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Abstract: Poster Presentations

Chest. 2007;132(4_MeetingAbstracts):505. doi:10.1378/chest.132.4_MeetingAbstracts.505
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PURPOSE: We evaluated characteristics of asthma care and documentation by pediatricians (P), pediatric pulmonologists (PP), adult pulmonologists (AP) and allergists (A) at an academic medical center.

METHODS: Practice habits and documentation was extracted from 120 charts randomly chosen from each practice. 4 charts were dropped from pediatrics <6 years of age (too young for objective testing). Pediatrics n= 26; Allergy n=30; Adult pulmonary n=30; Pediatric Pulmonary n=30; Total n= 116.

RESULTS: Use of controller medications (inhaled steroids & or leukotriene inhibitors) was documented in 73% of (P), 87% of (A); 93% of (AP) and 93% (PP). For those patients whose asthma was classified (n=62) there was an increasing trend to use inhaled steroids as asthma severity increased (p<0.001). Objective testing: *Peak flow use varied between practices. 0% of (PP) patients compared to 97% of (A) patients. *Spirometry testing was mostly performed by (AP) 97% and 100% of (PP) patients. *Full PFT's: 0% of (P); 86% of (A); 27% of (AP) and 24% of (PP) patients had them (p<.0001). Pediatricians do the least amount of asthma office testing, but they referred the most (92%). *Asthma action plans were rarely documented (13%) of (PP) charts (p<0.004).

CONCLUSION: The delivery and documentation of patient care varies greatly by practice. *Pediatricians tended to use less controller medications. Allergists used the least amount of leukotriene inhibitors. *All practices documented increasing use of inhaled steroids based on the severity of asthma. Despite the widespread requirement to classify asthma according to the NHLBI guidelines, this is rarely performed and documented in the practice settings of allergists or pulmonary specialists.* Hardly anyone uses asthma action plans.

CLINICAL IMPLICATIONS: Many agencies require the use of classifying asthma severity according to the guidelines, using peak flows and formulating asthma action plans. However,it was not documented with any consistency in the practices reviewed.

DISCLOSURE: Grace Trimmer, None.

Chest. 2007;132(4_MeetingAbstracts):506. doi:10.1378/chest.132.4_MeetingAbstracts.506
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PURPOSE: One of the primary reasons for insufficient control of bronchial asthma is lack of awarenss on the pattern and treatment strategy. There are myths observed in different groups of community. Doctors and paramedical personnel have an important role in correcting such myths. Information on the subject obtained in a selected group - fofth semester medical students in a medical college in south India formed the basis of this presentation.

METHODS: Medical students presently undergoing clinical training ( one year after basic preclinical phase) were selected for the study. A questionaire on the pattern and broad treatment strategy of the disease was handed over and student independenly asked to mark the answers. The data was computed .

RESULTS: There were 56 medical students. The observations are in approximate percentage in brackets. a) Bronchial asthma runs only in families (37.5) b) Steroid inhalers are the LAST choice in the treatment strategy (35.7) c) Inhalers cause addiction and can not be stopped (25) d) Inhalers cannot be used in pregnancy (32) e) Inhalers are dangerous in children (19.6) f) Tablets and injections are more effective (12) g) The choice of treatment in acute severe asthma: Inhalers (23), Nebulizers (64), Rotahaler (13) h) Diagnosis is made: Clinically (10); Spirometry (60); Radiology (9); arterial blood gas (7); History (14) i) Commonest cause is: Allergens (76); smoking (19); drugs (3.3); contact (1.7) j) The first line approach to severe asthma: oxygen (54) Inhalers (39); antibiotics (5.3); radiology (1.7).

CONCLUSION: There is insufficient knowledge on the pattern of bronchial asthma even among medical students, despite our state being highly literate. There is still scope for raising the awareness on steroid inhaler therapy and other lines of treatment. Patient / Physician medical education hence is still desired to curb this controllable disorder.

CLINICAL IMPLICATIONS: Physician must find time in educating asthmatics and families in reducing hospitalisation and morbidity.The role of steroid inhalers as preventer will be stressed.

DISCLOSURE: Gopinathan Pisharath, None.

Chest. 2007;132(4_MeetingAbstracts):507. doi:10.1378/chest.132.4_MeetingAbstracts.507
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PURPOSE: Asthma is the most common chronic lung disease. We have characterized clinical status and PF in chronic patients compared to those of lesser duration.

METHODS: Chronic >=30 years, control =10–15 years duration. All patients were non-smokers/ smoked < 10pack year (quit >30 years) and no other lung disease. Data obtained: gender, age, BMI, FEV1, FEV1% predicted pre and post-bronchodilator(BD), FVC, FEV1/FVC, DLCO, BD and inhaled corticosteroid (ICS) usage. Definition: change in serial studies as >150 mL for FEV1, >10% for DLCO, FEV1/FVC greater of pre or post BD.

RESULTS: Chronic group=64 patients (47 females). Mean age 54, 14 > 65 years, 16 <40. 35 obese, 14 morbidly; 22 overweight. For DLCO: 32 >80, 26 =60 –80, 6 <60. Of these 6, age 62 to 79, FEV1/FVC normal in 5. 26 patients >1 studies. Of these, 10 had a change in DLCO unrelated to change in FEV1. For FEV1/FVC: 42 >70%, 12 =60 −70, 8 =50–60, 2 <50. For FEV1%: 11 >80%, 26 =60–80, 27 <60. 98% used BD+ICS. Control group=29 patients (14 females). Mean age 33, 3 > 65 years, 25 <40. 9 obese, 3 morbidly; 7 overweight. For DLCO: 18 >80, 11 =60–80, none <60. For FEV1/FVC: 25 >70%, none =60–70, 3 =50–60, 1 <50. For FEV1%: 15 >80%, 8 =60–80, 6 <60. 62% used BD.

CONCLUSION: In this inner city community hospital, a typical chronic asthmatic uses BD/ICS, has 75% chance of being female, 90% being overweight/obese, 50% having mild/severe reduction in DLCO. A change in DLCO is not associated with a consistent change in FEV1. In both groups there was a similar frequency of mild/moderate decrease in DLCO but a severe decrease was seen only in the chronic group (10%). Of these 6 patients only one had a reduced FEV1/FVC.

CLINICAL IMPLICATIONS: A chronic asthmatic is likely: obese, female, 50%chance of low DLCO. Severe decrease in DLCO was seen only in the chronic group; these were older and did not show obvious airways obstruction.

DISCLOSURE: Zinobia Khan, None.

Chest. 2007;132(4_MeetingAbstracts):508. doi:10.1378/chest.132.4_MeetingAbstracts.508
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PURPOSE: Few asthmatic patients currently achieve control. Factors contributing to poor asthma control are low use of controller therapy, misuses of management guidelines and misestimating of asthma control by both patients and physicians. In low socioeconomic population comprehensive management efforts to reduce asthma morbidity have not been conclusive. The aim of our study is to identify contributing factors of uncontrolled asthma in this population independent of their low income.

METHODS: A low socioeconomic population seeking medical care in a nongovernmental organization (Hariri foundation) was studied. The foundation offers access to medical care ressources including physicians, laboratory exams and treatment at almost free prices. Asthma control test (ACT) was administered to 110 asthmatic patients scored on a scale from 5 (not controlled at all) to 25 (completely controlled). Asthmatics scored less than 20 are considered uncontrolled. Demographics data, starting age, seasonal and perennial disease, asthma severity, treatment and exposure to smoking were analyzed.

RESULTS: 62 patients (56.4%) have uncontrolled asthma and only 8 patients (7.3%) have complete control. Seasonal asthma was diagnosed in 75% of patients. Active and passive smokers are 19.1% and 29.1% respectively. Inhaled steroids, leukotrienes modifiers, long acting bronchodilators and short acting bronchodilators are used in 23.6%, 13.6%, 17.3% and 72.7% respectively. Patients asthma severity are distributed as GINA I (33.6%), GINA II (20.9%), GINA III (28.2%) and GINA IV (17.3%) are statistically correlated with the ACT score 23±1.7, 18±2.2, 14.8±3.6, 10.7±3.4 respectively (p < 10–3). Independent of GINA staging, multiple analysis using linear regression determined ACT score significant related to passive smoking (beta −3.23 SE 1.50 (p 0.036)) and perennial compared to seasonal asthma (beta −2.76 SE 1.47 (p 0.06)).

CONCLUSION: Control asthma necessitates supplementary management efforts to adapt treatment plan for the severity of the disease, to extend treatment period and to eliminate passive smoking.

CLINICAL IMPLICATIONS: Even with all medical resources and economic facilities, asthma control is still unsatisfactory in a low socioeconomic population.

DISCLOSURE: Moussa Riachy, None.

Chest. 2007;132(4_MeetingAbstracts):509. doi:10.1378/chest.132.4_MeetingAbstracts.509
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PURPOSE: To assess the effect of adherence to fluticasone propionate/salmeterol administered in a single device (FSC) on asthma-related exacerbations (emergency department visits [ED] or hospitalizations [IP]), use of rescue medications (short-acting beta-agonists [SABAs]), and costs.

METHODS: This was a retrospective observational analysis of the association between FSC adherence and risk of asthma-related exacerbations, use of rescue medications, and costs using a healthcare claims database representing >70 US health plans. Study subjects included those with diagnosis of asthma (ICD-9 493.xx), age ≥12 yrs, and ≥2 dispensings of FSC from January 2000 to September 2006 (first prescription = “index date”). Patients with <12 months continuous enrollment pre-index a COPD diagnosis or dispensing of ipratropium were excluded. Follow-up was defined as time from index date to disenrollment, discontinuation of FSC (180 days w/o supply), receipt of different controller medication, or 24 months post-index. Repeated measures regression was used to estimate the association between FSC adherence (medication possession ratio [MPR] = days of FSC supplied χ days of follow-up) during each 90-day interval post-index and risk of ED/IP, use of rescue medications, and asthma-related exacerbation costs in subsequent intervals controlling for demographics, time since index, comorbidities, pre-index medications, healthcare utilization, and costs.

RESULTS: 12,930 patients were identified: mean age 40 yrs, mean follow up 20 months. After adjusting for baseline characteristics, each 10% increase in MPR of FSC was associated with a 4.4% reduction in odds of ED/IP (95% CI 1.9% - 6.8%), a 2.0% reduction in SABA use (95% CI 1.5% - 2.4%) and a 8.8% decrease in asthma-related exacerbation costs (95% CI 8.1% - 9.6%).

CONCLUSION: Improved adherence with FSC is associated with reduced asthma-related ED/IP risk, reduced use of SABAs and reduced asthma exacerbation costs.

CLINICAL IMPLICATIONS: Clinicians may be able to improve asthma control reduce the risk and costs of asthma-related exacerbations by stressing adherence to FSC.

DISCLOSURE: Richard Stanford, No Product/Research Disclosure Information; Shareholder RS and DS hold shares in the sponsor, GSK; Employee RS and DS are employees of the sponsor, GSK; Consultant fee, speaker bureau, advisory committee, etc. MH and TD are were paid consultants on this study

Chest. 2007;132(4_MeetingAbstracts):510. doi:10.1378/chest.132.4_MeetingAbstracts.510
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PURPOSE: We had previously shown that the final common pathway of autonomic control of bronchomotor tone in asthma is through adrenoceptors and all the achievable bronchodilation was obtained with adrenergic agents (Jindal SK. Respiration 1989;56:56–21). The present study was undertaken to see whether there was any differential responsiveness of smoker asthmatics to salbutamol (S) and ipratropium bromide (IB) administration.

METHODS: We studied 30 patients of chronic stable asthma equally grouped into current smokers (Sm) and life time nonsmokers (NS). Smoking and bronchodilators were withheld 24 hours prior to the study while inhalational steroids were continued. After baseline spirometry, sequential doses of one agent, S or IB were given through a metered dose inhaler and a spacer to achieve the fullest expression of a particular neuronal mechanism (adrendergic or cholinergic) reflected by a plateau on the dose response (FEV1 and FVC) curves after which the other agent was administered for any additional bronchodilatation. The sequence of drug administration was reversed in the next experiment after 2 days.

RESULTS: Significant increases were seen in PEF and the spirometry indices following administration of either S or IB (Table 1). But the additional increases following the administration of second agent after a plateau response with the first was not statistically significant in both NS and Sm patients (Table 1), except that NS patients receiving IB first showed a better additional increment in FEV1 after S as compared to Sm patients.

CONCLUSION: The bronchodilatory responses of both NS and Sm to supramaximal doses of either S or IB were generally similar.

CLINICAL IMPLICATIONS: There is no additional bronchodilatory advantage of combining S and IB in either NS or Sm asthmatics.

DISCLOSURE: Surinder Jindal, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):511. doi:10.1378/chest.132.4_MeetingAbstracts.511
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PURPOSE: In patients with difficult to control asthma who meet established criteria, Omalizumab has been shown in multiple trials to be an effective treatment option. Inclusion criteria for these trials typically requires documentation of at least 12% reversibility. Studies to determine the efficacy of Omalizumab in asthmatics without documented reversibility have not been done. In an attempt to enforce “evidenced-based” practice patterns, some managed care organizations (MCOs) are restricting the use of Omalizumab to asthmatics with documented reversibility, despite the fact that many of these patients are already on one or more controller agents.

METHODS: The records of 38 consecutive patients treated with Omalizumab at a pulmonary and allergy specialty practice were reviewed to determine the relationship between reversibility and outcome. All patients met the accepted criteria for this treatment. Reversibility was defined as 12% or more improvement in FEV-1 on any spirometry prior to the first dose of Omalizumab, independent of whether or not the patient was on controller medication(s). Outcome was determined by the global assessment of the treating physician; “much better”, “better”, “slightly better” or “no better”. Those assessed as “much better” or “better” were classified as responders and those assessed as “slightly better” or “no better” were considered nonresponders.

RESULTS: Patients were followed for a mean of 39 months prior to the first dose of Omalizumab. 17 patients had documented reversibility and 20 were irreversible. Records of bronchodilator testing were not available in 1 patient. Overall 58% of patients receiving Omalizumab were classified as responders. In those with documented reversibility, the response rate was 59% and in those without reversibility the response rate was 55%.

CONCLUSION: Response to Omalizumab can not be predicted based on prior documentation of reversibility in patients otherwise meeting the criteria for this treatment.

CLINICAL IMPLICATIONS: The presence of reversibility on spirometry should not be used as a criteria in determining eligibility for Omalizumab treatment by MCOs since this practice deprives a significant number of asthmatics from receiving potentially effective therapy.

DISCLOSURE: Robert Sussman, No Product/Research Disclosure Information; Grant monies (from industry related sources) Clinical research: Glaxo, BI, Intermune, Actelion, Novartis, Astra-Zeneca, Altana, Dey; Consultant fee, speaker bureau, advisory committee, etc. Speakers bureau: Glaxo, BI, Novartis, Genetec, Pfizer, Schering, Oscient, Sepracor

Chest. 2007;132(4_MeetingAbstracts):512. doi:10.1378/chest.132.4_MeetingAbstracts.512
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PURPOSE: Asthma is a chronic inflammatory disorder of the airways in which many cells play a role, in particular mast cells, eosinophils (Eo), and T lymphocytes. Eosinophyls have an important role in the pathogenesis of bronchial asthma (BA). The following of their count and mediators in peripheral blood and BAL could be employed as a marker of the inflammation in asthmatic patients.

METHODS: We followed 30 patients with BA, treated with inhaled corticosteroids (IKS) (Spray Beclomethasone dipropionate) in doses of 1000-2000mg per day. We followed the Eo count, ECP and IL-5 in peripheral blood at the beginning of the study, after 2 and 6 months of the anti-inflammatory therapy.

RESULTS: We found a decrease of the Eo count from 292.66 ×106/l to 270 ×106/l, serum level of ECP from 22.92 to 19.36mg/l, and serum level of IL-5 from 44.94 to 37.84 pg/ml at the first control (after 2 months), and Eo count to 224.33 ×106/l, ECP to 14.47mg/l, and IL-5 to 30.44 pg/ml, 6 months from the treatment. The analysis of variance showed statistical significance of p<0.05 for this reduction.

CONCLUSION: We concluded that inhaled corticosteroids decrease the inflammation in BA and the eosinophyls, ECP and IL-5 are just another parameters for a follow up of this effect.

CLINICAL IMPLICATIONS: Biological markers of the inflammation can be used as a diagnostic parameter, and as e parameter for follow up of the therapy in asthmatics.

DISCLOSURE: Deska Dimitrievska, None.

Chest. 2007;132(4_MeetingAbstracts):513. doi:10.1378/chest.132.4_MeetingAbstracts.513
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PURPOSE: There are several internationally accepted guidelines for the management of asthma, we examined the utilization of these guidelines in the management of asthmatics as well as the use of inhaler devices among the asthmatics presenting for specialist assessment and treatment at Lagos, Nigeria.

METHODS: 106 consecutive patients with physician diagnosed asthma referred on account of poor control for specialist review participated in the study between April 2006 and March 2007. The setting was the chest clinic of the Lagos state university teaching hospital , Ikeja. Lagos Nigeria.The patients between age 13 and 64 years were interviewed about asthma control using previous hospitalization, frequency of nighttime symptoms, and frequency of emergency visits. Their knowledge of medications was assessed. Inhaler techniques were observed.

RESULTS: 52 (49.1%) had previous hospitalization for asthma. (50) 47.2% had weekly night time symptoms. 48 (45.3%) had exacerbations requiring treatment at the emergency room in the week preceding the interview.The meter dose inhaler was the commonest drug delivery device in use by 72 (67.9%) of the patients.32(30.2%)used a diskus. only 10 (10.6%) used nebulisers at any point.The inhaler technique was rated as Good in only 34 (47.2%) out of the 72 respondents and poor in 38 (52.8%). only 34 respondents satisfactorily performed all steps. (100) 94.3% skip their medication. Majority of the Asthmatics did not receive any Health education about their medical condition.Possession of peak flow meter and use was low among the patients with only 22(20.8%) possessing a peakflow meter. Only 26 (24.5%) of the Asthmatics received any form of health education.

CONCLUSION: Asthma control remains poor among the patients in Lagos, Nigeria. Poor knowledge of disease, medication use and inhaler techniques contribute significantly to this problem.

CLINICAL IMPLICATIONS: This study emphasized the importance of educating the patients on their disease, medication uses, inhalation techniques and home monitoring of asthma.It also showed the need to train asthma nurses and re-train health personnel in the utilization of current guidelines in the management of asthma in Lagos, Nigeria.

DISCLOSURE: Olayinka Adeyeye, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):514. doi:10.1378/chest.132.4_MeetingAbstracts.514
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PURPOSE: To determine the effects of flexible bronchoscopy (FB) on the cardiac double product (DP) in patients with normal and high screening pre-bronchoscopy systolic blood pressure (SSBP).

METHODS: A retrospective review of data from January 1, 2006 until March 31, 2006 of subjects who underwent FB was performed. Subjects were divided into 2 groups based on SSBP (>= 135 mmHg for the hypertensive group, < 135 for the non-hypertensive group). Screening and maximum values of DP during FB were obtained. The outpatient use of antihypertensives, particularly beta-blockers, was recorded.

