August 1997

Volume 42, Number 8

ISSN 0020-1324-RECACP

J^43'^'' International Respiratory Congress

December 6-9 • New Orleans, Louisiana

A MONTHLY SCIENCE JOURNAL41ST YEAR—ESTABLISHED 1956

Validation of Metabolic Cart for

Measurement of VqA/t

Bronchoalveolar Lavage: A Review

CRCE through the Journal

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VpcfateTUe (F^MI^^respiratory care meeting in the worCd

AA^ 43rcfInternationaf^spiratory Congress

of the

American Associationfor ^spiratory Care

(DecemSer 6-9, 1997 (Saturcfay-Tuesday)

Ernest% 'MoriafConvention Center • [Kew Orfeans

CONTINUING EDUCATION - "The AARC meeting is the best place to earn CRCE" stated an attendee at last

year's Congress in San Diego. When asked to elaborate, she added that at the AARC meeting she was "able to

accumulate all the CRCE hours required by her state licensure, from 7 am to 5 pm for four days." At the NewOrleans Congress you, too, can earn as much as 25 hours of continuing education.

ADVANCE PROGRAM - The official advance program for the 1997 Congress will be mailed in early

September. In addition to containing all the events scheduled for New Orleans, the program will include the reg-

istration fonn and instructions for you to make your hotel reservations.

WHAT TO DO IN NEW ORLEANS - The September issue ofAARC Times will contain all kinds of information

about New Orleans—from what to see, to what to do, to where to eat. In the meantime, ifyou want to read about the

"Big Easy," visit the New Orleans Convention & Visitors Bureau's website on the Internet (www.nawlins.com).

PROGRAM HOURS EXPANDED - The AARC Program Committee has decided to begin the educational pro-

grams during the four days of the Congress at 8:30 am instead of 9 am, as in past years. This change is necessitat-

ed to accommodate the large number of programs to the presented in New Orleans. Exhibit hours will be from 1

1

AM to 4 PM on the first three days and from 1 1 am to 3 pm on the last day.

Open Forum - The results of scientific studies by clinicians, managers, and educators will again be presented

during the popular Open Forum sessions at the 1997 Congress. Organized and presented by the journal

Respiratory Care, the Open Forum papers are clustered into Minisymposia—with posters, one-on-one discus-

sions, study implications, and group discussion. The history of the Minisymposia is one of stimulating interac-

tions and lively group discussions. CRCE credits are available for participation in the Open Forum. As each

minisymposium is completed, the abstract posters will be displayed on the Wall of Fame (located in the Exhibit

Hall), for the remaining days of the Congress.

MEDICAL DIRECTORS/RCPs INTERACTION SYMPOSIUM - The premier program at the 1997 Congress,

the New Horizons Symposium, will address the issue of medical directors/RCPs interaction in delivering respira-

tory care. Chaired by Dr. James Stoller of Cleveland, the symposium will discuss the issues of current roles of med-

ical directors; what can be done about the inactive medical director; the RCP/medical director team; and interac-

tion of the two outside the hospital environment. The symposium will end with a panel discussion. This is the 13th

year the AARC presents the New Horizons Symposium.

UNIOUE PHYSIOLOGY COURSE TO BE PRESENTED - For the first time ever, a clinical respiratory physi-

ology mini-course will be presented during the 1 997 Congress. A four-part series ofone-hour daily lectures, the mini-

course is designed to review basic physiology in a plain-speaking, clinically-focused way using case examples.

HEADOUARTERS HOTEL FOR 1997 CONGRESS - The New Orleans Hilton has been designated as the

headquarters hotel for the 1997 Congress. Located beside the banks of the mighty Mississippi River, the Hilton is

considered among the top five hotels in New Orleans.

The South Carolina Society for

Respiratory Care and the AARC present a

Special

Pre-(onvention

kminarTuesday, September 30, 1997

Pawley's Island, South Carolina

MAPPING A smmiDIBECTION fOR SKCiSS IN

THE (HANGING HEALTH

(ARE ENVIRONMENTThe 26th Annual Meeting and Exhibition of the

South Carolina Society for Respiratory Care (SCSRC)will be held at the beautiful Litchfield by the SeaHotel in Pawley's Island on October 1-3, 1997. This

year's convention will once again be preceded by a

special seminar organized in cooperation with the

American Association for Respiratory Care. Theseminar will present timely information on howrespiratory care practitioners and their employerscan change and benefit from today's health care

environment. The Special Seminar is approved for

6 hours of continuing respiratory care education

(CRCE) credit by the AARC.

RE/PIRATORy Q^REA Monthly Science Journal. Established 1956. Official Journal of the American Association for Respiratory Care

Contents ...Editor

Pat Brougher BA RRT

Managing Editor

Ray Masferrer BA RRT

Editorial Board

James K Stoller MD, Chairman

Cleveland Clinic Foundation

Cleveland. Ohio

Richard D Branson RRT

University of Cincinnati

Medical Center

Cincinnati. Ohio

Crystal L Dunlevy EdD RRT

Atlanta, Georgia

Charles G Durbin Jr MDThe University of Virginia

Health Sciences Center

Charlottesville. Virginia

Dean R Hess PhD RRT

Massachusetts General Hospital

Harvard Medical School

Boston. Massachusetts

Neil R Maclntyre Jr MD

Duke University Medical Center

Durham, North Carolina

Shelley C Mishoe PhD RRT

Medical College of Georgia

Augusta, Georgia

Joseph L Rau PhD RRT

Georgia State University

Atlanta. Georgia

August 1997

Volume 42, Number 8

Original Contributions

761 Validation of the Deltatrac Metabolic Cart for

Measurement of Dead-Space-to-Tidal-Voltime Ratio

by John C MacKinnon. Patricia L Houston, and Glenn P

McGuire—Toronto. Ontario. Canada

Reviews, Overviews, & Updates

765 Bronchoalveolar Lavage: A Useful Method for

Diagnosis of Some Pulmonary Disorders

b\ Ali Emad^Sliiraz. Iran

Graphics Corner

791

Letters

796

796

796

Excessive Work of Breathing, Active Exhalation,

and Retardation of Expiratory Flow: What's the

Problem and Where's the Problem?

by Richard D Branson. Robert S Camplicll. and Jay A

Johannigman—Cincinnati. Ohio

Asthma & SCUBA Diving

b\ Lawrence Martin—Cleveland. Ohio

Graphics Corner Makes Waves?

b\ Phil Mercurio—Albuquerque. New Mexico

Airflow Resistance & Zero Flow: An Apparent

Contradiction?

/)\ Robert Chatburn—Cleveland. Ohio

Historical Notes

798 "Nebulizer" from Effective Inhalation Therapy

by Edwin R Levine MD and published by National Cylinder Gas

Co in 1953. pages 150-154. submitted by Teri Nikolai Wilson—

Daxton. Ohio

Continuing Education Examination

800 CRCE through the Journal— 1997

Respiratory Care • August '97 Vol 42 No 8 747

The Wisconsin Society for Respi^toj^^affi^nd ttt^AABCi

WISCONSIN SOCIETY9:00 a.m. - 9:05 a.m.

Program OverviewPatrick J. Dunne, MEd, RRT,

Southwest Medical Emporium,Fullerton CA

9:05 a.m. -9:55 a.m.

Managing the "INs andOUTs" of Managed CarePatrick J. Dunne, MEd, RRTDiscusses the key concepts

underlying ttie managed care

movement and the resultant

changes the process brings to the

traditional health care delivery

paradigm. Explores the trend of

"risk-shifting" and its implications,

as well as the opportunities this

phenomena portends for respiratory

care practitioners in all care settings.

10:00 a.m. - 10:55 a.m.

Managing Acute Care in a

Managed Care EnvironmentKevin L. Shrake, MA, RRl,

FACHE, Memorial Medical

Center, Springfield IL

E.\plains how guidelines andprotocols fit into the managed care

environment. Describes how to

establish a utilization control

program that has gained widespread

acceptance from employees,

physicians, insurance companies,and administrative staff.

11:00 a.m. - 11:55 p.m.

A Guide to Disease andDemand ManagementPatrick J. Dunne, MEd, RRTDefines and discusses the key

attributes of disease and demandmanagement strategies. Focuses onthe application and use of these

concepts and techniques byrespiratory care practitioners.

Provides examples of successful

implementation and the value of

disease and demand management in

fostering change while safeguarding

quality health care services.

1:30 p.m. -2:25 p.m.

Developing CollaborativeRelationships withPhysiciansKevin L. Shrake, MA, RRT,

F.-XCHE

Describes proven skills to

communicate and collaborate withphysicians. Kxplaiiis the basis for the

development of key physicianbehavioral traits and how to

effectively ask for support for keyprograms.

MAPPING A

STRATEGIC

DIRECTION FOR

SUCCESS IN

THE CHANGING

HEALTH CARE

ENVIRONMENT

2:30 p.m. - 3:25 p.m.

Developing a PerformanceMeasurement System forRespiratory Care Services

Patrick J. Dunne, MEd, RRTDiscusses the growing demands in

health care for the collection,

analysis, and use of objective,

quantifiable information aboutprovider performance. Explores

various utilization and clinical

outcomes appropriate for

measurement by providers of

respiratory care services. Reviews

Oryx, the JC.'XHO's new initiative to

integrate the use of performancemeasures into the accreditation

process.

3:30 p.m. - 4:25 p.m.

Creating Opportunitiesthrough Career MarketingKevin I.. Shrake, MA, RRT,

FACHEPresents a systematic plan on howto create career opportunities byeffectively marketing skills andservices to key decision-makers andcolleagues. Outlines how to create

skills inventory, how to identify key

players, and choosing techniques to

prove value.

Conference

Thursday, October 2, 1997

MERRIMAC,WISCONSIN

The Annual I-'all Conference of the

Wisconsin Society for Respiratory Care

will be held at the beautiful Devil's

Head Resort in Merrimac on October

1-2, 1997. This year's conference will

include a special seminar organized in

cooperation with the American

Association for Respiratory Care. The

seminar will present timely

information on how respiratory care

practitioners and their employers can

change and benefit from today's

health care environment. The Special

Seminar is approved for 6 hours of

continuing respiratory care education

(CRCE) credit by the AARC.

Registration Fees(Pre-Registration Deadline: September 20, 1997)

' ^e-ReQistration AAP.C Memirer Nor-N/embef

-911 Conference $100 $125

"^oistration AAFiC Mefr.t::er Non-lvtefT'.bef

. ;--'ce $110 $135

For hotel room reservations and their special

rate for the WSRC Pall Conference, please call

the DcNil's Head Resort direct (1-800-472-6670)

and identify yourself as an attendee. RoomRate: 554 single/ double.

For additional information, please call or write

Al Ludin (414) 334-5533"i,r: Soc.e:v '; ^esp^faic^y Ca^e

P.O. Box 26646.;ivvaukee, Wi 53226

Assistant EditorKris Williams BA

Editorial Assistant

Linda Barcus BBA

Production CoordinatorKaren Singletern BS

Section EditorsRobert R Fluck Jr MS RRT

MS Jastremski MDBlood Gas Corner

Hugh S Mathewson MDDrug Capsule

John O Nilsestuen PhD RRTKen Hargett BS RRT

Roben Harwood MSA RRTGraphics Corner

Richard D Branson RRTRobert S Campbell RRT

Kittredge 's Corner

Charles G Ir\in PhD

Jack Wanger MBA RPFT RRTPFT Corner

Patricia Ann Doorley MS RRTCharles G Durbin Jr MDTest Your Radiologic Skill

Barbara Wilson MEd RRTJon Meliones MD

John Palmisano RRTCardiorespiratoiy Interactions

Consulting EditorsFrank E Biondo BS RRTHoward J Birenbaum MDRobert L Chatbum RRTDonald R Ellon MDRonald B George MDJames M Hurst MD

Robert M Kacmarek PhD RRTMichael McPeck BS RRT

David J Pierson MDJohn Shigeoka MD

Jeffrey J Ward MEd RRT

ProductionDonna Knauf

PublisherSam P Giordano MBA RRT

MarketingDale Gnffiths

Director

Tim GoldsburyDirector ofAdvertising Sales

Beth Binkley

Advertising Assistant

Editorial Office

11030 Abies Lane

Dallas TX 75229

(972) 243-2272

ContentsAugust 1997

Volume 42, Number 8

In This Issue

809750824824822813811

817818

AARC Membership Application

Abstracts from Other Journals

Advertisers Index & Help Lines

Author Index

Calendar of Events

Manuscript Preparation GuideMedWatchNew Products & Services

Notices

RUSPIRATORV Care llSSN 0020-1324, USPS OtSQ-NOl is published monthly by Daedalus Enterprises Inc. at

1 1030 Abies Lane. Dallas TX 75229-4593, for the American Association for Respiratory Care. One volume is pub-

lished per year beginning each January . Subscription rales are $65 per year in the US; S80 in all other countries (for

airmail, add S84).

The contents of the Journal are indexed in Hospital and Health Administration Index. Cumulative Index to Nurs-

ing and Allied Health Literature. Excerpla Medica. and RNdex Library Edition. Abndged versions of RESPIRV-

TORY Care are also published in Italian and Japanese, with peniiission from Daedalus Enterprises Inc.

Periodicals postage paid at Dallas TX and at additional mailing offices. POSTMASTER: Send address changes

to Respi]<.atory Care. Membership Office, Daedalus Enterprises Inc, 1 1030 Abies Lane, Dallas TX 7522y-45«

'

Printed in the United States ofAmerica Copyright ® 1997. by Daedalus Enterprises I:c.

RESPIRATORY CARE • AUGUST '97 VOL 42 NO 8 749

Abstracts Summ^iries of Pertinent Articles in Other JoumaI>

Editorials, Coinmenlaries, and Reviews To Note

Perioperative Cardiac Dysrlijthmias: Diagnosis and Management I Review)—JL Atlee. Anes-

thesiology 1997;86(fi):I.W7-l424.

The Outcomes of \ ery Low Birth Weight Infants: Arc We Aslting the Right Questions? (Com-

inentary)—MCMcCorniick. Pediatrics iyy7;99(6):869-876.

Intrapartum Hypoxic-Ischemic Cerebral Injury and Subsequent Cerebral Palsy: Medicole-

gal Issues ( Review )—JM Ferlnian. Pediatrics 1997;99(6):851-X57.

Downsizing Competence: The Myth of Quality or Let the Barber Do the Surgery (Editorial)

—

MS Braunstein. Chest 1997;) 1 1|6): 1478.

Noninvasive Positive Pressure V entilation for Acute Respiratory Failure: I'nderutilized or < )ver-

raled? RM Jasmer. JM Luce. MA Matthay, Chest 1997;! 1 1(6): 1672- 1678. Seethe related edilo-

rial: Noninvasive Positive Pressure Ventilation: A Positive View in Need ofSupportive Evidence—J/ Rosenberg. RS Goldstein. Chest 1997:1 1 H6):1479-I4H2.

Croup (Review)—GC Geelhoed. Pediatr Pul-

monol 1997:23:370.

the mode of administration will need to be decided

by the attending clinician.

brands and different diameters is mandatory prior

to their utilization.

The management of mild to severe croup has

undergone dramatic changes in the last 5 years,

primarily due to the increased understanding of

the benefits of treating it w ith steroids. Steroids

have been useil in the treatment of croup for many

years but. until recently, their use has remained

controversiiil. luirlier studies were ohen not blinded

or used inappropriate outcome measures, such as

respiratory rate, which have not provcti appropriate.

Two attempts to review the literature in 1980 and

1989 cautiously supported the use of steroids.

Despite these recommendations many practitioners

continued to \ lew croup in most cases as a benign

self-limited condition, and since steroids have

potential side effects, their use was not consid-

ered justified. More recently, however, a number

of developments such as the successful use of the

inhaled steroid budesonide and oral dexametha-

sone have reinforced the argument for using

steroids. Recent work has also shown that both

inhaled and systemic steroids work by I hour and

dramaticall) reduce morbidity and hospitaliza-

tion time. The demonstration that an oral dose of

0. 1 5 ing/kg desaniethasonc is as cffectiv e as kirger

doses has made the use of systemic steroids more

acceptable to many practitioners. All children with

croup severe enough to be admitted to hospital

should receive steroids. Two recent studies ha\ e

shown that steroids also benefited children whopresented to emergency de[)artinents for treatment,

but w hose croup was not considea'd se\ ea- enough

for admission. The type of steroid, the dose, and

Correctly Selecting a Liquid-Filled Nasogas-

tric Infant Feeding Catheter lo Measure Intra-

esophageal Pressure—CCJ Hartford. GO Rogers.

M.1 furner. Pediatr Pulmonol 1997:23:362.

Polyvinyl chloride iPVCl nasogastric feeding

catheters are used clinically to measure intra-

esophageal pressure as an estimate of pleural pres-

sure for calculating lung compliance in infants.

Tlie accuracy of pressure measurement of 4 French

gauge (HG) catheter sizes and 3 brands of liquid-

filled catheter manometer systems (CMS) was

evaluated by determining their resonance-fre-

quency amplitude and phase properties. .All CMSwere undeidaniix'd :uid a'sonated. No CMS e.vhib-

ited a uniform mean frequency response above

1 1 H/. The inaximum respiratory rate (Fr,) within

vv hich CMS could potentially measure dynamic

inlracsophageal pressure within a y/i error limit

was detemiined (F„): the highest mean V„ recorded

reliably in large-diameter catheters was 82

ba>aths/min. Significant CMS tliflerences in accu-

racy existed between catheter FG sizes and be-

tween catheters of similar diameters but differ-

ing brands. Correlation (r) between catheter inner

diameter and CMS Frr was 0.66 across brands.

In conclusion, intraesophagcal PVC liquid-filled

feeding catheters aiie suitable for estimating pleu-

ral pressures in subjects mechanically ventilated

vv ithout sharp inspiratory wavefonns or high res-

piratory rates. Quantitative frequency response

characterization ol ditlerent nasocastric catheter

Retrospecti> e Rev iew of the Effects of rhDNa-se

in Children vvllli Cystic Fibrosis—J Dav les. M-T

Trindade. C Wallis. M Rosenthal. O Craw lord.

A Bush. Pediatr Pulmonol 1997:23:243.

Trials of rhDNase in mixed groups of adults and

children with cystic fibrosis (CF) have demon-

strated improvements in lung function and well-

being. This has led to many pediauic CF patients

receiving regular rhDNase therap>' although their

response to treatment may not be the same as that

seen in adults. We have retrospectively reviewed

the effects ofrhDNa.se during the first yeiir of tlier-

apy in 65 children reeelv ing the dmg ;it 2 teni;iry

referral centers. Outcome measures included

changes in lung function, oxygen saturation, use

of inmivcnous antibiotics, and subjective improve-

ment. Median baseline lung function CJc of pre-

dicted) was 4S'7f for forced expiratory volume in

1 second (FEV I ) and .iX^r for forced vital capac-

ity (FVC). At 3-4 months following initiation of

therapy the group demonstrated median (9.S';i- CI)

increa.ses of 14.2-* (<iy/c CI 7.3: 21.1% ) in FEV,

and 79r (0: 14%) in FVC. Within this wide scal-

ier of responses, one-quarter of children deteri-

orated, but almost .5()7f showed significant im-

provements of > 10%. A similar pattern was seen

at 9 months, with median increases for the group

of 11.1% (0; 18.8%)inFEV|and5.6%(0; 17%)

in FVC. again with approximately one third of

the group deteriorating and one half improving

sisinificantlv . Intravenous antibiotic use decrea-sed

RESPIRATORS Care • August "97 Vol 42 No 8

Abstracts

significantly. Almost all the children (89%),

including those with a tall in lung function,

described subjecti\e improvement. There were

no predictive markers at baseline of a good

response to the drug. However, there was a good

correlation betw een lung function response at .^

months and that at 6. 9. and 12 months. Thus, chil-

dren respond to rhDNase at least as well a.s adults,

and a therapeutic trial is justified in those over

5 years with significantly impaired lung function.

Response is highly variable, making careful indi-

vidual assessment mandatory. Baseline charac-

teristics are not useful in predicting those chil-

dren who will respond well to treatment, but

long-term response to the drug can be predicted

on the basis of spirometric improvement at .^

months. Therefore, this would be a useful time

period for a therapeutic trial.

Hospitalization Patterns in Severe Acute

.\sthma in Children—S Schuh. D Johnson. D

Stephens. S Callahan. G Canny. Pediatr Pulmonol

1997;23;184.

We set out to determine associations betw een hos-

pitalization and disease severity before and 2 hour,

after initiation of a.sthma therapy in the Emergency

Department, and to describe the outcome of pa-

tients admitted and discharged. This is a retro-

spective review of data and charts from a ran-

domized, double blind, placebo-controlled trial

IRCT) of 120 asthmatics 5-17 years of age with

baseline forced expiratory volume in 1 second

(FEV| ) < .'i09r predicted, treated with .^ or 1 or

doses of nebulized ipratropium added to 3

albuterol nebulizations administered o\ er 1 hour.

None of the clinical parameters measured at base-

line were associated with hospitalization. How-

ever, by 2 hours after initiation of therapy, both

the FEV| percent of predicted values C^t pred) and

the total asthma score were associated w ith like-

lihood of hospital admission. Baseline O: satu-

ration < 92^* indicated a longer hospital stay (75..^

± 5 1 hours vs 4.3.0 ± 24.4 hours, p = 0.01 .5 1 and

a later onset of infrequent nebulizations (46.7 ±

35. 1 vs 26.6 ± 17.4 hours, p = 0.006). By 2 hours,

those with a post-treatment FEV] % pred < 30%

and an asthma score > 6 of 9 had a high likelihood

of hospitalization (86 and 80%. respectively, com-

bined probability 100%). whereas FEV 1 % pred

> 60% and total asthma score < 3 were associated

with successful discharge (probability of 92 and

83%. respectively). We conclude that pre-treat-

ment assessments were not associated with hos-

pitalization, while patients with posttreatment

FEVi % pred < 30% and a score > 6 had high like-

lihood of hospitalization.

.Aerosol Delivery to Wheezy Infants: A Com-

parison between a Nebulizer and Two Small

Volume Spacers—JH \\ ildhaber. SG Dcvada-

son. MJ Hayden. E Eber. QA Summers. PN

LeSouef Pediatr Pulmonol 1997:23:212.

Inhalation therapy for wheezy infants with either

a nebulizer or a pressurized metered dose inhaler

(pMDI) through a spacer is common practice. The

aim of our study was to compare aerosol deliv-

en to w heezv infants from a nebulizer and from

a pMDI via 2 small volume spacers. Twenty

wheezy infants (aged 4-12 months) were recruited.

They inhaled salbutamol from a Pari-Baby ' neb-

ulizer, from a detergent-coated Babyhalei'- . and

from a Nebuchamber'' in random order. A filter

was placed between the inhalation systems and

the patients. The amount of salbutamol deposited

on the filter was measured using an ultraviolet

spectrophotometer and was expressed as a per-

centage of the total nebulized or actuated doses.

The mean total iwhiilired dose for the P;in-Baby*

(1,030 ^g) was higher (p < 0.001 ) than the mean

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Abstracts

aciimied dose from a pMDI for the Babyhalei*

(374 jug) and for the Nebuchamber® (378 /Jg).

Mean drug deposition on the filter was 40.2% ( 1 50

^g) of the total actuated dose for the detergent-

coated Babyhaler® and 40.7';; ( 1 54 /jg) of the total

actuated dose for the Nebuchambei*\ There was

no significant difference in drug deposition on the

filter between the 2 spacers. Mean drug deposi-

tion on the filter was 25.3'7( (26()/jg) of the total

nebulized dose for the Pari-BabV* nebulizer. There

was no weight dependence in drug deposition on

the filter for the 2 spacers, but. drug deposition

increased with the subject's weight for the neb-

ulizer. We have shown that aerosol delivery' to

whee/y infants from a pMDI through small vol-

ume spacers is effective and that a higher per-

centage of the total amount of salbutamol is deliv-

ered than from a nebulizer. Tlie weight dependence

in drug deposition for the nebulizer can be of clin-

ical relevance.

A Prospective Study of the Safety of Tracheal

Extubation I'sing a Pediatric Airway Kxchangc

Catheter for Patients with a Known Difllcult

Airway—EPLoudcmiilk. M Hartmunnsgruber.

DP Stollzfus. PB Langevin. Chest 1W7:111

(6): 1660.

OBJECTIVE: To determine the usefulness of rou-

tinely inserting a hollow airway exchange catheter

(jet styletl prior to tracheal extubation of adull

patients with risk factors for difficult U'acheal intu-

bation. DESIGN: Prospective, 1-year study of 40

consecutive patients undergoing mechanical ven-

tilation who had one or more risk factors for dif-

ficult tracheal reintubation. SETTING: Surgical

ICU of a tertiary university medical center.

INTERVENrriONS: Study patients at risk fordil-

ficult tracheal reintubation were extubated using

a No. 1 1 Cook airway exchange catheter (CAEC ).

Following tracheal extubation. the CAEC was

secured, and humidified oxygen was insufflated

through the cenU"al lumen 1 2 to 8 Uniin) for a min-

imum of 4 hours, during which oxyhemoglobin

saturation (Spo,) and respiratory frequency were

monitored. Stridor or other signs of respiratory

difficulty were also assessed. The CAEC was

removed when it became clinically apparent that

the need for tracheal reintubation was unlikely.

When patients failed to respond to tracheal extu-

bation. the CAEC was used to facilitate reintu-

bation of these difficult airways. RESULTS: Res-

piratory distress necessitating tracheal reintubation

occurred in 3 of 40 patients (S'i ). One patient

failed to respond to tracheal extubation tw icc. None

of the patients developed oxyhemoglobin desat-

uration (SpO; < 90%) before or during tracheal rein-

tubation. All 4 reintubations were accomplished

during the first attempt using the CAEC as a stylet.

The CAEC was kept in the trachea for a inean

duration of 9.4 hours. There were no adverse

events documented. CONCLUSIONS: The No.

1 1 CAEC is a useful and effective tool for giv-

ing patients a trial of extubation .Administration

of oxygen through the CAEC diminishes the

potential for hypoxia while maintaining the abil-

ity to reintubate the U'achea, especially when rein-

tubation might prove challenging. Previous data

suggest that the CAEC is rigid enough to facil-

itate tracheal reintubation in adults; this was con-

firmed in the 3 patients in our study who required

tracheal reintubation. The risk of aspiration, baro-

trauma, or other airw ay trauma during prolonged

placement of the CAEC appears to be low (zero

incidence in 40 patients in this study), and use of

the No. 1 1 CAEC appeared to be safe. Since oxy-

gen can be delivered through the CAEC, it may

provide a means to safely e\ aluate an airway dur-

ing a trial of extubation, ie, a reversible extuba-

tion. Finally, oxygen administration through the

CAEC may obviate the need for face mask or nasal

cannula following tracheal extubation. See ilie

leldled editorial: Airway Exchange Cathetersji>r

Safe Extubation: The Clinical and Scientific

Details That Make the Concept Work—JL Benii-

mof. Chcsl 1997:1 1 U6t:l4K.^-l4fi5.

Ultrasonic Nehulization of .Mhuterol Is NoMore EITective Than Jet Nehulization for the

Treatment of Acute Asthma in Children—AKNiikanishi, BM Lamb, C Foster. BK Rubin. Chest

1997:1 11(6): 1505.

OBJECTIVE: Nebulizer systems used to gener-

ate therapeutic aerosols vary in their ability to

deli\ er medication to the airway. In a recent study

in 17 adults with stable asthma, albuterol given

using an ultrasonic nebulizer ( UN ) appeared to pa>-

duce greater bronchodilatation than the same dose

of albuterol given by ajet nebulizer (JNl. The pur-

pose of this smdy was to detemiine if the UN used

in that snjdy would produce a better bronchodilator

response in children with acute asthma than the

JN system that has been in use at Cardinal Glen-

non Children's Hospital. DESIGN: Randomized,

prospecti\e, unblinded study. SETTING: An urb;in

uni\ersity children's hospital emergency depart-

ment. PARTICIPANTS: One hundred thirteen

children, aged 7 to 16 years, who presented for

treatment of acute mixierately severe asthma com-

pleted this study. INTERVENTIONS: After ran-

domization and exclusion of dropouts. 46 childa'n

received albuterol by UN, and 67 were treated by

JN. MEASUREMENTS: Pulmoinirv function tests

(PFTs) by spirometry, pulse o\imetr\, and symp-

tom score at baseline and at 15 and 30 minutes fol-

lowing a single prescribed treatment. RESULTS:

Pl-T on entry to the study was the same in both

groups (FEV|; p > 0.97). I'he ch;mge in FEV| after

therapy (UN -i- 0.22 1. vs JN + 0.37 L) was sig-

nificant (p < 0.05) and favored JN. There was no

difference in the improvement in pulmonary func-

tion between JN and UN therapy in children with

an initial FEV|/FVC > 75% predicted but when

FI-;V|/1-VC < 75%. the improvement in FEV,

again favored the JN (UN -f 0.2 vs JN -i- 0.47; p

< 0.05). CONCLUSION: For the treatment of

acute exacerbations of asthma in children, there

is no greater bronchodilator response when al-

buterol is administered by a UN than by a JN.

Measurement of Respiratory Resistance in the

Emergency Department: Feasibility in \'oung

Children with Acute .Asthma—F Ducharme.

GM Davis. Chest 19y7;l! 1(6):15I9.

OBJECTIVES: To assess, in acutely ill asthmatic

children, the feasibility of obtaining reproducible

measurements of 2 independent lung function tests,

namely spirometry and respiratory resistance, using

the forced oscillation technique (Rfo). DESIGN/

SETTING: A prospective observational study of

150 previously untrained children, aged 2 to 17

years, treated for acute asthma in a tertiary-care

pediatric emergency department. ME.ASURE-

MENTS: Following a standardized physical exam-

ination. 3 measurements of respiratory resistance

by forced oscillation were attempted at 8 Hz (Rfoj)

and at 16 Hz (Rfoi6). followed by spirometry, all

using the same instrument (Custo Vii R; Custo

Med; Munich. Gennany). RESULTS: On the ini-

tial assessment. 9S (65*^; ) children, aged 2 to 17

years, were able to reprtxiucibly perform the Rfos

measurement. 77 (5 1 % ) were able to reproducibly

perform the Rfoi(, measurement, while only 65

(43%) subjects managed to reliably perform

spirometry. A notable proportion of preschool-

aged children cooperated w ith the Rfog technique:

19% of 3-year-olds. 40% of 4-year-olds, and 83%-

of 5-year-olds. Tlie superior success rate w ith Rfos

as compared with spirometry was seen in all age

groups but was most striking both in preschool-

ers (relative risk |RR1 = 10.5; 95% confidence

interval [CI], 8.0 to 13.8) and in children aged 6

to9 years (RR = 1.28; 95% CL 1.18 to 1.39). Rfo„

values correlated significantly with clinical mark-

ers of asthma severity such as respiratory rate (r

= 0.38) and heart rate (r = 0.23) as well as with

FEV| values (r- = 0.73). CONCLUSIONS: This

study demonstrates the feasibility of obtaining

reproducible measurements of respiratory resis-

tance in a notable proportion of untrained, acutely

ill. astlimatic children. The forced oscillation tech-

nique appears as an attractive alternative to objec-

tively assess lung function in children too young

or too ill to cooperate with spirometry.

Preoperative Spirometry and Laparotomy:

Blowing Away Dollars—LA De Nino. VA1 jwrencc. EC .-Vvcrvt. SO Hilscnbeck. R Dhanda.

CP Page. Chest 1W7:1 1 1(61:15.36.

