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MAY 2000
VOLUME 45
NUMBER 5

ISSN 0020-1324-RECACP

A MONTHLY SCIENCE JOURNAL
44TH YEAR— ESTABLISHED 1956

EDITORIALS

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

ORIGINAL CONTRIBUTIONS

Initial Experience with a Respiratory Therapist
Arterial Line Placement Service

CASE REPORTS

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

REVIEW ARTICLES

Dosing Strategies for Bronchodilator Resuscitation in
the Emergency Department

SPECIAL ARTICLES

Office Spirometry for Lung Health Assessment in Adults

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VENTILATION

Noninvasive Mechanical Ventilation: Its Role in Acute and
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Coping with the Pediatric Emergency

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Asthma Disease State Management: Establishing a Partnership

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Item VC96 $49.95 ($99.00 Nonmembers)

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MAY 2000 / VOLUME 45 / NUMBER 5

FOR INFORMATION,
CONTACT:

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Services

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Respiratory Care

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Respiratory Care

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Fax (703) 548-8499

EDITORIALS

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

ORIGINAL CONTRIBUTIONS

479
480

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

482

CASE REPORTS

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

REVIEWS, OVERVIEWS, & UPDATES

Bronchodilator Resuscitation in the Emergency Department

Part 2 of 2: Dosing Strategies

by James Fink and Rajiv Dhand — Hines, Illinois

486
491
494

497

RE/PIRATOR«J
Q\RE

RESPIRATORY CARE (ISSN 0020-1324. USPS 0489-

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

SPECIAL ARTICLES

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

513

PFT NUGGETS

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

531
533

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CONTINUED.

ALSO
IN THIS ISSUE

AARC Membership
543 Application

464

Abstracts from
Other Journals

552

Advertisers Index
& Help Lines

552

Author
Index

542

Calendar
of Events

545

Manuscript
Preparation Guide

549

MedWatch

541

New Products

551

Notices

RE/PIRATORy
QiRE

A Monthly Science Journal
Established in 1956

The Official Journal of the

American Association for

Respiratory Care

BOOKS, FILMS, TAPES, & SOFTWARE

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

COMING IN JUNE 2000

CONSENSUS STATEMENT AND

PROCEEDINGS OP THE
CONSENSUS CONPERENCE ON

AEROSOLS AND
DEUVERY DEVICES

Conference Co-Chairs:

myrna b doiovich p eng

neii r macintyre md faarc

535
536
537
538

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EDITORIAL OFFICE

EDITOR IN CHIEF

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

ASSOCIATE EDITORS

Richard D Branson RRT
University of Cincinnati
Cincinnati, Ohio

Charles G Durbin Jr MD
University of Virginia
Charlottesville, Virginia

EDITORIAL BOARD

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
FAARC

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
FAARC

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

SECTION EDITORS

Leonard D Hudson MD

University of Washington
Seattle, Washington

Robert M Kacmarek PhD RRT
FAARC

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
FAARC

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

STATISTICAL CONSULTANT

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

Abstracts

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
2000Feb;ll7(2):30l-303.

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
15;132(4):288-295.

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):
508-511.

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
5;320(723l):358-361.

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):
1826-1832.

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
status.

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

464

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):
242-249.

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-

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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:
354(9I93):185I-I858.

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 al.so 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

465

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

$2,000

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 info@aarc.org, or
access AARC Online at
http://www.aarc.org.

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
Dec7;131(ll):822-829.

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-
back.

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-
1092.

Respiratory Care • May 2000 Vol 45 No 5

467

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

requirements.

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
device.

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.

Accreditation

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.

Nursing:

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.

Registration

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)

CALL FOR MULTI-FACILITY DISCOUNT

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):

Name_

Title_

Department.
Facility

iAddress_

City/State/Zip_
Telephone

Bill To (IfD^erent From Uft):

Name_
ritle_

Department.
FaciUty

Address.

