Noninvasive Ventilation Reduces Intubation in Chest Trauma-Related Hypoxemia: A Randomized Clinical...
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Comment: In this study, copeptin levels performed as well as NIHSS scores in predicting long-term disability and all- cause mortality in patients with stroke. The question of whether or not the two values together offer anything more than each in isolation is not yet answered. Although when combined, the AUC values were statistically different, there was little clinical difference (0.79 vs. 0.75 and 0.89 vs. 0.85 are really too similar to be functionally different). Thus, the utility of this assay for emergency physicians is still very much in doubt. e ETHNIC DIFFERENCES IN PARENTAL PERCEP- TIONS AND MANAGEMENT OF CHILDHOOD FEVER. Cohee L, Crocetti M, Serwint J, Sabath B, Kapoor S. Clin Pediatr (Phila) 2010;49:221–7. In this cross-sectional study, the authors surveyed a conve- nience sample of 487 parents with children enrolled in two urban hospital-based clinics in Baltimore, MD regarding their perceptions and management of fever. The authors were spe- cifically interested in parents’ definition of fever, level of concern, and management of fever. Only 44% of parents iden- tified fever temperature as 38 – 41.67°C (100.4 –107°F); 67% of parents treated fevers 38°C (100.4°F). Eighty-five percent of parents would awaken a child to treat a fever, and 68% of parents were very worried about fevers. Cross-sectional anal- ysis showed that Caucasians were more likely to identify non- febrile and febrile temperatures correctly (92% and 53%, re- spectively), whereas Latinos were least likely (38% and 33%, respectively). Latinos were more likely to frequently check temperature, most likely to believe that fever can rise above 43.33°C (110°F), and least likely to alternate acetaminophen and ibuprofen for treatment of fever. African-Americans were most likely to believe that a temperature of 37.78°C (100°F) can cause harm (38%, vs. 18% in Caucasians and 11% in Latinos). [Charles M. Reynolds, MD Denver Health Medical Center, Denver, CO] Comment: This study suggests a significant difference in understanding of fever across different ethnic groups. Although the study may not be generalizable outside of the limited geographic area of interest to the authors, knowledge of these ethnic differences may help physicians design culturally sensi- tive fever-management plans. e NONINVASIVE VENTILATION REDUCES INTUBA- TION IN CHEST TRAUMA-RELATED HYPOXEMIA: A RANDOMIZED CLINICAL TRIAL. Hernandez G, Fernan- dez R, Lopez-Reina P, et al. Chest 2009;137:74 – 80. In this prospective, randomized, controlled trial, adult pa- tients with severe thoracic trauma were assigned to receive either non-invasive positive pressure ventilation or high-flow oxygen, with the primary outcome of interest being the inci- dence of endotracheal intubation. Inclusion criteria included adult patients admitted to the intensive care unit (ICU) for severe thoracic trauma who were 48 h from their initial trauma and had 8 h of hypoxemia. Specific parameters were defined to identify respiratory failure and the need for intuba- tion. In patients that did not have a contraindication, analgesia was provided in the form of regional anesthesia, usually epi- dural blocks. Respiratory rate, heart rate, blood pressure, and arterial blood gases were measured at 1 h, 2 h, 3–4 h, 6–8 h, 12 h, 24 h, and 72 h after presentation. Secondary endpoints were pneumothorax, pneumonia, sepsis, ICU days, in-hospital days, and mortality. The data were examined at two pre-set interim analysis points. A total of 79 patients were screened, and 50 patients were included in data analysis, with 25 patients in each of the two groups. The results of this analysis at the second of the two interim points indicated that non-invasive positive pressure ventilation significantly decreased the rate of endotracheal intubation (3/25 vs. 10/25), and the study was prematurely terminated. This relationship was consistent after adjusting for age, gender, Acute Physiology and Chronic Health Evaluation II score, and the presence of congestive heart failure. Additionally, those patients receiving non-invasive pos- itive pressure ventilation had a decreased number of in-hospital days, but did not have a decreased number of days spent in the ICU. Due to the low number of patients that required intubation in the positive pressure group, there was not sufficient power for analysis of early predictors of non-invasive ventilation failure. Limitations identified by the authors included that they did not reach the desired sample size and the impossibility to blind caregivers to group assignment. They also stated that congestive heart failure was four times more common in the positive pressure group, and that this is a condition that is recognized to benefit from positive pressure ventilation. How- ever, even when this entity was controlled for, the benefit continued to persist. The authors concluded that in patients with hypoxia related to severe thoracic trauma, the use of non- invasive mechanical ventilation reduced the need for intubation and length of stay. [Colleen Foster, MD Denver Health Medical Center, Denver, CO] Comments: This study would seem to indicate that non- invasive ventilation is helpful in preventing the need for endo- tracheal intubation in patients with thoracic trauma and hyp- oxia. However, because the study was terminated prematurely, the possibility of a type 1 error must be seriously considered. This is made even more likely by the fact that the presence of heart failure, a condition known to benefit from non-invasive ventilation, was four times greater in the treatment group. The results of this very small study would need to be duplicated in a larger population before any conclusions could be made. e INHALED CORTICOSTEROIDS VS PLACEBO FOR PREVENTING COPD EXACERBATIONS: A SYSTEM- ATIC REVIEW AND METAREGRESSION OF RAN- DOMIZED CONTROLLED TRIALS. Agarwal R, Aggarwal AN, Gupta D, Jindal SK. Chest 2010;137:318 –25. This systematic review and meta-regression analysis aimed to determine the efficacy of using inhaled corticosteroids to prevent chronic obstructive pulmonary disease (COPD) exac- erbations as compared to placebo. The authors performed a 130 Abstracts
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Transcript of Noninvasive Ventilation Reduces Intubation in Chest Trauma-Related Hypoxemia: A Randomized Clinical...
