Timothy Liesching

A randomised trial of lung sealant versus medical therapy for advanced emphysema

Uncontrolled pilot studies demonstrated promising results of endoscopic lung volume reduction using emphysematous lung sealant (ELS) in patients with advanced, upper lobe predominant emphysema. We aimed to evaluate the safety and efficacy of ELS in a randomised controlled setting. Patients were randomised to ELS plus medical treatment or medical treatment alone. Despite early termination for business reasons and inability to assess the primary 12-month end-point, 95 out of 300 patients were successfully randomised, providing sufficient data for 3- and 6-month analysis. 57 patients (34 treatment and 23 control) had efficacy results at 3 months; 34 (21 treatment and 13 control) at 6 months. In the treatment group, 3-month lung function, dyspnoea, and quality of life improved significantly from baseline when compared to control. Improvements persisted at 6 months with >50% of treated patients experiencing clinically important improvements, including some whose lung function improved by >100%. 44% of treated patients experienced adverse events requiring hospitalisation (2.5-fold more than control, p=0.01), with two deaths in the treated cohort. Treatment responders tended to be those experiencing respiratory adverse events. Despite early termination, results show that minimally invasive ELS may be efficacious, yet significant risks (probably inflammatory) limit its current utility. Emphysematous lung sealant therapy is highly efficacious in some patients, but benefits bring significant risks http://ow.ly/JJ2vg

Evaluation of the Total Face Mask for Noninvasive Ventilation to Treat Acute Respiratory Failure

BACKGROUND We hypothesized that the total face mask (TFM) would be perceived as more comfortable than a standard oronasal mask (ONM) by patients receiving noninvasive mechanical ventilation (NIV) therapy for acute respiratory failure (ARF) and would be quicker to apply by respiratory therapists. METHODS Sixty patients presenting with ARF were randomized to receive NIV via either an ONM or a TFM. Mask comfort and dyspnea were assessed using visual analog scores. Other outcomes included time required to apply, vital signs and gas exchange at set time points, and early NIV discontinuation rates (ie, stoppage while still requiring ventilatory assistance). RESULTS Mask comfort and dyspnea scores were similar for both groups through 3 h of use. The time required to apply the mask (5 min [interquartile range (IQR), 2-8] vs 3.5 min [IQR, 1.9-5]), and duration of use (15.7 h [IQR, 4.0-49.8]) vs 6.05 h [IQR, 0.9-56.7]) were not significantly different between the ONM and the TFM group, respectively. Except for heart rate, which was higher at baseline in the TFM group, no differences in vital signs or gas exchange were detected between the groups during the first 3 h (P > .05). Early NIV discontinuation rates were similar for both the ONM group and TFM group (40% vs 57.1%); however, eight patients in the TFM group were switched to an ONM within 3 h, and none from the ONM group was switched to a TFM (P < .05). CONCLUSIONS Among patients with ARF requiring NIV, the ONM and TFM were perceived to be equally comfortable and had similar application times. Early NIV discontinuation rates, improvements in vital signs and gas exchange, and intubation and mortality rates were also similar. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT00686257; URL: www.clinicaltrials.gov.

RANDOMIZED TRIAL OF BILEVEL VERSUS CONTINUOUS POSITIVE AIRWAY PRESSURE FOR ACUTE PULMONARY EDEMA

BACKGROUND Studies have shown different clinical outcomes of noninvasive positive pressure ventilation (NPPV) from those of continuous positive airway pressure (CPAP). OBJECTIVE We evaluated whether bilevel positive airway pressure (BPAP) more rapidly improves dyspnea, ventilation, and acidemia without increasing the myocardial infarction (MI) rate compared to continuous positive pressure ventilation (CPAP) in patients with acute cardiogenic pulmonary edema (APE). METHODS Patients with APE were randomized to either BPAP or CPAP. Vital signs and dyspnea scores were recorded at baseline, 30 min, 1 h, and 3 h. Blood gases were obtained at baseline, 30 min, and 1 h. Patients were monitored for MI, endotracheal intubation (ETI), lengths of stay (LOS), and hospital mortality. RESULTS Fourteen patients received CPAP and 13 received BPAP. The two groups were similar at baseline (ejection fraction, dyspnea, vital signs, acidemia/oxygenation) and received similar medical treatment. At 30 min, PaO2:FIO2 was improved in the BPAP group compared to baseline (283 vs. 132, p < 0.05) and the CPAP group (283 vs. 189, p < 0.05). Thirty-minute dyspnea scores were lower in the BPAP group compared to the CPAP group (p = 0.05). Fewer BPAP patients required intensive care unit (ICU) admission (38% vs. 92%, p < 0.05). There were no differences between groups in MI or ETI rate, LOS, or mortality. CONCLUSIONS Compared to CPAP to treat APE, BPAP more rapidly improves oxygenation and dyspnea scores, and reduces the need for ICU admission. Further, BPAP does not increase MI rate compared to CPAP.

Resource utilization and end-of-life care in a US hospital following medical emergency team-implemented do not resuscitate orders.

BACKGROUND Medical emergency teams frequently implement do not resuscitate orders, but little is known about end-of-life care in this population. OBJECTIVE To examine resource utilization and end-of-life care following medical emergency team-implemented do not resuscitate orders. DESIGN Retrospective review. SETTING Single, tertiary care center. PATIENTS Consecutive adult inpatients requiring a medical emergency team activation over 1 year. MEASUREMENTS Changes to code status, time spent on medical emergency team activations, frequency of palliative care consultation, discharges with hospice care. INTERVENTIONS None. RESULTS We observed 1156 medical emergency team activations in 998 patients. Five percent (58/1156) resulted in do not resuscitate orders. The median time spent on activations with a change in code status was longer than activations without a change (66 vs 60 minutes, P = 0.05). Patients with a medical emergency team-implemented do not resuscitate order had a higher inpatient mortality (43 vs 27%, P = 0.04) and were less likely to be discharged with hospice at the end of life than patients with a preexisting do not resuscitate order (4 vs 29%, P = 0.01). There was no difference in palliative care consultation in patients with a preexisting do not resuscitate versus medical emergency team-implemented do not resuscitate order (20% vs 12%, P = 0.39). CONCLUSIONS Despite high mortality, patients with medical emergency team-implemented do not resuscitate orders had a relatively low utilization of end-of-life resources, including palliative care consultation and home hospice services. Coordinated care between medical emergency teams and inpatient palliative care services may help to improve end-of-life care.

Implementation and outcomes of a medical emergency team (MET) e-learning program

We report the successful implementation and effectiveness of a edical emergency team (MET) e-learning training program. Timely monitoring and detection of hospital patient deterioation to enable activation of a MET team requires appropriate raining of all relevant staff.1 The following questions about MET eams remain unanswered: (a) Do MET teams reduce patient dverse events? (b) Which adverse events are reduced? (c) What is he optimum frequency of MET calls?2 Our e-learning program was introduced in January 2009 and ncluded a set of video slides, which included the following conents: