Clinical practice guidelines for suctioning the airway of the intubated and nonintubated patient.

OBJECTIVE: To provide physicians, physiotherapists, nurses and respiratory therapists with guidelines for the application of airway suctioning. DESIGN: This clinical practice guideline was developed using the model by Browman and colleagues. A working group of representatives from four professional colleges (nurses, physicians and surgeons, physiotherapists and respiratory therapists) and research experts was formed to conduct a systematic review, develop evidence-based recommendations and generate clinical practice guidelines. MEDLINE (1966 to 1998), CINAHL (1982 to 1997) and EMBASE (1974 to 1996) as well as the reference lists of identified articles were searched. Inclusion of articles was determined by at least two group members, and studies were classified according to type. Randomized, controlled; randomized; and nonrandomized crossover and comparative cohort trials were grouped by type of intervention and population for use in the development of recommendations. Other observational and animal studies dealing with adverse effects of suctioning were included in the review but were not used in the development of recommendations. Input on the evidence-based recommendations was sought and incorporated from members of all four professions and from experts on content and methodology. SETTING: Any setting (hospital or home) where suctioning is performed. POPULATION: Intubated and nonintubated adults, infants and children. RESULTS AND CONCLUSIONS: An attempt was made to develop recommendations in each of the subcategories of suctioning techniques addressed by at least one study. In some subcategories, definite recommendations were made (13 in adults, and three in children and infants); in other subcategories, insufficient evidence precluded recommendations. The recommendations addressed the following aspects of suctioning: preoxygenation, hyperinflation, insufflation, hyperoxygenation, hyperventilation, saline instillation, adaptor use, medication use, open and closed systems, and various types of catheters.

Bringing health services research to (and from) critical care.

Health services research has the potential to improve the care provided to patients in critical care settings by informing the decisions of managers and policy makers who establish many of the rules within which critical care is provided. Living up to this potential requires health services researchers in critical care to enhance the relevance of their research for managerial and policy decision makers and to undertake initiatives to increase the uptake of this research by these decision makers. Researchers can begin by asking questions from the perspective of managers and policy makers, not just from the perspective of patients and clinicians. Researchers can also design studies that will generate valid and generalizable research findings that can be acted on by these decision makers, not just studies that describe a problem or test new methods to describe a problem. Health services research is, after all, an applied field. But researchers may not want to stop there: they can engage in coordinated efforts to facilitate the uptake of their re-search findings, and do so by drawing on our evolving understanding of what works best with these decision makers. Opportunities such as the relaunch of a journal that takes seriously the challenge of informing decision making do not come along often. We hope researchers will rise to the challenge.

Withdrawal of life support: how the family feels, and why.

The objectives of this study were to develop an instrument to assess the satisfaction of family members with withdrawal of life support (WLS), and to determine which factors are associated with greater levels of satisfaction. To do this, we developed a self-administered questionnaire that was sent to the next-of-kin of intensive care unit (ICU) patients dying following WLS. Over a six-month period, 69 patients died following WLS in the ICU. Three letters were returned "address unknown", 33 did not respond, and 33 responded, of whom 29 agreed to participate (29/66 = 44% of those contacted). Of these, 24 (83%) strongly agreed with the patient's death being compassionate and dignified, one moderately agreed, one mildly agreed, one was neutral and two strongly disagreed. Items associated with greater satisfaction included: the process of WLS being well explained, WLS proceeding as expected, patient appearing comfortable, family/friends prepared for the decision, appropriate person initiating discussion, adequate privacy during WLS, chance to voice concerns. The study suggests factors that are important to consider in ensuring family comfort with the process of withdrawing life support.

Noninvasive positive pressure ventilation in the setting of severe, acute exacerbations of chronic obstructive pulmonary disease: more effective and less expensive.

