欢迎回到2010年一月网路播音.doc

啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊对於决定何时为最佳的拔管时间是需要经过详细临床上的变化评估.甚至在最佳的判断.另一个每天在加护病房的争议话题就是何时是气管切开术正确的时机.由Durbin,.啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊欢迎回到2010年一月网路播音啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊啊Welcome to the January 2010 Respiratory Care podcast. We begin the 55th volume of Respiratory Care with the papers from the 44th Journal Conference, Respiratory Care Controversies II. As pointed out by co-chairs Neil MacInyre and Richard Branson in their Foreword, the evidence base for many respiratory care diagnosis and management strategies is often incomplete and thus open to dispute. To address this, a unique pro-con format was used to frame controversial clinical questions. The presenters were asked to explore the extremes of each clinical question and then work towards a common ground. The papers that result from these presentations should prove clinically useful for the readers of the Journal as they explore these clinical questions in their own practice.歡迎回到2010年一月網路播音，第55期呼吸照護期刊開始於第44屆期刊會議文章-呼吸照護爭議2。共同主席Neil MacInyre與Richard Branson在前言中指出：許多呼吸照護診斷與管理策略的實證基礎是不完整且具爭議的。為了解決這個問題，一個獨特的“贊成-反對型式”用來構想具有爭議的臨床問題。發表者被要求探討每一個極端的臨床問題，然後努力達成一個共同的結論。當期刊讀者在臨床執行上探索這些問題時，這些陳述結果的文章應可以給期刊讀者提供有幫助的資訊。Healthcare screening for disease and the associated controversies are well known by anyone who reads a newspaper, watches the daily news on television, or listens to news on the radio. We begin with the paper, “Is There a Role for Screening Spirometry?” by MacIntyre and Selecky. In obstructive lung disease, the characteristic change in spirometry is a reduction in the FEV1 with respect to the vital capacity. Moreover, the severity of the obstruction can be graded by referencing spirometric measurements to age, sex, and height predicted normal values. Spirometry, however, should be considered a medical test, and not simply a vital sign that anyone can perform. Indeed, both technical issues and tester skills can profoundly affect the results and interpretations. Properly done spirometry can guide therapies and predict outcomes, but using spirometry to screen for obstructive lung disease in asymptomatic populations can be problematic, and the effects of screening spirometry on outcomes have yet to be determined. The value of spirometry is increased when it is of good quality, is interpreted properly, and is used in high-risk populations as a case-finding rather than a screening tool.任何有閱讀報紙、或由電視與廣播收看或收聽新聞的人，都應該對疾病的健康篩檢與其相關之爭議不會感到陌生。期刊開始於“肺量測定法篩檢是否具有重要性呢？”由MacIntyre及Selecky所著。在阻塞性肺疾病中，肺功能變化的特徵是在肺活量中的FEV1降低。此外，阻塞的嚴重程度，可以肺量測定依據年齡，性別和身高所提出預測正常值來做為分級參考。然而，肺量測定法應被視為一項醫療測試，而不僅僅是任何人都可以執行測量的生命徵象之一。事實上，包括技術問題和測試者的技能，都會對測試之結果與判讀有深遠的影響。正確的肺量測定結果可以對治療和結果之預測提供指引，但使用肺量測定來篩選無症狀之阻塞性肺疾病的族群卻可能會產生問題，以及影響肺量測定檢查結果的因子還尚未明確。只有當肺功能測量方法的品質良好、有被適當的判讀，且是用於高危險群病人，而非當做一種篩檢工具時，它的價值才能有所提升。 A very controversial topic that is discussed in the intensive care unit is whether or not steroids should be used. Next is the paper by Sessler and Gay, “Are Corticosteroids Useful in Late-Stage Acute Respiratory Distress Syndrome?” The acute respiratory distress syndrome is characterized by intense inflammation and alveolar-capillary disruption that can progress to a state of unresolving inflammation and disordered fibrosis, referred to as fibroproliferative, late-stage, or persistent ARDS. These pathophysiologic features may be responsive to corticosteroids, but early high-dose, short-duration therapy was proven ineffective. More