Should this patient use supplemental oxygen during commercial air flight?
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Aged↗
Biomedical subjects
J K Stoller
Publications and source records attributed to J K Stoller.
Persistent left superior vena cava: case report and literature review.
A persistent left superior vena cava (PLSVC) is the most common thoracic venous anomaly. It is a persistent remnant of a vessel that is present as a counterpart of normal right-sided superior vena cava (SVC) in early embryological development but normally disappears later. Although it can be easily diagnosed by the characteristic chest radiographic appearance of a pulmonary artery catheter (PAC) passed through it after being inserted into the left subclavian or jugular vein, its diagnosis is usually missed by the presence of normal (right) SVC and the passage of the catheter on the right side. Its diagnosis can be confirmed by many noninvasive and invasive tests, or it is incidentally diagnosed at thoracic surgery or autopsy. If it is not associated with other congenital cardiac anomalies, it is usually asymptomatic and hemodynamically insignificant. However, PLSVC has important clinical implications in certain situations. In this article, we describe a patient with bilateral SVC (a normal right SVC and a PLSVC) identified by a PAC in the PLSVC and the pacemaker wires in the right SVC. In addition, we review the literature on prevalence, embryological development, diagnosis, and clinical implications of PLSVC.
Aged↗
What causes an elevated diffusing capacity?
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Anti-Glomerular Basement Membrane Disease↗
The impact of a respiratory therapy consult service on house officers' knowledge of respiratory care ordering.
BACKGROUND: Although available studies show that implementation of respiratory care protocols by respiratory therapists can enhance the allocation of respiratory care services, concern has been expressed that respiratory therapists' involvement in assessing patients and in determining treatment plans may detract from medical trainees' education and experience in ordering respiratory care services. OBJECTIVE: Compare the rates of correct responses to case-based questions about respiratory care ordering in two groups of internal medicine house officers at academic medical centers: one group training at an institution using respiratory care protocols (The Cleveland Clinic Foundation) and the other group training in an institution at which respiratory care protocols have not been used (University of Nebraska). DESIGN: Prospective cohort study. SETTING: Two academic medical centers, one using respiratory protocols and the other not using respiratory care protocols. MEASUREMENTS: Percent of correct responses to questions regarding respiratory care management posed in 5 case studies administered to both groups. RESULTS: Responses were available from 41 and 17 internal medicine house officers at The Cleveland Clinic Foundation and University of Nebraska, respectively. Respondents represented postgraduate years one, two, and three, and constituted a similar percentage of all internal medicine house officers at each institution (33%). The rate of correct responses to the 20 questions posed in the 5 case studies was high overall (76.8%) and similar in the two house staff groups (77.2 +/- 11.6% at The Cleveland Clinic Foundation and 75.8 +/- 12.0% at University of Nebraska, p = 0.69). The 95% confidence interval for the difference straddled zero (-5.4%, 8.1%), making it very unlikely that any important difference exists between the two groups in rate of correct responses. Analysis of covariance also showed no difference between groups, suggesting that postgraduate training level did not affect this conclusion. In one of the 5 case studies, the percent of correct responses was higher among trainees where respiratory care protocols were in use (86.8 +/- 18% at The Cleveland Clinic Foundation vs 69.1 +/- 14% at University of Nebraska, p = 0.0001). CONCLUSIONS: In this comparison of internal medicine house officers' knowledge regarding respiratory care ordering at institutions using versus not using respiratory care protocols, the rates of correct responses by both groups were similar and unlikely to differ significantly. For one of the 5 case studies, respondents from the institution using respiratory care protocols scored significantly higher. Taken together, these results suggest that use of respiratory care protocols implemented by respiratory therapists does not detract from internal medicine trainees' expertise in respiratory care management. Whether these results generalize to other institutions or reflect expertise in actual practice remains uncertain.
Academic Medical Centers↗
Role of bronchoscopy in massive hemoptysis.
Massive hemoptysis accounts for a minority of all patients with hemoptysis but poses a major challenge for the acute and long-term treatment. Massive hemoptysis can lead to asphyxiation and airway obstruction, shock, and exsanguination. Bronchoscopy plays an integral part in managing massive hemoptysis in diagnosis and treatment (Table 5). Specifically, bronchoscopy allows lateralization and more specific localization of bleeding that is critically important for effective management. Furthermore, acute control of bleeding can sometimes be achieved with instruments and catheters placed through the bronchoscope or by agents instilled into the airways through the bronchoscope.
