Background Atelectasis, an important cause of impaired gas exchange during general anesthesia, may be eliminated by a vital capacity maneuver. However, it is not clear whether such a maneuver will have a sustained effect. The aim of this study was to determine the impact of gas composition on reappearance of atelectasis and impairment of gas exchange after a vital capacity maneuver. Methods A consecutive sample of 12 adults with healthy lungs who were scheduled for elective surgery were studied. Thirty minutes after induction of anesthesia with fentanyl and propofol, the lungs were hyperinflated manually up to an airway pressure of 40 cmH2O. FIO2 was either kept at 0.4 (group 1, n = 6) or changed to 1.0 (group 2, n = 6) during the recruitment maneuver. Atelectasis was assessed by computed tomography. The amount of dense areas was measured at end-expiration in a transverse plane at the base of the lungs. The ventilation-perfusion distributions (VA/Q) were estimated with the multiple inert gas elimination technique. The static compliance of the total respiratory system (Crs) was measured with the flow interruption technique. Results In group 1 (FIO2 = 0.4), the recruitment maneuver virtually eliminated atelectasis for at least 40 min, reduced shunt (VA/Q < 0.005), and increased at the same time the relative perfusion to poorly ventilated lung units (0.005 < VA/Q < 0.1; mean values are given). The arterial oxygen tension (PaO2) increased from 137 mmHg (18.3 kPa) to 163 mmHg (21.7 kPa; before and 40 min after recruitment, respectively; P = 0.028). In contrast to these findings, atelectasis recurred within 5 min after recruitment in group 2 (FIO2 = 1.0). Comparing the values before and 40 min after recruitment, all parameters of VA/Q were unchanged. In both groups, Crs increased from 57.1/55.0 ml.cmH2O-1 (group 1/group 2) before to 70.1/67.4 ml.cmH2O-1 after the recruitment maneuver. Crs showed a slow decrease thereafter (40 min after recruitment: 61.4/60.0 ml.cmH2O-1), with no difference between the two groups. Conclusions The composition of inspiratory gas plays an important role in the recurrence of collapse of previously reexpanded atelectatic lung tissue during general anesthesia in patients with healthy lungs. The reason for the instability of these lung units remains to be established. The change in the amount of atelectasis and shunt appears to be independent of the change in the compliance of the respiratory system.
Blood neutrophil-to-lymphocyte ratio (NLR) is higher in stable COPD than healthy controls and further increased in COPD exacerbations, and has been suggested as a predictor of exacerbations. Our aim was to study if NLR can predict future COPD exacerbations. In the Tools for Identifying Exacerbations (TIE) study, participants with physician-diagnosed and spirometry-verified COPD attended three yearly visits. Blood cell counts, spirometry and questionnaire-assessed exacerbation history (worsening of COPD leading to an unscheduled visit and/or use of antibiotics and/or use of oral corticosteroids) were collected at each visit. Subjects with available data on NLR and exacerbations at least at one follow-up visit were included (N=478, 42% males). At baseline, mean±SD FEV1 was 57±17% predicted, and median NLR 2.2, interquartile range (IQR) 1.7-3.1. Subjects with ≥1 exacerbation the preceding year (38%) had higher baseline NLR (median 2.5, IQR 1.8-3.5) than those with no exacerbation the preceding year (2.2, IQR 1.6-2.8, Mann-Whitney p<0.001). Subjects with ≥1 exacerbation the first year following baseline (32%) had higher baseline NLR (median 2.4, IQR 1.8-3.4) than those with no exacerbation the first year (2.2, IQR 1.6-2.9, Mann-Whitney p<0.001). In a three-level (longitudinal observations in subjects nested within study sites) mixed effects logistic regression model, NLR was associated with future exacerbations (OR 1.21, 95% CI 1.05-1.38) after adjustment for exacerbations the preceding year, blood eosinophils, COPD assessment test (CAT) score, BMI, smoking, use of inhaled corticosteroids, lung function, gender and age. In conclusion, NLR appears to have an independent prognostic value for future COPD exacerbations.