recently, several small and one moderate-size multicenter randomized controlled trial investigated low-to-moderate-dose prolonged corticosteroid treatment. The randomized controlled trial and meta-analysis consistently demonstrated improved oxygenation and shorter duration of mechanical ventilation with methylprednisolone. The largest randomized controlled trial also revealed less pneumonia and shock, and ICU stay, but more cases of severe myoneuropathy, with methylprednisolone. There were virtually identical 60-day and 180-day mortality rates for methylprednisolone and placebo in the largest randomized controlled trial. Sub-group analysis of that study showed significantly higher mortality with methylprednisolone than with placebo when enrollment occurred grater than13days after onset of ARDS, but small sample size and differences in subject characteristics probably confound those results. Most meta-analyses demonstrated trends toward better survival with methylprednisolone, and, when restricted to patients enrolled in randomized controlled trials who received prolonged administration of methylprednisolone that was initiated within the first 14days of ARDS, one meta-analysis demonstrated better survival with corticosteroids. Importantly, the aforementioned studies have methodological limitations, and the number of subjects enrolled was small. Experts differ in their recommendations regarding corticosteroids for late-stage ARDS, although one consensus group supported a weak recommendation of low-to-moderate-dose corticosteroids for ARDS of less than14days duration. If corticosteroids are administered, infection surveillance, avoidance of neuromuscular blockers, and gradual taper of corticosteroids are recommended.在加護病房是否應該使用類固醇是一個非常有爭議的話題。下一篇文章是由Sessler 及 Gay 所著“糖皮質激素有助於晚期急性呼吸窘迫徵候群嗎？” ARDS的特點是強烈的發炎和肺泡毛細血管破壞，並可以進展到無法緩解之發炎狀態和病態纖維化，因而被稱為纖維增生，晚期或持續ARDS。這些病理生理性特色可能會對皮質類固醇治療有反應，但早期高劑量，短期治療被證明是無效的。最近，一些小型和一個中等大小的多中心隨機控制試驗，研究低到中等劑量長期激素治療。在隨機控制試驗和整合分析皆一致地呈現，使用methylprednisolone可改善氧合和縮短機械通氣時間。最大的隨機控制試驗還顯示了肺炎、休克，及ICU停留時間的減少，但更多的個案使用methylprednisolone呈現嚴重 肌肉神經萎縮。在這個最大的隨機對照試驗，methylprednisolone和安慰劑有幾乎相同的60天及180天的死亡率。分組分析，這項研究表明，在ARDS發病後超過13天才使用methylprednisolone，死亡率明顯高於服用安慰劑，但可能因為小樣本規模和個案特點的差異可能混淆了結果。大多數綜合分析顯示傾向於使用methylprednisolone有更好的生存率，尤其是在ARDS發病 14天內加入這個隨機控制試驗接受長期服用methylprednisolone。另一綜合分析顯示使用皮質類固醇有更好地存活率。重要的是，上述試驗在研究方法方面有限制，而且加入個案數很小。專家們對於皮質類固醇用於晚期ARDS有不同的建議，儘管他們有一個共識來支持薄弱建議：在ARDS期間少於 14天時間時，由低到中等劑量的皮質類固醇治療。如果服用皮質類固醇，建議感染的監測，避免神經肌肉阻斷劑，及漸進的減少皮質類固醇劑量。The determination of optimal timing of extubation requires a thorough assessment of many clinical variables. Even with the best judgment, 520% of extubations fail and require re-intubation. The timing of extubation is particularly controversial in patients with depressed mental status and inability to follow commands. This is debated on a regular basis in the ICU. “Should Patients Be Able to Follow Commands Prior to Extubation?” is by King, Moores, and Epstein. The determination of optimal timing of liberation from mechanical ventilation requires a thorough assessment of multiple variables that can result in extubation failure. It is estimated that 5 to 20% of extubations fail. Traditional weaning parameters fail to predict extubation failure accurately, and attention has thus turned to improvements in extubation decision making through assessment of elements that may result in inability to protect the airway, such as excessive respiratory secretions, inadequate cough, and depressed mental status. Extubation