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MAY 2000 

ISSN 0020-1324-RECACP 



P i^yr 

Negative Pressure Ventilation in Infants with 
Acute Respiratory Failure 

W .fl^ 

Complications of Noninvasive Ventilation 

46th International Respiratory Congress 
October 7-10 • Cincinnati, Ohio 


Initial Experience with a Respiratory Therapist 
Arterial Line Placement Service 


Negative Pressure Ventilation via Chest Cuirass in 
Infants with Acute Respiratory Failure 

Inspissated Secretions Complicating Prolonged 
Noninvasive Ventilation 


Noninvasive Ventilation in Acute Respiratory Failure 
Associated with Oral Contrast Aspiration 


Dosing Strategies for Bronchodilator Resuscitation in 
the Emergency Department 


Office Spirometry for Lung Health Assessment in Adults 

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Noninvasive Mechanical Ventilation: Its Role in Acute and 
Chronic Respiratory Failure 

Reviews the histon' and the pros and cons of noninvasive ventilation, 
describes modalities currently available. Results of studies on acute and 
chronic respirator\' failure are reviewed, and acceptable indications for use 
of noninvasive ventilation are described. Considerations for selecting 
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NPPV in Acute and Long-Term Care 

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Neonatal Recognition and Stabilization of the Premature 
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Initial Treatment for the Pediatric Patient in Respiratory 


Outlines the symptoms and what immediate actions are necessary to 

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Coping with the Pediatric Emergency 

Provides an over\iew of how to assess the pediatric patient. Includes 
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system; recognition of the early signs respiratory distress; the equipment and 

preparation needed to deal with respiratory emergencies; and the priorities for 
management of pediatric respiratorv emergencies. Featuring Mark J. Heulitt, 
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Asthma Disease State Management: Establishing a Partnership 

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Asthma Disease Management: Using the Revised NAEPP 
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Chronic Obstructive Pulmonary Disease (COPD) Simulation 

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The Latest Word in the Treatment of COPD 
This videotape helps you understand what the barriers are to improved 
outcomes in COPD. Discusses the role of viral and bacerial infection in 
COPD exacerbation; the processes for clinical pathways development; and 
the appropriate ventilator management strategies in severe COPD. Featuring 
Steve Jenkinson, MD and Woodv \'. Kageler, MD. 90-min. videotape. 
Item VC96 $49.95 ($99.00 Nonmembers) 

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MAY 2000 / VOLUME 45 / NUMBER 5 


AARC Membership or Other AARC 

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Respiratory Care 

11030 Abies Ln 

Dallas TX 75229-4593 

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Respiratory Care 

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Fax (703) 548-8499 


The Use of Negative Pressure Ventilation in Infants with Acute 
Respiratory Failure: Old Technology, New Idea 

by Mark J Heulitt — Little Rock, Arkansas 

Complications of Noninvasive Ventilation 
by Nicholas S Hill — Providence, Rhode Island 



Initial Experience with a Respiratory Therapist Arterial Line Placement Service 
by Daniel D Rowley, David F Mayo, and Charles G Durbin Jr — Charlottesville, Virginia 



Negative Pressure Ventilation via Chest Cuirass to Decrease 
Ventilator-Associated Complications in Infants with Acute Respiratory 
Failure: A Case Series 

by Hilary Klonin, Brian Bowman, Michelle Peters — Durham, North Carolina 
Parakkal Raffeeq, Andrew Durward, Desmond J Bohn — Toronto, Ontario, Canada 
Jon N Meliones and Ira M Cheifetz — Durham, North Carolina 

Inspissated Secretions: A Life-Threatening Complication of Prolonged 

Noninvasive Ventilation 

by Kenneth E Wood, Anne L Platen, and William J Baches — Madison, Wisconsin 

The Use of Noninvasive Ventilation in Acute Respiratory Failure 
Associated with Oral Contrast Aspiration Pneumonitis 
by Jean I Keddissi and Jordan P Metcalf— Oklahoma City, Oklahoma 


Bronchodilator Resuscitation in the Emergency Department 

Part 2 of 2: Dosing Strategies 

by James Fink and Rajiv Dhand — Hines, Illinois 





190) is published monthly by Daedalus Enterprises Inc. at 
1 1030 Abies Lane, Dallas TX 75229-4593. for the Amer- 
ican Association for Respiratory Care. One volume is 
published per year beginning each January. Subscription 
rates are $75 per year in the US; $90 in all other countries 
(for airmail, add $94). 

The contents of the Journal are indexed in Hospital and 
Health Administration Index, Cumulative Index to Nurs- 
ing and Allied Health Literature. EMBASE/Exerpta Med- 
ica. and RNdex Library Edition. Abridged versions of 
Respiratory Care are also published in Italian. 
French, and Japanese, with permission from Daedalus En- 
terprises Inc. 

Periodicals postage paid at Dallas TX and at additional 
mailing offices. POSTMASTER: Send address changes to 
RESPIRATORY CarE. Membership Office. Daedalus En- 
terprises Inc. 1 1030 Abies Lane. Dallas TX 75229-4593. 

@ Printed on acid-free paper. 

Printed in the United States of America 

Copyright © 2000, by Daedalus Enterprises fnc. 


Office Spirometry for Lung Health Assessment in Adults: A Consensus 
Statement from the National Lung Health Education Program 

by Gary T Ferguson — Framington Hills, Michigan, Paul L Enright — Tucson, Arizona, 
A Sonia Buist — Portland, Oregon, and Millicent W Higgins — Ann Arbor, Michigan 



What Causes an Elevated Diffusing Capacity? 

by Terrence D Coulter and James K Stoller — Cleveland, Ohio 

A 56- Year-Old Woman with Mixed Obstructive and Restrictive Lung Disease 
by Saeed U Khan — Youngstown, Ohio and Mani S Kavuru — Cleveland, Ohio 


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AARC Membership 
543 Application 


Abstracts from 
Other Journals 


Advertisers Index 
& Help Lines 




of Events 


Preparation Guide 




New Products 




A Monthly Science Journal 
Established in 1956 

The Official Journal of the 

American Association for 

Respiratory Care 


Respiratory Care in Alternate Sites (Wyka KA) 

reviewed by Scon L Bartow — Milwaukee, Wisconsin, 

Dianne L Lewis — Naples. Florida, and Julien M Roy — Daytona Beach, Florida 

Case Studies in Allied Health Ethics (Veatch RM & Flack HE) 

reviewed by Arthur B Marshak — Loma Linda, California 

The Lung: Molecular Basis of Disease (Brody JS) 
reviewed by Thomas R Martin — Seattle, Washington 

Gastroesophageal Reflux Disease and Airway Disease (Stein MR, editor) 

reviewed by William M Corrao — Providence, Rhode Island 





Conference Co-Chairs: 

myrna b doiovich p eng 

neii r macintyre md faarc 


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A Monthly Science Journal 
Established in 1956 

The Official Journal of the 

American Association for 

Respiratory Care 

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


Richard D Branson RRT 
University of Cincinnati 
Cincinnati, Ohio 

Charles G Durbin Jr MD 
University of Virginia 
Charlottesville, Virginia 


Dean R Hess PhD RRT FAARC 

Massachusetts General Hospital 
Harvard University 
Boston, Massachusetts 

James K Stoller MD 

The Cleveland Clinic Foundation 

Cleveland, Ohio 

Alexander B Adams MPH RRT 

Regions Hospital 
St Paul, Minnesota 

Thomas A Barnes EdD RRT 

Northeastern University 
Boston, Massachusetts 

Michael J Bishop MD 

University of Washington 
Seattle, Washington 

Bartolome R Celli MD 

Tufts University 
Boston, Massachusetts 

Robert L Chatbum RRT 

University Hospitals of Cleveland 
Case Western Reserve University 
Cleveland, Ohio 

James B Fink MS RRT FAARC 

Hines VA Hospital 
Loyola University 
Chicago, Illinois 

Luciano Gattinoni MD 

University of Milan 
Milan, Italy 

John E Heffner MD 

Medical University of South Carolina 
Charleston, South Carolina 

Mark J Heulitt MD 

University of Arkansas 
Little Rock, Arkansas 


Leonard D Hudson MD 

University of Washington 
Seattle, Washington 

Robert M Kacmarek PhD RRT 

Massachusetts General Hospital 
Harvard University 
Boston, Massachusetts 

Toshihiko Koga MD 

Koga Hospital 
Kurume, Japan 

Marin H KoUef MD 

Washington University 
St Louis, Missouri 

Patrick Leger MD 
Clinique Meaicale Edouard Rist 
Paris, France 

Neil R Maclntyre MD FAARC 
Duke University 
Durham, North Carolina 

John J Marini MD 

University of Minnesota 
St Paul, Minnesota 

Shelley C Mishoe PhD RRT 

Medical College of Georgia 
Augusta, Georgia 

Marcy F Petrini PhD 

University of Mississippi 
Jackson, Mississippi 

Joseph L Rau PhD RRT FAARC 

Georgia State University 
Atlanta, Georgia 

Catherine SH Sassoon MD 
University of California Irvine 
Long Beach, California 

John W Shigeoka MD 

Veterans Administration Medical Center 

Salt Lake City, Utah 

Arthur S Slutsky MD 
University of Toronto 
Toronto, Ontario, Canada 

Martin J Tobin MD 

Loyola University 
Chicago, Illinois 

Jeffrey J Ward MEd RRT 
Mayo Medical School 
Rochester, Minnesota 

Robert L Wilkins PhD RRT 

Loma Linda University 
Loma Linda, California 


Gordon D Rubenfeld MD 

University of Washington 
Seattle, Washington 

Hugh S Mathewson MD 
Joseph L Rau PhD RRT FAARC 
Drug Capsule 

Charles G Irvin PhD 

Gregg L Ruppel MEd RRT RPFT FAARC 

PFF Comer 

Richard D Branson RRT 
Robert S Campbell RRT FAARC 
Kittredge's Comer 

Jon Nilsestuen PhD RRT FAARC 
Ken Hargett RRT 
Graphics Comer 

Patricia Ann Doorley MS RRT 
Charles G Durbin Jr MD 
Test Your Radiologic Skill 


Summaries of Pertinent Articles in Other Journals 

Editorials, Commentaries, and Reviews to Note 

Allergic Disorders— Holgate ST. BMJ 2000 Jan 22:320(7229):23 1-234. 

Disorders of Ventilation: Weakness, Stiffness, and Mobilization — Bach JR. Kang SW. Chest 

Factors Contributing to Pneumothorax after Thoracentesis — Diaz G, Castro DJ, Perez- 
Rodriguez E, Colt HG. Chest 2000 Feb;l 17(2):608-609. 

Value of 6-Min-Walk Test for Assessment of Severity and Prognosis of Heart Failure — 

Willenheimer R, Erhardt LR. Lancet 2000 Feb 12;355(9203):515-516. 

Update in Critical Care Medicine — Guntupalli KK. Fromm RE Jr. Ann Intern Med 2(XX) Feb 

Nicotine Addiction (editorial)— Moxham J. BMJ 2000 Feb 12;320(7232):39 1-392. 

Gas Embolism (review)— Muth CM. Shank ES. N Engl J Med 2000 Feb 17;342(7):476-482. 

Pharmacologic Paralysis and Withdrawal of Mechanical Ventilation at the End of Life — 

Truog RD. Burns JP, Mitchell C. Johnson J, Robinson W. N Engl J Med 2000 Feb 17;.342(7): 

Benzocaine-Induced Methemoglobinemia — Nguyen ST. Cabrales RE. Bashour CA. Rosen- 
berger TE Jr. Michener JA, Yared JP. Starr NJ. Anesth Analg 2000 Feb;90(2):369-371. 

Recent Advances: Recent Advances in Intensive Care (review) — Stott S. BMJ 2000 Feb 

Exacerbation of Acute Pulmonary Edema 
During Assisted Mechanical Ventilation Us- 
ing a Low-Tidal Volume, Lung-Protective 
Ventilator Strategy— Kallet RH. Alonso JA, 
Luce JM. Matthay MA. Chest 1 999 Dec; 1 1 6(6): 

STUDY OBJECTIVES: To assess the magni- 
tude of negative intrathoracic pressure develop- 
ment in a patient whose pulmonary edema 
acutely worsened immediately following the in- 
stitution of a low-tidal volume (V^) strategy. 
DESIGN: Mechanical lung modeling of patient- 
ventilator interactions ba.sed on data from a case 
report. SETTING: Medical ICU and laboratory. 
PATIENT: A patient with suspected ARDS and 
frank pulmonary edema. INTERVENTIONS: 
The patient's pulmonary mechanics and spon- 
taneous breathing pattern were measured. Sam- 
ples of arterial blood and pulmonary edema fluid 
were obtained. MEASUREMENTS: A standard 
work-of-breathing lung model was used to 
mimic the ventilator settings, pulmonary me- 
chanics, and spontaneous breathing pattern ob- 

served when pulmonary edema worsened. Com- 
parison of the pulmonary edema fluid-to-plasma 
total protein concentration ratio was made. RE- 
SULTS: The patient's spontaneous V^^ demand 
was greater than preset. The lung model re- 
vealed simulated intrathoracic pressure changes 
consistent with levels believed necessary to pro- 
duce pulmonary edema during obstructed 
breathing. A high degree of imposed circuit- 
resistive work was found. The pulmonary edema 
fluid-to-plasma total protein concentration ratio 
was 0.47, which suggested a hydrostatic mech- 
anism. CONCLUSION: Ventilator adjustments 
that greatly increase negative intrathoracic pres- 
sure during the acute phase of ARDS may 
worsen pulmonary edema by increasing the 
transvascular pressure gradient. Therefore, 
whenever sedation cannot adequately suppress 
spontaneous breathing (and muscle relaxants are 
contraindicated). a low-V, strategy should be 
m(xlified by using a pressure-regulated mode of 
ventilation, so that imposed circuit-resistive 
work does not contribute to the deterioration 

of the patient's hemodynamic and respiratory 

Percutaneous Transtracheal ,|el Ventilation: 
A Safe, Quick, and Temporary Way to Pro- 
vide Oxygenation and Ventilation When Con- 
ventional Methods are Unsuccessful — Patel 
RG. Chest 1999 Dec;l 16(6):1689-1694. 

INTRODUCTION: Percutaneous transtracheal 
jet ventilation (PTJV) with a large-bore angio- 
cath that is inserted through the cricothyroid 
membrane can provide immediate oxygenation 
from a high-pressure (50 lb per square inch) 
oxygen wall outlet, as well as ventilation by 
means of manual triggering. The objective of 
this retrospective study is to highlight the po- 
tential benellt of PTJV as a temporary lifesav- 
ing procedure during difficult situations when 
oral endotracheal intubation is unsuccessful and 
bag-valve-mask ventilation is ineffective for ox- 
ygenation during acute respiratory failure. 
METHODS: The medical records of 29 con- 
secutive patients who required emergent PTJV 


Respiratory Care • May 2000 Vol 45 No 5 

within the past 4 years were reviewed. PTJV 
was required because the pulse Oi saturation 
could not be maintained at > 909c with bag- 
mask-valve ventilation and because the airway 
could not be secured quickly with direct laryn- 
goscopy. RESULTS: The cricothyroid mem- 
brane was cannulated successfully in 23 pa- 
tients. In these patients, pulse O, saturation was 
raised to > 90% and was maintained with PTJV 
until the airway was secured. All but 3 of the 23 
patients were .subsequently intubated orally. In 
one patient. PTJV maintained adequate gas ex- 
change until an emergent tracheostomy was per- 
fonned. In two patients, airway exchange cath- 
eters were inserted into the trachea due to a 
small glottic aperture. The endotracheal tube 
was slid over the catheter. In 6 of the 29 pa- 
tients, there was difficulty inserting a catheter 
through the cricothyroid meinbrane or there was 
inability to insufflate the oxygen with a jet ven- 
tilator. There were no immediate fatalities from 
the use of PTJV. CONCLUSION: Ba.sed on the 
subsequent insertion of an endotracheal tube 
into the trachea, there were two important ben- 
efits in the patients who underwent PTJV suc- 
cessfully. First. PTJV provided effective oxy- 
genation, while allowing adequate time for upper 
airway visualization and passible suctioning of 
oropharyngeal .secretions. Second, tracheal in- 
tubation was subsequently easier, possibly be- 
cause the high tracheal pressure from the gas 
insufflation opened the collapsed glottis, mak- 
ing visualization of the glottic aperture better. 
PTJV is safe and quick in providing immediate 
oxygenation, and therefore should be consid- 
ered as an alternative to insistent, multiple in- 
tubation attempts, when neither bag-mask-valve 
ventilation nor endotracheal intubation is fea- 
sible in providing adequate gas exchange. 

Weapons of Mass Destruction Events with 
Contaminated Casualties: Effective Planning 
for Health Care Facilities — Macintyre AG. 
Christopher GW, Eitzen E Jr. Gum R. Weir S, 
DeAtley C, et al. JAMA 2000 Jan 12:283(2): 

Biological and chemical terrorism is a growing 
concern for the emergency preparedness com- 
munity. While health care facilities (HCFs) are 
an essential component of the emergency re- 
sponse system, at present they are poorly pre- 
pared for such incidents. The greatest challenge 
for HCFs may be the sudden presentation of 
large numbers of contaminated individuals. 
Guidelines for managing contaminated patients 
have been based on traditional hazardous ma- 
terial response or military experience, neither 
of which is directly applicable to the civilian 
HCF. We discuss HCF planning for terrorist 
events that expose large numbers of people to 
contamination. Key elements of an effective 
HCF response plan include prompt recognition 
of the incident, staff and facility protection, pa- 


A Spontaneously Breathing Lung Model 

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tient decontamination and triage, medical ther- 
apy, and coordination with external emergency 
response and public health agencies. Contro- 
versial a.spects include the optimal choice of 
personal protective equipment, establishment of 
patient decontamination procedures, the role of 
chemical and biological agent detectors, and 
potential environmental impacts on water treat- 
ment systems. These and other areas require 
further investigation to improve response strat- 

Supine Body Position As a Risk Factor for 
Nosocomial Pneumonia in Mechanically Ven- 
tilated Patients: A Randomised Trial — Dr- 

akulovic MB, Torres A, Bauer TT, Nicolas JM, 
Nogue S, Ferrer M. Lancet 1999 Nov 27: 

BACKGROUND: Risk factors for nosocomial 
pneumonia, such as gastro-oesophageal reflux 
and subsequent aspiration, can be reduced by 
semirecumbent body position in intensive-care 
patients. The objective of this study was to as- 
sess whether the incidence of nosocomial pneu- 
monia can also be reduced by this measure. 
METHODS: This trial was stopped after the 
planned interim analysis. 86 intubated and me- 
chanically ventilated patients of one medical 
and one respiratory intensive-care unit at a ter- 
tiary-care university hospital were randomly as- 

signed to semirecumbent (n=39) or supine 
(n=47) body position. The frequency of clini- 
cally suspected and microbiologically con- 
firmed nosocomial pneumonia (clinical plus 
quantitative bacteriological criteria) was as- 
sessed in both groups. Body position was ana- 
lysed together with known risk factors for nos- 
ocomial pneumonia. FINDINGS: The frequency 
of clinically suspected nosocomial pneumonia 
was lower in the semirecumbent group than in 
the supine group (three of 39 [8%] vs 16 of 47 
[34%]: 95% CI for difference 10.0-42.0, 
p=0.003). This was true for microbiolog- 
ically confirmed pneumonia (semirecumbent 
2/39 [5%] vs supine 11/47 [23%]: 4.2-31.8, 
p=0.018). Supine body position (odds ratio 6.8 
[1.7-26.7]. p=0.006) and enteral nutrition (5.7 
[ 1 .5-22.8], p=0.01 3) were independent risk fac- 
tors for nosocomial pneumonia and the fre- 
quency was highest for patients receiving en- 
teral nutrition in the supine body position (14/ 
28, 50%). Mechanical ventilation for 7 days or 
more (10.9 [3.0-40.4], p=0.00l) and a Glas- 
gow coma scale score of less than 9 were ad- 
ditional risk factors. INTERPRETATION: The 
semirecumbent body position reduces frequency 
and risk of nosocomial pneumonia, especially 
in patients who receive enteral nutrition. The 
risk of nosocomial pneumonia is increased by 
long-duration mechanical ventilation and de- 
creased consciousness. 

Respiratory Care • May 2000 Vol 45 No 5 


tL\:'0'^^£^^±f,'iaci^i.-MtirtimA:j^jiiAJK:K,' ■ 

2000 ARCF Award Programs 

Education Recognition Awards 
(Applications must be received by iVIay 31) 

• Morton B. Duggan,Jr., Memorial Education Recognition Award — $i,ooo 

• Jimmy A. Young Memorial Education Recognition Award — $i,ooo 

• NBRC/AMP William W. Burginjr., MD Education Recognition Award - $2,500 

• NBRC/AMP Robert M. Lawrence, MD Education Recognition Award — $2,500 

• William F. Miller, MD Postgraduate Education Recognition Award — $1,500 

• NBRC/AMP Gareth B. Gish, MS, RRT Memorial Postgraduate Education Recognition Award 
— $1,500 

Research Fellowships 

• Glaxo Wellcome Fellowship for Asthma Care Management Education— $3,500 

• Monaghan/Trudell Fellowship for Aerosol Technique Development — $1,000 

• Respironics Fellowship in Non-Invasive Respiratory Care — $1,000 

• Respironics Fellowship in Mechanical Ventilation— $1,000 

Literary Award 

• Dr. Allen DeVilbiss Literary Award 


Achievement Awards (Nominations must be received by May 31) 

• Forrest M. Bird Lifetime Achievement Award — $2,000 

• Dr. Charles H. Hudson Award for Cardiopulmonary Public Health — $500 

• Invacare Award for Excellence in Home Respiratory Care — $500 

Research Grants 

• NBRC/AMP H. Frederic Helmholz, Jr. MD Educational Research Fund — up to $3,000 
(Applications must be received by May 31) 

• Jerome M. Sullivan Research Fund — Awarded periodically 

Every year the American 
Respiratory Care Foundation 
joins with sponsors from the 
health industry to award more 
than $20,000 to respiratory 
therapists and physicians 
through its education 
recognition, fellowships, grants, 
and awards programs. For more 

information or to apply for 
one of these awards in 2000, 
contact the ARCF Executive 
Office, 11030 Abies Lane, 
Dallas, TX 75229-4593, (972) 
243-2272, fax (972) 484-2720, 
e-mail, or 
access AARC Online at 

Effect of Clinician Communication Skills 
Training on Patient Satisfaction: A Random- 
ized, Controlled Trial — Brown JB, Boles M, 
Mullooly JP. Levinson W. Ann Intern Med 1 999 

BACKGROUND: Although substantial re- 
sources have been invested in communication 
skills training for clinicians, little research has 
been done to test the actual effect of such train- 
ing on patient satisfaction. OBJECTIVE: To 
determine whether clinicians' exposure to a 
widely used communication skills training pro- 
gram increased patient satisfaction with ambu- 
latory medical care visits. DESIGN: Random- 
ized, controlled trial. SETTING: A not-for-profit 
group-model health maintenance organization 
in Portland, Oregon. PARTICIPANTS: 69 pri- 
mary care physicians, surgeons, medical sub- 
specialists, physician assistants, and nurse prac- 
titioners from the Permanente Medical Group 
of the Northwest. INTERVENTION: "Thriving 
in a Busy Practice: Physician-Patient Commu- 
nication," a communication skills training pro- 
gram consisting of two 4-hour interactive work- 
shops. Between workshops, participants 
audiotaped office visits and studied the audio- 
tapes. MEASUREMENTS: Change in mean 
overall score on the Art of Medicine survey 
(Healthcare Research, Inc., Denver, Colorado), 
which measures patients' satisfaction with cli- 
nicians' communication behaviors, and global 
visit .satisfaction. RESULTS: Although partici- 
pating clinicians' self-reported ratings of their 
communication skills moderately improved, 
communication skills training did not improve 
patient satisfaction scores. The mean score on 
the Art of Medicine survey improved more in 
the control group (0.072 [95% CI, -0.010 to 
0.154]) than in the intervention group (0.030 
[CI, -0.060 to 0.1201]). CONCLUSIONS: 
"Thriving in a Busy Practice: Physician-Patient 
Communication," a typical continuing medical 
education program geared toward developing 
clinicians' communication skills, is not effec- 
tive in improving general patient satisfaction. 
To improve global visit satisfaction, communi- 
cation skills training programs may need to be 
longer and more intensive, teach a broader range 
of skills, and provide ongoing performance feed- 

Is There a Preferred Technique for Weaning 
the Difficult-To-Wean Patient? A Systematic 
Review of the Literature — Butler R, Keenan 
SP, Inman KJ, Sibbald WJ, Block G. Crit Care 
Med 1999 Nov;27(l 1):233 1-2336. 

OBJECTIVE: To answer the following ques- 
tion: In difficult-to-wean patients, which of the 
three commonly used techniques of weaning 
(T-piece, synchronized intermittent mandatory 
ventilation, or pressure support ventilation) 
leads to the highest proportion of successfully 
weaned patients and the shortest weaning time? 

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DATA SOURCES: Computerized literature 
searches in MEDLINE (1975-1996), CINAHL 
(1982-1996), and Healthplan (1985-1996), ex- 
ploding all MEsh headings pertaining to Me- 
chanical Ventilation and Weaning. Searches 
were restricted to the English language, adults, 
and humans. Personal files were hand searched, 
and references of selected articles were re- 
viewed. STUDY SELECTION: a) Population: 
Patients requiring a gradual weaning process 
from the ventilator (either requiring prolonged 
initial ventilation of >72 hrs or a failed trial of 
spontaneous breathing after >24 hrs of venti- 
lation); b) Interventions: At least two of the 
following three modes of weaning from me- 
chanical ventilation must have been compared: 
T-piece, synchronized intermittent mandatory 
ventilation, or pressure support ventilation; c) 
Outcomes: At least one of the following: wean- 
ing time (time from initiation of weaning to 
extubation) or successful weaning rate (success- 
fully off the ventilator for >48 hrs); and d) 
Study design: Controlled trial. DATA EX- 
TRACTION: Two reviewers independently re- 
viewed the articles and graded them according 
to their methodologic rigor. Data on the success 
of weaning and the time to wean were summa- 
rized for each study. DATA SYNTHESIS: The 
search strategy identified 667 potentially rele- 
vant studies; of these, 228 had weaning as their 
primary focus, and of these, 48 addressed modes 

of ventilation during weaning. Only 16 of these 
48 studies had one of the specified outcomes, 
and only ten of these were controlled trials. Of 
the ten trials, only four fulfilled all our selec- 
tion criteria. The results of the trials were con- 
flicting, and there was heterogeneity among 
studies that precluded meaningful pooling of 
the results. CONCLUSIONS: There are few tri- 
als designed to determine the most effective 
mode of ventilation for weaning, and more work 
is required in this area. From the trials reviewed, 
we could not identify a superior weaning tech- 
nique among the three most popular modes, 
T-piece, pressure support ventilation, or syn- 
chronized intermittent mandatory ventilation. 
However, it appears that synchronized intermit- 
tent mandatory ventilation may lead to a longer 
duration of the weaning process than either T- 
piece or pressure support ventilation. Finally, 
the manner in which the mode of weaning is 
applied may have a greater effect on the like- 
lihood of weaning than the mode itself. 

Review of Therapeutically Equivalent Alter- 
natives to Short Acting Beta-2 Adrenoceptor 
Agonists Delivered via Chlorofluorocarbon- 
Containing Inhalers — Hughes DA, Woodcock 
A, Walley T. Thorax 1999 Dec;54(I2):1087- 

Respiratory Care • May 2000 Vol 45 No 5 


A Continuing Education Program 
of the /Vnierican j\ssociation 
for Respirator}' Care 

, Continuing Education Credit, 
il in the Convenience of Your Facility. 
!jO Planes. No Lon" Twines. No Hotel Rooin& 

Respiratory Ilierapists Earn i Hour of CE Credit for Each Program 
Nurses Earn 1.2 Hours of C£ Credit for Each Program 

Professor's Rounds topics are 

just what your staff ordered. 

Each program has been carefully 

selected from the suggestions 

participants provided after 

previous programs. Your staff 

will learn about the "hot topics" 

presented by experts on each 

subject. All in the convenience 

of your own facility. 

And, your staff will earn the 

continuing education credit 

they need as required by 

licensure and regulatory 


Eight Hot Topics 

Program #1 

Pulmonary Rehabilitation: What You Need to Know 

Videotape Available 

Presenters: Julien M. Roy, BA, RRT, FAACVPR, and Richard D. Branson, BA, RRT 
What constitutes a sound pulmonary rehabilitation program? How do you go about 
setting up a rehab program? What's the role of assessment in developing an exercise 
prescription for the rehab of your patients? What are the issues surrounding 
reimbursement and what does the future hold? Learn the answers to these questions 
and gain an appreciation for the importance of puhnonary rehabilitation to your 
faciUty and your patients. 

Program #3 

Drugs, Medications, and Delivery Devices of 

Importance in Respiratory Care 

Live Videocor\ference - April 25, 11:30 a.m.-i:oo p.m. Central Time 
Teleconference with Videotape - May 16, 11:30 a.m.-i2:00 Noon Central Time 
Presenters: James B. Fink, MS, RRT, FAARC and David J. Pierson, MD, FAARC 
Aerosol therapy is delivered to nearly 80% of respiratory patients. There are a 
number of new medications in development for both local and systemic 
administration to those patients. Which device to use, how to negotiate care 
plans, and how to educate both patients and caregivers are all topics that will be 
discussed. Perhaps of critical importance is getting the most medication delivered 
to the patient's lungs, which leads to a discussion of selecting the correct delivery 

Program #5 
Pediatric Ventilation: 

Kids Are Different 

Uve Videocor\ference - July 25, 11:30 a.m.-i:oo p.m. Central Time 
Teleconference with Videotape - August 15, 11:30 a.m.-i2:oo Noon Central Time 
Presenters: Mark Heulitt, MD, FAAP, FCCP and Richard D. Branson, BA, RRT 
There are significant differences in the anatomy and physiology of the respiratory 
systems between adults and children, posing problems for the practitioner attempting 
to mechanically ventilate a pediatric patient. Once the process is underway, the 
capabilities of the available mechanical ventilators and how they affect children 
pose additional problems. Children are so different, you need to stop and reassess 
actions you would normally take with an adult patient 

Program #7 

Managing Asthma: An Update 

Live Videoconference - September ig, 11:30 a.m.-i:oo p.m. Central Time 
Teleconference with Videotape - October 17, 11:30 a.m.-i2:oo Noon Central Time 
Presenters: PattiJoyner, RRT, CCM and Man Jones, MSN, RN, FNP, RRT 
Asthma management is a hot topic for discussion. Everyone wants to implement a 
program at his or her facility. What will make a program work, and how do you know 
if It's successful? This program will provide you with the information you have been 
looking for in order to implement a program and determine how successful the 
program really is. You will be given guidance on how to analyze outcomes measures 
from a successful program. 

Program #2 

Pediatric Asthma in the ER 

Videotape Available 

Presenters: Timothy R. Meyers, BS, RRT and Thomas J. Kalbtrom, RRT, FAARC 
The prevalence of pediatric a-sthma has increa-sed dramatically in the last few years. 
The National Asthma Education and Prevention Program has provided guidelines for 
management of pediatric asthma. This program will discuss these issues as well as the 
role of care paths in the management of the disease. Additionally, there have been 
some significant advances in coping with pediatric asthma in the ER. 

Program #4 

Cost-Effective Respiratory Care: You've Got to Change 

Live Videoconference - May 23, 11:30 a.m.-i:oop.m. Central Time 
Teleconference with Videotape - June 20, 11:30 a.m.-i2:oo Noon Central Time 
Presenters: Kevin L. Shrake, MA, RRT, FACHE, FAAMA, FAARC and Sam P. 
Giordano, MBA, RRT, FAARC 

Practitioners frequently confuse the implementation of protocol treatment and case 
management. Both programs, if successfully implemented, can lead to cost savings. 
The problem most practitioners face is how to identify where costs are avoided and 
resources are conserved. Perhaps most critical is ensuring that the correct care is 
delivered at the proper time. The health care practitioner is key to the ultimate success 
of these programs. 

Program #6 

What Matters in Respiratory Monitoring: 

What Goes and What Stays 

Live Videoconference - August 22, 11:30 a.m.-i:oo p.m. Central Time 
Teleconference with Videotape - September 26, 11:30 a.m.-i2:ooNoon Central Time 
Presenters: Dean R. Hess, PhD, RRT, FAARC and Richard D. Branson, BA, RRT 
The health care provider has an array of monitoring devices available in managing a 
patient. With all that technology available, which device is appropriate? What about 
those displays on ventilators? The availability of graphics during mechanical ventilation 
can provide a wealth of information. When is it essential? Under what circumstances 
should you pay close attention to those displays in the assessment of your patient? 

Program #8 

Routine Pulmonary Function Testing: Doing It Right 

Live Videocoi\ference - November 7, 11:30 a.m.-i:oo p.m. Central Time 
Teleconference with Videotape - December $, 11 :30 a.m.-i2:oo Noon Central Time 
Presenters: CarlD. Mottram, BA, RRT, RPFTandDavidJ. Pierson, MD, FAARC 

Puhnonary function testing at the bedside is being increasingly utilized as a diagnostic 
tool. Is it always appropriate? How can you assure competency of the person conducting 
the test? How can you aissure quality assurance outside the pulmonaiy fimction 
laboratory? This program will provide you with the information you need to assure that 
this diagnostic test is properly conducted outside the laboratoiy. 


Respiratory Care: 

Each program is approved for i hour of continuing education credit by Continuing Respiratory Care Education (CRCE). Purchase of 
videotapes only does not earn continuing education credit. Registrants must participate in the Hve program or the telephone seminar 
to earn continuing education credits. 


Each program is approved for 1.2 hours of continuing education credit by the Texas Nurse Association. Purchase of videotapes 
only does not earn continuing education credit. Registrants must participate in the live program or the telephone seminar to earn 
continuing education credits. 

Live Videoconference Requirements 

Sites must have satellite reception capabilities (with moveable dish), video monitor, a telephone, and an individual to proctor the 
program. Participants will view a live 90-minute satellite television broadcast with a live call-in question-and-answer session. 
Program materials for the live program include satellite coordinates, toll-free telephone number, continuing education packet, 
attendance log and reproducible course materials, post -test with answers, evaluation, and certificate of attendance. 

Teleconference with Videotape Requirements 

Sites must have a video monitor, a VCR, a telephone with speaker phone, and an individual to proctor the program. ParticipaAts 
will receive and view a 90-minute videotape and then call a toll-free number for a live 30-minute call-in question-and-answer 
session. Program materials for the telephone session include the toll-free telephone number, continuing education packet, 
attendance log, videotape and reproducible course materials, post-test with answers, evaluation, and certificate of attendance. 



D Sign Us Up for Continuing Education in the Convenience of Our Own Facility 

Single Programs: $245 per facility ($215 for AARC Members) 

Entire Series of Eight: $1,395 per facility-Save $565 ($1,225 for AARC Members-Save $495) 

Late Registration Fee: $15 (If registering within one week of program) 


n Payment Enclosed Charge to: D Visa D MasterCard D Purchase Order (P.O.) 

Credit Card or P.O. No. . 

Exp. Date_ 

Signature (Required for Credit Card and P.O.) . 

Amount of Order $ . 

AARC Member Numlxr . 
(Required/or Discount) 

Ship Program Materials To (No Post Office Boxes): 






Bill To (IfD^erent From Uft): 





Reception Options 

(You Must Select One Only) 
n Live Videoconference 
n Teleconference with Videotape 
D Videotape Only (No CE Credit)* 

Check the Desired Programs 

D Entire Series of Eight 

n»3 n»7 
D#4 n*8 

•Videotapes will not be available until after the live videooonferenoe 
and do not include course materials. 

AARC Professor's Rounds 

Phone (972) 243-2272 - Facsimile (972) 484-2720 - 11030 Abies Lane - Dallas, Texas 75229-4593 


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BACKGROUND: To study the transition from 
metered dose inhalers using chlorofluorocar- 
bons as propellants (CFC-MDIs) to non-CFC 
containing devices, a systematic review was con- 
ducted of clinical trials which compared the 
delivery of salbutamol and terbutaline via CFC- 
MDIs and non-CFC devices. METHODS: Pa- 
pers were selected by searching electronic da- 
tabases (MEDLINE. Cochrane, and BIDS) and 
further information and studies were sought 
from pharmaceutical companies. The studies 
were assessed for their methodological quality. 
RESULTS: Fifty three relevant trials were iden- 
tified. Most were scientifically flawed in terms 
of study design, comparison of inappropriate 
doses, and insufficient power for the determi- 
nation of therapeutic equivalence. Differences 
between inhaler devices were categorised ac- 
cording to efficacy and potency. Most trials 
claimed to show therapeutic equivalence, usu- 
ally for the same doses from the different de- 
vices. Two commercially available salbutamol 
metered dose inhalers using a novel hydrofluo- 
rocarbon HFC- 134a as propellant were equally 
as potent and efficacious as conventional CFC- 
MDIs, as were the Rotahaler and Clickhaler dry 
powder inhalers (DPIs). Evidence suggests that 
a dose of 200 microg salbutamol via CFC-MDI 
may be substituted with 200 microg and 400 
microg of salbutamol via Accuhaler and Dis- 
khaler DPIs, respectively. Terbutaline delivered 
via a Turbohaler DPI is equally as potent and 
efficacious as terbutaline delivered via a con- 
ventional CFC-MDI. CONCLUSIONS: When 
substituting non-CFC containing inhalers for 
CFC-MDIs, attention must be given to differ- 
ences in inhaler characteristics which may re- 
sult in variations in pulmonary function. 

Exploring Intermittent Transcutaneous COj 
Monitoring — Rauch DA, Ewig J, Benoit PE, 
Clark E, Bijur P. Crit Care Med 1999 Nov; 

OBJECTIVE: To explore the accuracy of a con- 
tinuous transcutaneous CO, (TC^q,) monitor, 
used in an intermittent rather than a continuous 
fashion, to obtain quick (<5 mins) COj read- 
ings. DESIGN: Prospective study. SETTING: 
An urban pediatric intensive care unit in a uni- 
versity teaching hospital. PATIENTS: A con- 
venience sample of pediatric patients with in- 
dwelling arterial catheters. INTERVENTION: 
Transcutaneous monitoring was done simulta- 
neous with anerial blood gas monitoring. MEA- 
were 49 simultaneous-readings on 19 patients, 
age 5 days to 16 years, with 13 different diag- 
noses. The TC(-o, was related to the P(-o, by a 
Pearson product coefficient of 0.79 (p< 0.0005), 
with a mean difference of 1.94 (TC(-o,>Pco, 
and 95% confidence interval of -0.12 to 4.07. 
The scatterplot produces a regression line char- 
acterized by the following equation: P^o, = 
(TC.„, X 1.05)-4.08. CONCLUSIONS: Further 

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study to evaluate intermittent TC^o, as a prac- 
tical clinical variable is warranted. This study 
should encourage refinement of the technology 
to be more accurate for this use. 

Beneficial Effects of Helium:Oxygen versus 
Air:Oxygen Noninvasive Pressure Support in 
Patients with Decompensated Chronic Ob- 
structive Pulmonary Disease — Jolliet P, Tas- 
saux D, Thouret JM, Chevrolet JC.Crit Care 
Med 1999 Nov;27( 1 1 ):2422-2429. 

OBJECTIVE: To test the hypothesis that, in 
decompensated chronic obstructive pulmonary 
disease (COPD), noninvasive pressure support 
ventilation using 70:30 helium:oxygen instead 
of 70:30 air:oxygen could reduce dyspnea and 
improve ventilatory variables, gasexchange, and 
hemodynamic tolerance. DESIGN: Prospective, 
randomized, crossover study. SETTING: Med- 
ical intensive care unit, university tertiary care 
center. PATIENTS: Nineteen patients with se- 
vere COPD (forced 1-sec expiratory volume of 
0.83 ± 0.3 1) hospitalized in the intensive care 
unit for noninvasive pressure support ventila- 
tion after initial stabilization with noninvasive 
pressure support for no more than 24 hrs after 
intensive care unit admission. INTERVEN- 
TIONS: Noninvasive pressure support ventila- 
tion was administered in the following random- 
ized crossover design: a) 45 min with air:oxygen 

or heIium:oxygen; b) no ventilation for 45 min; 
and c) 45 min with airoxygen or helium:oxy- 
SULTS: Air:oxygen and helium:oxygen de- 
creased respiratory rate and increased tidal 
volume and minute ventilation. Helium:oxygen 
decreased inspiratory time. Both gases increased 
total respiratory cycle time and decreased the 
inspiratory/total time ratio, the reduction in the 
latter being significantly greater with helium: 
oxygen. Peak inspiratory flow rate increased 
more with helium:oxygen. P^q, increased with 
both gases, whereas Paco, decreased more with 
helium:oxygen (values shown are mean ± SD) 
(52±6 torr [6.9±0.8 kPa] vs. 55±8 torr 
[7.3± 1. 1 kPa] and 48±6 torr [6.4±0.8 kPa] vs. 
54±7 torr [7.2±0.9 kPa] for airoxygen and 
helium:oxygen, respectively: p<0.05). When 
hypercapnia was severe (P^co, >56 torr [7.5 
kPa]), Paco, decreased by a 7.5 torr (1 kPa) in 
six of seven patients with helium:oxygen and in 
four of seven patients with air:oxygen (p< 0.01 ). 
Dyspnea score (Borg scale) decreased more with 
helium:oxygen than with airoxygen (3.7 ±1.6 
vs. 4.5±1.4 and 2.8±1.6 vs. 4.6±1.5 for air 
oxygen and heIium:oxygen, respectively; p< 
0.05). Mean arterial blood pressure decreased 
with airoxygen (76±12 vs. 82±I4 mm Hg; 
p< 0.05) but remained unchanged with helium: 
oxygen. CONCLUSION: In decompensated 
COPD patients, noninvasive pressure support 

Respiratory Care • May 2000 Vol 45 No 5 



ventilation with heliuni:oxygen reduced dys- 
pnea and Pjco, more than air:oxygen, modified 
respiratory cycle times, and did not modify sys- 
temic blood pressure. These effects could prove 
beneficial in COPD patients with severe acute 
respiratory failure and might reduce the need 
for endotracheal intubation. 

Oxygen Therapy During Exacerbations of 
Chronic Obstructive Pulmonary Disease — 

Agusti AG. Carrera M. Barbe F. Munoz A. To- 
gores B. EurRespir J 1999 Oct;l4(4):9.M-939, 

Venturi masks (VMs) and nasal prongs (NPs) 
are widely used to treat acute respiratory failure 
(ARF) in chronic obstructive pulmonary dis- 
ease (COPD). In this study, these devices were 
compared in terms of their potentiality to worsen 
respiratory acidosis and their capacity to main- 
tain adequate (> 90%) arterial oxygenation 
(S„(,,) through time (approximately 24 h). In a 
randomized cross-over study. 18 consecutive 
COPD patients who required hospitalization be- 
cause of ARF were studied. After determining 
baseline arterial blood gas levels (on room air), 
patients were randomized to receive oxygen 
therapy through a VM or NPs at the lowest 
possible inspiratory oxygen fraction that resulted 
in an initial Sj,,,, of a 90%. Arterial blood gas 
levels were measured again .30 min later (on 
Oi), and SjQ, recorded using a computer during 
the subsequent approximately 24 h. Patients 
were then crossed-over to receive O, therapy 
by means of the alternative device (NPs or VM), 
and the same measurements obtained again in 
the same order. It was observed that both the 
VM and NPs improved arterial oxygen tension 
(p<0.0001) to the same extent (p=NS). with- 
out any significant effect upon arterial carbon 
dioxide tension or pH. However, despite this 
adequate initial oxygenation, S^q, was < 90% 
for .3.7±3.8 h using the VM and for 5.4±5.9 h 
using NPs (p<0.05). Regression analysis 
showed that the degree of arterial hypoxaemia 
(p<0.05) and arterial hypercapnia (p<0.05) 
present before starting O, therapy and, partic- 
ularly, the initial S^o, achieved after initiation 
of O, therapy (p<0.oboi) enabled the time (in 
h) that patients would be poorly oxygenated 
(S„(), < 90%) on follow-up to be predicted. 
These findings suggest that, in order to main- 
tain an adequate (> 90%) level of arterial ox- 
ygenation in patients with chronic obstructive 
pulmonary and moderate acute respira- 
tory failure: 1) the initial arterial oxygen satu- 
ration on oxygen should be maximized when- 
ever possible by increasing the inspiratory 
oxygen fraction: 2) this strategy seems feasible 
because neither the VM nor NPs worsen respi- 
ratory acidosis significantly: and 3) the Venturi 
mask (better than nasal prongs) should be rec- 

Ventilatory Assistance Improves Exercise 
Endurance in Stable Congestive Heart Fail- 

ure— O'Donnell DE. D'Arsigny C, Raj S, Ab- 
dollah H, Webb KA. Am J Respir Crit Care 
Med 1999 Dec I ; 160(6): 1804- 18 1 1. 

