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Respiratory care : the official journal of the American Association for Respiratory Therapy

De
150 pages
December 1995 Volume 40, Number 12 ISSN0020-1324-RECACP 97 A MONTHLY SCIENCE JOURNAL 40TH YEAR—ESTABLISHED 1956 EditorialsCall for CPGs: Why, Whence, & Whither? 1996 Open Forum Abstracts Call for CPG Implementation & Early Deadline February 11, 1996! Assessment WOB with Ventilators for Long-Term Support Airway Management of the Chronically Intubated Patient Special Article from NHLBI: Sleep Apnea Clinical Practice Guidelines Assessing Response to Bronchodilator Therapy at Point of Care Discharge Planning for the Respiratory Care Patient Long-Term Invasive Mechanical Ventilation in the Home Capnography/Capnometry during Mechanical Ventilation Selection of an Aerosol Delivery Device for Neonatal and Pediatric Patients Polysomnography ' The act of Ins apprehending the inner nature ofthings ^ or of seeing intuitively, won'tL ook closely. energy expenditure. So youAccording to Dr. C. Price, M.D., CM., F.R.C.P. and Gail Lang, RRT, CreditHere lies the reflection of your good of waste your own energy attempting to Valley Hospital in Ontario Canada, judgement. In recognizing that your estimate the complete daily nutri- patients rely upon the most qualified tional picture from inconclusive spot"In our opinion, the 7250 clinical decisions, Nellcor Puritan provided an checks.
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December 1995
Volume 40, Number 12
ISSN0020-1324-RECACP
97
A MONTHLY SCIENCE JOURNAL
40TH YEAR—ESTABLISHED 1956
EditorialsCall for
CPGs: Why, Whence, & Whither?
1996 Open Forum Abstracts
Call for CPG Implementation &
Early Deadline February 11, 1996!
Assessment
WOB with Ventilators for Long-Term
Support
Airway Management of the
Chronically Intubated Patient
Special Article from NHLBI: Sleep
Apnea
Clinical Practice Guidelines
Assessing Response to Bronchodilator
Therapy at Point of Care
Discharge Planning for the Respiratory
Care Patient
Long-Term Invasive Mechanical
Ventilation in the Home
Capnography/Capnometry during
Mechanical Ventilation
Selection of an Aerosol Delivery Device
for Neonatal and Pediatric Patients
Polysomnography'
The act of
Ins
apprehending
the inner nature
ofthings
^
or of
seeing intuitively,
won'tL ook closely. energy expenditure. So youAccording to Dr. C. Price, M.D., CM.,
F.R.C.P. and Gail Lang, RRT, CreditHere lies the reflection of your good of waste your own energy attempting to
Valley Hospital in Ontario Canada,
judgement. In recognizing that your estimate the complete daily nutri-
patients rely upon the most qualified tional picture from inconclusive spot"In our opinion, the 7250
clinical decisions, Nellcor Puritan provided an checks.Metabolic Monitor
Bennett brings you effective informa- accurate assessment ofour
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tion tools for making them with confi- nutritional requirementspatient's
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Consider
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ASSESS to deliver those measurements with superior
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Evaluate response to therapy and
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REFERENCES t Peters Jl.^liinickefJ Cui'en ronnepis in nWBOing status aslhnrBlicusJflsspff Oft LOW RANGE
A=*rt,a trt,,, .... STANDARD RANGEf3(6) 829-849, 1992 2 NaliSal piwj'am- i^umines lortheDisgnm snd Mmage-
' 30 to 390 L/nnin
> Services, NIH No 91-3042 60 to 880 L/minmenlotMI\mM\ii^i.m.\}' 1991, Pud
3 Oaia on We HeaithScan Ptorfiict' °i.JM,ODiralaftG,'elal. An evaluation ol
'•''
llie accuracy ol Assess and Min)V/rni'iy>;i» ' >. '••.'V!X2) 358-362. 1991, 5,Gar()nmRM. Setting the standard
•>'Ctapo RO, Jaciison BR, et al Evaluit'C! accuracv and tm(od\Kil)ility ol peak llowtneters at 1.400m
flow monitoring.for peakCftM/ 948-952. 1992 AA710003-0 b/93 HeaitlScan ProducisW;(4) 't' 1993,
Circle 119 on reader service card
VisitAARC Booth 1310 In OrlandoRE/PIRATORy QiRE
A Monthly Science Journal. Established 1956. Official Journal of the American Association for Respiratory Care
Editor December 1995
Pat BrougherBA RRT Volume NumberContents ... 40, 12
Associate Editor
Kaye WeberMS RRT
Editorials
Editorial Office
1264 Clinical Practice Guidelines: Why, Whence, and
Abies11030 Lane
Whither?