OBJECTIVE: The use of noninvasive ventilation for patients with acute respiratory failure has become increasingly popular over the last decade. Although the literature provides good evidence for the effectiveness of noninvasive ventilation in addition to standard therapy compared with standard therapy alone in patients with chronic obstructive pulmonary disease (avoiding intubation and improving hospital mortality), the associated costs have not been rigorously measured. Adding noninvasive positive pressure ventilation (NPPV) to standard therapy in the setting of a severe, acute exacerbation of chronic obstructive pulmonary disease (COPD) in patients with respiratory acidosis who are at high risk of requiring endotracheal intubation is both more effective and less expensive. DESIGN: Economic evaluation based on theoretical model. SETTING: This analysis base case was modeled for a tertiary care, teaching hospital. PATIENTS OR OTHER PARTICIPANTS: Carefully selected patients with severe exacerbations of COPD. INTERVENTION: The two alternative therapies compared were standard therapy (oxygen, bronchodilators, steroids, and antibiotics) and standard therapy plus NPPV. MEASUREMENTS AND MAIN RESULTS: As the hypothesis was dominance, the main outcomes modeled and calculated were costs, mortality rate, and rates of intubation between the two interventions. To determine clinical effectiveness, we used a meta-analysis of randomized trials evaluating the impact of NPPV on hospital survival. A decision tree was constructed and probabilities were applied at each chance node using research evidence and a comprehensive regional database. To provide data for this economic evaluation, MEDLINE literature searches were conducted. Bibliographies of relevant articles were reviewed, as were personal files. To estimate the costs of the alternative therapeutic approaches, eight types of hospitalization days were costed using the London Health Sciences Center costing data. Sensitivity analyses were performed, varying all assumptions made. The meta-analysis yielded an odds ratio for hospital mortality in the NPPV arm, compared with standard therapy, of 0.22 (95% confidence interval, 0.10-0.66). By using baseline case assumptions, we found a cost savings of $3,244 (1996, Canadian), per patient admission, if NPPV were adopted in favor of standard therapy. These findings present a scenario of clear dominance for treatment with NPPV. Sensitivity analyses did not alter the results appreciably. CONCLUSIONS: We conclude that from a hospital's perspective, NPPV and standard therapy for carefully selected patients with acute, severe exacerbations of COPD are more effective and less expensive than standard therapy alone.

The Critical Care Research Network: a partnership in community-based research and research transfer.

The objectives of this study were to present a short history of the Critical Care Research Network (CCR-Net), describe its approach to health services research and to summarize completed and current research projects. In doing this, we explored the question is this research network accomplishing its goals? We reviewed the medical literature to identify studies on similar types of Networks and also the evidence supporting the methodology used by CCR-Net to conduct research using MEDLINE, HEALTHSTAR, CINAHL and the keywords network and health care or healthcare, benchmarking and health care or healthcare, and research transfer or research utilization. We also reviewed the bibliographies of retrieved articles and our personal files. In addition, we summarized the results of studies conducted by CCR-Net and outlined those currently in progress. A review of the literature identified studies on two similar networks that appeared to be succeeding. In addition, the literature was also supportive of the general process used by CCR-Net, although the level of evidence varied. Finally, the studies conducted to date within CCR-Net follow the suggested methodology. At the time of this preliminary communication CCR-Net appears to have adopted a valid approach to health services research within the area of Critical Care Medicine. Further direct evidence is required and appropriate studies are planned.

Sedation in the intensive care unit: a systematic review.

CONTEXT: Sedation has become an integral part of critical care practice in minimizing patient discomfort; however, sedatives have adverse effects and the potential to prolong mechanical ventilation, which may increase health care costs. OBJECTIVE: To determine which form of sedation is associated with optimal sedation, the shortest time to extubation, and length of intensive care unit (ICU) stay. DATA SOURCES: A key word search of MEDLINE, EMBASE, and the Cochrane Collaboration databases and hand searches of 6 anesthesiology journals from 1980 to June 1998. Experts and industry representatives were contacted, personal files were searched, and reference lists of relevant primary and review articles were reviewed. STUDY SELECTION: Studies included were randomized controlled trials enrolling adult patients receiving mechanical ventilation and requiring short-term or long-term sedation. At least 2 sedative agents had to be compared and the quality of sedation, time to extubation, or length of ICU stay analyzed. DATA EXTRACTION: Data on population, intervention, outcome, and methodological quality were extracted in duplicate by 2 of 3 investigators using 8 validity criteria. DATA SYNTHESIS: Of 49 identified randomized controlled trials, 32 met our selection criteria; 20 studied short-term sedation and 14, long-term sedation. Of these, 20 compared propofol with midazolam. Most trials were not double-blind and did not report or standardize important cointerventions. Propofol provides at least as effective sedation as midazolam and results in a faster time to extubation, with an increased risk of hypotension and higher cost. Insufficient data exist to determine effect on length of stay in the ICU. Isoflurane demonstrated some advantages over midazolam, and ketamine had a more favorable hemodynamic profile than fentanyl in patients with head injuries. CONCLUSION: Considering the widespread use of sedation for critically ill patients, more large, high-quality, randomized controlled trials of the effectiveness of different agents for short-term and long-term sedation are warranted.