RESULTS: Medical records pertaining to a total of 121 subjects were reviewed: 78 in the non-hypertensive group (Group A) and 43 in the hypertensive group (Group B). Forty-three subjects in Group A received antihypertensive medications, compared to 37 in Group B (p<0.005). The mean SSBP in Group A was 120 mmHg compared to 148.5 in Group B (mean difference of −28.4, p<0.001). The mean maximum DP was 11,861 in Group A compared to 14,434 in Group B (mean difference of 1754.6, p<0.001). The mean delta DP (maximum minus baseline DP) was 2745 for Group A compared to 2934 for Group B (p=0.718). Patients from either group who received beta-blockers had a significantly lower maximum DP (p=0.005) and maximum heart rate (p<0.001), but a non-significant difference of mean delta DP (p=0.556) compared to subjects who did not receive beta-blockers.

CONCLUSION: DP is significantly higher during FB in patients with an elevated SSBP compared to patients with normal SSBP. The difference between groups in the maximum DP appears to be due to the elevation in the baseline systolic blood pressure and not due to an augmented blood pressure response to FB. The use of beta-blockers is associated with a reduced DP during FB.

CLINICAL IMPLICATIONS: FB causes an increment in DP from baseline to a degree that has previously been associated with silent ischemia in patients with hypertension. The rate with which ischemia occurs and the potential use of prophylactic methods should be investigated.

DISCLOSURE: Javier Diaz, No Financial Disclosure Information; No Product/Research Disclosure Information

Topics: bronchoscopy , heart
Chest. 2007;132(4_MeetingAbstracts):515. doi:10.1378/chest.132.4_MeetingAbstracts.515
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PURPOSE: Thoracic Percutaneous Needle Aspiration (TPNA) and core needle biopsy (CNB) are common and safe procedures performed either by interventional radiologists or pulmonologists. Few pulmonary training programs offer training in TPNA.The purpose was to compare the yield and complications of TPNA/CNB when the procedure is performed by pulmonologist versus interventional radiologist.

METHODS: Retrospective review of records of patients that underwent TPNA/CNB from 2004 to 2006. At our institution the procedure is done either by a single radiologist or any of four pulmonologist supervising the fellows.

RESULTS: We identified 31 patients, mean age 61 years, 18 and 13 in the Pulmonary and Radiology group respectively. There were more patients with COPD and HIV infection in the pulmonary group; this was statistically significant (p 0.002). There were no differences for radiological characteristics,diagnostic yield or complications between the groups. Table 1 The yield was 50% in the Pulmonary versus 69% in the Radiology group. Malignancy was the most common diagnosis found. CNB was used in 22% and TPNA-only in 78% of pulmonary cases versus 54% and 46% for radiology; the difference was not significant. Table 2. A pathologist was present in the room only for pulmonary cases.

CONCLUSION: The diagnostic yield was similar in both groups. There was a trend for radiologist to have a higher yield; this could be due to expertise obtained by a single operator doing larger number of cases as well as special training in TPNA/CNB. In our study, the presence of a pathologist in the room did not increase the yield of the procedure.

CLINICAL IMPLICATIONS: Pulmonary fellowship programs that want to offer training in TPNA/CNB should develop a mechanism to achieve a minimum competencies in the procedure, this could mean limiting the number of faculty performing it or teaming with radiologist to train the pulmonary residents. Obtaining expertise in CNB is of the outmost importance to maximize yield of the procedure and decrease the need for further invasive diagnostic procedures.

DISCLOSURE: Ibrahim Abou Daya, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):516. doi:10.1378/chest.132.4_MeetingAbstracts.516
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PURPOSE: HDIR is used to treat endobronchial lung cancers with high dose radiation administered directly into the tumor. Due to its short treatment distance, HDIR maximizes the radiation dose given to tumor tissue while minimizing radiation effects on adjacent normal tissue. Current practice limits HDIR administration to proximal tumors seen via the videoscope or fluoroscopy. This report describes 3 patients with peripheral lung lesions effectively treated by HDIR with placement guided via ENB and REBUS.

METHODS: All three patients had non-small cell lung cancer. Two patients were classified as stage IIB (T2N1M0) and one as IA (T1N0M0). None of the patients were surgical candidates. The bronchoscope was inserted into the general airway where the peripheral lesion was located. Superdimension(TM) ENB was used for the procedures. Under ENB guidance, the ENB working channel was navigated to the peripheral tumor. The position was then confirmed via Olympus REBUS. Under fluoroscopic guidance, a 6 Fr. catheter(with distal tip sealed) was inserted through the working channel and into the peripheral lesion. Subsequently, a Varian VariSource HDIR apparatus was used to implant a 10 Cu Iridium-192 radioactive source into the catheter and a dose cloud treatment of 16 Gy was given according to a 3D CT planning program.

RESULTS: None of the three patients experienced post-procedure complications. One is alive 6 months and another 12 months post-procedure. Post treatment chest CT demonstrated dramatic interval decrease in tumor size in both patients. The third patient died one month post-procedure as a result of a myocardial infraction unrelated to the procedure. A 1 month post-procedure CXR documented interval decrease in tumor size.

CONCLUSION: Placement of HDIR by ENB and REBUS is a feasible treatment approach which demonstrates dramatic tumor regression and may decrease morbidity and increase survival rates by focusing radiation at the tumor site and adjacent lymphatic structures.

CLINICAL IMPLICATIONS: This technique may serve as a radiosurgical alternative to conventional surgery in non-operative lung cancer patients.

DISCLOSURE: Ajay Bedekar, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):517. doi:10.1378/chest.132.4_MeetingAbstracts.517
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PURPOSE: Existing techniques to measure airway lumen before and after therapeutic interventions for central airway obstruction are either subjective or labor intensive. In this paper we describe the use of digital image analysis software to quantify degree of airway narrowing in patients with various forms of central airway obstruction.

METHODS: Using “Image J”, a public domain image analysis program developed by National Institutes of Health (http://rsb.info.nih.gov/ij/) and previously validated in pediatrics, the degree of airway narrowing was calculated in pixels from still photos obtained during videobronchoscopy. This number was then used to calculate a Stenosis Index (SI) for patients with fixed central airway obstruction (i.e. tracheal stenosis, extrinsic compression, intraluminal tumor) and a Collapsibility Index (CI) for patients with expiratory central airway collapse [i.e. tracheobronchomalacia, excessive dynamic airway collapse (EDAC)]. SI was defined as (CSA normal- CSA stenosis) × 100%/ CSA normal, where CSA normal= Cross Sectional Area of the normal airway lumen proximal or distal to the stenotic lesion and CSA stenosis= Cross Sectional Area at the level of airway stenosis). CI was defined as (CSAi- CSAe) × 100%/ CSAi, where CSAe =Cross Sectional Area at end-expiration and CSAi = Cross Sectional Area at end-inspiration.

RESULTS: The SI and CI results for five patterns of central airway obstruction are demonstrated in Figure 1. Videobronchoscopic imaging and computer based analysis are illustrated using a case of fixed CAO (i.e. subglottic stenosis) and expiratory central airway collapse (i.e. EDAC) (Figure 2).

CONCLUSION: Morphometric bronchoscopy using calculated indices provides objective measurement of degree of airway narrowing for various forms of central airway obstruction.

CLINICAL IMPLICATIONS: The use of calculated indices potentially makes the labor intensive measurement of absolute cross sectional area unnecessary. Objective measurements of airway lumen before and after therapeutic interventions will allow studies to determine correlations between degree of airway narrowing, degree of ventilatory impairment and patient symptoms.

DISCLOSURE: Septimiu Murgu, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):518. doi:10.1378/chest.132.4_MeetingAbstracts.518
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PURPOSE: Airway complications after lung tranplantation range from 7 to 14% and include bronchial stenosis and bronchomalacia. Treatment of these complications include thermal ablation, balloon dilatation, and stent placement. The purpose of this study is to describe our experience with the Alveolus tracheobronchial stent in the management of these complications.

METHODS: The Alveolus tracheobronchial stent (Alveolus, Inc.) is a new, completely covered, self-expanding nitinol metallic stent. The stents were inserted via flexible bronchoscopy with conscious sedation. Stent deployment was performed under direct bronchoscopic visualization. The degree of stenosis pre and post-stent placement were estimated by bronchoscopic visualization using the proximal airway size as a reference.

RESULTS: Seven patients underwent stent implantation. Indications were stenosis (N=4), bronchomalacia (N=2), and stenosis plus bronchomalacia (N=1)along the anastomosis. The timing of intervention ranged from 3 to 19 months after transplantation. Adjunctive electrocautery was performed in 2 patients and balloon dilatation in 1 patient. The left mainstem bronchial anastomosis was stented in 4 patients and the right mainstem bronchial anastomosis in 3 patients. The average degree of stenosis decreased from 80% to 20%. Pulmonary function tests improved in all patients. Stent migration occurred in 1 patient with bronchomalacia. Other complications have not yet been observed.

CONCLUSION: Our initial experience with the Alveolus tracheobronchial stent as part of management of lung transplant anastomosis-related complications has been favorable. The stent is fully covered which may allow for stent removal at a later time once the stenosis has been maximally dilated and is stable. The potential for removability offers an advantage over current metal stents. Longer clinical follow-up will be required to compare the Alveolus stent to other metal and silicone stents in terms of migration, mucus retention, granulation tissue formation, and ease of removability.

CLINICAL IMPLICATIONS: The Alveolus tracheobronchial stent appears efficacious in the management of lung transplant anastomotic complications. Long term follow-up will be necessary to define the efficacy and complication profile of the Alveolus tracheobronchial stent in comparison to other metal stents and silicone stents.

DISCLOSURE: Sebastian Fernandez-Bussy, Consultant fee, speaker bureau, advisory committee, etc. Scientific advisory board for Alveolus, Inc.; Product/procedure/technique that is considered research and is NOT yet approved for any purpose. The Alveolus tracheobronchial stent is not approved for use in benign airway disease.

Chest. 2007;132(4_MeetingAbstracts):519. doi:10.1378/chest.132.4_MeetingAbstracts.519
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PURPOSE: Early diagnosis and specific therapy of opportunistic infections is the cornerstone of successful treatment in immunocompromised patients with fever and pulmonary infiltrates. Flexible bronchoscopy (FB) plays an important role in identifying the cause of pulmonary infiltrates in this patient population. The purpose of this study was to determine the diagnostic yield of FB and to evaluate the impact of bronchoscopic methods on therapeutic decisions and outcome in non-HIV immunocompromised patients with pulmonary infiltrates at our institution.

METHODS: Seventy-two consecutive episodes of pulmonary infiltrates in neutropenic hosts were prospectively evaluated during a 9 month period. The non-invasive diagnostic methods included serological tests, blood and urine antigen detection, and blood, sputum and tracheobronchial aspirate (TBAS) cultures. Bronchoscopic techniques included fibrobronchial aspirate (FBAS), protected specimen brush (PSB), bronchoalveolar lavage (BAL) and transbronchial biopsy (TBB).

RESULTS: A diagnosis was obtained in 55 (76%) of the 72 patients. The etiology of the pulmonary infiltrates was infectious in 43 (60%) and non-infectious in 12 (16%); 17 (24%) remained undiagnosed. Non-invasive techniques led to the diagnosis of pulmonary infiltrates in 14 patients (19 %). Bronchoscopic techniques led to the diagnosis of pulmonary infiltrates in 36 patients (50%): FBAS 27/72 (37.5%), BAL 28/72 (39%), and PSB 11/72 (15%), TBB 30/72 (42%). The combined diagnostic yield of BAL and TBB (70%; 95% CI, 57 to 80%) was higher than that of BAL alone (p < 0.01).The results obtained with the different bronchoscopic techniques led to a change in antibiotic treatment in 29 cases (40%).

CONCLUSION: Bronchoscopic procedures are useful techniques for the diagnosis of pulmonary infiltrates in immunocompromised patients, yielding a definitive answer in as many as 76% of cases and are an important tool in adjusting medical management.

CLINICAL IMPLICATIONS: TBB should be performed whenever possible in an attempt to optimize the diagnostic yield.

DISCLOSURE: Alexander Panda, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):520. doi:10.1378/chest.132.4_MeetingAbstracts.520
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PURPOSE: Bronchoscopic lung-volume reduction (LVR) may lead to improvement in pulmonary function and exercise tolerance in patients with severe heterogenous emphysema. We evaluated the feasibility and short term outcome for one-way valve placement (Emphasys EBV™) in patients with homogenous emphysema.A prospective pilot study for proof of principle and safety was conducted.

METHODS: 10 patients (5 women, 5 men) entered this pilot study. In all cases a homogenous distribution was confirmed by computer analysis of the emphysema score in the CT-scan. We performed unilateral LVR and aimed to occlude the lobe with the lowest perfusion, measured by nuclear scintigraphy. Symptoms were assessed with the SGRQ.

RESULTS: Preoperative mean forced expiratory volume in 1 second (FEV1) was 0.85 liters (range 0.55–1.36), mean residual volume was 5.07 liters (range 3.55–8.24) and six-minute-walk-test was 301 meters (range 150–480). Seven out of 10 patients reported symptomatic improvement, which was confirmed by better PFTs and 6MWT in 4 cases. When analyzing the data for the whole group, no major changes in lung function were evident at 30 days and 90 days. A trend towards improvement was observed in six-minutes-walk-test at 3 months (+20.9 m). No severe complications and no pneumothorax were noticed, but in one case the valves had to be removed after 90 days because of recurrent infections.

CONCLUSION: This first study shows that bronchoscopic lung volume reduction in patients with severe homogenous emphysema is feasible and safe and selected patients may benefit from the intervention. Longer term follow–up and patient selection criteria have to be examined in a larger trial.

CLINICAL IMPLICATIONS: Bronchoscopic LVR may be beneficial in patients with severe homogenous emphysema.

DISCLOSURE: Ralf Eberhardt, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):521. doi:10.1378/chest.132.4_MeetingAbstracts.521
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PURPOSE: The BODE index, a multifactoral 10-point scale of health status in COPD, is reported to better predict mortality than FEV1. Patients with higher BODE scores are at more risk of death than patients with lower scores. The extent to which BODE is associated with other measurements of health status was explored in a post hoc analysis of data pooled from 2 identically designed, randomized, 12-week, clinical trials of long acting β2-agonist (LABA) treatment in COPD patients.

METHODS: Of 1456 subjects in the trials (age ∼63 yrs, FEV1 [percent predicted] ∼41%),1437 had the components of the BODE index (body mass index, FEV1 [percent predicted], dyspnea from the MRC, and 6 minute walk distance) evaluated at baseline prior to dosing at the start of the studies. The rank correlation between these BODE scores and the Baseline Dyspnea Index (BDI) and St. George's Hospital Respiratory Questionnaire total score (SGRQ) at baseline was determined. In addition, the relationship between the baseline BODE score and the change in these measurements (Transition Dyspnea Index focal score [TDI], change in SGRQ) after 6 weeks of LABA or placebo therapy was also evaluated.

RESULTS: The mean (SD) baseline BODE score was 4.45 (1.7) units. BODE scores were observed to have a moderate correlation with BDI (r = −0.37; 95% CI: −0.41, −0.32; p<0.0001) and baseline SGRQ total scores (r = 0.38; 95% CI: 0.33, 0.42; p<0.0001). However, change in these indices with placebo or LABA treatment at 6 weeks demonstrated no association with BODE scores (TDI r=0.0004, p=0.989; change in SGRQ r=0.034, p=0.2318).

CONCLUSION: In this analysis, the BODE index was moderately correlated with BDI and baseline SGRQ total scores, but was not correlated with change in these indices.

CLINICAL IMPLICATIONS: Baseline BODE was correlated with other baseline measures of patient symptoms and function. The relation between change in the BODE index with COPD treatment and changes in meaningful patient outcomes requires additional study.

DISCLOSURE: Claudia Cote, No Product/Research Disclosure Information; Consultant fee, speaker bureau, advisory committee, etc. Special Issues Board member for Sepracor Inc.

Chest. 2007;132(4_MeetingAbstracts):522. doi:10.1378/chest.132.4_MeetingAbstracts.522
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PURPOSE: A polymorphism of TNF-α has been reported, but inconsistent results may arise from different populations of COPD. This research was conducted to study the TNF-α polymorphisms and to investigate the association between genetic polymorphisms and levels of TNF-α in the sputum.

METHODS: 25 COPD patients and 13 controls were recruited. Genomic DNA was used as a template for amplification by PCR to determine the TNF-α polymorphism. The products were investigated by auto-sequencing analysis. The level of TNF-α in induced sputum was measured by ELISA.

RESULTS: The levels of TNF-α were significantly increased in sputum of COPD patients(53.410.7pg/ Image not available) as compared with control subjects(19.711.9pg/Image not available). The level of TNF-α in induced sputum was inversely correlated with FEV1 (r= −0.42, p=0.008). The frequencies of GG genotype in the TNF-α gene promotor region were 88.0%(22/25) in the COPD and 84.6%(11/13) in the controls. The frequencies of GA genotype in the TNF- gene promotor region were 12.0%(3/25) in the COPD and 15.4%(2/13) in the controls. There was no association between TNF- polymorphism and TNF- levels of sputum.

CONCLUSION: The level of the TNF-α was markedly increased and inversely correlated with airflow obstruction. Although it has been speculated that TNF-α might have a causal relationship with COPD,TNF-α gene promoter polymorphism does not seem to play a major role as genetic risk factor in Korean COPD.

CLINICAL IMPLICATIONS: However, we cannot exclude that other mutations in the TNF gene complex may play a role. Further study in association with mutations in other genes will be needed.

DISCLOSURE: Sung Chul Lim, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):523. doi:10.1378/chest.132.4_MeetingAbstracts.523
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PURPOSE: Predictors of readmission for acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are not well defined. Identifying modifiable predictors may help reduce the burden of readmissions. The study was done to evaluate the role of serum magnesium in frequent readmissions.

METHODS: 100 patients admitted with a diagnosis of AECOPD to a tertiary care center from April 2004 to April 2006 were retrospectively followed from the time of index admission till next admission or death. Number of admissions was calculated for the year after index admission, and frequent readmission was defined as ≥3 per year. Patients with other respiratory diseases, renal failure and congestive heart failure were excluded. Serum magnesium was assayed at the time of admission by bichromatic photometry. Logistic regression analysis was used to find independent risk factors for readmission.

RESULTS: The mean age of patients was 71.9 (±10.9 SD) years. 57 were females. 90% were current or ex smokers. The median duration of time to next admission was 108 (range 2 to 842) days. 87% of patients were readmitted at least once during the first year of follow up and 5% died. 23% had frequent readmissions. 85% had received pneumococcal vaccine within 5 years and 29% received influenza vaccine in the current season. Frequency of readmissions was not influenced by the administration of inhaled or oral steroids, and diuretics at the time of discharge. Vaccination did not protect against frequent readmissions. Serum magnesium was lower in patients with frequent admissions (mean±SD 1.77±0.19 vs 1.86±0.24 mg/dl) and was the sole independent predictor of frequent readmissions (Adjusted Odds Ratio 0.001, 95% Confidence Intervals <0.001 to 0.70; p=0.039).

CONCLUSION: Lower serum magnesium level independently predicts readmission for AECOPD. This is an easily modifiable risk factor.

