Intubation and mechanical ventilation for COPD: development of an instrument to elicit patient preferences.

BACKGROUND: Whether to simply provide palliative care or to intubate and use mechanical ventilation (MV) in a patient with severe COPD in acute respiratory failure is a difficult decision. The outcome of MV cannot be accurately predicted. Some patients cannot be weaned from the ventilator; those who are weaned often return to chronic severe respiratory disability. It is important that patients participate in this decision, but assistance is required. To address these issues, we developed and pilot-tested an aid to assist patients with MV decisions. METHODS: A scenario-based decision aid was developed consisting of an audiocassette and a booklet describing intubation and MV and its possible outcomes. We used a probability tradeoff technique to elicit the patients' preferences and a decisional conflict scale to evaluate satisfaction. RESULTS: With the assistance of the decision aid, all patients (10 men and 10 women) reached a decision. Two men and all 10 women declined MV. Mean decisional conflict was low (2.2 of a possible 5; SD, 0.9). At 1 year, only two patients (11%) had changed their decision. The agreement between physicians and patients was 65%; between next-of-kin and patients, there was uniform disagreement. CONCLUSION: With the decision aid, stable decisions were made with satisfaction and confidence. Proxy decisions were incongruent, especially when made by family members. The strong gender effect should be further investigated. We suggest that the COPD decision aid be further tested in a community clinical setting.     

Perspectives on End-of-Life Treatment among Patients with COPD: A Multicenter,Cross-sectional Study in Japan

Chronic obstructive pulmonary disease (COPD) is a leading cause of mortality. Since patients with severe COPD may experience exacerbations and eventually face mortality, advanced care planning (ACP) has been increasingly emphasized in the recent COPD guidelines. We conducted a multicenter, cross-sectional study to survey the current perspectives of Japanese COPD patients toward ACP. “High-risk” COPD patients and their attending physicians were consecutively recruited. The patients’ family configurations, understanding of COPD pathophysiology, current end-of-life care communication with physicians and family members, and preferences for invasive life-sustaining treatments including mechanical ventilation (MV) and cardiopulmonary resuscitation (CPR) were evaluated using a custom-made, structured, self-administered questionnaire. Attending physicians were also interviewed, and we evaluated the patient–physician agreement. Among the 224 eligible “high-risk” patients, 162 participated. Half of the physicians (54.4%) thought they had communicated detailed information; however, only 19.4% of the COPD patients thought the physicians did so (κ score = 0.16). Less than 10% of patients wanted to receive invasive treatment (MV, 6.3% and CPR, 9.4%); interestingly, more than half marked their decision as “refer to the physician” (MV 42.5% and CPR 44.4%) or “refer to family” (MV, 13.8% and CPR, 14.4%). Patients with less knowledge of COPD were less likely to indicate that they had already made a decision. Although ACP is necessary to cope with severe COPD, Japanese “high-risk” COPD patients were unable to make a decision on their preferences for invasive treatments. Lack of disease knowledge and communication gaps between patients and physicians should be addressed as part of these patients’ care.     

Noninvasive ventilation in chronic obstructive pulmonary disease

Over the past 15 years, numerous studies have explored the possibility that intermittent ventilatory assistance using noninvasive ventilation is beneficial in patients with severe stable COPD. The results are conflicting and no sustained beneficial action has been proven, although some improvement in respiratory muscle function may occur after short-term rest, and lengthening of the total duration of sleep has been shown in a few studies. Based on the observation that studies with favorable findings have generally had considerably higher PaCO2s than studies with negative findings, the current consensus view is that patients with severe CO2 retention (PaCO2 > 50-55 mm Hg) warrant a trial of NPPV. In addition, the Health Care Financing Agency that determines Medicare reimbursement policy in the United States has recently published guidelines for use of NPPV in patients with severe stable COPD that are based partly on the consensus view. There remains a deficiency of evidence supporting this application, however, and no study has confirmed any survival benefit or sustained improvement in functional status. Of note, several uncontrolled studies suggest that days of hospital use may be reduced after initiation of NPPV in these patients, but confirmatory studies are pending. If NPPV is to be initiated in patients with severe stable COPD, a more difficult adaptation process should be anticipated than for patients with neuromuscular disease. Great care must be taken in selecting a proper mask and optimal ventilator settings, and patients usually require considerable reassurance and encouragement. Potential problems should be anticipated and prevented, if possible. With a patient and supportive approach and a willingness to devote time to the process, clinicians can help optimize the likelihood of success, but failure rates are apt to remain higher than for other forms of chronic respiratory failure until the patient subpopulations with COPD most likely to benefit from NPPV are better defined and improvements in mask and ventilator technology enhance tolerance rates.     

