American journal of respiratory and critical care medicine
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Am. J. Respir. Crit. Care Med. · Jan 1996
Comparative StudyResource use implications of do not resuscitate orders for intensive care unit patients.
This study describes the use of do not resuscitate (DNR) orders for ICU patients in four northeastern U. S. teaching hospitals and investigates the relationship between DNR orders and length of stay. The use of detailed data from the mortality probability model (MPM II) study on 6,290 consecutive ICU admissions to general adult medical and surgical ICUs during 1989 through 1991 allows us to control for severity of illness and the time during the ICU stay at which the DNR order was entered. ⋯ Nonsurvivors with early (first 24 h) DNR had shorter mean and median ICU and hospital stays than the comparison group of non-DNR patients. The percentage of patients with very long ICU (> 30 d) and hospital (> 60 d) stays was smaller among DNR patients. The use of DNR orders, particularly early in the ICU stay, may be associated with significant resource use reduction for an identifiable group of patients.
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Am. J. Respir. Crit. Care Med. · Jan 1996
Comparative StudyRisk factors for nosocomial pneumonia: comparing adult critical-care populations.
The purpose of the study was to examine risk factors for nosocomial pneumonia in the surgical and medical/respiratory intensive care unit (ICU) populations. In a public teaching hospital, all cases of nosocomial pneumonia in the surgical and medical/respiratory ICUs (n = 20, respectively) were identified by prospective surveillance during a 5-yr period from 1987-1991. Each group of ICU cases was compared with 40 ICU control patients who did not acquire pneumonia, and analyzed for 25 potential risk factors. ⋯ APACHE III score was found to be predictive of nosocomial pneumonia in the surgical ICU population, but not in the medical/respiratory ICU population. We conclude that certain groups deserve special attention for infection control intervention. Surgical ICU patients with high APACHE scores and receiving prolonged mechanical ventilation may be at the greatest risk of acquiring nosocomial pneumonia of all hospitalized patients.
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Am. J. Respir. Crit. Care Med. · Jan 1996
Comparative StudyAirways responsiveness, wheeze onset, and recurrent asthma episodes in young adolescents. The East Boston Childhood Respiratory Disease Cohort.
To describe the role of airways responsiveness in predicting incidence of wheeze in early adolescence and to examine the association between airways responsiveness and active asthma symptoms, children who had been tested for airways hyperresponsiveness were assessed prospectively. Of 770 children in the East Boston Childhood Respiratory Disease Cohort who were between 5 and 9 yr of age at time of entry into the study, 281 children received airways challenges during voluntary follow-up conducted between 1980 and 1986. Each subject presented a sequence of wheeze or asthma diagnosis reports along with a sequence of time-varying covariates, including airways challenge results and symptom and exposure information. ⋯ In the analysis of recurrent asthma episodes, airways responsiveness at a given visit was associated with a greater tendency to have an asthma diagnosis reported at the subsequent visit (OR = 4.2, 95% CI = 1.92, 9.23). For subjects presenting multiple airways responsiveness challenge studies, two successive positive airways responsiveness results were independently associated with a higher likelihood of recurrent asthma episodes. These results confirm the predictive importance of airways responsiveness in the natural history of the development and persistence of asthmatic symptoms.
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Am. J. Respir. Crit. Care Med. · Jan 1996
Comparative StudyEnvironmental tobacco smoke, wheezing, and asthma in children in 24 communities.
The association of exposure to environmental tobacco smoke (ETS) at home with asthma and several measures of wheeze was examined among 11,534 children aged 8 to 11 yr in 24 communities in the United States and Canada in 1988 through 1990. Information on the child's respiratory symptoms in the past year and history of exposure to ETS was provided by the child's mother on a questionnaire. After adjusting for potential confounders, children currently exposed to ETS were at greater risk of wheezing with colds (odds ratio [OR] = 1.7; 95% confidence interval [95% CI], 1.4 to 1.9), going to a hospital emergency room for wheeze (OR = 1.6; 95% CI, 1.2 to 2.2), and having persistent wheeze (OR = 1.4; 95% CI, 1.1 to 1.8). ⋯ In contrast to wheeze symptoms, active doctor-diagnosed asthma and asthma medication use were not significantly associated with ETS exposure at home, possibly reflecting underdiagnosis of asthma, reporting bias, or smoking cessation by parents whose child is labeled asthmatic. We conclude that exposure to ETS is associated with wheezing symptoms, medical therapy for wheezing, and wheezing-related emergency department visits in U. S. and Canadian children.
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Am. J. Respir. Crit. Care Med. · Jan 1996
Comparative Study Clinical Trial Controlled Clinical TrialSkeletal muscle microvascular blood flow and oxygen transport in patients with severe sepsis.
To compare skeletal muscle microvascular blood flow at rest and during reactive hyperemia in septic patients, a prospective, controlled trial was conducted on 16 patients with severe sepsis and a control group of 10 patients free of infection in the intensive care unit of a university hospital. Systemic hemodynamics, whole-body oxygen transport, and skeletal muscle microvascular blood flow at rest and during reactive hyperemia were measured. Reactive hyperemia was produced by arrest of leg blood flow with a pneumatic cuff; on completion of the 3 min ischemic phase the occluding cuff was rapidly deflated to 0. ⋯ Cyclic variation in blood flow (vasomotion) was observed in control subjects but not in septic patients. Skeletal muscle microvascular perfusion is altered in patients with severe sepsis despite normal or elevated whole-body oxygen delivery. These microvascular abnormalities may further compromise tissue nutrient flow and may contribute to the development of organ failure in septic patients.