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David J Pierson

Publications and source records attributed to David J Pierson.

14 recordsLinked to original sources
PubMed2006

Clinical practice guidelines for chronic obstructive pulmonary disease: a review and comparison of current resources.

The first clinical practice guidelines (CPGs) for the assessment and management of patients with chronic obstructive pulmonary disease (COPD) were published 30 years ago. These and subsequent CPGs issued by professional societies and other groups prior to 2000 were consensus recommendations based on expert opinion and available studies, and they have been criticized for being inconsistent and not explicitly evidence-based. The Global Initiative for Chronic Obstructive Lung Disease (GOLD), a joint project of the National Heart, Lung, and Blood Institute and the World Health Organization, released the first of a new generation of rigorous, evidence-based COPD guidelines in 2001. Since that time several other CPGs, notably those developed jointly by the American Thoracic Society (ATS) and the European Respiratory Society (ERS), and by the British National Collaborating Center for Chronic Conditions and Institute for Clinical Excellence, have also become available. While previous COPD guidelines had different severity-grading systems and differed in their therapy recommendations, the new CPGs are remarkably consistent and have very few areas of clinically relevant discrepancy. All are available free via the Internet, provide for regular revision and updating, and include materials for patients and the public, as well as for health-care providers. Although the GOLD and ATS-ERS guidelines both have international authorship and are intended for worldwide use, implementation of many of their recommendations (such as the requirement for spirometry in diagnosis and staging, an escalating management scheme that includes expensive inhaled medications and pulmonary rehabilitation, and consideration for lung-volume reduction surgery) remains beyond the reach of many patients and health care systems.

Evidence-Based Medicine↗
PubMed2006

Respiratory considerations in the patient with renal failure.

Lung and kidney function are intimately related in both health and disease. Respiratory changes help to mitigate the systemic effects of renal acid-base disturbances, and the reverse is also true, although renal compensation occurs more slowly than its respiratory counterpart. A large number of diseases affect both the lungs and the kidneys, presenting most often with alveolar hemorrhage and glomerulonephritis. Most of these conditions are uncommon or rare, although three of them--Wegener's granulomatosis, systemic lupus erythematosus, and Goodpasture's syndrome--are not infrequently encountered by respiratory care clinicians. Respiratory complications of chronic renal failure include pulmonary edema, fibrinous pleuritis, pulmonary calcification, and a predisposition to tuberculosis. Urinothorax is a rare entity associated with obstructive uropathy. Sleep disturbances are extremely common in patients with end-stage renal disease, with sleep apnea occurring in 60% or more of such patients. The management of patients with acute renal failure is frequently complicated by pulmonary edema and the effects of both fluid overload and metabolic acidosis. These processes affect the management of mechanical ventilation in such patients and may interfere with weaning. Successful lung-protective ventilation in patients with acute lung injury and renal failure may require modification of hemodialysis in order to combat severe acidemia. Hemodialysis-related hypoxemia, which was once believed to be the result of pulmonary leukostasis and complement activation, is explained by diffusion of CO2 into the dialysate, with concomitant alveolar hypoventilation in the process of maintaining a normal P(aCO2). Like acute lung injury, renal failure is a common complication of critical illness. An increasing body of evidence also supports the notion that the kidneys, like the lungs, are susceptible to injury induced as a result of positive-pressure mechanical ventilation.

Anemia↗
PubMed2005

Tracheostomy and weaning.

No hypothesis relating to respiratory care in the intensive care unit has proved more difficult to study in an objective fashion than the commonly held belief that tracheostomy hastens weaning from ventilatory support. Tracheostomy might facilitate weaning by reducing dead space and decreasing airway resistance, by improving secretion clearance, by reducing the need for sedation, and by decreasing the risk of aspiration. Available evidence indicates that dead space and airway resistance are in fact reduced, although whether the magnitude of these reductions explains the clinical observation of more rapid weaning after tracheotomy is less certain. Most of the data on this subject come from laboratory experiments and short-term physiologic studies on clinically stable patients, and the available evidence from clinical trials with weaning as a primary end point is scant. One large multicenter trial showed no advantage to early tracheotomy but demonstrated how difficult it is to get clinicians to manage their patients with regimens that go against their strongly held opinions. The most recent clinical trial found that percutaneous dilational tracheotomy performed in the first 2 days in patients projected to need > 14 days of ventilatory support greatly reduced ventilator and intensive care unit days, and decreased both the incidence of pneumonia and overall mortality, in comparison with tracheostomy done after day 14. Conducting such trials is difficult because of investigator and clinician bias, the inability to predict which patients will actually require prolonged mechanical ventilation, and several other factors discussed in this article. Tracheotomy probably does aid in liberating some patients from ventilatory support, but this may be as much from its effect on clinician behavior as from any physiologic impact.