OBJECTIVE: Increasing evidence indicates that

routine preoperative diagnostic spirometry (pul-

monary function tests |PFTsl) before elective

atxiominal surgery does not predict individual risk

of postoperative pulmonary complications and is

oveioitilizcd. Tliis economic evaluation estimates

potential savings from reduced use of preopera-

tive PFTs. DESIGN: Analyses of ( 1 ) real costs

(resource consumption to perform tests) and (2)

reimbursements (expenditures for charges) by

RESPIRATORY CARE • AUGUST "97 VOL 42 NO 8

Abstracts

third-party payers. SETTING; University-affil-

iated public and Veterans Affairs hospitals.

PATIENTS; .^dults undergoing elective abdom-

inal operations. MEASUREMENTS & RE-

SULTS; Average real cost of PFTs was $19.07

(95Vf confidence interval |CI|, S18.53 to $19.61 ).

based on a time and motion study. Average re-

imbursement expenditure by third-party payers

for PFTs was $85 (range. $33 to $150. <)59c CI.

$68 to $ 103). based on Medicare payment of $52

and a survey of 9 urban U.S. hospitals with a spec-

trum of bed sizes and teaching status. Estimates

Ironi published literature included the following;

( 1 1 iuinual number of major abdominal operations.

3.5 million; and ( 2 ) proportion of PFTs not meet-

ing current guidelines. 39^:;^ (95-* CI. 0.3 1 lo 0.47 ).

Local data were used when estimates were not

available in the literature; ( 1 ) proportion of laparo-

tomies that are elective. 76% (95% CI. 0.73 to

0.79); and (2) frequency of PFTs before laparo-

tomy, 69% (95% CI. 0.54 to 0.84). Estimated

annual national real costs for preoperative PFTs

are $25 million to $45 million. If use of PFTs were

reduced by our estimate for the proportion of PFTs

not meeting current guidelines, potential annual

national cost savings would be $7,925,411 to

$21,406,707. National reimbursement expendi-

tures by third-party payers range from more than

$90 million to more than $235 million. If use were

reduced, potential annual savings in reimburse-

ments would be $29,084,076 to $1 1 1.345.440.

Potential savings to Medicare approach $8 mil-

lion to $20 million annually. CONCLUSION;

Reduced use of PFTs before elective abdominal

surgery could generate substantial savings. Cur-

rent evidence indicates reduced use would not

compromise patients' outcomes.

Detection of Small Airway Dysfunction Using

Specific Airway Conductance—AG Bassiri. RE

Girgis, RL Doyle. J Theodore. Chest 1997;1 1

1

(6); 1533.

OBJECTIVE; To assess the potential utility of spe-

cific airway conductance (sGaw ) in detecting sm;ill

airways dysfunction, the postlung-transplant bron-

chiolitis obliterans syndrome (BOS) was used as

a model of small airways dysfunction. BOS is

defined as an otherwise unexplained 20% reduc-

tion in FEV|. We hypothesized that if sGaw is sen-

sitive to small airways dysfunction, it should

decrease before the decline in FEV|. DESIGN/

METHODS; The pulmonary function test and

sGaw ineasurements of patients who underwent

heart-lung orhilatend lung transplantation between

May 1981 and January 1993 were reviewed.

Patients with and without BOS were identified.

A significant decrease in sGaw was defined as a

20% fall from baseline. RESULTS; Twenty-six

BOS and 15 non-BOS patients had at least 3 sGaw

measurements such that trends could he examined.

Eleven of the 26 BOS patients (42% I had a sig-

nificant decrease in sGaw before a 20% decrease

in FEV|. as compared to 2 of the 15 non-BOS

patients (13%) (p = 0.08). In comparison. 12 of

the 26 BOS patients (46%) and 4 of the 15 non-

BOS patients (27%) had a significant decrease in

forced expiratory flow at 25 to 75% of the forced

lung volume (FEF:5.7s) (p = 0.32), an accepted

test of small airways dysfunction. CONCLUSION;

sGaw tended to decrease before FEVi in BOS.

The trend in sGaw was similar to the trend in

FEF>5-7.'i. We conclude that ( 1 ) small airways may

contribute more to airway conductance than pre-

viously thought, and (2) further prospective stud-

ies are warranted to better define the relative con-

tribution of small and large airways to sGaw.

Pressure vs Flow Triggering during Pressure

Support Ventilation—R Goulet. D Hess. RMKacmarek. Chest 1997;1 1 1(6);1649.

BACKGROUND; Adult mechanical ventilators

have traditionally been pressure- or time-triggered.

mmujjHh^^JifuCCnn

awaitsyou in !New Orleans

^suCts ofscientific studies wi[[6e presenteddaiCy at tfie

0(PE3^TO(RjJ%fo[[owed6y discussions oi interaction

among investigators oi oSservers

^serve time in your scHedutefor tfie (ypE^ To^RjJ'M

at the 43rdInternationaf^spiratory Congress

(DecemSer 6-9 in [New Orleans, Louisiana

J

RESPIRATORY CARE • AUGUST "97 VOL 42 NO 8 755

Abstracts

More recently, flow triggering has become avail-

able and some adull ventilators allow the choice

between pressure or flow triggering. Prior stud-

ies have supported the superiority of tlow trig-

gering during continuous positive airway pres-

sure, but few have compared pressure and tlow

triggering during pressure support ventilation

( PSV I. The purpose of this study vv as to compare

pressure and tlou triggering during PSV in adult

mechanically ventilated patients. METHODS: The

sUidy population consisted of 10 adult patients ven-

tilated with a mechanical ventilator (Nellcor Puri-

tan Bennett 7200ae) in the PSV mode. In random

order, we compared pressure triggering of-()..'i

H2O, pressure triggering -1 cm HiO. flow trig-

gering of 5/2 L/min. and tlow triggering 10/3

L/min. Pressure was measured for 5 niin at the

proximal endotracheal tube using a data acqui-

sition rate of 100 Hz. From the airway pressure

signal, trigger pressure (AP) was defined as the

difference between positive end-expiratory: pres-

sure (PEEP) and the maximum negative deflec-

tion prior to onset of the triggered breath. Pres-

sure-lime producl(PTP) was defined as the area

produced by the pressure wavefonn below PEEP

dunng onset of the triggered breath. Trigger time

(AT) wxs defined a.s the time interval below PEEP

during onset of the triggered breath. RESULTS:

A pressure trigger of -0.5 cm H^O was signifi-

cantly more sensitive than the other trigger meth-

ods for AP, PTP, and AT (p < 0.001 ). There was

also a significant difference between patients for

AP, AT. and PTP for each trigger method(p <

0.001). CONCLUSIONS: For this group of

patients, tlow uiggering was not superior to pres-

sure triggering at -0.5 cm HiO during PSV.

Lung Volume Reduction Surgery at a Com-

munity Hospital: Program Development and

Outcomes—PH Bagley. SM Davis. M O'Shea.

A-M Coleman. Chest 1 997; 1 1 1 (6): 1552.

OBJECTIVES: Description of the development

and results of a program in lung volume reduc-

tion surgery (LVRS) at a community hospital.

DESIGN: Prospective data collection. SETTING:

A .^20-bed community hospital. P.ATIENTS: Fifty-

five patients consecutively discharged from the

hospital following LVRS. The mean preoperative

FEVi averaged 28% (± 8%) of predicted values,

while the preoperative Pjco; averaged 49 mm Hg

(± 1 1.5 mm Hg). Forty-eight patients completed

a preoperative conditioning regimen and under-

went the procedure on an elective basis. Seven

patients underwent the procedure during a hos-

pital admission for a COPD exacerbation. Eight

patients required mechanical ventilation preop-

eratively, including 3 w ho had required long-term

mechanical ventilatory support. RESULTS: Three

patients (5%) died in the hospital following

surgery. One patient developed chronic ventila-

tor dependence. .'Ml 3 of the patients who required

long-tenn mechanical ventilation preoperatively

were weaned from the ventilator and returned

home. Follow-up pulmonary function testing is

available for 42 patients 3 months after surgery,

and for 20 patients 6 months after the operation.

At 3 months, tlie mean FEV| improved 0. 19 L (p

= 0.0002 ), the mean improvement for FVC was

0.37 L (p = 0.0001 ), and the mean drop in resid-

ual volume was 0.97 L (p = 0.0001 ). Similar

changes are seen at 6 months. Highly significant

improvements were also seen in quality of life

measurements and exercise perfomiance. The ben-

efits of surgical treatment of emphysema seeined

siinilar in both elective and urgent groups. CON-CLUSIONS: LVRS can be done safely and effec-

tively at a community hospital, with significant

iinprovemeni in pulmonary function and qualilv

of life.

Human and Financial Costs of Noninvasive

Mechanical \'entilation in Patients Affected by

COPD and Acute Respiratory Failure—S Na\ a,

I Evangelisti. C Rampulla. ML Compagnoni CFracchia. F Rubini. Chest 1997;! 1 1(6): 1631.

OBJECTIVES: It has been suggested that non-

invasive mechanical ventilation (NIMV) may be

a time-consuming procedure for medical and

paramedical personnel. We carried out a prospec-

tive uial in 10 consecutive COPD patients aimed

at assessing the human and economic resources

needed to ventilate patients by NIMV, and we

compared these with those needed by a group of

6 patients receiving invasive mechanical venti-

lation ( InMV ). DESIGN: The daily cost and the

minutes spent by medical doctors (MDs), respi-

ratory therapists (RTs), and nurses (Ns) were

recorded during the first 48 hours of ventilation

in 10 patients during NIMV (group A) and in 6

who received InMV (group B) after an initial

unsuccessful attempt with NIMV. In 2 subgroups

of patients (5 for group A and 4 for group B 1, the

analysis was also performed, except for RTs, for

the total length of mechanical ventilation. SET-

TING: A respiratory ICU. PATIENTS: At hos-

pital admission, the 2 groups of COPD patients

did not differ for blood gas values (Paco; = 88.2

±9.8 mm Hg for group A vs 90.5 ± 1 2.8 mm Hg

for group B. and pH = 7.2 1-(- 0.08 vs 7.20 -^ 0.08.

respectively) or for clinical and neurologic sta-

tus, but patients of group B had not tolerated

NIMV. MEASUREMENTS & RESULTS: The

total time spent at the bedside in the first 6 hours

did not differ between group A and B (group .A

= 72.3 min [MD]. 87.2 min |RT1. and 178.8 min

|N1 vs 98.8 min |MD].12.5 min [RT], and 197.6

nun |N| forgroupB). In the following 42 hours,

a plateau was reached so that there was a sig-

nificant reduction for both groups in the time of

assistance given by Ns (p < ().(X)I ) but not by MDsor RTs. The total costs were also not different

between the 2 grtiups ($806 + 73 [U.S. dollars/day]

vs S864 + 44 for group A and B. respectively).

In the subgroups monitored for the entire period

of ventilation, a significant reduction in the time

of assistance, for both MDs and Ns. wa.s observ ed

after approximately the first half CONCLU-SIONS: We conclude that in the first 48 hours of

ventilation, daily NIMV is neither more expen-

sive nor time-consuming and staff demanding than

InMV. After the first few days of ventilation.

NIMV was significantly less time-consuming tlian

InMV. for MDs and Ns, so that medical and

paramedical time expenditure seems not to be a

major problem during NIMV.

Posl-ICL Mechanical \ entilation: Treatment

of 1,123 Patients at a Regional Weaning Cen-

ter—DJ Scheinhorn, DC Chao. M Stearn-Has-

senptlug, LD LiiBree, DJ HelLsley. Che.st 1997;l 1

1

(6): 1654.

OBJECTIVES: To update our database, report-

ing changes in the results of weaning attempts and

profile of patients transferred to us after prolonged

mechanical ventilation (PMV) in the ICU,

DESIGN: Retrospective record review, with pros-

pective recording of physiologic measurements

on admission from mid- 1994. SETTING: Re-

gional weaning center(RWC). PATIENTS: Westudied 1.123 consecutive ventilator-dependent

patients transferred for attempted weaning over

an 8-year period. MEASUREMENTS & RE-

SULTS: Median (range) time of mechanical ven-

tilation prior to transfer to the RWC declined from

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RESPIRATOR'!' Care • August "97 Vol 42 No 8

Abstracts

37 ( 1 to 249) days in 1988 to 29 (1 to 120) days

in 1996 (p < 0.05). Acute physiology score of

acute physiology and chronic health evaluation

(APACHE) III was 32 (6 to 123) on RWC admis-

sion, equaling reported scores soon after ICU

admission. Comparing other data on admission

from 1988 to 1996. mean (± SD) serum albumin

level declined from 2.92 ± 0.58 to 2.43 + 0.50

g/dL, and alveolar-anerial oxygen pressure dif-

ference widened from 106 ± 50 to 139 ± 99 mmHg. Prevalence of stage II or worse pressure ulcer-

ation on admission increased from 34'7c in 1988

to 46'7c in 1995. Despite these trends, there has

been no significant change in patient outcome

(55.9% weaned, 15.6% failed to wean. 28.8%

died) or in median time to wean (29 [1 to 226]

days). Overall survival at 1 year after discharge

for the 8-year period is 37.9%, improving from

29% in 1988-1991 to 45% since 1992; survival

in weaned patients discharged to home has

improved from 45 to 59% during the respective

time periods. CONCLUSIONS; Pauents are being

transferred from the ICU to our RWC for at-

tempted weaning sooner in their course of PMV.

Although more severely ill on arrival than in past

years, mortality is unchanged, more than half ot

the patients continue to be successfully weaned,

and survival after RWC discharge is improved.

Comparative Physiologic Effects of Noninvasive

Assist-Control and Pressure Support Venti-

lation in Acute Hypercapnic Respiratory Fail-

ure—C Girault. J-C Richard. V Chevron. F

Tamion. P Pasquis. J Leroy, G Bonmarchand.

Chest 1997;lll(6):1639.

OBJECTIVE; To compare the effects of nonin-

vasive assist-control ventilation (ACV) and pres-

sure support ventilation (PSV) by nasal mask on

respiratory physiologic parameters and comfort

in acute hypercapnic respiratory failure ( AHRF).

DESIGN; A prospective randomized study. SET-

TING: A medical ICU. PATIENTS & INTER-

VENTIONS: Fifteen patients with COPD and

AHRF were consecutively and randomly assigned

to 2 nonin\asi\e ventilation (NIVl sequences with

ACV and PSV mode, spontaneous breathing (SB

)

via nasal mask being used as control. ACV and

PSV settings were always subsequently adjusted

according to patient's tolerance and air leaks. Frac-

tion of inspired oxygen did not change between

the sequences. MEASUREMENTS & RESLFLTS:

ACV and PSV mode strongly decreased the inspi-

ratory effort in comparison with SB. The total

inspiratory work of breathing (WOBinsp)

expressed as WOBinsp/tidal volume (Vy) and

WOBinsp/respiratory rate (RR), the pressure time

product (FTP), and esophageal pressure vanations

(APes) were the most discriminant parameters (p

< 0.001 ). ACV most reduced WOBinsp/Vr (p <

0.05), APes (p < 0.05), and PTP (0.01 ) compared

with PSV mode. The surface diaphragmatic elec-

tromyogram activity was also decreased >32%

as compared w ith control values (p < 0.01 ). w ith

no difference between the 2 modes. Simultane-

ously, NIV significantly improved breathing pat-

tern (p < 0.01 ) with no difference between ACVand PSV for Vj, RR, minute ventilation, and total

cycle duration. As compared to SB. respiratory

acidosis was similarly improved by both modes.

The respiratory comfort assessed by visual ana-

log scale was less with ACV ( 57.23 ± 30. 1 2 mm

)

than with SB (75.15 ± 18.25 mm) (p < 0.05) and

PSV mode (81.62 ± 25.2 mm) (p < 0.01 ) in our

patients. CONCLUSIONS; During NIV for

AHRF using settings adapted to patient's clini-

cal tolerance and mask air leaks, both ACV and

PSV mode provide respiratory muscle rest and

similarly improve breathing pattern and gas

exchange. However, these physiologic effects are

achieved with a lower inspiratory workload but

at the expense of a higher respiratory discomfort

with ACV than with PSV mode. See the rekned

editorial: Noninvasive Ventilation: A Welcome

Resurgence and a Plea for Caution RJ

DiBenedetto. AV Nguyen. Chest 1997: 111(6):

14S2-1483.

Health Care Utilization and Cost among Chil-

dren with Asthma Who Were Enrolled in a

Health Maintenance Organization—P Lozano,

P Fishman. M VonKorff, J Hecht. Pediatrics 1997;

99(6):757.

OBJECTIVE; To measure the impact of asthma

on the use and cost of health care by children in

a managed care organization. DESIGN: Popula-

tion-based historical cohort study. SETTING: Amedium-sized staff model health maintenance orga-

nization in western Washington state. SUBJECTS:

All 71,818 children, between age I to 17 years,

who were enrolled and used services during 1992.

OUTCOME MEASURES; Children were iden-

tified with one or more asthma diagnoses during

1992 using automated encounter data. Nonurgent

outpatient visits, pharmacy fills, urgent care vis-

its, and hospital days, as well as associated costs

were measured. All services were categorized as

asthma care or nonasthma care. Multivariate regres-

sion analysis was used to compute marginal cost

for asthma (difference in total cost between chil-

dren with asthma ;ind other children using services,

adjusted for covariates). RESULTS: Treated preva-

lence of asthma was 4.9%-. Children with asthma

incurred 88% more costs ($1,060.32 vs $563.81/yr),

filled 2.77 times as many prescriptions ( 1 1 .59 vs

4. 19/yr), made 65% more nonurgent outpatient vis-

its (5.75 vs 3.48/yr), and had twice as many inpa-

tient days (0.23 vs 0. 1 1/yr) compared with the gen-

eral population of children using services. Asthma

'A-

S-''~jr\/:'r--'><'-

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Look for^the RESPiiiAtof^AREipecial lis^

The September t997 i$s|ie of the joOrial^ll be devoted to

education—respiraitory care formal pfogramsyand curriculum,

continuing and ii»%rvice education, and patient education.

Original studies, statc^f-the-art reviews, .^ching features,

and reviews of instriici^jpnal material^^rWill be featured.

-T-::-. J

RESPIRATORY CARE • AUGUST '97 VOL 42 NO 8 757

Abstracts

care represented 37% of all health care received

by children with asthma, while the remaining 63'7r

were for nonasthma services. Almost two-thirds

of asthma-related costs were attributable to nonur-

gent outpatient care and prescriptions; only one

third was attributable to urgent care and hospi-

talizations. Controlling for age. sex. and comor-

bidities, the marginal cost of asthma was S6I5.17/yr

(95'/c confidence interval $.'ilJ2.7.1. S727.61). which

includes asthma as well as nonasthma services. This

ni;irgin;il cost represents 58'7( of all health care costs

for children with asthma. CONCLUSIONS: Chil-

dren with asthina use significantly more health ser-

vices (and incur significantly more costs) than other

children using services, attributable largely to

asthma care. The majority of all health care costs

for children with asthma were for nonasthma ser-

vices. Urgent care visits and hospitalizations are

less important components of asthma costs in this

managed care organization than has been found

in othernational studies.

Do Smokers Understand the Mortality Effects

of Smoking? Evidence from the Health and

Retirement Surv ey—M .Schi lenbaum. Am J Pub-

lic Health 1997;87(5):75.'i.

OBJECTIVES: This study examined whether

smokers recognize that smoking is likely to shorten

their lives and. if so. whether they understand the

magnitude of this effect. METHODS: People's

expectations about their chances of reaching age

75 were compared with epidemiological pre-

dictions from life tables for ne\er. former, cur-

rent light, and current heavy smokers. Data on

expectations of reaching age 75 came from the

Health and Retirement Survey, a national prob-

ability sample of adults aged 50 through 62 years.

Predictions came from smoking-specific life tables

constructed from the 1986 National Morl;ility Fol-

low back Survey and the 1985 and 1987 National

Health Interview Surveys. RESflLTS: Amongmen and women, the survival expectations of

never, foniicr. and current light smokers were close

to actuarial predictions. However, among current

heavy smokers, expectations of reaching age 75

were nearly twice as high as actuarial predictions.

CONCLUSIONS: These findings suggest that at

least heavy smokers significantly underestimate

their risk of premature mortality

Newhorn Screening for Cystic Fibrosis in Wis-

consin: Comparison of Biochemical and Molec-

ular Metho<ls -Rti Oregg. ,\ Simanlel. PM Far-

rell. R Koscik. MR Kosorok. A Laxova. et al.

Pediatrics I997;99(6):819.

OBJECTIVES: To evaluate neonatal screening

for cystic fibrosis (CF). including study of the

screening procedures and characteristics of false-

positive infants, over the past 10 years in Wis-

consin. An important objective evolving from the

original design has been to compare use of a sin-

gle-tier immunore.icliNe tripsinogen (IRT) screen-

ing method with that of a 2-tier method using FRT

and analyses of samples for the most common cys-

tic fibrosis transmembrane regulator (CFTRl

(AF508) mutation. We also examined the bene-

fit of including up to 10 additional CFTR muta-

tions in the screening protix'ol. METHODS: From

1985 to 1994. using either the IRT or IRT/ DNAprotocol. 220.862 and 104,.^()8 neonates, respec-

tively, were screened for CF. For the IRT protocol,

neonates with an IRT > 1 80 ng/mL were con-

sidered positive, and the standard sweat chloride

test was administered to determine CF status. For

the IRT/DNA protocol, samples from the orig-

inal dried-blood specimen on the Guthrie card of

neonates with an IRT > 1 10 ng/mL were tested

for the presence of the AF508 CFTR allele, and

if the DNA test revealed 1 or 2 AF508 alleles, a

sweat test was obtained. RESULTS: Both screen-

ing procedures had very high specificity. The sen-

sitivity tended to be higher with the IRT/DNA pro-

tocol, but the differences were not statistically

significant. The positive predictive value of the

IRT/DNA screening protocol was 15.2% com-

pared with 6.4% if the same samples had been

screened by the IRT method. Assessment of the

false-positive IRT/DNA population revealed that

the 2-tier method eliminates the disproportion-

ate number of infants with low Apgar scores and

also the high prevalence of African-Americans

identified previously in our study of newborns with

high IRT levels. We found that 55% of DNA-pos-

itive CF infants were homozygous for AF508 and

40% had 1 AF508 allele. Adding analyses for 10

more CFTR mutations has only a small effect on

the sensitivity but is likely to add significantly to

the cost of screening. CONCLUSIONS: Advan-

tages of the IRT/DNA protocol over IRT analy-

sis include improved positive predictive value,

reduction of false-positive infants, and more rapid

diagnosis with elimination of recall specimens.

Inhaled Nitric Oxide and Hypoxic Respirator)

Failure in Infants with Congenital Diaphrag-

matic Hernia—The Neonatal Inhaled Nitric

Oxide Study Group. Pediatrics I997;99(6):8.^8.

OBJECTIVE: We designed and conducted a ran-

domized, double-masked, controlled multicenter

study to determine whether inhaled nitric oxide

(INO) in temi and ne;ir-temi intiuits with congenital

diaphragmatic hernia (CDH) would reduce the

occurrence of death and/or the inilialion of extra-

corporeal membrane oxygenation (ECMO). PA-

TIENTS & METHODS: Infants ofM weeks ges-

tation or mon?. < 14 days of age with CDH. without

known structural heart disease, requiring assist-

ed ventilation for hypoxemic respiratory failure

with 2 oxygenation indices (OIs) of 25 or more

al Iea.st 15 minutes apart, were eligible for this trial.

Infants were centrally randomized and then

received masked treatment with 20 ppni NO or

1(K)% oxygen as control. Infants with less than a

full response to 20 ppm NO (increase in P^o; >

20 torr) after 30 minutes were evaluated at 80 ppm

NO/control study gas. RESULTS: The 28 control

and 25 treated infants enrolled by the 13 partic-

ipating centers were not significantly different at

randomization for any of the measured variables

including prerandomi/ation therapies and initial

OIs (45.8 ± 16.3 for controls. 44.5 ± 14.5 for INOl.

Death at < 1 20 days of age or the need for ECMOoccurred in 82% of conU'ol infants compared with

96% of INO infants (ns). Death occurred in 43%of controls and 48% of the INO group (ns), and

ECMO treatment was used for 54% of control and

80% of INO-treated infants. There was no sig-

nificant improvement in P;,o, (A PaO: 7.8 ± 19.8

vs 1 . 1 ± 7.6 torr. ns) nor significant reduction in

OI (-2.7 ± 23.4 vs 4.0 ± 14.8. ns) associated with

INO treatment. Mean peak nitrogen dioxide (NO:)

concentration was 1 .9 ± 1 .3 ppm and the mean

peak methemoglobin was 1 .6 ± 0.8 mg/dL. Noinfant had study gas discontinued for toxicity. There

were no differences between the control and INO

groups for the occurrence of intracranial hemor-

rhage, specific grades of intracranial hemorrhage.

peri\'entricular leukomalacia. brain infarction, and

pulmonary or gastrointestinal hemorrhages. CON-

CLUSIONS: .Although the immediate short-term

improvements in oxygenation seen in some treated

infants may be of benefit in stabilizing respond-

ing infants forfransport and initiation of ECMO.we conclude that for term and near-term infants

with CDH and hypoxemic respiratory failure unre-

sponsive to conventional therapy, inhaled NO ther-

apy as used in this trial did not reduce the need

for ECMO or death.

Hypoxic Pulmonarj N'asoconstriction in Non-

ventilated Lung .\reas Contributes to DilTer-

enccs in Hemodynamic and Gas Exchange

Responses to Inhalation of Nitric Oxide—

A

Benzing. G Mols. T Brieschal. K Geiger. Anes-

thesiology 1997:(S6)6: 12.54.

BACKGROUND: Enhancement of hypoxic pul-

monary vasoconstriction (HPV) in nonveniilaled

lung areas by almitrinc increases the respiratory

response to inhaled nitric oxide (NO) in patients

with acute respiratory distress syndrome ( ARDS).

Therefore the authors hypothesized that inhibi-

tion of HPV in nonventilated lung areas decreases

tlie respirator)' effects of NO. METHODS: Ele\en

patients with severe ARDS treated by \'enovenous

extracorporeal lung assist were studied. Patients'

lungs were ventilated at a fraction of inspired oxy-

gen (Fio,) of 1.0. By Viirying exttacorporeal blinid

fiow. mixed venous oxygen tension (Pq;: partial

oxygen pressure in mixed venous blood [Pvo:))

was adjusted randomly to 4 levels (means. 47. 54.

64. and 84 mm Hg). Extracorporeal gas flow was

adjusted to prevent changes in mixed venous car-

bon dioxide tension IPvro:!'' Hemodynamic and

gas exchange variables were measured at each

level before, during, and after 15 ppm NO. RE-

SULTS: Increasing Pvo; from 47 to 84 mm Hg

resulted in a progressive decrease in lung perfusion

pressure (PAP-PAWP; p < 0.05) and pulmonary

RESPIRATORY CARE • AUGUST "97 VOL 42 NO 8

Abstracts

vascular resistance index (PVRl; p < 0.05) and

in an increase in intrapulmonary shunt iQJQj: p

< 0.05). Pvco; iiniJ cardiac index did not change.

Whereas the NO-induccd reduction in PAP-PAWP

was smaller at high Pvo;. NO-niduced decrease

in Q^Qt was independent of baseline Pvo;- In

response to NO. arterial Po. increased more and

arterial oxygen saturation increased less at high

compared with low Pvo.-. CONCLUSION: In

patients with ARDS. HPV in nonventilated lung

areas modifies the hemodynamic and respiratory

response to NO. The stronger the HPV in non-

ventilated lung areas the more pronounced is the

NO-induced decrease in PAP-PAWP. hi contrast,

the NO-induced decrease in Q7Qt is independent

of Pvo: over a wide range of Pvo; levels. The

effect of NO on the ;irtenal oxygen tension \;iries

with the level of Pvci; by vinue of its location on

the oxygen dissociation curve.

Relative Risk in the News Media: A Quan-

tification of Misrepresentation—K Frost, E

Frank, E Maibach. Am J Public Health 1997;87

(5):842.

OBJECTIVES: This study quantifies the repre-

sentativeness with which the print news media

depict mortality. METHODS: The proportion of

mortality-related copy in samples of national print

media was compared with the proportion of actual

deaths attributable to the leading causes of U.S.

mortality over a 1-year period. RESULTS: For

every tested cause of death, a significant dis-

proportion was found between amount of text

devoted to the cause and the actual number of

attributable deaths. Underrepresented causes

included tobacco use (23%> of expected copy) and

heart disease (33%); overrepresented causes

included illicit use of drugs ( 1 ,740% ), motor vehi-

cles ( 1 ,280% ). and toxic agents ( 1 ,070% ). CON-

CLUSIONS: The news media significantly mis-

represent the prevalence of leading causes of death

and their risk factors. This misrepresentation may

contribute to the public's distorted perceptions of

health threats.

An Experimental .\nalysis of Socioeultural

Variables in Sales of Cigarettes to Minors

—

EA Klonoff H Landrine, R Alcaraz. Am J Pub-

lic Health 1997;87(5):823.

OBJECTIVES: This study assessed the role of age,

racial/ethnic group, and gender, as well as that of

other socioeultural variables, in minors' access

to tobacco. METHODS: Thirty-six minors at-

tempted to purchase cigarettes once in each of 72

stores (2.592 purchase attempts). The minors rep-

resented equal numbers of girls and boys; lO-year-

olds, 14-year-olds, and 16-year-oIds; and Whites,

Blacks, and Latinos, [iiual numbers of stores were

in Black, White, and Latino neighborhoods.

RESULTS: Older children were more likely than

younger ones to be sold cig;irettes. and Laitino chil-

dren were more likelv than Whites to be sold

cigarettes. Older Black children (irrespective of

gender) were the single most likely group to be

sold cigarettes. Cigiuettes were significantly more

likely to be sold to children by male than female

clerks and in specific siK'i(Kullural contexts. CON-

CLUSIONS: Interventions with retailers must

address socioeultural variables to impro\ e effec-

tiveness in reducing minors' access to tobacco.

A Symptom-Based Measure of the Severity of

Chronic Lunj; Disease: Results from the Vet-

erans Health Study—AJ Selim, XS Ren, GFincke, W Rogers, A Lee, L Kazis. Chest 1997;

lll(6):1607.

OBJECTIVES: We de\ eloped a symptom-based

measure of severity for chronic lung disease (CLD)

that can be readily administered in ambulatory care

settings and be used to supplement general health-

related quality of life (HRQoL) assessments and

pathophysiologic indicators in research and clin-

ical care. DESIGN: Cross-sectional data from the

Veterans Health Study, an observational study of

health outcomes in patients receiving Veterans

Affairs (VA) ambulatory care. SETTING: Four

VA outpatient clinics. STUDY SUBJECTS: Two

hundred ninety-two participants with CLD were

identified on the basis of patient report of having

a physician's diagnosis of chronic bronchitis,

emphysema, or asthma and either using inhaled

medications or having a productive cough on most

days for 3 months. MEASUREMENTS & RE-

SULTS: Participants were scheduled for an in-per-

son inten iew in which they completed a CLD ques-

tionnaire and measurements of peak expiratory flow

rate (PEFR). They were also mailed an HRQoLquestionnaire, the Short Form Health Survey (SF-

36). The CLD questionnaire included 6 symptom

items chosen by an expert panel (2 items each for

dyspnea, wheezing, and productive cough). The

combination of these items yielded a CLD sever-

ity index that coirelated significantly with all 8

scales of the SF-36 (range of r, -0.19 to -0.37; p

< O.OI ). In contrast, PEFR had statistically sig-

nificant correlations only with 2 SF-36 scales: phys-

ical functioning and bodily pain. CONCLUSIONS:

The CLD severity index is a reliable and valid

patient-administered instrument that may be used

to evaluate the effects ofCLD on general HRQoLand predict future health services.