DallasTX 75229 —by Dean Hess Boston. Massachusetts
(214)243-2272
1269 Guidelines: A Call for Local Implementation and
Assessment of ImpactEditorial Board
—hy Kingman P Strohl Cleveland. Ohio
JamesK StollerMD, Chairman
Cleveland Clinic Foundation Original Contributions
Cleveland, Ohio
Work of Breathing Imposed by Five Ventilators1270
RichardD Branson RRT
Used for Long-Term Support: The Effects ofPEEP
University of Cincinnati
and Simulated Patient Demand
Medical Center —by RichardD Branson and Kenneth Davis Jr Cincinnati. Ohio
Cincinnati, Ohio
Reviews, Overviews, & Updates
Crystal L Dunlevy EdD RRT
The Ohio State University
1279 Airway Management of the Chronically IntubatedColumbus, Ohio
Patient
CharlesG Durbin JrMD by George S Leisure, David J Stone, Burkliard F Spiekermann,
University Virginia and David L Bogdonojf^Cliarlottesville, VirginiaThe of
Health Sciences Center
Charlottesville. Virginia Special Article
Thomas D East PhD
1287 Sleep Apnea: Is Your Patient at Risk?
LDS Hospital
A special articlefrom the National Heart, Lung, ami Blood
University of Utah
Institute, reprinted with permission.
Salt Lake City, Utah
Guidelines, Recommendations, &Dean R Hess PhD RRT
Statements
Massachusetts General Hospital
Harvard Medical School
1299 AARC Clinical Practice GuidelinesBoston, Massachusetts
\. 1300 Assessing Response to Bronchodilator Therapy at
Neil R Maclntyre JrMD Point of Care
^ 1308 Discharge Planning for the Respiratory Care PatientDuke University Medical Center
1313 Long-Term Invasive Mechanical Ventilation in theDurham, North Carolina \
Home
ShelleyC Mishoe PhD RRT i- 1321 Capnography/Capnoinetry during Mechanical
Medical College of Georgia Ventilation
^Augusta, Georgia 1325 Selection of an Aerosol Delivery Device for
Neonatal and Pediatric Patients^
Joseph L Rau PhD RRT ^ 1336 Polysomnography
Georgia State University
Atlanta, Georgia
Re,spiratory • '95Care Dkcember Vol 40 No 12 1243YourTell Paitentb
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Introducing The Pulsair'\5 Liquid moment or inspiration arrd delivers the
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Visit AARC Booths 1010, 1012, and 1014 In OrlandoDecember 1995Managing Editor
... Contents Volume 40, Number 12
Ray MasferrerBA RRT
Assistant Editor
Books, Films, Tapes, & Software
Kris Williams BA
Mechanical Ventilation at Home: A1344 Assisted
AssistantEditorial
Practical Guide
Linda Barcus BBA —reviewed by Teri Nikolai Wilson Denton, Ohio
Section Editors
Robert R Fluck Jr MS RRT
Classic ReprintsMS JastremskiMD
Blood Gas Corner
Story1346 Retrospectroscope Redux: The Inside
Hugh S MathewsonMD — with permission, theby Julius H Comroe Jr Reprinted, from
Drug Capsule
13:381-385.American Review ofRespiratory Disease 1976:1
Branson RRTRichard D
of ReviewersRobert S Campbell RRT Appreciation
Kinrecige 's Corner
135 1 Listing of This Year's Manuscript & OPEN FORUM
CharlesG Irvin PhD
Reviewers
WangerMBA RPFTRRTJack
fFT" Corner
Annual Indexes for Volume 40, 1995
Patricia Ann Dooriey MS RRT
CharlesG Durbin JrMD
1352 Author Index
Tesi Your Radiologic Skill
1357 Subject Index