We postulated that ventilatory assistance dur- 
ing exercise would improve cardiopulmonary 
function, relieve exertional symptoms, and in- 
crease exercise endurance (Tn,,,) in patients with 
chronic congestive heart failure (CHF). After 
baseline pulmonary function tests. 1 2 stable pa- 
tients with advanced CHF (ejection fraction. 
24 ± 3% [mean ± SEM]) performed constant- 
load exercise tests at approximately 60% of their 
predicted maximal oxygen consumption 
(Vo,max) while breathing each of control (1 
cm HjO), continuous positive airway pressure 
optimized to the maximal tolerable level 
(CPAP = 4.8 ± 0.2 cm H^O) or inspiratory 
pressure support (PS = 4.8 ± 0.2 cm HjO). in 
randomized order. Measurements during exer- 
cise included cardioventilatory responses, 
esophageal pressure (Pes), and Borg ratings of 
dyspnea and leg discomfort (LD). At a stan- 
dardized time near end-exercise, PS and CPAP 
reduced the work of breathing per minute by 
39 ± 8 and 25 ± 4%, respectively (p < 0.01). 
In response to PS: T,;,,, increased by 2.8 ± 0.8 
min or 43 ± 14% (p < 0.01); slopes of LD- 
time. V(,,-time. V^-o.-time, and tidal Pes-time 
decreased" by 24 ± 10, 20 ± 1 1, 28 ± 8. and 
44 ± 9%. respectively (p < 0.0.5): dyspnea and 
other cardioventilatory paraineters did not 
change. CPAP did not significantly alter mea- 
sured exercise The increase in T||„, 
was explained primarily by the decrease in LD- 
time slopes (r = -0,71. p < 0.001) which, in 
turn, correlated with the reductions in V^.-time 
(r = 0.61, p < 0.01) and tidal Pes-time (r = 
0.52. p < 0.01 ). in conclusion, ventilatory mus- 
cle unloading with PS reduced exertional leg 
discomfort and increased exercise endurance in 
patients with stable advanced CHF. 

The Effect of Acute Respiratory Distress Syn- 
drome on Long-Term Survival — Davidson 
TA, Rubenfeld CD, Caldwell ES, Hudson LD, 
Steinberg KP. Am J Respir Crit Care Med 1999 
Dec 1:160(6): 1 838-1 842. 

Despite a great deal of information about the 
risk factors, prognostic variables, and hospital 
mortality in the acute respiratory distress syn- 
drome (ARDS). very little is known about the 
long-term outcomes of patients with this syn- 
drome. We conducted a prospective, matched, 
parallel cohort study with the goals of describ- 
ing the survival of patients with ARDS after 
hospital discharge and comparing the long-term 
survival of patients with ARDS and that of a 
group of matched controls. The study involved 
127 patients with ARDS associated with trauma 
or sepsis and 127 controls inatched for risk fac- 
tor (trauina or sepsis) and severity of illness 
who survived to hospital discharge. Time until 
death was used as the outcome measure. Sur- 

vival was associated with age, risk factor for 
ARDS, and comorbidity. There was no differ- 
ence in the long-term mortality rate for ARDS 
patients and that of inatched controls (hazard 
ratio for ARDS: I .(X): 95% confidence interval: 
0.47 to 2,09) after controlling for age. risk fac- 
tor for ARDS. comorbidity, and severity of ill- 
ness. We conclude that if sepsis or trauma pa- 
tients survive to hospital discharge. ARDS does 
not increase their risk of subsequent death. Older 
patients, patients with sepsis, and patients with 
comorbidities, regardless of the presence of 
ARDS. have a higher risk of death after hospi- 
tal discharge. For the purposes of clinical prog- 
nosis and cost-effectiveness analysis, the long- 
term survival of patients with ARDS can be 
modeled on the basis of age, underlying risk 
factor for ARDS, and comorbidity. 

Categorizing Asthma Severity — Colice GL. 
Burgt JV. Song J. Stampone P. Thompson 
PJ. Am J Respir Crit Care Med 1999 Dec 
1:160(6): 1962- 1967. 

The National Asthma Education and Preven- 
tion Program (NAEPP) Expert Panel II recoin- 
mended a stepped care pharmacotherapy ap- 
proach to asthma treatment based on an objective 
assessment of asthma severity using daytime 
symptoms, nocturnal symptoms, and physio- 
logic lung function. The worst grade of the in- 
dividual variables determines overall asthma se- 
verity. With this approach, patterns of asthma 
severity categorization itiight vary among indi- 
vidual variables: one variable might have a pre- 
dominant effect on overall categorization. Dur- 
ing the run-in. pretreatment phase of five 
controlled clinical trials, data from 7-14 inhaled 
steroid nonusers and 685 inhaled steroid u.sers 
on asthma control were collected and asthma 
severity categorized. In inhaled steroid nonus- 
ers nocturnal symptoms classified the majority 
of patients as severe, persistent, but wheeze clas- 
sified 27.3% of patients as mild, intermittent 
and 25.7% as mild, persistent. If the worst grade 
from the four asthma symptoms was used for 
severity grading, inost patients were categorized 
as severe, persistent. j3- Agonist use and FEV, 
classified most as moderate, persistent. There 
was poor correlation between variables in se- 
verity categorization. Severity grading for Eu- 
ropean patients was similar to that for U.S. pa- 
tients. Applying the Expert Panel II 
recommended method for asthina severity cat- 
egorization to a large data set illustrates that a 
single variable, nocturnal symptoms, deter- 
mined to a large extent overall categorization. 
Development of a validated method for asthma 
severity categorization is essential for using a 
stepped care approach to asthma phamiacother- 

How Does Patient Education and Self-man- 
agement Among A.sthnuitlcs and Patients 
with Chronic Obstructi\ e Pulmonary Disease 


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Affect Medication?— Gallefoss F, Bakke PS. 
Am J Respir Crit Care Med 1 999 Dec 1 ; 1 60(6): 

The effect of patient education on steroid in- 
haler compliance and rescue medication utili- 
zation in patients with asthma or chronic ob- 
structive pulmonary disease (COPD) has not 
been previously investigated in a single study. 
We randomized 78 asthmatics and 62 patients 
with COPD after ordinary outpatient manage- 
ment. Intervention consisted of two 2-h group 
sessions and 1 to 2 individual sessions by a 
trained nurse and physiotherapist. A self-man- 
agement plan was developed. We registered for 
12 mo medication dispensed from pharmacies 
according to the Anatomical Therapeutic Chem- 
ical (ATC) classification index. Steroid inhaler 
compliance (SIC) was defined as (dispensed/ 
prescribed) X 1 00 and being compliant as SIO 
75%. Among asthmatics 32% and 57% were 
compliant (p = 0.04) with a median (25th/75th 
percentiles) SIC of 55% (27/96) and 82% (44/ 
127) (p = 0.08) in the control and intervention 
groups, respectively. Patient education did not 
seem to change SIC in the COPD group. Un- 
educated patients with COPD were dispensed 
double the amount of short-acting inhaled /Sj- 
agonists compared with the educated group (p = 
0.03). We conclude that patient education can 

change medication habits by reducing the 
amount of short-acting inhaled ^2-'igo"is's be- 
ing dispensed among patients with COPD. Ed- 
ucated asthmatics showed improved steroid in- 
haler compliance compared with the uneducated 
patients, whereas this seemed unaffected by ed- 
ucation in the COPD group. 

Prospective Randomized Trial Comparing 
Bilateral Lung Volume Reduction Surgery 
to Pulmonary Rehabilitation in Severe 
Chronic Obstructive Pulmonary Disease — 

Criner GJ, Cordova FC, Furukawa S. Kuzma 
AM, Travaline JM, Leyenson V, O'Brien CM. 
Am J Respir Crit Care Med 1 999 Dec 1 ; 1 60(6): 

Several uncontrolled studies report improve- 
ment in lung function, gas exchange, and exer- 
cise capacity after bilateral lung volume reduc- 
tion surgery (LVRS). We recruited 200 patients 
with severe chronic obstructive pulmonary dis- 
ease (COPD) for a prospective randomized trial 
of pulmonary rehabilitation versus bilateral 
LVRS with stapling resection of 20 to 40% of 
each lung. Pulmonary function tests, gas ex- 
change, 6-min walk distance, and symptom- 
limited maximal exercise testing were done in 
all patients at baseline and after 8 wk of reha- 
bilitation. Patients were then randomized to ei- 

ther 3 additional months of rehabilitation or 
LVRS. Thirty-seven patients met study criteria 
and were enrolled into the trial. Eighteen pa- 
tients were in the medical arm; 15 of 18 pa- 
tients completed 3 mo of additional pulmonary 
rehabilitation. Thirty-two patients underwent 
LVRS (19 in the surgical arm, 13 crossover 
from the medical arm). After 8 wk of pulmo- 
nary rehabilitation, pulmonary function tests re- 
mained unchanged compared with baseline data. 
However, there was a trend toward a higher 
6-min walk distance (285 ± 96 versus 269 ± 
91 m, p = 0.14) and total exercise time on 
maximal exercise test was significantly longer 
compared with baseline values (7.4 ± 2. 1 ver- 
sus 5.8 ± 1.7 min, p < 0.001). In 15 patients 
who completed 3 mo of additional rehabilita- 
tion, there was a trend to a higher maximal 
oxygen consumption (V„,max)( 1 3.3 ± 3.0 ver- 
sus 12.6 ± 3.3, p < 0.08). In contrast, at 3 mo 
post-LVRS, FVC (2.79 ± 0.59 versus 2.36 ± 
0.55 L, p < 0.001) and FEV, (0.85 ± 0.3 ver- 
sus 0.65 ± 0. 16 L, p < 0.005) increased whereas 
TLC (6.53 ± 1.3 versus 7.65 ± 2.1 L, p < 
0.001) and residual volume (RV) (3.7 ± 1.2 
versus 4.9 ± 1 . 1 L, p < 0.001 ) decreased when 
compared with 8 wk postrehabilitation data. In 
addition. Paco^ decreased significantly 3 mo 
post-LVRS compared with 8 wk postrehabili- 
tation. Six-minute walk distance (6MWD), to- 


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tal exercise time, and Vo,max were higher after 
LVRS but did not reach statistical significance. 
However, when 13 patients who crossed over 
from the medical to the surgical arm were in- 
cluded in the analysis, the increases in 6MWD 
(337 ± 99 versus 282 ± 100 m, p < 0.001 ) and 
Vo,max (13.8 ± 4 versus 12.0 ± 3 mL/kg/min, 
p < 0.01 ) 3 mo post-LVRS were highly signif- 
icant when compared with postrehabi Illation 
data. The Sickness Impact Profile (SIP), a gen- 
eralized measure of quality of life (QOL), was 
significantly improved after 8 wk of rehabilita- 
tion and was maintained after 3 mo of addi- 
tional rehabilitation. A further improvement in 
QOL was observed 3 mo after LVRS compared 
with the initial improvement gained after 8 wk 
of rehabilitation. There were 3 (9.4%) postop- 
erative deaths, and one patient died before sur- 
gery ( 2.7% ). We conclude that bilateral LVRS, 
in addition to pulmonary rehabilitation, im- 
proves static lung function, gas exchange, and 
QOL compared with pulmonary rehabilita- 
tion alone. Further studies need to evaluate 
the risks, benefits, and durability of LVRS 
over time. 

Outcomes of Critically III Cancer Patients in 
a University Hospital Setting — Kress JP, 
Christenson J, Pohlman AS, Linkin DR. Hall 
JB. Am J Respir Crit Care Med 1999 Dec 

Critically ill cancer patients constitute a large 
percentage of admissions to tertiary care med- 
ical intensive care units (ICUs). We sought to 
describe outcomes of such patients, and to eval- 
uate how conditions commonly seen in these 
patients impact mortality. A total of 348 con- 
secutive medical ICU cancer patients were eval- 
uated. Subgroup comparisons included the three 
most common cancer types (leukemia, lym- 
phoma, lung cancer), as well as three different 
treatments/conditions (bone marrow transplant 
[BMT] versus non-BMT. mechanical ventila- 
tion |MV] versus non-MV. neutropenic versus 
non-neutropenic). There were no mortality dif- 
ferences between patients with leukemia, lym- 
phoma, or lung cancer. By logistic regression, 
mortality predictors were: MV. hepatic failure, 
and cardiovascular failure for the group as a 
whole (41% overall mortality): MV and allo- 
geneic (as compared with autologous) BMT for 
the BMT group (39% overall mortality): he- 
patic failure, cardiovascular failure, and persis- 
tent acute respiratory distress syndrome ( ARDS ) 
for the MV group (67% overall mortality); and 
MV for the neutropenic group (53% overall mor- 
tality). Neutropenia showed no independent as- 
sociation with mortality in the group as a whole 
or any subgroup analyzed. We conclude that 
respiratory, hepatic, and cardiovascular failure 
predict mortality, whereas neutropenia does not. 
Additionally, we have noted an encouraging im- 

provement in survival in many groups of criti- 
cally ill cancer patients. 

Synchronization of Radiograph Film Expo- 
sure with the Inspiratory Pause: Effect on 
the Appearance of Bedside Chest Radio- 
graphs in Mechanically Ventilated Patients — 

Langevin PB. Hellein V. Harms SM, Tharp WK, 
Cheung-Seekit C, Lampotang S. Am J Respir 
Crit Care Med 1999 Dec I:I60(6):2067-2071. 

The appearance of portable chest radiographs 
(CXRs) may be affected by changes in venti- 
lation, particularly when patients are mechani- 
cally ventilated. Synchronization of the CXR 
with the ventilatory cycle should limit the in- 
fluence of respiratory variation on the appear- 
ance of the CXR. This study evaluates the ef- 
fect of synchronizing the CXR film exposure 
with ventilation on the appearance of the radio- 
graph. Twenty-five patients who remained in- 
tubated postoperatively, were mechanically ven- 
tilated, and required a CXR were enrolled in 
this triple-blind, randomized prospective study. 
Each patient received one radiograph using con- 
ventional techniques and another using the in- 
tertace. The sequence of the two films was ran- 
domized, and the two films were taken on the 
same patient within a few minutes of each other. 
Hence, each patient served as his own control 
and the position of the patient, source-film dis- 

Respiratory Care • May 2000 Vol 45 No 5 



tance. intensity (Kvp), and duration of the ex- 
posure (niAs) were identical for the two films. 
Five board-certified radiologists were then asked 
to compare paired tllms for clarity of lines and 
tubes, definition of the pulmonary vasculature, 
visibility of the mediastinum, definition of the 
diaphragin, and degree of lung inflation. Radi- 
ologists were also asked to choose which films 
they preferred. A majority of board certified 
radiologists preferred CXRs taken with the in- 
terface in 21 of 25 patients (p < 0.0001 ). Fur- 
thermore, four of the five criteria evaluated were 
improved (p < 0.05) on synchronized CXRs. 
Synchronization of the bedside CXR with the 
end of inspiration ensures that they are always 
obtained at maximal inflation, which improves 
the appearance of a majority of radiographs by 
at least one of five criteria. 

Delays in Tuberculosis Isolation and Suspi- 
cion Among Persons Hospitalized with HIV- 
Related Pneumonia — Bennett CL, Schwartz 
DN, Parada JP, Sipler AM, Chmiel JS, DeHo- 
vitz JA, et al. Chest 2000 Jan; 1 1 7(1 ): 1 1 0- 1 1 6. 

BACKGROUND: Despite awareness of HIV- 
related tuberculosis (TB), nosocomial outbreaks 
of multidrug-resistant TB among HIV-infected 
individuals occur. OBJECTIVE: To investigate 
delays in TB isolation and suspicion among 
HIV-infected inpatients discharged with TB or 
Pneumocystis carinii pneumonia (PCP), com- 
mon HlV-related pneumonias. DESIGN: Co- 
hort study during 1995 to 1997. SETTING: For 
PCP, 1,227 persons who received care at 44 
New York City, Chicago, and Los Angeles hos- 
pitals. For TB, 89 patients who received care at 
five Chicago hospitals. MEASUREMENTS: 
Two-day rates of TB isolation/suspicion. RE- 
SULTS: For HIV-related PCP. Los Angeles hos- 
pitals had the lowest 2-day rates of isolation/ 
suspicion of TB (24.3%/26.6% vs 65.5%/66.4% 
for New York City and 62.8%/58.3% for Chi- 
cago, respectively; p < 0.001 for overall com- 
parison by chi" test for each outcome measure). 
Within cities, hospital isolation/suspicion rates 
varied from < 35 to > 70% (p < 0.(X)1 for 
interhospital comparisons in each city). The Chi- 
cago hospital with a nosocomial outbreak of 
multidrug-resistant TB from 1994 to 1995 iso- 
lated 60% of HI V-infected individuals who were 
discharged with a diagnosis of HIV-related TB 
and 52% discharged with HIV-related PCP, rates 
that were among the lowest of all Chicago hos- 
pitals in both data sets. CONCLUSION: Low 
2-day rates of TB isolation/suspicion among 
HIV-related PCP patients were frequent. One 
Chicago hospital with low 2-day rates of TB 
isolation/suspicion among persons with HIV- 
related PCP also had low 2-day rates of isola- 
tion/suspicion among confirmed TB patients. 
That hospital experienced a nos(Komial multi- 
drug-resistant TB outbreak. Educational efforts 
on the benefits of early TB suspicion/isolation 

among HIV-infected pneumonia patients are 

Heated Humidification or Face Mask to Pre- 
vent Upper Airway Dryness During Contin- 
uous Positive Airway Pressure Therapy — 

Martins De Araujo MT, Vieira SB. Vasquez 
EC, Fleury B. Chest 20(K) Jan; 1 17(1 ): 142- 147. 

Study objectives: The objectives of this study 
were (1) to evaluate the way in which nasal 
continuous positive airway pressure (CPAP) 
therapy influences the relative humidity (rH) of 
inspired air; and (2) to assess the impact on rH 
of the addition of an integrated healed humid- 
ifier or a full face mask to the CPAP circuitry. 
DESIGN: The studies were performed in 25 
patients with obstructive sleep apnea syndrome 
receiving long-term nasal CPAP therapy and 
complaining of na.sal discomfort. During CPAP 
administration, temperature and rH were mea- 
sured in the mask either during a night's sleep 
for 8 patients or during a daytime study in which 
the effects of mouth leaks were simulated in 17 
patients fitted with either a nasal mask (with or 
without humidification) or a face mask alone. 
SETTING: University hospital sleep disorders 
center. Measurements and results: Compared 
with the values obtained with CPAP alone, in- 
tegrated heated humidification significantly in- 
creased rH during the sleep recording, both when 
the mouth was closed (60 ± 14% to 81 ± 14%. 
p < 0.01) and during mouth leaks (43 ± 12%. 
to 64 ± 8%, p < 0.01). During the daytime 
study, a significant decrease in rH was observed 
with CPAP alone. Coinpared with the values 
measured during spontaneous breathing with- 
out CPAP (80 ± 2%), the mean rH was 63 ± 
9% (p < 0.01 ) with the mouth closed and 39 ± 
9% (p < 0. 01) with the mouth open. The ad- 
dition of heated humidification to CPAP pre- 
vented rH changes when the mouth was closed 
(82 ± 12%), but did not fully prevent the rH 
decrease during simulation of mouth leaks (63 ± 
9%) compared with the control period (80 ± 
2%, p < 0. 01). Finally, attachment of a face 
mask to the CPAP circuitry prevented rH 
changes both with the mouth closed (82 ± 9%) 
and with the mouth open (84 ± 8%). CON- 
CLUSIONS: These data indicate that inhaled 
air dryness during CPAP therapy can be signif- 
icantly attenuated by heated humidification, 
even during mouth leaks, and can be totally 
prevented by using a face mask. 

Internet-Based Home Asthma Telemonitor- 
ing: Can Patients Handle the Technology? — 

Finkelstein J. Cabrera MR, Hripcsak G. Chest 
2000 Jan; 1 17(1): 1 48- 155. 

Study objective: To evaluate the validity of spi- 
rometry self-testing during home telemonitor- 
ing and to assess the acceptance of an Internet- 
based home asthma telemoniloring system by 
a.sthma patients. DESIGN: We studied an In- 

ternet-based telenionitoring system that col- 
lected spirometry data and symptom reports 
from asthma patients' homes for review by phy- 
sicians in the medical center's clinical informa- 
tion system. After a 4()-min training session, 
patients completed an electronic diary and per- 
formed spirometry testing twice daily on their 
own from their homes for 3 weeks. A medical 
professional visited each patient by the end of 
the third week of monitoring, 10 to 40 min after 
the patient had performed self-testing, and asked 
the patient to perform the spirometry test again 
under his supervision. We evaluated the valid- 
ity of self-testing and surveyed the patients at- 
titude toward the technology using a staiidard- 
ized questionnaire. SETTING: Telenionitoring 
was conducted in patients' homes in a low- 
income inner city area. PATIENTS: Thirty-one 
consecutive asthma patients without regard to 
computer experience. Measurement and results: 
Thirty-one asthma patients completed 3 weeks 
of monitoring. A paired t test showed no dif- 
ference between unsupervised and supervised 
home spirometry self-lesting. The variability of 
FVC (4.1%), FEV, (3. 7%), peak expiratory 
flow (7.9%), and other spironietric indexes in 
our study was similar to the within-subject vari- 
ability reported by other researchers. Despite 
the fact that the majority of the patients (71% ) 
had no computer experience, they indicated that 
the self-lesting was "not complicated at all" or 
only "slightly complicated." The majority of 
patients (87. 1 % ) were strongly interested in us- 
ing home asthma telenionitoring in the future. 
CONCLUSIONS: Spirometry self-lesting by 
asthma patients during telenionitoring is valid 
and comparable to those tests collected under 
the supervision of a trained medical professional. 
Internet-based home asthma telemoniloring can 
be successfully implemented in a group of pa- 
tients with no computer background. 

The Control of Breathing in Clinical Prac- 
tice — Caruana-Monlaldo B. Gleeson K, Zwil- 
lich CW. Chest 2(H)() Jan;l 17( I ):2()5-225. 

The control of breathing results from a complex 
interaction involving the respiratory centers, 
which feed signals to a central control mecha- 
nism that, in turn, provides output to the effec- 
tor muscles. In this review, we describe the 
individual elements of this system, and what is 
known about their function in man. We outline 
clinically relevant aspects of the integration of 
himiaii ventilatory control system, anil describe 
altered function in response to special circum- 
stances, disorders, and medications. We em- 
phasize the clinical relevance of this topic by 
employing case presentations of active patients 
from our practice. 

A Randomized rrial of Nocturnal Oxygen 
Therapy in Chronic Obstructive Pulmonary 
Disease Patients — Chaoual A. Weil/enhlum E. 


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Kessler R, Charpentier C, Enrhart M, Schon R, 
et al. Eur Respir J 1999 Nov;14(5):1002-1008. 

The beneficial effects of nocturnal oxygen ther- 
apy (NOT) in chronic obstructive pulmonary 
disease (COPD) patients with mild-to-moderate 
daytime hypoxaemia (arterial oxygen tension 
[P.O,] in the range 7.4-9.2 kPa [56-69 mmHg)) 
and exhibiting sleep-related oxygen desatura- 
tion remains controversial. The effectiveness of 
NOT in that category of COPD patients was 
studied. The end points included pulmonary hae- 
modynamic effects after 2 yrs of follow-up, sur- 
vival and requirement for long-term oxygen 
therapy (LTOT). Seventy-six patients could be 
randomized, 41 were allocated to NOT and 35 
to no NOT (control). The goal of NOT was to 
achieve an arterial oxygen saturation of >90% 
throughout the night. All these patients under- 
went polysomnography to exclude an associ- 
ated obstructive sleep apnoea syndrome. The 
two groups exhibited an identical meansD day- 
time P„o, of 8.4±0.4 kPa (63±3 mm Hg) at 
baseline. Twenty-two patients (12 in the NOT 
group and 10 in the control group, p=0.98) 
required LTOT during the whole follow-up 
(35± 14 months). Sixteen patients died, nine in 
the NOT group and seven in the control group 
(p=0.84). Forty-six patients were able to un- 
dergo pulmonary haemodynamic re-evaluation 
after 2 yrs, 24 in the NOT and 22 in the control 
group. In the control group, mean resting pul- 
monary artery pressure increased from 19.8±5.6 
to 20.5 ±6.5 mm Hg, which was not different 
from the change in mean pulmonary artery pres- 
sure in the NOT group, from 18.3 ±4.7 to 
19.5 ±5.3 mm Hg (p= 0.79). Nocturnal oxygen 
therapy did not modify the evolution of pulmo- 
nary haemodynamics and did not allow delay in 
the prescription of long-term oxygen therapy. 
No effect of NOT on survival was observed, 
but the small number of deaths precluded any 
firm conclusion. These results suggest that the 
prescription of nocturnal oxygen therapy in iso- 
lation is probably not justified in chronic ob- 
structive pulmonary disease patients. 

Multiple Inhalers Confuse Asthma Pa- 
tients — van der Palen J, Klein JJ, van Herwaar- 
den CL, Zielhuis GA. Seydel ER. Eur Respir J 
1999 Nov; 14(5); 1 034- 1 037. 

This study investigated the influence of the use 
of different types of inhalers on the adequacy of 
inhalation technique among adult asthmatics. 
Three hypotheses were tested; first, patients us- 
ing only one type of inhaler will demonstrate 
adequate inhalation technique more often than 
those with two or more types. Secondly, pa- 
tients using a combination of dry powder in- 
halers (DPIs) will demonstrate correct inhala- 
tion technique more often than those using the 

combination of a metered dose inhaler (MDI) 
and a DPI. Thirdly, some inhalers or combina- 
tions of inhalers are more prone to erroneous 
inhalation technique than others. Adult outpa- 
tients with asthma who regularly used inhaled 
steroid therapy (n = 32l) participated in the 
study. The inhalers investigated were MDls on 
the one hand, and the DPIs Turbuhaler, Disk- 
haler, Cyclohaler, Inhaler Ingelheim and Ro- 
tahaler on the other. Of 208 adult asthmatics 
with only one inhaler, 71% made no inhalation 
errors versus 61% of 113 patients with two or 
more different inhalers. Of patients with a com- 
bination of DPIs 68% performed all essential 
checklist items correctly, versus 54% of pa- 
tients with the combination of "regular" MDI 
and DPI. Patients using only the Diskhaler made 
fewest errors. Whenever possible, only one type 
of inhaler should be prescribed. If a combina- 
tion is unavoidable, combinations of DPIs are 
preferable to MDI and DPI. The Diskhaler seems 
to be the most foolproof device. 

Randomized Controlled Trial of Volume- 
Targeted Synchronized Ventilation and Con- 
ventional Intermittent Mandatory Ventila- 
tion Following Initial Exogenous Surfactant 
Therapy — Mrozek JD, Bendel-Stenzel EM, 
Meyers PA, Bing DR, Connett JE, Mammel 
MC. Pediatr Pulmonol 2000 Jan;29(l):l 1-18. 

We set out to evaluate the impact of volume- 
targeted synchronized ventilation and conven- 
tional intermittent mandatory ventilation (IMV) 
on the early physiologic response to surfactant 
replacement therapy in neonates with respira- 
tory distress syndrome (RDS). We hypothesized 
that volume-targeted, patient-triggered synchro- 
nized ventilation would stabilize minute venti- 
lation at a lower respiratory rate than that seen 
during volume-targeted IMV, and that synchro- 
nization would improve oxygenation and de- 
crease variation in measured tidal volume (V^). 
This was a prospective, randomized study of 30 
hospitalized neonates with RDS. Infants were 
randomly assigned to volume-targeted ventila- 
tion using IMV (n = 10), synchronized IMV 
(SIMV; n = 10), or assist/control ventilation 
(A/C; n = 10) after meeting eligibility require- 
ments and before initial surfactant treatment. 
Following measurements of arterial blood gases 
and cardiovascular and respiratory parameters, 
infants received surfactant. Infants were stud- 
ied for 6 hr following surfactant treatment. In- 
fants assigned to each mode of ventilation had 
similar birth weight, gestational age, and Apgar 
scores at birth, and similar oxygenation indices 
at randomization. Three patients were elimi- 
nated from final data analysis because of ex- 
clusionary conditions unknown at randomiza- 
tion. Oxygenation improved significantly 
following surfactant therapy in all groups by 

1 hr after surfactant treatment (p < 0.05). 
No further improvements occurred with time. 
Total respiratory rate was lowest (p < 0.05) 
and variation in Vy was least in the A/C group 
(p < 0.05). Minute ventilation (V^), delivered 
airway pressures, respiratory system mechan- 
ics, and hemodynamic parameters were similar 
in all groups. We conclude that volume-targeted 
A/C ventilation resulted in more consistent tidal 
volumes at lower total respiratory rates than 
IMV or SIMV. Oxygenation and lung mechan- 
ics were not altered by synchronization, possi- 
bly due to the volume-targeting strategy. Of the 
modes studied, A/C, a fully-synchronized mode, 
may be the most efficient method of mechani- 
cal ventilator support in neonates receiving sur- 
factant for treatment of RDS. 

Early Prediction of Chronic Oxygen Depen- 
dency by Lung Function Test Results — Kav- 
vadia V, Greenough A, Dimitriou G. Pediatr 
Pulmonol 2000 Jan;29(I);19-26. 

Chronic oxygen dependency (COD) is a com- 
mon sequela to very premature birth. Steroid 
therapy may reduce COD if given within the 
first 2 weeks, but has important side effects. It 
is, therefore, crucial to identify an accurate pre- 
dictor of COD and hence only expose high-risk 
infants to intervention therapy. The aim of this 
study was to determine if, within 48 hr of birth, 
abnormal lung function predicted COD and 
whether such results performed better than 
readily available clinical data. Results from 100 
consecutive, very low birth-weight infants, me- 
dian gestation age 28 weeks (range, 24-33), who 
were ventilated within 6 hr of birth and sur- 
vived beyond 36 weeks postconceptional age 
(PCA), were analyzed. Lung volume was as- 
sessed by measurement of functional residual 
capacity (FRC) using a helium gas dilution tech- 
nique, and compliance was measured using ei- 
ther a passive inflation or an occlusion tech- 
nique. The maximum peak inflating pressure 
and inspired oxygen concentration within the 
first 48 hr were recorded. The infants who re- 
mained oxygen-dependent beyond 28 days (n = 
58) and 36 weeks PCA (n = 24) differed from 
the rest in being more immature (p < 0.001), 
more had a patent ductus arteriosus, and they 
had both a lower median lung volume (p < 
O.CX)l ) and lower compliance (p < 0.01 ) on day 
2. An FRC <I9 mL/kg and a low gestational 
age were the most accurate predictors of COD 
at 28 days. An FRC <I9 mL/kg on day 2 re- 
mained the best predictor of COD beyond 28 
days if only the 50 infants whose gestational 
age was s 28 weeks were considered. We con- 
clude that demonstration of a low lung volume 
in the first 48 hr helps to identify infants who 
might benefit from therapy aimed at preventing 


RESPIRATORY Care • May 2000 Vol 45 No 5 

^__ Editorials 

The Use of Negative Pressure Ventilation in Infants with Acute 
Respiratory Failure: Old Technology, New Idea 

In this issue of Respiratory Care, Klonin et al describe 
a case series of three patients who were supported on 
negative pressure ventilation (NPV).' NPV is not a new 
concept; as a matter of fact, devices have been described 
dating back to the early 1800s.- The device utilized in this 
series was the Hayek Oscillator (Breasy Medical Equip- 
ment Ltd, London, UK). It involves the use of a chest 
cuirass and does not require the patient to be intubated. 
This device offers several modes, including noninvasive 
ventilation around a negative baseline, continuous nega- 
tive pressure, and secretion clearance. The use of such a 
device, in a mode that does not require intubation, has 
advantages over invasive positive pressure ventilation 
(PPV) in that it allows preservation of airway defenses and 
avoidance of intubation-related trauma, as well as a reduc- 
tion in the incidence of nosocomial pneumonia. In the case 
series in this issue, two of the patients were not intubated, 
and in the third the device was used as an adjunct to PPV. 

See The Case Report on Page 486 

In pediatrics over the past 10 years, there has been a 
growing understanding of the role of iatrogenic lung injury 
in the mortality and morbidity of patients with acute re- 
spiratory failure.^'' A recent study by Fackler et al'^ has 
shown that mortality is decreasing in pediatric patients 
with acute respiratory distress syndrome. Some of this 
change can be attributed to the use of a lung-protective 
strategy with PPV and the use of a high-frequency oscil- 
lator. However, despite a decrease in the overall mortality 
in this study, there were subsets of patients who still had 
a high mortality. For example, in the Fackler study of the 
patients who were admitted to the pediatric intensive care 
unit with oncologic disease and respiratory failure, none 
survived. As exemplified in the first case in the Klonin 
series, patients with immunocompromise or oncologic dis- 
ease may benefit most from the advantages of noninvasive 
modes of ventilation, including NPV. Of course in oncol- 
ogy patients, the underlying cancer may dictate the patient's 
survival; however, an increase of survival of even 20% 
would be significant in a population with 100% mortality. 

Another intriguing use of NPV described in Klonin' s se- 
ries is as an adjunct to PPV in a patient on extracorporeal 
membrane oxygenation. In these patients, re-expansion of 
collapsed segments of the lung can be challenging. In our 
institution we have frequently resorted to bronchoscope and 

lavage to reopen lung segments that may have been delaying 
weaning of extracorporeal membrane oxygenation support.* 
The use of NPV to reopen lung segments is intriguing. 

More investigation is needed before NPV can be used to 
its greatest advantage. Reports such as the one in this 
issue, which describe a case series, are important to stir 
our interest in new technologies or reapplication of old 
technologies, but widespread use must be directed only 
after careful well-controlled studies. However, in the pe- 
diatric population who might most benefit from this tech- 
nology, the ability to perform randomized controlled trials 
is difficult and may require a new approach.^ I comph>nent 
the authors on an interesting series and encourage them to 
continue investigating the use of NPV in children. 

Mark J Heulitt MD 

Respiratory Care Services 

Arkansas Children's Hospital 

Section of Critical Care Medicine 

Department of Pediatrics 

University of Arkansas for Medical Sciences 

Little Rock, Arkansas 


1 . Klonin H. Bowman B. Peters M, Raffeeq P, Durward A, Bohn D, et 
al. Negative pressure ventilation via chest cuirass to decrease venti- 
lator-ass(Kiated complications in infants with acute respiratory fail- 
ure: a case series Respir Care 2000;45(5):486-490. 

2. Woollam CHM. The development of apparatus for intermittent neg- 
ative pressure respiration. Anaesthesia l976:31(4):537-547. 

3. Heulitt MJ. Anders M, Benham D. Acute respiratory distress syn- 
drome in pediatric patients: redirecting therapy to reduce iatrogenic 
lung injury. Respir Care l995:40(l):74-85. 

4. Heulitt MJ, Bohn D. Lung-protective strategy in pediatric patients 
with acute respiratory distress syndrome. Respir Care 1998;43(ll): 

5. Fackler J, Bohn D. Green T, Heulitt M, HirschI R, Klein M, et al. 
ECMO for ARDS: Stopping a RCT (abstract). Am J Respir Crit Care 
Med 1997:1.55(4 Pt 2).A504. 

6. Karlson KH Jr. Pickert CB, Schexnayder SM. Heulitt MJ. Rexible 
fiberoptic bronchoscopy in children on extracorporeal membrane ox- 
ygenation. Pediatr Pulmonol 1993;I6(4):2I5-2I8. 

7. Fuhrman BP, Abraham E. Dellinger RP. Futility of randomized, con- 
trolled ARDS trials-a new approach is needed. Crit Care Med 1999; 

Correspondence: Mark J Heulitt MD. Pediatric Critical Care Medicine, 
Arkansas Children's Hospital. 800 Marshall St MS 512-12. Little Rock 
AR 72202-3591. E-mail: 

Respiratory Care • May 2000 Vol 45 No 5 


Complications of Noninvasive Ventilation 

Noninvasive positive-pressure ventilation (NPPV) has 
gained wide acceptance as an effective modality in the 
management of patients with acute respiratory failure due 
to chronic obstructive pulmonary disease exacerbations.'-* 
For this indication, it rapidly alleviates respiratory distress, 
greatly reduces the need for intubation,- and in some stud- 
ies reduces morbidity, mortality,'-' and hospital length of 
stay.-''' For other indications, the evidence is not quite as 
strong, but recent controlled trials suggest that NPPV can 
bring about similar benefits in patients with a variety of 
nonchronic obstructive pulmonary disease types of respi- 
ratory failure,'' including hypoxemic respiratory failure and 
community-acquired pneumonia.* In general, NPPV is con- 
sidered safe, with most complications related to mask in- 
tolerance or air insufflation. Major complications have been 
reported relatively infrequently, although the caveat is al- 
ways given that patients must be carefully selected.'' 

See The Case Report on Page 491 

In this issue of Respiratory Care, a patient is reported 
who developed a life-threatening upper airway obstruc- 
tion, caused by a large desiccated concretion of mucus and 
blood lodged in the posterior oral pharynx, after using 
NPPV for 6 days.** Fortunately, the obstruction was 
promptly removed and the patient did well, but the inci- 
dent raises a number of issues regarding the management 
of noninvasive ventilation. 

First is the issue of patient selection. When selecting 
patients for noninvasive ventilation, clinicians must iden- 
tify those in need of ventilatory assistance and screen out 
those with mild respiratory insufficiency who can be man- 
aged with medical therapy alone. The clinician must then 
exclude, among those needing ventilatory assistance, those 
in whom noninvasive ventilation would be unsafe and who 
should be promptly intubated. The patient's ability to pro- 
tect the airway is one of the most important considerations 
when making this determination. Unquestionably, the pa- 
tient described in the case report had problems with airway 
protection and was clearly not an ideal candidate for non- 
invasive ventilation. He had an aspiration pneumonia and 
atelectasis, and had recently had major abdominal surgery 
that would have impaired his cough mechanism. In addi- 
tion, he was .severely hypoxic, presumably related to re- 
tained secretions from his pneumonia. Had he not been so 

reluctant, most reasonable clinicians probably would have 
intubated the patient and foregone noninvasive ventilation 

Another issue raised by the case regards the use of 
untested ventilator techniques. In this case, the patient was 
treated with 40 L/min of oxygen bled into the ventilator 
circuit to maintain oxygen saturation > 90%, even though 
the manufacturer recommends flows not exceeding 15 
L/min. The concerns are that flows this high might inter- 
fere with ventilator triggering and cycling, leading to pa- 
tient-ventilator asynchrony, and expose the patient to high 
volumes of dry gas that would be highly desiccating. In 
view of these considerations, the complications of secre- 
tion desiccation and retention that occurred in the reported 
case are hardly surprising. 

What lessons can be drawn from this case? The authors 
infer that the duration of NPPV should be limited. I take 
strong issue with this inference. Are we to abandon NPPV 
and intubate patients after some arbitrary time limit like 3 
days if ventilatory assistance is still required? I hardly 
think so. Although NPPV is ideally used for periods of a 
few hours to a few days in patients with reversible causes 
for their acute respiratory failure, there are many examples 
of patients who have had favorable outcomes after longer 
durations of NPPV, including the present one. the reported 
complication notwithstanding. Further, patients with un- 
derlying chronic respiratory failure might be discharged 
using long-term NPPV. 

One lesson I extract from this case is that the impor- 
tance of proper patient selection cannot be overempha- 
sized. Patients like the one reported, who have an impaired 
ability to protect the airway, should be treated with inva- 
sive mechanical ventilation unless there are mitigating con- 
siderations. In this case, the patient was reluctant to un- 
dergo intubation. When patients decline intubation, it is 
reasonable to try noninvasive ventilation in less-than-ideal 
candidates, as long as the patient and/or family is informed 
that they are using a form of life support, albeit noninva- 
sive, and if there is some expectation of reversibility. In 
this circumstance, a higher risk of complications such as 
secretion retention or plugging must be assumed. 

Another lesson I draw from this case is that we must be 
very careful when using techniques that are not routine or 
ignore the manufacturer's recommendations. In this case, 
the of higher than recommended oxygen flow increased 
the risk of secretion desiccation in a patient already at risk 


Respiratory Care • May 2000 Vol 45 No 5 

Complications of Noninvasive Ventilation 

for secretion retention. This practice cannot be condoned 
without further testing of the effects of ventilator trigger- 
ing and performance. I concur with the authors' advice, 
however, that when noninvasive ventilation is used for 
longer periods (ie, more than a day or two), particularly in 
patients at risk for secretion retention or using unorthodox 
oxygen flows, inspired air should be adequately humidi- 
fied using a heated humidifier. 

This case report does not change the contention that 
NPPV used in appropriately selected patients is generally 
safe and effective. However, we must be sensitive to the 
fact that many recipients are less than ideal candidates, 
often for justifiable reasons, and we must anticipate and 
try to prevent the potential complications. 

Nicholas S Hill MD 

Critical Care Medicine 

Rhode Island Hospital 

Department of Medicine 

Brown University 

Providence. Rhode Island 

2. Kramer N. Meyer TJ, Meharg J, Cece RD, Hill NS. Randomized, 
prospective trial of noninvasive positive pressure ventilation in acute 
respiratory failure. Am J Re.spir Crit Care Med 1995;151(6):1799- 

3. Brochard L. Mancebo J. Wysocki M. Lofaso F, Conti G. Rauss A. et 
al. Noninvasive ventilation for acute exacerbations of chronic ob- 
structive pulmonary disease. N Engl J Med 1995:333(13):817-822. 

4. Celikel T, Sungur M. Ceyhan B. Karakurt S. Comparison of nonin- 
vasive positive pressure ventilation with standard medical therapy in 
hypercapnic acute respiratory failure. Chest 1998; 1 14(6): 1636-1642. 

5. Antonelli M. Conti G. Rocco M. Bufi M. DeBlasi RA. Vivino G. et 
al. A comparison of noninvasive positive-pressure ventilation and 
conventional mechanical ventilation in patients with acute respira- 
tory failure. N Engl J Med I998;339(7):429^35. 

6. Confalonieri M, Potena A, Carbone G, Delia Porta R. Tolley EA, 
Meduri GU. Acute respiratory failure in patients with severe com- 
munity-acquired pneumonia: a prospective randomized evaluation of 
noninvasive ventilation. Am J Respir Crit Care Med 1999:160(5 Pt 
1): 1585-1591. 

7. Hill NS. Complications of noninvasive positive pressure ventilation. 
Respir Care I997:42(4):432^J42. 

8. Wood KE. Flaten AL. Backes WJ. Inspissated secretions: a life- 
threatening complication of prolonged noninvasive ventilation. Re- 
spir Care 2000;45(5):49l-493. 


I. Bott J. Carroll MP. Conway JH. Keilty SE. Ward EM. Brown AM. 
el al. Randomized controlled trial of nasal ventilation in acute ven- 
tilatory failure due to chronic obstructive airways disease. Lancet 
1993;.34l(8860): 15.5.5-1.5.57. 

Correspondence: Nicholas S Hill MD, Director, Critical Care Medicine, 
Rhode Island Hospital. APC Building. Suite 475. 593 Eddy St, Provi- 
dence, RI 02903-4923. E-mail: 

Respiratory Care • May 2000 Vol 45 No 5 


Original Contributions 

Initial Experience with a Respiratory Therapist Arterial Line 

Placement Service 

Daniel D Rowley RRT RPFT, David F Mayo RRT, and Charles G Durbin Jr MD 

BACKGROUND: Indwelling arterial lines are commonly used in critical care. To standardize and 
improve the placement of these devices, we developed and implemented a respiratory therapist- 
based line placement service. As a measure of the quality of the service, we assessed the success and 
complications encountered in the first 119 line placement attempts of this new service. METHODS: 
The following were recorded for each artery on which cannulation was attempted: the number of 
the attempt on which cannulation was successful; if a different person was able to cannulate the 
artery after initial failure; and whether any complications occurred. Success rate compared to the 
number of attempts was tested with chi-square. RESULTS: Respiratory therapists were successful 
in placing 80% of attempted lines on the first try, including all 18 of 18 dorsal pedis attempts. 
Ninety-seven percent (115 of 119) of attempted arteries were ultimately cannulated. Success on 
second attempts by the same person was less than if a difTerent, more experienced, person attempted 
the placement (p = 0.024). No complications were identified during the study. CONCLUSIONS: 
Initiation of a respiratory therapist-based arterial line placement service resulted in an acceptable 
cannulation success rate, without complications. Increased experience of the person attempting 
cannulation correlates with improved success. (Respir Care 2000;45(5):482-485] Key words: aiteiial 
line placement, arterial catheter, cannula, cannulation, specialized team, radial artery, pedal artery, Allen 's 


Indwelling arterial catheters (lACs) are used in criti- 
cally ill patients to facilitate blood pressure monitoring, as 
well as to reduce the need for repeated, painful punctures 
for arterial blood gas analysis and other laboratory tests.' 
In the surgical and trauma intensive care unit (STICU) at 
the University of Virginia, approximately 96% of patients 
undergo invasive arterial monitoring. Many individuals, 
including fourth-year medical students, obstetrics and gy- 

Daniel D Rowley RRT RPFT, David F Mayo RRT. and Charles G 
Durbin Jr MD are affiliated with Surgical Services, University of Vir- 
ginia Health System, Charlottesville, Virginia. 

