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Richard S Irwin
Chest 12/2002; 122(5):1837-9. · 5.25 Impact Factor
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American Journal of Respiratory and Critical Care Medicine 07/2002; 165(11):1469-74. · 11.08 Impact Factor
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ABSTRACT: To examine the effects of a mechanical ventilation weaning management protocol that was implemented as a hospital-wide, quality improvement program on clinical and economic outcomes.
Prospective, before-and-after intervention study. Data from a preimplementation year are compared with those of the first 2 yrs after protocol implementation.
Patients older than 18 yrs in diagnosis-related group 475 and group 483, who were admitted to the adult medical, surgical, and cardiac intensive care units (ICU) in a university hospital.
After the baseline year, a weaning management program was implemented throughout our institution. Primary endpoints were mortality, days on mechanical ventilation, ICU and hospital lengths of stay, hospital costs, and the percentage of patients requiring tracheostomy.
The number of patients increased from 220 in the baseline year (year 0) to 247 in the first year (year 1), then to 267 in the second year (year 2). The mean Acute Physiology and Chronic Health Evaluation (APACHE) II score increased from 22.2 to 24.4 in year 1 (p =.006) and to 26.2 in year 2 (p <.0005). When year 0 was compared with year 1, mean days on mechanical ventilation decreased from 23.9 to 21.9 days (p =.608), hospital length of stay decreased from 37.5 to 31.6 days (p =.058), ICU length of stay decreased from 30.5 to 25.9 days (p =.133), and total cost per case decreased from $92,933 to $78,624 (p =.061). When year 0 was compared with year 2, mean days on mechanical ventilation decreased from 23.9 days to 17.5 days (p =.004), mean hospital length of stay decreased from 37.5 to 24.7 days, mean ICU length of stay decreased from 30.5 to 20.3 days, total cost per case decreased from $92,933 to $63,687, and percentage of patients requiring tracheotomy decreased from 61% to 41% (all p <.0005). There was also a reduction in the percentage of patients requiring more than one course of mechanical ventilation during the hospitalization from 33% to 26% (p =.039), a total cost savings of $3,440,787 and a decrease in mortality between all 3 yrs from 32% to 28% (p =.062).
A multifaceted, multidisciplinary weaning management program can change the process of care used for weaning patients from mechanical ventilation throughout an acute care hospital and across multiple services. This change can lead to large reductions in the duration of mechanical ventilation, length of stay, and hospital costs, even at a time when patients are sicker.
Critical Care Medicine 06/2002; 30(6):1224-30. · 6.33 Impact Factor
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ABSTRACT: To psychometrically evaluate a cough-specific quality-of-life questionnaire (CQLQ) in adults.
Prospective evaluation of CQLQ using three different cohorts of adult subjects with cough.
Academic tertiary-care ambulatory medical facilities.
One hundred fifty-four subjects complaining of chronic cough, 30 of acute cough, and 31 smokers with cough.
Self-administration of the CQLQ in acute coughers, smokers, and chronic coughers before and after therapy.
Psychometric analyses including factor analysis (FA), and assessments of reliability and validity.
Acute and chronic cough data were subjected to FA, and the Cronbach alpha and interitem correlations were computed. FA of chronic and acute cough data (n = 184) revealed six subscales. The Cronbach alpha for the total CQLQ was 0.92, and it was 0.62 to 0.86 (mean, 0.76) for the six subscales. Interitem correlations for the total CQLQ ranged from -0.06 to 0.72, with a mean of 0.28. Test-retest reliability in 52 chronic coughers demonstrated nonsignificant changes with readministration of the questionnaire, and the intraclass correlation for total CQLQ was 0.89, and for the subscales the range was 0.75 to 0.93. Analysis of variance followed by tests of contrasts among all possible pairings of chronic coughers, acute coughers, and smokers showed significant differences (p < or = 0.001) among the groups. Posttreatment cure scores were significantly lower (p < or = 0.001) than pretreatment scores in 24 chronic coughers.
The 28-item CQLQ has dimensionality that is consistent with a cough-specific quality-of-life instrument. It is a valid and reliable method by which to assess the impact of cough on the quality of life of chronic and acute coughers, and the efficacy of cough therapies in chronic coughers.
Chest 04/2002; 121(4):1123-31. · 5.25 Impact Factor
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ABSTRACT: While medical therapy may fail to improve cough due to gastroesophageal reflux disease (GERD), it is not known if inadequate esophageal acid suppression is responsible.
