Reduction of bronchopulmonary dysplasia after participation in the Breathsavers Group of the Vermont Oxford Network Neonatal Intensive Care Quality Improvement Collaborative

OBJECTIVE

The objective of this study was to compare the primary and secondary outcomes of very low birth weight infants before and after participation in the Breathsavers Group of the Vermont Oxford Network-sponsored Neonatal Intensive Care Quality Collaborative.

METHODS

Hospitals that participated in the Breathsavers Group contributed clinical data on the outcomes of their very low birth weight infants to the Vermont Oxford Network using standardized clinical definitions, data forms, and inclusion criteria. Outcomes from the last year of the collaborative, 2003, were compared with those from the baseline year, 2001. Models for treatment practices and outcomes measures were adjusted for within-hospital correlation (clustering) and standard risk factors that were present at birth.

RESULTS

Bronchopulmonary dysplasia dropped significantly in 2003 compared with the baseline year. Survival improved but not significantly. In addition, severe retinopathy of prematurity, severe intraventricular hemorrhage, and supplemental oxygen at discharge dropped significantly. The use of conventional ventilation at any time during the initial hospitalization, postnatal steroids, and time to first dose of surfactant all decreased significantly. The use of nasal continuous positive airway pressure at any time during hospitalization increased. The use of high-frequency ventilation, delivery room intubation, and surfactant at any time during hospitalization did not change.

CONCLUSIONS

The Breathsavers Group improved both clinical care processes and clinical outcomes during the Neonatal Intensive Care Quality Collaborative.

Preschool healthcare utilisation related to home oxygen status

OBJECTIVE

To determine, in prematurely born children who had bronchopulmonary dysplasia (BPD), if respiratory morbidity, healthcare utilisation, and cost of care during the preschool years were influenced by use of supplementary oxygen at home after discharge from the neonatal intensive care unit.

DESIGN

Observational study.

SETTING

Four tertiary neonatal intensive care units.

PATIENTS

190 children, median gestational age 27 weeks (range 22-31), 70 of whom received supplementary oxygen when discharged home.

INTERVENTIONS

Review of hospital and general practitioner records together with a parent completed respiratory questionnaire.

MAIN OUTCOME MEASURES

Healthcare utilisation, cost of care, cough, wheeze, and use of an inhaler.

RESULTS

Seventy children had supplementary oxygen at home (home oxygen group), but only one had a continuous requirement for home oxygen beyond 2 years of age. There were no significant differences in the gestational age or birth weight of the home oxygen group compared with the rest of the cohort. However, between 2 and 4 years of age inclusive, the home oxygen group had more outpatient attendances (p = 0.0021) and specialist attendances (p = 0.0023), and, for respiratory problems, required more prescriptions (p<0.0001). Their total cost of care was higher (p<0.0001). In addition, more of the home oxygen group wheezed more than once a week (p = 0.0486) and were more likely to use an inhaler (p<0.0001).

CONCLUSIONS

Children with BPD who have supplementary oxygen at home after discharge have increased respiratory morbidity and healthcare utilisation in the preschool years.

Predictors of outcome in children with hydrocarbon poisoning receiving intensive care

The retrospective study included 48 children between 8.5 months--10 years, admitted to the PICU of an urban, tertiary care, teaching hospital in northern India from January 1995 to December 2001. Eighteen (38%) patients were hypoxemic on arrival, of which 8 (45%) required mechanical ventilation. Compared to the non-hypoxemic children, the hypoxemic patients were more likely to have received gastric lavage before arrival to our center (Odds Ratio 23.2, 95% CI 2.4 - 560.7) and had higher frequency of severe respiratory distress and leucocytosis (Odds Ratio 8.0, 95% CI 1.79 -38.6). On multiple regression analysis, we could not identify any particular variable that could predict hypoxemia. Secondary pneumonia developed in 16 (33.3%), with the duration of PICU stay being longer in these patients as against those who did not (144 hours vs 72 hours, p <0.05). Two (4.2%) children died and one suffered hypoxic sequelae. Prior lavage, hypoxemia at admission, need for ventilation, secondary sepsis and ventilator related complications were associated with poor outcome.