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ARCF to conduct

"SILENTAUCTION"

at the 43rd AARC International Respiratory Congress

Respiratory care professionals lool< forward to the American Association for Respiratory Care's (AARC) annual

meeting for its unparalleled educational opportunities and comradery. This year's 43rd International Respiratory

Congress in New Orleans, LA, is adding something new! In an effort to increase the amount of funds available

for research projects and other philanthropic programs, the American Respiratory Care Foundation (ARCF) is

planning its first-ever "Silent Auction" during the Congress, Dec. 6-9. The Silent Auction will offer attendees not

only a good time, but the chance to pick up bargains on personal electronics, respiratory equipment,

entertainment packages, and more!

Anyone wishing to donate an item to the Auction may do so by contacting Brenda DeMayo at the ARCF

Executive Office at (972) 243-2272. Donated items are 100 percent tax-deductible at full retail value.

For more detailed information on the Silent Auction, see page 68.

Original Contributions

Validation of the Deltatrac Metabolic Cart

for Measurement of Dead-Space-to-Tidal-Volume Ratio

John C MacKinnon MD ChB FFARCS, Patricia L Houston MD FRCPC,

and Glenn P McGuiie MD

INTRODUCTION: Determination of the volume of respiratory dead space

can be clinically useful. Measurements made with a Deltatrac metabolic cart

were used to determine dead-space-to-tidal-volume ratio (ViVVj) and were

compared to Vi/Vt determination by a standard method using a Douglas bag.

MATERIALS & METHOD: Thirty studies were performed on 26 mechan-

ically ventilated patients in the Medical/Surgical Intensive Care Unit. VdA't

was calculated using the EnghofF modification of the Bohr equation. RESULTS:

Values obtained using the Douglas bag ranged from 0.37 to 0.74. Simultaneous

measurements using the metabolic cart ranged from 0.40 to 0.78. The cor-

relation coefTicient was 0.92, the mean difference was 0.004 and the standard

deviation of the difference was 0.034. CONCLUSION: These data show that

the metabolic cart is as accurate as the Douglas-bag method for determina-

tion of VdA't- [RespirCare 1997;42(7):76l-764]

Introduction

Ventilation-perfusion inequality is the chief physiologic

abnomiahty in virtually all diseased lungs.' Determining the

physiological (ie. respiratory ) dead-space-to-tidal-volume ratio

(VdA't) in a critically ill patient may be clinically useful. Vdfor this purpose includes the volume of the conducting air-

ways plus the volume of lung units that are ventilated but not

perfused (ie, wasted ventilation) and is an indicator of the effi-

ciency of carbon dioxide removal. Units with high ventila-

tion-perfusion ratios do not eliminate carbon dioxide efficiently

so that wasted ventilation is a major determinant of ventila-

tion requirements. The high minute ventilation requirement

that accompanies a high VdA't may limit the patient's abil-

ity to be weaned from mechanical ventilation.

Measurement of gas exchange by indirect calorimetry has

many applications- ' in the intensive care unit (ICU). includ-

ing direct measurement of oxygen consumption (Woi) and CO2

production (Vco:) in ventilated patients. From those mea-

surements, nutritional (resting energy expenditure) and res-

piratory (oxygen cost of breathing) requirements can be esti-

mated. The metabolic cart has no software algorithm for

calculating Vd/Vt, but the data collected do allow this cal-

culation. This study was designed to validate the accuracy of

calculating Vn/Vj with the metabolic cart in comparison to

a standard method using a Douglas bag.'*

Methods & Materials

The authors are associated with the Department of Critical Care & Anaes-

thesia, The Toronto Hospital, Toronto. Ontario, Canada.

An abstract of this paper was printed in Clin Invest Med 1990;13:B18.

Correspondence & Reprints: Glenn McGuire MD. Department of Critical

Care & Anaesthesia, The Toronto Hospital. Western Division, .199

Bathurst Street, Toronto, Ontario, Canada M5T 2S8.

Patients identified by the staff physician in the Medical-

Surgical ICU as likely to have weaning problems by clini-

cal assessment were enrolled. With approval from The Toronto

Hospital Ethics Committee, informed consent was obtained

from the patient or from the patient's family if the patient

was mentally incompetent. Exclusion criteria included F(0;

requirements >0.60, recent myocardial infarction, and hemo-

dynamic instability.

RESPIRATORY CARE • AUGUST '97 VOL 42 NO 8 761

Validation of the Deltatrac Metabolic Cart

Measurements were made sequentially using first the

metabolic cart* and then the Douglas bag. The metabolic cart,

an indirect calorimetry device, has been previously described.^''

The blood gas analyzer is calibrated daily using standard cal-

ibration gases (nominal values 5% CO2, 21% O2, and 74%N^, ;ind 10.6% CO2 and 89.4% No). The metabt)lic cart is cal-

ibrated prior to each study using a standard calibration gas (4%

CO2 and 96% O2). In the first phase, mixed expired gases were

collected in the cart's built-in 4-L mixing chamber and an

infrared sensor measured the expired CO2 fraction (Fkcoi)-

The mean Fecch value was calculated from stable readings

obtained during a 5-minute period. The Pkco: was derived by

multiplying Fkco2 by the product of ambient barometric pres-

sure (PB) minus a 47 torr correction for water vapor (PBh2o)-^

PEC02 = Feco2 X (PB - PBh2o)-

In the second phase, exhaled gas was collected in a Dou-

glas bag during a 3-minute period to obtain the mixed expired

gases.^ At the midpoint of both gas collections, arterial blood

samples were obtained. The blood samples and mixed expired

ga.ses from the Douglas bag were immediately analyzed in

an automated blood gas analyzer. Three gas determinations

were made on each sample to obtain the mean value of Peco2-

The V[/Vt ratio was calculated using the Enghoff modifi-

cation of the Bohr equation.''

VdA't faCO:- Peco2

PaC02 '

Results

Values of Vf/Vj obtained using the Douglas-bag method

ranged from 0.37 to 0.74, whereas values obtained using the

metabolic cart ranged from 0.40 to 0.78 (Table 1 ). The cal-

culated correlation coefficient was 0.92 (Fig. 1 ). The meandifference was 0.004, and the standard deviation of the dif-

ference was 0.034 (Fig. 2). The 95% confidence interval for

the bias was -0.01 to -K).02. The 95% confidence interval for

the lower limit of agreement was -0.08 to -hO.04 and for the

upper limit of agreement was -1-0.05 to -K).09.

0.8 n

0.35 0.45 0.55 0-65

Douglas Bag

0,75

Fig. 1. Values for VdA/j obtained with the metabolic cart plotted

against those obtained using the Douglas-bag methodology. Cor-

relation coefficient = 0.92.

which assumes that arterial Pco; is equal to alveolar Pco2-

Data would be analyzed using an assessment of agreement

between two methods of clinical measurement as described

by Bland and Altman,** and the Pearson correlation coefficient

for the metabolic cart and Douglas-bag dead-space values

would be calculated.

Consecutive patients (a total of 26 of whom 2 were stud-

ied twice, and I was studied 3 times) were entered during an

8-month period. All were hemodynamically stable at the time

of the Vr/Vj determination. Of the 30 studies. 20 were per-

formed with patients on synchronized intemiittent mandatory

ventilation, 8 on assist/control ventilation, and 2 on contin-

uous positive airway pressure. Additional pressure support

of 5-25 cm HiO was supplied to 7 patients. Applied positive

end-expiratory pressure varied from 5-1 2.5 cm H2O, and the

F102 ranged from 0.35-0.50. AddiUonal information is sup-

plied in Table I.

U 0)

0.10-

Validation of the Deltatrac Metabolic Cart

Table 1 . Dead-Space-to-Tidal-Volume Ratios Obtained by Two Methods in 30 Studies of 26 Mechanically Ventilated Patients

Study Age/Sex Diagnosis (Patient Number) Ventilator Mode/Rate DB* VdA't MV Vj/Vt

3

4

6

7

8

9

10

II

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

34/F

73/F

73/F

80/F

75/M

67/F

65/M

78/M

87/F

74/M

78/F

69/F

68/M

68/M

48/M

68/M

69/M

78/F

76/F

69/F

54/M

85/F

39/F

76/M

75/M

75/M

88/M

42/M

72/F

42/M

Pancreatitis ( 1

)

Bronchiectasis (2)

Bronchiectasis (2)

Congestive heart failure (3)

COPD. pneumonia (4)

C0PD{5)

COPD, pneumonia (6)

Postoperative colectomy (7)

Left ventricular failure (8)

Ml, renal failure (9)

Pneumonia ( 10)

Aspiration (II)

COPD. Ml, pneumonia (12)

COPD. MI, pneumonia ( 12)

Paraplegia, pneumonia ( 13)

COPD, Ml, pneumonia (12)

Fractured femur, pneumonia (14)

Pancreatitis (15)

Cervical fractures (C6-7) rheumatoid lung (16)

Previous lobectomy (17)

COPD. respiratory arrest (18)

Metabolic alkalosis (19)

Morbid obesity (20)

Septic shock (21)

Respiratory arrest, ischemic heart disease (22)

Respiratory arrest, ischemic heart disease (22)

Septic shock (23)

Cranial arteriovenous malformation (24)

Pneumonia (25)

Guillain-Barre(26)

Bear

7200

7200

Bear

900C

Bear 2

MA 2+2

7200

7200

Bear

7200

Bear 2

7200

7200

7200

7200

Bear 2

7200

7200

7200

900C

7200

7200

900C

7200

7200

7200

7200

900C

7200

AC 16

AC 10

AC 10

AC 12

SIMV 10

SIMV6IMV 10

SIMV 6

SIMV 12

AC 12

SIMV 8

AC 12

AC 8

IMV 10

SIMV 10

AC 10

IMV 4

SIMV 6

CPAPSIMV 10

CPAPSIMV 10

SIMV 12

SIMV 12

SIMV 2

SIMV 2

SIMV 10

SIMV 8

SIMV 6

SIMV 10

0.47

0.66

0.74

0.57

0.65

0.67

0.68

0.56

0.60

0.54

0.60

0.70

0.60

0.54

0.55

0.48

0.66

0.55

0.37

0.55

0.69

0.72

0.59

0.59

0.64

0.59

0.54

0.47

0.55

0.43

0.46

0.65

0.78

0.53

0.67

0.65

0.70

0.55

0.58

0.55

0.56

0.70

0.55

0.56

0.53

0.52

0.58

0,53

0.44

0.61

0.64

0.72

0.56

0.60

0.64

0.59

0.58

0.48

0.52

0.40

*DB = Douglas bag; MC = melabolic cart; COPD = chronic obsUoictive pulmonary disease; MI = myocardial infarction; AC = assist-control; SIMV = synchronized intermil-

lenl mandatory ventilation; CPAP = continuous positive airway pressure.

ies using metabolic carts in the ICU.'' In-vitro validations of

the Deltatrac metabolic cart have reported a 3-5% mean error-''"

in measurement of Vco:- An accurate in-vivo reference is lack-

ing. Intrinsic error in the Douglas-bag method for measuring

dead space'" is related to the measurement of volume but is

also due to the loss of water vapor as the gases cool to room

temperature. Analysis of Peco; in the Douglas-bag method

uses a modified pH electrode rather than the infrared analyzer

used in the metabolic cart.

We chose to limit our subjects to those requiring a frac-

tional oxygen concentration <0.60 because ( 1 ) in our unit we

do not consider measuring dead space until we begin to wean

the patient from mechanical ventilation when Fjo: require-

ment is <0.60; (2) the software of the Deltatrac metabolic cart

does not accept inspiratory oxygen concentration >0.85.

Changes in V[/Vx occur with variations in respiratory pat-

tern. Changes in ventilator settings can significantly alter Vo/Vj

just as they may alter venous admixture, and VdA't may be

a comparably important variable to monitor in mechanically

ventilated patients." In the present study, a convenient method

for determining VdA't has been described and validated.

Although the physiologic principles determining VdA't

have been well described, prospective studies in patients with

respiratory failure may confirm the clinical usefulness of

repeated VdA't measurement. Other prospective studies could

include the effect of changing PaO: in patients with chronic

obstructive airways disease and the effects of positive end-

expiratory pressure and continuous positive airway pressure

on VdA't-

In Conclusion

Our data support the use of indirect calorimetry via metabolic

cart for determining dead-space-to-tidal-volume ratio. The

metabolic cart provides results as accurate as those obtained

with the Douglas-bag method or determination of VdA't-

PRODUCT SOURCES

Ventilators:

Puntan Bennett 7200a. Nellcor Puritan Bennett. Lenexa KS

Bennett MA 2+2, Nellcor Puritan Bennett, Lenexa KS

RESPIRATORY CARE • AUGUST "97 VOL 42 NO 8 763

Validation of the Deltatrac Metabolic Cart

Siemens Servo 900C, Siemens-Elema. Solna, Sweden

Bourns Bear 2, Bear Medical Systems. Riverside CA

Metabolic Cart:

Deltatrac, Sensormedics Corp. Anaheim C.'\

Blood Gas Analyzer:

Stat Profile 10. Nova Biomedical. Waltham MA

Douglas Bag:

Model 6100, Hans Rudolph Inc. Kansas City MO

Calibration Gases & Solutions:

Blood Gas Analyzer (5% COi, 21% O2. 74% Nj). Nova Biomedical.

Waltham MABlood Gas Analyzer (10.6% COi, 89.4% Ni). Canox Mississquqa,

Ontario, Canada

Metabolic Cart (4% CO2 & 96% O2). Sensormedics, Yorba Linda CA

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siolScand 1984;28(4):462-468.

Snyder JV. The development of supported ventilation: a critical sum-

mary. In: Snyder JV. Pmsky MR (editors). Oxygen transport in the

critically ill. Chicago: Y'ear Book Publishers; 1987.

43'''' International Respiratory Congress

December 6-9 • New Orleans, Louisiana

':>4 RESPIRATORY CARE • AUGUST '97 VOL 42 NO 8

Reviews, Overviews, & Updates

Bronchoalveolar Lavage:

A Useful Method for Diagnosis of Some Pulmonary Disorders

Ali Emad MD

Introduction

Technique

Fluid Constituents

Indications

Safety & Complications

BAL IN Disorders other than Interstitial Lung Disease

Infectious Diseases

Cancers

Asthma

Fat Embolism

Allograft Rejection

Acute Respiratory Distress Syndrome

BAL in Parenchymal/Interstitial Diseases

Comparison with Other Diagnostic Techniques

Common Findings

Idiopathic Pulmonary Fibrosis

Pulmonary Histiocytosis XSarcoidosis

Hypersensitivity Pneumonitis

Collagen Vascular Diseases & Vasculitis

Eosinophilic Lung Disease

Asbestosis

Silicosis

Alveolar Proteinosis

In Conclusion

Introduction

Bronchoalveolar lavage (BAL) is a useful method of obtain-

ing fluid from the airways and the alveoli.'' Components of

this fluid include cells, soluble proteins, and fats. The fluid

Dr Emad is Assistant Professor of Internal Medicine, Memazee Hospital

and Shiraz University of Medical Sciences. Shiraz. Iran.

Correspondence: Ali Emad MD. Assistant Professor of Internal Medi-

cine. Department of Internal Medicine, Nemazee Hospital. PO Box

71.U5-1674. Shira/ University of Medical Sciences, Shiraz. Iran.

is used as both a research and a clinical tool, and its value in

determining the pathogenesis of and in managing interstitial

lung diseases (ILDs) has been well established.' The appli-

cation of BAL has rapidly expanded to the diagnosis of other

pulmonary disorders, such as primary and metastatic lung

malignancy and pulmonary infections,"" and has improved

our understanding of immunopathogenic mechanisms in pul-

monary diseases such as asthma and acute respiratory distress

syndrome (ARDS),^" BAL is highly recommended as a means

of obtaining specimens from the lower respiratory tract for

microbiologic analysis in immunocompromised patients with

opportunistic infections of the lungs when results of other less

invasive procedures such as blood culture and sputum induc-

Respiratory Care • August "97 Vol 42 No 8 765

Bronchoalveolar Lavage

tion ;ire inconclusive.'" This is particularly true in patients with

human immunixJet'iciency virus (HIV) infection ;ind suspected

Pneumocystis carinii pneumonia when and it sputum is not

diagnostic." Microbiologic studies of BAL fluid have spe-

cial diagnostic value in mechanically ventilated patients in

whom nosocomial pneumonia is suspected.'- Knowledge of

the clinical utility and research applications of BAL in the eval-

uation and management of many pulmonary disorders is fun-

damental for physicians and investigators and those who assist

with bronchoscopic procedures.

Table 1 . Normal BAL Cell Findings in Healthy Non-Smoking

Subjects*

Cells Percent (%)

Macrophages

Lymphocytes

Neutrophils

Ldsinophils

<15

<3

<0.5

Based on data reported in References L 2. 1 8. 20. 2

1

Technique

After the fiberoptic bronchoscope (FOB ) has been inserted

and the search for abnonnalities in the respiratory tract is com-

plete, the tip of the FOB should be advanced into the desired

bronchus as far as possible until it is well wedged.' Biopsy

and brushing should be avoided before BAL.- ' If no lesions

or abnormalities are apparent on the chest radiograph, the

lingula, the right middle lobe, or the right or left lower lobes

are the preferred sites for BAL.' ' Boluses of 20 mL of phys-

iologic (ie. "normal") saline at 37 °C are injected. Immedi-

ately after each injection, the BAL fluid is collected by apply-

ing suction with a negative pressure of 50-100 torr.- ' The

total amount of fluid instilled in the lung should not exceed

3 niL/kg. with a maximum total of 300 mL." Overall, the

amount of BAL fluid collected is about 40-6()'7f of the vol-

ume in.stilled.'-* At lea.st. 25 mL of fluid should fie regained. '^'^

The recovered BAL fluid should be stored immediately at

4 °C and sent to the laboratory as soon as possible.'^ The oper-

ator qualifications, patient preparation, and safety precau-

tions are those indicated for FOB.'"" and careful imple-

mentation helps assure a safe procedure with useful results.

Fluid Constituents

Cells

BAL fluid contains millions of cells and I- 10 mg of pro-

tein." '^ In adults, macrophages constitute about 88-95% of

total recovered cells'**^' (Table Ii-^-'s^-^i). Lymphcx-ytes (<I5%)

and other less frequent cell lines make up the remainder

(<3'/( )."'-•-" These protein values and cell frequencies are sim-

ilar in infants and children except that the percentage of neu-

trophils is higher in infants.-- -' Macrophages originate in the

bone marrow'** and defend against organisms and antigens

deposited on alveolar surfaces. -* -''They also neutralize the

activity of proteolytic en/ymes.-'

The majority of lymphocytes, however, are derived from

bronchial lymphoid tissues and lymph nodes, with the rest

coming from the circulation.-** The majority of lymphocytes

recovered by BAL express markers typical for ""memoi^ lym-

phocytes."-'' T-cells are the main lymphocytes, and the ratio

of T-helper to T-suppressor cells is approximately 1 .8: 1.-'' The

ratio is less in children than in adults.-' Lymphocytes can

respond to different kinds of mitogens and antigens by secre-

tion of lymphokinase. leukocyte inhibitory factor, migratory

inhibitory factor, and local immunoglobulins.'"

Proteins & Other Materials

A variety of proteins can be recovered from BAL fluid-'-'"

(Table 2"). Albumin constitutes almost one third of the total

measurable protein in BAL fluid." '^ A number of im-

munoglobulins, primarily IgG and IgA. can also be detected.'"

The immunoglobulin in least concentration is IgM.'"-" and

some physicians believe that no IgM is present in BAL fluid.'"'

Free secretory pieces of IgA can be detected in BAL fluid

but are never seen in plasma.'" The amount of IgE in BALfluid is 0.06-0.3 jUg/mL. which is equal to that of plasma.'"

It is believed that neither IgM or IgD should be present in

BAL fluid.'

Table 2. Normal BAL ( 1,'iO-mL Saline) Proteins and Immunoglobulins

in Healthy Non-Smoking Subjects*

Proteins & tmmunoglobulins Percent (%) Total Protein Present

Albumin

IgG

IgA

IgM'

IgE

IgD

C4

C6

57. 1 ± 6..1

1.5.0 ±2.0

1 1.5 ±1.4

0.03 ± 0.03

0.00

0.00

0.34 ± 0.05

0.85 ±0.1

3

*Froni Reference 31

iSomc physicians helie\e that there is no IgM in the BAL fluid at all.-

Determinalion and measurement of absolute concentra-

tions of various en/\ ines and soluble components reco\ ered

by BAL, such as complements. '^ tumor necrt)sis factor alpha

(TNF-a)."* interleukins.''' angiotensin converting enzyme

(ACE).'*" elastasc" ^glucoronidase.''- a- 1 -proteinase in-

hibitor,'*' lysozymes,''- myeloperoxidase,''"' a-2-macroglob-

ulin,"''' a- 1 -antitrypsin.'"' and collagenasc" may be specially

reser\ ed for research purposes. •* Among all components of

, (^(j Respiratory Care • August "97 Vol 42 No 8

Bronchoalveolar Lavage

the complements. C4. C6, and factor B can be detected eas-

ily in BAL tluid."

The degree of activity of neutrophils in BAL fluid can be

assessed by measurement of myeloperoxidase.^'^ KL-6. a muci-

nous high-molecular-weight glycoprotein, can be used as a

marker for clinical diagnosis and for evaluation of disease activ-

ity in ILDs for research purposes."' Tumor markers are also

found in BAL fluid, but their presence does not always mean

that lung cancer is present.-''' It is likely that most tumor mark-

ers are produced as a consequence of damage to lung tissue,

especially in cigarette smokers.^- Another protein, fibronectin.

plays a role in phagocytosis and production of collagen fibers

and fibroblasts."^' hs concentration is markedly increased in

patients with pulmonary fibrosis and smoking patients with

chronic obstructive lung disease.'' "

Indications

BAL is performed in immunocompetent patients with atyp-

ical pneumonia,^" tuberculosis," suspected chronic aspiration.^^

eosinophilic lung disease," ARDS,* alveolar proteinosis.'''

and ILDs.''- It can be used in subjects with lung infiltrates,

those with acquired immunodeficiency syndrome (AIDS)."

and in immunocompromised or mechanically ventilated patients

with undiagnosed lung lesions.'- "' BAL can be safely per-

fomied in thrombocytopenic patients w ith undiagnosed lung

infiltrates''^ and is utilized as a research tool in many condi-

tions such as asthma.^

Safety & Complications

FOB with lavage is a rapid and safe procedure when per-

formed in a properly prepared patient by a competent oper-

ator who is aware of possible risks and has taken steps nec-

essary to minimize them."' '^ An early report suggested that

the incidence of minor complications is about 0.2% and of

major complications about 0.087r.'''^ Possible complications

include laryngospasm and bronchospasm,''''''^ fever, pneu-

monia,** cardiac arrhythmia,*'' hypoxia,™ small decreases in

forced vital capacity (FVC). the forced expiratory volume in

the first second (FEVi). and the peak expiratory flow ( PEFR ). '

'

pneumothorax,'- and. rarely, sepsis syndrome and death.'' The

complication rate is low if the bronchoscopist has a thorough

knowledge of the many pathophysiologic and technical facets

particular to bronchoscopy and BAL, particularly those encoun-

tered in intensive care unit (ICU) patients undergoing mechan-

ical ventilation.'^

BAL IN Disorders Other than ILD

Infectious Diseases

The etiology of respiratory infections may be obscure despite

recent advances in diagnostic technology, and clinical and radi-

ologic signs may not always be adequate to establish diag-

nosis.'"'' Although analysis of expectorated sputum, blood

culture, and serology can be used for diagnosis of some res-

piratory infections.'"'* FOB is a prcKedure that provides direct

access to both the bronchi and parenchyma for visualization

and sampling, even in critically ill patients."""*' The protected-

specimen brush (PSB) and BAL techniques, used safely in

different clinical settings, have good sensitivity in identify-

ing the pathiigen. but the specificity varies with the under-

lying status of the patient™' (Table 3'*-"'').

Acute Bacterial Pneumonia

Bacterial pneumonia is still an important cause of mor-

bidity and mortality, especially in elderly patients.''' A spe-

cific, responsible pathogen may not be reliably identified in

patients with community-acquired or nosocomial pneumo-

nia on clinical grounds and/or chest roentgenographic find-

ings alone.""" Sputum Gram-stain is a sensitive method for

the diagnosis of pneumococcal pneumonia, but its accuracy

for diagnosing infections caused by other pathogens has not

been established.'** Culture of expectorated sputum, often the

initial step in diagnosing community-acquired pneumonia,

can determine the pathogenic organisms in < 60% of cases,'''""

and is unreliable in patients w ith nosocomial pneumonias,

mainly because of colonization of the oropharynx.'""' Even

though blood cultures are frequently negative, they may be

useful for accurate diagnosis and should be obtained in patients

with bacterial pneumonias.""'"" The most accurate technique

for diagnosing community-acquired or nosocomial bacterial

pneumonia in critically ill patients, remains unclear, espe-

cially in the subgroup of patients requiring mechanical ven-

tilation. ""'Specific etiologic diagnosis in ventilator-associ-

ated pneumonia with its mortality rate of 20-50% is critical

and vital for management of these special patients.'"" The use

of transtracheal needle aspiration (in spite of few false-neg-

ative results) has diminished because of the high frequency

of false-positive cultures and risk of serious complications."

Transthoracic needle aspiration gives convincing information

w ith few false-positive results, but it is not a convenient rou-

tine method.''' With the recognized shortcomings of expec-

torated or aspirated secretions for establishing an etiologic diag-

nosis, physicians try to use bronchoscopy to obtain a variety

of diagnostic samples, including bronchial washes or brushes,

PSB brushings. BAL. and transbronchial biopsies.**'"*''"* Bron-

choscopy has been applied in three primary clinical settings:

the immunocompromised host, especially HIV-infected and

organ transplant patients: patients with ventilator-associated

pneumonia: and the nonventilated patient w ith severe, non-

resolving community- or hospital-acquired pneumonia.'*' The

diagnostic value of lower respiratory tract specimens obtained

by different bronchoscopic techniques remains a challenge.*''

Although it is claimed that for quantitative cultures of

samples from routine endobronchial aspiration with a value

Respiratory Care • August "97 Vol 42 No 8 767

Bronchoalveolar Lavage

Table 3. Sensitivity and Specitlcity of Microbiologic Studies from BAL

Sensitivity Specificity Remarks

Acute bacterial pneumonia in Up to 80%"-'

immunocompetent patients

Up to 100% »-«'

Nosocomial bacterial pneumonia Remains a challenge'*'*' Remains a challenge"'"'

in mechanically ventilated patients

Up to 87%«:

Mycohacleriiim riihcniilosis Up to 92%'''*

Cytomegalovirus pneumonia

Pneumocystis car'mii

Up to lOO'/f"-"

100%"'"'"

Culture: 85.7% to

100%«'«Culture: up to 70%"

Detection of CMV inclu- Detection of CMVsions: up to 21%j' inclusions: 98%'

In situ DNA hybridiza- In situ DNA hybridiza-

tion: 90%!* tion: 63%"'

Up to ^nv^-^ 100%'

Ouanlitalive culture with a cutoff point of >104 cfu/mL is

usually used

Quantitative culture with a cutoff point of >104cfu/mL

is usually used.

The presence of intracellular organisms within cells of BALmay provide a sensitive and specific means for early and

rapid diagnosis of pneumonia." ""

If the amount of antigen 5 is>1.000/Jg/mL. the diagnosis

of tuberculosis is specifically established ."'

Gen-Probe Amplified Mycobuclcriiim Uiherciilosis Direct

Test is used for rapid detection of tuberculosis in research

laboratories."-

A positive culture and positive cytology of BAL can

virtually establish the diagnosis; negative culture may rule

it out."'

In situ DNA hybridization is a rapid diagnostic method"*

Immunocytochemistry .studies is useful when a patient has

a positive culture and negative cytologic examination."-*"'

Amplification of CMV-DNA by polymerase chain

reaction is the most sensitive method.*"

Different staining may be used, including: Gram-Weigert.

Papanicolaous, methenamide silver. Grocott's. and Diff-

Quick."""""

of >10'' cfu/mL as a cutoff point, the sensitivity is 55% and

specificity 85%,"" it seems that quantitative cultures of PSBand BAL specimens are preferred methods for diagnosing

bacterial pneumonia,'"'" especially in immunocompromis-

ed patients.""*

Because of upper airway conlamination. cultures of bron-

chial washings or secretions obtained by bronchoscopy mayprovide misleading information and, therefore, are no longer

routinely recommended.'"*' They are only slightly better than

expectorated sputum for diagnosing bacterial pneumonia.'"*'

Quantitative cultures of samples obtained via PSB technique

with a value of >10' cfu/mL as a cutoff point are useful in dis-

tinguishing patients with and without pneumonia.'"' Sensi-

tivity varies from 36 to 72% and specificity from 85 to

93%.'"'""'" However, this procedure has shortcomings in

that results are not available immediately and a few false-neg-

ative results may be seen."^ The plugged telescoping-catheter

brush has been introduced by some physicians in some clin-

ical centers."^ It seems that its sensitivity is less than that of

BAL for the diagnosis of pneumonias in mechanically ven-

tilated patients.'"' BAL has been suggested to be of value in

establishing the diagnosis of pneumonia tecause the cells and

liquid recovered can be examined microscopically immedi-

ately after the procedure and are also suitable for quantita-

tive culture. "**'It is claimed that the examination of BAL lluid

with a clip-slide method is highly comparable to conventional

quantitative culture methods for diagnosing bacterial pneu-

monia in immunocompetent patients."''

The quantitative method of culturing BAL tluid may solve

the problem of contamination caused by bronchoscopy.-*' The

presenceof >1 ()().()()() cfu/mL of aerobic bacteria in the BALspecimen can be highly specific (up to 100% ) and sensitive

(up to 80%) for sepiiration of patients with bacterial pneuinonia

from those with chronic bronchitis, resolving bacterial pneu-

monia, and nonbacterial lung disorders,'' '*-'*'^ but the quan-

titative method is not useful in differentiating bacterial col-

onization of the airways from nosocomial pneumonia in the

mechanically ventilated patient.**^ Cytologic analysis that incor-

porates microscopic identification of intracelluku' organisms

recovered by BAL and quantitative culture of samples may

provide a sensitive and specific means for e;uiy and rapid diag-

nosis of pneumonia in intubated patients who are mechani-

cally ventilated, although the sensitivity of this technique is

l(n\ er than with either PSB or BAL.*"*

Respiratory Care • August "97 Vol 42 No 8

Bronchoalveolar Lavage

BAL is useful in the diagnosis of bacterial pneumonia in

children as well as in adults,'"* especially in those hospital-

ized children with resistant pneumonia."'* If patients are already

receiving antibiotics, the quantitative culture may be falsely

negative or falsely positive.'-'"-' I do not recommend BALfor evaluation of pneumonia in patients who are currently

receiving antibiotics or who have a recent history of antibi-

otic use.