is particularly controversial in patients with depressed mental status and inability to follow commands. When looking at univariate analyses, the reported studies are relatively evenly divided among those that did and did not find that inability to follow commands increases the risk of extubation failure. In addition, although extubation failure is a risk factor for poor overall outcome in heterogeneous populations, its impact on the patient failing with neurologic dysfunction has not been adequately determined. One limiting factor in all reported studies is how “inability to follow commands” is defined. The majority of studies use the Glasgow coma score, but this is difficult to determine in the intubated patient. Moreover, using the cutoff of Glasgow coma score8, favored by many authors, is questionable, as some patients with higher scores may be unable to follow commands. Currently it is agreed that many patients who are unable to follow commands, but have the ability to clear pulmonary secretions, can be safely extubated. A prospective, randomized trial using a more specific definition of “following commands” would certainly help remove some of the uncertainty in this patient population.對於決定何時為最佳的拔管時間是需要經過詳細臨床上的變化評估。甚至在最佳的判斷下，仍有5-20的拔管會失敗，且需要重新再插管。若是在病人精神狀態呈現低下或是無法遵循命令的情況之下拔管的時機更是有爭議。這個情形在加護病房是被經常爭論的。”病人在拔管之前應該要能遵循指示命令?”由 King, Moores和Epstein等三位學者所提出。決定脫離機械通氣的最佳時間點是需要經過詳細評估其變化，因為反覆不定的狀況會造成拔管失敗。估計約有5-20會發生拔管失敗。傳統的呼吸器脫離參數無法準確的預測拔管；因而考慮其他可以增進決定拔管判斷因素，經由評估可能會造成無法維持呼吸道通暢的要素，例如過多的呼吸道分泌物、不適當的咳嗽、低下的精神狀態。拔管在病人精神狀態呈現低下或是無法遵循指示命令情況之下特別有爭議。在單變量的分析裡，這些研究對無法遵循指示命令是否會增加拔管失敗風險之分析結果是相等的。另外，雖然拔管失敗在錯綜的群族對整體不良結果是一項危險因素，其對於病人有神經肌肉功能不良時的影響仍沒有適當的論斷。在所有描述性研究有一個限制的要素是如何來定義”不能遵循指示命令”。大多數的研究都採用Glasgow昏迷指數，不過這在插管的病人中難以評估。此外，許多作者較贊成將Glasgow昏迷指數8當成一個指標，但是，卻有些病人有較高的指數仍無法遵循指示命令。目前有些病人其無法遵循指示命令，但是有能力清除肺部的分泌物，可以成功的拔除管子。一個前瞻性的，隨機選擇試驗使用一個較明確的定義”遵循指示命令”應該可以幫助排除這類病人的不確定性。Next we have the paper, “Are Sleep Studies Appropriately Done in the Home?” by Gay and Selecky. For many years the greatest barrier to the diagnosis and treatment of obstructive sleep apnea, or OSA, was recognizing the disease. That obstacle is now fading as more physicians of all types are aware of the high prevalence of OSA and the consequences of untreated OSA. Sleep-laboratory polysomnography has long been considered the accepted standard for OSA diagnosis, and became a lucrative practice. This, unfortunately, led to a concentration on diagnosis rather than management of OSA. Although several portable brands of portable polysomnograph have been approved for home polysomnography, obstacles to reimbursement (primarily from government, but also from private payers) have prevented widespread home polysomnography. Over the last 2decades many scientific studies have supported a strong correlation between the findings from home polysomnography and sleep-laboratory polysomnography. However, limited data are available from good outcomes-oriented studies, so controversy surrounds home polysomnography in the diagnosis of OSA. The authors review the evidence and debate whether sleep studies are appropriately done in the home.再來我們要探討” 在家進行睡眠研究合適嗎？” 由Gay和Selecky兩位學者所提出。多年來，對於阻塞性睡眠呼吸中止症，或稱OSA的診斷與治療的最大障礙，在於辨識此疾病。隨著目前越來越多的不同領域的醫師們，開始意識到此疾病的高盛行率，以及未經治療的OSA的後果，此障礙症正在逐漸減少中。睡眠-研究室的多重睡眠電圖長久以來被認為是診斷OSA的標準方法，使它成為一項獲利頗豐的業務。不幸的，如此使得對OSA的關注多集中在診斷，而非處置。雖然有許多可在家裡使用的移動式多重睡眠電圖廠牌被核准認使用，但是對於款項的補助有障礙(主要是從政府，或是有些私人的付款)阻礙了在家使用多重睡眠電圖的普及性。在持續這20年間許多科學研究強力的支持在家使用多重睡眠電圖所得到的結果和睡眠-研究室多重睡眠電圖之間的關聯。然而，以有限的數據採結果為方向的研究，仍有許多對於在家使用多重睡眠電圖來診斷OSA的爭議。