Pulmonary alveolar proteinosis causing severe hypoxemic respiratory failure treated with sequential whole-lung lavage utilizing venovenous extracorporeal membrane oxygenation: a case report and review.

Pulmonary alveolar proteinosis is characterized by the accumulation of proteinaceous material in the alveoli leading to varying degrees of impairment in gas exchange. Generally, the degree of hypoxemia is mild, and it is rare to have respiratory failure requiring mechanical ventilation. We present a 53-year-old woman with the most severe degree of hypoxemia associated with alveolar proteinosis reported in the English-language adult literature. Her therapy of sequential whole-lung lavage performed while receiving venovenous extracorporeal membrane oxygenation in one operative session is the first reported successful use of this approach.

Inpatient care of the adult with an exacerbation of cystic fibrosis.

Patients with cystic fibrosis (CF) are living longer, albeit with chronic and progressive lung disease. Pulmonary exacerbations in CF are characterized by an increase in respiratory symptoms and a decrease in pulmonary function and gas exchange. Exacerbations that do not respond to outpatient management require hospitalization. Complications of CF can be devastating and life-threatening. Care of these patients is challenging not only because of the scope and severity of their medical problems, but also because of the need to coordinate services and to maintain continuity during transitions between hospital and home.

Effect of the Passy-Muir tracheostomy speaking valve on pulmonary aspiration in adults.

PURPOSE: We determined instances of aspiration in adults with tracheostomies and investigated the effect of the Passy-Muir tracheostomy speaking valve on occurrences of aspiration. METHODS: Adults with tracheostomies scheduled for videofluoroscopic swallowing examinations who met inclusion criteria were enrolled. According to study protocol, 6 presentations of thin liquids were recorded, 3 with and 3 without the Passy-Muir tracheostomy speaking valve. If a cuffed tube was present, the cuff was deflated fully for all presentations. RESULTS: Seven of 15 subjects aspirated material on 1 or more presentations of thin liquid. Five subjects aspirated material only with the Passy-Muir tracheostomy speaking valve off, whereas 2 subjects aspirated material with and without the valve. No subject aspirated material while the valve was on exclusively. Aspiration was significantly less frequent with the Passy-Muir tracheostomy speaking valve on than with it off. CONCLUSIONS: Clinically unapparent aspiration occurs commonly in patients with tracheostomies. An expiratory occlusive valve can reduce, though not eliminate, occurrences of aspiration. CLINICAL IMPLICATION: The benefit of the Passy-Muir tracheostomy speaking valve should be evaluated in selected patients who aspirate liquid.

Variability in performance of timed walk tests in pulmonary rehabilitation programs.

STUDY OBJECTIVE: To describe variability in the conduct of walk tests in pulmonary rehabilitation programs. DESIGN: : Analysis of information obtained by means of a structured written questionnaire. SETTING: Outpatient pulmonary rehabilitation programs in the United States and Canada. PARTICIPANTS: Clinical coordinators of 75 pulmonary rehabilitation programs. INTERVENTIONS: None RESULTS: Timed walk tests were obtained in 71 of 99 programs surveyed. Considerable variability in all aspects of testing practices was evident. Fifty-seven respondents (80%) based results on a single walk. Walk tests were completed in a hallway (73%), on a walking track (9%), and on a treadmill (7%). In 29 programs (44%), a walk supervisor carried or pulled the oxygen source, while in 25 programs (38%), the oxygen was carried or pulled by the patient. Informal nonstandardized instructions were provided to patients prior to walking in 41 programs (58%). In 53 programs (76%), the walk supervisor could direct a patient to speed up, to slow down, or to rest. Evaluations of breathlessness and perceived exertion were measured during the walk by 73% and 16% of programs, respectively. CONCLUSIONS: Practices regarding performance of timed walk tests are poorly standardized among pulmonary rehabilitation programs. Further research is needed to evaluate the impact of certain variations in testing practices on test results.

Comparison of hallway and treadmill six-minute walk tests.

