Thoracic ultrasonography: a narrative review.

This narrative review focuses on thoracic ultrasonography (lung and pleural) with the aim of outlining its utility for the critical care clinician. The article summarizes the applications of thoracic ultrasonography for the evaluation and management of pneumothorax, pleural effusion, acute dyspnea, pulmonary edema, pulmonary embolism, pneumonia, interstitial processes, and the patient on mechanical ventilatory support. Mastery of lung and pleural ultrasonography allows the intensivist to rapidly diagnose and guide the management of a wide variety of disease processes that are common features of critical illness. Its ease of use, rapidity, repeatability, and reliability make thoracic ultrasonography the "go to" modality for imaging the lung and pleura in an efficient, cost effective, and safe manner, such that it can largely replace chest imaging in critical care practice. It is best used in conjunction with other components of critical care ultrasonography to yield a comprehensive evaluation of the critically ill patient at point of care.

Results of a programme to improve house staff use of metered dose inhalers and spacers.

PURPOSE: Metered dose inhalers (MDIs) and spacers are used widely in the treatment of asthma. Medical personnel who are responsible for training patients must themselves be proficient with the devices. The proficiency of a group of new medical interns with use of MDI and spacer devices was determined, and improvement in their use of these devices was sought. SUBJECTS: Fifty six medical interns tested at the start of their first house staff training year. METHODS: The ability of medical interns to use MDIs and spacers was assessed using a visual scoring system before and after a large group lecture emphasising proper device use and once again after an intensive one-on-one training session with an attending physician. RESULTS: Initially, only 5% used an MDI perfectly. This improved to 13% after a lecture and demonstration, and 73% after an intensive one-on-one session. Almost no new interns could use a collapsible or tube spacer properly initially. This improved to 15% and 29% respectively after a lecture. After one-on-one training, correct technique was increased to 69% for collapsible spacer and 95% for the tube spacer. Analysis of individual steps of MDI use showed that interns had particular difficulty in coordinating actuation with inhalation. The tube spacer appeared easiest to learn. CONCLUSIONS: Incoming medical house staff have limited ability to use MDI with and without spacers. A large group lecture is relatively ineffective when compared with a one-on-one training session in training with these devices.

Results of a program to improve the process of inpatient care of adult asthmatics.

OBJECTIVE: To assess the effectiveness of a program to improve care of adult patients hospitalized for asthma. DESIGN: Retrospective analysis of patient and house staff education, patterns of medication use, spacer use, peak flowmeter use, and length of stay before and after team intervention. SETTING: A 960-bed teaching hospital in New York City. PATIENTS: All patients admitted to the hospital with a primary diagnosis of acute asthma exacerbation for 2 separate similar calendar periods, 1 year apart, before and after program intervention. We excluded patients who were hospitalized for less than 24 h or greater than 10 days. The preintervention group comprised 61 patients and the postintervention group 65 patients, well matched in their demographic characteristics and severity of disease. INTERVENTIONS: Using a team approach, we analyzed the process of inpatient treatment of asthma exacerbation, identified root causes for quality deficiency, and implemented specific improvements in the process. These included dedicated nurses who focused on the education of care providers and patients, a personalized attending-intern educational approach, and improvement in the supply and delivery of spacers, peak flowmeters, and medications to the patients. RESULTS: There was a significant increase in use of spacers, peak flowmeters, and inhaled corticosteroids. Systemic corticosteroid and methylxanthine use declined. Length of stay was reduced without increasing early hospital readmission rates. CONCLUSIONS: This program improved the treatment process of adults hospitalized for asthma.

Outcome of intensive care in patients with HIV infection.

