particle's depth
<
1

of penetration into the bronchial

Dolovich

and others have shown increased dep-

tree
1

is

inversely proportional to the particle's size


;u.m are

down

to

osition in the lung

when

the

MDI

is

placed 4

cm from

an

/xm. Particles

so small, light, and stable that

open mouth. This technique improves lung deposition while


decreasing oral deposition. Similarly,

a large proportion entering the lung

do not deposit and are

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

evaporation of the propellants and for the particles to age


prior to impacting

on a surface. The dose of medication


smaller than with the nebulizer.

expected to dein the respirable

with the

MDI

is

much

> 50%

of

its

total

dose of aerosol

range.'" Nebulizer performance varies with diluent vol-

Differences during Mechanical Ventilation

ume, gas flow, density, operating pressure, and nebulizer model. '0" During mechanical ventilation, nebulizers producing aerosols with

MMADs

Deposition of aerosol in the endotracheal tube and ventilator circuit

of 1-3

/i,m are

more

likely

was thought

to significantly

reduce the fractract.

to achieve deposition in the

lower respiratory
circuit

tract since

tion of aerosol delivered to the

lower respiratory

larger particles impact

on the ventilator

and endo-

Until recently, the consensus

was

that the efficiency of

tracheal tube.'' Within the limits of the design of the nebulizer, the

aerosol delivery to the lower respiratory tract in


ically ventilated patients

mechan-

higher the gas pressure or flow (or both) to the

was much lower

that that in

nebulizer, the smaller the particle size generated."


ever, nebulizers that produce a smaller particle

Howsize may

bulatory patients.

""

To

better understand the

amcomplex array

of factors that influence aerosol deposition in mechanically ventilated patients (Fig.


1

more time to deliver a standard dose of medication. Ambient humidity and temperature also
require considerably
affect the particle size

),''

a comparison of differ-

ences between aerosol therapy

in

mechanically ventilated

and the concentration of drug

re-

and ambulatory patients

is

discussed below.

maining

in the nebulizer.

Evaporation of water and adia-

batic expansion of gas can reduce the temperature of the

aerosol to as

much

as 5

below ambient temperature.

The

Ventilator-Patient Interface

Aerosol particles entrained into a warm, fully saturated gas


stream increase in
size.

The

ventilator circuit

is

typically a closed system that

is

pressurized during operation, requiring the nebulizer or

The Metered Dose Inhaler


The
with

MDI

to be attached with connectors that maintain the in-

tegrity of the circuit.

The

MDI

cannot be used with the

MDI

canister contains a pressurized mixture of pro-

actuator designed by the manufacturer:


third-party actuator
is

Use of a generic
respirable

pellants, surfactants, preservatives,

and flavoring agents,

required. Size, shape, and design of

1%
is

of the

total

contents being active drug. This

these actuators greatly effects the

amount of

mixture

released from the canister through a metering


fit

drug available to the patient and

may

vary with different

valve and stem, which

into an actuator boot designed


to function
in actuator

MDI

formulations."*

and extensively tested by the manufacturer


with their specific formulation. Small changes

Breath Conflgurations
During controlled mechanical ventilation (CMV), the
pattern and rate of inspiratory gas flow, as well as the rate

design can change the characteristics and output of the


aerosol from an
takes

MDI. Aerosol production from an MDI


Aerosolization of the liquid released from

20 msec.

the metered dose canister begins as the propellants vaporize or "flash," leaving the actuator in a

and pattern of breathing, may


ble conditions tend to

differ

from

that during sponsta-

"plume," and convelocity of the

taneous respiration. Ambulatory patients under normal,

tinues as the propellant evaporates.


liquid spray leaving the

The

have sinusoidal inspiratory flow

MDI

is

15

m/s, falling by

50%

patterns with peak flows of

30 L/min, whereas ventilators

within 0.

as a cloud develops

and moves away from the


produced from the flash of

may

use square or decelerating

wave forms with considambulatory patient,


all

actuator orifice.'-

The

particles

erably higher flow rates.

As

in the

Respiratory Care

January 1999 Vol 44

No

55

Bronchodilator Therapy

in

Mechanically Ventilated Patients

Ventilator

Rdatfd

Deoice Relatt-d-MDI

Dru^ Related
Dose
Aerosol particle size Duration of achon

Mode
Tidal

of ventilation

Type of spacer or adapter used


Position of spacer in circuit

volume

Respiratory rate

Timing of

MDI

actuation

Duty cycle
Inspiratory

waveform

Breath triggering mechanism

Device Related-NehuUrpr

Type of nebulizer used Continuous/ intermittent operation Duration of nebulization


Position in the circuit
Circuit Rdaled

Endotracheal tube Inhaled gas humidity Inhaled gas density/viscosity


Fig.
1

Severity of airway obstruction Mechanism of airway obstruction

Presence of dynamic hyperinflaHon


Patient-ventilator synchrony

Factors influencing lower respiratory tract deposition of aerosol

in

mechanically ventilated patients. MDI

metered

dose

inhaler. (Modified

from Reference

4,

with permission.)

of these factors influence aerosol delivery to the lower


respiratory tract.

using an aerosol

in a hot,

high-humidity climate
in

may

well

experience a similar reduction

delivered dose.

The Airway
Although the endotracheal tube (ETT)

The Assessment
The common method
flow
rates.

is

commonly con-

to assess patient response to bronis

sidered the major point of impaction of aerosol during

chodilator administration

through changes

in expiratory

mechanical ventilation, other factors merit consideration.

The conduit between

the aerosol device and the lower


is

During mechanical ventilation, forced expiratory maneuvers are often impractical and rarely performed.

respiratory tract in mechanically ventilated patients

Most
in

investigators have relied

on changes

in the inspira-

nar-

rower than the oropharynx and has abrupt angles


90-degree connector often used
circuit
to

tory airway resistance to quantitate a bronchodilator effect


(eg, the

connect the ventilator

mechanically ventilated patients.

wye

to the

ETT), which
that are not

result in points of

impacair-

tion

and turbulence

found

in the

normal

way. While the


interior surface

ETT is narrower than the trachea, its smooth


may
create a

Evaluation of Lower Respiratory Tract Aerosol Delivery with Bench Models of Mechanical
Ventilation

more laminar-flow path than

the structures of the glottis and be less of a barrier to

aerosol delivery than the ventilator circuit. In support of


this

In vitro studies using


tilation

bench models of mechanical venin

view,

we

recently found that twice as

much

aerosol

have been very helpful

determining the effect of

from the

MDI

deposited in the ventilator circuit than in the

each of a large number of variables on aerosol deposition. "*"2''

ETT

during

CMV.'^

These models provide an inexpensive mechaunder controlled conditions

nism

to study specific factors

The Environment
Ventilator circuits are typically designed to provide heat

without the tedium associated with in vivo studies. De-

pending upon the type of model used, the efficiency of the


aerosol delivery to the lower respiratory tract has been

reported to vary from

to

42%

with nebulizers "*-2i.24 ^p^j

and humidity
an increase

to inspired gas to

compensate for bypassing

from 0.3%

to

97.5%

with MDIs'^-^z-zs (pjg. 2). These

the normal airway.


in

Humidity has been shown to relate to particle size and reduced deposition during
is

studies used different methods, and the

models simulated

the clinical scenario to a variable degree.

The use of a
facilitate

CMV,
unique

but no data exist to suggest that this reduction


to the ventilated patient.

standardized model for in vitro studies of aerosol deposition during

The ambulatory

patient

mechanical ventilation could greatly

56

Respiratory Care January 1999 Vol 44

No

Bronchodilator Therapy

in

Mechanically Ventilated Patients

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

of mechanical ventilation for the lower-respiratory-

tract delivery of aerosol


bars); the

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,''^

directly at the distal

end of the endotracheal tube. Studies:

O'Riordan.^^Thomas,^' O'Doherty.^"

Rau,22 Taylor,23

Diot,^'' Fink.^^

(Modified from Reference 4, with permission.)

comparison between the


(Fig. 3).

results of various investigators

Position

and Method of Connecting


tiie

tlie

Aerosol Gen-

When

standardized methods are used, the proporto the


is

erator in

Ventilator Circuit.

Placement of a nebis

tion of the
tract

nominal dose delivered

lower respiratory

ulizer at a distance of

30

cm from

the endotracheal tube

with nebulizers and


device).''^--*-''

MDIs

similar

(~15%

with

more

efficient than

placement between the patient

and

each

the endotracheal tube because the ventilator tubing acts as

a spacer for the aerosol to accumulate between inspira-

Aerosol-Generating Devices
Nebulizers.
highly

tions. "-"-''2*'

Addition of a spacer between the nebulizer

and the endotracheal tube further modestly increases aero-

The

efficiency of aerosol generation varies

sol delivery.-'*

among

different brands of nebulizers.'' For contin-

uous aerosol generation, a nebulizer unit powered by pressurized gas from a piped (wall) system, cylinder, or

Metered Dose

Inlialers.

Several types of commercially

com-

available adapters are available to connect the


ister to the ventilator circuit.

MDI

can-

pressor

is

connected

in the ventilator circuit. Alternatively,

the air flow generated by a ventilator can be used to

power

MDIs

can be used with adapt-

the nebulizer during inspiration (intermittent operation).

ers that attach directly to the endotracheal tube or with


in-line devices that are placed in the inspiratory

separate line provides driving pressure and gas flow from


the ventilator to a nebulizer connected in the ventilator
circuit.

limb of the

ventilator circuit.

The

latter

include

chamber adapters, such

Operating the nebulizer during inspiration only

as cylindrical spacers
is

and reservoir devices, or noncham-

more

efficient than continuous aerosol generation.-''

Howto

ber devices (Fig. 4). Both in vitro and in vivo studies have

ever, the driving pressure provided

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).-''

much lower than that provided commonly available


This reduction
in

device results in a four- to- six-fold greater delivery of


aerosol than

MDI

actuation into a connector attached di-

(> 50

driving

rectly to the endotracheal tube,----*-'^""' or into an in-line

pressure from the ventilator reduces the efficiency of pneu-

device that lacks a chamber." Actuation of an

MDI

into an

matic nebulizers, thus increases the

MMAD and can mark-

elbow adapter out of synchrony with inspiratory


achieved negligible aerosol delivery
tory
tract.--*

air

flow

edly reduce the amount of aerosol delivered to the lower


respiratory tract.

to the

lower respira-

This observation

may

explain the lack of ther-

Respiratory Care

January 1999 Vol 44

No

57

Bronchodilator Therapy

in

Mechanically Ventilated Patients

MDI
Medianlcal Breath Generator

Spacer

Endotracheal Tube

Spontaneous Breath Generator

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.

Diagram of a bench model used to


1

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.)

apeutic effect with this type of adapter after administration

Characteristics of the Ventilator Circuit

of very high doses of albuterol (100 puffs, 1.0


albuterol) with an MDI.-^^

mg

of

Endotracheal Tube Size.


dotracheal tube
is

Aerosol impaction

in the

en-

thought to significantly reduce the


in

effi-

ciency of aerosol delivery

mechanically ventilated pa-

Aerosol Particle Size

tients.

The

efficacy of aerosol delivery decreases

when

narrow endotracheal tubes


In

(internal diameter of 3 or

ambulatory patients, aerosols with a higher propor-

mm)
sol

are used in pediatric ventilator circuits.^''""'

6 However,

tion of respirable particles

(MMAD

of 1-5 ixm) are more


tract.

the efficiency with

which various nebulizers delivered aero-

efficient for aerosol delivery to the

lower respiratory

beyond the endotracheal tube did not vary between

In mechanically ventilated patients, the ventilator circuit

tube sizes ranging in internal diameter from 7 to 9 mm.'"'

and endotracheal tube act as baffles


eter particles en route to the

that trap larger-diamtract.

lower respiratory

The

Heating and Humidiflcation


and nebul izers by

Heating and humidifica-

MMAD of aerosols produced by different brands of nebulizers varies

tion of inhaled gas decreases aerosol deposition with

MDIs

40%,

''24.25,34
'

probably due to increased

widely." Nebulizers producing aerosols with

particles of

<

particle loss in the ventilator circuit (Fig. 5). Therefore,

2 ixm are likely to produce greater deposi-

some
fier

investigators have proposed bypassing the humidi-

tion in the lower respiratory tract of ventilator-supported


patients."-'^

during aerosol administration.* Absence of humidifl-

When

actuation of the

MDI

into a spacer

was

cation

may

not pose problems during the brief period re-

synchronized with inspiration, a significant proportion of


aerosol emerging from the distal end of the endotracheal

quired to administer a bronchodilator with an

MDI;
this

however, some nebulizers require up


plete aerosolization,--*

to

tube was in the respirable range, with a


/Ltm.^'*

MMAD

35 min to com-

of

and inhalation of dry gas for

Therefore, deposition in the lower respiratory tract


is

length of time can be detrimental to the airway mucosa. In


addition, disconnection of the ventilator circuit,

of mechanically ventilated patients

likely to be

more

which

is

efficient with devices that generate aerosols with a

MMAD

required to bypass the humidifier, interrupts ventilation

of 1-3 ixm.

and may increase the

risk

of ventilator-associated pneu-

58

Respiratory Care January 1999 Vol 44

No

Bronchodilator Therapy

in

Mechanically Ventilated Patients

into a cylindrical spacer

synchronized with inspiration

re-

sulted in

30% greater efficiency of aerosol delivery com6).--*

pared with actuation during expiration (Fig.

Aerosol
if

can be delivered during assisted


patient
is

modes of ventilation
was up
to

the

breathing in synchrony with the ventilator. We-''

found

that albuterol deposition

23%

higher in

vitro during simulated spontaneous breaths (continuous

positive airway pressure) than with controlled breaths of

equivalent

Vj Vy

(Table

1).

For efficient aerosol delivery to the lower respiratory


tract,

the

of the ventilator-delivered breath must be

larger than the

tracheal tube.

Vj

volume of the ventilator tubing and endoof > 500 mL in adults are associated
1),'''-'^

with adequate aerosol delivery (see Table

but the

higher pressures required to deliver a larger


detrimental to the lungs. Aerosol delivery
is

Vj can be

directly cor-

related with higher duty cycle (ratio of inspiratory time to


total
is

breathing cycle time [Ti/T-tot])''''^ This relationship

easily understood with nebulizers because a longer T,

allows a higher proportion of the aerosol generated by the


nebulizer to be inhaled with each breath. Because nebulizers generate aerosol
Fig. 4. Different

over several minutes, a longer T,

types of commercially available spacers/adapters

has a cumulative effect in improving aerosol delivery. In


addition, the diluent

ventilator circuit. A, In-line adapter; B,

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

the duration of treatment

influence nebulizer efficiency.''^-"

MDIs produce

aerosol

over a

finite portion

of a single inspiration and the mechis

chamber; E, aerosol cloud enhancer spacer, w/ith which the MDI flume is directed away from the patient. (Modified from Reference
4, with permission.)

anism by which a longer T, increases aerosol delivery

unclear. Perhaps aerosol particles that deposit in the spacer

and ventilator tubing are swept off the walls and entrained

by longer periods of inspiratory flow.


monia. With nebulizers, administration of aerosols
circuit
in a

dry
ad-

Approximately

may

be of some hypothetical advantage

when

administered by an
tilated patients,-^^

5% of the nominal MDI is exhaled in

dose of albuterol
mechanically ven-

ministering expensive agents (eg,

DNase)

to reduce the

whereas

< 1%
'

amount of medication
treatment,
ventilator circuit.

required. For routine bronchodilator

are used in ambulatory patients.


tion

is exhaled when MDIs The mean exhaled frac-

we recommend

nebulizer use with a humidified

(7%) with use of nebulizers

in

mechanically venti-

lated patients is similar to that with

MDIs. but

there

is

considerable variability between patients (coefficient of

Density of the Inhaled Gas.


gas
(ie,

Inhalation of a less dense

variation,

74%). '
depends
with a

helium-oxygen

[heliox]), decreases the turbulence

The

validity of the results of laboratory studies


to

associated with high inspiratory flow rates during mechanical ventilation.

on the extent
vivo situation.

which the models


have performed

truly replicate the in


in vitro tests

Therefore, breathing heliox

may improve

We

aerosol deposition during mechanical ventilation.^'' Studies in

model

that provides accurate

and reproducible

results.

The

ambulatory patients with airway obstruction revealed

use of such a standardized model could be very helpful in

higher aerosol retention

when

they are breathing heliox

comparing the

results of various investigators,

and

in cor-

instead of air."-^* Preliminary reports indicate up to

50%

relating in vitro findings with the results of in vivo deposition studies.'''

increase in deposition of albuterol from an

MDI

during

CMV

of a simulated adult patient

when

breathing heliox

compared

to that while breathing air or

oxygen."
ventilator

Methods

to Assess

Lower Respiratory Tract Aerosol

Deposition In Vivo
Ventilator

Mode and

Settings.

The

mode
Radionuclide Studies
Imaging of radiolabeled aerosols has
traditionally

and settings influence aerosol delivery in mechanically


ventilated patients. For optimal aerosol delivery, actuation

of an

MDI

into a spacer needs to be synchronized with the

been
in

precise onset of inspiratory air flow. Actuation of an

MDI

employed

to assess total

and regional aerosol deposition

Respiratory Care January 1999 Vol 44

No

59

Bronchodilator Therapy

in

Mechanically Ventilated Patients

>
"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

of mechanical ventilation with dry


is

and humidified

ventilator circuits.

The

delivery of aerosol to the major airways


**,

reduced by

40% when the circuit is

humidified.

*,

<

0.05;

<

0.01; *", p

<

0.001. Studies: O'Riordan.i^ Fuller,'" Diot.^" Fink^^ (From Reference 4, with

permission.)

30

25

20
CO

Bronchodilator Therapy

in

Mechanically Ventilated Patients

Table

Effect of Tidal

Volume

(V-^)

and Ventilatory

Mode on

Aerosol Delivery

Bronchodilator Therapy

in

Mechanically Ventilated Patients

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.

Pulmonary deposition of aerosol generated by nebulizers (open bars) and MDIs


in vivo.

(solid bars) with

radiolabeled aerosols

Deposition of aerosol varied from


in

2.2%

to

15.3%

with nebulizers

from 3.2%) to 6.8% with MDIs. The humidifier was bypassed

the study reported by O'Riordan et

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):

Maclntyre,"' Fuller, i=Thomas,' O'Riordan.ss Fuller,i5 Fuller,

^i

Fuller.^i

(From Reference

4, with

permission.)

15%

of the nominal dose being delivered under optimal

from 4 puffs of an

MDI

with a chamber adapter in a

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

humidified circuit (15% deposition).

The recommended technique of


differs

aerosol administration

during mechanical ventilation with a nebulizer (Table 2)

from

that with an

MDI

(Table

3).

62

Respiratory Care January 1999 Vol 44

No

Bronchodilator Therapy

in

Mechanically Ventilated Patients

1.50

-,

Table

2.

Technique for Using Nebulizers


Patients

in

Mechanically Ventilated

1.25

Place drug solution in nebulizer to optimal

fill

volume (2-6 mL).*


from the patient

2.

Place nebulizer in inspiratory line


wye."*

at least

30

cm

1.00

3.

Ensure airflow of 6-8 L/min through the nebulizer.* Ensure adequate


duty cycle
tidal

a
0.75
-

4.

volume (a 500

mL

in adults).

Attempt

to use

>

0.3, if possible.
to

5.

Adjust minute volume, sensitivity trigger, and alarms


for additional air flow through the nebulizer,
if

compensate

required.

^ o
h V

0.50

5.

Turn off flow-by or continuous flow mode on

ventilator,

remove

heat and moisture exchanger from between nebulizer and patient.


6.

Observe nebulizer for adequate aerosol generation throughout use.


Disconnect nebulizer when
all

0.25

7.

medication

is

nebulized or

when no

more aerosol
conditions.

is

being produced. Store nebulizer under aseptic

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.

of a nebulizer varies between

known

before using any of these devices.


is

Comparison

of

serum

albuterol levels, per puff, witfi conwitfi

Placement of the nebulizer, placed between the ventilator and the inspiratory limb
efficient for aerosol delivery than

more

trols

(normal volunteers using metered dose inhaler

holding

placement between the inspiratory limb and the


latter

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

be more efficient for aerosol delivery.

Some

ventilators provide inspiratory gas


to

flow to the nebulizer. Continuous gas flow from an external source can also be used
the nebulizer.

power

humidified ventilator circuit.


ically ventilated

patients

The serum albuterol levels in mechanwere comparable to those achieved in the


into the patient's respiratory tract

normal volunteers. (From Reference 44, with permission.)

when

the spacer

is

pulled

Care of Spacers and Nebulizers

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

Several investigators have

shown

suggesting contamination problems with administration of


aerosol from the

in-line in the ventilator circuit

can become contaminated


This
often a product
is

MDI

during

CMV.

with bacteria, which are then carried as microaerosols directly to the

lower respiratory

tract.

is

Efficacy of Bronchodilator Administration during

of condensate within the ventilator circuit, which


to retrograde

subject

Mechanical Ventilation
Bronchodilators are

contamination from the patient. Such con-

tamination has been demonstrated after single use of a


nebulizer.-*'^

among

the

most commonly

u.sed

The Centers

for Disease Control

and Preven-

drugs in patients admitted to the intensive care unit;^ they


are chiefly used in mechanically ventilated patients with

tion (Atlanta)
at the start

recommend

that nebulizers should be sterile

of nebulization, and after each use, they should


circuit,

severe asthma or chronic obstructive pulmonary disease

be removed from the ventilator


cleaned with
sterile water, rinsed,

disassembled,

(COPD).32'*7-54 Since the presence of air-flow limitation


in

and

air dried.

Care should

mechanically ventilated patients

is difficult

to predict

on

be taken

to store the nebulizer aseptically

between uses.

clinical grounds,*"' the efficacy of bronchodilators in a het-

Failure by respiratory care practitioners to observe these

erogenous population of mechanically ventilated patients


needs further study.
istration has

guidelines has resulted in epidemics of nosocomial pneumonia."** In addition, single-dose

response to bronchodilator adminafter administration of either


''''''^'^"

ampules of drug are pre-

been observed

ferred over the use of multi-dose vials,

which more readily

aerosolized
ergic

jS-adrenergic-'--"*-*'^-'''

or anticholin-

become contaminated.

Similarly, the collapsible

chamber

bronchodilators. ''^''o

Inhaled isoproterenol, '^-^'^

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

isoetharine,'* metaproterenol,''' fenoterol,^" and albuterol 49.51-54 aji

produce significant bronchodilatation when

administered to mechanically ventilated patients. In patients

by using the heated-wire type of


vent the condensate in

circuits or heat

and mois-

with

COPD receiving mechanical ventilation, a comwas shown

ture exchangers. Furthermore, care

must be taken to prethe spacer from being washed down

bination of fenoterol and ipratropium bromide


to

be more effective than ipratropium alone."

Respiratory Care

January 1999 Vol 44

No

63

Bronchodilator Therapy

in

Mechanically Ventilated Patients

Table

3.

Technique

for

Using Metered Dose Inhalers (MDIs)

in

nomena

time constant inhomogeneities within


pulmonary
tissues.*' Similarly,

the lung

Mechanically Ventilated Patients.

("pendelluft") and the visco-elastic behavior or stress relaxation of the

1.