Prescribing oxygen therapy. An audit of oxygen prescribing practices on medical wards at North Shore Hospital, Auckland, New Zealand

AIM

To assess the frequency and accuracy of inpatient oxygen prescription at North Shore Hospital, Auckland.

METHOD

Between 14 April 2005 and 14 May 2005, 100 medical inpatients receiving oxygen therapy were randomly selected for chart review. For each patient, the clinical diagnosis, oxygen prescription (if present), and initial medical plan were analysed in conjunction with the oxygen flow rate and oxygen saturations (as documented in the observation chart).

RESULTS

Only 8% of patients receiving oxygen had it prescribed in their medication chart. The majority (75%) of oxygen prescriptions were inadequate.

CONCLUSION

Current rates of oxygen prescription on medical wards at North Shore Hospital, Auckland, are unsatisfactory. This poor oxygen prescription rate carries serious potential consequences.

Unstudied infants: outcomes of moderately premature infants in the neonatal intensive care unit

BACKGROUND

Newborns of 30-34 weeks gestation comprise 3.9% of all live births in the United States and 32% of all premature infants. They have been studied much less than very low birthweight infants.

OBJECTIVE

To measure in-hospital outcomes and readmission within three months of discharge of moderately premature infants.

DESIGN

Prospective cohort study including retrospective chart review and telephone interviews after discharge.

SETTING

Ten birth hospitals in California and Massachusetts.

PATIENTS

Surviving moderately premature infants born between October 2001 and February 2003.

MAIN OUTCOME MEASURES

(a) Occurrence of assisted ventilation during the hospital stay after birth; (b) adverse in-hospital outcomes-for example, necrotising enterocolitis; (c) readmission within three months of discharge.

RESULTS

With the use of prospective cluster sampling, 850 eligible infants and their families were identified, randomly selected, and enrolled. A total of 677 families completed a telephone interview three months after hospital discharge. During the birth stay, these babies experienced substantial morbidity: 45.7% experienced assisted ventilation, and 3.2% still required supplemental oxygen at 36 weeks. Readmission within three months occurred in 11.2% of the cohort and was higher among male infants and those with chronic lung disease.

CONCLUSIONS

Moderately premature infants experience significant morbidity, as evidenced by high rates of assisted ventilation, use of oxygen at 36 weeks, and readmission. Such morbidity deserves more research.

Negative impact of chronic obstructive pulmonary disease on the health-related quality of life of patients. Results of the EPIDEPOC study

BACKGROUND

COPD is currently the fourth cause of morbidity and mortality in the developed world. Patients with COPD experience a progressive deterioration and disability, which lead to a worsening in their health-related quality of life (HRQoL). The aim of this work is to assess the Health-Related Quality of Life (HRQoL) of patients with stable COPD followed in primary care and to identify possible predictors of disease.

METHODS

It is a multicenter, epidemiological, observational, descriptive study. Subjects of both sexes, older than 40 years and diagnosed of COPD at least 12 months before starting the study were included. Sociodemographic data, severity of disease, comorbidity, and use of health resources in the previous 12 months were collected. All patients were administered a generic quality-of-life questionnaire, the SF-12, that enables to calculate two scores, the physical (PCS-12) and the mental (MCS-12) component summary scores.

RESULTS

10,711 patients were evaluated (75.6% men, 24.4% women), with a mean age of 67.1 years (SD 9.66). The mean value of FEV1 was 35.9 +/- 10.0%. Mean PCS-12 and MCS-12 scores were 36.0 +/- 9.9 and 48.3 +/- 10.9, respectively. Compared to the reference population, patients with COPD had a reduction of PCS-12, even in mild stages of the disease. The correlation with FEV1 was higher for PCS-12 (r = 0.38) than for MCS-12 (r = 0.12). Predictors for both HRQoL components were sex, FEV1, use of oxygen therapy, and number of visits to emergency rooms and hospital admissions. Other independent predictors of PCS-12 were age, body mass index and educational level.

