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Respiratory Therapists' Experiences and Attitudes Regarding Terminal Extubations and End-of-Life Care
Τρίτη, 5 Ιουλίου 2016, 1:30:07 μμ | Grandhige, A. P., Timmer, M., O'Neill, M. J., Binney, Z. O., Quest, T. E.
BACKGROUND:Respiratory therapists (RTs) routinely care for patients with life-limiting illnesses and in some hospitals are responsible for terminal extubations. Data on how such experiences affect RTs are scarce. The objective of this work was to survey RTs at 2 academic medical centers about their experiences caring for patients with terminal extubations.METHODS:An online survey was distributed to the hospitals' RTs. Survey data included demographics and experiences with end-of-life care and terminal extubations. The survey was derived from previously published questionnaires plus input from hospital RT leaders.RESULTS:Sixty-five of 173 RTs (37.6%) responded. Of these, 42.4% were ≥50 y old, and 62.7% were female. 20.3% had ≤5 y experience; 52.5% had ≥16 y. 93.8% self-reported being involved in at least one terminal extubation; of those, 36.1% reported performing ≥20. Nearly half (47.5%) wanted to be involved in family meetings discussing terminal extubations, but just 6.6% were frequently involved. Only 32.3% felt that they received adequate education regarding terminal illness in RT school; 32.3% reported gathering this knowledge while working. 60.0% wanted more formal education around terminal patient care. 27.9% reported sometimes being uncomfortable with performing a terminal extubation; most of these rarely felt that they had the option not to perform the extubation.CONCLUSIONS:RTs are rarely involved in end-of-life discussions despite a desire to be, and they experience situations that generate discomfort. There is demand for more formal RT training around care for terminal patients. Clinical protocols that involve RTs in meetings before ventilator withdrawal should be considered.
Perception of Exercise-Induced Bronchoconstriction in College Athletes
Τρίτη, 5 Ιουλίου 2016, 1:30:07 μμ | Burnett, D. M., Vardiman, J. P., Deckert, J. A., Ward, J. L., Sharpe, M. R.
BACKGROUND:Exercise-induced bronchoconstriction (EIB) can lead to long-term respiratory illness and even death. EIB prevalence rates are both high and variable in college athletes. Also, prevalence rates may be underestimated due to ineffective screening. The purpose of this study is to investigate the prevalence of EIB and the perceived impact of EIB in college athletes via a self-report questionnaire.METHODS:A self-report EIB questionnaire was administered to college athletes on 8 different sports teams. Information collected was used to identify athletes who self-reported: (1) a history of EIB and/or asthma, (2) respiratory symptoms during exercise, (3) medication use, and (4) concern about EIB.RESULTS:Results showed that 56 of 196 athletes (28.6%) self-reported a history of EIB or asthma. Over half (52%) reported a history of EIB/asthma or current EIB symptoms. Forty-six of the 140 athletes (32.9%) who did not report a history of EIB or asthma indicated symptoms of EIB during sports, training, or exercise. Fourteen of 56 athletes (25%) self-reporting a history of EIB or asthma did not report the use of a respiratory medication. Nineteen of 196 athletes (9.7%) reported being concerned that EIB was adversely affecting their sports performance.CONCLUSIONS:College athletes self-report a high prevalence of EIB or asthma. Although college athletes may not report a history of EIB or asthma, they indicate symptoms of EIB. A majority of athletes reported a history or current symptoms related to EIB or asthma. Many athletes with a history of EIB or asthma are not taking any asthma medication. Last, athletes report concern about EIB adversely affecting their sports performance. More work is needed using a combination of a screening questionnaire and standardized EIB testing to develop a validated tool for accurately screening and diagnosing EIB in college athletes.
Using a Post-Intubation Checklist and Time Out to Expedite Mechanical Ventilation Monitoring: Observational Study of a Quality Improvement Intervention
Τρίτη, 5 Ιουλίου 2016, 1:30:07 μμ | McConnell, R. A., Kerlin, M. P., Schweickert, W. D., Ahmad, F., Patel, M. S., Fuchs, B. D.