Assure

tidal

volume

>

500

mL

airway oc-

(in adults)

during assisted

ventilation.
2.

clusion at end-exhalation produces an increase in airway

Aim

for an inspiratory time (excluding the inspiratory pause)

>

0.3

pressure, and

its

plateau value signifies the level of auto-

of total breath duration.


3.

or intrinsic positive end-expiratory pressure (PEEPi).*"

Ensure

that the ventilator breath is .synchronized with the patient's

From
tient)

these measurements (in a passively ventilated pa-

inspiration.
4. 5.

by use of a square wave inspiratory flow

pattern,

Shake the

MDI

vigorously.
in

respiratory mechanics can be calculated as

Place canister in actuator of a cylindrical spacer situated


inspiratory limb of ventilator circuit.*

6.

Actuate

MDI

to synchronize with precise onset

of inspiration by

the ventilator."
7.
8.

Rrs

max =

Lipeak
air

"plat J

flow

Allow passive exhalation.


Repeat actuations after 20-30
s until total

dose

is

delivered.*

*With MDIs

it

is

preferable to use a spacer thai remains in the veiitiiator

cireiiil

so that

Rrs min

[Pipeak

MnitJ

air

flow

disconnection of the ventilator circuit can be avoided during bronchodilator treatment.

Although bypassing the humidifier can

increa.se aerosol delivery,

it

prolongs the time for each

treatment and requires disconnection of the ventilator circuit.


'

In

ambulatory patients with an

MD!

placed inside the mouth, actuation

is

recommended

A Rrs =

Rr,

max R min
Tidal
[Pp,

briefly after initiation of inspiratory air flow. In mechanically ventilated patients,

when an

MDI

and spacer combination

is

used, actuation should be synchronized with onset of

inspiration.

"The manufacturer recommends repeating the dose after


within

min: however.
delivery.'^

MDI

actuation

20-30

s after

the prior dose does not

compromise drug

Respiratory system compliance (CrJ

Volume

- PEEP,]

Most mechanically
Bronchodilator Efficacy

ventilated patients with

COPD

demSince

onstrate a decrease in values of R,.j.max and R,.^min fol-

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

AR^s did not decrease significantly after albuterol administration in

our

studies,-'''-'''*

it

appears that the effect of

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

ministration depends on the patient's airway geometry,


severity of disease, presence of mucus, the effects of in-

compliance of the respiratory system)

in

our patients

improved
at the

after albuterol administration but

flammation and other drugs, and the degree of airway


responsiveness.

was not
that

significantly different than the value at baseline.-'''

Once

a threshold response has

been

For the clinician

bedside,

it

is

important to realize

achieved, higher doses of the same drug produce minimal


further increase in bronchodilatation.

any respiratory

effort

by

the patient reduces or elim-

inates the ability to reliably

measure changes

in

ohmic

Most
dilators

investigators have assessed the effect of broncho-

resistance. Consequently, extrapolation of these measure-

on inspiratory airway resistance

to

determine their

ments of changes
ful

in resistance

may

only be clinically use-

clinical efficacy.
tilated patients is

Airway
at

resistance in mechanically ven-

with patients

who

are totally passive, or paralyzed,

commonly measured by performing


is

rapid

during mechanical ventilation.

airway occlusions

constant flow inflation.*' In this tech-

The occurrence of
to predict in

a bronchodilator response

is

difficult

nique, a breath hold

performed

at end-inspiration

by

mechanically

ventilated patients. Neither an

occluding the expiratory port (Fig.

10).

The airway occlu-

elevated airway resistance nor the presence of expiratory


air

sion produces an immediate drop in airway pressure (Ppeak)


to a

flow limitation

is

predictive of a response to broncho-

lower

initial

pressure

clines gradually to reach a

The pressure then deplateau after 3-5 s (Ppiai)- The


(Pjnii).

dilators in ventilator-dependent patients.''''

Moreover, the

technique of administration has a marked

influence on the

value of

P|i,

can be determined by back extrapolation of


This permits

effects of bronchodilator administration with an

MDI. Early
re-

the slope of the latter part of the airway pressure, tracing


to the

studies in the anesthesia literature


sults

showed promising

time of airway occlusion.

''^

total

or

following bronchodilator administration by an


-''*'''*

maximal
into a
flects the

inspiratory resistance (R,.^max) to be partitioned


re-

minimal inspiratory resistance (Rmin), which

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,

tilator-supported patients (Fig. 11).

More

recently,

it

has

64

Respiratory Care

January 1999 Vol 44 No

Bronchodilator Therapy

in

Mechanically Ventilated Patients

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

Waveforms depicting the key parameters


in

response to inhaled bronchodilators. Resistance

is

determined by difference
the airway pressure
falls

peal< airway pressure (P peal<)


initial

and plateau pressure


is

(P plat). A, Following a rapid airway occlusion,

to an

plateau (P

init)

and over 3 s

stabilizes to the final

plat. B,

Following a rapid occlusion

during expiration, the intrinsic positive end-expiratory pressure (PEEPi)

determined. (From Reference 53, with permission.)

been established that effective use of an

MDI

for bron-

chodilator administration in ventilator-supported patients


requires actuation into a spacer placed in the inspiratory

limb of the ventilator

circuit.
is

The

best results are obtained

when

the

MDI

actuation

synchronized with the onset of

inspiration.

'^--5''

Bronchodilator Dose

On

the basis of earlier data that aerosol deposition


in
it

markedly lower
latory patients,

mechanically ventilated than


that higher

in

was ambu-

was recommended

doses of
0.0
2.5 5.0 7.5

bronchodilators be required for ventilator-supported patients.^


ified.

However, the precise dosing regimen was not spec-

10.0

12.5

15.0

This led some investigators to propose that the dose

Dose
Fig. 11. Effect of albuterol

(albuterol,

mg)
in

of bronchodilators should be titrated to their physiologic


effect in ventilator-supported patients.''- Significant bron-

on flow-resistive pressure
rapid
fall in

10 me-

chanically ventilated patients. Administration of 2.5

mg of albuterol

chodilation has been reported with administration of 2.5

with a nebulizer

NEB) produced a

flow-resistive pres-

mg
an

of albuterol with a standard nebulizer under less than


1

sure (21.5

5.7

cm HjO
in

at baseline vs 17.6

5.4 after albuterol;

optimal conditions (see Fig.

)'1

p or 4 puffs (400 jxg) with

<

0.01).

cumulative dose of 7.5

mg

of albuterol

produced
in

incremental benefit
with values with 2.5
resistive

8 of the 10 patients, with a decrease

MDI

(Fig. 12).'-*

The

MDI was

administered to stable

flow-rooistive pressure to 15.8

3.6

cm HjO

(p

>

0.05 compared
in

COPD patients through a humidified ventilator circuit with


a chamber-style adapter placed in the inspiratory limb at the

mg

albuterol). In contrast,

no change

flow-

pressure occurred after administration of up to 100 puffs

wye; actuations were synchronized

to inspiration, with

of albuterol with a

metered dose inhaler and elbow adapter (MDI).

(Modified from Reference 32, with permission.)

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

routine clinical setting, higher doses of

bronchodilators

may be needed
if

in

patients with severe


is

summary, when the technique of administration carefully executed, most stable mechanically ventilated

airway obstruction or
not optimal.

the technique of administration

patients with

COPD

achieve near maximal bronchodilata-

However,

further studies are

needed

to assess

tion after the administration of

4 puffs of albuterol with an

the duration of the bronchodilator effect in order to estab-

MDI

or 2.5

mg

of albuterol with a nebulizer.

Respiratory Care January 1999 Vol 44

No

65

Bronchodilator Therapy

in

Mechanically Ventilated Patients

22

20

p<0.001

o
q> (0

\ O
E o D E
12
i\

_j

ty

oJ
1

Bronchodilator Therapy

in

Mechanically Ventilated Patients

100-1

8 *

16 puffs

p<0.05 p<0.01

90-

E
*->

<D
(O

80

Bronchodilator Therapy

in

Mechanically Ventilated Patients

aerosol generator to the circuit and


cuit, the

its

position in the cirset16.

tilated patients:

comparison of dose

to the lungs.

Am

Rev Respir Dis

timing of aerosol generation, the ventilator

1990; 141 (3):440-444.

tings, circuit humidification, endotracheal tube size, aero-

Aerosol consensus statement. Consensus Conference on Aerosol Delivery.

sol particle size,

and the severity and nature of the


17.

Chest 1991;100(4):1 106-1 109.


J,

Fink JB, Dhand R, Grychowski


in vitro

Fahey

PJ,

Tobin MJ. Reconciling

obstruction in the patient's airways) influence the effi-

and

in

vivo measurements of aerosol delivery from a me-

ciency of aerosol deposition and therapeutic response.

We

tered-dose inhaler during mechanical ventilation and defining effi-

have shown that 4 puffs (0.4 mg) of albuterol with an

MDI
18.

ciency-enhancing factors. Ain


press).

Respir Crit Care

Med

1999;159

(in

and spacer

in a

humidified ventilator circuit produce sig-

nificant bronchodilatation in

most patients with

stable
is

Fuller

HD, Dolovich MB, Chambers


J

C,

Newhouse MT. Aerosol

COPD, and

further bronchodilatation with higher doses

delivery during mechanical ventilation: a predictive in vitro lung

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-

Am Rev Respir Dis

I992;I45(5):

tained with 6 to 12 times the dose given by a nebulizer.

1117-1122.
20.

Greater doses of bronchodilator with an

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

required in patients with acute severe airway ob-

struction.
21.

and nebulizer type, position,

and volume of

fill.

Am

Rev Respir Dis 1992;146(2):383-388.


CJ, Treacher DF,

ACKNOWLEDGMENT
Supported by a Department of Veterans Affairs Research Service
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Thomas SHL, O'Doherty MJ, Page


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877.

Nunan TO.
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Delivery of ultrasonic nebulized aerosols to a lung model during

Am

Rev Respir Dis 1993;148(4

22.

Rau

JL,

Harwood

RJ, Groff JL. Evaluation of a reservoir device for


in vitro

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in

72.

Bowton DL. Goldsmith

WM,

Haponik EF.

Sub.stitution of meteredin

MA, Reyes
ventilated

A. Comparison of one versus two bronchodilators


Intensive Care

dose inhalers for hand-held nebulizers: success and cost savings


large, acute-care hospital.

COPD patients.

Med

1994:20(3): 199-202.

Chest I992;10I(2):305-308.

Respiratory Care January 1999 Vol 44

No

69

Special Article

Quantitating Caregiver Work Load in the ICU: Intervention Scoring System


Dinis Reis Miranda

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

ing the consumption of nursing


level, the listed items
cific

manpower

at the patient

do not include either basic or spe-

nursing activities that are considered to be time-con-

and assessing the corresponding nursing work load

in

suming.

the intensive care unit (ICU). In 1981, the

Acute Physiolscores-

These arguments ignore the


the instrument

fact that the

development of
and
if

ogy and Chronic Health Evaluation

(APACHE)

was

largely based

on the documented printhis

made
As

their very successful appearance, using severity

of

ciple that severity of illness correlates significantly

illness for

benchmarking case mix and predicting outcome.


illness

almost linearly with nursing work load. In


patient's condition

way,

a consequence, of the 2 original applications of TISS,

were appropriately characterized by

that of

measuring severity of

has become an his-

"therapeutic" items involving nursing activities (eg,

me-

torical objective,

while the indication of TISS for measurthe

chanical ventilation, dialysis.

Swan Ganz

catheter and car-

ing nursing
last

work load has remained unchanged over


fact, the
it

diac output), several basic or associated nursing activities

25 years. As a matter of

worldwide use of

could be omitted from the score, either for scientific (eg,


increasing inter-rater reliability), or for operational reasons
(eg,

TISS has increased


stratifying the case

substantially, as

has been recognized

as a robust instrument of research in the

ICU

setting for

reducing scoring cumbersomeness).

mix of groups of

patients,^ for sup-

Let

me

illustrate this

with an example from the original

porting studies on the use of resources,"* and for general

TISS: "controlled ventilation with muscle relaxants" scores

management

purposes.-''

4 points; "intermittent mandatory ventilation," 3 points;


"spontaneous breathing via endotracheal tube," 2 points.

See The Related Editorial on Page 22

However, the experienced nurse knows


indicated

that the 3rd item

&

may demand much more nursing work than either

The Original Study on Page 29

of the other two. The additional points attributed to the


other items therefore correspond to nonscored nursing ac-

Confirming the importance of the instrument, several

tivities

associated with a higher severity of illness.

It

is

improvements have been introduced, and other versions of

interesting to note that this allocation of points corresponded


to a hierarchy
in the

TISS have made their appearance in The important distinction to make here

the last decade.*^**


is

of patterns of ventilatory support advocated

that the

APACHE

1970s, based on the notion that

more severely

ill

and other scoring systems with similar design include


"physiologic variables" related to severity of illness, with
the

patients should never breathe spontaneously. All these in-

dividual items concerning ventilatory support were clustered into


1

aim of predicting outcome, whereas TISS includes

item during the developmental analysis of


is

"therapeutic variables" related to severity of illness, with


the

TISS-28,^ as the actual use of various ventilatory modes


indeed not necessarily associated with severity of

aim of measuring nursing work load. The nursing profession has been critical of TISS
is

illness.

for not

Another interesting example can be given from the simplification of

sufficiently expressing all the nursing activities in the

ICU.

TISS-28

into the

Nine Equivalents of NursIn

This criticism

based on the fact

that,

by aiming

at scor-

ing

Manpower Use Score (NEMS).


4 points, and
"left

TISS-28, "single

vasoactive medication" scores 3 points, "multiple vasoactive medication,"


Dinis Reis Miranda

atrium monitoring," 8

MD, Head

of the Health Research Unit, University

points; in

NEMS,

after the decision

was made

to

exclude

Hospital of Groningen, Groningen, Netherlands.

this last item, "single

vasoactive medication" scores 7 points


points.
last

Correspondence: Dinis Reis Miranda

MD,

Head, Health Research Unit,


I,

and "multiple vasoactive medication," 12


It

University Hospital of Groningen, Hanzeplein

9700

BR

Groningen,

deserves mention with respect to these

2 versions

Netherlands, d.reis.miranda@chirc.azg.nl.

of the score that the reduction of items concerned mainly

70

Respiratory Care January 1999 Vol 44

No

QUANTITATING CAREGIVER

WORK LOAD

IN

THE ICU

nursing activities listed in the original TISS that did not


necessarily correspond to the severity of illness of the

It is

therefore important to bear in

mind

that

TISS

is

an

objective and simple-to-use instrument, which allows for

involved patients. Yet, besides being simpler to score and


describing better the actual practices in the ICUs. these
scores remained robust in comparison to the original score.

various and often rather complex associations: First,


primarily measures severity (or rather, operational
plexity) of illness in the

TISS com-

ICU. Second, the association be(1

Because of the criticisms made by the nursing profes-

tween TISS and the consumption of nursing manpower

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

TISS-28 point corresponding

to 10.8

min of

work'')

was

established and validated in multicenter studies. This association (in itself reflecting average values)

was

strength-

ened (made meaningful) by the inclusion of some nursing


activities. Finally, the inclusion

of other items (fine-tuning

procedures) might prepare the instrument for measuring


the

independent populations. This

is

an important point, be-

work load of other

professional activities in the ICU, for

cause the nursing activities in the ICU, other than those


relating to the severity of illness of the patients

under care,
say

example, those of intensivists and respiratory therapists.

are very

much
more

affected by local views, available resources,


it

My

final

comment concerns

this last point.

TISS can be

and cultural circumstances. Therefore,


that the

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

specific nursing activities in

ICU and

the score increases, the less universal the score

becomes.
al''

FTEs

in

view of the number and

One

interesting result of the study

by Clini

et

is

that
their

the type of patients admitted to the unit.'" In


tries, all

some coun-

they found a large

and significant correlation between

nursing activities are performed by the same type

"dependence nursing scale" (DNS) and


the scored items

NEMS.

That 3 of

of nursing professional (eg, registered intensive care nurses); in

were identical

in

both therapeutic indexes

other countries, however, task differentiation takes

contributed to this high correlation


well in their population!).

(NEMS performed very


by the nursing pro-

place,

and some

activities otherwise

performed by

nurse
(eg,

are

performed by 2 or more nursing professionals

The important point

in the criticism
is

nursing aides). TISS applies to both situations, as the eventual distribution

fession regarding TISS, however,

that there are indeed

of tasks concerns the same function, de-

several nursing activities that represent increased


load,

work

spite the different


this is a

work force organization. Besides, and


all

and

that are related to particular patient conditions,

key aspect,

the professionals involved belong

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

process of including this type of "patient

and function differentiation has increased


tries to the

some coun-

condition-related nursing activities" in a

new

version of

point that

some

activities are

now performed by

TISS-28. Using a Delphi methodology, 25 nurses and physicians

people belonging to other distinct professional groups (eg,


respiratory therapists, social workers, research or administrative assistants).

from

all

around the world were asked

to identify

these patient condition-related nursing activities. After 3

These separate professional groups usuto the nursing staff (and budget) of the

rounds of questions and responses,

we

obtained consensus
ally

do not belong

regarding 5 categories of activities: (1) monitoring and


titration (eg, related to restlessness), (2)

ICU. The professional content of these "other groups," as


well as the performed activities and duties, are rather
in

hygiene (eg,

in-

continence, barrier nursing), (3) mobilization (eg, team


lifting), (4)

new

support of patients and relatives (eg, feeding,

many

countries and

may be

seen as complementary to

organ donation), and (5) management and administrative activities (eg, research, coordination with other disciplines).

the nursing activities in the

ICU. The actual TISS-scores


Clini et al')

(including the
these

DNS-score of

do not cover
in the

An

international panel of nurses and physicians then

made

new

activities,

because they were not included

a detailed description of the additional items to be in-

actual developmental research of TISS.

cluded

in the

new TISS-28. The important

feature of these
is

descriptions, besides avoiding equivocal interpretations,


that they intend to attribute a time

dimension to each new

REFERENCES
1.

(sub)item.

The (average) time consumed by each of these


be determined during the field validation of
Cullen DJ, Civetta JM. Briggs BA. Ferrara LC. Therapeutic intervention scoring system: a method for quantitative comparison of
patient care. Crit
2.

activities will

the study, as

was done

for the original TISS-28. This

is

relevant, as the simple description of the nursing activities


will likely

prove to offer insufficient basis for the evaluin the

Knaus

Care Med 1974;2(2):57-60. WA, Zimmerman JE. Wagner DP. Draper EA.

Lawrence DE.

ation of

work load

ICU.

APACHE-acute physiology and

chronic health evaluation; a physi-

Respiratory Care January 1999 Vol 44

No

71

QUANTITATING CAREGIVER

WORK LOAD

IN

THE ICU

ologically based classification system. Crit Care

Med

198I;9(8):

Miranda DR, de Rijk A, Schaufeli W. Simplified therapeutic


vention scoring system; the TISS-28 items

inter-

591-597.
3.

results

from a multi-

Kreling B, Robinson

DK, Bergner M. Data

collection strategies in

center study. Crit Care

Med

1996;24(l):64-73.

SUPPORT.
4.

Clin Epidemiol 1990;43 Suppl:5S-9S.

Clermont G. Angus DC, Linde-Zwirble


Measuring resource use
in the

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

with computerized therapeutic


1

intervention scoring system-based data. Chest 1998;


5.

13(2):434-442.

CHni E, Vitacca M, Ambro.sino N. Dependence nursing

scale

(DNS);

Moreno

R. Reis

Miranda D. Nursing

staff in intensive care in

Eu-

a method to assess the effect of nursing workload in a respiratory


intermediate intensive care unit. Respir Care 1999;44(l):29-37.
10.

rope: the

mismatch between planning and

practice.

Chest 1998;

113(3);752-758.
6.

Reis Miranda D, van der Veen


In;

J,

Moreno

R. Patients and facilities.

Cullen DJ, Nemeskal

AR, Zaslavsky AM.


1.

Intermediate TISS: a

new

Reis Miranda D, Ryan

DW,

Schaufeli

WB,

Fidler

(eds).

Or-

therapeutic intervention scoring system for

non-ICU

patients. Crit

ganisation and

management of

intensive care; a prospective study in

Care

Med

1994;22(9); 1406-141

12 European countries. Heidelberg/Berlin

Germany; Springer, 1997.

72

Respiratory Care January 1999 Vol 44

No

Mani S Kavuru

MD and James K Stoller MD, Series Editors

PFT Nuggets

A New

Feature for the Journal: Introducing

PFT Nuggets

With

this

volume of the Journal, we introduce

new,
"nug-

to

be experts about graphical

data.

Because PFTs feature

regular feature which

we

call

PFT

Nuggets.

Named

elements of graphical data, they (eg, flow-volume loops,

gets" with the intention of providing a valuable item in a

and spirograms) are the province for respiratory care practitioners' expertise.

compact package,

this series will consist

of a number of

installments, each of

which

will present a brief clinical


test

How

will this

new

feature be presented in the Journal?

vignette and a related


sult.

pulmonary function

(PFT)
is

re-

Readers can expect 2


easily be

PFT

nuggets

in

each regular volume

On
is is

the basis of the case details, a question

posed

over the next year. Although the contributed nuggets can

that

clinically

common and

important and to which the

grouped logically by topic

(eg,

flow-volume loops,

reader

challenged to respond.

brief discussion in each

lung volume measurements, etc), each volume will feature


2 nuggets that are not logically connected. For example, a

installment answers the question, emphasizing interpretation of the

PFT

results and,

we
this

believe, providing a clin-

case highlighting interpretation of the flow-volume loop

ically relevant

nugget for respiratory care practice.


ask:

may accompany
spirometry.

a case discussing end-of-test criteria for


in

The reader may


believe that

Why

new

feature?

The Editors
valuable

Our purpose

avoiding logical grouping

is

to

PFT Nuggets
PFTs

offers several

new and

preserve the challenge of each nugget, thus eliminating the


clues that

benefits to the Journal's readers. First, a thorough under-

come from grouping


and

related cases.

standing of

is critical

for respiratory clinicians, both

As

the editors of this series,

we

think that

PFT Nuggets

when

they are actually performing the tests and when, in

will provide instructive that is presented in a


clinical learning

clinically relevant material

their care of patients, they are interpreting the results.

To

way

that simulates the process of

the extent that this important information

is

sometimes
in clinical

and

is

fun. In this regard,

we hope
of the

this

inadequately understood but

is

commonly used

new

feature will advance the purposes of the Journal in


clinical expertise
re-

practice, this feature addresses an important part of the

enhancing the knowledge and


spiratory care

respiratory care curriculum. Second, because clinicians


learn through clinical encounters, these "case-based" nug-

community.

gets are designed to optimize clinicians' education

by simDirector,

ulating clinical experiences. Third,

by

virtue of their tech-

Mani S Kavuru Pulmonary Function Laboratory


James

MD
MD

nical orientation,

respiratory care practitioners are

graphically oriented practitioners

who

are often regarded

Stoller

Vice-Chairman, Division of Medicine


Correspondence: Mani S Kavuru

MD.

Director.
Critical

Pulmonary Function

Laboratory, Department of Pulmonary

&

Care Medicine. Cleve-

Department of Pulmonary and

Head, Section of Respiratory Therapy Critical Care Medicine

land Clinic Foundation, 9500 Euclid Avenue, Cleveland

OH

44195-

The Cleveland

Clinic Foundation

5038.