City/State/Zip_
Telephone___

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;
27{II):2358-2360.

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-
SUREMENTS AND MAIN RESULTS: There
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-
gen. MEASUREMENTS AND MAIN RE-
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

471

Abstracts

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 disea.se 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-
ommended.

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 respon.ses. 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-
apy.

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

472

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Abstracts

Affect Medication?— Gallefoss F, Bakke PS.
Am J Respir Crit Care Med 1 999 Dec 1 ; 1 60(6):
2000-2005.

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):
2018-2027.

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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474

Respiratory Care • May 2000 Vol 45 No 5

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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
1;160(6):1957-1961.

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

475

Abstracts

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
needed.

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.

476

Respiratory Care • May 2000 Vol 45 No 5

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Circle 121 on product info card

Abstracts

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
COD.

478

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

REFERENCES

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):
952-960.

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;
27(2):431^33.

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: HeulittMarkJ@exchange.uams.edu.

Respiratory Care • May 2000 Vol 45 No 5

479

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
altogether.

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 u.se of higher than recommended oxygen flow increased
the risk of secretion desiccation in a patient already at risk

480

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-
1806.

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.

REFERENCES

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: nicholas_hill@brown.edu.

Respiratory Care • May 2000 Vol 45 No 5

481

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
test.

Background

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: ddr8a@hscmail.mcc.virginia.edu.

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.

Methods

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

482

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.

Results

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
Attempted

No. Successful

Comments

Radial
Dorsal Pedal

101
18

97
18

13 in burned
patients

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
Attempts

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

Never

attempt number a

(3)

chi-square = 0.0024,

nd outcome: success or failure.

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

483

Respiratory Therapist Arterial Line Placement Service

Discussion

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 disea.se.

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-
stances.

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 ro.se, approaching the success on the first try. This

484

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.

Conclusions

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.

REFERENCES

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
l995:IO(6):424-^32.

3. Stein JM. Placing arterial lines. Emerg Med l983;15(9):22l-225,
230.

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
l986:IO(2):22{)-222.

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
I997;51(l):47^8.

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):
37-39.

Respiratory Care • May 2000 Vol 45 No 5

485

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.

Introduction

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:
cheif0O2(g'mc.duke.edu.

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
pneumonia.'"-"

See The Related Editorial on Page 479

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

486

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
(ECMO).

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-
azole.

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

487

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

488

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.

Discussion

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-
ance."'"

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

489

Negative Pressure Ventilation via Chest Cuirass

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

Summary

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.

REFERENCES

1 . Fulkerson WJ, Maclntyre NR. Complications of mechanical venti-
lation. Prob Respir Care 1991;4(I):1-I35.

2. McCuIloch TM, Bishop MJ. Complications of translaryngeal intu-
bation (review). Clin Chest Med I991;12(3):507-521.

3. de Blic J, Delacourt C, Scheinmann P. Ultrathin flexible bronchos-
copy in neonatal intensive care units. Arch Dis Child I99I;66(I2):
1383-1385.

4. Little LA, Koenig JC Jr, Newth CJL. Factors affecting accidental
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490

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.

Introduction

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
NPPV.

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
attempted.

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.
Wisconsin.

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.
E-mail: kew@medicine.wisc.edu.

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

491

Inspissated Secretions

SPECfMEN DATE

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.

Discussion

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

492

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.

REFERENCES

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;
25(6):567-573.

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-
369.

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):
359-372.

12. Hess D. Noninvasive positive pressure ventilation: predictors of suc-
cess and failure for adult acute care applications. Respir Care 1997;
42(4):424-431.

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

493

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.

Introduction

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 Disea.se 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:
jeank2@yahoo.com.

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
bronchus.

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

494

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
lobe.

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.

Discussion

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-
tion.-**

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

495

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.

REFERENCES

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-
434.

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
I990;323(22):I523-1530.

.'). 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-
1806.

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;
l()7(3):76l-768.

