Bhakti K. Patel

Impact of Mobile Tablet Computers on Internal Medicine Resident Efficiency

performance, and people will inevitably use the Internet to voice opinions, so why not capture this information in a useful form. Arguments against using this data include the selection bias by those leaving reviews, the lack of meaningful data on technical quality of health care, and straining of physician-patient relationships. Although our results do not counter all of these arguments against, they suggest that discretionary patient ratings, obtained through a Web site, may be a more useful tool than previously considered for both patients and health care workers. If patients are making choices based on this information, they can be reassured that the ratings are not entirely misleading and may be providing relevant information about health care quality. In his book The Wisdom of Crowds, James Surowiecki argues that a diverse collection of “independently deciding individuals” is likely to make better predictions and decisions than single individuals or even experts. At least to an extent, the self-selecting crowd of patients appears to be wise. The use of Web-based patient ratings has become common in other industries such as hotels and restaurants, and consumers value these rankings in making choices. We believe that the information provided by these Web sites, although flawed, represents a potentially important development in the measurement of health care quality.

Effect of Noninvasive Ventilation Delivered by Helmet vs Face Mask on the Rate of Endotracheal Intubation in Patients With Acute Respiratory Distress Syndrome: A Randomized Clinical Trial

IMPORTANCE Noninvasive ventilation (NIV) with a face mask is relatively ineffective at preventing endotracheal intubation in patients with acute respiratory distress syndrome (ARDS). Delivery of NIV with a helmet may be a superior strategy for these patients. OBJECTIVE To determine whether NIV delivered by helmet improves intubation rate among patients with ARDS. DESIGN, SETTING, AND PARTICIPANTS Single-center randomized clinical trial of 83 patients with ARDS requiring NIV delivered by face mask for at least 8 hours while in the medical intensive care unit at the University of Chicago between October 3, 2012, through September 21, 2015. INTERVENTIONS Patients were randomly assigned to continue face mask NIV or switch to a helmet for NIV support for a planned enrollment of 206 patients (103 patients per group). The helmet is a transparent hood that covers the entire head of the patient and has a rubber collar neck seal. Early trial termination resulted in 44 patients randomized to the helmet group and 39 to the face mask group. MAIN OUTCOMES AND MEASURES The primary outcome was the proportion of patients who required endotracheal intubation. Secondary outcomes included 28-day invasive ventilator-free days (ie, days alive without mechanical ventilation), duration of ICU and hospital length of stay, and hospital and 90-day mortality. RESULTS Eighty-three patients (45% women; median age, 59 years; median Acute Physiology and Chronic Health Evaluation [APACHE] II score, 26) were included in the analysis after the trial was stopped early based on predefined criteria for efficacy. The intubation rate was 61.5% (n = 24) for the face mask group and 18.2% (n = 8) for the helmet group (absolute difference, -43.3%; 95% CI, -62.4% to -24.3%; P < .001). The number of ventilator-free days was significantly higher in the helmet group (28 vs 12.5, P < .001). At 90 days, 15 patients (34.1%) in the helmet group died compared with 22 patients (56.4%) in the face mask group (absolute difference, -22.3%; 95% CI, -43.3 to -1.4; P = .02). Adverse events included 3 interface-related skin ulcers for each group (ie, 7.6% in the face mask group had nose ulcers and 6.8% in the helmet group had neck ulcers). CONCLUSIONS AND RELEVANCE Among patients with ARDS, treatment with helmet NIV resulted in a significant reduction of intubation rates. There was also a statistically significant reduction in 90-day mortality with helmet NIV. Multicenter studies are needed to replicate these findings. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01680783.

Prevalence, clinical features, and CPAP adherence in REM-related sleep-disordered breathing: a cross-sectional analysis of a large clinical population

PurposeDue to inconsistent definitions used in the literature, the prevalence of rapid eye movement (REM)-related sleep-disordered breathing (SDB) has been quite variable and its clinical significance remains unclear. This study aimed to compare the prevalence of and clinical characteristics between various criteria for defining REM-related SDB. We also investigated how frequently CPAP therapy was recommended in patients with REM-related SDB and if they had lower CPAP adherence compared to non-stage-specific SDB.MethodsIn this cross-sectional study, we evaluated 1,019 consecutive adults referred for a polysomnogram for suspicion of SDB. The prevalence of REM-related SDB was calculated based on “traditional criteria” commonly reported in the literature and a “strict criteria” that minimized the contribution of SDB during non-REM sleep.ResultsThe prevalence of REM-related SDB ranged from 13.5% to 36.7%. There were no clinically significant differences between the strict definition and the traditional definition of REM-related SDB. REM-related SDB was more prevalent in women, younger individuals and African Americans. Compared to non-stage-specific obstructive sleep apnea (OSA), patients with REM-related SDB were equally symptomatic and hypersomnolent. CPAP titration was recommended in 88% of patients with REM-related SDB vs. 94% of patients with non-stage-specific OSA (p < 0.001). There was no significant difference in CPAP adherence between the two groups.ConclusionsRegardless of how REM-related SDB is defined, it was highly prevalent in our large clinical cohort. Compared to non-stage-specific OSA, these patients were equally hypersomnolent and adherent to CPAP therapy despite having overall significantly milder OSA. Further research is needed to better establish whether these patients will derive any benefit from long-term CPAP therapy.