Cleveland, Ohio

Respiratory Care

January 1999 Vol 44

No

73

Borderline Normal?
Albert Rafanan

MD

and Mani S Kavuru

MD
Man

Case Summary

Table

1 .

Results of Screening Spirometry on a 50- Year-Old

during an "Executive Physical"

A
163
1.

50-year-old man, asymptomatic nonsmoker, has an


is

Test

Predicted

Prebronchodilator

Predicted

"executive physical" and a spirogram

performed.

He

is

FEV,

(L)

cm

tall

(Table

1).

Is this

spirogram normal?

2.

Why?
Discussion

Strictly speaking,

based on the American Thoracic Sostrategies,' the listed spi-

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,

ratio are all

above the "lower

limits of

normal." Using Crapo's regression equation for males


in litersBTPs)

0.0414

X Ht
is

(cm) minus 0.0244

age (years) minus 2.19] for a 50-year-old


tall,

the predicted

mean FEV,

3.34 L.

X who is 163 cm The 95% confiL.^.

dence interval (CI) for FEV, for a


fore, the

man

is

0.842

There5"'

"lower limit of normal" defined as below the


is

percentile
the

3.34

L minus

0.84

or 2.50 L. In this patient,

measured FEV, of 2.61

L is above the 2.50 L "lower limit

of normal" or within the normal range. In the absence of a CI


value as in this case,
it

can be calculated by 1.64

the

standard error of estimate (SEE) (or 1.64

0.486

0.80).

Broadly speaking, the 2 sources of variation

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

other sources of variation being

considered

noise.-*

The
is

typical strategy in

pulmonary funcmeasured
val-

tion interpretation

to

compare

a patient's

ues with published reference values generated from pop-

Drs Rafanan and Kavuru are

affiliated with the

Department of Pulmonary

& Critical Care Medicine. Cleveland Clinic Foundation, Cleveland, Ohio.


Correspondence; Mani S Kavuru

MD.

Director,

Pulmonary Function
Care Medicine,

Laboratory, Department of Pulmonary

&

Critical

Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland

OH

44195-5038.

r
REFERENCES
American Thoracic Society. Lung function
erence values and interpretative strategies.

Borderline Normal?

3.

testing; selection of ref-

Am

Rev Respir Dis 1991:

4.

144(5):1202-1218.

Crapo RO, Morris AH. Gardner RM. Reference spirometric values


using techniques and equipment that meet

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.

ured spirometric indices: what

is

significant? Chest 1981:80(1):

Am

Rev Respir Dis 1981:123(6):659-664.

97-99.

Respiratory Care January 1999 Vol 44

No

75

56- Year-Old

Smoker With Dyspnea

Naresh Mansharamani

MD

and Mani

S.

Kavuru

MD

Case Summary

decline in lung function. All of these statements remain


speculative.

56-year-old male active smoker

pack per day for

Although various indices have been used


bronchodilator response, the most

to express
are:^

40 years) presents with a history of chest tightness and difficulty in breathing with frequent awakenings at night.

commonly used
1

(1) absolute change (forced expiratory volume in

second

The symptoms were


respiratory infection.

first

noted after a recent

viral

upper

[FEV|] postbronchodilator minus FEV, prebronchodi lator),

He

has some dyspnea with exertion.

(2)

change as the percentage of prebronchodilator

His physical examination including the chest examination


is

value (FEV, postbronchodilator minus

FEV, prebronchodichange as a per-

normal. Chest x-ray

is

normal. Results of screening


1

lator/FEV| prebronchodilator

100), (3)

spirometry are shown in Table


1.

centage of predicted value (FEV, postbronchodilator mitests?

How

do you

interpret the

pulmonary function
agonists

nus FEV, prebronchodilator/FEV| predicted

100).

2. Is there a significant 3.

response to albuterol?
j3

Although the most commonly used of these


is

is

change as a
is

Do you

think that therapy with

indi-

percentage of the

initial

prebronchodilator value, this

cated?

also the parameter that has been reported to be

most dewith

Discussion

pendent on baseline airway caliber. Specifically, greater


bronchodilator percentage response
is

seen

in patients

Although an acute one-time response


chodilator
is

to

an inhaled bron-

greater initial air flow obstruction. Preliminary data suggest that


less

assessed frequently in pulmonary function

change as a percent of predicted value may be

laboratories in patients with air flow obstruction,

many
is

dependent on baseline airway caliber and

may

offer

questions remain regarding the usefulness of this practice.

some advantages." Bronchodilator responsiveness has been


studied in epidemiologic studies involving a general population as well as selected groups of patients.
that
It

Discussion continues regarding such questions as what


the best parameter to measure,
reversibility,

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

the clinical implication of

no response

to bron-

change of between 150-200


of measurement variability

mL is likely to be on the basis


itself.''''

chodilators.

The following

are

commonly

offered reasons

Although certain

for performing a postbronchodilator study:- (1) bronchodilator response could help establish a diagnosis (presum-

dices of small airway disease, such as forced expiratory

flow between

25% and 75%


is

of the forced

vital

capacity

ably a positive bronchodilator response would favor asth-

(FEFjs.v,), have been used

to assess bronchodilator re-

ma), (2) a bronchodilator response

may

justify a

more

sponse, there

a great deal

more

variability in these tests,

aggressive therapy with bronchodilators, (3) a positive re-

with higher coefficients of variation. Also, these parameters are

sponse

may

predict a response to steroid therapy, and (4)

dependent on forced
If the

vital

capacity

(FVC) and

a bronchodilator response

may be

helpful prognostically,

forced expiratory time.

FVC

changes between the

possibly implying a better prognosis and slower rate of

pre- and postbronchodilator study, the postbronchodilator

FEF2575
value.

is

not comparable with the prebronchodilator

Although volume adjustment for FEFi^.vj has been


is

Dr Kavuru
this

is

affiliated with the

Department of Puhnonary

&

Critical

used, this strategy


studies

less than satisfactory. Also, clinical

Care Medicine, Cleveland Clinic Foundation, Cleveland. Ohio.


partment of Pulmonary

When

show
is

that less than

8%

of bronchodilator responcriteria alone in the

paper was prepared. Dr Mansharamani was affiliated with the De-

siveness

identified

by FEF2,75
criteria.''

& Critical Care Medicine, Cleveland Clinic Founand


is

dation. Cleveland. Ohio,

currently affiliated with the Department

absence of meeting FEV,

of Pulmonary

&

Critical

Care Medicine. Boston Deaconess Hospital.

The American Thoracic Society


adults
if

guidelines

recommend

Boston, Massachusetts.

that a significant response to a bronchodilator exists in

the percent

change
is

is

s 2%
1

Correspondence: Mani S Kavuru

MD.

Director.
Critical

Pulmonary Function

Laboratory, Department of Pulmonary

&

Care Medicine. Cleve-

change

in

FEV,

or

FVC

greater than

and the absolute 200 mL." Studies

land Clinic Foundation, 9.S00 Euclid Avenue, Cleveland

OH

44195-

suggest that the use of bronchodilator response to separate

5038.

asthmatic patients from patients with chronic obstructive

76

Respiratory Care January 1999 Vol 44

No

A
Table

56-Year-Old Smoker With Dyspnea

Results of Screening Spirometry on a 56-Year-Old

Man

with Dyspnea

Drug
Hugh S Mathewson

MD and Joseph

L Rau PhD RRT.

Section Editors

Capsule

opioids and Respiratory Depression


Thomas

Davis

CRNA MAE

and Hugh S Mathewson

MD

Nearly

all

experienced respiratory care practitioners have


in the in-

pounds
in

that
1.

have agonist or antagonist properties are shown

witnessed opioid-induced respiratory depression


tensive care unit, or have been

Table

Many

gradations exist between pure opioid

summoned
is

to the postan-

receptor agonists, such as morphine and fentanyl congeners,

esthesia care unit to provide support for respiratory failure

and pure antagonists such as naloxone. So-called


such as butorphanol and nalbuphine, can

caused by opioids. The problem


tive in restoring

usually remediable with-

partial agonists,

out delay; naloxone or other antidotes are promptly effec-

provide analgesia to a limited degree without respiratory


depression.

normal breathing. However, deaths from

They can be used

to treat the

depression of

opioid overdose are occasionally reported, and some of


these fatal occurrences are preventable. Fear of respiratory

potent opioids; one study demonstrated that nalbuphine

can restore respiratory function with minimal loss of analgesic effect."

depression has induced physicians to underuse opioids for

cancer pain.'--^ Recent appeals

to state

medical boards have


be adequately pro-

Noninvasive routes of opioid administration, such as


transdermal or transmucosal, have

been made

to assure that pain control

become more widely


still

vided in patients with cancer and other intractable causes.-*

used, but the hazard of respiratory depression

exists.
is si-

Monitoring of opioid
oxygenation,
is

effects, especially

on ventilation and
and
is

Another approach

to

minimizing opioid depression

the

answer

to this problem'^

the

multaneous administration of nondepressant analgesics.

theme of

this article.
is

Respiratory depression by opioids


ever, the response to a given dose
patients.
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

preparations. However, ketorolac, another nonsteroidal an-

When

the initial parenteral dose


effects be observed

given,

(NSAID) has become widely used


is

as

important that

its

and recorded, since


are

a parenteral supplement to opioids.

Another class of drugs

subsequent doses will probably be required.^ This principle also applies


utilized.

under study for

this
is

purpose

a-2 adrenergic agonists, of

when

other

modes of administration
is

which clonidine

the best

known. Although these agents


produce analgesia, they

The

introduction of patient-controlled analgesia

act synergistically with opioids to

and neuraxial (spinal or epidural) administration

based

do not contribute
bert," are

to respiratory depression.'-

on the assumption

that pain control

can be achieved with


patient can titrate

greater continuity and less risk.

The

The opioid receptors, as classified by Atcheson and Lamshown in Table 2. Recent research, both experis

intravenous opioids with patient-controlled analgesia in


proportion to the level of pain intensity.^
Intrathecal

imental and clinical,

directed toward development of


It

opioid congeners with less respiratory depressant effect.


is

and epidural opioids causing respiratory de-

generally accepted that central opioid analgesia

is

me-

pression are emphasized in a recent review.** Epidural opioid analgesia has

diated through the ju.-receptor.


sion
is

Whether respiratory depresis

become an

established

method of pain
partic-

similarly mediated

is

unclear; there

evidence that
it

control during obstetrical labor and delivery, but both fetal

6-receptor stimulation

may

be contributory.'-* In humans
/i-

and maternal depression can


action

occur.**

Neonates are

may

be possible to synthesize opioids that are

but not

ularly vulnerable to opioid-induced apnea. Also, this side


is

likely to occur in the frail elderly.'"

Opioid com-

6-stimulant. 6-receptor agonists that reverse respiratory

depression have been found, but significant analgesia


lacking.'-'*

is

An

animal study showed

that muscarinic stim-

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

ulation produced by physostigmine or carbachol decreased

fentanyl-induced respiratory and circulatory depression."'

affiliated with the

Department of Anesthesiology. Uni-

No

subsequent formulations utilizing

this

mechanism have

Kansas Medical Center. Kansas City. Kansas.

been advanced for


It

clinical investigation.

Correspondence: Hugh S Mathewson


tory Care Education. University of

MD.

Medical Director of Respira-

has long been

known

that pain antagonizes opioidre-

Kansas Medical Center, 3901 Rain-

induced depression and tends to maintain the normal


spiratory response.

bow

Blvd. Kansas City.

KS 66160-7282.

The underlying

postulate

is

that pain

78

Respiratory Care January 1999 Vol 44

No

Opioids and Respiratory Depression

Table

Opioid Agonists and Antagonists

Agonists

Morphine
Meperidine
Fentanyl
Sufentanil
Alfentanil

Remifentanil
Agonist-antagonists

Pentazocine

Butorphanol

Nalbuphine
Buprenorphine

Dezocine
Antagonists

Naloxone
Naltrexone
Nalniefene

Table

2.

Classification of Opioid Receptors"

Effect

M-1

Opioids and Respiratory Depression

5.

Mulroy MF. Monitoring opioids (review). Reg Anesth 1996:21(6


Suppl):89-93.

13.

Atcheson R, Lambert

DC

Update on opioid receptors

(editorial).

Br
14,

Anaesth 1994:73(2): 132-1 34.


is

6.

Pasero CL. McCaffery M. Avoiding opioid-induced respiratory depression.

Freye E, Latasch L. Portoghese PS. The delta receptor


sufentanil-induced respiratory depression
diate different effects.

involved in

Am
J

Nurs l994;94(4):24-30.

opioid subreceptors medifferent subreceptors.

7.

Sinatra RS. Current methods of controlling post-operative pain (re-

Eur

Anaesthesiol I992:9(6):457^62.

view). Yale
8.

Biol

Med

199h64(4):3.'51-374.

15
(re-

Freye E. Schnitzler M, Schenk G. Opioid-induced respiratory depression and analgesia

Chaney MA. Side


view).

effects of intrathecal

and epidural opioids

may be mediated by

Can

Anaesth l995:42(10):891-903.

9.

Bruelle P, Ferrer

JM. Macheboeuf M, Roert C. Viel

E,

Eledjam

JJ.

16.

[The use of opioids by the regional route


thesiol 1991;39(2):97-103.
10.

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

in the frail elderly (re17.

view). Clin Geriatr


11

Med

1996;12(3):583-599.

Borgbjerg

FM.

Nielsen K. Franks

J.

Experimental pain stimulates

Bailey PL. Clark NJ. Pace

NL. Stanley TH, East KA, van Vreeswijk


1):

respiration and attenuates morphine-induced respiratory depression:

H,

el al.

Antagonism of postoperative opioid-induced respiratory


18.

a controlled study in

depression: nalbuphine versus naloxone. Anesth Analg I987;66(l

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

Toxicol Clin Toxi-

DA, Duncan SR,

Segal IS.

Maze M.

Ventilatory effects of

col 1998;36(1-2):11-17.
19.

clonidine alone and in the presence of alfentanil, in


teers.

human

volun-

Diehl DL. Acupuncture"s transition to credibility


the latest chapter.
J

in the

United States:

Anesthesiology 1992;76(6):899-905.

Altern

Complement Med 1997:3(4):421^23.

80

Respiratory Care January 1999 Vol 44

No

Listing

and Reviews of Books and Other Media. Note


RhSPiRATORV Cark.

lo publishers:

Send review copies of books,

films, lapes. and software to

6(K1 Ninth

Avenue. Suite 702. Seattle

WA

98104.

Books, Films, Tapes, & Software

Methods

in

Pulmonary Research.

Stefan

Methods," contains a very interesting and


well-presented chapter on aerosols and a

are described in the literature, thus enabling

Uhlig and Aubrey

E Taylor,

Editors. Hard-

one

to

view the data and conclusions


critical light.

in a

cover, illustrated, 541 pages. Basel/Boston/


Berlin: Birkauser Verlag: 1998; $130.00.

chapter on cryopreservation. In addition,


there
is

more informed and

a particularly well referenced ap-

This
text is
tist.

new

international multi-authored
at the

pendix containing useful respiratory physiologic data of various animal species.

Simon

Hillier

MD
Care

Medical Director. Respiratory Care


Section of Pediatric Anesthesia and
Critical

aimed primarily
editors,

basic scien-

The

from Germany and the

Generally the authors succeed

in their

U.

S., state that


is

the major purpose of this

aim of bringing readers "up


the various techniques;
ters are

to speed" in

book

as a resource for investigators

who

most of the chapand feachapters

Department of Anesthesia
Riley Hospital for Children
Indianapolis, Indiana

plan to incorporate these scientific tech-

good

starting places for the inves-

niques within their own laboratories. Therefore, this

tigator considering the applicability


sibility

volume

is

of most value to the

of a given technique.

The

Essentials of

Cardiopulmonary Exercise

basic scientist involved in pulmonary research, and


it

are generally well balanced, despite the ex-

Testing. Jonathan
illustrated,

Myers PhD. Hardcover,

is

not surprising that the

maand

pectation that a certain

amount of bias could

177 pages. Champaign, IL: Hu-

have been introduced by the authors, have invested a significant portion of

who
their

man

Kinetics; 1996. $24.00.

jority of the authors are basic .scientists

that

most of the methods they describe


specifically

are
\

animal

methods.

How-

scientific careers developing expertise in

their specific experimental

methods. The

ever, there are several chapters that include

discussions of clinical

human

editors deserve credit in this regard.

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

attractively presented with

good

inches, but
tion.

it

is

packed with useful informais

methods.
lustrations

accompanying most chapters.

The book

divided into 7 chapters


in exercise

Of

the

20 primary authors, 7
1

from
is
1

well indexed, with few typographical er-

covering a range of topics

phys-

North America,

3 are from Europe, and

rors.

The

references appear to be reason-

iology and testing including: the cardiopul-

from Australia. The book contains 20 chapters

ably current, although there are very few

monary response
bration of

to exercise, use

and

cali-

and

is

divided into 7 sections: airways,

from 1997.
this

It

is

impossible for a book of

commonly used measurement


hemodynamic
is

vessels,

edema, airway liquid (including


fi-

type to cover every experimental

devices, applications to disease states, and a

surfactant), cell culture, histology, and,


nally, aerosols

method, and some omissions are inevitable.

chapter on invasive
testing.

exercise

and cryopreservation. Each


unique advantages and dis-

However,

this

reviewer was surprised


the impor-

chapter provides a discussion of the rationale, technique,

that there

was no discussion of
for determination of

The book's intended audience


cians, nurses

"techni-

tant techniques of fluorescent microsphere

and other individuals" perform-

advantages, and important findings to date

methods

pulmonary
Both these

ing cardiopulmonary exercise testing;

how-

of various scientific techniques.

blood flow distribution or of the multiple


deals with
inert gas elimination technique.

ever,

it

is

quite appropriate for

anyone
test-

The

first

section in the

book

involved with cardiopulmonary exercise


ing.

airways and contains chapters on the mea-

methods have
and disease.

significantly

enhanced our
in

The 2

introductory chapters are particu-

surement of lung function


explants,

in rodents,

lung

understanding of lung function

health

larly well written

and provide an organized

and tracheal preparations, and an

introduction to exercise physiology and mea-

excellent chapter
lung.
ters

on

the isolated perfused

The chapter on

aerosols contains

some

surement.
is

particular strength of this

book

The

section

on vessels includes chapmicroscopy of the airway

interesting information that

might be of

the use of tables and figures that not only

on

intravital

value to the interested respiratory care practitioner,


is

reinforce textual material but also


rize

summaFor

circulation, the bronchial circulation,

and

although most of

this

information

and present data

in

new ways

that clarify

vascular occlusion techniques to determine

readily available elsewhere in clinical


I

difficult topics in exercise physiology.

segmental resistance and compliance. The


section concerning
ters
ical

textbooks.

suspect

that,

in

general, the

example, within the

first

10 pages of the text

edema

contains chap-

remainder of

this text will

be of limited

the author gives a graphical

summary of physthat
I

on lymphatics, experimental and clinmeasurement of pulmonary edema,


microscopy of surface lung

value as a resource for physicians, therapists, technicians,

iologic responses to progressive exercise

and nurses, unless they


in the basic

workload
seen.

that is

one of the best

have

neurogenic inflammation of the airways,

are actively laboratory.

working

science

As
I

a physician

who

has performed car15

and

intravital

The book may be

useful to the

diopulmonary exercise
years,

tests for nearly

vessels and
tion

interstitial pressure.

The

sec-

readership of this Journal as a resource for

found

this helpful in

and

will use this

concerning airway liquid contains

those

who

wish to understand more

fully

type of

summary
is

my

future teaching.

The

chapters on transport processes, bronchoalveolar lavage, and assessment of surfactant


function.

some of the

laboratory techniques described

writing style

clear and

more conversational

in the basic science

and

clinical literature.

than technical, particularly appealing to those

The The

section on histology contains

By

reviewing this

text, the

Journal reader

new

to the field.

chapters on
diology.

lung ultrastructure

and autora"Further

should understand more fully the merits and


limitations of the scientific

The

stated

aim of

the text

is

to provide a

final section, entitled

methods

that

reference or introductory text for tho.se in-

Respiratory Care January 1999 Vol 44

No

81

Books, Films, Tapes,

&

Software

volved in clinical or research use of exercise testing, with particular

Laboratory Exercises for Competency


Respiratory Care. Thomas
J

in

ture format.

As

practitioners,

we all

develop

emphasis on gas

Butler

MS

a "scripf regarding our explanations of pro-

exchange.
in this aim.

believe that the author succeeds

RRT RPFT,
and Robert
trated,

Janice

Close

RRT RPFT,
illus-

cedures to patients. The student should be

The progression of chapters leads

Close RRT. Soft-cover,

allowed sufficient freedom to develop his


or her

the reader through the basics of physiology,

577 pages. Philadelphia: F

Davis

own

comfortable "script," while pro-

equipment setup, and measurements. Exercise texts tend to be dense,

Co; 1998. $47.95.

viding valuable information to their patients.

packed with math-

ematical equations, and difficult to read. This

The ever-changing world of health care makes the education of respiratory care practitioners

As educators, we provide guidelines for safe


and effective
care, while the developing

book

is

quite readable. For example, the

an enduring challenge. The scope

practitioners interpret this information

and
eth-

author's description of joules, mets, and ex-

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

compassion, assessment, and

critical

"Cardiopulmonary Responses
clarifies

to Exercise,"

The

student of respiratory care


first

may

thinking must be solid and only then will


these developing practitioners be ready for
the challenge of putting these guidelines into
action.
I

an area that

is

frequently difficult

be studying for the

time, or the student

for those

new

to the subject.

Chapter 4, "In-

may

well be a health care practitioner re-

formation from Ventilatory Gas Exchange


Data," also presents clear and accurate explanations of what
individuals.
is

learning important information.

believe the text met these intended

Laboratory Exercises for Competency


in Respiratory Care, authored by respiratory care educators, gives us a dependable

goals as stated in the Introduction.

a "black

box

" to

many

Home
ventilator

care techniques are not covered,

The book is technically well assembled. The type font is easily readable
and the tables and figures are clearly drawn

except for a single section in the chapter on

yet flexible educational tool.

The student
of

in

modes. This omission may be un-

the laboratory setting has the opportunity to


fail

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.

propriate for the length of the book.

kind to guide these opportunities toward consistent, safe,

The only major shortcoming of the book


is

and effective

practice.

While

Ideally, standardized

approaches can

Chapter

5,

"Applications in Cardiovascu-

intended for students, the book could also

be taught and applied

in the

home

as they

lar

and Pulmonary Disease." The sections

be used to update and re-educate staff members in the institutional setting

are applied in the hospital setting. Proce-

on cardiac disease are reasonably complete,


covering coronary disease, valvular heart
disease, congestive heart failures,

who have

dures for proper metered dose inhaler administration via a ventilator circuit

completed
ucation.

their

own

formal health care ed-

were cu-

and other

riously absent. Otherwise, the content covers


vii

topics in detail.

However, a scant 1-1/4 pages


pulmonary diseases, a major

The Preface on Page

caught

my

at-

all

areas of standard, institutional respira-

are devoted to

tention; the authors refer to

"cookbook meth-

tory care.

Each chapter includes an

intro-

area of clinical and research effort in car-

odologies" and their "avoidance of stifling


intellectual curiosity."
I was interested in book would use to help

duction,

list

of objectives, and key terms.


for the exercises is

diopulmonary exercise
tual discussion

testing.