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
l989;95(4):865-870.

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):
705-715.

496

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

Introduction

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
Summary
Conclusion

[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.

Introduction

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.
California.

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

* 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

497

Bronchodilator Resuscitation in the Emergency Department

Table 1 . Recommendations from the Physicians ' Desk Reference^

Adults

Children

Comments

Albuterol

nebulizer

2.5 mg in 3 mL NS
q4-6h

0.10-0.15 mg/kgq4-6h

MDI

2 puffs q 4-6 hours

2 puffs q 4-6 h

Ipratropium

bromide

nebulizer

0.5 mg in 3 mL NS
q6-8h

Not specified for < 12 years of age

MDI

2 puffs (36 /ig)

Not specified for < 1 2 years of age

q6-8h

£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-
ufacturers.

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
ED.

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-

498

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

Medication

Adults

Children

Comments

Inhaled short-acting B-, agonists
Albuterol

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
continuously

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

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

Anticholinergics
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)

Steroids
Prednisone

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
nebulization

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

499

Bronchodilator Resuscitation in the Emergency Department

r- 1.5

u
«

O
10

0.5

(n = 24)

(n = 45)

(n = 105)

(n = 127)

(n = 129)

(n = 121)

I (n = 102)

(n = 68)

(n=67)

(n = 38)

(n = 25)

(n = 124)

■ Fenoterol ° Albuterol

(n = 17)

{n = 15)

ve # Puffs 4

Fenoterol 800

1200

tsoo

2000

2400

2800

3200

Albi

iterol 400

600

800

1000

t200

1400

teoo

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

500

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)

7.5

.-JiT

- 5'

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

0.0

2.5

5.0

7.5

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
permission.)

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-
mission.

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-

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

501

Bronchodilator Resuscitation in the Emergency Department

80
70

-60

o
^50

0)
Q.

^40

JTso

0.0 1.2 2.4 3.6 4.8 6.0 7.2
Salbutamol (mg)

80
70

^60

^ 50
0)

•s 40
o

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-
apy.

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

502

Respiratory Care • May 2000 Vol 45 No 5

Bronchodilator Resuscitation in the Emergency Department

?40

CB
Q.

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
nebulization.

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

503

Bronchodilator Resuscitation in the Emergency Department

100

2.5

>
UJ

(0
<

1.5

0.5

0 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

-L.

_l_

10 20 30 40

SO 60

(min)

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-
apy.

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
36.8%.

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

5()4

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Bronchodilator Resuscitation in the Emergency Department

JS
u

eo-1

so-

PJ 40

FEV1 (CN)
« FEV1 (IN)

— I —
60

— I —
90

— 1 — > — 1 — ■ — I — ' — I — I 1-

120 150 180 210 240

time(min)

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-

0 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

Respiratory Care • May 2000 Vol 45 No 5

505

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

Results

Children

Papo (1993)1*

Moler (1995)"

Khine (1996)2"

Adults

Lin (1993)20

Rudnitsky

(1993)21

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

min

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
MDl/HC)

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
responses.

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

continuous.

Both groups improved, with no difference between
groups.

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

,Valved02Mask

To Infusion pump
and (Vibrated

'V Connector

Non - nebreathing
Reservoir Bag
with Valve

ToFtownelBf

02Air
Blender

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-
lization.

Intuitively, nebulizing undiluted bronchodilator should
allow delivery of a do.se 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
Resuscitation

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
patients.

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

507

Bronchodilator Resuscitation in the Emergency Department

PEF (% Predicted)

70-

65-

60-

55-

50 H

40 H

Table 4. Rate of Patients Hospitalized from the Emergency
Department

35-

Ipratropium
Saline solution

120

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

Moderate
Asthma

Severe
Asthma

434

Beta agonist alone

36.5%

Beta agonist with

27.4%*

ipratropium bromide

•p < 0.05

tp = 0.02

Adapted fmm Reference 39.