In order to decrease the chance of contamination, in addi-

tion to the usual method of BAL with FOB, new techniques

such as nonbronchoscopic protected BAL'-- luid bronchoscopic

protected BAL'-' have been introduced. Nonbronchoscopic

protected BAL is performed by blindly advancing a large

catheter with a distal polyethylene glycol plug into the dis-

tal airways. After the catheter is wedged in a peripheral

bronchus, the plug is expelled with 10 niL of air; and a sec-

ond catheter is passed through the first one and advanced as

far as possible—at least 3 cm beyond the distal tip of the first

catheter. Results with this technique have a sensitivity of 80%

and specificity of 60% .'--

Lavage can be performed by inserting a I2-gauge Foley

balloon-tipped catheter into the endobronchial tree—an ap-

proach that does not require bronchoscopy and is as reliable

as BAL in diagnosing lower respiratory tract infection.'-'^'-'

It is interesting to note that BAL performed with a pediatric

bronchoscope prosides a BAL yield in mechanically ventilated

patients comparable to the yield with an adult bronchoscope. '-''

Mycobacterium tuberculosis

Acid-fast bacilli can be identified in smears of sputum in

40-60% of pulmonary tuberculosis ca.ses. ;ind Lowenstein cul-

tures may yield positive resuhs in 62-92% of such patients.'-''

Many patients with pulmonary tuberculosis may have neg-

ative smears for acid-fast bacilli, and in some cases the diag-

nosis is made exclusively by FOB.'-** Routine cultures of

bronchial aspirates have been positive in 83% of cases and

have been the only means of diagnosis in 45%.'-' Although

gastric lavage has a high diagnostic yield for pulmonary tuber-

culosis in children.^" FOB with BAL has proved to be the most

effective method, leading to diagnosis in up to 92% of

cases.-''^'*"" If adequate caregiver precautions are taken, early

BAL can be undertaken when the diagnosis of pulmonary

tuberculosis is uncertain.'" If the amount of xylocaine used

during FOB is high, the incidence of false-negative results

increases because bacterial growth is suppressed. "-

Although patients with miliary tuberculosis have low yields

from sputum culture, cultures of BAL specimens obtained by

FOB have been reported to be positive in 100% of cases."''

Epithelioid cell granulomas may be seen in BAL fluid of

patients with miliary tuberculosis."'' The presence of mult-

inucleated giant cells in BAL fluid does not always mean that

the patient has tuberculosis because such cells may be found

in other conditions, such as viral infections.'-'''-'"'

Recent studies have revealed that TBSA (tuberculostearic

acid) assay of BAL fluid is a highly specific method for diag-

nosis in patients with smear-negative pulmonary tuberculo-

sis, and it is more sensitive than the microscopic study of BALtluid.'""'^ Although the detection of antibodies such as IgA

and IgG to tuberculosis antigens in BAL may have no spe-

cific diagnostic value, greater specificity has been observed

with an assay based on purified Antigen S.**- If the amount

of Antigen 5 (one of the mycobacterium antigens) is > 1,000

jUg/mL. the diagnosis of tuberculosis is specifically established.

However, this level of antigen is not present in all patients

with tuberculosis.''-

The nucleic acid amplification technique (Mycobacterium

tuberculosis Direct Test), a valuable method for rapid detec-

tion of tuberculosis that can be applied to BAL fluid,'''* is com-

ing into general use. Measurement of the level of adenosine

deaminase in BAL fluid may be helpful.'"'"* However, adeno-

sine deaminase activity is not specific for tuberculosis because

it may also be increased in sarcoidosis.'-"*

Both pulmonary tuberculosis and sarcoidosis are char-

acterized by an increased percentage of lymphocytes in BALfluid, with a similar proportion of activated T-cells. In con-

trast to active sarcoidosis in which an elevated ratio of CD4to CDS cells is characteristic, in most pulmonary tuberculosis

patients the CD4-CD8 ratio is within the normal range. "'' Adecreased CD4-CD8 ratio with an increase in CD8 in BALfluid of patients with tuberculosis without HIV infection has

also been observed.''"' Because alveolar macrophages are acti-

vated in the alveolar inflammation of active pulmonary tuber-

culosis, a variety of cytokines, such as interleukin-l j3(IL-l

beta), interleukin-6 (IL-6), and TNF-a, are increased in the

BAL fluids of these patients.'"" Soluble CD 14, a cell-surface

glycoprotein expressed mainly on mature monocytes and

macrophages, may be increased in BAL fluid of patients with

pulmonary tuberculosis and in patients with sarcoidosis.'''-

It is important to note that extension and spreading of tuber-

culosis rarely occur after FOB and BAL. ''*''"

Other Pneumonias

Direct fluorescent antibody (DFA) staining of sputum is

commonly used for diagnosis of Legionnaire's disease. '"" The

moderate sensitivity of the test may be increased by collecting

sputum by transtracheal aspiration.''"' Kohorst et al''*' in 1983

reported that DFA staining of BAL fluid is rapid, safe, and

specific for Legionnaire's disease,'"" with prior administra-

tion of antibiotics for short periods of time (at least up to 48 h)

not affecting the results.'^**

Cytomegalovirus (CMV) is an important source of mor-

bidity and mortality in immunocompromised patients, and

a rapid and reliable method to confirm the diagnosis is vital

and essenfial.'^'''^' CMV infecfion is conventionally diag-

nosed in the laboratory by tube-cell-culture assays or by

detection of characteristic viral inclusions in histologic sec-

Respiratory Care • August '97 Vol 42 No 8 769

Bronchoalveolar Lavage

tions.'^" FOB with BAL is the best method for its diag-

nosis.''"'-''- Methods for detection of CMV in BAL spec-

imens, include ( 1 ) spin amplification followed by staining

with a monoclonal antibody to the early nucle;ir antigen (EA-

assay); (2) cytologic examination for viral inclusions; (3)

in situ DNA hybridization; (4) and conventional tissue cell

culture."'^''^ The monoclonal antibody method permits easy

and rapid detection ofCMV in BAL specimens.'^' As diag-

nostic tests for CMV pneumonia, EA-assay has been reported

to have a positive predictive value of 45%, conventional

culture 57%, and cytology 100%.'*'' The sensitivity of the

conventional viral culture of BAL specimens varies from

86 to 100% for diagnosis ofCMV pneumonia.'""-' and its

specificity is about 70%.'" The sensitivity of detection of

CMV inclusions on cytologic examination of BAL spec-

imens may reach 2 1 % for diagnosing CMV pneumonia, with

a specificity at 98%.'''* As a result, it seems that a positive

culture and positive cytology from BAL can virtually estab-

lish the diagnosis ofCMV pneumonia, whereas a negative

culture may rule it out."'''

Immunocytochemistry utilizing monoclonal antibodies in

BAL specimens may be useful for diagnosis ofCMV pneu-

monia when a patient has a positive culture and negative cyto-

logic results from BAL fluid because the presence ofCMVas shown by cultures does not always indicate a clinically rel-

evant inlection.'"'" It may indicate development ofCMV pneu-

monitis before cytologic changes are evident.''''

Conventional CMV cultures may become positive within

about 21 days, whereas in situ DNA hybridization is ready

within 24 hours. ''^ Thus, in situ DNA hybridization is a use-

ful rapid method for the detection ofCMV in BAL specimens,

and its sensitivity is 90% and specificity 63%."*''''' Amplifi-

cation ofCMV-DNA by polymerase chain reaction seems to

be the most sensitive methcxl for the detection ofCMV in BALspecimens, and its sensitivity is claimed to be 100% for diag-

nosis ofCMV pneumonia.'^''

The simplest method for diagnosis of lung involvement

by StroiigylDulcs stervolaris is Gram-stain of sputum.''''' Other

diagnostic methods are bronchial baishing''''' and biopsy, and

analysis of pleural effusion.'"'^ A 1988 paper reported that BALis also a good diagnostic method.'"''^ Pulmonary microsporid-

iosis can also be detected by BAL fluid.''^''

Invasive pulmonary aspergillosis is difflcult to diagnose,

and, unfoilunately. sputum analysis has a lov\ yield with a low

specificity and sensitivity."'" Invasive diagnostic methods

include transtracheal aspiration.""' percutaneous needle biopsy,

bronchial brushing, and transbronchial biopsy."'- Comput-

erized tomography of the chest is valuable for early diagnosis

of aspergillosis."'" and the other good diagnostic method is

FOB with BAL."'^ Tlie detection of hyphae in BAL specimens

has a sensitivity of 53% and specificity of 97%, and culture

of BAL fluid is positive in 23% of patients with invasive pul-

monary aspergillosis."'^

It is true that open lung biopsy has the highest yield for diag-

nosis of fungal infections in immuntK'ompromised patients,'*'

but BAL can also be useful and is recommended."'''""''*

FOB with analysis and quantitative culture of BAL fluid

is the first choice in all patients infected with HIV who pre-

sent with pulmonary infiltrates.'^" ''- HIV-infected patients

with pneumonia with or without peripheral neutropenia have

similar findings in BAL lymphocytes subsets, expressed as

a decrease in T4-T8 ratio.'''

Pneumocystis carinii pneumonia (PCP) occurs at some point

in approximately 85% of patients with AIDS ""* and is the most

treatable disease in patients with HIV infection.'^- Patients

characteristically complain of dyspnea, fever, and nonpro-

ductive cough. Such symptoms in a patient with HIV infec-

tion should be carefully evaluated.''- '^^ Closed or open lung

biopsy, ''-'' transthoracic lung aspiration,' '"' bronchial brush-

ing.'" tracheal aspiration.'^'* induced sputum.'^'' and serologic

studies'''" are used for its diagnosis. Although it has been sug-

gested that sputum examination not be used for routine eval-

uation in the diagnosis of PCP in patients with AIDS because

of its low sensitivity.'^' analysis of induced sputum is gen-

erally accepted as a preliminary method in patients with

advanced HIV infection and suspected pcP.'^''i«.is3

Because of the alveolar invasion associated with PCP, BALhas a high-yield for PCP diagnosis."*'' It is preferred when

and if sputum is nondiagnostic because it is simple, safe and

presents a low risk of bleeding or pneumothorax."*'' ''*'' BALhas been shown to be inore sensitive than brush biopsy for

the diagnosis of PCP in AIDS patients.'"* Staining the BALfluid by Papanicolaou technique is sufficient for the diagnosis

of a heavy Pneumocystis infection.'''^ Encysted sporozoites

within the alveolar casts can be identified on Papanicolaou-

stained slides vt' BAL specimens in most cases, "''"^"It should

be mentioned that the pre.sence of encysted sporozoites within

alveolar casts is pathognomonic for PCP.'"" but if the num-

ber of cysts is small. Papanicolaou staining is not adequate,

and staining with methenamide silver'"'-'- or Gram-Weigert,

Grocott methenamine-silver nitrate, indirect immunofluo-

rescence assay, or toluidine blue O may be required.'"' '•'*^ Other

accurate methods for detection off. carinii in BAL are Diff-

Quik. fungifluor stain, and direct immunofluorescence test."*'*

The use of antimonoclonal 3F6 of the mouse with im-

munofluorescence has been shown to have a higher sensitivity

for delecting the cysts of P. carinii than does Grocott's, Giemsa

or Papanicolaou stain."*'"'*' P. carinii can be detected by apply-

ing polymerase chain reaction (PCR) in BAL fluids,''"'*- but

PCR is not believed to be clinically useful for detection off.

carinii in BAL specimens.'''- In other words, P. carinii DNAamplification by PCR should be reserved for those AIDSpatients who have negative results on cytologic examination

of BAL samples by routine staining but are judged on clin-

ical grounds to have PCP.''" It is interesting to note that the

level of surfactant protein A (SP-A) is decrea.sed in BAL flu-

ids of HIV-infected patients with P. carinii.'"''*

Toxoplasmosis (infection with Toxoplasma gondii) is a seri-

• 70 Rhspiraiurv Care • August '97 Vol 42 No 8

Bronchoalveolar Lavage

ous and potentially fatal opportunistic infection in patients

with AIDS. Although toxoplasmosis can be diagnosed from

BAL and induced sputum,'*^^ tissue culture has been reported

to be a more powerful tool for diagnosis and also for mon-

itoring the effects of treatment than BAL tluid culture.''"'

Cancers

FOB with biopsy gives excellent results with an accurate

pathologic-anatomic diagnosis in centrally located pulmonary

malignancies.''*' Peripheral lesions also can be diagnosed by

percutaneous transthoracic needle biopsy or by transbronchial

biopsy via the FOB.''" BAL fluid can be useful for the diag-

nosis of a number of primary and secondary malignancies ot

the lung.''^*''*'' A pulmonary infiltrate in a patient with malig-

nancy has many possible causes, including infection, pulmonary

hemorrhage, the disease itself, and the effects of cytotoxic drugs

or radiation. Specific diagnosis may be difficult on initial eval-

uation, but further information obtained by FOB and BAL may

solve the problem.-""-'"

BAL fluid for cellular interpretation should be carefully pro-

cessed.-"- -"' Although Wright-Giemsa and Gram stains are

optimal techniques for BAL cellular differentiation, tumor cells

cannot be easily identified with these stains. Therefore, smears

of the BAL fluid should be stained by Papanicolaou or Diff-

Quik method.-"- -"' and the technique of immunogold-silver

staining may identify the monoclonal B-cell populations.-'"

Severe dysplastic changes, seen in a variety of pulmonary

disorders such as pneumonia, viral infections, and following

chemotherapy, may be difficult to differentiate from malig-

nant processes.-"^ If abnormal BAL cells are suspected to be

malignant, flow cytometi7 is recommended to analyze the DNAcontents of atypical epithelial cells to allow for the exclusion

of malignancy if no aneuploid DNA is found.-*

Primary & Secondary Solid Lung Tumors

Primary pulmonary malignancies, such as squamous-cell

carcinoma, the small- and large-cell carcinomas, adeno-

carcinoma, and bronchoalveolar-cell carcinoma may be diag-

nosed by cytologic examination of BAL specimens.-"'--"'--''*

The sensitivity of BAL is higher than that of brushing and

washing for the diagnosis of lung malignancies but similar

to that of transbronchial biopsy and Wang needle biopsies.-'"

Correlation between cancer subtypes as determined by BALand tissue biopsy is 0.79.-"'' BAL tluid cytology may occa-

sionally increase the yield for diagnosing a peripheral lung

lesion suspected to be malignant and may give the only pos-

itive result.-"''-I"

Hematologic Malignancies

BAL can be diagnostic for a variety of hematologic malig-

nancies including leukemia,-' ' plasma-cell dyscrasia,-'- myco-

sis fungoides,-" and Waldenstrom's macroglobulinemia.-'''

Hodgkin's disease and non-Htx]gkin"s lymphoma may be diag-

nosed by the presence of Sternberg-Reed cells,-''--'^ analy-

sis of the proteins in lavage fluids,-'^ clonal analysis of BALcells,-"*-'" and molecular biologic studies of BAL fluid.--"

BAL may be useful also for the diagnosis of T-cell lym-

phoma.--' Overall, it can be concluded that BAL has an appre-

ciable value for diagnosis of lymphoproliferative disorders

of the lungs,-'*"-------^ especially by its DNA analysis when lym-

phocyte subpopulations show aneuploidy or a definable mon-

oclonal surface marker or both.--""

Metastatic Malignancies

The effectiveness of BAL for detecting pulmonary metas-

tases of prostatic adenocarcinoma,--'' ovarian carcinoma,--*

breast,--' and papillary thyroid carcinoma,--** has been well

confirmed. In addition to examinations of spuUim and bronchial

washing, BAL may be diagnostic for patients with lymphangitic

carcinomatosis.--''--^"

A variety of tumor markers or "tumor antigens," such as

carcinoembryonic antigen, tissue polypeptide antigen, CanAg

30, neuron-specific enolase, chorionic gonadotrophin, and fer-

ritin may be expressed by cancer cells in serum and lavage

fluid.-" Application of immunocytochemical techniques to

identify these tumor markers, particularly when combined with

other diagnostic procedures currently in use, can be an effec-

tive accessory for diagnosis of lung carcinoma.-'- It should

be mentioned that tumor markers may be elevated in BALfluid in other diseases such as pulmonary alveolar proteinosis

and in healthy smokers.-'' -'' The measurement of carci-

noembryonic antigen in BAL fluid has a sensifivity of 50%

and specificity of 597c in lung cancer detection.-'' The level

of hyaluronic acid in BAL fluid is increased in patients with

lung cancer, especially those with small-cell carcinoma.--'*"

Detection of K-ras oncogene mutations in BAL fluid may

lead to earlier cancer diagnosis and, therefore, less need for

invasive diagnosis procedures,-" The level of secretory IgA

has no value for diagnosis of lung cancers, and it is suggested

that it not be relied upon.-'** The level of prostaglandin E2,

which has a role in immunologic processes, may markedly

increase (as compared to the levels in other diseases) in the

BAL fluid of patients with lung cancers, especially those with

squamous-cell carcinoma.-"

Asthma

BAL has been used to investigate the pathogenesis of asthma

although earlier clinicians tried to avoid performing FOB and

BAL in asthmatic patients because of documented severe bron-

chospasm during and after the procedure.-""' However, more

recently it has been demonstrated that BAL can be used in

stable patients with a mild-to-moderate asthma.-'" FEV| and

maximal expiratory flow at 50% of expired vital capacity

Respiratory Care • August '97 Vol 42 No 8 771

Bronchoalveolar Lavage

( Vn,ax-5n'7, ) do decrease after FOB and BAL; however, if asth-

matic patients are well controlled prior to the procedure, the

decreases are not important.-'"-''- The safety of BAL in cases

of moderate-to-severe asthma is unknown; at least one group-""

has reported that < 10% of cases may develop mild-to-mod-

erate bronchospasm that responds well to intravenous amino-

phylline or 13-2 agonists. However, it is probably prudent to

avoid BAL in patients with moderate-to-severe asthma. -"*-

Charcot-Leyden crystals, Curschmann's spirals, sloughed

epithelial cells, and hyperplastic ciliated columnar epithe-

lial cells may be found in BAL fluid of patients with asthma.

The number of eosinophils, concentration of eosinophil

cationic protein and interleukin-8 (IL-8), and histamine level

may also increase.-^ -""'

Tlie potent bronchoconstrictors Substance P and neurokinin

A may be increased in asthmatic patients.-"" The bron-

choconstrictor effect of substance P may in part result from

activation of mast cells of the bronchial airways;-'*'* it has been

claimed that interleukin-1 /3(IL-1 /i) plays an important role

in nocturnal airway inflammation and obstruction.-'''

Fat Embolism

Fat embolism syndronie occurs mainly in victims of trauma,

and its diagnosis on clinical grounds may sometimes be dif-

ficult. Presence of lipids in urine and circulating fat globules

in senim have poor diagnostic sensitivity and specificity.-''"'-'-

One report-""' has continued that microscopic examination

of the recovered BAL cells stained with a specific dye for neu-

tral fat can establish the diagnosis by rapid detection of abnor-

mal fat globules. This is a highly specific method with a cut-

off point of 3% of oil-red, O-positive alveolar macrophages

in BAL defining a positive BAL study.-" No false-negative

or positive results were seen.--^"

Allograft Rejection

Endotoxin level, which plays a role in liver transplant rejec-

tion and acute graft-vorsus-host disease, can be elevated in

the recipient's BAL fluid during lung transplant rejection.-^""

An increased ratio of IgG2 to IgG 1 in BAL fluid can also be

useful as a marker.-"

Acute Respiratory Distress Syndrome

ARDS, the must severe form of acute lung injur>, is char-

acterized by hypoxemia despite high concentrations of sup-

plcniental oxygen, ditfuse pulnionary infiltrates on chest

radiograph, decreased lung compliance, pulmonary hyper-

tension, and the absence of congestive heail failure.-'"' Acute

lung injury can be defined as a syndrome v\ iih a rapid alter-

ation of alveolar wall permeability leading to impairment

of gas exchange following exposure to noxious environmental

or endogenous agents. -^^

Although the precise mechanisms operative in acute lung

injury ;ire unknown, some aspects of the pathogenesis ofARDShave been established from the results of BAL in these patients.^

The accumulation of neutrophils w ithin the lower respiratory

tract and other findings from patients with ARDS suggest that

lung injury may be initiated by the release of some endoge-

nous mediators, such as tumor necrosis factor (TNF), inter-

leukin- 1 , and granulocyte elastase, from activated neutrophils

and macrophages into the circulation,-^'*"-''" especially when

the syndrome is sepsis induced.-*' Continuing injury may result

from persistent release of inflammatory cytokines, and mul-

tiple organ failure and unfavorable outcome may be seen in

ARDS patients who have persistent cytokine elevation.-'^' Medi-

ators, including products of complement activation and arachi-

donic acid metabolism, may amplify the inflammatory

response.'' In many ARDS patients, high levels of neutrophil

elastolytic activity in the lungs are associated with reduced

a- 1 -antiprotease function.-''- In other words, net lung protease-

antiprotease balance in ARDS is shifted largely in favor of

the antiproteases.-''-'

The accumulated neutrophils within the respiratory tract

can generate oxygen radicals that result in lipid peroxidation,

which may contribute to acute lung injury in patients with

ARDS.-*^ BAL specimens from normal subjects have a potent

antioxidant activity due priniarily to the serum proteins—U"ans-

ferrin and ceruloplasmin. Therefore, these antioxidants mayplay a role in regulating tissue injury in .ARDS.-''^ -'''

Prolonged mechanical ventilation predisposes patients to

the development of pulmonary and extrapulmonary infec-

tions.-'''' Making a distinction between the two on clinical

grounds is difficult, if not impossible. Although pneumonia

is often seen in patients with ARDS,-'* diagnosis of pneumonia

is generally difficult to establish by clinical criteria alone

because release of inflammatory cytokines with flbropro-

liferation causes fever and leukocytosis.-''' Empirical u.se of

broad-spectRim antibiotics in niechanicall\ \entilated patients

without pneumonia may do hami by facilitating colonization

and superinfection with vimlent organisms.-''** Another impor-

tant role for BAL in ARDS is in the diagnosis of nosocomial

pneumonia.''" Although it is claimed that 4()'/r potassium

hydR)xide prepiirations of BAL that reveal elastin fibers have

a lOO'yf specificity in diagnosing bacterial pneumonia in

mechanically ventilated patients, these methods are not spe-

cific for nosocomial pneumonia in patients with ARDS.'"* It

is worth mentioning that FOB and BAL can be performed

safely and iire reasonably v\ ell-tolerated in patients w ith ARDSin spite of their critical illness.-''''

BAL IN Parenchy\ul/Intersth lAi. Diseases

ILDs are a heterogeneous group of disorders of the lower

respiratory tract characterized by degeneration of the alve-

olar wall and loss of functional alveolocapillary bed.-™-"

The list of ILDs with unknown cau.ses is Ions, but alveoli-

Respiratorv Care • August "97 Vol 42 No 8

Bronchoalveolar Lavage

tis due to chronic inflammatory processes is the hallmark of

the disease.-''"

Comparison with Other Diagnostic Techniques

In addition to computerized tomography (CT) of the chest,

three major techniques are used for the evaluation of patients

with alveolitis:-'"'-"'

( 1

)

For gallium scanning, gallium-67 citrate (50 /jci/kg of

body weight) is infused intravenously, and after 48 to 72 hours

of infusion, patients are scanned. Patients with active alve-

olitis can accumulate the isotope in lung parenchyma, and scan-

ning provides a rough indication of the density of activated

macrophages in the lower respiratory tract.-'^-

(2) The definitive method for diagnosing alveolitis is lung

biopsy but. of course, it is an invasive method.-'-'

(3) BAL may be useful for diagnosing, .staging, and assess-

ing clinical progression in some ILD, but it has no value for

diagnosis in others, such as amyloidosis and lymphan-

giomyomatosis.-'^^-'"' When done in appropriately selected

cases, BAL is a safe procedure. Major complications are rare

in patients with a FEV| > 1 liter. PaO: > 75 torr (with or with-

out supplementary oxygen), no CO: retention, no active car-

diac disease, and no coagulation disorders.''--''' It appears that

BAL is the most sensitive primary method to assess activity

and staging.'-"

In general, no correlation is seen between the type or sever-

ity of linear infiltrates in chest radiographs and the results of

BAL because only pulmonary inflammation, not fibrosis, can

be detected by lavage, and chest radiographs cannot provide

a basis for distinguishing between inflammation and fibro-

sis. In addition, parenchymal lung involvement with abnor-

mal results from BAL may occur in some patients with ILD

who have normal chest roentgenograms.-'"'

Common Findings

Tables 4"--'* and 521.279-289 summarize information obtained

and important points related to the use of BAL in the diag-

nosis and monitoring of ILDs.

Cellularity

Cellularity of BAL fluid is increased in ILDs,-'"' and sub-

jects can be divided into two groups: tho.se with lymphocyte

predominance and those with neutrophil predominance. '^-''

This is valuable for discriminating among patients with sar-

coidosis, hypersensitivity pneumonitis, and idiopathic pul-

monary fibrosis, or IPF2'"'02 (Xable 6).

IgG-Secreting Cells

It is beheved that IgG-secreting cells significantly increase

in the BAL fluid of patients with all forms of ILD. which may

Table 4. Types of Alveolitis Revealed by BAL Analysis and the

Differential Diagnosis

Alveolitis Type Differential Diagnosis

Neutrophilic (increased

macrophages and neutrophils)

Lymphocytic (increased

lymphcytes and macrophages)

Diseases marked by IPF- '-"•-'*'

(histiocytosis X. asbestosis.-*- hyper-

sensitivity pneumonitis. ARDS.

BOOP.-*' smokmg. chronic ILD due to

collagen vascular disease.-'-™-'"-**

Sarcoidosis.-'-" hypersensitivity

pneumonitis.-' berylliosis, tubercu-

losis, lymphoma, drug-induced

pneumonitis.-'*'' interstitial pneumonitis

due to autoimmune thyroid disease,-*'

BOOP.-'*' radiation pneumonitis,-** and

collagen vascular disease.-'-''*-'''

Drug-induced interstitial lung

diseases.-*" fibrosing alveolitis in

systemic sclerosis,-*' BOOP,'" Churg-

Strauss syndrome. Loeffler's

syndrome, and chronic eosinophilic

pneumonitis.-'"'*

Mixed (cellularity is mixed) Late-stage sarcoidosis, drug induced

pneumonitis,*'* and. rarely. IPF.""'

Eosinophilic

(eosinophils predominate)

Table ."i. Salient Points Regarding BAL & Interstitial Lung Disease

• Analysis of BAL fluid can reveal alveolitis before damage to lung

parenchyma has occurred.-'-'^-"

• IgM level is increased only in hypersensitivity pneumonitis and

rheumatoid arthritis.-"-'""

• Although BAL and gallium scan are useful in assessment of some

ILD.-'- -'* evidence is needed to demonstrate the benefit of routinely

adding them to evaluation and follow-up of patients with ILD.

• BAL analysis reveals 4 types of alveolitis; categorization aids the

differential diagnosis

explain the increased ratio of IgG to albumin in lavage

fluid.-""*'"' It has been shown that steroid therapy can reduce

the number of these cells, and, thus, determination of IgG-

secreting-cell levels may provide a sensitive method for assess-

ment of disease activity and a good index for evaluation of

response to treatment.-'"*-'"'

Angiotensin-Converting Enzyme

ACE can be detected in the BAL fluid of patients with all

variants of ILD.'"*' The elevated ACE concentration corre-

lates with the BAL lymphocyte count in patients with sar-

coidosis'"'* and with the neutrophilic cell counts in patients

with IPF.'">*

RESPIRATORY CARE • AUGUST "97 VOL 42 NO 8 773

Bronchoalveolar Lavage

Tahle 6. BAL Findings in Hypersensitivity Pneumonitis, Idiopathic

Pulmonary Fibrosis, and Sarcoidosis*

Idiopathic Pulmonary Hypersensitivity

Fibrosis PneumonitisSarcoidosis

Neutrophils severe increase

Eosinophils normal'

Lymphocytes normal*

T4/T8*

IgG

IgE

IgA

IgM

C4C6

normal

moderate increase

normal

normal

normal

normal

normal

normal'

normal'

severe increase

decreased

moderate increase

normal

normal*

moderate increase

normal

normal

normal'

normal'

moderate increase

increased

moderate increase

normal

normal

normal

normal

normal

» Based on References 1, 21. 302-30.5

t Mild to moderate increase only in the acute torm

$ .Sometimes increased

§ Normal T4/T8 is approximately 1 X/l.'-*

Fibronectin & Vitronectin

Fibronectin, a large glycoprotein, secreted by fibroblasts

and some other cells^'" is found in plasma and tissues.'"

Fibronectin is normally found in BAL fluid"- but has been

shown to be significantly increased in most patients with

ILD.^'-* Vitronectin is another glycoprotein, the concentra-

tion of which may increase in patients with ILD. It may influ-

ence cell growth and differentiation through interaction with

the terminal component of the complement cascade, coag-

ulation system, and cell surfaces. '''^

Histamine, Tryptase, & Mast Cells

Histamine and tryptase are normally present in BAL fluid,'''

but histamine and tryptase levels increase in patients with ILD

who subsequently develop pulmonary flbrosis."*"^ The

increased histamine level is due to the increased number of

mast cells,'"*"'' which can be easily identifled in BAL fluid

by applying toluidine blue stain after methanol flxation.-'^"

Cells

The total number of BAL cells increases significantly,'-''

with neutrophils predominating (average. 35%)."-'' These

cells play an impoiiant role in the pathogenesis of IPF because

they can damage the lung parenchyma by secreting enzymes

like collagenase.'-'' Finding collagenase in BAL specimens

of patients with IPF favors its role in the pathogenesis of

this di.sease; therefore, the collagenase level provides a use-

ful means for sequentially staging the functional status of

the alveolitis.'-''

Sometimes, the number of lymphocytes is increased in

IPF,'-' and eosinophils are also markedly increased in the active

stage.- ^The number of neutrophils and eosinophils cor-

relates well with the degree of disease activity and disease

course."" A negative correlation has been observed between

the absolute number and percentage of eosinophils and patient

survival.'-** In patients who have a higher neutrophil cell count,

the gallium-67 scan is strongly positive.'-''

Glucocorticoid therapy can modify the inflammatory pro-

cess, reducing the number of neutrophils but not changing the

eosinophil count.-**' A high eosinophil count has been reported

to be associated with a poor response to steroid therapy,'-'

whereas the presence of lymphocytosis is regarded as a fa-

vorable response to such treatment."" Rudd et al'" believe

that patients with high neutrophil and eosinophil counts with-

out asscxiated lavage lymphocytosis rarely improve with steroid

therapy. Serial BAL-cell analysis can be used to assess clin-

ical response of patients with IPF to steroid therapy. "-

Patients with IPF who have a persistently positive gallium-

67 scan ;ind a neutrophil proportion > 10% in their lavage fluid

for a period of 6 months have a marked deterioration in lung

function, as compared with patients who have < 10% neu-

trophils or a negative scan or both over the same period.'-'''"

In IPF. the cell distribution in BAL fluid has been shown

to be correlated with the histologic findings of open lung

biopsy.'-- Of course, it should be mentioned that cigarette

smoking can strongly influence BAL cellularity.'"^

Methionine

Idiopathic Pulmonary Fibrosis

The diagnosis of idiopathic pulmonary fibrosis (IPF) is one

of exclusion,'-" with most patients presenting at between 40

and 60 years of age with dyspnea and, less often, dry cough.'-'

The end result of IPF in untreated patients is irreversible lung

flbrosis. with an average life span in untreated patients of only

47 months from the onset of the symptoms.'-- IPF is reversible

in the alveolitis stage, but once fibrosis develops, it does not

respond to treatinent. Tests to diagnose, follow up. and mon-

itor patients with IPF include chest radiographs, spirometry,

diffusion capacity, and blood gas analysis.'-' Of course, these

tests may be normal in patients with mild fibt-osis.-*'

PhagcK-ytic cells can oxidize methionine to methionine sul-

foxide by secretion of oxygen-derived free radicals. Anincrea.sed ratio of methionine to metliionine sulfoxide correlates

with the number of neutrophils in the BAL fluid, but not with

the nuiTiber of macrophages."''

