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ABSTRACT: It is unclear if lung perfusion can predict response to lung volume reduction surgery (LVRS).
To study the role of perfusion scintigraphy in patient selection for LVRS.
We performed an intention-to-treat analysis of 1,045 of 1,218 patients enrolled in the National Emphysema Treatment Trial who were non-high risk for LVRS and had complete perfusion scintigraphy results at baseline. The median follow-up was 6.0 years. Patients were classified as having upper or non-upper lobe-predominant emphysema on visual examination of the chest computed tomography and high or low exercise capacity on cardiopulmonary exercise testing at baseline. Low upper zone perfusion was defined as less than 20% of total lung perfusion distributed to the upper third of both lungs as measured on perfusion scintigraphy.
Among 284 of 1,045 patients with upper lobe-predominant emphysema and low exercise capacity at baseline, the 202 with low upper zone perfusion had lower mortality with LVRS versus medical management (risk ratio [RR], 0.56; P = 0.008) unlike the remaining 82 with high perfusion where mortality was unchanged (RR, 0.97; P = 0.62). Similarly, among 404 of 1,045 patients with upper lobe-predominant emphysema and high exercise capacity, the 278 with low upper zone perfusion had lower mortality with LVRS (RR, 0.70; P = 0.02) unlike the remaining 126 with high perfusion (RR, 1.05; P = 1.00). Among the 357 patients with non-upper lobe-predominant emphysema (75 with low and 282 with high exercise capacity) there was no improvement in survival with LVRS and measurement of upper zone perfusion did not contribute new prognostic information.
Compared with optimal medical management, LVRS reduces mortality in patients with upper lobe-predominant emphysema when there is low rather than high perfusion to the upper lung.
American Journal of Respiratory and Critical Care Medicine 10/2010; 182(7):937-46. · 11.08 Impact Factor
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ABSTRACT: There is increasing evidence that survivors of ARDS may have impairments in cognitive function, mood and quality of life. This study investigated associations between cognitive impairment, mood disorders and quality of life in a select group of ARDS survivors.
A cross-sectional study was conducted to describe the specific impairments in cognitive function, mood and quality of life in a group of 79 self-selected ARDS survivors who contacted an Internet-based support site. A battery of cognitive tests was administered by telephone interview. Standardized scores on cognitive tests were compared with normative values and tested for associations with indices of anxiety, depression and quality of life.
Cognitive impairment was found in 56% of subjects. Compared with population norms, 24% of subjects had deficiencies in short-term memory (P = 0.04) and 29% in executive functioning (P = 0.001). Moderate or severe anxiety was present in 48% of the study population, and 34% had moderate or severe depression. Moderate or severe anxiety was present in 61% of subjects with evidence of cognitive impairment as compared with 31% of subjects without. Subjects with cognitive impairment scored worse than subjects without cognitive impairment on most subscales of the SF-36 and the Sickness Impact Profile questionnaire.
Significant cognitive abnormalities may be present in long-term ARDS survivors, particularly in memory and executive function. Impairments in cognition appear to be associated with significantly increased anxiety and worse quality of life.
Respirology 02/2009; 14(1):76-82. · 2.42 Impact Factor
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ABSTRACT: Intraabdominal pressure is measured conventionally at end-expiration; however, the significance of forced exhalation on this measurement has not been evaluated previously. Using data from a previous prospective cohort study of the incidence of intraabdominal hypertension and abdominal compartment syndrome in medical intensive care unit patients, the authors evaluated 65 strip-chart recordings obtained from 28 patients who had measurements of intraabdominal pressure and airway pressures taken simultaneously. Forced exhalation was identified by a rise in intraabdominal pressure during exhalation. Forced exhalation was observed in 4 patients; with a mean intraabdominal pressure increase of 14.3 +/- 1.3 mm Hg at end-exhalation, compared with a decrease of -2.5 +/- 1.2 mm Hg in 24 patients without forced exhalation and absolute pressures of 28.0 +/- 6.6 versus 13.8 +/- 3.9 mm Hg (P < .001). However, there was no difference in end-inspiratory values. Forced exhalation is not uncommon in acutely ill, mechanically ventilated medical intensive care unit patients and may increase intraabdominal pressure significantly to values that exceed the diagnostic threshold for abdominal compartment syndrome.
Journal of Intensive Care Medicine 05/2008; 23(4):268-74.