163

271

10.7%

52.6%

10.1%

37.5%t

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

508

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).

-•-Combinatton

30%

-^-Control

25%

20%

]

k^"'^^

15%

l^^^^^^

'Zl^^^---—'

10%

1 2 3

Hour

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.

Summary

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

Respiratory Care • May 2000 Vol 45 No 5

509

Bronchodilator Resuscitation in the Emergency Department

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

Study (year)

Patient Population (n)

Medication/Dose

Duration

Results

Children

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
dose

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

ALB.

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
Adults

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

IB/l.Omg

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
IB/l.Omg/h

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

4 h Frequent low doses of ALB associated with

increased vomiting (relative ri.sk 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

hospitalization.

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.

Conclusion

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
therapy.

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

510

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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45. Stoodley RG. Aaron SD. and Dales RE. The role of ipratropium
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RE/PIRi!^y QVRE

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512

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,
spirometry.

Background

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,
Michigan.

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
obtained.

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

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

Respiratory Care • May 2000 Vol 45 No 5

513

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
disappointing.

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
conferences.

Indications for Office Spirometry

Recommendation

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
that;

a. minimizes the false-positive and false-negative
rates,

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-

514

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-

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515

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
States.-^-^

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
life.^^-5^

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-

plied.""

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

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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^)

Never

Smoker (%)

Men

Women

Men

Women

Men

Women

17-24

5.9

2.2

1.5

0.0

2.9

3.0

25-34

5.3

3.3

0.3

3.0

2.6

2.0

35-44

5.2

6.7

2.6

2.2

2.3

45-54

13.1

19.2

4.1

4.0

2.8

1.8

55-64

21.3

28.4

8.8

10.5

3.3

3.5

65-74

30.9

20.9

13.6

14.6

2.9

3.0

75-89

24.8

15.4

13.8

12.8

9.1

2.7

Totals*

9.6

rale for all age gmups.

9.6

6.5

6.7

2.9

2.5

*Values given

as abnomiality

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517

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

States

gible in United

Prevalence of Low
Function (%)

Lung

Men

Women

Men

Women

Smokers, age a 45 y
Symptomatic
Asymptomatic

7,620,000
4,770,000
2,850,000

6,670,000
4,100,000
2,560,000

19.0

25.1

8.9

22.4
27.5
14.4

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

okers

utrition Examination Survey III
asymptomatic.

19,000,000

13,000.000

6,000,000

25,200,000
19.000,000
6,200,000

11.1

12.3

8.6

7.2
7.7
5.5

*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
Affordable

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-
uations).

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 increa.se
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.

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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.

Recommendation

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. '^"'

Recommendation

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.'^"*'

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519

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
recommend.

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

Recommendation

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

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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-
mated).

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.

The

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
mo.st 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
Reported

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.

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Office Spirometry for Lung Health Assessment

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

Messages:

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
longer."

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

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

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 la.sl 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
Spirometers

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
test.

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.

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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-
tablished.

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
Conditions

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
temperature.

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

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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-
ommendations.

ACKNOWLEDGMENTS

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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spirometry workshops. Chest 1999;116:416-423.

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Office Spirometry for Lung Health Assessment

Appendix 1
Office Spirometer Validation Studies

Background

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).

(joals

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.

Methods

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

(continued)

Respiratory Care • May 2000 Vol 45 No 5 527

Office Spirometry for Lung Health Assessment

Appendix 1
(continued)

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.

(continued)

528 Respiratory Care • May 2000 Vol 45 No 5

Office Spirometry for Lung Health Assessment

Appendix 1
(continued)

Measurements

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
results?

2. Why is the Dlco elevated?

3. What are the possible causes of this elevation?

Table 1 . Pulmonary Function Test Results

Test

Predicted

Prebronchodilator

Predicted

FEV, (L)

4.%

3.40

FVC(L)

4.09

2.49

FEV,/FVC

0.82

0.73

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

24.5

31.8

130

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

Discussion

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: stollej@ccf.org.