CLINICAL IMPLICATIONS: Serum magnesium levels should be ascertained in all patients with AECOPD. Further studies are needed to find the effect of long term magnesium supplementation on rate of readmission.

DISCLOSURE: Surya Prakash Bhatt, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):524. doi:10.1378/chest.132.4_MeetingAbstracts.524
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PURPOSE: Alpha One Antitrypsin Deficiency (AATD) is a hereditary disorder characterized by deficiency in a serum protease inhibitor. This deficiency predisposes patients to early onset emphysema through uncontrolled proteolytic attack in the lung. There is great variability in the age of onset of clinically recognizable lung disease amongst AATD patients. Estimates of the frequency of deficiency phenotypes in the United States population predict anywhere from 40,000 to 100,000 patients should have AATD. Less than 7000 are currently diagnosed. We hypothesized that one reason for the expected/diagnosed discrepancy is the lack of testing in populations outside the ATS/ERS guidelines. Our clinic undertook a serial screening protocol of all obstructed lung disease patients, regardless of age, race or level of obstruction.

METHODS: Patients were approached for consent into the study if they demonstrated obstruction on pulmonary function testing (defined as an FEV1 of less than 80% predicted with normal volumes) or a diagnosis of an obstructive lung disease (asthma, COPD, Bronchiectasis), regardless of degree of obstruction.

RESULTS: 254 continuous consented obstructive lung disease patients were tested for AATD. Age ranged from 22 to 75. Four non-related AATD patients with PiZZ have been found to date, and 1 PiSZ has been found. 4 of the 5 patients were diagnosed over the age of 45, including one at age 62; well beyond the recommended age range of the ATS/ERS guidelines. Each patient had greater than a 20-pack year tobacco history.

CONCLUSION: AATD is a serious under-diagnosed medical condition that leads to significant morbidity and mortality. The ATS/ERS guidelines suggest testing in pre-defined settings of disease, such as early-onset emphysema and family history of early emphysema. However, our clinical experience in testing has revealed limitations in the current ATS/ERS guidelines.

CLINICAL IMPLICATIONS: Age of the patient and number of pack-years should not dictate testing for AATD. All obstructed patients should be offered AATD testing.

DISCLOSURE: Douglas Hogarth, No Product/Research Disclosure Information; Other free AATD test kits provided by Baxter

Chest. 2007;132(4_MeetingAbstracts):525. doi:10.1378/chest.132.4_MeetingAbstracts.525
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PURPOSE: To estimate the prevalence of arrhythmias and associated cardiovascular conditions in Russian patients with chronic obstructive pulmonary disease (COPD).

METHODS: 168 hospitalized men with exacerbation of COPD were included in this study. The mean age of the patients was 62.9±10.1 years. All the patients underwent physical examination. Also laboratory tests (LDL-cholesterol, whole capillary blood glucose) and instrumental investigations (electrocardiography, echocardiography, ambulatory 24-hour Holter recording) were performed.

RESULTS: Supraventricular arrhythmias was detected in 23.8% of cases (40 patients): atrial fibrillation - in 16.8% (28 patients), atrial premature complexes - in 7.1% (12 patients). Ventricular arrhythmias (ventricular premature complexes) was detected in 5.9% (10 patients). All patients with arrhythmias were cigarette smokers (mean smoking history was 39.8±8.9 pack-years). Associated cardiovascular conditions were revealed in 26 patients (65% of cases) with arrhythmias. History of myocardial infarction and angina were detected in 8 patients (20% of cases), arterial hypertension in 6 patients (15% of cases) and pulmonary hypertension in 12 patients (30% of cases) with arrhythmias.

CONCLUSION: Our study confirmed high prevalence of arrhythmias in Russian patients with COPD. Also our study confirmed high prevalence of associated cardiovascular conditions in COPD patients with arrhythmias.

CLINICAL IMPLICATIONS: Physicians should detect and treat these conditions to prevent severe complications and increase quality of life in COPD patients.

DISCLOSURE: Vasiliy Pyankov, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):526. doi:10.1378/chest.132.4_MeetingAbstracts.526
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PURPOSE: Active and passive smoking are important risk factors for the Romanian population. Both pregnant women and their babies are exposed to health problems. The objective of our study was to determine the smoking prevalence of Romanian pregnant and confined women and to identify in the same time the smoking consequences on their babies.

METHODS: In three maternity services from Bucharest an original questionnaires (with 20 questions) was distribute and a CO measurement was made.

RESULTS: 160 pregnant and confined women with age between 18–40 years old were analysed; 31.3% were smokers (over the average of the prevalence to Romanian women −28%) with an average by 5–10 cigarettes/day (for 46% of them). A lot of them were primipara, but we had also a confined at seven pregnancy, smoker, whose child had only 920g. Regarding smoking in pregnancy, 58% of them smoked in precedent pregnancy and 78% were smoking during this pregnancy. We found a value of CO >11ppm only in 0.05% of smokers, so among smokers the majority of them are occasionally smokers at the moment of our enquiry and smokes a cigarette in more than ten minute. All of them are exposed at passive smoke at office and home. The most frequent complications were bleedings (18%) and low weight at born (12%).

CONCLUSION: The study demonstrate that we have still great problem with the level of education of our pregnant women. Lack of information and the absence of cessation programmes for this sample of population maintain the high smoking prevalence at pregnant women in Romania.

CLINICAL IMPLICATIONS: The study demonstrate that we have still great problem with the level of education of our pregnant women.

DISCLOSURE: Ioana Munteanu, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):527. doi:10.1378/chest.132.4_MeetingAbstracts.527
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PURPOSE: The extent of smoking related problems on health and economy are increasingly alarming worldwide. In the last few years, a great number of subjects, specially in the developing world are smoking narghile. Epidemiologic studies on narghile are an essential heuristic contribution. The objectives of this study are to describe the social and cultural characteristics of narghile- smokers as compared to regular tobacco smokers.

METHODS: 37 579 files of men and women consulting at Hariri Foundation (22 centers all over Lebanon) between 2003 and 2005 were studied. Exclusive Narghile smokers and cigarettes smokers are compared regarding age, sex, starting age and level of education.

RESULTS: 13776 persons (36.6%) are smokers of whom 88% smoke mostly cigarettes. 1529 subjects (11.1%) are exclusive smokers of narghile with an average prevalence of 4.06%. Smokers of narghile are younger than the smokers of cigarette with an average age of 36.2 ± 8.63 and 42.52 ± 1.87 respectively. Women (56.57%) consuming Narghile are more frequent compared to men (43.43%) with a gender ratio H/F of 0.77. A great number (38.95%) of narghile smokers are recent consumers with exposure beginning since less than 5 years. They are different from the smokers of cigarettes who are in majority (72.2%) older smokers of more than 10 years. Illiterate subjects are frequently smokers of narghile than of cigarettes (36.2 % and 24.2 % respectively).

CONCLUSION: : Smoking narghile is gaining popularity specially among youngsters and women reaching the level of a plague.

CLINICAL IMPLICATIONS: Smoking narghile, an increasing phenomenon with specific smoker's profile, is becoming a public health issue to be taken into account through anti-tobacco campaigns.

DISCLOSURE: Moussa Riachy, None.

Topics: smoking , cigarettes
Chest. 2007;132(4_MeetingAbstracts):528. doi:10.1378/chest.132.4_MeetingAbstracts.528
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PURPOSE: Chronic obstructive pulmonary disease (COPD) is the fourth-leading cause of death in the United States (US). In addition to mortality, COPD exacerbations can result in substantial medical resource use. There are currently several treatments for COPD, including short-acting beta agonists, long-acting beta agonists, and inhaled corticosteroids.

METHODS: A decision-analytic model was constructed to examine the lifetime cost-effectiveness of salmeterol/fluticasone propionate (FSC), salmeterol (SAL),and fluticasone propionate (FP), salmeterol (SAL), fluticasone compared with placebo (PLA). All patients were able to take short-acting bronchodialators and anticholinergics. Disease severity, number and duration of exacerbation, and patient survival were obtained from a head-to-head, multicenter, randomized, double-blind controlled trial. Patients in the trial were adult patients between 40 and 85 years of age with an established history of COPD with a pre-bronchodilator FEV1 < 60% predicted at entry. Resource use, medical costs, and utility weights and costs were extracted from the published literature. Drug costs were taken from standard US published costing sources. Outcomes included number of exacerbations, symptom-free days, life-years, quality-adjusted life-years (QALY), and incremental cost per life-year or QALY. One-way and probabilistic sensitivity analyses were performed.

RESULTS: Compared to PLA, treatment with FSC was associated with an improvement in expected life-years (0.31) and QALY (0.20), where FP was not associated with an improvement in either. The incremental cost per QALY gained for FSC and SAL compared with PLA were $43,806/QALY and $16,732/QALY, respectively. Thus, treatment of COPD with FSC or SAL are cost-effective (assuming a $50,000/QALY threshold) compared to placebo.

CONCLUSION: FSC and SAL were found to reduce mortality and number of exacerbations and improve life-years and QALYs in patients with COPD compared to PLA or other therapies alone. Despite an increase in drug costs, treating COPD with FSC and SAL are cost-effective strategies compared with placebo.

CLINICAL IMPLICATIONS: Costs and benefits should be considered when choosing an appropriate treatment for patients with COPD.

DISCLOSURE: Christopher Blanchette, No Product/Research Disclosure Information; University grant monies NA; Grant monies (from sources other than industry) NA; Grant monies (from industry related sources) NA; Shareholder GlaxoSmithKline; Employee Employee of GlaxoSmithKline; Fiduciary position (of any organization, association, society, etc, other than ACCP NA; Consultant fee, speaker bureau, advisory committee, etc. NA; Other NA

Chest. 2007;132(4_MeetingAbstracts):529. doi:10.1378/chest.132.4_MeetingAbstracts.529
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PURPOSE: A new fixed dose combination (FDC) of Cefixime (200 mg)+Erdostein(300 mg)(C+E) has been recently developed. This study was undertaken to compare the efficacy, safety and tolerability of this formulation and FDC of Amoxycillin (500 mg)+ Bromhexine(8 mg) (A+B)in Indian patients with acute exacerbations of chronic bronchitis(AECB).

METHODS: Adult patients (216) with AECB fulfilling the selection criteria were enrolled in this prospective double blind, randomized comparative study after approval by respective Institutional review boards(4). Patients were treated with one capsule of either C+E (110) bd or A+E(106) tds, for 10 days after obtaining their informed consent. Efficacy outcome were improvements in cough, sputum characteristics, dyspnea and auscultatory findings, microbiological and radiological improvements, physicians and patients’ global assessment of efficacy. Safety and tolerability was assessed through monitoring adverse events and laboratory tests.

RESULTS: A total 207 patients completed the study with 10 drop-outs (6 in C+E and 3 in A+B). An early significant relief was observed in the clinical signs and symptoms by day 3 in C+E compared to A+B. At the end of the study there was a significant reduction in cough (C+E −90.2% vs 83.6% (A+B)). A significantly greater number of patients in C+E reported no sputum(85.6% vs. 74.7% (A+B)). Percentage of patients with improved air entry was greater in C+E (90.4%) vs A+B(75.7%) as was reduction in FEV1(C+E(79.0%) vs.73.3%(A+B)). Foreign sounds like ronchi and wheezing improved significantly. As per both physicians’ and patients’ assessments therapy was rated as excellent in a 46.2% and 49% respectively patients in C+E compared to A+B(28.2% and 33% respectively). Diarrhea was reported in a fewer 9.1% patients in the C+E compared to 14.2% in A+B. No abnormalities were reported in laboratory parameters.

CONCLUSION: Therapy with the FDC of Cefixime+ Erdosteine b.d. resulted in a faster and better symptomatic relief of AECB compared to the FDC of Amoxicillin +Bromhexine t.d.s and was also better tolerated.

CLINICAL IMPLICATIONS: FDC of C+E is a better therapeutic option compared to the FDC of A+B in patients with AECB.

DISCLOSURE: Akhilesh Sharma, No Product/Research Disclosure Information; Employee Dr Akhilesh Sharma and Dr Vidyagauri Baliga are full time employees of Glenmark Pharmaceuticals Ltd.

Chest. 2007;132(4_MeetingAbstracts):530. doi:10.1378/chest.132.4_MeetingAbstracts.530
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PURPOSE: Efficacy of antimicrobials for acute exacerbations of chronic bronchitis (AECB) episodes to prevent hospitalization and slow decline in pulmonary function in patients with chronic obstructive pulmonary disease (COPD) is controversial.Previously, a study performed at our medical center identified risk factors for antimicrobial failure and further hospitalization for AECB treatment. A similar study in COPD patients to better understand antimicrobial utilization in AECB and its impact on outcome is being described here.

METHODS: All medical records from COPD patients seen at the Pulmonary Clinic, Creighton University Medical Center were retrospectively reviewed from 2000-2006 to capture AECB episodes and antimicrobial selection. Antimicrobial failure was defined as an AECB episode that did not respond to therapy and necessitated a new antimicrobial prescription within 2 weeks.

RESULTS: A total of 1199 medical records were reviewed, of which 45 patients had 108 episodes (mean 2.5 episodes/patient; range 1–19) of AECB requiring antimicrobial with or without corticosteroid therapy. Mean + SD values for age, weight, and body mass index of patients were 60.3 + 10.2 years, 171.2 + 56.7 pounds, and 28.3 + 8.1 kg/m2. Fifty-three episodes (49%) were patients receiving home oxygen and 64% were female. Mean patient FEV1 was 1.30 L (50.1% predicted) and the FEV1/FVC 51.3%. A total of 86% and 55% of AECB episodes were in patients receiving inhaled or oral corticosteroids. Mean antimicrobial length of therapy was 8.6 + 4.0 days. Overall, 81% of all AECB episodes were successfully treated. A significant correlation was determined between antimicrobial length of therapy and increased corticosteroid requirement during AECB (p < 0.03). Antimicrobial failure rates were significantly higher (p<0.05) in AECB episodes treated with macrolides (azithromycin and clarithromycin 39%) compared to fluoroquinolones (levofloxacin and moxifloxacin 16%). AECB episodes treated with amoxicillin/clavulanate had intermediate failure rate (25%).

CONCLUSION: AECB episodes treated with fluoroquinolones were treated successfully more often than those treated with other antimicrobial categories.

CLINICAL IMPLICATIONS: AECB episodes treated with fluoroquinolones are less likely to fail and require additional therapy within 2 weeks.

DISCLOSURE: Julie Chang, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):531. doi:10.1378/chest.132.4_MeetingAbstracts.531
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PURPOSE: Formoterol is a long-acting selective β2-agonist with a rapid onset and history of safety and efficacy in the treatment of respiratory disease. Formoterol fumarate inhalation solution (FFIS) has been developed for maintenance treatment of COPD. The long-term safety of FFIS was compared to formoterol fumarate (FA) delivered by dry powder inhalation (DPI) over a 12-month period.

METHODS: This was a 52-week open-label extension study, which followed a 12-week randomized, double-blind, placebo- and active-controlled study. Subjects with moderate-to-severe COPD and no significant comorbidities received either 20 mcg nebulized FFIS or 12 mcg FA by DPI twice daily for one year. Safety evaluations included adverse event (AE) monitoring, 12-lead ECGs, clinical laboratory results, vital signs, and physical examinations.

RESULTS: 569 subjects were enrolled (mean age 64 yrs, 53% male), and over 85% completed ≥6 months treatment with >90% compliance. Approximately 74% of subjects experienced an AE, the most common of which was COPD exacerbation (16% FFIS, 18% FA). The incidence of AEs, serious AEs and discontinuations for AEs was similar between the FFIS and FA groups. ECG results were similar with no treatment-related increases in cardiac arrhythmias, heart rate, or QTc prolongation. There were no clinically important changes from baseline in laboratory tests, including serum potassium and glucose, vital signs, or physical examinations. Changes from baseline to Week 52 for glucose and potassium were +0.4 mg/dL and 0.0 mEq/L, respectively, in the FFIS group.

CONCLUSION: Twice daily nebulized formoterol was well tolerated over 12 months of treatment in subjects with moderate-to-severe COPD. Results from this open-label safety study indicate FFIS is a safe option for long-term maintenance therapy of bronchoconstriction associated with COPD.

CLINICAL IMPLICATIONS: Nebulized delivery of formoterol provides a safe treatment alternative for COPD patients who prefer or require nebulization. Twice daily nebulized formoterol provides an effective and well-tolerated long-term maintenance treatment for COPD.

DISCLOSURE: Sammy Campbell, No Product/Research Disclosure Information; Grant monies (from industry related sources) Sammy Campbell: Grant monies (non-industry): none Grant monies (industry): Astra-Zeneca, Novartis; Employee Kimberly Denis-Mize and Mike Rinehart are employees of Dey, LP, Sammy Campbell: Employee-University of Arizona (only); Consultant fee, speaker bureau, advisory committee, etc. Sammy Campbell: Consultant, speaker bureau, advisory committee: Schering, Sepracor, Pfizer, Boehringer-Ingelheim

Chest. 2007;132(4_MeetingAbstracts):532. doi:10.1378/chest.132.4_MeetingAbstracts.532
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PURPOSE: Association between severe nutritional depletion and COPD has long been recognized. In managing COPD, clinicians give emphasis on drug treatment alone, giving least or no importance on nutritional supplementation. One of the goals in treating stable COPD patients with malnutrition is to correct the malnutrition without increasing the respiratory quotient and production of CO2. This study evaluated efficacy of high vegetable fat and low carbohydrate diet in malnourished patients with stable COPD on some aspects of anthropometry and pulmonary functions.

METHODS: 54 male COPD patients with low body weight (<90% ideal body weight), attending out patient department, were randomized to the ‘control’ group (26), who received ad lib diet with concomitant drug regimen and the ‘experimental’ group (28), which received modified diet (carbohydrate 25%, protein 30% and vegetable fat 45%) with concomitant drug regimen. Measurement on anthropometry (body weight, mid arm circumference), respiratory rate and pulmonary functions (FVC, FEV1, FEV1/FVC ratio, PEFR) were taken as baseline and after 30, 60 and 90 days.

RESULTS: In the trial group, the mean percentage of predicted body weight significantly increased at the end of day-90 (90.10 + 7.05 vs. 84.40 + 5.17; P<0.001). This improvement is also significant in comparison to the findings of control group at day-90 (90.10 + 7.05 vs. 84.46 + 5.83; P<0.05). At the end of day-90, significant improvement in respiratory rate was noted in the trial group in comparison to control group (P<0.001). All measurements of pulmonary functions and mid arm circumference also showed trend of improvement.

CONCLUSION: Provision of high vegetable fat and low carbohydrate diet may cause clinical improvement in malnourished stable COPD patients. However, the intervention is time-intensive and costly. More detailed work of alternative out patient strategies of controlled supervision combined with larger sample size is indicated to delineate the full therapeutic potential of nutritional support for this clinical population.

CLINICAL IMPLICATIONS: Clinician should offer high vegetable fat and low carbohydrate diet to COPD patients for better outcomes.

DISCLOSURE: Taskina Ali, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):533. doi:10.1378/chest.132.4_MeetingAbstracts.533
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PURPOSE: Treatment adherence for chronic obstructive pulmonary disease (COPD) reduces costly outcomes including emergency department visits and hospitalizations. It is unclear whether adherence rates of initial maintenance therapy differ by various controllers.