More

Equipment required
listed, as

tex-

and

clinical

examples need

the approach the

well as a thorough description of

to

be devoted

to the effects of

pulmonary

stimulate critical thinking in the lab or clinic.

each exercise to be performed. Each chapter

disease on exercise performance.


ical laboratories are

Many clin-

Upon
spired

reading the Introduction,

was

in-

proceeds with a review of the preceding

presented with the pa-

by the author's views on the intended


text. I

procedural information called the Laboratory Report and offers Critical Thinking

tient referred

from the pulmonary clinic with

use of the

would encourage

instruc-

tors to read the Introduction

mild chronic obstructive lung disease or


asthma, but with significant dyspnea.
tailed

aloud or give

Questions.

A deis

time prior to the


to read
it

start

of lab for each student


careful reading will

The Procedural Competency Evaluations


(PCEs)
at the

critically.

understanding of the effects of pullimitation

end of each chapter enable the

monary

allow both students and instructors to clearly understand the evaluation objectives.

student to be evaluated after "mastering"


the procedure.

on exercise capacity

The PCEs provide feedback

crucial for the individual involved with clinical exercise testing.

From an educator's standpoint, I was also


pleased to discover an accompanying Instructor's

to the student in both the cognitive/motor

and affective learning domains. In a more


detailed look at the

Aside from
able, clear,

this, I

found the book readin


its

Guide online

at the
I

Davis

PCEs,

wondered why

and logical
it

approach and

World Wide
this text.

Web

site.

believe this re-

the scale (pass/fail) for performance of as-

would recommend
cise physiology

as a reference or in-

source will help instructors get the most from

sessment, implementation, and follow-up


utilized a different scale than the Perfor-

troductory text for those interested in exer-

and

testing.

The order and organization of


familiar and logical in sequence.

topics are
I

mance

Criteria

( I

through 5)

at the

end of
an-

appreci-

the procedure performance section.

The

Joshua

Benditt

MD

ated the breadth and depth of the sections


that

swer was found

in the author's

statement
uti-

Director of Respiratory Care Services


University of Washington Medical Center

document procedures,

as nearly

all

stan-

that the procedure should


lizing the

be attempted
"a
skill

dard institutional procedures are addressed

PCE

only

when
to

has been

Division of Pulmonary

by
the

the text.

It

would be outside
it

the intent of

mastered." The student's perception of


"mastery"

& Critical

Care Medicine

book and make

too lengthy to try to

may need

be validated as the
subjectivity of this
revisited

Department of Medicine
University of Washington School

include every minute detail of, for example,

quarter progresses.

The
is

explaining the entire rationale of pursed

lip

part of the evaluation

when

the

of Medicine
Seattle,

breathing to a patient. This level of detail

author mentions "significant prompting" by


the instructor.
I

Washington

could be included

in the lecture text

or lec-

would explore the usage of

82

Respiratory Care

January 1999 Vol 44 No

Books, Films, Tapes,

&

Software

a larger,

more

criteria-laden,

and possibly

basic concepts and principles of medical in-

reader to self-test to as great a degree as he

less subjective scale in the

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

ences allow the reader to quickly review


relevant background material, as necessary,

The Laboratory Rules and Safety


efficient learning experience.

and lay the foundation for the specialized


discussions of cardiovascular, respiratory

of the text gives guidelines for a safe and

before continuing. Although the level of detail

As

an instruc-

system, and chemical measurements in the

may be greater than most clinicians need


it

tor looking for standardization

of proce-

succeeding chapters. Clinical laboratory and


radiology instrumentation are each covered
in their

in routine use, the fact that

is

there

if

and

dures,

found the inclusion, where avail-

when

it

is

needed

is

comforting. All clini-

able,

of

American
The

Association

for

own
and

chapters. Chapters

on

thera-

cians and technicians involved with medical instrumentation

Respiratory Care Clinical Practice Guidelines encouraging.

peutic and prosthetic devices (including ventilators)

should have a working


in

increasing use of

electrical safety

round out the

knowledge of many of the topics covered


this text, especially the chapter

these guidelines should help to simplify

body of the book. The numerous appendices cover the standard prefixes and units of
the

on

electrical

teaching of respiratory care procedures.

The
il-

safety.

appendices and numerous illustrations were


helpful and informative.
lustrations

Systeme Internationale

(SI),

physical
the

A
phy

great deal of care

was taken

to

make
to

The

variety of

constants, and

common
is

abbreviations.
at the

book

visually appealing.

Good

typogra-

was

also impressive. Finally, the


in

While

this

work

aimed squarely

in larger

type sizes allows this


in the usually less

work

glossary of key terms presented


ter

each chap-

biomedical engineering student (senior to


graduate level),

be easily read

than opti-

was another pleasing

addition.

much of
its

the information

mal lighting conditions of the average medical facility.

The book
usage;
all

is

well designed for student

contained within

pages

may be of

value

of the pages, including the index,

to respiratory therapists, nurses,

and physi-

tions are

The clear and concise illustraaccompanied by well-written

are 3-hole-punched

and perforated, although

cians.

Of special

interest will

be the discus-

captions that, for the most part, do not force


the reader to return to the text for explanations.

these perforations might cause problems

sions of pulmonary measurements, blood


analysis, ventilators,

with

lost

pages due to heavy use. Overall.


text to

and

electrical safety.

As

with any good textbook, there are


printing errors (one of

found the
tional

be suitable for our educaI

The conceptual

level

of the discussion in
all cli-

few typographic or
the

program and

am

considering

it

for

the chapters should be accessible to

few obvious

errors occurs in Figure 3.7a,

use in the near future.

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

terest primarily to clinical

and biomedical

Medical Instrumentation: Apis

Respiratory Care Department

engineers and technicians.

plication

and Design

a well written text

Providence General Medical Center


Everett.
Seattle Central

As a biomedical

engineering text and sur-

which provides the reader or student with a


gentle introduction to medical instrumentation design. This

Washington Washington

vey of medical instrumentation with an emphasis on design, the book


is

Community College
Seattle,

an outstanding
is

volume would make an

success.

The choice of

subjects
is

well

excellent addition to the reference shelf of

Medical Instrumentation: Application and Design. 3"' ed. John G Webster, Editor.

thought out, and the material

presented in

any respiratory care department, especially


departments with research programs.

a very readable style (for a textbook).

The

Hardcover,

illustrated.

691 pages.

New

chapters are presented in a logical order and


relate well to

York: John Wiley

& Sons Inc.

1998. $87.95.

each other. Each chapter pro-

Matthew

Sailors

BEBME MEBE

Like previous editions, the third edition


of John

vides both discussions on the conceptual


level, as well as technical

Medical Informaticist

Webster's Medical Instrumen-

and engineering

Cottonwood Hospital
Doctoral Student

tation: Application
origin, acquisition,

and Design covers

the

details so that readers of all interest levels

and processing of bio-

will find

something useful. The combina-

Department of Medical Informatics


University of Utah

logical signals

from an engineering design

tion of integrated

examples (with solutions)

viewpoint. The opening chapters cover the

and homework-style problems allows the

Murray, Utah

Respiratory Care

January 1999 Vol 44

No

83

The American Association for Respiratory Care


Clinical Practice Guidelines
Removal of the Endotracheal Ibbe Single-Breath Carbon Monoxide Diffusing Capacity, 1999 Update
Suctioning of the Patient in the

Home
and Evaluation of Response

Selection of Device, Administration of Bronchodilator,


to

Therapy in Mechanically Ventilated Patients


RespirCare 1999;44{l}:85-n3
Previously Published Guidelines:

>

Spirometry, 1996 Update


Selection of an
Patients

via Nasal Prongs or Nasopharyngeal


'

Tube

Oxygen Delivery Device for Neonatal and Pediatric

Surfactant Replacement Therapy


Static

'

Lung Volumes
Respir Care 1994;39(8):797-836

Selection of a Device for Delivery of Aerosol to the Lung

Parenchyma
>

Training the Health-Care Professional for the Role of Patient and

Caregiver Educator

Transport of the Mechanically Ventilated Patient


Fiberoptic Bronchoscopy Assisting

Providing Patient and Caregiver Training

Resuscitation in Acute Care Hospitals


Intermittent Positive Pressure Breathing

Respir Care 1996;41(7):629-663

Bland Aerosol Administration


Respir Care 1993:38(11): 1169-1200

Assessing Response to Bronchodilator Therapy

at

Point of Care

Discharge Planning for the Respiratory Care Patient

Long-Term Invasive Mechanical

Ventilation in the

Home

Directed

Cough
Artificial

Capnography/Capnometry during Mechanical Ventilation


Selection of an Aerosol Delivery Device for Neonatal and Pediatric
Patients

Endotracheal Suctioning of Mechanically Ventilated Adults

and Children with


Airways
Analysis and Hemoximetry

In-Vitro

pH and Blood Gas

Polysomnography

Single-Breath Carbon Monoxide Diffusing Capacity Use of Positive Airway Pressure Adjuncts to Bronchial

RespirCare 1995:40(12}: 1300-1 343


Defibrillation during Resuscitation

Hygiene Therapy
RespirCare 1993;38(5):495-521
Patient- Ventilator

Management of Airway Emergencies


Infant/Toddler Pulmonary Function Tests

System Checks

Humidification during Mechanical Ventilation


Selection of Aerosol Delivery Device

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

Transcutaneous Blood Gas Monitoring for Neonatal and Pediatric


Patients

Capillary Blood

Gas Sampling

for Neonatal

and Pediatric Patients

Blood Gas Sampling Oxygen Therapy in the Home


Arterial

or Extended Care Facility

Body Plethysmography
Respir Care 1992:37(8):882-922
Respir Care 1994;39(12): 1170-1 190

Incentive Spirometry

Pulse Oximetry

Ventilator Circuit

Changes

Delivery of Aerosols to the Upper Airway

Oxygen Therapy
Spirometry

in the

Acute Care Hospital

Neonatal Time-Triggered, Pressure-Limited, Time Cycled

Postural Drainage Therapy

Mechanical Ventilation

Application of Continuous Positive Airway Pressure to Neonates

Respir Care 1991:36(12): 1398-1426

84

Respiratory Care January 1999 Vol 44

No

Guidelines, Recommendations,

& Statements

AARC Clinical Practice Guideline


Removal of the Endotracheal Tube
RET
1.0

PROCEDURE
adult, pedi-

taneous ventilation and should not require high levels

Removal of the endotracheal tube from atric, and newborn patients.

of positive airway pressure to maintain normal

arterial

blood oxygenation.

4.1 Patients in

whom

further medical care


futile

is

RET 2.0 DESCRIPTION/DEFINITION:


To ensure
patient safety, the patient with a

considered (and explicidy declared)

may

tempo-

have the endotracheal tube removed despite


continuing indications for the
artificial

rary, artificial translaryngeal

airway should have the

airway.

device removed at the earliest appropriate time. Occasionally, acute airway obstruction of the artificial

4.2 Acute artificial airway obstruction

manif

dates immediate endotracheal tube removal

airway due to mucus or mechanical deformation

the obstruction cannot be cleared rapidly. Rein-

mandates immediate removal of the

artificial air-

tubation or other appropriate techniques for


reestablishing the airway must be used to maintain effective gas

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).

2.1 Prolonged translaryngeal intubation

is

asso-

RET 5.0 CONTRAINDICATIONS:


There are no absolute contraindications
tion;
tion, positive

ciated with

many complications
-

including but

to extuba-

not limited to sinusitis,'

vocal cord injury,'


'"^'^

however, some patients will require reintubapressure ventilation, continuous posi-

laryngeal injury,^' laryngeal stenosis,^' tracheal


injury,*^*

hemoptysis," and pulmonary infection.

tive

airway pressure, noninvasive ventilation, or

2.2 Extubation

may

result in

upper airway ob" laryngeal

high inspired oxygen fraction to maintain acceptable gas exchange after extubation.
tive reflexes are usually

struction

from laryngospasm,"

Airway protecfol-

edema,"" " or supraglottic obstruction;-" pul-

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.

RET 3.0 SETTINGS:


The endotracheal tube should be removed in an environment in which the patient can be physiologically monitored and in which emergency equipment
and appropriately trained health care providers with
airway management
able.
skills are

RET 6.0 HAZARDS/COMPLICATIONS:


6.1

Hypoxemia
is

after extubation

may

result

from but

not limited to

6.1.1 failure to deliver adequate inspired

oxygen
airway;

fraction through the natural upper

immediately avail-

6.1.2 acute upper airway obstruction; 6.1.3 development of postobstruction pul-

RET 4.0 INDICATIONS/OBJECTIVES:


When
the airway control afforded by the endotrais

monary edema;
6.1.4 bronchospasm;

cheal tube

deemed

to

be no longer necessary for

6.1.5

development of
pulmonary

atelectasis, or lung

the continued care of the patient, the tube should be

collapse;

removed. In general, the patient should be capable


of maintaining a patent airway and adequate spon-

6.1.6

aspiration;

6.1.7 hypoventilation

Respiratory Care

January 1999 Vol 44 No

85

AARC Guideline: Removal of the Endotracheal Tube

6.2 Hypercapnia after extubation


caused by but
is

may be

pH

not limited

to:

and arterial partial pressure of carbon dioxide during spontaneous ventilation;-'-^

6.2.1 upper airway obstruction resulting

from edema of the trachea, vocal cords, or


larynx;
6.2.2 respiratory muscle weakness; 6.2.3 excessive

8.1.3
8.1.4

adequate respiratory muscle


inspiratory pres-

strength;

work of breathing;
futility is

sure

maximum negative > 30 cm H2O;-"'


body weight;"

6.2.4 bronchospasm.

8.1.5 vital capacity greater than 10


ideal

mL/kg

6.3 Death

may occur when medical

the reason for

removing the endotracheal

tube.

8.1.6 pressure measured across the di-

RET 7.0 LIMITATIONS OF METHODOLOGYA^ALIDATION OF RESULTS


Patients

aphragm during spontaneous less than 15% of maximum;


tion

ventilation

8.1.7 spontaneous exhaled minute ventila-

may need reintubation immediately


due

or after

< 10

L/min.-'

some

interval

to inappropriate extubation, pro-

8.1.8 in adults, respiratory rate

< 35

dur-

gression of underlying disease, or development of a

ing spontaneous breathing;'" in infants and

new disorder. A trial of extubation may be used in some marginal patients with the expectation that the
need for reintubation
is likely.

children, acceptable rate decreases with

age and can be predicted and measured


with good repeatability

when determined

by

stethoscope.""

The need

to reinsert
is

an

artificial

airway following

8.1.9 in adults, a rapid shallow breathing

extubation

not necessarily an indication of poor

index (RSB, respiratory rate-to-tidal-vol-

practice. Inadequate airway

maintenance and

fail-

ume

ratio)

of

<

98-130;"""" in infants and

ure of reintubation
practice.

may

be an indication of poor

children, neither a ntodified

CROP

index

(derived from compliance, resistance,


oxygenation, and ventilating pressure) nor

The

failure

and complication

rates of extubation

a modified

RSB

has been shown to be a

can be used as quality monitors.

superior discriminator between successful

and unsuccessful

extubation.^'"'^)

RET 8.0 ASSESSMENT OF NEED


The endotracheal tube should be removed
as soon

8.1.10 thoracic compliance > 25 H20;^'

mL/cm

as the patient no longer needs an artificial airway.


Patients should be capable of adequate spontaneous

work of breathing < 0.8 J/L;"""*'^^ 8.1.12 oxygen cost of breathing < 15%
8.1.11
total;^'^"

ventilation and should not require high levels of

positive airway pressure or inspired

oxygen
F102

to

8.1.13 dead-space-to-tidal-volume ratio


0.6;'"

<

maintain adequate

arterial

blood oxygenation. (Ex-

perience suggests
0.40.)

PEEP <10 cm H2O and

8.1.14 absolute tracheal pressure in the


first 0.1
H20;'^'

second of occlusion < 6


is

cm

" (This measurement

primarily a

8.1 Patients receiving an artificial airway to facilitate

research tool.)

treatment of respiratory failure should

8.1.15

maximum

voluntary ventilation >

be considered for extubation when they have

twice resting minute ventilation.-'


8.2. In addition to treatment

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-

ure, artificial airways are

sometimes placed for


is

airway protection. Resolution of the need for


airway protection
limited to
8.2.1

pressure of oxygen on in-

may

be assessed by but

not

spired oxygen fractions provided with

simple oxygen devices and with low levels

normal consciousness,'^'

of positive airway pressure;

8.2.2 adequate airway protective reflexes,''' 8.2.3 easily

8.1.2 the capacity to maintain appropriate

managed

secretions.

86

Respiratory Care

January 1999 Vol 44 No

AARC Guideline: Removal of the Endotracheal Tube

8.3 In addition to resolution of the processes re-

10.1.10 Pulse oximeter


10.1.11 Supplies for arterial puncture and

quiring the insertion of an artificial airway,

is-

sues that should be considered in


prior to extubation are 8.3.1

all

patients

blood gas analysis.


10.2 Personnel

no immediate need for reintubation

10.2.1 Level-II personnel, credentialed

anticipated;

and/or licensed health care personnel with


'*

8.3.2 no previously identified difficulties

with

intubation;''^

8.3.3 presence of gas leak around the de-

flated

cuff with positive pressure

breaths;"^'

8.3.4 evidence of stable, adequate

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

dynamic function;^"^ 8.3.5 evidence of stable nonrespiratory


functions;"""

of invasive airways should be immediately available

8.3.6 electrolyte values within normal


range.'**'

whenever extubation

is

per-

formed.

10.2.2 Level-I personnel, credentialed

RET 9.0 ASSESSMENT OF OUTCOME


Removal of
the endotracheal tube should be fol-

and/or licensed health care personnel with

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

cal examination, auscultation, invasive

outcome may be assessed by physiand


arterial

noninvasive measurements of
values,

blood gas

the artificial airway, anyone with airway

and chest radiography.

maintenance

skills

may remove

the endolife.'"

9.2 Quality of the procedure can be systemati-

tracheal tube to save the patient's

by monitoring extubation complications and the need for reintubation.


cally assessed

RET 11.0 MONITORING


The success of removal of
the endotracheal tube

RET 10. RESOURCES


10.1 Equipment:
10.1.1

can be monitored by examining the frequency of


reintubation and frequency of complications.

When

Oxygen source

a patient experiences an unplanned self-extubation

10.1.2 Devices to deliver oxygen-enriched gas mixtures


10.1.3 High-volume suction source

and does not require reintubation, this suggests that planned extubation should have been considered
sooner."'*

10.1.4 Pharyngeal and tracheal suction


catheters

RET

12.0

FREQUENCY

10.1.5 Self-inflating or non-self-inflating

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

airway. Acute, artificial airway obstruction


at

may

occur

any time and must be recognized and

10.1.8 Translaryngeal intubation equip-

treated immediately.

ment (laryngoscope
teries, stylettes)

blades, handles, bat-

RET 13.0 INFECTION CONTROL


Caregivers should exercise Standard Precautions
for
all

10.1.9 Equipment for establishing an

emergency surgical airway (scalpel, lidocaine with epinephrine, appropriately


sized endotracheal or tracheostomy tubes)

patients, follow

control of exposure to

recommendations for tuberculosis and droplet nu-

CDC

clei,"'* and, in addition, institute appropriate pre-

Respiratory Care

January 1999 Vol 44 No

87

AARC Guideline: Removal of the Endotracheal Tube

cautions empirically for airborne, droplet, and con14.

I99I;3(4):3I4-3I6.

Guffin TN, Har-el G, Sanders A, Lucente FE, Nash M.

tact agents

pending confirmation of diagnosis

in pa-

Acute postobstructive pulmonary edema. Otolaryngol

tients

suspected of having serious infections."


15.

Wilson

Head Neck Surg I995;l 12(2):235-237. GW, Bircher NG. Acute pulmonary edema
after

devel-

Endotracheal Tube Removal Working Group


Charles

oping
illofac

laryngospasm: report of a case.

Oral

Max-

Surg I995;53(2):2I 1-214.


associated with tracheal

G Durbin Jr MD,

Chairman

Charlottesville

VA

16.

Hartley

M, Vaughan RS. Problems


Br
J

Robert S Campbell RRT. Cincinnatti

Richard

D Branson RRT,

OH Cincinnati OH

extubation.
17.

Anaesth l993;71(4):56l-568.
Elkharrat
laits

Darmon JY, Rauss A, Dreyfuss D, Bleichner G,


D, Schlemmer B,
et al.

Evaluation of risk factors for

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62. Clochesy

Med

1984;144(5):1012-1016.

Chest 1995; 108(4): 10 18- 1020.


B.

46. Kirton

Morgan JP, Windsor J, Civetta JM. Elevated imposed work of breathing masquerading as ven-

OC, DeHaven
weaning

cally critically

JM, Daly BJ, Montenegro HO. Weaning chroniventilatory ill adults from mechanical support: a descriptive study. Am J Crit Care
1995;4(2):93-99.

tilator

intolerance. Chest 1995;108(4): 1021-1025.

47. Shikora

SA,

Bistrian

OR, Borlase BC, Blackburn GL,

63. Biery

DR, Marks JD, Schapera A, Autry M, Schlobohm


Katz JA. Factors affecting perioperative pulmonary
in

Stone

MD,

Benotti PN.

Work

of breathing: reliable pre-

RM,

dictor of

weaning and extubation. Crit Care

Med

function

acute

respiratory

failure.

Chest

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AARC Guideline: Removal of the Endotracheal Tube

1990;98(6): 1455- 1462.


64.

dictors for reintubation. Chest 1994;105(5):1496-1503.


72. Epstein

Hammond MD,

Bauer KA, Shaqj JT, Rocha RD. Respira-

SK. Etiology of extubation

failure

and the predic-

tory muscle strength in congestive heart failure. Chest

tive value of the rapid

shallow breathing index.

Am

1990;98(5): 1091-1094.
65. Sapijaszko

Respir Crit Care


73.

Med

1995;152(2):545-549.

MJ, Brant R, Sandham D, Berthiaume Y. Nonintensive care unit patients. Crit Care

Whelan

J,

Simpson SQ, Levy H. Unplanned extubation:


Chest 1994;105(6):1808-1812.

respiratory predictor of mechanical ventilation depen-

predictors of successful termination of mechanical ventilatory support.

dency
66.

in

Med

1996;24(4):601-607.

74. Tindol

GA

Jr,

DiBenedetto RJ, Kosciuk L. Unplanned ex-

Smith IE, Shneerson JM.

progressive care

programme

tubations. Chest 1994;105(6):1804-1807.

for prolonged ventilatory failure; analysis of outcome.

75. Vassal T,

Anh NG,

Gabillet

JM, Guidet B, Staikowsky


unit. Intensive

F,

Br J Anaesth 1995;75(4):399-404.
67.

Offenstadt G. Prospective evaluation of self-extubations


in a

Scheinhom DJ, Hassenpflug M, Artinian BM, LaBree L, Catlin JL. Predictors of weaning after 6 weeks of mechanical ventilation. Chest 1995;107(2):500-505.

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Care

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1993;19(6):340-342.
76. Franck LS,

68. Aubier

M, Murciano D, Lococguic Y,

Viires N, Jacquens

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care.

