Respiratory Dysfunct..

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Respiratory Dysfunct..

  1. 1. Respiratory Dysfunction Naisan GarrawayNaisan Garraway Najib AyasNajib Ayas
  2. 2. The Case  69 yr old male with a 3-day history of69 yr old male with a 3-day history of worsening SOB and increase use of hisworsening SOB and increase use of his puffers. He denies chest pain. He alsopuffers. He denies chest pain. He also describes a productive cough with greendescribes a productive cough with green sputum. He has a known history of COPDsputum. He has a known history of COPD and quit smoking 1 month ago but had a 40-and quit smoking 1 month ago but had a 40- pack year history. He has had multiplepack year history. He has had multiple admissions for COPD exacerbations butadmissions for COPD exacerbations but never intubated.never intubated.
  3. 3. The case  His past history isHis past history is significant for Type IIsignificant for Type II DM diet controlled,DM diet controlled, HTN, anterior resectionHTN, anterior resection 5 yrs ago for5 yrs ago for diverticulitis and a largediverticulitis and a large incisional hernia, whichincisional hernia, which he is booked for repairhe is booked for repair in 2 monthsin 2 months
  4. 4. The case  His meds include: Atrovent 4 puffs QID,His meds include: Atrovent 4 puffs QID, Ventolin 2 puffs QID, Cipro (he bought inVentolin 2 puffs QID, Cipro (he bought in Mexico) prn, ECASA 81 mg, Ramipril 5Mexico) prn, ECASA 81 mg, Ramipril 5 mg OD, Cold-FX (during the wintermg OD, Cold-FX (during the winter months)months)  He is allergic to Penicillin (anaphylaxis)He is allergic to Penicillin (anaphylaxis)
  5. 5. The Case  He lives with his wife and has a son inHe lives with his wife and has a son in Medical School in Scotland. He quitMedical School in Scotland. He quit smoking 1 month ago and drinks 1-2 beer asmoking 1 month ago and drinks 1-2 beer a week.week.
  6. 6. In the ER  He was seen by the ER doc and was notedHe was seen by the ER doc and was noted to be alert, SOB with a RR of 20 but couldto be alert, SOB with a RR of 20 but could speak 3-5 word sentences, audible wheezesspeak 3-5 word sentences, audible wheezes bilaterally, no peripheral edema, unable tobilaterally, no peripheral edema, unable to see JVP, no abdominal pain, obvioussee JVP, no abdominal pain, obvious reducible incisional hernia. BP 150/90, HRreducible incisional hernia. BP 150/90, HR 120, and temp 37.5120, and temp 37.5
  7. 7. In the ER  showed WBC 14.8, Hb 140, Plts 400showed WBC 14.8, Hb 140, Plts 400 normal coags. Lytes were Na 138, K 3.5,normal coags. Lytes were Na 138, K 3.5, Cl 100, CO2 35, Creat 160, and BUN 12.Cl 100, CO2 35, Creat 160, and BUN 12.  An ECG showed sinus tachy with poor RAn ECG showed sinus tachy with poor R wave progression in the lateral leads. Awave progression in the lateral leads. A CXR showed hyperinflation with possibleCXR showed hyperinflation with possible “streaking” in the RLL“streaking” in the RLL
  8. 8. CXR
  9. 9. In ER  An IV was started and he was given nebs ofAn IV was started and he was given nebs of Atrovent and Ventolin. 100 mgAtrovent and Ventolin. 100 mg hydrocortisone was given IV. The CTUhydrocortisone was given IV. The CTU Snr was consulted and said would be rightSnr was consulted and said would be right there but was dealing with a septic patientthere but was dealing with a septic patient on the ward.on the ward.
