Ruben D. Restrepo

Medication adherence issues in patients treated for COPD

Although medical treatment of COPD has advanced, nonadherence to medication regimens poses a significant barrier to optimal management. Underuse, overuse, and improper use continue to be the most common causes of poor adherence to therapy. An average of 40%–60% of patients with COPD adheres to the prescribed regimen and only 1 out of 10 patients with a metered dose inhaler performs all essential steps correctly. Adherence to therapy is multifactorial and involves both the patient and the primary care provider. The effect of patient instruction on inhaler adherence and rescue medication utilization in patients with COPD does not seem to parallel the good results reported in patients with asthma. While use of a combined inhaler may facilitate adherence to medications and improve efficacy, pharmacoeconomic factors may influence patient’s selection of both the device and the regimen. Patient’s health beliefs, experiences, and behaviors play a significant role in adherence to pharmacological therapy. This manuscript reviews important aspects associated with medication adherence in patients with COPD and identifies some predictors of poor adherence.

AARC Clinical Practice Guideline: Transcutaneous Monitoring of Carbon Dioxide and Oxygen: 2012

An electronic literature search for articles published between January 1990 and September 2011 was conducted by using the PubMed, CINAHL, SCOPUS, and Cochrane Library databases. The update of this clinical practice guideline is the result of reviewing a total of 124 articles: 3 randomized controlled trials, 103 prospective trials, 1 retrospective study, 3 case studies, 11 review articles, 2 surveys and 1 consensus paper on transcutaneous monitoring (TCM) for PtcO2 and PtcCO2. The following recommendations are made following the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria: (1) Although PtcCO2 has a good correlation with PaCO2 and is a reliable method to evaluate plasma CO2 levels, it is recommended that arterial blood gas values be compared to transcutaneous readings taken at the time of arterial sampling, in order to verify the transcutaneous values, and periodically as dictated by the patients clinical condition. (2) It is suggested that PtcCO2 may be used in clinical settings where monitoring the adequacy of ventilation is indicated. (3) It is suggested that PtcO2 and PtcCO2 may be used in determining the adequacy of tissue perfusion and monitoring of reperfusion. (4) It is suggested that TCM should be avoided in the presence of increased thickness or edema of the skin and/or subcutaneous tissue where the sensor is applied. (5) It is recommended that sites used for a TCM be changed as often as necessary and that they be alternated and observed to avoid thermal injury. Manufacturer recommendations should be followed.

Humidification During Invasive and Noninvasive Mechanical Ventilation: 2012

We searched the MEDLINE, CINAHL, and Cochrane Library databases for articles published between January 1990 and December 2011. The update of this clinical practice guideline is based on 184 clinical trials and systematic reviews, and 10 articles investigating humidification during invasive and noninvasive mechanical ventilation. The following recommendations are made following the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) scoring system: 1. Humidification is recommended on every patient receiving invasive mechanical ventilation. 2. Active humidification is suggested for noninvasive mechanical ventilation, as it may improve adherence and comfort. 3. When providing active humidification to patients who are invasively ventilated, it is suggested that the device provide a humidity level between 33 mg H2O/L and 44 mg H2O/L and gas temperature between 34°C and 41°C at the circuit Y-piece, with a relative humidity of 100%. 4. When providing passive humidification to patients undergoing invasive mechanical ventilation, it is suggested that the HME provide a minimum of 30 mg H2O/L. 5. Passive humidification is not recommended for noninvasive mechanical ventilation. 6. When providing humidification to patients with low tidal volumes, such as when lung-protective ventilation strategies are used, HMEs are not recommended because they contribute additional dead space, which can increase the ventilation requirement and PaCO2. 7. It is suggested that HMEs are not used as a prevention strategy for ventilator-associated pneumonia.

Near-fatal asthma: recognition and management

Purpose of review Near-fatal asthma continues to be a significant problem despite the decline in overall asthma mortality. The purpose of this review is to discuss recent advances in our understanding of the pathophysiology, diagnosis and treatment of near-fatal asthma. Recent findings Two distinctive phenotypes of near-fatal asthma have been identified: one with eosinophilic inflammation associated with a gradual onset and a slow response to therapy and a second phenotype with neutrophilic inflammation that has a rapid onset and rapid response to therapy. Patients who develop sudden-onset near-fatal asthma seem to have massive allergen exposure and emotional distress. In stable condition, near-fatal asthma frequently cannot be distinguished from mild asthma. Diminished perception of dyspnea plays a relevant role in treatment delay, near-fatal events, and death in patients with severe asthma. Reduced compliance with anti-inflammatory therapy and ingestion of medications or drugs (heroin, cocaine) have been associated with fatal or near-fatal asthma. Summary Near-fatal asthma is a subtype of asthma with unique risk factors and variable presentation that requires early recognition and aggressive intervention.