The objective of this study was to apply extended NO analysis for measurements of NO dynamics in the lung, divided into alveolar and airway contribution, in amateur runners and marathoners.The athletes participated in either a marathon or a half marathon. The athletes self-reported their age, weight, height, training distance per week, competing distance, cardio-pulmonary health, atopic status, and use of tobacco. Measurements of exhaled NO (FENO) with estimation of alveolar NO (CANO) and airway flux (JawNO), ventilation, pulse oximetry, and peak flow were performed before, immediately after, and 1 hour after completing the race.At baseline the alveolar NO was higher in amateur runners, 2.9 ± 1.1 ppb (p = 0.041), and marathoners, 3.6 ± 1.9 ppb (p = 0.002), than in control subjects, 1.4 ± 0.5 ppb. JawNO was higher in marathoners, 0.90 ± 0.02 nL s-1 (p = 0.044), compared with controls, 0.36 ± 0.02 nL s-1, whereas the increase in amateur runners, 0.56 ± 0.02 nL s-1, did not attain statistical significance (p = 0.165). Immediately after the race there was a decrease in FENO in both amateur runners and marathoners, whereas CANO and JawNO were decreased in marathoners only.Our results support the view that there is an adaptation of the lung to exercise. Thus strenuous exercise increased both airway and alveolar NO, and this might in turn facilitate oxygen uptake.
Background: The oleic acid‐induced lung injury (OAI) model is considered to represent the early phase of acute respiratory distress syndrome (ARDS). Its inherent properties are important for the design and the interpretation of interventional studies. The aim of this study was to describe the evolution of morphometric lung changes during OAI using computed tomography (CT) analysis. Furthermore, the effect of a temporary change in positive end‐expiratory pressure (PEEP) was evaluated. Methods: Fifteen anaesthetized pigs were ventilated in volume‐controlled mode with a baseline PEEP of 5 cm H 2 O. Helical CT scans were taken at baseline and 1 h after oleic acid injection. The PEEP was then either increased to 10 cm H 2 O ( n = 5), decreased to 0 cm H 2 O ( n = 5) or kept constant ( n = 5) for 30 min. For the next 30 min, the baseline PEEP level was applied in all animals before the final CT scans 2 h after the induction of OAI. Dimensional and volumetric changes were determined from radiographical attenuation values. Results: There was a major decrease in gas volume and an increase in tissue volume within the first hour. A net increase in total lung volume, with a larger transverse area but no displacement of the diaphragm, was manifest after 2 h. A minor increase in volume of non‐aerated lung, located to the caudal region, was observed during the second hour. The tidal volume was redistributed to the middle and apical regions. The temporary change in PEEP did not influence the morphological progress of OAI. Conclusion: Decreased gas volume and increased tissue volume are the dominating morphometric characteristics of oleic acid lung injury, occurring mainly within the first hour. With these changes manifest, the course of injury is not affected by a limited period of moderately changed PEEP during the second hour. The net increase of total lung volume suggests a predominance of oedema formation over airway and alveolar collapse.
To assess sustainability of an intervention used to implement pressure ulcer prevention.The Promoting Action on Research Implementation in Health Service, framework was used to develop an intervention aimed to implement evidence-based pressure ulcer prevention in a hospital setting. A short-term follow-up showed that significantly more patients received pressure ulcer prevention. A qualitative process evaluation gave support that the intervention and the implementation process changed the understanding and approach to working with pressure ulcer prevention from treating to preventing.The study had a sequential mixed method approach, combining quantitative and qualitative data. For the quantitative data, baseline and short-term follow-up (6-8 months) data reported in an initial study were compared with long-term follow-up (36-42 months) data (n = 259 patients). For the qualitative data, interviews with registered nurses (n = 20), assistant nurses (n = 7) and first-line managers (n = 5) were performed.The performance of pressure ulcer prevention was sustained 3 years from its conception. The number of patients with pressure ulcers was reduced (P = 0.021). Systematic work with quality measurements, support from first-line managers, internal facilitation, collaboration and pressure ulcer prevention skills could explained the sustainability. Obstacles to achieve high-quality pressure ulcer prevention were inadequate communication, high workloads and high rates of new and substitute nurses.Three different components for sustainability on the micro-level are described; benefits for the patients, the need for routinization and development over time. Threats to sustainability are described as factors on the macro-level. There needs to be collaboration in the healthcare organization from the micro-to-macro levels, and committed experienced nurses are needed to obtain high-quality sustainable pressure ulcer prevention.