Is there a preferred technique for weaning the difficult-to-wean patient? A systematic review of the literature.

OBJECTIVE: To answer the following question: 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? DATA SOURCES: Computerized literature searches in MEDLINE (1975-1996), Cinahl (1982-1996), and Healthplan (1985-1996), exploding all Mesh headings pertaining to Mechanical Ventilation and Weaning. Searches were restricted to the English language, adults, and humans. Personal files were hand searched, and references of selected articles were reviewed. 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 ventilation); b) INTERVENTIONS: At least two of the following three modes of weaning from mechanical ventilation must have been compared: T-piece, synchronized intermittent mandatory ventilation, or pressure support ventilation; c) OUTCOMES: At least one of the following: weaning time (time from initiation of weaning to extubation) or successful weaning rate (successfully off the ventilator for >48 hrs); and d) STUDY DESIGN: Controlled trial. DATA EXTRACTION: Two reviewers independently reviewed the articles and graded them according to their methodologic rigor. Data on the success of weaning and the time to wean were summarized for each study. DATA SYNTHESIS: The search strategy identified 667 potentially relevant 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 selection criteria. The results of the trials were conflicting, and there was heterogeneity among studies that precluded meaningful pooling of the results. CONCLUSIONS: There are few trials 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 technique among the three most popular modes, T-piece, pressure support ventilation, or synchronized intermittent mandatory ventilation. However, it appears that synchronized intermittent 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 likelihood of weaning than the mode itself.

How to use articles about diagnostic technology: gastric tonometry.

PURPOSE: Periodic diagnostic tests and continuous and intermittent monitoring are integral to critical care medicine. The focus of this article is understanding the impact of existing diagnostic technology, as well as that of new diagnostic technology. DATA SYNTHESIS: We use literature about gastric tonometry to illustrate eight steps for assessing the value of diagnostic technology. METHODS: These steps focus on how the technology works in the laboratory, its range of uses and diagnostic accuracy, its impact on healthcare workers, the decision making process, and patient outcomes, as well as issues of access, cost, and application in your own setting. CONCLUSIONS: Awareness of the scope and quality of research evaluating new and existing diagnostic technology is central to modern critical care practice.

The attributable morbidity and mortality of ventilator-associated pneumonia in the critically ill patient. The Canadian Critical Trials Group.

To evaluate the attributable morbidity and mortality of ventilator-associated pneumonia (VAP) in intensive care unit (ICU) patients, we conducted a prospective, matched cohort study. Patients expected to be ventilated for > 48 h were prospectively followed for the development of VAP. To determine the excess ICU stay and mortality attributable to VAP, we matched patients with VAP to patients who did not develop clinically suspected pneumonia. We also conducted sensitivity analyses to examine the effect of different populations, onset of pneumonia, diagnostic criteria, causative organisms, and adequacy of empiric treatment on the outcome of VAP. One hundred and seventy-seven patients developed VAP. As compared with matched patients who did not develop VAP, patients with VAP stayed in the ICU for 4.3 d (95% confidence interval [CI]: 1.5 to 7. 0 d) longer and had a trend toward an increase in risk of death (absolute risk increase: 5.8%; 95% CI: -2.4 to 14.0 d; relative risk (RR) increase: 32.3%; 95% CI: -20.6 to 85.1%). The attributable ICU length of stay was longer for medical than for surgical patients (6. 5 versus 0.7 d, p < 0.004), and for patients infected with "high risk" organisms as compared with "low risk" organisms (9.1 d versus 2.9 d). The attributable mortality was higher for medical patients than for surgical patients (RR increase of 65% versus -27.3%, p = 0. 04). Results were similar for three different VAP diagnostic criteria. We conclude that VAP prolongs ICU length of stay and may increase the risk of death in critically ill patients. The attributable risk of VAP appears to vary with patient population and infecting organism.

Patients readmitted to the intensive care unit during the same hospitalization: clinical features and outcomes.