CONCLUSION

Patients with stable COPD show a reduction of their HRQoL, even in mild stages of the disease. The factors determining the HRQoL include sex, FEV1, use of oxygen therapy, and number of visits to emergency rooms and hospital admissions.

How long do patients spend weaning from CPAP in critical care?

The purpose of this project was to audit clinical practice and to investigate the time taken to wean patients using continuous positive airway pressure (CPAP) as a method of respiratory support prior to the introduction of a weaning protocol. Data was collected over a two-month period and 43 patients were included in the audit. Criteria for inclusion were that each patient had previously received mechanical ventilation and was subsequently weaned with the aid of CPAP or had received CPAP and was weaning from CPAP alone. The average time taken to wean was 95 hours (3.96 days) and ranged from one to 41 days. There was no correlation between the length of weaning time and the patient's APACHE II Score or the length of time spent on invasive ventilation prior to weaning on CPAP. However, there was a consistency in the time spent on CPAP as a percentage of the total weaning time. The audit identified large variations in the process and time taken to wean patients from CPAP. This might suggest that CPAP is used in a routine or arbitrary manner rather than a selective response to patients' specific needs.

Short-burst oxygen therapy for COPD patients: a 6-month randomised, controlled study

Short-burst oxygen therapy (SBOT) remains widely advocated for patients with chronic obstructive pulmonary disease (COPD), despite a lack of supporting evidence. The aim of this randomised, double-blind, placebo-controlled, parallel group study was to determine whether SBOT improves health-related quality of life (HRQL) or reduces acute healthcare utilisation in patients discharged following an acute exacerbation of COPD. Consecutive patients were screened; 78 of 331 were eligible for randomisation to cylinder oxygen, cylinder air or usual care following discharge. Patients were elderly with high acute healthcare utilisation, forced expiratory volume in one second of <1 L and had dyspnoea limiting daily activity but were not hypoxaemic at rest. Over the 6-month study period, there were no significant differences between patient groups in HRQL (Chronic Respiratory Questionnaire (CRQ), 36-item Short-Form Health Survey, Hospital Anxiety and Depression Scale) except for CRQ emotion domain. There were no significant differences in acute healthcare utilisation. Time to readmission was greatest in the usual care group. Cylinder use was high initially, but rapidly fell to very low levels within weeks in both cylinder oxygen and air groups. In conclusion, the availability of short-burst oxygen therapy for chronic obstructive pulmonary disease patients discharged from hospital following an acute exacerbation did not improve health-related quality of life or reduce acute healthcare utilisation. These results provide no support for the widespread use of short-burst oxygen therapy.

Acute life threatening events among infants on home oxygen

BACKGROUND

Chronic lung disease (CLD) of prematurity is associated with significant morbidity, and infants discharged home in oxygen are particularly vulnerable.

AIM

To assess the incidence of acute life threatening events (ALTEs) during 12-month follow-up of CLD infants discharged home receiving supplemental oxygen.

METHOD

All infants discharged over a one-year period were studied. Pre-discharge oxygen requirements were set on clinical grounds. Before discharge, oxygen saturations were recorded blind using a data-logger. Infant's oxygen requirements, hospital attendances, and details of ALTEs were recorded over the subsequent year.

RESULTS

Sixteen infants were studied. Median (range): birth-weight 938 grams (448 - 1,638); gestational age 28 weeks (24 - 32); discharge oxygen requirement 0.20 litres/minute (0.05 - 0.50). Eight infants subsequently had one or more ALTEs. Discharge oxygen saturation profiles were significantly lower in these infant when compared to those not having ALTEs (p < 0.05), despite receiving supplementary oxygen.

CONCLUSIONS

Before discharge home, formal oxygen saturation studies should be performed in infants receiving supplementary oxygen to ensure optimum oxygen delivery.

Factors related to variability in long-term oxygen therapy prevalence

OBJECTIVE

To analyse the variability of long term oxygen therapy (LTOT) prevalence according to several organisational and population factors.