Aim. To assess the discriminative and construct validity of the Multidrug‐Resistant Bacteria Attitude Questionnaire and to study registered nurses’ knowledge of, behaviour toward and emotional responses to patients with multidrug‐resistant bacteria in relation to how they understand their own, managers’ and politicians’ responsibility for adherence to preventive measures for infection control. Background. Multidrug‐resistant organisms are a global problem and an essential topic in healthcare regarding patient safety improvement. Design. Descriptive and correlational cross‐sectional survey. Method. Data were collected in a non‐random sample consisting of 397 registered nurses; district, haematology or infection registered nurses. One‐way analysis of variance and independent t ‐tests were used for comparisons and a principal component analysis was performed. Results. Discriminative and construct validity were supported, as the infection registered nurses generally had higher scores on knowledge, behaviour and emotional response, compared with district registered nurses and haematology registered nurses and the three‐factor solution was confirmed. Registered nurses with higher scores on knowledge and emotional response attributed greater responsibility to themselves and to politicians. The Multidrug‐Resistant Bacteria Attitude Questionnaire was translated using a forward‐back translation process. Conclusion. The questionnaire has adequate psychometric properties. Insufficient knowledge of, behaviour toward and emotional response to patients with multidrug‐resistant bacteria were described, but the registered nurses did estimate their own responsibility for adherence to preventive measures for infection control as being great or very great. Relevance to clinical practice. There is a considerable need to improve knowledge, behaviour and emotional response regarding infection prevention measures among healthcare workers. The hospital management are responsible for such improvements and the Multidrug‐Resistant Bacteria Attitude Questionnaire is useful in identifying such needs, as it has adequate psychometric properties and is able to discriminate between groups. Evaluation among healthcare workers may indicate where to situate additional training, as this is of clinical significance for safe care.
Introduction: Assessments of the usefulness of exhaled nitric oxide (NO) in the treatment of asthma have given conflicting results. It is not always obvious if atopic status has been tested in these evaluations. Objectives: The aim of the study is to use extended NO analysis to characterize subjects from a random sample populations with focus on rhinitis and asthma. Methods: Data were extracted from the European Community Respiratory Health Survey II. A subgroup from the Uppsala site that had had their NO measured at multiple flow rates was included (n = 284). The nonlinear model for NO parameters was used. Atopy was defined as having a titre against at least one of the tested allergens ≥0·35 kU l−1. Bronchial responsiveness was assessed by methacholine challenge. Results: Subjects with non-atopic rhinitis or non-atopic asthma could not be separated from healthy subjects regarding NO parameters. There was a gradual increase with atopy in airway diffusion rate (DawNO); healthy subject 8·0 (7·3, 8·8), healthy atopic 8·8 (6·7, 11·5), atopic rhinitis 10·6 (9·0, 12·4) and atopic asthma 11·2 (9·9, 28·3) ml s−1 [geometrical mean (CI95%)]. There was a correlation between bronchial responsiveness and DawNO in atopic rhinitis (r = −0·41, P<0·01), and bronchial responsiveness and airway wall content of NO (CawNO) in atopic asthma (r = −0·56, P<0·001). Conclusion: It is of importance to characterize atopic status when evaluating the association between NO and asthma. Our results indicate that the use of extended NO analysis, with particular attention to DawNO and CawNO, may be useful in monitoring treatment for rhinitis and asthma.
Nitric oxide from the gas exchange area, but not from the airways, is increased in subjects with chronic obstructive pulmonary disease with low oxygen saturation after physical testinghttp://bit.ly/2ItUJy6
Introduction Chronic obstructive pulmonary disease (COPD) is traditionally perceived as Th1-inflammation, but some patients have Th2-inflammation. A high fraction of exhaled nitric oxide (FENO) is seen in asthma with Th2-inflammation, justifying FENO as a point-of-care biomarker. The use of FENO in COPD is much less frequent. We aimed to review the evidence in favor of FENO measurement in COPD and discuss its potential usefulness in clinical settings.
 scale(.21174)'%3e%3cpath d='m52.487 177.086 13.018 11.852 11.762-11.762 11.896 12.266 12.846-11.358 11.827 12.43 13.339-11.013 10.897 12.728 13.27-10.145 13.947 12.319'/%3e%3ccircle cx='89.425' cy='154.584' r='5.167'/%3e%3ccircle cx='111.237' cy='156.047' r='5.167'/%3e%3ccircle cx='30.05' cy='16.5' r='4'/%3e%3c/g%3e%3c/svg%3e)