Capnography/Capnometry During Mechanical Ventilation: 2011

We searched the MEDLINE, CINAHL, and Cochrane Library databases for articles published between January 1990 and November 2010. The update of this clinical practice guideline is based on 234 clinical studies and systematic reviews, 19 review articles that investigated capnography/capnometry during mechanical ventilation, and the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. The following recommendations are made following the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) scoring system: (1) Continuous-waveform capnography is recommended, in addition to clinical assessment to confirm and monitor correct placement of an endotracheal tube. (2) If waveform capnography is not available, a non-waveform exhaled CO2 monitor, in addition to clinical assessment, is suggested as the initial method for confirming correct tube placement in a patient in cardiac arrest. (3) End-tidal CO2 (PETCO2) is suggested to guide ventilator management. (4) Continuous capnometry during transport of the mechanically ventilated patients is suggested. (5) Capnography is suggested to identify abnormalities of exhaled air flow. (6) Volumetric capnography is suggested to assess CO2 elimination and the ratio of dead-space volume to tidal volume (VD/VT) to optimize mechanical ventilation. (7) Quantitative waveform capnography is suggested in intubated patients to monitor cardiopulmonary quality, optimize chest compressions, and detect return of spontaneous circulation during chest compressions or when rhythm check reveals an organized rhythm.

Incentive Spirometry: 2011

We searched the MEDLINE, CINAHL, and Cochrane Library databases for articles published between January 1995 and April 2011. The update of this clinical practice guideline is the result of reviewing a total of 54 clinical trials and systematic reviews on incentive spirometry. The following recommendations are made following the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) scoring system. 1: Incentive spirometry alone is not recommended for routine use in the preoperative and postoperative setting to prevent postoperative pulmonary complications. 2: It is recommended that incentive spirometry be used with deep breathing techniques, directed coughing, early mobilization, and optimal analgesia to prevent postoperative pulmonary complications. 3: It is suggested that deep breathing exercises provide the same benefit as incentive spirometry in the preoperative and postoperative setting to prevent postoperative pulmonary complications. 4: Routine use of incentive spirometry to prevent atelectasis in patients after upper-abdominal surgery is not recommended. 5: Routine use of incentive spirometry to prevent atelectasis after coronary artery bypass graft surgery is not recommended. 6: It is suggested that a volume-oriented device be selected as an incentive spirometry device.

Aerosol Delivery Device Selection for Spontaneously Breathing Patients: 2012

Using an electronic literature search for published articles indexed in PubMed between January 1990 and August 2011, the update of this clinical practice guideline is the result of reviewing 84 clinical trials, 54 reviews, 25 in vitro studies, and 7 evidence-based guidelines. The recommendations below are made following the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria: 1: It is recommended that selection of the appropriate aerosol generator and interface be made based on the patients age, physical and cognitive ability, cost, and the availability of the prescribed drug for use with a specific device. 2: Nebulizers and pressurized metered-dose inhalers (pMDIs) with valved holding chambers are suggested for use with children ≤ 4 years of age and adults who cannot coordinate the use of pMDI or dry-powder inhaler (DPI). 3: It is suggested that administration of aerosols with DPIs be restricted to patients ≥ 4 years of age who can demonstrate sufficient flow for the specific inhaler. 4: For patients who cannot correctly use a mouthpiece, aerosol masks are suggested as the interface of choice. 5: It is suggested that blow-by not be used for aerosol administration. 6: It is suggested that aerosol therapy be administered with a relaxed and nondistressed breathing pattern. 7: Unit dose medications are suggested to reduce the risk of infection. 8: It is suggested that nebulizer/drug combinations should be used as approved by the FDA. 9: It is recommended that healthcare providers know the correct use of aerosol generators; they should teach and periodically re-teach patients about how to use aerosol devices correctly. 10: It is suggested that intermittent positive-pressure breathing should not be used for aerosol therapy. 11: It is recommended that either nebulizer or pMDI can be used for aerosol delivery during noninvasive ventilation.

