Effects of posture on stimulated ventilation in quadriplegia.

Quadriplegics are able to compensate for alterations of operational length of the diaphragm by reflexly increasing neural drive to the diaphragm. This increase in neural drive is adequate to maintain required tidal volume and minute ventilation during quiet breathing in these patients with limited inspiratory muscle function. It is not known, however, if this neural compensation is sufficient to preserve ventilation when the diaphragm is stressed by simultaneously changing its operational length and increasing ventilatory demands. This issue was explored in 7 quadriplegics whose vital capacity was reduced to 15 to 53% of predicted. The diaphragm was stressed by shortening its length from the supine to a 60 degree tilted position, and also by inducing hyperventilation by having the subjects rebreathe 7% CO2. Response to this stress was recorded by monitoring the ventilatory response to rebreathing CO2 (delta VE/delta PCO2), and also by measuring mouth pressure 0.1 s after occluding the airway at the start of inspiration during CO2 rebreathing (delta P0.1/delta PCO2). A change from the supine to the tilted position caused an increase in resting end-expiratory volume of 0.8 +/- 0.2 L (SD) and therefore shortened the diaphragm. Despite this shortening of diaphragm length and the stress of CO2 rebreathing, there was no significant change in delta VE/delta PCO2 and delta P0.1/delta PCO2 with changes in posture. The delta VE/delta PCO2 was 0.82 +/- 0.42 L/min/mm Hg supine versus 0.95 +/- 0.65 L/min/mm Hg when tilted. The delta P0.1/delta PCO2 was 0.18 +/- 0.08 cm H2O/mm Hg supine versus 0.20 +/- 0.10 cm H2O/mm Hg tilted.(ABSTRACT TRUNCATED AT 250 WORDS)

Physicians' and nurses' attitudes toward withholding treatment in a community hospital.

Physician and nurse attitudes regarding aggressiveness of patient care were prospectively surveyed by questionnaire in a small rural community hospital. All patient admissions during one year, excluding routine obstetrical cases, were surveyed. Physicians and nurses used a simple continuous scale to indicate care level (1 = comfort care to 5 = full care). Nurses were more willing than physicians to limit care efforts for patients (mean scores of 4.35 vs 4.79, respectively). Both physicians and nurses indicated nearly identical factors important in making decisions to limit full resuscitative efforts: quality of life, nature of underlying illness, and age. A significant communication gap existed between nurses and physicians regarding aggressiveness of care: physicians indicated communication with nursing staff in 564 cases; nurses acknowledged this in only 56 of these same cases. These data suggest that current policies regarding do not resuscitate (DNR) orders should be broadened to include guidelines for less than full aggressive patient care. These policies should ensure adequate, documented communication between professional staff, patients, and others significantly involved with patient care decisions.