Weaning from prolonged mechanical ventilation

The development of weaning failure and need for PMV is multifactorial in origin, involving disorders of pulmonary mechanics and complications associated with critical illness. The underlying disease process is clearly important when discussing mechanisms of ventilator dependence; interventions therefore must be tailored to individual patients. Unfortunately, the main conclusion that can be drawn from the sum of the studies investigating patients on PMV to date is that an evidence-based approach to weaning is not possible and more research needs to be done. New studies need to incorporate severity-of-illness scores and an assessment of principal and comorbid conditions to allow for comparison of the findings from different centers. The best approach to a patient requiring PMV after exclusion of easily treatable conditions is not known. The literature regarding both acute and chronic cases suggests that a systematic approach to weaning involving the participation of multiple caregivers, including nurses, physicians, and respiratory, physical, and speech therapists facilitates liberation from MV. Although a gradual decrement in ventilator support would seem prudent, Scheinhorn et al have begun to identify a subpopulation of patients who can tolerate an acceleration of the weaning process. Given the known complications associated with MV, it is crucial that further research be performed to identify patients as soon as they are capable of breathing spontaneously. The literature demonstrates through multiple studies that satisfactory patient outcomes are attainable and can be achieved at LTAC facilities in a more cost-effective manner than in an ICU setting. The trend toward the concentration of patients into specialized regional weaning centers should facilitate the research process and continue to improve outcomes in this population.     

COPD--moving beyond bronchodilation

The burden of chronic obstructive pulmonary disease (COPD) remains very high. Till recently clinical approach of COPD patients was focused on measuring airflow limitation during exercise and treating airway obstruction with inhaled bronchodilators and corticosteroids. This approach stems from an old definition of COPD, mainly consisting of airflow limitation with poor reversibility after bronchodilation. The concept of COPD has changed strikingly in the last years. Many recent studies have shown that COPD is a systemic disease affecting not only the lungs but many other organs of the patient. Laboratory cardiopulmonary exercise testing assesses physiological and biological reserves. However, it is not the most suitable test to assess the functional state of a systemic disease such as COPD. We need simpler exercise tests that can be used on larger scales. The 6-minute walk test has been shown to be highly reproducible and reflects real life limitations of these patients better. It allows precise measurements of medical intervention and is a good predictor of mortality, provided clinicians respect the defined standards of this test. It should be associated with a more systemic index such as the BODE index to better find disease-modifying interventions and improve the outcome of COPD patients. On the other hand routine measurement of spirometry in the general population by primary care physicians should be promoted as it decreases smoking habits and helps better detecting and management of COPD patients. Specialists should support primary care physicians to spread these new concepts of COPD throughout the medical community.     

In-hospital and 5-year mortality of patients treated in the ICU for acute exacerbation of COPD: a retrospective study