Bronchoscopy↗
Pulmonary complications of mechanical ventilation.
Although life-saving, mechanical ventilation may be associated with many complications, including consequences of positive intrathoracic pressure, the many aspects of volutrauma, and adverse effects of intubation and tracheostomy. Optimal ventilatory care requires implementing mechanical ventilation with attention to minimizing adverse hemodynamic effects, averting volutrauma, and effecting freedom from mechanical ventilation as quickly as possible so as to minimize the risk of airway complications.
Critical Illness↗
A comparative analysis of arranging in-flight oxygen aboard commercial air carriers.
INTRODUCTION: As air travel has become more commonplace in today's society, so too has air travel by oxygen-using individuals. Because there is little oversight or standardization of in-flight oxygen by the Federal Aviation Administration, individual airlines' policies and practices may vary greatly. On the premise that such variation may cause confusion by prospective air travelers, we undertook the current study to describe individual air carriers' policies and practices and to provide guidance to future air travelers. METHODS: Data were collected by a series of telephone calls placed by the study investigators to all commercial air carriers listed in the 1997 Cleveland Metropolitan Yellow Pages. The callers were registered respiratory therapists who identified themselves as inexperienced oxygen-requiring travelers wishing to arrange in-flight oxygen for an upcoming trip. Standard questions were asked of each carrier that included the following: Did the carrier have a special "help desk" to assist with oxygen arrangements? What oxygen systems, liter flow options, and interface devices were available? What was the charge for oxygen? How was the charged determined? What documentation from the physician was required? How much notification was required by the airline before the actual flight? In addition to recording these responses, the total amount of time spent on the telephone by the caller was logged along with the number of telephone calls and number of people spoken to in arranging in-flight oxygen. To compare oxygen charges between airlines, we calculated charges based on a "standard trip," which was defined as a nonstop, round-trip lasting 6 h in which the traveler used a flow rate of 2 L/min. RESULTS: Of the 33 commercial air carriers listed in the directory, 11 were US-based carriers and 22 were international-based carriers. Seventy-six percent of the airlines offered in-flight oxygen. For the 25 carriers offering in-flight oxygen, mean phone time required to make the arrangements was 9.96+/-4.8 min (range, 3 to 20 min). No more than two telephone calls were required to make oxygen arrangements. Most carriers required 48- to 72-h advance notice, with a single carrier requiring 1-month advance notice. Most carriers required some notification of oxygen needs by the traveler's physician. There was a great variation in oxygen device and liter flow availability. Liter flow options ranged from only two flow rates (36% of carriers) to a range of 1 to 15 L/min (one carrier). All carriers offered nasal cannula, which was the only device available for 21 carriers (84%). Actual charges for in-flight oxygen also varied greatly. Six carriers supplied oxygen free and 18 carriers charged a fee (range, $64 to $1,500). One airline allowed the traveler to bring one "E" cylinder with no fee assessed. For 14 of the 18 carriers that charged, the charge for the standard trip ranged from $100 to $250. CONCLUSIONS: (1) As expected from the lack of standard regulations, the availability, costs, and ease of implementing in-flight oxygen vary greatly among commercial air carriers. (2) Because the expense of in-flight oxygen is usually borne by the traveler (rather than by insurers), prospective travelers should consider charges for oxygen use when choosing an airline. (3) In the context that the current study shows substantial variation in oxygen policies, costs, and services among commercial air carriers and that such policies may change over time, our findings encourage the prospective air traveler needing in-flight oxygen to "shop around."
Aircraft↗
Risk factors for an outbreak of multi-drug-resistant Acinetobacter nosocomial pneumonia among intubated patients.