METHODS: We used a large health plan database to identify individuals aged 40 and older with evidence of COPD through medical claims with International Classification of Disease, Ninth Revision (ICD-9) diagnosis codes between 1/1/2001 and 8/30/2003. All patients were required to have 18 months of continuous enrollment (12 months pre-index and 6 months post-index). Index date were set as the patient's first pharmacy claim for ipratropium (IPR), salmeterol (SAL), inhaled corticosteroids (ICS), fluticasone and salmeterol combination (FSC), or IPR and albuterol (IPA). Patients were not permitted to receive any COPD treatment other than oral corticosteroids, short-acting β2 agonists (SABA), or theophylline in the 12 months prior to the index date. Adherence rates were measured in both refill counts as well as annual medication possession ratios (MPR). Ordinary least squares (OLS) regression was used to compare the MPR by treatment groups while controlling for key variables.

RESULTS: In all, 9,743 patients were identified, 1,486 IPR, 842 SAL, 2,903 ICS, 2,254 FSC and 2,258 IPA. 65% of the FSC group had refills compared to 40% of SAL, 37% of ICS, 43% of IPA, and 42% of IPR. The mean refill counts (standard deviation) were 3.13 (2.90) for FSC, 2.31 (2.32) for SAL, 1.94 (1.88) for ICS, 2.56 (2.96) for IPA, and 2.57 (2.96) for IPR. MPRs were 0.26 (0.24) for FSC, 0.19 (0.19) for SAL, 0.16 (0.15) for ICS, 0.21 (0.24) for IPA, and 0.21 (0.24) for IPR. Compared to FSC, the MPR for IPR was 5% lower (p<0.001), ICS was 9% lower (p<0.0001), IPA was 5% lower (p<0.0001), and SAL was 7% lower (p<0.0001).

CONCLUSION: Patients initiating FSC had a significantly higher MPR and refill count indicating better adherence to their initial maintenance therapy than patients initiating IPR.

CLINICAL IMPLICATIONS: Adherence is an important factor in determining patient treatment options.

DISCLOSURE: Christopher Blanchette, No Product/Research Disclosure Information; University grant monies NA; Grant monies (from sources other than industry) NA; Grant monies (from industry related sources) NA; Shareholder GlaxoSmithKline; Employee Employee of GlaxoSmithKline; Fiduciary position (of any organization, association, society, etc, other than ACCP NA; Consultant fee, speaker bureau, advisory committee, etc. NA; Other NA

Chest. 2007;132(4_MeetingAbstracts):534. doi:10.1378/chest.132.4_MeetingAbstracts.534
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PURPOSE: : To evaluate an entirely outpatient-based program of pulmonary rehabilitation in patients with chronic obstructive pulmonary disease COPD, using St.George's Respiratory questionnaire (SGRQ), the 6-minutes walking test (6-MWT) and BODE index as the primary outcome measures.

METHODS: A prospective, parallel-group controlled study of an outpatient rehabilitation program in 80 patients with COPD (67 men and 13 women; mean age 64.8 +/−10.6 years; FEV1, 42.8% +/−7.6% of the predicted value. The active group (n=40) took part in a 14-week of rehabilitation program [3h/wk, 1.5h of education and exercise and 1.5h of cycling]. The control group (n=40) was reviewed routinely as medical outpatients. The following evaluations were carried out at study entry and after14 weeks: (1) pulmonary function studies ;( 2) 6-minutes walking test 6MWT; (3) quality of life; and (4) BODE index.

RESULTS: The following patients completed the study: 35patients (87.5%) from the active group (mean age, 63.7+/−11.9 years; mean FEV1, 41.9+/−2.6% of the predicted value); and 36patients (88%) from the control group(mean age, 65.9+/−10.3 years; mean FEV1,43.33+/−3.6% of the predicted value). We found no changes in pulmonary function parameters in the active group and the control one at 14weeks.While, there were significant changes within the components of the SGRQ (12.3 for the score total) for the patients of the active group but not for the patients of the control one (only 1.5 for the score total), A significant increase in the distance of the 6-MWT in the patients of the active group but not for the patients of the control one, and a decrease from 6 to 4 was noted in the score of the active group's BODE index without any change in the control group's one.

CONCLUSION: An outpatient-based of 14-week rehabilitation program significantly improved the quality of life and exercise tolerance without any change in the pulmonary function in patients with moderate COPD, and there was a decrease in the risk of death in rehabilitated patients as measured using the BODE index.

CLINICAL IMPLICATIONS: OUTPATIENT RESPIRATORY REHABILITATION.

DISCLOSURE: Barakat Shahin, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):535. doi:10.1378/chest.132.4_MeetingAbstracts.535
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PURPOSE: The present study is designed to investigate benefits of a short outpatient program of IMT on inspiratory muscle performance, exercise capacity, perception of dyspnoea and the inspiratory fraction (IF).

METHODS: Thirty patients (24 males, 6 females) with significant COPD (FEV1/FVC= 46.21+/−6.7% predicted, FEV1= 33.6+/- 8.04 % predicted) were recruited in this study and had 3 months of IMT ( 30 minutes /day for 6 days/week) in an outpatient clinic.

RESULTS: Following IMT, there was a statistically significant increase in inspiratory muscle performance (an increase of the PI,max from 59+/- 19.1 % to 79+/- 21.85% pred; p= 0.0342), a decrease in dyspnoea (from 5.8+/- 0.78 to 1.9+/- 0.57 ; p=0.0001), an increase also in the distance walked during the 6MWT(from 245+/−52.37 to 302+/−41.30 m) and finally an increase in the IF (the new prognostic factor in COPD) from 27.6+/- 9.7% to 31.4 +/- 9.8%.

CONCLUSION: The present study concludes that in patients with significant chronic obstructive pulmonary disease, inspiratory muscle training results in improvement in performance, exercise capacity, sensation of dyspnoea and moreover an improvement in the prognostic factor IF.

CLINICAL IMPLICATIONS: Static lung hyperinflation has important clinical consequences in patients with chronic obstructive pulmonary disease (COPD). That most of these patients have respiratory and peripheral muscle weakness, therefore dyspnoea and functional exercise capacity may improve as a result of inspiratory muscle training.

DISCLOSURE: Barakat Shahin, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):536. doi:10.1378/chest.132.4_MeetingAbstracts.536
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PURPOSE: Cigarette smokes contain large numbers of free radicals, superoxide anion and nitrogen oxide causing oxidative damage of body tissues and cells. A prospective interventional study was carried out to observe the effects of supplementation of antioxidant vitamins on lung functions in male smokers.

METHODS: 200 apparently healthy male smokers (age range 30 - 50 years), consuming cigarette for >11 pack years, were selected. They were divided into 4 groups of whom 3 groups were supplemented with vitamin A 10,000 IU daily, vitamin C (ascorbic acid) 500 mg daily, vitamin E (alpha-tocopherol) 200mg daily and the 4th one with combination of all three antioxidant vitamins, for consecutive 2 months. Pulmonary variables such as FVC, FEV1, FEV1/ FVC ratio and PEFR were measured at the beginning, after 2 months supplementation with antioxidants and at the end of next 6 months without any supplementation to observe the retention effects. 50 apparently healthy age matched non-smoker males were taken as control group, whose above mentioned pulmonary variables were observed for comparison.

RESULTS: The mean of percentage of predicted values of all the pulmonary variables in all the 4 experimental groups were significantly raised (p<0.001) following supplementation of either single or combined vitamins though the values did not reach the corresponding values observed in control subjects. The difference of improvement among various supplementation groups was not significant. However, combined vitamins yielded higher trend of improvement.Again all of these lung function parameters were significantly (p<0.001) decreased at the end of the 6 months of withdrawal of supplementation in comparison to their values at 2nd months of supplementation, indicating insignificant retention effect.

CONCLUSION: The results of the study reveal that lung functions are decreased in smokers and significant improvement of which may occur following 2 months supplementation of vitamins like vitamin A, vitamin C and vitamin E. However the retention effect was not satisfactory.

CLINICAL IMPLICATIONS: Clinicians may prescribe anti-oxidant supplementations for smokers to improve their lung functions.

DISCLOSURE: Kazi Bennoor, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):537. doi:10.1378/chest.132.4_MeetingAbstracts.537
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PURPOSE: The explanation for pleural effusion after cardiac surgery is unclear. The objectives of this study is to describe the patient's characteristics, pleural fluid findings, and pathologic condition in patients with large pleural effusion occurring after coronary artery bypass grafting (CABG).

METHODS: Post CABG patients who underwent therapeutic thoracocenteses and blind pleural biopsy for symptomatic pleural effusion between January 2006 and December 2006 in Chest Diseases Hospital in Kuwait were a prospectively evaluated. Chest radiographs were reviewed and information on pleural fluid findings, biopsy results was obtained.

RESULTS: During the study, 51 patients were identified; 39 men and 12 were women. All patients underwent internal mammary artery grafting. The mean left ventricular ejection fraction was 52%.All patients were dyspneic and had large (>30% of the hemithorax) effusions on chest radiograph. All effusions were persisted after 2 or more thoracocenteses. Bloody pleural effusion occurred early <3 weeks in 34 patients and nonbloody effusion occurred late > 3 weeks in 17 (p=0.01). Patients and pleural fluid characteristics are shown in table 1. Forty biopsy specimens showed pleural thickening characterized by dense fibrous tissues with associated mononuclear cell infiltration while 11 specimens showed only clotted blood. The degree of inflammation and fibrosis correlated with the interval between CABG and pleural surgery. Early post CABG patients with bloody effusions showed more inflammation with abundant lymphocytes. Late cases showed predominantly mature fibrosis (Figure). Recurrence of effusion occurred in 5/34 of patients with bloody effusion and 11/17 of patients with nonbloody effusion (p=0.002). Pleurodesis was necessary in 10 patients.

CONCLUSION: Characteristics of bloody early effusions and nonbloody effusions differ significantly, suggesting a different pathogenesis. Pleural fluid and tissue in early bloody effusion were characterized by lymphocytosis. With time, the inflammatory changes were replaced by fibrosis.

CLINICAL IMPLICATIONS: Persistent post-CABG effusion can occur and in some cases require intervention.

DISCLOSURE: Adel Ayed, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):538. doi:10.1378/chest.132.4_MeetingAbstracts.538
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PURPOSE: Sternal wound infections continue to persist, complicating cardiac surgical procedures and representing significant added hospital costs and are potentially life threatening. Sternal wounds have identical components of that of prosthetic joint replacements; metal, bone and fat. Our orthopedic colleagues have been successful at limiting prosthetic joint infections with the routine use of Pulsed Irrigation with antibiotic solution.

METHODS: Rates of sternal wound infections for this study were recorded for years 2004 consequetively through the 1st quarter of 2007. These rates are also tracked by the New York State Department of Health. The protocol change of using the Stryker InterPulse pulsed suction irrigation system with 3 liter normal saline bags containing 1 million units of Polymyxin and 100,000 units of Bacitracin began 2006. One surgeon's pre and post protocol change was compared for sternal wound infection rates, controlling for differences in surgeons technical variables.

RESULTS: The protocol change in irrigation amounted to a low volume irrigation of the sternal wound prior to closure, with a bulb syringe of 50,000 units of Bacitracin to a high volume irrigation of the wound, utilizing a battery operated hand held pulsed suction irrigator. The high volume irrigant was 3 liters of normal saline containing 1 million units of Polymyxin and 100,000 units of Bacitracin. The 2004 total cases was 259 with 13 infections for a rate of 5%. 2005 was 297 cases with 10 infections for a rate of 3.4%. In 2006, the year of the initiation of the new protocol, there were 268 cases with 5 infections for a rate of 1.9%, statistically significant. For 1st quarter 2007 62 cases with no infections.

CONCLUSION: Pulsed irrigation of the sternal wound prior to closure with high volume antibiotic irrigation containing Polymyxin and Bacitracin may be valuable in decreasing the incidence of sternal wound infections.

CLINICAL IMPLICATIONS: The routine use of pulsed irrigation of antibiotic solutions after joint replacements may be advisable for sternal wounds, given the similarities of the components including metal, bone and fat.

DISCLOSURE: Alan Hartman, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):539. doi:10.1378/chest.132.4_MeetingAbstracts.539
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PURPOSE: The clustering of several metabolic factors in a combination of high blood glucose, high blood pressure, high lipid profile and/or obesity are know to be metabolic syndrome which is a risk factor of coronary artery disease. Diabetes is a known risk factor of short- and long-term death after coronary artery bypass grafting (CABG). However, long-term results after CABG with metabolic syndrome with or without diabetes is unknown. Thus, we retrospectively investigated the survival after CABG in patients with metabolic syndrome classified by the presence or absence of diabetes.

METHODS: A total of 1183 isolated CABG was performed between 1984 and 1992, consecutively. Follow-up was completed by telephone interview or contacts with primary care physicians. Prior to surgery, 551 patients were met the criteria of metabolic syndrome, defined as 3 or more out of 5 following criteria; fasting blood glucose greeter than 100 mg/dl, body mass index greater than 25, triglycerides greater than 150 mg/dl, or blood pressure greater than 130/80 mm/Hg. The patients survival analysis was performed by Kaplan-Meier methods and compared between the patients with or without diabetes, defined fasting blood glucose greater than 126 mg/dl or a requirement of anti-diabetic treatment.

RESULTS: All patients were completed survey with a mean follow-up period of 10.5 years. Among the patients with metabolic syndrome, 372 patients were diabetic and 179 were not diabetic. 10 and 15 years survival were 66% and 42% in diabetes, respectively, 80% and 57% in non-diabetes (p<0.001). The survival rate of patients without diabetes but with metabolic syndrome was not significantly different from the patients without metabolic syndrome (10 and 15 years survival rate of 80% and 66%, respectively), p=0.28.

CONCLUSION: The long-term survival of patients with metabolic syndrome with diabetes was significantly worse than that without diabetes. However, patients with metabolic syndrome without diabetes are similar to the patients without metabolic syndrome.

CLINICAL IMPLICATIONS: Diabetes plays key role in the patients with metabolic syndrome in terms of long-term survival after CABG.

DISCLOSURE: Hitoshi Hirose, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):540. doi:10.1378/chest.132.4_MeetingAbstracts.540
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PURPOSE: We hypothesized that during acute right ventricular pressure overload (RVPO) hemodynamic perturbations and their consequences may develop in the peripheral vascular territories with weak autoregulation –namely, mesenteric bed –despite the absence of any central systemic circulatory perturbation.

METHODS: The systolic right ventricular pressure was increased in 7 dogs from 28.3±2.8 to 56.2±5.3mmHg and kept constant for 60 minutes (51.3±7.8mmHg; p<0.05) by banding the main pulmonary artery (PAB). Central systemic and mesenteric hemodynamic parameters were monitored. Blood gases, plasma ET-1 levels, H+-donating ability and free radicals were measured at 15min intervals. Mesenteric vascular reactivity was determined before and after 60min PAB.

RESULTS: At 60min PAB: although CO and MAP showed no changes, mesenteric vascular resistance was significantly increased (1.21±0.2 vs. 0.88±0.1mmHg *min/ml at baseline); in spite of stable arterial gas parameters, mesenteric oxygen extraction was also increased (40.8±4% vs. 26.2±5.6% at baseline, p<0.05); systemic arterial ET-1 levels were more elevated (2.54±0.37 pg/ml vs. 0.78±0.08 pg/ml at baseline, p<0.001) than the venous (1.95±0.08 pg/ml vs. 0.94±0.12 pg/ml, p<0.05), whereas arterial H+-donating ability was respectively reduced (24.3±1.8% vs. 47.2±2.9%, p<0.05) and mesenteric venous free radical concentration increased (49.0±0.9 vs. 41±2.1 *106 RLU, p<0.05); endothelium-dependent relaxation of the superior mesenteric artery to Ach was blunted (–51.31±11.76% vs. –95.91±10.44%, p<0.02), whereas endothelium-independent relaxation to SNP was preserved (–85.12±15.16% vs. –95.84± 17.52%).

CONCLUSION: Circulatory deficiency resulting from pulmonary ET-1 overproduction via free radical mechanisms rather than central hemodynamic impairment leads to mesenteric endothelial dysfunction after acute RVPO.

CLINICAL IMPLICATIONS: Chronic right ventricular pressure overload that occurs in several types of heart as well pulmonary diseases may compromise left ventricular function and impair peripheral perfusion through inceased release of Et-1 leading to intestinal hypoperfusion that may act as a trigger of the pro-inflammatory state in worst cases leading to acute respiratory distress syndrome, multiorgan failure, shock and death. Et-1 antagonsists adn ECE hemmers should be considered as possible postoperative therapeutic tools.

DISCLOSURE: Terezia Andrasi, None.

Chest. 2007;132(4_MeetingAbstracts):541. doi:10.1378/chest.132.4_MeetingAbstracts.541
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PURPOSE: Significant infundibular stenosis and significant tricuspid regurgitation (TR) occasionally result from severe pulmonary valve stenosis (PS) in adults, and adversely impact the morbidity and mortality if patients undergo surgery. The aim of the study was (1) to evaluate the long-term outcome of pulmonary balloon valvuloplasty (PBV) in adults (2) to evaluate the effect of successful PBV on severe infundibular stenosis and severe TR.

METHODS: PBV was performed in 90 patients (49 females, 41 males) mean age 23 ±9; (range: 15–54) years with congenital pulmonary valve stenosis. Clinical and Doppler echocardiography follow-up was performed for 4 –18 (mean 10 ± 4.9) years after PBV repeat cardiac catheterization was performed in 53 patients 1-2 years after PBV.

RESULTS: There were no immediate or late deaths. The mean catheter peak pulmonary gradient (PG) before and immediately after PBV, and at intermediate follow-up was 105 ± 3, 34 ± 26 (p <0.0001) and 17 ± 14 (p < 0.0001) mm Hg, respectively. The corresponding values for right ventricular pressure were 125 ± 38, 59 ± 21 (p <0.0001) and 42 ± 12 (p <0001) mm Hg, respectively. The infundibular gradient immediately after PBV was 31 ± 23 mm Hg and regressed at intermediate F/U to 14 ± 9 mm Hg (p < 0.0001), whilst cardiac index improved from 2.68 ± 0.73 to 3.1 ± 0.4 l/min/m2 (p < 0.05) at intermediate follow up. Doppler PG before PBV and at intermediate and long-term follow-up were 91 ± 33 mm Hg, 28 ± 12 mm Hg (p < 0.0001) and 26 ± 11 mm Hg (p = 0.2), respectively. New mild pulmonary regurgitation (PR) was noted in 24 patients. Significant TR in seven patients regressed or disappeared after PBV.

CONCLUSION: 1) Long-term results of PBV in adults are excellent. 2) Severe infundibular stenosis and severe TR regressed after successful PBV.

CLINICAL IMPLICATIONS: Hence, PBV should be considered as the treatment of choice for PS even in the presence of severe infundibular stenosis or severe TR.

DISCLOSURE: Walid Hassan, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):542. doi:10.1378/chest.132.4_MeetingAbstracts.542
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PURPOSE: It is generally believed that deployment of multiple stents during percutaneous coronary intervention (PCI) is associated with higher incidence of complications. The objective of the study was to determine the incidence of major adverse cardiac outcomes (MACE) associated with multiple stent deployment and its comparison with the deployment of single stent.

