Prognostic variables and decannulation of tracheostomy in the long-term acute care environment: a case for clinician-driven decision-making.

Purpose: Tracheostomy is a necessary procedure required for prolonged mechanical ventilation in long-term acute care hospitals (LTACH). Many factors influence successful decannulation, or tracheostomy removal, and it is unclear what factors are essential for determining decannulation. The purpose of this study was to determine retrospective performance of single prognostic variables for successful decannulation, like peak expiratory flow measurement, overnight oximetry testing, and blood gas analysis. Methods: A retrospective analysis of a three-year period to investigate the association between peak flow (PF) measurements ≥160 L/min, successful overnight oximetry (ONO), sex, and decannulation success. Average PF measurements, arterial blood gas (ABG), days on mechanical ventilation, LTACH length of stay (LOS), and age were also investigated. Results: We examined the records of 135 patients, 127 of which were successfully decannulated. PF measurements ≥160 L/min (p=0.16), sex (p<0.05) and passing ONO (p<0.05) were significantly different between successfully and unsuccessfully decannulated patients; mean ABG (pH, pCO2, pO2), mechanical ventilation days, LOS, and age were not significantly different (p>0.05). Conclusions: These results suggest no single prognostic variable can predict decannulation outcomes. Rather, clinical judgment of experienced medical professionals appears sufficient to achieve a 94% decannulation success rate. Additional investigation is required to determine what metrics are necessary, or if clinical judgment alone can predict decannulation success.

The association between beta-natriuretic peptide (BNP) serum levels and liberation from mechanical ventilation.

Prolonged time on mechanical ventilation is associated with multiple consequences for both the patient and medical facility. Based on anecdotal evidence that sustained elevation of beta-natriuretic protein (BNP) during a patient's stay in a long-term acute care hospital (LTACH) was associated with failure to wean from prolonged mechanical ventilation, we investigated if there is an association between a decrease in BNP levels during one's stay and successful weaning from prolonged mechanical ventilation. We performed a retrospective study of 66 patient records revealing no correlation between lowering BNP levels and probability of liberating a patient from prolonged mechanical ventilation in an LTACH environment where the probability of liberation from mechanical ventilation is high (> 85%). BNP measurements by itself does not appear to be a helpful tool in the likelihood of liberation from mechanical ventilation AUC = 0.61 (CI: 0.48-0.72). In an LTACH setting with high success rates of liberation from mechanical ventilation, it does not appear to be necessary to trend BNP measurements in attempts to liberate patients from prolonged mechanical ventilation.

Smoking cessation and outcome after ischemic stroke or TIA.

OBJECTIVE: To assess whether smoking cessation after an ischemic stroke or TIA improves outcomes compared to continued smoking. METHODS: We conducted a prospective observational cohort study of 3,876 nondiabetic men and women enrolled in the Insulin Resistance Intervention After Stroke (IRIS) trial who were randomized to pioglitazone or placebo within 180 days of a qualifying stroke or TIA and followed up for a median of 4.8 years. A tobacco use history was obtained at baseline and updated during annual interviews. The primary outcome, which was not prespecified in the IRIS protocol, was recurrent stroke, myocardial infarction (MI), or death. Cox regression models were used to assess the differences in stroke, MI, and death after 4.8 years, with correction for adjustment variables prespecified in the IRIS trial: age, sex, stroke (vs TIA) as index event, history of stroke, history of hypertension, history of coronary artery disease, and systolic and diastolic blood pressures. RESULTS: At the time of their index event, 1,072 (28%) patients were current smokers. By the time of randomization, 450 (42%) patients had quit smoking. Among quitters, the 5-year risk of stroke, MI, or death was 15.7% compared to 22.6% for patients who continued to smoke (adjusted hazard ratio 0.66, 95% confidence interval 0.48-0.90). CONCLUSION: Cessation of cigarette smoking after an ischemic stroke or TIA was associated with significant health benefits over 4.8 years in the IRIS trial cohort.

The use of a home exercise program based on a computer system in patients with chronic obstructive pulmonary disease.

PURPOSE: To test the effectiveness of a home exercise program based on a user-friendly, computer system, the Nintendo Wii Fit. METHODS: In this longitudinal study, 25 clinically stable patients with chronic obstructive pulmonary disease began a 6-week nonintervention (baseline) period followed by 12 weeks of Wii exercise training at home. Patients were instructed to exercise 5 or more days per week. Exercise capacity, health status, and dyspnea were evaluated after home exercise training. RESULTS: Evaluable data were available in 20 patients after home exercise training; their force expiratory volume in 1 second was 45 ± 16%. Following 12 weeks of Wii exercise training, the Endurance Shuttle Walk Test increased by 131 ± 183 seconds over the baseline determination (P = .005). Significant improvements were also noted in arm-lift and sit-to-stand repetitions, the total score, and the emotion dimension of the Chronic Respiratory Questionnaire. Men had significantly greater increases in the Endurance Shuttle Walk Test than women, although their self-reported exercise durations were similar. There were no significant adverse outcomes. CONCLUSION: This study suggests that 12 weeks of regular, home exercise based on an interactive entertainment computer system can lead to positive short-term outcomes.

Resistant mycobacterium tuberculosis: report of a family in Connecticut

Continuing surveys of Mycobacterium tuberculosis both in the United States and Canada, have demonstrated a stable level of resistance to the primary chemotherapeutic agents. The two countries have noted an increased incidence of resistant M tuberculosis in immigrants from Asia and in the Hispanic population.