METHODS

Prospective multicentre survey in 29 public hospitals (population 6,796,964) recording data on the organisational structure of the participating centres and factors related to LTOT prevalence. Official figures were also obtained from local health authorities on the prevalence and cost of LTOT.

RESULTS

The overall prevalence of LTOT was 184 per 100000 population (range 71-473). There was a specific unit or staff member for LTOT supervision in 17 (58.6%) centres, giving a lower prevalence (169 vs. 237/ 100000; P = 0.03). The altitude of the participating centres (median 92 m, mean 275 m; range 4-848 m) was found to influence LTOT prevalence (r = 0.73; P = 0.005). In the linear regression analysis, the coefficient of determination for altitude was 0.504. Other factors, such as percentage of population aged over 65 years, the attitude of prescribers towards patients with low adherence, current smokers or those with a PaO2 = 61 mmHg, were not related to LTOT prevalence.

CONCLUSIONS

Altitude and the existence of a specific unit or staff member for LTOT supervision significantly influence LTOT prevalence.

A clinical pathway for bronchiolitis is effective in reducing readmission rates

OBJECTIVE

To examine the use of a clinical pathway in the management of infants hospitalized with acute viral bronchiolitis.

STUDY DESIGN

A clinical pathway with specific management and discharge criteria for the care of infants with bronchiolitis was developed from pathways used in tertiary care pediatric institutions in Australia. Two hundred and twenty-nine infants admitted to hospital with acute viral bronchiolitis and prospectively managed using a pathway protocol were compared with a retrospective analysis of 207 infants managed without a pathway in 3 regional and 1 tertiary care hospital.

RESULTS

Readmission to hospital was significantly lower in the pathway group (P = .001), as was administration of supplemental fluids (P = .001) and use of steroids (P = .005). There were no differences between groups in demographic factors or clinical severity. The pathway had no overall effect on length of stay or time in oxygen.

CONCLUSIONS

A clinical pathway specifying local practice guidelines and discharge criteria can reduce the risk of readmission to hospital, the use of inappropriate therapies, and help with discharge planning.

[Cost and management of asthma exacerbations in Spanish hospitals (COAX study in hospital services)]

OBJECTIVE

The prevalence and associated health cost of asthma have been increasing in developed countries, and 70% of the overall disease cost is due to exacerbations. The primary objective of this study was to determine the hospital cost of an asthma exacerbation in Spain. The secondary objective was to determine what maintenance treatments patients were using to control asthma before the exacerbation and how the exacerbation was treated. The study formed part of a broader study (COAX II), with the same objectives in each of the 8 participating European countries.

PATIENTS AND METHODS

Prospective observational study that enrolled 126 patients with an asthma exacerbation treated in the usual way in 6 Spanish hospitals over a 3-month period (from January 1 to March 31, 2000).

RESULTS

According to the criteria of the Global Initiative for Asthma, 33.3% of the exacerbations were mild, 38.9% moderate, 26.2% severe, and 1.6% were associated with risk of imminent respiratory arrest. Use of corticosteroids was widespread among patients with moderate and severe asthma, but only 68% of the patients with severe asthma used long-acting beta2 agonists. The mean cost was 1555.70 Euros (95% confidence interval [CI], 1237.60 Euros-1907.00 Euros), of which 93.8% (1460.60 Euros; 95% CI, 1152.50 Euros-1779.40 Euros) was due to direct costs, and 6.2% (95.10 Euros; 95% CI, 35.50 Euros-177.00 Euros) to indirect costs. Cost rose with increasing severity of the exacerbation--292.60 Euros for a mild exacerbation, 1230.50 Euros for a moderate exacerbation, and 3543.10 Euros for a severe exacerbation.

CONCLUSIONS

The mean cost was 1555.70 Euros. The costs of moderate and severe exacerbations were 4 and 12 times that of a mild exacerbation, respectively. Long-acting beta2 agonists were less widely used than recommended by the guidelines for treatment of moderate and severe persistent asthma leading to asthma exacerbations.