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

531

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.

REFERENCES

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);
2185-2198.

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-
794.

6. Smith TC, Rankin J. Pulmonary diffusing capacity and the capillary
bed during Valsalva and Miiller maneuvers. J Appl Physiol 1969;
27(6):826-833.

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-
1396.

532

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-
rometry?

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

Discussion

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;
Saeedk@pol.net.

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

533

Mixed Obstructive and Restrictive Lung Disease

Table 1. Spirometry and Plethysmography Results

Test

Predicted

Measured

% Predicted

FVC(L)

2.63

1.49

FEV, (L)

2.12

0.88

FEV,/FVC

0.81

0.59

—

Plethysmography

Helium dilution

% Predicted

FRC(L)

2.50

1.94

4.61

183

RV(L)

1.73

1.12

4.05

234

TLC (L)

4.49

2.76

5.87

131

RV/TLC

0.39

0.41

—

0.69

—

Dlco (mL/mm Hg/s)

16.6

4.44

—

Dl/Va

4.70

1.61

—

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
volume.

REFERENCES

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):
571-580.

4. Slone RM. Gierada DS. Radiology of pulmonary emphysema and
lung volume reduction surgery. Semin Thorac Cardiovasc Surg 1 996:
8(0:61-82.

5. Pare PD. Wiggs BJ. Coppin CA. Errors in the measurement of total
lung capacity in chronic obstructive lung disea.se. Thorax 1983:38(6):
468^71.

6. Piquet J. Harf A. Lorino H. Allan G. Bignon J. Plethysmographic
measurement of lung volume in chronic obstructive pulmonary dis-
ea.se: influence of the panting pattern. Bull Eur Physiopathol Respir
1984:20(l):31-36.

534

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.
$25.95.

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 mo.st 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
benefits.

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
well.

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

535

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 u.se 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 increa.se comfort and compliance and
are fust becoming an integral part of CPAP
therapy.

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-
ment.

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
library.

Scott L Bartow MS RRT

Ventilatory Care Management of

Wisconsin

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

REFERENCE

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 ca.ses used,
of which only 10 deal directly with respi-
ratory care. There is one dental hygiene

536

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 ca.se 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 ca.se
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
care.

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 ca.ses that re-
flect issues faced by allied health profes-
sionals, and this is both a strength and a
limitation.

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 ca.ses 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 disea.ses. 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

537

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
entertaining.

Thomas R Martin MD

Division of Pulmonary and

Critical Care Medicine

Seattle VA Medical Center

University of Washington School of

Medicine

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 disea.se 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
presented.

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-

538

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
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would like to receive, and provide all the information requested. Cards
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Sweepstakes rules may be requested by e-mail at info@aarc.org.

Respiratory Care • May 2000 Vol 45 No 5

539

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I ASSOCIATION

AMERICAN ASSOCIATION FOR _l
RESPIRATORY CARE

Educate your patients, staff, and the public on
the value of cardiorespiratory health through
the books, manuals, videos, posters, and even
T-shirts available from the AARC. So for RC
Week or year round, check these pages for your
educational and promotional needs.

Call 972.243.2272 for information.

MATION
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AND ST4RT BUYING!

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to RESPIRATORY CARE, New Products & Services Dept. 1 1030 Abies Lane. Dallas TX 75229^593.

The Reader Service Card can be found at the back of the Journal.