INTRODUCTION: Acinetobacter baumanii is a Gram-negative coccobacillus that is normally a commensal pathogen but can be a nosocomial pathogen. An epidemiologic study was performed to investigate an outbreak of A baumanii that occurred in our medical intensive care unit (MICU) from March to September 1995. METHODS: A case-control study was performed by retrospective chart review, comparing case patients to randomly selected patients who were mechanically ventilated in the MICU for at least 1 week during the outbreak. A case patient was defined as any patient with an Acinetobacter infection in which the epidemic strain was considered to be a pathogen. The epidemic strain was defined by its antibiogram. Case patients and control patients were compared for age, gender, underlying disease, acute physiology and chronic health evaluation III score, length of MICU stay, prior antibiotic use, presence of fever, sepsis, type of pulmonary infiltrate, and outcome. Environmental and hand-washing studies also were performed during the period of the outbreak. Molecular typing was performed on available bloodstream isolates. RESULTS: There were 15 cases of A baumanii nosocomial pneumonia. Fifty percent were bacteremic; one chart was unavailable for review. Twenty-nine patients were identified as control patients. The mean age for case patients was 50 (range, 21 to 84). The mean duration of time from admission to the ICU to infection was 12.8 days (range, 4 to 40). Sepsis developed in 35% of the case patients. Forty-three percent of the case patients died during their hospitalization, with two of those deaths attributed to Acinetobacter infection. Univariate analysis showed that prior use of ceftazidime was associated with infection with Acinetobacter (11/14 case patients compared to 11/29 control patients; p < 0.01). Pulsed-field gel electrophoresis revealed two strains to be responsible for the outbreak. Hand washing was performed before patient contact by only 10% of health-care workers, and only 32% washed their hands after patient contact. CONCLUSION: The use of ceftazidime was associated with an increased risk of nosocomial pneumonia with resistant strains of Acinetobacter. Health-care workers need to improve compliance with hand-washing recommendations.
Acinetobacter Infections↗
Four-year experience with a unit for long-term ventilation (respiratory special care unit) at the Cleveland Clinic Foundation.
BACKGROUND: In the context that special weaning units have been advocated as effective alternatives to the ICU for weaning selected patients, we initiated a Respiratory Special Care Unit (ReSCU) at the Cleveland Clinic Hospital in August 1993. The goals of the ReSCU were the following: (1) to wean ventilator-dependent patients when possible; and (2) when weaning was not possible, to optimize patient and family instruction for patients going home with ventilatory support. This study presents our 4-year experience with 212 patients managed in the ReSCU and analyzes clinical features associated with favorable clinical outcomes. METHODS: The features of the ReSCU include six private beds in a pulmonary inpatient ward staffed by nurses with special pulmonary expertise; 24-h respiratory therapy supervision; bedside and central noninvasive monitoring (i.e., continuous pulse oximetry, end tidal capnometry, and ventilator alarms); and a multidisciplinary approach involving dietitians, physical therapists, occupational therapists, social workers, and speech pathologists. All ReSCU patients were cared for primarily by a pulmonary/critical care attending physician and fellow, with consultative input solicited as deemed necessary. The criteria for admission to the ReSCU included hemodynamic stability; absence of an arrhythmia requiring telemetry; and in the attending physician's judgment, the ability to benefit from the ReSCU. RESULTS: Between August 23, 1993, and August 31, 1997, 212 patients were admitted to the ReSCU. The median age was 68 years old; 55% were women; 86% were white; and 55% were transferred from the medical ICU. Underlying reasons for ventilator dependence were ARDS from a nonsurgical cause (33%), ARDS following surgery (18%), status post-cardiothoracic surgery (13%), status post-thoracic surgery (12%), and COPD (12%). The median length of ReSCU stay was 17 days (interquartile range, 10 to 29 days). Eighteen percent (n = 38) died during the hospitalization. Among the 174 survivors, complete ventilator independence was achieved in 127 patients (60% of the 212 patient cohort), 28 patients were ventilator dependent (13% of 212 patients), and the remaining 19 patients (9%) required partial ventilatory support. Univariate analysis regarding the association of baseline characteristics with death identified lower albumin and transferrin levels, increasing age, and the physician's estimate of lower weaning likelihood as significant correlates of death. In contrast, achieving complete ventilator independence was associated with a higher serum albumin level, a nonmedical ICU referral source, a cause of respiratory failure other than COPD, and a physician's estimate of higher weaning likelihood. To analyze the financial impact of the ReSCU, we assumed that ReSCU patients would have otherwise stayed in the medical ICU and compared the charges (ICU vs ReSCU) with, for a subset of patients, the true costs of ReSCU vs. ICU care. Analyses of both charges and cost differences showed similar savings associated with ReSCU care ($13,339 per patient [charges] and $10,694 per patient [costs]). CONCLUSIONS: We conclude the following: (1) the rate of achieving complete ventilator independence in the ReSCU was high; and (2) based on our achieving clinical outcomes, which are comparable to the most favorable rates reported in other series from ventilator units, we conclude that the ReSCU can be an effective and cost-saving alternative to the ICU for carefully selected patients.