AARC Clinical Practice Guideline: Blood Gas Analysis and Hemoximetry: 2013

We searched MEDLINE, CINAHL, and Cochrane Library database for articles published between January 1990 and December 2012. The update of this clinical practice guideline is based on 237 clinical trials, 54 reviews, and 23 meta-analyses on blood gas analysis (BGA) and hemoximetry. The following recommendations are made following the Grading of Recommendations Assessment, Development, and Evaluation scoring system. BGA and hemoximetry are recommended for evaluating a patients ventilatory, acid-base, and/or oxygenation status. BGA and hemoximetry are suggested for evaluating a patients response to therapeutic interventions. BGA and hemoximetry are recommended for monitoring severity and progression of documented cardiopulmonary disease processes. Hemoximetry is recommended to determine the impact of dyshemoglobins on oxygenation. Capillary BGA is not recommended to determine oxygenation status. Central venous BGA and hemoximetry are suggested to determine oxygen consumption in the setting of early goal-directed therapies. For the assessment of oxygenation, a peripheral venous PO2 is not recommended as a substitute for an arterial blood measurement (PaO2). It is not recommended to use venous PCO2 and pH as a substitute for arterial blood measurement of PaCO2 and pH. It is suggested that hemoximetry is used in the detection and evaluation of shunts during diagnostic cardiac catheterization.

The Role of Nebulized Therapy in the Management of COPD: Evidence and Recommendations

Abstract Current guidelines recommend inhalation therapy as the preferred route of drug administration for treating chronic obstructive pulmonary disease (COPD). Previous systematic reviews in COPD patients found similar clinical outcomes for drugs delivered by handheld inhalers - pressurized metered-dose inhalers (pMDIs), dry powder inhalers (DPIs) - and nebulizers, provided the devices were used correctly. However, in routine clinical practice critical errors in using handheld inhalers are highly prevalent and frequently result in inadequate symptom relief. In comparison with pMDIs and DPIs, effective drug delivery with conventional pneumatic nebulizers requires less intensive patient training. Moreover, by design, newer nebulizers are more portable and more efficient than traditional jet nebulizers. The current body of evidence regarding nebulizer use for maintenance therapy in patients with moderate-to-severe COPD, including use during exacerbations, suggests that the efficacy of long-term nebulizer therapy is similar, and in some respects superior, to that with pMDI/DPIs. Therefore, despite several known drawbacks associated with nebulized therapy, we recommend that maintenance therapy with nebulizers should be employed in elderly patients, those with severe disease and frequent exacerbations, and those with physical and/or cognitive limitations. Likewise, financial concerns and individual preferences that lead to better compliance may favor nebulized therapy over other inhalers. For some patients, using both nebulizers and pMDI/DPI may provide the best combination of efficacy and convenience. The impact of maintenance nebulizer treatment on other relevant clinical outcomes in patients with COPD, especially the progressive decline in lung function and frequency of exacerbations, needs further investigation.

Protocol-Driven Ventilator Management in Children: Comparison to Nonprotocol Care

The purpose of this study was to compare ventilator weaning time, time to spontaneous breathing, and overall ventilator hours duration with use of a ventilator management protocol (VMP) versus standard nonprotocol-based care in a pediatric intensive care unit. A multidisciplinary task force developed a comprehensive protocol for ventilator management with four specific phases: initial ventilator set up and adjustment, weaning, minimal settings, and spontaneous mode prior to extubation. Medical records of ventilated patients both before and after protocol implementation were reviewed. A total of 187 patients were studied (89 nonprotocol and 98 VMP patients). No differences were seen between groups in PRISM scores, Murray scores, or oxygenation indices, but VMP patients were significantly younger (P= .03). Ventilator weaning times (P= .005) and time to spontaneous breathing modes (P= .006) were significantly decreased in VMP patients compared to nonprotocol patients, but overall ventilator duration was not significantly different. No significant differences were seen in extubation failure, use of corticosteroids, or use of racemic epinephrine between groups. Use of an institution-specific VMP developed by a multidisciplinary team was associated with significantly reduced ventilator weaning time and time to spontaneous breathing. Further studies are needed.