Tow Keang Lim

Noninvasive ventilation in hypercapnic acute respiratory failure due to chronic obstructive pulmonary disease vs. other conditions : effectiveness and predictors of failure

ObjectiveThis study compared the effectiveness of noninvasive ventilation (NIV) and the risk factors for NIV failure in hypercapnic acute respiratory failure (ARF) due to chronic obstructive pulmonary disease (COPD) vs. non-COPD conditions.Design and settingProspective cohort study in the medical intensive care unit of a university hospital.Patients and participants111 patients with hypercapnic ARF, 43 of whom had COPD exacerbations and 68 other conditions. Baseline characteristics of the two groups were similar.Measurements and resultsThe risk of NIV failure, defined as the need for endotracheal intubation, was significantly lower in COPD than in other conditions (19% vs. 47%). High APACHE II score was an independent predictor of NIV failure in COPD (OR 5.38 per 5 points). The presence of pneumonia (OR 5.63), high APACHE II score (OR 2.59 per 5 points), rapid heart rate (OR 1.22 per 5 beats/min), and high PaCO2 1xa0h after NIV (OR 1.22 per 5xa0mmHg) were independent predictors of NIV failure in the non-COPD group. Failure of NIV independently predicted mortality (OR 10.53).ConclusionsNoninvasive ventilation was more effective in preventing endotracheal intubation in hypercapnic ARF due to COPD than non-COPD conditions. High APACHE II score predicted NIV failure in both groups. Noninvasive ventilation was least effective in patients with hypercapnic ARF due to pneumonia.

The changing face of healthcare worker perceptions on powered air‐purifying respirators during the SARS outbreak

Objectives:u2003 Before the advent of severe acute respiratory syndrome (SARS), use of the powered air‐purifying respirator (PAPR) in the setting of pulmonary tuberculosis has been controversial. Data regarding health care worker (HCW) perceptions and problems encountered with the use of the PAPRs were lacking.

Transbronchial needle aspiration: initial experience in routine diagnostic bronchoscopy.

BACKGROUNDnTransbronchial needle aspiration (TBNA) has been shown to be useful not only for the diagnosis and staging of lung cancer, its most widely studied indication, but also for many of other clinical indications. Despite this, it remains largely underutilized, mainly because of concerns with poor yield, safety, lack of experience of the bronchoscopist, and lack of cytopathological support.nnnOBJECTIVEnTo study the clinical utility and yield of TBNA as an adjunct to other conventional procedures in diagnostic bronchoscopy at a centre that was relatively inexperienced with this technique, but where there was availability of rapid on-site evaluation (ROSE). Most of the major indications for TBNA in both malignant as well as benign disease were included.nnnSETTINGnUniversity Teaching Hospital naïve to the procedure.nnnPATIENT AND METHODSnForty-five consecutive patients who underwent TBNA as part of diagnostic bronchoscopy during a 2-year study period.nnnRESULTSnTBNA gave a yield of 65% for evaluation of mediastinal disease, both benign and malignant. The overall diagnostic utility for all indications was 71% and there were no complications.nnnCONCLUSIONSnWe conclude that TBNA is a useful and safe adjunct to diagnostic bronchoscopy in routine clinical practice. It has a satisfactory yield even with an inexperienced team, if used with ROSE.

Use of traditional versus electronic medical-information resources by residents and interns

Background: Little is known about the information-seeking behaviour of junior doctors, with regard to their use of traditional versus electronic sources of information. Aims: To evaluate the amount of time junior doctors spent using various medical-information resources and how useful they perceived these resources to be. Methods: A questionnaire study of all residents and interns in a tertiary teaching hospital in July and August 2004. Results: In total, 134 doctors returned the completed questionnaires (response rate 79.8%). They spent the most time using traditional resources like teaching sessions and print textbooks, rating them as most useful. However, electronic resources like MEDLINE, UpToDate, and online review articles also ranked highly. Original research articles were less popular. Conclusion: Residents and interns prefer traditional sources of medical information. Meanwhile, though some electronic resources are rated highly, more work is required to remove the barriers to evidence-based medicine.

How residents and interns utilise and perceive the personal digital assistant and UpToDate

BackgroundIn this era of evidence-based medicine, doctors are increasingly using information technology to acquire medical knowledge. This study evaluates how residents and interns utilise and perceive the personal digital assistant (PDA) and the online resource UpToDate.MethodsThis is a questionnaire survey of all residents and interns in a tertiary teaching hospital.ResultsOut of 168 doctors, 134 (79.8%) responded to the questionnaire. Only 54 doctors (40.3%) owned a PDA. Although these owners perceived that the PDA was most useful for providing drug information, followed by medical references, scheduling and medical calculators, the majority of them did not actually have medical software applications downloaded on their PDAs. The greatest concerns highlighted for the PDA were the fear of loss and breakage, and the preference for working with desktop computers and paper. Meanwhile, only 76 doctors (56.7%) used UpToDate, even though the hospital had an institutional subscription for it. Although 93.4% of these users would recommend UpToDate to a colleague, only 57.9% stated that the use of UpToDate had led to a change in their management of patients.ConclusionAlthough UpToDate and various PDA software applications were deemed useful by some of the residents and interns in our study, both digital tools were under-utilised. More should be done to facilitate the use of medical software applications on PDAs, to promote awareness of tools for evidence-based medicine such as UpToDate, and to facilitate the application of evidence-based medicine in daily clinical practice.

Bedside pleural procedures by pulmonologists and non-pulmonologists: a 3-year safety audit

Pleural procedures such as tube thoracostomy and chest aspirations are commonly performed and carry potential risks of visceral organ injury, pneumothorax and bleeding. In this context limited information exists on the complication rates when non‐pulmonologists perform ultrasound‐guided bedside pleural procedures. Bedside pleural procedures in our university hospital were audited to compare complication rates between pulmonologists and non‐pulmonologists.

Severe community-acquired pneumonia: timely management measures in the first 24 hours

Mortality rates for severe community-acquired pneumonia (CAP) range from 17 to 48 % in published studies.In this review, we searched PubMed for relevant papers published between 1981 and June 2016 and relevant files. We explored how early and aggressive management measures, implemented within 24 hours of recognition of severe CAP and carried out both in the emergency department and in the ICU, decrease mortality in severe CAP.These measures begin with the use of severity assessment tools and the application of care bundles via clinical decision support tools. The bundles include early guideline-concordant antibiotics including macrolides, early haemodynamic support (lactate measurement, intravenous fluids, and vasopressors), and early respiratory support (high-flow nasal cannulae, lung-protective ventilation, prone positioning, and neuromuscular blockade for acute respiratory distress syndrome).While the proposed interventions appear straightforward, multiple barriers to their implementation exist. To successfully decrease mortality for severe CAP, early and close collaboration between emergency medicine and respiratory and critical care medicine teams is required. We propose a workflow incorporating these interventions.