OBJECTIVE: To determine the clinical features and outcomes of patients readmitted to the intensive care unit (ICU) during the same hospital stay and the causes for these readmissions. DESIGN: Multicenter, cohort study. SETTING: Three ICUs from two teaching hospitals and four ICUs from four community hospitals. PATIENTS: All ICU admissions were collected prospectively for a registry database in the seven ICUs. We retrospectively analyzed ICU admissions between January 1, 1995 and February 29, 1996. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: During the study period, 236 (4.6%) of the patients discharged alive from the ICU were readmitted to the unit. Patients with gastrointestinal (GI) and neurologic diagnoses had the highest readmission rate. Of the readmissions, 45% had recurrence of the initial disease, 39% experienced new complications, and 14% required further planned operation. Among patients readmitted for the same illness, cardiovascular and respiratory problems were the most frequent diagnoses. Of patients readmitted with a new diagnosis, 30% initially had GI diseases, while respiratory diseases accounted for 58% of the new complications. Readmissions within 24 hrs occurred in 27% of all readmissions. Patients requiring readmission had a higher hospital mortality rate (31.4%) compared with those not requiring readmission (4.3%, p < .001), even after adjustment for disease severity score (odds ratio = 5.93, p < .001). CONCLUSIONS: Patients with GI and neurologic diseases are at greatest risk of requiring ICU readmission. Respiratory diseases are the major reason for readmission due to new complications. Readmitted patients have a high risk of hospital death that may be underestimated by the usual physiologic indicators on either initial admission or readmission. Further studies are required to determine if patients at risk for readmission can be identified early to improve the outcome.

Ventilatory care in a selection of Ontario hospitals: bigger is not necessarily better! Critical Care Research Network (CCR-Net).

OBJECTIVE: To determine whether there is variability in the structure and process of ventilatory care in intensive care units (ICUs) of the hospitals of Southwestern Ontario. DESIGN: Self-administered questionnaire-based survey. SETTING: ICUs of selected community and teaching hospitals of Southwestern Ontario. PARTICIPANTS: Head of respiratory therapy service of respective hospitals; in those hospitals without respiratory therapists, the ICU nurse manager. INTERVENTION: Self-administered questionnaire. OUTCOME MEASURE(S): The availability of different models of ventilators and respiratory therapist and physician coverage were assessed. In addition, the use of clinical practice guidelines, respiratory therapists, and the nursing role in ventilatory care were determined. RESULTS: In general, the structure of ventilatory care, including availability of different modes of ventilation, and coverage by respiratory therapists and physicians was more comprehensive in larger hospitals. However, the availability of some modes of ventilation varied more than expected among hospitals of comparable size. Similarly, variability in the process of ventilatory care, defined by the availability of clinical practice guidelines and the roles of respiratory therapists varied both within and among hospitals of different size. CONCLUSIONS: The structure and process of ventilatory care in this sample of Southwestern Ontario ICUs was found to be variable. Not all this variability could be accounted for by hospital size, suggesting a potential for improvement in overall ventilatory care. Further study is required before any specific recommendations can be considered.

The effect of positive pressure airway support on mortality and the need for intubation in cardiogenic pulmonary edema: a systematic review.

OBJECTIVE: To critically appraise and summarize the trials examining the addition of continuous positive airway pressure (CPAP) or noninvasive positive pressure ventilation (NPPV) to standard therapy on hospital mortality, need for endotracheal intubation, and predischarge left ventricular function in patients admitted to the hospital with cardiogenic pulmonary edema with gas exchange abnormalities. DATA SOURCES: We searched MEDLINE (1983 to June 1997) and bibliographies of all selected articles and review articles. We also reviewed the abstracts from the proceedings of relevant meetings from 1985 to 1997. STUDY SELECTION: (1) POPULATION: patients presenting to hospital with cardiogenic pulmonary edema; (2) intervention: one of the following three: (a) the use of CPAP and standard medical therapy vs standard medical therapy alone; (b) the use of NPPV and standard medical therapy vs standard medical therapy alone; and (c) the use of NPPV and standard therapy vs CPAP and standard therapy; (3) outcome: hospital survival, need for endotracheal intubation, or predischarge left ventricular dysfunction; and (4) study design: randomized controlled trial (RCT); if there were fewer than two RCTs, other study designs were included. DATA EXTRACTION: Two authors independently extracted data and evaluated the methodologic quality of the studies. DATA SYNTHESIS: CPAP was associated with a decrease in need for intubation (risk difference, -26%, 95% confidence intervals, -13 to -38%) and a trend to a decrease in hospital mortality (risk difference, -6.6%; +3 to -16%) compared with standard therapy alone. There was insufficient evidence to comment on the effectiveness of NPPV either compared with standard therapy or CPAP and standard therapy. Evidence was also lacking on the potential for either intervention to cause harm. CONCLUSIONS: A modest amount of favorable experimental evidence exists to support the use of CPAP in patients with cardiogenic pulmonary edema. CPAP appears to decrease intubation rates and data suggest a trend toward a decrease in mortality, although the potential for harm has not been excluded. The role of NPPV in this setting requires further study before it can be widely recommended.