Humans↗
PubMed2004

Changing pattern of ventilator settings in patients without acute lung injury: changes over 11 years in a single institution.

STUDY OBJECTIVES: To determine whether the widely accepted concept of using lower tidal volume (Vt) values in patients with ARDS or obstructive lung disease has affected the pattern of ventilator settings in mechanically ventilated patients who do not have one of these conditions. DESIGN AND PATIENTS: We performed a retrospective chart review of all patients who had experienced out-of-hospital cardiac arrest and had received ventilatory support for > or = 1 day at a university-affiliated county hospital during the years 1990, 1991, 1992, 1995, 1998, 1999, and 2000. RESULTS: In 139 such patients, the mean final Vt values used on the first day of mechanical ventilation were 11.7, 12.4, 11.3, 9.6, 9.7, 9.2, and 9.8 mL/kg in those years, respectively. Multivariate analysis revealed that increasing year (beta-coefficient = -0.24; p = 0.001) and the presence of pulmonary edema (beta-coefficient = -1.2; p = 0.001) were independent predictors of the use of lower Vt values. Patients managed with a low Vt (ie, < 10 mL/kg; mean [+/- SD] Vt, 8.4 +/- 1.3 mL/kg) had a significantly higher incidence of atelectasis than the patients who were managed with traditional, larger Vt values (ie, > or = 10 mL/kg; mean Vt, 11.8 +/- 1.5 mL/kg) [61.1% vs 36.7%, respectively; p = 0.02]. Multivariate analysis revealed that the mean Vt used on days 1, 2, and 3 (<10 mL/kg or > or = 10 mL/kg) was the only predictor of the development of atelectasis during the first 3 days of mechanical ventilation (odds ratio, 0.33; p = 0.015). There was no difference in the incidence of pneumonia, the number of days spent receiving mechanical ventilation, Pao(2)/fraction of inspired oxygen ratio, or respiratory system compliance between the low Vt group and the traditional Vt group. CONCLUSION: Currently, physicians at our hospital use lower Vt values than they have in the past. This is associated with the increase in the incidence of atelectasis in the patients who received ventilation using low Vt values.

Aged↗
PubMed2004

Translating new understanding into better care for the patient with chronic obstructive pulmonary disease.

Despite an enormous amount of research and many official statements, the definition, diagnosis, and staging of chronic obstructive pulmonary disease (COPD) remain inconsistent, and we have yet to agree on who should be tested with spirometry or on where and how to do it. We know that inflammation, not just airflow limitation, is important in determining the course of COPD, especially with respect to exacerbations. We can detect and treat alpha-1 antitrypsin deficiency, an under-recognized condition, but whether alpha-1 antitrypsin augmentation therapy affects the disease's clinical course remains unclear. Smoking cessation is the most important of all interventions for COPD, with proven techniques and adjuncts, but implementation remains difficult and success rates are disappointingly low. Similarly, pulmonary rehabilitation has well-documented benefits but is grossly underutilized because it is difficult to pay for and is not made available to most patients. Symptoms, costs, and other outcomes can be improved through comprehensive disease management, including the use of practice guidelines, yet multiple barriers prevent the potential benefits of these interventions to patients from being realized. Many patients who do not meet threshold oxygenation criteria for oxygen therapy during the daytime desaturate during sleep, but evidence that nocturnal oxygen administration benefits these patients is lacking. However, other sleep-related breathing disorders are common in COPD patients. Lung volume reduction surgery has recently been shown to improve function and survival for certain COPD patients, but lung transplantation has generally been disappointing. New pharmaceutical agents are being developed for treating COPD, and at least one of them (tiotropium) should soon be available in the United States. Noninvasive ventilation is effective in treating acute decompensations of COPD and should be the standard of care in that setting; evidence supporting its use in stable patients with end-stage disease is scant. Appropriate palliative care can greatly benefit patients and their families in the terminal phase of COPD and needs to be more widely applied.