  10. 10. Later that day  2 hours later the patient was assessed by CTU and2 hours later the patient was assessed by CTU and was found to be obtunded but would rouse to awas found to be obtunded but would rouse to a loud voices. His BP was 140/81, HR 130 regular,loud voices. His BP was 140/81, HR 130 regular, RR 10, temp 37.8, and a sat of 88%RR 10, temp 37.8, and a sat of 88%  An ABG was done stat: 7.15/75/104.8/36.An ABG was done stat: 7.15/75/104.8/36.  You get the call just having resuscitated a septicYou get the call just having resuscitated a septic CTU patient on the ward, to get down to the ERCTU patient on the ward, to get down to the ER ASAPASAP
  11. 11. Assessment  As you get there your keen Jr resident hasAs you get there your keen Jr resident has arrived first and tells you the story.arrived first and tells you the story.  1. What is the differential diagnosis?1. What is the differential diagnosis? GordGord
  12. 12. Hypercapnic Respiratory Failure  Chronic obstructive pulmonary diseaseChronic obstructive pulmonary disease  EmphysemaEmphysema  Chronic bronchitisChronic bronchitis  Neuromuscular disordersNeuromuscular disorders  Amyotrophic lateral sclerosisAmyotrophic lateral sclerosis  Muscular dystrophyMuscular dystrophy  Diaphragm paralysisDiaphragm paralysis  Guillain-Barré syndromeGuillain-Barré syndrome  Myasthenia gravisMyasthenia gravis
  13. 13. Hypercapnic Respiratory Failure  Chest wall deformitiesChest wall deformities  KyphoscoliosisKyphoscoliosis  FibrothoraxFibrothorax  ThoracoplastyThoracoplasty  Central respiratory drive depressionCentral respiratory drive depression  Drugs - Narcotics, benzodiazepines,Drugs - Narcotics, benzodiazepines, barbituratesbarbiturates  Neurologic disorders - Encephalitis,Neurologic disorders - Encephalitis, brainstem disease, traumabrainstem disease, trauma  Primary alveolar hypoventilationPrimary alveolar hypoventilation  Obesity hypoventilation syndrome
  14. 14.  MI/CHFMI/CHF  PEPE Pulmonary Embolism in Patients with Chronic Obstructive Pulmonary Disease Ann Intern Med. 2006;144:390-396.  Showed a 25% prevalence of PE in patients with COPD hospitalized for severe exacerbation of unknown origin.  Clinical factors associated with PE were previous thromboembolic disease, malignancy, and decrease in PaCO2 of at least 5 mm Hg
  15. 15. BiPAP  You notice the RT is preparing the BiPAPYou notice the RT is preparing the BiPAP ventilator.ventilator.  2. What is the role of BiPAP in COPD2. What is the role of BiPAP in COPD exacerbation/acute respiratory failure?exacerbation/acute respiratory failure? GordGord
  16. 16. NIPPV  Two meta-analysis found that patients randomized to receive NIPPV had a statistically significant decrease in the need for invasive mechanical ventilation and in the risk of death  Keenan SP, et al: Effect of noninvasive positive pressure ventilation on mortality in patients admitted with acute respiratory failure: a meta-analysis. Crit Care Med 1997.  Thys F, et al: Noninvasive ventilation for acute respiratory failure: a prospective randomized placebo-controlled trial. Eur Respir J 2002
  17. 17. NIPPV  Exacerbations of COPD with rapid clinical deterioration should be considered candidates for NIPPV  International consensus conferences in intensive care medicine: noninvasive positive pressure ventilation in acute respiratory failure. Am J Respir Crit Care Med 2001, 163:283– 291.
  18. 18. NIPPV Noninvasive ventilation in acute respiratory failure Nicholas S. Hill, et al; Crit Care Med 2007 Vol. 35,  Review of the literature supports that an initial trial with NIV is not deleterious, even in severely ill COPD patients ( eg pH <7.2) (Conti et al 2002, Squadrone et al 2004)  The “scant & conflicting data” suggests a cautious trial of NIV in COPD pts with severe pneumonia is warranted.
  19. 19. Predict failure?