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Respiratory care protocols in postanesthesia care.
Respiratory care protocols have been developed for specific therapies that include the following: oxygen titration, weaning from mechanical ventilation, sampling arterial blood gases, managing bronchospasm and secretions, treating atelectasis, endotracheal extubation, and managing the postextubation airway. Although relatively little attention has been given to using protocols in postanesthesia care, this environment lends itself to applying protocols. In this context, studies have examined and support the use of protocols for titrating supplemental oxygen, weaning patients from mechanical ventilation, and sampling arterial blood gases. As with other previously mentioned respiratory protocols, these protocols have shown efficacy for improving allocation of respiratory care services, cost savings, and favorable clinical outcomes. On this basis, while recognizing the need for further studies, respiratory care protocols implemented by respiratory therapists can be beneficial in the postanesthesia care setting.
Algorithms↗
Augmentation therapy for severe alpha 1-antitrypsin deficiency: is the jury still out on a trial?
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Humans↗
Randomized controlled trial of physician-directed versus respiratory therapy consult service-directed respiratory care to adult non-ICU inpatients.
Although current evidence suggests that respiratory care protocols can enhance allocation of respiratory care services while conserving costs, a randomized trial is needed to address shortcomings of available studies. We therefore conducted a randomized controlled trial comparing respiratory care for adult non-ICU inpatients directed by a Respiratory Therapy Consult Service (RTCS) versus respiratory care by managing physicians. Eligible subjects were adult non-ICU inpatients whose physicians had prescribed specific respiratory care services. Consecutive eligible patients were approached for consent, after which a blocked randomization strategy was used to assign patients to (1) Physician-directed respiratory care, in which the prescribed physician respiratory care orders were maintained (n = 74), or (2) RTCS-directed respiratory care, in which the physician's respiratory care orders were preempted by a respiratory care plan generated by the RTCS (n = 71). Specifically, these patients were evaluated by an RTCS therapist evaluator whose respiratory care plan was based on sign/symptom-based algorithms drafted to comply with the American Association for Respiratory Care (AARC) Clinical Practice Guidelines. Appropriateness of respiratory care orders was assessed as agreement between the prescribed respiratory care plan and an algorithm-based "standard care plan" generated by an expert therapist who was blind to the patient's actual orders. The compared groups were similar at baseline regarding demographic features, admission diagnostic category, smoking status, and Triage Score (mean, 3.8 +/- 0.9 SD [RTCS] versus 3.7 +/- 1.0). Similarly, no differences were observed between RTCS-directed and physician-directed respiratory care regarding hospital mortality rate (5.7 versus 5.6%), hospital length of stay (7.9 +/- 9.0 versus 7.7 +/- 7.3 d), total number of respiratory care treatments delivered (30.3 +/- 30 versus 31.6 +/- 30.5), or days requiring respiratory care (4.2 +/- 5.2 versus 4.1 +/- 3.6). Notably, using both a stringent (S) and a liberal (L) criterion for agreement, RTCS-directed respiratory care demonstrated better agreement with the "standard care plan" (82 +/- 17% [S] and 86 +/- 16% [L]) than did physician-directed respiratory care (64 +/- 21% [S] and 72 +/- 23% [L]) (p < 0.001). Finally, the true cost of respiratory care treatments was slightly lower with RTCS-directed respiratory care (mean, $235.70 versus $255.70/pt, p = 0.61). We conclude that (1) compared with physician-directed respiratory care, the RTCS prescribed a similar number and duration of respiratory care services at a slight savings (that did not achieve statistical significance) and without any increased adverse events; and (2) compared with physician-directed respiratory care, RTCS-directed respiratory care showed greater agreement with Clinical Practice Guideline-based algorithms.
