Ultrasound assessment of congenital fetal lung masses and neonatal respiratory outcomes.

OBJECTIVE: Fetal congenital lung masses generate concern for compromised postnatal respiratory function. Congenital pulmonary adenomatoid malformation volume ratio (CVR) has been used to predict the risk of hydrops fetalis and need for antenatal intervention. This study investigates whether CVR could be used to predict neonatal respiratory outcomes. METHODS: The ultrasounds of fetuses diagnosed with a lung mass between 2005 and 2013 were reviewed. CVR was calculated at each ultrasound using the formula for a prolate ellipse divided by head circumference. The pregnancy outcome and information about NICU admission for respiratory insufficiency were collected. RESULTS: Forty-two fetuses were diagnosed with a lung mass during the study period. CVR prior to 24 weeks and between 24 and 32 weeks were associated with NICU admission (p < 0.0001 and <0.008, respectively). CVR increased up to 32 weeks and decreased thereafter for most subjects. The decrease in CVR beyond 32 weeks was larger for cases that required NICU admission (p = 0.002). For a CVR cut-off of <0.5, the sensitivity was 100%, the specificity 85.7%, and negative predictive value was 100% for regular nursery care. CONCLUSION: In pregnancies diagnosed with fetal lung masses, CVR predicted normal respiratory outcomes and need for NICU admission. This information may be helpful for delivery planning. © 2015 John Wiley & Sons, Ltd.

Neonatal nasal intermittent positive pressure ventilation: a survey of practice in England.

BACKGROUND: Less invasive techniques of respiratory support are increasingly popular. OBJECTIVE: To determine how widespread the use of neonatal nasal intermittent positive airway pressure (NIPPV) has become and describe the range of practice used in NIPPV in England. METHODS: 95 English Neonatal intensive care units were asked to provide information about NIPPV devices, interfaces, indications, guidelines, use of synchronisation, complications, settings and weaning. RESULTS: 91 (96%) units replied. NIPPV was used by 44/91 (48%) units; few complications were seen. 34/44 (77%) used a synchronising device, 35/44 (80%) used NIPPV for "rescuing" babies for whom continuous positive airway pressure failed-59% routinely after extubation and 16% as a first-line treatment. A wide range of pressure and rate settings were used. CONCLUSIONS: In England, NIPPV is commonly used, with considerable variability in the techniques applied. The wide range of clinical approaches highlights the paucity of evidence available. More evidence is needed to establish best practice.

Predictors of patient adherence to long-term home nebulizer therapy for COPD. The IPPB Study Group. Intermittent Positive Pressure Breathing.

STUDY OBJECTIVE: Patients with moderate to severe COPD are frequently prescribed expensive and complicated therapies that require adjustments in usual activities of daily living. However, little is known about factors that are associated with adherence to such treatment. The objective of this study was to identify characteristics of patients who were adherent to long-term home nebulizer therapy. DESIGN: Patients were stratified into two adherence groups based on average minutes of nebulizer use each day. A logistic regression model was developed to predict adherence based on baseline variables. A questionnaire was administered to patients to assess reasons for adherence to therapy. SETTING: Five clinical centers in the United States and Canada. PARTICIPANTS: Nine hundred eighty-five patients with moderate to severe COPD enrolled in the Intermittent Positive Pressure Breathing (IPPB) Trial. INTERVENTIONS: Long-term home IPPB and nebulizer therapy. MEASUREMENTS AND RESULTS: Altogether 50.6% of patients were adherent, and 49.4% were nonadherent. Among baseline variables, good adherence was predicted by white race, married status, abstinence from cigarettes and alcohol, serum theophylline level > or = 9 micrograms/mL, more severe dyspnea, and reduced FEV1 (p < 0.05). Subjects who were adherent to nebulizer therapy were older, better educated, had a stable lifestyle, were more likely to report that the therapy made them feel better, and were more likely to keep clinic appointments. CONCLUSIONS: Sociodemographic, physiologic, and quality of life variables were associated with adherence to long-term nebulizer therapy.

Patient-ventilator interaction during synchronized intermittent mandatory ventilation. Effects of flow triggering.