Circulatin}» Immune Complexes

Deposition of immune complexes has a principal role in

the pathogenesis of IPF,"^ and circulating immune complexes

increase in patients with IPF.'"' Tliese immune complexes may

also be detected in the BAL fluid, and it is postulated that they

can be fomied in situ or from deposition of circulating immune

/74 RESPIRATORY CARE • AUGUST '97 VOL 42 NO 8

Bronchoalveolar Lavage

complexes within the lung and can stimulate phagocytic cells

to release chemotactic factors."'''" The detection of circu-

lating immune complexes predicts a high likelihood of response

to steroid therapy.'"*

Immunoglobulins

Immunoglobulin levels increase significantly in BAL fluid

of patients with IPF.^^^ It is thought that IgG is locally pro-

duced because the ratio of IgG to albumin is higher in BALfluid than the ratio of IgG to albumin in serum.''"' '•*'' The

presence of IgG in BAL fluid suggests that a type-Ill immune

reaction is involved.'" IgM is not found in the BAL fluids

of these patients, and the total IgA-albumin level is normal,

but the level of monometric IgA-level increases.^"' Its pres-

ence may be due to degeneration of local IgA by inflam-

matory processes.^"

Among all variants of ILD, IgE level is reduced only in

BAL fluid of patients with IPF. This suggests that allergic re-

actions have no role in the pathogenesis of IPF.""

Complement

No changes occur in levels ofC4 and C6 in BAL fluid, and

it appears that local complement is not involved in immuno-

logic reactions in these patients."''^^"'

Lipids

Phospholipids are the main components of lung surfactant,

and phospholipids like sphingomyelin and ethanolamine are

normally found in lavage fluid. '^' Although the total phos-

pholipid level is reduced in patients with IPF,'''''•*' the per-

centage of phosphotidylglycol (PG) is decreased and that of

phosphotidylinositoi (PI) is increased, and, hence, the ratio

of PG to PI is reduced. Therefore, the higher the phospholipid

level, the better the patient's prognosis.''"

In summitry, BAL is useful for diagnosis and management

of patients with IPF.'-^ Neutrophils predominate and a com-

bination of increased neutrophils and eosinophils is seen in

most IPF patients. -^"-^ Increased lymphocyte counts suggest

a favorable response to steroid therapy in IPF patients, whereas

a high eosinophil count has been reported to be associated with

a poor response.'-"""

Pulmonary Histiocytosis X

Three systemic diseases are characterized by abnormal

proliferation of mononuclear phagocytic cells—Letterer-

Siwe, Hand-Schiiller-Christian, and pulmonary histiocy-

tosis X.'-'s

Histiocytosis X cells, which are closely related to Langer-

han's cells in normal skin, are identified by X bodies;'^'' are

characterized by the absence of pigmented bodies, a con-

voluted nucleus, and pentalaminar cytoplasmic structures;

and are about 40-45 /im in width. '''^ These histiocytes can

express a specific CD-I antigen recognized by the monoclonal

antibody anti-Tft.''*"

Most patients presenting with histiocytosis X are between

20 and 40 years old and complain of dyspnea, dry cough, and

chest pain. Pneumothorax occurs in 10-20% of cases, but skin,

bone, and posterior pituitary involvement are less frequently

seen.-'''^ Chest films reveal irregular nodules in upper and mid-

lung fields, superimposed on a delicate cystic pattern.'''"

Langerhan's cells are not normally found in BAL fluid;

therefore, immunodetection of Langerhan's cells with X bod-

ies may establish the diagnosis."' '^-It should be mention-

ed that these cells are not pathognomonic because smaller

numbers have been detected in BAL fluid of patients with

bronchoalveolar carcinoma, other fibrotic lung diseases, and

in healthy smokers."' It is interesting to note that all patients

with histiocytosis X have > 5% CD-I -positive Langerhan's

cells, whereas in other disorders and in healthy cigarette

smokers < 3.6% of such cells are found."' '-''"'

The number of macrophages is significantly increased, and

up to 20% are histiocytes X cells."- '"" Because macrophages

can release a number of mediators that enhance fibroblast activ-

ity, pulmonary fibrosis eventually develops.'''- Eosinophils

may constitute up to 7% of total BAL cell counts; however,

their role is yet to be determined, and occasionally, the num-

ber of neutrophils and lymphocytes may increase slightly.-''^

Increased levels of IgG support a possible immunologic com-

ponent to the pathogenesis of histiocytosis X.'"'^ BAL cell-

structure findings iire almost normal by light microscopy, but

ultrastructural cell analysis reveals abnormalities.''"'

In summary, all cell lines—including neutrophils, eosin-

ophils, and, especially, macrophages are increased in BALfluid in pulmonary histiocytosis X. -'''"-""'

Immunodetection of Langerhan's cells with X bodies in BALfluid may establish the diagnosis although such cells are not

pathognomemic, and a false-negative result may be seen."'"-

Sarcoidosis

Disease Characteristics

Sarcoidosis is a multisystem disease of unknown etiology

characterized by noncaseating epithelioid granulomata and

enhanced cellular immune processes at the sites of involve-

ment."' The respiratory system is the most common site of

involvement, although any organ may be involved."*-"' This

disease most commonly occurs in black and young people,**^

and patients may present: (1 ) as asymptomatic, (2) with con-

stitutional symptoms, and/or (3) with symptoms related to spe-

cific organ involvement.""""-"''-"" Of those patients with lung

involvement, 5-10% eventually develop pulmonary fibrosis.

The major symptoms are dyspnea, dry cough, and, less com-

monly, chest pain.

Respiratory Care • August '97 Vol 42 No 8 775

Bronchoalveolar Lavage

Diagnosis

Open lung biopsy, gallium-67 scan, and BAL are used

in diagnosis and evaluation (Table 6), with open lung biopsy

providing the highest diagnostic yield"'' "''and with a high

correlation between biopsy and BAL findings.'** In sarco-

idosis, the ratio of CD4 to CDS T-cells is 4 to 10 times that

in the BAL fluid of normal subjects and subjects with other

interstitial lung disorders, such as IPF, histiocytosis X, and

collagen vascular diseases."''' This ratio can also help dif-

ferentiate sarcoidosis from hypersensitivity pneumonitis

because the number of CDS cells increases in pneumonitis

and the CD4-CDS ratio decreases."''' A CD4-CD8 ratio of

< 1:1 basically excludes the diagnosis of sarcoidosis.'"^

The presence of multiple noncaseating granulomata in

a transbronchial lung biopsy specimen plus a BAL fluid

CD4-CD8 ratio > 4: 1 has been reported to have a 1 00% pos-

itive predictive value for differentiation of sarcoidosis from

other diseases.'"^

BAL fluid in sarcoidosis is characterized by an increase

in proportion and number of lymphocytes,'*'-'** with lym-

phocytosis considered to be present when lymphocytes con-

stitute > 15% of cells. Lymphocytes constitute about 60% of

total recovered BAL cells,-'' but this kind of lymphocytosis

is not specific for sarcoidosis, sometimes being present in dis-

eases like tuberculosis, cancer, hypersensitivity pneumoni-

tis, and berylliosis.'*'

In most patients with ILD and in most healthy persons, 60-

65% of BAL lymphcK-ytes are T-cells, but in s;ircoidosis T-cells

may constitute up to 90 ± 4% of total lymphocytes.'*" The pro-

portion of B cells, however, is normal and that of the Null cells

is reduced."""'

Although lymphocytopenia with reduced T-cell activity

has been demonstrated in the blood of subjects with sar-

coidosis, T-cells in BAL fluid aie active and produce an aver-

age of more than 25 times the level of chemotactic factor per

cell than do sarcoid blood T-lymphocytes; therefore, blood

mononuclear cells are attracted to the lungs."- Further, sar-

coid patients who smoke have a higher number of lympho-

cytes in BAL fluid than do patients who do not smoke.'*""

Finally, it is these immunologic reactit)ns that lead to gran-

uloma formation within lung tissue."''

Intensity of Alveolitis & Prognosis

Although some correlation has been established between

;m elevated ratio ofCW to CDS in BAL fluid or increased BALlymphocyte count and poor prognosis, overall no conclusive

data verify that lavage cell analysis provides a sensitive and

specific means of a.ssessing the intensity of alveolitis or a ratio-

nal basis for therapy and follow-ups of patients with sar-

coidosis."'' '-"* However, assessing the state of the lung T-lym-

phocytes, the lung mononuclear phagocytes, or both, mayprovide information regarding the intensity of alveolitis.-""-"*'

Despite the fact that the level of lavage ACE is increased

and correlates well with uptake of 67-gallium and the num-

ber of lavage lymphocytes, it has a limited clinical applica-

tion because of its wide distribution and its being influenced

by cigarette smoking."'"

Chest fdm findings include enlargement of the intratho-

racic lymph nodes and/or lung infiltrates and depend on the

radiologic stage of the disease."*' Classic roentgenographic

manifestations of sarcoidosis, (ie, reticulonodular, acinar, and

fihrotic patterns in chest radiographs and CT scans) do not

correlate well with the severity of alveolitis."*- Pulmonary sar-

coidosis patients usually have skin anergy, but this anergy does

not correlate well with the intensity of alveolitis.'*'

A high association exists between positivity of the gallium-

67 scan and intensity of inflammation in alveolitis, and, there-

fore, such scans may be useful for characterizing severity and

anatomic location of parenchymal inflammation."**

The number of macrophages may increase in BAL fluid,

but their proportion is reduced. Of total recovered BAL cells,

up to 30% are macrophages involved in the inflammatory pro-

cesses of the sarcoid lung and stimulating T-cell replication

by release of interleukin-l."*-^"*' TTiese cells also release inter-

feron, which augments release of interleukin-l and inter-

leukin-6. "**"*** (Interferon is not present in detectable quan-

tities in BAL fluid of normal healthy persons.'*-^)

CD 1 4, a myeloid differentiation antigen, is increased in

active sarcoidosis."*" Multinuclear giant cells (macrophages

with more than 8 nucleoli) may also be found in the BAL fluid.

However, their presence does not correlate with severity of

disease (clinical assessment), proportion of BAL lymphocytes,

results of gallium-67 scan, or serum-ACE level.'""

In contrast to IPF, neutrophilia is not characteristic ofBALfluid of patients with sarcoidosis, and if neutrophils and eosino-

phils are present, they always constitute < 5% of total BAL cell

count.""* Sarcoid patients with lung involvement and a high neu-

trophilic BAL cell count may develop pulmonary fibrosis.'"'

ACE and adenosine deaminase enzyme may be elevated

in BAL fluid of sarcoidosis patients.'"-^ '"' and procollagen

type-Ill aminoterminal peptide and hyaluronan levels may

be increased (reflecting disease activity), but their determi-

nation is largely confined to research laboratories.'"'''"''

Most sarcoid patients with only extrapulmonary mani-

festation (no pulmonary symptoms or radiologic abnormal-

ities) have alveolitis as proved by BAL studies.'"* Therefore,

overall, BAL is more sensitive than either 67-gallium scan

or serum-ACE levels for the assessment and staging of latent

alveolitis. BAL fluid studies suggest that alveolitis clearly pre-

cedes any granuloma formation and may be present in an

asymptomatic patient.'"'

Hypersensitivity Pneumonitis

Hypersensitivity pneumonitis (HP), also known as extrin-

sic alveolitis, is an acute or chronic disease of the lower res-

Respiratory Care • August '97 vol 42 No 8

Bronchoalveolar Lavage

piratory tract caused by inhalation of antigenic organic

dusts.'-'^''-'^*""* In its acute form, it is characterized by fever.

cough, dyspnea, and alveolar infiltration, with symptoms usu-

ally developing 4- 1 2 hours after exposure. The chronic form

is associated witli dyspnea on exertion, cough, and weight loss.*"'

Both cell-mediated and humoral factors are involved in

the pathogenesis of HP.''''''*°'^"' and a T-lymphocyte-medi-

ated immune process is considered to contribute.*''--'^'''

Inter-

stitial and alveolar mononuclear cell infiltration with gran-

uloma formation has been demonstrated in histologic suidies.*'-'

Because lymphocytic alveolitis is characteristic of this dis-

ease, the BAL fluid is full of lymphocytes, which average 60-

70% of BAL cell count.-'' Most are CD8-h T-cells, and, thus,

the ratio of CD4-t- to CD8-(- is < 1 (in contrast to sarcoidosis).**

Both helper and suppressor T-cells express activated antigens

(la) on their surfaces,*'' and the presence of activated T-lym-

phocytes in BAL tluid indicates that a local immune mech-

anism is involved.** Macrophages represent 30% of the BALcell population.-'"*'''

In the acute phase of HP, neutrophilia may be present in

BAL fluid within 4-6 hours after antigenic exposure. The sec-

ond phase follows with a mononuclear cell infiltration that

can lead to granuloma fonnation and fibrosis.-*'""" Neutrophils

may constitute 8-41% of total cells, supporting the idea that

immune complex mechanism may be involved in patho-

genesis.'*"'' Basophils, mast, and plasma cells account for up

to 6% of total BAL cells.-'' Plasma cells are not normally pre-

sent in the BAL fluid of healthy adults and are mainly increased

in patients with HP.""- A direct relationship exists between

the presence of plasma cells and severity of alveolitis.-*"

Levels of IgM and IgG are increased in the BAL fluid, the

IgG-albumin ratio is much higher in HP than in sarcoidosis,-'"

and the level of IgM (almost never found in the BAL fluid

of healthy persons) is characteristically increased.-"-'"* The

total IgA level is within normal range, but the relative pro-

portion of monometric IgA is increased.-'*

Fibronectin and vitronectin are increased in patients with

HP and may play a role in tissue remodeling and fibrosis."*

In summary, lymphocytes predominate in BAL fluid of

patients with HP (60-70%).-" In contrast to patients with sar-

coidosis, the ratio of CD4-H to GD8-I- in HP is < 1:*'<' there-

fore, a marked lymphocytosis and a low CD4-I-CD8-I- ratio

strongly suggests HP.-" -** The level of IgM is characteris-

tically increased.-"'^'*

Collagen Vascular Diseases & Vasculitis

Scleroderma

Scleroderma, a disease of unknown etiology, can involve

the lung with acute manifestations of interstitial involvement,

vasculitis, and fibrosis, with IPF being a major cause of morbid-

ity and mortality.*"-"^ BAL findings resemble the findings

of lavage in IPF in many cases,-*'"*" with neutrophilic alveo-

litis being the characteristic feature in most such patients. Acute-

phase inflammatory cytokines, such as interleukin-1 a(IL-a)

and TNF-a, are increased in the alveolitis of scleroderma.-*"

BAL is a useful method for evaluating disease activity-*'^

and is more sensitive than pulmonary function tests.'"'' Patients

with persistent alveolitis experience more rapid deterioration

of pulmonary function than do those without alveolitis: there-

fore, the intensity of alveolitis determines functional dete-

rioration and outcome."-" The greater the number of neutrophils,

the more rapid the disease progression.-'*-"'-"'

Some patients with noninflammatory lung involvement and

inactive fibrosis may have a normal BAL analysis.-*-' Treat-

ment with corticosteroids does not seem to change inflam-

matory cell levels in serial BAL studies or gallium-67 scans. *--

Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a systemic disease that may

involve the lung, with possible pulmonary manifestations

including pleurisy, Caplan"s syndrome, pulmonary arteritis

with or without hypertension, necrobiotic nodules, and dif-

fuse interstitial disease."*-' -*-" ILD in RA usually occurs in

patients with established RA but sometimes precedes arthritic

symptoms.-'-'-*-'* The most common symptoms are dyspnea

and nonproductive cough; less common are fever, hemopt-

ysis, and chest pain."-' Radiologic findings in the diffuse inter-

stitial lung disease of RA are similar to those of IPF."-' Evi-

dence of neutrophilic alveohtis is tlie main feature of the BALfluid of such subjects."-*" Increased levels neutrophilic elas-

tase. myeloperoxidase, and their markedly enhanced chemo-

tactic activity, indicate that neutrophils may play an impor-

tant role in the inflammatory response involved."-' Subtypes

of lung T-lymphocytes have been detected, and the T-lym-

phocyte leu3/leu2A ratio may be reduced."-" Some patients

with no grossly detectable lung involvement may have abnor-

mal BAL fluid and evidence of T-lymphocytic alveolitis, a

possible clue to future lung involvement."-"

Increased local producfion of IgM as reflected in BALfluid-'

-"-'* indicates that immune complexes may have a role

in the inflammatory events."-"

BAL can be used for the assessment of lung involvement

in RA, with increased lymphocyte levels indicating subclinical

lung involvement and a good prognosis, whereas increased

neutrophil levels or elevated levels of markers for fibrosis such

as collagenase, fibronectin. and type-Ill procollagen, indicate

that the patient has an advanced alveolitis, and serious pul-

monary complications are likely to develop."-*

Ankylosing Spondylitis

Although fibrobullous apical pulmonary disease is the clas-

sic feature of ankylosing spondylitis, it is uncommon; restric-

tive lung disease is the more common presentation."-^ BALfluid analysis is not useful for evaluation of subclinical alve-

Respiratory Care • August "97 Vol 42 No 8 777

Bronchoalveolar Lavage

olitis because the lymphocyte percentage and CD4+-CD8+ratio does not differ from those of normal subjects."""

Wegener's Granulomatosis

In active Wegener's granulomatosis, the number of neu-

trophilic cells is significantly increased, and eosinophils are

also increased.^" Because antineutrophilic cytoplasmic anti-

body ( ANCA) can be detected in these patients but is absent

from BAL fluid of healthy persons and those with IPF, the

presence of ANCA can differentiate between Wegener's and

other alveolitis disorders associated with neutrophilia.'"- The

level of IgG is decreased.'*"

Summary

In summary, BAL studies have shown that 46% of patients

with collagen vascular disease but no apparent pulmonary

involvement have subclinical alveolitis.-'*-''"'

Subclinical alveolitis is not associated with pulmonary

function test deterioration during the first year but function

becomes abnormal in untreated patients.''"''"'

The 2 fonns of alveolitis associated with collagen vascular

disease are neutrophilic alveolitis, seen in progressive sys-

temic sclerosis, RA, polymyositis, and mixed connective tis-

sue diseases. -'•-*'''-^-*' and lymphocytic alveolitis, seen in Sjo-

gren's syndrome.-**^

Eosinophilic Lung Diseases

Lung disorders such as Loeftler's syndrome, allergic bron-

chopulmonary aspergillosis, chronic eosinophilic pneumo-

nia, and Churg-Strauss va.sculitis can present with eosinophilic

infiltrates.^'^ In these diseases, regardless of the level of blood

eosinophils. BAL tluid has a high eosinophil count.'*"*^''

(Eosinophils are the least frequent cells in BAL fluid of healthy

subjects, <0.57f.p""^

Although a high eosinophil count (a value of 4% as a cut-

off point) in BAL lluid may be seen in IPF, allergic bron-

chopulmonary aspergillosis, sarcoidosis, histiocytosis X, and

asthma,'"-''"'^*''-'* the term eosinophilic alveolitis should be

reserved for Loeffler syndrome, chronic eosinophilic pneu-

monia, (which may progress to IFF),-'" and Churg-Strauss

vasculitis because their BAL fluids demonstrate a high BALeosinophil count ( 20-90% ).^'"

BAL may be useful for diagnosis of some eosinophilic lung

diseases, especially when peripheral eosinophilia is absent

and chest radiographs are atypical or normal.'"'*''''"

.\sbestosis

Puinion;ir\ manifestations ot asbestosis include pleuriil effu-

sion, pleural fibrosis with or without calcification, lung and

pleural cancers, and ILD. Pulmonary asbestosis may be ini-

tiated by local lung inflammation, with many patients exhibit-

ing a neutrophilic and/or eosinophilic alveolitis.""-" Those whohave crackles on auscultation but no radiologic or physiologic

evidence of the disease have a neutrophilic-eosinophilic alve-

olitis.'"* Although many patients with asbestosis are cigarette

smokers, the increased number of neutrophils is not related

to cigarette smoking alone.'*'*'

Neutrophils can damage lung parenchyma by release of

a variety of mediators (eg, collagenase) that can be detected

in BAL fluid.**- Eosinophils also play a role in pathogene-

sis of the disea.se by releasing some other mediators such as

a major basic protein.'**- In BAL fluid, the average percent-

age of neutrophils is 19%. and eosinophils 4%.**' Higher per-

centages of these cells are associated with a longer history

of exposure, more severe parenchymal damage, and current

cigarette smoking.**'

Macrophages accumulate in the lower respiratory tract and

may have a protective role.*** Lymphocytes are increased in

BAL fluids of asbestos workers, ranging from 12-47%.**'

Decreased CD4-I- to CD8-I- ratio has been confirmed by BALfluid analysis; therefore, altered cellular immunoregulation

may play a role in pathogenesis of asbestosis.**'

Because asbestos bodies are the hallmark of exposure to

asbestos fibers, detection of asbestos bodies in sputum or

BAL fluid is useful to separate subjects who have had an

exposure to asbestos from other patients. Asbestos bodies

are found in sputum of < 50% of cases of asbestosis;**'' BALhas proved to be a better method for detection of asbestos

bodies than sputum examination.**' Asbestos bodies may

rarely be seen in BAL fluid of normal healthy persons (<

I AB/mL).**** Although a positive lavage (more than 1

AB/mL) is not pathognomonic for asbestosis, in the pres-

ence of ILD it can reliably indicate the presence of asbesto-

sis**'' because asbestos bodies are rarely detected in other

ILDs.*'" The stage of pleural plaques does not correlate with

the number of asbestos bodies in the BAL fluid.*"

Silicosis

Silicosis may present as an acute or chronic disease.*'-

Lavage studies have shown increases in lymphocytes and

macrophages, and during the first 2 weeks of exposure, a

small number of neutrophils are seen, but later mononuclear

cells accumulate.*"

Silica dust is initially engulfed by macrophages, which

then liberate a fibrogenic factor that can stimulate fibroblasts.

Pulmonary fibrosis subsequently develops with production

of collagen by fibroblasts.*'**" Silicosis can be diagnosed

by identifying silicon crystals in BAL fluid and in macro-

phages.*"' The number of both B and T-cells increases. Dur-

ing early exposure, the ratio of T4 to T8 cells is normal, but

the ratio gradually increases.*" Elevated levels of type-II cells

have been reported.*-"''

IgG. IgA. and IgM are locally produced and increased in

778 Respiratory Care • August "97 Vol 42 No 8

Bronchoalveolar Lavage

BAL fluid and may indicate the presence of a subclinical

immune response.^^** Total phospholipid content is reduced,

but this does not correlate with either radiologic or functional

markers of disease severity.'*-^'

Alveolar Proteinosis

Pulmonary alveolar proteinosis, or phospholipidosis, is a

diffuse lung disease in which a dense PAS-positive phos-

pholipid material accumulates in alveoli; however, the sep-

tal architecture of the lung interstitium is preserved.-""' Chest

radiographs may reveal alveolar or combined alveolar and inter-

stitial patterns, but a bat-wing appearance with sparing of

costophrenic angles is a classic finding.""'' The most common

symptoms are dyspnea and a nonproductive cough.""'"

An intrapulmon;iry shunt (Qs/Qt) > ^^'^'^ with an increased

serum lactate dehydrogena.se (LDH) concentration""^-""^' strongly

favors the diagnosis of alveolar proteinosis, but their absence

does not exclude the diagnosis.""^"

BAL has been suggested for diagnosis of this disease.""*"*''

The characteristic histologic pictures of diffuse granular stain-

ing interspersed with large eosinophilic bodies. PAS-positive

staining of the proteinaceous material, the presence of a few

alveolar macrophages and no intlamniatory cells, and the

opaque and/or milky appearance of returned fluid strongly

suggest the diagnosis.''' *-** Phospholipids constitute the major

component of the precipitated fraction of BAL fluid."""' with

55% of dry weight of insoluble components being lipids.^"**

Although normal LDH values for BAL tluid have not been

determined, the level is markedly increased in alveolar pro-

teinosis compared to levels in normal subjects. Therefore, it

seems that injui^ and cell death may be involved.*' BAL can

be used for the treatment of patients with alveolar pro-

teinosis.*'""'" BAL. both whole-lung and lobar, has been used

for the treamient of alveolar proteinosis with evidence of symp-

tomatic, physiologic, and radiologic improvement.*''"'^'

In Conclusion

Fiberoptic bronchoscopy with bronchoalveolar lavage

remains an effective and safe technique for diagnosing and

evaluating a variety of disorders in both chronically and acutely

ill subjects. Careful attention should be paid to patient prepa-

ration, lavage technique, and specimen processing.

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Schmidt B, Teschler H, Kroegel C, Konietzko N. Mattthyus H, Costa-

bel U. Bronchoeilveohtr cell profiles in Wegener granulomatosis (WG),

chronic eosinophilic pneumonitis (CEP), and Churg-Stfauss syndrome

(CSS). Eur Respir J 1989:2(Suppl 8), 6415.

.Mien JN, Davis WB. Pacht ER. Diagnostic significance of increa.sed

bronchoalveolar lavage fiuid eosinophils. Am Rev Respir Dis

1990:142(3):642-647.

Pesci A. Bertorelli G, Mangenelli P, Mori PA, Strinati F, Marangio

E, et al. Bronchoalveolar lavage in chronic eosinophilic pneumonia.

Analysis of six cases in comparison with other interstitial lung dis-

eases. Respiration 1988;.54(Suppl): 16-22.

Olivieri D, Pesci A, Bertorelli G. Eosinophilic alveolitis in immuno-

logic interstitial lung disorders. Lung 1990;168(Suppl):964-973.

Grandordy B. Hubert J, Marsac J, Chretien J. Relationship between

alveolar eosinophils (AE) and blood eosinophils in bronchopulmonary

disease. Am Rev Respir Dis 1983:127:142.

Rola-Pleszczynski M, Masse S, Sirois P. Lemaire I. Begin R. Early

effects of low-doses exposure to asbestos on local cellular immune

responses in the lung. J Immunol 1981;127(6):2535-2538.

Begin R, Cantin A, Drapeau G. Lamoureux G, Boclor M. Masse S,

Rola-Pleszczynski M. Pulmonary uptake of gallium-67 in a.sbestos-

exposed humans and sheep. Am Rev RespirDis 1983; 127(5 1:623-630.

Gellert AR. Langford JA, Winter RJ. Uthayiikumar S. Sinha G, Rudd

RM. Asbestosis: assessment by bronchoalveolar lavage and mea-

surement of pulmonary epithelial permeability. Thorax 1985:40(7):

.508-514.

Wagner JC, Berry G. Skidmore JW, Timbrell V. The effects of the

inhalation of asbestos in rats. Br J Cancer 1974;29(3):252-269.

Gellert AR. Macey MG, Uthayakumar S. Newland AC, Rudd RM.

Lymph(x;yte subpopulations in bronchoalveolar lavage tluid in asbestos

workers. Am Rev Respir Dis 1985;132(4):824-828.

Roggli VL, Grecnberg SD, McLarty JW, Hurst GA, Hieger LR, Far-

ley ML. Mabry LC. Comparison of sputum and lung asbestos body

counts in former asbestos workers. Am Rev RespirDis 198(1; 122(6):

941-945.

Nair P, Rupawate RU, Prabhakaran LC, Bijur S. Kamat SR. Eval-

uating computed tomography and broncho alveolar lavage in early

diagnosis of pulmonary asbestosis. Sarcoidosis I991;8(2):l 15-1 19.

Karjalainen A, Anttila S, Mantyla T. Taskinen E, Kyyronen P, Tuki-

ainen P. .Asbestos bodies in bronchoalveolar lavage fiuid in relation

to occupational history. .Am J Ind Med 1 994:26(5 ):645-654.

Schwartz DA. GaKin JR. Burmeister LF, Merchant RK, Dayton CS.

Merchant JA, Huniiingh;ike CiW. The clinical ;uid reliability of asbestos

bodies in bronchoalveolar fiuid. Am Rev Respu'Dis 1991; 144(3, Part

I):684-688.

450. De-Vuyst P, Jedwab J, Dumortier P, Vandermoten G, Vande-Weyer

R, Yamault JC. Asbestos bodies in bronchoalveolar lavage. Am Rev

RespirDis 1982;126(6):972-976.

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Orlowski E. Pairon JC. Ameille J. Janson X, Iwatsubo Y, Dufour G,

et al. Pleural plaques, asbestos exposure, and asbestos bodies in bron-

choalveolar lavage fluid. Am J Ind Med 1994:26(31:349-358.

452. Occupational silicosis-Ohio. MMWR Morb Mortal Wkly Rep 1995:

44:61-64.

453. Suuhar D. Harbeck RJ, Manson RJ. LymphcKyte populations in lung

tissue, bronchoalveolar lavage fiuid, and peripheral bloods in rat at

various times during the development of silicosis. Am Rev Respir

Dis 1989:139:28-32.

454. Benson SC, Belton JC, Scheve LG. Regulation ol lung fibroblast pro-

liferation and protein synthesis by bronchiolar lavage in experimental

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455. Lapp NL, Castranova V. How silicosis and coal workers' pneu-

moconiosis develop—a cellular assessment. Occup Med 1993:8(1):

35-56.

456. Saenghirunvattana S, Chaaienpan P, Bixmpucknavig V, Sriurairatana

S, Apibal S. Silicosis in ceramic-industry workers with particular ref-

erence to the diagnostic value of bronchoalveolar lavage. J Med Assoc

Thai 1991;74(8):358-.^62.

457. Schuyler MR, Gaunter HR, Stankus RP, Kaimal J, Hoffman E, Sal-

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458. Calhoun WJ, Christman JW, Ershler WB, Grahan WG, Davis GS.

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et al. Phospholipid content of bronchoalveolar lavage fluid in gran-

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JC, Bellon G. Pulmonary alveolar proteinosis: experience with eight

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Composition of bronchoalveolar lavage effluents from patients with

pulmonary alveolar proteinosis. Lab Invest 1978;39(4):342-357.

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monary alveolar phospholipoproteinosis: experience with .34 cases

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47 1

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Brach BB, Harrel JH. Moser KM. Alveolar proteinosis: lobar lavage

by fiberoptic bronchoscopic technique. Chest 1976:69(2):224-227.

-90 Respiratory Care • August "97 Vol 42 No 8

Jon Nilsestuen PhD RCP RRT. Robert Harwood MSA RRT. Ken Hargett BS

RCP RRT, Section Editors. Submissions from readers are encouraged. Please

follow the Manuscript Preparation Guide and submit to RESPIRATORY CARE

Journal Office. 1 KBO Abies Lane. Dallas, Texas 75229. Graphics Comer

Excessive Work of Breathing, Active Exhalation, and Retardation of

Expiratory Flow: WTiat's the Problem and Wliere's the Problem?

Richard D Branson RRT, Robert S Campbell RRT, and Jay AJohannigman MD

Case Summary

A 72-year-oId black woman was admitted to the emergency

department complaining of repeated bouts of lightheadedness

and syncope. Her past medical history was positive for coro-

nary artery disease, hypertension, and peripheral vascular dis-

ease. She had no surgical history. An anterior-posterior chest

film demonstrated a widened mediastinum, nearly two thirds

of the chest width. An aortogram demonstrated a dissecting

aneurysin of the thoracic aorta.

She was taken to the operating room where repair of the

aneurysm was completed. Her postoperative course was com-

plicated by a massive pulmonary embolus, respiratory fail-

ure, and congestive heart failure. After a 4-week period of

mechanical ventilation, her condition had improved and she

was extubated. Immediately after extubation she became dys-

pneic and hypoxemic and required reintubation. She was

mechanically ventilated for 4 more days, at which time the

decision was made to perform a tracheotomy and place a gas-

trostomy tube in preparation for long-term-care placement.