METHODS: Study cohort was formed by all patients who had percutaneous intervention done during January 2003 to August 2004 at our institution. A retrospective review of their medical records was done to obtain data regarding cardiac risk factors, medications at discharge and MACE [cumulative of death, myocardial infarction(MI) and target vessel revascularization (TVR)].

RESULTS: A total of 333 patients underwent PCI who were followed up for a mean duration of 36 ± 5 months. 208 patients (62%) received a single stent whereas the remaining 38% received two or more stents. Cardiac risk factors and medications at discharge were similar in patients with single or multiple stent deployment. 21 patients (10%) in single stent group and 7 patients (6%) in multiple stent group had MI (p value=0.15). Both groups had similar TVR and MACE over the follow up period of 3 years(Table 1).

CONCLUSION: There is no significant association between the number of stents deployed during PCI and the incidence of long term adverse cardiac outcomes.

CLINICAL IMPLICATIONS: This study provides long term outcome data on multiple stent deployment during percutaneous coronary interventions.

DISCLOSURE: Darpan Bansal, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):543. doi:10.1378/chest.132.4_MeetingAbstracts.543
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PURPOSE: To evaluate if newly detected Glucometabolic abnormalities (GA) during acute coronary syndromes (ACS) hospitalization remain unchanged after hospital discharge.

METHODS: Prospective study of 89 patients consecutively admitted for ACS, with newly recognized GA based on oral glucose tolerance test (OGTT). Patients started on antidiabetic treatment during hospitalisation were excluded. One year after hospital discharge patients were reassessed regarding anthropometric measurements, HbA1c, uric acid and OGTT.

RESULTS: In the initial evaluation, 43.8% of patients had diabetes mellitus (DM), 40.4% impaired glucose tolerance (IGT), 9.0% impaired fasting glucose (IFG) and 6.7% both prediabetic states. The second evaluation showed some changes in glucidic profile. In DM group, 69.2% improved its glucidic profile; in IGT group 44.4% improved, 25.0% worsened its glucidic profile and 30.6% remained unchanged; in IFG group 37.5% improved its glucidic profile, 37.5% changed to DM and 25% kept its glucidic profile; in IFG + IGF group 50.0% improved, 33.3% worsened and 16.7% kept its glucidic profile. Spearman correlation coefficients were used to identify factors associated with worsening of basal GA. IFG at baseline, previous coronary artery disease and uric acid were the only variables significantly correlated with glucidic profile worsening (r=0.210, p=0.048; r=0.230, p=0.030; r=0.224, p=0.039, respectively). On multivariate analysis, uric acid was the only independent predictor of progression towards a more severe glucidic profile (p=0.047).

CONCLUSION: Newly diagnosed GA are common among ACS patients without previous DM, but they frequently change after hospital discharge. In this population, uric acid was a marker of progression towards a more severe glucidic profile.

CLINICAL IMPLICATIONS: GA are an important risk factor for acute ACS. Several trials have shown the usefulness of its systematic evaluation during ACS hospitalisation. However, the evolution of each newly diagnosed glucometabolic abnormality after an ACS is still unknown.

DISCLOSURE: Natalia Antonio, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):544. doi:10.1378/chest.132.4_MeetingAbstracts.544
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PURPOSE: To identify the culprit lesion severity in STEMI patients.

METHODS: Patients who received thrombolytic therapy for STEMI in the emergency department (ER) between October 2005 and June 2006 and had clinical and electrocardiographic criteria of reperfusion (resolution of chest pain, >70% resolution of ST-segments and presence of reperfusion arrhythmias) were included in the study. Patients who subsequently underwent rescue PCI or had a history of prior PCI or CABG were excluded. Cardiac risk factors and demographic data were collected. Coronary angiography was performed at a mean of 48 hrs from presentation to ER. Quantitative coronary analysis (QCA) was performed offline. The severity of culprit lesion was assessed in two nearly orthogonal views in all patients. Patients were divided into four groups based on stenosis severity. Group1: 0–49%; Group 2: 50–69%; Group 3: 70–89% and Group 4: > 90%.

RESULTS: Study cohort was formed by 119 patients. Mean age was 63 ± 12 years and 86% were males. Forty-nine percent were active smokers, 23% were diabetics, 48% had hypercholesterolemia, 54% had hypertension and 26% had family history of coronary artery disease. Culprit vessel distribution was as follows: Left anterior descending 42% (n=49), left circumflex 13% (n=15) and right coronary artery 45% (n=55). The degree of culprit lesion stenosis varied from 35–95%, mean 80 ± 13%. The distribution of culprit lesion severity was as follows: Group 1: 3 % (n= 4); Group 2: 4% (n=5); Group 3: 56% (n=66); and Group 4: 37% (n=44).

CONCLUSION: Culprit lesion severity greater than 70% accounted for majority of STEMI. Moderately stenotic lesions account for only a small number of STEMI.

CLINICAL IMPLICATIONS: This study provides new data on the severity of culprit lesion stenosis in Acute ST elevation MI. The prevailing paradigm that rupture or erosion in non occlusive plaques is the precipitating event in the genesis of acute coronary syndromes may be too simplistic and insufficient to explain these events in a large majority of patients.

DISCLOSURE: Kunal Sarkar, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):545. doi:10.1378/chest.132.4_MeetingAbstracts.545
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PURPOSE: Antithrombin therapy with heparin is the evidence-based standard treatment in patients with NSTE ACS. UFH is to be preferred in high-risk NSTE-ACS patients with planned invasive strategy. The most vulnerable part of its application is correct dosing. The aim of this analysis was to define the risk factors which are associated with the problematic dose titration of UFH in high risk NSTE ACS patients.

METHODS: We analysed a group of 267 patients with high risk NSTE ACS managed with an early (≤;48h) invasive strategy and treated with the recommended dose of UFH (a bolus of 60–80 U/kg and an initial infusion of 12–15 U/kg per hour). The subsequent dose was adjusted after measurement of aPTT, using the nomogram. The goal for activated partial thromboplastin time was 45–70 seconds.

RESULTS: 29% of patients had a therapeutic initial aPTT value (6h after starting therapy). Half of them were overcoagulated, and 22% of patients were undertreated. By continuing therapy, the proportion of optimally treated patients increased. 40% of patients reached the therapeutic dose after 12 hours of treatment, and 58% after one day. Undertreatment is a problem in ≤;65-year old men. Women and older patients have a higher risk of overdose(fig). The patients with a therapeutic dose of UFH had the lowest occurrence of combined clinical end-point death and/or re-catheterization(5%). The highest occurrence of these events were in undertreated patients(7,2%). Overcoagulated patients had the highest rate of hemorrhage(10%). Renal function per se did not influence the anticoagulation activity of UFH. We discovered a correlation between renal function and loss of haemoglobin in patients treated with a full dose of UFH (r=0,212;p=0,019; R2–0,448)(fig).

CONCLUSION: The recommended weight adjusted first dose of UFH led to an optimal antithrombin effect in less then one third of high risk patients.

CLINICAL IMPLICATIONS: An expert consensus on more precise dose guidelines for UFH is needed. The dose of UFH can be not only weight, but also age and sex adjusted.

DISCLOSURE: Zuzana Motovska, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):546. doi:10.1378/chest.132.4_MeetingAbstracts.546
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PURPOSE: Long term safety of drug eluting stents (DES) is controversial. There is growing concern regarding late stent thrombosis, and associated myocardial infarction and mortality with DES. The objective of the study was to determine the long term outcome of DES and its comparison with bare metal stents (BMS).

METHODS: Study cohort was formed by all patients who had percutaneous intervention (PCI) done from January 2003 to August 2004 at our institution. A review of their medical records was done to obtain data regarding cardiac risk factors, medications at discharge, angiographic details and outcomes including death, target lesion revascularization (TLR), stent thrombosis and major adverse cardiac event (MACE).

RESULTS: A total of 465 interventions using stents were done in patients who were followed up for a mean duration of 36 ± 5 months. Cardiac risk factors and medications at discharge were similar in patients with DES and BMS (Table 1). There were more smokers in the group that received DES. Vessels implanted with DES had a smaller mean diameter compared to BMS (2.9 mm vs. 3.2, p=0.001) and had longer lesions (mean length 19 mm vs. 15 mm, =0.001).The long term outcome was similar between the two groups (Table 2).

CONCLUSION: Over 3 years of follow up, DES had similar rate of death, TLR, stent thrombosis, and MACE as did patients with BMS despite smaller coronary diameter and longer length.

CLINICAL IMPLICATIONS: This study provides data about the long term outcomes and safety of DES in the “real world” setting.

DISCLOSURE: Raghu Muppidi, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):547. doi:10.1378/chest.132.4_MeetingAbstracts.547
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PURPOSE: Intensivists and “closed” intensive care units have been shown to reduce expenditures (Leap Frog). However, staffing shortages and cost of training have limited the number of intensivist-managed units to less than 5% as well as closed units to fewer than 25%. Several groups reported improved outcomes on transition to closed units but to date a study of concurrently operating open and closed units overseen by the same intensivists has not been published. We undertook the study of two newly built, coexisting units—one a traditional “open” ICU (faculty and non-faculty) and a second “closed” unit. We hypothesized that the “closed,” dedicated faculty intensivist-run unit would demonstrate improved utilization.

METHODS: A retrospective review of all admissions identified 445 medical patients admitted to the “closed” ICU and 569 to the “open” ICU. Pediatric, surgical and outlier patients were excluded. The primary outcomes were intensive care unit length of stay (ICU-LOS) and adjusted length of stay (ALOS). Secondary outcomes were “rollups” of in-hospital spending. For length of stay, data was log transformed and 2-tailed t-tests were applied. Age, ethnicity, consultation rates, and APRDRG severity did not differ significantly between intensive care units.

RESULTS: Initial ICU-LOS was 3.8 days for the “closed” unit and 4.5 days for the open unit (p<0.0001). ALOS was 12.1 for “closed” and 14.3 for “open.” (p value <0.02). Average pharmacy costs were $3045 and $4372 respectively (p< 0.001). Inhalational therapy costs were $1779 and $2881 (p <0.0001). Diagnostic imaging averaged $1810 and $2241 (p<.01). Clinical laboratory costs averaged $1382 and $1833 (p<.0001). Average hospital costs were $37,126 and $40,444 (p=0.17). Overall faculty case LOS was 10.3 versus 13.9 for non-faculty (p<0.0001).Consultation rates by faculty and non-faculty physicians were significantly different.

CONCLUSION: This study validates the efficiency of faculty intensivists in closed units. The combination of dedicated intensivists, presence on a faculty service, and a closed intensive care unit appeared to confer the greatest efficiency.

CLINICAL IMPLICATIONS: The findings support the concept of closed units run by dedicated, faculty intensivists.

DISCLOSURE: Dani Hackner, No Financial Disclosure Information; No Product/Research Disclosure Information

Topics: intensivist
Chest. 2007;132(4_MeetingAbstracts):548. doi:10.1378/chest.132.4_MeetingAbstracts.548
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PURPOSE: Specific features of different populations may influence the results of prognostic indexes. Along with its Global Equation, SAPS 3 comprises seven other equations developed to consider such regional features. This study intends to evaluate the performance of these equations in the same population in a general intensive care unit in Brazil.

METHODS: We analyzed prospectively collected data from January 1st to August 31st, 2006. From the 544 admissions, we excluded 42 (7.72%) readmissions. In the 502 included patients, we analyzed the Standardized Mortality Rate (SMR), calibration through the Hosmer-Lemeshow® test, and discrimination through the under the ROC curve area (aROC). The endpoint was death or hospital discharge. Calculations were achieved through the EXCEL 2000 Microsoft Corporation and MedCalc Version 7.0.0.4 Frank Schoonjans programs. The presented Confidence Interval (CI) is 95%.

RESULTS: The calculated SMR for the different equations was: .8182 (CI .6664 –.9944) for Central/South America; 1.0051 (CI .8145 –1.2151) for Eastern Europe; 1.0385 (CI .8459 –1.2622) for Southern Europe; 1.0644 (CI .8670–1.2937) for Global; 1.1415 (CI .9297–1.3873) for North Europe; 1.1608 (CI .9454–1.4108) for Australasia; 1.1760 (CI .9578–1.4293) for North America, and 1.2590 (CI 1.0254–1.5302) for Western Europe. Discrimination was adequate for Eastern Europe (P= .4777), Global (P= .1110), North Europe (P= .0851) Southern Europe (P= .0839) Central/South America (P=.0578) and inadequate for Australasia (P=.0288) Western Europe (P= .0073) and North America (P= .0011). Discrimination was adequate for all studied equations (aROC > .8).

CONCLUSION: SAPS 3 Global, Central/South America, Eastern Europe, North Europe, and Southern Europe equations showed similar performances in the studied population.

CLINICAL IMPLICATIONS: SAPS 3 Global, Central/South America, Eastern Europe, North Europe, and Southern Europe might be applicable to the studied population.

DISCLOSURE: Carlos Alves, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):549. doi:10.1378/chest.132.4_MeetingAbstracts.549
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PURPOSE: High-fidelity patient simulation provides a unique opportunity to develop clinical skills through participation in controlled scenarios. At our institution, simulation plays an integral role in the education of senior medical students during a mandatory 4 week clerkship in critical care. As a part of the final examination, students are required to assess and manage patients with progressive circulatory shock and acute respiratory failure. Previous studies have demonstrated that evaluation of performance is aided by the use of a global score of performance and a checklist score of expected actions. The purpose of this study was to determine the correlation between a global score and a checklist score in this setting.

METHODS: One hundred consecutive senior medical students were tested on the final day of a critical care clerkship. Performance was assessed during a 15 minute patient simulation by use of a validated binary checklist of 25 expected actions including intubation, placement of a central venous catheter and use of vasoactive agents. In addition a validated global score on a scale of 1 to 10 was generated. This score was based on evaluator assessment of student confidence, ability to integrate data, and speed of decision making. A scatter plot was used to relate the two scores and a best-fit line was generated.

RESULTS: A correlation for the data revealed that the checklist and global scores were significantly related, r = + 0.65, p < 0.001, 2 tails.

CONCLUSION: There is a moderate positive relationship between checklist scoring and global scoring of student performance during simulation of a critically ill patient after completion of a clerkship incorporating simulation-based activities. These scoring instruments are complimentary. Their combined use enhances overall assessment of student performance.

CLINICAL IMPLICATIONS: Both scoring instruments should be used in the comprehensive evaluation of student performance in this educational setting.

DISCLOSURE: Rajesh Balagani, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):550. doi:10.1378/chest.132.4_MeetingAbstracts.550
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PURPOSE: Bed rest has been shown to be the most frequent transient risk factor responsible for deep venous thrombosis. Low mobility and bed rest are likely universal even during short-term hospitalization but not well-documented in terms of severity. The objective of this study was to assess if patients with short hospital stays have significant restriction of ambulation, as compared to outpatients.

METHODS: Ambulatory patients age 50–80 were recruited from inpatient and outpatient population. Inpatients were included in the study for hospitalizations under 72 hours in length. Pedometer were placed on them, which measured steps/hour and distance/hour on study participants. Patients with recent surgery or DVT, were excluded from the study. In outpatient population data was collected for 72 hours.

RESULTS: 40 outpatients and 29 inpatients were studied. Age and gender were similar in both groups. See table. Inpatient population had a significant and severe decrease in mobility as compared to out patient population (table 1). Age inversely correlated with mobility in both outpatients as well as inpatients (r = 0.6 and 0.37 respectively; p <0.05).

CONCLUSION: Our study demonstrates significant decrease in mobility in all categories in patients with even short-term hospitalizations.

CLINICAL IMPLICATIONS: This may be an important risk factor for development of venous stasis and deep venous thrombosis. Efforts must be undertaken to change the culture regarding mobility in hospitalized patients.

DISCLOSURE: Salim Surani, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):551. doi:10.1378/chest.132.4_MeetingAbstracts.551
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PURPOSE: Serum albumin (SA) is a useful marker of nutritional status. The current work was conducted to study the SA levels at presentation and early hospital stay of critically ill patients requiring mechanical ventilation and to correlate them with outcome of these patients.

METHODS: Fifty two critically ill patients (Mean age 45±19 yrs, M:F 37:15) who required at least 5 days of mechanical ventilation were included over a 6 month period. All patients surviving for less than 3 days were excluded. All management decisions including those related to nutritional support were the prerogative of the ICU team. SA estimation was done on day 1, 3,5,10 and 15. Hospital mortality was the primary outcome variable.

RESULTS: Study group consisted of patients with sepsis (n=12, 24%), chronic obstructive pulmonary disease (n=11, 22%), and severe pneumonia (n=10, 20%) among others. Hospital mortality was 40% (n=21). Mean SA levels showed consistent fall during hospital stay (mean SA on day 1, 3, 5, 10 & 15 were 3.2±0.7 gm%, 2.9±0.6 gm%, 2.9±0.6 gm%, 2.8±0.6 gm%, 2.7±0.65 gm% respectively). There was no statistically significant difference between day 1 mean SA levels for survivors and non-survivors. On the other hand, the difference between the two groups became statistically significant day 3 onwards and remained so subsequently (Figure). On comparing the outcome between the patients divided into two groups based on cutoff of SA levels of 3 gm%, it was found that outcome was not different for day 1 & 3. However, mortality for patients with SA < 3 gm% was significantly higher than those with SA > 3 gm% at day 5 (52.6% vs. 9.5%, OR, 95% CI: 10.5, 1.9–58.5, P=0.003) and remained so later.

CONCLUSION: In critically ill patients, nutritional status as estimated by SA levels, tends to deteriorate during the hospital stay. In comparison to SA levels at presentation, those done later are better predictors of mortality.

CLINICAL IMPLICATIONS: Serial estimations of SA levels may provide useful prognostic information in critically ill patients.

DISCLOSURE: Amit Banga, None.

Chest. 2007;132(4_MeetingAbstracts):552. doi:10.1378/chest.132.4_MeetingAbstracts.552
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PURPOSE: Identification of the prognostic factors associated with mortality in a immunossupressed patients (IP) admitted in medical intensive care unit (ICU).

METHODS: All IP admitted in the ICU between January 1st 2005 and December 31st 2006 were reviewed. Demographic factors, admision diagnosis (AD), immunosuppression etiology (IE), severity scores (APACHE II, SAPS II), P02/Fi02 ratio, number of organ failure at admission (NOFA), conventional mechanical ventilation, non-invasive ventilation and mortality were get in. Patients with acute coronary syndrome, patients without tumoral grown evidence in the last 5 years and those that were in the postoperatory period of tumoral resection were excluded.

