Amy R. Blanchard

High‐Risk Tracheostomy: Exploring the Limits of the Percutaneous Tracheostomy

Objectives: Modifications of the percutaneous tracheostomy (PercTrach) technique have made this a straightforward and safe procedure in appropriately selected patients. We sought to determine its value in high‐risk patients.

Sedation and analgesia in intensive care: Medications attenuate stress response in critical illness

PREVIEW Sedation and analgesia are often used in critical care patients to alleviate pain, anxiety, and the stress response. These techniques are not interchangeable, but their effects can be synergistic. Occasionally, neuromuscular blockade is necessary. In this article, Dr Blanchard discusses indications for sedation, analgesia, and neuromuscular blockade, as well as monitoring techniques and adverse effects.

Percutaneous Tracheostomy: Don't Beat Them, Join Them†

Objectives: The introduction of percutaneous tracheostomy (PercTrach) has resulted in tension over the scope of practice between otolaryngologists and pulmonary/critical care (PCC) specialists. We sought to determine the value of a collaborative approach to the performance of PercTrach at the bedside in the intensive care unit setting.

Obstructive Sleep Apnea Syndrome

Obstructive sleep apnea syndrome is caused by upper airway collapse during inspiration, causing intermittent hypoxemia, hypercapnia, acidosis, sympathetic nervous system activation, and arousal from sleep. Nighttime blood pressure is higher, but unexpectedly, daytime hypertension occurs. The prevalence of hypertension is very high and the incidence of hypertension increases as the number of apneic and hypopneic events per hour rises. Obesity is a major predisposing factor for the development of obstructive sleep apnea. Daytime sleepiness, snoring, and breathing pauses are important symptoms to elicit from the patient or sleep partner. Resistant hypertension is an important clue. Overnight polysomnography is required for diagnosis. Weight loss, avoidance of nocturnal sedatives, cessation of evening alcohol ingestion, and avoidance of the supine position during sleep are initial therapeutic actions in mild obstructive sleep apnea syndrome. Continuous positive airway pressure is the treatment of choice for patients unable to find relief from lifestyle changes. Blood pressure modestly improves with treatment.

A comparison of polysomnography and the SleepStrip in the diagnosis of OSA

Objective To investigate the role of a portable screening device (SleepStrip) in the diagnosis of obstructive sleep apnea (OSA). Methods and Materials Prospective, nonrandomized double-blinded single cohort study at an academic health center. Patients with suspected OSA scheduled for an attended overnight Level I polysomnogram (PSG) and who consented to participate in the study wore the SleepStrip device at home the night after the PSG. The apnea-hypopnea index (AHI) determined by PSG was compared with the results of the SleepStrip recording. Results Thirty-seven patients with a mean age of 52.1 ± 12.2 years and mean body mass index of 35.7 ± 5.2 participated in the study. The overall agreement between the AHI and the SleepStrip results using Cohens Kappa value was 0.139 (P = 0.19). The sensitivity and specificity of the SleepStrip for diagnosing severe OSA when the AHI was >40 were 33.3% and 95% (P = 0.05). When the AHI was >25, the SleepStrip sensitivity and specificity were 43.8% and 81.3% (P = 0.26). The sensitivity and specificity of the SleepStrip for diagnosing OSA in patients with an AHI >15 were 54.6% and 70%, respectively (P = 0.26). Conclusion The SleepStrip has a low correlation with the AHI as measured by PSG. Further studies are needed before this device can be recommended as a screening tool for the diagnosis of OSA. EBM rating: B-2b

100 Consecutive collaborative percutaneous tracheostomies

Objectives We previously introduced the concept of the collaborative percutaneous tracheostomy (PercTrach) performed in conjunction with pulmonary medicine/critical care (PCC), and now present a robust experience that validates our original concept of exploiting subspecialty expertise. Methods One hundred consecutive PercTrachs were performed. The PCC team performed bronchoscopic guidance, while the otolaryngology team performed the PercTrach using the Blue Rhino introducer set. Demographic data were gathered. Results One hundred PercTrachs were performed between May 2003 and December 2005. The mean ± SD patient age was 54.3 ± 15.9 years. Procedural times ranged from 5 to 37 minutes, with a mean of 12.9 ± 5.7 minutes. Surgical complications included one patient with bleeding who required surgical intervention. Conclusions and Significance There are numerous benefits to capitalizing on the respective expertise represented by otolaryngology and PCC including conservation of operating room time, rapid and safe establishment of the tracheostomy, and educational benefits for both programs.

Treatment of acute exacerbations of COPD.

Chronic obstructive pulmonary disease (COPD), the fourth leading cause of death in the United States, is increasing worldwide and is projected to be the third leading cause of death in the United States by the year 2020 (1). It affects nearly 16 million Americans, and more than

Treatment of COPD exacerbations. Pharmacologic options and modification of risk factors.

18 billion is spent annually on medications, physician visits, and hospitalizations. COPD is characterized by chronic airflow obstruction with episodic acute exacerbations, which result in increased morbidity and mortality. Patients hospitalized with exacerbations have an overall mortality rate of 3% to 4%, and up to 24% of patients requiring care in the intensive care unit die (2). Since forced expiratory volume in 1 second correlates closely with life expectancy and exacerbation rate, early diagnosis (through spirometric testing) and prevention may reduce acute exacerbations and health care costs.

Prediction of the final MSLT result from the results of the first three naps.

PREVIEW Acute exacerbations of chronic obstructive pulmonary disease (COPD) pose a continuing threat to quality and length of life in affected patients. As the prevalence of the disease increases, early diagnosis and appropriate interventions become even more crucial. In this article, Dr Blanchard provides a concise overview of risk factors for exacerbations of COPD, current pharmacologic options, and more advanced treatment measures for patients with acute respiratory failure.

In CVD with moderate-to-severe obstructive sleep apnea, adding CPAP to usual care did not reduce major CV events

OBJECTIVES To determine if the mean sleep latency (mSL) and the presence of significant sleep onset rapid eye movement periods (SOREMPs) can be predicted from the results of the first three naps in selected patients undergoing multiple sleep latency test (MSLT). METHODS Retrospective analysis of a number of MSLTs to identify the tests in which the mSL category and the presence of > or =2 naps with SOREMPS can be accurately predicted from the sleep latencies (SLs) of and SOREMPs in the first three naps. RESULTS The study included 588 consecutive MSLTs performed on 552 patients during a 3-year period. (1) The mSL was normal (> or =10 min) for all MSLTs (n=90, 15%) if either (a) the SL was normal in each of the first three naps, or (b) SL was 20 min for any two of the first three naps. (2) The mSL was low (<5 min) or borderline (> or =5 and <10 min) for 99% MSLTs with SL in the low or borderline categories, respectively. (3) The accuracy of predicting > or =2 naps with SOREMPs was 100% (normal SL), 96% (borderline SL), and 89% (low SL). (4) The mSL category (normal or low) and the presence of > or =2 naps with SOREMPs were predicted with 100% accuracy in 23% of all MSLTs. CONCLUSIONS The category of mSL can be predicted with >99% accuracy, if SL is normal, borderline, or low in each of the first three naps, or if the patient does not sleep in any two of the first three naps. MSLT can probably be shortened to three naps in up to 23% to reduce time, labor, discomfort, and cost of the test.