  20. 20. Sinuff et all Chest2003;123:2062-73 Review by Peñuelas et al. CMAJ 2007;177(10):1211-8
  21. 21. Obtunded Patient  3. Is there a role for NIPPV in the obtunded3. Is there a role for NIPPV in the obtunded hypercarbic COPD patient?hypercarbic COPD patient? GordGord
  22. 22. Noninvasive Positive-Pressure Ventilation To Treat Hypercapnic Coma Secondary to Respiratory Failure Gumersindo Go´nzalez Dý´az,et al CHEST 2005; 127:952–960  The randomized studies excluded pts withThe randomized studies excluded pts with decreased LOCdecreased LOC  Concern of aspiration riskConcern of aspiration risk  International consensus conference considered GCS <10 as contraindication  Never evaluated prospectively
  23. 23. Decreased LOC  Prospective, observational study between January 1, 1997, and May 31, 2002  Patients with GCS score <8 and CO2 retention formed one group, and those without coma served as a comparison group.  Excluded if another cause for LOC was found
  24. 24. Decreased LOC  Total of 958 pts started NIPPVTotal of 958 pts started NIPPV  95 (10.1%) had GCS scores on admission <8  NIPPV success was similar in both groups  hospital mortality was not significantly different
  25. 25. Outcomes
  26. 26. Conclusions for Coma  Coma should no longer be considered a contraindication to NPPV therapy.
  27. 27. NIPPV in Patients With Acute Exacerbations of COPD and Varying Levels of Consciousness Scala, et al; CHEST 2005; 128:1657–1666  A 5-year case-control study with a prospective data collection.  Study confirms that NPPV may be successfully applied to patients experiencing COPD exacerbations with milder ALCs, the rate of failure in patients with severely ALCs (ie, Kelly score > 3) is higher, though better than expected, so that an initial attempt with NPPV may be performed
  28. 28. Ventilation  You decide to intubate the patient instead and itYou decide to intubate the patient instead and it goes ahead smoothly. Your medical student saidgoes ahead smoothly. Your medical student said he had heard these patients can get auto peep andhe had heard these patients can get auto peep and that it can be BAD!that it can be BAD!  4. What would be your initial ventilator settings4. What would be your initial ventilator settings including what measures can be done to minimizeincluding what measures can be done to minimize auto peep in the ventilated COPD patient?auto peep in the ventilated COPD patient? YoanYoan
  29. 29. Goals for COPD patients  Adequate patient monitoringAdequate patient monitoring  Optimize ventilator settings to minimizeOptimize ventilator settings to minimize excessive work of breathingexcessive work of breathing  Assure SynchronyAssure Synchrony  Detect auto-PEEP and prevent barotraumaDetect auto-PEEP and prevent barotrauma  Prevent further respiratory muscle atrophyPrevent further respiratory muscle atrophy  Intubate using the widest diameter ET tubeIntubate using the widest diameter ET tube possible (R = 8nl /possible (R = 8nl / ππrr 44 ))
  30. 30. Mechanical Ventilation  Mode?Mode?  Volumes/Pressures?Volumes/Pressures?  Flow Rate?Flow Rate?  RR?RR?  pH?pH?  I:E ratio?I:E ratio?  PEEP?PEEP?  FiO2FiO2
  31. 31. Auto-PEEP  When the expiratory time is not long enough to allow exhalation of all tidal volume auto-PEEP is generated.
  32. 32. Airway Pressures
  33. 33. PEEPi + PEEPe Ranieri et al Eur Respir J, 1996, 9, 1283– 1292
  34. 34. The Unit  The patient is brought up to “The Unit” andThe patient is brought up to “The Unit” and your Jr has finished the admission ordersyour Jr has finished the admission orders and wants to review them with you.and wants to review them with you.  5. What treatments do you want to ensure5. What treatments do you want to ensure the patient receives?the patient receives? YoanYoan
  35. 35. Orders  Sedation?Sedation?  Bronchodilators?Bronchodilators?  Steroids?Steroids?  Antibiotics?Antibiotics?  Nutrition?Nutrition?  Insulin?Insulin?  Heliox?Heliox?  Further investigations?Further investigations?