STUDY OBJECTIVES: The prognosis of patients with COPD requiring admission to the ICU is generally believed to be poor. There is a paucity of long-term survival data. We undertook a study to examine both the in-hospital and 5-year mortality rates and to identify the clinical predictors of these outcomes. DESIGN: We conducted a retrospective cohort study of 57 patients admitted to the ICU between January 1999 and December 2000 for acute respiratory failure attributable to COPD. RESULTS: The mean (+/-SD) age of the study population was 70 +/- 8 years. More than 90% of patients required intubation, and the mean duration of mechanical ventilation (MV) was 2.3 +/- 2.2 days. The in-hospital mortality rate for the entire cohort was 24.5%. The mortality rates at 6 months and 1, 3, and 5 years were 39.0%, 42.7%, 61.2%, and 75.9%, respectively, following admission to the ICU. The median survival time for all patients was 26 months. The mortality rate at 5 years was 69.6% for patients who were discharged alive from the hospital. Using multivariate analysis, hospital mortality correlated positively with age, previous history of MV, long-term use of oral corticosteroids, ICU admission albumin level, APACHE (acute physiology and chronic health evaluation) II score, and duration of hospitalization. No factors predictive of mortality at 5 years were identified. CONCLUSIONS: We support previous findings of good early survival and significant but acceptable long-term mortality rates in patients who have been admitted to the ICU for acute exacerbation of COPD. Increased age, previous history of MV, poor nutritional status, and higher APACHE II score on ICU admission could be identified as risk factors associated with increased mortality rates. Long-term survival of patients with COPD who required MV for an acute exacerbation of their disease cannot be predicted simply from data available at the time of intubation. Physicians should incorporate these factors in their decision-making process.     

Why High-Intensity NPPV is Favourable to Low-Intensity NPPV: Clinical and Physiological Reasons

High-intensity non-invasive positive pressure ventilation (NPPV) was originally described for chronic hypercapnic chronic obstructive pulmonary disease (COPD) patients in 2009, and refers to a specific ventilatory approach whereby NPPV settings are aimed at achieving the lowest arterial partial pressure of carbon dioxide (PaCO₂) values possible. Thus, high-intensity NPPV requires ventilator settings to be increased in a stepwise approach to either an individually tolerated maximum, or to the levels necessary to achieve normocapnia. This differs from the classic approach to low-intensity NPPV, which comprises considerably lower ventilator settings and typically fails to lower elevated PaCO₂ values. The ongoing discussion about whether or not long-term NPPV should be used in chronic hypercapnic COPD patients is based on the observation that many studies in the last two decades have failed to provide evidence for this particular patient cohort. In addition, these trials preferably used low-intensity NPPV. There is now, however, increasing evidence to suggest that high-intensity NPPV is capable of improving important physiological parameters such as blood gases and lung function, as well as health-related quality of life. Moreover, this approach also produced positive outcomes following two recent randomized controlled trials, e.g., improved survival rates in stable COPD patients, and admission-free survival in patients with persisting hypercapnia following acute in-hospital NPPV to treat acute acidotic respiratory failure. As a consequence, the time has now come to evaluate the impact of long-term NPPV on both the physiological and clinical outcomes, with emphasis on the different approaches to NPPV. Therefore, the aim of the current review article is to elaborate on the clinical and physiological reasons for why high-intensity NPPV is favourable to low-intensity NPPV.     

Clinical approach to patients with chronic obstructive pulmonary disease and cardiovascular disease

It has long been recognized that reduced lung function is a major risk factor for cardiac death. It has also become clear that cardiac events are the major cause of death for patients with chronic obstructive pulmonary disease (COPD) with all stages of disease. These associations could be from shared risk factors, most notably cigarette smoking. However, there are mechanistic and physiologic relationships that could account for these associations. This raises the possibility that treatment of COPD could benefit cardiac risks. Despite this, the monitoring of lung function in cardiac patients is not routine. Neither is optimization of lung function, although it may greatly benefit exercise training designed to minimize cardiac risks and symptoms. Conversely, many patients with COPD are at greater risk for cardiac disease than may be recognized, because their COPD is often undiagnosed. Recognition of increased risk could impact the aggressiveness with which other risk factors, hypertension, and hypercholesterolemia are managed. Finally, the interactions between cardiac and pulmonary disease have important implications for the development of novel therapies. It is plausible that treatment of pulmonary inflammation characteristic of COPD will alter cardiac risk. Such an approach would offer a novel approach for the development of treatments for these common conditions.     