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ABSTRACT: Current guidelines recommend surgical lung biopsy for diagnosis of interstitial lung diseases (ILDs) in selected patients. To shed light on the risk-benefit ratio for this recommendation, we examined the morbidity and mortality associated with video-assisted thoracoscopic surgical (VATS) lung biopsy in a group of outpatients.
A retrospective cohort study was conducted of 68 consecutive ambulatory patients with radiographically apparent interstitial lung disease (ILD) referred for VATS biopsy during a 6-year period. Incidence of postoperative mortality, prolonged air leaks, pneumonias, and re-admissions were calculated. Risk factors for complications of surgery were examined.
Three deaths occurred within 60 days after biopsy for a mortality rate of 4.4% (95% confidence interval [CI], 1% to 12%), and 19.1% (95% CI, 11% to 31%) experienced one or more complications of surgery. Risk factors for morbidity included preoperative dependence on oxygen therapy and pulmonary hypertension. The three patients who died had usual interstitial pneumonia on their biopsy specimen and were reintubated postoperatively for acute lung injury. Aggregation of articles published over the past 10 years reporting on surgical lung biopsy for the diagnosis of ILD yielded a postoperative mortality rate of 2% to 4.5%.
VATS lung biopsy for diagnosis of ILD, even in ambulatory patients, is not an entirely benign procedure. Biopsy rarely may trigger an acute exacerbation of usual interstitial pneumonitis. The risk of postoperative complications appears to be greatest in those dependent on oxygen and those who have pulmonary hypertension. This information may be used in weighing the risk-benefit ratio of biopsy in individual patients.
The Annals of thoracic surgery 04/2007; 83(3):1140-4. · 3.74 Impact Factor
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JAMA The Journal of the American Medical Association 10/2006; 296(11):1397-400. · 30.03 Impact Factor
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ABSTRACT: Describe initial development and validation of a test battery composed of established instruments designed to detect, via telephone interview, cognitive abnormalities in survivors of acute respiratory distress syndrome.
Two cross-sectional studies were performed, including the following phases: (1) initial battery construction, (2) feasibility, (3) item reduction, (4) convergent and divergent validity, and (5) telephone administration compared with in-face interviews in a separate population.
There was a broad range of cognitive function detected in the derivation population, and all subjects completed the interview. There was convergence of cognitive impairment with moderate/severe anxiety (P = .008), the Sickness Impact Profile Psychosocial Summary Score (mean difference, 15.3; 95% CI, 7.74-22.9; P = .0001), and the mental health domains of the Short Form 36. Subjects with cognitive impairment had no detectable difference in the physical function domains of the Short Form 36. When administered to the validation population, telephone tests of memory, attention, reasoning, and executive functions had good intraclass correlation with the in-face interviews (P < .01).
Detection of cognitive abnormalities in acute respiratory distress syndrome survivors using a telephone-administered test battery derived from standard cognitive tests is feasible and has evidence of construct validity. This battery may be useful as a research tool when in-face interviews are not feasible.
Journal of Critical Care 06/2006; 21(2):125-32. · 2.13 Impact Factor
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ABSTRACT: In July 2001, the United States Joint Commission on Accreditation of Health care Organizations adopted a new leadership standard that requires department heads in health care organizations to perform at least one Failure Mode and Effects Analysis (FMEA) every year. This proactive approach to error prevention has proven to be highly effective in other industries, notably aerospace, but remains untested in acute care hospitals. For several reasons, the intensive care unit (ICU) potentially is an attractive setting for early adoption of FMEA; however, successful implementation of FMEA in ICUs is likely to require strong, effective leadership and a sustained commitment to prevent errors that may have occurred rarely or never before in the local setting. This article describes FMEA in relation to critical care medicine and reviews some of the attractive features together with several potential pitfalls that are associated with this approach to error prevention in ICUs.
Critical Care Clinics 02/2005; 21(1):21-30, vii. · 2.05 Impact Factor
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ABSTRACT: Improved outcomes with expanding treatment options for patients with pulmonary arterial hypertension present the opportunity to consider additional end-points in approaching therapy, including factors that influence health-related quality of life. However, comparatively little is known about health-related quality of life and its determinants in patients with pulmonary arterial hypertension.
Health-related quality of life was evaluated in a cross sectional study of 155 outpatients with pulmonary arterial hypertension using generic and respiratory-disease specific measurement tools. Most patients had either World Health Organization functional Class II or III symptoms. Demographic, hemodynamic and treatment variables were assessed for association with health-related quality of life scores.