  36. 36. Weaning  After a few days, some improvement is seen. HisAfter a few days, some improvement is seen. His FiO2 requirements are 30% and his lungs soundFiO2 requirements are 30% and his lungs sound much clearer. He has also been weaned down tomuch clearer. He has also been weaned down to pressure support. The RT mentioned the weaningpressure support. The RT mentioned the weaning indices for the day with a PO2/FiO2=300, RSBI ofindices for the day with a PO2/FiO2=300, RSBI of 120. Your medical student looks confused and120. Your medical student looks confused and asks:asks:  6. What are weaning indices and what is the6. What are weaning indices and what is the evidence for their use?evidence for their use? YoanYoan
  37. 37. RSBI  This is f/VTThis is f/VT  Yang, KL, Tobin, MJ (1991) A prospectiveYang, KL, Tobin, MJ (1991) A prospective study of indexes predicting the outcome of trialsstudy of indexes predicting the outcome of trials of weaning from mechanical ventilation.of weaning from mechanical ventilation. N EnglN Engl J MedJ Med 324324,1445-1430,1445-1430  Shown to be predictive of extubation ifShown to be predictive of extubation if <<105105
  38. 38. RSBI Frutos-Vivar, et al 2006;130;1664-1671 Chest Risk Factors for Extubation Failure in Patients Following a Successful Spontaneous Breathing Trial
  39. 39. Spontaneous Breathing Trial ELY et al; N Engl J Med 1996;335:1864- 9.)  RCT of 300 vented pts in ICU&CSICURCT of 300 vented pts in ICU&CSICU  All pts screened daily for PaO2/FiO2>200,All pts screened daily for PaO2/FiO2>200, PEEPPEEP<<5, f/Vt <105, good cough, no5, f/Vt <105, good cough, no pressorspressors
  40. 40. SBT  Intervention group then underwent SBT forIntervention group then underwent SBT for 2 hours that morning2 hours that morning  If passed a note was left on the chartIf passed a note was left on the chart  Controls only had the daily assessmentControls only had the daily assessment
  41. 41. SBT results
  42. 42. Asynchrony  Five days later, your patient is still requiring aFive days later, your patient is still requiring a PSV of 10 and PEEP 5. The RT notes somePSV of 10 and PEEP 5. The RT notes some asynchrony as well. The bright Jr resident pipesasynchrony as well. The bright Jr resident pipes up and says he heard about a different form ofup and says he heard about a different form of ventilation called PAV that might help with this.ventilation called PAV that might help with this.  7. What is PAV and how does it work?7. What is PAV and how does it work? SteveSteve
  43. 43. PAV (Proportional Assist Ventilation)  ventilator amplifies the patient'sinspiratory effort without any preselected target volume orpressure  Aim is to allow the patient to attain their own ventilation and breathing pattern Younes M. Proportional assist ventilation, a new approach to ventilatory support. Am Rev Respir Dis 1992;145:114–20
  44. 44. PSV vs PAV  Varelmann, et al; Crit Care Med 2005; 33:1968 –1975)  12 pts in randomized clinical crossover  Increasing vent demand by adding dead space  Cardiorespiratory, ventilatory, and work of breathing variables were assessed
  45. 45. Results  No major differences in cardiorespiratory function between dynamic and constant inspiratory pressure assistance.