Comorbidity↗
PubMed2004

Acute inhalation injury with evidence of diffuse bronchiolitis following chlorine gas exposure at a swimming pool.

A previously healthy 23-year-old man with nonproductive cough and sore throat presented to the hospital a few hours after chlorine gas exposure at a fitness center swimming pool. Initial physical examination and chest radiograph were normal. Thirty-six hours later he developed worsening dyspnea and cough, with development of blood-tinged sputum. Arterial blood gas analysis showed mild hypoxemia and a subsequent chest radiograph demonstrated diffuse tiny nodular opacities. Findings on a thin-section computed tomogram of the chest were consistent with diffuse bronchiolitis. Pulmonary function tests showed a mild obstructive abnormality and he demonstrated substantial bronchodilator response. The patient was treated with oral corticosteroids and an inhaled beta(2) agonist, to which he responded well, with full clinical recovery occurring over 5 months. This manifestation of chlorine gas exposure at a swimming pool is unusual.

Acute Disease↗
PubMed2004

Case reports in respiratory care.

The information in a case report should be viewed cautiously in terms of generalization beyond the reported example. Appropriately written and interpreted, however, a case report can be a valuable contribution to medical knowledge and educational for both author and reader. This article discusses the essential components of a case report, important issues of patient confidentiality, and how authorship should be determined. It then describes 10 common pitfalls in case report writing. These are inexperience, insufficient documentation of the case, insufficient awareness of practice beyond one's own clinical setting, describing substandard care, illogical or unphysiologic intervention, poor focus of presentation and discussion, inappropriate manuscript format, poor writing, ineffective illustrations, and poor use of references. The article then presents 10 specific ways to avoid or deal with these pitfalls, with the aim of increasing the likelihood that a prospective author's manuscript will be accepted for publication. These ways include seeking appropriate assistance with writing, documenting the case as thoroughly as possible, and carefully justifying any new technique or intervention. Authors are urged to expend the time and effort required to prepare the manuscript properly, using the journal's guidelines and paying special attention to illustrations and references, and also to have the manuscript read by a local colleague before formal submission. After submission, authors should view the receipt of reviewers' comments and subsequent manuscript revision as necessary and positive steps toward successful publication.

Authorship↗
PubMed2004

How to write an abstract that will be accepted for presentation at a national meeting.

Preparation, submission, and presentation of an abstract are important facets of the research process, which benefit the investigator/author in several ways. Writing an abstract consists primarily of answering the questions, "Why did you start?" "What did you do?" "What did you find?" and "What does it mean?" A few practical steps in preparing to write the abstract can facilitate the process. This article discusses those steps and offers suggestions for writing each of an abstract's components (title, author list, introduction, methods, results, and conclusions); considers the advantages and disadvantages of incorporating a table or figure into the abstract; offers several general writing tips; and provides annotated examples of well-prepared abstracts: one from an original study, one from a method/device evaluation, and one from a case report.

Abstracting and Indexing↗
PubMed2004

The top 10 reasons why manuscripts are not accepted for publication.

This article discusses why many research projects that have been presented in abstract form are never published as full articles, and lists 10 reasons why manuscripts are not accepted for publication in Respiratory Care. Some of these reasons are easily avoidable or readily overcome. Included in this category is submission of manuscripts that do not correspond to the kinds of articles the Journal publishes, either in subject matter or in format. Poor writing impedes peer review and is unlikely to prejudice editors in an author's favor, although it is seldom the primary reason for rejection. Common deficiencies in the methods, results, and discussion sections prevent initial acceptance for publication but are at least potentially amenable to correction. More serious are fundamental defects in study design, which although correctable at the inception of a project, often doom the paper once the study has been completed. Two problems that are especially unfortunate for authors and potential readers alike are failing to revise and resubmit a manuscript after initial peer review and never preparing a full manuscript in the first place, after presentation of the work in abstract form. This special issue of Respiratory Care and other cited publications offer practical resources for authors to use in overcoming each of these problems.