Impact of Early Mobilization on Glycemic Control and ICU-Acquired Weakness in Critically Ill Patients Who Are Mechanically Ventilated

BACKGROUND ICU-acquired weakness (ICU-AW) has immediate and long-term consequences for critically ill patients. Strategies for the prevention of weakness include modification of known risk factors, such as hyperglycemia and immobility. Intensive insulin therapy (IIT) has been proposed to prevent critical illness polyneuropathy. However, the effect of insulin and early mobilization on clinically apparent weakness is not well known. METHODS This is a secondary analysis of all patients with mechanical ventilation (N = 104) previously enrolled in a randomized controlled trial of early occupational and physical therapy vs conventional therapy, which evaluated the end point of functional independence. Every patient had IIT and blinded muscle strength testing on hospital discharge to determine the incidence of clinically apparent weakness. The effects of insulin dose and early mobilization on the incidence of ICU-AW were assessed. RESULTS On logistic regression analyses, early mobilization and increasing insulin dose prevented the incidence of ICU-AW (OR, 0.18, P = .001; OR, 0.001, P = .011; respectively) independent of known risk factors for weakness. Early mobilization also significantly reduced insulin requirements to achieve similar glycemic goals as compared with control patients (0.07 units/kg/d vs 0.2 units/kg/d, P < .001). CONCLUSIONS The duel effect of early mobilization in reducing clinically relevant ICU-AW and promoting euglycemia suggests its potential usefulness as an alternative to IIT.

Expectations of iPad Use in an Internal Medicine Residency Program: Is It Worth the “Hype”?

Background While early reports highlight the benefits of tablet computing in hospitals, introducing any new technology can result in inflated expectations. Objective The aim of the study is to compare anticipated expectations of Apple iPad use and perceptions after deployment among residents. Methods 115 internal medicine residents received Apple iPads in October 2010. Residents completed matched surveys on anticipated usage and perceptions after distribution 1 month prior and 4 months after deployment. Results In total, 99% (114/115) of residents responded. Prior to deployment, most residents believed that the iPad would improve patient care and efficiency on the wards; however, fewer residents “strongly agreed” after deployment (34% vs 15% for patient care, P<.001; 41% vs 24% for efficiency, P=.005). Residents with higher expectations were more likely to report using the iPad for placing orders post call and during admission (71% vs 44% post call, P=.01, and 16% vs 0% admission, P=.04). Previous Apple iOS product owners were also more likely to use the iPad in key areas. Overall, 84% of residents thought the iPad was a good investment for the residency program, and over half of residents (58%) reported that patients commented on the iPad in a positive way. Conclusions While the use of tablets such as the iPad by residents is generally well received, high initial expectations highlight the danger of implementing new technologies. Education on the realistic expectations of iPad benefits may be warranted.

The Changing Landscape of Noninvasive Ventilation in the Intensive Care Unit

Traditionally, endotracheal intubation has been used as a treatment for patients with respiratory failure who require mechanical ventilation. Although intubation can be life saving, it is also associated with significant morbidity.1 Immunocompromised patients with acute hypoxemic respiratory failure are at particularly high risk; these patients often require high levels of ventilatory support (ie, positive end-expiratory pressure [PEEP] and fractions of inspired oxygen [Fio2]). Intubated patients usually require sedative medications, analgesic agents, or both and are at risk for many complications seen in the intensive care unit (ICU), such as ventilator-associated pneumonia, ICU-acquired weakness,2 venous thromboembolism,3 delirium, and cognitive dysfunction.4 As such, these patients typically have a high associated mortality, estimated at approximately 50%.5

No Exit: Identifying Avoidable Terminal Oncology Intensive Care Unit Hospitalizations

