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... crucial role, as they are delegated the task of obtaining and reporting weaning parameters. It follows that accuracy is related to measurement techniques, with uniform techniques likely to produce the most reliable information. Available guidelines are general and lack explicit details. This in turn allows some latitude in these measurements.
The results of this survey confirm the wide diversity in measurement techniques of weaning parameters among respiratory therapists. The differences involve nearly every facet of measurement, and occur among therapists from different hospitals, as well as among therapists in the same hospital. There is no consensus as to which measures constitute weaning parameters. No parameter was named by all of the respondents, although four were noted in > 90 % (MIP, VT, VE, and RR) and are often considered the core group of weaning parameters. Although the Fb/VT ratio has gained support as the single most predictive measurement in weaning, (Sassoon CSH, Te TT, Mahutte CK, et al. ) it was specifically noted by < 20 %. However, the ratio is derived from RR and VT, and therefore, if not specifically reported, easily calculated.
It was also marked more often by therapists from teaching hospitals, suggesting that the Fb/VT ratio may not be embraced as widely in community hospitals as teaching institutions. Among the many variations in measurement, two areas are especially noteworthy. First, there is considerable variation in the ventilator mode used to record these variables. Most therapists (85 %) made measurements in the CPAP mode, with a minority of respondents using a T-tube. In addition, there is no uniformity in the amount of supplemental pressure present during measurement. Added pressure during measurement adds another layer of complexity to this issue.
Minimal amounts of pressure are based on the premise that the pressure eliminates the resistance of the end tracheal tube, providing a more accurate assessment of a patients status. (Sassoon CSH, Te TT, Mahutte CK, et al. ) It is unclear if this is a valid assumption. There is no consensus as to the exact pressure required to compensate for the end tracheal tube, and there may not be an attainable consensus. (Sassoon CSH, Te TT, Mahutte CK, et al. ) A patients work of breathing can be reduced with small amounts of CPAP or PS. (IBID) It follows that measurement over the range of pressures (1 to 10 cm [H. sub. 2 ] O) reported in this survey could also change a patients weaning parameters. The effect of added pressure on one parameter (Fb/VT ratio) alters its ability to predict successful exudation. The original report identified a threshold value of 105, obtained with patients breathing through a T-tube. (IBID) Other investigators have examined the ratio with patients receiving partial support (CPAP or PS) or combinations of both modes with different levels of pressure or have followed the ratio over time. (Sassoon CSH, Te TT, Mahutte CK, et al. ) They have either reported a decline in its predictive capability or a need to adjust the ratio higher when using added pressure. The time to record values represents the other major area of variation in measurement.
The responses (< 1 s to 15 min) in Table 2 outline this variation. A better appreciation of the importance of time can be gained by reviewing the MIP. Early investigations utilized 30 to 50 s of airway occlusion in this measurement. (Morganroth ML, Morganroth JL, Nett LM, et al. ) Marini and colleagues demonstrated continued increasing negative pressures that plateau after 20 s. Branson and colleagues found maximal pressures required a minimum of 12 s, and recommend 15 s of airway occlusion. It follows that the MIP should be recorded after 15 to 25 s of airway occlusion. In this survey, only 5 % reported airway occlusion for 16 to 20 s.
None responded with > 20 s. The most frequent response of 2 to 4 s is an inadequate occlusion time, and would likely underestimate this parameter. Almost 40 % report using the ventilator software package in order to improve the quality of testing by using high tech. This might minimize concerns with standardization, but these packages also underestimate the MIP. (Morganroth ML, Morganroth JL, Nett LM, et al. ) This becomes evident when examining the MIP measurement of one ventilator. In the Puritan Bennett 7200 a ventilator (Puritan Bennett; Carlsbad, CA), activation of the maneuver initiates a 10 -s time frame for measurement. (IBID) Inspiration closes the proportional solenoid valves of the ventilator and occludes the airway for 3 s. Exhalation ends the maneuver, and the maximum negative pressure generated is reported as the MIP.
The 3 -s period is much less than the recommended time frame for airway occlusion and only one breath is reported. Other software packages may have different algorithms, but it is not surprising that this package underestimates the MIP. Based on this survey, the vast majority of patients undergoing MIP measurements do not have the airway occluded for the recommended amount of time. Other areas that may lead to variations in the MIP include issues with reproducibility, maximal effort, and test-to-test variation. (Morganroth ML, Morganroth JL, Nett LM, et al. ) If decision making is based on this parameter, numerous management issues can be affected, including the timing of weaning trials, exudation, and tracheotomy.
Although there is much debate on the clinical utility of weaning parameters, it is self-evident that they must be obtained in a standardized fashion. Only then can values be considered reflective of a patient's status and confidently incorporated into clinical decision making. It is acknowledged that the role of weaning parameters has decreased over the past decade. However, one third of therapists in this survey report making measurements more than six times a week and only two respondents reported zero parameters a week. This suggests that physicians still use these measurements in patient management.