Two days after the tracheotomy, the critical care staff was

asked to evaluate the patient. The patient was observed to be

tachypneic. diaphoretic, and actively exhaling. Changes in

Mr Branson is Assistant Professor of Surgery. Mr Campbell is Senior

Research Associate, and Dr Johannigman is Assistant Professor of

Surgery. University of Cincinnati. Division of Trauma/Critical Care

—

Cincinnati. Ohio.

ventilator mode, tidal volume, and respiratory rate did not alle-

viate the dyssynchrony and dyspnea. In fact, her respiratory

rate and tidal volume were nearly identical in the continuous

mandatory ventilation mode (both volume- and pressure-con-

trolled), intemiittent mandatory ventilation mode, and spon-

taneous mode (with and without pressure support). Her active

expiratoPt' phase was peiplexing and could not be alleviated

with sedation.

In an effort to eliminate any patient-ventilator dyssyn-

chrony issues as a cause of her dyspnea, she was placed in

the continuous positive airway pressure (CPAP) mode. At

10 cm HiO CPAP the patient's respiratory rate was 21

breaths/min. tidal volume 1010 mL, minute ventilation 22

L/min. and inspiratory-to-expiratory time ratio (I:E ) 1 :3.6.

The flow and volume tracings from the Puritan Bennett

7200ae ventilator are shown in Figure 1.

120-1

V(L/min)

1201.2'

Vt(L)

-0 4-1

INSP

SEC

EXH

SEC

Fig. 1 . Flow and volume tracings from the Puritan Bennett 7200ae

ventilator in a patient who was experiencing dyspnea.

How would you answer these questions?

What abnormal findings are seen in the flow tracing?

What abnormal findings are seen in the volume tracing?

Answers on next page

RESPIRATORY CARE • AUGUST "97 VOL 42 NO 8 791

Graphics Corner

Answers

Ventilator Scalars: Both tracings in Figure 1 show evidence

of a prolonged expiratory phase and air trapping. The vol-

ume and flow signals demonstrate a rapid rise during inspi-

ration with a slow, gradual reaim to baseline during expiration.

The volume signal also demonstrates an expired tidal volume

larger than the inspired tidal volume. This suggests either an

error in the flow sensor calibration or persistent air trapping.

Active exhalation observed in this patient despite the ven-

tilator mode and level of support suggested that air trapping

was the likely cause. Information from sensors in the ven-

tilator circuit were helpful in this instance but did not give

a complete picture of the patient's respiratory mechanics. Wedecided that determining her work of breathing and observ-

ing esophageal pressure might be helpful in elucidating the

etiology of her dyspnea.

The inability to change patient respiratory rate and tidal

volume despite increasing ventilatory support, coupled with

the findings in Figure 1, suggested a need for further eval-

uation of respiratory mechanics. An esophageal catheter was

placed, and a separate flow transducer was placed at the prox-

imal endotracheal tube and connected to a respiratory mon-

itor (BiCore CP-IOO. Allied Healthcare Products. Riverside

CA). The patient remained on CPAP at 10 cm H^O. Airway

pressure, volume, flow, and esophageal pressure tracings are

shown in Figure 2.

2;

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Respiratory Care • August '97 Vol 42 No 8 793

Graphics Corner

Answers

Volume & Flow Tracings: Both the vDlume and flow trac-

ing continue to demonstrate a prolonged expiratory phase

suggestive of an increase in expiratory resistance. The bipha-

sic pattern seen in the expiratory flow tracing also suggests

that the obstruction is variable (that is. as the patient in-

creases intrapulnionary pressure during active exhalation,

flow increases).

Airway Pressure: The proximal airway pressure tracing demon-

strates a negative pressure deflection of > 10 cm H2O prior

to triggering of the demand valve. Sensitivity was set at - 1 .0

cm HiO. Large pressure swings during spontaneous breath-

ing are associated with an elevated work of breathing.' The

cause of this elevation in respiratory work may be due to in-

appropriate sensitivity setting, a ptxirly responsive demand \ alve.

or intrinsic pulmonary disease. In this case, her intrinsic abnor-

mality was the cause of her increased work of breathing.

Esophageal Pressure: CPAP was 10 cm HiO when the trac-

ings were made. During exhalation, the patient's end-expi-

ratory esophageal pressure was 38 cm H2O. Active expira-

tory muscle contraction results in elevated esophageal pressure

and suggests air trapping secondaiy to expiratory How obstmc-

tion. The patient's esophageal pressure tracing also denK)n-

strates a negative pressure deflection of nearly 30 cm H2Oprior to ventilator triggering. Her measured work of breath-

ing during this time was 2.72 j/L. Normal work of breathing

is0..S-().7j/L.-

Analysis & Discussion

The ventilator flow and volume tracings clearly suggest

the presence of an expiratory flow limitation. After our ini-

tial evaluation, we suctioned the patient without difficulty,

and a small volume of white mucus was obtained. We had

no ditficulty passing ihe suction catheter through the trache-

ostomy tube and encountered no resistance suggestive of

obstruction. Troubleshooting the ventilator circuit, humid-

ifler. and exhalation val\ e revealed patent tubing and prop-

erly functioning equipment.

The esophageal pressure tracing is particularly interest-

ing in this ca.se. With certain assumptions, esophageal pres-

sure can be used to estimate pleural pressure.' The observation

of active exhalation and no subjective evidence of a reduc-

tion in the work of breathing regardless of ventilator settings

prompted us to u.se esophageal pressure monitoring. Our ini-

tial intent was to use the monitor to determine a ventilatory

technique that would reduce her work ot breathing.

The quantitation of esophageal pressure allows determi-

nation of intrinsic positive end-expiratory pressure, or auto-

PEEP, in spontaneous breathing patients and calculation of

the work of breathing. Quantitation of auto-PEEP provides

the difference between airway and esophageal pressure prior

to the onset of flow during a patient-triggered breath; the work

of breathing is represented by the area of the esophageal pres-

sure-volume curve below baseline."' Both measurements are

invalidated by expiratory muscle effort.^ The use of the expi-

ratory muscles during exhalation is abnormal because exha-

lation should be passive. When the expiratory muscles are

active, intrathoracic pressure can be increased even in the

absence of air-trapping. In such instances, esophageal pres-

sure measurements are elevated due to patient effort rather

than to an increa.se in lung volume. In our patient, both air trap-

ping and expiratory muscle effort contributed to the end-expi-

ratory esophageal pressure of 38 cm H2O. Despite these dif-

ficulties, the measurement of esophageal pressure at 30 cmH2O above airway pressure during spontaneous breathing was

helpful in our decision-making.

The elevated esophageal pressure coupled with no cause

e)f flow resistance in the ventilator, ventilator circuit, and pa-

tient airway led us to look for an intrapulnionary cause of

obstiTjction. Aerosolized bronchodilators throughout the day

had failed to provide any relief. A bedside fiberoptic bron-

choscopy revealed a normal-appearing trachea. However, dur-

ing expiration, the posterior wall of the trachea collapsed, leav-

ing a narrow, crescent-shaped opening, inadequate for complete

expiration. This closing of the trachea required the patient to

activate expiratory muscles to overcome the resistance, with

passive exhalation followed by active exhalation creating the

biphasic flow in the expiratory flow waveform.

Tracheomalacia is a rare but well-described complication

of prolonged tracheal intubation.* However, in this instance

the interior of the trachea appeared completely normal. There

was no evidence of ulceration or necrosis of the tracheal wall

near where the endou^acheal tube cuff had been. The mucosa

was pink and devoid of secretions or cellular debris. In this

instance, the weakening of the posterior tracheal wall was

created by external pressure. The patient's initial aortic

aneurysm had been in the aortic arch. Repair of the defect

coupled with her prolonged illness and month-long period

of tracheal intubation led to the weakened trachea. A wire,

re-enforced endotracheal tube was inserted through the tra-

cheostomy site past the area of collapse, and the balloon was

inflated. Her symptoms were ameliorated immediately. She

was seen by otolaryngology and scheduled for repair of the

trachea at a later date.

In Conclusion

Respiratory distress in the ventilated patient can be mul-

tifactorial. In the case reported here, the rare complication of

tracheomalacia froin external compression was identified with

Ihe help of graphic monitoring of airway pressure, volume,

and flow. Use of esophageal pressure monitoring added addi-

tional information that was helpful in elucidating the etiol-

ogy of the problem. When flow and volume monitoring sug-

44 Respiratory Care • August '97 Vol 42 No 8

Graphics Corner

gest norma] inspiratory resistance with marked expiratory flow

obstruction, the practitioner should progress logically through

the steps of troubleshooting. In our case, this included con-

firming patency of the airways (patient and mechanical) by

passing a suction catheter; evaluating the integrity of the ven-

tilator circuit and ventilator exhalation valve by visual inspec-

tion, and verifying normal operation of the ventilator when

disconnected from the patient: and evaluating intrathoracic

causes of expiratory flow limitation (eg, bronchospasm, for-

eign body, and mucus plugs). The absence of inspiratory flow

resistance in the presence of marked expiratory flow resis-

tance and active expiratory effort led us to the diagnosis prior

to confirmation by bronchoscopy.

REFERENCES

1

.

Opt Holt TB, Hall MW, Bass JB, Allison RC. Comparison otchanges

in airway pressui^ during continuous positive airway pressure (CPAP)

between demand and continuous flow devices. Respir Care 1982;27

(10):1200-I209.

2. Otis AB. The work ot breathing. Physiol Rev 1954-.34:449-4.';8.

3. Daly WJ, Bonduranl S. Direct measurement of respiratory pleural

changes in normal man. J .Appl Physiol 1963;18:513-518.

4. Otis AB. Fenn WO. Rahn H. The mechanics of breathing in man.

J Appl Physiol 1950;2:592-607.

5. Knowles JH, Henry SK, Rahn H. Possible errors using esophageal

balloon in determination of pressure volume characteristics of the

lung and thoracic cage. J Appl Physiol 1959;14:523-530.

6. Colice GL, Strukel TA. Dain B. Laryngeal complications of prolonged

intubation. Chest 1989;96:877-884.

43'^'' International Respiratory Congress

December 6-9 • New Orleans, Louisiana

RESPIRATORY CARE • AUGUST "97 VOL 42 NO 8 795

Letters

Letters addressing topics of current intei^sl or materia] in RESPIRATORY CARE will be considered for publication. The Editors inay accept or

decline a letter or edit without changing the author's views. The content of letters as published may simply reflect the author's opinion or inter-

pretation of information—not standard practice or the Journal's recommendation. Authors of criticized material will have the opportunity to

reply in print. No anonymous letters can be published. Type letter double-spaced, mark it "For Publication," and mail it to RESPIRATORY

Care. 1 1030 Abies Lane, Dallas TX 75229-4593.

Asthma & SCUBA Diving

I read with interest the letter from Gin-

ger E Benlifer PhD, regarding her husband's

tragic SCUBA diving death from an asth-

matic reaction [RespirCare 1997;42(6):652].

You replied that ". . .the recent literature sug-

gests that no consensus exists regarding the

likelihood of the occurrence of complications

from SCUBA diving in asthmatics." Nor will

there likely be any consensus, because

"asthma" is such a variable condition, and

the risks are more theoretical than proven

with any hard data.

The issue is an old one; in the SCUBAcommunity asthma and diving have been

talked, written, and argued about for years.

I recently had opportunity to review the

world's literature on the subject, and wrote

a chapter, with all the references, for a book

on SCUBA diving medicine and physiology.

I have also posted the entire asthma chap-

ter on the Internet; interested readers can find

it at http://www.mtsinai.org/pulmonary/

books/scuba/asthma.htm. TTie chapter's title,

appropriately, is "Should Asthmatics Not

Scuba Dive?"

Lawrence Martin MD FACP FCCPChief, Pulmonary Division

Mt Sinai Medical Center

Cleveland, Ohio

Graphics Corner Makes Waves?

I read with interest the Graphics Comer,

"A Patient in Status Asthmaticus: What

Does the Waveform Confirm'.'" by Robert

HanvcKxi MSA RRT. Lynda Tlioma.s Good-

fellow MBA RRT. DiAnn Uirson RRT. and

Robert Aranson MD in the March 1997

issue of RE.SP1RATORY Care. The Dis-

cussion section was well presented and

nicely summarized the information and

action to take when using graphic wave-

forms and esophageal manometry to inon-

itor patients.

However, the authors stated in Part 2 that

the How setting was increased from 50

L/min, as correctly depicted in Part I . Fig-

ure I . to 100 L/min. 1 noticed that in Part 2,

Tracing A. the L/sec scale is 2 versus 1 in

Part 1 . Because 2 L/s equals 1 20 L/min and

the peak flow in this tracing can be seen to

just exceed the I L/s line (or 60 L/min), the

actual rate would appear to be 70-80 L/min.

not 100 L/min as the authors contend.

Tracing B. while I do note a percepti-

ble increase in the peak flow tracing com-

pared to Tracing A. does not reach the 2 L/s

line or 120 L/min as the authors contend

but appears to be 80-90 L/min. Were the

authors using the graphics to measure and

monitor delivered flows or were they rely-

ing on the mechanical ventilator's setting?

Which method do the authors recommend?

Because this article was published in Graph-

ics Corner, am I correct to assume that a

graphics monitor would be the preferred ref-

erence for ventilator monitoring and setting

changes when evaluating a patient in sta-

tus asthmaticus?

The authors' main point. "In tracing B,

the hyperinflation and PEEP, have been elim-

inated...."because "increasing the flow re-

duced the inspiratory time {T|) and increased

the Te [expiratory time] . . .

;" therefore, "the

reduction in trapped air is .seen in the return

of the flow curve to baseline before the next

breath is delivered. .

." appears to be contra-

dicted by the tracings of esophageal pres-

sure (Pes). The tracing in Part I and the trac-

ings in Part 2: A and B depict the Pes to be

consistently hovering around 20 cm HiO

regardless of peak flows and changes in T|

or Te. Am I correct in deducing that there

is significant pressure remaining in the lung

at end expiration (intrinsic PEEP)?

From reviewing the authors' waveforms,

it appears that there was no significant

change in the patient's air trapping even

though inspiratory flow was increased and

the patient's expiratory flow did return to

baseline. Was the lesson to be learned froin

these tracings that—despite some appropriate

ventilator manipulations—the patient was

left with considerable trapped air (PEEP;)

as evidenced by the eosphageal pressure

readings? Would it have been interesting and

instructive to see the effect on the eosphageal

pressure tracing of lowering or discontin-

uing the exffinsic PEEP of 10 cm H;0? Whywas this possible intervention not included

and demonstrated in the article?

Whereas the authors did address the Pes

and its effect on patient triggering, lung

compliance, and hemodynamics, I am left

wondering why they omitted a discussion

of whether or not information from Pes

could provide assistance in evaluating

chani;es in ventilator settings and their sub-

sequent influence on PEEPj in the patient

with status asthmaticus.

Phil Mercuric BA RRTRespiratory Care Department

University of New Mexico Health

Sciences Center

Albuquerque, New Mexico

Airflow Resistance & Zero Flow:

An Apparent Contradiction?

Jon Nilsestuen and Ken Hargett have

made a valuable contribution with their

review of patient-ventilator graphic analy-

sis.' This is a complex topic that is rarely

treated well in respiratory therapy textbooks.

There is one concept in particular that res-

piratory therapists have often confused. That

is the definition and interpretation of

"dynamic compliance." Nilsestuen and Har-

gett have correctly defined dynamic com-

pliance as the slope of the pressure-volume

curve between points of zero flow. However,

they state that "the dynamic measurement

includes both the elastic and resistive char-

acteristics of the system. . .."

It may be con-

fusing to many readers how airtlow resis-

tance can play a part when the measurements

are made during zero flow. Perhaps the

authors could expand on this issue and clar-

ify the apparent contradiction.

Robert L Chatburn RRTDirector. Respiratory Care Department

University Hospitals of Cleveland

Assistant Professor

Department of Pediatrics

Case Western Reserve University

Cleveland. Ohio

REFERENCES

1 . Nilsestuen JO, Hargett K. Managing the

patienl-vcntilator system using a graphic

analysis: an overv iew and introduction to

graphics comer. RespirCare 1996:41(12):

1105-1122.

Editors' Note: The Section Editors for Gra-

phics Comer are developing features to ad-

dress the points raised by Mr Mercurio and

Mr Chatburn. Please look for these inter-

esting and informative case smdies in an up-

coming issue of RE.SP1RATORY Care.

ElESPIRATORY CARE • AUGUST '97 VOL 42 NO 8

i/h-NlM/ O^JuyM-

i-1, 1W

AARC Practice GuidelinesCPG 1 — Spirometry, 1996 Update $1

CPG 2 — Oxygen Therapy in Acute Care Hospital $1

CPG 3 — Nasotracheal Suctioning $1

CPG 4 — Patient-Ventilator System Checks $1

CPG 5 — Directed Cough $1

CPG G — In-Vitro pH and Blood Gas Analysis and Hemoximetry • $1

CPG 7 — Use of Positive Airway Pressure Adjuncts to Bronchial

Hygiene Therapy • $1

CPG B — Sampling for Arterial Blood Gas Analysis $1

CPG 9 — Endotracheal Suctioning of Mechanically Ventilated

Adults and Children with Artificial Airways $1

CPGIO — Incentive Spirometry • $1

CPGll — Postural Drainage Therapy • $1

CPG12 — Bronchial Provocation $1

CPG13 — Selection of Aerosol Delivery Device $1

CPG14 — Pulse Oximetry $1

CPG15 — Single-Breath Carbon Monoxide Diffusing Capacity $1

CPGIG — Oxygen Therapy in the Home or Extended Care Facility • $1

CPG17 — Exercise Testing for Evaluation of Hypoxemia

and/or Desaturation $1

CPG18 — Humidification during Mechanical Ventilation $1

CPG19 — Transport of the Mechanically Ventilated Patient $1

CPG20 — Resuscitation in Acute Care Hospitals $1

CPG21 — Bland Aerosol Administration $1

CPG22 — Fiberoptic Bronchoscopy Assisting $1

CPG23 — Intermittent Positive Pressure Breathing (IPPB) $1

CPG24 — Application of CPAP to Neonates Via Nasal Prongs or

Nasopharyngeal Tube • $1

CPG25 — Delivery of Aerosols to the Upper Ain«ay $1

CPG2G — Neonatal Time-Triggered, Pressure-Limited, Time-Cycled

Mechanical Ventilation $1

CPG27 — Static Lung Volumes $1

CPG2B — Surfactant Replacement Therapy $1

CPG29 — Ventilator Circuit Changes $1

CPG30 — Metabolic Measurement using Indirect Calorimetry

during Mechanical Ventilation $1

CPG31 — Transcutaneous Blood Gas Monitoring for

Neonatal & Pediatric Patients $1

CPG32 — Body Plethysmography $1

CPG33 — Capillary Blood Gas Sampling for Neonatal & Pediatric Patients $1

CPG34 — Defibnllation during Resuscitation $1

CPG35 — Infant/Toddler Pulmonary Function Tests $1

CPG3G — Management of Airway Emergencies • $1

CPG37 — Assessing Response to Bronchodilator Therapy at Point of Care $1

CPG3B — Discharge Planning for the Respiratory Care Patient • $1

CPG39 — Long-Term Invasive Mechanical Ventilation in the Home $f

CPG40 — Capnography/Capnometry during Mechanical Ventilation • $1

CPG41 — Selection of an Aerosol Delivery Device for Neonatal

and Pediatric Patients $1

CPG42 — Polysomnography $1

CPG43 — Selection of an Oxygen Delivery Device for Neonatal and

Pediatric Patients $1

CPG44 — Selection of a Device for Delivery of Aerosol to the Lung

Parenchyma • $1

CPG45 — Training the Health-Care Professional for the Role of Patient and

Caregiver Educator • $1

CPG4G — Providing Patient and Caregiver Training $1

CPG99 - Complete Set

in Binder $35($60 nonmembers) (-i-$7.00 for Shipping and Handling)

American Association for Respiratory Care

11030 Abies Ln., Dallas, TX 75229-4593

Call (972) 243 2272 orfax to (972) 484-2720

with MasterCard, Visa, or

Purchase Order Number

Texas cuitomen only, pleoie add S 25% sales tax (including shipping charges) Texas customers that ore exempt Irom sales tax must attach an exemption certificate Prices subject to change ^

Historical NotesContributions lo this section are welcome. Send double-spaced typed material (and illustraiitms if pertinent) to

Hisu>rical Notes. RESPIRATORY CARP., 1 1030 Abies Lane, Dallas TX 75229-4593. Identify source of material

and include your name, credentials, and address.

Nebulizer

An Excerpt from 1953

The nebulizer is an instmment designed to produce a spray

of liquid particles microscopic in size. These mix with the

inspired air as a fine mist and the liquid is deposited on the

mucous membrane of the respiratory passages. The location

of the settling of the mist will be determined by two factors:

1 , the size of the p;irticles; 2. the current inspired air. The small-

er the particle size, the more easily it is carried by the air cur-

rent and will thus settle when the flow of air has stopped. The

distribution of such p;ulicles then inay reach down to the small-

est of bronchial tubes and into the alveoli. This is true only

of particles around the size of one micron. The larger the par-

ticle, the sooner it will come to rest and thus has its greatest

concentration in the upper air passages, mouth, and pharynx.

Purpose

Nebulization is a method of depositing drugs in respira-

tory mucous membrane. These can accomplish four things:

1

.

Antibiotic and antibacterial action. Drugs used thus are pen-

icillin, streptomycin, tyrothricin, etc.

2. Antispasmodic action, e.g., adrenalin, vaponefrin, isuprel,

etc.

3. Liquefaction of secretion with detergents, ammonium chk>

ride, Kl, etc.

4. Humidification.

Equipment

Tlie type of nebuli/er will be determined by the function

to which it is put. If it is necessary to deposit material deep

ill the bronchial tree, such as in the treatment of deep bronchial

Frmii Effective Inhalation Thcrai>\. wrillen by l-'dwin K Lcvinc MD in

cooperation with Alvan L Baracli MD. J Winthrop Peabody MD. and

Maurice Segal MD. and published in 1953 by the National Cylinder Gas

Co of Chicago. Dr Levine. a chest physician, was an early champion of

our profession and President of the American Association for Inhalation

Therapy in W52 (the only physician in the Association's history to so

serve). The other authors were also pioneers in pulmonary medicine and

inhalation therapy.

This excerpt was inade available to Rlspir.Mokv C.\Rr. by Teri Nikolai

Wilson RR I RPFT. United Healthcare of Ohio, Centerville. Ohio.

infections, the equipment must produce small droplets of

a size not larger than three inicrons. For this the vaponefrin

or DeVilbiss 40 nebulizers are satisfactory in any one of the

many variations and models in which they have been placed

on the market.

If more than one or two c.c. is to be nebulized at one time,

or if the aerosol must be inhaled consistently for any definite

period, the NCG Humidifier-Nebulizer is the most efficient.

This will yield a constant stream of finely divided droplets

for as long a period as is required. Since there is a reservoir

which may be refilled without interrupting therapy, this is the

ideal equipment for continuous aerosol therapy over a period

of hours or days.

All nebulizers require a stream of gas to nebulize the liq-

uid. This stream is produced by a hand bulb, a hand pump,

motor driven pumps, and oxygen cylinders. The NCG Humid-

ifier-Nebulizer should always be used with the oxygen cylin-

der only. The hand bulb is effective only when a few drops

of the solution are used at any one time such as is the case

in the use of antispasmodic drugs. When as much as one c.c.

is required for a single treattnent. most patients will find the

necessity of squeezing a bulb for a period of five to ten min-

utes an excessively fatiguing process. For this reason a pump

or an oxygen cylinder is necessary for adequate treatment in

any of these cases.

Use

Antibiotic solutions—in the treatment of bronchiectasis,

chronic bronchitis, asthma, and some pneumonias—as finely

nebulized solutions or aerosols, are one of the most effec-

tive tiiethods. This is generally combined with medication

for cough and postural drainage. Frequently antispasmodic

drugs are mixed with the antibiotic solution. In most of these

cases it is important that the medicament reach deep into the

chest into the small bronchi. To accomplish this one c.c. of

the prescribed solution is placed in the nebulizer and all stop-

pers removed. Some nebulizers are simple; others contain

rebreathing bags: some, bulbs or bags to be placed in hot water

or other variations. These changes and viuiations are designed

for specific treatment; the essential aspect is the stream of

fine tnist that comes out of the mouth of the nebulizer.

Unless the nebulizer is used as a part of a mask or with

a rebreathing apparatus connected with it. it is best that it

'•8 RiispiRATORY Care • August "97 Vol 42 No 8

Historical Note

should not be inserted into the mouth. There are two reasons

for this.

First, if it is designed to mix the mist with inspired air this

will best be done by holding the nebulizer a little in front of

the open mouth. In this case air flows in or around the mist

and an effective mixture results, carrying the aerosol wher-

ever the air goes. It follows logically that the deeper the res-

piration, the greater the amount of aerosol which will reach

into the bronchi and the less proportionately will remain in

the mouth and the throat.

The second reason is to prevent the accumulation in the

mouth and throat and prevent the irritation that is sometimes

caused by this. For this reason it is generally desirable to fol-

low aerosol drugs with the inhalation of 0.5 to 1 c.c. of nor-

mal saline through the same nebulizer. This washes out the

mouth and throat, removing the objectionable taste and dimin-

ishing the chance of irritation.

Some people recommend the use of a Y tube to prevent

waste of the aerosol. It is reasoned that only during inspira-

tion is it desirable to produce the mist. With the Y tube all of

the gas will pass out the open end because of the difference

of pressure, and only when this end is closed will gas pass

through the nebulizer. Thus by placing the thumb over the op-

en end of the Y tube the nebulizer can be set in action, and

when it is desired to stop the flow of mist the thumb is removed.

This is very effective for patients whose coordination and sense

of timing are excellent. Studies have shown, however, that

the average patient wastes more solution by faulty timing in

the use of the Y tube than is wasted in expiration. For that rea-

son, in most cases it is most desirable to omit this part of the

apparatus and to have the solution running constantly.

The customai7 concentrations of antibiotics which are used

today, such as 50,000-200,000 units of penicillin per c.c, are

so great that an adequate amount is always deposited in the

bronchi if the technique is proper, even if all the solution is

not actually inhaled into the trachea. When using the oxygen

cylinder, there is no fixed rate of flow that is proper, since this

varies with the type of nebulizer, density of the solution, res-

piration of the patient, etc. In general it should take about ten

minutes to nebulize 1 c.c. solution.

In special cases, where the patient is unable to co-oper-

ate, a demand type of valve is used which opens only dur-

ing inspiration and is closed during expiration. These are gen-

erally used with the mask nebulizer combination.

43'^'' International Respiratory Congress

December 6-9 • New Orleans, Louisiana

Respiratory Care • August '97 Vol 42 No 8 799

fBmim

CRCE through theJournal—1997

CRCE through the Journal, a program for AARC members to gain credit for con-

tinuing education, is now in its eighth year. Through reading RESPIRATORY CARE

—

the science journal for respiratory care practitioners—and completing this examination,

AARC members may earn credit for continuing education.*

This 50-item, multiple-choice examination is based on papers published from July

1996 through June 1997 in RESPIRATORY CARE. The issue and page numbers of the

paper on which a question is based are shown in brackets following the question. You

may consult the cited paper; however, we encourage you to read the paper in its entirety

before answering the question. Choose the single most-correct answer, and mark the

answer sheet, which is locatedfollowing Page 808.

Mail your completed answer sheet by September 30. 1997. Answer sheets postmarked

after September .^0 will not be proces.sed. The Answer Key for CRCE through the Jour-

nal will be published in the October Issue of RESPIRATORY CARE. No scores will be

available from the AARC until the 1997 CRCE Transcripts are mailed in early 1998.

We iire indebted to the co-authors of the test: Crystal L Dunlevy EdD RRT, Consultant

—

Atlanta, Georgia; Lisa M Bueltel MS RRT. Education & Research Coordinator, Cen-

tral Ohio Breathing Association—Columbus. Ohio; Gregory Hagan MAE MA RRT.

Associate Professor, Respiratory Care, Madison\ ille Community College—Madisonville,

Kentucky; David F Pennaman MS RRT. Program Director, Respiratory Care, Madis-

onville Health Technology Center—Madisonville, Kentucky; and Barbara Rushley RRT,

Director of Asthma Services. Central Ohio Breathing Association—Columbus, Ohio.

*The acceptance of tliese credits for the fulfillment of license-mandated continuing education is dictated solely by

the licensure law of each individual state.

^00 Respiratory Care • August '97 Vol 42 No 8

CRCE THROUGH THE JOURNAL

QUESTIONS: Pleasefollow the instructions on the previous page, and record your answers on

the perforatedform providedfollowing page 808.

1 . According to Granger, the only oxygen-tension-

based index of gas exchange to estimate shunt

not affected by Fio: is the:

a. P(A-a)02-

b. PaO:/PAO:.

C. PaoVFlO:-

d. estimated venous admixture.

e. respiratory index.

[July 1996;41(7):586-594J

4. McCarthy and Stoller report that during spirom-

etry a modified technique that encourages the

subject to relax as compared to the standard

blow, blow, blow technique produces:

a. an unacceptable end-of-test criterion.

b. increased lightheadedness.

c. larger FVCs.

d. decreased FEV|S.

e. increased transpulmonary pressures.

[September 1996;41(9):826-828]

When applying therapist driven protocols as a

measure of the ability to develop appropriate

care plans, Meredith et al conclude that:

a. students from baccalaureate-degree pro-

grams perform better than those from associ-

ate degree programs.

b. staff therapists perfonn better than instnictors.

c. the ability to develop appropriate care plans

is directly related to reading ability.

d. current training in assessment skills is ade-

quate.

e. to develop expertise in applying algorithms,

students as well as staff therapists should

write patient care plans.

[July 1996;41(7):595-600]

Which of the following statements is not true

according to the study conducted by Reick con-

cerning auto-PEEP and manual resuscitators?

a. Respiratory care students set the highest

flows of all health care practitioners studied.

b. Nurses set higher flows than respiratory care

practitioners.

c. All health care practitioners set oxygen flows

higher than those recommended by the man-

ufacturers.

d. Increased airway resistance resulted in an

earlier appearance of auto-PEEP.

e. Reduced pulmonary compliance resulted in

higher auto-PEEP values.

[November 1996;41(11): 1009-1012]

3. Branson and Davis suggest that with respect to

passive humidifiers (PH):

a. the resistance offered by a PH may be of little

importance to a sedated and paralyzed

patient in the operating room.

b. the smaller the dead-space volume of the PH,

the greater the moisture output.

c. a PH with a moisture of >32 mg H2O/L is

recommended for ICU patients.

d. PH complications cannot be prevented by

algorithms.

e. the dead space volume of a PH is of little

consequence for the spontaneously breathing

patient.

[August 1996;41(8):736-743]

6. With regard to measurement theory and equip-

ment evaluation. Chatburn argues that:

a.

b.

d.

calibration of equipment decreases the

chances of random error,

repeated measurements with a device reduce

the chances of systematic error,

in assessing the agreement between old and

new models of blood gas analyzers, the / test

should be employed.

the most widely misused indicator of agree-

ment between various devices is the Pearson

product moment correlation coefficient.

Respiratory Care • August '97 Vol 42 No 8 801

CRCE THROUGH THE JOURNAL

e. knowing how single measurements from

devices compare to known values or other

values yields only misinformation.

[December 1996;41( 12): 1092- 10991

d. laryngospasm

e. increased airway secretions

[March 1997;42(3):292-293]

7. According to London, which of the following

statements is not true?

a. Managed care has resulted in the decreased

utilization of technical and professional ser-

vices.

b. Respiratory care practitioners (RCPs) are

well suited to lead multidisciplinary teams.

c. RCPs need to increase their involvement in

asthma education.

d. Multiskilling of RCPs results in role ambigu-

ity and decreased job satisfaction.

e. Outcomes management of chronic obstruc-

tive lung disease should produce clinical and

cost improvements.