A version of this paper was presented at the during the American Asso- 
ciation for Ri-:spiKATORY Cark's Opkn Forum at the 44"' International 
Respiratory Congress, November 7- 1 0, 1 998, Atlanta, Georgia. 

Correspondence: Daniel D Rowley RRT RPFT, Surgical and Trauma 
Intensive Care Unit, Hospital of the University of Virginia, Charlottes- 
ville VA 22908. E-mail: 

necology residents, surgery residents, anesthesiology res- 
idents, and emergency medicine residents, rotate through 
the STICU and participate in placement of lACs. We iden- 
tified a need to standardize and improve the quality of lAC 
placement and maintenance, as well as to enhance the 
house staff educational experience. 

Since respiratory therapists (RTs) routinely draw arte- 
rial blood percutaneously, it was felt that they could easily 
learn the skills necessary to place lACs. The RTs consist 
of a small number of individuals. Once trained, they could 
oversee and teach the rotating house staff the skill of lAC 
placement. In this report we describe the initial success 
rate for lAC placement by RTs during the initiation of an 
arterial line placement service. 


Each participating therapist completed a self-directed, 
didactic program, attended and completed demonstration 
laboratory exercises, and completed a competency check- 
off that included being evaluated by a more experienced 


Respiratory Care • May 2000 Vol 45 No 5 

Respiratory Therapist Arterial Line Placement Service 

individual while placing the first several arterial catheters. 
The written materials included textbook sections and an 
article by Franklin, "The Technique of Radial Artery Can- 
nulation," from the Journal of Critical Illness.^ At our 
institution, lACs are sutured in place to prevent accidental 
removal. RTs were instructed in suturing using two-handed 
or instrument-tie surgical knots. Several catheter insertion 
techniques are described in the literature and these were 
demonstrated to the group of participating RTs by the 
anesthesiology unit-based attending staff.' The preferred 
technique at our institution is a single arterial entry with a 
20 gauge catheter-over-a-needle, as we believe this re- 
duces the risk of arterial thrombosis. If this approach is 
unsuccessful, a through-and-through or a guidewire tech- 
nique may be used. RTs are permitted to infiltrate the skin 
with 1% lidocaine (without epinephrine) if the patient is 
not allergic to local anesthetics. After completing the di- 
dactic component, each participating therapist was directly 
observed by a faculty anesthesiologist or anesthesiology 
resident during placement of at least the first three lACs. 
Following success in three lAC placement attempts, the 
RT was deemed competent and his performance for this 
study was recorded. 

For the purpose of the study, all attempts at line place- 
ment were counted. Each separate skin penetration was 
considered an attempt, but insertion and withdrawal to the 
skin without arterial penetration was not counted as a sep- 
arate attempt. After one or two unsuccessful attempts, a 
different individual (physician or RT) was asked to per- 
form the next attempt. Location of the artery, number of 
attempts, success of cannulation, and complications were 
recorded. Complications were divided into immediate and 
delayed. Immediate complications were identified and re- 
corded by the operator, and consisted of noticeable hema- 
toma, complaints of pain or paraesthesia, digital blanch- 
ing, or fracture of the catheter. Late complications were 
ascertained by daily nursing care observations and included 
distal embolization, evidence of local infection, inadver- 
tent line removal, or line failure. Catheter-related blood 
stream infections were diagnosed if patients had signs of 
infection, positive blood cultures, a positive catheter tip 
culture for the same organism, and no other infection source. 
Confirmation of infection was provided by the hospital 
epidemiologist. Success or failure for each line placement 
attempt was compared using the chi-square test. 


Data were collected for all RT-attempted lAC place- 
ments during the first 8 months following establishment of 
the service. A quality assurance data sheet was completed 
by the therapist attempting to insert the line and reviewed 
within 48 hours by one of the authors (DDR). Missing or 
unclear information was obtained by interviewing the RT 

Table I. Number of Attempts, Arterial Location, and Success Rates 
for Arterial Line Placement 

Arterial Site 

No. Arteries 

No. Successful 


Dorsal Pedal 



13 in burned 

chi-square = 0.39, dorsal pedal versus radial cumulative success. 

who performed the cannulation. Twelve therapists com- 
pleted the competency process, and their experience is 
reported in this paper. Each therapist attempted to cannu- 
late an average of 8 arteries, individual experience ranging 
from a low of 5 attempts to a high of 20 attempts. Place- 
ment success is summarized in Tables 1 and 2. 

There were no immediate complications recorded dur- 
ing the 119 I AC placement attempts. No patient developed 
a late complication, although several lines were removed 
because of poor function (failure to correlate with cuff- 
measured blood pressure). Ninety-five of the total arteries 
attempted (80%) were cannulated successfully on the first 
try, including all 18 of the 18 dorsalis pedis artery at- 
tempts. Eleven additional radial arteries were cannulated 
on a second try, but the overall success rate for this attempt 
was only 46%. However if a second person was asked to 
make the second attempt, the success rate improved, and 
more experienced individuals inserted 9 of these 1 1 lACs 
on the second attempt, bringing the cumulative success 
rate for two attempts to 87%. If three or more attempts 
were needed, the chance of success on these attempts rose 
to 69% and cumulative success rose to 97%. Third at- 
tempts were always performed by a more experienced per- 
son, RTs being equal to physicians in success on this third 
attempt. Three percent of arteries chosen for placement 
were never able to be cannulated by anyone. Chi-square 
analysis indicated that the probability of success declined 
on successive attempts (p = 0.0024), primarily because of 
the poor success of a second attempt by the first (less 
experienced) operator. 

Table 2. Success Rate of Arterial Cannulation on Successive 

Successful On 

No. Lines 

Cumulative % Comments 

First Attempt 



Second Attempt 


89 2nd person success: 4 
by MDs, 5 by RTs 

Third Attempt 


97 2nd person success: 3 
by MDs, 4 by RTs 



attempt number a 


chi-square = 0.0024, 

nd outcome: success or failure. 

Respiratory Care • May 20(X) Vol 45 No 5 


Respiratory Therapist Arterial Line Placement Service 


Although we are aware that percutaneous arterial cath- 
eterization is a procedure performed by RTs at some in- 
stitutions, we were unable to find published documenta- 
tion specifically relating to its performance by RTs. There 
are no published data on the frequency of success with 
lAC placement by any specific caregiver group. Our initial 
experience demonstrates that RTs can safely insert arterial 
catheters with a high degree of success, following com- 
pletion of an arterial cannulation competency program. 
None of the RTs had extensive experience in lAC place- 
ment prior to initiation of this service, and only one RT 
included in the study contributed a significant number of 
the data points (20 lACs). The high rate of lAC use in our 
STICU reflects the high acuity of patients and an aggres- 
sive clinical practice bias toward invasive patient moni- 
toring. With this aggressive approach, our patient outcomes 
remain better than predicted by the Acute Physiology and 
Chronic Health Evaluation (APACHE) II system. The fre- 
quent use of lACs provides an opportunity for RTs to 
quickly acquire the skills and experience needed to pro- 
vide an lAC line insertion service. 

The advantages of a specialized team for provision of 
services carrying patient risk have been convincingly dem- 
onstrated in other areas of clinical practice. Insertion and 
care of central lines used for chemotherapy and hyperali- 
mentation by a special team results in a significant reduc- 
tion in infectious complications and line failures.'*-^ Con- 
sistency and attention to important details probably account 
for these improvements.'* Cost may also be reduced if 
invasive lines are inserted and managed by specialized 
teams. ^ We expect similar improved outcomes with the 
RT lAC placement service. 

The most commonly observed and reported complica- 
tions of arterial cannulation include bleeding, distal i.sch- 
emia, and infection.'" In one large study, rates for I AC 
infection were reported as ranging from 0.4-0.7%, bleed- 
ing from 1.8-2.6%, and arterial insufficiency from 3.4- 
4.6% of patients." In our experience to date, we have not 
observed any clinically important bleeding from insertion 
sites. We also have not noted any distal arterial ischemia, 
catheter-related .sepsis, or infection at the catheter site. Our 
patients may have been a low-risk group for complica- 
tions, since the referring clinicians knew that the line place- 
ment service was in its infancy. There is no objective 
evidence that this referral bias existed, but if it was present, 
we would expect the complication rate to rise as more 
difficult and higher risk patients are cannulated. 

Though we established no absolute contraindications to 
arterial cannulation, relative contraindications do exist and 
were considered during the patient assessment. Some rel- 
ative contraindications included the presence of poor cir- 
culation at the insertion site, peripheral va.scular 

diabetes, coagulopathy, overlying bum scar, and vessels 
that have undergone vascular surgery or grafts. If any of 
these factors were present, consultation with the referring 
physician was sought prior to attempting line placement. 

The radial artery is commonly selected as a site for 
arterial cannulation because of its ease of cannulation and 
low frequency of complications. Most hands have a pal- 
mar arch supplied with collateral circulation through the 
ulnar artery. It has been suggested that the Allen's test is 
a quick, easy, and safe way to assess for collateral circu- 
lation of the hand. We did not require a "positive" Allen's 
test (rapid ulnar filling of the thenar eminence with radial 
artery occlusion), since it is known that this test yields a 
high incidence of false positive and false negative results. '^ 
Use of the dorsalis pedis artery for lAC placement is fre- 
quently practiced by anesthesiologists in the operating 
room, but success in the ICU is not reported in the medical 
literature.'^-"' Like the hand, circulation to the entire foot 
is usually provided by at least two large, separate arteries: 
the posterior tibial artery and the dorsalis pedis artery. As 
with the hand, confirmation of collateral flow may be 
achieved by compression of each of these vessels, but 
ischemic complications appear unrelated to the status of 
the collateral flow. Caution is advised in interpreting the 
systolic and diastolic blood pressure from this location, 
because pressure wave reflections widen the pulse pres- 
sure, with a resulting rise of systolic and lowering of di- 
astolic pressure.''^ Mean pressure is much less affected by 
this wave phenomenon. 

Arterial thrombosis is a frequent occurrence following 
lAC placement, occurring in 8-30% of patients."' Type of 
catheter, size of catheter, size of vessel, and duration of 
cannulation influence the frequency of arterial thrombosis. 
However, thrombosis is of little clinical importance, be- 
cause recannulization occurs and ischemia is very rare. 
Thrombosis should be suspected if one encounters diffi- 
culty threading a catheter into a vessel that has previously 
been catheterized. Often the radial pulse is easily palpable 
but disappears on ulnar artery occlusion, suggesting ulnar 
filling of the distal radial artery through the palmar arch. 
We did not systematically evaluate our patients for this 
complication, but did suspect it occurred in several in- 

The success of arterial cannulation appears to depend on 
the skill and experience of the clinician, but is influenced 
by the arterial anatomy. As most of the operators in this 
report had placed very few catheters (less than 20). it is 
gratifying that 80% were successful on the first attempt. 
We noted that if the catheter was not successfully placed 
during the first attempt, the chances of successful place- 
ment by the same, inexperienced operator during the next 
attempt was very low. If an experienced individual made 
the second attempt or the third attempt, the success rate for 
this try, approaching the success on the first try. This 


Respiratory Care • May 2000 Vol 45 No 5 

Respiratory Therapist Arterial Line Placement Service 

supports the conclusion that operator skill and experience 
are important in success. We did not have enough data on 
individual RTs to determine if increased experience pro- 
duced a greater success rate. However, since there was no 
difference if the next attempt was by a physician or an- 
other therapist, it appears that RTs can quickly develop 
adequate expertise in this procedure. However, there was 
an inadequate number of second and third attempts by RTs 
and physicians statistically to compare these individual 
groups' success rates. Unfavorable patient anatomy was an 
infrequent problem, possibly contributing to the 39f failure 
rate by all individuals. 


The advent of an arterial line insertion service in our 
STICU has been rewarding for RTs. Because they were 
allowed to learn and use this new procedure, subjective job 
satisfaction increa.sed. RTs are now increasingly consulted 
as a resource for hard-to-place lines. They are teaching the 
procedure to other therapists throughout the hospital and 
residents from all services as they rotate through the unit. 
Critically ill patients have benefited from RTs securing 
arterial lines quickly when a resident is performing other 
procedures on the patient or occupied elsewhere. Medical 
student learning is improved by having expert instructors 
available and willing to assist with acquiring arterial line 
placement skills. 


1. Durbin CG. Do arterial lines equal unnecessary testing? (editorial) 
Chest l995;108(l):7-8. 

2. Franklin C. The technique of radial artery cannulation: tips for max- 

imizing results while minimizing the risk of complications. J Crit Illn 

3. Stein JM. Placing arterial lines. Emerg Med l983;15(9):22l-225, 

4. Nelson DB, Kien CL. Mohr B. Frank S. Davis SD. Dressing changes 
by specialized personnel reduce infection rates in patents receiving 
central venous parenteral nutrition. JPEN J Parenter Enteral Nutr 

5. Bishop-Kurylo D. The clinical experience of continuous quality im- 
provement in the neonatal intensive care unit. J Perinat Neonatal 
Nurs I998l12(I):51-57. 

6. Edwards DP, Brookstein R. Hickman lines inserted and managed by 
a general surgical team: longevity and complications. Br J Clin Pract 

7. Faubion WC. Wesley JR. Khalidi N, Silva J. Total parenteral nutri- 
tion catheter sepsis: impact of the team approach. JPEN J Parenter 
Enteral Nutr 1986:l0(6):642-645. 

8. Maki DG. Yes. Virginia, aseptic technique is very important: max- 
imal barrier precautions during insertion reduce the risk of central 
venous catheter-related bacteremia. Infect Control Hosp Epidemiol 
1 994; 1 5(4 Pt l):227-230. 

9. Gianino MS. Brunt LM. Eisenberg PG. The impact of a nutritional 
support team on the cost and management of multilumen central 
venous catheters. J Intraven Nurs 1992;l5(6):327-332. 

10. Norwood SH, Cormier B. McMahon NG. Moss A. Moore V. Pro- 
spective study of catheter-related infection during prolonged arterial 
catheterization. Crit Care Med 1988;16(9):836-839. 

1 1 . Frezza EE. Mezghebe H. Indications and complications of arterial 
catheter use in surgical or medical intensive care units: analysis of 
4932 patients. Am Surg I998;64(2):I27-13I. 

1 2. Glavin RJ. Jones HM. Assessing collateral circulation in the hand: 
four methods compared. Anaesthesia l989:44(7):594-595. 

13. Johnstone RE, Greenhow DE. Catheterization of the dorsalis pedis 
artery. Anesthesiology 1973;39(6):654-655. 

14. Youngberg JA. Miller ED Jr. Evaluation of percutaneous cannula- 
tions of the dorsalis pedis artery. Anesthesiology I976:44( I ):80-83. 

15. ORourke MF. Yaginuma T. Wave reflections and the arterial pulse. 
Arch Intern Med I984:144(2):366-371. 

16. Bedford RF. Radial artery function following percutaneous cannu- 
lation with 18- and 20-gauge catheters. Anesthesiology 1977.47(1): 

Respiratory Care • May 2000 Vol 45 No 5 


Case Reports 

Negative Pressure Ventilation via Chest Cuirass to Decrease 

Ventilator-Associated Complications in Infants with Acute 

Respiratory Failure: A Case Series 

Hilary Klonin BM BS, Brian Bowman MD PhD, Michelle Peters RRT, Parakkal Raffeeq MD, 
Andrew Durward MD, Desmond J Bohn MD, Jon N Meliones MD, and Ira M Cheifetz MD 

Pulmonary and nonpulmonary complications of invasive positive pressure ventilation are well 
documented in the medical literature. Many of these complications may be minimized by the use of 
noninvasive ventilation. During various periods of medical history, negative pressure ventilation, a 
form of noninvasive ventilation, has been used successfully. We report the use of negative pressure 
ventilation with a chest cuirass to avoid or decrease the complications of invasive positive pressure 
ventilation in three critically ill infants at two institutions. In each of these cases, chest cuirass 
ventilation improved the patient's clinical condition and decreased the requirement for more in- 
vasive therapy. These cases illustrate the need for further clinical evaluation of the use of negative 
pressure ventilation utilizing a chest cuirass. [Respir Care 2000;45(5):486-490] Key words: nonin- 
vasive ventilation, negative pressure ventilation, chest cuirass ventilation, secretion clearance, mechan- 
ical ventilation, extracorporeal membrane oxygenation, respiratory failure. 


Traditionally, mechanical ventilator support for re- 
spiratory distress and respiratory failure has been inva- 
sive positive pressure ventilation (PPV). However, there 
have been periods of time, such as during the polio 
epidemic, when negative pressure ventilation (NPV) has 
been successfully used on a relatively large scale. In the 
past, NPV has not remained popular because of techni- 
cal limitations of NPV and difficulty performing gen- 
eral patient care in the "iron lungs." In order to reduce 
iatrogenic complications of invasive mechanical venti- 

Hilary Klonin BM BS. Brian Bowman MD PhD, Michelle Pelers RRT. 
Jon N Meliones MD, and Ira M Cheit'etz. MD are affiliated with the 
Department of Pediatric Critical Care Medicine. Duke Children's Hos- 
pital. Durham, North Carolina. Parakkal Raffeeq MD, Andrew Durward 
MD, and Desmond J Bohn MD are affiliated with the Hospital for Sick 
Children, Toronto, Ontario, Canada. 

Ms Peters presented a version of this paper at the American AsscKiation 
for Respiratory Care Opkn Forum during the 44th International Respi- 
ratory Congress, November 7-10. 1998 in Atlanta, Georgia. 

Correspondence: Ira M Cheifetz MD. Duke Children's Hospital. Duke 
University Medical Center, Box .1046. Durham NC 27710. E-mail: 

lation, a renewed emphasis on noninvasive ventilation, 
including NPV, is surfacing. 

Complications of intubation and invasive PPV are well 
documented.' Potentially serious airway complications that 
involve the endotracheal tube (ETT) include incorrect ETT 
placement, traumatic injury during intubation, ETT ob- 
struction, and ETT displacement.'-- Prolonged intubation 
may cause sinusitis, nasal septum injury, subglottic steno- 
sis, and the development of airway granulomas from re- 
peated endotracheal tube suctioning. '-'' Additionally, ac- 
cidental extubations may result in considerable morbidity 
or even mortality.'' Conventional positive pressure me- 
chanical ventilation may lead to clinically important pul- 
monary complications, including .secondary lung injury.''-'' 
Invasive PPV has been associated with the development of 
hyaline membrane formation and the potential for subse- 
quent increases in ventilatory support,**-^ Patients receiv- 
ing mechanical ventilation are also at risk for nosocomial 

See The Related Editorial on Page 479 

The potential complications associated with PPV extend 
beyond the respiratory system. Adverse sequelae to the 


Respiratory Care • May 2000 Vol 45 No 5 

Negative Pressure Ventilation via Chest Cuirass 

cardiovascular and neurologic systems may occur. Sub- 
stantial levels of conventional mechanical ventilatory sup- 
port may lead to cardiovascular compromise with decreased 
cardiac output and compromised oxygen delivery.'- The- 
sedation and analgesia required for patients to tolerate in- 
vasive ventilation can result in the need for prolonged 
ventilation because of oversedation." Withdrawal symp- 
toms may develop in certain patients and may require a 
lengthy tapering of opiates and/or benzodiazepines. 

The many difficulties associated with intubation and 
invasive PPV have lead clinicians to explore other means 
of respiratory support. Noninvasive ventilation avoids the 
need for an artificial airway while allowing for improved 
communication, coughing, and swallowing. Oral feeding 
may also be better tolerated. Noninvasive ventilation can 
be administered by both positive and negative pressure 
and may require substantially less sedation than invasive 
ventilatory techniques. 

One of the currently available negative pressure venti- 
lators is the Hayek Oscillator (Breasy Medical Equipment 
Ltd, London, UK).'-'-''' The Hayek Oscillator consists of a 
chest cuirass attached to a piston pump that provides NPV 
at both conventional and high-frequency rates. The base- 
line negative pressure is produced by a vacuum pump. The 
chest cuirass is a lightweight, flexible chest enclosure with 
foam rubber around the edges to provide an airtight seal 
over the chest and abdomen. 

The Hayek Oscillator offers several modes, including 
noninvasive ventilation around a negative baseline, con- 
tinuous negative pressure (the negative pressure equiva- 
lent of continuous positive airway pressure), and secretion 
clearance. The secretion clearance mode consists of oscil- 
lations around a negative baseline followed by an artificial 
"cough." This artificial cough has a prolonged inspiratory 
phase followed by a forced short expiratory phase. The 
secretion clearance mode in combination with high-fre- 
quency external chest wall oscillation has been shown to 
increase mucociliary clearance in a canine model.'*-''' 

Negative pressure ventilation using a chest cuirass has 
been previously reported in the literature for various pur- 
poses, including ventilatory support for patients (1) after 
congenital heart surgery, (2) with neuromuscular disease, 
(3) during failed fiberoptic intubation, (4) after lung re- 
section for bullous emphysema, and (5) during microlaryn- 
geal surgery.'*-23 In this case series, we report additional 
uses of chest cuirass NPV in the neonatal population. These 
cases illustrate the use of noninvasive NPV to avoid or 
decrease the complications of PPV in three critically ill 
infants. In this series, NPV was utilized in separate in- 
stances to avoid intubation, avoid reintubation, and facil- 
itate weaning from extracorporeal membrane oxygenation 

Case 1 

A 6-month-old male infant was transferred to Duke Chil- 
dren's Hospital from a local referring hospital with a three- 
week history of diarrhea and increasing respiratory dis- 
tress. The infant developed worsening respiratory failure 
with peripheral oxygenation saturations of 80% on a frac- 
tion of inspired oxygen (F|q ) of 0.60. A chest radiograph 
revealed a lingular infiltrate. Bronchoscopy confirmed the 
diagnosis of Pneumocystis carinii pneumonia. The patient's 
provisional diagnosis by immunologic testing was X-linked 
y globinopathy, and the patient was started on co-trimox- 

Upon arrival to the pediatric intensive care unit, the 
infant was in respiratory failure, with a respiratory rate of 
60 breaths jier minute, severe intercostal retractions, grunt- 
ing, and nasal flaring. An arterial blood gas analysis indi- 
cated: pH 7.40, arterial partial pressure of carbon dioxide 
38 mm Hg, arterial partial pressure of oxygen (Pao,).137 
mm Hg, arterial oxygen saturation 96% on face mask with 
F|o, of 1.0. Additionally, the patient was noted to have 
decreased perfusion with weakly palpable peripheral pulses 
and prolonged capillary refill. 

In an attempt to decrease the work of breathing and 
improve oxygenation, the patient was initiated on contin- 
uous negative airway pressure (-6 to -8 cm HjO) using a 
Hayek Oscillator. Shortly after initiating continuous neg- 
ative pressure via chest cuirass, the patient's respiratory 
rate decreased to 40 breaths per minute. The F,q^ was 
weaned from 1.0 to 0.80 while maintaining oxygen satu- 
ration above 95%. However, over the next several hours 
the patient's oxygen saturation again decreased to < 90% 
with the F|o, remaining at 0.80. The infant's ventilatory 
support was, therefore, changed to intermittent NPV with 
a ventilatory rate of 40 breaths per minute and peak in- 
spiratory and expiratory pressures of -18 cm HjO and -2 
cm HjO, respectively. On these settings, the patient had 
decreased work of breathing, as evidenced by decreased 
retractions, grunting, and nasal flaring. The F|o, delivered 
via face mask was weaned to 0.60 while maintaining ox- 
ygen saturation > 95%. The infant did not develop a met- 
abolic acidosis on arterial blood gas analysis, and lactic 
acid levels never exceeded 2. 1 mmol/L. 

The negative inspiratory pressure was maintained be- 
tween -18 cm HjO and -22 cm HjO for three days, with 
continued respiratory improvement. Subsequently, the pa- 
tient improved with routine supportive care. The infant 
had progressive normalization of respiratory effort, respi- 
ratory rate, and oxygenation. By day 10 of hospitalization, 
he was receiving 1-2 L/min of oxygen via nasal cannula. 
By hospital day 1 2, the patient no longer required supple- 
mental oxygen. At that time, the infant received a bone 
marrow transplant for treatment of his immunodeficiency 
syndrome and was transferred from the intensive care unit. 

Respiratory Care • May 2000 Vol 45 No 5 


Negative Pressure Ventilation via Chest Cuirass 

He did not require further admission to the intensive care 
unit during his hospital course. 

Case 2 

A 4-month-old former 26-week premature male infant 
(birthweight 905 g) was admitted to a referring hospital 
after a respiratory arrest at his home. At the time of his 
arrest, emergency medical service personnel performed 
the initial intubation and resuscitation. The infant's med- 
ical history was notable for chronic lung disease (OLD) of 
prematurity and recurrent apnea. 

At a local hospital, the infant experienced progressive 
respiratory deterioration requiring increasing ventilatory 
support and a trial of high-frequency positive pressure 
oscillatory ventilation. The initial chest radiograph revealed 
diffuse air space disease consistent with an intercurrent 
respiratory viral infection. For transfer the infant was placed 
on pressure control ventilation: ventilatory rate 40 breaths 
per minute, peak inspiratory pressure 33 cm H^O, positive 
end-expiratory pressure 10 cm H^O, mean airway pressure 
(P^^) 21 cm H2O, inspiratory time 0.7 seconds, and Fk,, 
1.0. The calculated oxygenation index [(P;,^^, X F|„ X 
100)/P.,oJ was 19. On transfer to Duke Children's Hospi- 
tal, the infant was placed on pressure control/pressure sup- 
port ventilation: ventilatory rate 25 breaths per minute, 
peak inspiratory pressure 37 cm H^O, positive end-expi- 
ratory pressure 8 cm HoO, pressure support 10 cm HjO, 
inspiratory time 0.6 seconds, and F|q^ 1 .0. He was extubated 
after one week of conventional mechanical ventilation. 

After extubation the infant was noted to have a bulbar 
palsy, with inability to swallow his secretions, as well as 
weakened cough and gag reflexes. The postextubation chest 
radiograph showed collapse of his left lung and right upper 
lobe (Fig. lA). At this same time, clinical evaluation re- 
vealed an increased respiratory rate to 60 breaths per minute, 
.subcostal retractions, and grunting. Because of the pa- 
tient's history of CLD. the medical care team desired to 
avoid reintubation and PPV. Thus, continuous negative 
pressure of -30 cm H2O was initiated in an attempt to 
decrease his work of breathing and to improve the atelec- 
tasis. Additionally, every 2-3 hours the infant was placed 
in the secretion clearance mode, with three minutes of 
oscillation at 600 cycles per minute and three minutes 
of "cough" at 60 cycles per second. In an effort to 
support his hypotonic upper airway, nasal continuous 
positive airway pressure of 6-10 cm HjO was applied. 
During NPV, enteral feeding was successfully accom- 
plished via a nasoduodenal tube. After two days the left 
lung re-expanded, and after an additional day the right 
lung expanded (see Fig. IB). He was gradually weaned 
off NPV over the next two days. His lungs remained 
expanded, and he was transferred back to his previous 
care facility two days later. 

Fig. 1. A 4-month-old former 26-week premature maie infant with 
history of chronic lung disease. The infant was intubated for an 
intercurrent viral illness. Figure 1A (upper) represents severe atel- 
ectasis after extubation. Figure 1 B (lower) represents substantial 
improvement in the atelectasis after treatment with negative pres- 
sure ventilation, including use of the secretion clearance mode. 

Case 3 

A 16-month-old infant was referred to Toronto Sick 
Children's Hospital, having developed respiratory failure 
and a clinical diagnosis of bronchiolitis obliterans. On 
conventional mechanical ventilation, the infant developed 
progressive hypoxia and hypercarbia. Respiratory deteri- 
oration persisted despite a trial of high-frequency positive 
pressure oscillatory ventilation. Diffuse airway plugging 
and atelectasis was noted. Despite daily bronchoscopic 
alveolar lavage and administration of acetylcysteine (Mu- 
comyst), DNAase, and exogenous surfactant, the atelecta- 
sis persisted. The patient's hospital course was compli- 
cated by the development of a life-threatening cardiac 
arrhythmia, further respiratory compromise and hemody- 
namic instability necessitating venoarterial ECMO. The 
oxygenation index immediately prior to ECMO was 60. 
During his ECMO course, he suffered a pulmonary hem- 
orrhage on day 8. The patient was unable to be weaned off 
ECMO because of inadequate oxygenation despite high 


Respiratory Care • May 2000 Vol 45 No 5 

Negative Pressure Ventilation via Chest Cuirass 

positive pressures on conventional mechanical ventilation. 
The pulmonary dynamic compliance remained at 0.35 
mL/cm HiO/kg. 

After 1 8 days of ECMO the infant was placed on chest 
cuirass NPV at a rate of 30 breaths per minute with an 
inspiratory to expiratory ratio of 1:1, inspiratory pressure 
of -25 cm H2O. expiratory pressure of 5 cm HjO, and two 
cycles of secretion clearance every two hours. Addition- 
ally, the positive pressure conventional ventilator was set 
to deliver a pressure support of 10 cm H^O and a positive 
end-expiratory pressure of 5 cm H^O. These ventilatory 
settings produced good chest movement and did not inter- 
fere with the patient's hemodynamic status. While on the 
Hayek Oscillator, a large increase in secretions occurred, 
and the secretions were easily lavaged with routine endo- 
tracheal tube suctioning. After 24 hours the dynamic com- 
pliance doubled to 0.72 mL/cm H20/kg. After 48 hours 
the oxygenation index fell to 5, and the infant was suc- 
cessfully decannulated from ECMO. The patient remained 
on conventional mechanical ventilation for an additional 
three days and was subsequently weaned to nasal cannula 
oxygen. The infant was successfully transferred back to 
the referring hospital. 


Chest cuirass NPV may be used to avoid the potentially 
deleterious effects of invasive PPV. The potential benefi- 
cial effects of NPV can be divided into several categories, 
including reduced airway complications, improved pulmo- 
nary parenchymal inflation at reduced airway pressures, 
reduced cardiovascular compromise, decreased sedation 
requirements, and improved enteral nutrition. The cases 
described in this paper illustrate some of these potential 
benefits of chest cuirass NPV. 

By eliminating the need for intubation, the potential 
airway complications associated with invasive PPV'—' can 
be completely avoided. Barotrauma, also associated with 
PPY .'>-7 (.^j^ be avoided by the use of NPV. Not only does 
NPV avoid the detrimental effects that PPV can have on 
hemodynamics, NPV may actually improve the patient's 
hemodynamic status, '*'''-2'*-' NPV may minimize seda- 
tion requirements, as it is generally well tolerated by most 
patients. Additionally, enteral feeding is usually well tol- 
erated in patients treated with NPV alone. 

Our first case in this series demonstrates the use of NPV 
to avoid intubation in a critically ill infant with Pneumo- 
cystis carina pneumonia. Original assessments of patients 
with Pneumocystis carinii pneumonia requiring mechani- 
cal ventilation report a mortality of > 80% in adults and 
50% in children.-*'-' However, more recent reports indi- 
cate that the initiation of adjuvant therapy with corticoste- 
roids, as well as earlier recognition of this disease, has led 
to an increase in the survival rate of patients with acquired 

immunodeficiency syndrome and respiratory failure sec- 
ondary to pneumonia.-** '" In the patient presented, ste- 
roids were felt to be contraindicated because of his con- 
genital immune deficiency syndrome. In view of historically 
poor results with ventilation of severely immunocompro- 
mised patients, we wished to avoid intubation and PPV. In 
this patient, NPV indeed saved this child from the risks of 
ventilator-associated pneumonia, barotrauma, and possible 
need for inotropic support. 

The second infant that we described had CLD of pre- 
maturity, or bronchopulmonary dysplasia, which has been 
well described as a complication of PPV." Although reven- 
tilation for lung expansion was an option, this patient's 
lungs were already severely damaged and would have been 
vulnerable to further ventilatory trauma by PPV. The use 
of continuous negative pressure for alveolar recruitment 
combined with the physiotherapy mode for secretion clear- 
ance was effective in improving the patient's clinical course 
while avoiding PPV. This method has not previously been 
documented in the literature. 

The patient in Case 3 was failing to show improvement 
despite maximal standard therapy. An oxygen index of > 
40 prior to ECMO has been associated with a mortality 
of > 80%.-'- The patient's ECMO course was complicated 
by a pulmonary hemorrhage, emphasizing the need to re- 
move this infant from ECMO as soon as possible. How- 
ever, a pulmonary compliance of < 0.6 mL/cm H^O/kg 
has been associated with failure to wean from ECMO.^^ 
Since this patient's pulmonary compliance failed to im- 
prove despite maximal "conventional" therapy, it was felt 
that further options were limited. The secretion clearance 
mode on the Hayek Oscillator offered this child chest phys- 
iotherapy and the ability to mobilize secretions. The im- 
proved secretion clearance helped to increase the infant's 
pulmonary compliance from 0.35 mL/cm HjO/kg to 0.72 
mL/cm H^O/kg. This may be because of the effect of 
high-frequency chest oscillation on mucociliary clear- 

Limitations of Negative Pressure Ventilation 

Chest cuirass NPV is associated with few complica- 
tions; however, some limitations do exist. Attention must 
be paid to the skin where the chest cuirass is fitted. Correct 
placement of the chest cuirass is important to facilitate a 
good seal and to minimize skin injury. A relative contra- 
indication to NPV is fixed upper airway obstruction, as 
negative pressure may exacerbate problems with air flow 
via the Bernoulli effect. As demonstrated in Case 2, this 
limitation of NPV may be avoided by the concurrent use 
of nasal continuous positive airway pressure. Another lim- 
itation is that there is not a simple method to measure 
minute ventilation. This lack of a monitoring capability 
may cause anxiety for the patient care team when NPV is 

Respiratory Care • May 2000 Vol 45 No 5 


Negative Pressure Ventilation via Chest Cuirass 

first introduced and may partially explain the lack of wide- 
spread acceptance of NPV for acute respiratory failure. 


In conclusion, the three patients presented help to dem- 
onstrate that noninvasive NPV may be used to suit differ- 
ent scenarios not previously reported. The effects of this 
relatively new mode of ventilation, especially with high- 
frequency external chest wall oscillation (secretion clear- 
ance mode), on mucociliary clearance are largely unex- 
plored in humans. Clinical trials in conditions with severe 
airway plugging such as cystic fibrosis and acute chest 
syndrome in sickle cell disease would be highly informa- 
tive. Additionally, there is a need for improved respiratory 
support for patients with immunosuppression. Chest cui- 
rass NPV may provide a partial solution that avoids many 
of the pitfalls of previous ventilation strategies. 


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Hayek Oscillator during microlaryngeal surgery. Anaesthesia 1995; 


Respiratory Care • May 2000 Vol 45 No 5 

Inspissated Secretions: A Life-Threatening Complication of Prolonged 

Noninvasive Ventilation 

Kenneth E Wood DO, Anne L Platen RRT, and William J Backes RRT 

Noninvasive Ventilation is frequently initiated in an attempt to avoid the complications of invasive 
mechanical ventilation. The optimal duration of this strategy is unclear, as prolonged noninvasive 
ventilation has associated complications. This case report illustrates the development of life-threat- 
ening inspissated secretions precipitating airway obstruction as a consequence of prolonged non- 
invasive ventilation. [Respir Care 2000;45(5):49 1-493] Key words: noninvasive ventilation, bi-level 
positive airway pressure, inspissated secretions, humidification. 


Noninvasive positive-pressure ventilation (NPPV) has 
gained acceptance in the support of patients with acute and 
chronic respiratory failure.' *• The use of noninvasive ven- 
tilation may decrease the need for endotracheal intubation 
and the associated complications such as nosocomial pneu- 
monia, barotrauma, and aspiration.''-^-'- It is considered a 
safe modality, with relatively few complications when uti- 
lized in appropriately selected patients. Reported NPPV 
complications include pressure sores, discomfort from the 
tension of the mask, and conjunctivitis.'-'* '^ Gastric insuf- 
flation and pulmonary barotrauma are potential complica- 
tions but occur infrequently because of the relatively low 
(< 30 cm HjO) pressures generated. '""'^ Dryness in the 
upper airway and nasal congestion are common but gen- 
erally not believed to be problematic consequences of 

Case Summary 

A 66-year-old alcoholic white male presented to his 
primary care physician with rectal bleeding subsequently 
found to be secondary to a rectal carcinoma. The patient 
underwent an abdominal peritoneal resection, but his post- 

operative course was complicated by renal failure and re- 
spiratory insufficiency secondary to volume overload, prob- 
able aspiration pneumonitis, and bibasilar atelectasis. With 
the patient on a high-flow nonrebreather face mask, an 
initial arterial blood gas analysis revealed pH 7.39, partial 
pressure of carbon dioxide 36 mm Hg, partial pressure of 
oxygen 65 mm Hg, bicarbonate 21.2 mmol/L, and 92% 
oxygen saturation. Subsequently, the patient decompen- 
sated, with clinically evident increased work of breathing 
(WOB) and inability to achieve oxygen saturation above 
90%. Because the patient clearly expressed reluctance to 
be intubated, a trial of continuous positive airway pressure 
was undertaken. Using 7.5 cm HjO continuous positive 
airway pressure with a 0.7 fraction of inspired oxygen, 
arterial blood gas analysis revealed pH 7.4, partial pres- 
sure of carbon dioxide 40 mm Hg. partial pressure of 
oxygen 123 mm Hg, bicarbonate 24.7 mmol/L, and oxy- 
gen saturation 97%. After a 48-hour period of respiratory 
stability, the patient was unable to maintain oxygen satu- 
ration above 90% with continuous positive airway pres- 
sure. Given his refusal to be intubated, a trial of NPPV was 

See The Related Editorial on Page 480 

Kenneth E Wood DO is the Director of the Trauma and Life Sup- 
port Center, and Anne L Flaten RRT and William J Backes RRT are 
afniiated with the Respiratory Care Department and the Trauma and Life 
Support Center. University of Wisconsin Hospital and Clinics. Madison. 

Correspondence; Kenneth E Wood DO, Trauma and Life Support Center, 
University of Wisconsin Hospital and Clinics, Section of Pulmonary and 
Critical Care Medicine, H6/380, 600 Highland Ave, Madison WI 53792. 

The BiPAP S/T-D 30 (Respironics, Murrysville. Penn- 
sylvania) was used in the spontaneous mode, with an in- 
spiratory positive airway pressure of 10 cm HjO and end- 
positive airway pressure of 5 cm HjO, applied with a full 
face mask. Substantial improvement in clinical status and 
oxygenation was noted, but in order to maintain arterial 
oxygen saturation of 90%, an oxygen bleed-in of 40 L/min 
was required. For the next 96 hours the patient only tol- 
erated very short periods of time independent of NPPV. 

Respiratory Care • May 2000 Vol 45 No 5 


Inspissated Secretions 



Fig. 1. Mass of inspissated secretions and blood removed from 
the epiglottic area. 

Efforts to titrate down the oxygen bleed-in resulted in 
decreased oxygen saturation and clinically apparent in- 
creased WOB. After 6 days of continuous noninvasive 
support, the patient was noted to have dry oral mucosa 
with dried secretions in his mouth and posterior pharynx. 
As a consequence, NPPV was discontinued and the patient 
was placed on an 80% aerosol mask. This transition was 
initially well tolerated, for one hour. Subsequently, the 
patient developed inspiratory stridor that progressively be- 
came more pronounced and was associated with tachypnea 
and increased WOB. No improvement was noted when 
NPPV was reinstituted. The patient complained of a for- 
eign body sensation in the back of his throat, so the na- 
sogastric tube was removed. The patient immediately be- 
came more stridorous, with decreasing oxygen saturation 
and respiratory distress. Intubation via direct laryngoscopy 
was attempted, but a large object (Fig I ) was occluding the 
vocal cords. This was removed with a Magill forceps and 
the patient immediately regained unlabored spontaneous 
respiration, and oxygen saturation improved markedly. The 
patient was returned to a 90% aerosol mask and over the 
next several days made a complete respiratory recovery, 
without further use of NPPV. Close examination of the 
extracted object, measuring 5X7 cm, revealed a combina- 
tion of inspissated secretions and blood. No histological 
examination of the mass was performed. Given the pro- 
drome of inspiratory stridor, it would seem most likely that 
the mass of inspissated secretions had partially fractured, 
causing incomplete airway occlusion. Subsequent removal 
of the nasogastric tube probably allowed the remainder of 
the recovered mass to detach from the posterior pharynx. 


This case illu.strates the application of NPPV support for 
a patient with hypoxemic respiratory failure in whom in- 

tubation was not an option. Although our patient did not 
manifest hypercapnia, he clearly exhibited signs of respi- 
ratory muscle fatigue associated with impending hypox- 
emic respiratory failure. 

Antonelli et al compared NPPV with standard treatment 
using supplemental oxygen administration to avoid endo- 
tracheal intubation in recipients of solid organ transplan- 
tation with acute hypoxemic respiratory failure.'"^ They 
found that the use of NPPV was associated with a signif- 
icant reduction in the rate of endotracheal intubation, rate 
of fatal complications, length of stay in the intensive care 
unit by survivors, and intensive care unit mortality. 

Prior to institution of NPPV, this patient had difficulty 
maintaining oxygen saturations > 90%, with associated 
labored respirations at a rate of 35 breaths per minute. Post 
institution of NPPV, the patient's WOB diminished sub- 
stantially, as did his respiratory rate. 

The BiPAP S/T-D30 unit is a low-pressure, electrically 
driven ventilation system with electronic pressure con- 
trols. It is primarily intended to augment patient ventila- 
tion by supplying pressurized air through a patient circuit. 
Oxygen delivery can be accomplished by using an external 
oxygen source that is bled into the patient circuit. The 
actual inspired oxygen concentration will vary, depending 
on the inspiratory and expiratory positive airway pressure 
settings, patient breathing pattern, mask fit, and leak rate. 
Manufacturer recommendations suggest the use of oxygen 
flow of < 15 L/min. However, when confronted with the 
occasional patient with hypoxemic respiratory failure who 
requires additional supplemental oxygen, we have found it 
necessary to use higher flows to achieve adequate oxygen 
delivery. Using higher flows may alter the pressure and 
flow delivery, and potentially interfere with the triggering 
mechanism. Therefore, it is necessary to assure that the 
delivered pressures and flows are appropriate for the pa- 
tient. This requires a clinical assessment of the patient's 
response, while adjusting the inspiratory positive airway 
pressure and expiratory positive airway pressure levels. 

We have found that using up to 40 L/min of oxygen can 
improve oxygen delivery. The use of such high flows has 
been investigated. Quinn found that flows of 40 L/min did 
not impair triggering or increase WOB.'^ Taylor et al as- 
sessed the performance of the BiPAP sytem with an aux- 
iliary high flow and found that high auxiliary flow into the 
BiPAP circuit did not affect the ability to trigger in any 
clinically important manner." They did express concern 
about retrograde flow into the BiPAP unit. In these in- 
stances we use a respiratory pressure valve (Respironics. Pitts- 
burgh, Pennsylvania, P/N 302418) to prevent retrograde flow 
back into the electrical component of the machine. 

The use of humidiflcation with NPPV is considered 
optional and often only utilized when the patient has symp- 
toms of nasal or oral dryness. When indicated, a cold 
water passover humidifier is usually used. Based on our 


Respiratory Care • May 2000 Vol 45 No 5 

Inspissated Secretions 

experience with this case, a cold water passover humidifier 
does not provide adequate humidification when using high- 
flow supplemental oxygen for sustained periods. A heated 
humidification system may provide more optimal humid- 
ification by increasing the overall relative humidity of the 
gas flow. 

We bench tested the humidity output of the flat Respi- 
ronics humidifier and a heated humidifier in similar sce- 
narios. Using 2 Whisper Swivels (Respironics, Murrys- 
ville, Pennsylvania, P/N 3321 13) and 30 L/min bias flow 
of oxygen, the cold passover humidifier produced 33-34% 
relative humidity at 23.8° C. The same setup with a heated 
humidifier produced 100% relative humidity at 28.1° C. 
Based on these results, we have instituted a policy of 
utilizing heated humidification at a temperature of 28° C 
when using NPPV with high-flow supplemental oxygen. 

