Paul Nuccio | Boise State University (original) (raw)

Papers by Paul Nuccio

Critical Care Medicine, 2014

OBJECTIVE: We used spatial modeling to identify well-defined areas of the US where stroke related... more OBJECTIVE: We used spatial modeling to identify well-defined areas of the US where stroke related death rates were disproportionately high (hot spots) or low (cold spots). BACKGROUND: Geographic disparities in stroke mortality are well described. To reduce geographic disparities, identification of contiguous areas of the US that have a high burden of cerebrovascular disease is critical. DESIGN/METHODS: US county death data from the 2010 Multiple Cause of Death data files (National Center for Health Statistics) were combined with 2010 Area Resource File demographic data. Stroke deaths were identified using previously described ICD-10 (I60-69). Local tests of spatial autocorrelation (LISA statistic) were conducted in ArcGIS to identify locations where disproportionately high or low stroke death rates were clustered. RESULTS: Across 3133 counties in the United States the median age-adjusted stroke mortality rate for adults (18+) was 59.9 deaths per 100,000 people (IQR 46.8-76.6). There...

Critical Care Medicine, 2014

Considered as a long course of chronic disease that is characterized by repeated exacerbations an... more Considered as a long course of chronic disease that is characterized by repeated exacerbations and remissions, chronic obstructive pulmonary disease (COPD) indisputably leads to a clear and steady decline.1 For the purposes of this paper, focus will be given to the two diseases that are considered to be the hallmark of COPD: chronic bronchitis and emphysema. More specifically, this article will explore various methods for controlling the sometimes devastating symptoms associated with COPD toward the end of life.

Annals of Pharmacotherapy, 2015

Flolan (iFLO) and Veletri (iVEL) are 2 inhaled epoprostenol formulations. There is no published l... more Flolan (iFLO) and Veletri (iVEL) are 2 inhaled epoprostenol formulations. There is no published literature comparing these formulations in critically ill patients with refractory hypoxemia. To compare efficacy, safety, and cost outcomes in patients who received either iFLO or iVEL for hypoxic respiratory failure. This was a retrospective, single-center analysis of adult, mechanically ventilated patients receiving iFLO or iVEL for improvement in oxygenation. The primary end point was the change in the PaO2/FiO2 ratio after 1 hour of pulmonary vasodilator therapy. Secondary end points assessed were intensive care unit (ICU) length of stay (LOS), hospital LOS, duration of study therapy, duration of mechanical ventilation, mortality, incidence of adverse events, and cost. A total of 104 patients were included (iFLO = 52; iVEL = 52). More iFLO patients had acute respiratory distress syndrome compared with the iVEL group (61.5 vs 34.6%; P = 0.01). There was no difference in the change in the PaO2/FiO2 ratio after 1 hour of therapy (33.04 ± 36.9 vs 31.47 ± 19.92; P = 0.54) in the iFLO and iVEL groups, respectively. Patients who received iVEL had a shorter duration of mechanical ventilation (P < 0.001) and ICU LOS (P < 0.001) but not hospital LOS (P = 0.86) and duration of therapy (P = 0.36). No adverse events were attributed to pulmonary vasodilator therapy, and there was no difference in cost. We found no difference between iFLO and iVEL when comparing the change in the PaO2/FiO2 ratio, safety, and cost in hypoxic, critically ill patients. There were differences in secondary outcomes, likely a result of differences in underlying indication for inhaled epoprostenol.