Consulting Editors
NOTICES
Biondo BS RRTFrank E
Howard J BirenbaumMD 1373 1995 ARCF Literary Award Winners
Robert L Chatburn RRT
Donald R EltonMD
In This Issue
Ronald B GeorgeMD
1246 Abstracts from other Journals
JamesM HurstMD
1384 Advertisers Index & Help Lines
RobertM Kacmarek PhD RRT
1384 Author Index
Michael McPeck BS RRT
1383 Calendar of Events
David J PiersonMD
1379 Call for Open Forum AbstractsJohn ShigeokaMD
1374 Manuscript Preparation GuideJeffrey J Ward MEd RRT
1381 MedWatch
1378 New Products & ServicesProduction
Steve Bowden
Donna Knauf
Karen Singleterry
Marketing
Director
Enterprises Inc. at 1 1030 Abies Lane.Dale Griffiths Re.spir.ator\ Care (ISSN 0020-1324) is published monthly by Daedalus
volume is published per year begrimingDallasTX 73229-4593, for the American Association for Respiratory Care. One
rates are per year in the US; $80 in all other countries (for airmail, add $84).Advertising Assistant each January. Subscription $65
The contents of the Journal are indexed in Hospital and Health Administration Inde.x. Cumulative Index to
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versions ofRESPIRATORYCare are alsoNursing and Allied Health Literature, and Excerpta Medica. Abridged
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Second class postage paid at Dallas TX. POSTMASTER; Send address changes to CARE, Mem-Advertising
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'95Respiratory Care • December Vol 40 No 12 1245—
i)f Pcrlincnl ArliclcsAbstracts
P.ditorials, Commentaries, and Reviews To Note
Smoking and Health: Physician Responsibility A Statement ofthe Joint Committee on and Health (special report)—American College ofChest Physicians; American Tho-
racic Society; Asia Pacific Society of Respirology; Canadian Thoracic Society; European Respi-
ratory and International Union Against Tuberculosis and Lung Disease. Chest
1995;I08(4):1 118-1 121.
A.ssessment ofAsthma in the Workplace (statement)—Chair: M Chan-Yeung. Chest
1995;1()8(4):1084-1117.
The Challenge ofTuberculosis: Statements on Global Control and Prevention (statement)
DA Enarson, J Grosset. A Mwinga, ES Hershfield. R O'Brien, S Cole, L Reichman. and
1995;.''46:8()9.finalized by conference participants, Washington DC, Sept U-l.*), 1995. Lancet
Towards the Elimination ofTuberculosis (editorial)—R Horton. Lancet 1995;346:790.
Standardization ofSpirometry, 1994 Update (statement)—The American Thoracic Society
Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. Am J Respir
107-1CritCare 1995;I52;1 136.
Continuing Patient Care with Metered-Dose (FP), Single-do.se studies ofsalbutamol, 2(X) Ambient Air Pollution and Hospitalization forfug,
Woodcock.Inhalers—A J Aerosol Med 1995;8 withHFA 134ahave been shown to provide equiv- Congestive Heart Failureamong Elderly Peo-
(Suppl2);S-5. alent protection against bronchial provocation by ple in Seven Large US Cities—RD Moms,
histamine in both adults and children with asth- EN Naumova, RL Munasinghe. Am J Public
International guidelines recommend inhaled ther- ma when compared with the currently available Health 1995;85(10):136I.