BACKGROUND:Delayed mechanical ventilation monitoring may impede recognition of life-threatening acidemia. Coordination of multidisciplinary processes can be improved by using a checklist and time-out procedure. The study objective was to evaluate process-related outcomes after implementation of a post-intubation checklist and time out.METHODS:An observational study of a 24-bed medical ICU in Philadelphia, Pennsylvania, was conducted from January to December 2011. A random sample of mechanically ventilated adults was selected from the pre-intervention (n = 80) and post-intervention (n = 144) periods. The primary outcome was the proportion of subjects with an arterial blood gas (ABG) result within 60 min of mechanical ventilation initiation. Secondary outcomes included rates of respiratory acidosis, moderate-severe acidemia (pH < .001). Transfer from referring institutions (23% checklist initiation rate, P = .006) negatively impacted checklist use. Implementation challenges included frequent stakeholder turnover, undefined process ownership, and lack of real-time performance feedback.CONCLUSIONS:A post-intubation checklist and time out improved the timeliness of mechanical ventilation monitoring through more rapid assessment of arterial blood gases. Implementing this peri-intubation procedure may reduce the risks associated with transitioning to full mechanical ventilatory support. Optimal implementation necessitates strategies to surmount organizational and behavioral barriers to change.
Oronasal and Tracheostomy Delivery of Soft Mist and Pressurized Metered-Dose Inhalers With Valved Holding Chamber
Τρίτη, 5 Ιουλίου 2016, 1:30:07 μμ | Berlinski, A., Cooper, B.
BACKGROUND:Some pediatric tracheostomized patients who receive inhaled drugs undergo decannulation, and it is unknown whether the dose has to be adjusted. Pressurized metered-dose inhalers (pMDIs) and soft mist inhalers (SMIs) used with valved holding chambers (VHCs) made of non-electrostatic material are available. We hypothesized that using an SMI and changing the delivery route from tracheostomy to oronasal would increase lung dose.METHODS:Four units of a metallic VHC were studied with albuterol hydrofluoroalkane (pMDI) and albuterol/ipratropium bromide with an SMI using an anatomically correct in vitro model of a 5-y-old spontaneously breathing tracheostomized child. The drug was captured in a filter and was termed lung dose. We tested breathing patterns with tidal volumes of 50, 155, and 300 mL. A mask and a special adapter were used as interfaces for oronasal and tracheostomy delivery, respectively. Spectrophotometry (276 nm) was used to determine albuterol concentration.RESULTS:The use of SMI resulted in a higher lung dose than the pMDI for all tested conditions except delivery through tracheostomy with tidal volume of 155 mL (P = .69). Switching from oronasal to tracheostomy delivery increased the lung dose for all tested conditions except for the pMDI with the 300-mL tidal volume (P = .83). The use of SMI resulted in higher deposition in the tracheostomy tube than the pMDI.CONCLUSIONS:In general, an SMI delivers a higher lung dose than a pMDI when using a metallic spacer during oronasal and tracheostomy route with the latter providing a higher lung dose.
Standardization of Sonographic Diaphragm Thickness Evaluations in Healthy Volunteers
Τρίτη, 5 Ιουλίου 2016, 1:30:07 μμ | Carrillo–Esper, R., Perez–Calatayud, A. A., Arch–Tirado, E., Diaz–Carrillo, M. A., Garrido–Aguirre, E., Tapia–Velazco, R., Pena–Perez, C. A., Espinoza–de los Monteros, I., Meza–Marquez, J. M., Flores–Rivera, O. I., Zepeda–Mendoza, A. D., de la Torre–Leon, T.
BACKGROUND:B-mode ultrasound can be used to measure diaphragm thickness at the zone of apposition. We believe it is necessary to develop normal values for diaphragm thickness at rest in a large group of healthy subjects and compare them with international results.METHODS:Ultrasound measurements of diaphragm thickness at expiratory rest were taken in 109 healthy individuals, with results stratified by sex, body mass index, and thorax circumference. The following methods were used for analysis and interpretation. Multivariable databases with descriptive statistical analyses were made. The Pearson chi-square test was used to evaluate the distribution between variables. Additionally, mean and SD values were calculated. For standardization, the data were separated by sex within a 95% CI, and we calculated a Z test. A 95% CI was also constructed for proportion analyses.RESULTS:One hundred nine healthy volunteers were included in the study, and the correlation between the body mass index and thorax circumference values with a Pearson chi-square test resulted in an r = 0.69. Additionally, the average value of diaphragmatic thickness was 0.19 ± 0.04 cm (95% CI 0.17–0.20 cm) for men and 0.14 ± 0.03 cm (95% CI 0.13–0.15 cm) for women (P = .001). There was no relation between body mass index thorax circumference, and diaphragmatic thickness.CONCLUSION:Real-time ultrasound of the diaphragm is a simple, inexpensive, and portable imaging technique that can provide qualitative anatomical information. The findings in this study show that sonographic diaphragm evaluations can be applied to the general population.