Vaughan B, Wallace J: Extubation and reintuNICU: identifying opportunities to improve

Y, Squara P, Pariente R. Effect of hypophosphatemia on


diaphragmatic contractility in patients with acute respiratory failure.

PediatrNurs 1992;18(3):267-270.
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J,

1985;313(7):420-424.

Committee, Centers for Disease Control and Prevention.


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Viires N, Piquet

Murciano D, Blanchet

Guidelines for Isolation Precautions in Hospitals. Atlanta

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preventing the transmission of Mycobacterium tuberculosis in health-care facilities.

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Register 1994;59(208), Friday Oct 28, 1994: 54242-

54303. www.cdc.gov

Interested persons

may photocopy

these Guidelines for noncommercial purposes of scientific

or educational advancement. Please credit

AARC and RESPIRATORY CARE Journal.

90

Respiratory Care

January 1999 Vol 44 No

'

AARC Clinical Practice Guideline


Single-Breath Carbon Monoxide Diffusing Capacity, 1999 Update

DLCO
ide

1.0

PROCEDURE
monox-

DLCOsb

is

measured

is

also

commonly

report-

Single-breath diffusing capacity for carbon

(DLCOsb), sometimes referred to as the transfer factor for carbon monoxide (TCO).

body temperature and pressure, saturated with water


ed; the units for the are liters at

VA

vapor (BTPS).
2.3

The

ratio

of

DLCO to VA is also commonly

DLCO 2.0 DESCRIPTION/DEFINITION


The
Care
first

reported as the

DL/VA or simply DA'A.

American Association

for Respiratory

(AARC)

single-breath diffusing capacity (DL-

DLCO 3.0 SETTINGS:


3.1

COsb) Clinical Practice Guideline (CPG) was published in 1993, and was based largely on the American Thoracic Society (ATS) 1987 recommendations.'

Pulmonary function laboratories

3.2 Cardiopulmonary laboratories

3.3 Clinics

Since that time, the

ATS

has published

new
re-

3.4 Physicians' offices

recommendations.- This updated


flects the

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.

DLCO 4.0 INDICATIONS:


Tests of diffusing capacity

may be

indicated for

(Specific conditions and direction of change in

DLCO are shown in the Appendix.):


4.1 evaluation and follow-up of parenchymal

lung diseases including: idiopathic pulmonary


fibrosis (IPF, also

known

as usual interstitial

pneumonitis, or UIP) and bronchiolitis obliter-

ans organizing pneumonia

(BOOP, or crypto-

genic organizing pneumonia, COP), diseases


associated with dusts such as asbestos, or drug

Diffusing capacity

is

measurement of carbon

reactions (eg, from amiodarone) or related to


sarcoidosis;" and for quantification of disability associated with interstitial lung disease;
^

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

4.2 evaluation and follow-up of

emphysema

allow determination of the gas exchanging

and cystic

fibrosis;""

and differentiating among

capability of the lungs. Although several different

chronic bronchitis, emphysema, and asthma in


patients with obstructive patterns;
tification

methods of measuring DLCO have been described, the most commonly used technique is the singlebreath maneuver, or

and for quan-

of impairment and disability.

DLCOsb- For purposes of this guideline, recommendations associated with the

4.3 evaluation of cardiovascular diseases (eg,

primary pulmonary hypertension, acute or


edema);'*

re-

DLCOsb

are referenced.^

Many

of these standards

current thromboembolism, or pulmonary


4.4 evaluation of pulmonary involvement in
systemic diseases (eg, rheumatoid
arthritis, sys-

apply indirectly to other methods of measuring diffusing capacity.


2.1

DLCO is usually expressed in mL CO min


temperature and pressure dry

torr' at standard

temic lupus erythematosus);'"


4.5 evaluation of the effects of chemotherapy

(STPD).
2.2

The alveolar volume (VA)

at

which the

agents or other drugs (eg, amiodarone,

Respiratory Care

January 1999 Vol 44 No

91

AARC Guideline: Carbon Monoxide Diffusing Capacity,

1999

Update

bleomycin) known to induce pulmonary dysfunction;'-"

DLCO 7.0 LIMITATIONS OF METHODOLOGYA^ALIDATION OF RESULTS: 7.1 Limitations of the common


for

4.6 evaluation of pulmonary hemorrhage;'^


4.7 as an early indication of certain pulmonary
infections (eg, Pneumocystis pneumonia);'"

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.^"

4.8 prediction of arterial desaturation during


exercise in

some

patients with lung disease.""*

DLCO 5.0 CONTRAINDICATIONS


5.1 Absolute contraindications to performing a

7.1.1.1 For adolescent boys(> 15 years

of age) and adult men, the

Hb

is

adjust-

diffusing capacity test are

ed to a value of 14.6 g/dL:

5.1.1 the presence of carbon


toxicity

monoxide

Hb-adjusted

DLCO = observed DLCO (10.22


Hb)/1.7Hb.

-t-

5.1.2 dangerous levels of

oxyhemoglobin

7.1.1.2 For children

<

15 years of age

desaturation without supplemental oxygen.

and
Hb-adjusted

women

the

Hb

is

adjusted to a

5.2 Relative contraindications to performing a


diffusing capacity test are

value of 13.4 g/dL:

DLCO = observed DLCO (9.38


Hb)/1.7Hb.

-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;

7.1.2 For purposes of interpretation,

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

5.2.2 a large meal or vigorous exercise

DLCO

increases with increasing al-

immediately before the


5.2.3

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

DLCO (1.0 + 0.0035(PaO2


or

120])

Altitude-adjusted

DLCO

= measured
150])
-

DLCO (1.0 + 0.0031(Pio2torr].)

ed or maintained or the unavailability of a


qualified operator.

(where estimated P102 = 0.21 [PB


7.1.4

47

4-minute minimum interval


test

DLCO 6.0 HAZARDS/COMPLICATIONS:


6.1

should elapse between subsequent malung


ei-

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

the upright seated position


ed.

body position; is recommend-

trathoracic pressure) maneuver. Either of these

can result
heart and

in alteration

of venous return to the

7.1.6

6.2 Interruption of supplemental


result in

pulmonary capillary blood volume. oxygen may

Abnormal breathholding maneuvers (Valsalva or Muller) alter DLCO.-'

7.1.7 Other factors that

may alter measure-

oxyhemoglobin desaturation. 6.3 Transmission of infection is possible via


improperly cleaned mouthpieces or as a conse-

ment of DLCO include recent alcohol consumption," vigorous exercise, smoking,


diurnal variation, and bronchodilators.-'

quence of the inadvertent spread of droplet nuclei or

7.1.8 Pregnancy (first trimester only) has

body

fluids (patient-to-patient or patient-

been reported

to

be associated with an

in-

to-technologist).

crease in DLCO.-"* Menstruation

may

also

92

Respiratory Care

January 1999 Vol 44 No

AARC Guideline: Carbon Monoxide Diffusing Capacity,

1999 Update

influence

DLCO."

valve and circuit


source
is

(if a

compressed gas

7.1.9 Breathhold time should be calculat-

used).

ed using the method of Jones-Meade."


Other methods

7.4.7 Chemical absorbers (for

CO2 and

may produce

significantly

H2O)

or selectively permeably tubing


at the

different results.

should be replaced

frequency rec-

7.2 Large interlaboratory differences in mea-

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

saturated (as indicated by color change) or

sooner. In addition, the chemical absorbers should be placed in the proper

order

(ie,

CO2

absorber should precede

H2O

absorber), should be replaced

when

exhausted, and should be arranged according to


7.4.8

how

alveolar gas

is

analyzed.

Normal standard

subjects (biologic
to establish intra-

controls)

may be used

subject coefficient of variation and to


serve as a quality control population.

DLCO

8.0

ASSESSMENT OF NEED

(see Sec-

tion 4.0 Indications)

performed, using a 3.00

(min-

imum)
7.4.2

syringe. Spirometer

must maintain
.

DLCO 9.0 ASSESSMENT OF TEST QUALITY:


Individual test maneuvers and results should be
evaluated according to the
9.1

accuracy with varying gas concentrations


a 2-point calibration before

Gas analyzers should be subjected to each test. Manufacturers should be encouraged to provide software and techniques by which
analyzer linearity

ATS

recommendations.-

Use of proper quality-controlled equipment.

9.2 Provision of test instructions before testing

may

be easily checked

(eg, dilution technique).

Gas analyzer

lin-

earity should

be

7.4.2.1 within
full

span, of

1%, from zero to maximal value over the


test,

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

patients with moderate to

duration of the

severe airway obstruction.


9.4 Breathhold times of 9-1
1

7.4.2.2 formally checked at least


quarterly.^"

seconds, with no

evidence of leaks or Valsalva or Miiller maneuvers.

Timing device should be checked every 3 months'" and be accurate within


7.4.3

9.5 After the breathhold, there should be appropriate clearance of

1%

over a 10-second period.

7.4.4

The
1.5

entire circuit resistance should


at a

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

the circuit resistance to

exceed recom-

space) should be 0.75-1.00 the subject's

The washout volume (ie, dead L or 0.50 L if

VC

is

less than 2.0 L. If a

The apparatus dead space should be


L. In-line filters need to be account-

<

0.

washout volume other than 0.75-1.00 L must be used, it should be noted.


9.5.2 If an in-line filter
is

ed for when determining entire system dead space as well as discard volume (before alveolar collection).

used,

when

de-

termining discard volume, the


space must be accounted
for.

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

required for 6 L/s flow through a

Respiratory Care

January 1999 Vol 44 No

93

AARC Guideline: Carbon Monoxide Diffusing Capacity,

1999

Update

pie should be 0.5-1.0 seconds.


9.6

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.

values should be reproor 3

and training

ducible to within
is

We

min torr recommend empirically


'

mL CO

',

respiratory therapy or

program in pulmonary function


in biolog-

technology or 2 years of college


ical sciences

no more than 4-6 maneuvers be performed.

and mathematics) and 2 or


spirometry, lung

9.7

The subject should have refrained from

more years performing

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.

volumes, and diffusing capacity tests."

One or more of the following credentials is recommended: RPFT, CPFT, RRT,


CRT.

9.8 Corrections for Hb,

COHb

should be

in-

cluded as noted above (Sections 7.1.1 and


7.1.2); correction for tests
is

DLCO

11.0

MONITORING:

(Also see Section


'

performed
is

at altitude

9.0 Assessment of Test Quality)

recommended.

If

Hb correction

made, both
values

the corrected and uncorrected

DLCO

The following should be evaluated during the performance of the DLCO measurement to assess the
validity of the results:

should be reported.

11.1 Acceptability of the maneuvers and repro-

DLCO 10.0 RESOURCES


10.1 Equipment:

ducibility of

DLCOsb:

11.1.1 patient positioning: subjects should

10.1.1 Volume-measuring device must

meet or exceed ATS recommendations.


10.1.2 Appropriate gas analyzers depen-

be seated for at least 5 minutes prior to testing and should remain seated throughout the

DLCO testing session,


tests to

dent on the methodology employed; certified calibration gases for use before each
series of

11.1.2 interval between tests: at least 4

minutes between sequential


elimination of tracer gas,

allow

measurements.
for analysis of total

10.1.3

COoximeter

11.1.3 reproducibility, with at least 2 ac-

Hb

and

COHb is

strongly

recommended.

ceptable tests that are within

10%

or 3

10.2 Personnel: Diffusing capacity tests should

be performed under the direction of a physician


trained in

mL CO(STPD)/min/mm Hg age DLCO.


tions), effort

of the aver-

pulmonary function

testing.

The

11.2 Level of understanding (of test instruc-

value of diffusing capacity results can be com-

promised by poor patient instruction secondary


to inadequate technologist training. Thus, tech-

and cooperation by the subject. 11.3 Equipment function or malfunction (eg,

calibration), with

equipment quality control


is

nologists should have

documented

training,
dif-

performed as recommended, any time accuracy


is

with continued competency assessments in

suspect or

if

the equipment

moved

to a dif-

fusing capacity administration and recognition

ferent location.

of errors encountered in the testing process as well as a sound understanding of pulmonary

11.3.1

Volume

calibration

and leak testing

performed on a daily
11.3.2
quarterly,

basis,

pathophysiology. Diffusing capacity testing

Gas analyzer

linearity

checked

may be performed by
for either Level
I

persons
II.

who meet criteria

or Level
I:

11.3.3 Timer tested quarterly 11.3.4 Tests on standard subjects (biologic

10.2.1 Level ing

The

technologist perform-

DLCO should be a high school gradudemonstrated


abil-

controls, or bio-QC)should be perat least

ate or equivalent with a


ity to

formed

on a quarterly basis and


is

perform basic pulmonary function

any time accuracy


tested

suspect.-

studies such as spirometry (and

Level
tests

DLCOsb). personnel should perform DLCO

11.3.4.1 Standard subjects should be

more frequendy

initially to estab-

only under the supervision of a Level

lish statistical variation for

comparison.

94

Respiratory Care

January 1999 Vol 44 No

AARC Guideline: Carbon Monoxide Diffusing Capacity,

1999 Update

11.3.4.2

It is

Bio-QC
tervals."

at

advantageous to perform weekly or semi-monthly in-

cautions empirically for airborne, droplet, and contact agents


tients

pending confirmation of diagnosis

in pa-

suspected of having serious infections."

11.4 Reference equations: each laboratory


should select reference equations appropriate
for the

13.2 Proper use of barrier devices (eg, protective gloves)

may be

useful to prevent spread of

methods and the population

tested.

contagion via direct contact. Hand washing

11.5 Inspired oxygen concentration: test gas concentration should be 20.93% and at sea
level pressure. Subjects should

remain off supminutes prior to

must always be performed between patients, and protective gloves must be worn if there are open cuts, or sores, on the technologist's
hands.-

plemental oxygen for

at least 5

performing the

first test.

Technologists should

document
ty to

(in the final report)a patient's inabilial-

remain off supplemental oxygen for the

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.

Mycobacterium tuberculoorganisms, recommended

11.6

The
The

final report

should contain a statement


should contain the
(Hb,

sis or other airborne

about
11.7

test quality.

precautions are:"

final report

DLCO,
and

the corrected

DLCO

COHb,
(ie,

altitude),

the

Hb

value used for correction.

The alveolar

volume (VA) and DLA'A


ing capacity to the lung

the ratio of diffus-

volume at which the measurement was made) may be included in


the report. These values are helpful for purpos-

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

department specially venti-

lated for isolation patients.

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

not possible, the

patient be returned to the isolation


as soon as possible,

room

and the testing room


1

being corrected [eg, corr

DLCO

(Hb), corr

be closed for a minimum of


13.3.2

to 2 hours.

DLCO (CO)].
11.8

DLCOsb

results should

be subject to ongo-

Pulmonary function technologists performing procedures on patients with


potentially infectious airborne diseases

ing review by a supervisor, with feedback to the

technologist. Quality assurance


quality

(QA) and/or
ini-

should wear a personal respirator that


meets

improvement (QI) programs should be


basis.

OSHA recommendations,

especial-

designed to monitor the technologist both


tially

ly if the testing itself induces coughing.''

and on an ongoing

13.4 The mouthpiece, tubing, and any parts of


the system that

come

into contact with the sub-

DLCO 12.0 FREQUENCY: The frequency at which DLCO


tion(s) to

ject should be disposable or sterilized

between
It

measurements

patients. If sterilization

is

not feasible, then

should be repeated depends on the clinical quesbe answered.

high-level disinfection should be performed.


is

unnecessary to routinely clean the interior


13.4.1 Visible condensation, from expirate,

surface of the spirometer.

DLCO 13.0 INFECTION CONTROL:


Diffusing capacity tests are relatively safe procedures, but the possibihty of cross-contamination exists,

warrants cleaning of the system be-

fore testing another patient.

either

from the patient-patient or patient-tech-

13.4.2 Bacterial filters that allow rebreathing

nologist interface.''

may

be used
is

in circuit,

although

13.1 Technologists should exercise Standard Pre-

their efficacy

not well documented.

cautions for

all pafients,

follow recommendations

However, such

filters

may impose added

of the Centers for Disease Control and Prevention


for control of exposure to tuberculosis

resistance during inspiration or expiration

and droplet

and affect the timing of the


neuver. If a
filter is

DLCO
filter

ma-

nuclei, and, in addition, institute appropriate pre-

used, the

dead-

Respiratory Care

January 1999 Vol 44 No

95

AARC Guideline: Carbon Monoxide Diffusing Capacity,

1999

Update

space volume should be considered in the


calculation of

with bleomycin-containing combination chemotherapy.

DLCO and VA.


Group

Cancer Chemother
15.

& Pharmacol

1993;32:407-409.

Crapo RO, Forster

Diffusion Capacity Working

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

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GR, Saber FA, Gaensler EA. Determination of severe


(disability) in interstitial lung disease.
1

Peavy HH, Summer

WR,

Gurtner G. The effects of acute

impairment

Am
23.

ethanol ingestion on pulmonary diffusing capacity.

Rev Respir Dis 980; 2 :647-659.


1 1

Chest 1977;4:488-492.

5.

Ogilvie C. The single-breath carbon monoxide transfer test

Lawson WH.

Effect of drugs, hypoxia, and ventilatory

ma-

25 years on: a reappraisal.


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2.

Clinical considerations (ed-

neuvers on lung diffusion for

CO in man. J Appl Physiol


MC, Moran
the pul-

Thorax 1983;38:5-9.
Clinical
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testing: a

1972;32:788-794.

6.

Morris

AH, Kanner RE, Crapo RO, Gardner RM.


2nd
ed. Salt

Milne JA, Mills RJ, Coutts JRT, MacNaughton


F,

pulmonary function
tory procedures,

manual of uniform labora-

Pack AI. The

effect of

human pregnancy on
monoxide
as

Lake

City: Intermountain

monary

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measured

Thoracic Society, 1984.


7.

by the single breath method. Clin Sci Mol


1977;53:271-276.
25. Sansores R,

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Knudson RJ, Kaltenbom W, Burrows B. Single breath carbon monoxide transfer factor in different forms of
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Gibson N, Abboud R. Variation of pulmonary

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diffusing capacity

(DLCO)

during the menstrual


Part

Thorax 1990;45:514-519.

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in pa-

Am

Rev Respir Dis 1991; 143(4,

8.

Light

RW, George RB.

Serial

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26. Clausen
J,

tients with acute heart failure.

Arch Intern

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Crapo R, Gardner RM. Interlaboratory compar-

1983;143:429-43.
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isons of pulmonary function testing (abstract).

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Rev

Gibson GJ, Edmunds JP, Hughes and lung involvement


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GRV. Diaphragm function


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Respir Dis

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from 13 laboratories
1991;36:1375-1382.
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metropolitan area. Respir Care

Gross M, Esterly JR, Earle RH. Pulmonary alterations


systemic lupus erythematosus.
1972;105:572-577.

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Rev Respir Dis

Hathaway EH, Tashkin DP, Simmons MS.


variability in serial

Intra-individual

measurements of DLCO and alveolar


in eight healthy subjects

11.

Frank ST,

Weg

JG, Harkeroad LE, Fitch RF. Pulmonary

volume over one year


1989;140:1818-1822.
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using

dysfunction in rheumatoid disease. Chest 1973;63:27-34.


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three independent systems.

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Rev Respir Dis


a per-

Comis RL. Bleomycin pulmonary


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Oncol, 1992;19(Suppl 5):64-70.

Crapo RO, Gardner RM.


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RP, Wilcox PA. The effect of irradiation on lung


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1986; 134:856.
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31.

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96

RESPIRATORY CARE

JANUARY 1999 VOL 44 NO

AARC Guideline: Carbon Monoxide Diffusing Capacity,

1999

Update

personnel qualifications.
1986;134(3):623-624.
32.

Am

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Committee, Centers for Disease Control and Prevention.


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J.

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JS, Hospital Infection Control Practices Advisory

54303. www.cdc.gov

Appendix Follows

Respiratory Care

January 1999 Vol 44 No

97

A ARC Guideline: Carbon Monoxide Diffusing Capacity,

1999

Update

APPENDIX
Factors that Result in a Decrease in

DLCO

Factor
Deficiency in red blood cells

Condition Giving Rise to Factor

Anemia
Multiple pulmonary emboli, early collagen-vascular disease, early sarcoidosis, miliary tuberculosis

Loss of pulmonary capillary bed with relatively normal lung volume


Loss of functioning alveolar-capillary (A-C) bed with increased lung volume
Loss of functioning A-C bed with decreased lung

Emphysema

volume

Parenchymal restrictive processes including pulmonary resection, idiopathic interstitial fibrosis, asbestosis, scleroderma lung disease, histiocytosis-X,

sarcoidosis,

pneumonia

Failure of inspired air to reach alveoli, or poor dis-

Seen occasionally with severe obstruction during


asthmatic or bronchitic attack; seen frequently with

tribution of ventilation with low, normal or in-

creased lung volume

emphysema and poor effort


Factors that Result in an Increase in

DLCO

Factor
Increase in pulmonary capillary blood volume

Condition Giving Rise to Factor


Left heart failure, left-to-right shunt
fect,
(atrial septal

de-

anomalous pulmonary venous

return), exercise

Increase in red blood cells

Early polycythemia

Specific Abnormalities

Leading

to

an Increase in

DLCO*

Abnormality

Precipitation Condition

Lung compression
Increased airway resistance

Scoliosis, obesity, pectus

excavatum
airway lesions

Asthma, cystic

fibrosis, central

Pulmonary vascular congestion


Intrapulmonic hemorrhage

Congestive heart

failure, regurgitative valvular disease

Pulmonary hemosiderosis, Goodpasture's syndrome, hemothorax

'Physiologic' leaks

Tympanic

rupture, tracheoesophageal fistula

*The
listed

clinician should be suspicious if a patient with

any of the abnormalities and/or precipitating condition

proves to have a normal diffusing capacity.


Interested persons

may photocopy

these Guidelines for noncommercial purposes of scientific

or educational advancement. Please credit

AARC and RESPIRATORY CARE Journal.


Respiratory Care

98

January 999 Vol 44 No


1

'

AARC Clinical Practice Guideline


Suctioning of the Patient in the

Home

HCS
cial

1.0

PROCEDURE
artifi-

advisable include those


2.1.1.1 requiring only nasal or oropha-

Suctioning of the patient (with or without an


nasal, oropharyngeal,

airway) cared for in the home. This includes

ryngeal suctioning;''
2.1.1.2 without an endotracheal airway,

and endotracheal suctioning.

whose

vital capacity

and muscle

HCS 2.0 DESCRIPTION


Suctioning
is

strength are adequate to produce an effective cough;

component of bronchial hygiene

mechanical aspiration of secretions from the nasopharynx, oropharynx, and trathat involves the

2.1.1.3

whose

ventilatory drive has

been demonstrated to stem from hypoxia;'"

chea.

The airway may be

in its natural state or artifi-

cial (as

with a tracheostomy) or surgically altered

2.1.1.4 with a demonstrated tolerance


for the procedure with
tions.

(as with a laryngectomy).

The

patient

may

or

may

no adverse reac-

not be receiving mechanical ventilation.

The proce-

dure includes patient preparation, the actual suctioning event, and follow-up care and observation

2.1.4 Preoxygenation and/or hyperinflation

may be

indicated

in:

of the patient.
2.1 Patient preparation.