apy over oral therapy for asthma because ofgreater CFC preparations. In a subsequent 4-week study,
efficacy and safety. Metered-dose inhalers (MDIs) both formulations had similar effects on morn- OBJECTIVES: Preexisting data sets were used
deliveryare the system of choice for the major- ing peak How and the patients helic\ed that the to investigate the association between hospital ad-
ity of patients with asthma. They have been well 2 preparations were equivalent. Single doses of missions for congesti\ e heart failure and air pol-
tried and tested and proven to be safe, reliably de- salmelerol, 50 /Jg and 100 pg, provide equal pro- lutants. METHODS: Medicare hospital admissions
livering a reproducible and precise dose, and ac- tection against bronchial provocation by metha- data, ambient air pollution monitoring data, and
for85%count ofthe400 million inhalers currently choline compared with the respective dose ofthe meteorological data were used to create daily val-
sold worldwide. Current products using chloro- cuiTentCFC formulation. A 4-week study com- ues of hospital admissions for congestive heart
fluorocarbon (CFC) 1 1/12 as the propellant are paring both preparations showed equivalent ef- failure, maximum hourly temperature, and max-
being reformulated. Under the Montreal Proto- fect with similar improvements in morning peak imum hourly levels of carbon monoxide, nitro-
col, CFCs arc to be phased out worldwide, though flow for both preparations. A double-blind study gen dioxide, sulfur dioxide, and ozone. Data were
MDIs have been granted temporary exemption, has compared FP, 250 twice daily, withHFA compiled for each of 7 cities (Chicago, Detroit,^g
thus until 1997.Two propellant.s,far hydrofluoro- 134a and the current CFC formulation in mod- Houston, Los Angeles, Milwaukee, New York,
alkane (HFA) 1 34a and 227, have been identified erate asthmatics prc\ iously taking up lo S(l(l and Philadelphia) for 1986 tlirough 1989. Single-/jg
by to corticosicroid.the pharmaceutical industry replace CFCs. aday of inhaled Morning peak How pollulant and multipollutant models with ad-
However, they have different properties and re- improved by approximately 20 IVmin in both ta'at- justments for temperature, seasonal effects, and
formulation has been sur- weekly useddifficult in relation to nient groups. Monitoring ofadverse events and cycles were in conducting negative
factants, valves and elastomeric seals. The man- clinical and laboratory test data has shown a very binomial regression analyses. RESULTS: Am-
ufacturing pnKCss has been re-engineered similar levels were positivelyto take profile for safety and tolerability ofHFA bient carbon monoxide as-
place at high pressure, because at nomial pressure 1 34a formulations when compared with current sociated with hospital admissions for congestive
HFA l.Wa is gas, in contrast witha CFC 1 1 which CFC formulations, with no new or unexpected ad- heart failure in the single-pollutant and multi-
is a liquid at rtxim temperature. Glaxo has carried verse events in over 2,000 patients. Both pro- pollutant models for each of ttie 7 cities. The rela-
out an extensive toxicological assessment ofHFA pellants will be available during the transition pe- tive risk ofhospital admission for congestive heart
134a and thorough clinical testing has shown it riod. Doctors and patients will continue to see the failure associated with an increase of 10ppm in
to be well tolerated. To dale they have carried out need forMDIs and tliey will remain the most wide- carbon monoxide ranged from 1 . 1 in New York
safely and efficacy testing on reformulations of ly used delivery system for asihnta Iherapy into lo 1 37 in Los Angeles.CONCLUSIONS: Hos-
salbutamol, salinelerol, and fluticasone propionate the next millennium. pital admissions for congestive heart failure ex-
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Abstracts
vari- compressed air, the feasibility of nebulization of za has substantia! health-relatedhibited a consistent association with daily and economic ben-
ations in ambient carbon monoxide. This asso- the immunoglobulin solution (IVIG, Sando- efits for healthy, working adults. See the related
was independent of season, temperature, globulin" ) had to be tested. The therapeutic ef- ecliloiial: Influenza Vaccine Healthyciation for
and other major gaseous pollutants. fect of a drug delivered via inhalation is propor- Adults?—PA Patriaicu. RA Strikas. NEnglJMed
tional to the mass ofaerosol deposited in the lungs.