In a prospective, before-and-after interventional trial, we assessed the effects of antireflux surgery in eight patients whose chronic coughs were due to GERD resistant to intensive medical therapy. All patients met a profile predicting that cough was likely due to GERD and had an initial positive 24-h esophageal pH monitoring study, and then underwent serial 24-h esophageal pH monitoring on gradually intensified medical therapy until the percentage of time that esophageal pH was < 4 was zero and there were no acid reflux events > 4 min. The effects of medical and surgical therapy on cough were assessed clinically by a visual analog scale (VAS) and the Adverse Cough Outcome Survey (ACOS).
Before surgery (median, 23.7 days), patients still complained of cough, VAS score was 73.1 +/- 6.1, and ACOS score was 15.0 +/- 1.1. After surgery (median, 41.2 days and 1 year), cough improved in all, VAS score decreased to 19.1 +/- 8.3 and 22.6 +/- 8.1 (p = 0.001), respectively, and ACOS score decreased to 2.0 +/- 1.3 and 3.6 +/- 2.3, respectively (p = 0.002).
Antireflux surgery can improve chronic cough due to GERD resistant to intensive medical therapy. There is a clinical profile that can predict when GERD is the likely cause of cough. GERD cannot be excluded on clinical grounds as the potential cause of cough. The term acid reflux disease, when applied to chronic cough due to GERD, can be a misnomer.
Chest 04/2002; 121(4):1132-40. · 5.25 Impact Factor
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ABSTRACT: The purpose of this study was to assess the stability of stored capsaicin solutions and the actual concentrations of prepared solutions. Capsaicin solutions ranging in concentration from 0.5 to 128 microM were mixed and analyzed using high performance liquid chromatography. Samples of varying concentrations were then stored under 4 environmental conditions: 4 degrees C and protected from light, room temperature (RT) exposed to light, RT protected from light, and -20 degrees C and protected from light. The concentrations were measured every other month for 1 year. Actual concentrations of freshly prepared solutions were on average 88.3% of predicted. For solutions stored at 4 degrees C, there was a decrease only in the lower concentrations (0.5, 1, and 2 microM) after 2 months (P=0.003). Solutions stored at RT exposed to light decreased in concentration after 6 months (P=0.020), and solutions stored at RT protected from light decreased in concentration after 4 months (P=0.026). The group stored at -20 degrees C decreased in concentration after 1 year (P=0.033). We conclude that the actual concentration of capsaicin solution is less than predicted, and solutions of 4 microM or higher concentration are stable for 1 year if stored at 4 degrees C protected from light.
Pulmonary Pharmacology & Therapeutics 02/2002; 15(6):529-34. · 2.80 Impact Factor
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ABSTRACT: Gastro-esophageal reflux disease (GERD) and postnasal drip syndrome (PNDS) are common causes of chronic cough. In patients with normal chest radiographs, GERD most likely causes cough by an esophageal-bronchial reflex. When GERD causes cough, there may be no gastrointestinal symptoms up to 75% of the time. While 24-h esophageal pH monitoring is the most sensitive and specific test in linking GERD and cough in a cause and effect relationship, it has its limitations. There is no general agreement on how to best interpret the test and it cannot detect non-acid reflux events. While some patients improve with minimal medical therapy, others require intensive regimens. Surgery may be efficacious when intensive medical therapy has failed. Because there are no pathognomonic findings of PNDS, the diagnosis is inferential and is based upon a combination of clinical findings, the results of ancillary testing, and the response to specific therapy. Specific therapy depends upon the rhinosinus disease(s) causing the PND. A common error in managing PNDSs is to assume that all H(1)-antagonists are equally efficacious. The second-generation, relatively non-sedating H(1)-antagonists have been found to be less effective than the first-generation agents in treating cough due to non-histamine-mediated PNDSs.
Pulmonary Pharmacology & Therapeutics 02/2002; 15(3):261-6. · 2.80 Impact Factor
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ABSTRACT: As coughing can cause profound physical and psychosocial complications, it has the potential to lead to a decrease in health-related quality of life (HRQoL). Two studies have prospectively shown that cough can adversely affect HRQoL. The first utilized the Sickness Impact Profile, a non-illness specific measure of health-related dysfunction that measured the effect of patients' health dysfunction on usual daily activities; it has not been psychometrically tested to assess the effects of cough. The second utilized a cough specific quality of life questionnaire that assessed the 28 most common and important reasons why patients seek medical attention because of coughing. It has been found to be a reliable and valid tool for evaluating the impact of acute and chronic cough on adult patients and a valid method by which to assess the efficacy of cough therapies for chronic cough. Because HRQoL is of the highest importance to patients and a cough specific HRQoL instrument assesses the impact of cough in a way no other type of measure does, a cough specific HRQoL instrument should be considered for routine use to optimally evaluate the impact of cough on patients and assess the efficacy of cough modifying agents.