Lung-volume reduction surgery for severe emphysema: appraisal of its current status

PURPOSE OF REVIEW: Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the United States, as well as a major cause of disability. In its end stages, its inexorable progression results in profound suffering for those afflicted. Medical therapy has proven largely ineffective in improving dyspnea and functional status, and does not alter pulmonary function. Over the past decade, lung-volume reduction surgery (LVRS) has been proposed as a palliative treatment for certain subgroups of COPD patients with emphysema, but initial enthusiasm over its application had been confounded by uncertainty about the potential cost and morbidities associated with LVRS, as well as durability of its beneficial effects. Longer-term follow-up data of initial uncontrolled trials along with several landmark controlled trials have recently been published, offering insight as to the "proper" place of LVRS in the treatment of these unfortunate patients. This review will summarize and offer perspective on these recent findings, as well as offer thoughts on recent refinements in preoperative imaging assessment, and pioneering efforts in less invasive bronchoscopic lung-volume reduction that should further aid the clinician in defining who should benefit from this treatment approach. RECENT FINDINGS: Lung-volume reduction surgery can result in demonstrable benefit in selected subgroups of COPD patients with upper-lobe disease and poor exercise capacity before surgery with improvements in six-minute walk distances, forced expiratory volume in the first second (FEV1), dyspnea scores and quality-of-life scores, and decreases in residual volume (RV) as well as the need for supplemental oxygen. Patients with FEV1 less than 20% of predicted and either homogeneous emphysema or diffusing capacities (DLCO) less than 20% of predicted do not benefit from LVRS and have unacceptable peri-operative mortalities. Costs to society are high, with a cost of $98,000 per quality-adjusted-life year gained over a 2-year period if only those with upper-lobe disease are offered the procedure. SUMMARY: Lung-volume reduction surgery can improve both objective and subjective measures of lung performance in properly selected COPD patients. Durable effects of up to 5 years have now been demonstrated. As costs (both fiscal and emotional) of such an approach are high, refinement in patient selection remains a current goal in the surgical approach to COPD.     

Long-term management of chronic obstructive pulmonary disease: A survey of collaboration among physicians involved in pulmonary rehabilitation in Japan

BackgroundThis study evaluated the implementation of pulmonary rehabilitation (PR), and the extent of the collaboration between primary care and chest physicians involved in the management of chronic obstructive pulmonary disease (COPD) in Japan.MethodsThe survey was conducted in 2006 via post and facsimile and included all medical institutions approved by the Japan Respiratory Society.ResultsIn total, 176 institutions responded (response rate, 27%); a PR program was conducted at 55.1% of these institutions throughout Japan, but with regional differences. The mean duration of each session in an outpatient setting was 30 min with 2 sessions per week, and the mean length of hospitalization was 2–3 weeks. Although 33% of the hospitals adopted PR programs, on a scale from none (0) to maximum achievement (100), the accomplishment score was 48. Similarly, the mean satisfaction level score for collaboration was 44. The main problem arising with regards to chest physicians’ referral to general physicians was the reluctance of patients or family members (88%). Chest physicians believed that general physicians should perform early screening of patients and manage early exacerbations, including educating patients of the need to discontinue smoking.ConclusionsMost chest physicians in Japan were not satisfied with the status of long-term COPD management. PR for COPD patients and collaboration between primary care physicians and specialists remain problematic in Japan. Moreover, there are widespread regional differences in terms of implementation. Sharing and implementing appropriate clinical information with primary care physicians according to current clinical guidelines should be emphasized.     

Questionnaire on the attitude of the physicians in educating the elderly patients with chronic obstructive pulmonary disease about smoking cessation

Smoking status, the extent of recognition of the relationship between smoking and COPD, and actual nature of education for smoking cessation by physicians have not yet been fully elucidated. To investigate perceptions about education for smoking cessation in the elderly by physicians who work in the clinic, questionnaires were sent to the 1,012 physicians who belong to the Yokohama City Medical Association. Of these, 311 respond and their data (31%) were included in the analysis. The questionnaire included questions on the importance of smoking cessation in the elderly, on the perception about the relationship between smoking and various diseases, and actual education for smoking cessation. The smoking status of the physicians themselves was also investigated. The distribution of current smokers, ex-smokers, and non-smokers among the physicians was 13%, 33%, and 54%, respectively. Seventy-five percent of ex-smokers answered that their experience of smoking cessation influenced their patient education for smoking cessation, and 39% of smokers answered that their smoking status did not influence it. Only 53% of the physicians replied that they actually performed education for smoking cessation to the elderly, and 8% of them replied that they hardly perform any or do not perform it. Smoking cessation is thought to be the only way to prevent the development of COPD. However, only a half of physicians recognized the importance of smoking cessation for the treatment and control of COPD in the elderly. In addition, less than one third of physicians perform nicotine replacement therapy for smoking cessation. Enlightenment for physicians should be needed to make them perform education for smoking cessation more aggressively.     