Airway management before, during and after extubation: a survey of practice in the United Kingdom and Ireland

Summary Complications at extubation remain an important risk factor in anaesthesia. A postal survey was conducted on extubation practice amongst consultant anaesthetists in the United Kingdom and Ireland. The use of short acting drugs encourages anaesthetists to extubate the trachea at lighter levels of anaesthesia. The results show that oxygen (100%) is not routinely administered either before extubation or en route to the recovery area. A trend towards a head up or sitting position at extubation is emerging. However, further research into the use of these positions is required. Airway related complications at extubation are relatively frequent but are usually dealt with by simple basic measures. The role of drugs such as propofol in decreasing the incidence of these complications needs further evaluation. Some of these results give concern for patient safety and for training. The importance of teaching and adherence to continued oxygenation until complete recovery is strongly emphasised. Nerve stimulators should be used continually as standard monitoring throughout the anaesthetic period when muscle-relaxing drugs are part of the anaesthetic technique.

Pulmonary hypertension in advanced sarcoidosis: epidemiology and clinical characteristics

Pulmonary hypertension (PH) is a predictor of poor outcome in sarcoidosis. Little is known about the epidemiology of PH in sarcoidosis. The current authors reviewed the records of patients with sarcoidosis listed for lung transplantation in the USA between January 1995 and December 2002. PH was defined as a mean pulmonary artery pressure of >25 mmHg and severe PH as a mean pulmonary artery pressure of > or =40 mmHg. The cohort included 363 patients of whom 73.8% had PH. Neither spirometric testing nor the need for corticosteroids was associated with PH. Subjects with PH required more supplemental oxygen (2.7+/-1.8 L.min(-1) versus 1.6+/-1.4 L.min(-1)). The cardiac index was lower in individuals with PH, whereas the pulmonary capillary wedge pressure was higher. In multivariate analysis, supplemental oxygen remained an independent predictor of PH, whereas the relationship between cardiac index and PH was no longer significant. As a screening test, the need for oxygen had a sensitivity and specificity of 91.8% and 32.6%, respectively. Pulmonary hypertension is common in advanced sarcoidosis. The need for oxygen correlates with pulmonary hypertension. Since pulmonary hypertension is associated with poor outcomes and because simple clinical criteria fail to identify patients with sarcoidosis and pulmonary hypertension, more aggressive screening for this should be considered.

Results of a survey of patients with alpha-1 antitrypsin deficiency

BACKGROUND

alpha(1)-Antitrypsin deficiency (AATD) is an uncommon genetic disease which occurs in 1-2.5% of Americans with chronic obstructive pulmonary disease (COPD). Little is known about current demographics of AATD.

OBJECTIVES

This survey study reviews the clinical characteristics of diseased individuals in North America.

METHODS

A survey of members from the mailing lists of US AATD patient support organizations was commissioned with duplicate persons omitted. The survey was mailed to 5,222 unique individuals with AATD. Questionnaires were returned by 1,953 individuals, including 1,810 with severe deficiency, 93 with the carrier state and 41 who were caregivers of others.

RESULTS

The majority (81%) of participants reported COPD with symptoms of asthma, chronic bronchitis, and emphysema, usually in combination. The mean age of respondents [53.1 +/- 13.2 (SD) years] is older than the general US population. Lung or liver transplantation was reported by 9% of all respondents (n = 175), including 66 single lung transplants, 68 double lung transplants, and 47 liver transplants. Another 6.6% (n = 128) reported that they were currently on a transplant list. Twenty-one percent of lung transplants report continuing augmentation therapy use. Augmentation use is reported by 75% of those with obstructive lung disease. The majority of patients with liver disease also have COPD.

CONCLUSIONS

AATD remains a devastating illness for many of those affected as reflected in a high incidence of transplantation for liver and lung disease.

Adherence to the Swiss guidelines for management of COPD: experience of a Swiss teaching hospital

QUESTIONS UNDER STUDY

Swiss guidelines for the management of chronic obstructive pulmonary disease (COPD) were published in 2002. We aimed at assessing adherence to the proposed guidelines by the physicians in charge for all patients referred to our hospital for acute exacerbations of COPD over a one year period.