Prevalence of sleep disordered breathing in a population of Canadian grainworkers.

OBJECTIVES: To determine the prevalence of sleep disordered breathing (SDB) in a Canadian population of industrial workers (grainworkers). To determine the clinical features that are predictive of SDB and the validity of self-reported snoring. DESIGN: Cross-sectional, interviewer-administered questionnaire with selective recruitment of subjects for home sleep monitoring. SETTING: Community setting, Vancouver, British Columbia. PARTICIPANTS: All male grainworkers at grain elevators in Vancouver were approached for completion of a questionnaire. Eighty-three per cent of 524 subjects completed the questionnaire and were divided by presumed risk for SDB into four groups. All subjects in the highest risk group (group 1- frequent snoring and witnessed apneas) and a random sample of 40 subjects in the other three groups (group 2 - frequent snoring without witnessed apneas; group 3 - infrequent snoring rare; group 4 - nonsnoring) were approached for home sleep monitoring and 42% consented. INTERVENTIONS: Interviewer-administered questionnaire and home sleep monitoring. RESULTS: The overall prevalence of SDB in this relatively overweight group was estimated to be 25%, with a stepwise increase from group 4 to group 1 (7%, 29%, 40%, 60%). Presence of snoring and witnessed apneas, a greater body-mass index and a larger neck circumference were associated with SDB. Self-reported snoring was not found to be predictive. CONCLUSIONS: This first study of the prevalence of SDB in Canada suggests that SDB is at least as prevalent in Canada as in other industrialized nations and may actually be more common than previously thought. Further studies are required to determine the morbidity, mortality and economic loss associated with SDB in industrial workers.

An evidence-based approach to noninvasive ventilation in acute respiratory failure.

This article reviews the literature of noninvasive positive pressure ventilation (NPPV) in patients with acute respiratory failure. The article divides acute respiratory failure into the categories of primary ventilation failure and oxygenation failure, and examines various diagnostic groups within these categories. Although the use of NPPV for patients with acute respiratory failure of other etiologies requires further study, the authors conclude that there is sufficient evidence to support the use of NPPV in acute, severe exacerbations of chronic obstructive pulmonary disease.

Withdrawal and withholding of life support in the intensive care unit: a comparison of teaching and community hospitals. The Southwestern Ontario Critical Care Research Network.

OBJECTIVES: To compare the incidence of withdrawal or withholding of life support (WD/WHLS), and to identify similarities and differences in the process of the withdrawal of life support (WDLS) between teaching and community hospitals' intensive care units (ICUs). DESIGN: Prospective cohort study, with some data obtained by retrospective chart review. SETTING: The ICUs of three teaching hospitals and six community hospitals. PATIENTS: All patients who died in these nine ICUs over a 6-mo period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Data on admitting diagnosis, cause of death, mode of death (death despite active treatment, withdrawal or withholding of life support), those initiating and involved in WDLS, and modalities of life support withdrawn were gathered for patients dying in the ICU over a 6-mo period. One hundred sixty patients in community hospitals and 292 in teaching hospitals died in their respective ICUs over the 6-mo period. We found a difference in the distribution of mode of death between community hospitals and teaching hospitals, resulting from a greater proportion of patients dying as a result of withholding life support in community hospitals (11.9% vs. 3.8% withheld, respectively, p = .004). Among the six community hospitals and three teaching hospitals, we found a difference in the proportion of patients dying despite active treatment compared with those dying as a result of WD/WHLS (p = .042 and p = .044, respectively). Initiation of WDLS by physicians was more frequent at teaching hospitals (81% vs. 61%, p = .0005), while families more commonly initiated WDLS at community hospitals (34% vs. 19%, p = .005). A greater proportion of patients in teaching hospitals were receiving mechanical ventilation (99% vs. 89%) and vasopressors (76% vs. 65%) before WDLS. Similar proportions had mechanical ventilation withdrawn (68% and 74%, community hospitals and teaching hospitals, respectively), while there was a trend for fewer patients in community hospitals to have vasopressors withdrawn (56% vs. 70%, p = .082). The time to death after WDLS had begun was longer in community hospitals compared with teaching hospitals (0.74 +/- 1.38 days vs. 0.27 +/- 0.79 [SD] days, p = .0028). CONCLUSIONS: The incidence of WD/WHLS was similar in community hospitals and teaching hospitals; however, withholding of life support was more common in community hospitals. The process of WDLS appears to differ between community hospitals and teaching hospitals.

