Pre-ascent measurement of HRV in normoxia was found to be of better diagnostic accuracy for AMS prediction than all measures of HRV in hypoxia, and better than peripheral oxygen saturation monitoring.

BACKGROUND AND OBJECTIVE: Decreasing practice variation and following clinical guidelines improve patient outcomes and reduce costs. Inhaled nitric oxide (iNO) is an effective but expensive treatment of pulmonary hypertension and right heart failure in patients with congenital or acquired heart disease. Our objective was to implement standardized initiation and weaning guidelines for iNO usage in the cardiothoracic ICU (CTICU) to reduce variation in use while maintaining quality patient care. METHODS: All CTICU patients who received iNO from January 2011 to December 2012 were retrospectively reviewed. Standardized iNO initiation and weaning guidelines were implemented in January 2012. Variables before and after guideline implementation were compared. RESULTS: From January to December 2011, there were 36 separate iNO events (6% of CTICU admissions; n = 547). Mean ± SD iNO usage per event was 159 ± 177 hours (median: 63 hours; range: 27–661 hours). From January to December 2012, there were 47 separate iNO events (8% of CTICU admissions; n = 554). Mean iNO usage per event was 125 ± 134 hours (median: 72 hours; range: 2–557 hours). Initiation guideline compliance improved from 83% to 86% (P = .9); weaning guideline compliance improved from 17% to 79% (P < .001). Although mean iNO usage per event decreased, there was no significant reduction in utilization of iNO (P = .09). CONCLUSIONS: Implementation of standardized iNO initiation and weaning guidelines in the CTICU was successful in reducing practice variation supported by increasing guideline compliance. However, decreasing practice variation did not significantly reduce iNO utilization and does not necessarily reduce cost.

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A combination of helium and oxygen (heliox) can facilitate gas exchange and limit peak inspiratory pressures through reduced resistance to gas flow and decreased turbulent flow. The combination of these gases has been used for a variety of upper and lower airway conditions, including patients who were spontaneously breathing, receiving noninvasive ventilation, as well as during mechanical ventilation. To date, there are no reports regarding the use of heliox in patients with bronchiolitis obliterans syndrome following lung transplantation. We report the use of such a combination of gases in 2 patients with bronchiolitis obliterans syndrome following lung transplantation as a supportive measure to facilitate ventilation during the initial treatment course for acute respiratory failure in the ICU. A heliox mixture was administered with noninvasive ventilation and with mechanical ventilation through the ventilator in a heart-lung transplant recipient and a lung transplant recipient, respectively.

Background:Inhaled nitric oxide (iNO) is a potent pulmonary vasodilator used off-label to treat refractory hypoxemia in the pediatric intensive care unit (PICU). However, clinical practice varies widely, and there is limited evidence to support this expensive therapy. Our objective was to test whether implementation of a clinical guideline for iNO therapy would decrease practice variability, reduce ineffective iNO utilization, and control iNO-related costs.Methods:We used quality improvement (QI) methodology to standardize the use of iNO in a single quaternary care PICU (noncardiac). All PICU patients receiving iNO therapy between January 1, 2010, and December 31, 2013, were included. The QI intervention was the development and implementation of a clinical guideline for iNO initiation, continuation, and weaning. iNO use was monitored using statistical process control charts.Results:We derived baseline data from 30 preguideline patients (35 separate iNO courses) compared with 33 postguideline patients (36 separate iNO courses). Despite similar baseline characteristics, disease severity, and degree of hypoxemia, postguideline patients had a shorter median [interquartile range (IQR)] duration of iNO therapy than preguideline patients [76 (48–124) hours versus 162 (87–290) hours; P < 0.0001]. We have sustained the reduced iNO usage throughout the postguideline period. Postguideline patients also had improved provider documentation and a median iNO cost savings of $4,600.Conclusions:Implementation of iNO usage guidelines was associated with decreased iNO usage and cost of iNO therapy in the PICU.