[⇓][1] 

SERIES “ATS/ERS TASK FORCE: STANDARDISATION OF LUNG FUNCTION TESTING” 

Edited by V. Brusasco, R. Crapo and G. Viegi 

Number 2 in this Series

 [1]: #F13

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Standardisation of spirometry

Background Traditional approaches to mechanical ventilation use tidal volumes of 10 to 15 ml per kilogram of body weight and may cause stretch-induced lung injury in patients with acute lung injury and the acute respiratory distress syndrome. We therefore conducted a trial to determine whether ventilation with lower tidal volumes would improve the clinical outcomes in these patients. Methods Patients with acute lung injury and the acute respiratory distress syndrome were enrolled in a multicenter, randomized trial. The trial compared traditional ventilation treatment, which involved an initial tidal volume of 12 ml per kilogram of predicted body weight and an airway pressure measured after a 0.5-second pause at the end of inspiration (plateau pressure) of 50 cm of water or less, with ventilation with a lower tidal volume, which involved an initial tidal volume of 6 ml per kilogram of predicted body weight and a plateau pressure of 30 cm of water or less. The primary outcomes were death before a patient was discharged home and was breathing without assistance and the number of days without ventilator use from day 1 to day 28. Results The trial was stopped after the enrollment of 861 patients because mortality was lower in the group treated with lower tidal volumes than in the group treated with traditional tidal volumes (31.0 percent vs. 39.8 percent, P=0.007), and the number of days without ventilator use during the first 28 days after randomization was greater in this group (mean [+/-SD], 12+/-11 vs. 10+/-11; P=0.007). The mean tidal volumes on days 1 to 3 were 6.2+/-0.8 and 11.8+/-0.8 ml per kilogram of predicted body weight (P Conclusions In patients with acute lung injury and the acute respiratory distress syndrome, mechanical ventilation with a lower tidal volume than is traditionally used results in decreased mortality and increases the number of days without ventilator use.

Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome.

According to W. Edwards Deming, American companies require nothing less than a transformation of management style and of governmental relations with industry. In Out of the Crisis, originally published in 1982, Deming offers a theory of management based on his famous 14 Points for Management. Management's failure to plan for the future, he claims, brings about loss of market, which brings about loss of jobs. Management must be judged not only by the quarterly dividend, but by innovative plans to stay in business, protect investment, ensure future dividends, and provide more jobs through improved product and service. In simple, direct language, he explains the principles of management transformation and how to apply them.

Out of the Crisis

Objective:To provide an update to the “Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock,” last published in 2008.Design:A consensus committee of 68 international experts representing 30 international organizations was convened. Nominal groups were assembled at ke

Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012.

The acute respiratory distress syndrome (ARDS) was defined in 1994 by the American-European Consensus Conference (AECC); since then, issues regarding the reliability and validity of this definition have emerged. Using a consensus process, a panel of experts convened in 2011 (an initiative of the European Society of Intensive Care Medicine endorsed by the American Thoracic Society and the Society of Critical Care Medicine) developed the Berlin Definition, focusing on feasibility, reliability, validity, and objective evaluation of its performance. A draft definition proposed 3 mutually exclusive categories of ARDS based on degree of hypoxemia: mild (200 mm Hg < PaO2/FIO2 ≤ 300 mm Hg), moderate (100 mm Hg < PaO2/FIO2 ≤ 200 mm Hg), and severe (PaO2/FIO2 ≤ 100 mm Hg) and 4 ancillary variables for severe ARDS: radiographic severity, respiratory system compliance (≤40 mL/cm H2O), positive end-expiratory pressure (≥10 cm H2O), and corrected expired volume per minute (≥10 L/min). The draft Berlin Definition was empirically evaluated using patient-level meta-analysis of 4188 patients with ARDS from 4 multicenter clinical data sets and 269 patients with ARDS from 3 single-center data sets containing physiologic information. The 4 ancillary variables did not contribute to the predictive validity of severe ARDS for mortality and were removed from the definition. Using the Berlin Definition, stages of mild, moderate, and severe ARDS were associated with increased mortality (27%; 95% CI, 24%-30%; 32%; 95% CI, 29%-34%; and 45%; 95% CI, 42%-48%, respectively; P < .001) and increased median duration of mechanical ventilation in survivors (5 days; interquartile [IQR], 2-11; 7 days; IQR, 4-14; and 9 days; IQR, 5-17, respectively; P < .001). Compared with the AECC definition, the final Berlin Definition had better predictive validity for mortality, with an area under the receiver operating curve of 0.577 (95% CI, 0.561-0.593) vs 0.536 (95% CI, 0.520-0.553; P < .001). This updated and revised Berlin Definition for ARDS addresses a number of the limitations of the AECC definition. The approach of combining consensus discussions with empirical evaluation may serve as a model to create more accurate, evidence-based, critical illness syndrome definitions and to better inform clinical care, research, and health services planning.

Acute respiratory distress syndrome: the Berlin Definition.

Rigorous genotype-phenotype association research depends on scientific rigor at multiple scales of investigation.

Background Left atrial (LA) wall fibrosis has been demonstrated to play a major role in the pathogenesis and treatment response of atrial fibrillation (AF). The DECAAF study demonstrated that quantification of LA fibrosis by delayed-enhancement MRI (DE-MRI) predicts outcomes after AF catheter ablation. Currently, a number of catheter ablation methods targeting specific regions of the LA are used, including pulmonary vein isolation and posterior wall debulking. We investigate the role of spatial distribution of fibrosis in the LA on outcomes after catheter ablation.

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Regional left atrial wall fibrosis and recurrence after atrial fibrillation ablation

It is not enough to merely manage medical information. It is difficult to justify the cost of hospital information systems (HIS) or intensive care unit (ICU) patient data management systems (PDMS) on this basis alone. The real benefit of an integrated HIS or PDMS is in decision support. We recently went to the bedside of a critically ill patient and counted the current information categories (not repeated measures) that were reviewed for physician decision making. The total was in excess of 236! Dr. Eddy summarized it best: “It is simply unrealistic to think that individuals can synthesize in their head scores of pieces of evidence, accurately estimate the outcomes of different options, and accurately judge the desirability of those outcomes for patients…. All confirm what would be expected from common sense: The complexity of modern medicine exceeds the inherent limitations of the unaided human mind.” Although there are a variety of HIS and ICU PDMS systems available there are few that provide ICU decision support.

Critical Care Decision Support Systems

We have developed methods which utilize the computer to gather and analyse clinical data on all patients in our hospital. If the patient data shows a life threatening result the computer automatically alerts the medical staff.1 We have evaluated this system and its clinical use over the past two years.

Alan H. Morris

Papers

Rigorous genotype-phenotype association research depends on scientific rigor at multiple scales of investigation.

Regional left atrial wall fibrosis and recurrence after atrial fibrillation ablation

Critical Care Decision Support Systems

Computerised Medical Decision-Making — An Evaluation in Acute Care

23 – Is Extracorporeal Life Support for Adults with Acute Respiratory Distress Syndrome Useful?