PURPOSE Terminal oncology intensive care unit (ICU) hospitalizations are associated with high costs and inferior quality of care. This study identifies and characterizes potentially avoidable terminal admissions of oncology patients to ICUs. METHODS This was a retrospective case series of patients cared for in an academic medical centers ambulatory oncology practice who died in an ICU during July 1, 2012 to June 30, 2013. An oncologist, intensivist, and hospitalist reviewed each patients electronic health record from 3 months preceding terminal hospitalization until death. The primary outcome was the proportion of terminal ICU hospitalizations identified as potentially avoidable by two or more reviewers. Univariate and multivariate analysis were performed to identify characteristics associated with avoidable terminal ICU hospitalizations. RESULTS Seventy-two patients met inclusion criteria. The majority had solid tumor malignancies (71%), poor performance status (51%), and multiple encounters with the health care system. Despite high-intensity health care utilization, only 25% had documented advance directives. During a 4-day median ICU length of stay, 81% were intubated and 39% had cardiopulmonary resuscitation. Forty-seven percent of these hospitalizations were identified as potentially avoidable. Avoidable hospitalizations were associated with factors including: worse performance status before admission (median 2 v 1; P = .01), worse Charlson comorbidity score (median 8.5 v 7.0, P = .04), reason for hospitalization (P = .006), and number of prior hospitalizations (median 2 v 1; P = .05). CONCLUSION Given the high frequency of avoidable terminal ICU hospitalizations, health care leaders should develop strategies to prospectively identify patients at high risk and formulate interventions to improve end-of-life care.

Face Mask vs Helmet for Noninvasive Ventilation—Reply

Face Mask vs Helmet for Noninvasive Ventilation To the Editor Dr Patel and colleagues randomized 83 patients with acute respiratory distress syndrome (ARDS) to receive noninvasive ventilation (NIV) delivered by helmet or face mask.1 The helmet was significantly more effective in preventing the need for intubation. It was interesting that the most common cause of intubation in the helmet group was neurologic impairment (62.5%), which contrasts with our clinical experience. We speculate that an increased incidence of unrecognized CO2 retention and hypercapnic encephalopathy may have occurred during the helmet NIV. Different from other NIV interfaces, the helmet behaves as a semi-closed environment, where the amount of CO2 rebreathing depends only on the metabolic production of CO2 and the fresh gas flow flushing its volume.2 In this study, helmet NIV was applied using a critical care mechanical ventilator, a setting already demonstrated to predispose to significant CO2 rebreathing because of the low rate of fresh gas flow delivered.2,3 Nevertheless, the authors reported an unexpectedly high ventilator fresh gas flow, “typically between 100 to 200 L/min” that “was always easily achievable with modest pressure support settings.” We wonder if the authors had considered the peak inspiratory flow without taking into account that CO2 rebreathing in the helmet depends on the inspiratory minute ventilation delivered by the ventilator,2-4 which is much lower in magnitude (10-30 L/min).3,4 Another relevant issue is that during NIV delivered by mechanical ventilator, the rate of fresh gas flow strictly depends on the patient’s ventilatory effort. Any abrupt reduction in minute ventilation because of impending muscle exhaustion or impaired respiratory drive, such as from encephalopathy or use of sedatives, immediately decreases the fresh gas flow, with a proportional increase in CO2 concentration inside the helmet. Consequently, a dangerous cycle of acute CO2 overload, neurologic impairment, and decreased minute ventilation may rapidly lead to NIV failure and the need for intubation. Because this phenomenon may develop rapidly, it easily could be missed by the periodic arterial blood sampling performed in the study. Continuous monitoring of CO2 concentration inside the helmet3 may be useful to monitor rebreathing severity. To safely use the helmet, physicians must understand its unique physiologic behavior in terms of CO2 rebreathing. Although the potential occurrence of severe hypercapnia should not limit the use of the device, major efforts are needed to prevent and promptly recognize this life-threatening complication.

High-Flow Nasal Oxygen—The Pendulum Continues to Swing in the Assessment of Critical Care Technology

