Weaning strategies and protocols

By Michele Vitacca

in Non-invasive Ventilation and Weaning: Principles and Practice

To this end, new strategies and protocols for weaning from mechanical ventilation are clearly needed in the daily practice of healthcare.While unnecessary delays in withdrawing mechanical ventilation can increase the risk of complications, prolong ICU stay and significantly amplify healthcare costs, premature attempts at withdrawal of mechanical ventilation might lead to development of severe distress, hamper the recovery process and further delay weaning.4 Physicians often fail to recognize patients who may already be ready for extubation. Studies among patients who areThe chapter presents the state of the art of the weaning process including use of protocols derived from mechanical ventilation in patients with chronic obstructive pulmonary disease or those who experienced acute respiratory failure. The weaning process is a delicate time in the medical history of a patient who survives an acute episode of respiratory failure and spends a period of time under mechanical ventilation. In fact, during the period of mechanical ventilation, there are a lot of implications that are currently somehow underestimated in daily medical practice: occupation of beds, healthcare costs, burden for the families and for the patients themselves. Although these occurrences are quite common and critical, there are no clear guidelines on the minimal criteria required for assessing the correct weaning time for different diseases, or on the need for a screening test prior to a spontaneous breathing test. It is also crucial to identify the patients who can be considered possible successful responders to the weaning process. A careful review of the literature shows the crucial role of the respiratory therapist in the multidisciplinary team (physician, nurse, respiratory therapist and family as well), who should be involved in such a delicate process.

Determinants of Carbon Dioxide Tension

Shahrokh Javaheri 

in Acid-Base Disorders and Their Treatment

The major function of the respiratory system is to maintain normal arterial blood partial pressures of the two vital respiratory gases, O2 and CO2, and a normal pH. This important regulatory function is automatically controlled, and is referred to as the homeostatic (chemostatic or metabolic) function. Homeostatic regulation is achieved by adjustment of ventilation to the metabolic (O2 consumption=CO2 production) and acid-base needs of the organism (1). The respiratory system is also utilized for behavioral (nonhomeostatic) functions such as phonation and swallowing. The act of breathing, therefore, is complex and needs to be governed precisely by a set of hierarchically arranged control systems. The focus of this chapter is chemical control of breathing and regulation of PCO2.

Exhaled Nitric Oxide, Carbon Monoxide, and Breath Condensate

Sergei A. Kharitonov, Peter J. Barnes

in Disease Markers in Exhaled Breath

Many lung diseases, including asthma, chronic obstructive pulmonary disease (COPD), bronchiectasis, cystic fibrosis, and interstitial lung disease, involve chronic inflammation and oxidative stress. Yet these are not measured directly in routine clinical practice because of the difficulties of monitoring inflammation. In asthma, fiber-optic bronchial biopsies have become the “gold standard” for measuring inflammation in the airway wall, but this is an invasive procedure that is not suitable for routine clinical practice and cannot be repeated often. It is also unsuitable for use in children and patients with severe disease. Symptoms may not accurately reflect the extent of underlying inflammation, due to differences in perception and masking by bronchodilators in airway disease. Measurement of airway hyperresponsiveness by histamine or methacholine challenge has been used in asthma as a surrogate marker of inflammation, but interpretation is confounded by the use of bronchodilator therapy. Furthermore, it is difficult to perform this measurement in children and in patients with severe disease.

Coping and Self-Management Strategies for Dyspnea

Virginia Carrieri-Kohlman

in Dyspnea

Despite optimal medical and pharmacological therapy, at one time oranother, most individuals with cardiopulmonary disease will experience either acute or chronic progressive dyspnea (shortness of breath). Whetherexperiencing acute dyspnea during a limited period or consistently withactivities of daily living, people need interventions or strategies that theyare confident will help them reduce and control this life-threatening, dis-tressing symptom. The purpose of this chapter is to review the theoreticalfoundations for ‘‘coping’’ and ‘‘self-management’’ strategies to reduceshortness of breath, to present the evidence from controlled studies forthe effectiveness of these strategies, and to discuss clinical and patient experiences that suggest efficacy of strategies when a scientific foundationis not available.