[January 1997;42(l ):30-42]

10. What conclusion can be drawn from the study

conducted by Pina et al regarding the use of

nose clips and pulmonary function testing?

a. Nose clips should be used in adults when

measuring PEFR.

b. Nose clips should be used in children with

cystic fibrosis when measuring FEVi.

c. When measuring FEF25.75 in obstructed and

unobstructed adults, there is no statistically

significant difference with and without the

use of nose clips.

d. Nose clips should be used in patients with

palatofacial deformities.

e. When measuring FEVi in unobstructed

adults, nose clips should be used.

[May 1997;42(5):492-4971

8. DeAbate et al argue that oral levofloxacin

should be considered as an empirical agent for

acute bacterial exacerbation of chronic bronchi-

tis because:

a. it is from two to four times more potent in

vitro than isofloxacin, and it penetrates well

into bronchioiar tissue and sputum.

b. it is highly effective against HaemophiJus

influenzae, the most common pathogen asso-

ciated with chronic bronchitis.

c. many pathogens may have a high probability

of resistance to traditional antibiotics but not

to levolloxacin.

d. all of the above.

e. a and c only.

[Februarv 1 997;42( 2):206-2 1 .![

9. During ketamine administration which of the

following would not be expected to occur?

a. an increase in pulmonary vascular resistance

b. inhibition of vagal outflow

c. dysphoric reactions

11. According to Mathewson and DeVane. what

class of drugs in combination with sulfon-

amides can prevent the progression of lung

infections by Pneitmucyslis caiiniil

a. antiprotozoan

b. antimicrobial

c. anticancer

d. antimalarial

e. antifolate

[July 1996;41(7):625-627]

12. After reviewing a hospital respiratory care

assessment-treatment program. Shrake et al

reported all of the following outcomes except?

a. Participation in the protocol process in-

creased significantly.

b. Physicians accepted the plan 90-97% of the

time.

c. More than $15,000 was saved during the 3

months.

d. Overall treatment volume increased.

e. Results were duplicated hospitalwide.

[August 1 996:4 1(8):703-7 II]

802 Respiratory Care • August "97 Vol 42 No 8

CRCE THROUGH THE JOURNAL

13. Dennison et al found which statement to be true

about the performance of the Serv02 oxygen-

control system?

a. 02% was maintained and C02% was elimi-

nated.

b. 02% fluctuated greatly with port-holes open

and diaphragms in place.

c. Only low levels of CO2 were capable of

being flushed.

d. 02% fluctuated and C02% was eliminated.

e. Diaphragms over rear port holes are not nec-

essary for use in patient care.

[August 1996;41(8):724-7271

14. Which conclusion is supported by the results of

the study by Chatbum et al?

a. Neonatal airway leak can be minimized with

pressure-controlled ventilation.

b. Neonatal airway leak can be minimized with

flow-controlled ventilation.

c. Neonatal airway leak cannot be minimized

with any mode of ventilation.

d. Longer inspiratory times, regardless of

mode, minimizes airway leak.

e. Flow controlled ventilation with long inspi-

ratory time minimizes airway leak.

[August 1996:4U8);728-735J

15. After comparing three humidification techniques,

what did Branson and associates conclude?

a. Nosocomial pneumonia is influenced by the

humidification device utilized.

b. Hygroscopic condenser humidifier (HCH)

use in surgical patients is safe and effective.

c. Medical patients meet HCH criteria more

often than surgical patients.

d. For 1 day use, a heated-wire circuit is less

costly than one without heated wires.

e. After 5 days, the non-heated-wire circuit cost

decreases.

[September 1996;41(9):809-816]

16. According to the study of NO and NO2 analyz-

ers by Betit et al, the NO2 readings varied the

most when the delivered O2 concentration was:

a. =0.21,[NO]>40ppmb. >0.21,[NO]>40ppmc. >0.21,|NO|<40ppmd. =0.21,[NO]<40ppme. =0.21,[NO] = 40ppm

[September 1996;41(9):817-825]

17. In the study by Mortimer et al, under what cir-

cumstance was NO delivery with high-fre-

quency jet ventilation (HFJV) adequate?

a. when NO levels were measured at the inspi-

ratory limb

b. when NO levels were measured at the expira-

tory limb

c. when CV pressures interrupted HFJVd. when CV pressures did not interrupt HFJVe. when high mean airway pressures were used

with HFJV[October 1 996:4 1(10):895-902]

The implementation of a respiratory therapy

assessment team may be associated with which

of the following outcomes for patients re-admit-

ted to the ICU, according to Kirby and Durbin?

a. reduced mortality

b. decreased re-admission rate

c. reduced premature discharge

d. decreased length of hospital stay

e. decrease in respiratory deterioration

[October l996;41(10):903-907]

19. From the paper by Mason and Miller, which of

the following is not a benefit of the Circulaire

Nebulizer System?

a. fewer side-effects

b. reduced environmental contamination

c. increased depth of penetration

Respiratory Care • August '97 Vol 42 No 8 803

CRCE THROUGH THE JOURNAL

d. reduced extra-pulmonary deposition in the

body

e. protection for the caregiver

[November 1996;41(11): 1006-1008]

20. In the study by AUaway et al. what percentage

of patients who received smoking-cessation

counseling from an RCP, were tobacco free at

follow-up?

a. 77%b. 55%c. 42%d. 30%e. 3%

[November 1996;41(11):1026-1029]

21. According to Monem et al, in manual volume-

controlled ventilation for neonates which of the

following is undesirable?

a. F,o:Of 100%

b. lower PIPmax value

c. consistent volume

d. greater PlPjitt range

e. consistent rate

[December 1996;41(12):1083-1089]

22. All but which of the following was not reported

in Ahmad and colleagues' study of cost effec-

tiveness?

a. "High-volume" respiratory care treatments

for non-ICU patients have decreased.

b. The average number of respiratory therapy

treatments per non-ICU patient has de-

creased.

c. Overall number of hospital admissions

decreased.

d. Total cost of major therapies for the non-ICU

patient decreased.

e. Mean cost per patient of respiratory care ser-

vices decreased.

[January l997;42(l):43-53]

23. Mishoe and Maclntyre report that continuing

education to expand the professional role of the

RCP can be enhanced by which of following?

a. lectures

b. mini-lectures

c. theory models

d. performance models

e. science models

[January 1997;42(I):7I-91]

24. From the paper by Cornish, which of the fol-

lowing is not one of the reasons cited to use the

RCP in extended care facilities?

a. experience in protocols and clinical pathways

b. comprehensive assessment skills

c. ability to provide patient, family, and staff

education

d. experience with intensive or emergency care

e. ability to provide total patient care

[January 1997;42(1):I27-132J

25. From the paper by Dunne, which of the follow-

ing does not describe how the RCP in the home

care setting is suited to enhance collaborative

self-management?

a. follow-up visits

b. patient-caregiver education

c. medication administration

d. initial and ongoing assessments

e. consultative services

[January 1997;42( I):!33-I401

26. According to Chatbum et al, how can mechani-

cal ventilation outcomes in the pediatric ICU be

improved?

a. increasing tidal volumes

b. decreasing practice variance

c. drawing more frequent ABG's

d. decreasing PS levels

e. increasing the frequency of CPAP trials

[February 1997;42(2):221-225]

804 Respiratory Care • August "97 Vol 42 No 8

CRCE THROUGH THE JOURNAL

27. According to Keenan and Martin, which of the

following indicates readiness for extubation in a

patient who is breathing at a comfortable rate on

VSV?

a. Vt is 1-2 mL/kg, PIP = 20 cm H2O. oxygena-

tion = 100%

b. Vt is 3-6 mL/kg, PIP < 20 cm H2O, oxygena-

tion is adequate

c. Vt is 6-8 mL/kg. PIP = 20 cm H^O. oxygena-

tion is adequate

d. Vt is 5-7 mL/kg, PIP = 20 cm H2O, oxygena-

tion is adequate

e. Vt is 3-6 mL/kg, PIP > 20 cm H2O, oxygena-

tion is adequate

[March 1997;42(3):28 1-287]

28. According to Volsko and Chatbum, how can ac-

cidental extubations in neonates be reduced?

a. Use a Logan-bow for infants < 1 .5 kg.

b. Use conventional taping for infants < 1 .5 kg.

c. Use a Logan bow for all neonates.

d. Use conventional taping for all neonates.

e. Use a Logan-bow for infants > 1 .5 kg.

[March 1997;42(3):288-291]

29. According to the NAEPP Report II. long-tenn

daily peak-flow monitoring is helpful in manag-

ing patients with moderate-to-severe, persistent

asthma for all but which of the following rea-

sons?

a. to detect early changes in disease status that

require treatment

b. to provide a quantitative measure of impair-

ment

c. to evaluate responses to changes in therapy

d. to evaluate responses to changes in chronic

maintenance therapy

e. to provide assessment of severity for patients

with poor perception of airflow obstruction

[May 1997;42(5):499-510]

30. Which of the following is considered a long-

acting ^agonist?

a. pirbuterol

b. salmeterol

c. albuterol

d. epinephrine

e. terbutaline

[May 1997;42(5):499-5I0]

31. Based on the medical literature cun^entiy avail-

able:

a. Pressure-targeted ventilators (PTVs) are

unable to meet patients' ventilatory demands

as well as standard ICU ventilators.

b. PTVs are able to meet the ventilatory

demands of patients as well as standard ICU

ventilators.

c. PTVs are not as well tolerated as volume

ventilators.

d. PTVs are best used in patients who have poor

lung compliance.

e. PTVs are unable to meet inspiratory de-

mands of most patients.

[April 1997;42(4):380-388]

32. All but which of the following are true regard-

ing use of noninvasive positive pressure venti-

lation (NPPV) in patients with exacerbations of

COPD?

a. NPPV has been shown to decrease incidence

of intubation.

b. NPPV is associated with a lower mortality

rate.

c. Use of NPPV in this population should still

be considered experimental.

d. NPPV is appropriate for routine use in this

patient population.

e. NPPV should only be used in those institu-

tions where personnel have expertise in its

application.

[April I997;42(4):394-402]

33. According to a 1993 study published in Chest

and cited by Bach, which NPPV interface is the

most preferred by patients receiving long-term

daytime support?

Respiratory Care • August "97 Vol 42 No 8 805

CRCE THROUGH THE JOURNAL

a. nasal mask

b. full face mask

c. lipseal

d. nasal pillows

e. mouthpiece

[April 1997;42(4):403-413]

34. What is the most well-documented clinical indi-

cation for the use of NPPV in the pediatric pop-

ulation?

a. neuromuscular disease

b. acute hypoxemic respiratory failure

c. nocturnal obstructive hypoventilation

d. central hypoventilation syndrome

e. chronic obstructive disease

[April 1997;42(4):414-423]

35. In Hess' review of seven controlled studies

involving NPPV, which of the following state-

ments is true?

a. Most of these excluded COPD patients from

the study population.

b. Only pressure ventilation was used.

c. Rate of intubation was lower for NPPVpatients compared to those who received

conventional therapy.

d. All studies showed a reduced length of stay

with NPPV use.

e. All studies reported significant cost savings

with use of NPPV.

[April 1997;42(4):424-431]

36. Complications associated with noninvasive

positive pressure ventilation include all but

which of the following?

a. nasal congestion

b. eye irritation

c. gastric insufflation

d. atelectasis

e. air leaks

[April 1997;42(4):432-442]

37. When patients are satisfied with their care,

which of the following is less likely to occur?

a. increased compliance

b. better tolerance of uncomfortable proce-

dures/treatments

c. enhanced trust between patient and caregiver

d. diminished stress

e. intolerance of delays

[May 1997;42(5):5 11-516]

38. According to Djunaedi and colleagues, their

ventilatory management protocol produced

which of the following patient outcomes, as

compared to conventional care?

a. no difference in level of patient comfort

b. no difference in time taken to respond to

abnormal blood gas or oximetry values

c. earlier initiation of weaning

d. decreased duration of mechanical ventilation

time

e. no difference in ability to totally rest patients

in acute respiratory failure

[June 1997;42(6):604-6I0]

39. According to Pfaff and others, the ATEM(assessment tool for equipment management)

has benefits over other similar instruments.

These benefits include all but which of the fol-

lowing?

a. improved patient compliance

b. improved detection of knowledge deficits

c. more easily understood documentation

d. more objective review of client knowledge

e. allows for evaluation of change in knowl-

edge over time

[June I997;42(6):61i-6I6J

40. Concerning the heating of gases higher than

body temperature in the treatment of hypother-

mia or cold water near-drowning:

a. The AHA, ACLS, and AARC agree on the

appropriate range of inspired gas tempera-

ture.

S06 Respiratory Care • August "97 Vol 42 No 8

CRCE THROUGH THE JOURNAL

b. There are several humidifiers designed

specifically for this purpose currently on the

market.

c. Patients who receive heated humidified gas

lose significantly less heat than those who do

not receive special therapy.

d. Heated, humidified gases to victims of cold

water near-drowning is a stabilization tech-

nique, rather than a primary rewamiing tech-

nique, according to a leading advocate.

e. The medical literature overwhelmingly sup-

ports the heating of inspired gases for the

treatment of cold water near-drowning or

hypothermia.

[June 1997:42(6):617-6191

4 1 . Robert Thompson's study of ventilator-associated

pneumonia (VAP) referenced CDC guidelines

that recommend ventilator circuits be changed:

a. every 24 hours.

b. every 48 hours.

c. less frequently than every 48 hours.

d. every 7 days.

e. every 14 days.

[July 1996;41(7):60 1-606]

42. In his operational evaluation of the Bird Avian

Transport Ventilator, Op't Holt reported vari-

ance in respiratory rate and tidal volume that he

considered to be:

a. potentially harmful.

b. not clinically important.

c. out of compliance with published guidelines.

d. dangerous to patient welfare.

e. beneficial to the patient.

[August 1996;41(8):7 14-723]

43. The precision and accuracy data calculated for

the point-of-care fluorescent optode blood gas

analyzer, studied by Maclntyre et al, were:

a. clearly in violation of CLIA guidelines.

b. sufficient to reject this form of measurement.

c. acceptable for transport purposes only.

d. comparable to or better than results from

other studies.

e. significantly better than that of the Radiome-

ter ABL-500.

[September 1996;41(9):800-804]

44. Electrolyte-balanced syringes studied by Haver

et al were shown to:

a. grossly reduce Ca"^ measurements.

b. result in Ca"^ measurements that were signif-

icantly higher than control values.

c. cause unpredictable Ca^ concentration mea-

surements.

d. result in Ca^ measurement differences that

were not statistically significant from con-

trols.

e. consistently and falsely increase Ca*^ mea-

surements.

[September 1996;41(9):805-808]

45. Croci and colleagues reported that higher pres-

surization rates in pressure support ventilation:

a. significantly reduce imposed work of breath-

ing.

b. do not affect work of breathing.

c. slightly increase work of breathing.

d. dramatically increase work of breathing.

e. eliminate any concern for work of breathing.

[October 1996:41 (10):880-884]

46. In their comparison of the Puritan Bennett 335

and Respironics BiPAP S/T. Hill and colleagues

found that:

a. all patients found the Puritan Bennett 335

easier to breathe with.

b. patients using the Respironics BiPAP S/T

had improved acid base status.

c. in the Bennett 335, excessive sensitivity of

the IPAP-to-EPAP trigger may reduce tidal

voluine.

d. the Respironics BiPAP S/T was a more effec-

tive ventilator.

Respiratory Care • August "97 Vol 42 No 8 807

CRCE THROUGH THE JOURNAL

e. the Puritan Bennett 335 was a superior venti-

lator in all respects.

[October 1996;41(10):885-894]

47. Patel, Petrini, and Norman's study of various

methods of delivered CPAP, pressure support,

and T-piece weaning reported that work of

breathing was:

a. significantly higher on CPAP.

b. not statistically different.

c. highest in pressure support.

d. significantly less in T-piece breathing.

e. detrimentally high in pressure support.

[November 1996;41( 11 ): 1013-1019]

d. interdependence is an elusive goal for the

therapist.

e. interdependence is a characteristic of effec-

tive people.

[January 1997;42( 1):1 16-126]

49. Mathewson and Mathewson reported that

angiotensin converting enzyme (ACE) in-

hibitors frequently cause the side effect of:

a. bronchospasm.

b. pulmonary edema.

c. pulmonary interstitial fibrosis.

d. chronic nonproductive cough.

e. idiopathic pulmonary hypertension.

[May 1997;42(5):517-519]

48. In his discussion of the role of the respiratory

therapist in the ICU, Hess claims that, with re-

gard to interdependence:

a. therapists should be independent practition-

ers.

b. interdependence has been detrimental to the

development of the respiratory care profes-

sion.

c. therapists are incapable of interdependence

with other disciplines.

50. According to Turner, when noninvasive posi-

tive pressure ventilation is prescribed, which

factor should be considered when selecting the

most appropriate interface?

a. presence of sinusitis

b. tidal volume

c. forced vital capacity

d. SpO:

e. external PEEP level

[April 1997;42(4):389-393]

Make sure to double check your work and to mark the answer

sheet clearly. Mail your completed answer sheet by September 30,

1997 to

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Look for the answers in the October 1997 issue of RESPIRATORY

Care.

80S Respir.atory Care • August "97 Vol 42 No 8

RE/PIRATORy C&RE

We are pleased to offer CRCE through the Journal for 1 997. On the other side of this page,

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questions. Complete the grids by using these rules:

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Follow all instructions explicitly. Failure to do so may cause technical problems that could

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Questions concerning the examination should be directed to the CRCE Coordinator, (972)

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Remember, the acceptance of these credits for the fulfillment of license-mandated continu-

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Signature Date

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right-hand column, then complete the applicable section. All information

requested below must be provided, except where indicated as optional.

See other side for more information and fee schedule. Please sign and

date opplication on reverse side and type or print clearly. Processing of

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D Active

Associate

Z-i Foreign

n Physician

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n Special

D Student

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Social Security No.

Home Address

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State .Zip

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Z_ Technical Director

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Hove you ever been a member of the AARC?

If so, when? From t

Preferred mailing address: . Home _. Business

^^y^merican Association for Respiratory Core • 1 1030 Abies Lane

FOR ACTIVE MEMBERAn rndividual is eligible if he/she lives m the U S or its territories or wos on Active Memberprior to moving outside its borders or territories, and meets ONE of the followinq criteria: (1)

IS legally credentiated as a respiratory care professional if employed in a state triot mandates

such, OR (2) IS a groduate of an accredited educational program in respiratory core, OR (3)

holds o credentiar issued by the NBRC An individual who is an AARC Active Member in

good stonding on December 8, 1994, will continue os such provided his/her membershipremoins in good standing

PLEASE USE THE ADDRESS OF THE LOCATION WHERE YOU PERFORM YOUR JOB, NOTTHE CORPORATE HEADQUARTERS IF IT IS LOCATED ELSEWHERE.

Place of Employment^

Address

City_

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Phone No.

Medical Director/Medical Sponsor

.

FOR ASSOCIATE OR SPECIAL MEMBERIndtviduols who hold o position related to respiratory care but do not meet the requirements

of Active Member sholl be Associate Members They hove oil the rights and benefits of the

Association except to hold office, vote, or serve os choir of a standing committee The

following subclasses of Associate Membership are avoiloble Foreign, Physician, andIndustrial (individuals whose primary occupation is directly or indirectly devoted to the

manufacture, sole, or distribution of respiratory core equipment or supplies] Special

Members are those not working in a respiratory core-relofed field

PLEASE USE THE ADDRESS OF THE LOCATION WHERE YOU PERFORM YOUR JOB, NOTTHE CORPORATE HEADQUARTERS IF IT IS LOCATED ELSEWHERE

Place of Employment .

Address

City

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Phone No.

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FOR STUDENT MEMBERIndividuals will be classified as Student Members if they meet all the requirements for

Associate Membership and ore enrolled in on educational program in respiratory care

accredited by, or in the process of seeking accreditation from, on AARC-recognized ogency.

SPECIAL NOTICE — Student Members do not receive Continuing Respiratory Care Education

(CRCE) transcripts. Upon completion of your respiratory care education, continuing education

credits may be pursued upon your reclassification lo Active or Associate Member.

School/RC Program

Address

City

State

Phone No.

.Zip

Length of program1 year

Z~ 2 years

Expected Dote of Graduation (required information)

Month Year

D 4 years

Other, specify

.

Dallas, TX 75229-4593 • (972) 243-227 ; (972) 484-t iM

Demographic QuestionsWe request that you answer these questions in order to help us

design services and programs to meet your needs.

Check the Highest Degree Earned

U High School

n RC Graduate Technician

D Associate Degree

n Bachelor's Degree

n Master's Degree

n Doctorate Degree

Number of Years in Respiratory Care0-2 years Z. 11-15 Years

D 3-5 years D 16 years or more

D 6-10 years

Job Status

D Full Time

n Part Time

Credentials

a RRT

D CRHn Physician

n CRNAD RN

Salary

D Less than $10,000

D $10,001 -$20,000

D $20,001 -$30,000

n $30,001 -$40,000

D $40,000 or more

D LVN/LPN

D CPFT

D RPFT

D Perinotal/Pediatric

PLEASE SIGNI hereby apply for membership in the American Association for Respiratory Care

and have enclosed my dues. If approved for membership in the AARC, I will

obide by its bylaws and professional code of ethics I authorize investigofion of

all stotements contained herein and understand that misrepresentations or

omissions of facts called for is cause for rejection or expulsion.

A yearly subscription to RESPIRATORY Care journal and AARC Times mogozine

includes an ollocation of $6 50 from my dues for each of these publicolions

NOTE. Contributions or gifts to the AARC are not tax deductible as charitable

contributions for income tax purposes- However, they may be tax deductible as

ordinary and necessary business expenses subject to restrictions imposed as a

result of association lobbying activities. The AARC estimates that the

nondeductible portion of your dues — the portion which is allocable to lobbying

— is 26%

Signature

Date

Membership FeesPayment must accompany your application to the AARC. Fees ore for 12

months. (NOTE: Renewal fees are $65.00 Active, Associate-Industrial or

Associate-Physician, or Special status; $80.00 for Associate-Foreign status; and

$35.00for Student status).

D Active

MErJOfccHFor VOLUNTARY rerorting

hv health professionals of ad\ erse

events and product problems

FDA Use Only (Resp Care)

THF H>\ MIKU M I'KIIDUI 1 > KhI'llkllsc. I' k I u.K V M

A. Patient information1 Patient identifier

In confidence

2 Age at time

of event:

Date

of birtli:

3 Sex

I Ifemale

I I

male

Page

4 Weigfit

kgs

B. Adverse event or product problemAdverse event ana jr Product problem le g detects malfunctions)

2 Outcomes attributed to adverse event

(ctieck all tfiat apply)

deatti

I Ilife-tfireatening

[ I

hospitalization - initial or prolonged LJ o'^er

I I

disability

I Icongenital anomaly

I Irequired intervention to prevent

permanent impairment/damage

3 Date of

event

4 Date of

this report

5 Describe event or problem

6 Relevant tests/laboratory data, including dales

Other relevant history, including preexisting medical conditions (e g ,allergies,

race, pregnancy, smoking and alcohol use, hepatic/renal dysfunction, etc)

Mailto: MinW.MCH or FAX to:

5600 Fishers Lane 1 -800-FDA-01 78Rockville, MD 20852-9787

Triage unit

sequence «

C. Suspect medication(s)1 Name iqive labeled suengm .\ niir labeler, if known)

#1

2 Dose, frequency & route used

#1

»2

»2

3 Therapy dates (if unknown, give duration)

Irorrvio ioi Desi eslimalel

#1

4 Diagnosis for use (indicalioni

#1

6 Lot # (if known)

#1

«2

7 Exp. date (if known)

#1

#2

9 NDC # (for product problems only)

5 Event abated after use

stopped or dose reduced

#1 Dyes Dno Dgg^py"''

#2 Dyes Dno D^^^Py"'

8 Event reappeared after

reintroduction

«l Dyes Dno Dgg^Py"'"

#2 Dyes Dno Dgg^Py"'

10- Concomitant medical products and therapy dates (exclude treatment of event)

D. Suspect medical device

3 Manufacturer name & address

1 Brand name

2 Type of device

6

model # _

catalog #

serial #

lot #

other «

4 Operator of device

I I

health professional

I Ilay user/patient

I Iother;

5 Expiration date

7. If implanted, give dateImo-aavyi;

8 If explanted, give date

9 Device available for evaluation? (Do not send to FDA)

I Iyes EH ho EH returned to manufacturer on

10 Concomitant medical products and therapy dates (exclude treatment of event)

E. Reporter (see confidentiality section on back)

1 Name & address phone #

Health professional?

yes no

Occupation

If you do NOT want your identity disclosed to

the manufacturer, place an " X " in this box. EH

4 Also reported io

I I

nianu'acturer

EH us;;r lacility

II

distributor

FDA Form 3500 1/96) Submission of 3 report does not constitute an admission that medical personnel or the product caused or contributed to the ev

ADVICE ABOUT VOLUNTARY REPORTING

Report experiences with:

• medications (drugs or biologies)

• medical devices (including in-vitro diagnostics)

• special nutritional products (dietary

supplements, medical foods, infant formulas)

• other products regulated by FDA

Report SERIOUS adverse events. An event

is serious when the patient outcome is:

• deatti

• life-threatening (real risk of dying)

• hospitalization (initial or prolonged)

• disability (significant, persistent or permanent)

• congenital anomaly

• required intervention to prevent permanent

impairment or damage

Report even if:

• you're not certain the product caused the

event

• you don't have all the details

Report product problems - quality, performanceor safety concerns such as:

• suspected contamination

• questionable stability

• defective components

• poor packaging or labeling

• therapeutic failures

How to report:

• just fill in the sections that apply to your report

• use section C for all products except

medical devices

• attach additional blank pages if needed

• use a separate form for each patient

• report either to FDA or the manufacturer

(or both)

Important numbers:• 1-800-FDA-0178

• 1-800-FDA-7737

• 1-800-FDA-1088

• 1-800-822-7967

to FAX report

to report by modemto report by phone or for

more information

for a VAERS form

for vaccines

If your report involves a serious adverse eventwith a device and it occurred in a facility outside a doc-

tor's office, that facility may be legally required to report to

FDA and/or the manufacturer. Please notify the person in

that facility who would handle such reporting.

Confidentiality: The patient's identity is held in stnct

confidence by FDA and protected to the fullest extent of

the law. The reporter's identity, including the identity of a

self-reporter, may be shared with the manufacturer unless

requested otherwise. However, FDA will not disclose the

reporter's identity in response to a request from the

public, pursuant to the Freedom of Information Act.

The public reporting burden lor this collection of inlormalion

has been estimated to average 30 minutes per response,including the time for reviewing instructions, searching exist-

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Send comments regarding this burden estimate or any other

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OHHS Reports Clearance Oftice

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An agency may not conduct oi sponsorand a person is not required lo respond lo,

a collection ot information unless il displaysa currently valid OPklB control number

Please do NOTreturn this formto either of theseaddresses

U.S. DEPARTMEr*T OF HEALTH AND HUMAN SERVICESPublic Health Service • Food and Drug Administration

FDA Form 3500-back Please Use Address Provided Below - Just Fold In Thirds, Tape and Mail

Department of

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Public Health Service

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NO POSTAGENECESSARYIF MAILEDIN THE

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POSTAGE WILL BE PAID BY FOOD AND DRUG ADMINISTRATION

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||||,|||M<ltll.llll.tllilltl..lMilllll<l.llllll.ll

RE/PIRATORy QiRE

Manuscript Preparation Guide

General Information

Respiratory Care welcomes original manuscripts related to the

science and technology of respiratory care and prepared accord-

ing to these Instructions and the Unijonn Recjuiremeius for

Manuscripts Submitted to Biomedical Journals [Respir Care 1 997;

42(6):623-634]. Manuscripts are blinded and reviewed by pro-

fessionals who are experts in their fields. Authors are responsible

for all aspects of the manuscript and receive galleys to proofread

before publication. Each accepted manuscript is copyedited so that

its message is clear and it confomis to the Journal's style. Published

papers are copyrighted by Daedalus Inc and may not be published

elsewhere without permission.

Editorial consultation is available at any stage of planning or writ-

ing. On request, specific guidance is provided for all publication cat-

egories. To receive these Instructions and related materials, write

to Respiratory Care. 1 1030 Abies Lane. Dallas TX 73229-4593.

call (972) 243-2272. or fax (972) 484-6010.

Publication Categories & Structure

Research Article: A report of an original investigation (a study).

It includes a Title Page. Abstract, Introduction. Methods. Results.

Discussion. Conclusions. Product Sources. Acknowledgments. Ref-

erences. Tables. Appendices. Figures, and Figure Captions.

Evaluation of Device/Method/Technique: A description and eval-

uation of an old or new device, method, technique, or modification.

It has a Title Page, Abstract, Introduction, Description of De-

vice/Method/Technique, Evaluation Methods, Evaluation Results,

Discussion, Conclusions, Product Sources, Acknowledgments, Ref-

erences, Tables, Appendices. Figures, and Figure Captions. Com-

parative cost data should be included wherever possible.

Case Report: A report of a clinical case that is uncommon, or was

managed in a new way, or is exceptionally instructive. All authors

must be associated with the case. A case-managing physician must

either be an author or furnish a letter approving the manuscript. Its

components are Title Page. Abstract, Introduction, Case Summa-

ry, Discussion, References, Tables, Figures, and Figure Captions.

Review Article: A comprehensive, critical review of the literature

and state-of-the-art summary of a pertinent topic that has been the

subject of at least 40 published research articles. Title Page. Out-

line, Introduction, Review of the Literature, Summary, Acknowl-

edgments, References. Tables, Appendices, and Figures and Cap-

tions may be included.

Overview: A critical review of a pertinent topic that has fewer than

40 published research articles.

Update: A report of subsequent developments in a topic that has

been critically reviewed in this Journal or elsewhere.

Point-of-View Paper: A paper expressing personal but substanti-

ated opinions on a pertinent topic. Title Page. Text, References, Tables,

and Illustrations may be included.

Special Article: A pertinent paper not fitting one of the foregoing

categories may be acceptable as a Special Article. Consult with the

Editor before writing or submitting such a paper.

Editorial: A paper drawing attention to a pertinent concern; it may

present an opposing opinion, clarify a position, or bring a problem

into focus.

Letter: A signed communication, marked "For publication."

about prior publications in this Journal or about other pertinent top-

ics. Tables and illustrations may be included.

Blood Gas Corner: A brief, instmctive case report involving blood

gas values

—

with Questions. Answers, and Discussion.

Drug Capsule: A mini-review paper about a drug or class of drugs

that includes discussions of pharmacology, pharmacokinetics,

and pharmacotherapy.

Graphics Corner: A briefcase report incorporating waveforms for

monitoring or diagnosis—with Questions. Answers, and Discussion.

Kittredge's Comer: A brief description of the operation of respiratory

care equipmenl—w ith information from manufacturers and edito-

rial comments and suggestions.

PET Corner: Like Blood Gas Corner, but involving pulmonary

function tests.

Cardiorespiratory Interactions. A case report demonstrating the

interaction between the cardiovascular and respiratory systems. It

should be a patient-care scenario; however, the case—the central

theme—is the .systems interaction. CRl is characterized by figures,

equations, and a glossary. See the March 1996 Issue of RESPIRA-

TORY Care for more detail.

Test Your Radiologic Skill: Like Blood Gas Comer, but involv-

ing pulmonary medicine radiography ;ind including one or more radio-

graphs; may involve imaging techniques other than conventional

chest radiography.

Review of Book, Film, Tape, or Software: A balanced, critical

review of a recent release.