Respiratory care, Jan 18, 2014

Transcutaneous carbon dioxide (PtcCO2 ) monitoring is rarely used in the acute hospital setting, ... more Transcutaneous carbon dioxide (PtcCO2 ) monitoring is rarely used in the acute hospital setting, where serial samples of arterial blood are instead taken to measure carbon dioxide tension (PaCO2 ). In this pilot observational study, we assessed the potential of PtcCO2 monitoring to calculate pH and guide management of acute noninvasive ventilation (NIV). Ten subjects with acute hypercapnic respiratory failure were recruited. All had arterial lines placed to guide acute NIV. PtcCO2 was monitored for 12 h (TOSCA TCM4) and compared with PaCO2 . Noninvasive transcutaneous pH was determined from PtcCO2 and calculated bicarbonate and then compared with true arterial pH. Agreements between PCO2 and pH methods were assessed using Bland-Altman analysis of limits of agreement and Pearson correlation coefficients. Hypothetical adjustments to acute NIV settings were based on transcutaneous data alone and evaluated in comparison with true management. Pain scores for each method were compared usi...

Hospital Practice, 2011

Tracheostomies have become a typical component of the management of patients with prolonged respi... more Tracheostomies have become a typical component of the management of patients with prolonged respiratory failure. There are, however, relatively few studies from which to establish an accepted standard of care with regard to the specific features, daily care, and removal of tracheostomy tubes. Consequently, these decisions are sometimes guided by myth and misconception. In this article, we review the different types of tracheostomy tubes with their respective advantages and disadvantages, basic principles of care, recognition of complications, speech with a tracheostomy tube, and the process by which they may sometimes be removed.

Expert Review of Respiratory Medicine, 2014

Current clinical guidelines recommend capnography as one of the best non-invasive methods to asse... more Current clinical guidelines recommend capnography as one of the best non-invasive methods to assess adequacy of ventilation in the non-intubated patient. Alveolar hypoventilation or respiratory depression is a serious event that occurs in a variety of clinical settings where patients receive sedatives and opioids. With the large number of procedures performed outside the operating room under the effects of sedatives and the increased use of patient-controlled analgesia, the need for capnography for monitoring has dramatically increased. Despite the succesful use of capnography to monitor ventilation in the operating room over several decades, other clinical areas have been very slow adapters of the technology and still rely heavily upon pulse oximetry to detect hypoventilation. This article reviews the most current evidence for using capnography in the non-intubated patient and summarizes the results of outcome measures reported in recent clinical trials. Capnography should be routinely used for non-intubated patients at risk for respiratory depression, in particular those receiving supplemental oxygen.

rtmagazine.com

... Failure to follow appropriate screening and treatment protocols may ultimately result in the ... more ... Failure to follow appropriate screening and treatment protocols may ultimately result in the untimely return of an age-old enemy. Paul Nuccio, RRT, FAARC, is the director of respiratory care at Boston's Brigham and Women's Hospital. ... JAMA. 2001;286:2015-2022. 4. Bloom BR. ...

Journal of Critical Care, 2013

Journal of Critical Care, 2011

Noninvasive positive pressure ventilation (NPPV) can improve outcomes of critically ill patients.... more Noninvasive positive pressure ventilation (NPPV) can improve outcomes of critically ill patients. Early and simple predictors of NPPV outcome could improve clinical management of patients with respiratory failure. A prospective observational study was conducted in a medical intensive care unit of a tertiary medical center. Patients requiring NPPV were included and followed. Clinical data including respiratory mechanics at the time of NPPV initiation, and clinical outcomes were recorded. Data were analyzed to identify variables that distinguished NPPV success or failure. A total of 133 patients were included in the study. Noninvasive positive pressure ventilation success rate was 41%. Patients diagnosed with malignancy had only 29% NPPV success rate. Among patients without malignancy, higher oxygen saturation, oxygen saturation/fraction of inspired oxygen (SF) ratios, and SF/minute ventilation ratios were associated with NPPV success. Receiver operating characteristic curve analyses identify SF ratio less than 98.5 to be a specific (89% specificity, P = .013) predictor of NPPV failure. Furthermore, for patients requiring at least 24 hours of NPPV support, tidal volume/predicted body weight ratio negatively correlated with respiratory improvement. For patients without malignancy, SF ratios at the time of NPPV initiation discriminated NPPV success and failure, and could be used to help guide the management of critically ill patients who require ventilatory support.