RESULTS: In the study period 2042 patients were admitted, 49 of them were IP and they had the following characteristics: 30 men (61,22%) and 19 woman (38,78%), aged 62.1±15.7, APACHE II 22.65±8, SAPS II 55.65±27, P02/Fi02 176.65±82, NOFA 2.59±1.22, VM 67.3%, VNI 22.4%, mortality was 26.5% (n 13). Immunossupresion origin was 53,1% solid organ cancer, 14.2% haematology disease, 12.2% immunologic disease under immunossupresor treatment (methotrexate or cyclophosphamide), 10.2% were treated with corticosteroids, 6.1% were organ transplant recipients under immunossupresor treatment, and 4.1% were VIH. AD in ICU was: 44.9% acute respiratory failure, 26.5% septic shock, 16.3% neurological cause, 12.3% others (hemorrhagic and distributive shock). Mortality was related with the higger APACHE II (29,08 vs 20.33, p=0.001), the higger SAPS II (71,62 vs 57,08, p=0.004), higger NOFA (p=0.001). There was not relationship with sex (p=0.741), age (65.46 vs 60.89, p=0.454), P02/Fi02 (143.46 vs 188.64, p=0.1), AC (Chi2=0.879, p=0.830), immunosuppression etiology (Chi2=0.404, p=0.132), nor mechanical ventilation received (Chi2=0.4, p=0.132). Multivariant analysis related mortality with NOFA (p=0.16) and APACHE II (p=0.16). For every organ failure probability of death is increased a 270% [OR=2.7(IC95%;1.2–6.2)].

CONCLUSION: Two prognostic factors were associated with mortality in immunossupressed patients admitted in ICU, they are the number of organ failures and the higger APACHE II score.

CLINICAL IMPLICATIONS: Early ICU admission of immunosuppressed ill critical patients could improve their outcome.

DISCLOSURE: Jorge Sinclair-Avila, None.

Chest. 2007;132(4_MeetingAbstracts):553. doi:10.1378/chest.132.4_MeetingAbstracts.553
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PURPOSE: The RIFLE criteria (acronym indicating Risk of renal dysfunction; Injury to the kidney; Failure of kidney function, Loss of kidney function and End-stage kidney disease) was designed to provide a standardized method of classifying and reporting acute renal failure in the intensive care unit (ICU). No study in critically ill patients has reported the incidence of Loss of kidney function (“L”) and End-stage kidney disease (“E”) with the RIFLE classification. The aim of this study was to characterize acute kidney injury defined by the maximum RIFLE classification, including patients that meet criteria for “Loss” and “End-stage”.

METHODS: Retrospective cohort study, data including age, gender, race, urine output, baseline and worst creatinine levels; and Acute Physiology and Chronic Health Evaluation (APACHE) III scores were collected from the institutional APACHE III database.Consecutive critically ill patients >18 years of age admitted to three ICUs of two tertiary care hospitals from January 2003 to December 2006, excluding those who denied research authorization, had a history of chronic renal replacement,or were admitted for low risk monitoring only.

RESULTS: Of 11291 patients who met the inclusion criteria, 1218 (10%) patients died in the hospital. There were 54% male patients, 90% were Caucasian, mean age (±SD) was 63± 17; median APACHE III score was 53 (IQR 38–69), and median baseline serum creatinine was 1.1 (IQR 0.9–1.4). Baseline creatinine levels were available for 11316 patients. No acute kidney injury was found in 5872 patients (50%), 3381 patients (29%) were classified as Risk, 1326 (12%) as Injury, and 715 (6%) as Failure. Follow up after ICU admission showed that 102 patients (1%) met criteria for Loss, and 248 (2%) for End-stage renal disease after development of acute kidney injury in the ICU.

CONCLUSION: A significant number of patients who developed acute kidney injury in the ICU, met criteria for “Loss” and “End-stage” according to the RIFLE classification.

CLINICAL IMPLICATIONS: Substantial number of critically survivors of acute kidney injury progress to loss and end-stage renal disease according to RIFLE criteria.

DISCLOSURE: Rodrigo Cartin-Ceba, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):554. doi:10.1378/chest.132.4_MeetingAbstracts.554
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PURPOSE: Severe Sepsis (SS) is associated with acute organ dysfunction. An abnormal activation of the coagulation system may result in a thrombotic obstruction of the microvasculature, and contribute to the pathogenesis of organ failure. This procoagulant state can cause a consumption coagulopathy and the formation of microthrombi in small vessels; thereby disrupting blood flow. Even with stable systemic hemodynamics, the compromised microcirculation may contribute to regional hypoxia, and cause multiple organ failure (MOF). SS is also characterized by a concurrent inhibition of physiologic anticoagulant mechanisms. Activation of the coagulation system leads to an increased consumption of Protein-C(PC) and Antithrombin-III(AT-III), augmenting the procoagulant state.

METHODS: 50 patients hospitalized in the ICU with a diagnosis of sepsis were included. They were screened for these variables: 1-All cause mortality during hospitalization, 2-Number of organs showing acute dysfunction, 3-Intubation and Assisted-Ventilation (IAV), 4-Vasopressor-Agents (VA), 5-Serial dosage of PC and AT-III, 6-Sites of infections.

RESULTS: All cause mortality was 50% (25/50). 94% (47/50) developed SS, with an average of 4.3 dysfunctional organs per patient. IAV was required in 80% of patients (40/50), and VA in 72% (36/50). A fall in PC was observed in 85% of patients with SS (40/47), and in 88% of the ones who died (22/25). Values of PC averaged 0.71UN/l (Normal: 0.63–1.22) in patients with no organ dysfunction (n=3), and 0.42UN/l in patients with SS (n=47). A fall in AT-III was seen in 93% of patients with SS (42/45), and in 95% of the ones who died (21/22). Values of AT-III averaged 0.45UN/l (Normal: 0.78–1.34) in patients with SS (n=45). A significant decrease in platelets was documented in 53% of patients with SS (25/47).

CONCLUSION: Low levels of PC and/or AT-III may identify patients at risk of developing SS and MOF. A decrease in these natural anticoagulants may facilitate microvascular thrombosis; thus reducing blood flow to vital organs; causing hypoxia, cellular distress, and ultimately MOF.

CLINICAL IMPLICATIONS: Microcirculatory dysfunction has a key role in the pathophysiology of SS and MOF. Early identification of patients at risk of microthrombosis is essential. Thus, reliable markers are definitely needed. Presently, the only criteria of acute hematological dysfunction (e.g. for giving Drotrecogin-Alfa) is based on the platelet count. Among our patients with SS, more individuals showed a drop in PC (85%) and AT-III (93%) than a fall in platelets (53%). Decreases in PC and AT-III may also occur earlier than the reduction in the platelets, rending these natural anticoagulants useful markers in the evaluation of the septic patient.

DISCLOSURE: Jean-François Mathieu, None.

Chest. 2007;132(4_MeetingAbstracts):555. doi:10.1378/chest.132.4_MeetingAbstracts.555
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PURPOSE: Compare salivary cortisol dosage, considered to have a good correlation with serum free cortisol, with total serum cortisol in critical care patients.

METHODS: We studied 47 patients, grouped in 2 different categories: 27 with severe sepsis (SS) and 20 stable pos operative patients (PO) in their last day on intensive care unit (ICU). We include 19 normal controls for comparison. Salivary and serum cortisol were measured on admission in the septic group and in the morning before ICU discharge in the pos operative patients. All the patients and controls also had serum protein (albumin) measured. Salivary cortisol: measured with microplate enzime immunoassay (EIA) by Diagnostic Systems Laboratories® (DSL® –Webster, Texas). Serum total cortisol: measured with Immulite® chemiluminescent immunoassay by Diagnostic Product Corporation® (DPC® –Los Angeles, CA).Serum albumin: measured with Vitros® “dry chemistry” bromcresol green albumin method, by Ortho-Clinical Diagnostics® (J & J® –Rochester NY).

RESULTS: Median salivary cortisol was 14 times higher in SS patients than controls while this difference in median total plasmatic cortisol was only the double (p<0.05) (Table 1). Serum protein levels were uniformly below 2g/L in SS patients.

CONCLUSION: We conclude that salivary cortisol, a broadly available method but still not routinely used, can be a better method to assess hypothalamic-pituitary-adrenal axis in critical care patients, in which serum total cortisol is greatly influenced by low levels of protein, a common complication of these patients.

CLINICAL IMPLICATIONS: Salivary cortisol can become a good , easy and confiable test for the diagnosis of adrenal insufficiency in critical care patients. It is still necessary to determine normal salivary cortisol levels in these patients to establish this criteria.

DISCLOSURE: Eduardo Sad, None.

Chest. 2007;132(4_MeetingAbstracts):556. doi:10.1378/chest.132.4_MeetingAbstracts.556
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PURPOSE: Pulse oximetry readings are of utmost importance in Intensive Care Units but in low peripheral perfusion states the readings become unreliable. Our purpose was to compare tissue perfusion and tissue oxygen saturation at low flow states.

METHODS: We studied the effect of cuff inflation to a pressure of 20mm Hg above systolic blood pressure and sustained for 2 to 3 minutes on the trend of tissue oxygenation (StO2, Hutchinson) and perfusion index (PI).

RESULTS: In a patient with high PI, cuff inflation caused the StO2 to first increase by 5% before falling steeply to 10% below baseline StO2, at a rate faster than a patient who had a low baseline PI. On cuff deflation, the rate of increase of StO2 was faster than the rate of fall and was accompanied with an overshoot of about 5%. On the contrary, in a patient with low PI of less than 1.4 there was a very gradual return of StO2 to the baseline on cuff deflation with no overshoot noted. The trend of PI also showed a fall and rise with cuff inflation and deflation in the patient with the high PI. However the change in PI preceded the change in StO2 by about a minute and the nadir of the PI readings preceded the nadir of the StO2 readings. In the patient with the PI of less than 1.4, cuff inflation failed to produce any further fall of PI.

CONCLUSION: The perfusion index is a less sensitive estimate of tissue perfusion versus StO2. The rapidity of recovery of StO2 following temporary cuff occlusion provides a more accurate estimate of tissue hypoxia compared to a single reading of StO2.

CLINICAL IMPLICATIONS: For noninvasive estimation of tissue oxygenation in low perfusion states, StO2 is more sensitive than the perfusion index. StO2 recovery rates following arterial occlusion by cuff is a better estimate of hypoxia than the perfusion index.

DISCLOSURE: Parijat Joy, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):557. doi:10.1378/chest.132.4_MeetingAbstracts.557
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PURPOSE: Hyperbaric oxygen (HBO) has well documented as well as potentially beneficial effects with respect to managing sepsis. Well documented effects include providing an environment so neutrophils can kill bacteria though their oxygen dependent mechanisms, augmenting the effects of certain antibiotics and static/cidal effects on microorganisms especially anaerobes. Recent reports show potentially beneficial effects of HBO in mediating the effects of sepsis that are elaborated through sub-cellular mechanisms. This presentation examines these new potentially clinically beneficial roles of HBO.

METHODS: A Medline search using the key words “hyperbaric oxygen” and “sepsis” discovered 150 publications. Of these, 11 were experimental studies and 5 clinical trials. From this information, we discovered 8 different mechanisms of HBO that have potential roles in mediating the effects of sepsis and are herein reported.

RESULTS: The following mechanisms of HBO at the sub-cellular level have potential applications for mediating the effects of sepsis: 1) Protection through the interleukin-10 mechanism, 2) “Super-induction” of heme oxygenase-1 by pretreatment with HBO, 3) Inhibition of pulmonary-inducible nitric oxide (NO) synthase expression to attenuate lipopolysaccharide-induced acute lung injury, 4) Attenuation of inflammatory mediators and free radicals with repeated exposures of HBO, 5) Modification of the nuclear factor-kappa B activation in the intestinal mucosa with attenuation of sequential NO overproduction and myeloperoxidase activation, 6) Reduction of bacterial proliferation and translocation in the small intestine, 7) Preservation of RBC deformability and 8) Production of scavengers to mediate the effects of reactive oxygen species.

CONCLUSION: At this time insufficient data is available to justify the routine use of HBO in sepsis based on the subcellular mechanisms listed above.

CLINICAL IMPLICATIONS: We feel that there is a potential role for HBO in severe sepsis and septic shock when tissue oxygenation is severely impaired.

DISCLOSURE: Igor Aksenov, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):558. doi:10.1378/chest.132.4_MeetingAbstracts.558
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PURPOSE: To evaluate the impact of clinical pharmacy consults on the clinical and economic outcomes associated with severe sepsis and septic shock.

METHODS: Charleston Area Medical Center (CAMC) encourages clinical pharmacy consults to promote adherence to the recommendations for early goal-directed therapy, which is achieved through direct interaction with the nurses and physicians at the patient's bedside. Since the implementation of clinical pharmacy consults at CAMC's General Hospital (February 2006), data has been retrospectively collected during February –July 2006 in order to assess the impact of clinical pharmacy consults on mortality associated with severe sepsis and septic shock. Additional data was collected from the same six-month period in 2005 in order to assess the influence of consults on hospital length of stay (LOS) and cost associated with hospitalization for the treatment of severe sepsis and septic shock.

RESULTS: A total of 115 patients were admitted to intensive care units at the General Hospital with ICD-9 procedure codes for severe sepsis and septic shock during the study period. Clinical pharmacy services were consulted in 58 (50.4%) of these patients. The implementation of clinical pharmacy sepsis consults resulted in a 21.8% improvement in outcome when comparing mortality rates of patients with consults versus those without (40.7% without consult vs. 18.9% with consult). In addition, hospital LOS for patients with sepsis decreased by 24% (3.9 patient days) over the studied period when compared to February –July of 2005, accounting for a projected one-year cost avoidance of $600,000.

CONCLUSION: Implementation of clinical pharmacy sepsis consults has resulted in the achievement of several significant endpoints including a reduction in sepsis-associated mortality, hospital LOS, and a decrease in costs associated with hospitalization for severe sepsis and septic shock.

CLINICAL IMPLICATIONS: A clinical pharmacy consult model for sepsis promotes multidisciplinary management of a complex clinical condition. This multidisciplinary model has resulted in improved outcomes, reduced hospital costs, and an overall improvement in the management of sepsis at an institutional level.

DISCLOSURE: Audis Bethea, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):559. doi:10.1378/chest.132.4_MeetingAbstracts.559
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PURPOSE: Patients with community-acquired pneumonia (CAP) comprised 35.6% of the PROWESS study and 33.1% of the placebo arm. We investigated the use of CURB-65, the Pneumonia Severity Index (PSI) and APACHE II prediction scores to identify the CAP population from the PROWESS placebo arm at the greatest mortality risk.

METHODS: Patients were classified as having CAP if the lung was the primary infection site and the patient originated from home. The abilities of CURB-65, PSI and APACHE II scores to determine 28-day and in-hospital mortality were compared using receiver operator characteristic (ROC) curves and the associated areas under the curve.

RESULTS: PROWESS enrolled 278 CAP patients in the placebo arm. The areas under the ROC curves for PSI =5, CURB-65 ≥3, and APACHE II ≥25 for predicting 28-day (c =0.65, 0.66, 0.64, respectively) and in-hospital mortality (c =0.65, 0.65, 0.64, respectively) were not statistically different from each other. The 28-day mortality of patients with a PSI score =5, CURB-65 ≥3 and APACHE II ≥25 was 41.6%, 37.9%, and 43.5% respectively.

CONCLUSION: Despite early diagnosis and appropriate antibiotic therapy, conventionally treated CAP with PSI scores =5, CURB-65 scores ≥3, or APACHE II ≥25 has an unacceptably high mortality. In this study, PSI, CURB-65 and APACHE II scoring systems perform similarly in predicting 28-day and in-hospital mortality.

CLINICAL IMPLICATIONS: The PSI and APACHE II are cumbersome and time-consuming to perform while CURB-65 is simple and rapid and may provide more efficient risk stratification in patients with severe CAP. CTR#1678.

DISCLOSURE: Guy Richards, No Product/Research Disclosure Information; Shareholder I hold shares of stock in Eli Lilly and Company; Employee I am a full-time employee of Eli Lilly and Company

Chest. 2007;132(4_MeetingAbstracts):560. doi:10.1378/chest.132.4_MeetingAbstracts.560
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PURPOSE: Using the Surviving Sepsis Campaign(SSC)data base, this study compares characteristics, treatments and outcomes of septic shock (SS) patients diagnosed in the emergency department (ED) to patients developing SS in the intensive care unit (ICU).

METHODS: The population studied included patients admitted to the medical/surgical intensive care unit of an urban tertiary care medical center during Mar - Dec 2006. 28 SS patients diagnosed in the ED and 10 SS patients diagnosed in the ICU were included . Analysis of acute physiology and chronic health evaluation (APACHE II) scores, systemic manifestations (SSC sepsis screening tool), infection source, hemodynamics, mechanical ventilation (MV), ICU length of stay (LOS) and mortality were reviewed.

RESULTS: ICU SS patients had APACHE II scores of 30.9±5.6 compared to 21.8±7.7 for ED patients, (p = 0.01). A median of 3.3 systemic manifestations of infection were present in ED compared to 2.3 in the ICU patients. Pneumonia was the primary infection in the ICU and urinary tract infection in the ED group. ICU patients had a higher percentage of MV (100%) use during the first 24 hours of shock onset, compared to ED patients 46.4%, (p = 0.01). Inspiratory plateau pressures were higher in the ICU patient group (22±3.2) compared to the ED patient group (16±2.8), (p= 0.03). ICU mortality was 80% compared to 25% for ED patients, (p = 0.01).

CONCLUSION: Mortality was higher in ICU diagnosed SS patients as was use of MV in the first 24 hrs. MV was observed to be related to high mortality in both the ED and ICU patients. Higher APACHE II scores were related to an increase in mortality risk for the ICU patients.

CLINICAL IMPLICATIONS: The data suggest patients who developed SS in ICU are at high risk of death compared to those presenting with SS to the ED. Need for MV may be an important predictor for outcome.

DISCLOSURE: Zhen Wang, No Financial Disclosure Information; No Product/Research Disclosure Information

Topics: septic shock
Chest. 2007;132(4_MeetingAbstracts):561. doi:10.1378/chest.132.4_MeetingAbstracts.561
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PURPOSE: The prompt diagnosis of shock states leads to early, goal directed therapy and decreased morbidity and mortality. The accuracy of physical examination in differentiating shock syndromes is not well established. The aim of this study was to determine the accuracy of examination parameters in different shock syndromes.

METHODS: Retrospective review of 30 patients in shock admitted to a tertiary care intensive care unit with 10 patients in each of the major shock classes; distributive, cardiogenic, and hypovolemic. Screening of shock was performed according to following criteria: systolic blood pressure of < 90 or a drop ≥40 mmHg from baseline on two successive measurements 10 minutes apart in the absence of vasoactive medications, or a shock index (heart rate/systolic blood pressure) >1, or a lactate >3 mg/dL regardless of blood pressure. Trauma patients, patients with an age <16, or those without research authorization were excluded. Data on demographics, heart rate, blood pressure, jugular venous distention (JVD), the presence of warm or cold skin temperature, rales on lung examination, and an S3/S4 gallop were recorded.

RESULTS: Patients with hypovolemic shock were older compared to distributive or cardiogenic shock patients (p<0.02). No difference in mean arterial pressure existed between the three groups. Patients with cardiogenic shock were more likely to have JVD (80% vs. 20% vs. 0%; p<0.02), cold skin (57.1% vs. 14.3% vs. 28.5%; p<0.003), and pulmonary rales (75% vs. 16.7% vs. 8.3%; p<0.0002) compared to those with distributive and hypovolemic shock. Patients with distributive shock trended toward a higher median shock index compared to hypovolemic and cardiogenic shock patients (1.28 vs. 1.21 vs 1.02; p<0.056).

CONCLUSION: Patients in cardiogenic shock present with jugular venous distention, rales, and cool skin and patients with distributive shock may have higher shock indexes.