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
format provides more room per tracing,
so reports are sharp and easy to read. For
more information from Futuremed, cir-
cle number 190 on the reader service
card in this issue, or send your request
electronically via "Advertisers Online"
at http://www.aarc.org/buyers_guide/

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-
play; full pressure range (4-18 cm H2O);
adjustable ramp selector, variable ramp
starting pressure; 12-volt adaptable; and
affordably priced. For more information
from Nidek Medical, circle number 191
on the reader service card in this issue,
or send your request electronically via
"Advertisers Online" at http://www
.aarc.org/buyers_guide/

Automated STAT Analysis Quality
Control. Radiometer introduces
AutoCheckTM, a device they describe as
ideal for complete automation of the
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
electronically via "Advertisers Online"
at http://www.aarc.org/buyers_guide/

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
offers 10 test panels, need of only one
small whole blood sample (as little as
105 mL) for a complete 14 test profile,
90-second turnaround time, and more.
For more information from Nova
Biomedical, circle number 193 on the
reader service card in this issue, or send
your request electronically via
"Advertisers Online" at http://www,
aarc.org/buyers_guide/

RESPIRATORY CARE • MAY 2(X)0 VOL 45 NO 5

541

Not-for-profit organizations aie offered a free advertisement of up lo eight lines to appear, on a space-available

basis, in Calendar of Events in RESPIRATORY CARE. Ads for other meetings are priced at $5.50 per line and require

an insertion order. Deadline is the 20th of the month two months preceding the month in which you wish the ad lo run.

Submit copy and insertion orders to Calendar of Events, RESPIRATORY CARE, 1 1030 Abies Lane, Dallas TX 75229-4593.

Calendar
of Events

AARC & AFFILIATES

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
fsrc@inetwjiet.

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 fsrc@inetw.net.

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.
aarc.org/continuing_education/
sunimer_forum.

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

542

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 www.aarc.org/continuing_
education/sumnier_foruni.

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
(315)464-6872.

June 20— Teleconference with
Videotape

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,

Minnesota

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®
fhpcare.com, or Carl Mottram at
mottram .carl @ mayo.edu .

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
SMc@UMCWY.org.

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
Course

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.

RESPIRATORY CARE • MAY 2000 VOL 45 NO 5

_yv_

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
Associate

n Foreign

D Physician

D Industrial
D Special
D Student

Last Name _
First Name

Social Security No.

Home Address

City

State

.Zip

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 DME/HME

D Home Health Agency

n Educational Institution

n Manufacturer or supplier

n Other, specify

Date of Birth (optional)

Sex (optional)

U.S. Citizen?

Yes

Have you ever been a member of the AARC?
If so, when? From

Preferred mailing address: D Home D Business

For office use only

FOR ACTIVE MEMBER

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.

PLEASE USE THE ADDRESS OF THE LOCATION WHERE YOU PERFORM YOUR JOB, NOT
THE CORPORATE HEADQUARTERS IF IT IS LOCATED ELSEWHERE.

Place of Employment

Address "_

City

State

.Zip

Phone No. I

Medical Director/Medical Sponsor

FOR ASSOCIATE OR SPECIAL MEMBER

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.

PLEASE USE THE ADDRESS OF THE LOCATION WHERE YOU PERFORM YOUR JOB, NOT
THE CORPORATE HEADQUARTERS IF IT IS LOCATED ELSEWHERE.

Place of Employment

Address

City

State

.Zip

Phone No. (

FOR STUDENT MEMBER

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

Address

City

State Zip

Phone No.

Length oi program

□ 1 year
n 2 years

Bxpected Date of Graduation (REQUIRED
INFORAAATION)

D 4 years

D Other, specify .

Month

Year

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^^ ■ '

:'M.^ii^^i^iS:L

BRSHIP APPLICATION

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

Credentials

r: RRT

D CRT

D Physician

D CRNA

D RN

Salary

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

D LVN/LPN

n CPFT

n RPFT

n Perinatal/Pediatric

PLEASE SIGN

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%.

Signafurm
Doto

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)

$102.50

n Special

$ 87.50

D Student

$ 45.00

TOTAL

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

TOTAL

GRAND TOTAL = Membership Fee
plus optional sections

$15.00
$20.00
$15.00
$15.00

$15.00
$20.00
$15.00
$15.00
$15.00

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 /_

Signature

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

RE/PIRATORy CaRE

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-
Iine.org/joumals/resource/unifreqr.htm). 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
Acknowledgments.