  46. 46. PAV  8. Is there evidence it helps with patient8. Is there evidence it helps with patient vent asynchrony?vent asynchrony? SteveSteve
  47. 47. Giannouli, et al. Response of ventilator dependent patients to different levels of pressure support and proportional assist. Am J Respir Crit Care Med. 1999;159:1716 –1725.  found lower rates of ineffective triggering with PAV than with PSV, because tidal volume was smaller at high levels of assistance and because ventilator insufflation time was limited
  48. 48. Asynchrony  9. What other techniques can be used to9. What other techniques can be used to decrease asynchrony?decrease asynchrony? SteveSteve
  49. 49.  Adjusting the Inspiratory Trigger  Adjusting PEEP  Adjusting the Pressure Support Level  Increasing the expiratory trigger (% inspiratory flow)  Neurally adjusted ventilatory assist (NAVA)
  50. 50. VIDD  After 10 days in the unit the patient is still unableAfter 10 days in the unit the patient is still unable to fully wean off the ventilator. During roundsto fully wean off the ventilator. During rounds your great and mighty staff asks you:your great and mighty staff asks you:  10. What is ventilator induced diaphragm10. What is ventilator induced diaphragm dysfunction-VIDD and how does it effectdysfunction-VIDD and how does it effect weaning?weaning? ScottScott
  51. 51. VIDD  a loss of diaphragmatic force- generating capacity that is specifically related to the use of mechanical ventilation.  Inactivity of diaphragm during MV
  52. 52. VIDD  VIDD is a diagnosis of exclusion based on  (1) an appropriate clinical history of having undergone a period of controlled mechanical ventilation (CMV), and  (2) other possible causes of diaphragmatic weakness having been sought and ruled out
  53. 53.  Atrophy, oxidative stress, myofibrillar disruption, and various remodeling responses within diaphragm muscle fibers  Animal studies suggest that the onset of VIDD during CMV is rapid  Minimize non-spont vent, steroids and maximize nutrition  antioxidants?
  54. 54. Tracheostomy  She then asks you if we should consult for aShe then asks you if we should consult for a trach in this patient?trach in this patient?  11. When is the best timing for a11. When is the best timing for a tracheostomy and does it reduce ICU lengthtracheostomy and does it reduce ICU length of stay?of stay? ScottScott
  55. 55. Trach Timing  lack of adequately sized, randomized, prospective controlled studies  most recommendations are based on consensus opinions of clinical experts
  56. 56. Trach  Indications for tracheostomy include  failure of extubation,  upper airway obstruction,  airway protection and airway access for secretion removal,  avoidance of serious oropharyngeal and laryngeal injury from prolonged translaryngeal intubation
  57. 57. MacIntyre NR, Cook DJ, Ely EW Jr, et al. Chest 2001; 120 (6 Suppl):375S–395S.  ACCP guidelines suggest that tracheostomy should be considered after an initial period of stabilization on the ventilator (generally, within 3–7 days), when it becomes apparent that the patient will require prolonged ventilator assistance
  58. 58. Groves and Durbin Jr,Current Opinion in Critical Care 2007, 13:90–97  Review of literature on trachsReview of literature on trachs  a number of retrospective studies and a single prospective study have shed some light on timing of trach  Most reports favor the performance of tracheostomy within 10 days of respiratory failure
  59. 59. Summary of Trials
  60. 60. Sleep  The nurse also mentions the patient hasThe nurse also mentions the patient has been having difficulty sleeping most nightsbeen having difficulty sleeping most nights (who doesn’t).(who doesn’t).  12. What is the impact of ventilator12. What is the impact of ventilator settings on sleep patterns?settings on sleep patterns? ScottScott
  61. 61. Parthasarathy; Am J Respir Crit Care Med Vol 166. pp 1423–1429, 2002  performed polysomnography on 11 criti- cally ill patients  examined whether the presence of backup rate on assist-control ventilation would decrease apnea- related arousals and improve sleep quality.  patients receiving mechanical ventilation have severely fragmented sleep
  62. 62. Sleep  the number of arousals and awakenings, was greater during pressure support than during assist-control ventilation: 79+7 versus 54+7 events per hour (p=0.02)  6 pts had central apneic episodes on PSV  addition of dead space produced a mean increase in end-tidal CO2 of 4.3 mm Hg, which resulted in a decrease in the frequency of central apneas
  63. 63. PAV vs PSVin Sleep  Bosma, et al; Crit Care Med 2007; 35:1048–1054  13 pts in crossover study13 pts in crossover study  Overall sleep quality was significantly improved on proportional assist ventilation (p < .05) due to the combined effect of  fewer arousals and awakenings per hour (3.5 vs. 5.5),  and greater rapid eye movement (9% vs. 4%) and slow wave sleep(3% vs. 1% )
  64. 64.  Patient-ventilator asynchronies per hour were lower with PAV than with PSV (24 vs. 53 ; p =.02) and correlated with the number of arousals per hour (RR =.65, p=.0001).