Patients with pulmonary arterial hypertension suffered severe impairments in both physical and emotional domains of health-related quality of life. Patients with idiopathic ("primary") pulmonary arterial hypertension had the best, and those with systemic sclerosis the worst health-related quality of life. Greater six-minute walk distance correlated with better health-related quality of life scores, as did functional Class II versus Class III symptoms. Hemodynamic measurements, however, did not correlate with health-related quality of life scores. No differences in health-related quality of life were found between patients who were being treated with calcium channel antagonists, bosentan or continuously infused epoprostenol at the time of quality of life assessment.
Health-related quality of life is severely impaired in patients with pulmonary arterial hypertension and is associated with measures of functional status. Specific associations with impaired health-related quality of life suggest potential areas for targeted intervention.
Respiratory research 02/2005; 6:92. · 3.36 Impact Factor
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ABSTRACT: The effects of pulmonary arterial hypertension on brain function are not understood, despite patients' frequent complaints of cognitive difficulties. Using clinical instruments normally administered during standard in-person assessment of neurocognitive function in adults, we assembled a battery of tests designed for administration over the telephone. The purpose was to improve patient participation, facilitate repeated test administration, and reduce the cost of research on the neuropsychological consequences of acute and chronic cardiorespiratory diseases. We undertook this study to validate telephone administration of the tests.
23 adults with pulmonary arterial hypertension underwent neurocognitive assessment using both standard in-person and telephone test administration, and the results of the two methods compared using interclass correlations.
For most of the tests in the battery, scores from the telephone assessment correlated strongly with those obtained by in-person administration of the same tests. Interclass correlations between 0.5 and 0.8 were observed for tests that assessed attention, memory, concentration/working memory, reasoning, and language/crystallized intelligence (p < or = 0.05 for each). Interclass correlations for the Hayling Sentence Completion test of executive function approached significance (p = 0.09). All telephone tests were completed within one hour.
Administration of this neurocognitive test battery by telephone should facilitate assessment of neuropsychological deficits among patients with pulmonary arterial hypertension living across broad geographical areas, and may be useful for monitoring changes in neurocognitive function in response to PAH-specific therapy or disease progression.
Respiratory research 01/2005; 6:39. · 3.36 Impact Factor
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ABSTRACT: Abstract
Background
Improved outcomes with expanding treatment options for patients with pulmonary arterial hypertension present the opportunity to consider additional end-points in approaching therapy, including factors that influence health-related quality of life. However, comparatively little is known about health-related quality of life and its determinants in patients with pulmonary arterial hypertension.
Methods
Health-related quality of life was evaluated in a cross sectional study of 155 outpatients with pulmonary arterial hypertension using generic and respiratory-disease specific measurement tools. Most patients had either World Health Organization functional Class II or III symptoms. Demographic, hemodynamic and treatment variables were assessed for association with health-related quality of life scores.
Results
Patients with pulmonary arterial hypertension suffered severe impairments in both physical and emotional domains of health-related quality of life. Patients with idiopathic ("primary") pulmonary arterial hypertension had the best, and those with systemic sclerosis the worst health-related quality of life. Greater six-minute walk distance correlated with better health-related quality of life scores, as did functional Class II versus Class III symptoms. Hemodynamic measurements, however, did not correlate with health-related quality of life scores. No differences in health-related quality of life were found between patients who were being treated with calcium channel antagonists, bosentan or continuously infused epoprostenol at the time of quality of life assessment.
Conclusion
Health-related quality of life is severely impaired in patients with pulmonary arterial hypertension and is associated with measures of functional status. Specific associations with impaired health-related quality of life suggest potential areas for targeted intervention.
Respiratory Research. 01/2005;
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Critical Care Medicine 11/2004; 32(12):A83. · 6.33 Impact Factor
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ABSTRACT: Pulmonary fibrosis and atherosclerosis have many similarities at the histopathologic level. Moreover, fibrotic lung diseases exhibit systemic effects and have the potential to affect the vasculature beyond the lung. The existence of a relationship between the two, however, has not been studied.
To investigate whether fibrotic lung disorders may predispose to atherosclerosis, we conducted a cross-sectional study of 630 patients referred for lung transplantation evaluation at a university hospital. We compared the prevalence of angiographic coronary artery disease (CAD) in patients with fibrotic vs nonfibrotic lung diseases.
