Do Not Attempt Cardiopulmonary Resuscitation orders in acute medical settings: a qualitative study.

BACKGROUND: Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders have been shown to be independently associated with patients receiving fewer treatments, reduced admission to intensive care and worse outcomes even after accounting for known confounders. The mechanisms by which they influence practice have not previously been studied. OBJECTIVES: To present a rich qualitative description of the use of the DNACPR form in a hospital ward setting and explore what influence it has on the everyday care of patients. DESIGN: Multi-source qualitative study, primarily using direct observation and semi-structured interviews based on two acute wards in a typical middle-sized National Health Service hospital in UK. RESULTS: The study identified a range of ways in which DNACPR orders influence ward practice, beyond dictating whether or not cardiopulmonary resuscitation should be attempted. Five key themes encapsulate the range of potential impacts emerging from the data: the specific design and primacy of the form, matters relating to clinical decision making, staff reflections on how the form can affect care, staff concern over 'inappropriate' resuscitation, and discussions with patients/relatives about DNACPR decisions. Overall, it was found that while the DNACPR form is recognized as serving a useful purpose, its influence negatively permeated many aspects of clinical practice. CONCLUSION: DNACPR orders can act as unofficial 'stop' signs and can often signify the inappropriate end to clinical decision making and proactive care. Many clinicians were uncomfortable discussing DNACPR orders with patients and families. These findings help understand why patients with DNACPR orders have worse outcomes, as such they may inform improvements in resuscitation policies.

Creatine supplementation during pulmonary rehabilitation in chronic obstructive pulmonary disease.

BACKGROUND: Skeletal muscle wasting and dysfunction are strong independent predictors of mortality in patients with chronic obstructive pulmonary disease (COPD). Creatine nutritional supplementation produces increased muscle mass and exercise performance in health. A controlled study was performed to look for similar effects in 38 patients with COPD. METHODS: Thirty eight patients with COPD (mean (SD) forced expiratory volume in 1 second (FEV(1)) 46 (15)% predicted) were randomised to receive placebo (glucose polymer 40.7 g) or creatine (creatine monohydrate 5.7 g, glucose 35 g) supplements in a double blind trial. After 2 weeks loading (one dose three times daily), patients participated in an outpatient pulmonary rehabilitation programme combined with maintenance (once daily) supplementation. Pulmonary function, body composition, and exercise performance (peripheral muscle strength and endurance, shuttle walking, cycle ergometry) took place at baseline (n = 38), post loading (n = 36), and post rehabilitation (n = 25). RESULTS: No difference was found in whole body exercise performance between the groups: for example, incremental shuttle walk distance mean -23.1 m (95% CI -71.7 to 25.5) post loading and -21.5 m (95% CI -90.6 to 47.7) post rehabilitation. Creatine increased fat-free mass by 1.09 kg (95% CI 0.43 to 1.74) post loading and 1.62 kg (95% CI 0.47 to 2.77) post rehabilitation. Peripheral muscle performance improved: knee extensor strength 4.2 N.m (95% CI 1.4 to 7.1) and endurance 411.1 J (95% CI 129.9 to 692.4) post loading, knee extensor strength 7.3 N.m (95% CI 0.69 to 13.92) and endurance 854.3 J (95% CI 131.3 to 1577.4) post rehabilitation. Creatine improved health status between baseline and post rehabilitation (St George's Respiratory Questionnaire total score -7.7 (95% CI -14.9 to -0.5)). CONCLUSIONS: Creatine supplementation led to increases in fat-free mass, peripheral muscle strength and endurance, health status, but not exercise capacity. Creatine may constitute a new ergogenic treatment in COPD.

Performance enhancement in chronic obstructive pulmonary disease.

BACKGROUND: Exercise limitation is a hallmark of chronic obstructive pulmonary disease (COPD) and is integral to the associated impaired health status of these patients. The poor exercise tolerance is multifactorial in origin, relating to airflow obstruction, disadvantageous lung mechanics, reduced oxygen delivery and skeletal muscle dysfunction. A number of interventions have been studied to determine whether they can impact on exercise performance. The most evidence-based of these is exercise training, which along with other approaches, both previously investigated and putative, are discussed in this review.

The pattern and timing of breathing during incremental exercise: a normative study.

Clinical evaluation of the pattern and timing of breathing during submaximal exercise can be valuable for the identification of the mechanical ventilatory consequences of different disease processes and for assessing the efficacy of certain interventions. Sedentary individuals (60 male/60 female, aged 20-80 yrs) were randomly selected from >8,000 subjects and submitted to ramp incremental cycle ergometry. Tidal volume (VT)/resting inspiratory capacity, respiratory frequency, total respiratory time (Ttot), inspiratory time (TI), expiratory time (TE), duty cycle (TI/Ttot) and mean inspiratory flow (VT/TI) were analysed at selected submaximal ventilatory intensities. Senescence and female sex were associated with a more tachypnoeic breathing pattern during isoventilation. The decline in Ttot was proportional to the TI and TE reductions, i.e. TI/Ttot was remarkably constant across age strata, independent of sex. The pattern, but not timing, of breathing was also influenced by weight and height; a set of demographically and anthropometrically based prediction equations are therefore presented. These data provide a frame of reference for assessing the normality of some clinically useful indices of the pattern and timing of breathing during incremental cycle ergometry in sedentary males and females aged 20-80 yrs.