  65. 65. BiPAP and re-intubation  The next day the patient is on PSV 6 and PEEP ofThe next day the patient is on PSV 6 and PEEP of 5, is alert, afebrile, and has and passed his SBT.5, is alert, afebrile, and has and passed his SBT. You feels it is time to pull the tube. 1 hour later,You feels it is time to pull the tube. 1 hour later, the patient becomes tachypneic and looks like hethe patient becomes tachypneic and looks like he might fail extubation. Your very astute Jr said hemight fail extubation. Your very astute Jr said he has read something about using BiPAP to preventhas read something about using BiPAP to prevent re-intubation.re-intubation.  13. What is the evidence to use BiPAP to13. What is the evidence to use BiPAP to extubate/prevent re-intubation?extubate/prevent re-intubation? DaveDave
  66. 66. NIPPV and Extubation  Keenan, et al; JAMA. 2002;287:3238-3244  RCT  81 patients who required ventilatory support for more than 2 days and who developed respiratory distress within 48 hours of extubation.  Stnd therapy vs NIPPV+Stnd therapyStnd therapy vs NIPPV+Stnd therapy
  67. 67. Results  there was no difference in the rate of reintubation (72% vs 69%; relative risk, 1.04; 95% confidence interval, 0.78- 1.38) or hospital mortality (31% for both groups; relative risk, 0.99; 95% confidence interval, 0.52-1.91).
  68. 68.  Pts with COPD were excluded after 1 year because they thought it was unethical due to strong established literature supporting the use of NPPV for COPD exacerbations
  69. 69. NIPPV for Respiratory Failure after Extubation Esteban, ET AL; N Engl J Med 2004;350:2452-60.  Multicenter, randomized trial  Electively extubated after mechanical ventilation and who had respiratory failure within 48 hours  There was no difference found (rate of reintubation, 48% in both groups; RR in the NIPPV group, 0.99; 95 percent CI, 0.76 to 1.30).
  70. 70.  Rate of death in the intensive care unit was higher in the NIPPVgroup (25% vs. 14%; RR 1.78; 95 percent confidence interval, 1.03 to 3.20; P=0.048)  Likely due to increase time to re- intubation  Only 10% had COPD
  71. 71. Noninvasive positive-pressure ventilation in acute respiratory failure Peñuelas et al, CMAJ 2007;177(10):1211-8  Review of literature  the early use of NIPPV can prevent respiratory failure after extubation and decrease the need for reintubation.  further studies that better define the population of patients at risk for respiratory failure after extubation may be necessary.