Critical Care Medicine, 2014

OBJECTIVE: We used spatial modeling to identify well-defined areas of the US where stroke related... more OBJECTIVE: We used spatial modeling to identify well-defined areas of the US where stroke related death rates were disproportionately high (hot spots) or low (cold spots). BACKGROUND: Geographic disparities in stroke mortality are well described. To reduce geographic disparities, identification of contiguous areas of the US that have a high burden of cerebrovascular disease is critical. DESIGN/METHODS: US county death data from the 2010 Multiple Cause of Death data files (National Center for Health Statistics) were combined with 2010 Area Resource File demographic data. Stroke deaths were identified using previously described ICD-10 (I60-69). Local tests of spatial autocorrelation (LISA statistic) were conducted in ArcGIS to identify locations where disproportionately high or low stroke death rates were clustered. RESULTS: Across 3133 counties in the United States the median age-adjusted stroke mortality rate for adults (18+) was 59.9 deaths per 100,000 people (IQR 46.8-76.6). There...

Critical Care Medicine, 2014

Considered as a long course of chronic disease that is characterized by repeated exacerbations an... more Considered as a long course of chronic disease that is characterized by repeated exacerbations and remissions, chronic obstructive pulmonary disease (COPD) indisputably leads to a clear and steady decline.1 For the purposes of this paper, focus will be given to the two diseases that are considered to be the hallmark of COPD: chronic bronchitis and emphysema. More specifically, this article will explore various methods for controlling the sometimes devastating symptoms associated with COPD toward the end of life.

Annals of Pharmacotherapy, 2015

Flolan (iFLO) and Veletri (iVEL) are 2 inhaled epoprostenol formulations. There is no published l... more Flolan (iFLO) and Veletri (iVEL) are 2 inhaled epoprostenol formulations. There is no published literature comparing these formulations in critically ill patients with refractory hypoxemia. To compare efficacy, safety, and cost outcomes in patients who received either iFLO or iVEL for hypoxic respiratory failure. This was a retrospective, single-center analysis of adult, mechanically ventilated patients receiving iFLO or iVEL for improvement in oxygenation. The primary end point was the change in the PaO2/FiO2 ratio after 1 hour of pulmonary vasodilator therapy. Secondary end points assessed were intensive care unit (ICU) length of stay (LOS), hospital LOS, duration of study therapy, duration of mechanical ventilation, mortality, incidence of adverse events, and cost. A total of 104 patients were included (iFLO = 52; iVEL = 52). More iFLO patients had acute respiratory distress syndrome compared with the iVEL group (61.5 vs 34.6%; P = 0.01). There was no difference in the change in the PaO2/FiO2 ratio after 1 hour of therapy (33.04 ± 36.9 vs 31.47 ± 19.92; P = 0.54) in the iFLO and iVEL groups, respectively. Patients who received iVEL had a shorter duration of mechanical ventilation (P < 0.001) and ICU LOS (P < 0.001) but not hospital LOS (P = 0.86) and duration of therapy (P = 0.36). No adverse events were attributed to pulmonary vasodilator therapy, and there was no difference in cost. We found no difference between iFLO and iVEL when comparing the change in the PaO2/FiO2 ratio, safety, and cost in hypoxic, critically ill patients. There were differences in secondary outcomes, likely a result of differences in underlying indication for inhaled epoprostenol.