METHODS

In a prospective observational study, data from a questionnaire and from records of all patients referred to our hospital with acute exacerbation of COPD were collected. Diagnostic steps as well as therapeutic and prophylactic interventions were reviewed. Where applicable, interventions were stratified according to proposed levels of evidence A-D.

RESULTS

45 patients in whom the diagnosis of COPD had been made before were included. Diagnosis was established by spirometry in 71%, in the remaining diagnosis was based on clinical grounds only. Non-smoking advice was given to 69%, and 16% were offered a nicotine-replacement trial (level A). Information about a disease management plan was given in 40% of the patients (level B), 22% had done a six minute walking distance test. 27% of the patients had participated in a pulmonary rehabilitation program (level A). 93% were on regular bronchodilator therapy (level B), and 56% had regular inhaled corticosteroids (level B).

CONCLUSION

Confirmation of the diagnosis of COPD by spirometry is lacking in a significant number of patients. Most patients were treated with regular bronchodilators, however, relevant over-treatment with beta-adrenergic substances and overuse of inhaled corticosteroids in mild disease stages are common. Efforts for disease prevention and education as well as awareness of the potential benefits of pulmonary rehabilitation programs are still insufficient. Efforts to improve the adherence to the Swiss guidelines for the management of COPD should be intensified.

Omissions and errors during oxygen therapy of hospitalized patients in a large city of Greece

Omissions and errors are commonly found concerning hospital oxygen use and the use of nebulizers. The aim of the study was to record oxygen use in seven hospitals located in a large district city of Greece. Another aim was to record the use of nebulizers in the same hospitals. We included 105 head nurses (HNs) working in seven hospitals of a large city district of Greece. Data were collected after interviewing each HN using a questionnaire and completing an anonymous data form. Data are expressed as percentages and analyzed using the chi-square test. We found that 41% of HN believed O(2) is a gas that improves patient's dyspnea. The majority of the nurses (88.6%) stated that there was no protocol for O(2) therapy in the departments in which they worked. We found that O(2) therapy was commonly started, modified, discontinued by nurses in the absence of a medical order. Oxygen therapy was commonly not guided by arterial blood gas (ABG) analysis. We also found that there are no guidelines to prevent O(2) therapy interruption during intra-hospital transportation, and that few measures were taken to prevent O(2) explosion. In 95.2% of the departments the nebulizers were filled with tap water and were not changed on a daily basis (81.2%). Our results indicate that educational programmes, nursing protocols and guidelines are becoming mandatory in our country in order to ensure the proper use of O(2) therapy and nebulizers.

A meta-analysis of ibuprofen versus indomethacin for closure of patent ductus arteriosus

Ibuprofen (IBU) has previously been shown to be as effective as indomethacin (INDO) in closing the patent ductus arteriosus (PDA) of preterm infants, without severely affecting renal hemodynamics or basal cerebral blood flow. We conducted a meta-analysis of randomized trials to compare the efficacy and safety of IBU and INDO for treatment of PDA. Data from the nine relevant trials ( n =566), showed no significant difference in the efficacy of IBU and INDO in PDA closure ( P =0.70). However, five trials ( n =443) provided serum creatinine concentration data that revealed a significantly lower increase favoring IBU ( P < 0.001), and urine output data that showed a significantly lower decrease favoring IBU ( P < 0.001). In two trials ( n =188) the proportion of infants who required postnatal oxygen therapy at 28 days (defined as chronic lung disease) was significantly higher with IBU (52/94; 55.3%) than with INDO (38/94; 40.4%, P < 0.05). No statistically significant differences were found in mortality, intraventricular hemorrhage, necrotizing enterocolitis, surgical ligation, sepsis, retinopathy of prematurity, periventricular leukomalacia, length of hospital stay, gastrointestinal bleeding, re-opening of PDA, back-up treatment, surfactant therapy, or days on a ventilator.