Biomedical Research↗
PubMed2003

Practice variation in respiratory therapy documentation during mechanical ventilation.

STUDY OBJECTIVES: Implementation of new ventilatory strategies such as lung-protective ventilation for ARDS will require a multidisciplinary approach with considerable physician and respiratory therapy (RT) interaction. One of the key factors in this communication is complete and accurate RT documentation of ventilator settings. Few studies have explored the quality and variability of this documentation. DESIGN: Population-based cross-sectional study. SETTING: Seventeen adult hospitals in King County, WA. PARTICIPANTS/INTERVENTIONS: We compared the blank RT ICU flow sheet for each institution to the 1992 American Association for Respiratory Care (AARC) clinical practice guidelines (CPGs) for patient-ventilator system checks. We interviewed RT managers at each hospital about their practices. Finally, we reviewed selected charts of patients with acute lung injury (ALI) or ARDS from each hospital to evaluate the documentation. MEASUREMENTS/RESULTS: We found substantial variability in RT documentation practices and in their extent of compliance with the AARC CPGs. Only 15 of 52 items recommended by the AARC CPGs were included on blank RT flow sheets of every hospital in our study, and only 26 of 52 items were found on charts of ALI/ARDS patients at most hospitals (ie, > or =10 of 17 hospitals). Only 10 of 17 RT department managers reported using the AARC CPGs as a basis for their documentation policies. Items necessary for the implementation of lung-protective ventilation for ALI/ARDS patients were recorded inconsistently and were not included in the AARC CPGs. Plateau pressure was found on all reviewed charts of ALI/ARDS patients at only 10 of 17 hospitals. CONCLUSIONS: Considerable variability exists in RT documentation practices. We suggest that new guidelines be developed for documenting the care of patients receiving mechanical ventilation, in light of recent data on ventilator weaning and the management of ALI/ARDS, and that their effect on practice and outcomes be evaluated.

Cross-Sectional Studies↗
PubMed2002

Indications for mechanical ventilation in adults with acute respiratory failure.

Increased understanding of the mechanisms and effects of acute respiratory failure has not been accompanied by more precise criteria by which the clinician can determine when intubation should be carried out and invasive positive-pressure ventilation (IPPV) instituted in a given patient. The indications traditionally offered in reviews and textbooks have tended to be either so broad as not to be very helpful in an individual case, or of questionable clinical relevance and too cumbersome for practical use. This review updates the indications for IPPV in adult patients with acute respiratory failure by examining available evidence from clinical trials and by considering new management alternatives that have become available in the last 20 years. Indications for IPPV based on specific threshold values for P(CO2) and pH or on various indices of arterial oxygenation have generally not been validated by clinical evidence, and it is unlikely that any cutoff value would be applicable to all patients or all categories of acute respiratory failure. Stated another way, there is probably no single value for arterial P(CO2), pH, or P(O2) that by itself constitutes an indication for IPPV. Compelling face validity justifies the use of IPPV in cases of apnea or when it appears certain that respiratory arrest is about to occur. However, dyspnea, tachypnea, or the subjective impression of respiratory distress are probably not in themselves justification for emergency intubation. It should be possible to avoid IPPV and its attendant complications in many cases of acute hypercapnic respiratory failure. In acute exacerbations of chronic obstructive pulmonary disease, noninvasive positive-pressure ventilation (NPPV) should be the initial ventilation approach unless the patient has one of several specific exclusion criteria such as cardiovascular instability or severely impaired mental status. It may also be possible to avoid intubation through the use of NPPV in certain immunocompromised patients with early acute hypoxemic respiratory failure. However, in other settings of acute hypoxemic respiratory failure, such as acute lung injury and acute respiratory distress syndrome, this has not been shown. The use of IPPV may improve outcomes in patients with severe cardiogenic shock. However, IPPV has not proven to be beneficial in traumatic brain injury and flail chest, in the absence of other indications.

Acute Disease↗