Respiratory care, Jan 18, 2014

Transcutaneous carbon dioxide (PtcCO2 ) monitoring is rarely used in the acute hospital setting, ... more Transcutaneous carbon dioxide (PtcCO2 ) monitoring is rarely used in the acute hospital setting, where serial samples of arterial blood are instead taken to measure carbon dioxide tension (PaCO2 ). In this pilot observational study, we assessed the potential of PtcCO2 monitoring to calculate pH and guide management of acute noninvasive ventilation (NIV). Ten subjects with acute hypercapnic respiratory failure were recruited. All had arterial lines placed to guide acute NIV. PtcCO2 was monitored for 12 h (TOSCA TCM4) and compared with PaCO2 . Noninvasive transcutaneous pH was determined from PtcCO2 and calculated bicarbonate and then compared with true arterial pH. Agreements between PCO2 and pH methods were assessed using Bland-Altman analysis of limits of agreement and Pearson correlation coefficients. Hypothetical adjustments to acute NIV settings were based on transcutaneous data alone and evaluated in comparison with true management. Pain scores for each method were compared usi...

Hospital Practice, 2011

Tracheostomies have become a typical component of the management of patients with prolonged respi... more Tracheostomies have become a typical component of the management of patients with prolonged respiratory failure. There are, however, relatively few studies from which to establish an accepted standard of care with regard to the specific features, daily care, and removal of tracheostomy tubes. Consequently, these decisions are sometimes guided by myth and misconception. In this article, we review the different types of tracheostomy tubes with their respective advantages and disadvantages, basic principles of care, recognition of complications, speech with a tracheostomy tube, and the process by which they may sometimes be removed.

Expert Review of Respiratory Medicine, 2014

Current clinical guidelines recommend capnography as one of the best non-invasive methods to asse... more Current clinical guidelines recommend capnography as one of the best non-invasive methods to assess adequacy of ventilation in the non-intubated patient. Alveolar hypoventilation or respiratory depression is a serious event that occurs in a variety of clinical settings where patients receive sedatives and opioids. With the large number of procedures performed outside the operating room under the effects of sedatives and the increased use of patient-controlled analgesia, the need for capnography for monitoring has dramatically increased. Despite the succesful use of capnography to monitor ventilation in the operating room over several decades, other clinical areas have been very slow adapters of the technology and still rely heavily upon pulse oximetry to detect hypoventilation. This article reviews the most current evidence for using capnography in the non-intubated patient and summarizes the results of outcome measures reported in recent clinical trials. Capnography should be routinely used for non-intubated patients at risk for respiratory depression, in particular those receiving supplemental oxygen.

rtmagazine.com

... Failure to follow appropriate screening and treatment protocols may ultimately result in the ... more ... Failure to follow appropriate screening and treatment protocols may ultimately result in the untimely return of an age-old enemy. Paul Nuccio, RRT, FAARC, is the director of respiratory care at Boston's Brigham and Women's Hospital. ... JAMA. 2001;286:2015-2022. 4. Bloom BR. ...

Journal of Critical Care, 2013

Journal of Critical Care, 2011

Noninvasive positive pressure ventilation (NPPV) can improve outcomes of critically ill patients.... more Noninvasive positive pressure ventilation (NPPV) can improve outcomes of critically ill patients. Early and simple predictors of NPPV outcome could improve clinical management of patients with respiratory failure. A prospective observational study was conducted in a medical intensive care unit of a tertiary medical center. Patients requiring NPPV were included and followed. Clinical data including respiratory mechanics at the time of NPPV initiation, and clinical outcomes were recorded. Data were analyzed to identify variables that distinguished NPPV success or failure. A total of 133 patients were included in the study. Noninvasive positive pressure ventilation success rate was 41%. Patients diagnosed with malignancy had only 29% NPPV success rate. Among patients without malignancy, higher oxygen saturation, oxygen saturation/fraction of inspired oxygen (SF) ratios, and SF/minute ventilation ratios were associated with NPPV success. Receiver operating characteristic curve analyses identify SF ratio less than 98.5 to be a specific (89% specificity, P = .013) predictor of NPPV failure. Furthermore, for patients requiring at least 24 hours of NPPV support, tidal volume/predicted body weight ratio negatively correlated with respiratory improvement. For patients without malignancy, SF ratios at the time of NPPV initiation discriminated NPPV success and failure, and could be used to help guide the management of critically ill patients who require ventilatory support.