Fibrotic lung diseases were associated with an increased prevalence of CAD compared with nonfibrotic diseases after adjustment for traditional risk factors (odds ratio, 2.18; 95% confidence interval, 1.17-4.06). The magnitude and significance of this association were maintained when only nongranulomatous fibrotic disease or its subset, idiopathic pulmonary fibrosis, was examined. The strength of the relationship between fibrotic disorders and CAD increased when multivessel disease was analyzed (odds ratio, 4.16; 95% confidence interval, 1.46-11.9). No significant association was detected for granulomatous fibrotic disorders (odds ratio, 1.56; 95% confidence interval, 0.47-5.16; P =.47), although this subgroup had fewer cases of CAD for analysis.
These findings support an association between fibrotic lung disorders and CAD. Further research is necessary to confirm this relationship and to explore the pathologic processes underlying, and potentially linking, these 2 conditions.
Archives of Internal Medicine 04/2004; 164(5):551-6. · 11.46 Impact Factor
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John Hansen-Flaschen
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ABSTRACT: Nearly one quarter million Americans die with or of advanced chronic obstructive pulmonary disease (COPD) each year. Many patients die after a prolonged functional decline that is accompanied by much suffering. Though difficult prognostically and emotionally, anticipation of death opens the door to planning and preparing for terminal care. Epidemiologists have begun to identify characteristics of COPD patients who are most likely to die within 6-12 months, including severe, irreversible airflow obstruction, severely impaired and declining exercise capacity and performance status, older age, concomitant cardiovascular or other co-morbid disease, and a history of recent hospitalizations for acute care. Clinicians are encouraged to raise the difficult subject of planning for death when many of these characteristics apply. Patients with far-advanced disease are often receptive to the recommendation of a dual agenda: "Hope for and expect the best, and prepare for the worst." Medical advance planning is best pursued in an out-patient office during a prescheduled, 3-way conversation between patient, health care proxy, and physician. An advance directive can be written after the meeting to summarize the conversation. Clinicians should consider recommending hospice care when a COPD patient is at high risk of respiratory failure from the next chest infection and in need of frequent or specialized home care. Preparation for death should include a realistic appraisal of the prospects for dying peacefully at home and a contingency plan for terminal hospitalization, should the need arise.
Respiratory care 02/2004; 49(1):90-7; discussion 97-8. · 2.01 Impact Factor
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ABSTRACT: Patients at the Philadelphia Veterans Affairs Medical Center frequently voice concern that air exposure during lung cancer surgery might cause tumor spread. Several African-American patients asserted that this belief was common in the African-American community.
To assess the prevalence of the belief that air exposure during lung cancer surgery might cause tumor spread and gauge the influence of this belief on the willingness of African-American and white patients to have lung cancer surgery.
Prospective questionnaire survey.
Philadelphia Veterans Affairs Medical Center and University of Pennsylvania, Philadelphia, Pennsylvania; Los Angeles Veterans Affairs Medical Center, Los Angeles, California; and Medical University of South Carolina, Charleston, South Carolina.
626 consecutive patients in pulmonary and lung cancer clinics.
None.
38% of patients (61% of whom were African American and 29% of whom were white) stated that they believe air exposure at surgery causes tumor spread. The most significant predictor of belief was African-American race (odds ratio, 3.5 [95% CI, 1.9 to 6.5]), even after controlling for other relevant variables in a multivariable analysis. Nineteen percent of African Americans stated that this belief was a reason for opposing surgery, and 14% would not accept their physicians' assertion that the belief is false. These rates were also statistically significantly higher among African-American than white patients.
Belief in accelerated tumor spread at surgery is prevalent among general pulmonary outpatients and lung cancer clinic patients facing lung surgery, particularly among African-American patients. Our findings may pertain to key racial disparities in lung cancer surgery and survival rates and suggest that culturally sensitive physician training or outreach programs directed at disparate beliefs and attitudes may help to address racial discrepancies in health care outcomes.
