- Email: [email protected]
Noninvasive Ventilation for Patients With Neuromuscular Disease and Acute Respiratory Failure: Response
4 Servera E, Sancho J, Zafra MJ, et al. Alternatives to endotracheal intubation for patients with neuromuscular disease. Am J Phys Med Rehabil 2005; 84:851– 857
Response To the Editor: We strongly agree with Sancho and Servera et al that patients with acute respiratory failure (ARF) associated with neuromuscular disease (NMD) can be treated successfully with noninvasive ventilation (NIV) in the critical care setting. We did not mention this in our recent review1 but did not mean to suggest that such patients should be excluded as candidates for NIV. Our review was an update focusing on developments over the previous several years. Applications of NIV for ARF in NMD patients are relatively uncommon in most acute care hospitals,2 and there have been few recent relevant publications. Also, as Servera et al point out, there are no randomized controlled trials evaluating this application of NIV, although this should not discourage the use of NIV for appropriate NMD patients. However, NIV should be used with extreme caution in NMD patients with rapidly progressive NMD syndromes such as myasthenia gravis or Guillian Barre syndrome, especially when bulbar muscles are involved. In the outpatient setting, NIV for NMD has assumed a more prominent role as the ventilatory mode of first choice for most such patients.3 When these patients have acute exacerbations, we have them go on NIV around the clock and use cough-assist techniques such as the mechanical inexsufflator as often as necessary to facilitate secretion removal.4 Acute hospitalization can be very disruptive for NMD patients who are unfamiliar to the hospital and its staff, and can be successfully managed at home by experienced family members and well-trained caregivers. When such patients must be hospitalized, usually because of difficulty in handling secretions, we agree that they should be placed in a specialized unit, usually an ICU, and not on a regular medical floor where the nursing staff is usually inadequately equipped to prevent problems with secretion retention. Techniques to aid secretion removal must be applied aggressively, but even then temporary intubation may be necessary. Once secretions have abated, though, the patient can often be extubated and NIV resumed. Nicholas S. Hill, MD, FCCP Erik Garpestad, MD, FCCP John Brennan, MD Boston, MA The authors have no conflicts of interest to disclose. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: Nicholas S. Hill, MD, FCCP, Division of Pulmonary, Critical Care and Sleep Medicine, Tufts-New England Medical Center, Box 257, 750 Washington St, Boston, MA 02111-1526; e-mail: [email protected] DOI: 10.1378/chest.07-2460
References 1 Garpestad E, Brennan J, Hill NS. Noninvasive ventilation for critical care. Chest 2007; 132:711–720 2 Meduri GU, Turner RE, Abou-Shala N, et al. Noninvasive positive pressure ventilation via face mask. Chest 1996; 109:179 –193 3 Mehta S, Hill NS. Noninvasive ventilation. Am J Respir Crit Care Med 2001; 163:540 –577 4 Bach JR, Ishikawa Y, Kim H. Prevention of pulmonary www.chestjournal.org
morbidity for patients with Duchenne muscular dystrophy. Chest 1997; 112:1024 –1028
Resource Utilization in Patients Undergoing Early Goal-Directed Therapy for Severe Sepsis and Septic Shock To the Editor: In a recent issue of CHEST (August 2007), I read the commendable work of Jones et al1 with great interest. In their study, the authors found that the hospital length of stay (LOS) was 1.2 days longer in the early goal-directed therapy (EGDT) group (7.9 vs 9.1 days, respectively), whereas the mean ICU LOS was 1.8 days longer in the EGDT group (2.0 vs 3.8 days, respectively).1 These findings deserve further mention. In their landmark study, Rivers et al2 reported a similar hospital LOS between an EGDT group and a standard-therapy group (13.0 vs 13.2 days, respectively). The difference in the LOS observed in the reports by Jones et al1 and Rivers et al2 could be attributed to the dissimilar severity of the conditions of the patients studied, as was mentioned by Jones et al.1 Another likely explanation is, in the study by Jones et al,1 the utilization of vasopressors and mechanical ventilation was more prevalent in the EGDT group. While the number of ventilator days were not different between the two groups, the use of mechanical ventilation and vasopressors might inadvertently lengthen ICU LOS by increasing the need for ICU-based monitoring and observation. Speculations aside, an important point is that resource utilization was increased when EGDT was implemented in patients with fewer risks of death from septic shock. A recent analysis by Huang et al3 found that EGDT could be cost-effective, assuming that LOS and mortality are reduced. While more reproducible cost-benefit analyses of EGDT are needed, clinicians should perhaps be wary of the potential unfavorable effects on hospital resource allocation when EGDT is used in less critically ill patients with low predicted mortality rates. Petey Laohaburanakit, MD, FCCP Pulmonary Consultants and Sleep Specialists Medford, OR The author has reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: Petey Laohaburanakit, MD, FCCP, Pulmonary Consultants and Sleep Specialists, 555 Black Oak Dr, Suite 300, Medford, OR 97504; e-mail: [email protected] DOI: 10.1378/chest.07-2206
References 1 Jones AE, Focht A, Horton JM, et al. Prospective external validation of the clinical effectiveness of an emergency department-based early goal-directed therapy protocol for severe sepsis and septic shock. Chest 2007; 132:425– 432 2 Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345:1368 –1377 3 Huang DT, Clermont G, Dremsizov TT, et al. Implementation of early goal-directed therapy for severe sepsis and septic shock: a decision analysis. Crit Care Med 2007; 35:2090 –2100 CHEST / 133 / 1 / JANUARY, 2008