  72. 72. Prognosis  The patient does well and only requiresThe patient does well and only requires BiPAP for 12 hours. Your medical studentBiPAP for 12 hours. Your medical student then asks:then asks:  14. What is the short and long-term14. What is the short and long-term prognosis for a person with COPD who hasprognosis for a person with COPD who has required mechanical ventilation?required mechanical ventilation? DaveDave
  73. 73. Exacerbation of COPD: A Retrospective Study In-Hospital and 5-Year Mortality of Patients Treated in the ICU for Acute Chua Ai-Ping, et al; Chest 2005;128;518-524  Retrospective cohort study of 57 patients  More than 90% of patients required intubation  The in-hospital mortality rate for the entire cohort was 24.5%.  mortality rates at 6 months and 1, 3, and 5 years were 39.0%, 42.7%, 61.2%, and 75.9%,  median survival time for all patients
  74. 74. Outcome  3-month mortality rate after ICU discharge was 11%.  only IBW predicted three-month survival rate Vitacca, et al; CHEST 2005  Hospital mortality 15% (predicted 30%)Hospital mortality 15% (predicted 30%)  Incidence of sepsis and number of organ failuresIncidence of sepsis and number of organ failures were higher in non-survivorswere higher in non-survivors Afessa et al, Crit Care Med 2002Afessa et al, Crit Care Med 2002
  75. 75. Lung Reduction Surgery  The patient’s son arrives from Scotland and thanksThe patient’s son arrives from Scotland and thanks you all for the wonderful care of his father. Heyou all for the wonderful care of his father. He then states that he has been reading on Lungthen states that he has been reading on Lung Volume Reduction Surgery and wonders if itVolume Reduction Surgery and wonders if it would help his father.would help his father.  15. What is LVRS and is there evidence of15. What is LVRS and is there evidence of benefit in COPD?benefit in COPD? DaveDave
  76. 76. LVRS •First introduced by Brantigan in 1957 Brantigan, A surgical approach to pulmonary emphysema. Am Rev Respir Dis 1959; 80:194.
  77. 77. A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema. Fishman et al, N Engl J Med 2003 May 22;348(21):2059-73  1218 pts with severe emphysema1218 pts with severe emphysema underwent pulmonary rehab and wereunderwent pulmonary rehab and were randomly assigned to LVRS or to receiverandomly assigned to LVRS or to receive continued medical treatmentcontinued medical treatment  Overall, surgery increases the chance ofOverall, surgery increases the chance of improved exercise capacity but did notimproved exercise capacity but did not confer a survival advantage over medicalconfer a survival advantage over medical therapytherapy
  78. 78.  There was a survival advantage forThere was a survival advantage for patients with both predominantly upper-patients with both predominantly upper- lobe emphysema and low base-linelobe emphysema and low base-line exercise capacity.exercise capacity.
  79. 79. The Effect of Lung Volume Reduction Surgery on Chronic Obstructive Pulmonary Disease Exacerbations Washko et al; Am J Respir Crit Care Med Vol 177. pp 164–169, 2008  To examine the effect, and mechanism of potential benefit, of LVRS on COPD exacerbations by comparing the medical and surgical cohorts of the National Emphysema Treatment Trial (NETT).
  80. 80. LVRS  no difference in exacerbation rate or time to first exacerbation between the medical and surgical cohorts during the year before study randomization  Post randomization, the surgical cohort experienced an approximate 30% reduction in exacerbation frequency(P=0.0005)
  81. 81.  LVRS increased the time to first exacerbation in both subjects with and without a prior history of exacerbations (P=0.0002 and P=0.0001, respectively)
  82. 82. Effect of Bronchoscopic Lung Volume Reduction on Dynamic Hyperinflation and Exercise in Emphysema Nicholas, et al; Am J Respir Crit Care Med Vol 171  Endobronchial valve placement can improve lung volumes and gas transfer in patients with chronic obstructive pulmonary disease and prolong exercise time by reducing dynamic hyperinflation.
  83. 83. Bonus Time  Bonus questions: 1. Is there any evidenceBonus questions: 1. Is there any evidence that Cold-FX works?that Cold-FX works?
  84. 84.  2. Should this patient have his large2. Should this patient have his large ventral hernia repaired in the future and ifventral hernia repaired in the future and if so, using what technique?so, using what technique?
  85. 85. Hernia Repair  Factors to considerFactors to consider  Size of hernia and risk of incarcerationSize of hernia and risk of incarceration  Overall health of patientOverall health of patient  Lap vs OpenLap vs Open

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