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PubMed1987

Iatroepidemics: a probe to examine systematic preventable errors in (chest) medicine.

Iatroepidemics are extreme examples of the inadequacies and errors that are prevalent in medicine. Their causes and evaluation are useful in demonstrating that medicine has a potentially destructive side as well as a highly constructive one. In the 1960s, the ATS left the sanitoria and joined the mainstream of medicine. In the 1980s it has become apparent that formal connections with science are not enough to ensure maximal safety for our patients. Nor are these connections sufficient to ensure maximal effectiveness of the measures we use to treat patients. A new awareness of our collective responsibility for improved patient outcome would be the obvious first step. Translating this sense of responsibility into new organizational approaches could place the ATS at the forefront of providing needed, and perhaps inevitable, reforms of medicine generally.

Diagnosis, Differential↗
PubMed1999

How do general practitioners respond to reports of abnormal chest X-rays?

General practitioners (GPs) in the UK have long had direct access to hospital radiological services, which in theory shortens investigation time and improves the quality of service. Chest X-rays (CXRs) account for a substantial proportion of requests, and we investigated what happened when an abnormality was detected. In one year, 204 GPs in the Nottingham area requested CXRs in 605 patients. 362 were reported normal, 165 abnormal but hospital follow-up not indicated and 71 abnormal with radiological follow-up or hospital referral indicated (mass lesion suspicious of tumours 27, infective shadowing 35, other 9). 64 of the 71 were seen in hospital within three months, and in those with suspected cancer the median time to follow-up was 20 days. These results show that GPs do act on the results of abnormal CXRs, but only 37% of those with a mass suspicious of cancer were seen in hospital within two weeks as recommended by the British Thoracic Society. Time might be saved if GPs agreed to direct referral from the radiology department to respiratory physicians.

Adolescent↗
PubMed1999

The efficacy of a custom-fabricated nasal mask on gas exchange during nasal intermittent positive pressure ventilation.

Commercially available nasal masks have a large mask volume and give rise to considerable air leaks around the mask during nasal intermittent positive pressure ventilation (NIPPV) which may reduce alveolar ventilation (VA per breath). The effects of a custom-fabricated nasal mask (F-mask) versus a commercially available mask (C-mask) on arterial blood gas measurements, dead space including both physiological and apparatus dead space (VD), air leak and VA per breath were compared in patients with restrictive thoracic disease during short-term NIPPV sessions while using a volume cycled ventilator with equivalent settings for both masks. The mask volume of the C-mask was significantly larger than that of the F-mask (p<0.003). The arterial carbon dioxide tension (Pa,CO2) during NIPPV with either the F-mask (5.56+/-1.35 kPa) (mean+/-SD) or the C-mask (6.87+/-0.96 kPa) was significantly lower than during spontaneous breathing (7.75+/-0.81 kPa; p<0.003), but the Pa,CO2 decreased more during NIPPV with the F-mask than with the C-mask (p<0.003). The VD was significantly smaller (p<0.03), the air leak was significantly less (p<0.03), and the VA per breath was significantly larger (p<0.03) during NIPPV with the F-mask than with the C-mask. In conclusion, nasal intermittent positive pressure ventilation with the F-mask was more effective than nasal intermittent positive pressure ventilation with the commercially available mask due to its smaller dead space and less air leak. Further studies are needed to extend these results to all the commercially available-masks.

Blood Gas Analysis↗
PubMed2000

Actinomycosis in HIV infection: a review of a rare complication.

The emergence of the human immunodeficiency virus (HIV) and the onset of the AIDS epidemic has been associated with the frequent presentation of otherwise rare opportunistic infections and neoplasms. Despite the impairments of cellular and humoral immunity that accompany HIV infection, the prevalence of actinomycosis in the HIV-infected population has remained low. This article reviews previously reported cases of actinomycosis in HIV-positive and AIDS patients. Microbiological, pathological, diagnostic, clinical and therapeutic aspects of actinomycosis in this population are discussed. Clinicians should be aware of the possibility of actinomycosis as the cause of a persistent inflammatory lesion in these patients and know the correct techniques for collecting and submitting tissue specimens for anaerobic culture.

AIDS-Related Opportunistic Infections↗
PubMed1990

Vertebral hydatidosis and paraplegia.

We report the management of two children and 11 adults with paraplegia secondary to vertebral hydatidosis. Destruction of pedicles, posterior vertebral elements and discs as well as the vertebral bodies was common and all six patients with thoracic disease had involvement of adjacent ribs. The 13 patients had a total of 42 major surgical procedures; two patients died from postoperative complications and four from complications of the disease and paraplegia. All eight patients initially treated by laminectomy or anterior decompression alone relapsed within two years and seven required further surgery. Circumferential decompression and grafting gave the best results, six of nine patients being in remission an average of three years and six months later. The prognosis for such patients is poor; remission is the aim, rather than cure. Anthelminthic drugs may improve the prognosis, but radical surgery is likely to remain the keystone of treatment in the foreseeable future.

Adolescent↗
PubMed1995

Nasal intermittent positive pressure ventilation. Analysis of its withdrawal.