This case report illustrates a previously unreported com- 
plication of noninvasive ventilation that resulted in life- 
threatening airway compromise. Given the growing reli- 
ance on NPPV to support patients with respiratory failure, 
such scenarios are likely to increase in frequency. Pro- 
spectively identifying potential risk factors — such as the 
use of a full face mask as opposed to a nasal mask, ante- 
cedent dehydration, inadequate cough, and depressed con- 
.sciousness — against the background of inadequate humid- 
ification with high oxygen flows for prolonged durations 
of continuous support should enable clinicians to identify 
patients at risk for complications. A heightened sense of 
awareness of the problem, limiting the duration of NPPV, 
and the use of humidification can serve to limit such life- 
threatening complications. 


1. Benhamou D. Girault C. Faure C. Portier F. Muir JF. Nasal mask 
ventilation in acute respiratory failure: experience in elderly patients. 
Chest I992;102(.^):912-9I7. 

2. Meduri GU. Fox RC, Abou-Shala N, Leeper KV, Wunderink RG. 
Noninvasive mechanical ventilation via face mask in patients with 
acute respiratory failure who refused endotracheal intubation. Crit 
Care Med 1 994:22(10): 1 584- 1 590. 

3. Meduri GU. Turner RE. Atwu-Shala N. Wunderink R. Tolley E. 
Noninvasive positive pressure ventilation via face mask: first-line 

intervention in patients with acute hypercapnic and hypoxemic re- 
spiratory failure. Chest I996:109(l):179-I9.1. 

4. Servera E. Perez M. Marin J. Vergara P. Castano R. Noninvasive 
nasal mask ventilation beyond the ICU for an exacerbation of chronic 
respiratory insufficiency. Chest 1995:108(6):1572-1576. 

5. Antonelli M, Conti G. Rocco M. Bufi M. De Blasi R. Vivino G. et 
al. A comparison of noninvasive positive-pressure ventilation and 
conventional mechanical ventilation in patients with acute respira- 
tory failure. N Engl J Med l998;.^39(7):429--t.15. 

6. Celikel T, Sungur M, Ceyhan B. Karakurt S. Comparison of nonin- 
vasive postitive pressure ventilation with standard medical therapy in 
hypercapnic acute respiratory failure. Chest 1998;l 14(6):I636-I642. 

7. Nourdine K, Combes P, Carton M, Beuret P. Cannamela A. Ducreux 
JC. Does noninvasive ventilation reduce the ICU nosocomial infec- 
tion risk? A prospective clinical survey. Intensive Care Med 1999; 

8. Guerin C. Girard R. Chemorin C. De Varax R. Foumier G. Facial 
mask noninvasive mechanical ventilation reduces the incidence of 
nosocomial pneumonia: a prospective epidemiological survey from a 
single ICU. Intensive Care Med 1 997:23(10): 1 024- 1 032. Published 
erratum appears in Intensive Care Med I99H:24(I):27. 

9. American Respiratory Care Foundation. Consensus statement. Non- 
invasive positive pressure ventilation. Respir Care 1997:42(4):365- 

10. Keenan SP. Kemerman PD, Cook DJ. Martin CM, McCormack D, 
Sibbald WJ. Effect of noninvasive positive pressure ventilation on 
mortality in patients admitted with acute respiratory failure: a meta- 
analysis. Crit Care Med 1997:25(10): 1685- 1692. 

1 1 . Keenan SP, Brake D. An evidence-based approach to noninvasive 
ventilation in acute respiratory failure. Crit Care Clin 1998:14(3): 

12. Hess D. Noninvasive positive pressure ventilation: predictors of suc- 
cess and failure for adult acute care applications. Respir Care 1997; 

1 3. Hill NS. Complications of noninvasive positive pressure ventilation. 
Respir Care 1997;42(4):432-442. 

14. Hotchkiss JR. Marini JJ. Noninvasive ventilation: an emerging sup- 
portive technique for the emergency department (review). Ann Emerg 
Med 1998:32(4):470-479. 

15. Antonelli M. Conti G. Bufi M. Costa MG. Lappa A. Rocco M. et al. 
Noninvasive ventilation for treatment of acute respiratory failure in 
patients undergoing solid organ transplantation: a randomized trial. 
JAMA 2000;283(2):235-241. 

16. Quinn WW. Controlled Fi02 Delivery with the BiPAP S-T/D (ab- 
stract). Respir Care I994;39(l 1):1 102. 

17. Taylor A. Hirsch C. Hess D. Kacmarek RM. Evaluation of BiPAP 
with auxiliary high flow (abstract). Respir Care 1994:39(1 l):l 101. 

Respiratory Care • May 2000 Vol 45 No 5 


The Use of Noninvasive Ventilation in Acute Respiratory Failure 
Associated with Oral Contrast Aspiration Pneumonitis 

Jean I Keddissi MD and Jordan P Metcalf MD 

Noninvasive ventilation (NIV) has been used to treat patients witli acute respiratory failure, in- 
cluding cases of pneumonia. We used this technique in the management of an 83-year-old patient 
with acute respiratory failure secondary to inadvertent administration of oral contrast material into 
the lung, and who did not want to be intubated. NIV resulted in immediate improvement of 
respiratory status. The patient was weaned from NIV over the next 24 hours and eventually 
discharged from the hospital. [Respir Care 2000;45(5):494-496] Key words: noninvasive ventilation, 
aspiration pneumonitis, acute respiratory failure, oral contrast, do-not-resuscitate order. 


Invasive mechanical ventilation is commonly used in a 
variety of clinical conditions, including respiratory arrest, 
airway compromise, severe acidosis, hypercapnic enceph- 
alopathy, and hemodynamic instability. It is also used to 
treat patients suffering acute respiratory failure (ARF) who 
do not respond to oxygen supplementation. This improves 
gas exchange and reduces the work of breathing. ' How- 
ever, it can lead to major complications, including noso- 
comial pneumonia, barotrauma, and tracheal injury.--^ 

Recently, several studies suggested that noninvasive ven- 
tilation (NIV) could reduce the need for endotracheal in- 
tubation,'' * the length of intensive care unit and hospital 
stay,^-^ and possibly the mortality rate.^' 

In this report, we describe the use of NIV in an elderly 
patient suffering hypoxemic respiratory failure secondary 
to the inadvertent administration of oral contrast material 
into the lung, and in whom endotracheal intubation was 
not an option. 

Case Summary 

An 83-year-old nursing home resident was referred to 
our facility for evaluation of abdominal pain. The patient 

Jean I Keddissi MD and Jordan P Metcalf MD are affiliated with the 
Pulmonary and Critical Care Medicine Section of The University 
of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma. 

Correspondence: Jean I Keddissi MD, Pulmonary and Critical Care Med- 
icine, University of Oklahoma Health Sciences Center, 920 Stanton L 
Young Boulevard, WP 1310, Oklahoma City OK 73104. E-mail: 

had a history of dementia, peptic ulcer disease, colon pol- 
yps, and diverticulosis. By family request, the patient had 
standing orders not to receive cardiopulmonary resuscita- 
tion or intubation. 

He was transferred to our facility to have a computed 
tomography (CT) scan of the abdomen with oral contrast 
to evaluate the abdominal pain. Because of his dementia 
and noncooperation, the nursing staff placed a nasogastric 
tube, and administered diatrizoate meglumine/diatrizoate 
sodium solution (MD-Gastroview, Mallinckrodt, St Louis, 
Missouri) through the tube. Immediately after the admin- 
istration of the contrast, the patient's respiratory status 
began to deteriorate, with tachypnea, wheezing, and de- 
creased oxygen saturation. The nasogastric tube was im- 
mediately removed. A chest radiograph and a chest CT 
scan showed contrast material in the left lower lobe (Figs. 
1 and 2). This was strongly believed to be secondary to 
malposition of the nasogastric tube in the left main stem 

The patient was transferred to our intensive care unit. 
His respiratory rate was 60 breaths per minute. He was 
using his accessory muscles and had diffuse wheezing, 
with decreased air movement bilaterally. Arterial blood 
gas analysis on 2 L of oxygen showed pH 7.43, partial 
pressure of carbon dioxide 35 mm Hg, and partial pressure 
of oxygen 57 mm Hg. 

Attempts to improve the patient's oxygenation with a 
higher fraction of inspired oxygen, using a nonrebreathing 
mask, had no significant effect. He remained tachypneic 
(respiratory rate in the 60s) and continued to use his ac- 
cessory muscles. His oxygen saturation remained in the 
mid-80s. Because of clear do-not-resuscitate/do-not-intu- 
bate wishes (which were confirmed with the patient's fam- 
ily), a decision was made to place the patient on NIV with 


Respiratory Care • May 2(XX) Vol 45 No 5 

Noninvasive Ventilation in Acute Respiratory Failure 

Fig. 1 . Chest radiograph showing contrast material in the left lower 

Fig. 2. Chest computed tomography showing the presence of con- 
trast material in the left lower lobe. 

bi-level nasal positive airway pressure (BiPAP, Respiron- 
ics, Murrysville, Pennsylvania), with an inspiratory posi- 
tive airway pressure of 10 cm H2O and an end-positive 
airway pressure of 5 cm HjO, in spontaneous mode. Ox- 
ygen was bled in at 10 L/min. These initial settings have 
been recommended for patients with hypoxemic respira- 
tory failure.'" The patient tolerated them very well. He was 
also started on inhaled bronchodilators, intravenous ste- 
roids, and broad-spectrum antibiotics. 

With the application of NIV, the patient's respiratory 
status started to improve. Within two hours, his respiratory 
rate decreased to the mid-20s and he stopped using his 
accessory muscles. Arterial blood gas analysis showed pH 
7.41, partial pressure of carbon dioxide 28 mm Hg, and 

partial pressure of oxygen 77 mm Hg. By the next day, the 
patient's condition permitted discontinuation of BiPAP, 24 
hours after it was started. 

The patient's hospitalization was complicated with pneu- 
monia (methicillin-resistant Staphylococcus aureus and 
Klebsiella pneumoniae) and the development of acute re- 
nal failure. With antibiotic therapy and supportive mea- 
sures, his overall condition improved. His abdominal CT 
scan was unremarkable, and his abdominal pain resolved 
within two days of admission, with no specific therapy. He 
was discharged two weeks after admission. On discharge, 
he only required albuterol on an as-needed basis. 


In this case report, we described our experience with 
NIV in a not-infrequently encountered situation, an iatro- 
genic complication leading to ARF in an elderly patient 
who did not want invasive ventilatory support (ie, intuba- 
tion and mechanical ventilation). 

It is unlikely that the episode was secondary to aspira- 
tion of gastric material. The chest radiograph and chest CT 
did not show any contrast material in the right lung. The 
CT of the abdomen showed no contrast material in the 
stomach, and the episode occurred almost immediately 
after the administration of the contrast material. Our pa- 
tient most likely had the nasogastric tube placed in the left 
main bronchus. Therefore, we believe this case is the first 
successful treatment of oral contrast-induced iatrogenic 
respiratory failure with NIV. 

Numerous studies of NIV in ARF patients have docu- 
mented improvement in both physiologic measurements 
and clinical outcomes. NIV has the advantage of preserv- 
ing normal swallowing, feeding, and speech, while im- 
proving the patient's respiratory status, and appears to be 
much safer than invasive mechanical ventilation in terms 
of the risk of nosocomial pneumonia." 

Meduri et al found that face mask ventilation produces 
clinical and physiologic improvements similar to those 
produced by invasive mechanical ventilation.'- Arterial 
partial pressure of oxygen, arterial partial pressure of car- 
bon dioxide, and pH all improved with BiPAP ventilatory 
support in patients with ARF of various etiologies.'" 

NIV has also been found to result in improved clinical 
outcomes. Several studies have found that, in selected ARF 
patients, NIV reduced the need for mechanical ventila- 

Patients with ARF secondary to pneumonia were stud- 
ied and found to benefit from NIV in terms of the need for 
mechanical ventilation and, possibly, mortality. '^ This find- 
ing was also confirmed in an elderly population.'" 

This therapy may be more effective in hypercapnic re- 
spiratory failure. Wysocki et al found that in patients with 
chronic obstructive pulmonary disease (COPD) exacerba- 

Respiratory Care • May 2000 Vol 45 No 5 


Noninvasive Ventilation in Acute Respiratory Failure 

tions, only those with a partial pressure of carbon diox- 
ide > 45 mm Hg benefited from NIV.^ ''' They also noted 
that NIV was very effective in respiratory decompensation 
occurring after extubation in surgical patients. 

In people who refuse endotracheal intubation, as in our 
case, NIV has also been shown to be effective and ac- 
cepted by patients. In a case series of 1 1 terminally ill 
patients with ARF who did not want endotracheal intuba- 
tion, 7 patients responded to NIV and were ultimately 
discharged from the hospital.'* 

A decrease in the length of intensive care unit stay has 
also been shown with NIV. Brochard et al found that the 
use of NIV permitted an earlier discharge for patients with 
COPD exacerbation."^ Antonelli et al reached the same 
conclusion in patients with ARF of other etiologies.'' 

As has been summarized in a recent meta-analysis, the 
improvement in in-hospital mortality with the use of NIV 
has not been clearly established in all subsets of patients 
with respiratory failure, although it appears to occur in 
patients with COPD and hypercapnia.'^ Wysocki et al found 
that it reduced mortality only in patients with hypercap- 
nia.* Kramer et al failed to show significant mortality re- 
duction, but this study was small and mortality in both 
arms of the study was low.* Another well done prospective 
study did not show any significant difference in mortality, 
compared to conventional ventilation, in a mixed group 
that did not include patients with COPD.^ 

The complications of NIV. compared to conventional 
ventilation, are rare and generally minor. The most serious 
is the possibility of aspiration secondary to insufflation of 
the stomach. This is believed not to be a major concern 
with pressure < 30 cm HjO.''' Facial skin necrosis is 
reported in 7-10% of patients. Rapid healing occurs spon- 
taneously after discontinuing the mask. Other possible com- 
plications include conjunctivitis and pneumothorax.'^ 

In conclusion, noninvasive positive pressure ventilation 
is a safe and effective mode of ventilatory support in many 
ARF patients. It is also, as we demonstrated here, an ef- 
fective alternative to invasive conventional ventilation in 
patients with iatrogenic complications who do not want to 
be intubated. 


1, Tobin MJ. Mechanical ventilalion (review). N Engl J Med 1994; 
3.10(1 5): 1056- 1061. 

2. Pingleton SK. Complications of acute respiratory failure. Am Rev 
Respir Dis 1988;1.37(6):146.VI493. 

3. Stautfer JL, Silvestri RC. Complications of endotracheal intubation, 
tracheostomy, and artificial airways. Respir Care 1982:27(4):417- 

4. Brochard L, Isabey D, Piquet J. Amaro P. Mancebo J, Messadi AA, 
et al. Reversal of acute exacerbations of chronic obstructi\e lung 
disease by inspiratory assistance with a face mask. N Engl J Med 

.'). Brochard L, Mancebo J, Wysocki M, Lofaso F, Conti G, Rauss A, et 
al. Noninvasive ventilation for acute exacerbations of chronic ob- 
structive pulmonary disease. N Engl J Med l995:333(l3):8l7-822. 

6. Kramer N. Meyer TJ, Meharg J. Cece RD. Hill NS. Randomized, 
prospective trial of noninvasive positive pressure ventilation in acute 
respiratory failure. Am J Respir Crit Care Med I995;I5 1(6): 1799- 

7. Antonelli M, Conti G, Rocco M. Bufi M, De Blasi RA. Vivino G, et 
al. A comparison of noninvasive positive-pressure ventilation and 
conventional mechanical ventilation in patients with acute respira- 
tory failure. N Engl J Med 1998;339(7):429-43.5. 

8. Wysocki M. Trie L. Wolff MA. Millet H. Herman B. Noninvasive 
pressure support ventilation in patients with acute respiratory failure: 
a randomized comparison with conventional therapy. Chest 1995; 

9. Keenan S, Kemerman PD, Cook DJ. Martin CM. McCnrmack D, 
Sibbald WJ. Effect of noninvasive positive pressure ventilation on 
mortality in patients admitted with acute respiratory failure: a meta- 
analysis. Crit Care Med 1997:25(10): 1685-1692. 

10. Pennock BE, Kaplan PD, Carlin BW. Sabangan JS, Magovem JA. 
Pressure support ventilation with a simplified ventilatory support 
system administered with a nasal mask in patients with respiratory 
failure. Chest I99I:I00(5):I.371-I.376. 

1 1. Nava S, Ambrosino N, Clini E. Prato M, Orlando G. Vitacca M. et 
al. Noninvasive mechanical ventilation in the weaning of patients 
with respiratory failure due to chronic obstructive pulmonary dis- 
ease. Ann Intern Med l998;128(9):72l-728. 

12. Mediiri GU, Conoscenti CC, Menashe P. Nair S. Noninvasive face 
mask ventilation in patients with acute respiratory failure. Chest 

13. Meduri GU, Turner RE, Abou-Shala N, Wunderink R, Tolley E. 
Noninvasive positive pressure ventilation via face mask: first-line 
intervention in patients with acute hypercapnic and hypoxemic re- 
spiratory failure. Chest I996;I09(I):179-I93. 

14. Benhamou D, Girault C. Faure C. Portier F, Muir JF. Nasal mask 
ventilation in acute respiratory failure: experience in elderly patients. 
Chest 1992;I02(3):912-917. 

15. Wysocki M. Trie L, Wolff MA, Gertner J, Millet H, Herman B. 
Noninvasive pressure support ventilation in patients with acute re- 
spiratory failure. Chest I993;l()3(3):9()7-913. 

16. Meduri GU, Fox RC, Abou-Shala N. Leeper KV. Wunderink RG. 
Noninvasive mechanical ventilation via face mask in patients with 
acute respiratory failure who refused endotracheal intubation. Crit 
Care Med 1994;22( 10): 1584- 1590. 

17. Abou-Shala N, Meduri U. Noninvasive mechanical ventilation in 
patients with acute respiratory failure. Crit care Med 1996:24(4): 


Respiratory Care • May 2000 Vol 45 No 5 

Reviews, Overviews, & Updates 

Bronchodilator Resuscitation in the Emergency Department 
Part 2 of 2: Dosing Strategies* 

James Fink MS RRT FAARC and Rajiv Dhand MD 


Why the Patient in the Emergency Department Is Different 

Dose Determination 

Intermittent Therapy 

Continuous Bronchodilator Therapy 

Devices Used for Continuous Nebulization 

Undiluted Nebulizer Solutions 
Role of Anticholinergics in Bronchodilator Resuscitation 

[Respir Care 2000;45(5):497-512] Key words: bronchodilator resuscitation, 
emergency department, acute airway obstruction, aerosol therapy, dosing strat- 
egies, anticholinergics, beta agonists, continuous nebulizer therapy, intermit- 
tent nebulizer therapy. 


Resuscitate. From the Latin resuscitare — to stir up again 
or revive. Merriam-Webster's International Dictionary 

Aerosolization of fast-acting bronchodilators provides 
rapid relief of life-threatening symptoms of acute airway 
obstruction. When standard doses of bronchodilators do 
not produce substantial symptomatic relief, the clinician 
faces a dilemma of providing adequate bronchodilators to 
resuscitate the patient while protecting the patient from 
undue risks associated with such treatment. A variety of 
strategies for bronchodilator resuscitation have been de- 

James Fink MS RRT FAARC and Rajiv Dhand MD are affiliated with 
the Division of Pulmonary and Critical Care Medicine. Loyola Univer- 
sity of Chicago Stritch School of Medicine. Hines Veterans Affairs Hos- 
pital. Mines. Illinois. Since this paper was written. Mr Fink has also 
t)ecome the Director of Respiratory Programs at AeroGen, Sunnyvale. 

Correspondence: James Fink MS RRT FAARC, AeroGen. 1310 Orleans 
Drive. Sunnyvale CA 94089. E-mail: 

* For the first part of this article, see: Fink J. Dhand R. Bronchodilator 
resuscitation in the emergency department. Part I of 2: Device selection. 
Respir Care 1 999; 44( 1 1 ): 1 353- 1 374. 

scribed, ranging from frequent administration of standard 
doses to continuous administration of high doses of one or 
more medications. 

In the first part of this review,' we explored the role of 
device selection in effectively administering bronchodila- 
tors to infants, children, and adults with severe asthma 
exacerbations in the emergency department (ED). In this 
second installment, we review the evidence supporting 
various strategies for bronchodilator resuscitation in the 
same group of patients. The available evidence should 
help us to determine whether the dose and frequency of 
administration of j3 agonists makes a significant difference 
in the treatment of severe asthma in the ED. In addition, 
we address the possible benefits of combining anticholin- 
ergics with /3 agonists for bronchodilator therapy in the 
ED setting. 

Why the Patient in the Emergency 
Department Is Different 

For the patient with acute severe airway obstruction, a 
number of factors (ie, airway inflammation, airway ob- 
.struction. and ineffective ventilatory patterns) may impair 
the ability of aerosols to have an optimal effect. A state of 
refractoriness to bronchodilator therapy, induced by severe 

Respiratory Care • May 2000 Vol 45 No 5 


Bronchodilator Resuscitation in the Emergency Department 

Table 1 . Recommendations from the Physicians ' Desk Reference^ 






2.5 mg in 3 mL NS 

0.10-0.15 mg/kgq4-6h 


2 puffs q 4-6 hours 

2 puffs q 4-6 h 




0.5 mg in 3 mL NS 

Not specified for < 12 years of age 


2 puffs (36 /ig) 

Not specified for < 1 2 years of age 


£12 puffs/24 h 

Higher dose or frequency not recommended 
Higher dose or frequency not recommended 

NS = nebulizer solution. MDI = metered-dose inhaler. 

airway inflammation, may prevent the patient from re- 
sponding to treatment, despite increases in the frequency 
and dose of the bronchodilator. Another possibility is that 
with severe obstruction of the airways, most of the inhaled 
drug deposits at sites of airway narrowing, and less med- 
ication is delivered to the desired site of action. In this 
scenario, the desired response may be elicited by admin- 
istering a higher dose of the drug in an attempt to enhance 
deposition of the drug in less severely obstructed airways. 

Dosing recommendations by the manufacturers, includ- 
ing both quantity and frequency of drug administration, 
usually reflect the minimum amount of bronchodilators 
required to improve expiratory flow in a stable patient 
with moderate airway obstruction, with maximum safety 
(or minimum adverse effects). These recommendations typ- 
ically follow a template based on recommendations (Table 
1) made with similar drugs that have been previously ap- 
proved by the Food and Drug Administration. In contrast, 
the National Institutes of Health (NIH) recommend admin- 
istration of bronchodilators with larger doses and at greater 
frequency than those used in treating patients with mod- 
erate airway obstruction, employing either a nebulizer or a 
metered-dose inhaler with holding chamber (MDI/HC) for 
aerosol delivery (Table 2).^ In these guidelines, which are 
largely a consensus among experts, there are substantial 
differences in the doses and frequency of administration of 
various medications from those recommended by the man- 

In an informal poll of ED practices within our own 
community, we found that current practice in most EDs is 
to administer bronchodilator therapy with nebulizers (Fink 
J, Dhand R, unpublished data, 1999). Furthermore, when 
"standard therapy" did not provide relief, the common 
clinical practice was to administer the dose recommended 
for stable patients at more frequent intervals. In general, 
there was considerable variation in the approach to bron- 
chodilator therapy among the various EDs. The following 
review summarizes the evidence supporting "aggressive" 
strategies for bronchodilator resuscitation, including the 

recommendations of the NIH, in an attempt to standardize 
treatment of patients with severe asthma presenting to the 

Dose Determination 

The administration of /3 agonists is associated with ad- 
verse effects ranging from tremor, to headache and nausea, 
to cardiotoxicity. The imperative to give enough broncho- 
dilator to optimize response is balanced against the con- 
cerns of toxicity. Do increasing doses of /Sj-specific bron- 
chodilators improve response in patients with severe airway 
obstruction? To answer this question, the following studies 
offer guidance in determining efficacy and toxicity asso- 
ciated with increasing doses of j8 agonists in the ED. 

Intermittent Therapy 

To assess the safety and efficacy of high doses of albu- 
terol delivered via MDI/HC in the ED. Newhouse et al 
enrolled 257 patients with severe asthma (forced expira- 
tory volume in the first second [FEV,] < 34% of pre- 
dicted) in a multicenter, randomized, double-blind, paral- 
lel-group study." The patients received up to 16 puffs of 
either albuterol (100 /u.g/puff) or fenoterol (200 /xg/puff) 
(Fig. 1). Initially, 4 puffs were given at 30-second inter- 
vals, with an additional 2 puffs given every 10 minutes up 
to a maximum cumulative dose of 16 puffs. Therapy was 
stopped earlier if adverse effects were intolerable to the 
patient or if the previous dose produced £ 10% improve- 
ment in FEV I . There were no differences between groups 
on entry into the study. In both groups, the most com- 
monly received total dose was 8 puffs, but the median dose 
received was 10 puffs. Thirty-two patients (12.5%) re- 
ceived the maximum of 16 puffs. A plateau for FEV, was 
reached in 62% of the patients in both groups. Dose titra- 
tion was ended prematurely in only one patient from the 
fenoterol group, due to tremor. A 10%) decrease in FEV, 
between treatments, suggesting a paradoxical response, oc- 


Respiratory Care • May 2(XX) Vol 45 No 5 

Bronchodilator Resuscftation in the Emergency Department 

Table 2. National Institutes of Health Recommendations for Dosages of Drugs for Asthma Exacerbations in Emergency Medical Care or Hospital 





Inhaled short-acting B-, agonists 

nebulizer solution (5 mg/mL) 

MDI (90 fig/puff) 

Bitolterol and pirbuterol 

2.5-5 mg q 20 min for 3 doses, 
then 2.5-10 mg q 1—4 h as 
needed, or 10-15 mg/h 

4-8 puffs q 20 min up to 4 h, 
then q 1^ h as needed 

Systemic (injected) fi, agonists 

Epinephrine 1 : 1.000 ( 1 mg/mL) 0.3-0.5 mg q 20 min for 8 doses 

Terbutaline (1 mg/mL) 0.25 mg q 20 min for 3 doses SQ 

Ipratropium bromide 
nebulizer solution (0.25 mg/mL) 0.5 mg q 30 min for 3 doses, 

then q 2-4 h as needed 

MDI (19 /xg/puff) 


4-8 puffs as needed 

120-180 mg/d in 3 or 4 divided 
doses for 48 h. then 60-80 mg/d 
until PEF reaches 109c of 
predicted or personal best. 

0.15 mg/kg (minimum dose 2.5 
mg) q 20 min for 3 doses, 
then 0.15-0.3 mg/kg. up to 10 
mg q 1 -4 h as needed, or 0.5 
mg/kg/h by continuous 

4-8 puffs q 20 min for 3 doses, 
then q 1^ h as needed 

0.01 mg/kg up to 0.3-0.5 mg 
q 20 min for 3 doses SQ 

0.01 mg/kg q 20 min for 3 
doses, then q 2-6 h as 
needed SQ 

0.25 mg q 20 min for 3 doses, 
then q 2^ h 

4-8 puffs as needed 

1 mg/kg q 6 h for 48 h. then 
1-2 mg/kg/d (maximum = 60 
mg/d) in 2 divided doses until 
PEF reaches 70% of predicted 
or personal best. 

Only selective P2 agonists are 
recommended. For optimal 
delivery, dilute aerosols to 
minimum of 4 mL at gas flow of 
6-8 L/min. 

As effective as nebulized therapy if 
patient is able to coordinate 
inhalation maneuver. Use spacer/ 
holding chamber. 

Have not been studied in severe 
asthma exacerbations. 

No proven advantage of systemic 

therapy over aerosol. 
No proven advantage of systemic 

therapy over aerosol. 

May mix in same nebulizer with 
albuterol. Should not be used as 
first-line therapy, should be 
added to /Sj agonist therapy. 

Dose delivered from MDI is low 
and has not been studied in 
asthma exacerbations. 

Adult "burst" at discharge: 40-60 
mg in single or 2 divided doses 
for 3-10 d. Child "burst" at 
discharge: 1-2 mg/kg/d, 
maximum 60 mg/d for 3-10 d. 

NS - nebulizer solution. MDI = melered-dose inhaler. PEF - peak expiratory flow. SQ = subcutaneous. (Adapted from Reference 3.) 

curred in 15% of the patients. In those patients receiving 
the maximum dose, fenoterol achieved a greater increase 
in FEV, than albuterol (p < 0.03) (see Fig. 1). Serum 
potassium decreased significantly in both groups, and the 
decrease with fenoterol (0.23 ± 0.04 mmoI/L) was greater 
than with albuterol (0.006 ± 0.03 mmol/L, p < 0.01). 
There was a slight increase in the Q-T(c) interval on the 
electrocardiogram, and patients in the fenoterol group, es- 
pecially those not receiving oxygen, had a greater increase 
in Q-T(c) interval than those receiving albuterol (p < 0.05). 
The authors concluded that the changes in Q-T(c) were not 
clinically important and that both fenoterol and albuterol 
were safe in the dosages studied. 

Rodrigo and Rodrigo treated 1 1 adults with severe acute 
asthma with 400 /xg of albuterol administered via MDI/HC 
at 10-minute intervals for 3 hours (2.4 mg/h, 7.2 mg total 
dose).* The improvements in FEV, and peak expiratory 

flow (PEF) were dose-related and the mean improvements 
from baseline were 90.4% for FEV, and 80.1% for PEF 
(p < 0.01). Heart rate was reduced with treatment (p < 
0.01), with no prolongation in the Q-T(c) interval. De- 
creases in serum potassium were not significant (4.23 ± 
0.53 mmol/L at baseline and 3.99 ± 0.62 mmol/L after 
treatment). There were no significant changes in oxygen 
saturation determined via pulse oximetry, nor in plasma 
glucose. The mean end-treatment serum albuterol level 
was 10.0 ± 1.67 ng/mL. These data indicate that the treat- 
ment of acute asthma in the ED with 2.4 mg of albuterol 
per hour via MDI/HC produces satisfactory bronchodila- 
tion with minimal extrapulmonary effects, and avoids toxic 
serum concentrations of albuterol. 

When Lin and Hsieh treated 7 adult patients with acute 
asthma in the ED via continuous nebulizer (0.4 mg/kg/h of 
albuterol over 4 h), they found serum albuterol levels of 

Respiratory Care • May 2000 Vol 45 No 5 


Bronchodilator Resuscitation in the Emergency Department 

r- 1.5 








(n = 24) 

(n = 45) 

(n = 105) 

(n = 127) 

(n = 129) 

(n = 121) 


I (n = 102) 

(n = 68) 


(n = 38) 

(n = 25) 

(n = 124) 

■ Fenoterol ° Albuterol 

(n = 17) 

{n = 15) 


ve # Puffs 4 







Fenoterol 800 








iterol 400 







Cumulative Dose (fig) 

Fig. 1. Improvements of forced expiratory volume in the first second (FEV,) for the entire study population {n = 256) of adults suffering 
severe asthma, after administration of fenoterol or albuterol via metered dose inhaler with holding chamber. There vi^as a greater degree of 
bronchodilation with fenoterol than with albuterol, the difference being most pronounced in patients receiving a cumulative dose of 16 puffs. 
{From Reference 4, with permission.) 

37.7 ± 15.1 (SD) ng/mL, a mean increase in FEV, of 
36.8%, and significant increase in heart rate over time.'' In 
contrast, the dosing strategy employed by Rodrigo and 
Rodrigo (equivalent to 37 /ag/kg/h via MDI/HC) resulted 
in mean serum albuterol levels of 10.0 ng/mL, with a mean 
FEV I increase of 90.4%. The difference may be due to 
reduction in systemic bioavailability because of gastroin- 
testinal absorption; oropharyngeal deposition of albuterol 
is reduced to :s 1% with an MDI and valved holding 
chamber.^ Moreover, increased deposition of albuterol in 
the conducting airways with the MDI/HC combination, 
compared to that achieved with a nebulizer, may explain 
the greater improvement in FEV, with the MDI/HC. 

Similar to the observations of Lin and Hsieh, Schuh et 
a!** found that heart rate increa.sed with nebulized albuterol 
at 0.15 mg/kg/h (serum albuterol level 12.4 ng/mL) and 
0.45 mg/kg/h (serum albuterol level 19.8 ng/mL). Cola- 
cone et al'^ reported a significant increase in heart rate in 
the group receiving 2.5 mg of albuterol every 30 minutes 
via small-volume nebulizer (SVN), compared to the 
MDI/HC group receiving 0.4 mg per treatment at the same 
interval. In that study, heart rate in 10 of the SVN group 
increased > 20 beats per minute, whereas only 4 patients 
in the MDI/HC group experienced a similar increase in 
heart rate.^ In addition, Kerem et al observed that in chil- 
dren with acute asthma, heart rate increased in those treated 
with albuterol via nebulizer (1.5 mg/kg) but decreased in 
those treated via MDI-HC (0.6-0.8 mg).'" 

In a subsequent investigation, Rodrigo and Rodrigo" 
compared 400 jxg of albuterol to 600 fig of albuterol ad- 
ministered via MDI/HC every 10 minutes during 3 hours 
in 22 patients with severe asthma (total dose 7.2 mg vs 
10.8 mg). PEF and FEV, improved in both groups, with a 
trend toward greater improvement with the higher dose, 
but there were no significant differences between groups. 
A significant net reduction in heart rate occurred with the 
lower dose (p < 0.01), whereas the higher dose produced 
an increase in heart rate (p < 0.001) and was associated 
with a higher incidence of tremor, headache, palpitations, 
and anxiety. Serum potassium levels decreased moderately 
with both doses. These data indicate that the treatment of 
severely asthmatic patients with 2.4 mg of albuterol per 
hour via MDI/HC (4 puffs at lO-min intervals) produces 
satisfactory bronchodilation, low serum concentrations, and 
minimal extrapulmonary effects, and suggest that the higher 
dose increases toxicity without producing additional clin- 
ical benefit. 

The same investigators administered albuterol, either 
via MDI/HC at 2.4 mg/h or via nebulizer at 6 mg/h (1.5 
mg of albuterol at 15-min intervals), to adult patients with 
severe asthma (FEV, < 50%).'- These doses were based 
on the calculated efficiency of pulmonary deposition for 
the two methods of aerosol administration. Over 3 hours, 
improvements in FEV, and PEF were similar in the two 
groups. The relationships between cumulative dose of al- 
buterol and change in FEV, showed a significant linear 


Respiratory Care • May 2(X)0 Vol 45 No 5 





40 - 

30 - 



Bronchodilator Resuscitation in the Emergency Department 

r- % Pred. PEF 

N = 92 








20 "- 

^ % Fred. PEF 

0.0 2.5 5.0 

Albuterol (mg) 





- 5' 

— #— admitted N = 31 
— ^-. discharged N = 6 1 





Albuterol (mg) 

Fig. 2. Peak expiratory flow (PEF) percent of predicted in response to cumulative dose of albuterol with nebulizer for severe asthma for total 
study population (n = 92) (left), and dose response for patients discharged (n = 61) and admitted (n = 31) (right). (From Reference 14, with 

relationship for both devices (r = 0.97, p = 0.0 1 ). These 
authors concluded that the therapeutic responses produced 
by 2.5 mg of albuterol via nebulizer or 1 mg of albuterol 
via MDI/HC are equivalent. Serum albuterol levels were 
lower in the MDI/HC group (10.1 ± 1.6 ng/mL) than in 
the nebulizer group (14.4 ± 2.3 ng/mL, p = 0.0003). The 
higher serum levels may account for patients in the neb- 
ulizer group having a higher incidence of tremor and anx- 
iety (p < 0.04). These data support previous estimates by 
Blake et al, using bioassay methods in asthmatics, that 10 
puffs from an MDI (1.0 mg) deliver similar amounts of 
albuterol to lung receptors as 2.5 mg of nebulizer solution 
(1:2.5 ratio). '^ 

In 1997, Strauss et al administered 2.5 mg of albuterol 
via nebulizer every 20 minutes for 3 doses to 92 adults 
patients with acute asthma. '■* Only 66% of the subjects 
improved sufficiently to be discharged from the ED (Fig. 
2). Of those, 56% required < 5.0 mg of drug to reach the 
discharge threshold, whereas the remainder needed 7.5 
mg. In the remaining 34% of patients requiring admission, 
albuterol was ineffective, and these patients required 3.8 ± 
0.4 days of inpatient care. The authors concluded that 
although approximately 70% of patients with severe asthma 
responded to doses between 2.5 mg and 7.5 mg of albu- 
terol, the nonresponders consistently required hospital ad- 

To determine the factors contributing to outcome, Ro- 
drigo and Rodrigo'^ examined response patterns to high 
doses of albuterol in 1 1 6 adults with acute severe asthma. 
Patients were treated with 400 \i.% of albuterol via MDI/HC 
at 10-minute intervals over 3 hours.''' A dose-related im- 
provement in PEF was found across all patients (Fig. 3, 
left), but subgroup analysis revealed that the 35 patients 
who required admission had an insufficient response to 
albuterol, whereas 81 patients (70%) responded adequately 
to albuterol and were discharged (see Fig. 3, right). Of the 
responders. 70% required < 2.4 mg of albuterol to reach 
discharge threshold, and the remaining 30% required > 
3.6 mg of albuterol (Fig. 4). The most important predictors 
of outcome were PEF percent of predicted, PEF, and PEF 
variation over baseline measured at 30 minutes, rather than 
the values of PEF or PEF percent of predicted obtained at 
initial presentation to the ED. 

Emerman, Cydulka, and McFadden conducted a ran- 
domized, double-blind study in which albuterol, either 2.5 
mg or 7.5 mg, was nebulized every 20 minutes for a total 
of 3 doses."" All 160 adult patients with severe asthma in 
the ED received 60 mg of prednisone orally. Pretreatment 
FEV, was 36.9 ± 16.6% of predicted in the low-dose 
group, versus 41.5 ± 15.4% of predicted in the high-dose 
group (p = not significant). There were no differences 
between the low-dose and high-dose groups in improve- 

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Bronchodilator Resuscitation in the Emergency Department 











0.0 1.2 2.4 3.6 4.8 6.0 7.2 
Salbutamol (mg) 




^ 50 


•s 40 

U. 30 





-Admitted N = 35 * Discharged N = 81 

— \ 1 1 [ 1 \ 1 

0.0 1.2 2.4 3.6 4.8 6.0 7.2 

Salbutamol (mg) 

Fig. 3. Change in peak expiratory flow (PEF) in response to cumulative doses of inhaled albuterol administered via metered dose inhaler vi^ith 
holding chamber, shovi/s significant improvement in 116 acute asthmatics (left). Subgroup analysis (right) of patients discharged from the 
emergency department (n = 61) shows substantial improvement with each successive dose, whereas response was relatively flat for those 
patients admitted to the hospital (n = 35). Bars represent standard deviations. (From Reference 1 5, with permission.) 

ment in FEV, (50.3% vs 44.6%) or admi.ssion rate (43% vs 
39%). The authors found no advantage to routine admin- 
istration of doses higher than 2.5 mg of albuterol every 20 
minutes in their patients, but suggested that there might be 
an advantage to higher doses of albuterol in patients with 
the most severe airway obstruction. 

Can dose response to albuterol provide a reasonable 
predictor of hospital admission for severe asthma? From 
the investigations of both Strauss et al'"* and Rodrigo and 
Rodrigo,'-^ those patients requiring hospital admission from 
the ED had a much flatter dose response to albuterol than 
those patients who were discharged, and their PEF re- 
mained below 40% of the predicted level. In contrast, the 
"responders" achieved nearly double their baseline value 
of PEF percent of predicted during the course of therapy. 
Early identification of those patients least likely to respond 
to /3 agonists may be of great interest in our efforts to 
optimize allocation of staff resources in the ED. 

In summary, doses of albuterol as high as 2.4 mg/h via 
MDI/HC and 30 mg/h administered intermittently via neb- 
ulizer may be safe and effective in resuscitating patients 
with acute severe airway obstruction in the ED. Increasing 
dose or frequency of /3 agonists resulted in increasing 
response in most patients, particularly in patients with 
greater severity of airway obstruction. However, approx- 
imately 30% of the most severe asthma cases do not re- 
spond to high doses of j8 agonists at any dose, and require 
hospital admission for more prolonged treatment. Based 

on the studies discussed above, the optimum dose of al- 
buterol for treatment of severe asthma in the ED is be- 
tween 1.2 mg/h and 2.4 mg/h via MDI/HC, and between 
2.5 mg/h and 15 mg/h via nebulizer. These dose ranges are 
consistent with the NIH recommendation to administer 
4-8 puffs via MDI/HC or 2.5-5.0 mg of albuterol via 
nebulizer every 20 minutes. 

Moreover, a strategy of administering up to 1.2 mg (12 
puffs) of albuterol via MDI/HC or 5.0-7.5 mg of albuterol 
via nebulizer as initial treatment for severe airway obstruc- 
tion in the ED may serve the dual purposes of providing 
rapid relief of symptoms in those patients who can respond 
to the jS agonists, as well as allowing identification of 
those "nonresponders" who require more prolonged ther- 

Continuous Bronchodilator Therapy 

Intermittent nebulizer treatments at 3-4-hour intervals 
are commonly employed for bronchodilator administration 
in stable patients with moderate airway obstruction. For 
treatment of the severely asthmatic patient who does not 
respond to a standard dose of j3 agonist, the NIH' recom- 
mends intermittent treatments at intervals ranging from 
every 20 minutes to every I hour. Because nebulization 
takes approximately 10 minutes to administer each treat- 
ment, every-20-minule treatments requires virtually con- 
tinuous attendance by a respiratory therapist or other care 


Respiratory Care • May 2000 Vol 45 No 5 

Bronchodilator Resuscitation in the Emergency Department 








Salbutamol Dose (mg) 

Fig. 4. Percentage of patients discharged and the cumulative dose 
of albuterol administered. Approximately half of patients discharged 
responded to 1.2 mg (12 puffs) of albuterol, and two thirds re- 
sponded to 2.4 mg (24 puffs) administered via metered dose in- 
haler with holding chamber. (From Reference 1 5, with permission.) 

provider for aerosol administration. Continuous adminis- 
tration of bronchodilator aerosols appears to reduce the 
amount of staff time required to provide comparable dos- 
age to the patient, but the impact of continuous therapy on 
patient response to the therapy is less well defined. 

In 1988. Moler, Hurwitz. and Custer reported results of 
continuous nebulizer therapy (CNT) in 19 patients with 27 
admissions for severe asthma and impending respiratory 
failure who failed to respond to methylprednisolone, am- 
inophylline, and intermittently nebulized terbutaline. '^ Ter- 
butaline was continuously administered via face mask and 
nebulizer at a dose equal to the most frequent previous 
intermittent hourly dose (4 mg/h). Therapy was stopped in 
a mean of 15.4 hours (maximum 37 h). During 8 hours of 
continuous therapy, the clinical asthma score improved 
and arterial carbon dioxide tension decreased a mean of 
1 1.7 mm Hg. The average heart rate did not increase over 
baseline measurements through 24 hours of CNT. This 
investigation showed that CNT was a safe and effective 
method to administer bronchodilator therapy. 

Five years later. Papo, Frank, and Thompson'** reported 
on 17 pediatric patients with severe asthma and impending 
respiratory failure (Woods asthma score s 5) who were 
admitted to a pediatric intensive care unit. The patients 
were randomized to receive albuterol via continuous neb- 
ulization (0.3 mg/kg/h, n = 9) or intermittent nebulization 
(0.3 mg/kg over 20 min every h, n = 8). All patients 
received aerosol therapy through the same delivery sys- 

tem. Patients were determined to no longer be in impend- 
ing respiratory failure when their asthma score was < 5 
for 4 consecutive hours. Patients in the continuous therapy 
group improved more rapidly and were out of impending 
respiratory failure sooner than patients in the intermittent 
therapy group: continuous group mean 12 hours (range 
4-24 h) versus intermittent group mean 18 hours (range 
12-24 h, p = 0.03). Bedside respiratory therapy time eval- 
uated by relative value units was less for patients who 
received continuous nebulization (continuous group aver- 
aged 14 relative value units vs 33 relative value units in 
the intermittent group, p = 0.001 ). Hospital stay was shorter 
for patients who received albuterol continuously (80 h 
[range 51-173 h]) than for those who received albuterol 
intermittently (147 h [range 95-256 h], p = 0.043). He- 
modynamics, serum potassium, and creatine phosphoki- 
nase concentrations did not differ before and after the 
study in either group. The authors concluded that in chil- 
dren with impending respiratory failure due to s&vere 
asthma, CNT with albuterol resulted in more rapid clinical 
improvement, reduced duration of hospital stay, and less 
respiratory therapist time at the bedside than intermittent 

Katz et al administered albuterol continuously for s 24 
hours to 19 infants and children, and found no evidence of 
cardiotoxicity." Lin et al randomly assigned adult patients 
with acute exacerbations of asthma to receive 30 mg of 
albuterol (15 mg/h) via either continuous or intermittent 
aerosolization.-o A decrease in heart rate in both groups 
indicated the lack of significant chronotropic effects at this 
dose of albuterol. Both treatments resulted in spirometric 
improvement, without a significant treatment difference 
for the entire group. A higher rate of increase in FEV, 
percent of predicted was observed with continuous nebu- 
lization than with intermittent nebulization (p = 0.03) in a 
subgroup analysis of patients with an initial FEV, < 50% 
of predicted (Fig. 5). The authors concluded that a possible 
benefit of the continuous method was observed in patients 
with initial FEV, < 50% of predicted, but future studies 
should examine whether CNT has a reproducible advan- 
tage over intermittent nebulization in the subgroup of pa- 
tients with more severe airway obstruction. 