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
retrieval.)

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-
1088.

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;
1977:26-42.

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)

rcjoumal@aarc.org

rcjkk@oz.net

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.

•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

Er:)i)fccH

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:

Date
of birth:

3 Sex

I I female
I I male

Page

4 Weigfit

.lbs
kgs

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
event

"•- 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)
#1

2 Dose, frequency & route used

3. Therapy dates (if unknown, give duration)

tfom/lo (Of besr eslimatej
#1

*»2

4 Diagnosis for use (indication)
#1

6. Lot # (if known)

7. Exp. date (if known)
#1

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
reintroduction

#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 #

lot#

other #

4 Operator of device

I I health professional
I I lay user/patient
n other:

5 Expiration date

(mo/day/yr)

7. If implanted, give date

(mo/day/yr)

8. If explanted, give date

(mo/day/yrl

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.

ADVICE ABOUT VOLUNTARY REPORTING

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
event

• 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

for a VAERS form

for vaccines

If your report involves a serious adverse event
with a device and it occurred in a facility outside a doc-
tor's office, that facility may be legally required to report to
FDA and/or the manufacturer. Please notify the person in
that facility who would handle such reporting.

Confidentiality: The patient's identity is held in strict
confidence by FDA and protected to the fullest extent of
the law. The reporter's identity, including the identity of a
self-reporter, may be shared with the manufacturer unless
requested otherwise. However, FDA will not disclose the
reporter's identity in response to a request from the
public, pursuant to the Freedom of Information Act.

The public reporling burden for this collection of information
has been estimated to average 30 minutes per response,
including the time for reviewing instructions, searching exist-
ing data sources, gathering and maintaining the data needed,
and completing and reviewing the collection of information.
Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions
for reducing this burden to:

DHHS Reports Clearance Office
Paperwork Reduction Project (0910-0291)
Hutjert H. Humphrey Building. Room 531 -H
200 Independence Avenue. S.W.
Wasiiington, DC 20201

An agency may not conduct or sponsor,
and a person is not required to respond to.
a collection of information unless it displays
a currently valid OMB control number.*

Please do NOT
return this form
to either of these
addresses.

FOAForm35oo-b.ck PlGasG Usc Addtess Provided Below - Just Fold In Thirds, Tape and Mall

Department of

Health and Human Services

Public Health Service

Food and Drug Administration

Rockville, MD 20857

Official Business

Penalty for Private Use $300

NO POSTAGE

NECESSARY

IF MAILED

IN THE

UNITED STATES

OR APO/FPO

BUSINESS REPLY MAIL

FIRST CLASS MAIL PERMIT NO. 946 ROCKVILLE, MD

POSTAGE WILL BE PAID BY FOOD AND DRUG ADMINISTRATION

MEL^S^^TCH

The FDA Medical Products Reporting Program
Food and Drug Administration
5600 Fishers Lane
Rockville, MD 20852-9787

I, ,1,111, .,!,.!,. 1,1. ,. I. llilMl...lliilili.. I. iltll

Notices

Notices of competitions, scholarships, fellowships, examination dates, new educational programs,

and the like will be listed here free of charge. Items for the Notices section must reach the Journal 60 days

before the desired month of publication (January 1 for ihe March issue. February I for the April issue, etc). Include all

pertinent information and mail notices to RESPIRATORY CARE Notices Dept, 1 1030 Abies Lane. Dallas TX 75229-4593.

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,
Mari Jones MSN RN RRT— Video September 19; Audio October 17

Routine Pulmonary Function Testing: Doing It Right — Carl D
Mottram RRT RPFT; Host, David Pierson MD— Video November 7;
Audio December 5

RESPIRATORY Care Journal
has been selected by the Litera-
ture Selection Technical Review

Committee of the National
Library of Medicine to be

indexed and included in \ndex
Medicusdind MEDLINE, which

is available online in the U.S.

and throughout the world. All
articles in the Journal

beginning with the January

2000 issue will be included.