Mullidru^-Resistant Tuberculosis in Patients For a fixed breathing pattern, the amount deposited
Infection—EE Telzak. K Scpko- per unit oftime in the thoracic region depends on Delivery and Retention ofan Insulin Aerosol»ithuut Hl\'
witz, P Alpert, S Mannheimer, F Medard,W El- mass flowrate and distribution ofaerosol mass by Produced by a New Jet Nebulizer—J Jendle,
Sadr, S Blum. A Gagliardi, N Salomon.G Turett. droplet size. Both these variables were detemiincd BE Karlberg, J Persliden. L Fninzen,M Arborelius
N Engl J Med 1995;333( 14):907. in relation to the weight concentration (osmolality ). Jr. J Aerosol Med 1995:8(3):243.
viscosity, and surface tension of the IVIG solu-
BACKGROUND: Investigations ofoutbreaks of tion for 4 compressed air nebulizers. The mass This study describes the delivery and distribution
multidrug-resistant tuberculosis have found low flowrate ofthe spray decreases as the weight con- of an aerosol generated by a jet nebulizer
' increases,rates of treatment response and very high mor- centration of the solution but droplet (MAXIN*) in an experimental animal model.
tality, and they have mainly involved patients with size distribution does not change. If the IVIG so- Anesthetized, intubated and ventilated piglets in-
airflow radiolabeledadvanced human immunodeficiency vims (HIV) lution does not exceed 5% and the rate is haled technetium dlethylenetrlamine-
infection. For patients without HIV infection. 1 6 L/min, a mass flow ofabout 150mg to 250mg penta-acetic acid ('"""Tc-DTPA) through the en-
study reported an overall rate of response to tfeat- (7.5 to 12.5 mg IVIG) per minute is obtained, de- dotracheal tube. The lungs were excised en bloc
menl o{5b9c, and the mortality from tuberculo- pending on the physical characteristics of the neb- and scintigraphed, using a computerizedgamma
evaluatesis was 229c.We investigated treatment response ulizer used. Low mass median diameter of about camera to the pattern ofdistribution. By
and mortality rates in 26 HIV-negative patients 2 pm and a mass distribution with a high per- nebulizing radiolabeled '-^I-insulin and comparing
inNew York with multidrug-resistant tuberculosis. centage ofthe droplets below 6jjm will allow op- the activity deposited on inspiratory and expiratory
METHODS: We obtained detailed data from 7 timum intrapuhiionary deposition in infants. electrostatic filters, delivery and retention of neb-
wasteaching hospitals in New York City on patients ulized insulin assessed. The distribution of
with multidrug-resistant tuberculosis—defined as The Effectiveness of Vaccination against In- aerosol in the lungs was very even and reached
tuberculosis resistant at least to isoniazid and ri- fluenza in Healthy. Working Adults the most peripheral parts. The delivery ofnebu-
fampin—who were HIV-negalive on serologic KL Nichol. A Lind. KL Margolis,M Murdoch. lized insulin was calculated to be 88.9 ± 5.3% and
testing. Lengths of times from diagnosis to the ini- R McFadden. M Hauge. S Magnan. M Drake. 36. 1 ± 8.8% of the insulin delivered to the res-
tiation of appropriate therapy and from the ini- N Engl J Med 1995:333( 14):S89. piratory tract was retained. The immediate local
tiation of therapy to conversion to neg- effects of insulin aerosol administration on the
ative cultures were assessed. Therapeutic responses BACKGROUND: Altliough intluenza causes sub- lungs were evaluated using light microscopy. No
were evaluated by both microbiologic and clin- stantial morbidity and mortality in all age groups, adverse effects were observed at histopatholog-
ical criteria. RESULTS: Between March 1991 and current recommendations emphasize annual im- ic examination of the lung tis.sue.CONCLUSION:
September 1994, 26 HIV-negative patients were munization for people at high risk for compli- This study shows a high penetration of aerosol to
identified and treated. Ofthe 25 patients forwhom cations of influenza.We conducted a double-blind, the peripheral parts of the lung and efficient de-
adequate data were available for analy.sis, 24 (96%) placebo-controlled trial of vaccination against in- livery of nebulized insulin when using the
had clinical responses: all 1 7 patients forwhom fluenza in healthy, working adults. METHODS: MAXIN-nebulizer.