Physiologic responses to long-term ventilation

Long-term MV, delivered by way of a tracheostomy or noninvasive mask, often is indicated in patients with restrictive or neuromuscular pulmonary diseases and occasionally in patients with severe obstructive hypercapnic respiratory failure. Regardless of the mode of ventilation, respiratory physiology seems to be significantly impacted in these patients. Although the effects of ventilation can be unpredictable, they often seem to be favorable. Selected patients can develop increased sensitivity to hypercapnia, with subsequent improvements in blood gas tensions and decreased pulmonary artery pressures, which result in augmented cardiac function and greater tolerance to exercise. The patient-ventilator interaction, mode of ventilation, and degree of support should be considered when managing these patients. For some patients, particularly patients with fibrotic lung disease or COPD, chronic MV likely does not alter pathophysiology or improve prognosis.     

Inhaled corticosteroids in chronic obstructive pulmonary disease: is there a long-term benefit?

PURPOSE OF REVIEW: The use of inhaled corticosteroids is one of the most controversial issues in COPD pharmacotherapy. Experts disagree about the benefits and harms of ICS for patients with COPD, yet a majority of patients with COPD are being treated with inhaled corticosteroids. This is a review of the most recent literature on this subject. RECENT FINDINGS: Evidence suggests that ICS, with or without a long-acting beta2-agonist, are cost-effective in reducing exacerbation rates and retarding the decline in health status of COPD patients, although they do not significantly modify the rate of decline in FEV1 or change mortality. This discrepancy is likely related to the differences in pathology of COPD when compared with asthma. Evidence also suggests that ICS may be safe regarding the effects on adrenals and bone mineral density. We have yet to identify reliable criteria for predicting a response to ICS in COPD, but it has become clear that in mild disease, no beneficial effect has been demonstrated. SUMMARY: In contrast to asthma, inhaled corticosteroids should not be used as a first-line medication in patients with COPD. Identification of patients with COPD who might benefit from long-term treatment with ICS remains paramount.     

Patient-physician communication about end-of-life care for patients with severe COPD.

Since patients with chronic obstructive pulmonary disease (COPD) infrequently discuss treatment preferences about end-of-life care with physicians, the goal of the present study was to identify which specific areas of communication about end-of-life care occur between patients with severe COPD and their physicians, and how patients rate the quality of this communication. A total of 115 patients with oxygen-dependent COPD, identified in pulmonary clinics in three hospitals and through an oxygen delivery company, were enrolled in this study. A 17-item quality of communication questionnaire (QOC) was administered to patients, along with other measures, including satisfaction with care. The patients reported that most physicians do not discuss how long the patients have to live, what dying might be like or patients' spirituality. Patients rated physicians highly at listening and answering questions. Areas patients rated relatively low included discussing prognosis, what dying might be like and spirituality/religion. Patients' assessments of physicians' overall communication and communication about treatment correlated well with the QOC. Patients' overall satisfaction with care also correlated significantly with the QOC. In conclusion, this study identifies areas of communication that physicians do not address and areas that patients rate poorly, including talking about prognosis, dying and spirituality. These areas may provide targets for interventions to improve communication about end-of-life care for patients with chronic obstructive pulmonary disease. Future studies should determine the responsiveness of these items to interventions, and the effect such interventions have on patient satisfaction and quality of care.     

Do all mechanically ventilated pediatric patients require continuous capnography?