Preparing the Manuscript

Print on one side of white bond paper, 8.5 in.x 1 1 in. (216 x 279 mm)

with margins of at least 1 in. (25 mm) on all sides of the page. U.se

double-spacing throughout the entire manuscript. Use a standard

font (eg, Times, Helvetica, or Courier) at least 10 points mi s:/., aid

Respiratory Care Manuscript Preparation Guide, Revised 6/97

Manuscript Preparation Guide

do not use italics except for special emphasis. Number ail pages in

upper-right comers. Indent paragraphs 5 spaces. Do notjustify. Do

not put authors' names, institutional atl'iliations or allusions to

institutional affiliations in the text, or other identitkation any-

where except on the title page. Repeat title only (no authors) on

the abstract page. Begin each of the following on a new page: Title

Page, Abstract. Text, Product Sources List, Acknowledgments. Ref-

erences, each Table, and each Appendix. Use standard Hnglish in

the first person and active voice.

Center main section headings on the page and type them in cap-

ital and small letters (eg. Introduction. Methods, Results. Discus-

sion). Begin subheadings at the left margin and type them in cap-

ital and small letters (eg. Patients, Equipment, Statistical Analysis).

References. Cite only published works as references. Manuscripts

accepted but not yet published may be cited as references: desig-

nate the accepting journal, followed by (in press), ;uid provide 3 copies

of the in-press article for reviewer inspection. Cite references in the

text with superscript numerals. Assign numbers in the order that ref-

erences are fust cited. On the reference page, list the cited works

in numerical order. Follow the Journal's style for references. Abbre-

viate journal names as in liulc.x Medicits. List all authors.

Article in a journal caiTving pagination throughout volume:

Rau JL, Harwood RJ. Comparison of nebulizer delivery methods

through a neonatal endotracheal tube; a bench study. Respir Care

IW2;37(I1):1233-I240.

Article in a publication that numbers each issue beginning with

Page I

:

Bunch D. Establishing a nal!on;il database lor home Ciue. AARC Times

l')91;l.';(Mar):61,62,64.

Corporate author journal article:

,\merican Association for Respiratory Care. Criteria lor establish-

ing units for chronic ventilator-dependeiil palienis in Imsplials. Respir

Care I9X8;.^.3(I I ):l()44-l()46.

Article in journal supplement: (Journals differ in their methods of

numbering and identifying supplements. Supply sufllcient information

to promote retrieval.)

Reynolds HY. Idiopathic inlersiitlal pulmonary lihrosis. Chesi 1986;

89(3Suppl);l39S-143S.

Abstract in journal: (Abstracts citations ;u"e to be avoided. Those more

than 3 years old should not be cited.)

,Slevcns DP. .Scavenging riUivirin from an oxygen HckkI io reduce envi-

ronmenlal exposure ( abstract ). Respir Care I99();3ri( 1 1 ): 1087-1088.

Editorial in journal:

[•nnglit P. Can we relax during spiromclry? (editorial). Am Rev Respir

Dis I993;I48(2);274.

Editorial with no author given:

Negative-pressure ventilation for chronic obstructive pulmonary dis-

ease (editorial), l.ancel I992;,340(8833):I44()-144I.

Letter in journal:

Aelon\ Y. Ethnic norms lor pulmonarj' luncuon tests (letter). Chest

I99l;99(4);10.')l.

Paper accepted but not yet published:

Hess D. New therapies for asthma. Respir Care (year, in press).

Personal author book: (For any book, specific pages should be cited

whenever possible.)

DeReniee RA. Clinical profiles of diffuse interstitial pulmonary dis-

ease. New York: Futura; 1990. p. 76-85.

Corporate author book:

Americiui Medical Association Dcp;irtinent of Drugs. AMA drug eval-

uations. 3rd ed. Littleton CO: Publishing Sciences Group; 1977.

Chapter in book with editor(s):

Pierce AK. Acute respiratory failure. In; GuenterCA, Welch MH,ediU)rs. Pulmonary medicine. Philadelphia; JB LippincoU; 1977.

Tables. Use consecutively numbered tables to display information.

Start each table on a separate page. Number and title the table and

give each column a brief heading. Place explanations in footnotes,

including all nonstandard abbreviations and symbols. Key the foot-

notes with conventional designations (*, t, +, 11,11. **, tt) in con-

sistent order, placing them superscript in the table body. Do not use

horizontal or vertical rules or borders. Do not submit tables as pho-

tographs, reduced in size, or on oversize paper. Use the same type-

face as in the text.

Illustrations. Graphs, line drawings, photographs, and radiographs

are figures. Use only illustrations that clarify and augment the text.

Number them consecutively as Fig. I . Fig. 2, and so forth accord-

ing to the order by which they are mentioned in the text. Be sure all

figures are cited. If iiny figure was previously published, include copy-

right holder's written permission to reproduce. Figures for publi-

cation must be of professional quality. Data for the original

graphs should be available to the Fxlitor upon request. If color is essen-

tial, consult the Editor lor more information. In reports of animal

experiments, use schematic drawings, not photographs. A letter of

consent must accttmpany any photograph of a person. Do not place

titles and detailed explanations on figures; put this information in

figure captions. If possible, submit radiographs as prints and full-

size copies of film.

Drugs. Identify precisely all drugs and chemicals used, giving gener-

ic names, doses, and routes of administration. If desired, brand names

may be given in parentheses after generic names. Drugs should be

listed on the product-sources page.

("oinniercial Products. In parentheses in the text, identify any com-

mercial producl (including model number if applicable) the first time

it is mentioned, giving the manutaclurcr's name, city, and state or

country. If four or more products arc mentioned, do not list any man-

ufacturers in the text; instead, list them on a Product Sources page

at the end of the text, before the References. Provide model num-

bers when available and manufacturer's .suggested price, if the study

has cost implications.

Ethics. When reporting experiments on human subjects, indicate

that procedures were conducted in accordance w ith the ethical stan-

dards of the World Medical Association Declaration of Helsinki

IRespir Care 1 9y7;42(6):635-636| or of the institution's committee

Respiratory Care Manuscript Preparation Guide. Revised 6/97

Manuscript preparation Guide

on human experimentation. State that informed consent was

obtained. Do not use patient's names, initials, or hospital numbers

in text or illustrations. When reporting experiments on animals, indi-

cate that the institution's policy, a national guideline, or a law on

the care and use of laboratory animals was followed.

Statistics. Identify the statistical tests used in analyzing the data,

and give the prospectively determined level of significance in the

Methods section. Report actual p values in Results. Cite only text-

book and published article references to support choices of tests. Iden-

tify any general-use or commercial computer programs used, nam-

ing manufacturers and their locations. These should be listed on the

product-sources page.

Units of Measurement. Express measurements of length, height,

weight, and volume in metric units appropriately abbreviated: tem-

peratures in degrees Celsius: and blood pressures in millimeters of

mercury (mm Ha). Report hematologic and clinical-chemistry mea-

surements in conventional metric and in SI (Systeme Internationale)

units. Show gas pressures (including blood gas tensions) in torr.

List SI equivalent values, when possible, in brackets following non-

Si values—for example, "PEEP. 10 cm HjO [0.981 kPa]." For con-

version to SI, see Respiratory Care 1988:33(10):861-873

(Oct 1988), 1989:34(2): 14."; (Feb 1989). and 1997:42(6):639-640

(June 1997).

Conflict of Interest Authors are asked to disclose any liaison or finan-

cial arrangement they have with a manufacturer or distributor whose

product is part of the submitted manuscript or with the manufacturer

or distnbutor of a competing product. (Such arrangements do not

disqualify a paper from consideration and are not disclosed to review-

ers.) A statement to this effect is included on the cover-letter page.

(Reviewers are screened for possible conflict of interest.)

Abbreviations and Symbols. Use standard abbre\ iations and sym-

bols. Avoid creating new abbreviations. Avoid all abbreviations

in the title and unusual abbreviations in the abstract. Use an abbre-

viation only if the term occurs several times in the paper. Write out

the full term the first time it appears, followed by the abbreviation

in parentheses. Thereafter, employ the abbreviation alone. Never

use an abbreviation without defining it. Standard units of mea-

surement can be abbreviated without explanation (eg. 10 L/min.

IStorr. 2.3kPa).

Please use the following forms: cm HiO (not cmH20). f (not bpm).

L (not 1). L/min (not LPM. l/min. or 1pm). mL (not ml), mm Hg (not

mmHg). pH (not Ph or PHl. p > 0.001 (not p>0.001 ). s (not sec).

SpO: (pulse-oximetry saturation). See RESPIRATORY CARE: Stan-

dard Abbreviations and Symbols [RespirCare l997;42(6):637-642].

Computer Disliettes. Authors are encouraged to submit electron-

ic versions of manuscripts as well as printed copies (3.5 in. diskettes

in Macintosh or IBM-DOS format). Label each diskette with date;

author's name: name and version of word-processing program used;

and filename(s). Software used to produce graphics and tables should

be similarly identified. Do not write on diskette labels except with

felt-tipped pen. If revision of a manuscript is required as a condi-

tion of acceptance for publication, we ask that an electronic version

of revision be supplied to facilitate copyediting and production.

Prior and Duplicate Publication. Work that has been published

or accepted elsewhere should not be submitted. In special instances,

the Editor may consider such material, provided that permission to

publish is given by the author and original publisher. Please con-

sult the Editor before submitting such work.

Authorship. All persons listed as authors should have participat-

ed in the reported work and in the shaping of the manuscript: all must

have proofread the submitted manuscript: and all should be able to

publicly discuss and defend the paper's content. A paper with cor-

porate authorship must specify the key persons responsible for the

article. Authorship is not justified solely on the basis of solicitation

of funding, collection or analysis of data, provision of advice, or sim-

ilar services. Persons who provide such ancillary services exclusively

may be recognized in an Acknowledgments section.

Permissions. The manuscript must be accompanied by copies of

permissions to reproduce previously published material (figures or

tables): to use illustrations of. or report sensitive personal infonnation

about, identifiable persons: and to name persons in the Acknowl-

edgments section.

Reviewers. Please supply the names, credentials, affiliations, address-

es, and phone/fax numbers of three professionals whom you con-

sider expert on the topic of your paper. Your manuscript may be sent

to one or more of them for blind peer review

.

Submitting the Manuscript

Mail three copies [1 copy with author(s) name(s). affiliation! s). 2

copies without name(s) and affiliation(s) for reviewers] of the

manuscript, figures, and 1 diskette, and the Cover Letter &Checklist to RESPIRATORY CARE, 1 1030 Abies Lane. Dallas TX75229-4593. Do not fax manuscripts. Protect figures with cardboard.

Keep a copy of the manuscript and figures. Receipt of your manuscript

will be acknowledged.

Editorial Office:

Respiratory Care11030 Abies Lane

Dallas TX 75229-4593

(972) 243-2272 (telephone)

(972) 484-6010 (fax)

e-mail: respircare@aarc.org

Respiratory Care Manuscript Preparation Guide. Revised 6/97

Cover Letter & ChecklistA copy of this completed form must accompany all manuscripts submitted for publication.

Title of Paper;

Publication Category:

Autfiors:

Authior to be Contacted: Phione: FAX:

Mailing Address of Contact Author:

Reprints: Z Yes G No

"We, the undersigned, have all participated in the work reported, proofread the accompanying manuscript, and approve its

submission for publication." Please phnt and include credentials, title, institution, academic appointments, city and state. If more

than 4 authors, please use another copy of this form.*

"Author Data: .

Author Signature/Date

"Author Data:

"Author Data:

"Author Data:

Author Signature/Date

Author Signature/Date

Author Signature/Date

Has this research been presented in a public forum? ^ Yes _ No

If yes, where, when and by whom?

Has this research received awards? Yes No

If yes, please describe.

Do any of the authors have a financial interest in the products mentioned in this paper or competing products?

D Yes D No If yes, please disclose:

Checklist:

Is double-spacing used throughout entire manuscript?

Are all pages numbered in upper-right corners?

D Are all references, figures, and tables cited in the text?

D Has the accuracy of the references been checked, and are they correctly formatted?

D Have SI values been provided?

V Has all arithmetic been checked?

_ Have generic names of drugs been provided?

D Have necessary written permissions been provided?

D Have authors' names been omitted from text and figure labels?

D Have copies of 'in press' references been provided?

D Has the manuscript been proofread by all the authors?

Respir.aTORY Care Manuscript Preparation Guide, Revised 6/97

News releases about new products and services will be considered tor publication m this section. There is no charge tor

these listings. Send descriptive release and glossy black and while photographs to RhSPlRATOR^' Care Journal. Ne\v

Products and Services Dept. 1 1030 Abies Lane. Dallas TX 75229-4593, The Reader Service Card immedialel> follows

the authors & advertisers index at the back of the Journal,

New Products

& Services

Tracheotomy Procedure Kit Transtra-

cheal Systems Inc otYers the FastTract"'

Procedure Kit. The kit features a tracheal

punch and stent and is fully compatible

with the SCOOP oxygen catheter. The

company claims that the kit. developed

by an otolaryngologist, can allow for

SCOOP delivery within 24 hours of the

procedure, reduces the tract maturation

period, and eliminates lost tract poten-

tial. A Fast Tract Clinical Guide ac-

companies the kit, and a video is avail-

able by request. For details from

Transtracheal Systems Inc. circle Read-

er Service Number 160.

Filters. Nellcor Puritan Bennett in-

troduces a new line of reusable and dis-

posable inspiratory filters. The reusable

Re/Flex™ and disposable D/Flex'" fil-

ters measure 10 cm in length. 7 cm in

width, and 6 cm in depth. According to

the manufacturer, small dimensions

make the filters easy to install. In ad-

dition, the filters can be used with ven-

tilators, oxygen concentrators, and con-

tinuous positive airway pressure units.

The Re/Flex filter, designed to withstand

up to 100 sterilizations, is available in

5 configurations: Bennett barb. ISO

standard, or a barb/ISO combination.

(The barb and ISO/barb are available

with or without a coupling.) The D/Flex

filter is offered in 3 configurations. Both

filters can withstand high-volume ven-

tilator settings, and they maintain a fil-

tration efficiency at 99.9% viral/bac-

terial factor. For details about leakage

and resistance, select Reader Service

Number 161.

FlowMeter. The Litermeter is the

newest addition to Erie Medical's prod-

uct line. According to the company the

meters are designed to assess higher

flow accuracy in hospitals, home care,

and emergency care. The meter is cal-

ibrated in 0.5 L increments for flows of

6 to 15 L/min. For information about

the product, select Reader Service Num-

ber 162.

Software Package. The Teleform

Standard Version 5.2 and its counter-

part. Tele/o/7?! Elite Version 5.2, are up-

graded by Cardiff Software Inc. The

company says that the new systems are

compatible with Windows 95/NT. The

standard version is a single-user, data

collection application. TTie elite version

features Teleform Stats (a system that

helps monitor productivity and system

efficiency), support for Optika and Wa-

termark document management ( pro-

grams that allow forms to be scanned

or faxed into a database). Castelle Fax-

Press fax server support, enhanced NCSrecognition, and Thumbnail Scan Dis-

play. In addition, the elite version can

also use the Telcl'orm Internet Solution

add-on. To contact the company for

more infonnation. circle Reader Service

Number 16.^.

Disposable Mouthpieces. Color-

coded, di.sposable, cardboard mouthpieces

are now available from Vacumeuics Inc.

According to a company press release,

the new inouthpieces fit most spirome-

ters. The color ctxle was develojjed to re-

duce confusion in reordering. Each

mouthpiece has a nonstick coafing that

prevents it from sticking to the patient's

lips. Visit VacuMed's website at www.

vacumed.com or circle Reader Service

Number 164 for information.

Drying Tubes. ME-series drying tubes

are available from Perma Pure Inc.

Perma's drying tubes replace ordinary

sample lines that connect a patient air-

way to a gas analyzer. Water vapor from

the patient's breath passes through the

dryer's Nafion " membrane and evap-

orates into the surrounding air. The

company says that the dryers' unique

membrane permeation devices provide

sterile humidification and eliminate boil-

ers and bubblers and the associated risk

of bacterial contamination. The tubes

measure from 1 50-600 mm in length

with 1- or 1.3-mm diameters. Circle

Reader Service Number 165. for details

from the company.

Respiratory Care • August "97 Vol 42 No 8 817

Notices

Notices t)t Loinpeiilioiis, scholarships, fellowships, cxaniination dales, new cducaiional prnjjrams, and the like will be listed here Iree ol

charge. Items for the Notices section must reach the Journal 60 days before the desired month of publication (January 1 for the March issue.

February I for the April issue, etc). Include all pertinent information and mail notices lo RESPIRATORY CARE Notices Dept. 1 1030 Abies

Lane. Dallas TX 73229-4593.

Final Deadline: October 1, 1997

for AARC's$1,000,000 Research Program

Research designed to study the relationships between

clinical interventions by respiratory care professionals

(RCPs) and the outcomes of care may qualify for research

grants available from the American Association for Respi-

ratory Care.

The agenda for this research project includes the exami-

nation of the outcomes of care provided by RCPs with

expanded roles and/or scope of practice in various settings

and outcomes of systems of respiratory care services deliv-

ery in various settings.

The researcher(s) will be sent a complete application

when the "Research Plan Abstract" form is approved. To

obtain the abstract form or for more information, call (972)

243-2272. Hurry! the final deadline is October I, 1997.

Continuing Education: Respiratory

Seminars Available on Cruise Line

Six hours of CRCE credits can be earned this summer

on a Gulf cruise. These cruises are offered through D&DTravel, which is owned and operated by respiratory thera-

pists. Scheduled seminar cruises are August 30 and

September 20, but additional cruises can be scheduled for

groups of 30 or more. For more information call toll free

(888) 882-2210 or e-mail ddtravel@wf.net. Or visit D&DTravel on the internet at http://www.adverworld.com/ID/

0016/9444/index.html or http://www.adverworld.com/

expresspress/ddtravel

Helpful Web Sites

American Association for Respiratory Care

http://www.aarc.org

Free access to MEDLINE is now available on our

web site

National Board for Respiratory Care

http://www.nbrc.org

Applied Measurement Professionals Inc

http://www.applmeapro.com

The American Academy of Pediatrics

http://wwvv.aap.org

Extracorporeal Life Support Organization

http://wvvvv.mcd.umicli.edu/clso/

U.S. Department of Health and HumanServices, Health .\dvice

http://www.healthfinder.gov

Food and Drug Administration

http://www.fda.gov

National Asthma Kducation Prevention

Program (aiidelines, 2nd Kdition

http://wwvv.nhlbi.iiih.gov/nhlbi/kuig/asthmayprof/

asthgdln.htm

The National Board for Respiratory Care— 1997 Examination Dates and Fees

Kxamiiiation

CRTT F.vaminaluiii

RRT Exaiiiinaliuii

RPFI" Examination

Kxamination Date

Novenilicr S. 1997

Application Deadline: .Seplcmhci 1. 1997

December 6. 1997

Application Deadline: Ausiust I. 1997

December 6. 1997

Applicalion Deadline: .Sepiemher I. 1997

Kxamination Fee

Notices

National Respiratory Care WeekOctober 12-18, 1997

Ideas and products for Respiratory Care Week are

available in this issue and the 1997 RC Week Catalog

mailed with the June issue ofAARC Times. Call the RCWeek hotline at (972) 406-4684.

ASTM Standardsvia Fax

The American Society for Testing and Materials

(ASTM) now offers WEBFAXX, a new option available at

http://www.astm.org in the "Search for Standards" area.

Copies of the standards, once requested, can be sent

within 10 minutes to any fax machine.

The copies cost $0.75 in the United States. Canada, and

Mexico and $1 ..'iO in all other countries.

Respiratory Care Special Issue

The September 1997 issue of the Journal will be

devoted to education—respiratory care formal programs

and cuniculum, continuing and in-service education, and

patient education.

mi|C^ambha ^ ^^ta

Exciting. Informative. A Real"Professor's Rounds" conferences are unique opportunities for you and your staff to learn from some of the most skilled, knowledgeable,

and successful people in fiealth care. Leaders. People who know what is happening in health care—Sheryl Haneckow, Thomas

Kallstrom, Barbara Wilson, Gretchen Lawrence, Jon Nifsestuen, end Sam Giordano.

Literally thousands of health care professionals will view these programs and earn continuing education credit. You'll learn new tactics and strategies

for the new era of health care. Subscribing to "Professor's Rounds" will save you months of reading, listening, digging, comparing, and learning aoout

the new health care and technologies and procedures. Register now for an exciting and informative journey

Videotape TeleconferencesEveryone In your facility can earn one liour of continuing education credit for each

"Professor's Rounds" program. You are provided with a 90-minute videotape to view

prior to a live 30-minute telephone question-and-answer session with the expert. The

only equipment required is a VHS videotape player, a television monitor, and a

telephone/speaker phone. The registration fee for the Video Teleconference does not

include the Live Television Videoconference

I. Mechanical Ventilation: Managing Tubes and Aerosols

April 15, 12:30-1 p m. Eastern Time, 9:30 am. Pacific Time

Approved for One tiour of Continuing Education Credit

II. Waveform Analysis and Interpretation

May 21, 12:30-1 p.m Eastern Time, 9:30 am. Pacific Time

Approved for One Hour of Continuing Education Credit

III. JCAHO Problematic Areas for Respiratory

Care Services

June 9, 12:30-1 p.m. Eastern Time, 9:30 a.m. Pacific Time

Approved for One Hour of Continuing Education Credit

IV. Asthma Disease Management:Using the Revised NAEPP Guidelines in Practice

July 16, 12:30-1 p m. Eastern Time, 9:30 a.m. Pacific Time

Approved for One Hour of Continuing Education Credit

V. Initial Treatment for the Pediatric Patient in

Respiratory Distress

August 20, 12:30-1 p.m Eastern Time, 9.30 am. Pacific Time

Approved for One Hour of Continuing Education Credit

VI. Nitric Oxide: Issues and Ansvi^ersSeptember 8, 12:30-1 p,m. Eastern Time, 9:30 am. Pacific Time

Approved for One Hour of Continuing Education Credit

Supported in part by an educational grant from

Sievers Instruments Inc./Pulmonox Medical Corporation

VII. Reimbursement: Solving the Puzzle

November 3, 12:30-1 p,m. Eastern Time, 9:30 am. Pacific Time

Approved for One Hour of Continuing Education Credit

VIII. Marketing Services to Managed Core Organizations:

Not Just for ManagersDecember 1 , 12:30-1 p.m Eastern Time, 9:30 a.m. Pacific Time

Approved for One Hour of Continuing Education Credit

Live Television VideoconferencesYou and each member of your staff can earn one hour of continuing education credit

for each "Professor's Rounds" program without leaving your facility. Each live

90-minute program is interactive to give you the opportunity to osk questions and

discuss the issues further Earn continuing education credit by viewing the program

live or by tape delay. You will need satellite reception capabilities (KU analog or

C Band) and a viewing room with a video monitor and telephone The registration

fee for the Live Television Videoconference does not include the Video

Teleconference.

I. Mechanical Ventilation: Managing Tubes and Aerosols

March 18, 12:30-2 p.m. Eastern Time, 9:30 am Pacific Time

Approved for One Hour of Continuing Education Credit

II. Waveform Analysis and Interpretation

April 29, 12:30-2 p,m Eastern Time, 9:30 am. Pacific Time

Approved for One Hour of Continuing Education Credit

III. JCAhIO Problematic Areas for Respiratory

Care Services

May 20, 12:30-2 p.m. Eastern Time, 9:30 am. Pacific Time

Approved for One Hour of Continuing Education Credit

IV. Asthma Disease Management:Using the Revised NAEPP Guidelines in Practice

June 24, 12:30-2 p,m. Eastern Time, 9,30 am. Pacific Time

Approved for One Hour of Continuing Education Credit

V. Initial Treatment for the Pediatric Patient in

Respiratory Distress

July 15, 12:30-2 p,m Eastern Time, 9:30 am. Pacific Time

Approved for One Hour of Continuing Education Credit

VI. Nitric Oxide: Issues and AnswersAugust 26, 12:30-2 p m. Eastern Time, 9:30 am. Pacific Time

Approved for One Hour of Continuing Education Credit

Supported in part by an educotional grant from

Sievers Instruments Inc./Pulmonox Medical Corporation

VII. Reimbursement: Solving the Puzzle

October 14, 1230-2 p,m Eastern Time, 9:30 am. Pacific Time

Approved for One Hour of Continuing Education Credit

VIII. Marketing Services to Managed Care Organizations:

Not Just for ManagersNovember 1

1, 12 30-2 p m. Eastern Time, 9:30 am Pacific Time

Approved for One Hour of Continuing Education Credit

L

Videotapes

Videotapes of the programs will be available after

each Live Television Videoconference, Sites

purchasing videotapes only do not earn continuing

education credit. To earn conlinuinq education,

participants must view the program at a site

registoed for the Live Television Videoconference or

the Video Teleconference, If you hove any questions,

please call !'72) 243-2272.

Accreditation

Each staff member co-spieling CRCE requirements

earns one continuing education credit for

participating in each program in the 1997

"Professor's Rounds" series. If you subscribe to the

entire series, you and staff members con each earn a

total of eight continuing educotion credits. However

participants must view the program at a site

registered for a Live Television Videoconference or at

a site registered for a Videotape Teleconference in

order to receive credit. Videotape-only purchasers

do not qualify for continuing education credit.

Requirements

Live Television Videoconference—You will

need satellite reception capabilities, a viewing

room, o television monitor, and o telephone.

Registrotion fee Is for the live television broadcast

only. It does not Include both the Live Television

Videoconference and Videotape Teleconference.

Videotape Teleconference—A videotape of

the programs is provided to registered Videotape

Teleconference sites after the live program. The

only equipment required is a VHS videotape

ployer, a television monitor, and a telephone/

speaker phone. Registration fee is for the

Videotape Teleconference only. It does not include

both the Videotape Teleconference and Live

Television Vldeoconference.

Vldeotapes Only—Videotapes of the program

will be available after the live television broadcast.

Note: Purchasers of videotapes only are not

eligible for continuing educotion credit

Eye-Opener. Probably All Threei ]997 ''Professor's Rounds'' Registration Form

To register, please complete the form below. Make checks payable to the AARC. Moil registration form to: American Association for

Respiratory Care, AARC Videoconferences, 1 1030 Abies Lane, Dallas, Texas 75229-4593. Purchase orders and credit card orders

may be faxed to (972) 484-2720 or (972) 484-6010.

Method of Payment: D Check enclosed in the amount of $

Bill my credit cord: " Visa _ MasterCard

Card Number Expiration Date

Calendar

of Events

Not-ror-prot1l organi/jlions are oflered a free adveniscinent ol up to eight lines to appear, on a space-available basis, in Calendar of Events in

RhSPIRATORY CAR1-. Ads for other meetings arc priced at $5.5(J per line and require an insertion order. Deadline is the 20th of the inonlh (wo

months preceding the motlth in which you wish the ad to run. Submit copy and insertion orders to Calendar of Events. RESPIR.ATORY CARE,

I lll.W Abies Une, Dallas TX 75229-45W.

AARC & AFFILIATES

Augu,st 20—Live Telephone Question-and-Answer Session

View "Initial Trciiltiiciu lor Ihc PdJiatric Patient in Respiratory Distress," Part .S ol AARC's 1997 "Professor's Rounds" and

participate in a live telephone question-and-answer session troni \2.M) to 1 PM Eastern Time.

CRCE: 1 credit hour.

Contact: To receive the video and register, call the AARC at (972) 243-2272.

August 26^Live Video Conference

"Nitric Oxide: Issues and Answers," Part 6 of the AARC's 1997 "Professor's Rounds." airs from 12:30 to 2 PM Eastern Time.

CRCE: I credit hour.

Contact: To register, call the AARC at (972) 243-2272.

September 8—Live Telephone Question-and-Answer Session

View "Nitric Oxide: Issues and Answers," Part 6 of the AARC's 1997 "Professor's Rounds." and participate in a live telephone

question-and-answer session from 12:30 to 1 PM Eastern Time.

CRCE: 1 credit hour.

Contact: To receive the video and register, call the AARC at (972) 243-2272.

September 17-19—Maryland and District of Columbia Societies

16th Annual Educational Symposium the Conference by the Sea—Respiratory Care Practitioners Reaching for the Future—at the

Sheraton Fiiuntainbleau Hotel. Ocean City. Maryland. A management track covering managed care issues is also featured.

Contact: Elgloria Harrison at (410) .'S7S-S60() e\t 211.

OTHER MEETINGS

September 5-9—American College of Chest Physicians

6lh Critical Care Medicine Review (September Course) at the New York Hilton and Towers. New York. New York.

Contact: ACCP. Product and Registration Services. 3300 Dundee Rd, Northbrook IL 60062. (800) 343-2227, fax (847) 498-5460,

e-mail: registration@chestnet.org.

September 19-21—Extracorporeal Life Support Organization

9th Annual Meeting at the Atheneum Suite Hotel, Detroit, Michigan.

Contact; Phoebe Hankins at (313) 998-6600, e-mail: phankinsCn'umich.edu.

September 25-26—INFOCARESecond .Annual Neonatal/Pediatnc Respnalory/Critical Care Symposium at the Sheraton l-iesta Beach Resort. South Padre

Island, Texas.

Contact: Ralph Miller. INI-(3CARE, 3.'iO San Roman Rd, Los Fresnos TX 78566, (210) 233-5645 or fax (210) 233-1010.

October 16-18—Norwalk Hospital

Second Annual Norwalk Hospital State-of-the-Art Update in Hyperbaric Medicine. Norwalk, Connecticut.

Contact: Dennis Selmont EdD, Norwalk Hospital. Hyperbaric Medicine. Maple Street. Norwalk CT 06856. or

http://hyperbaric.norwalkhospital. norwalk. ct. us.

October 17—Children's Medical Center of Dallas

Annual Pediatric Rcsptraloiy Care Seminar "Spotlight on VOSS, " Dallas, Texas

Contact: SairaRahim at (214) 640-2000 ext 3890.

;?2 Respiratory Care • August '97 Vol 42 No 8

Calendar of Events

February 13-15, 1998—Japan Society for Therapeutics and Engineering

lOlh Conference ot the Japan Society for Therapeutics and Engineering and the 1998 Pan-Pacific Forum on Respiratory Care in

Fukuoka. Japan. Abstracts must be submitted (in English) to the Conference Secretariat no later than August 31, 1997. Only

abstracts accompanied by the registration fee will be accepted for presentation. Authors will be informed of the abstract's

acceptance by September 30. 1997.

Contact: Secretariat Office. Japan Society for Therapeutics and Engineering. Pan Pacific Forum on Respiratory Care 1998. Koga

Hospital Medical Research Institute. 120 Tenjin-cho. Kurume 830 Japan. Phone: 81-942-39-6992. Fax: 81-942-39-5763. e-mail:

sasakhp@kurume.ktam.or.jp.

March 25-28, 1998—.American Lung .Association of the Northern Rockies

17th Annual Big Sky Pulmonary and Critical Care Medicine Conference in Big Sky, Montana.

Contact: Earl Thomas. 825 Helena Ave. Helena MT. 59601-3459. (406) 442-6556. Fax: (406) 442-2346. e-mail: alamtwy@aol.com.

RESPIRATORY CARE • AUGUST "97 VOL 42 NO 8 823

Authors

in This Issue

BraiiMMi. Richard D 791

Campbell. Robert S 791

Chatburn. Robert 796

Emad. Ali 765

Houston, Patricia L 761

Johannigman. Jay A 791

MacKinnon. John C 761

Martin, Lawrence 796

McGuire, Glenn P 761

Mercurio. Phil 796

Wilson, Teri Nikolai 798

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V-?A Respirakwy Care • August '97 Vol 42 No 8

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