2.1.4.1 pediatric patients with decreased respiratory reserve;


2.1.4.2 patients

2.1.1

Whenever

possible, the patient

who have been docuoxygen desatura-

should be encouraged to clear the airway

mented

to experience

by directed cough or other airway clearance techniques.'

tion during the suctioning event as evi-

denced by pulse oximetry;


possible, the patient
2.1.4.3 patients

2.1.2

Whenever

who

exhibit cardiac

should be taught to perform this procedure for himself.^^


2.1.3 Preoxygenation or hyperinflation
prior to the suctioning event

dysrhythmias during the suctioning


event;

2.1.4.4 patients

who

are receiving con-

may

not be

tinuous supplemental oxygen.


2.1.5

routinely indicated for


for in the

all

patients cared

When preoxygenation
it is

and/or hyper-

home. Whenever possible the

inflation are indicated,


that this

recommended

patient's response to suctioning during his

be done manually using a resusci-

stay in the acute care or long-term care facility

tation

bag with supplemental oxygen, as


in the

should be made a part of the dis-

appropriate. All caregivers should receive

charge summary, and the health care professional establishing the patient in the

thorough instruction
tation bags

use of resusci-

home

should request

this information.

and manual hyperventilation techniques; improper or imprecise use of


resuscitation bags for hyperinflation can

Experience with neuromuscular patients

cause lung injury and respiratory alkalosis. If

suggests that hyperinflation


vital

when
is

the

hyperoxygenation or hyperventila-

capacity of such patients

< 1.5L

tion are not required, tidal

volume may be

makes

tracheal suctioning unnecessary.'*

conserved by passing the suction catheter


through the port cap on the swivel adapter
of the ventilator
circuit.

Other patients for


or hyperinflation

whom

preoxygenation

may

not be necessary or

Respiratory Care

January 1999 Vol 44 No

99

AARC Guideline:

Suctioning of the Patient

in

the

Home

2.1.6

Normal

saline solution should not

be

2.3 Follow-up care: Following the suctioning event

instilled routinely but

only
'^

when

specifi-

cally medically indicated"


to stimulate

(for example,

2.3.1 the patient should be monitored


for adverse reactions;'"*
2.3.2 the patient in

cough"").
event: Actual introduction

2.2

The suctioning

whom pre-procedure
the

of the suction device (catheter or oral suction


tip) into the

hyperoxygenation and/or hyperinflation


.

naso- or oropharynx, or into the

tra-

chea via the laryngostoma or artificial airway should be in accordance with existing Clinical
Practice Guidelines.''"
2.2.1
It is

was indicated should be treated by same method(s) post-procedure.'"-'

HCS 3.0 SETTING


accepted practice
This guideline applies only to the
ting. Alternate care sites
bilitation, or skilled

common and

home

care set-

to use 'clean' rather than sterile technique

such as subacute, reha-

during suctioning

in the

home

environ-

nursing facilities should use

ment, although scientific evidence to support or discount either technique in

Guidelines for suctioning in the acute care


setting.'*'*'

home

care

is

lacking."

2.2.2 Clean (non-sterile) gloves should be

HCS 4.0 INDICATIONS


The primary
tient

used when

endotracheal suctioning

is

per-

indication for suctioning the pa-

formed. Gloves reduce the risk of introduction of inoculant to the patient's


air-

cared for at

home

is

the patient's inability

to adequately clear the airway

by cough. The

way,'^ the risk of cutaneous infection in the caregiver, and transmission of organ-

need for airway clearance


4.1

is

evidenced by:

more frequent or congested-sounding

isms to
essary

others."* Gloves may not be necwhen oropharyngeal suctioning is


'"

cough;
4.2 coarse rhonchi and expiratory wheezing audible to the patient and/or caregiver

performed.
2.2.3

At the conclusion of the sucfioning

with or without auscultation;


4.3 visible secretions;

event, the catheter or tonsil tip should be

flushed by suctioning recently boiled or


distilled

4.4 increased peak pressures during vol-

water to rinse away mucus,

fol-

ume-cycled mechanical ventilation;


4.5 decreased tidal volumes during pres-

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;

4.7 suspected aspiration of gastric or

lowed

to air dry

Up should be aland then be stored in a


man-

upper airway secretions;


4.8 otherwise unexplained increase in
shortness of breath, respiratory rate, or
heart rate;

clean, dry area.

2.2.4 Suction catheters treated in the

ner described

may

be reused.

We

recom-

4.9 decreases in vital capacity and/or oxy-

mend

that the catheters

be discarded after

gen saturation
plugging.-^

(as indicated

24 hours although no evidence for or


against this can be found. Tonsil tips

oximetry), thought to be related to

by pulse mucus

may

be cleaned, boiled, and reused indefinitely. If it is

feasible to clean the suction deit

HCS 5.0 CONTRAINDICATIONS


When
no absolute contraindications exist and failure to suction can
suctioning
is

vice and subject


tion,
it

to high level disinfec-

indicated,

lost.^"

may be reused until its integrity is The importance of mechanical


(ie,

prove to be more detrimental than potential adverse reactions. Routine or 'scheduled' suctioning, with

cleaning cannot be overemphasized

removal of mucus and other organic material).

no indication of need

is

not recom-

mended.

100

Respiratory Care

January 1999 Vol 44 No

AARC Guideline:

Suctioning of the Patient

in

the Home

HCS 6.0 HAZARDS/COMPLICATIONS


Because the suctioning event is inherently the same in the home as in the critical care setting, the possible hazards and complications are the same. Dislodgement and introduction into the
lower airway of bacteria colonizing the tracheal
tube has been demonstrated. Further, the bacterial

other caregivers. The suctioning procedure

can be considered successful and the need for

suctioning affirmed by one or more of the


following:
9.1 removal of secretions;

9.2 improvement in breath sounds;

9.3 decreased peak inspiratory pressure

count introduced
is

saline

instilled.'-"

may be increased when The home care patient is

during volume-cycled mechanical ventilation;

not monitored by any except the most basic

9.4 increased tidal volume delivery during

methods, and the patient must be closely observed for


6.1
all

pressure-cycled mechanical ventilation;


9.5 clearing of cough;

of the following:
as indicated by such monitoring has

oxygen desaturation
if

9.6 improvement in oxyhemoglobin saturation as reflected

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;

9.7 subjective improvement as reported

by

patient;

9.8 a decrease in respiratory and heart rate

and decreased shortness of breath.

HCS

10.0

RESOURCES

6.6 pulmonary atelectasis;


6.7

bronchospasm or bronchoconstriction;

plies to

6.8 airway infection;

Equipment: Equipment and supused for suctioning the home care patient may include:
10.1
10.1.1 electrically

6.9 bleeding or hemorrhage from the air-

powered aspirator

way;
6.10 hypertension;
6.11 hypotension.

with a calibrated, adjustable regulator

and collection bottle with overflow


protection.
tor

battery-powered aspira-

may

be needed for the patient

who
fail-

HCS 7.0 LIMITATIONS OF PROCEDURE


Endotracheal suctioning
is

leaves the

home

or lives in an environ-

not a benign procesensitive

ment subject
ures;

to frequent

power

dure, and the caregiver should remain


to possible
all
ty.

hazards and complications, taking

10.1.2 suction catheters, sized appropriately.

necessary precautions to ensure patient safeSecretions in the peripheral airways cannot

Open suction systems are used most frequently. (The use of closed

be removed by suctioning. Optimal humidification of inspired gases

and appropriate systemic

systems has not been demonstrated to be medically indicated in the patient

hydration
airway

is

important to the maintenance of

who is not

immunosuppressed'*);

integrity.

10.1.3 tap water that has been boiled,


stored in a closed, clean container, and

HCS 8.0 ASSESSMENT OF NEED


The
ing
patient should be periodically assessed

used within 24 hours of boiling to flush

by

the catheter. (Water directly from the


tap should not be used because of the
possibility of contamination.'*)

the caregiver to determine the need

for suction-

when

itself.

the need does not obviously present For patients on long-term mechanical

10.1.4 clean or sterile gloves as indicated; barrier protection


fection
is

ventilation, this assessment should be included


in the patient/ventilator

when

active in-

system check.-'

present or suspected;

10.1.5 manual resuscitator

when hyper-

HCS 9.0 ASSESSMENT OF OUTCOME


Results and observations related to suctioning should be recorded to inform and alert

inflation

is

medically indicated;

10.1.6 oxygen source


genation
is

when preoxy-

medically indicated;

Respiratory Care

January 1999 Vol 44 No

101

AARC Guideline:

Suctioning of the Patient

in

the Home

10.1.7 sterile normal saline for instillation

ed

ability to effectively

when medically

indicated;

and clean,
store

disinfect,

wash hands and properly

10.1.8 oral suction device (eg, tonsil


tip);

equipment and supplies.

10.1. 9 sterile distilled and/or recently

HCS
The

11.0

MONITORING

boiled water and cleaning solution.

patient should be monitored to ascertain ef-

10.2 Personnel:

As

stated previously, the

fectiveness of the procedure and to detect any

patient should be trained in self-care

adverse reaction. Variables to be monitored


clude:

in:

whenever possible.
patient
is

In the event that the

unable to perform the proce-

11.1 breath sounds,

dure, the bedside caregivers (family

mem-

11.2 skin color

including

the presence

bers, personal care attendants, other des-

or absence of cyanosis,

ignated care givers) should be thoroughly

11.3 respiratory rate and characteristics, 11.4 heart rate,

trained and demonstrate their ability to

perform the procedure and clean and care


for equipment.'^

11.5 sputum characteristics (color, vol-

ume, consistency, odor)


11.6 blood pressure,

Only credentialed or licensed professional staff with documented


10.2.1
specialized training and experience in

11.7 ventilator variables (including tidal

volume, peak inspiratory pressure, respiratory rate, expiratory pressure),

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,

11.8 oxygen saturation by pulse oximetry

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

10.2.2 All caregivers should


strate a

All caregivers should practice infection control

procedures appropriate to the


ment.-'

cedure and the ability to perform the


procedure competently, including:
10.2.2.1

To

the extent feasible, patients should

be protected from visitors and caregivers with


active viral

knowledge of proper use


supplies;

and bacterial infections

that are air-

and assembly of all necessary equip-

borne or spread by direct contact.

ment and

10.2.2.2 ability to recognize that


suctioning
is

indicated;

10.2.2.3 ability to assess effective-

Immunizations recommended by the Centers for Disease Control and Prevention should be current in both caregivers and patient. When

ness of the procedure;

HIV

and/or hepatitis or other bloodborne infec-

10.2.2.4 ability to monitor vital


signs, assess the patient's condition,

tion are

known

to

tient's status is

be present or when the paunknown and when infection


is

and appropriately respond

to

com-

with organisms spread by droplet infection

plications or adverse reactions;

known

or suspected, specific precautions

10.2.2.5 ability to perform the pro-

should be instituted."

cedure with the least amount of risk


of introducing inoculant into the patient's

With

all

patients the steps undertaken are

airway;

13.1 proper handwashing before and after

10.2.2.6 knowledge of infection


control procedures and demonstrat-

performing the procedure;


13.2 clean or sterile suctioning technique

102

Respiratory Care

January 1999 Vol 44 No

AARC Guideline:

Suctioning of the Patient

in

the Home

as indicated;

morbidity for patients with Duchenne muscular dystrophy. Chest 1997:112:1024-1028.

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

9 American Association for Respiratory Care

AARC Clinical

practice guideline: nasotracheal suctioning Respir Care

1992:37r8):898-901.
10.

Naigow D. Powaser

MM.

The

effect of different endotra-

following
13.3.2 a 60-minute soak in a solution of

cheal suction procedures on arterial blood gasses in a

controlled experimental model. Heart


1977:6:808-816.
1

&

ung

vinegar and water with an acetic acid


content

1.

Estes RJ. Meduri

GU. The pathogenesis


I.

of ventilator-assotranscolo-

>

\.259c (The vinegar solution


reused.);"''"'

ciated pneumonia.

Mechanisms of bacterial

should not be

nization and airway inoculation. Intensive Care

Med

13.3.3 quaternary ammonium compound (prepared and reused according


to manufacturer's instructions);-''-'

1995;2U4):365-383.
12.

Ackerman MH. The


ing.

effect of saline lavage prior to suction-

Am J Crit Care

1993; 2:326-330.
saline

13.

Hagler

DA, Traver GA. Endotracheal


Care 1994: 3:444-447.
J.

and suction

13.3.4 glutaraldehyde;-'

catheters: sources of lower airway contamination

Am

13.3.5 boiling

when equipment

with-

Crit

stands such procedures;

14 Bostick

Wendilgass ST. Normal saline

instillation as part

13.4 proper storage of equipment and supplies

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

13.5 proper disposal of spent supplies and


infectious waste.-''
16.

American Association

for Respiratory Care.

AARC

Clini-

Respiratory

Home

Care Working Group

cal practice guideline: endotracheal suctioning of

me-

chanically ventilated adults and children with artificial

Susan LMcInturffRRTRCP, Chairman, Bremerton

WA

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Barry J Make
Peggi Rohart Allan

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1984:33:80-85.
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MA

Saposnick

RRT.RCP, Boston MA MS RRT, Sharon Hill PA

Centers for Disease Control Prevention. Guidelines for prevention of nosocomial pneumonia. Part
1
:

issues

on pre-

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1-01-1996. www.cdc.gov
26.

Working Group,. American Respiratory Care Foundation.


Guidelines for disinfection of respiratory care equip-

Chatbum RL. Decontamination of


Care 1989;34(2):98-109.

respiratory care equip-

ment: what can be done, what should be done. Respir

ment used
808.

in the

home. Respir Care 1988;33(9):801-

27.

Chatbum RL, Kallstrom TJ, Bajaksouzian


of acetic acid with a quaternary

S.

A comparison
Care

29.

Ralph IG. Infectious waste management: a home care


sponsibility.

re-

ammonium compound

Home Healthcare Nurse

1993;1 1:25-33.

for disinfection of hand-held nebulizers. Respir

Interested persons

may photocopy

these Guidelines for noncommercial purposes of scientific

or educational advancement. Please credit

AARC and RESPIRATORY CARE Journal.

104

Respiratory Care

January 1999 Vol 44 No

AARC Clinical Practice Guideline


Selection of Device, Administration of Bronchodilator,

and Evaluation

of Response to Therapy in Mechanically Ventilated Patients

BDMV 1.0 PROCEDURE:


Device selection, bronchodilator administration, and evaluation of response to therapy during mechanical ventilation.

mechanically ventilated adult patients (1.0-15.3

%) compared to nonintubated, ambulatory


14%).-^

adult

subjects in ambulatory adult patients (102.3.1 In-vivo studies of aerosol deposition

The reader

is

referred to previ-

ously published Guidelines addressing aspects of


aerosol administration and delivery.
'"*

from nebulizers during mechanical

venti-

lation report 1.2%,-' 2.22%,--' 2.9%,-'

and

BDMV 2.0 DESCRIPTION:


The
selection of a device and strategy for administration, the administration,

15.3%-" in adults, and 0.22% in infants.-'

Similar studies using


1

MDI

reported 6-

and the evaluation of

re-

1%'"'* in adults

and 0.9

in infants.-'

sponse of patients to bronchodilator aerosol during

2.3.2 Factors that affect lower respiratory


tract deposition include: aerosol device

mechanical ventilation.
2.1 Devices include metered dose inhaler

selected,'-'""""
its

how

it is

operated,"-'"-'"'-"

placement

in relation to the ventilator

(MDI) with adapter and chamber


elbow and
catheter;

or inline

circuit/patient,'' the ventilator selected,"

pneumatic nebulizer; small

the ventilator settings


lation,''

volume nebulizer (SVN) large volume nebulizer (LVN); ultrasonic nebulizer. (Although experience suggests that inhalers that dispense dry

and mode of ventihumidity," " drug formulation,


is

'"'* drug dose, and caliber of the airway.-'

2.3.3 Assessment

necessary to deterfrere-

powder

are not suitable for use in ventilator cir-

mine the appropriate dose, optimal


sponse to therapy.'"

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

quency of administration, and overall

An

empirical

trial

of

bronchodilator

is

recommended
in

in

any

mechanically ventilated patient


potential indication exists.^"

whom a

fants receiving

mechanical ventilation."-'
'^
'*"

In-

2.4 Because delivery doses

is

reduced, increased

haled beta-adrenergic'
bronchodilators'^

and anticholinergic

may be

required to provide desired or op-

are effective in mechanical-

timal effect. Patients should be monitored to

ly ventilated patients. Inhaled isoproterenol hy-

determine effect of dose and to support

initial

drochloride,""' isoetharine mesylate," metapro-

and continued treatment.""-"

terenol sulfate,'" fenoterol,''' and albuterol"-'''

can

all

produce clinically important bronchodi-

BDMV3.0 SETTING:
Aerosolized bronchodilator therapy via mechanical
ventilator can be provided in a

lation. In ventilator-supported

COPD

patients,

fenoterol in combination with ipratropium bro-

number of

settings

mide was more effective than ipratropium


alone. '* Inhaled beta adrenergic and anticholin-

including: hospital,

home, and subacute or extended

care facility.

ergic drugs are effective in ventilated infants

and neonates with acute, subacute, and chronic


lung
disease.'*"-"

BDMV 4.0 INDICATIONS:


Bronchodilator aerosol administration and evaluation of response are indicated

2.3 Aerosol deposition


eral,

in the

lung has, in gen-

whenever bronis

been shown

to be

reduced in intubated.

choconstriction or increased airways resistance

Respiratory Care

January 1999 Vol 44 No

105

AARC GUIDELINE:

SELECTION OF DEVICE

documented

or suspected in patients during

me-

6.6.1 Addition of gas to the ventilator cir-

chanical ventilation:

from a nebulizer may inciease volumes, flows, and peak aiiway pressures,
cuit

BDM V 5.0 CONTRAINDICATIONS:


5.1

thus altering the intended pattern of venti-

Some assessment maneuvers may

be con-

lation. Ventilator setting

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

the additional gas

tlow during nebulization must be reset


the end of the treatment.

may be

contraindicated

6.6.2 Addition of gas from a nebulizer


into the ventilator circuit

some

patients.

Consult the package insert for

may

result in the

product-specific contraindications.

patient's

becoming unable

to trigger the

ventilator during nebulization,^' leading to

BDMV 6.0 HAZARDS/COMPLICATIONS:


6.1 Specific assessment procedures
""

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

inherent hazards or complications: (eg, inspiratory pause, expiratory pause).^'

CFCs used

as

propellants in MDIs."** Adverse cardiac effects

6.2 Inappropriate device selection or inappropriate use of device and/or technique variables

recommended
life

because of the short half


s),

may

result in underdosing.'

of CFCs in the blood (< 40


result in

particularly

when

6.3 Device malfunction

may

reduced

at least a short interval is

maintained between

drug delivery and

may

possibly compromise
circuit.''*""'

successive doses.^"

the mtegrity of the ventilator

6.4 Complications of specific pharmacologic


agents. Higher doses of beta agonists delivered

BDMV 7.0 LIMITATIONS OF PROCEDURE OR DEVICE:


7.1 During mechanical ventilation, the deposition of drug to the lower respiratory tract
is re-

by an
fects

MDI

or nebulizer

may

cause adverse

ef-

secondary to systemic absorption of the


atrial

drug or propellants. The potential for hypokalemia and


mias

duced. Doses should be adjusted to compensate


for reduced delivery. Variables should be opti-

and ventricular dysrhythill

may

exist with high doses in critically

mized

to

enhance medication delivery.

patients.-"-*"

7.2 Ventilator
position.

6.5 Aerosol medication, propellants, or cold,

modes and settings can affect deLung-model studies suggest that low

dry gas that bypasses the natural upper respiratory tract

inspiratory flows, use of decelerating flow in-

may

cause bronchospasm or
*

irritation

stead of square wave, tidal volume

> 500 mL,

of the airway.^'

Although the efficiency of

aerosol delivery from an

MDI

can be increased

and increased duty cycle (inspiratory phase) are all associated with improved aerosol deposition.'^''' '""

by actuating the canister into a narrow gauge


catheter with the catheter positioned at the end

Spontaneous inspiration through the


to controlled, assist/control

ventilator circuit increased lung deposition

of the endotracheal tube.

A study in rabbits-" has

compared

and pres-

shown

that

such introduction produces necro-

sure support ventilation.'*

tizing inflammation

and mucosal ulceration,

7.3 Humidification of inspired gas during

me-

probably from the topical effect of the oleic acid used for its surfactant property and the
chlorofluorocarbons (CFCs). Such administration
is

chanical ventilation reduces aerosol deposition to

the lower respiratory tract by approximately

40%." " Because


that humidity

these in vitro studies suggest


al-

not recommended.

The

results of further

markedly decreases aerosol, the

study are needed to support or


practice.

condemn

this

ternatives are to bypass the humidifier during

aerosol therapy, which

may

dry the airway and

6.6

The aerosol device

or adapter used and

offset the effect of the increased delivery, or to retain the humidifier

technique of operation
sensitivity of the

may

affect ventilator
alter the

and increase the dose of bron-

performance characteristics and/or


alarm systems.

chodilator.

It is

probably better to retain the hu-

midifier and increase the dose of bronchodilator.

106

Respiratory Care

January 1999 Vol 44 No

AARC Guideline:

Selection of Device

7.4 Placement of the aerosol device in the ventilator circuit affects the

vivo experiments have associated


endothelial

amount of drug

deliv-

damage

at the

carina in

ered to the lungs." Placing the nebulizer 30

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

port clinical use of such devices at


this time.'"-'"

an

artificial

nose

is in

use,

it

7.6.1.4

MDI

actuation

is

performed

should be removed during aerosol administration."

manually and should be synchronized with the beginning of inspiration."'' Actuating an

7.5 Coordination of aerosol generation with


ventilator triggering (initiation of inspiratory

MDI out of synchrony with the inspiratory airin

gas flow) improves delivery of drug to the


lung."

flow has been shown to result


lower airway."
7.6.2 Small

negligible aerosol delivery to the

7.6 Limitation of specific devices


7.6.1

The

MDI MDI cannot be used for the

volume nebulizer

mechani-

7.6.2.1 Differences in placement of

cally ventilated patient with the actuator

nebulizer in the ventilator circuit can


result in large variances in

designed for use by the spontaneously


breathing patient with a natural airway.

drug de-

livered to the lung."

An

actuator designed specifically for


is

me-

chanical ventilation
tion of an

required for actua-

MDI

into the ventilator circuit.

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

type of nebulizer, different models

of the same type, and gas source,


pressure, and flow.

and

in vivo

-""'''

Both have found

7.6.2.3

Gas flow and

the pressure

driving a pneumatic nebulizer

may

combination of an

MDI

and

chamber device results in a four- to sixfold increase in delivery of


a

aerosol over

MDI

actuation into an

elbow connector (without chamber)


attached directly to the endotracheal

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."

tube or into an inline adapter with-

out chamber. This correlates with


clinical response studies

7.6.2.4 Nebulizer output and effi-

showing

ciency are affected by

fill

volume

clinical response with as little as 4

and

flow."-""

puffs of albuterol'" whereas an

7.6.2.5 Nebulizers in line with the


ventilator circuit tend to collect con-

elbow adapter demonstrated no sponse with 100 actuations of


buterol.^

real-

densate

when

not in use and should

be removed from ventilator circuit

7.6.1.2 Small-gauge adapters with

between treatments.
7.6.2.6 Nebulizers are vulnerable to

closed suction devices.


adapters.