The Carbon Neutral Public Sector

Published in Public Management Review

Amanda BallIan MasonSuzana GrubnicPhil Hughes

This paper argues for research into the effectiveness of government strategies for a ‘carbon neutral public sector’. We review initiatives in three OECD countries: New Zealand, Australia and the UK. In all jurisdictions, government agencies have consistently stressed ‘leading by example’ as a rationale for adoption. ‘Direct mandate’ by the Prime Minister (NZ); ‘organic development’ from wider central government sustainability initiatives (UK); and a more ‘laissez faire’ approach by Australian Federal and State Governments, were identified as the general pathways leading to implementation. Our assessment indicates: a lack of understanding of the implementation process for carbon neutrality; a need to identify and critically examine the ‘offset threshold’ at which mitigation efforts cease and offsetting is adopted; an absence of any evaluation of the ‘leading by example’ rationale; a lack of inter-country comparisons; a gap in understanding the relationship with economic and social aspects of sustainability; and a need to evaluate the utility of core government departments as the focus of carbon accounting. We urge colleagues to consider research in this area with a view to contributing to the interdisciplinary solutions which we believe are required.

Carbon neutral destinations: a conceptual analysis

Published in Journal of Sustainable Tourism

Stefan Gössling 

This paper provides a critical review of the concept of “carbon neutrality” for tourism destinations within the framework of the UNWTO’s Davos Declaration, a document ascribing responsibilities to various actors in the tourism industry to engage in greenhouse gas emission reductions. The paper assesses the planning frameworks of countries engaging with the concept, discusses the measures that can be taken to achieve “carbon neutrality”, along with an evaluation of some of the theoretical and practical implications. An increasing number of destinations now plan to become “carbon neutral”, often as a response strategy to pressure on the tourism industry to reduce its emissions of greenhouse gases. They aim to mitigate their contribution to global warming, and to develop their tourism industries by enhancing their image as being environmentally pristine and sustainable.

Hybrid buildings: a pathway to carbon neutral housing

Published in Architectural Science Review

Peter W. NewtonSelwyn N. Tucker 

In the residential sector, there is growing interest in the concept of carbon neutral and net zero energy housing within the context of emerging climate change mitigation and energy security strategies. A hybrid building represents a new class of dwelling capable of achieving net zero energy, carbon neutral or zero carbon status. This article reports on the carbon footprints of alternative configurations of a hybrid building, where variations in performance are explored across different types of residential structure (detached, medium density, high-rise), different energy ratings of the shell, number and mix of domestic appliances in use, and type of distributed or local energy generation technology employed. Hybrid building pathways to zero carbon housing are identified, delivering average savings of approximately 11 tonnes CO2-e per year per dwelling compared with new detached project homes designed to current 5-star energy standards.

New Zealand 's abandonment of the Carbon Neutral Public Service programme

Published in Climate Policy

Jeff Birchall 

In 2009, New Zealand’s new National-led government abandoned the Carbon Neutral Public Service (CNPS) programme, a Labour-led government initiative intended to help Government achieve carbon neutrality within its core agencies. This short analysis article provides an overview and brief assessment of the CNPS initiative by drawing on the relevant scholarly literature and public documents relating to New Zealand’s climate change agenda. It is argued that although the CNPS programme faced a range of challenges it was successful in some respects. Although the Labour-led government was keen to act on climate change mitigation, New Zealand no longer intends to take a lead on carbon neutrality under the National-led government.

Aboveground carbon stocks in oil palm plantations and the threshold for carbon - neutral vegetation conversion on mineral soils

Published in Cogent Environmental Science

Ni’matul KhasanahMeine van NoordwijkHarti NingsihSerge Wich 

The carbon (C) footprint of palm oil production is needed to judge emissions from potential biofuel use. Relevance includes wider sustainable palm oil debates. Within life cycle analysis, aboveground C debt is incurred if the vegetation replaced had a higher C stock than oil palm plantations. Our study included 25 plantations across Indonesia, in a stratified study design representing the range of conditions in which oil palm is grown. From allometric equations for palm biomass and observed growth rates, we estimated the time-averaged aboveground C stock for 25-year rotation and 95%-confidence interval to be 42.07 (42.04–42.10) Mg C ha−1 for plantations managed by company on mineral soils, 40.03 (39.75–40.30) Mg C ha−1 for plantations managed by company on peat, and 37.76 (37.42–38.09) Mg C ha−1 for smallholder oil palm on mineral soils. Oil palm can be established C debt-free on mineral soils with aboveground C stocks below these values; neutrality of mineral soil C pools was documented in a parallel study. Acknowledging variation in shoot:root ratios, the types of vegetation that can be converted debt-free to oil palm include grasslands and shrub, but not monocultural rubber plantations, rubber agroforest, and similar secondary or logged-over forests of higher C stock.