Rudnitsky et al-' studied patients who presented to the 
ED with moderate to severe asthma and who did not im- 
prove after initial treatment with 2.5 mg nebulized albu- 
terol followed by 125 mg Solu-Medrol (orally or intrave- 
nously). The continuous group (n = 47) received albuterol 
in normal saline to a total volume of 70 mL nebulized over 
2 hours (5 mg/h), whereas the intermittent group (n = 52) 
received 2.5 mg of nebulized albuterol at 30, 60, 90, and 
120 minutes after the initial treatment (total dose = 10 mg 
in each group). PEF and admission rates were comparable 
between groups over the 2-hour study period (p = not 
significant). However, for patients with initial PEF < 200 

Respiratory Care • May 2000 Vol 45 No 5 


Bronchodilator Resuscitation in the Emergency Department 



























10 20 30 40 50 60 70 80 90 100 110 
I ■ I • I • I ■ 1 ■ 1 — ■ I ■ I ■ I ■ I ■ I ■ I ■ 

Subjects with initial FEV, > 50% predicted 

Subjects with initial FEV, < 50% predicted 
I I I I I I I ■ I I I I I I I ■ I i I ' I ' I ■ 

Subjects with initial FEV, > 50% predicted 

'■ Subjects with initial FEV, < 50% predicted 



10 20 30 40 

SO 60 


70 80 90 100 1 10 

Fig. 5. Differential response of forced expiratory volume in the first 
second (FEV,) percent of predicted (top panel) and FEV, (bottom 
panel), with treatment stratified by moderate severity (initial FEV, > 
50% of predicted, top two lines) and greater severity (FEV, < 50% 
of predicted, bottom two lines) at baseline. Continuous nebulizer 
group = dashed lines. Intermittent nebulization = solid lines. 
Though there was no difference in response between groups in 
the less severely obstructed patients, significantly greater improve- 
ment was observed with continuous therapy, compared to inter- 
mittent treatment, in patients with more severe airway obstruction. 
(From Reference 20, with permission.) 

L/min, there was a greater change in baseline PEF in the 
continuous nebulization group (n = 35) (135 ± 35 L/min 
to 296 ± 98 L/min at 120 min) than in the intermittent 
nebulization group (« = 34) ( 1 37 ± 45 L/min to 244 ± 8 1 
L/min at 120 min, p = 0.01). Discharge ratios for this 
subgroup analysis were better in the continuous group (19: 
24) than the intermittent group (11:24, p = 0.03). Mean 
heart rate decreased more with continuous nebulization 
(102 ± 21 bpm at baseline to 90 ± 18 bpm) than with 
intermittent nebulization (109 ± 22 bpm at baseline to 
104 ± 16 bpm) at 120 minutes (p = 0.02). 

In patients with PEF s 200 L/min, the results obtained 
with CNT were comparable to those with intermittent ther- 
apy, but CNT may provide some advantages in patients 
with initial PEF < 200 L/min (such as decreased admis- 
sion rate and improved PEF), compared with standard ther- 

To study the feasibility of using high-dose, continuous- 
ly-aerosolized albuterol, Lin, Smith, and Hergenroeder-^ 
treated adults with 0.4 mg/kg/h albuterol via continuous 
nebulization over 4 hours. Serum albuterol levels at the 
end of treatment were s 25 ng/mL in all but one patient. 
For the entire group, heart rate increased by a mean of 
16.3%. At the end of 4 hours, the net increase in FEV, was 

In 1995, Moler treated 16 children (ages 6-16) with 16 
mg of terbutaline administered over an 8-hour period via 
continuous nebulization or by intermittent treatments with 
4 mg of terbutaline every 20 minutes over 2 hours.^^ Im- 
provement in symptoms and pulmonary function, as well 
as plasma terbutaline levels, were similar in the two groups. 

Reisner, Kotch, and Dworkin evaluated the efficacy of 
high-dose /3 agonist therapy in 22 nonsmoking patients 
with acute severe asthma who presented to the ED with 
PEF < 60% of predicted.2'' Patients were randomized to 
receive albuterol either intermittently (2.5 mg every 20 
min) or continuously (7.5 mg/h) over 2 hours, with eval- 
uation extending to 4 hours. All patients received 125 mg 
methylprednisolone intravenously on initiation of the study. 
In both groups, spirometry values doubled from baseline 
over the 4-hour period (p < 0.0001). FEV, did not differ 
significantly between groups at any time interval (Fig. 6). 
Improvement in PEF and FEV, occurred from 120 min- 
utes to 240 minutes in both groups (p < 0.000 1 ). 

Levitt, Gambrioli, and Fink-' conducted a randomized, 
double-blind, placebo-controlled study of 40 adult patients 
in the ED with acute exacerbations of chronic obstructive 
pulmonary disease (COPD) or asthma (FEV, < 30% pre- 
dicted). Patients received continuous nebulization (15 
mg/h) of albuterol or normal saline via large-volume neb- 
ulizer (LVN) and intermittent treatment with up to 24 
puffs per hour (2.4 mg/h) of albuterol or placebo via MDI/ 
HC. Over a 3-hour period, both groups had significant 
improvements in FEV,, PEF. and Borg score, with no 
differences between the two groups. Most patients had > 
100% improvement from baseline of PEF or the ratio of 
FEV I to forced vital capacity. Many patients in the MDI/HC 
group had maximum response with the first 1 2 puffs ( 1 .200 
|u,g) of albuterol. Approximately two thirds of patients in 
each group were discharged from the ED at or before 3 
hours, without undergoing relapse in the next 72 hours. 
Tremor or tachycardia necessitating discontinuation of ther- 
apy was not observed in any patient, nor was intubation or 
mechanical ventilation required in any patient. The authors 
concluded that efficacy of albuterol administered via CNT 


Respiratory Care • May 2000 Vol 45 No 5 

Bronchodilator Resuscitation in the Emergency Department 







PJ 40 



FEV1 (CN) 
« FEV1 (IN) 


— I — 

— I — 

— 1 — > — 1 — ■ — I — ' — I — I 1- 

120 150 180 210 240 


Fig. 6. Forced expiratory volume in the first second (FEV,) percent 
change from baseline versus time for continuous (CN) and inter- 
mittent (IN) nebulizer treatment. Improvement is significant in both 
groups of patients by 30 minutes, w/ith no difference betw/een 
groups over 4 hours. Bars represent standard deviations. (From 
Reference 24, virith permission.) 

was similar to that achieved by administration of the drug 
via MDI/HC. 

In 1996. Khine, Fuchs. and Saville studied 70 children 
(ages 2-18) presenting to the ED with moderate to severe 
asthma exacerbations (asthma score ^ 8), randomized to 
receive albuterol either intermittently (0.15 mg/kg/dose 
every 30 min) or continuously (0.3 mg/kg/h) for a maxi- 
mum of 2 hours.-'' All patients received prednisone at 
entry into the study. Nine of the 35 patients (26%) in the 
intermittent group and 8 of the 35 patients (22%) in the 
continuous group were hospitalized (p = not significant). 
Although the duration of ED therapy was comparable in 
the two groups, the time spent by respiratory care practi- 
tioners in delivering asthma therapy to each patient was 
significantly less for the continuous group than for the 
intermittent group (mean 30.3 min vs 5 1 .9 min per patient, 
p < 0.001). There were no major adverse effects in either 
study group. 

Shrestha et aF^ randomized adult patients suffering from 
acute asthma presenting to the ED with FEV, < 40% of 
predicted into 4 treatment groups. Patients were treated 
with a high (7.5 mg/h) or standard (2.5 mg/h) dose of 
albuterol administered continuously or intermittently (s 
20 min/h) for 2 hours. The improvements in FEV, from 
baseline (1.07 L for the high-dose continuous group, and 
1 .02 L for the standard-dose continuous group) were sig- 

HlQh dOM. conllnoous 

B Standaid doM, cononuous 

B High doM. rwuriy 

D SMndvildON.liauty 

0(i« hoor FEV. 1 Two hour FEV-1 

Tim* of FEV.1 m«asur«nwnt 

Fig. 7. Forced expiratory volume in the first second (FEV,) at base- 
line, 1 hour, and 2 hours of treatment with high and standard dose 
with continuous and intermittent nebulization. (From Reference 
27, with permission.) 

nificantly greater than the improvement seen with ^stan- 
dard-dose intermittent treatment (0.72 L, p < 0.05 for 
each) (Fig. 7). The improvement in FEVj with the high- 
dose intermittent treatment was intermediate in magnitude 
(0.09 L). FEV, increased similarly in the two groups treated 
with continuous nebulization. Serum potassium decreased 
in all groups, but the decrease was more pronounced in the 
groups treated with high doses of albuterol. Only one pa- 
tient (high-dose continuous treatment group) developed 
hypokalemia (< 3.0 mmol/L). The high-dose hourly-treated 
group had the highest incidence of adverse effects, and the 
standard-dose continuously treated group had the lowest. 
The authors concluded that for this patient population, the 
standard-dose continuous treatment (2.5 mg/h) had the 
greatest improvement in FEV, with the least number of 
adverse effects, compared to the other groups. 

Baker et al-** conducted a retrospective, case-controlled 
analysis comparing 40 matched pairs of patients admitted 
to a medical intensive care unit with severe asthma exac- 
erbations who received albuterol via continuous or inter- 
mittent therapy. Continuous therapy was administered for 
a mean of 1 1 ± 10 hours. Clinical response, safety, mor- 
bidity, and mortality were similar in both groups. 

In summary, the safety and efficacy of continuous /3 
agonist administration is similar to intermittent nebuliza- 
tion at comparable doses, but less clinician time is required 
at the bedside for administration of continuous nebuliza- 
tion (Table 3). In several studies, symptoms were relieved 
faster and to a greater extent with continuous than with 
intermittent administration of albuterol. The incidence of 
adverse effects was higher with intermittent therapy than 
with continuous administration at comparable hourly doses. 
For ED patients with severe airway obstruction who do not 
experience sufficient relief of symptoms after the first hour 
of aggressive therapy via intermittent nebulization of /3 
agonists, initiation of continuous nebulization may be a 

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Bronchodilator Resuscitation in the Emergency Department 

Table 3. Randomized Clinical Trials of Continuous Versus Intermittent Administration of Bronchodilators 

Study (year) 

Patient Population (;i) Treatment/Medication/Dose Duration 



Papo (1993)1* 

Moler (1995)" 

Khine (1996)2" 


Lin (1993)20 



Severe asthma (17) 

Moderate asthma (16) 

Cont/ALB/0.3 mg/kg/h 
lnt/ALB/0.3 mg/kg q 1 h 
(20-min treatment) 

Cont/rERB/2 mg/h 
Int/TERB/4 mg q 2 h 

Moderate to severe asthma Cont/ALB/0.3 mg/kg/h 
(70) Int/ALB/0.15 mg/kg q 30 


Moderate to severe asthma Cont/ALB/15 mg/h 
(38) Int/ALB/5 mg q 20 min 

Moderate to severe asthma Cont/ALB/5 mg/h 

(99) lnt/ALB/2.5 mg q 30 min 

Reisner (1995)2'' Moderate asthma (22) 

Cont/ALB/7.5 mg/h 
lnt/ALB/2.5 mg q 20 min 

Uvitt (1995)25 Severe asthma/COPD (40) Cont/ALB/15 mg/h 

lnt/ALB/< 2.4 mg/h (via 

Shrestha ( 1 996)2' Severe asthma ( 1 65 ) 

4-24 h More rapid improvement, shorter LOS and decreased 
clinician time with continuous nebulization. 

8 h 




< 4 h 

3 h 

Cont/ALB/2.5 or 7.5 mg/h 2 h 
lnt/ALB/2.5 or 7.5 mg q 1 h 

Similar plasma levels of terbutaline and cardiovascular 

Both groups improved with no difference between 
groups. Significant time savings with continuous. 

Decrease in heart rate in both groups. 
Patients with FEV, < 50% of predicted had faster 
improvement with continuous. 

Both groups similar improvement and admission rate. 
Patients with PEF < 200 L/min had greater 

improvement in PEF and lower admission rale with 


Both groups improved, with no difference between 

Both groups improved, with no difference between 

FEV I improved more with continuous low and high 
dose than with intermittent low dose. 

Com = continuous nebulization. ALB = albuterol. Inl = inlermillent ncbulizalion. TERB = terbutaline. LOS = length of stay. FEV, = forced expiratory volume in the first second. PEF = peak 
expiratory fiow, COPD - chronic obstructive pulmonary disease. MDl/HC - metered-dose inhaler with holding chamber. 

practical approach to provide optimal dosing in a cost- 
effective manner. 

Devices Used for Continuous Nebulization 

Continuous nebulization can be delivered via LVN or 
SVN. LVN capacities range from 50-200 mL, holding 
sufficient medication for 4-8 hours of continuous nebu- 
lization. SVN reservoirs range from 5-15 mL, and are 
commonly used for intermittent administration of standard 
doses of bronchodilators. 

Raabe et aP** reported on the operating characteristics of 
the HEART nebulizer, an LVN designed for continuous 
nebulization. Typically, the nebulizer is operated with 
10-15 L/min of air or oxygen, and aerosolizes 30-56 mL 
of solution per hour, with a mass median aerodynamic 
diameter of 2.0 ± 2.7 /i,m. Approximately 90% of the dose 
reaching the patient's mask was contained in respirable 
particles. Over 8 hours of operation, concentration of al- 
buterol in the reservoir doubled because of evaporation of 
the solvent. 

The HOPE nebulizer is a high-flow LVN with two gas 
inlets, one operating the nebulizer at 12-13 L/min and the 
other inlet capable of a secondary gas flow > 40 L/min. 
This closed dilution system allows precise control of the 
fraction of inspired oxygen, with sufficient tlow to meet 
patient inspiratory flow needs, even when combined with 
use for positive airway pressure, as well as the ability to 
entrain helium oxygen without reducing aerosol output.'" 

The SVN may be attached to an infusion pump or re- 
filled as needed, depending on the volume of the reservoir, 
drug concentration, and total drug output (Fig. 8). Berlin- 
ski and Waldrep" determined the aerodynamic profile, 
drug output (total and in respirable range), solution output, 
and changes in reservoir albuterol concentration of a jet 
nebulizer with large (250 mL), medium (45 mL), and small 
(18 mL) reservoirs (the small reservoir was attached to an 
infusion pump). The mass median aerodynamic diameter 
(1.8-2.2 jLtm) was similar in each configuration and was 
unaffected by reservoir size. The large reservoir had the 
highest output of respirable drug (8.03 ± 2.4 mg/h), com- 
pared to medium and small reservoirs (5.7 ± 2.5 mg/h and 


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Bronchodilator Resuscitation in the Emergency Department 


To Infusion pump 
and (Vibrated 

'V Connector 

Non - nebreathing 
Reservoir Bag 
with Valve 



Fig. 8. Adaptation of a nebulizer with a needle and Infusion pump 
to allow/ continuous injection of medication into the nebulizer. 
Blended oxygen is used to provide a precise fraction of inspired 
oxygen to both the nebulizer and reservoir bag. A valved oxygen 
mask is used to reduce entrainment of room air. (From Reference 
23, with permission.) 

5.85 ± 0.5 mg/h, respectively). Drug concentration in the 
reservoirs of these devices did not change significantly 
over 4 hours of continuous operation. 

McPeck et al"*^ compared operating characteristics of 
several nebulizers in providing continuous nebulization of 
albuterol with simulated adult and pediatric breathing pat- 
terns. With an adult breathing pattern, the Aerotech II and 
PowerMist SVNs delivered 5.14 mg and 3.74 mg of albu- 
terol per hour, respectively, and with a pediatric pattern, 
2.97 mg/h and 2.48 mg/h respectively. The HEART LVN 
delivered less albuterol to the simulated airway than either 
of the SVNs (ranging from 0.87 mg/h to 3.48 mg/h for 
adult breathing patterns and 0.41 mg/h to 1.83 mg/h with 
the pediatric pattern), the lower output being partly attrib- 
uted to the 6-foot-long tubing used with the HEART neb- 
ulizer but not with the SVNs. Though drug delivery to the 
simulated patient was similar for continuous and intermit- 
tent SVNs, the authors cautioned that nebulizer outputs in 
children may differ from those in adults, because children 
have different breathing patterns than adults. 

Undiluted Nebulizer Solutions 

Nebulization of undiluted bronchodilators has been ad- 
vocated as a method of delivering higher doses of drugs to 
the lung. We were unable to find randomized controlled 
studies utilizing the administration of undiluted j3 agonist 
via nebulizer. Similarly, no evidence suggests that the ad- 
dition of normal saline to the bronchodilator enhances the 
response of the patient to j3 agonists. The contribution of 
saline in the nebulizer appears to be limited to improving 
the nebulizer efficiency by reducing the proportion of med- 

ication remaining in the dead volume at the end of nebu- 

Intuitively, nebulizing undiluted bronchodilator should 
allow delivery of a faster than using more dilute 
solution, with similar response time per milligram of drug 
deposited in the lungs. The amount of medication placed 
in the nebulizer must exceed the residual or dead volume 
of the nebulizer, commonly requiring a dose > 2 mL for 
the typical SVN. Although specialty nebulizers incorpo- 
rating expiratory reservoirs or collection bags, one-way 
valves, or breath actuation may improve efficiency of de- 
livering medications in the ED, these advantages have not 
been found to result in improved clinical response, and 
would seem to be of least theoretical advantage when ad- 
ministering undiluted albuterol. There is no evidence that 
administration of undiluted bronchodilators with any spe- 
cialty nebulizer provides additional clinical benefit com- 
pared to the same dose or concentration of the drug pro- 
vided with a standard nebulizer or MDI/HC. 

Role of Anticholinergics in Bronchodilator 

Ipratropium bromide has been well accepted as the bron- 
chodilator of choice for COPD patients, but its role in the 
treatment of asthma is controversial. The combination of 
/S, agonist and anticholinergic bronchodilator has been 
shown to elicit a greater effect than either bronchodilator 
alone, in the treatment of stable COPD. Campbell con- 
ducted a double-blind, 29-day trial involving 357 COPD 
patients, comparing combined albuterol and ipratropium 
bromide therapy (via MDI) to albuterol therapy alone." 
Efficacy measurements at 15, 30, and 60 minutes after the 
treatment, on day 1 and day 29, showed greater peak and 
mean FEV, improvement with combined therapy. 

Using nebulized solutions of albuterol and ipratropium 
bromide individually and in combination, in a 6-week, 
3-period, crossover phase followed by a 6-week parallel 
phase. Gross et al randomized 863 COPD patients to each 
of 6 treatment sequences." The use of combined therapy 
resulted in 24% more improvement in FEV, than albuterol 
alone (p < 0.001) and 37% more than ipratropium bro- 
mide alone (p < 0.0001 ). This raises the question of whether 
this combination therapy might similarly benefit asthma 

Everard and Kurian reviewed the available literature 
through 1 997 to determine whether there was evidence to 
support the use of anticholinergic therapy in the treatment 
of wheezy infants.^' They found that in one study in the 
ED setting, the use of ipratropium bromide in addition to 
/3 agonist conferred a therapeutic advantage compared to j3 
agonist alone. However, another investigation in a similar 
population failed to show differences in the frequency of a 
perceived "excellent" response, change in respiratory rate, or 

Respiratory Care • May 2000 Vol 45 No 5 


Bronchodilator Resuscitation in the Emergency Department 

PEF (% Predicted) 





50 H 


40 H 

Table 4. Rate of Patients Hospitalized from the Emergency 


Saline solution 





Time (Minutes) 

Fig. 9. Percent of predicted peak expiratory flow (PEF) (mean ± 
SE) measured at 30-minute intervals in patients who received al- 
buterol and ipratropium bromide, or albuterol and saline placebo. 
Children who received ipratropium bromide had greater improve- 
ment in PEF percent of predicted than the placebo group at 60 
minutes (p = 0.02), 90 minutes (p = 0.002), and 120 minutes (p < 
0.0001). (From Reference 38, with permission.) 

improvement in arterial oxygen saturation when ipratropium 
bromide was added to /3 agonist, versus )3 agonist alone. 

Karpel et al-'* administered either 2.5 mg of albuterol or 
albuterol mixed with 0.5 mg of ipratropium bromide at 
entry and 45 minutes later to 384 patients with acute asthma 
in the ED. Although the combined therapy group had more 
responders at 45 minutes, the two groups had responded 
similarly at the end point of the study, and they were 
unable to demonstrate significant additive benefit of com- 
bined therapy. Similarly. McFadden et al" reported a se- 
ries of 254 patients who were randomized between their 
standard albuterol regimen and the addition of 1 .0 mg of 
ipratropium bromide. They found no influence of ipratro- 
pium bromide on discharge/admission patterns from the 
ED, hospital length of stay, rate of improvement of the 
patient, or the level of PEF achieved. 

Qureshi, Zaritsky, and Lakkis randomly assigned 90 
children (ages 6-18) to receive nebulized albuterol solu- 
tion (0.15 mg/kg) every 30 minutes and oral steroids with 
the second dose of albuterol.^** In addition, patients re- 
ceived either ipratropium bromide (500 /ig/dose) or pla- 
cebo with the first and third dose of albuterol. Children 
who received ipratropium bromide had greater improve- 
ment in PEF percent of predicted than the placebo group, 
at 60 minutes (p = 0.02), 90 minutes (p = 0.002), and 120 
minutes (p < 0.0001 ) (Fig. 9). Twenty percent of patients 
receiving ipratropium bromide and 3 1 % of those receiving 
placebo required hospitalization (p = not significant). 

Subsequently, Qureshi et al^'' reported that the addition 
of ipratropium bromide to albuterol and corticosteroid ther- 

All Patients 





Beta agonist alone 


Beta agonist with 


ipratropium bromide 

•p < 0.05 

tp = 0.02 

Adapted fmm Reference 39. 







apy significantly decreased the hospitalization rate in chil- 
dren with severe exacerbations of asthma. In a double- 
blind, placebo-controlled study. 434 children (ages 2-18) 
with moderate to severe asthma treated in the ED were 
randomized to receive either 2.5 mg or 5 mg of albuterol 
every 20 minutes for 3 doses and then as needed. Pred- 
nisone (2 mg/kg) was given with the second dose of al- 
buterol. The combined treatment group received 500 /xg 
(2.5 mL) of ipratropium bromide with the second and third 
dose of albuterol. The rate of hospitalization was lower in 
the children receiving ipratropium bromide (59 of 215 
children. 27.4%) than those in the control group (80 of 219 
children, 36.5%, p = 0.05). For patients with moderate 
asthma (PEF 50-70% of predicted), hospitalization rates 
were similar in the two groups. In patients with severe 
asthma (PEF < 50% of predicted), the addition of ipra- 
tropium bromide reduced the need for hospitalization (Ta- 
ble 4). 

Zorc et al'*" treated 427 children (ages > 12 mo) with 
moderate and severe asthma with a standardized ED pro- 
tocol: 3 nebulizer treatments with albuterol (2.5 mg/dose/kg 
weight < 30 kg, otherwise 5 mg/dose) and oral prednisone 
(2 mg/kg up to 80 mg). Patients received either ipratro- 
pium bromide (250 /itg/dose) or normal saline ( 1 mL/dose) 
with each of the first 3 nebulized albuterol doses. Patients 
receiving ipratropium bromide had 13% shorter treatment 
time (mean of 185 min in combined therapy group vs 213 
min in the control group) and fewer total albuterol doses 
(median 3 in combined therapy group vs 4 in control group). 
Admission rates did not differ significantly (18% vs 22% 
in control). The addition of 3 do,ses of ipratropium bro- 
mide to an ED treatment protocol for acute asthma was 
associated with reductions in duration and amount of treat- 
ment before discharge. 

To assess the effect on FEV, and clinical outcomes of 
adding ipratropium bromide to salbutamol in the treatment 
of asthma. Lanes et aH' performed a pooled analysis of 3 
randomized, double-blinded clinical trials conducted in the 
United States. Canada, and New Zealand. Adult patients 
presenting to the ED with acute asthma (/; = 1,064) re- 
ceived 2.5 mg of albuterol via nebulizer, with or without 


Respiratory Care • May 2000 Vol 45 No 5 

Bronchodilator Resuscitation in the Emergency Department 

0.5 mg of ipratropium bromide. Medications were admin- 
istered at baseline (and at 45 min in the United States 
trial). FEV| was measured at baseline, 45 minutes, and 90 
minutes, with telephone follow-up 48 hours after discharge. 
Adding ipratropium bromide to albuterol in the treatment 
of acute asthma produced a small improvement in lung 
function, and reduced the risk of the need for additional 
treatment, subsequent asthma exacerbation, and hospital- 
ization. These benefits were independent of the amount of 
j3 agonist used earlier in the attack. 

Lin et aV~ studied 55 adult asthmatics with PEF < 200 
L7min. In a randomized, double-blind, placebo-controlled 
trial, patients were assigned to nebulizer treatment with 
2.5 mg of albuterol alone (3 doses at 20-min intervals) or 
the same albuterol regimen plus ipratropium bromide (0.5 
mg with the first treatment only). Increases in PEF and 
PEF percent of predicted were greater with combined ther- 
apy (P < 0.(X) 1 ), and admission rate was lower (3/27 for 
combined therapy vs 10/28 for albuterol alone). Improve- 
ments in pulmonary function and outcomes as reported in 
this study suggest that ipratropium bromide has a place in 
the treatment of the most severely ill patients with asthma. 

Ducharme and Davis-*' compared albuterol nebulized in 
frequent low doses (0.075 mg/kg every 30 min) with and 
without the addition of ipratropium bromide (250 /ig). and 
high doses (0.15 mg of albuterol/kg every 60 min) in 
children with mild and moderate asthma. The primary end 
point was improvement in respiratory resistance. Second- 
ary end points included pulse oximetry, corticosteroid use, 
patient disposition and relapse status. The degree of bron- 
chodilation observed after frequent low doses was similar 
to that after hourly high doses of albuterol (relative risk = 
0.9 [95% confidence interval 0.7, 1.3]) or the addition of 
ipratropium bromide vs placebo (relative risk = 1.0 [95% 
confidence interval 0.8, 1.3]). Of the 298 children (ages 
3-17), 15% were admitted to the hospital and 14% had 
relapses. No differences were observed in other secondary 
end points. Albuterol in frequent low doses was associated 
with increased vomiting (relative risk = 2.5 [95% confi- 
dence interval 1.1, 6.0]). Their results do not support the 
use of frequent low doses of nebulized albuterol or the 
addition of ipratropium bromide with the low dose, com- 
pared with hourly high doses of albuterol in children with 
mild or moderate asthma. 

Weber et al^ compared continuous nebulization of al- 
buterol (10 mg/h) with and without ipratropium bromide 
(1.0 mg/h) in 67 adult asthmatics with mean PEF < 45% 
of predicted, over 3 hours. Combination therapy tended to 
produce a greater improvement in PEF (mean 6.3% greater 
than albuterol alone), reduced odds of hospital admission 
(0.88), and shorter ED stay (mean difference of 35 min). 
However, differences in the parameters evaluated were not 
statistically different (Fig. 10). 















1 2 3 


Fig. 1 0. Change in peak expiratory flow (PEF) percent of predicted 
from baseline in patients receiving continuous nebulization with 
albuterol and ipratropium bromide (combined, upper line) or albu- 
terol and placebo (control, lower line). The difference between the 
groups was not significant at 1 , 2, or 3 hours. (From Reference 44, 
with permission.) 

A recent meta-analysis of clinical trials results by Stood- 
ley. Aaron, and Dales'''' suggests that supplementary ther- 
apy with ipratropium bromide may be useful in treating 
adults with acute asthma exacerbations. Dales, at the Uni- 
versity of Ottawa, pooled data from 10 randomized, dou- 
ble-blind, placebo-controlled trials involving 1 .377 patients 
with acute asthma exacerbations, in which inhaled ipra- 
tropium bromide was used in addition to inhaled /3 ago- 
nists. Compared with placebo, ipratropium bromide treat- 
ment was associated with a pooled 7.3% improvement in 
lung function (FEV,). Similarly, trials in which PEF was 
used showed a 22.1% greater PEF improvement with the 
addition of ipratropium bromide to albuterol. In the three 
studies for which data were available, the ipratropium bro- 
mide combination was associated with a 0.73 relative risk 
of hospitalization. 

Ba.sed on these studies, it appears that combination ther- 
apy with a /3 agonist and ipratropium bromide provides the 
greatest benefit in the most severely ill asthma patients 
(Table 5). In no case did the addition of ipratropium bro- 
mide increase toxicity or adverse reactions. 


Patients presenting to the ED with severe exacerbation 
of airway obstruction require a more aggressive treatment 
strategy than the standard doses and frequency of /3 ago- 
nists recommended by the manufacturer. Up to 70% of 
patients with severe airway obstruction will respond to 
increasing doses of bronchodilators (up to 1.0-2.4 mg/h of 
albuterol via MDI/HC and 5.0-30 mg/h via nebulizer), 
whereas approximately 30% of patients do not respond 

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Bronchodilator Resuscitation in the Emergency Department 

Table 5. Randomized Placebo-Controlled Clinical Trials of Combined Albuterol and Ipratropium Bromide 

Study (year) 

Patient Population (n) 





Qureshi (1997)'* Moderate to severe asthma ALB/0.15 mg/kg q 30 min 

(90) IB/0.5 mg with first and third dose 

Qureshi (1998)"* Moderate to severe asthma ALB/2.5-5.0 mg q 30 min 

2-18 years (434) IB/0.5 mg with second and third 

Zorc (1999)-"' Moderate to severe asthma ALB/2.5-5.0 mg 

> 1 2 months (427) IB/0.25 mg 

2 h IB improved PEF percent of predicted over 


2-4 h IB group had lower hospitalization rate in 

patients with PEF < 50% of predicted (p 
< 0.05). 

£4 h IB group had shorter treatment time and 

required fewer treatments (p < 0.05) 

Ducharme (1998)^' Acute asthma 3-17 years ALB/0.075 mg/kg q 30 min with 
(298) or without IB/0.25 mg vs 0.15 

mg/kg q 60 min 

Lanes (1998)^1 Acute asthma (1,064) ALB/2.5 mg 

IB/0.5 mg baseline and at 45 min 

Karpel (1996)* Asthma (384) 

ALB/2.5 mg 

IB/0.5 mg baseline and 45 min 

McFadden (1997)" Moderate asthma (254) ALB/2.5 mg 


Lin (1998)« 

Weber (1999)« 

Severe asthma (55) 

Severe asthma (67) 

ALB/2.5 mg q 20 min X 3 
IB/0.5 mg with first dose 

ALB/10 mg/h continuous 

ALB = albuterol. IB = ipratropium brnmidc, PEF ^ peak expiratory flow, ED ^ emergency department. 

4 h Frequent low doses of ALB associated with 

increased vomiting (relative 2.5). No 
benefit with IB. 

90 min with IB group had small improvement in lung 
48-h follow- function, decreased need for additional 
up treatment, subsequent exacerbation, and 


2 h No benefit with IB over ALB alone. 

2 h No benefit with IB over ALB alone. 

2 h IB group had greater improvement in PEF 

and PEF percent of predicted, and lower 
admission rate. 

3 h Trend with IB: 6.3% better improvement in 

PEF, decreased odds of hospital 
admission, and shorter ED stay (35 min). 

sufficiently and require hospitalization. Aggressive dosing 
with bronchodilators for 30 minutes improves the ability 
to predict which patients will require admission, compared 
to predictions made before starting treatment. 

The advantage of high-dose /3 agonist administration 
appears to be greatest in patients with the most severe 
airway obstruction. Patients with moderate airway obstruc- 
tion may gain less additional benefit from higher than 
standard doses of j3 agonists, but the risk of adverse effects 
with high doses of albuterol in this population is only slightly 
higher than that with lower doses. Titrating the dose of bron- 
chodilator to response of the individual patient may be the 
best strategy for resuscitating these patients. 


In this series we have reviewed the available evidence 
indicating that MDI/HC is equivalent to nebulizer therapy 
for treatment of infants, children, and adults with moderate 

to severe asthma in the ED. In children, the use of MDI/HC 
may confer some advantage in terms of reduced treatment 
time and systemic adverse effects compared to nebulizer 

Standard doses of /3 agonist provided at high frequency 
are less effective than the same dose administered contin- 
uously. Reports of advantages in clinical outcome with 
continuous nebulization of j3 agonists, compared to intermit- 
tent nebulization, are mixed, but continuous aerosol therapy 
clearly requires less therapist or clinician time at the bedside 
than low-dose, high-frequency intermittent therapy. 

Higher doses of )3 agonists do not appear to make a 
substantial difference in outcomes for treatment of mild 
and moderate asthma, but produce relief of symptoms in a 
higher proportion of patients with more severe asthma. 
The addition of anticholinergic bronchodilators with /3 ago- 
nists confers additive benefits in the treatment of the most 
severe exacerbations of asthma, compared to /3 agonist 
alone, especially in children. The potential of reducing 


Respiratory Care • May 2000 Vol 45 No 5 

Bronchodilator Resuscitation in the Emergency Department 

hospitalization of severe asthmatics by 5% easily offsets 
the costs of adding ipratropium bromide to standard /3 
agonist regimens. 


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27. Shrestha M. Bidadi K, Gourlay S, Hayes J. Continuous vs intermit- 
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29. Raabe OG. Wong TM. Wong GB. Roxburgh JW. Piper SD. Lee JI. 
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32. McPeck M, Tandon R, Hughes K, Smaldone GC. Aerosol delivery 
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'J>l . 







Respiratory Care • May 2000 Vol 45 No 5 

Special Articles 

Office Spirometry for Lung Health Assessment in Adults: 
A Consensus Statement from the National Lung Health 

Education Program 

Gary T Ferguson MD, Paul L Enright MD, A Sonia Buist MD, and Millicent W Higgins MD 

Chronic obstructive pulmonary disease (COPD) is easily detected in its preclinical pliase using 
spirometry, and successful smoking cessation (a cost-effective intervention) prevents further disease 
progression. This consensus statement recommends the widespread use of office spirometry by 
primary-care providers for patients ^ 45 years old who smoke cigarettes. Discussion of the spi- 
rometry results with current smokers should be accompanied by strong advice to quit smoking and 
referral to local smoking cessation resources. Spirometry also is recommended for patients with 
respiratory symptoms such as chronic cough, episodic wheezing, and exertional dyspnea in order to 
detect airways obstruction due to asthma or COPD. Although diagnostic-quality spirometry may be 
used to detect COPD, we recommend the development, validation, and implementation of a new 
type of spirometry — office spirometry — for this purpose in the primary-care setting. In order to 
encourage the widespread use of office spirometers, their specifications differ somewhat from those 
for diagnostic spirometers, allowing lower instrument cost, smaller size, less effort to perform the 
test, improved ease of calibration checks, and an improved quality-assurance program. |Respir 
Care 2000;45(5):5 13-530] Key words: chronic obstructive pulmonary disease, risk assessment, smoking, 


During the last 40 years, the desire to reduce the mor- 
bidity, mortality, and expense of common chronic diseases 
in the United States has led to successful programs de- 
signed to identify and' modify risk factors such as hyper- 
tension and hypercholesterolemia.'"' The primary and sec- 

Gary T Ferguson MD is affiliated with Botsford Pulmonary Associates, 
Framington Hills, Michigan. Paul L Enright MD is affiliated with the 
University of Arizona, Tucson, Arizona. A Sonia Buist MD is affiliated 
with Oregon Health Sciences University, Portland, Oregon. Millicent W 
Higgins MD is affiliated with the Univei^ity of Michigan. Ann Arbor, 

A complete list of the National Heart Lung and Blood Institute (NHLBI)- 
American College of Chest Physicians (ACCP) Consensus Conference 
participants. NHLBI-sponsored National Lung Health Education Pro- 
gram (NLHEP) Conference participants, members of the Spirometry Sub- 
committee of the NLHEP, and members of the Executive Committee of 
the NLHEP is located in Appendix 2. 

Although representatives from the National Institute for Occupational 
Safety and Health (NIOSH) participated in the NLHEP conferences and 

ondary prevention of disease through early recognition 
and intervention has become a key strategy, leading to the 
preparation of guidelines by various expert panels that 
recommend specific screening and monitoring programs."*"^ 
Despite evidence documenting the very high burden of 
suffering and the economic cost of chronic respiratory 
diseases,^ and despite calls for methods to reduce the im- 
pact of COPD,''^ recent consensus statements on the man- 
agement of COPD have not addressed the early assess- 
ment of respiratory function in people at risk for chronic 
respiratory diseases.'^"'" Although standards for the per- 
formance of spirometry are well established, ' "* and although 
diagnostic quality spirometers are widely available, pri- 

reviewed drafts of this document, official approval from NIOSH was not 

Copies of this paper can be ordered from the American College of Chest 

Physicians (1-800-343-2227: 1-847-498-1400). 

© 2000 American College of Chest Physicians. Reprinted, with permis- 
sion, from Chest 2000:117:1146-1161. 

Respiratory Care • May 2000 Vol 45 No 5 


Office Spirometry for Lung Health Assessment 

mary-care physicians rarely use spirometry to detect COPD 
in smokers or to detect astlima or COPD in patients with 
respiratory symptoms. '"""'^ 

The failure of spirometry to meet the requirements for 
effective screening in general unselected populations (re- 
gardless of smoking status or symptoms) provided the ba- 
sis for the unwillingness to support efforts to detect COPD 
early in its course, although the use of spirometry for "case 
finding" in patients who seek medical care for "unrelated" 
symptoms (during a clinical encounter), and who are at 
high risk for COPD due to a history of heavy cigarette 
smoking, was supported by a 1983 official statement of the 
American Thoracic Society (ATS)."^ Several lung func- 
tion tests that initially were thought to be sensitive to early 
disease of small airways (closing volumes and nitrogen 
washout curves, for example) were too complex and were 
found not to predict the subsequent development of 
COPD.'^"^^ When the use of spirometry was initially sug- 
gested for identifying smokers with asymptomatic lung 
disease,^^'^"* little evidence could be found to suggest that 
early identification of COPD would have any impact on its 
course. Although there was mounting evidence that spon- 
taneous smoking cessation improved the rates of decline in 
lung function toward normal,"^"'' selection bias and other 
factors may have accounted for these changes. Further- 
more, outcomes in most smoking cessation programs were 

Since then, results from the National Health and Nutri- 
tion Examination Survey (NHANES) III and the multi- 
center Lung Health Study (LHS) have provided a new 
basis for early identification and intervention in COPD."^'^^ 
The LHS was the first study to demonstrate prospectively 
that early intervention in smokers identified to be at risk 
for COPD could modify the natural history of the disease. 
Both the NHANES III and the LHS also documented the 
ability of spirometry to detect mild air flow abnormalities 
in thousands of cigarette smokers, many of whom did not 
have symptoms that would have prompted them to seek 
medical attention. 

Increased awareness of these issues has led to the for- 
mation of the National Lung Health Education Program 
(NLHEP), a project jointly sponsored by several profes- 
sional societies crossing various medical disciplines and 
specialties.'^'' The program is designed to increase the aware- 
ness of lung health in patients, health care practitioners, 
and health care organizations. As a part of the NLHEP, a 
subcommittee was organized to reevaluate the role of sim- 
ple lung function testing as a tool for assessing lung and 
overall health. Following an extensive literature review, 
Gary Ferguson developed the first draft of this report in 
early 1998, which then was reviewed by the NLHEP 
spirometry subcommittee. The American College of 
Chest Physicians (ACCP) and the National Heart, Lung, 
and Blood Institute (NHLBI) then held a conference on 

August 18, 1998, to review the report further. Paul En- 
right then revised the document based on discussions 
and comments from the conference attendees. The re- 
vised report was again reviewed during a second con- 
ference sponsored by the NHLBI in Bethesda, Mary- 
land, on March 26, 1999. Both conferences included 
experts in spirometry and evidence-based medicine, in- 
cluding representatives from several professional asso- 
ciations and governmental agencies. This document rep- 
resents the contributions of the participants of these 

Indications for Office Spirometry 


Primary care providers (PCPs) should perform an office 
spirometry test for patients S: 45 years old who report 
smoking cigarettes (current smokers and those who quit 
during the previous year) in order to detect COPD. 

Rationale: Several well recognized criteria have been 
established for the use of medical tests that have been 
proposed for the early detection of disease,'^"^^"* and spi- 
rometry for the detection of COPD in adult cigarette smok- 
ers fulfills all of these criteria: 

1. The disease, if not detected early, would go on to 
cause substantial morbidity or mortality; 

2. Treatment is available that is more effective when 
used at the early stage before the development of 
symptoms than when used after the symptoms de- 
velop; and 

3. A feasible testing and follow-up strategy is available 

a. minimizes the false-positive and false-negative 

b. is relatively simple and affordable, 

c. uses a safe test, and 

d. includes an action plan that minimizes potential 
adverse effects. 

The above criteria are usually applied to screening tests, 
defined as medical tests done for individuals who have no 
symptoms or signs that suggest the possibility of disease. 
Office spirometry is considered to be a part of a clinical 
evaluation and does not fall under the definition of a screen- 
ing test when performed for patients with respiratory symp- 
toms who are seen during a clinical encounter (whether or 
not they have a history of cigarette smoking). Also, if the 
patient has been diagnosed as having tobacco addiction (a 
disease with a code in the International Classification of 
Diseases, ninth revision), office spirometry may be indi- 
cated to assess the severity of that disease and is not then 
considered to be a screening test. Although the NLHEP 
does not recommend office spirometry for screening un- 


Respiratory Care • May 2000 Vol 45 No 5 

Office Spirometry for Lung Health Assessment 

selected populations or for testing patients who have no 
cardiopulmonary risk factors, the next section of this doc- 
ument provides evidence that office spirometry fulfills all 
of the criteria listed above when it is used to detect COPD 
in adult smokers. 

The Disease, If Not Detected Early, Would Go On to 
Cause Substantial Morbidity or Mortality 

COPD is the most important lung disease encountered 
and the fourth leading cause of death in the United States, 
and it affects at least 16 million people. ^'^^ Of the top 
causes of mortality in the United States, only the death rate 
for COPD continues to rise, increasing by 22% in the past 
decade. The 10-year mortality rate for COPD after diag- 
nosis is > 50%.'^ In addition, the number of patients with 
COPD has doubled in the last 25 years, with the preva- 
lence of COPD now rising faster in women than in men.^^ 
Although the frequency of hospitalization for many ill- 
nesses is decreasing, the number of hospital discharges for 
COPD rose in the last decade. COPD causes 50 million 
days per year of bed disability and 14 million days per 
year of restricted activity.'"^'"' COPD causes about 1 00,000 
deaths per year, 550,000 hospitalizations per year, 16 mil- 
lion office visits per year, and $13 billion per year in 
medical costs, including homecare.^^ 

Treatment Is Available That Is More Effective When 
Used at the Early Stage of COPD, Before the 
Development of Symptoms, Than When Used After 
Symptoms Develop 

COPD is a slowly progressive, chronic disease charac- 
terized by cough, sputum production, dyspnea, air flow 
limitation, and impaired gas exchange.""^ The early and 
common symptoms of chronic cough and sputum produc- 
tion usually are ignored by the patient (and often their 
physicians) as normal or expected for a smoker, and no 
intervention is deemed necessary. The disease usually is 
not diagnosed until the patient experiences dyspnea with 
only mild exertion, which interferes with the patient's qual- 
ity of life. The diagnosis of COPD is made by clinicians 
(1) by noting the presence of at least one risk factor in the 
patient's medical history (usually > 20 pack-years of cig- 
arette smoking), (2) by documenting moderate to severe 
air flow limitation using a diagnostic spirometry test, and 
(3) by excluding heart failure and asthma as the causes of 
air flow limitation.'" 