Synchronized intermittent mandatory ventilation (SIMV) intermixes assisted and spontaneous breaths. Its ability as a weaning technique has been questioned on the basis that patients show little adaptation to ventilator assistance. We studied inspiratory effort and patient-ventilator interaction at different levels (SIMV, 100, 50, and 0%) of flow-triggered SIMV versus pressure-triggered SIMV in patients during the weaning period. The two triggering systems were evaluated during constant flow and constant pressure mandatory SIMV breaths. Inspiratory effort was estimated as the esophageal pressure time product (PTP) per breath (PTP/b) and per minute (PTP/min). The PTP/b and PTP/min of both mandatory and spontaneous breaths were significantly lower during flow triggering than during pressure triggering SIMV, irrespective of the ventilatory mode. During pressure-triggered SIMV PTP/b and PTP/min were identical for mandatory and spontaneous breaths, whereas during flow-triggered SIMV PTP/b and PTP/min were significantly lower for mandatory than for spontaneous breaths. This difference was greatest when flow triggering and constant pressure ventilation were associated. These data show that flow triggering reduces inspiratory effort during both mandatory and spontaneous SIMV breaths and obtains a better patient-ventilator interaction.

Ordering respiratory care services for hospitalized patients: practices of overuse and underuse.

Because of recent concerns about misallocation of respiratory care services and analyses suggesting that limiting services to comply with established guidelines reduces unneeded therapies without compromising quality of care, the authors audited the records of 170 patients newly ordered to receive at least one of five respiratory therapies (oxygen therapy, incentive spirometry, bronchopulmonary hygiene, aerosolized bronchodilator therapy, or intermittent positive pressure breathing) at The Cleveland Clinic Foundation. In reviewing whether the therapies that were ordered complied with published guidelines for these services, we found that 25.2% were "not indicated." This over-ordering incurred unnecessary total charges of $11,937 ($206.16 per patient) and occupied therapist time that could have been better allocated to other services. These costs were offset by the finding that 10.5% of the patients were not ordered to receive indicated respiratory therapies. Our proposed strategy of initiating protocols for ordering and providing respiratory care services (ie, via a respiratory care consult service) is an appealing means to address this misallocation, but it requires further evaluation.

Use of a computerized respiratory care record system to study utilization of IPPB therapy.

Increases in the utilization of respiratory therapy and the need to avoid its misuse have placed increasing management responsibilities on medical and technical supervisors of respiratory care services. To improve our managerial capabilities we designed a computerized respiratory care record system. Respiratory therapists use specially designed forms to record initial respiratory assessments and subsequent progress notes. A computer program allows secretaries to enter information from the forms into a data base. Another program tabulates information from the data base. As an example of the usefulness of this system we present a study of the utilization of intermittent positive-pressure breathing (IPPB) therapy in patients undergoing intrathoracic or upper abdominal surgery. Although all such patients were routinely educated preoperatively in the use of IPPB, chest physiotherapy, and incentive spirometry, the study revealed that only 14% of the patients received IPPB postoperatively, whereas more than 90% received chest physiotherapy and incentive spirometry. As a result of our findings we are saving time and money by discontinuing routine IPPB education for this population.

Evaluating the changing role of respiratory therapy services at two hospitals.

An analysis of respiratory therapy services at two general hospitals showed a notable change from 1971 to 1979. There was a large decrease in intermittent positive-pressure breathing (IPPB) treatments at both hospitals. These were partially replaced with general chest physiotherapy maneuvers at one hospital and with incentive spirometry at another. Both hospitals demonstrated a substantial increase in time spent in management of mechanical ventilators. Staffs had increased along with time spent per patient. The reduction in IPPB was not associated with lower costs of respiratory therapy service at either hospital but, rather, a shift in the types of service performed. These changes must be considered in determining cost-effectiveness of respiratory therapy services.

Magnitude of use and costs of in-hospital respiratory therapy.

Respiratory therapy services have expanded in the 3 decades since World War II and now account for approximately 3% of hospital expenditures. The types of services performed have changed; the number of intermittent positive-pressure breathing treatments has markedly decreased since peak usage in th early 1970s, whereas the use of ventilator care and incentive spirometry has increased. The continued increase in respiratory therapy costs may reflect both inflationary pressures and the labor-intensive shift to increased involvement in critical care units.

Intermittent positive-pressure breathing. A critical appraisal.

There are relatively few valid indications for the use of intermittent positive-pressure breathing (IPPB). It is of limited or no value as prophylaxis of postoperative pulmonary problems (pneumonia, atelectasis) or as a means of delivering aerosol medications or treating stable chronic obstructive pulmonary disease. In these situations, IPPB has few if any advantages over voluntary hyperventilation or deep breathing.