A systematic review of the cost-effectiveness of noncardiac transitional care units.

OBJECTIVE: To critically appraise and summarize the studies examining the cost-effectiveness of noncardiac transitional care units (TCUs). DATA SOURCES: We conducted a computerized literature search using MEDLINE, and Current Contents from January 1, 1986 to December 31, 1995 and HealthSTAR from January 1, 1989 to December 31, 1995 with the key words intermediate care unit, respiratory care unit, and step-down unit. Bibliographies of all selected articles and review articles were examined. Personal files were also reviewed. STUDY SELECTION: (1) POPULATION: patients in a noncardiac TCU of an acute-care institution; (2) intervention: addition of a noncardiac TCU to the institution; and (3) outcomes: patient outcome-survival and associated costs. DATA EXTRACTION: The necessary data were abstracted and study validity was evaluated by two independent reviewers using a modification of previously published criteria. DATA SYNTHESIS: The studies were summarized qualitatively; upon inspection, they were too heterogeneous to allow quantitative analysis. While the studies all claimed that their TCUs were cost-effective, the economic evaluation designs were flawed to such an extent that the validity of the conclusions is suspect. CONCLUSIONS: To date, the evidence in the literature is insufficient to determine under which circumstances, if any, TCUs are a cost-effective alternative technology to the traditional institution with only ICU and general ward beds.

Determining the potential need for a bereavement follow-up program: how well are family and health care workers' needs currently being met?

The purpose of the study was to determine the need for a bereavement follow-up program for either the families of patients dying in a critical care unit or the health care workers who care for these patients. Two questionnaires, the first a telephone administered questionnaire to all consenting family members of patients dying in the critical care unit, and the second a self-administered questionnaire administered to all health care workers in the critical care unit, were developed and piloted for content validity and clarity. The data was analyzed using descriptive statistics. Family members of 42 patients who died in the critical care unit were interviewed (54% response rate). During the critical care unit stay most family members obtained support from family and friends. While 70% listed health care workers as a source of support, 50% were satisfied with the support from staff. After a family member had died, 40% of those interviewed did not identify a specific source for support and 48% were interested in obtaining information on community resources available for aid in the bereavement process. The results from 117 (79% response rate) health care workers revealed that 30% were either uncomfortable or only somewhat comfortable with the dying process and the support available for them to deal with the death of their patients. The authors identified a need for bereavement follow-up programs for both the families of patients who die in the critical care unit and for the health care workers who care for these patients.

Effect of noninvasive positive pressure ventilation on mortality in patients admitted with acute respiratory failure: a meta-analysis.

OBJECTIVE: To critically appraise and summarize the trials examining the addition of noninvasive positive pressure ventilation to standard therapy on hospital mortality and need for endotracheal intubation in patients admitted with acute respiratory failure. DATA SOURCES: We searched MEDLINE (1966 to September 1995) and key references were searched forward using the Scientific Citation Index (SCISEARCH). Bibliographies of all selected articles and review articles were examined. Authors of all selected and review articles were contacted by letter to identify unpublished work. STUDY SELECTION: a) POPULATION: patients with acute respiratory failure; b) intervention: noninvasive positive pressure ventilation; c) outcome: mortality and/or endotracheal intubation; and d) design: randomized, controlled study. Two of us independently selected the articles for inclusion; disagreements were settled by consensus. Seven (three unpublished) of 212 initially identified studies were selected. DATA EXTRACTION: Two authors independently extracted data and evaluated methodologic quality of the studies. DATA SYNTHESIS: Noninvasive positive pressure ventilation was associated with decreased mortality (odds ratio = 0.29; 95% confidence interval 0.15 to 0.59) and a decreased need for endotracheal intubation (odds ratio = 0.20; 95% confidence interval 0.11 to 0.36). Sensitivity analysis suggested a greater benefit of noninvasive positive pressure ventilation in patients with chronic obstructive pulmonary disease (COPD). The inclusion/exclusion of unpublished trials did not influence these results. CONCLUSIONS: The addition of noninvasive positive pressure ventilation to standard therapy in patients with acute respiratory failure improves survival and decreases the need for endotracheal intubation. However, this effect is restricted to patients whose cause of acute respiratory failure is an exacerbation of COPD. Further research is warranted to determine whether noninvasive positive pressure ventilation confers benefit in patients without COPD who have acute respiratory failure.