With most patients in modern ICUs requiring mechanical ventilation, any technology that may lead to more optimal ventilatory strategies would be invaluable in the management of critically ill patients. The focus of most ventilator strategies is protecting the lung from the deleterious effects of mechanical ventilation. Every effort is made to minimize the duration of mechanical ventilation while optimizing the potential for successful extubation. A concise organized plan based on objective criteria that is adjusted to meet changes in patient status is clearly recommended. Continuous capnographic monitoring provides clinicians with clear, precise, objective data that may prove beneficial in the design and implementation of mechanical ventilatory strategies. There are no clear-cut methods for achieving the optimal ventilator strategy for a specific patient. Although guidelines and management theories exist throughout the medical literature, in practice, they often merely serve as loose guidelines. The dynamic properties of an acutely ill patient make the management of mechanical ventilation an ongoing process requiring clinical assessment and planning by multidisciplinary members of the patient care team. Comprehensive evaluation of ventilatory management strategies and patient responses must be made by a collaborative effort of physicians, respiratory care practitioners, and nurses. An objective, consistent approach to the overall management is essential. Although still controversial, it is the authors' opinion that volumetric capnograph provides the data necessary to establish adequate gas delivery, optimal PEEP, and effective ventilation with the least amount of mechanical assistance, regardless of clinician or institutional preferences.     

Evaluation of intermittent long-term negative-pressure ventilation in patients with severe chronic obstructive pulmonary disease

We tested the hypothesis that intermittent ventilatory assistance in patients with severe chronic obstructive pulmonary disease (COPD) improves pulmonary function and exercise capacity. Twenty stable patients with severe COPD were recruited from outpatient pulmonary clinics and were randomized to use a poncho wrap, negative-pressure ventilator or to receive standard care. After 6 months, the patients receiving standard care were switched over to the ventilator and vice versa, and follow-up was continued for an additional 6 months. After 3 to 6 months of ventilator use, we observed no clinically significant improvements in FEV1, FVC, blood gas determinations, maximal inspiratory and expiratory pressures, and exercise duration. However, 11 of our patients dropped out of the study because of an inability to tolerate the ventilator, and all but one of the nine who completed the study expressed dissatisfaction with it, using it for less time (4.1 h/day) than we recommended. Musculoskeletal pain and inconvenience were the most frequently voiced complaints. Because we did not document that ventilator use actually rested the respiratory muscles in our patients and because duration of ventilator use may have been too brief, we cannot conclude that intermittent rest of respiratory muscles in patients with severe COPD fails to bring about improvement. On the other hand, our results demonstrate that the poncho wrap ventilator is poorly tolerated by patients with severe COPD in a typical outpatient setting. We suggest that future trials seek to utilize better tolerated ventilatory assist devices.     

Patterns of care for COPD by Japanese physicians

OBJECTIVE: COPD treatment guidelines are available worldwide, yet it is not known how widely they are followed. This study evaluated the clinical care of COPD patients in Japan as compared to guideline recommendations. METHODS: A sample of general and specialist physicians was selected from private outpatient clinics and public hospitals in Japan. Physicians were provided two clinical vignettes (COPD and asthma) and asked to make a diagnosis. They were next asked to define diagnostic tests and treatment recommendations specifically for a COPD patient. Responses were compared to recommendations from current COPD guidelines. RESULTS: For the COPD unknown vignette, 6.2% of physicians diagnosed COPD while 54% diagnosed chronic bronchitis or emphysema. For COPD diagnosis, 81.9% of physicians recommended a CXR, 49.1% spirometry, and 17.7% a computed tomography scan. The most frequently recommended medication for a newly diagnosed COPD patient was theophylline (37.2%) followed by expectorants (32.1%) and inhaled anticholinergics (25.9%). Inhaled beta-agonists were recommended by fewer than 20% of all physicians. CONCLUSION: Care for COPD patients by selected Japanese physicians diverges from published practice guidelines. COPD is an infrequently used diagnostic label; diagnostic evaluation is characterized by a high use of computed tomography scans, particularly by specialists; and bronchodilator use was low.     