No

pub-

lished data support the use of these

contamination, posing consequent


increased risk for nosocomial infecdon."'"

7.6.1.3

Small-gauge

tracheal

catheter adapter. Although initial ex-

7.6.2.7 Because of the relatively


large

periments suggest high-dose delivery to the lung (>

amount of medication

that

is

90%

in vitro), in

exhaled by the patient or that by-

Respiratory Care

January 1999 Vol 44 No

107

AARC Guideline:

Selection of Device

passes the patient into the expiratory


limb, placing a
ry limb
filter in

9.1.1.2 Ascertain clinical indicators or

the expirato-

need for therapy


9.1.1.3 Identify possible contraindications

may

reduce drug deposition

on pneumotachographs or transducers and thus help maintain their accuracy. 7.6.4

9.1.2 During therapy, identify:


9.1.2.1 adverse responses;

LVN:

9.1.2.2 any clinical change


line;

from base-

7.6.4.1 Concentration of medication

delivered

may

vary during treatment

9.1.2.3 lack of response.

due
^Qj^

to
63-66

changing dilution of medicais

9.1.3 Following therapy, identify


9.1.3.1 adverse responses

and

7.6.4.2 Close monitoring

required.

9.1.3.2 presence or absence of therapeutic responses


9.1.4 For trend analysis, identify:
9.1.4.1

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

9.1.4.2 need to 9.1.4.3 need to

modify dose;

USN
it

modify therapy;

Although
use of the

has been suggested that the


lead to bronchodila-

9.1.4.4 need to discontinue;

USN may

9.1.4.5

apparent

changes

in

tor delivery greater than with a

comparaevaluation:

bronchial responsiveness.

gle dose

by pneumatic nebulizer, evidence

9.2 Action based on result of assessment and

is lacking.''*"

9.2.1 increase or decrease dose;

BDMV 8.0 ASSESSMENT OF NEED:


8.1

9.2.2 change or add medications;

The presence of one

or

more of

the follow-

9.2.3 continue or discontinue therapy.

ing in the mechanically ventilated patient suggests the need for bronchodilator administration:

(Discontinuance of bronchodilator thera-

py should be considered in patients in whom no objective or subjective response


is

8.1.1 previous demonstrated response to

seen after repeated administration.*"'

bronchodilator;
8.1.2 presence of

9.3 Documentation

auto-PEEP not eliminatincreased inspirato-

9,3,1 Patient response to medication

ed with reduced
ratory time ratio;

rate,

9.3.1.1 Medication: type, dose, and

ry flow, or decreased inspiratory to expi-

time received
9.3.1.2 Responses
vital signs,

measured including

8.1.3 increased airway resistance as evi-

lung function as reflected


in

denced by
8.1.3.1 increased

by changes
peak inspiratory pres-

peak inspiratory pressure

(PIP), plateau pressure (Ppiat), auto-

sure and plateau pressure difference;

PEEP
tions.

(PEEPi), and bedside observa-

8.1.3.2

wheezing or decreased breath

sounds;
8.1.3.3 intercostal and/or sternal retractions;

9.3.1.3

Note observations

relative to

time of administration

8.1.3.4 patient-ventilator dysynchrony.

BDMV 10.0 RESOURCES


10.1 Equipment
10.1.1 Ventilator with

8.2 Response to therapy should be evaluated in


all

patients receiving bronchodilator therapy.^

manometer and

ca-

pability to

measure end-inspiratory and

BDMV 9.0 ASSESSMENT OF OUTCOME


9.1 Evaluation of need

end-expiratory pause.
10.1.1.1

9.1.1

and response Assessment prior to therapy:

Equipment required
Pneumotachograph

for

mea-

suring auto-PEEP
10.1.1.2
for

9.1.1.1 Establish baseline condition

moni-

108

Respiratory Care

January 1999 Vol 44 No

AARC Guideline:

Selection of Device

toring pressure, flow, and

volume

and document measures of response


use of diary and peak flow meter);

es-

changes

at the airway.

tablished by the patient's care plan (eg,

10.1.2 Pulse oximeter 10.1.3 Stethoscope 10.1.4 Cardiac monitor,

10.2.2.2 use proper technique in ad-

when

available

ministering medication;
10.2.2.3 maintain and clean equipment;

10.2 Personnel:'-"

10.2.1 Level

II

personnel

licensed or

10.2.2.4 instruct patients in proper


breathing patterns and coughing techniques;
10.2.2.5 modify therapy in response to

credentialled respiratory care practitioner


(eg,

RRT, RPFT, CRT) or persons with

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

monitored variables, severi-

symptoms, or adverse reactions, and communicate any modifications


with Level
II

provider or physician.

10.2.2.6 Understand and

comply with

Standard Precautions.
10.2.3

effects of specific medication and

When

mechanically ventilated pa-

equipment; 10.2.1.4 instruct patients in proper


breathing patterns and coughing techniques;

tients are cared for in the


tient,

home, the pa-

family member, or designated care-

giver providing routine maintenance ther-

apy must know and demonstrate


to:

ability

10.2.1.5 modify technique in response


to adverse reactions;

10.2.3.1 monitor or measure response


to bronchodilator in

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

the patient's care plan (eg, Pinspi


Ppla.);'"

10.2.3.2 use proper technique for adresults

document

ministration of medication and use of

of auscultation, inspection, and assess-

devices correctly (eg,

MDI with

spacer,

ment of vital ment


ics Pinsp
-

signs;

SVN, USN);"
10.2.3.3 properly use and clean equip-

10.2.1.9 perform, interpret, and docuPpiat

or ventilatory

mechan-

ment;
10.2.3.4 modify dosages and/or fre-

10.2.1.10 understand and comply with

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

for long-term ventilator-dependent patients

BDMV

11.0

MONITORING:(bronchodilator

should be able to teach family


or other designated care giver

response)
11.1 Patient observation

members

to assess need for and response to bron-

11.1.1 General appearance, presence of

chodilators and develop, teach, and as-

tremor
11.1.2

sess self-care plans for the patient or


the family care giver.

Use of accessory muscles or padysynchrony

tient-ventilator

10.2.2 Level-I personnel

licensed or

11.2 Percussion and auscultation, including


presence or absence of wheezing'^

credentialled respiratory care practitioner


(eg,

CRT, CPFT) or person with docutraining

mented equivalent

and

ability to:

10.2.2.1 observe, measure, monitor.

symptoms and vital signs'11.4 Improvement in dyspnea-"' 11.5 Changes in SaO,-" or SpOj
11.3 Patient

'"*

Respiratory Care

January 1999 Vol 44 No

109

"

AARC Guideline:

Selection of Device

11.8 Changes in exercise performance" 11.9 Clianges in ventilator variables^^


11.9.1 Pinsp-Ppiat difference

without disinfection. Nebulizers should be changed


or sterilized at conclusion of dose administration or

11.9.2 Inspiratory and expiratory resis-

tance.(Changes in minimal inspiratory resistance (Rsmin) and/or

24-hour intervals with continuous administraand whenever visibly soiled. Nebulizers should not rinsed with tap water between treatments
at

tion''

maximal

inspirato-

ry resistance (Rsmax) are being used as a

Medications should be handled aseptically.

research

tool.'"'

11.9.3 Expiratory flow, flow- volume loop

Medications from multidose-dose sources


carded after 24 hours.

in acute

11.9.4

Auto-PEEP reduction

care facilities must be handled aseptically and dis-

11.10 Subjective response


11.11 Changes in sputum clearance

11.12 Changes in

arterial

blood gas values

Synopsis

11.13 Adverse response to drug

Recommendations

for Bronchodilator Delivery

BDMV 12.0 FREQUENCY:


12.1 Acute, unstable patient
12.1.1 Full assessment with
first

during Mechanical Ventilation


treatment
1.

Ventilator Settings

12.1.2 Assessment with documentation of


all

Caution:
tor is

If

gas other than that from the ventila-

appropriate monitored variables before


after

used to power the nebulizer, that flow

may

af-

and

each treatment, with monitoring

fect the delivered tidal

volume, the inspired oxygen

of breath sounds, vital signs, side effects


during therapy, Pinsp and Ppiat 12.1.3 Frequency of physical
Pinsp
tus.
-

concentration, and the patient's ability to trigger the


ventilator.
It

may be

necessary to decrease the set


increased to maintain an ap-

exam and
sta-

tidal

volume. For a patient triggering the ventilator,

Ppiat

should be based on patient

the rate

may need to be

propriate minute ventilation

12.1.4

SpOj should be monitored continu-

Recommendations: Consider
not otherwise contraindicated

the following, if
(1)

ously, if available.

Use of a

tidal

12.1.5 Continue assessment at each level

volume > 500

mL

for adults; (2) addition of an in-

of dose to optimal response for patient.


12.2 Stable patient
12.2.1

The

Pinsp-Ppiat difference

should be

measured before and


therapy.

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,

the inspiratory-to-expiratory-time ratio


tively

is

subjec-

12.2.1.1 Periodic reevaluation for re-

sponse to therapy.

12.2.1.2 Standard frequency with albuterol and ipratropium should be every 4

and physiologically appropriate and autois not increased);(3) because spontaneous breaths may improve aerosol deliver, spontaneous

PEEP

breathing should not be suppressed during aerosol

hours and/or as required.


12.2.1.3 Other drugs, frequency based

therapy unless the patient's ability to trigger the

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

cause heated circuit malfunction;

13.0

INFECTION CONTROL:
Standard Precautions as

(2)

an

artificial

nose, or heat-and-moisture exchangis

CDC

CDC

recommendaand droplet

er,

must be removed before aerosol therapy

tions to control exposure to tuberculosis

begun.

nuclei.""

Recommendations: Although humidified gas


has been shown to reduce aerosol delivery by as

Nebulizers should not be used between patients

much

as

40%,

the humidifier should remain inline

110

Respiratory Care

January 1999 Vol 44 No

AARC Guideline: Selection of Device

2.

because of the risks associated with the delivery of


dry gas.

American Association

for Respiratory Care.

AARC Clinical AARC Clinical

practice guideline: delivery of aerosols to the upper air-

An

increase in aerosol dose

may compen3.

way. RespirCare 1994:39(8)803-807.

sate for this effect.


3.

American Association
therapy
1307.
at

for Respiratory Care.

Metered Dose Inhaler Use Caution: The dose delivered from an

practice guideline: assessing response to bronchodilator

MDI

is re-

point of care. Respir Care 1995;40(12):1300-

duced significantly by

failure to actuate the inhaler


4.

American Association

for Respiratory Care.

AARC Clinical
Respir Care
In vitro assess-

with the onset of inspiration.

practice guideline: selection of a device for delivery of

Recommendations:
chamber device;
ration; (3)

(1)

Use an

(2) actuate the

MDI fitted with a MDI manually and


5.

aerosol to the lung parenchyma.


1996;41(7):647-653.

synchronize actuation with the beginning of inspi-

Everard

ML, Devadason SG, LeSouef PN.

4 puffs are the usual recommended dose;

ment of drug delivery through an endotracheal tube using a dry powder inhaler delivery system. Thorax
1996:51(l):75-77.
6.

however, greater doses

may be

required

when

clini-

cal monitoring of the patient suggests incomplete or

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

Hill Publishing Co.,

New York

Do

not leave athe nebulizer inline


7.

1994:1077-1123.

Manthous, CA, Hall JB, Schmidt.GA,


ically ventilated patients.

Wood LDH. MeRev Respir Dis

between aerosol treatments;


er every

(2)

change the nebuliz-

tered-dose inhaler versus nebulized albuterol in mechan-

24 hours; (3) do not rinse the nebulizer


8.

Am

with tap water.

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

R, Jubran A, Tobin MJ. Bronchodilator delivery by


in

metered-dose inhaler

ventilator-supported patients.

Am J Respir Crit. Care Med


10.

1995;151:1827-1833.

Dhand
PJ,

R, Duarte

AG, Jubran A, Jenne JW, Fink JB, Fahey


to bronchodilator deliv-

Tobin MJ. Dose response

5.

Patient Monitoring

ered by metered-dose inhaler in ventilator-supported pa-

Monitor the response


ment.

to therapy with

each

treat1

tients.
1.

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1991;99:66-71.

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American Association for Respiratory Care

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DemographU Quesiions
We
request that you answer these questions
in

order to help us

design services and programs to meet your needs.

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High School

D D D D

RC Graduate

Technician

Associate Degree
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1999 Respiratory
science journal,

Care Open Forum


FORMAT AND TYPING INSTRUCTIONS
Accepted abstracts
will be

The American Association for Respiratory Care and its RESPIRATORY CARE, invite submission of
abstracts will be reviewed,

brief abstracts related to any aspect of cardiorespiratory care.

photographed and reduced by

The

and selected authors

will be

40%;
have
or

therefore, the size of the original text should be at least

invited to present posters at the

OPEN FORUM

during the

10 points. Abstracts should be 400 words or less and


1 clear,

may
of

AARC

International Respiratory Congress in Las Vegas,


will

concise table or figure.

A font like Helvetica


The
first line

Nevada, December 13-16, 1999. Accepted abstracts


published in the

be

Geneva makes

the clearest reproduction.


title

November

1999 issue of RESPIRATORY Care.

the abstract should be the

in all capital letters. Title

should

Membership

in the

AARC is not required for participation.


ARCF

explain content. Follow

title

with names of all authors (includ-

All accepted abstracts are automatically considered for

ing credentials), institution(s), and location; underline presenter's name.

research grants.

gle spaced in a single

Type or electronically print the abstract sinparagraph in the space provided on


one
letter
is

SPECIFICATIONS READ CAREFULLY!


An
abstract

the abstract blank. Insert only

space between sen-

tences. Text submission

on diskette

encouraged but must

may report (1) an original study, (2) the eval-

be accompanied by a hard copy. Data

may be submitted in

case series. Topics

uation of a method, device or protocol, or (3) a case or may be aspects of adult acute care, continuing care/rehabilitation, perinatology/pediatrics, cardio-

table form, or a simple figure may be included provided it fits within the space allotted. No figure, illustration, or table
is

to

pulmonary technology, or health care delivery. The abstract may have been presented previously at a local or regional
but not national

mation requested.

be attached to the abstract form. Provide all author inforA clear photocopy of the abstract form may

be used. Standard abbreviations


explanation;

may be employed

without

meeting and should


The

not have been published


abstract
is

new

or infrequently used abbreviations should

previously in a national journal.

the only evi-

dence by which the reviewers can decide whether the author


should be invited to present a poster
at the

OPEN FORUM.

be spelled out on first use. Any recurring phrase or expression may be abbreviated, if it is first explained. Check the abstract for ( 1 ) errors in spelling, grammar, facts, and figures; (2) clarity of language;

Therefore, the abstract must provide all important data, findings, and conclusions. Give specific information.

and

(3)

conformance

to these

Do not write

specifications.

An

abstract not prepared as requested

general statements, such as "Results will be presented" or

not be reviewed. Questions about abstract preparation

"Significance will be discussed."

be telephoned to the editorial at (972) 406-4667.

may may staff of RESPIRATORY CARE

ESSENTIAL CONTENT ELEMENTS


Original study. Abstract must include
(
1

Background:

to submit abstracts early. Abstracts

Early Deadline Allowing Revision. Authors may choose postmarked by April 2,


will

statement of research problem, question, or hypothesis; (2)

1999

be reviewed and the authors notified by

letter

only

Method: description of research design and conduct in sufficient detail to permit judgment of validity; (3) Results: statement of research findings with quantitative data and statistical analysis; (4) Conclusions: interpretation of the meaning
of the results.

to be mailed

by

May 7,

1999. Rejected abstracts will be accom-

panied by a written critique that should, in

many cases,

enable

authors to revise their abstracts and resubmit them by the Final

Deadline (June

11, 1999).

Method, device, or protocol evaluation. Abstract must


include
(
1 )

Final Deadline. The mandatory Final Deadline

is

June

1 1

Background: identification of the method, device,


its

1999 (postmark). Authors


tion

will

be notified of acceptance or rejec-

or protocol and

intended function; (2) Method: descrip-

b\

letter only.

These

letters will

be mailed by August 25,

tion of the evaluation in sufficient detail to permit judgment

1999.'

of its objectivity and validity; (3) Results: findings of the evaluation; (4) Experience: summary of the author's practical experience or a lack of experience; (5) Conclusions: interpretation of the evaluation and experience. Cost comparisons should

of the completed abstract form, diskette

Mailing Instructions. Mail (do not fax!) 2 clear copies (if possible), and a
to:

stamped, self-addressed postcard (for notice of receipt)

be included where possible and appropriate. Case report. Abstract must report a case that

1999 Respiratory
is

Care Open Forum

uncom-

mon or of exceptional educational


standing the case. (2) Case
details

value and must include (1)

Dallas

11030 Abies Lane TX 75229-4593

Introduction: relevant basic information important to under-

Summary:

patient data

and response,

of interventions. (3) Discussion: content should reflect results of literature review. The author(s) should have been
actively involved in the case and a case-managing physician

submit your Open

forum

abstract electronically

visit

www.rcjournal.com

must be a co-author or must approve the report.

1999 Respiratory

Care Open Forum

Abstract

Form
1

Title

must be in all upper case (capital)


letters,

authors'

full

names and
Follow

text in

upper

and lower case.


2.
title

with

all

authors' names, includ-

ing credentials (underline presenter's


institution,

name),

and

location.
3.

Do
(ie,

not justify

leave a 'ragged'

right margin).
4.

Do not
less

use type size than 10 points. (Do not exceed 400


words.)

5.

All text and the table, or figure, must


fit

into

the rectangle shown.

(Use only

clear,

con-

cise table or figure.)


6.

Submit 2 clean copies. This form may be photocopied


if

multiple

abstracts are to be

submitted.

Mail original & 1 photocopy (along with


postage-paid postcard) to

1999 Respiratory

Care Open Forum


Dallas

11030 Abies Lane TX 75229-4593

Earlv Deadline
April 2, 1999 (postmark)

is

June

Final Deadline is 11, 1999 (postmark)

Electronic

Submission

Is

Now

Available. Visit

www.rcjournal.com
to find out

more

13.9

cm

or 5.5"

Name &

Credentials

Mailing Address

Voice Phone & Fax

Name &

Credentials

Mailing Address

Voice Phone & Fax

RE/PIRAJO^ORE
Manuscript Preparation Guide
General Information
Point-of-View Paper:
ated opinions

A paper expressing personal but substantitopic. Title Page, Text, References, Tables,

on a pertinent

Respiratory Care welcomes original

manuscripts related to the

and

Illustrations

may be

included.

science and technology of respiratory care and prepared accord-

ing to these Instructions and the Uniform Requirements for

Special Article:
categories

A pertinent paper not fitting one of the foregoing


a Special Article. Consult with the

Manuscripts Submitted to Biomedical Journals [Respir Care 1997;


42(6):623-634]. Manuscripts are blinded and reviewed by professionals

may be acceptable as

Editor before writing or submitting such a paper.

who

are experts in their fields. Authors are responsible

for all aspects of the manuscript

and receive galleys


is

to proofread

Editorial:

A paper drawing attention to a pertinent concern: may


it

before publication. Each accepted manuscript


its

copyedited so that

present an opposing opinion, clarify a position, or bring a problem


into focus.

message

is

clear

and

it

conforms

to the Journal" s style. Published

papers are copyrighted by Daedalus Inc and

may

not be published

elsewhere without permission.


Editorial consultation
ing.
is

Letter:

signed communication, marked "For publication,"


this Journal or

available at any stage of planning or writ-

about prior publications in


ics.

about other pertinent top-

On request, specific guidance is provided for all publication cat-

Tables and illustrations

may

be included.
blood

egories.
to

To receive these Instructions and related materials, write Respiratory Care, 600 Ninth Avenue, Suite 702, Seattle WA
call

Blood Gas Comer:


gas values

A brief,

instructive case report involving

98104,

(206) 223-0558, or fax (206) 223-0563.

with Questions, Answers, and Discussion.


A mini-review paper about a drug or class of drugs
pharmacology, pharmacokinetics,

Publication Categories

& Structure

Drug Capsule:

that includes discussions of

Researcli Article:
It

A report of an original investigation (a study).


Methods, Results,

and pharmacotherapy.

includes a Title Page, Abstract, Introduction.

Graphics Corner:

A briefcase report incorporating waveforms for

Discussion, Conclusions, Product Sources, Acknowledgments, References, Tables, Appendices, Figures, and Figure Captions.

monitoring or diagnosis

with

Questions, Answers, and Discussion.

Kittredge's

Comer:

Evaluation of Device/Metliod/Teclinique:
uation of an old or
It

A description and eval-

A brief description of the operation of respiratory


edito-

care equipment
rial

with information from manufacturers and


suggestions.

new

device, method, technique, or modification.

comments and

has a Title Page, Abstract, Introduction, Description of Device/Method/Technique, Evaluation Methods, Evaluation Results, Discussion, Conclusions, Product Sources, Acknowledgments, References, Tables, Appendices, Figures, and Figure Captions. parative cost data should be included wherever possible.

PFT

Corner: Like Blood Gas Comer, but involving pulmonary


tests.

function

ComCardiorespiratory Interactions.
interaction

A case report demonstrating the

Case Report:

A report of a clinical case that is uncommon, or was


new way,
or
is

managed

in a

exceptionally instructive. All authors

must be associated with the case.

A case-managing physician must


Case Summa-

between the cardiovascular and respiratory systems. It should be a patient-care scenario; however, the case the central theme is the systems interaction. CRI is characterized by figures, equations, and a glossary. See the March 1996 Issue of RESPIRA-

either be an author or furnish a letter approving the manuscript. Its

TORY Care for more detail.


Test

components
ry,

are Title Page, Abstract, Introduction,

Discussion, References, Tables, Figures, and Figure Captions.

Your Radiologic Skill: Like Blood Gas Comer,


may

but involv-

ing pulmonary medicine radiography and including one or more radio-

Review
and

Article:

A comprehensive, critical review of the literature


summary of a
pertinent topic that has been the
articles. Title

graphs;

involve imaging techniques other than conventional

state-of-the-art

chest radiography.

subject of at least
line, Introduction,

40 published research

Page, Out-

Review of the

Literature,

Summary, Acknowl-

Review of Book, Film, Tape, or Software:


review of a recent release.

balanced, critical

edgments, References. Tables, Appendices, and Figures and Captions

may be

included.

Preparing the Manuscript


Overview:

A critical review of a pertinent topic that has fewer than


articles.

40 published research
Update:
been

Print

on one

side of white
1

bond paper,
in.

8.5

in.

1 1

in.

(2

6 x 279

mm)
Use

with margins of at least

(25

mm) on all sides of the page.

report of subsequent developments in a topic that has

critically

reviewed

in this Journal or elsewhere.

double-spacing throughout the entire manuscript. Use a standard font (eg. Times, Helvetica, or Courier) at least 10 points in size, and

RESPIRATORY CARE Manuscript Preparation Guide, Revised

2/98

Manuscript Preparation Guide

do not use

italics

except for special emphasis.

Number all pages

in

Paper accepted but not yet published:


Hess D.

upper-right comers. Indent paragraphs 5 spaces.

Do notjustify. Do

New therapies for asthma.