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130 Abstracts
Comment: In this study, copeptin levels performed as wells NIHSS scores in predicting long-term disability and all-ause mortality in patients with stroke. The question of whetherr not the two values together offer anything more than each insolation is not yet answered. Although when combined, theUC values were statistically different, there was little clinicalifference (0.79 vs. 0.75 and 0.89 vs. 0.85 are really too similaro be functionally different). Thus, the utility of this assay formergency physicians is still very much in doubt.
ETHNIC DIFFERENCES IN PARENTAL PERCEP-IONS AND MANAGEMENT OF CHILDHOOD FEVER.ohee L, Crocetti M, Serwint J, Sabath B, Kapoor S. Clinediatr (Phila) 2010;49:221–7.
In this cross-sectional study, the authors surveyed a conve-ience sample of 487 parents with children enrolled in tworban hospital-based clinics in Baltimore, MD regarding theirerceptions and management of fever. The authors were spe-ifically interested in parents’ definition of fever, level ofoncern, and management of fever. Only 44% of parents iden-ified fever temperature as 38–41.67°C (100.4–107°F); 67% ofarents treated fevers � 38°C (100.4°F). Eighty-five percent ofarents would awaken a child to treat a fever, and 68% ofarents were very worried about fevers. Cross-sectional anal-sis showed that Caucasians were more likely to identify non-ebrile and febrile temperatures correctly (92% and 53%, re-pectively), whereas Latinos were least likely (38% and 33%,espectively). Latinos were more likely to frequently checkemperature, most likely to believe that fever can rise above3.33°C (110°F), and least likely to alternate acetaminophennd ibuprofen for treatment of fever. African-Americans wereost likely to believe that a temperature of � 37.78°C (100°F)
an cause harm (38%, vs. 18% in Caucasians and 11% inatinos).
[Charles M. Reynolds, MD
Denver Health Medical Center, Denver, CO]
Comment: This study suggests a significant difference innderstanding of fever across different ethnic groups. Althoughhe study may not be generalizable outside of the limitedeographic area of interest to the authors, knowledge of thesethnic differences may help physicians design culturally sensi-ive fever-management plans.
NONINVASIVE VENTILATION REDUCES INTUBA-ION IN CHEST TRAUMA-RELATED HYPOXEMIA: AANDOMIZED CLINICAL TRIAL. Hernandez G, Fernan-ez R, Lopez-Reina P, et al. Chest 2009;137:74–80.
In this prospective, randomized, controlled trial, adult pa-ients with severe thoracic trauma were assigned to receiveither non-invasive positive pressure ventilation or high-flowxygen, with the primary outcome of interest being the inci-ence of endotracheal intubation. Inclusion criteria includeddult patients admitted to the intensive care unit (ICU) forevere thoracic trauma who were � 48 h from their initial
rauma and had � 8 h of hypoxemia. Specific parameters were eefined to identify respiratory failure and the need for intuba-ion. In patients that did not have a contraindication, analgesiaas provided in the form of regional anesthesia, usually epi-ural blocks. Respiratory rate, heart rate, blood pressure, andrterial blood gases were measured at 1 h, 2 h, 3–4 h, 6–8 h,2 h, 24 h, and 72 h after presentation. Secondary endpointsere pneumothorax, pneumonia, sepsis, ICU days, in-hospitalays, and mortality. The data were examined at two pre-setnterim analysis points. A total of 79 patients were screened,nd 50 patients were included in data analysis, with 25 patientsn each of the two groups. The results of this analysis at theecond of the two interim points indicated that non-invasiveositive pressure ventilation significantly decreased the rate ofndotracheal intubation (3/25 vs. 10/25), and the study wasrematurely terminated. This relationship was consistent afterdjusting for age, gender, Acute Physiology and Chronicealth Evaluation II score, and the presence of congestive heart
ailure. Additionally, those patients receiving non-invasive pos-tive pressure ventilation had a decreased number of in-hospitalays, but did not have a decreased number of days spent in theCU. Due to the low number of patients that required intubationn the positive pressure group, there was not sufficient poweror analysis of early predictors of non-invasive ventilationailure. Limitations identified by the authors included that theyid not reach the desired sample size and the impossibility tolind caregivers to group assignment. They also stated thatongestive heart failure was four times more common in theositive pressure group, and that this is a condition that isecognized to benefit from positive pressure ventilation. How-ver, even when this entity was controlled for, the benefitontinued to persist. The authors concluded that in patients withypoxia related to severe thoracic trauma, the use of non-nvasive mechanical ventilation reduced the need for intubationnd length of stay.
[Colleen Foster, MD
Denver Health Medical Center, Denver, CO]
Comments: This study would seem to indicate that non-nvasive ventilation is helpful in preventing the need for endo-racheal intubation in patients with thoracic trauma and hyp-xia. However, because the study was terminated prematurely,he possibility of a type 1 error must be seriously considered.his is made even more likely by the fact that the presence ofeart failure, a condition known to benefit from non-invasiveentilation, was four times greater in the treatment group. Theesults of this very small study would need to be duplicated inlarger population before any conclusions could be made.
INHALED CORTICOSTEROIDS VS PLACEBO FORREVENTING COPD EXACERBATIONS: A SYSTEM-TIC REVIEW AND METAREGRESSION OF RAN-OMIZED CONTROLLED TRIALS. Agarwal R,ggarwal AN, Gupta D, Jindal SK. Chest 2010;137:318 –25.
This systematic review and meta-regression analysis aimedo determine the efficacy of using inhaled corticosteroids torevent chronic obstructive pulmonary disease (COPD) exac-
rbations as compared to placebo. The authors performed a