肺心病急性发作期患者的组织氧合状态及机械通气对其影响

目的观察慢性阻塞性肺疾病（ＣＯＰＤ）所致肺心病急性发作期合并Ｉ型呼吸衰竭患者机体组织细胞的氧合状态及机械通气对其影响。方法利用胃粘膜组织内ｐＨ（ｐＨｉ）技术测定１９例ＣＯＰＤ所致肺心病急性发作期合并Ｉ型呼吸衰竭患者机械通气前后及脱机前后ｐＨｉ的变化。结果发现机械通气前ｐＨｉ的三次结果分别为７．１８±０．０６,７．１９±０．０４,７．１８±０．０６,均明显低于７．３２;行机械通气后ｐＨｉ逐渐上升,４天后＞７．３２;脱机前及脱机后ｐＨｉ变化不明显。相关分析显示ｐＨｉ与动脉血ｐＨ（ｐＨａ）、硅胶囊内二氧化碳分压（ＰｇＣＯ２）与动脉血二氧化碳分压（ＰａＣＯ２）无相关性（ｒ＝０．３５２和０．４２１,Ｐ均＞０．０５）,提示ｐＨｉ的测定不受合并高碳酸血症的影响。结论肺心病急性发作期合并Ｉ型呼吸衰竭时存在组织氧合不良。ｐＨｉ的测定对指导临床治疗具有十分重要的意义,并有可能作为指导撤机的一项指标。     

呼吸机依赖患者相关危险因素分析

目的：分析有创机械通气患者呼吸机依赖的相关危险因素。方法选取2008年1月至2012年6月在我院呼吸内科重症监护室住院的372例有创机械通气患者的临床资料进行分析。结果372例有创机械通气患者中,呼吸机依赖组91例。年龄≥70岁、既往有慢性阻塞性肺疾病（COPD）、心功能≥NYHAⅢ级、脑血管意外并吸入性肺炎、脓毒症休克、合并多器官功能障碍综合征（MODS）、体质量指数＜18.5kg/m2、运动神经元病与呼吸机依赖关系密切。结论对于≥70岁患者,既往有COPD病史患者应尽早脱机,根据病情行有创-无创通气序贯治疗;另外积极改善心功能,加强肺部及全身感染的控制,加强营养支持,预防MODS的发生是减少呼吸机依赖患者的有效措施。     

Treatment preferences for resuscitation and critical care among homeless persons

CONTEXT: Homeless people are at increased risk of critical illness and are less likely to have surrogate decision makers when critically ill. Consequently, clinicians must make decisions independently or with input from others such as ethics committees or guardians. No prior studies have examined treatment preferences of homeless to guide such decision makers. DESIGN: Interviewer-administered, cross-sectional survey of homeless persons. SETTING: Homeless shelters in Seattle, WA. PARTICIPANTS: Two hundred twenty-nine homeless individuals with two comparison groups: 236 physicians practicing in settings where they are likely to provide care for homeless persons and 111 patients with oxygen-dependent COPD. MEASUREMENTS: Participants were asked whether they would want intubation with mechanical ventilation or cardiopulmonary resuscitation in their current health, if they were in a permanent coma, if they had severe dementia, or if they were confined to bed and dependent on others for all care. RESULTS: Homeless men were more likely to want resuscitation than homeless women (p < 0.002) in coma and dementia scenarios. Homeless men and women were both more likely to want resuscitation in these scenarios than physicians (p < 0.001). Nonwhite homeless were more likely to want resuscitation than white homeless people (p < 0.033), and both were more likely to want resuscitation than physicians (p < 0.001). Homeless are also more likely to want resuscitation than patients with COPD. The majority (80%) of homeless who reported not having family or not wanting family to make medical decisions prefer a physician make decisions rather than a court-appointed guardian. CONCLUSIONS: Homeless persons are more likely to prefer resuscitation than physicians and patients with severe COPD. Since physicians may be in the position of making medical decisions for homeless patients and since physicians are influenced by their own preferences when making decisions for others, physicians should be aware that, on average, homeless persons prefer more aggressive care than physicians. Hospitals serving homeless individuals should consider developing policies to address this issue.