The LHS was a randomized clinical trial that demon- 
strated that COPD could be detected in its early stages in 
smokers with few symptoms."** Spirometry tests were per- 
formed for > 70,0(X) women and men who were current 
smokers (without regard to symptoms), 35 to 59 years old, 
from nine United States communities and Winnipeg, Can- 

ada.^' About 25% of those tested were found to have 
borderline to moderate air flow obstruction. An additional 
5% had severe air flow obstruction (< 50% of predicted), 
and they were excluded from the study and referred for 
treatment. Those taking medications for asthma also were 
excluded. About 6,0(X) smokers with borderline to mod- 
erate air flow obstruction were recruited and were fol- 
lowed up for 5 years. About half of the participants re- 
ported chronic cough (with a wide range of 26 to 81%, 
depending on gender, age group, and clinic site). Wheez- 
ing on most days and nights was reported by about one 
third of participants; only 2.8% reported a current diagno- 
sis of asthma but were not taking any prescription medi- 
cations for asthma.^" Those who continued to smoke were 
documented to have faster rates of decline in lung func- 
tion. Importantly, participation in a smoking cessation pro- 
gram significantly decreased the rate of decline in lung 
function in these individuals relative to those who contin- 
ued to smoke. Those participants who continued not to 
smoke (sustained quitters) showed a small improvement in 
lung function over the first year compared to continuing 
smokers (mean rise in FEV,, 57 mL vs mean fall in FEV,, 
38 mL. respectively) and had reduced rates of decline over 
the remaining 4 years of study (mean rate of decline in 
FEV|, 34 vs 63 mL/yr, respectively)."** Thus, the rate of 
decline of FEV, following successful smoking cessation 
was very similar to that seen in healthy nonsmoking adults 
(28 to 35 mL/yr).-*-^'^ 

In addition to documenting the benefits of .smoking ces- 
sation in modifying the natural history of COPD, the LHS 
documented the ability to successfully intervene with an 
intense smoking cessation program in relatively asymp- 
tomatic smokers."** At least 35% of the subjects studied 
were able to quit smoking for extended periods of time, 
and 22% of the subjects were able to quit and sustain 
smoking cessation for 5 years (as compared to 6% in the 
usual care group). The smoking recidivism rates during the 
5 years equaled the repeat quitter rates, such that 35% of 
the subjects were nonsmokers at any cross-sectional pe- 
riod of time. Of course, smoking cessation rates are likely 
to be lower in primary care settings when compared to a 
clinical trial.^-^'^"* 

Effective smoking cessation methods available to pri- 
mary care practitioners have dramatically improved in the 
last several years. Detailed recommendations are now avail- 
able that synthesize the expanding smoking cessation 
knowledge base.'*^"'^ Awareness of different stages in the 
process of behavioral change have allowed for more fo- 
cused efforts on subjects likely to quit smoking."*^'*** In 
addition, increasing success with repeated attempts at smok- 
ing cessation now is recognized. Significant advances in 
the understanding and treatment of nicotine addiction also 
have occurred."*^ Nicotine gum and patches^" are now avail- 
able over the counter in the United States. Bupropion hy- 

Respiratory Care • May 2000 Vol 45 No 5 


Office Spirometry for Lung Health Assessment 

drochloride (Zyban, Glaxo Wellcome, Research Triangle 
Park, North Carolina), an oral medication that is even 
more effective than nicotine patches,'""''" now is available 
by prescription in the United States. Comprehensive and 
effective community based smoking cessation programs 
also are available in most communities in the United 

Recognizing that individual rates of decline in lung func- 
tion vary, the LHS clearly documents that spirometry can 
identify large numbers of adult smokers at risk for COPD, 
and that smoking cessation programs can impact posi- 
tively on the progression of COPD in those smokers who 
successfully quit. The regular use of )3 agonists or ipra- 
tropium in current or former smokers with airways ob- 
struction, but without asthma, apparently has no effect on 
COPD progression. "'^■"^''■^■^ However, there is some recent 
evidence that high-dose inhaled corticosteroids given to 
smokers with spirometric evidence of mild to moderate air 
flow limitation reduces morbidity, improves quality of 

Spirometry Testing Probably Enhances Smoliing 
Cessation Rates 

Previous studies of lung function testing in the general 
population have had mixed results, with some showing no 
effect'*^ and others suggesting that knowledge of an ab- 
normal lung function test doubled the likelihood of quit- 
ting smoking, even when no other interventions were ap- 


A recent review " concluded that spirometry 

meets all the criteria for a test for the early detection of 
COPD, except that there is no conclusive evidence that 
spirometry adds to the efficacy of standard smoking ces- 
sation advice, which is based on current clinical practice 
guidelines."*^ Two randomized clinical trials that address 
this issue have been performed. The first study of 923 
Italian smokers found a i-year quitting rate of 6.5% in 
those who received counseling with spirometry, 5.5% in 
those with counseling alone, and 4.5% in those who re- 
ceived only brief physician advice.''" These rates did not 
differ significantly, but only half of the study participants 
who were asked to visit a laboratory for spirometry testing 
ever did so, and there was no evidence that the spirometry 
results even were discussed with those who performed the 
test; therefore, the study probably had inadequate power to 
show a difference (a type II error). The .second study was 
population based and identified 2,610 young men who 
were current smokers, age 30 to 45 years, had low 
FEV I values, and were from 34 cities in Norway.'*'' A ran- 
dom half of the men were mailed a personalized letter 
from a physician stating that they should quit smoking 
because they were at increased risk for smoking-reiated 
lung disease because of their low lung function. A 15-page 
smoking cessation pamphlet that emphasized behavioral 

modification was included in the letter. The self-reported 
12-month sustained smoking cessation rates were 5.6% in 
the minimalist intervention group vs 3.5% in the control 
group (who were not informed of their spirometry results). 
After adjusting for age of smoking onset, cigarettes smoked 
per day, and history of asbestos exposure, the letter de- 
scribing the abnormal spirometry results was responsible 
for a 50% improvement in the smoking cessation rates 
(p < 0.01). Even a I to 2% improvement in smoking 
cessation rates would result in a very large absolute num- 
ber of lives saved each year in the United States.^* 

The Relationship Between Spirometry and COPD 

Various studies have determined COPD risk factors. 
COPD occurs predominantly in current and former ciga- 
rette smokers, and there is a dose-response relationship. 
The risk of COPD is strongly associated with the intensity 
and duration of smoking.'*"''^''** Other factors that also 
increase COPD risk, but less commonly or to a lesser 
degree, include occupational dust exposure,'"'^ environmen- 
tal tobacco smoke,''** exposure to environmental air pollu- 
tion,^" a rare genetic deficiency of a (-antitrypsin,^' a his- 
tory of childhood respiratory infections,^" and the presence 
of airway hyperresponsiveness, as measured by spirome- 
jj.y 73.74 gygp moderate COPD cannot be detected reliably 
by a medical history or physical examination. ''''"''' 

Abnormal spirometry (ie, limitation of expiratory air 
flow, airways obstruction, or a low FEV|/FVC ratio) is a 
strong predictor for rapid progression of COPD."** The 
degree of airways obstruction correlates closely with patho- 
logic changes in the lungs of smokers and patients with 
COPD.^** Spirometry results are also a strong independent 
predictor of morbidity and mortality due to COPD,''^**" 
mortality due to cardiovascular disease,**' lung cancer, **^'*"' 
as well as all-cause mortality. ^'*'^^ 

A Feasible Testing Strategy Is Available That 
Minimizes the Rates of False-Positive and False- 
Negative Results 

The accuracy of a test for the early detection of disease 
is measured in terms of two indexes: sensitivity and spec- 
ificity.'' A test with poor sensitivity will miss cases (true 
positive results), producing false-negative results, while a 
test with poor specificity will result in healthy persons 
being told that they have the disease, producing false- 
positive results. 

An accepted reference standard (a "gold standard") must 
be available to provide the means for distinguishing be- 
tween true positive and false-positive results from the new 
test. The traditional "gold standard" for the diagnosis of 
COPD is the pathologic examination of lung tissue,^* but 
this confirmation of the disease is inappropriate in routine 


Respiratory Care • May 20(X) Vol 45 No 5 

Office Spirometry for Lung Health Assessment 

practice due to the invasive nature of a lung biopsy. The 
finding of abnormally low lung densities on a high-reso- 
lution computed tomography lung scan in adult smokers is 
very highly correlated with the pathologic grading of em- 
physema**^ and, therefore, may soon be considered a sec- 
ondary reference for COPD, but high-resolution computed 
tomography lung scans are infrequently performed clini- 
cally due to their high cost. COPD, as determined by high- 
resolution computed tomography lung scans, is moder- 
ately correlated with lung function testing (FEV|/I^C ratio 
and diffusing capacity of the lung for carbon monoxide) in 
adult smokers,*^ but emphysema (lung tissue destruction 
accompanied by lung hyperinflation) is only one compo- 
nent of COPD and may not be an important predictor of 
morbidity and mortality, independent of air flow obstruc- 
tion. The widely accepted definition of COPD progression 
is an abnormal rate of decline in lung function. ^^'^'^ The 
normal annual decline in FEV, in healthy, never-smoking 
adults who are 35 to 65 years old has been determined by 
several longitudinal studies to be a mean of 30 mL7yr with 
an upper limit of the normal range of SOmL/yr, which may 
be used to define "rapid fallers."**^ 

It is important that a high proportion of those who test 
positive actually have disease (positive predictive power). 
This proportion is higher when the prevalence of disease is 
high. The best estimates of the prevalence of air flow 
obstruction and COPD in the United States population are 
now available from NHANES III (conducted from 1988 to 
1994). In NHANES III, spirometry was measured in a 
sample of > 16,000 adults who represented the noninsti- 
tutionalized population of the United States. About 29% of 
all the adult participants reported current smoking, and 
24% were former smokers. Normal reference values of 
several spirometry variables were developed from the 
"healthy" subset of the nonsmoking men and women who 
were free of respiratory symptoms and diseases. Lower 
limit of normal (LLN) values, which were specific for age, 
sex, and height, were set at the fifth percentile of the 

reference population values."^ For this report, prevalence 
rates of low lung function in the United States population 
were estimated by defining low lung function as an FEV,/ 
FEVf, ratio less than the LLN and an FEV, value less than 
the LLN. See Table 1 for the results. 

Prevalence rates of low lung function increase with age 
and are highest in current smokers, intermediate in former 
smokers, and lowest in never smokers. Rates are similar in 
men and women. Compared with rates in never smokers, 
rates are more than five times as high in current smokers 
at s 45 years old and are more than three times as high in 
former smokers ^ 55 years old. Prevalence rates also were 
compared in men and women who reported any respira- 
tory condition or symptom with those who did not. A 
report of any of the following placed the individual in the 
symptomatic group: a doctor' s diagnosis of asthma, chronic 
bronchitis, or emphysema; cough or phlegm on most days 
for a 3 consecutive months during the year; shortness of 
breath on mild exertion: or chest wheezing or whistjing 
apart from colds. Rates of low lung function were consis- 
tently three or more times higher in symptomatic men and 
women than in those who were asymptomatic. 

We recommend that all patients s 45 years old who are 
current smokers, as well as those with respiratory symp- 
toms, perform office spirometry or diagnostic spirometry. 
Based on the NHANES III study, the numbers of patients 
eligible for spirometry under these recommendations, and 
the expected yield of abnormal spirometry tests are given 
in Table 2. About one quarter of current cigarette smokers 
with a respiratory symptom, a total of 9 million persons in 
the United States, can be expected to have low lung func- 
tion (airway obstruction). Smokers s 45 years old without 
respiratory symptoms also have a relatively high abnor- 
mality rate: about 9% of men and 14% of women. On the 
other hand, current and former smokers < 45 years old 
have spirometry abnormality rates that are similar to those 
of healthy never smokers (about 5%), reducing the value 
of spirometry testing of young adult smokers. Asymptom- 

Table I . Prevalence of Low Lung Function in the National Health and Nutrition Examination Survey III of the Adult United States Population 

Age Group (y) 

Current Smoker (Vc) 

Former Smoker (9^) 


Smoker (%) 


























































rale for all age gmups. 






*Values given 

as abnomiality 

Respiratory Care • May 2000 Vol 45 No 5 


Office Spirometry for Lung Health Assessment 

Table 2. Number of Men and Women Eligible for Spirometry Testing in the United States and the Prevalence of Low Lung Function* 

Population Data 

Number of Persons El 


gible in United 

Prevalence of Low 
Function (%) 






Smokers, age a 45 y 







Symptomatic, age > 25 y 
Never smokers and former sm 
Current smokers, age 25^44 


utrition Examination Survey III 









*Estimated from the National Health and N 
Sec text for definitions of symptomatic and 

atic former smokers ages s 55 years also have a spirom- 
etry abnormality rate of 5%. 

Office Spirometry Is Relatively Simple and 

Spirometry is a relatively simple, noninvasive test. Of- 
fice spirometry takes only a few minutes of the patient's 
and technician's time and includes a few athletic type 
breathing maneuvers of 6-second duration. The economic 
costs of a spirometry test include the cost of the instrument 
and the cost of personnel time (both training and testing). 
Diagnostic spirometers currently cost about $2,000, and 
about $10 of time per test is spent in testing (including 
training time) and disposable supplies. Office spiro- 
meters will cost < $800 and require even less testing 
time than diagnostic spirometers. Adding a post-broncho- 
dilator spirometry test for asthma adds about 15 minutes 
to the test time (but is not needed for COPD eval- 

related to false-positive or even true positive test results 
could lead to alterations in lifestyle and work and to seek- 
ing medical attention. Another potential adverse effect is 
the unmeasured risk of reinforcing the smoking habit in 
some of the four of five adult smokers who are told that 
they have normal results for spirometry testing. However, 
the clinician should counteract this possibility by taking 
the opportunity to tell the patient that normal results for 
spirometry testing do not mean that the patient's high risk 
of dying from a heart attack, lung cancer, or other smok- 
ing-related diseases is substantially reduced; therefore, 
smoking cessation remains very important. 

Finally, the risk of an adverse effect caused by the in- 
tervention for COPD (smoking cessation) is very small. 
The side effects of over-the-counter nicotine replacement 
are minimal. Successful smoking cessation leads to a small 
average increase in body weight,**'^ but the slight 
in medical risk from minor weight gain is far exceeded by 
the benefits due to reduced morbidity and mortality and 
the economic savings in cigarette and cleaning costs. 

Spirometry Safety 

Any medical test has both tangible and intangible costs. 
Adverse effects may occur ( 1 ) due to the procedure itself, 
(2) due to the investigation of abnormal results, or (3) due 
to the treatment of detected abnormalities or diseases. ''■^■'"* 
There are no adverse side effects from spirometry testing, 
other than occasional minor discomfort. However, inves- 
tigation and confirmation of abnormal spirometry results 
in some patients will cost both time and money and may 
result in psychological and social harm in some patients. 
The cost of diagnostic spirometry to confirm air flow ob- 
struction when performed in a hospital-based pulmonary 
function (PF) laboratory ranges from $20 to $60. The es- 
timated travel time, waiting time, and testing time spent by 
the patient ranges from I to 3 hours. The possible psycho- 
logical impact of being labeled as "ill" by self and others 

The Action Plan 

Even when test quality seems good, diagnostic spirom- 
etry is highly recommended to confirm abnormal office 
spirometry findings prior to initiating an expensive workup 
or an intervention with negative economic consequences 
(such as a recommendation to change jobs or to prescribe 
a medication). 

The key focus of the NLHEP program is prevention and 
early intervention. Validated abnormal test results in a 
smoker should lead to a more detailed history and exam- 
ination for pulmonary disease and cardiovascular risk fac- 
tors (including hypertension, diabetes mellitus, obesity, 
hypercholesterolemia, etc). Consideration should be given 
to the presence of pulmonary diseases other than COPD, 
including asthma, restrictive lung and chest wall diseases, 
neuromuscular diseases, and cardiac disease. 


Respiratory Care • May 2(XX) Vol 45 No 5 

Office Spirometry for Lung Health Assessment 

When airway obstruction is identified in a smoker, the 
primary intervention is smoicing cessation. In the event 
that a patient with airway obstruction continues to smoke 
cigarettes, a renewed or increased effort to assist with 
smoking cessation is essential. Future research may deter- 
mine that other interventions, such as anti-inflammatory 
therapy, are effective in selected patients with airway ob- 
struction. Referral to a subspecialist for further diagnostic 
testing should be considered in some patients, such as 
those in whom bronchiectasis or other lung diseases are 
suspected. Pre- and post-bronchodilator diagnostic spirom- 
etry is indicated if asthma is suspected. 


Primary-care physicians should perform an office spi- 
rometry test in patients with respiratory symptoms such as 
chronic cough, sputum production, wheezing, or dyspnea 
on exertion in order to detect asthma or COPD. 

Rationale: Analyses of data from a population sample of 
25-75-year-old white men in Tucson. Arizona, found that 
spirometry abnormality rates increased in those who re- 
ported respiratory symptoms, after excluding those who 
reported a physician diagnosis of asthma, chronic bron- 
chitis, or asthma.''" Abnormal spirometry was defined as 
an FEV| below the LLN, using the reference equations 
from the study by Crape et al,''' which reported spirometry 
reference values very similar to the NHANES III values. 
The comparison subjects, never smokers without respira- 
tory symptoms, had a 3.8% spirometry abnormality rate, 
while asymptomatic former smokers and current smokers 
had abnormality rates of 9.2% and 11%, respectively. 
Former smokers and current smokers with any of three 
respiratory symptoms (chronic cough and sputum, dys- 
pnea walking on level ground, or attacks of dyspnea with 
wheezing) had abnormality rates of 25.6% and 14.1%, 
respectively. These abnormality rates, and those from 
NHANES III (see Tables I and 2), demonstrate that the 
presence of respiratory symptoms in a former or current 
cigarette smoker substantially increases their pretest prob- 
ability (risk) of having air flow obstruction (low lung func- 
tion) or COPD. 

The National Health Interview Survey (conducted from 
1993 to 1995) estimated that 4 million adults (4.5% of 
those age 35 to 65 years) have asthma (by self-report) and 
that 630,000 emergency department visits for asthma oc- 
cur each year in this age group.^" A survey of 59 primary- 
care practices with 14.000 patients in Wisconsin reported 
an asthma prevalence of 6.2% in adults (& 20 years old), 
half of whom reported adult onset of the disease.^"* An 
additional 3.3% of the patients without a diagnosis of asthma 
reported attacks of wheezing with dyspnea during the pre- 
vious year, suggesting, along with other investigations. 

that asthma is underdiagnosed in adults.'^ Spirometry is 
recommended by current clinical guidelines for patients 
with symptoms that suggest asthma, in order to help con- 
firm the diagnosis. '^"' 


Primary-care physicians may perform an office spirom- 
etry test for patients who desire a global health assessment 
(risk assessment). 

Rationale: Lung function testing is now recognized as a 
measure of global health, predicting all-cause mortality 
and morbidity in adults. '^'^'^''"''^ In addition, lung function 
test results and changes in lung function over time have 
been shown to identify patients at high risk for lung can- 
cer,**"'*'' and at increased risk for coronary artery disease,^* 
congestive heart failure,*^ stroke and other heart and blood 
vessel disaeses,'"" and altered mental function in later xears 
of life.'*" Early identification and recognition of increased 
global health risks also may allow for evaluation and for 
prevention and early intervention in other risk areas ap- 
propriate to each of these nonpulmonary disease catego- 
ries. Office spirometry also may identify patients with 
subclinical asthma or restrictive lung processes in both 
adults and children, leading to the institution of appropri- 
ate evaluations and treatments. Although prophylactic in- 
terventions such as vaccination are recommended for pa- 
tients with respiratory illnesses, only a small percentage of 
them receive influenza and pneumococcal vaccines.'"^ 

In adults, early intervention following early identifica- 
tion of lung function abnormalities can lead to improved 
smoking cessation, to occupational, avocational, or envi- 
ronmental changes, and to increased awareness and atten- 
tion to cancer, cardiac, and other nonpulmonary health 
issues associated with abnormal lung function. Early iden- 
tification of lung function abnormalities in relatively 
asymptomatic patients may provide "teachable moments" 
or specified times for a given patient when there is an 
increased awareness and response to medical education 
and intervention. Such moments may lead to an increased 
responsiveness to smoking cessation and to enhanced op- 
portunities for other preventive therapies or modification 
of identifiable risk factors. 

Why Not Use Peak Flow? 

Assuming that lung function testing of selected individ- 
uals is a useful part of health care, it is essential that the 
test chosen is the best available. First, it must be able to 
detect mild disease. Although many lung function tests are 
available, previous studies examining the value of these 
tests have shown that most of them are unacceptable or 
ineffective as tools for the early detection of COPD.'^"*' 

Respiratory Care • May 2000 Vol 45 No 5 


Office Spirometry for Lung Health Assessment 

The exceptions are peak expiratory flow (PEF) and spi- 
rometry. PEF measurements are recommended for asthma 
management by current cHnical practice guidelines, but 
spirometry is recommended to help make the diagnosis of 
asthma.''** Likewise, we do not recommend the use of PEF 
to evaluate patients for COPD. The advantages of PEF 
tests are the following: measurements within a minute (three 
short blows) using simple, safe, hand-held devices that, 
typically, cost < $20. On the other hand, the disadvan- 
tages of using PEF when compared to spirometry are as 
follows: PEF is relatively insensitive to obstruction of the 
small airways (mild or early obstruction); PEF is very 
dependent on patient effort; PEF has about twice the in- 
tersubject and intrasubject variability; '^'^ and mechanical 
PEF meters are much less accurate than spirometers.'^ 

Tracking Changes in Lung Function 

Tracking of lung function over time has potential ad- 
vantages over a single test."*'* However, there are no pub- 
lished data demonstrating that when the results of the first 
spirometry test are normal in a high-risk patient the mea- 
surement of annual changes in lung function (tracking) in 
the primary-care setting is better than simply repeating 
office spirometry at 3-year to 5-year intervals, which we 

In occupational medicine, diagnostic-quality spirometry 
tests often are performed regularly for the surveillance of 
employees at high risk.'"'*"''^ Annual tests increase the 
likelihood of detecting changes in lung function earlier, 
when compared to less frequent testing intervals. Infre- 
quent testing (eg, every 5 years) may delay identification 
of lung function abnormality, reducing the benefits of iden- 
tification, prevention, and early intervention in lung dis- 
ease. However, when testing is performed more frequently, 
and when a less-than-optimal spirometry quality-assurance 
program is used, the false-positive rate increases. Office 
spirometry may be indicated for patients who report work- 
place exposures to chemicals, dusts, or fumes that are 
known to cause lung disease; however, a discussion of 
testing for occupational lung disease is beyond the scope 
of this document. 

Technical Requirements for Ofllce Spirometers 


A new category of spirometers, office spirometers, 
should be available for use in the primary-care setting. 
Each new model must successfully pass a validation study 
(see Appendix 1). 

rometry measurements depending on both the equipment 
and proper test performance. Although simple to learn, 
spirometry is an effort-dependent test that requires a co- 
operative patient and a trained person capable of admin- 
istering the test. Specific recommendations have been de- 
veloped by the ATS and other professional organizations 
to ensure accurate and reproducible measurements when 
using diagnostic spirometers. '■'•'°*"'°^ In many cases, a 
diagnostic spirometer that meets ATS standards will be the 
preferred choice for a hospital, outpatient clinic, or doc- 
tor's office since it permits diagnostic and follow-up test- 
ing (tracking) of lung function. Currently available diag- 
nostic spirometers also may be used in the primary-care 
setting to evaluate smokers for COPD. However, some 
characteristics of diagnostic spirometers create a barrier to 
their widespread use for this purpose. Advantages of the 
newly proposed category of office spirometers for this 
purpose include lower instrument cost, smaller size, less 
effort to perform the test, improved ease of calibration 
checks, and an improved quality-assurance program. Of- 
fice spirometers should not be utilized for diagnostic test- 
ing, surveillance for occupational lung disease, disability 
evaluations, or research purposes. 

Current ATS recommendations for diagnostic spirome- 
try' must be followed for office spirometry, except for the 
following seven factors. 

L Office Spirometers Must Only Report Values for 
FEV„ FEVfi, and the FEVi/FEV^ Ratio 

The reported FEV, and FEV^, values should be rounded 
to the nearest 0.1 L and the percent of predicted as an 
integer (for instance, 72%); and the FEV |/FEV(, ratio should 
be calculated as a fraction with only two decimal places 
(for instance, 0.65). An indication should be made next to 
the reported value (an asterisk for instance) when the pa- 
tient's values fall below the LLN range for the variable. 
The false-positive rate increases when additional variables 
(for instance, the midexpiratory phase of forced expiratory 
fiow) are used to define abnormality."" 

Rationale: Spirometry is a simple test that measures the 
volume of air expelled from fully inflated lungs as a func- 
tion of time.'" Following inspiration to a maximal lung 
volume, the patient is instructed to exhale as fast and hard 
as possible. Many lung function indexes may be derived 
from spirometry; however, the most valuable indexes are 
the total volume t>f exhaled air and the FEV , . ' 

2. The ATS End-of-Test Criteria Should Be Modified 
for Office Spirometry 

Rationale: Traditionally, spirometry has been u.sed as a 
diagnostic test, with the usefulness and accuracy of spi- 

Rationale: The measurement of FVC should be replaced 
by that of FEV^, so that each maneuver need last for only 


Respiratory Care • May 2000 Vol 45 No 5 

Office Spirometry for Lung Health Assessment 

6 seconds. The advantages of using FEV^, for office spi- 
rometry are the following: ( 1 ) it is easier for the patient 
and the technician when maneuvers last only 6 seconds; 
(2) technical problems with flow sensors related to accu- 
rately measuring very low flows over several seconds of 
time (resolution and zero drift) are minimized; (3) the 
FEVft is more reproducible than the FVC in patients with 
airways obstruction; (4) using the FEV^ reduces the over- 
all time to perform a test; and (5) shorter maneuvers re- 
duce the risk of syncope. The FEV^ has long been pro- 
posed as a surrogate measurement for FVC;"~ however, 
reference values for FEV,, and the FEVi/FEV^ ratio have 
only recently become available."^ The validity of using 
FEV(, as a surrogate for FVC is now being established. For 
example, unpublished data from the LHS suggest that the 
FEV,/FEVf, ratio is as good as the FEV|/FVC ratio in 
predicting the decline in FEV, over the subsequent 5 years 
in adult smokers. Some healthy children and some young 
adults empty their lungs before 6 seconds has elapsed; in 
those cases, their FVC and FEV^, values should be con- 
sidered equivalent if their end-of-test volume is not too 
high (suggesting that their FEV,, has been underesti- 

3. Airway Obstruction Will Be Interpreted When the 
FEV,/FEVft Ratio and the FEV, Percent of Predicted 
Are Both Below Their LLNs 

The FEV , percent of predicted may optionally be used 
to categorize the severity of the abnormality (Table 3). 
Report FEV , as a percent of predicted to patients. This is 
"the number" the patient should remember. 

Rationale: The ATS recommends that the FEV /FVC 

ratio be used to diagnose airways obstruction. 


FEV|/FEV,, ratio is a good surrogate for the FEV, /FVC 
ratio (see above). The LLN is now well defined for all ages 
of African Americans, Hispanic Americans, and whites, 
with a mean of about 73%. ranging from 70 to 76%, de- 
pending on age, gender, and race."^ 

This recommendation for using the FEV|/FEV(, ratio 
with office spirometers should not discourage clinicians 
from continuing to use an older diagnostic-quality spirom- 
eter that reports the FEV|/FVC ratio and its LLN, but not 
the FEV|/FEV„ ratio. However, the FVC is defined as the 
maximum amount of air that the patient can exhale, and adult patients can exhale more air after 6 seconds. 
Therefore, when using traditional reference equations and 
an interpretation of airways obstruction based on the FEV,/ 
FVC ratio, airway obstruction may be missed (a false- 
negative result) if the patient is not coached to exhale 
completely (usually s: 10 seconds). 

In patients with COPD, the FEV, percent of predicted is 
directly proportional to their quality of life and ability to 
perform exercise." ' Clinicians and patients understand the 
semiquantitative terms mild, moderate, and severe better 
than percent of predicted when discussing the relative se- 
verity of diseases. A stronger admonition and the patient's 
adherence to the recommended intervention may be more 
likely when the abnormality is reported as moderate or 
severe. Also, when the abnormality is moderate or severe, 
the likelihood that the test result is falsely positive is much 
lower than when the abnormality is mild. The severity 
category cut-points suggested in Table 3 (40% and 60%) 
correspond roughly to z scores of 2 and 3 in the distribu- 
tion of the percent of predicted for FEV, in patients with 
COPD. and are in widespread clinical use.""' 

Table 3. Interpretation of Office Spirometry Results 

1. First ensure that test quality is good (see Table 4). 

2. Use the NHANES III reference values to calculate predicted values 
and LLNs for the FEV,. FEV^. and FEV,/FEV(, ratio (this should 
be done automatically by the spirometer). 

3. If the FEV,/FEV^ ratio and the FEV, are both below the LLN in a 
test with good quality, airways obstruction is present. Report the 
FEV, percent of predicted to the patient. Optionally, the severity of 
the obstruction may be graded using the FEV , percent of predicted 
as follows: 

FEV, LLN to 60% of predicted FEV, = "mild obstruction" 
40-59% of predicted FEV, = "moderate obstruction" 
< 40% of predicted FEV , = "severe obstruction" 

4. If FEV I /FEV,, ratio is above the LLN but the FEV^ is below the 
LLN. the patient ha.s a low vital capacity, perhaps due to restriction 
of lung volumes. 

NHANES III = National Health and Nutrition Examination Survey III 

LLN = lower limit of normal 

FEV I = forced expiratory volume in the first second 

FEV^ - forced expiratop. \olume in the first 6 second> 

4. Automated Maneuver Acceptability and 
Reproducibility Messages Must Be Displayed and 

Rationale: Many performance standards essential to re- 
liable spirometry measurements' already have been auto- 
mated and included within spirometry devices to reduce 
the likelihood of poor-quality test results."*""'""* Addi- 
tional built-in performance checks are necessary for office 
spirometers that do not display or print spirograms or flow- 
volume curves, which the technician or physician can re- 
view for acceptability and reproducibility of the maneu- 
vers. Table 4 lists quality control (QC) criteria that must be 
monitored electronically along with recommended mes- 
sages to be displayed when these maneuver quality errors 
are detected. These thresholds were designed so that > 
90%; of adult patients (even the elderly) can pass all the 
QC checks within five maneuvers if coached by a techni- 
cian who has good training, motivation, and experience. 

Respiratory Care • May 2000 Vol 45 No 5 


Office Spirometry for Lung Health Assessment 

Table 4. Recommended Automated Maneuver Quality Control 
Checks, Messages, and Grades 


If the BEV is > 150 mL, display "don't hesitate." 
If the PEFT is > 120 ms, display "blast out faster." 
If the FET is < 6.0 s and EOTV* is > 100 mL, display "blow out 

If the PEF values do not match within 1 .0 L/s, display "blast out 

If the FEV(i values do not match within 150 mL, display "deeper 

After two acceptable maneuvers that match, the message is "good 
test session." 
Quality Control Gradest 

A = At least two acceptable maneuvers, with the largest two FEV, 
values matching within 100 mL and the largest two FEV^ values 
matching better 100 mL. 
B = At least two acceptable maneuvers, with FEV, values matching 

between 101 and 150 mL. 
C = At least two acceptable maneuvers, with FEV, values matching 

between 151 and 200 mL. 
D = Only one acceptable maneuver, or more than one, but the FEV, 

values match > 200 mL (with no interpretation). 
F = No acceptable maneuvers (with no interpretation). 

*A large EOTV indicates Ihat a volume-time plateau wa.s not obtained, so the FEVj, was 

probably underestimated. The appropriate PEFT and EOTV thresholds depend on several 

chaiBcteristics of the spirometer, such as frequency response, sampling rates, and filtering of 

the flow signal. For instance, for a given model of office spirometer, the PEFT threshold of 

120 ms may be changed if based on the 9.')th percentile of PEFT from studies in which 

experienced technicians test > 200 adults. The 95th percentile of PEFT for school-age 

children and adolescents is about 160 ms. 

tA quality control grade, which indicates the degree of confidence in the results, should be 

calculated, displayed, and reported along with the numeric results and the interpretation 

BEV = back extrapolated volume 

PEFT = time to peak flow 

FET = forced expiratory time 

PEF = peak expiratory How 

EOTV = end-of-test volume (calculated as the change in exhaled volume during the 0.5 s 

of the maneuver). 

FEV(^ = forced expiratory volume in die first 6 seconds 

Devices should present the numeric spirometry results and 
interpretations only if all maneuver QC criteria are met. 
While we believe that these electronic quality checks will 
reasonably ensure good-quality tests, studies are necessary 
to validate their performance in primary-care settings. 

5. Displays and Printouts of Spirograms and Flow- 
Volume Curves Will Be Optional for Office 

umes, and the rare upper airways obstruction." ' ""^ How- 
ever, a graphic display or a printer usually increases the 
size, cost, and complexity of spirometers, reducing their 
widespread acceptability in the primary-care setting. It is 
also likely that many technicians and physicians will not 
learn to recognize the patterns of unacceptable spirometry 
maneuvers and that many physicians will not recognize 
the patterns of abnormality. We believe that automated- 
maneuver QC checks and messages are generally more 
reliable now for quality-assurance purposes than are pro- 
grams to teach pattern recognition of spirometry graphs, 
although no published studies demonstrate this. 

6. Office Spirometers Must Be Sold With Easy-to- 
Understand Educational Materials 

These educational materials should include procedure 
manuals, audiovisual instructional aids (such as a video- 
tape or multimedia CD ROM), and patient handouts that 
describe the potential risks and benefits of NLHEP spi- 
rometry, interpretation of the results, and limitations of the 

Rationale: It is unlikely that many primary-care physi- 
cians will spend the time and money necessary to send 
their technician or nurse to a 2-day spirometry training 
course."^' Emphasis in training materials must be placed 
on effective interactions between the technician and the 
patient when performing spirometry tests (Table 5). In 
order to minimize the number of breathing maneuvers 
needed to obtain a good-quality test session, technicians 
always must demonstrate the correct maneuver themselves 
before instructing patients to perform them. The technician 
must then enthusiastically coach and watch the patient 
throughout the three phases of each maneuver: ( 1 ) maxi- 
mal inhalation, (2) blast out quickly, and (3) continue ex- 
halation for 6 seconds. Most maneuver errors are easily 
recognized by watching the patient. When the technician 
or the automated spirometer maneuver QC checks detect 
poor-quality maneuvers, the technician must tell the pa- 
tient what went wrong and again demonstrate how to per- 
form the maneuver correctly. After eight maneuvers are 
performed and the test session is of poor quality, the test 
should be rescheduled for a later date. 

Rationale: Standards for diagnostic spirometry require 
that graphs of the maneuvers be produced so that techni- 
cians who perform the tests, physicians who interpret the 
results, and those who later review the test reports may 
recognize problems with maneuver quality.'^ The graphs 
also assist physicians in the recognition of the character- 
istic patterns of different types of abnormalities, such as 
generalized airways obstruction, restriction of lung vol- 

Table 5. Spirometry Steps 

1. Measure standing height in stocking feet. 

2. Record age, gender, height, and ethnicity. 

?i. Explain and demonstrate the correct maneuver, 

4. Coach and walch the patient perform each maneuver. 

5. Repeat until two acceptable and matching maneuvers are obtained. 


Respiratory Care • May 2000 Vol 45 No 5 

Office Spirometry for Lung Health Assessment 

7. Simple Inexpensive Solutions Should Be Developed 
to Replace the Daily Use of 3-L Calibration Syringes 
to Check the Accuracy of Office Spirometers 

Rationale: One-liter calibration syringes may be as ef- 
fective as 3-L syringes, and they are smaller and less ex- 
pensive. It is also possible that precisely manufactured 
plastic (Mylar, 3M Corp, St. Paul, Minnesota) bags could 
be used to check volume accuracy on a daily basis. How- 
ever, until alternative calibration methods are proven to 
check spirometer calibration effectively, the use of cali- 
brated 3-L syringes on a regular basis is necessary. If a 
calibration syringe is not available in a primary-care set- 
ting, calibration checks using a standard 3-L calibration 
syringe may be performed at regular intervals by a local 
diagnostic PF laboratory at minimal cost. A proper interval 
cannot be arbitrarily set for all spirometers. Manufacturers 
should validate the acceptable calibration interval speci- 
fied for their office spirometers that ensures that they re- 
main accurate when used as directed in the primary-care 
setting. Third-party testing of the between-sensor (within- 
batch) accuracy of single-use flow sensors should be es- 

Periodic testing of a biological control also should be 
used to check the long-term performance of office spirom- 
eters. The individuals chosen as biological control subjects 
must be > 25 years old and must not have an obstructive 
lung disease. Their FEV,and FEVj, first must be measured 
on 10 days, and the average values and ranges must be 
calculated. The range of measurements for FEV, and FEV^ 
(largest minus smallest) should not exceed 10% of the 
average value, otherwise a different biological control sub- 
ject should be chosen. If disposable flow sensors are used, 
the biological control subject may reuse a single-flow sen- 
sor, and it should be stored with the subject's name on it. 
The biological control subject then should be tested on 
each day that patients are tested. If the control subject's 
measured FEV, or FEV^ is > 10% from the average value, 
the test should be repeated. If the FEV, remains "out of 
bounds," even after replacing or cleaning the sensor, the 
device should not be used on patients until repaired. 

The FEV, and FEVg Must Be Corrected to BTPS 

The device should sense the temperature automatically 
if necessary for accurate body temperature, ambient tem- 
perature, and saturation with water vapor (BTPS) correc- 
tions. The technician should not be asked to enter the 

Rationale: The measurement of ambient or spirometer 
temperature and barometric pressure may not be needed 
for some spirometers in which the design allows the use of 

a fixed BTPS correction factor."^ Errors in measuring 
FEV, and FEV^ must remain < 3% (according to BTPS 
testing methods recommended by the ATS). Manufactur- 
ers must specify the range of ambient temperatures and 
altitudes in which the results remain accurate. 

The Current ATS Recommendations Regarding 
Measures to Avoid Cross-Contamination Should Be 
Followed by Those Using Office Spirometers 

Staff performing spirometry tests must be instructed to 
wash their hands before and after assisting each patient 
with the test. If patients are only exhaling through the 
devices, proper use of disposable mouthpieces is all that is 
needed to minimize the risk of the transmission of infec- 
tions. In particular, disposable in-line filters are not man- 
dated. '"'"^ All devices should be inspected and kept clean 
to meet good hygiene standards. Devices with completely 
disposable flow sensors or with mouthpieces that |iave 
one-way valves should be used if testing is to be per- 
formed in patients likely to inhale through the mouthpiece. 
Manufacturers should give explicit instructions about clean- 
ing techniques and frequency of cleaning. 

A New Billing Code Should Be Created for Office 
Spirometry Tests 

Rationale: Charges should be kept as low as possible but 
should at least cover the real costs of the test. It seems 
imprudent to charge patients or third-party insurers for 
diagnostic-quality spirometry tests when office spirometry 
tests are performed, since office spirometry tests will re- 
quire less expensive instruments, less technician time, and 
less training to interpret. 

Further Research 

There is insufficient published evidence related to many 
of the technical and procedural issues associated with the 
above recommendations for office spirometry. More de- 
tailed information is needed about the following issues: 
levels of training required to obtain results of acceptable 
quality; levels of inaccuracy and imprecision; reliability; 
durability; and the necessary frequency and type of cali- 
bration checks (see Appendix 1 ). Outcomes to be assessed 
include sensitivity of detection, frequency of false-positive 
test results, and the overall impact on patient care, quality 
of life, and cost-benefit analyses. These issues should be 
examined both for pulmonary diseases and as a part of 
total health care. Additional areas requiring research in- 
clude the role of office spirometry in lower risk individ- 
uals (ie, nonsmokers, former smokers, and those without 
respiratory symptoms) and the prospective utility of office 
spirometry in the intervention and management of global 

Respiratory Care • May 2000 Vol 45 No 5 


Office Spirometry for Lung Health Assessment 

disease processes. Research in these areas is strongly en- 
couraged in order to validate and improve the above rec- 


The authors thank MilHcent Higgins from the University of Michigan. 
David Mannino from the Centers for Disease Control, and Gregory Wag- 
ner and Kathleen Fedan from the National Institute for Occupational 
Safety and Health, who collaborated to provide new analyses for this 
document from the NHANES III database. 


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Office Spirometry for Lung Health Assessment 

Appendix 1 
Office Spirometer Validation Studies 


The NLHEP recommends the widespread use of spirometry by primary-care physicians (PCPs) for 
detecting COPD in adult smokers and describes a new type of spirometer for this purpose: the office 
spirometer. The value of spirometry for aiding the diagnosis of COPD and asthma, when performed by 
trained technicians using diagnostic spirometers that meet current ATS recommendations, is widely 
accepted. The accuracy and precision of diagnostic-quality spirometry performed in the hospital PF 
laboratory, pulmonary research clinic, and occupational clinic settings by technicians who are trained 
and have considerable experience performing spirometry have been studied by many investigators and 
found to be acceptable for the purposes of detecting airways obstruction in individuals and for 
detecting abnormal declines in FEVi in groups of adults. However, the first prospective study of 

> 1,000 spirometry tests performed by nurses in the outpatient clinics of 30 randomly selected PCPs in 
New Zealand found that less than one third of the test sessions included at least two acceptable 
maneuvers."* About one third of the maneuvers had a "slow start" (peak expiratory flow time [PEFT] 

> 85 ms [a substantially stricter criterion than those in the NLHEP document]). About two thirds of the 
maneuvers lasted for < 6 seconds (forced expiratory time [FET] < 6 s), and visual inspection of the 
volume-time curves suggested that most of these short-duration maneuvers underestimated the FVC 
(did not achieve an end-of-test plateau). On the positive side, after attending a 2-hour spirometry 
training workshop, nurses were much more likely to obtain acceptable test sessions. These results 
confirm the necessity for each new office spirometry system to have a "real-world" validation study 
before it is marketed. 

Several factors other than mstrument accuracy are known to influence the real-world accuracy and 
repeatability of spirometry tests. These factors include the following: the technician's training, 
experience, number of tests performed per month, motivation, motivational skills, and patience; the 
patient's coordination, cooperation, strength, endurance, and motivation; maneuver and test session 
quality feedback (to the technician and patient); the training materials that accompany the spirometer; 
the type and frequency of calibration checks and actions taken to remedy equipment and sensor 
problems; the testing environment (space, lighting, noise, time constraints, and other stressors); and 
changes in these factors over the time period of measurement (eg, differing technicians, updated 
software, new flow sensors, etc). 


The goal of an office spirometer validation study is to compare the spirometer's screening and tracking 
performance in adult patients in the PCP setting with that of diagnostic spirometers used by trained 
technicians. The following study protocol is designed to apply to any model of office spirometer. It is 
designed to be performed in a reasonable amount of time (6 months) and with reasonable resources 
(< $50, 000 if a price of < $20 per test is negotiated with the PF laboratory). In order to minimize post 
study criticism, the limits of acceptable outcomes have been predetermined. The manufacturer or 
distributor of all office spirometers that claim to meet NLHEP specifications must conduct this study 
for that model and include the published results of the study with each office spirometer sold. 


A study coordinator with experience in clinical trials, without a conflict of interest (such as one that an 


Respiratory Care • May 2000 Vol 45 No 5 527 

Office Spirometry for Lung Health Assessment 

Appendix 1 

employee of the office spirometer manufacturer or distributor would have), shall be selected. Exactly 
the same instrument, sensors, manuals, calibration tools, accessories, and training materials that are 
sold (or provided) commercially as the spirometry system shall be used in the validation study. The 
same amount of in-service training with the same type of personnel shall be used during the study that 
will be used for actual commercial training (for instance, 45 min with a local distributor). The setting, 
staff, and patients will be selected to optimize the generalizability of the results to the real world. A 
single, representative sample of the office spirometer shall first undergo (and pass) independent testing 
for FEVi and FEVf, accuracy and reproducibility, which will be performed by a third party using 
current ATS recommendations' and a spirometry waveform generator, including four waveforms 
generated using BTPS conditions (body temperature humidified air). All disposable flow sensors used 
for testing shall be saved in a plastic bag, labeled with the date and patient identification number, and 
sent to the study coordinator at the end of the study. 