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Response To the Editor: We strongly agree with Sancho and Servera et al that patients with acute respiratory failure (ARF) associated with neuromuscular disease (NMD) can be treated successfully with noninvasive ventilation (NIV) in the critical care setting. We did not mention this in our recent review1 but did not mean to suggest that such patients should be excluded as candidates for NIV. Our review was an update focusing on developments over the previous several years. Applications of NIV for ARF in NMD patients are relatively uncommon in most acute care hospitals,2 and there have been few recent relevant publications. Also, as Servera et al point out, there are no randomized controlled trials evaluating this application of NIV, although this should not discourage the use of NIV for appropriate NMD patients. However, NIV should be used with extreme caution in NMD patients with rapidly progressive NMD syndromes such as myasthenia gravis or Guillian Barre syndrome, especially when bulbar muscles are involved. In the outpatient setting, NIV for NMD has assumed a more prominent role as the ventilatory mode of first choice for most such patients.3 When these patients have acute exacerbations, we have them go on NIV around the clock and use cough-assist techniques such as the mechanical inexsufflator as often as necessary to facilitate secretion removal.4 Acute hospitalization can be very disruptive for NMD patients who are unfamiliar to the hospital and its staff, and can be successfully managed at home by experienced family members and well-trained caregivers. When such patients must be hospitalized, usually because of difficulty in handling secretions, we agree that they should be placed in a specialized unit, usually an ICU, and not on a regular medical floor where the nursing staff is usually inadequately equipped to prevent problems with secretion retention. Techniques to aid secretion removal must be applied aggressively, but even then temporary intubation may be necessary. Once secretions have abated, though, the patient can often be extubated and NIV resumed. Nicholas S. Hill, MD, FCCP Erik Garpestad, MD, FCCP John Brennan, MD Boston, MA The authors have no conflicts of interest to disclose. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: Nicholas S. Hill, MD, FCCP, Division of Pulmonary, Critical Care and Sleep Medicine, Tufts-New England Medical Center, Box 257, 750 Washington St, Boston, MA 02111-1526; e-mail: [email protected] DOI: 10.1378/chest.07-2460
References 1 Garpestad E, Brennan J, Hill NS. Noninvasive ventilation for critical care. Chest 2007; 132:711–720 2 Meduri GU, Turner RE, Abou-Shala N, et al. Noninvasive positive pressure ventilation via face mask. Chest 1996; 109:179 –193 3 Mehta S, Hill NS. Noninvasive ventilation. Am J Respir Crit Care Med 2001; 163:540 –577 4 Bach JR, Ishikawa Y, Kim H. Prevention of pulmonary www.chestjournal.org
morbidity for patients with Duchenne muscular dystrophy. Chest 1997; 112:1024 –1028
Resource Utilization in Patients Undergoing Early Goal-Directed Therapy for Severe Sepsis and Septic Shock To the Editor: In a recent issue of CHEST (August 2007), I read the commendable work of Jones et al1 with great interest. In their study, the authors found that the hospital length of stay (LOS) was 1.2 days longer in the early goal-directed therapy (EGDT) group (7.9 vs 9.1 days, respectively), whereas the mean ICU LOS was 1.8 days longer in the EGDT group (2.0 vs 3.8 days, respectively).1 These findings deserve further mention. In their landmark study, Rivers et al2 reported a similar hospital LOS between an EGDT group and a standard-therapy group (13.0 vs 13.2 days, respectively). The difference in the LOS observed in the reports by Jones et al1 and Rivers et al2 could be attributed to the dissimilar severity of the conditions of the patients studied, as was mentioned by Jones et al.1 Another likely explanation is, in the study by Jones et al,1 the utilization of vasopressors and mechanical ventilation was more prevalent in the EGDT group. While the number of ventilator days were not different between the two groups, the use of mechanical ventilation and vasopressors might inadvertently lengthen ICU LOS by increasing the need for ICU-based monitoring and observation. Speculations aside, an important point is that resource utilization was increased when EGDT was implemented in patients with fewer risks of death from septic shock. A recent analysis by Huang et al3 found that EGDT could be cost-effective, assuming that LOS and mortality are reduced. While more reproducible cost-benefit analyses of EGDT are needed, clinicians should perhaps be wary of the potential unfavorable effects on hospital resource allocation when EGDT is used in less critically ill patients with low predicted mortality rates. Petey Laohaburanakit, MD, FCCP Pulmonary Consultants and Sleep Specialists Medford, OR The author has reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: Petey Laohaburanakit, MD, FCCP, Pulmonary Consultants and Sleep Specialists, 555 Black Oak Dr, Suite 300, Medford, OR 97504; e-mail: [email protected] DOI: 10.1378/chest.07-2206
References 1 Jones AE, Focht A, Horton JM, et al. Prospective external validation of the clinical effectiveness of an emergency department-based early goal-directed therapy protocol for severe sepsis and septic shock. Chest 2007; 132:425– 432 2 Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345:1368 –1377 3 Huang DT, Clermont G, Dremsizov TT, et al. Implementation of early goal-directed therapy for severe sepsis and septic shock: a decision analysis. Crit Care Med 2007; 35:2090 –2100 CHEST / 133 / 1 / JANUARY, 2008
315