Based on responses to this survey, it is conceivable that weaning parameters obtained in the same hospital on the same day by different therapists on the same patient could be very different because of differences in measurement technique. Patients with borderline weaning parameters would be most affected by this lack of standardization, but all patients risk misclassification. This study was designed to assess the measurement of weaning parameters by the respiratory therapists of one community. Although limited in scope, it represents both private and public hospitals and is likely representative of the practice in other communities.
These results also raise questions about other practices, specifically trials of spontaneous breathing. Although this was not specifically addressed by the questionnaire, there is likely a similar degree of variation with respect to the conduct of the trials using T-tube, CPAP, or CPAP plus PS. The results of this survey reinforce the need for standardization of all techniques, as well as continued study of the parameters that may better identify a patients ability to tolerate exudation. Many old wives tales, superstitions, and just plain stupidity abound about SIDS. From chiropractors claiming stress on the atlas while transverse the birth canal to stories about suffocation from the ammonia in urine, SIDS has suffered from the ignorant (NCHS, 1988) Articles and reports about SIDS often appear in the news media.
Periodically such reports imply that the cause has been discovered. It is important to restate that SIDS continues to be an unsolved problem. Even with current scientific knowledge, SIDS victims cannot be identified beforehand (NCHS, 1988). The National Center for Health Statistics recommended that in 1992 that infants be placed on their back, as studies have shown this has reduced the rate of SIDS in some areas. Death from aspiration of vomit is much rarer than SIDS. Not all doctors are convinced, and babies have died of SIDS while sleeping on their side or back.
While the infant is awake and observed, some tummy time is necessary for developmental reasons. Side sleeping is less risky than stomach sleeping, and there are several devices to help you keep your infant propped up, but as soon as they start squirming a lot you probably cannot use them (NCHS, 1992). Constant worrying about the possibility of SIDS and constant checking on the baby will not safeguard a child from SIDS. It will only serve to exhaust the parents and to increase their worries. The first few months and beyond is a time best spent by enjoying, loving, and watching your child grow and develop. Recognize the fact that you are not alone in your concern for your child.
Remember that SIDS is not a common occurrence of every 1000 babies born, 998 infants will NOT become SIDS victims (NCHS, 1992). Any sudden, unexpected death threatens ones safety and security. We are forced to confront our own mortality (Corr, 1991). This is particularly true in a sudden infant death. Quite simply, babies are not supposed to die.
Because the death of an infant is a disruption of the natural order, it is traumatic for parents, family, and friends. The lack of a discernible cause, the suddenness of the tragedy, and the involvement of the legal system make a SIDS death especially difficult, leaving a great sense of loss and a need for understanding (Corr, et al. , 1990). Bibliography: Corr, C. A. , Fuller, H. , Barnickol, C. A. , and Corr, D. M. (Eds).
Sudden Infant Death Syndrome: Who Can Help and How. New York: Springer Publishing Co. , 1991 Goto, P. G. and Becker man, R. C. Sudden Infant Death Syndrome.
Current Problems in Pediatrics 20 (6): 299 - 346, June 1990. Hoffman HJ, Hillman LS. Epidemiology of the sudden infant death syndrome: maternal, neonatal, and post neonatal risk factors. Clin Perinatol 1992: 19: 717 - 37.
National Center for Health Statistics. Advanced Mortality Statistics for 1989. Monthly Vital Statistics Report, Vo; . 40, No. 8, Supp. 2 January 7, 1992, p. 44 National Center for Health Statistics. Advanced Report of Final Mortality Statistics, 1988.
Monthly Vital Statistics Report, Vol. 39, No. 7, Supp. 1990, p. 33 Willing, M. , James, L. S. and Catz, C. Defining the Sudden Infant Death Syndrome: Deliberations of an Expert Panel Convened by the National Institute of Child. Manthous CA, Schmidt GA, Hall JB. Liberation from mechanical ventilation.
Chest 1998; 114: 886 - 901 Yang KL, Tobin MJ. A prospective study of indexes predicting the outcome of trials of weaning from mechanical ventilation. N Engl J Med 1991; 324: 1445 - 1450 Morganroth ML, Morganroth JL, Nett LM, et al. Criteria for weaning from prolonged mechanical ventilation. Arch Intern Med 1984; 144: 1012 - 1016 Sassoon CSH, Te TT, Mahutte CK, et al. Airway occlusion pressure: an important indicator for successful weaning in patients with chronic obstructive pulmonary disease.
Am Rev Respir Dis 1987; 135: 107 - 113.
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Research essay sample on Sudden Infant Death Syndrome Vital Statistics
