AARC Congress 2014 Gazette for Thursday, Dec. 11
Donald F Egan Scientific Memorial Lecture
What Have We Learned about Noninvasive Ventilation in the Past 20 Years?
By Laurent Brochard MD
Editor’s Note: Dr. Brochard presented the Egan Lecture this morning. Here’s his recap for those who were unable to attend.
Noninvasive ventilation (NIV) appeared both in the world of home ventilation and in ICUs at the end of the 1980s and beginning of the 1990s. I was involved in research in the early assessment of pressure support ventilation in intubated patients, and it rapidly seemed obvious to me that this improvement in synchronized ventilation could be used through a face mask to treat acute hypoventilation and respiratory acidosis.
Patients with COPD were obvious candidates. The use of NIV in these patients resulted in at least three consequences. First, it enormously helped us understand the pathophysiology of acute respiratory failure in these patients and the importance of supporting the work of the respiratory muscles. Second, it allowed us to avoid the need for endotracheal intubation, reducing many of the ICU complications and considerably changing the prognosis for these patients. More than 20 years later, NIV has become the gold standard for treating acute exacerbations of chronic respiratory failure.
Third, it opened the door to all kinds of other indications for NIV. A frequent one became cardiogenic pulmonary edema, especially when associated with ventilatory failure. The field of hypoxemic failure includes heterogeneous patients, and NIV was shown to be efficient at avoiding intubation. Indications had to be very carefully selected, however, and simply delaying intubation could become a risk for these patients. Patients with immunosuppression seemed to particularly benefit from NIV. I am convinced that NIV will find its right place in this indication; but more work is needed to delineate indications, timing, technique, and clinical criteria for intubation.
Interestingly, alternatives to the classical NIV techniques are emerging — such as high-flow oxygen therapy — which will also play a role. NIV has been found to have interesting effects to prevent reintubation in patients at risk of extubation failure or in the post-operative period. In these indications, NIV should not be applied to all patients nor at a late stage. Preventive use in patients with risk factors seems to be the key. In summary, NIV has enormously changed the way we deliver ventilatory support in the ICU, reducing the need for endotracheal intubation and sedation and improving the outcome of many ICU patients.
Dr. Brochard is the Keenan Chair for Critical Care and Respiratory Medicine at the Keenan Research Centre at St. Michael’s Hospital and director of the interdepartmental division of critical care medicine at the University of Toronto, both in Toronto, Canada.
37th Annual Sputum Bowl Tonight
Preliminary competitions on Tuesday and Wednesday featured teams from the AARC State Societies. Now four remain in each of the two categories. Among the Student teams battling it out tonight are California, Colorado, Louisiana, and Michigan. Then the Practitioner teams take the stage to battle for our iconic Sputum Bowl trophy: California, Louisiana, North Carolina, and Pennsylvania. The fun starts at 5 pm at the Mandalay Bay Resort and Convention Center Mandalay GH and will end when a Sputum Bowl champion has been crowned.
Half-time entertainment is David Crowe, a 20-year veteran of the comedy stage. He has been featured on Showtime and his own 1-hour comedy special “Crooked Finger,” along with numerous appearances on Comedy Central, Bob&Tom Radio, SeriusXM, and Pandora.
The event is supported by an unrestricted grant from Covidien.
Current Management of the Refractory Asthmatic Patient: Importance of Accurate Phenotyping
by James T Good Jr MD FACP FCCP
Editor’s Note: Dr. Good presented the Petty Lecture yesterday morning. Here’s his recap for those who were unable to attend.
Asthma is a heterogeneous condition. Its natural history includes acute episodic exacerbations against a background of chronic persistent inflammation that is frequently associated with persistent symptoms and reduced lung function. Because many other cardiopulmonary disorders may present with similar symptoms of cough, wheeze, shortness of breath, and chest tightness, it is essential to establish the diagnosis of asthma with a 12% improvement in FEV1 following bronchodilator and/or a positive provocative test such as a methacholine challenge.
Once a diagnosis of asthma is established, a therapeutic plan using NAEPP guidelines should be implemented based on the severity of the disease and the need for control. When these guidelines are followed and adequate asthma control is not accomplished, we must look for those factors (such as allergies, infection, and environmental irritants) that result in poor control. The refractory asthmatic represents a different type of patient who generally continues to have symptoms and abnormal pulmonary function in spite of high doses of inhaled corticosteroids with or without systemic steroids.
We have developed a system using fiberoptic bronchoscopy with endobronchial biopsies, brushes, and bronchoalveolar lavage to identify 5 asthmatic phenotypes:
- Gastroesophageal/laryngopharyngeal reflux
- Tissue eosinophilia
- Subacute bacterial/fungal infection
- Combination (1, 2 and 3)
We have demonstrated that specific, directed therapy based on phenotype results in improvement in the Asthma Control Test and pulmonary function in all groups except for Nonspecific. Bronchoscopic evaluation of the airway can provide important information toward characterizing refractory asthma so as to better individualize therapeutic options and improve asthma control and lung function in patients with difficult-to-treat asthma.
Dr. Good is a professor of medicine at National Jewish Health in Denver, CO.
Keynote Session Emphasizes Ways To Prevent Patient Care Errors
Michael A.E. Ramsay MD FRCA and patient safety advocate Patricia LaChance discussed how RTs can minimize adverse patient events during the Congress Keynote Address yesterday morning. “You are the front line of patient safety, you’re out there salvaging our patients who get into trouble,” said Dr. Ramsay. “I just think there is a lot more that we can have you do. We need to involve you more in patient pre-op assessment of the fit, healthy patients so they will not get into major trouble.”
Patients, nurses, respiratory therapists, hospital administrators, and equipment manufacturers are coming together in the Patient Safety Movement to build a culture of patient safety that is all about fighting the lack of education and technology and eliminating blind spots in order to ensure patient care safety.
Dr. Ramsay pointed out that a major problem is opioid-induced respiratory depression, in that it can be masked by the use of post-op supplemental oxygen because the O2 saturation is normal. What caregivers may not see is that the CO2 has gotten very high and the respiratory rate has dropped very low. “These adverse events should not happen… particularly with your help,” Dr. Ramsay told respiratory therapists attending. He noted that RTs should be involved right up front to be sure patients don’t get into trouble with opioid-induced respiratory depression. “It’s so simple if we have the tools and the knowledge that you all have to prevent these adverse events,” he emphasized.
In today’s session, Dr. Ramsay talked with Patricia LaChance, the wife of a patient who died from a preventable hospital error. She is now an advocate for ensuring patient safety through better education and monitoring.
“My husband and I didn’t understand how dangerous his sleep apnea was,” she explained. She said she wished she had known then what she knows now so she could have pushed further the issues she brought up to each of the staff caring for him. “I trusted the caregivers,” she said. After his death, it was learned that 13 errors had taken place in his care. “It’s very important that respiratory therapists be brought in at pre-surgery to assess each patient like my husband and be a part of the care plan,” she said.
“I appreciate being here. Thank you so much for inviting me. I believe that we can make a change — each of us who has suffered through it,” she emphasized.
The Keynote Address was supported by an unrestricted educational grant from Masimo.