Respir Care (year,

in press).

not put authors' names, institutional affiliations or allusions to


institutional affiliations in the text, or other identification any-

Personal author book: (For any book, specific pages should be cited

where except on the

title

page. Repeat

title

only (no authors) on

whenever possible.)
DeRemee RA. Clinical profiles of diffuse
ease.
interstitial

the abstract page. Begin each of the following on a

new

page: Title

pulmonary

dis-

Page, Abstract, Text, Product Sources

List,

Actcnowledgments, Ref-

New

York: Futura; 1990.

p.

76-85.

erences, each Table, and each Appendix.


the first person

Use standard English

in

and active voice.


in cap-

Corporate author book:


American Medical Association Department of Drugs.
uations, 3rd ed. Littleton

Center main section headings on the page and type them


ital

AM A dmg eval1977.

and small and small

letters (eg. Introduction,


at the left

Methods, Results, Discusin cap-

CO: Publishing Sciences Group;

sion).
ital

Begin subheadings

margin and type them

letters (eg. Patients,

Equipment,

Statistical Analysis).

Chapter in book with


Pierce

editor(s):
In:

AK. Acute respiratory failure.

Guenter CA, Welch

MH, edi-

References. Cite only published works as references. Manuscripts


accepted but not yet published

tors.

Pulmonary medicine. Philadelphia: JB Lippincott; 1977:26-42.

may
by

be cited as references: desig(in press),

nate the accepting journal, followed

and provide 3 copies

Tables. Use consecutively numbered tables to display information.


Start

of the in-press

article for

reviewer inspection. Cite references in the

each table on a separate page.

Number and title

the table and

text with superscript numerals.

Assign numbers

in the
list

order that ref-

give each column a brief heading. Place explanations in footnotes,


including
all

erences are
in

first cited.

On

the reference page,

the cited

works

nonstandard abbreviations and symbols.


t, t, . H,

Key

the foot-

numerical order. Follow the Journal's style for references. Abbre-

notes with conventional designations (*,


sistent order, placing

% **, tt) in con-

viate journal

names

as in Index Medicus. List all authors.

them superscript

horizontal or vertical rules or borders.


Article in a journal carrying pagination throughout volume:

in the table body. Do not use Do not submit tables as pho-

tographs, reduced in size, or on oversize paper.

Use

the

same type-

Rau

JL,

Harwood

RJ.

Comparison of nebulizer delivery methods

face as in the text.

through a neonatal endotracheal tube: a bench study. Respir Care


1992;37(11):1233-1240.
Illustrations. Graphs, line drawings, photographs,
.,

and radiographs

Article in a publication that

numbers each issue beginning with

Use only illustrations that clarify and augment the text. Number them consecutively as Fig. 1, Fig. 2, and so forth accordare figures.

Page

1:

ing to the order by which they are mentioned in the text.


Establishing a national database for home care.

Be

sure

Bunch D.

AARC Times

all

figures are cited. If any figure

was previously published, include

1991;15(Mar):61,62,64.

copyright holder's written permission to reproduce. Figures for


publication must be of professional quality. Data for the original

Corporate author journal

article:

graphs should be available to the Editor upon request. If color


Criteria for establishtial,

is

essen-

American Association for Respiratory Care.


Care 1988;33(1 1):I044-1046.

consult the Editor for more information. In reports of animal

ing units for chronic ventilator-dependent patients in hospitals. Respir

experiments, use schematic drawings, not photographs.

A letter of

consent must accompany any photograph of a person.

Do not place

Article in journal supplement: (Journals differ in their

methods of

titles

and detailed explanations on figures; put

this information in

numbering and identifying supplements. Supply


to

sufficient information

figure captions. If possible, submit radiographs as prints and fullsize copies of film.

promote

retrieval.)
interstitial

Reynolds HY. Idiopathic

pulmonary

fibrosis.

Chest 1986;

Drugs. Identify precisely


ic

all

drugs and chemicals used, giving generIf desired,

89(3Suppl):I39S-l43S.
Abstract in journal: (Abstracts citations are to be avoided. Those

names, doses, and routes of administration.


in

brand names

more

may be given
listed

parentheses after generic names. Drugs should be

than 3 years old should not be cited.)


Stevens DP. Scavenging ribavirin from an oxygen hood to reduce envi-

on the product-sources page.


In parentheses in the text, identify

Commercial Products.
it is

any com-

ronmental exposure (abstract). Respir Care 1990;35(1

1):

1087-1088.

mercial product (including model


Editorial in journal:
Enright P.

number if applicable)
city,

the first time

mentioned, giving the manufacturer's name,

and

state or

Can we relax during spirometry? (editorial).

Am Rev Respir

country. If four or

more products

are mentioned,

do not

list

any man-

Dis 1993;I48(2):274.
Editorial with

ufacturers in the text; instead,


at the

list

them on a Product Sources page

end of the

text,

before the References. Provide model


if

num-

no author given:

bers

when available and manufacturer's suggested price,

the study

Negative-pressure ventilation for chronic obsfructive pulmonary dis-

has cost implications.

ease (editorial). Lancet 1992;340(8833):1440-I441.

Ethics.
Letter in journal:

When

reporting experiments on

human

subjects, indicate

that procedures
for

were conducted

in

accordance with the ethical stan-

Aelony Y. Ethnic norms


1991;99(4):1051.

pulmonary function

tests (letter).

Chest

dards of the World Medical Association Declaration of Helsinki


[Respir Care l997;42(6):635-636] or of the institution's committee

RESPIRATORY CARE Manuscript

Preparation Guide, Revised 2/98

Manuscript Preparation Guide

on human experimentation. State


obtained.
in text

that

informed consent was


or hospital numbers

will be

acknowledged.
are encouraged to submit electronin.

Do not use

patient's

names,

initials,

Computer Disliettes. Authors


ic

or illustrations.

When

reporting exf)eriments on animals, indi-

versions of manuscripts as well as printed copies (3.5

diskettes

cate that the institution's policy, a national guideline, or a law

on

in

Macintosh or

IBM-DOS

format). Label each diskette with date;

the care and use of laboratory animals

was followed.
used
in

author's name;

name and

version of word-processing program used;


to

and filename(s). Software used


Statistics. Identify the statistical tests

produce graphics and tables should

analyzing the data,


in the

be similarly identified.

Do not write on diskette labels except with


is

and give the prospectively determined level of significance

felt-tipped pen. If revision of a manuscript


tion of acceptance for publication,

required as a condi-

Methods
tify

section.

Report actual p values


article references to

in Results. Cite

only text-

we

ask that an electronic version

book and published

support choices of tests. Iden-

of revision be supplied to facilitate copyediting and production.

any general-use or commercial computer programs used, nam-

ing manufacturers and their locations.

These should be

listed

on the

Prior and Duplicate Publication.

Work that has been

published

product-sources page.

or accepted elsewhere should not be submitted. In special instances,


the Editor

may consider such

material, provided that permission to

Units of Measurement. Express measurements of length, height,


weight, and volume in metric units appropriately abbreviated; temperatures in degrees Celsius; and blood pressures in millimeters of

publish

is

given by the author and original publisher. Please conbefore submitting such work.

sult the Editor

mercury

(mm Hg).

Report hematologic and clinical-chemistry meain SI

Authorsliip. All persons listed as authors should have participat-

surements in conventional metric and


units.

ed
(Systeme Internationale)
torr.

in the reported

work and

in the

shaping of the manuscript;


all

all

must

Show

gas pressures (including blood gas tensions) in

have proofread the submitted manuscript; and


publicly discuss

should be able to

List SI equivalent values,

when

anddefend

the paper's content.

possible, in brackets following non-

A paper with cor-

Si

values for example, "PEEP, 10 cm H2O

porate authorship must specify the key persons responsible for the
[0.981 kPa]." For conarticle.

version to SI, see

RESPIRATORY Care

Authorship

is

not justified solely on the basis of solicitation

1988;33( I0):861-873 (Oct

of funding, collection or analysis of data, provision of advice, or similar services.

1988), 1989;34(2):I45(Feb 1989), and 1997;42(6):639-640 (June


1997).

Persons

who provide such ancillary services exclusively

may be

recognized in an Acknowledgments section.

Conflict of Interest Authors are asked to disclose any liaison or financial

Permissions. The manuscript must be accompanied by copies of


permissions to reproduce previously published material (figures or
tables); to

arrangement they have with a manufacturer or distributor whose


is

product

part of the submitted manuscript or with the manufacturer

use illustrations

of,

or report sensitive personal information

or distributor of a competing product. (Such arrangements


disqualify a paper
ers.)

do not

about, identifiable persons; and to

name persons

in the

Acknowl-

from consideration and are not disclosed

to review-

edgments

section.

A statement to this effect is included on the cover-letter page.


interest.)

(Reviewers are screened for possible conflict of

Reviewers. Please supply the names, credentials,


es,

affiliations, address-

and phone/fax numbers of three professionals


one or more of them for blind peer review.

whom

you con-

Abbreviations and Symbols. Use standard abbreviations and symbols.

sider expert
to

on the topic of your paper. Your manuscript may be sent

Avoid creating new abbreviations. Avoid


and unusual abbreviations

all

abbreviations

in the title

in the abstract.

Use an abbre-

viation only if the term occurs several times in the paper. Write out

the full term the first time

it

appears, followed by the abbreviation

in parentheses. Thereafter,

employ

the abbreviation alone.


it.

Never

use an abbreviation without defining

Standard units of mea-

surement can be abbreviated without explanation (eg. 10 L/min,


15 torr, 2.3 kPa).
Please use the following forms: cm H2O (not cmH20), f (not bpm), L (not 1), IVmin (not LPM, l/min, or Ipm), mL (not ml), mm Hg (not mmHg), pH (not Ph or PH), p > 0.00 (not p>0.001). s (not sec), Spo: (pulse-oximetry saturation). See RESPIRATORY CARE:
1

Standard Abbreviations and Symbols [Respir Care I997;42(6):637642].

Editorial Office:

Submitting the Manuscript

RESPIRATORY CARE
600 Ninth Avenue, Suite 702 Seattle A 98104
affiliation(s), 2

Mail three copies

[1

copy with author(s) name(s),


and the Cover Letter

copies without name(s) and affiliation(s) for reviewers] of the manuscript, figures,

and

diskette,

& Checklist to

(206) 223-0558 (voice) (206) 223-0563 (fax)


e-mail: rcjournal@aarc.org

Respiratory Care, 600 Ninth Avenue, Suite 702, Seattle WA 98 104. Do not fax manuscripts. Protect figures with cardboard. Keep
a copy of the manuscript and figures. Receipt of your manuscript

kreilkamp@aarc.org

Respiratory Care Manuscript

Preparation Guide. Revised 2/98

COVER LETTER & CHECKLIST


A copy
of this

completed form must accompany

all

manuscripts submitted for publication.

Title of

Paper:

Publication Category: _

Corresponding

Authior:

Phone:

FAX:

Mailing Address:
Reprints:

Yes

No

E-mail Address:.

"We, the undersigned, have all participated in the work reported, proofread the accompanying manuscript, and approve mission for publication." Please print and include credentials, title, institution, academic appointments, city and state. than 4 authors, please use another copy of this form.*

its
If

sub-

more

*First Author:.

Author Signature/Date.

Second Author:
Author Signature/Date,
*Third Author:

Author Signature/Date_
'Fourth Author:

Author Signature/Date.

Has
If

this

research been presented

in

any public forum?

Yes

No

yes, where,

when and by whom?


Yes

Has
If

this

research received any awards?

No

yes, please describe.

Has
If

this

research received any grants or other support, financial or material?

Yes

No

yes, please describe.


to)

Do any of the

authors of this manuscript have a financial interest in (or a commercial or consulting relationship Yes products or manufacturers mentioned in this paper or any competing products or manufacturers?
yes, please describe.

any

of the

No

If

Have you enclosed a copy


Is

of the

manuscript on diskette?

double-spacing used throughout entire manuscript?


all all

Are Are

pages numbered

in

upper-right corners?
in

references, figures, and tables cited

the text?

Has the accuracy of the references been checked, and are they correctly formatted? Have SI values been provided? Has all arithmetic been checked? Have generic names of drugs been provided? Have necessary written permissions been provided? Have authors' names been omitted from text and figure labels? " Have copies of 'in press' references been provided? Has the manuscript been proofread by all the authors? Have the manufacturers and their locations been provided for all devices and equipment used?

Respiratory CARF. Manuscript

Preparation Guide, Revised 2/98


Not-for-profit organizations are offered a free advertisement of up to eight lines to appear, on a space-available
basis, in

Calendar of Events
is

in

RESPIRATORY CARE. Ads

for other

meetings are priced


the
1

at

$5.50 per line and require


the ad to run,

an insertion order. Deadline

the 20th of the

month two months preceding

month

in

which you wish

Submit copy and insertion orders to Calendar of Events. RESPIRATORY CARE.

1030 Abies Lane. Dallas

TX

75229-4593.

Calendar of Events

AARC & AFFILIATES


February 23, 1999
Live Videoconference. Participate
live,
first

Contact: Angle Heretine (609) 784-0340


April 21-23,
in a

Users Network, and the

AARC,

is

scheduled for the Caribe Royale

1999 Cincinnati. Ohio


II

Resort Suites. Topics include

The 26th Annual Region


Indiana, Kentucky, and
affiliates

noninvasive ventilatory assistance


the

in

90-minute

satellite

broadcast of the

Conference will be presented by the

home, ICU, ER, and long-term

installment of the

AARC's

1999

Ohio

care sites; nutritional issues for


ventilated patients; diagnosis and

"Professor's

Rounds"

series

and receive

with an excellent mix of

one

CRCE credit hour.

"Assessing the

current topics and dynamic speakers.

diagnostic methods; ethical issues;

Respiratory Patient" will be broadcast

Contact: Call (800) 691-3046, Mail

and telemonitoring
available.

in the

home.

from 11:30-1 p.m. (CT).

Box
at

I,

or visit their

web

site at

Continuing education credits

Contact: Call the


(972) 243-2272.

AARC

http://www.bright.net/~dsibb/
reg2rc.htni.

Contact: (800) 343-2227

March
the

16,

1999
installment of the

April 23-25, 1999

March
Kingsport, Tennessee
its

16-19,

1999 Brussels,
Symposium

Teleconference. After viewing a tape of


first

The TSRC presents

Belgium

annual

AARC's 1999
"Assessing

convention and exhibition. The

New

The 19th

International

"Professor's

Rounds"

series,

Millennium: Somewhere Over the

the Respiratory Patient," participate in

Rainbow,

at the

Meadowview

on Intensive Care and Emergency Medicine will be head at the Congress Center
in Brussels.

Resort

a live telephone question-and-answer


session (1 1:30-12

and Convention Center. Topics will


include clinical, management,
patient assessment, and student

noon CT) and receive

Contact: Ana Maria de Campos


32.2 555 3215 ore-mail

at

one

CRCE credit hour.

Contact: Call the

AARC

at

sympicu@resulb.ulb.ac.be.
April 20-23
Florida
All Children's Hospital of St.

issues. 13 contact hours are available.

(972) 243-2272 to receive the 90-

Contact: Colleen Schabacker

Clearwater Beach.

minute video tape and register for


the teleconference.

(615)384-1731

Other Meetings
March 31-April
Utah
1,

1999&// Lake
its

City,

Petersburg, FL, will host their 1999

February 13-20, 1999 5r. Moritz,

Neonatal/Pediatric Transport

The

USRC

is

hosting

annual

Switzerland

Conference

at the

Hilton Clearwater
titled

convention

at the Salt

Palace

The Seventh Winter Symposium on


Intensive Care Medicine will be held
in St.

Beach Resort. The conference,


Redefining State of the Art,

Forecast for a

New Millennium:

Respiratory Therapists Shine

Moritz and

is

jointly sponsored

includes a pre-conference lab and


offers 23

Through. Topics will include patient


assessment, protocols, ventilator

by the European Society of Intensive


Care Medicine and the Society of
Critical

CEUs.
at

Contact: Connie Spadaccino


ext.
at

waveform management, and


alternative therapies.

Care Medicine (USA).

(727) 892-4240 or (800) 456-4543,

Contact: Ana Maria de Campos


at

4240.

Contact: Jim Keenan

32.2 555 3215 ore-mail

June 12-16, 1999

International
at

(801)588-3077, e-mail
pcjkeena@ihc.coin.

sympicu@resulb.ulb.ac.be.

Society for Aerosols in Medicine


12th International Congress
the

February 21-25
April 7-9,

Keystone. Colorado

1999 Gulf Shores.


Society for Respiratory
state educational

Alabama The Alabama


Care
will

The Children's National Medical Center presents their 15th Annual

Austria Center in Vienna, Austria.

Topics include aerosol drug


delivery, aerosol deposition

CNMC

be hosting their
at the

Symposium on ECMO and Advanced Therapies for Respiratory


nitric oxide,

and

clearance, cellular and molecular


interactions, environmental

meeting

Gulf State Park Resort

Failure at the Keystone Resort.

Hotel and Convention Center.

Topics include
ventilation.

neonatal

aerosols, standardization, aerosol

Contact: David Howard


(205) 761-4573 or e-mail

pulmonary support, and

liquid

diagnostics, and aerosol therapy.

CME, CEU, CRCE

and

Contact: Vienna Academy of


Postgraduate Medical Education

William.Howard@bhsala.com.
April 13-14,

perfusion recertification credit


available.

1999 King

of Prussia.

Contact:

ECMO at (202) 884-5018

and Research. Alser Strasse 4, A- 1090 Vienna, Austria. Phone

Pennsylvania

The PSRC

will host their

2nd Annual

March

14-17

Orlando, Florida

Eastern Regional Conference

&

Noninvasive Ventialtion, the seventh


international conference of the

(+43/1)405 13 83-22, fax (-1-43/1) 405 13 83-23, e-mail medacad@via.at.

Exhibition at the Holiday Inn. Guest


speakers include

Sam Giordano, MBA,

American College of Chest


Physicians, Independent Ventilator

RRT, and Richard Branson, BA, RRT.

RESPIRATORY CARE

JANUARY 1999 VOL 44 NO

125

Notices of competitions, scholarships, fellowships, examination dates,

new

educational programs,

and the

like will

be

listed

here free of charge. Items for the Notices section must reach the Journal 60 days
1

Notices

before the desired month of publication (January


pertinent information and mail notices to

for the

March

issue,

February
1

for the April issue, etc). Include all

RESPIRATORY CARE

Notices Dept,

1030 Abies Lane, Dallas

TX

75229-4593.

Helpful LUeb.Sites
American Association for Respiratory Care
http://www.aarc.org

eaao
ATIONAL

<^

Current job American Respiratory Care Foundation


listings

fellowships, grants,

&

awards

Clinical Practice Guidelines


National Board for Respiratory Care http://www.nbrc.org

Respiratory Care online


http://www.rcjournal.com

LAS VEBASJ NEVADA

997 Subject and Author Indexes Contact the editorial


1

staff

Asthma Management Model System


http://www.nhlbi.nih.gov

The National Board


Examination

for Respiratory

Care

1999 Examination Dates and Fees


Examination Fee
$120 (new applicant)
80
120
(reapplicant)

Examination Date
July 10, 1999

CRTT Examination

Application Deadline:

May

1,

1999

RRT Exainination
CPFT Examination

December

4,

1999
1,

written only

(new applicant)

Application Deadline: August

1999

80 written only (reapplicant)


130

June

5,

1999
1,

(new applicant)
(reapplicant)

Application Deadline. April

1999

100

For information about other services or

fees, write to the National

Board for Respiratory Care,


nbrc-info@nbrc.org

8310 Nieman Road, Lenexa

KS

66214, or

call

(913) 599-4200,

FAX (913) 541-0156,or e-mail:

126

Respiratory Care

January

1999

vol 44 No

Y
NOTICES

WATCH FOR
S

New Federal Register Notices Now Available


The Center
for Devices

and Radiological Health announces the

PECI AL ISSUES OF
R
E S

new Facts-on-Demand FOD notices Federal Register. The new publications: FOD#774
publication of

Medical

in the

ATO CARE
I

Devices; Preemption of State Product Liability Claims; Proposed Rule; FOD#607 Rebuilders, Reconditioners,

and "As Is" Remarketers of Medical Devices; Review and Revision of Compliance Policy Guides and Regulatory Requirements; Request for Comments and Information; Proposed Rule; and FOD#513 Medical Devices; Reports of Corrections and Removals; Stay of Effective Date of InformaServices,

N HALED N ITRIC

tion Collection Requirements; Stay of Effective Date of Final

Regulation. For
call (800)

more information about Facts-on-Demand 899-0381 or (301) 826-0111. The FOD system is also
at w.fda.gov/cdrh/fedregin.html.

on the Internet

OXIDE
FEBRUARY 1999

Web Site Link to Fellowships, Scholarships, & Grants


The American Association
for Respiratory Care's

web

site

con-

tains important information about fellowships, scholarships,

and research grants. International fellowships, education scholarships, research fellowships, and other grand programs are described in detail. The site also contains information
about the $1,000,000 Research Fund, a restricted fund to sponsor research initiatives that document the clinical and economic impact of respiratory care professionals in the delivery of health care. To apply, a "Research Plan Abstract" must be submitted to the AARC by February 1, 1999. To find out more about these programs, log on at www.aarc.org.

MARCH

1999

AARC, Affiliates Set Conference Schedules


The AARC and many of the
for
affiliates have set their schedules 1999 conferences and seminars. Foremost among AARC's offerings are its Summer Forum (July 16-18) and Annual International Respiratory Congress (Dec. 13-16). Additionally, the AARC will be co-sponsoring the 7th International Conference on Non-invasive Ventilation on March 14-17, 1999 in Orlando. Check out the AARC's website at www.aarc.org for all meeting registration materials and a list of affiliate

(^n

this issue

conferences.

1999

%dl

Videoconference Program Set; Nursing CEUs


Offered A series of eight videoconferences are scheduled for
1999 through the AARC Professor's Rounds series, which are now approved for nursing CEUs as well as CRCE credit. Topics are: respiratory assessment, asthma management, ventilator management, disease management, pediatric emergencies, COPD, PEEP, and respiratory pharmacology.

CRCE Online Debuts


Now you can earn continuing education on the Internet from the AARC through its new CRCE Online website. After you pay
number of continuing education units you wish to attempt (by submitting your credit card number on a secure server site), you are given access to the list of courses. Read the material, take the test, and then print out a certificate showing you passed. Your participation will also be noted on your CRCE record with the AARC. Log on to the AARC's website at www.aarc.org and look for CRCE Online.
for the

c^ee j)aae 119

RESPIRATORY CARE

JANUARY

1999

VOL 44 NO

127

Authors in This Issue


Ambrosino, Nicolino
Basile,

29
82
81

Miyagawa, Tetsuo
Morfei, Joseph

22
45 38

John

Benditt, Joshua

O A

Nagel,

Mark

W
L

CHni, Enrico
Davis,

29 78
24, 53 24, 53

Rafanan, Albert

74
38

Thomas

Rau, Joseph

Dhand, Rajiv
Fink,

Reis Miranda, Dinis


Sailors,
Stoller,

70
83

James B

Simon Kavuru, Mani S


Hillier,

81
73, 74, 76

R Matthew James K
Jerome

73

Sullivan,

22 26
53

Mansharamani, Naresh

76 78 38

Swenson, Eric

Mathewson, Hugh S
Mitchell, Jolyon

Tobin, Martin J
Vitacca, Michele

P
To
at

29

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RESPIRATORY CARE,

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RESPIRATORY CARE,

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