The 6-min walk test (SMWT) performed in the hallway (HW) is used as a clinical indicator of functional capacity in patients with lung disease. A 6-min walk test utilizing a treadmill (TM) is easier to perform and allows easier patient monitoring. Therefore, we formulated a standardized TM SMWT protocol and compared the results with those of a HW SMWT. All patients were enrolled in a pulmonary rehabilitation program. Patients with current infection, recent change in inhaled medications or oral steroid use, and significant cardiovascular disease were excluded. Each subject performed three HW SMWTs and three TM SMWTs assigned randomly on subsequent days. There was a 30-min rest between each walk and at least a 48-h rest between each test day. All patients completed both HW and TM SMWT within 7 d. Supplemental oxygen was utilized or increased if the saturation fell below 88%. The best of the three tests was used for data analysis. Twenty-one subjects completed the protocol. The mean age was 65 +/- 10.9 yr (range, 35 to 79 yr). Ten subjects were receiving supplemental oxygen. The mean FEV(1) was 1.07 +/- 0.53 L. The mean HW SMWT distance was 1,228 +/- 255 ft (range, 612 to 1,679 ft) and the mean TM SMWT distance was 1,060 +/- 389 ft (range, 475 to 1,819 ft), which were statistically different (p = 0.01). The mean difference was 168 +/- 280 ft (range, -326 to 743 ft). Oxygen saturation and supplemental oxygen requirements did not differ significantly. The intra-test variability of the three HW SMWTs was similar to the three TM SMWTs and no significant difference in the coefficient of variation was found. A standardized TM SMWT is feasible and allows easier patient monitoring, but there is a statistically significant difference between the HW and TM SMWT distance and therefore they are not interchangeable. However, the intratest reproducibility of the TM and HW SMWTs are similar when three walks are performed in a single test session. The role of the TM SMWT in pulmonary rehabilitation requires further exploration.

Loss of pulmonary function gains after lung volume reduction surgery.

Lung volume reduction surgery (LVRS) has been demonstrated to improve lung function, exercise tolerance and quality of life. However, the duration of improvement is unknown. While the maximal duration of improvement cannot be determined at this time due to an inadequate period of follow-up, we have observed in some patients significant and relatively rapid declines in gains following LVRS. We describe 6 patients who increased FEV1 by at least 10% of the predicted value after LVRS and subsequently experienced rapid loss of the increment in FEV1 (mean loss 79%, 95% CI 58-100%) over a period ranging from 14 to 20 months following surgery.

Lung volume reduction surgery: an analysis of hospital costs.

OBJECTIVE: Lung volume reduction surgery (LVRS) represents a potential breakthrough in the management of advanced emphysema, although questions remain about clinical and economic implications of widespread application of LVRS. In this report, we describe hospital costs, excluding physicians' fees, for LVRS. DESIGN: Hospital charges were obtained from billing records and converted to costs by applying multiple cost-to-charge ratios. SETTING: A large, urban academic medical center. PATIENTS: Fifty-two consecutive patients who received bilateral LVRS through a median sternotomy between April 1995 and August 1996. RESULTS: Median hospital stay was 10 days (mean= 14.8+/-12.8 days; range=3 to 48 days), including 2 days (mean=6+/-9.2 days; range=1 to 35 days) in the ICU. One hospital death occurred. Hospital costs per case ranged from $11,712 to $121,829, with mean costs of $30,976 and median costs of $19,771. Costs were related significantly to duration of ICU stay and length of hospitalization. Patients who accrued the highest costs were significantly older than the remainder of the sample (69.3 years vs 62.4 years). CONCLUSIONS: Hospital costs of LVRS vary significantly but are related directly to hospital stay. Identification of factors associated with prolonged stays can be used in assessing benefits and risks of LVRS against utilization of health-care dollars.

Pulmonary aspiration in hospitalized adults.

Until recent years, pulmonary aspiration attracted remarkably little clinical investigation. Although aspiration was considered a common occurrence in hospitalized individuals, with serious and even fatal consequences, clinicians had limited scientific data to guide practice. Consequently, approaches to this problem were based largely on unsystematic observations, intuition, and tradition. Recent investigations on the subjects of aspiration have increased our understanding of patients at risk for aspiration, the value of diagnostic methods, and the efficacy of interventions to prevent or limit aspirations. Results of these studies call to question many time-honored adages and practices. Considerable uncertainty remains and more investigation is necessary before management decisions can be characterized clearly and clinical strategies defined. This review focuses on pulmonary aspiration and enteral feeding in the critically ill adult. Factors implicated in aspiration in this population are highlighted and evidence to support the application of interventions prescribed commonly is presented.

The technique of pleurodesis.

Pleurodesis may be indicated for pleural effusions (with careful patient evaluation) or recurrent pneumothoraces. It is contraindicated if tube thoracostomy fails to reexpand the lung and, possibly, if patients are candidates for lung transplantation or have congestive heart failure. We perform pleurodesis through an indwelling chest tube (alternative methods are thoracoscopy and thoracotomy). Common sclerosants include talc, doxycycline, minocycline, and bleomycin. Intrapleural administration of lidocaine may control pain, but injections of morphine or meperidine almost always are needed.

Pulmonary aspiration in mechanically ventilated patients with tracheostomies.