CONCLUSION

ibuprofen and indomethacin have similar efficacy in patent ductus arteriosus closure, but preterm infants treated with ibuprofen experience lower serum creatinine values, higher urine output, and less undesirable decreased organ blood flow and vasoconstrictive adverse effects.

Patterns of helium-oxygen (heliox) usage in the critical care environment

The objective of this study was to describe the patterns of heliox use in critical care units of an academic medical center. The design was a prospective case series involving 7 critical care units of an academic medical center. All patients receiving heliox therapy over a 4-year period were studied, with prospective recording of patient demographics and the location, mode, indication for, and duration of heliox use. Use pattern comparisons based on anatomic location (upper vs lower airway) and age group (pediatric vs adult) were performed by alpha(2) analysis and unpaired Student t test. Eighty-nine patients, aged 17.4 +/- 20.9 years, received heliox for 30.5 +/- 44.6 hours on 92 occasions. Pediatric (</= 18 years) applications accounted for 72.8% of heliox use. Use was greater in frequency and scope during the final 2 study years, particularly in adults. Applications were split between upper airway (47%) and lower airway (53%) disorders. Airway manipulation was required in more adults (7/16) than in children (3/27) with upper airway obstruction (P < .05). The use patterns mirrored current literature emphases on postextubation stridor and asthma. This is the first description of heliox use patterns in the tertiary care critical care environment. Heliox use may be as dependent on practitioner experience as on published data. As a benign and relatively inexpensive therapy, heliox use should continue to be attractive, although ongoing study regarding efficacy in a number of settings is indicated.

Patient–oxygen dissociation curves: surveying the spectrum of oxygen‐delivery methods

OBJECTIVE

To describe the spectrum of oxygen-delivery methods.

DESIGN

Clinical audit.

SETTING

Medical wards of a tertiary referral teaching hospital in August 2004.

PARTICIPANTS

98 medical patients receiving supplemental oxygen.

RESULTS

Of the 98 patients, 40 were not receiving oxygen by customary methods. In classifying the patterns of oxygen delivery, we describe the transcephalic, submental, and (inadvertent) rectal approaches, as well as lachrymal insufflation and the "Venturi cravat". We also describe novel oxygen-weaning methods, including the half-wean, reverse wean, and placebo wean.

CONCLUSIONS

Many patients receive oxygen by unconventional methods. We postulate that this is evidence of a renewed interest in the historical routes of oxygen delivery.

Value of supplemental interventions to enhance the effectiveness of physical exercise during respiratory rehabilitation in COPD patients. A systematic review

BACKGROUND

There is a controversy about the additional benefit of various supplemental interventions used in clinical practice to further enhance the effectiveness of respiratory rehabilitation in patients with Chronic obstructive pulmonary disease (COPD). The aim of this research was to assess randomised controlled trials (RCTs) testing the additional benefit of supplemental interventions during respiratory rehabilitation in COPD patients.

METHODS

Systematic review with literature searches in six electronic databases, extensive hand-searching and contacting of authors. Two reviewers selected independently eligible RCTs, rated the methodological quality and extracted the data, which were analyzed considering the minimal important difference of patient-important outcomes where possible.

FINDINGS

We identified 20 RCTs whereof 18 provided sufficient data for analysis. The methodological quality was low and sample sizes were too small for most trials to produce meaningful results (median total sample size = 28). Data from five trials showed that supplemental oxygen during exercise did not have clinically meaningful effects on health-related quality of life while improvements of exercise capacity may be even larger for patients exercising on room air. RCTs of adding assisted ventilation, nutritional supplements or a number of anabolically acting drugs do not provide sufficient evidence for or against the use any of these supplemental interventions.

INTERPRETATION

There is insufficient evidence for most supplemental interventions during respiratory rehabilitation to estimate their additional value, partly due to methodological shortcomings of included RCTs. Current data do not suggest benefit from supplemental oxygen during exercise, although the methodological quality of included trials limits conclusions. To appropriately assess any of the various supplemental interventions used in clinical practice, pragmatic trials on respiratory rehabilitation of COPD patients need to consider methodological aspects as well as appropriate sample sizes.