CLINICAL IMPLICATIONS: Accurate physical examination findings may lead to an earlier diagnosis and therapy of a shock state. Prospective studies are needed to determine the sensitivity and specificity of specific physical findings.

DISCLOSURE: Richard Patch, No Financial Disclosure Information; No Product/Research Disclosure Information

Topics: shock , syndrome , accuracy
Chest. 2007;132(4_MeetingAbstracts):562. doi:10.1378/chest.132.4_MeetingAbstracts.562
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PURPOSE: Multi-drug resistant (MDR) pathogens and limited antimicrobials in development pose a major challenge for the management of infections. Collecting aggregate susceptibility data through the ARM program allows institutions to documents trends in antimicrobial susceptibilities and compare these data with local, regional, and national rates.We performed a pilot study that hypothesized data from the ARM program would identify unique institutional trends in antibiotic resistance that would differ from national rates.

METHODS: Antibiogram/sensitivity reports from a single medical center were incorporated into the database between 2001 and 2005. Data were reviewed for resistance trends for Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Proteus mirabilis, Streptococcus pneumoniae, Stapylococcal aureus, methicillin-resistant Staphyloccal aureus (MRSA), Enterococcus faecium, and Enterococcus sp.

RESULTS: For E.coli, increasing resistance was found for ampicillin, levofloxacin, ciprofloxacin, and piperacillin. All were consistent with national averages, except ampicillin which was slightly higher. For K. pneumoniae, ciprofloxacin and levofloxacin resistance trended higher, along with most cephalosporins; however, all rates were below national averages. For P. aeruginosa, an increasing trend was identified for ceftazidime and imipenem, but both rates were lower than national averages. For P. mirabilis, increased resistance was found for ampicillin, ciprofloxacin, and imipenem. Resistance rates for ciprofloxacin were higher than national averages. For S. aureus, increased resistance was seen with erythromycin, ciprofloxacin, levofloxacin, and oxacillin. Methicillin-resistant S. aureus (MRSA) rates were higher than national averages. No trends were identified for Enterococcus sp. and S. pneumoniae. Penicillin-resistant S. pneumoniae rates are higher than national averages.

CONCLUSION: Aggregate ARM data identified resistance trends for E. coli, K. pneumoniae, P. aeruginosa, P. mirabilis, S. aureus, and MRSA that were often different from national rates.

CLINICAL IMPLICATIONS: Identifying institutional trends allows benchmarking for appropriate interventions and validates antibiotic stewardship. In addition, stable resistance rates allow institutions to justify current formularies and treatment pathways with the ability to revise based on future results.

DISCLOSURE: Shawn Anderson, No Product/Research Disclosure Information; Grant monies (from industry related sources) The ARM Program receives un-restricted educational grants from Astra-Zeneca and Roche Pharmaceuticals

Chest. 2007;132(4_MeetingAbstracts):563. doi:10.1378/chest.132.4_MeetingAbstracts.563
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PURPOSE: To review our clinical experience with intravenous recombinant activated factor VII (rFVIIa) in critically ill cancer patients with severe hemorrhage.

METHODS: Retrospective analysis of the medical records of all cancer patients who were treated with rFVIIa for severe hemorrhage and were admitted to the ICU at a tertiary care cancer center between January 2004 and December 2006. The following variables were collected: demographics, admitting service, severity of illness as measured by Mortality Probability Model II score (MPM-II) on ICU admission, use of vasopressors (VP) and mechanical ventilation (MV), source of hemorrhage, quantity of blood products transfused during the ICU stay, doses of rFVIIa administered, and ICU and hospital length of stay (LOS) and mortality.

RESULTS: Of 1390 patient admissions to the ICU during the 3-year period, 14 (1%) received rFVIIa for severe hemorrhage. The mean age was 49 years and 50% were male. Eight patients were medical cancer patients and 6 were postoperative surgical cancer patients. The mean MPM-II score was 38%. Seventy-nine percent of patients required MV and 36% received VP. The sources of hemorrhage were: multiorgan (n=3), hepatic (n=3), hemothorax (n=2), vascular (n=2), pulmonary (n=1), intracranial (n=1), gastrointestinal (n=1), and genitourinary (n=1). On average, patients received 10 units of red blood cells, 9 units of plasma, and 7 units of platelets. The average total dose of rFVIIa per patient was 36 mg and the average number of doses given was 7. Bleeding was controlled in 91% of patients. The mean ICU and hospital LOS were 15 and 32 days, respectively. The ICU mortality rate was 29% while the combined ICU and hospital mortality rate was 50%.

CONCLUSION: Recombinant factor VIIa was effective in controlling hemorrhage in a vast majority of critically ill cancer patients. However, the combined ICU and hospital mortality of these patients remained high.

CLINICAL IMPLICATIONS: The use of rFVIIa should be considered for the treatment of severe hemorrhage in cancer patients admitted to the ICU.

DISCLOSURE: Mohit Chawla, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):564. doi:10.1378/chest.132.4_MeetingAbstracts.564
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PURPOSE: Guidelines for the use stress ulcer prophylaxis in critically ill patients have been well documented, yet inappropriate use continues. The purpose of our study was to evaluate factors that contribute to the overuse of stress ulcer prophylaxis.

METHODS: A retrospective review of all intensive care unit (ICU) patients admitted over a two month time period from a single, tertiary hospital was performed. Appropriate and inappropriate use of stress ulcer prophylaxis based on evidence based institutional guidelines were documented and then compared based on admitting service specialty and level of training of person writing the order.

RESULTS: The study included 103 ICU patients (55.3% male). Average length of hospital, ICU, and ventilator days were 6.3 days, 2.9 days, and 1.3 days, respectively. Stress ulcer prophylaxis was inappropriately used in 40 patients (38.8%) and inappropriately withheld in 5 patients (4.9%) for an overall noncompliance rate of (43.7%). The average amount of time for the inappropriate use of stress ulcer prophylaxis was 4.1 days. Inappropriate use of stress ulcer prophylaxis was significantly related to specialty of admitting service (surgery 25.5% vs. medicine 50.0%, p=0.011) and level of training of person writing the order (attending 36.8% vs. resident 61.1%, p=0.037).

CONCLUSION: Noncompliance with institutional guidelines for stress ulcer prophylaxis remains a problem in ICU patients. Factors that increase the likelihood of the inappropriate use of stress ulcer prophylaxis include being admitted to a medicine service and the order being written by a resident physician.

CLINICAL IMPLICATIONS: Ongoing education remains the key to improve compliance amongst all physicians. Inappropriate use of pharmacologic agents has significant cost implications.

DISCLOSURE: Ronald Sing, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):565. doi:10.1378/chest.132.4_MeetingAbstracts.565
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PURPOSE: Inhalational lung injury (ILI) increases the incidence of acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) in burn patients. Nebulized heparin (NH) and N-acetylcysteine (NA) [(NH-NA)] have been shown to decrease morbidity and mortality in both sheep models and pediatric patients. In this study, we investigated the potential benefits of NH-NA in adult patients with ILI.

METHODS: We reviewed the records of all mechanically ventilated adult subjects admitted to our burn unit over a one-year period with a diagnosis of ILI confirmed by bronchoscopy and treated with NH-NA (NH-NA group). We calculated APACHE-III scores on admission in addition to daily Lung Injury Score (LIS) for seven days. LIS was determined by averaging the scores of chest roentgenogram, PaO2/FiO2, PEEP, and respiratory system compliance. The NH-NA group was divided into five APACHE-III subgroups and matched with ILI patients who were treated in our burn unit over a four-year period before the initiation of NH-NA protocol (Non-NH-NA).

RESULTS: Nine patients in the NH-NA group and seven in the Non-NH-AC group met our inclusion and exclusion criteria and had APACHE III score greater than 35 (mean 46.66 vs. 44.86, p=0.38). In the first two ICU days mean LIS were 0.76±0.53 vs. 1.23±0.88 (p=0.08) for NH-NA and Non-NH-NA patients respectively. Mean LIS during the first week were 0.91±0.14 vs. 1.79±0.41, (p<0.01) for NH-NA and Non-NH-NA patients respectively. In addition, 11% (1/9) of the patients in NH- NA group and 43% (3/7) patients in the Non-NH- NA group died during the first ICU week.

CONCLUSION: Nebulized heparin and N-acetylcysteine reduced lung injury scores in adult burn patients with smoke inhalation injury and high APACHE III scores during the first week of treatment.

CLINICAL IMPLICATIONS: These results support the previously reported benefits of NH-AC in patients with ALI/ARDS after ILI and highlight the need to start NH-AC therapy as early as possible after ILI. Our final report will shade light on the role of the NH-AC treatment in ILI patients with lower APACHE-III scores.

DISCLOSURE: Abel Rivero, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):566. doi:10.1378/chest.132.4_MeetingAbstracts.566
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PURPOSE: Chlorine is a chemical with widespread industrial use. Chlorine gas was used as a weapon in the first World War with devastating consequences. More recently, attempts at weaponizing chlorine have been made during attacks with vehicle borne improvised explosive devices (VBIEDs) in Iraq. We report our experience with the care of nine patients who suffered acute respiratory distress syndrome (ARDS) following chlorine gas exposure.

METHODS: On January 28th, 2007, nine patients were admitted to the intensive care unit (ICU) of Ibn Sina Hospital, a United States Army Combat Support Hospital (CSH), following exposure to chlorine gas after a VBIED attack. Data from mechanical ventilator settings and measurements, arterial blood gases, and clinical records for nine patients were reviewed and extracted.

RESULTS: All patients were adult males who arrived to our facility within approximately eight hours of the incident. Only one patient had suffered significant thoracic trauma from the blast. All patients developed ARDS by the first hospital day with a mean partial pressure of arterial oxygen (PaO2) to fraction of inspired oxygen (FiO2) ratio (P:F) of 101 and a mean oxygenation index (OI) of 28.5. Eight of nine patients were placed on airway pressure release ventilation due to refractory hypoxemia. All were treated with inhaled albuterol and fluticasone; three patients received intravenous corticosteroids during their hospitalization. Eight patients survived to discharge from the ICU while breathing without assistance. The ninth patient died following 21 days of mechanical ventilation after developing ventilator associated pneumonia. Of the survivors, the mean days requiring mechanical ventilation were 8.1 (range, 2–16). At the time of discharge from the ICU, survivors had a mean P:F of 211 (range, 152–265) and OI of 7.0 (range, 4.8–8.7).

CONCLUSION: Intense exposure to chlorine gas can result in profound hypoxemia and ARDS. With supportive care, patients may demonstrate rapid improvement.

CLINICAL IMPLICATIONS: In cases of ARDS following chlorine gas exposure, early supportive care with mechanical ventilation should be pursued. Inhaled beta-agonists and corticosteroids are treatments that deserve consideration.

DISCLOSURE: David Bell, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):567. doi:10.1378/chest.132.4_MeetingAbstracts.567
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PURPOSE: Acute life-threatening dyspnea is a common challenge that physicians encounter. Rapid diagnostic bedside tests to aid clinical impressions are needed. Ultrasonography has assisted clinicians in various critical care settings. The purpose of this study was to assess the utility of an ultrasound-based algorithm during rapid response team(RRT) evaluations of acute life-threatening dyspnea.

METHODS: The study took place over six months starting July 1, 2006 in an urban hospital with a RRT led by internal medicine residents and pulmonary/critical care fellows. During a rapid response called for dyspnea, the RRT leader assessed the patient and was asked to give a pre-ultrasound physician diagnosis. Using an ultrasound-based algorithm, non RRT pulmonary/critical care fellows trained in lung, vascular, and cardiac ultrasonography, performed a directed ultrasound examination . Ultrasonography specifically evaluated for sliding lung, B lines, consolidation pattern, pleural effusions, deep vein thrombosis, and estimation of ejection fraction. An ultrasound diagnosis was formulated from the following possibilities: acute cardiogenic pulmonary edema, Chronic Obstructive Pulmonary Disease exacerbation/Asthma exacerbation, pneumonia, Acute Respiratory Distress Syndrome/noncardiogenic pulmonary edema, and pulmonary embolus. Pre-ultrasound physician diagnoses and ultrasound diagnoses were compared to each other and to the final diagnoses.

RESULTS: The study enrolled 12 patients. Pre-ultrasound physician diagnoses were in concordance with final diagnoses in 6/12 (50%) cases. Ultrasound diagnoses were in concordance with final diagnoses in 8/12 (66%) cases. Pre-ultrasound physician diagnoses and ultrasound diagnoses agreed 4/12 (30%) of time. In 4/12 (30%) cases ultrasound would have correctly changed management, but incorrectly changed management in 2/12 (16%) cases. In 2/12 (16%) cases, pre-ultrasound physician diagnoses and ultrasound diagnoses were incorrect. Time for ultrasound diagnoses ranged from 60–270 seconds.

CONCLUSION: An ultrasound dyspnea algorithm can rapidly modify initial bedside clinical diagnosis. These changes appear to be more often correct than incorrect.

CLINICAL IMPLICATIONS: Ultrasonography may aid clinicians in quickly diagnosing and treating acute dyspnea.

DISCLOSURE: Eli Gavi, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):568. doi:10.1378/chest.132.4_MeetingAbstracts.568
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PURPOSE: Bronchoscopic bronchoalveolar lavage(B-BAL) and non-bronchoscopic BAL(NB-BAL) procedures are commonly used for diagnosing pneumonia and sepsis in critically ill myelosuppressed cancer patients. There is concern that the BAL procedure is associated with complications, in particular bleeding. Available guidelines for platelet triggers do not address safe platelet levels for BAL procedures. A platelet count of <50 K/UL has been commonly used as a trigger for platelet transfusion for invasive procedures. We studied the platelet levels and complications related to BAL procedures in our oncological intensive care unit (ICU).

METHODS: Following IRB approval, medical records of all adult ICU patients who underwent a BAL procedure between 8/1/2006 and 10/31/2006 were retrospectively studied. B-BAL was performed by physicians and NB-BAL was performed by respiratory therapist (RT) according to departmental policy using 16 Fr Kimberly Clark's protected BAL catheter. The lowest acceptable platelet count for RT performed NB-BAL was 20 K/UL.

RESULTS: A total of 115 patients (solid tumor 66%, hematological malignancies 46%) underwent BAL procedures between 8/1/2006 and 10/31/2006. B-BAL was performed in 59 (51%), NB-BAL in 42 (37%) and both B-BAL and NB-BAL in 14 (12%). The median platelet level in B-BAL group was 104 (Range 5–731) and in NB-BAL was 123 (Range 23–429). There were 24 (33%) in the B-BAL and 10 (18%) in the NB-BAL group who had platelet counts <50 K/UL. The platelet count was <30 K/UL in 15(21%)in B-BAL group and 4 (7%) in NB-BAL group. The procedure was well tolerated by all patients in the B-BAL group. There was only one complication (hypotension) reported in the NB-BAL group and this patient had a platelet count of 202 K/UL. No procedure related bleeding complications were noted in either group.

CONCLUSION: Despite thrombocytopenia, no major adverse events including bleeding was noted in this patient population.

CLINICAL IMPLICATIONS: Physician performed B-BAL and RT performed NB-BAL procedures can be safely done in critically ill cancer patients with thrombocytopenia. A structured guideline and policy is important for RT led procedures.

DISCLOSURE: Shubhra Ghosh, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):569. doi:10.1378/chest.132.4_MeetingAbstracts.569
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PURPOSE: In the intensive care setting accurate measurements of oxygenation are crucial to making therapeutic decisions. Unfortunately, invasive monitoring methods, such as central venous oxygen saturation, are prone to complications and not readily available. Although standard pulse oximetry is noninvasive and readily available, it may provide an erroneously high estimate of tissue oxygenation in peripheral vasodilated states. On the contrary, in the setting of vasopressor therapy, pulse oximetry often fails to obtain a reading secondary to vasopressor-mediated peripheral vasoconstriction. Our aim was to compare non-invasive NIRS tissue oximetry versus pulse oximetry for reliable measurements of oxygenation in septic patients.

METHODS: Patients undergoing vasopressor therapy in intensive care were monitored using both the pulse oximeter (SpO2, Agilent) and the In-Spectra NIRS tissue oximeter (StO2, Model 650, Hutchinson) device. Both of these obtained their readings from the same hand for close comparability. The pulse oximeter probe was fitted to the thumb and the tissue oxygen probe was fitted to the thenar eminence. Readings were obtained over 24 to 48 hours for each patient. Data with resolution of 1–5 minutes for SpO2 and 2 seconds for StO2 were downloaded into MS Excel for analyses.

RESULTS: At high dose vasopressor therapy the StO2 was consistent with the clinical picture of the patient whereas the SpO2 failed to pick up any signal. In one particular dying patient, the tissue oxygen monitor was able to generate readings till the moment of death and even beyond complete cessation of respiration to the point of zero tissue oxygenation.

CONCLUSION: Tissue oxygen monitoring based on the principle of Near Infrared Spectroscopy (NIRS) is a more sensitive non-invasive measure of oxygenation compared to conventional pulse oximetry.

CLINICAL IMPLICATIONS: In septic patients undergoing vasopressor therapy, continuous measurement of blood oxygenation by pulse oximetry becomes erroneous and unreliable. Tissue oxygen saturation measurement is a superior way to continuously monitor the patient's clinical status and guide therapeutic decisions.

DISCLOSURE: Parijat Joy, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):570. doi:10.1378/chest.132.4_MeetingAbstracts.570
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PURPOSE: To describe the incidence of acute renal injury (ARI) and assess risk factors for ARI for patients requiring surgical intervention for peripheral vascular disease (PVD) Intensive Care Unit (ICU) admission.

METHODS: We identified patients with PVD admitted postoperatively to a 20-bed vascular surgical ICU. We retrieved the following data from the electronic medical records: demographics, severity of illness as measured by the Acute Physiology and Chronic Health Evaluation (APACHE) III prognostic model, baseline and worst creatinine level. In patients with ARI we assessed fluid balance on the day of surgery and the duration of surgery and anesthesia. We calculated odds ratio (OR) and 95% confidence interval (CI) when appropriate. P values less than 0.05 were considered significant.

RESULTS: 125 patients were included in the study. Patients’ mean (SD) age was 67.5(15.5) years and 53(42%) were female. Sixteen patients (13%) had femoro-femoral bypass, 21 (17%) had femoro-popliteal bypass, 26 (21%) had surgical thrombectomy, and 60 patients (49%) had other peripheral vascular graft surgeries. Patients with ARI had fluid balance of 4.4 liters (3.1–6.4) on the operative day. Median (IQR) anesthesia and surgery durations were 6(5–8) and 5.5(3.6–7) hours respectively.Eleven patients (9%) developed ARI. Seven patients (64%) their creatinine raised by 1.5 to 2 times the baseline. Three (27%) had transient loss of their renal function. One (9%) developed ESRD. Higher APACHE III score was a risk for ARI. Age, gender, and baseline creatinine did not increase the risk for ARI. The APACHE III predicted mortality rate was 3.0% and the observed 28-mortality rate was 7%. Logistic regression including ARI and APACHE III predicted mortality rate showed that ARI is not independently associated with 28-day mortality, OR with 95% CI 3.37 (2.72 –28.9) (P = 0.165).