Helpful LUeb.Sites

American Association for Respiratory Care

http://www.aarc.org

— Current job listings

— American Respiratory Care Foundation
fellowships, grants, St awards

— Clinical Practice Guidelines

National Board for Respiratory Care

http://www.nbrc.org

Respiratory Care online

http://www.rcjournal.com

— Subject and Author Indexes

— Contact the editorial staff

— Open Forum; submit your abstract online

Astlima Management
Model System

http://www.nhlbi.nih.gov

Keys to Professional Excellence

http://www.aarc.org/keys/

The National Board for Respiratory Care —
Examination Dates and Fees for 2000

Examination Fees

$190 (new applicant)
$150(reapplicant)

$250 (new applicant)
$220 (reapplicant)

$200 (new applicant)
$170 (reapplicant)

$250 (new applicant)
$ 1 70 (reapplicant)

$190 (new - written only)

$200 (new - CSE only)

$390 (new - both)

For infortnation about other services or fees, write to

the National Board for Respiratory Care,

8310 Nieman Road, Lenexa KS 66214, or call

(913) 599-4200, FAX (913) 541-0156,

ore-mail: nbrc-info@nbrc.org

Examination

CRT

Perinatal/Pediatric
CPFT
RPFT

RRT

(Written & CSE)

RESPIRATORY CARE • MAY 2000 VOL 45 NO 5

551

Authors
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

Advertisers
in This Issue

To advertise in RESPIRATORY CARE, contact Tim Goldsbury, 20 Tradewinds Circle, Tequesta FL 33469

at (561) 745-6793, Fax (561) 745-6795, e-mail: goldsburyls'aarc.org, for rales and media kits. For recruitment/
classified advertising contact Beth Binkley, Marketing Assistant for RESPIRATORY CARE, at (972) 243-2272,
Fax (972) 484-6010. Dale Clriffiths is the Marketing Director for RESPIRATORY CARE.

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Copyright information. Respiratory Care is copyrighted by
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written permission of Daedalus Enterprises Inc is prohibited. Permission to
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American Association for Respiratory Care (AARC), or Daedalus Enter-
prises Inc. Neither are the Editors, the AARC, or the Publisher responsible
for the consequences of the clinical applications or use of any meth(xls or de-
vices described in any article or advertisement.

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1 1030 Abies Lane, Dallas TX 75229-4593, or call (972) 243-2272.

SUBSCRIPTION Rates for Associations. Basic annual subscrip-
tions are offered to members of associations according to their member-
ship enrollment: 101-500 members = $l3.50/year; 501-1.500 = $13/year;
1,5(X)-I0,(XX) = $l2..50/year: more than 10.000 = $1 1.50/year. Individual
subscriptions ar available at these rates: $75/year ( 1 2 issues in the United States
or Puerto Rico; $9()/year in other countries. For information, contact Ray
Masferrer at (972) 243-2272.

Change of address. Notify the AARC at (972) 243-2272 as soon as pos-
sible of any change in address. Note the subscription number (from the
mailing label) and your name, old address, and new address. Allow 6
weeks for the change. To avoid charges for replacement copies of missed is-
sues, requests must be made within 60 days in the US and 90 days in other
countries.

Manuscripts. The Journal publishes clinical studies, method/device
evaluations, reviews, and other materials related to cardiopulmonary med-
icine and research. Manuscripts may be submitted to the Editorial Office. RES-
PIRATORY Care, 600 Ninth Avenue, Suite 702, Seattle WA 98104. In-
structions for authors are printed in every issue. An expanded version of
the Instructions is available from the editorial office.

552

RESPIRATORY CARE 'MAY 2000 VOL 45 NO 5

in a smal

an MDI
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Pulmonary Function

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facility

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10 a EducaUon

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IV POSITION

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Authors
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

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552

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