Nasal intermittent positive pressure ventilation (NIPPV) applied during sleep has been demonstrated to be useful in the treatment of restrictive thoracic diseases (RTD). The purpose of this study was to evaluate the repercussions of a withdrawal period from NIPPV of 15 days. This would be sufficient time for patients to go on trips without the respirator. It was hypothesized that once daytime improvement was achieved and was stable, it could be maintained for this period of time. Five volunteer patients with severe RTD who had been receiving treatment with nocturnal NIPPV for at least 2 months before and who had improved at least 5 mm Hg in daytime PO2 and PCO2 were included in the study. No significant differences were disclosed clinically or with arterial blood gas levels, spirometry results, lung volumes, airway resistances, or maximal muscle pressures 15 days following the withdrawal. However, in the sleep studies, a severe worsening of gas exchange was observed, mainly during rapid eye movement (REM) sleep, as well as a trend toward a more disturbed sleep pattern and more important alterations in cardiac rhythm. Consequently, withdrawing the treatment with nocturnal NIPPV cannot be recommended, at least for this particular removal period. Moreover, alterations in daytime gas exchange were found to originate in those produced during REM sleep through the blunting of the respiratory center to CO2. The NIPPV obstructs this mechanism, preventing the deterioration of gas exchange during sleep.

Adolescent↗
PubMed2001

Is it safe for patients with chronic hypercapnic respiratory failure undergoing home noninvasive ventilation to discontinue ventilation briefly?

STUDY OBJECTIVES: A brief discontinuation (< 1 week) of long-term ventilation may be necessary in patients who are not totally ventilator-dependent in cases of technical problems, intolerable nasal irritation, upper airway congestion, or travel. We examined the incidence, timing, and causes of possible clinical deterioration after a brief withdrawal of ventilation in patients with chronic respiratory failure (CRF) who were well-established on long-term noninvasive mechanical ventilation (NIMV). STUDY DESIGN: Prospective clinical study. PATIENTS: Eleven inpatients in clinically stable condition (COPD, 6 patients; and restrictive thoracic disease [RTD], 5 patients) who had severe CRF (PaCO(2), > 50 mm Hg) and had been receiving NIMV for (mean +/- SD) 19.3 +/- 5.3 months were enrolled. INTERVENTIONS AND MEASUREMENTS: Arterial blood gas (ABG) levels, maximal inspiratory pressure (PImax), breathing pattern, dyspnea rating, and life symptoms (measured by a questionnaire) were recorded daily after NIMV withdrawal for 6 days or until the patients showed clinical and/or ABG level deterioration. Pulmonary function tests were performed and neuromuscular drive was measured at the beginning and the end of the study. RESULTS: Five of the 11 patients (45.4%) [COPD, 3 patients; and RTD, 2 patients] were reconnected to a ventilator before the scheduled time because of ABG level deterioration. Despite these changes, none of the patients reported severe worsening of symptoms or other medical complications. The patients whose ABG levels worsened had statistically significant decreases in tidal volume and PImax, suggesting that the development of alveolar hypoventilation was related to respiratory muscle weakness. CONCLUSIONS: A brief discontinuation of NIMV in patients who were affected by chronic hypercapnic respiratory failure and were well-established on NIMV is associated with a relatively high incidence of ABG level worsening due to the development of alveolar hypoventilation. If NIMV must be briefly interrupted for clinical reasons, the patient should be monitored closely for abrupt worsening, and prompt technical intervention should be provided if a ventilator fails.

Adult↗
PubMed2004

Tolerance and physiologic effects of nocturnal mask pressure support vs proportional assist ventilation in chronic ventilatory failure.

STUDY OBJECTIVES: To compare the tolerance and physiologic effects of a 5-night treatment with either nasal proportional assist ventilation (PAV) or pressure support ventilation (PSV) in patients with chronic ventilatory failure. DESIGN: Cross-over, randomized, controlled study. SETTING: Rehabilitation units of pneumology department. PATIENTS OR PARTICIPANTS: Four patients with COPD and 10 patients with restrictive thoracic diseases with chronic hypercapnia (median baseline Paco(2), 55.1 mm Hg) were studied. INTERVENTIONS: In a cross-over study, nasal PAV and PSV set at the patient's comfort were randomly applied during 5 consecutive nights (with a 2-night washout period). MEASUREMENTS AND RESULTS: Continuous nocturnal pulse oximetric saturation (Spo(2)) and arterial blood gas results at wake-up were evaluated at baseline during spontaneous breathing and on the fifth day of ventilatory support. Dyspnea, sleep quality, adaptation, and comfort at inspiration and expiration by visual analog scale (VAS) were evaluated every day as well as a side effects score. On the fifth day, there were no significant differences in daytime Paco(2) (median PAV, 53.3 mm Hg; median PSV, 50.2; p = 0.168). Mean nocturnal Spo(2) improved significantly with both PAV and PSV without any significant differences between modes (baseline median, 92%; PAV median, 94.5%; PSV median, 95%). The percentage of the study night spent < 90% Spo(2) (T90) was slightly but significantly higher with PAV than with PSV (median PAV T90, 4%; median PSV T90, 2%; p = 0.049). The VAS symptom score was similar at day 5 between modes; however, nasal and oral dryness were lower (p = 0.05) and alarm noise was higher (p = 0.037) with PAV. CONCLUSIONS: After 5 days of treatment, both modes had similar tolerance, and were equally effective in reducing daytime hypercapnia and improving nocturnal saturation and symptoms. However, PAV induced less nasal and oral dryness but was associated with higher alarm noise.

Adult↗