This month's Editor's choice evaluates a smoking cessationprogram for parents of patients treated at a children's hospital. Taylor et al remind us that children are the most frequent victimsof second-hand smoke and the least able to avoid exposure. Theprogram included counseling and nicotine replacement therapyduring hospitalization followed by an outpatient referral. In thisstudy half of participants were able to quit before discharge. Goodfellow contributes an editorial pointing out that this is a goodstart for smoking cessation, but cautions that longitudinal studiesconfirming long-term cessation are needed.
Gallo de Moraes and colleagues describe the implementation ofa protocolized treatment of ARDS at the Mayo Clinic. The emphasisof the protocol was early use of prone position in selected subjects. The results demonstrated earlier use of prone position, higherPEEP, and lower driving pressure, as well as a shorter ICU andhospital length of stay. However, mortality was unchanged. Spinaet al contribute a similar paper regarding ARDS management atMassachusetts General Hospital. Their approach used a lung rescueteam (LRT) for the management of refractory hypoxemia. The LRTevaluated respiratory mechanics using esophageal manometry,echocardiography and electrical impedance tomography. Evaluationby the LRT resulted in changes to patient management in two-thirds of subjects primarily through optimizing PEEP. Ratanoand Fan provide an editorial that reviews the importance of bothprotocolized management of ARDS and individualized treatmentby experts. They provide guidance based on evidence from theliterature identifying interventions of merit, those that shouldn't beused, and those that require additional research.
Zhang et al evaluated lung function in children with asthma,trying to define indicators for determining severity of illness. Theymeasured traditional pulmonary function indices and calculatedthe mean value of angle β. They found that angle β improved thesensitivity and specificity of exacerbation evaluations.
Kohlbrenner and colleagues evaluated the 1-minute sit-to-standtest (STS) to evaluate exercise capacity in transplant candidates. They noted strong correlations between the STS and the 6-minutewalk distance. However, the STS elicited greater dyspnea and loweroxygen saturation. They suggest the STS may be used when a walktest is not practical.
Elbehairy and others describe the impact of an ambulatoryclinic for the treatment of dyspnea in subjects with COPD. Theyretrospectively reviewed 45 COPD subjects and found thatinterventions reduce dyspnea in approximately half of subjects. Importantly, those subjects with a reduction in dyspnea had feweremergency room visits compared to non-responders.
In a study of adults with community acquired pneumonia(CAP), Rice and colleagues found that walking, measured by stepcount was reduced in subjects with frailty. They measured walkingand non-walking time using a wearable activity monitor. Subjectswith CAP spent little time walking and those with a higher dailystep count had a shorter hospital length of stay. Greater frailty wasassociated with a two-fold reduction in step count.
Liu et al provide an evaluation of factors impacting thewillingness of family members to consider palliative care in subjectsrequiring prolonged mechanical ventilation in Taiwan. Regulatoryand prospective payment changes governing long term care recentlychanged and knowledge of these changes was not uniform. Two-thirds of families were willing to agree to palliative care. These dataconfirm the need to have subjects express their end of life choicesand the need for cultural competence among caregivers.
Houze and others evaluated the rate of extubation failure related to upper airway secretions and aspiration. In a prospective observational trial, patients on mechanical ventilation > 6 dayshad a 9-point swallowing assessment prior to extubation. Of 159subjects, 16 required re-intubation in the first 72 hours, 7 related toexcessive secretions/aspiration. They found that presence of one orboth gag reflexes was associated with a reduced reintubation ratesecondary to aspiration.
Qui and colleagues performed an observational study ofpostoperative monitoring in subjects using oximetry, capnography,and noninvasive respiratory rate and volume monitoring. Device-specific alarm types, rates, and respective actions were recordedand analyzed. They found that nuisance alarms were more commonwith oximetry and capnography compared to rate and volumemonitoring. Adherence was also greater with rate and volumemonitoring.
Poncin et al compared 6 oscillatory positive expiratory pressure(PEP) devices in a bench model of active expiratory flow. Usinga pulmonary waveform generator they measured PEP, oscillationfrequency and amplitude. The noted significant differences inperformance of devices. The therapeutic impact of these findingsrequires patient testing to determine optimal characteristics.
Burnett and others compared physical activity level andperception of exercise in a group of subjects with cystic fibrosis(CF). Subjects were interviewed and completed self-reportedquestionnaires. Most subjects preferred walking and two-thirdsfelt exercise was important. Barriers to exercise included lack ofenergy, self-discipline and time constraints. The authors suggestthat understanding perceptions can improve coaching of CF subjectsregarding exercise.
Nakagawa and colleagues evaluated risk factors for inspiratorymuscle weakness in subjects with heart failure. They recordedhealth risk factors as well as pulmonary and echocardiographicfunction. Half of subjects demonstrated inspiratory muscleweakness, which was associated with lower left ventricular ejectionfraction, smoking history and lower systolic blood pressure. Theability of inspiratory muscle training (IMT) to remedy inspiratorymuscle weakness requires further study.
Jacobs and colleagues contribute an invited review onextracorporeal carbon dioxide removal during continuous renalreplacement therapy (CRRT). They note that almost half of patientswith ARDS develop renal failure. Since a number of these patientsrequire CRRT, systems adapted from CRRT platforms with bloodflows under 500 mL/min could achieve significant CO2 elimination.
Coudroy et al provide a systematic review of NIV on intubationrate in de novo respiratory failure. They identify 14 studiescontributing 750 subjects, demonstrating an intubation rate of 39%. Higher PEEP was associated with lower intubation rate.
Seixas and colleagues contribute a systematic review on IMT inolder adults. A review of the literature identified 7 trials involving248 subjects. Studies revealed a positive trend towards theeffectiveness of IMT for improving inspiratory muscle performancein the elderly. A period of 4 weeks appears to be a minimum timeframe.
Lie et al and Chatburn and Mireles-Cabodevila contribute Year in Review papers on high flow nasal cannula and patient ventilatorsynchrony, respectively. Both feature seminal work published in thelast 12 months.
Hess provides a new feature, the Cochrane Corner. These summaries highlight the key points of Cochrane Reviews developedby the Cochrane Rehabilitation Group. This first feature addressesthe question, “Should noninvasive ventilation be used for treatmentof acute cardiogenic pulmonary edema?” Cochrane Corners will become a routine feature in the Journal.
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