Recruitment of Primary Care Physicians 

Thirty PCPs shall be recruited from advertisements offering "a free spirometer and 6 months of 
spirometry supplies." At least two regions of the United States shall be represented. At least five PCPs 
(either medical doctors or doctors of osteopathy) shall be selected from each of the following 
specialties: family practice, general internal medicine, and general surgery. Allergists and pulmonary 
specialists shall be excluded. Staff who report that they have personally performed > 100 spirometry 
tests during the previous 5 years shall be excluded. PCPs who have used a spirometer in their office 
during the previous year shall be excluded. Each PCP must agree to perform spirometry testing for at 
least 20 adult patients per month (an average of one patient per weekday) for 6 months. The altitude of 
each office (within 500 feet) shall be recorded. 

Recruitment of Patients 

Inclusion criteria are consecutive outpatients, age 45 to 85 years, who are current cigarette smokers or 
who quit smoking during the previous year. Patients with asthma (according to self-report or the 
medical record) and those previously noted to have a significant response to inhaled bronchodilators 
(FEVi increases, > 12% and > 0.2 L) shall be excluded from the study, since their FEVi values have 
inherently high short-term variability. 

Follow-up Testing 

At least one patient per week shall be asked by each PCP to return to their clinic within 1 month for 
repeat spirometry testing. A contract shall be made with a local hospital-based PF laboratory to 
perform follow-up diagnostic spirometry (including printed volume-time and flow-volume curves, but 
without a physician interpretation) on a subset of study patients. All patients with abnormal spirometry 
test results shall be scheduled to perform diagnostic spirometry testing at a local hospital-based PF 
laboratory within 2 weeks of the screening spirometry test. The cost of the diagnostic testing, and a 
$20 reimbursement for each patient, shall be paid for by the study. The PF lab shall send a copy of the 
results to the study coordinator. The results of the follow-up spirometry tests shall not be sent to the 
PCP until the end of the study. 


528 Respiratory Care • May 2000 Vol 45 No 5 

Office Spirometry for Lung Health Assessment 

Appendix 1 


The long-term accuracy of a random sample of five of the study spirometers shall be measured by a 
third party using a waveform generator at the beginning and at the end of the 6-month study. A 
random sample of five used flow sensors shall be obtained for the long-term accuracy testing at the 
end of the study. 

The demographics of all patients tested shall be determined and stored for analysis. The demographics 
must include a unique patient identification number, age, gender, height, weight, race, smoking status, 
asthma status, date, and technician identification number. The following parameters shall be stored 
digitally for all (or the best three) spirometry maneuvers: FEVj, FEVg, back extrapolation volume, 
PEFT, PEF, FET, sequence number, and the 50-point flow-volume curve (the average flow during 
each 2% segment of the FEVe). This may require modifications to the office spirometers used in the 
study (when compared to those that will be sold commercially). These modifications should be 
designed to minimize technician interaction with the recording device. A written log shall be kept by 
the office staff of any problems with the spirometer, any calibration checks performed, any 
preventative maintenance, and any repairs. 

Statistical Analysis 

The study coordinator shall determine the long-term accuracy of the office spirometer instruments by 
comparing the baseline and 6-month FEV| and FEV6 measurements from the "gold standard" 
waveform generator and the records of repairs, updates, or replacements. The quality of all spirometry 
test sessions (screening, follow-up, and diagnostic) shall be graded by the study coordinator using the 
stored data and the criteria listed in Table 4 of this document. The rates, trends, and correlates of 
unacceptable-quality test sessions (QC grades, D or F) shall be determined using logistic regression. 

The false-positive and false-negative rates for detecting airways obstruction (after allowing for 3% 
error in the measured FEVi/FEVe, ratio) shall be determined by comparing the office spirometry results 
with the valid follow-up diagnostic tests performed in the PF laboratory. Results from the 
diagnostic-quality spirometry tests that are determined by the study coordinator (using the printed 
reports from the PF lab) to be valid (QC grades, A or B) are assumed for the purposes of this study to 
be the "gold standard." Both the false-negative rate and the false-positive rate shall be < 5% for the 
office spirometry system to be considered acceptable. 

The value of office spirometry for "tracking" purposes shall be determined by calculating the 
short-term coefficient of repeatability of FEV| for the subset of patients who performed repeat tests. 
Acceptable repeatability is for > 95% of the patients to have repeat FEV| values that match within 
0.30 L. The predictors of poor repeatability shall be determined by logistic regression. 

Respiratory Care • May 2000 Vol 45 No 5 529 

Office Spirometry for Lung Health Assessment 

Appendix 2 
Participants and Committee Members 

Participants in the NHLBI/ACCP Consensus Conference. August 18, 1998. Chicago, Illinois. 

William Bailey MD, Gary Ferguson MD, Michael Alberts MD, A Sonia Buist MD, 

Paul L Enright MD, John Hankinson PhD, Millicent Higgins MD, Deborah Shure MD, 

James Stoller MD, Brian Carlin MD, Ray Masferrer RRT, Gregory Wagner MD, David Mannino MD, 

Gail Weinmann MD, Robert O Crapo MD, Bettina Hilman MD, John W Georgitis MD, 

James Fink MS RRT FAARC, and Edward A Oppenheimer MD. ACCP staff: Sydney Parker PhD, 

David Eubanks EdD RRT, Mary Katherine Krause, and Barbi Mathesius. 

Participants in the NHLBI-Sponsored NLHEP Conference. March 26, 1999, Bethesda, Maryland. 

Thomas Petty MD FAARC (chair), William Bailey MD, Frank Bright MD, Bartolome Celli MD, 
Catherine Gordon RN MBA, A Sonia Buist MD, James Cooper (HCFA), Dennis Doherty MD, 
Paul Enright MD, Gary Ferguson MD, Millicent Higgins MD, Ray Masferrer RRT, Sreehar Nair MD, 
Louise Nett RN RRT FAARC, Edward Rosenow MD, Deborah Shure MD, and Gregory Wagner MD. 
NHLBI staff: Frederick Rohde, Suzanne Hurd PhD, Gregory Morosco PhD, and J Sri Ram PhD. 

Members of the Spirometry Subcommittee of NLHEP 

Gary T Ferguson MD (chair), William C Bailey MD, A Sonia Buist MD, Robert Crapo MD, 
Dennis Doherty MD, Paul Enright MD, Millicent Higgins MD, Ray Masferrer RRT, 
Louise Nett RN RRT FAARC, Stephen Rennard MD, Thomas Petty MD FAARC, James Stoller MD, 
and Gail Weinmann MD. 

Members of the Executive Committee of NLHEP 

Thomas Petty MD FAARC (chair), William Bailey MD, John B Bass Jr (representing the American 
College of Physicians), Gary Ferguson MD, Millicent Higgins MD, Leonard D Hudson MD 
(representing the American Thoracic Society), Suzanne S Hurd PhD (representing the NHLBI), 
Ray Masferrer RRT (representing the American Association for Respiratory Care), Sreedhar Nair MD, 
Louise M Nett RN RRT FAARC, Stephen Rennard MD, Deborah Shure MD, and 
Gail Weinmann MD. 

530 Respiratory Care • May 2000 Vol 45 No 5 

Mani S Kavum MD and James K Stoller MD. Series Editors 

PFT Nuggets 

What Causes an Elevated Diffusing Capacity? 

Terrence D Coulter MD and James K Stoller MD 

Case Summary 

A 46-year-old male with Goodpasture's syndrome 
treated with prednisone for 20 years presents with wors- 
ening shortness of breath and dyspnea on exertion, asso- 
ciated with a nonproductive cough. Chest auscultation re- 
veals diffuse crackles. The chest radiograph shows bilateral 
alveolar infiltrates. You are concerned about an infection 
or alveolar hemorrhage. Table 1 shows the results of pul- 
monary function testing. 

1. How do you interpret the pulmonary function test 

2. Why is the Dlco elevated? 

3. What are the possible causes of this elevation? 

Table 1 . Pulmonary Function Test Results 






FEV, (L) 












D,^o (mL/min/mm Hg) 




Predicted = mean predicted values as per Crapo et al' 

% Predicted = Actual value expressed as a percentage of the mean predicted value 

FEV I = forced expiratory volume in the first second 

FVC = forced vital capacity 

FEV|/FVC = rauo of FEV, to FVC 

D,^ = luing diffusing capacity for cartwn monoxide 


The diffusing capacity of the lungs (Dl) is the measure- 
ment of the transfer of oxygen in inspired gas to pulmo- 

Terrence D Coulter MD and James K Stoller MD are affiliated with the 
Department of Pulmonary and Critical Care Medicine, The Cleveland 
Clinic Foundation. Cleveland. Ohio. 

Correspondence: James K Stoller MD, Department of Pulmonary and 
Critical Care Medicine/A90. The Cleveland Clinic Foundation, 9500 
Euclid Avenue, Cleveland OH 44106. E-mail: 

nary capillary blood. Several factors determine the extent 
of oxygen transfer, which are expressed in the equation: 

1/Dl = 1/Dm + 1/(0 X VJ 

Where D^, represents membrane diffusing capacity, 8 is 
the binding rate for oxygen and hemoglobin, and V^ is the 
hemoglobin volume. D^^ is further influenced by the.area 
of the alveolar capillary membrane, thickness of the mem- 
brane, and difference in oxygen tension between alveolar 
gas and venous blood. 

Measuring the diffusing capacity of oxygen (DlqJ is 
technically difficult. A much easier method is measuring 
the diffusing capacity of carbon monoxide (Dlco)' which 
provides an accurate reflection of the diffusion of oxygen. 
Although several techniques for estimating Dlco have been 
described, the most commonly used is the single-breath 
method (SB-Dlcq)- During this procedure, the patient ex- 
hales to residual volume and inhales to total lung capacity 
a gas mixture containing a very low concentration of car- 
bon monoxide (CO). The breath is held for 10 seconds, 
followed by complete exhalation, and the alveolar gas is 
collected and analyzed. Average normal values range from 
20 to 30 mL/min/mm Hg, but, like spirometry, normal 
values depend on size, gender (lower in females), and age 
(decreased with age).^ 

Most disease states cause a decrease in Dlco because of 
decreased area for diffusion due to capillary volume loss 
(eg. emphysema), increased thickness of the alveolar-cap- 
illary membrane (eg, fibrosis, edema), decreased CO up- 
take capacity (eg, anemia), or increased CO back pressure 
(eg, high carboxyhemoglobin in smokers). On the other 
hand, increased Dlco i^ occasionally encountered and 
should prompt consideration of other diseases. 

Many common causes of increased Dlco involve 
changes in physiologic variables. For example, correction 
for hemoglobin is necessary, because patients who are 
polycythemic have an increased red blood cell mass and 
thus an increased area for diffusion, "* Maneuvers that in- 
crease pulmonary blood volume include the supine posi- 
tion (leading to increased perfusion to the upper lobes),'' 
vigorous exercise and bronchodilators (by improving ven- 
tilation-perfusion matching),** and inspiring against a closed 

Respiratory Care • May 20(X) Vol 45 No 5 


What Causes an Elevated Diffusing Capacity? 

airway (Miiller maneuver with resultant increase in in- 
trathoracic blood volume)/' Other conditions that can lead 
to increased capillary blood volume include massive obe- 
sity, the first trimester of pregnancy J and left-to-right in- 
tracardiac shunt. 

Corrections must also be made for altitude, because the 
increased driving pressure of CO due to hypoxemia in- 
creases the binding rate for CO and hemoglobin (6) and 
leads to higher Dl^o values.- Elevated Dlco measure- 
ments have been documented during space flight, because 
of the effects of zero gravity, which allows even blood 
distribution throughout the lungs and increased pulmonary 
capillary blood volume.** Menstruation also increases dif- 
fusing capacity, presumably because of changes in hor- 
mone concentrations.** 

A more serious cause of elevated Dlco' ^nd the expla- 
nation of the present case, is intra-alveolar hemorrhage. 
Hemoglobin in the alveolar space combines with CO to 
artificially increase the calculated uptake.'" Examples of 
diseases characterized by intra-alveolar bleeding that may 
elevate the Dlco value are Wegener's granulomatosis, id- 
iopathic pulmonary hemosiderosis, and, as in the present 
case, Goodpasture's syndrome. Although Dlco ''' '■^ '^P^' 
cific test in the appropriate clinical setting, the sensitivity 
may lessen with delays in testing, as older hemoglobin 
loses its ability to bind CO. 

In summary, when faced with an abnormally elevated 
Dlco- the astute clinician must first exclude causes due to 
altered physiology (eg, polycythemia). Accuracy of equip- 
ment, calibration of gas analyzers, quality of test perfor- 
mance, and choice of reference equations will affect the 
interpretation of reported Dlco values. If the measured 
value is believed to be valid, then clinical correlation with 

the abnormal value should be made, with attention to the 
previously mentioned physiologic states. In the appropri- 
ate clinical context, elevation of the Dlco value should 
prompt suspicion of diseases that cause alveolar bleeding. 


1. Crapo RO, Morris AH, Gardner RM. Reference .spirometric values 
using techniques and equipiiienl ihat meet ATS recommendations. 
Am Rev Respir Dis 1981;123(6):6.'i9-664. 

2. American Thoracic Society. Single-breath carbon monoxide diffus- 
ing capacity (transfer factor): recommendations for a standard tech- 
nique- 1 995 update. Am J Respir Crit Care Med 1995; 152(6 Pt 1); 

3. Cotes JE. Lung function: assessment and application in medicine, 
4th ed. Oxford: Blackwell Scientific Publications. 1979:203:329. 

4. AARC Clinical Practice Guideline. Single-breath carbon monoxide 
diffusing capacity, 1999 update. Respir Care 1999;44(l):91-98. 

5. Lawson WH Jr. Effects of drugs, hypoxia, and ventilatory maneuvers 
on lung diffusion for CO in man. J Appl Physiol 1972;32(6):788- 

6. Smith TC, Rankin J. Pulmonary diffusing capacity and the capillary 
bed during Valsalva and Miiller maneuvers. J Appl Physiol 1969; 

7. Milne JA, Mills RJ, Coults JRT. MacNaughton MC, Moran F, Pack 
Al. The effect of human pregnancy on the pulmonary transfer factor 
for carbon monoxide as ineasured by the single-breath method. Clin 
Sci Mol Med 1977:5.3(3):271-276. 

8. Verbanck S. Larsson H, Linnarsson D, Prisk GK. West JB. Paiva M. 
Pulmonary tissue volume, cardiac output, and diffusing capacity in 
sustained microgravily. J Appl Physiol 1 997:83(3 );8 10-8 16. 

9. Sansores RH, Gibson N. Abboud R. Variation of pulmonary CO 
diffusing capacity (DLCO) during the menstrual cycle (abstract). Am 
Rev Respir Dis 1991:143(4 Pt 2):A759. 

10. Ewan PW, Jones HA. Rhodes CG. Hughes JMB. Detection of in- 
trapulmonary hemorrhage with carbon monoxide uptake: application 
in Goodpasture's Syndrome. N Engl J Med 1976;295(25):1391- 


Respiratory Care • May 2000 Vol 45 No 5 

A 56- Year-Old Woman with Mixed Obstructive and 
Restrictive Lung Disease 

Saeed U Khan MD and Mani S Kavuru MD 

Case Summary 

A 56-year-old woman presents with progressive short- 
ness of breath on exertion for the past 4 years. Her breath- 
ing has deteriorated rapidly over the last year, and her 
walking distance has reduced to approximately 200 feet on 
level ground. She smoked one pack per day for 14 years, 
but quit smoking 10 years ago. Her father suffered from 
severe emphysema and died of respiratory failure at the 
age of 64. On physical examination, she was mildly short 
of breath at rest. Lung auscultation revealed bilateral in- 
spiratory and expiratory rhonchi. A chest radiograph 
showed hyperinflation of both lungs, with prominent bul- 
lae, mainly in the lower zones. 

Arterial blood gases on room air were: pH 7.43, arterial 
partial pressure of carbon dioxide 33 mm Hg, arterial par- 
tial pressure of oxygen 62 mm Hg, bicarbonate 2 1 .8 mEq/L, 
a 1 -antitrypsin level 32.6 mg/dL (normal range 93-224 
mg/dL). Table 1 shows the results of spirometry. 

1 . What accounts for the restrictive defect seen on spi- 

2. What is the significance of the discrepancy in mea- 
sured volumes between the helium dilution method and 


The spirometry results show a pattern of mixed severe 
air flow obstruction (ie, the ratio of forced expiratory vol- 
ume in the first second [FEV,] to forced vital capacity 
[FVC] is reduced) and restriction (ie, FVC is reduced). 
Typically, with obstructive airways disease, the expiratory 
component is characterized by an increase in functional 
residual capacity (FRC) and a decrease in the inspiratory 
capacity (IC = total lung capacity [TLC] - FRC) with a 

Saeed U Khan MD is afflliated with the Sleep Program at Eastern Ohio 
Pulmonary Consultants. Youngstown. Ohio. Mani S Kavuru MD is af- 
flliated with the Depanment of Pulmonary and Critical Care Medicine, 
The Cleveland Clinic Foundation, Cleveland, Ohio. 

Correspondence: Saeed U Khan MD. Eastern Ohio Pulmonary Consult- 
ants, 960 Windham Court, Youngstown OH 44512. E-mail; 

subsequent increase in residual volume (RV) because of 
air trapping and dynamic hyperinflation. Also, the TLC 
increases and the vital capacity is preserved as long as 
muscle power is adequate to overcome obstruction to air 
flow. As obstruction worsens, the expiratory reserve ca- 
pacity portion of the vital capacity decreases as RV in- 
creases. Therefore, vital capacity becomes reduced. This 
decrease in FVC secondary to severe expiratory air flow 
obstruction is sometimes labeled "pseudorestriction." 
Strictly speaking, a pure restrictive process generally re- 
duces all of the lung volumes and capacities (FRC, expi- 
ratory reserve capacity, TLC). With severe obstructive dis- 
ease, obstruction to inspiratory flow may accompany 
expiratory air flow obstruction and further complicate in- 
terpretation. If muscle strength decreases, inspiratory ob- 
struction may lead to a decrease of IC and TLC as well. 
Based on spirometry alone, without a formal measurement 
of FRC or TLC, it is difficult to be certain whether the 
decrease in FVC represents "pseudorestriction" or a true, 
superimposed, restrictive process. 

Patients with severe chronic air flow obstruction and 
emphysema often have large trapped gas volumes, asso- 
ciated with bullous changes on imaging studies. This 
trapped gas and bullous disease either represents air that is 
not in communication with the airways or that communi- 
cates extremely slowly. If helium dilution or nitrogen wash- 
out methods are used to determine lung volumes, these 
methods do not measure the noncommunicating volume 
and may thus significantly underestimate FRC or RV. The 
calculated TLC (TLC = IC + FRC) may be within normal 
limits. Body plethysmography, on the other hand, mea- 
sures all the intrathoracic gas volume (including the gas 
not in communication with the mouth or air trapped in 
bullae).- In healthy subjects and in patients with mild air 
flow obstruction, the lung volumes obtained by the helium 
dilution technique correspond well with those obtained by 
body plethysmography. However, in severe air flow ob- 
struction (eg, FEV I /FVC < 0.40), the helium dilution tech- 
nique usually yields lower values because of the presence 
of trapped air.^ The difference between body plethysmog- 
raphy and TLC measured by the helium dilution technique 
is often used to quantify the trapped gas volume and the 
degree of hyperinflation of the lungs. This determination 

Respiratory Care • May 2000 Vol 45 No 5 


Mixed Obstructive and Restrictive Lung Disease 

Table 1. Spirometry and Plethysmography Results 




% Predicted 





FEV, (L) 









Helium dilution 

% Predicted 













TLC (L) 












Dlco (mL/mm Hg/s) 











Mean predicted values per Crapo et al' 

FVC = forced vital capacity 

FEV, = forced expiratory volume in the first second 

FEV|/FVC = ratio of KEV, to FVC 

FRC = functional residual capacity 

RV = residual volume 

TLC = total lung capacity by helium dilution 

RV/TLC = ratio of RV to TLC 

Dijco = diffusing capacity for carbtm monoxide 

D^/V^ = ratio of diffusing capacity to alveolar volume 

may be useful when evaluating patients with severe bul- 
lous emphysema for lung volume reduction surgery.'' Pre- 
liminary data suggest that patients with a marked degree of 
hyperinflation and trapped gas improve most following 
this surgery. The magnitude of increase in TLC required 
for lung volume reduction surgery is controversial because 
the helium dilution technique has a tendency to underes- 
timate TLC, whereas body plethysmography may overes- 
timate TLC (eg, because of inclusion of intraluminal gas in 
the stomach).''* 

There are several advantages and disadvantages to the 
available methods for measuring lung volumes.- The ad- 
vantages with the dilution technique include portability of 
inexpensive equipment, relative simplicity of the proce- 
dure, and the need for only minimal cooperation from the 
patient. The disadvantages include the inability to measure 
trapped gas volumes, and the necessity for prolonged re- 
breathing for equilibration. 

The advantages of plethysmography are that the proce- 
dure is brief, the patient is attached to a mouthpiece for a 
short time, it does not require a special gas mixture, and it 
measures all of the gas in the patient's lungs. There are a 
number of disadvantages to plethysmography, including 
the need for expensive and bulky equipment, as well as the 
need of technical skill for maintaining the equipment. Also, 
some patients find it difficult to get in and out of the box 
or do not tolerate the confined space. Finally, plethysmog- 
raphy measures all the compressible gas within the body. 

including gas in the stomach or gastrointestinal tract, and 
may thus overestimate the intrathoracic gas volume. 

The patient described had severe bullous emphysema on 
the basis of a, -antitrypsin deficiency. Spirometry showed 
a mixed obstructive and "pseudorestrictive" abnormality. 
The TLC as measured by plethysmography does not show 
restriction, and in fact shows hyperinflation. The differ- 
ence in TLC measured by the dilution technique and by 
plethysmography (ie, 3.11 L) represents the trapped gas 


1 . Crapo RO, Morris AH. Gardner RM. Reference spironietric values 
using techniques and equipment that meet ATS recommendations. 
Am Rev Respir Dis 1981:12.3(6):659-664. 

2. Coates AL. Peslin R, Stocks J. Measurement of lung volumes by 
plethysmography. Eur Respir J 1997;10(6):1415-1427. 

3. Mitchell MM. Renzetti AD Jr. Evaluation of a single-breath method 
of measuring total lung capacity. Am Rev Respir Dis 1968:97(4): 

4. Slone RM. Gierada DS. Radiology of pulmonary emphysema and 
lung volume reduction surgery. Semin Thorac Cardiovasc Surg 1 996: 

5. Pare PD. Wiggs BJ. Coppin CA. Errors in the measurement of total 
lung capacity in chronic obstructive lung Thorax 1983:38(6): 

6. Piquet J. Harf A. Lorino H. Allan G. Bignon J. Plethysmographic 
measurement of lung volume in chronic obstructive pulmonary dis- influence of the panting pattern. Bull Eur Physiopathol Respir 


RESPIRATORY Care • May 2000 Vol 45 No 5 

Reviews of Books and Other Media. Note to publishers: Send review copies of books, films, 
lapes, and software lo Re:spiRATORy Care, 600 Ninlh Avenue. Suite 702. Seattle WA 98104. 

Books, Films, 
Tapes, & Software 

Respiratory Care in Alternate Sites. Ken- 
neth A Wyka MS RRT. Albany: Delmar 
Publishers. 1997. Softcover, 306 pages. 

This book covers pulmonary rehabilita- 
tion, home care, and subacute care, and is 
directed to a readership of respiratory ther- 
apists (RTs). recent graduates, and students. 
Each chapter begins with well-defined key 
terms and objectives. At the end of each 
chapter are review questions, a summary, 
and suggested reading, which help the reader 
with the objectives. Many of the chapters 
also include case studies, which make this 
book a good resource for school programs. 

The first chapter reviews the impact of 
health care reform on respiratory care. It 
discusses the results of the prospective pay- 
ment system on acute care facilities and the 
development of managed care programs. 
Terms such as capitation, health mainte- 
nance organization, preferred provider or- 
ganization, and integrated delivery system 
are well defined. It refers to the American 
Association for Respiratory Care Clinical 
Practice Guidelines and how they are useful 
in many sites and situations, such as dis- 
charge planning, and in development of 
pathways and protocols. Because the book 
was published in 1997. some of the state- 
ments are no longer true. For example: "Or- 
ganizations are studying the respiratory care 
practitioner's role and value because posi- 
tions in hospital-based respiratory care de- 
partments have decreased while positions at 
alternate sites have increased both in num- 
ber and scope. It is safe to assume that this 
trend will continue." With the implementa- 
tion of the prospective payment system in 
long-term care, the American Association 
for Respiratory Care estimates that 75% of 
the RTs who had been working in skilled 
nursing facilities are no longer employed.' 

The chapters on pulmonary rehabilitation 
cover selection of patients, key elements of 
a program, measuring and assessing out- 
comes, and reimbursement. The first chap- 
ter gives an introduction to pulmonary re- 
habilitation, identifying the differences 
between outpatient hospital and comprehen- 
sive outpatient rehabilitation facility. The 
rationale for pulmonary rehabilitation, with 
goals, objectives, and outcomes, comple- 
ment this chapter. Again since the book was 

published in 1997, the lists of references 
and suggested reading at the end of the chap- 
ter are very useful, but not as complete, 
since there has been much more material 
written since 1996 that impacts the delivery 
of pulmonary rehabilitation. 

The chapter on selecting patients identi- 
fies the basis for patient selection and test- 
ing regimen. Too much emphasis is placed 
on cardiopulmonary exercise testing. It al- 
most advises the reader that you cannot do 
pulmonary rehabilitation without this test 
pre- and post-program. In reality, the 
6-minute and 1 2-minute walk test have been 
very useful tools for evaluation and selec- 
tion of patients for programs. This test is 
not identified as an assessment tool, but as 
a patient exercise. It might suggest to many 
that without the cardiopulmonary exercise 
testing it is not indicated to do pulmonary 
rehabilitadon. Patients suffering severe 
chronic obstructive pulmonary disease can- 
not perform the cardiopulmonary exercise 
testing because of its difficulty and should 
not be excluded from pulmonary programs. 
Research has proven on multiple times the 
usefulness of pulmonary rehabilitation with 
such patients. This chapter is well written to 
impart a full understanding of cardiopulmo- 
nary exercise testing and the mechanisms 
behind the test. 

The chapter on key elements of a pul- 
monary rehabilitation program describes 
program format and compares the advan- 
tages and disadvantages of individual ver- 
sus group programs. It also reviews pro- 
gram components and contains information 
ranging from space requirements to equip- 
ment selection. Certain equipment, such as 
carbon dioxide monitors, peak flow meters, 
rowing machines, and stair steppers, are only 
indicated and used by a very small popula- 
tion of pulmonary rehabilitation patients, pri- 
marily because of the cost and increased 
physical demands on chronic obstructive 
pulmonary disease patients. The functions 
and responsibilities of all practitioners in- 
volved are excellent. The author included 
some very useful examples of forms to doc- 
ument education to exercise, as well as a 
good list of educational booklets available 
on the market today. This was an excellent 
chapter that all practitioners need to read to 
help them develop a state of the art pro- 

gram. It also describes program marketing, 
implementation, and treatment plan. 

The next chapter identifies the process of 
outcome assessment, which is crucial today 
in any program's survival. Its methods of 
measuring and assessing outcomes still iden- 
tify cardiopulmonary exercise testing as an 
essential tool. This is an expensive tool for 
assessment and not affordable for pro- 
grams. The reader should be advised to re- 
search other less expensive tools available 
today to measure adequate outcomes. It 
also reviews program results and findings 
of collected data on patient outcomes and 

The chapter on reimbursement covers 
factors affecting patient costs, charges, bill- 
ing practices, and coding systems. The in- 
formation is well written. All practitioners 
reading this chapter are advised to inquire 
about billing practices for their individual 
states, since they vary greatly among re- 
gions in the United States. It also gives a 
great deal of information on disease coding 
and current procedural terminology codes 
commonly used nationwide. It explains the 
common procedural terminology coding 

The chapters on home care begin with an 
overview of the current home care environ- 
ment, with an explanation of the history and 
current driving forces. On Page 141, the 
chapter states that equipment is approved 
by and paid for by the Health Care Financ- 
ing Administration through Medicare, based 
on monthly rentals, or, in some cases, capped 
rentals. It would be more complete if it stated, 
"purchase, monthly rentals or, in some cases, 
capped rental." 

The chapter on patient selection and dis- 
charge planning covers the definition of 
homebound patients. It may be appropriate 
to note that this definition is controversial 
and potentially problematic in the home care 
environment, because Medicare inconsis- 
tently applies the definition of home care 
and reserves the right to retroactively apply 
a more restrictive definition. On Page 155, 
in the paragraph on discharge planning, a 
sentence begins "This type of care is rec- 
ommended when the. ..." The statement is 
in reference to the previous sentence, iden- 
tifying candidates for outpatient or home 
care. The ellipsis mark that follows seems 

Respiratory Care • May 2000 Vol 45 No 5 


Books, Films, Tapes, & Software 

to contradict the use of home care. This is 
confusing and should only apply to candi- 
dates for outpatient services. The introduc- 
tion also states that home care is more fi- 
nancially responsible. While true in many 
cases (and data continue to accumulate ver- 
ifying this statement), it is not always the 
case. The cost of home care can exceed the 
cost of care in a long-term care facility. The 
concept is basically sound, but not an ab- 
solute. Therefore, it is appropriate to eval- 
uate each situation. Page 1 56 shows the qual- 
ifying Medicare guidelines for the payment 
of home oxygen. The guidelines listed here 
are incomplete, but the full guidelines are 
described on Page 237. 

Page 1 56 indicates that patients with ob- 
structive sleep apnea (OSA) may require 
continuous positive airway pressure 
(CPAP), oxygen, and aerosol therapy. We 
are not familiar with the use of aerosol ther- 
apy in the treatment of OSA. The author 
may be referring to the use of humidifica- 
tion with the CPAP device. Page 1 6 1 notes 
"Availability of nursing agencies." It may 
be more accurate to state "nursing care." 
Agencies may or may not be involved, and 
there is a trend (particularly with state Med- 
icaid funding) for independent nurses to pro- 
vide care. Page 161 also states that, "While 
financial considerations should never be a 
contributing factor in the delivery of 
care. ..." Though the author's intent is 
known, financial considerations are and 
must be considered. What should not be a 
factor is the quality of the selected care pro- 
vided once the decision to accept the patient 
is made, upon consideration of the financial 
limitations and realities. 

Chapter 9 covers home respiratory equip- 
ment and therapeutics. Page 176 refers to a 
'T*" cylinder. While this is not technically 
incorrect, since some providers this large 
cylinder size, other cylinder sizes are more 
commonly used. Perhaps a complete listing 
would be appropriate or a note that the "T" 
cylinder is not a common cylinder size or 
that other cylinder sizes are also used. Page 
1 75, under "Comparing the Three Oxygen 
Delivery Systems," the equipment selection 
process often includes cost and/or payer re- 
imbursement in the decision-making pro- 
cess. This was not included in the book. 
Page 1 82 notes that optional humidifiers can 
be added ". . . if na.sal drying is a problem." 
It is noteworthy that humidifiers have proven 
to comfort and compliance and 
are fust becoming an integral part of CPAP 

In the chapter entitled "Protocols and Pro- 
cedures of Care Delivery," under the sec- 
tion "Airway Management," on Page 198, 
it is difficult to understand the addition of 
"and after sterilizing technique" to the state- 
ment. "Other major concems regarding air- 
way management focus on safe suction 
pressures, proper technique involving hy- 
perinflation, and oxygenation before and 
after suction attempts." Perhaps, it referred 
to the general concern of "clean" or "ster- 
ile" technique when suctioning. Under 
"Continuous Positive Airway Pressure and 
Bilevel Pressure Therapy," it states that a 
physician "must specify a ramp time." We 
are not aware of any such requirement. It is 
generally done at the discretion of the RT. 
In fact, at least one manufacturer has it as a 
built-in feature. 

Page 199, under "Diagnostic Testing and 
Patient Evaluation," contains the following 
sentence: "However, respiratory care prac- 
titioners connected with a home medical 
equipment provider should not be involved 
with any assessment of a patient's oxygen- 
ation because it is a conflict of interest." 
The author is correct in that Medicare (and 
often Medicaid) prohibit the RT from qual- 
ifying/assessing the patient for the purpose 
of oxygen reimbursement. However, the RT 
is often requested to qualify nongovernment 
patients and all patients (including govern- 
ment) on an ongoing basis. The RT should 
be involved with assessing a patient's oxy- 
gen needs (with the one exception noted). 

Chapter 1 1 , "Home Care Accreditation 
and State Licensing Requirements." was a 
great overview! In Chapter 1 2. "Reimburse- 
ment for Respiratory Care," on Page 237, 
under "Reimbursement for Other Respira- 
tory Home Care Equipment," the author 
states that "Portable nebulizers are catego- 
rized as a routinely purchased item." This 
has changed, and currently they are catego- 
rized as a "capped rental item." 

The chapters on subacute care are well 
organized and written in a readable style. 
TTiey cover topics such as core elements of 
an ideal program, causes of the growth of 
subacute care, discharge planning, accredi- 
tation, and reimbursement of respiratory ser- 
vices. In the chapter on accreditation there 
is a statement that is incorrect. "As with 
hospital care. Medicare reimbursement for 
inpatient care al subacute facilities depends 
on accreditation by the Joint Commission 
on Accreditation of Healthcare Organiza- 
tions." Most skilled nursing facilities and 
subacute care facilities iire not thus accred- 

ited, but do receive Medicare reimburse- 

The last chapter, on patient and family 
education, is a good resource for the prac- 
titioner who is becoming more involved in 
education but has no formal training. It pre- 
sents at an understandable level Bloom's 
educational domains, as well as teaching 
methodologies. The final parts of this chap- 
ter are on asthma education. They are very 
informative and stimulating. This is an ex- 
cellent chapter applicable to all sites. 

Respiratory Care in Alternate Sites is 
well written and comprehensive in its cov- 
erage. There are a few typographical errors. 
References are useful but a little outdated. 
Illustrations are clearly presented and the 
index is thorough. We all agree that it is a 
welcome addition to any home or school 

Scott L Bartow MS RRT 

Ventilatory Care Management of 


Milwaukee, Wisconsin 

Dianne L Lewis MS RRT 

Acute and Subacute Care Consultant 
Naples, Florida 

Julien M Roy RRT 

Pulmonary Rehabilitation Services 

Halifax Community Health System 

Daytona Beach. Florida 


I . Muse & Associates (commissioned by the 
American Association for Respiratory 
Care). A comparison of Medicare nursing 
home residents who receive services from 
a respiratory therapist with those who do 
not. 1999. 

Case Studies in Allied Health Ethics. Rob- 
ert M Veatch and Harley E Flack. Upper 
Saddle River. New Jersey: Prentice Hall. 
1997. Hardcover, 290 pages, $57.47. 

This is a well written, easy to read case 
study based textbook aimed at the allied 
health student and graduate. The allied 
health fields covered include dietetics, 
health information management, medical 
technology, occupational therapy, physi- 
cian assistant, physical therapy, radiologic 
technology, respiratory care, and speech- 
language-hearing. There are 8 1 used, 
of which only 10 deal directly with respi- 
ratory care. There is one dental hygiene 


Respiratory Cark • May 20{)() Vol 45 No 5 

Books, Films, Tapes, & Software 

and one social work case study, but none 
relating to speech-language-hearing. 

The book is divided into 4 parts: an in- 
troduction, which lays the foundation and 
guides the reader to what to expect later in 
the book: a section on ethics and values: a 
section dealing with ethical principles: and 
a section on special problem areas. An ap- 
pendix follows, listing the codes of ethics of 
the 9 allied health fields, as well as a glos- 
sary of terms used throughout the text. A 
shaded box surrounds the number and title 
of each case study. 

The authors" apparent goal is to develop 
a systematic approach to the topic of ethics 
in allied health by asking: ( 1 ) What makes 
right acts right? (discussed in the section on 
ethics and values). (2) What kinds of acts 
are right? (in the section on ethical princi- 
ples). (3) How do rules apply to specific 
situations? and (4) What ought to be done 
in specific cases? The latter two questions 
are explored in the fourth section, dealing 
with special problems. The purpose is to 
answer the questions by using studies 
from the various allied health professions as 
examples. This is accomplished in each of 
the 14 chapters by a general introduction to 
the topic, presentation of the problem in the 
case study, then an explanation of how the 
solution to the problem is obtained by ex- 
ploring its various sides. No attempt is made 
to dictate what in the opinion of the authors 
is the right response in each case, but the 
reader is guided through the thinking pro- 
cess by comments, explanations, and ques- 
tions that help solve the problem. The in- 
formation gained is then the basis for the 
next case study. 

For the student or practitioner this book 
has advantages and disadvantages. The 
studies are not grouped together by profes- 
sion but are woven throughout the various 
issues discussed. To find the ones pertinent 
to respiratory care, the reader has to wade 
through all of them. TTiere is a table of con- 
tents for the cases, but it is not helpful in 
this respect. The 10 case studies dealing with 
respiratory care issues are well developed 
and pertinent to clinical practice. Cases ex- 
plore issues of disagreement with physi- 
cian's moral judgment (#4). going on strike 
to benefit the profession (#15). promise- 
keeping to patients (#.38), patient confiden- 
tiality (#39). charting treatments that were 
not done (#43). withdrawing ventilator care 
(#46). discussion of f)oor prognosis/do-not- 
resuscitate (#72). brain death (#77), patient's 
advance directives versus family's wishes 

(#79). and workload triage (#81). Some of 
the other cases may be adapted easily to the 
profession (eg, #1, #2, #6, #34), while the 
rest are more specific to the other allied 
health professions (eg. abortion, genetics, 
mental health). They do. however, present 
an opportunity for the practitioner to learn 
more about the rationale for the decisions of 
fellow team members who provide patient 

The strengths of this text are in the wide 
variety of case studies used, clarity of pre- 
sentation, and pertinence to the allied health 
profession. The cases used are written at a 
level that a student or practitioner would 
easily understand, and the text flows 
smoothly and logically, so the concepts are 
readily grasped. The authors have brought 
together a broad selection of that re- 
flect issues faced by allied health profes- 
sionals, and this is both a strength and a 

In trying to present case studies that rep- 
resent all areas of allied health, the number 
of total cases presented for each profession 
is limited. For example only 6 cases are 
presented related to the field of radiologic 
technology, 7 each for dietetics and health 
information management, and 8 for physi- 
cian assistant. This limitation prevents cov- 
erage of ethical dilemmas in any one field 
from being thorough. Instructors, students, 
and practitioners may be reluctant to adopt 
or purchase a book with so few cases that 
pertain directly to their profession. The med- 
ical ethics presented in this book are from 
the point of mainstream Judeo-Christian tra- 
ditions. Only one case (#29) addresses an 
issue from the Islamic tradition. Although 
Buddhism, Christian Science, and Jehovah's 
Witnesses are briefly mentioned in the text, 
no case studies are presented. This limits 
the effectiveness of the text in preparing 
readers to address ethical issues pertinent to 
those traditions. There is also a lack of con- 
sistency in the fonnat of the case studies. 
Some of the have discussion ques- 
tions separate from the case (eg. #19. #21. 
#22). others have questions as part of the 
case (eg. #1. #2. #3), while still others have 
no discission questions at all (eg. #16. #28. 
#31). One other minor inconsistency fol- 
lows Case 39. dealing with patient infonna- 
tion confidentiality. Reference is made to 
an older (1988) version of the Occupational 
Therapy Code of Ethics, which has more 
specific language addressing this issue, 
whereas the appendix references the 1994 
version, which has more general language. 

No reference is made in the text to address 
this difference. 

Overall, this is an excellent text, clearly 
presenting relevant information in the field 
of medical ethics in the allied health pro- 
fessions. It would make a valuable addition 
to the library of any respiratory therapy in- 
structor or department manager. Respiratory 
care educators will find the text informa- 
tive, but will probably not require students 
to purchase it as part of the core curriculum. 

Arthur B Marshak RRT RPFT 

Department of Cardiopulmonary Sciences 
Loma Linda University 
Loma Linda. California 

The Lung: Molecular Basis of Disease. 

Jerome S Brody MD. Philadelphia. Penn- 
sylvania: WB Saunders. 1998. Hardcover, 
illustrated, 218 pages. $52. 

The Lung: Molecular Basis of Disease. 
by Jerome Brody. is a wonderful over\ iew 
of the molecular basis of pulmonary medi- 
cine. Unlike many books dealing with the 
scientific basis of pulmonary medicine, this 
book is written by a single author who has 
an expert's overview of the field. The book 
is a pleasure to read, as Dr Brody's literary 
writing style brings to mind the prose of 
Lewis Thomas in The Lives of a Cell. Basic 
concepts in molecular biology are presented 
clearly and concisely, and then specific dis- 
eases are used to show how advances in 
molecular medicine have changed our un- 
derstanding of the pathogenesis and treat- 
ment of lung High quality illustra- 
tions in each chapter illustrate key points 
and provide a visual basis for understanding 
major concepts and techniques. 

The opening chapter. ""The Basics," gives 
an overview of concepts in molecular biol- 
ogy that is understandable for anyone with 
a background in biology. This chapter is a 
welcome tutorial on the structure of DNA. 
the cellular machinery that replicates DNA, 
and the steps that lead from DNA to pro- 
cessed and secreted proteins. The chapter 
on tuberculosis is a readable description of 
the way molecular biology has revolution- 
ized the understanding and diagnosis of tu- 
berculosis. The reader also learns how mo- 
lecular epidemiology has provided tools to 
trace emerging patterns of resistance in my- 
cobacteria. The chapter on alveolar proteino- 
sis shows how surprising findings in trans- 
genic mice, created for a completely 
different rea.son. led to a fundamental un- 
derstanding of the pathogenesis of this rare 

Respiratory Care • May 2000 Vol 45 No 5 


Books, Films, Tapes, & Software 

but often fatal disease. The chapters on a,- 
antitrypsin deficiency and cystic fibrosis 
provide understandable illustrations of how 
molecular biology has led to understanding 
the fundamental defects in these diseases. 
In addressing gene therapy for cystic fibro- 
sis, the problems and frustrations encoun- 
tered by gene therapy programs are ex- 
plained. The chapter on lung cancer provides 
a fascinating overview of the genes that reg- 
ulate the cell cycle and the genetic muta- 
tions that change cycling cells from normal 
to malignant. A wonderful chapter on de- 
velopmental biology provides a clear back- 
ground about how genes operate in the nor- 
mal development of any organism. 
Fascinating descriptions of key molecular 
experiments show the importance of master 
genes that turn on and off development of 
specific organs, such as the eye. The ac- 
quired immunodeficiency syndrome virus 
and the mechanisms by which it destroys 
the T cell-mediated immune system are 
made clear in the chapter on acquired im- 
munodeficiency syndrome. The last chapter 
touches on the Human Genome Project and 
the advances that are promised from under- 
standing the identity of all of the genes in 
the human genome. Asthma is used as an 
example of a complex disease that has mul- 
tiple genetic determinants. 

This book is a starting place for individ- 
uals who would like to learn more about 
concepts in molecular biology and the ap- 
plication of these concepts to specific dis- 
eases. The chapters in this book could be 
used as core text for a scientific reading 
club comprised of individuals who are in- 
terested in learning about molecular biol- 
ogy in a way that is both informative and 

Thomas R Martin MD 

Division of Pulmonary and 

Critical Care Medicine 

Seattle VA Medical Center 

University of Washington School of 


Seattle, Washington 

Gastroesophageal Reflux Disease and 
Airway Disease. Mark R Stein, editor. 
(Lung Biology in Health and Disease, Vol- 
ume 129, Claude Lenfant, Executive Edi- 
tor.) New York: Marcel Dekker. 1999. Hard- 
cover, illustrated, 364 pages, $185. 

The association between airway disease 
and gastroesophageal reflux disease 
(GERD) has been known for many years. 

In Gastroesophageal Reflux Disease and 
Airway Disease, edited by Mark R Stein 
MD. this association is brought together in 
13 excellently written chapters that span the 
spectrum beginning with the embryologic 
origins of the gut and airways and ending 
with a discussion of GERD and airways 
disease in the geriatric patient. Stein and his 
coauthors have put together a book based 
on a large body of scientific evidence, with 
appropriate reviews of a number of articles 
to support this association. 1 believe this 
book is targeted for those who are primarily 
treating patients with airways disease and 
concomitant GERD. However, the detailed 
scientific evidence explaining the mecha- 
nisms of GERD and its therapy are also 
suited to the gastroenterologist. I believe this 
book is not intended for respiratory thera- 
pists, anesthesiologists, primary care physi- 
cians, or nurses unless they have a specific 
interest in this topic. 

