Noninvasive ventilation as ceiling of therapy in end-stage chronic obstructive pulmonary disease

The benefits of noninvasive ventilation (NIV) for acute hypercapnic respiratory failure caused by chronic obstructive pulmonary disease (COPD) are well recognized and consequently its use is widespread. Prognostication in advanced COPD is imperfect, limiting accurate identification of 'end-stage' COPD. Decisions regarding withholding invasive ventilation are largely dependent upon prognostication. In patients where 'invasive' ventilation is not considered to be in their best interests, NIV will be the ceiling of therapy. In this patient group, NIV is extremely valuable in reducing mortality and providing valuable symptomatic benefit. We discuss the use of NIV in the management of an acute exacerbation of 'end-stage' COPD where NIV is the ceiling of therapy, the use of advanced directives and the implications of the Mental Capacity Act 2005 on decisions regarding end-of-life care. We highlight areas where further research would be useful. © SAGE Publications 2008

Inhaled nitric oxide therapy in adult cardiac surgery

Nitric oxide (NO) is a naturally-occurring free radical that exists as a colorless and odorless gas. In biological solutions, NO is highly diffusible both in water and through biological membranes, with a half-life measured in seconds. Prior to the recognition that NO was the same molecule as an endothelium-derived relaxing factor some 20 years ago it was considered to be mainly an environmental pollutant. However, NO is now recognized as an endogenously produced vasodilator that modulates vascular tone and, thereby, regulates systemic and pulmonary blood flow. It has also been found to have diverse roles throughout mammalian physiology, including neurotransmission and host defense

The use of the Tempa.Dot thermometer in routine clinical practice

SIR—The Tempa.Dot single-use thermometer has been in use in the UK for over 10 years and in the USA for nearly 30 years. Over the last 7 years it has been marketed by 3M Health Care Limited. Its use in the NHS followed the European Union Directive to reduce the medical use of mercury. It also has the advantages of lack of cross-infection risk and more rapid recordings. A sensor matrix at the tip of the thermometer consists of 50 temperature-indicating dots, each with a melting point separation of 0.1 °C. At any given temperature within the range 35.5–40.4 °C, all dots with a melting point at or below that temperature change colour from beige to bright blue. Temperature readings are indicated by the number on the thermometer that corresponds with the row of the last blue dot plus 0.1 °C for every blue dot in that row greater than one. Tempa.Dot complies with European published standard EN-12470- 02(P2). This requires the mean accuracy to be within 0.1 °C for each do

Critical care as part of respiratory training in the UK

Experience in critical care medicine is mandatory for all respiratory trainees in the UK with a need for 60 days (3 months) minimum placement in an intensive care unit (ICU). The Respiratory Critical Care Group of the British Thoracic Society1 recently reported a survey in which there was widespread agreement with this requirement, although it was inadequately provided by a number of programmes. In addition, a proportion of trainees indicated the intention to subspecialise in intensive care medicine and were concerned that their ICU experience was diluted by having responsibilities such as acute general medical takes during their attachment. We recently carried out an email survey of anaesthetic and respiratory trainees and directors of intensive care which provides additional useful information