OBJECTIVES: To examine ICU admission rates and diagnoses of patients with HIV infection and to determine the outcomes of different critical illnesses. DESIGN: Consecutive enrollment of patients admitted to the ICU with confirmed HIV infection or an AIDS-defining diagnosis. SETTING: Medical ICU of an urban teaching hospital. PATIENTS: 65 adult patients with documented HIV infection or AIDS-defining disorder. INTERVENTIONS: Standard care. RESULTS: In 1 year, there were 1,550 hospital admissions for patients with HIV infection, and 65 (4.2%) were admitted to the ICU. The mortality rate of patients admitted to the ICU was 51%; 35 (54%) were admitted with respiratory failure, 22 of whom had Pneumocystis carinii pneumonia (PCP). Sixteen patients with PCP required mechanical ventilation, and 13 (81%) died despite treatment with adjunctive corticosteroids. Other causes of respiratory failure included bacterial pneumonia, pulmonary tuberculosis, adult respiratory distress syndrome, and pulmonary Kaposi's sarcoma. Overall, 22 of 35 (63%) patients with respiratory failure died in the hospital. Thirty patients (46%) were admitted because of sepsis, neurologic disease, congestive heart failure, hypotension, or drug overdose. These patients had a mortality rate of 37%. Prior antiretroviral and anti-Pneumocystis prophylaxis did not influence outcome, but a body weight of 10% or more below ideal at the time of admission predicted poor survival. CONCLUSION: There is a diverse range of indications for critical care in patients with HIV infection. Although respiratory failure due to PCP was the most common reason for admission to the ICU, it accounted for only 34% of the cases. The prognosis of PCP in patients who require mechanical ventilation despite adjunctive corticosteroid treatment is poor.

Demographic influences on asthma hospital admission rates in New York City.

Surveillance reports describe an increase in asthma prevalence, and cite New York City as an area of excessive asthma mortality. To assess trends and the influence of geography, race, and ethnicity on hospital admission rates for asthma between 1989 and 1991, data of all admissions for asthma to New York City hospitals were reviewed. The average citywide annual hospital admission rate was 681 per 100,000 population, and the racial and ethnic distribution was 1,003 per 100,000 Hispanic patients, 810 per 100,000 for blacks, and 242 per 100,000 for whites (p < 0.0001). Bronx and Manhattan had the highest admissions rates, and contained a few zip codes with very high rates. In these zip codes, admission rates were consistently highest among Hispanics, followed by blacks and whites. New York City asthma admission rates increased 12.7 percent during the study. Very high admission rates among Hispanic patients and high rates in blacks, in specific geographic areas, are responsible for this trend. Targeted education and treatment programs could reduce hospital admissions and mortality in small geographic areas with high asthma morbidity.

Results of a program to reduce admissions for adult asthma.

STUDY OBJECTIVE: To determine the effect of an outpatient program designed to reduce readmissions for asthma exacerbations among adults with asthma. DESIGN: Randomized patient selection with crossover. SETTING: Bellevue Hospital, New York City, New York. PATIENTS: We identified 104 adult asthmatics who had previously required multiple hospitalizations for asthma attacks. Forty-seven patients were randomly assigned to an intensive outpatient treatment clinic and 57 patients continued to receive their previous outpatient care. Nineteen patients from this latter group were then crossed to the intensive outpatient therapy clinic. INTERVENTIONS: Attenders of the intensive outpatient treatment program were treated with a vigorous medical regimen and educational program. Emphasis was placed on teaching patients aggressive self-management strategies in case of marked asthma exacerbation. MEASUREMENTS AND MAIN RESULTS: The main measurement used to determine efficacy of the study program was readmission rate and hospital days used. Prospective comparison of treated compared with untreated patients indicated that program enrollment resulted in a threefold reduction in readmission rate and a twofold reduction in hospital day use rate (P less than 0.004 and P less than 0.02, respectively). Using retrospective data with patients serving as their own controls, we found a threefold reduction in readmission rate and in hospital day use (P less than 0.003) during a 32-month follow-up period. A similar magnitude of reduction in hospital utilization was found when patients were crossed over to the intensive treatment group (P less than 0.004). CONCLUSIONS: By using a vigorous medical regimen and intensive educational program, we were able to decrease hospital use among a group of adult asthmatics who had previously required repeated readmissions for acute asthma exacerbations.