作者們回顧檢閱證據並且辯論睡眠的研究在家執行是否合宜。Another controversial topic debated daily in the ICU is the correct timing of tracheostomy. “Should Tracheostomy Be Performed as Early as 72 Hours in Patients Requiring Prolonged Mechanical Ventilation?” is by Durbin, Perkins, and Moores. Advances in treating the critically ill have resulted in more patients requiring prolonged airway intubation and respiratory support. If intubation is projected to be longer than several weeks, tracheostomy is often recommended. Tracheostomy offers the potential benefits of improved patient comfort, the ability to communicate, opportunity for oral feeding, and easier, safer nursing care. In addition, less need for sedation and lower airway resistance (than through an endotracheal tube) may facilitate the weaning process and shorten intensive care unit and hospital stay. By preventing microaspiration of secretions, tracheostomy might reduce ventilator-associated pneumonia. There is controversy, however, over the optimal timing of the procedure. While there have been many randomized controlled trials on tracheostomy timing, most were insufficiently powered to detect important differences, and systematic reviews and meta-analyses are limited by the heterogeneity of the primary studies. Based on the available data, the authors think it is reasonable to perform early tracheostomy in all patients projected to require prolonged mechanical ventilation. Unfortunately, identifying those patients can be difficult, and for many patient populations we lack the necessary tools to predict prolonged ventilation. The authors propose an early-tracheostomy decision algorithm. This algorithm may prove useful, but ideally this should be validated in a clinical study.另一個每天在加護病房的爭議話題就是何時是氣管切開術正確的時機.。由Durbin、Perkins和Moores提出的 “長期機械通氣的病人是否應該在早期的72小時執行氣管切開術？重症疾病的先進治療導致更多的病人需要長期的氣道插管和呼吸支持。如果插管預計將超過幾個星期，經常會建議要做氣管切開術。氣管切開術提供的潛在好處是改善病人舒適性、溝通能力、增加經口進食機會及更容易、更安全的護理。此外，較少需要鎮靜劑，降低氣道阻力（相較於經由氣管內管），這一切將有利於呼吸器脫離及縮短重症加護病房及住院時間。經由預防微量氣道分泌物吸入，氣管切開術也可以減少呼吸器相關性肺炎。但無論如何，執行的最佳時間之選擇仍是有爭議的。雖然對氣管切開術時機有很多的隨機控制試驗，但對發現重要的差異性多半缺乏有力的檢定力，且系統回顧和綜合分析也受限於原始研究調查的異質性。根據現有資料，作者認為對預期需要長期機械通氣的病人進行早期氣管切開術是合理的。不幸的是，要認定哪些病人卻是困難的，對於許多病人族群，我們也缺乏必要的工具或方式來預測他們是否需要長期通氣。作者提出早期氣管切開術的判定的演算法。該演算法也許是有用的，但理想的情況應該是，由臨床研究再做確認。Prone positioning is one of the rescue therapies considered in patients with ARDS and refractory hypoxemia. It is accepted that prone positioning can improve gas exchange in patients with severe hypoxemia refractory to standard ventilatory manipulations. The final paper this month is Fessler and Talmor. Its title is, “Should Prone Positioning Be Routinely Used for Lung Protection During Mechanical Ventilation?” Prone positioning has been known for decades to improve oxygenation in animals with acute lung injury and in most patients with ARDS. The mechanisms of this improvement include a more uniform pleural-pressure gradient, a smaller volume of lung compressed by the heart, and more uniform and better-matched ventilation and perfusion. Prone positioning has an established niche as an intervention to improve gas exchange in patients with severe hypoxemia refractory to standard ventilatory manipulations. Because the lung may be more uniformly recruited and the stress of mechanical ventilation better distributed, prone positioning has also been proposed as a form of lung-protective ventilation. However, several randomized trials have failed to show improvements in clinical outcomes of ARDS patients, other than consistently better oxygenation