The book's first chapter begins with the 
embryologic origins of the gut and lung. 
While this chapter may not have been ab- 
solutely necessary for this publication, it out- 
lines the origins of the upper and lower re- 
spiratory tract as well as the esophagus and 
stomach. It clearly defines the potential 
physiologic relationships between these two 
organ systems and sets the stage for under- 
standing the potential for overlap between 
diseases that affect the two systems sepa- 
rately. The next 12 chapters comprehen- 
sively review a number of clinical syn- 
dromes associated with GERD, as well as 
the therapy, both medical and surgical, for 
these conditions. 

Chapter 2, "Inflammation in Asthma: The 
Role of Nerves and Potential Influences of 
GERD," by BJ Canning, is an excellent re- 
view of inflammation in asthma, a topic that 
is incredibly complex but is presented in a 
way that is easily understood. The author 
presents a comprehensive review of the lit- 
erature defining the mechanisms of inflam- 
mation in asthma, supported by referencing 
an extensive number of articles. Specific at- 
tention is given to the nervous system and 
its involvement in influencing inflammation 
in the airways. The section on the specific 
effect of esophageal reflux and its effect on 
nerve-mediated inflammation is probably 
the best and most readable discussion of 
this topic that 1 have read. 

Chapter 3, "Diagnosis of GERD," by PO 
Katz and DO Castell, makes a comprehen- 
sive diagnostic approach to the patient with 
suspected gastroesophageal and air- 

ways disease. An algorithm, which appears 
easy to use, is presented clearly. The au- 
thors then define the benefits of all of the 
diagnostic tools used in the evaluation of 
GERD. They stress the use of bimodal pH 
probe analysis, a test that is essential to mak- 
ing the diagnosis of GERD. This chapter 
supports many of the other chapters, be- 
cause it gives the reader a knowledge base 
to understand the diagnostic approaches de- 
scribed in subsequent chapters. 

In Chapter 4. "The Manifestafions of 
GERD," by JA Koufman. reviews a topic 
that I believe is probably unknown to most 
pulmonologists and gastroenterologists: la- 
ryngopharyngeal reflux. The clinical mani- 
festations of this condition, as well as other 
otolaryngologic problems, is very well re- 
viewed. The use of appropriate diagnostic 
testing is stressed in this discussion. 

In Chapter 5, "GERD: A Major Factor 
in Chronic Cough," by CJ Mello, reviews 
an extensive literature supporting the diag- 
nosis of chronic cough as the sole manifes- 
tation of GERD. The importance of diag- 
nostic testing is underscored. Strong 
recommendation for appropriate medical 
therapy (stressing the need for prolonged 
medical therapy) and surgical therapy is 

In Chapter 7, "GERD, Airways Disease, 
and the Mechanisms of Interaction." by SM 
Harding, the author presents a comprehen- 
sive discussion of the mechanisms of action 
between airways disease and GERD. She 
reviews a more extensive literature concern- 
ing the mechanisms of GERD and bron- 
chial asthma than that described in Chapter 
6, "The Prevalence of GERD in Asthma." 
by SJ Sontag, where the author spends the 
majority of the paper discussing one of his 
own articles. In Harding's discussion there 
are different interpretations made of some 
of the same articles presented in Chapter 6. 
The fact that authors are reviewing similar 
articles and lending different interpretations, 
I believe, helps the reader understand this 
complex literature better. 

Chapter 8. "Medical Treatment of GERD 
and Airways Di.sease," by MS Kavuru and 
JE Richter. and Chapter 9, "Surgical Treat- 
ment of GERD with Emphasis on Respira- 
tory Symptoms," by SR DeMeester and TR 
DeMeester, provide sufficient infomiation 
so that the reader can become expert in treat- 
ing this condition. In Chapter 9 there is an 
algorithm that looks at the evaluation that 
must be done before surgical intervention is 
considered. There is also a lengthy discus- 


Respiratory Care • May 2000 Vol 45 No 5 

Books, Films, Tapes, & Software 

sion about when it is appropriate to treat 
surgically, considering the potential for fail- 
ure of medical therapy, problems with drugs, 
drug interactions, and cost effectiveness. 
Chapter 10. "GERD and Airways Disease 
in Children and Adolescents." by SJ McGe- 
ady. Chapter 1 1 . "Respiratory Complica- 
tions of Reflux Disease in Infants," by SR 
Orenstein. and Chapter 13. "Odds and Ends 
in the State of the Art." by MR Stein, com- 
plete the discussion of GERD and asthma 
in infants, children, adolescents, and the ge- 
riatric patient. These three chapters clearly 
describe how GERD is not only a disease of 
adults, but can have clinically important 
manifestations in all age groups. 

The editor has presented his spectrum of 
topics in an organized fashion. I might have 
rearranged the order of the topics in the 

book chronologically, discussing diseases in 
infants, children, and adolescents first, fol- 
lowed by adults, and subsequently the ge- 
riatric population. However, the order in 
which the book is presented does not take 
away from its purpose. Overall. I found no 
typographical errors. The clarity of the il- 
lustrations is good, with the exception of 
Chapter 1 . where the reproductions of the 
embryonic cross sections did not achieve an 
appropriate level of clarity. The tables and 
algorithms are easy to follow and are pre- 
sented in a way that they can be applied 
clinically. Overall, the style of all the au- 
thors was very easy to read. The bibliogra- 
phies are quite comprehensive and exten- 
sive, as well as being up to date. Conclusions 
based on scientific evidence reproduced 
from the references were clear and succinct. 

clearly supporting the facts that the authors 
wanted to present. 

This book is mandatory reading for any- 
one involved in the treatment of pulmonary 
diseases, as well as those with an interest in 
esophageal diseases. The caliber of the 
manuscripts is superior, and the compila- 
tion of all of these chapters into one book 
makes for a substantially better understand- 
ing of the relationships between gastro- 
esophageal disease and airways disease. 

William M Corrao MD 

Department of Medicine 

Division of Pulmonary. Sleep, and 

Critical Care Medicine 

Rhode Island Hospital 

Brown University School of Medicine 

Providence, Rhode Island 

WmA Free Trip to the 

2000 AARC International 

Respiratory (congress in 

Cincinnati, Ohio, October 7-10 

All you have to do is request information from tfie advertisers In this issue. 

How to Enter 

To receive information from advertisers in this issue, simply fill out the 
postage-paid Product Information card and drop it in any US mailbox. 
Your name m\\ automatically be entered in a sweepstakes drawing for 
the Grand Prize which Includes round-trip airfare for two to Cincinnati, 
Ohio from any domestic US airport, 4 nights, hotel accommodations, 
and one registration to the 46th International Respiratory Congress. To 
enter you must circle the numbers for the product Information that you 
would like to receive, and provide all the information requested. Cards 
may also be faxed to (609) 786-4415 or enter Online by requesting 
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Sweepstakes rules may be requested by e-mail at 

Respiratory Care • May 2000 Vol 45 No 5 






Volume 44 is bound in a blue-buclcram cover and may be imprinted, free of 
charge, with your name or the name of your organization. Each volume is 
MO for current AARC members ond ^80 for non-members. Shipping is in- 
cluded for U.S. and Canadian residents. 

Available for a limited time, older bound volumes at discounted rotes. 


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New Products 
& Services 

3-Channel ECG. Futuremed introduces 
the EZ-3, a device the company de- 
scribes as a small, low cost alternative to 
standard 3-channel ECGs. Futuremed 
says the EZ-3 is lightweight and durable, 
making it ideal for in-house use or on the 
road (a rechargeable battery allows up to 
3 hours of operation in any setting). 
Company press materials say that this 
device has a high resolution printer that 
generates 3 channel tracings of 12 simul- 
taneous leads and that the ECGs wide 
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CPAP Device. Nidek Medical Products 
Inc introduces the Silenzio Elite CPAP, 
another addition to the NiPap Sleep 
Series. According to Nidek press materi- 
als the new product is designed with the 
following features: compact design 2.5 
lbs; 4"H X 8 "W x 11 "D), low noise (less 

than 38 dBA), illuminated digital dis- 
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adjustable ramp selector, variable ramp 
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Automated STAT Analysis Quality 
Control. Radiometer introduces 
AutoCheckTM, a device they describe as 
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STAT analysis quality control process. 
The company says this device is an in- 
tegrated part of the ABL™700 Series 
STAT analyzer, which measures pH, 
blood gases, oximetry, electrolytes, and 
metabolites. According to Radiometer, 
AutoCheck eliminates the time-con- 
suming manual procedures for measur- 
ing quality control solutions on the ana- 
lyzer and state that tests showed work 
time on running QC measurements was 
reduced by more than 80%. The compa- 
ny also says the AutoCheck can be re- 
motely monitored and controlled from a 
central PC with the Radiance^^ STAT 
Analyzer Management Software. For 
more information from Radiometer, cir- 
cle number 192 on the reader service 
card in this issue, or send your request 
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Analyzer. Nova Biomedical has intro- 
duced the Stat Profile M7 analyzer, 
which they describe as the first to offer 

blood gases, Chem 7 (Na*, K*, CI', 
TCO2, Glu, Urea, Crea), Hct/Hb, ionized 
calcium, lactate, and oxygen saturation 
on a single, test selective analyzer. 
Company press materials say the device 
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of Events 


May 30-June I— Orlando. Florida 

The FSRC will hold its Sunshine 
Seminar 2000 at the Wyndham Palace 
Resoit and Spa at Lake Buena Vista. 
The program will feature 32 
educational lectures on a wide range 
of respiratory care topics. Up to 18 
CEUs available. An exhibit hall with 
up to 75 exhibitors is planned, and an 
attendance of 1 ,000 is expected. 
Contact: For registration and 
exhibitor information, contact Judy 
Cook at (407) 841-51 1 1, ext. 8466, or 
the FSRC executive office at (561) 
546-1863. Toll-free line for in-Florida 
calls is (800) 447-FSRC. E-mail 

June 1-2— Orlando, Florida 

The FSRC will sponsor a Smoking 
Cessation Counselor Training 
Workshop at the Wyndham Palace 
Resort and Spa at Lake Buena Vista. 
The program will be presented by 
Jeffery Belle, PhD, RRT, nationally 
recognized expert on smoking 
cessation counseling, and Linda 
Ferry, MD, MPH, developer of 
Zyban. Attendees who complete the 
16-hour session and successfully pass 
the test are eligible to become 
Smoking Cessation Counselors. 
Attendees will also be eligible for 16 
CEUs toward state licensure. Space is 
limited to the first 50 registrants. 
Contact: For information, contact Pat 
Nolan at (561) 546-1863. Toll-free 
line for in-Florida calls is (800) 447- 
FSRC. E-mail 

June 2-4— Vail, Colorado 

The AARC Summer Forum will be 
held at the Vail Marriott Mountain 
Resort and is approved for up to 
16.75 hours CRCE credit. The three- 
day sessions will cover education, 
management, and general topics. 
Contact: For more information, call 
(972) 243-2272 or log on to www. 

June 4-5— Va/7, Colorado 

The AARC's Disease Management of 
Asthma Course will be held at the 
Vail Marriott Mountain Resort 
immediately following the Summer 


Forum. Twelve hours of CRCE credit 
are available. Attendance at the 
Summer Forum is not required to 
attend this course. Contact: For more 
information, call (972) 243-2272 or 
log on to 

June 14-16— Round Top, New York 

The New Jersey and New York State 
Societies for Respiratory Care host 
their 1 3th annual Spring Forum 
(formerly known as the 
Managers/Educators "Rocking Chair" 
Conference) at the Riedlbauer Resort. 
Speakers include AARC President 
Garry Kauffman, Clatie Campbell, 
Ralph Cavallo, Ken Wyka, Joe 
Sorbello, John Rutkowski, Sandy 
McCleaster, and George Gaebler. 
Topics will cover time management, 
team building, reducing apathy, and 
instilling motivation. Nine CRCE 
units have been requested. It is open 
to all RCPs but should be of special 
interest to supervisors, managers, 
educators, and those practicing in 
alternate sites. Contact: Ken Wyka 
at (201) 288-3959 or Joe Sorbello at 

June 20— Teleconference with 

After viewing a tape of the fourth 
installment of the AARC's 2000 
"Professor's Rounds" series, "Cost- 
Effective Respiratory Care: You've 
Got to Change," participate in a live 
telephone question-and-answer 
session (1 1:30-12 noon CT) and 
receive one CRCE credit hour 
(nurses earn 1 .2 hours of CE credit). 
Contact: To receive the 90-minute 
videotape and register for the 
teleconference, call the AARC at 
(972) 243-2272. 

July 25— Live Videoconference 

Participate in a live, 90-minute 
satellite broadcast of the fifth 
installment of the AARC's 2000 
"Professor's Rounds" series and 
receive one CRCE credit hour 
(nurses earn 1 .2 hours of CE credit). 
"Pediatric Ventilation: Kids Are 
Different" will be broadcast from 
1 1:30-1 p.m. (CT). Contact: For 
more information, call the AARC at 
(972) 243-2272. 

September 20-22— Rochester, 


The Minnesota Society for 
Respiratory Care host their 31st 
Annual Fall State Conference — 
"Too Hot to Handle." Contact: For 
more information, contact Laurie 
Tomaszewski at (65 1 ) 232-1922, 
Carolyn Dunow at dunowc®, or Carl Mottram at 
mottram .carl @ . 

Other Meetings 

June lS-l6—Cheyenne, Wyoming 

United Medical Center will hold its 
Annual Critical Care Seminar at the 
Terry Bison Ranch just eight miles 
south of Cheyenne on the Wyoming 
and Colorado border. Topics include 
hemodynamic monitoring, balloon 
pump troubleshooting, acute ML status 
asdima, acute head injury and 
neuromuscular crisis in the adult and 
pediatric patient, RSV in the newborn 
and children, and variances in care and 
monitoring of the ventilator patient. 
Ten CEUs have been requested from 
the AARC. Contact: Contact Steve 
McPherson at (307) 633-7700 or 

August 13-19— Hobertus, Wisconsin 

The American Lung Association of 
Metropolitan Chicago is looking for a 
volunteer RT with a special interest 
in respiratory care for children. The 
RT will volunteer their time and 
provide structured asthma education 
one hour a day to children at the 1 8th 
annual CampACTION at YMCA 
Camp Minikani. The RT will also 
provide individual education in the 
cabins. Up to eight CEU credits are 
available. CampACTION is staffed 
24 hours a day by physicians, nurses, 
an RT. and a pharmacist. Contact: If 
interested, call Evet Hexamer at 
(312) 243-2000, ext. 260. 

Practical Spirometry Certification 

Two-day hands-on NIOSH-approved 
course presented by Mayo 
Pulmonary Services: Sept. 29-30 in 
Chicago, IL; and Nov. 9-10 in 
Rochester, MN. NIOSH approval 
#57. Approved by AAOHN for 15.6 
contact hours. Contact: For further 
details, call (800) 533-1653. 



American Association for Respiratory Care 

Please read the eligibility requirements for each of the classifications in the 

right-hand column, then complete the applicable section. All information 
requested below must be provided, except where indicated as optional. 
See other side for more information and fee schedule. Please sign and dote 
application on reverse side and type or print clearly. Processing of applica- 
tion takes approximately 1 5 days. 

n Active 

n Foreign 

D Physician 

D Industrial 
D Special 
D Student 

Last Name _ 
First Name 

Social Security No. 

Home Address 




Phone No. 

Primary Job Responsibility fcfiecfr one only) 

D Technical Director 

n Assistant Technical Director 

D Pulmonary Function Specialist 

D Instructor/Educator 

n Supervisor 

D Staff Therapist 

D Staff Technician 

n Rehabilitation/Home Care 

D Medical Director 

D Sales 

D Student 

n Other, specify 

Typo of Business 

Zj Hospital 

n Skilled Nursing Facility 


D Home Health Agency 

n Educational Institution 

n Manufacturer or supplier 

n Other, specify 

Date of Birth (optional) 

Sex (optional) 

U.S. Citizen? 



Have you ever been a member of the AARC? 
If so, when? From 



Preferred mailing address: D Home D Business 

For office use only 


An individual is eligible if he/she lives in the U.S. or its territories or was an Active Member 
prior to moving outside its borders or territories and meets ONE of the following criteria: (I ) is 
legolly credentialed as o respirotory care professional if employed in a state that mandates 
such, OR [21 is a graduate of on accredited educational program in respiratory care, OR (31 
holds o creclential issued by the NBRC. An individual who is an AARC Active Member in good 
standing on December 8, T994, will continue as such provided his/her membership remains in 
good standing. 


Place of Employment 

Address "_ 




Phone No. I 

Medical Director/Medical Sponsor 


Individuals who hold a position related to respiratory care but do not meet the requirements of 
Active Member shall be Associote Members. They hove oil the rights and benefits of the Asso- 
ciation except to hold office, vote, or serve as choir of a standing committee. The following sub- 
classes of Associate Membership ore available: Foreign, Physician, ond Industrial (individuals 
whose primary occupation is directly or indirectly devoted to the manufacture, sole, or distribu- 
tion of respiratory care eauipment or supplies). Special Members ore those not working in a 
respiratory care-related field. 


Place of Employment 





Phone No. ( 


Individuals will be classified as Student Members if tfiey meet all tfie requirements for Associate 
Membership and are enrolled in on educational program in respiratory care accredited by, or 
in the process of seeking accreditation from, on AARC -recognized agency. 

SPECIAL NOTICE — Student Members do not receive Continuing Respirotory Care Education 
(CRCE) transcripts. Upon completion of your respiratory care education, continuing education 
credits may be pursued upon your reclassification to Active or Associote Member. 

School/RC Program 



State Zip 

Phone No. 

Length oi program 

□ 1 year 
n 2 years 

Bxpected Date of Graduation (REQUIRED 

D 4 years 

D Other, specify . 



American Association for Respiratory Care • 11 030 Abies Lane > Dallas, TX 75229-4593 • [972] 243-2272 • Fox [972] 484-2720 

American Association for Respiratory Care 

i-^M.-^-^/if-.^^^^St^'W^i^X^S^ik/^^M^^ ■ ' 



Demographic Quesiions 

We request that you answer these questions in order to help us 
design services and programs to meet your needs. 

Cheek the Highest Degree Earned 

a High School 

D RC Graduate Technician 

n Associate Degree 

n Bachelor's Degree 

D Master's Degree 

n Doctorate Degree 

Number of Years In Respiratory Care 

G a2 years .. 11-15 Years 

D 3-5 years D 1 6 years or more 

n 6-10 years 

Job Status 

a Full Time 

D Part Time 


r: RRT 


D Physician 




n Less than $ 1 0,000 

D $10,001 -$20,000 

D $20,001 -$30,000 

D $30,001 -$40,000 

D $40,000 or more 




n Perinatal/Pediatric 


I hereby apply for membership in the American Association for Respiratory Care 
and have enclosed my dues If opproved for membership in the AARC, I will abide 
by its bylaws and professional code of ethics, I authorize investigation of all state- 
ments contained herein and understand that misrepresentations or omissions of 
focts called for is cause for rejection or expulsion. 

A yearly subscription to RESPIRATORY CARE journol and AARC Times magazine 
includes an otlocotion of $1 1 ,50 from my dues for each of these publications. 

NOTE: Contributions or gifts to the AARC are not tax deductible as charitable con- 
tributions for income tax purposes However, they may be tax deductible as ordi- 
nary and necessary business expenses subject to restrictions imposed as a result of 
association lobbying activities The AARC estimates that the nondeductible portion 
of your dues — the portion which is allocable to lobbying — is 26%. 


MembBrship Fees 

Payment must accompany your application to the AARC. Fees are for 12 
months. (NOTE: Renewal fees are $75.00 Active, Associate-Industrial or Associ- 
ate-Physician, or Special status; $90.00 for Associate-Foreign status; and 
$45.00 for Student status). 

n Active 

$ 87.50 

D Associate (Industrial or Physician) 

$ 87.50 

n Associate (Foreign) 


n Special 

$ 87.50 

D Student 

$ 45.00 



Specialty Sections 

Established to recognize the specialty areas of respiratory care, these sections 
publish a bi-monthly newsletter that focuses on issues of specific concern to that 
specialty. The sections also design the specialty programming at the national 
AARC meetings. 

D Adult Acute Core Section 
n Education Section 
D Perinatal-Pediatric Section 
□ Diagnostics Section 
D Continuing Core- 
Rehabilitation Section 
D Management Section 
n Transport Section 
D Home Core Section 
n Subacute Core Section 


GRAND TOTAL = Membership Fee 
plus optional sections 



D Total Amount Enclosed/Charged $ 
D Please charge my dues (see below] 

To charge your dues, complete the following: 
D MasterCard 
n Visa 

Card Number 

Card Expires /_ 


Mail application and appropriate fees to: 
American Association for Respiratory Care • 1 1 030 Abies Lane • Dallas, TX 75229-4593 

[972] 243-2272 • Fax [972] 484-2720 


Manuscript Preparation Guide 

Respiratory Care welcomes original manuscripts related to the sci- 
ence and technology of respiratory care and prepared according to the 
following instructions and the Uniform Requirements for Manuscripts 
Submitted to Biomedical Journals (available at http://www.acpon- Manuscripts are blinded and 
reviewed by professionals who are experts in their fields. Authors 
are responsible for obtaining written permission to publish previ- 
ously-published figures and tables from the original copyright hold- 
er. Accepted manuscripts are copyedited for clarity, concision, and 
consistency with RESPIRATORY Care format. Before publication, 
authors receive page proofs for minor correction. Published papers 
are copyrighted by Daedalus Inc and may not be published elsewhere 
without permission. Editorial consultation is available at any stage 
of planning or writing fof any submission; contact the Editorial Office. 

ing physician must either be an author or furnish a letter 
approving the manuscript. Must include; Title Page, Abstfact, Intro- 
duction, Case Summary, Discussion, and References. May also 
include: Tables, Figures (if so, must include Figure Legends), and 

Point-of-View Paper: A paper expressing personal but substanti- 
ated opinions on a pertinent topic. Must include; Title Page, Text, 
and References. May also include Tables and Figures (if so, must 
include Figure Legends). 

Drug Capsule: A miniature review paper about a drug or class of 
drugs that includes discussions of pharmacology, pharmacokinet- 
ics, or pharmacotherapy. 

Categories of Articles 

Research Article; A report of an original investigation (a study). 
Must include Title Page, Abstract, Key Words, Background, 
Methods, Results, Discussion, Conclusions, and References. May 
also include Tables, Figures (if so, must include Figure Legends), 
Acknowledgments, and Appendices. 

Graphics Corner: A briefcase report discussing and illustrating 
waveforms for monitoring or diagnosis. Should include Questions, 
Answers, and Discussion sections. 

Kittredge's Comen A brief description of the operation of respiratory 
care equipment. Should include information from manufacturers and 
editorial comments and suggestions. 

Review Article: A comprehensive, critical review of the literature 
and state-of-the-art summary of a topic that has been the subject of 
at least 40 published research articles. Must include; Title Page, Out- 
line, Key Words, Introduction, Review of the Literature, Summa- 
ry, and References. May also include; Tables, Figures (if so, must 
include Figure Legends), and Acknowledgments. 

Overview; A critical review of a pertinent topic that has fewer than 
40 published research articles. Same structure as Review Article. 

Update: A report of subsequent developments in a topic that has 
been critically reviewed in RESPIRATORY Care or elsewhere. Same 
structure as a Review Article. 

PFT Corner: A brief, instructive case report including pul- 
monary function testing, accompanied by a review of the relevant 
physiology and appropriate references to the literature. 

Test Your Radiologic Skill: A brief, instructive case report involv- 
ing pulmonary medicine radiography and including one or more radio- 
graphs. May involve imaging techniques other than conventional 
chest radiography. 

Review of a Book, Film, Tape, or Software: A balanced, critical 
review of a recent release. RESPIRATORY Care does not accept unso- 
licited book reviews; please contact the Editor if you have a sug- 
gestion for a book review. 

Special Article: A pertinent paper not fitting one of the other categories. 
Consult with the Editor before writing or submitting such a paper. 

Editorial: A paper addressing an issue in the practice or adminis- 
tration of respiratory care. It may present an opposing opinion, clar- 
ify a position, or bring a problem into focus. 

Letter: A brief, signed communication responding to an item pub- 
lished in RESPIRATORY Care or about other pertinent topics. Tables, 
Figures, and References may be included. The letter should be marked 
"For Publication." 

Case Report: Report of an uncommon clinical case or a new or 
improved method of management or treatment. A case-manag- 

Preparing the Manuscript 

Print on one side of white 8.5x11 inch paper, with margins of at 
least I inch on all sides. Double-space the text and number the pages. 
Do not include author names, author institutional affihations, or allu- 
sions to institutional affiliations anywhere except on the title page. 
On the Abstract page include the tide but do not include author names. 
Begin each of the following on a new page; Title Page, Abstract, 
Text, Acknowledgments, References, each Table, each Figure, and 
each Appendix. Use standard English in the first person and active 
voice. Type all headings in initial-capital letters (eg. Background, 
Methods, Patients, Equipment, Statistical Analysis, Results, Dis- 
cussion). Center the main section headings and place second-level 
headings on the left margin. 

Respiratory Care Manuscript Preparation Guide, Revised 12/99 

Manuscript Preparation Guide 

Abstract. Please ensure that the abstract does not contain any facts 
or conclusions that do not also appear in the body text. Limit the 
abstract to no more than 400 words. 

Key Words. Research, Review, Overview, and Special Articles 
require Key Words. On the Abstract or Outline page, include a list 
of 6 to 10 key words or two- word phrases. 

References. Assign reference numbers in the order that articles are 
cited in your manuscript. At the end of your manuscript, list the cited 
worics in numerical order. Abbreviate journal names as in Index Medi- 
cus. List all authors. The following examples show RESPIRATORY 
Care's style for references. 

Article in a journal carrying pagination throughout the volume: 

Rau JL, Harwood RJ. Comparison of nebulizer delivery meth- 
ods through a neonatal endotracheal tube: a bench study. Respir 
Care 1992;37(11):1233-1240. 

Article in a publication that numbers each issue beginning with Page 1 : 

Bunch D. Establishing a national database for home care. AARC 
Times 1991 ;15(Mar):61, 62,64. 

Corporate author journal article: 

American Association for Respiratory Care. Criteria for estab- 
lishing units for chronic ventilator-dependent patients in hospitals. 
Respir Care 1988;33( 11): 1044- 1046. 

Article in journal supplement: (Journals differ in numbering and iden- 
tifying supplements. Supply information sufficient to allow 

Reynolds HY. Idiopathic interstitial pulmonary fibrosis. Chest 
1986; 89(3 Suppl):139S-143S. 

Abstract in journal: (Abstracts citations are to be avoided, and those 
more than 3 years old should not be cited.) 

Stevens DP. Scavenging ribavirin from an oxygen hood to reduce 
environmental exposure (abso-act). Respir Care 1990;35(1 1): 1087- 

Editorial in a journal: 

Enright P. Can we relax during spirometry? (editorial). Am Rev 
Respir Dis 1993;148(2):274. 

Editorial with no author given: 

Negative-pressure ventilation for chronic obstructive pul- 
monary disease (editorial). Lancet 1992:340(8833): 1440-1441. 

Letter in journal: 

Aelony Y. Ethnic norms for pulmonary function tests (letter). 
Chest 1 99 1;99(4): 1051. 

Corporate author book: 

American Medical A.ssociation Department of Drugs. AMA drug 
evaluations, 3nd ed. Littleton CO: Publishing Sciences Group; 1977. 

Book: (For any book, specific pages should be cited whenever ref- 
erence is made to specific statements or other content.) 

DeRemee RA. Clinical profiles of diffuse interstitial pul- 
monary disease. New York: Futura; 1990:76-85. 

Chapter in book with editor(s): 

Pierce AK. Acute respiratory failure. In: Guenter CA, Welch MH, 
editors. Pulmonary medicine. Philadelphia: JB Lippincott; 

Paper accepted but not yet published: 

Hess D. New therapies for asthma. Respir Care (year, in press). 

Personal communication of unpublished data not yet accepted for 
publication: You must obtain written permission to cite unpublished 
data received via personal communication. Do not number such ref- 
erences, but instead make parenthetical reference in the body text 
of your manuscript. Example: "Recently, Jones found this treatment 
effective in 45 of 83 patients (Jones HI, University of the Cascades, 
1999, personal communication)." 

Tables. Tables should be consecutively numbered. Start each table 
on a separate page. Number and title the table and give each column 
a brief heading. Place explanations in footnotes, including all non- 
standard abbreviations and symbols. Key the footnotes with the fol- 
lowing symbols, superscripted, in the table body, and in the following 
order: *, t, I, §. II, % **. tt. Do not use horizontal or vertical 
rules or borders. Do not submit tables as photographs, reduced in 
size, or on oversize paper. 

Figures (iUustrations). Figures include graphs, line drawings, pho- 
tographs, and radiographs. Use only illustrations that clarify and aug- 
ment the text. Number figures consecutively as Figure 1 , Figure 2, 
etc. All the figures must be mentioned in the text. Every figure should 
have a legend (a title and/or description explaining the figure). Fig- 
ure legends should appear as separate paragraphs at the end of the 
manuscript (after the References section), in the same computer file 
as the manuscript (not in a separate file, as with the tables and fig- 
ures). Do not create scanned versions of figures borrowed from other 
publications; clear photocopies are preferable. To include figures 
previously published in other publications, you must obtain permission 
from the original copyright holder (see below). Figures must be of 
professional quality and a copy of the article from which the figure 
came should be available. If color is essential to the figure, consult 
the Editor for more information. In reports of animal experiments, 
use schematic drawings, not photographs. A letter of consent must 
accompany any photograph of an identifiable person. If possible, 
submit radiographs as prints and full-size copies of film. 

Drugs. Precisely identify all drugs and chemicals used, giving gener- 
ic names, doses, and methods of administration. Brand names may 
be given in parentheses after generic names. 

Commercial Products. In the text, parenthetically identify com- 
mercial products only on first mention, giving the manufacturer's 
name, city, and state or country. Example: "We performed spirom- 

Respiratory Care Manuscript Preparation Guide, Revised 12/99 

Manuscript Preparation Guide 

etry (1085 System, Medical Graphics, Minneapolis, Minnesota)." 
Provide model numbers if available, and manufacturer's suggest- 
ed price, if the study has cost implications. 

Permissions: You must obtain written permission to use pictures 
of identifiable individuals or to name individuals in the Acknowl- 
edgments section. You must obtain wrinen permission from the orig- 
inal copyright holder to use figures and tables from other publica- 
tions. Copies of all applicable permissions must be on file at 
Respiratory Care before a manuscript goes to press. Copyright 
is most often held by the journal or book in which the figure or table 
originally appeared and applies to the creativity, style, and form in 
which the facts/data are presented to the reader; the facts themselves 
are not copyright-protectable. Therefore, if you were asking per- 
mission to reproduce a table or figure directly from a journal or book, 
or with minor adaptations, permission would be necessary. How- 
ever, if you intend to exu-act some data from text or illustrations and 
present them in an entirely new form, permission would not be need- 
ed. Simply cite the source of the data using the following statement: 
"Figure adapted from data published in ..." 

Ethics. When reporting experiments on human subjects, indicate 
that procedures were conducted in accordance with the ethical stan- 
dards of the World Medical Association Declaration of Helsinki (see 
Respir Care 1997;42(6):635-636) or of the institution's committee 
on human experimentation. State that informed consent was 
obtained. Do not use patient's names, initials, or hospital numbers 
in text or illustrations. When reporting experiments on animals, indi- 
cate that the institution's policy, a national guideline, or a law on 
the care and use of laboratory animals was followed. 

Statistics. Identify the statistical tests used in analyzing the data and 
give the prospectively determined level of significance in the Meth- 
ods section. Report actual p values in the Results section. Cite only 
textbook and published article references to support choices of tests. 
As with commercial products (see above), parenthetically identi- 
fy any general-use or commercial computer programs used. 

Units of Measurement. Express measurements of length, height, 
weight, and volume in metric units appropriately abbreviated; tem- 
peratures in degrees Celsius; and blood pressures in millimeters of 
mercury (mm Hg). Report hematologic and clinical-chemistry mea- 
surements in conventional medic and in SI (Systeme Internationale) 
units (units and conversion factors listed at Respir Care 
1997;42(6):640). Show gas pressures (including blood gas tensions) 
in millimeters of mercury (mm Hg). 

abbreviations. Do not use abbreviations in the title, in section head- 
ings, and do not use unusual abbreviations in the abstract. Use an abbre- 
viation only if the term occurs 4 or more times in the paper. Define 
all abbreviations (ie, write out the full term on first mention, followed 
by the abbreviation in parentheses) and thereafter use only the abbre- 
viation. Standard units of measurement and scientific terms can be 
abbreviated without explanation (eg, L/min, mm Hg, pH, O2). 
Please use the following forms: cm H2O (not cmH20), f (not bpm), 
L (not I), L/min (not LPM, l/min, or Ipm), mL (not ml), mm Hg 
(not mmHg), pH (not Ph orPH). p > 0.001 (not p>O.OOI), s (not sec), 
SpOj (arterial oxygen saturation measured via pulse-oximetry). 

Prior and Duplicate Publication. In general, do not submit work 
that has been published or accepted elsewhere, though in special 
instances the Editor may consider such material if the original pub- 
lisher grants permission. Please consult the Editor before submit- 
ting such work. 

Authorship. All persons listed as authors should have participat- 
ed in the reported work and in the shaping of the manuscript, all must 
have proofread the submitted manuscript, and all should be able to 
publicly discuss and defend the paper's content. A paper of corporate 
authorship must specify the key persons responsible for the article. 
Attribution of authorship is not based solely on solicitation of fund- 
ing, collection or analysis of data, provision of advice, or similar ser- 
vices. Persons who provide such ancillary services may be recog- 
nized in an Acknowledgments section. 

Reviewers: Please supply the names, credentials, affiliations, address- 
es, and phone/fax numbers of 3 professionals whom you consider 
expert on the topic of your paper. Your manuscript may be sent to 
one or more of them for blind peer review. 

Submitting the Manuscript 

Submit three printed copies and one (3.5-inch) computer diskette. 
The printed copies should each include photocopies of all of the Fig- 
ures, Tables, and Appendixes. On the diskette, the manuscript should 
be in one file and the tables in a separate file. If soft copies of the fig- 
ures are available, they should also be in a separate file. However, 
do not create scanned versions of figures borrowed from other pub- 
lications; clear photocopies are preferable. Include the completed 
Cover Letter and Checklist (see next page) and permission letters. 
Mail to Respiratory Care, 600 Ninth Avenue, Suite 702, Seat- 
tle WA 98104. Do not fax manuscripts. Receipt will be acknowledged. 

Conflict of Interest. On the cover page, authors must disclose any 
liaison or financial arrangement they have with a manufacturer or 
distributor whose product is addressed in the manuscript or with the 
manufacturer or distributor of a comf>eting product. Such arrange- 
ments do not disqualify a paper from consideration and are not dis- 
closed to reviewers. Reviewers are screened for possible conflict 
of interest. 

Abbreviations and Symbols. Use standard abbreviations and sym- 
bols, listed at Respir Care I997;42(6):637-642. Donotcreatenew 

Respiratory Care 
Editorial Office: 

600 Ninth Avenue. Suite 702 
Seattle W A 98104 

(206) 223-0558 (voice) 

(206) 223-0563 (fax) 

Respiratory Care Manuscript Preparation Guide, Revised 12/99 

Cover Letter & Checklist 

A copy of this completed form must accompany all manuscripts submitted for publication. 

Title of Paper: 

Publication Category: 

Corresponding Author: 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 its sub- 
mission for publication." Please print and Include credentials, title. Institution, academic appointments, city and state. If more 
than 4 authors, please use another copy of this form.* 

*First Author: 

Author Signature/Date. 

•Second Author: 

•Third Author: 

Author Signature/Date. 

Author Signature/Date. 

•Fourth Author: 

Author Signature/Date, 

Has this research been presented In any public forum? □ Yes □ No 
If yes, where, when and by whom? 

Has this research received any awards? □ Yes □ No 
If yes, please describe. 

Has this research received any grants or other support, financial or material? □ Yes □ No 
If yes, please describe. 

Do any of the authors of this manuscript have a financial Interest in (or a commercial or consulting relationship to) any of the 
products or manufacturers mentioned In this paper or any competing products or manufacturers? □ Yes □ No 

If yes, please describe. 

□ Have you enclosed a copy of the manuscript on diskette? 

□ Is double-spacing used throughout entire manuscript? 

□ Are all pages numbered In upper-right corners? 

□ Are all references, figures, and tables cited in 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 Care Manuscript Preparation Guide, Revised 12/99 



For VOLUNTARY reporting 

by health professionals of adverse 

events and product problems 

FDA Use Only (Resp Care) 

DA \uni( \i i'R(>DUt:Ts REPORTiNc; pr<)c;ram 

A. Patient information 

1 Patient identifier 

In confidence 

2 Age at time 
of event: 


of birth: 

3 Sex 

I I female 
I I male 


4 Weigfit 


B. Adverse event or product problem 

1 LJ Adverse event ando 

I i Product problem (e.g.. defects/malfunctions) 

2 Outcomes attributed to adverse event , — , 

(Check all that apply) U disability 

rn (jeath CD congenital anomaly 

I — I (mo/day/yr) Qj required intervention to prevent 

! I life-ttireatening permanent impairment/damage 

I I hospitalization - initial or prolonged Lj other: 

3 Date of 

"•- Jay yf| 

4 Date of 
tfiis report 

5 Describe event or problem 

6 Relevant tests/laboratory data, including dates 

7 Other relevant history, including preexisting medical conditions (eg. allergies. 
race, pregnancy, smoking and alcohol use. hepatic/renal dysfunction, etc.) 

Mail to: MEDWaTCH or FAX to: 

5600 Fishers Lane 1 -800-FDA-01 78 

Rockville, MD 20852-9787 


Triage unit 
sequence t 

C. Suspect medication(s) 

1 Name igive labeled strength & mfr/labeler. if known) 


2 Dose, frequency & route used 



3. Therapy dates (if unknown, give duration) 

tfom/lo (Of besr eslimatej 


4 Diagnosis for use (indication) 


6. Lot # (if known) 


7. Exp. date (if known) 


9 NDC # (for product problems only) 

5 Event abated after use 
stopped or dose reduced 

*1 Dyes Dno Dgg^Py"'' 

#2 Dyes Dno D^"'' 

8 Event reappeared after 

#1 Dyes Dno ngg^Fy"'' 

#2 Dyes Dno Dgg^fy"' 

10 Concomitant medical products and therapy dates (exclude treatment of event) 

D. Suspect medical device 

1 Brand name 

2 Type of device 

3 Manufacturer name & address 


model # _ 

catalog # 

serial # 


other # 

4 Operator of device 

I I health professional 
I I lay user/patient 
n other: 

5 Expiration date 


7. If implanted, give date 


8. If explanted, give date 


9. Device available for evaluation? (Do not send to FDA) 
I I yes Lj h° LJ returned to manufacturer on 

10 Concomitant medical products and therapy dales (exclude treatment of event) 

E. Reporter (see confidentiality section on back) 

Name & address 

phone # 

2 Health professional? 

□ yes □ no 

3. Occupation 

5. If you do NOT want your identity disclosed to 
the manufacturer, place an " X " in this box. Q 

4 Also reported to 

I I manufacturer 
I I user facility 
I I distributor 

FOA Form 3500 1/96) Submisslon of a report does not constitute an admission that medical personnel or the product caused or contributed to the event. 


Report experiences with: 

• medications (drugs or biologies) 

• medical devices (including in-vitro diagnostics) 

• special nutritional products (dietary 
supplements, medical foods, infant formulas) 

• other products regulated by FDA 

Report SERIOUS adverse events. An event 
is serious when the patient outcome is: 

• death 

• life-threatening (real risk of dying) 

• hospitalization (initial or prolonged) 

• disability (significant, persistent or permanent) 

• congenital anomaly 

• required intervention to prevent permanent 
impairment or damage 

Report even if: 

• you're not certain the product caused the 

• you don't have all the details 

Report product problems - quality, performance 
or safety concerns such as: 

• suspected contamination 

• questionable stability 

• defective components 

• poor packaging or labeling 

• therapeutic failures 

How to report: 

• just fill in the sections that apply to your report 

• use section C for all products except 
medical devices 

• attach additional blank pages if needed 

• use a separate form for each patient 

• report either to FDA or the manufacturer 
(or both) 

Important numbers: 

• 1-800-FDA-0178 

• 1-800-FDA-7737 

• 1-800-FDA-1088 

• 1-800-822-7967 

to FAX report 

to report by modem 

to report by phone or for 

more information 

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ScA,t«Lutt<t Pt6^fe^4,6-'i4- ^O'Uttd^. 2000 

Drugs, Medications and Delivery Devices of Importance in 
Respiratory Care — Jim Fink MS RRT; Host, David Pierson 

MD — Video April 25; Audio May 16 

Cost Effective Respiratory Care: You've Got to Cliange — 

Kevin Shrake MA RRT FACHE; Host, Sam P Giordano MBA 
RRT— Video May 23; Audio June 20 

Pediatric Ventilation: Kids Are Different — Mark Heulitt MD; 
Host. Richard Branson RRT — Video July 25; Audio August 15 

What Matters in Respiratory Monitoring: What Goes and 
What Stays— Dean Hess PhD RRT FAARC; Host. Richard Bran- 
son RRT — Video August 22; Audio September 26 

Managing Asthma: An Update — Patti Joyner RRT CCM; Host, 
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Routine Pulmonary Function Testing: Doing It Right — Carl D 
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(Written & CSE) 



in This Issue 

Backes, William J . . 
Bartow. Scott L . . . . 
Bohn, Desmond J . . 
Bowman, Brian .... 

Buist, A Sonia 

Cheifetz, Ira M .... 
Corrao, William M . 
Coulter, Terrence D . 

Dhand, Rajiv 

Durbin Jr, Charles G 
Durward. Andrew . . 
Enright, Paul L .... 
Ferguson, Gary T . . . 

Fink, James 

Flaten, Anne L 

Heulitt, Mark J 

Higgins, Millicent W 

.491 Hill, Nicholas S 480 

.535 Kavuru, Mani S 533 

.486 Keddissi. Jean I 494 

.486 Khan. Saeed U 533 

.513 Klonin, Hilary 486 

.486 Lewis, Dianne L 535 

.538 Marshak, Arthur B . . . 536 

.531 Martin, Thomas R 537 

.497 Mayo, David F 482 

.482 Meliones, Jon N 486 

.486 Metcalf, Jordan P 494 

.513 Peters, Michelle 486 

.513 Ratfeeq, Parakkal 486 

.497 Rowley, Daniel D 482 

.491 Roy, Julien M 535 

.479 StoUer, James K 531 

.513 Wood, Kenneth E 491 

in This Issue 

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Fax (972) 484-6010. Dale Clriffiths is the Marketing Director for RESPIRATORY CARE. 



Circle # 



Amethyst Research 
Bio-logic Systems Corp 
DHD Healthcare 
Hans Rudolph, Inc. 
Hy'Tape International 
Ingmar Medical Inc 
Mallinckrodt Inc 
Monaghan Medical Corp 
Monaghan Medical Corp 
Siemens Medical Systems 
SIMS-Porlex, Inc. 
Vortran Medical 

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Lung Model 








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Lung Simulation 












Aero Eclipse 




Clinical Management Program 




Arterial Blood Sampling Devices 




Respiratory Products 




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Mav2000 ExDires 8/15/00 

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of Monaghan Medical Corporation 
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in This Issue 

Backes, William J . . 
Bartow, Scott L . . . . 
Bohti, Desmond J . . 
Bowman, Brian . . . . 

Buist, A Sonia 

Cheifetz, Ira M .... 
Corrao, William M . 
Coulter, Terrence D . 

Dhand, Rajiv 

Durbin Jr, Charles G 
Durward. Andrew . . 
Enright, Paul L .... 
Ferguson, Gary T . . 

Fink, James 

Flaten, Anne L . . . . 
Heulitt, Mark J . . . . 
Higgins, Millicent W 

in This h 


Amethyst Research 
Bio-logic Systems C( 
DHD Healthcare 
Hans Rudolph, Inc. 
HyTape Internationa 
Ingmar Medical Inc 
Mallinckrodt Inc 
Monaghan Medical C 
Monaghan Medical C 
Siemens Medical Sys 
SIMS-Portex, Inc. 
Vortran Medical 


Hill, Nicholas S 480 

Kavuru, Mani S 533 

Keddissi, Jean I 494 

Khan, Saeed U 533 

Klonin, Hilary 486 

Lewis, Dianne L 535 

Marshak, Arthur B . . . 536 

Martin, Thomas R 537 

Mayo, David F 482 

Meliones, Jon N 486 

Metcalf, Jordan P 494 

Peters, Michelle 486 



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The «/ . 

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1 M 


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