dataon microbiologic response were available had In the fall of 1994, we recruited working adults
such a response. The median times from diagnosis from 18 to 64 years ofage from in and around (he Bacterial Pneumonia in Persons Infected with
to the Initiation of appropriate therapy and from Minneapolis-St Paul area and randomly assigned the Human Immunodeficiency Virus
the initiation oftherapy to culture conversion were them to receive either influenza vaccine or place- RE Hirschtlck. J Glassroth.MC Jordan,TC Wil-
44 days (range, to 181 ) and 69 days (range, 2 bo injections. The primary study outcomes in- cosky, JM Wallace, PA Kvale, N Markowitz,
to 705), respectively. Side effects requiring the cluded upper respiratory illnesses, absenteeism MJ Rosen, BT Mangura. PC Hopewell, the Pul-
discontinuation of medication occurred in 4 of 23 from work because of upper respiratory illness- monary Complications ofHIV Infection Study
patienLs (17%) who were tfeated with second-line es, and visits to physicians" offices for upper res- Group. N Engl J Med I995;333(13):845.
antituberculosis medications. The median follow- piratory illnesses. The economic benefits of vac-
up for the 23 patients who responded and who re- cination were analyzed by estimating the direct BACKGROUND: Patients with human immuno-
ceived appropriate therapy was 91 weeks (range. and indirect costs associated with immunization deficiency virus (HIV) infection are at increased
41 to 225). CONCLUSIONS: In this report from and with upper respiratory illnesses. RESULTS: risk for bacterial pneumonia in addition to op-
New York City. HIV-negative patients with multi- We enrolled a total of849 subjects. Baseline char- portunistic infection. However, the risk factors
drug-resistant tuberculosis, contrary to previous acteristics were similar in the 2 groups. During for bacterial pneumonia and its incidence in this
994-reports, responded well to appropriate chemother- the follow-up period, consisting of the 1 1995 populallon are not well defined. METHODS: In
apy, both clinically and microbiologically. Inlluenza season (December 1, 1994. through a multicenter. prospective, observational study,
M;irch 31, 1995), thosewho received the vaccine we monitored 1,130 HIV-positive and I67HIV-
Physical Properties of Aeri>s<ili/ed linmuno- reported 259r fewer episodes ofupper respiratory negative participating adults for up to 64 months
l>lobulin for Inhalation Therapy—PC Rimens- illness than those who received the placebo (105 for pulmonary disease. The HIV-positive group
berger. C Roth. J Aerosol Med 1995;8(3):255. vs 140 episodes/100 subjects, < 0.001 ), 437r comprised 814 homosexual or bisexual men, 261p
fewer days ofsick leave from work due to upper injection drug users, and 55 female partners of
Animal studies suggest that passive immuniza- respiratory illness (70 vs 1 22 days/100 subjects, HIV-infected men. RESULTS: There were 237
tion = HIV-by Intratracheal application ofgammaglob- p 0.001 ). and44% fewer visits to physicians" episodes of bacterial pneumonia among the
ulins may succeed in treating small children and offices for upper respiratory illnesses (3 1 vs 55 positive participants (rate, 5.5/l(X) person-years),
with = among HIV-neg-infant.s severe lower respiratory u-act infection visits/100 subjects, p 0.004). The cost savings as compiuicd with 6 episodes the
caused by respiratory syncytial virus (RSV). Since were estimated to be $46.85/pcrson vaccinated. ative participants (rate, 0.9/ l(X) person-years: <p
proteins foam easily when stirred used with Vaccination 0.(K)1 rate of bacterial pneumonia increa.sedup or CONCLUSIONS: against inlluen- ). The
').'SRi si'iRAi()k> Caui-. • i:)i:('i:mbi:r Vol 40 No 121248

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