Annals of internal medicine 11/2003; 139(7):558-63. · 16.73 Impact Factor
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ABSTRACT: This report evaluates the validity of a new method for verifying self-reported smoking status in patients presenting for pulmonary medicine treatment. A prospective comparison was made between self-reports of smoking status and a new semiquantitative, enzyme-linked, immunosorbent assay-based method testing for the presence of a prime nicotine metabolite, cotinine. Results were validated by gas chromatography/mass spectrometry. Data were collected in an urban, academic, tertiary health care setting. The study included 76 consecutive new patients presenting to participating clinical practices at the Pulmonology or Thoracic Surgery Services. Before taking a smoking history, patients were informed that their urine would be tested onsite for the presence of nicotine using a new method, the NicoMeter, for determining tobacco product exposure, followed by more standard laboratory testing. The level of agreement between the biochemical measurement types was excellent, kappa = 0.777. The new biochemical measurement type used was easy to use. Self-reported smoking status corresponded closely to biochemical testing. However, there was a 5.3-9.5% misclassification of smoking status among the group studied, depending upon the measurement type used. Among 32 lung cancer patients, 15.6%, most likely misrepresented their current smoking status. The NicoMeter appears to be a valid and useful method for confirming self-reported smoking status. Lung cancer patients had a higher rate of inaccurate nonsmoking compared with patients with nonmalignant pulmonary disease. The findings have implications for investigators who accept self-reported smoking status without biochemical verification.
Cancer Epidemiology Biomarkers & Prevention 11/2002; 11(10 Pt 1):1123-5. · 4.12 Impact Factor
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David A Lipson,
David A Roberts, John Hansen-Flaschen,
Thomas R Gentile,
Gordon Jones,
Alan Thompson,
Ivan E Dimitrov,
Harold I Palevsky,
John S Leigh,
Mitchell Schnall,
Rahim R Rizi
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ABSTRACT: Conventional nuclear ventilation/perfusion (V/Q) scanning is limited in spatial resolution and requires exposure to radioactivity. The acquisition of pulmonary V/Q images using MRI overcomes these difficulties. When inhaled, hyperpolarized helium-3 ((3)He) permits MRI of gas distribution. Magnetic labeling of blood (arterial spin-tagging (AST)) provides images of pulmonary perfusion. Three normal subjects, two patients who had undergone single lung transplantation for emphysema, and one subject with pulmonary embolism (PE), were imaged. (3)He distribution and blood perfusion appeared uniform in the normal subjects and throughout the lung allografts. Gas distribution and perfusion in the emphysematous lungs were non-uniform and paralleled radiographic abnormalities. AST imaging alone revealed a lower-lobe wedge-shaped perfusion defect in the patient with PE that corresponded to computed tomography (CT) imaging. Hyperpolarized (3)He gas is demonstrated to provide ventilation images of the lung. Blood perfusion information may be obtained during the same examination using the AST technique. The sequential application of these imaging methods provides a novel tool for studying V/Q relationships.
Magnetic Resonance in Medicine 07/2002; 47(6):1073-6. · 2.96 Impact Factor
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ABSTRACT: Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) have been well described in surgical patients. Large-volume resuscitation is thought to be a risk factor for IAH/ACS in this group. However, little is known of the incidence of IAH/ACS in critically ill medical patients. The authors aim to ascertain the incidence of ACS in critically ill medical patients receiving large-volume resuscitation. Over an 8-month study period, the authors performed a prospective cohort study of medical intensive care unit (ICU) patients with a minimum net positive fluid balance of 5 L within the preceding 24 hours. The primary outcome of interest is the development of ACS, defined as an intra-abdominal pressure (IAP) > or = 20 mm Hg associated with new organ dysfunction. IAP was measured by transducing bladder pressure and was recorded along with fluid balance at enrollment and every 12 hours thereafter up to 96 hours. The setting is a medical ICU at a major university hospital. Of the 468 medical ICU admissions screened, 40 (8.5%) were identified who met the 24-hour fluid balance inclusion criterion. Upon enrollment, this cohort had a mean Acute Physiology And Chronic Health Evaluation II score of 23 and a median positive fluid balance of 6.9 L. Thirty-four of the 40 study patients (85%) had intra-abdominal hypertension (IAP > or = 12 mm Hg). During the study period, 13 of the 40 (33%) patients developed IAP > or = 20 mm Hg and 10 (25%) met the criteria for ACS. None underwent laparotomy. ACS is frequently found in critically ill medical patients receiving large-volume resuscitation. The clinical significance of this finding remains unclear. However, routine monitoring of IAP should be considered in medical patients with a 5-L net positive fluid balance in 24 hours. Future studies are warranted to evaluate clinical outcomes of medical patients with ACS and risk factors for its development.
Journal of Intensive Care Medicine 22(5):294-9.