Pulmonary Pharmacology & Therapeutics 02/2002; 15(3):283-6. · 2.80 Impact Factor
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The American Journal of Gastroenterology 06/2000; 95(7):1834-1836. · 7.28 Impact Factor
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ABSTRACT: An understanding of the anatomic, physiologic, and pathophysiologic aspects of cough is necessary to appropriately diagnose and treat patients with cough. In the majority of persons, cough that is acute and self-limiting is usually secondary to a viral upper respiratory tract infection; cough that is chronic and persistent is usually due to chronic bronchitis or postnasal drip. In the remaining persons, to determine the cause of cough, it is necessary to systematically consider anatomic locations where receptors and afferent nervous pathways are located. Definitive treatment of cough depends on determining its precise cause and then initiating specific therapy for the underlying disorder. Only when the cause of cough remains unknown or when cough performs no useful function and its complications represent a potential hazard to the patient, should symptomatic treatment be considered. Combination cough preparations should not be prescribed.(Arch Intern Med 137:1186-1191, 1977)
Archives of Internal Medicine 137(9):1186-1191. · 11.46 Impact Factor
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ABSTRACT: Study objectives were to evaluate the 1-hour decision point for discharge or admission for acute asthma; to compare this decision point to the admission recommendations of the Expert Panel Report 2 (EPR-2) guidelines; to develop a model for predicting need for admission in acute asthma. The design used was a prospective preinterventional and postinterventional comparison. The setting was a university hospital emergency department. Participants included 50 patients seeking care for acute asthma. Patients received standard therapy and were randomized to receive albuterol by nebulizer or metered-dose inhaler with spacer every 20 minutes up to 2 hours. Symptoms, physical examination, spirometry, pulsus paradoxus, medication use, and outcome were evaluated. Based on clinical judgment, the attending physician decided to admit or discharge after 1 hour of therapy. Outcome was compared to the EPR-2 guidelines. Post hoc statistical analyses examined predictors of the need for admission from which a prediction model was developed. Maximal accuracy of the admit versus discharge decision occurred at 1 hour of therapy. Using FEV(1) alone as an outcome predictor yielded suboptimal performance. FEV(1) at 1 hour plus ability to lie flat without dyspnea were the best indicators of response and outcome. A model predictive of the need for admission was developed. It performed better (P =.0054) than the admission algorithm of the EPR-2 guidelines. The decision to admit or discharge acute asthmatics from the ED can be made at 1 hour of therapy. No absolute value of peak flow or FEV(1) reliably predicts need for hospital admission. The EPR-2 guideline thresholds for admission are barely adequate as outcome predictors. A clinical model is proposed that may allow more accurate outcome prediction.
Journal of Intensive Care Medicine 18(5):275-85.
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ABSTRACT: To determine whether the cough of the common cold arises from upper respiratory stimuli and whether antihistamine-decongestant therapy is an effective treatment for this cough, we prospectively evaluated volunteers with uncomplicated common colds in a randomized, double-blind, placebo-controlled study. After completing a standardized questionnaire and undergoing a physical examination, throat-culturing, and pulmonary function testing, subjects took the active drug or identical-appearing placebo for 7 days while they kept a diary in which they ranked the severity of 17 symptoms for 14 days. Pulmonary function testing was repeated, on average, on Days 4, 8, and 14. Forty-six percent of the variation in cough severity could be explained by throat-clearing and 47% of the variation in throat-clearing severity by postnasal drip. FIF50%, the only physiologic parameter that significantly correlated with cough, rose as cough severity fell. Antihistamine-decongestant therapy reduced postnasal drip and significantly decreased the severity of cough, nasal obstruction, nasal discharge, and throat-clearing during the first few days of the common cold. In addition, cough was 20 to 30% less prevalent in the active drug group within 3 days of starting therapy. We conclude that the cough of the common cold arose from upper respiratory tract stimuli and that cough and other cardinal symptoms of the common cold were reduced with antihistamine-decongestant therapy when these symptoms were at their worst.
Stephen Baker.