Adult↗
Pulmonary alveolar proteinosis: clinical features and outcomes.
INTRODUCTION: Pulmonary alveolar proteinosis (PAP) is a rare disease of unknown etiology and variable natural history. To date, the largest series from a single institution has consisted of 68 individuals. To extend the understanding of the clinical features and natural history of PAP, we present a series of 24 patients with PAP from a single institution. METHODS: Patients with PAP were identified by a review of The Cleveland Clinic Foundation discharge database from 1965 to 1995. After identification, a chart review of the 24 selected patients was conducted. Charts were abstracted for historical, diagnostic, and therapeutic features. Diagnosis was confirmed by a review of the lung biopsy, where it was available, by a lung pathologist. Follow-up by telephone was performed with 19 patients. RESULTS: Most patients (70%) were male, and smoking was common (75%; mean pack-years, 29) in the group. The mean age at initial evaluation was 43 years. Presenting symptoms were as follows: 19 patients (79%) reported dyspnea, 19 patients (79%) reported a cough, 4 patients (17%) reported hemoptysis, and 3 patients (13%) reported chest pain. The earliest available spirometry after presentation of symptoms showed a prediction of mean FEV1 of 74% (range, 45 to 99%) and a prediction of mean FVC of 76% (range, 41 to 99%). The diagnosis of PAP was established by transbronchial biopsy alone in 7 patients (29%) and by open-lung biopsy alone in 17 patients (71%). Whole lung lavage was deemed necessary in 13 patients (54%); 3 patients underwent lavage of one lung only, and 10 patients underwent bilateral whole lung lavage. Whole lung lavage was required only once in 46% of patients, and from two to four times in the remainder of patients. During the follow-up period (mean length of follow-up, 8.5 years; range, 5 months to 21 years), 25% of the patients died, but none as a result of sequelae of PAP. Half of the survivors reported persistent symptoms. CONCLUSIONS: In this series, which represents one of the largest single institutional experiences with PAP reported, the clinical features are largely consistent with previously reported cases. However, contrary to early reported experiences in which open-lung biopsy was frequently required to establish PAP and in which whole lung lavage was needed, transbronchial biopsy established the diagnosis in 29% of patients and whole lung lavage could be deferred in 46% of patients.
Adult↗
Oxygen and aerosolized drug delivery: matching the device to the patient.
The variety of devices for administering supplemental oxygen and aerosolized drugs for hospital inpatients allows physicians to tailor the therapy to patient's needs, but presents a challenge in determining which device is best for the individual patient. We describe the selection process, appropriate use, and the advantages and disadvantages of various devices.
Administration, Inhalation↗
Inpatient management of chronic obstructive pulmonary disease.
Initial steps in treating an acute exacerbation of COPD include identifying the underlying cause and addressing whether ICU admission is warranted. For nonintubated hospitalized patients, current recommendations include supplemental oxygen to achieve PaO2 of 60 to 65 mm Hg, inhaled bronchodilators, perhaps using both beta-adrenergic and anticholinergic agents, and intravenous corticosteroids. For patients with purulent exacerbations, antibiotics may confer benefit. Directed coughing to encourage secretion clearance is advised if the patient's spontaneous cough is inadequate. Finally, as discussed elsewhere in this issue, noninvasive positive pressure ventilation may lessen mortality and help avert the need for intubation in selected patients. Ancillary treatments include prophylaxis against venous thromboembolism and, as discharge nears, attention to updating vaccinations (e.g., pneumococcal and influenza) and to homegoing needs (e.g., instruction in bronchodilator administration techniques, adequacy of home care, and rehabilitation).
Algorithms↗
Contributions of respiratory care practitioners to intensive care: a review.