CONCLUSION: ARI is common in patients with peripheral vascular surgery admitted to the ICU. Higher APACHE III score is a risk for developing ARI. ARI does not independently increase 28-day mortality.

CLINICAL IMPLICATIONS: In ICU; ARI is a common complication of PVD surgeries.

DISCLOSURE: Salam Salman, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):571. doi:10.1378/chest.132.4_MeetingAbstracts.571
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PURPOSE: To sterilize colonized airway by multirresistent Acinetobacter baumanii (MAB) with aerosol's colimicine (AE) and to prevent mechanical ventilation associated pneumonia (MVAP).

METHODS: Inclusion criteria: patients admitted in critical care unit (ICU) with mechanical ventilation (MV), ABM isolation in bronquial secretions, and blood species culture negatives. Exclusion criteria: 1, MVAP: patients with a new infiltrate in thorax radiography and one of the following: temperature >38°C or hypothermia; leucocytes >12.000/μL or <4000/μL; and purulent bronchial secretions; 2. a new organ disfuction whose origin was septic; 3, colimicine contraindication. Drug administration: 1, Collection of take bronchial secretions and blood specimen; 2. bronchodilator administrations if they were necessaries before AC administration; 3. colimicine administration (sodium colistimetate) 1 million UI in sterile water down 5cc/8h; for patients under MV we used Evita-4 and Evita-2 (Dräger) ventilators; if the patient was breathing spontaneously through a tracheostomy we applied AC with a casserole connectted to oxygen (8lpm); 4, intravenous colimicine (IVC) doses were <60kg=50.000 UI/kg/24h, >60 kg=1-2 millions/8h; 5. we took away one bronchial specimen/week and when physician considered necessary; 8, when tracheostomy or orotracheal tube were removed, we stopped drug administration.

RESULTS: 27 patients were enrolledd. We distinguised five groups: control group (n=11) nobody received colimicine; Group 1: patients received AC and/or IVC (n=16); Group 2: patients received only AC (n=8); Group 3: patients received only IVC (n=5); and Group 4: patients received AC+IVC (n=3). We didn’t found relation between AC administration and VMAP (Chi2 0.052;p=0.678), neither with IVC (Chi2 0.374;p=0,547) or AC+IVC administration (Chi2 1,131;p=0,396). Mortality was: control group, 36.4%; group 1, 37,5% (Chi2 0.004;p=0.952), group 2, 25% (Chi2 0.277;p=0,494); group 3, 40% (Chi2 0,019;p=0,654) and group 4, 66,7% (Chi2 0,884;p=0,385). No difference with control group was detected.

CONCLUSION: Colimicine administration hasn’t influence over NAVM prevention and associated mortality in patients with airway colonization by MBA.

CLINICAL IMPLICATIONS: AC administration could decrease NAVM incidence. Larger and randomized clinical trial are necessaries to clear the role of AC in airway colonization by MBA.

DISCLOSURE: Jorge Sinclair-Avila, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):572. doi:10.1378/chest.132.4_MeetingAbstracts.572
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PURPOSE: The purpose of this study is to calculate the mechanical properties of the respiratory system noninvasively during pressure-preset ventilation (pressure-control; PCV). During a PCV breath, flow declines gradually as alveolar pressure rises. The pressure-time waveform is quite linear and contains quantitative information regarding resistance and compliance of the respiratory system. We use a novel method to calculate resistance and compliance during PCV and compare with those obtained during volume-preset ventilation (constant flow volume assist control; ACV).

METHODS: Twelve mechanically ventilated patients were enrolled. Initial application of ACV or PCV was determined by randomization. During ACV, a 0.4 second end-inspiratory pause was set and the following measured: peak pressure (Ppeak); plateau pressure (Pplat), end-expiratory pressure (PEEP or autoPEEP using the end-expiratory port occlusion technique), tidal volume (VT) and inspiratory flow rate. During PCV, inspiratory pressure, PEEP (or autoPEEP), and tidal volume were recorded and the flow versus time waveform was printed for analysis. The linear component of the pressure-time waveform was extrapolated to time and flow axes (visual best fit). Using the equation of motion for the respiratory system, assuming a non-linear resistance (resistance proportional to the square of flow), we calculated resistance and compliance. During ACV, compliance was calculated as VT/(Pplat-PEEP) and resistance as (Ppeak –Pplat)/Flow.

RESULTS: The mean compliance during PCV was 37.1 mL/cm H2O (S.D. 15.7) and during ACV was 36.9 mL/cm H2O (S.D. 12.2). The mean resistance during PCV was 15.3 cmH2O/(l/s) (S.D. 5.5) and during ACV was 12.9 cmH2O/(l/s) (S.D 3.6).Comparing ACV and PCV, a strong correlation is evident between compliance (r2 = 0.72, p-value 0.0005) and resistance (r2 = 0.51, p-value 0.0088).

CONCLUSION: During PCV the inspiratory flow waveform is linear and its slope contains information regarding resistance and compliance. These values correlate strongly to those obtained during ACV.

CLINICAL IMPLICATIONS: This demonstrates a noninvasive method of assessment of respiratory mechanics during PCV which could be used to assess patients’ respiratory function over time and in response to interventions.

DISCLOSURE: Nicole Collett, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):573. doi:10.1378/chest.132.4_MeetingAbstracts.573
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PURPOSE: The Rapid Shallow Breathing Index (RSBI), as measured by Yang and Tobin in 1991, has long been the gold standard for assessment of a patients’ readiness to be weaned from the ventilator. There is little data regarding collection via hand-held spirometer vs. collection via mechanical ventilator.

METHODS: An RSBI via each method was observed 15 minutes apart for each sample during weaning assessment. During hand-held spirometer assessment, the patient was removed from the ventilator and placed on the spirometer with a one-way valve. The first 30 seconds of spontaneous breathing were discarded, and the spirometer was reset. The practitioner then recorded the respiratory rate and minute volume for the next 60 seconds.During assessment via mechanical ventilator, the ventilator mode was changed to CPAP, and pressure support was set to 0. The first 60 seconds of spontaneous breathing were discarded. The practitioner then recorded the respiratory rate and minute volume for the next 2 minutes.

RESULTS: After performing a total of 38 observations using both methods, we analyzed the results using the paired t-test, Peason correlation coefficient, and Spearmans’ rho methodologies. There was a positive correlation between hand-held spirometer scores and ventilator scores for both Peason Correlation coefficient (.77) and Spearmans’ rho (.69). We did not observe any statistically significant differences in scores between the two groups.

CONCLUSION: RSBI results were unaffected by choice of method in this study. The high positive correlation and lack of statistically significant differences between the two collection methods illustrate the ability of current technology to measure RBSI accurately through a mechanical ventilator.

CLINICAL IMPLICATIONS: Measurement of the RSBI via mechanical ventilator may allow clinicians to address the issues of cost management, patient safety and infection control while maintaining the reliability and reproducibility of an index considered to be a clinical standard since 1991.

DISCLOSURE: Joan Cecich, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):574. doi:10.1378/chest.132.4_MeetingAbstracts.574
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PURPOSE: Little is known about the potential hemodynamic benefits of continuous ketamine sedation and analgesia in adult ICU patients.

METHODS: In a pilot multi-center, prospective, double-blind, randomized controlled trial (Supported by a grant from the American Lung Association) we screened 66 adult ICU patients who required sedation and analgesia. Patients meeting entry criteria were randomized to continuous infusion of ketamine or fentanyl for ≥24 hours to achieve a Ramsay Sedation Scale of “4”.

RESULTS: In addition to demographic data, we recorded mean blood pressure, (MBP), heart rate, requirements of any intravenous (IV) vasopressor and airway resistance. Sixty % of patients (3/5) received ketamine with low dose midazolam for 24 hours followed by midazolam only, while 40% (2/5) received fentanyl infusion. MAP was statistically significant higher in the study compare to the control group (p<.05), figure 1. Furthermore, patients who received ketamine did not required any additional vasopressors & were less likely to be diagnosed with shock state, comparing to the fentanyl group (p<.05). In addition, we measured the airway resistance for both groups prior to both sedatives infusion and every four hours thereafter. There was statistically significant decrease in the airways resistance in the study group compared to the control group with (30±2.2%, % vs. 58.3±2.8 p<.05). Furthermore there was a trend for less need for bronchodilators use in the study group vs. the control group, but that was not statistically significant (p=0.13). With the unique design of the study, there were no complications after ketamine infusion including hallucinations or nightmares.

CONCLUSION: This preliminary report illustrated the possible value of ketamine for continuous ICU sedation and analgesia with more stable or improvement in MBP, decreased need for IV vasopressors and decrease in airway resistance in the study group.

CLINICAL IMPLICATIONS: The results of our ongoing study will provide more information about the impact of ketamine in early weaning from mechanical ventilation and hence decrease in ICU length of stay.

DISCLOSURE: Elamin Elamin, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):575. doi:10.1378/chest.132.4_MeetingAbstracts.575
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PURPOSE: Respiratory insufficiency is the major cause of mortality in patients with ALS. Ventilators, although life-saving, are inconvenient and associated with significant risks and alternate therapies to prevent or manage respiratory muscle decline in ALS is needed. The motor point diaphragm pacing stimulation (DPS) system has become a standardized minimally invasive laparoscopic technique that can provide ventilation in spinal cord injured patients. We postulate that therapeutic DPS will delay respiratory failure in ALS patient.

METHODS: As part of an FDA trial, patients underwent outpatient laparoscopic diaphragm motor point mapping with electrode implantations. Stimulus/output characteristics of each electrode were determined and diaphragm conditioning initiated. ALS patients conditioned their diaphragms with 5 daily stimulation sessions of 30 minutes each . Each patient had three extensive lead-in assessments that were continued post implantation of the DPS system.

RESULTS: Sixteen patients have been safely implanted with no adverse events. Feeding tubes were safely simultaneously placed in 7 patients. In all patients, more fluoroscopically observed diaphragm excursion occured with diaphragm stimulation than under maximal voluntary effort. DPS significantly increases muscle thickness when assessed with ultrasound (p-value 0.02). After conditioning the diaphragm with the DPS, preliminary results show an average rate of decline in FVC of 1.3% per month from the pre-implantation decline of 3.1% a month, which extrapolates to an additional 15 months of ventilator free survival. Additional findings include: DPS can convert fast twitch glycolytic (IIb) to functional slow twitch oxidative muscle (I) fibers; DPS improves posterior lobe lung ventilation; DPS increases lung compliance leading to decreased work of breathing; and patients have started utilizing DPS to improve nighttime ventilation.

CONCLUSION: The DPS system can be safely implanted and utilized in ALS patients, with a documented decrease in the decline of respiratory failure leading to increased survival. A multi-center pivotal trial is now enrolling patients and collecting data.

CLINICAL IMPLICATIONS: The ability to specifically target and improve diaphragm function with the DPS system will increase therapeutic options in these patients.

DISCLOSURE: Raymond Onders, No Product/Research Disclosure Information; Shareholder Myself, my university and my hospital have intellectual property rights and founded a company that manufactures some technology used in this study

Chest. 2007;132(4_MeetingAbstracts):576. doi:10.1378/chest.132.4_MeetingAbstracts.576
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PURPOSE: Close to 20% of ICU patients require PMV (MV > 21 days). The increase in ICU survival, widespread use of NIV, and development of “weaning” units may have impacted in the number and location of these patients. We conducted this study to determine the number and location of PMV individuals in Massachusetts and compared the results with 2 surveys conducted 20 and 10 years ago.

METHODS: A web based survey, was sent to all (113) respiratory care managers practicing in the acute (ACH), long-term acute (LTACH) and home care (HCC) setting in the state.

RESULTS: The response rate was 53%. Thirty-nine (65%) from ACH, 10 (17%) from LTACH, 8 (13%) from HCC and 3 (5%) from other settings. In Massachusetts there are 18 LTACH and 12 HCC that provide home MV. Therefore, response rates in these categories are 56% and 67% respectively. We counted 982 mechanically ventilated patients, 464 (47%) met criteria for PMV. Seventy-two PMV individuals were in ACH, 171 in LTACH and 221 at home; 20 years trend is shown on Figure 1. Of the 221 patients at home, 69 % had neuromuscular disease, 23% COPD and 8% other. The ages were: <18 years (38%), 18 and 65 years (52%) and > 65 years (10%). Most patients (76%) were ventilated via tracheostomy, 14% via nasal mask and 10% via facemask. The duration of MV was < 18hs/day in 96 % of the patients. Limitations for home discharge: 1. Lack of family support, 2. Lack of reimbursement by insurers for home nursing, 3.Economical limitation.

CONCLUSION: The number of PMV patients in Massachusetts is increasing 7.4 /100.000 population (2.8 in 1983). More patients are cared at home particularly for neuromuscular diagnosis.

CLINICAL IMPLICATIONS: LTACH may have decongested our ICU's and possibly offered a more appropriate setting to train family members as healthcare givers in the home. However, placement at home remains difficult to achieve.

DISCLOSURE: Miguel Divo, No Product/Research Disclosure Information; No Financial Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):577. doi:10.1378/chest.132.4_MeetingAbstracts.577
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PURPOSE: Although life-sustaining, inappropriately administered oxygen therapy may result in untoward patient outcomes. Potential complications associated with oxygen therapy include:- Absorption atelectasis- Hypoventilation- Retrolental fibroplasia- Pulmonary Oxygen Toxicity. The purpose of this study was to assess the knowledge of oxygen therapy and delivery modalities among ICU personnel in a University Hospital setting.

METHODS: North Shore University Hospital is an academic tertiary care center in a 15 hospital system. There are 750 acute care beds and 17 bed medical intensive care unit (MICU). There are 1200 admissions per year to the MICU and the average initial APACHE 3 score for the MICU is 74.A 13-question survey was developed by the Director of Respiratory Therapy and reviewed by the Medical Director of Critical Care and the Chairman of Medicine to assess two areas of knowledge: Basic Oxygen therapy considerations and artifcial airway care. Each item was a multiple choice question with one correct reponse.The survey was administered to 73 subjects. They included 25 respiratory therapists, 30 registered nurses, and 18 medical residents.

RESULTS: Frequency and percentages were calculated for nominal data. Ranges, means, and medians were calculated for scores of oxygen therapy knowlege.

CONCLUSION: The benefit assessment of oxygen therapy or any therapeutic modality on clinical outcomes presumes that the care provider possesses the skills and knowledge to optimally utilize the equipment and simultaneously minimize the potential complications. The results of our study are disturbing as the application of oxygen therapy and airway care are fundamental to overall ICU care and error in the planning or application can lead to increased morbidity and mortality.The main limitation of this study relates to its small sample size. Inspite of this limitation, the magnitude of the difference and the consistency of the findings provide confidence that these may be truly representative of practice in this area.

CLINICAL IMPLICATIONS: There are differences in the fund of knowledge surrounding oxygen therapy among ICU personnel. These differences could have a significant impact on the quality and safety of patient care.

DISCLOSURE: Alphonso Quinones, No Financial Disclosure Information; No Product/Research Disclosure Information

Chest. 2007;132(4_MeetingAbstracts):578. doi:10.1378/chest.132.4_MeetingAbstracts.578
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PURPOSE: Current regulatory payment policy increasingly reflects the assumption that reliable costs and outcomes comparisons for mechanically ventilated patients can be made between short-term acute care (STAC) and long-term acute care (LTAC) settings. This study tested the hypothesis that STAC patients on mechanical ventilation are relatively homogeneous, as determined by discharge ventilation status and discharge destination.

METHODS: Medical records from a university-affiliated tertiary hospital were obtained for every in-patient discharged with ventilator-associated DRG numbers 475, 541, 542 and 565 in 2006 (n=301). Charts were abstracted for length of stay, discharge ventilator status, and discharge disposition, categorized as deceased, formal home health care (HHC), in-patient rehabilitation facility (IRF), skilled nursing facility (SNF), or long term acute care (LTAC) hospital.

RESULTS: The average length of stay was 24 +/- 23 days (range 1–137 days). For all patients, 29% died prior to discharge, and 53% remained on mechanical ventilation. Considerable heterogeneity by discharge destination and ventilator status was seen. Of the 215 patients (71%) that were discharged alive, 46% were discharged to an LTAC; with HHC, SNF, and IRF receiving 21%, 17% and 16% of discharges, respectively. At the time of transfer to LTAC, 21% had weaned. Conversely, patients discharged to IRF, HHC, or to a SNF with a chronic vent unit, had successfully weaned in 94%, 89% and 97% of cases, respectively. For STAC DRG 475 discharges to SNF, IRF, HHC, LTAC and death, wean rates were 100, 93, 85, 37 and 17%, respectively (p<0.0001). Similar patterns were observed when data was stratified by other vent-related DRGs.

CONCLUSION: Mechanically ventilated patients represent a clinically variable group, even within distinct vent-related DRGs. STAC ventilated patients discharged to LTAC are more likely to remain mechanically ventilated and thus more seriously ill and medically complex than those discharged to other post acute locations, where continued mechanical ventilation is rare.

CLINICAL IMPLICATIONS: Stratification by ventilator-related DRGs is inadequate for making valid cost and quality comparisons across care settings for mechanically ventilated patients.

DISCLOSURE: Sean Muldoon, No Product/Research Disclosure Information; Employee SRM is an employee of Kindred Healthcare, a provider of LTAC services. However, he did not perform chart abstracting or data analysis.

Chest. 2007;132(4_MeetingAbstracts):579. doi:10.1378/chest.132.4_MeetingAbstracts.579
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PURPOSE: Vibration response imaging (VRI) is a novel dynamic imaging technique that measures vibration energy of lung sounds. The purpose of this study is to determine if VRI is useful in tracking therapeutic response in acute heart failure patients.

METHODS: We performed VRI on 7 consecutive acute heart failure (AHF) patients on admission to emergency department (ED) and 2–11 days later prior to hospital discharge (following clinical and chest radiographic improvement). Inclusion criteria for analysis was history and risk factors plus chest radiographic diagnosis of AHF. Four to twelve expiratory cycles free of noise or artifacts were chosen and images were analyzed at maximum inspiratory vibration energy. Areas of both lungs were calculated digitally using the program Image J. In addition the average of the maximal inspiratory vibration energy from the chosen cycles, expressed as vibration units (VU) was analyzed. Statistical analysis was performed using t-test.

RESULTS: The total mean areas of both lungs were 59174 ± 6391 pixels and 73385± 5602 pixels (mean±SD) in AHF patients before and after therapy, respectively (p = 0.01). The mean vibration energy of both lungs were 6553270 ± 4861595 VU and 984069± 934172 VU (mean ±SD) in AHF patient before and after therapy, respectively (p = 0.02).

CONCLUSION: There was an increase in the areas of the VRI images and a decrease in vibration energy at maximal inspiration energy following therapy for AHF.

CLINICAL IMPLICATIONS: Because the VRI image is normalized (black referred to highest energy area and white to a pre-defined minimum), increase in size of image is by definition more homogeneous distribution of vibration. Acute pulmonary edema appears to increase lung vibration. Treatment of pulmonary edema is associated with decreased vibration and greater VRI area, the later likely related to a more even distribution of vibration. VRI may be useful in tracking therapeutic response in acute heart failure patients.

DISCLOSURE: Zhen Wang, No Financial Disclosure Information; No Product/Research Disclosure Information

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  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543