Standard oxygen by mask or nasal prongs has been the firstline therapy for patients with acute hypoxemic respiratory failure (AHRF), followed by intubation to provide invasive mechanical ventilation for patients for whom this approach has failed. Although intubation and subsequent invasive mechanical ventilation can be lifesaving, these procedures are associated with many complications1 and some patients with comorbidities—for example, those who are immunosuppressed—have disproportionately high morbidity and mortality.2 Two technologies have been developed to bridge the therapy gap between standard oxygen therapy and invasive mechanical ventilation: noninvasive ventilation (NIV) and high-flow nasal oxygen therapy. Although there is controversy about how these technologies fit in the management of AHRF, they share a similar proliferation based on early enthusiasm followed by widespread adoption and over time a tempering of expectations related to ongoing evaluation in randomized clinical trials. Although NIV was first introduced in the 1940s, its popularity for the care of immunosuppressed patients with AHRF increased when initial clinical trials reported substantial improvements in mortality and a reduction in rates of endotracheal intubation.3,4 These data and an observational study of 1302 immunosuppressed patients were the basis for a conditional recommendation for the use of NIV in immunocompromised patients with AHRF before intubation in the current European Respiratory Society/American Thoracic Society guidelines.5 However, a recent multicenter, randomized trial by Lemiale et al6 of 374 immunosuppressed patients showed that early NIV compared with standard oxygen therapy was not associated with clinical benefits. In addition, a post hoc analysis of the FLORALI trial, comparing high-flow nasal oxygen therapy with NIV and standard oxygen therapy in AHRF, suggested that NIV might be associated with an increased risk of intubation and mortality in this subgroup of patients with AHRF.7 Given the pendulum swing in optimism for NIV, could there be a role for high-flow nasal oxygen therapy in immunocompromised patients? This technology has been widely adopted, and its popularity has been driven by early positive studies, the improvement in physiologic parameters seen during its use (particularly an increase in the ratio of PaO2 to fraction of inspired oxygen [FIO2]), and a general ease of application.8,9 However, robust studies clarifying the niche this technology best serves have been lacking, especially in the immunosuppressed patient population. In this issue of JAMA, Azoulay and colleagues10 address this question. In this multicenter trial, the authors recruited 776 immunosuppressed patients with AHRF and randomized them to receive high-flow nasal oxygen therapy vs standard oxygen therapy. Based on their calculated PaO2:FIO2 ratio both at and 6 hours after randomization and the high mortality in both the intervention and the control groups, the population studied was appropriate in regard to degree of hypoxemia and severity of illness to warrant consideration of innovative therapies beyond routine initial oxygen therapy to improve outcome. However, no significant benefit from use of high-flow oxygen therapy was seen. Intubation rates were similar in both groups, 150 of 388 (38.7%) with high-flow oxygen therapy and 170 of 388 (43.8%) with standard oxygen therapy. Similarly, 28-day mortality was not significantly different between groups—138 of 388 (35.6%) with high-flow oxygen therapy and 140 of 388 (36.1%) with standard oxygen therapy. Theremayhavebeensomeadverseeffectsofhigh-flownasal oxygen therapy in the trial. The authors point out that patients who received high-flow oxygen therapy had a longer intensive careunit(ICU)staywhencomparedwithpatientsreceivingstandard oxygen therapy (8 days vs 6 days), although the difference was not statistically significant (P = .07). This observation is common in clinical practice, whereby patients with AHRF who receive high-flow oxygen therapy are considered to need a high-maintenance, high-cost admission to an ICU until they can be transitioned to standard oxygen therapy. Furthermore, because there are no precise guidelines for weaning from highflow therapy, its use may lead to increased and perhaps unnecessary use of hospital and critical care resources. The medical community’s craving for innovation often fuels overzealous enthusiasm for positive results of interventions in preliminary studies that are subsequently contradicted when larger, multicenter trials are undertaken.11 One reason for early enthusiasm is that physicians do not want to withhold potentially beneficial therapies from patients. This is especially true in critical care when the intervention is perceived to have a pathophysiologic rationale. However, once a technology has been adopted, it is difficult to de-adopt, even if later, more robust evidence suggests that its continued use is unjustified.16 Even when trials have negative results, researchers and clinicians often seek to find subgroups that may have some benefit (such as with trials of colloids in shock or of activated protein C in severe sepsis) so that innovation is not wasted. However, if therapies are posited to have a role in important subgroups, it is important that such a role be demonstrated with adequate rigor in prospective clinical trials.12,13 Related article Opinion

Impact of Vasoactive Medications on ICU-Acquired Weakness in Mechanically Ventilated Patients

Background Vasoactive medications are commonly used in the treatment of critically ill patients, but their impact on the development of ICU‐acquired weakness is not well described. The objective of this study is to evaluate the relationship between vasoactive medication use and the outcome of ICU‐acquired weakness. Methods This is a secondary analysis of mechanically ventilated patients (N = 172) enrolled in a randomized clinical trial of early occupational and physical therapy vs conventional therapy, which evaluated the end point of ICU‐acquired weakness on hospital discharge. Patients underwent bedside muscle strength testing by a therapist blinded to study allocation to evaluate for ICU‐acquired weakness. The effects of vasoactive medication use on the incidence of ICU‐acquired weakness in this population were assessed. Results On logistic regression analysis, the use of vasoactive medications increased the odds of developing ICU‐acquired weakness (odds ratio [OR], 3.2; P = .01) independent of all other established risk factors for weakness. Duration of vasoactive medication use (in days) (OR, 1.35; P = .004) and cumulative norepinephrine dose (&mgr;g/kg/d) (OR, 1.01; P = .02) (but not vasopressin or phenylephrine) were also independently associated with the outcome of ICU‐acquired weakness. Conclusions In mechanically ventilated patients enrolled in a randomized clinical trial of early mobilization, the use of vasoactive medications was independently associated with the development of ICU‐acquired weakness. Prospective trials to further evaluate this relationship are merited. Trial Registry ClinicalTrials.gov; No.: NCT01777035; URL: www.clinicaltrials.gov