Through the years, the professional practice of respiratory care has continually evolved to include management of critically ill patients. Although the functions and duties of respiratory care practitioners (RCPs) in this setting may vary across different institutions, it is widely recognised throughout the United States that RCPs contribute importantly to intensive care unit (ICU) outcomes. The American Association for Respiratory Care (AARC) has painstakingly established guidelines to more precisely define the role of RCPs in performing procedures in the ICU. Published studies demonstrate the added value of RCPs' collaboration in several ICU activities, including placement of arterial catheters, sampling of arterial blood gases, endotracheal intubation, and management of and weaning from mechanical ventilation. Other ICU activities in which RCPs participate include assisting with bronchoscopy, obtaining haemodynamic measurement, and indirect calorimetry and supporting specialised techniques such as extracorporeal membrane oxygenation (ECMO) and continuous veno-venous haemofiltration and/or haemodiafiltration (CVVH/CVVHD). Based on the demonstrated impact of RCPs and their technical and cognitive training, a continuing role expansion for RCPs in the ICU is expected.
Airway Obstruction↗
Evaluation of the reliability of computed tomographic criteria used in the diagnosis of round atelectasis.
The purpose of this controlled study was to determine the diagnostic accuracy of computed tomography (CT) in the diagnosis of round atelectasis (RA). We reviewed two groups of chest CT scans of 22 patients (with 24 masses). Group 1 scans represent 10 patients (12 masses) known to have RA, and Group 2 scans represent 12 patients with "RA look-alike" masses. Scans in both groups were selected for review by two of the authors and later independently reviewed by the other authors, who were blind to the actual diagnosis. Scans were rated for the presence/absence of 18 features ascribed to RA in the literature and assigned a percent probability of RA by each rater. Consensus was achieved for discordant ratings, and the individual percent probabilities were averaged to create a consensus probability. ROC curve analysis of the consensus percent probability showed that diagnostic accuracy significantly exceeded chance [area under curve (AUC) = 0.95, p < 0.001]. Of all the features of RA examined, the presence of converging bronchovascular markings discriminated best between RA and "RA look-alikes" (sensitivity 83%, specificity 92%, likelihood ratio 11). Presence of adjacent pleural thickening and pleural-based location were even more sensitive features of RA (100% each), but lacked specificity (33 and 67%, respectively; likelihood ratios 3 and 1.5, respectively). We conclude that (a) although the diagnostic accuracy of CT for RA was high in this series, radiographic diagnosis is imperfect and that (b) the presence of converging bronchovascular markings was the best discriminator between the two groups, but that no single CT feature permitted perfect discrimination.
Aged↗
Baseline characteristics of enrollees in the National Heart, Lung and Blood Institute Registry of alpha 1-antitrypsin deficiency. Alpha 1-Antitrypsin Deficiency Registry Study Group.
OBJECTIVE: alpha 1-Antitrypsin (alpha 1-AT) deficiency is a hereditary disorder characterized by a high risk for the development of emphysema at an early age. In 1988, the National Heart, Lung and Blood Institute, National Institutes of Health, initiated a registry of individuals with alpha 1-AT deficiency to help define the natural history and clinical course of this disorder. This article describes demographic and clinical characteristics of subjects enrolled in the Registry at baseline. DESIGN: Prospective longitudinal natural history study. SETTING: Thirty-seven clinical centers in the United States (36 centers) and Canada (one center). PATIENTS: There were 1,129 subjects 18 years of age or older with severe deficiency of alpha 1-AT, defined as having serum alpha 1-AT levels < or = 11 mumol/L confirmed by a Central Phenotyping Laboratory, or a ZZ or ZNull genotype identified by genomic DNA analysis. RESULTS: Most enrollees were symptomatic white subjects in their fourth to sixth decade, with a ZZ phenotype, a history of having smoked cigarettes, and pulmonary function tests demonstrating a pattern consistent with emphysema. Interestingly, only a small percentage were current smokers on enrollment, suggesting that this population is amenable to smoking cessation. A subgroup of individuals in the Registry with relatively normal lung function were younger, more likely to have never smoked and more likely to have come to medical attention owing to a family history of alpha 1-AT deficiency rather than symptomatic involvement. CONCLUSIONS: These results emphasize the need for increased awareness and early detection of alpha 1-AT deficiency. In this endeavor, dissemination of the information contained in the Registry to health-care professionals and the general population, along with initiation of appropriate preventative measures before significant lung damage has occurred, could have considerable benefits for individuals with this condition.
Adult↗