The purpose of this descriptive study was to evaluate feeding aspirations in adult patients receiving long-term mechanical ventilatory support, including the incidence of aspirations, the frequency of silent (clinically inapparent) aspirations, and differences between aspirators and nonaspirators. Aspiration data were determined by review of videofluoroscopic (VF) tapes of modified barium swallow procedures performed on 83 medically stable patients admitted to a chronic ventilator unit. Demographic and clinical variables were obtained from review of subjects' medical records. Forty-two subjects (50 percent) aspirated during VF testing and 37 of 48 (77 percent) aspirations were silent. Subjects who aspirated were significantly older than those who did not aspirate (p = 0.007). Swallowing disorders were common, particularly disturbances of the pharyngeal phase. We conclude that feeding aspiration is seen frequently in patients with tracheostomies receiving prolonged positive pressure mechanical ventilation. Advanced age increases the risk of aspiration in this population. Episodes of aspiration are not consistently accompanied by clinical symptoms of distress to alert the bedside observer to their occurrence.

Tuberculosis update: new challenges of an old disease.

Tuberculosis has re-emerged as a major threat to personal and public health in the United States. Hospitals are high-risk environments for tuberculosis transmission, and nursing is a high-risk occupation for tuberculosis infection. It is essential for nurses to thoroughly understand and strictly adhere to infection control practices to prevent tuberculosis transmission in health care settings.

A preliminary investigation of opinions and behaviors regarding advance directives for medical care.

BACKGROUND: Advance directives are a means of promoting patient autonomy in end-of-life decisions but are used infrequently. A recent federal law requires healthcare organizations to provide information to patients about advance directives. This study explored attitudes and behaviors related to the use of advance directives in three areas: familiarity with advance directives, reasons for completing or not completing advance directives and preferences for receiving information about advance directives. METHODS: A questionnaire was administered by personal interview to a nonrandomized convenience sample of 46 inpatients and 50 outpatients at a large, tertiary care, urban academic medical center in the summer of 1991. RESULTS: Most respondents (77%) had heard of either the living will or durable power of attorney for healthcare, but only 52% correctly understood the purpose of these documents. Twenty-nine percent of the sample had executed an advance directive. Those who had advance directives were older and considered themselves less healthy than did those without advance directives. Unfamiliarity with advance directives and procrastination were cited most often as reasons for not having an advance directive. Most subjects (65%) had spoken with someone, usually a family member or close friend, about preferences for treatment during a critical illness. Although they had rarely discussed advance directives, 83% anticipated that they would be comfortable doing so with a physician or a nurse. CONCLUSIONS: Advance directives are used infrequently to document treatment preferences. The success of programs to promote greater use of advance directives depends on a clearer understanding of the factors that influence both decision and action to execute an advance directive. Patients claim to be comfortable in discussing the topic and prefer that such discussions occur in the outpatient setting.

Patients' preferences for intensive care.

OBJECTIVES: To determine patients' preferences for intensive care and to evaluate the influence of a recent ICU experience on preferences for future ICU treatment. DESIGN: Survey of nonrandomized patient sample using structured interviews. SETTING: Large, urban, tertiary academic medical center. PATIENTS: Eighty-four adult inpatients discharged from the medical ICU between June and August 1990. MEASUREMENTS: Agreement with life-supportive care under each of four potential outcome scenarios was assessed on a 5-point scale. An overall preference score was created by summing scores for the four items. Patients were also asked about their recent experiences in the ICU. RESULTS: Patients identified sources of stress associated with their ICU stay, yet most (76%) rated their ICU experience positively. Preferences for future intensive care varied with perceived outcome, and were strongest for health restoration and weakest for persistent vegetative states. No significant relationships were found between ICU preferences and any demographic or clinical variable except race. CONCLUSIONS: Patients tolerate intensive care well and desire it to restore health. Most patients modify their desire for intensive care if less favorable outcomes are likely. Patients' preferences for intensive care cannot be predicted from demographic features or previous ICU experiences.

Prolonged ventilator dependence: economic and ethical considerations.

Patients who receive ventilator treatment tend to be older and sicker than ever before, factors that contribute to the complexity of ventilator weaning. The provision of prolonged ventilator support entails a commitment of expensive hospital resources, yet survival is often poor. Consideration must be given to limiting ventilator treatment in instances when benefit is highly unlikely or when the burdens of treatment outweigh benefits. Decisions to withhold or withdraw mechanical ventilation must be made with full knowledge and understanding of relevant ethical principles. If ventilator support is to be terminated, this should be accomplished according to institutional protocols that take into account these ethical considerations, as well as the medical and legal facts that apply.

Advances in patient care management: the NRCU.

The noninvasive respiratory care unit has become an important advance in patient management. The NRCU allows for better use of special-care beds and represents a more cost-effective approach to the care of a number of ventilator-dependent patients or other respiratory patients. This article describes the NRCU, discusses clinical experiences and focuses on practical issues related to patient management in the NRCU.