Correlation Between Maximum Inspiratory Pressure and Hand-Grip Force in Healthy Young and Middle-Age Individuals
Τρίτη, 5 Ιουλίου 2016, 1:30:07 μμ | Efstathiou, I. D., Mavrou, I. P., Grigoriadis, K. E.
BACKGROUND:This study aimed to examine the relationship between hand-grip force and maximum inspiratory pressure (PImax) in healthy young and middle-age individuals.METHODS:All individuals underwent assessment of inspiratory muscle strength by maximum inspiratory pressure using a U-type water manometer and evaluation of hand-grip force by a hydraulic hand dynamometer.RESULTS:The correlation of PImax and hand-grip force was strong (r = 0.76). A multilinear regression model was built to investigate the ability of various parameters, such as hand-grip force, sex, and body mass index measurements, to predict PImax. PImax can be accurately predicted by 80% (r = 0.76) with a simple equation of easily evaluable factors, such as hand-grip force, body mass index, and sex.CONCLUSION:The results showed significant correlation between hand flexors' force and strength of inspiratory muscles in healthy individuals. This appears to be an easy way to evaluate the results indirectly and can help to assess the relationship between hand flexor and inspiratory muscle capacity, especially the diaphragm. Our study should be viewed as a hypothesis-generating one, and further studies are required in the population of critically ill or difficult-to-wean patients. (ClinicalTrials.gov registration NCT02423616.)
Blunted Hypercapnic Respiratory Drive Response in Subjects With Late-Onset Pompe Disease
Τρίτη, 5 Ιουλίου 2016, 1:30:07 μμ | De Vito, E. L., Monteiro, S. G., Aruj, P. K.
BACKGROUND:Patients with late-onset Pompe disease develop progressive hypercapnic respiratory failure that can be disproportionate to the respiratory muscle compromise and/or thoracic restriction. Although recent studies have reported the presence of a blunted hypercapnic respiratory response in some subjects with neuromuscular disorders and chronic hypercapnia, no study has evaluated the integrity of the respiratory drive in subjects with late-onset Pompe disease. Thus, we endeavor to determine the CO2 rebreathing response in subjects with late-onset Pompe disease.METHODS:Respiratory muscle strength was assessed by measuring the maximum inspiratory pressure, and the maximum expiratory pressure. The maximum inspiratory pressure reflects the strength of the diaphragm and other inspiratory muscles, whereas the maximum expiratory pressure reflects the strength of the abdominal muscles and other expiratory muscles. We studied the hypercapnic drive response (measured as the ratio of the change in airway-occlusion pressure 0.1 s after the start of inspiration and end-tidal PCO2 in 13 subjects with late-onset Pompe disease and 51 healthy controls.RESULTS:Overall inspiratory muscle strength was within normal limits or slightly diminished in the late-onset Pompe disease group. Five subjects (38.5%) were chronically hypercapnic, and 9 (69.2%) had an increased breath-holding time. Compared with controls, the change in airway-occlusion pressure 0.1 s/change in end-tidal CO2 pressure slope (hypercapnic respiratory drive) was lower in the late-onset Pompe disease group (median 0.050 [interquartile range 0.027–0.118] vs 0.183 [0.153–0.233], P < .001). Nine subjects (69.2%) had a blunted change in airway-occlusion pressure 0.1 s/change in end-tidal carbon dioxide pressure slope.CONCLUSIONS:Subjects with late-onset Pompe disease had an impaired hypercapnic respiratory drive response. The clinical impact of this phenomenon in this subject subset deserves further investigation.
Reproducibility of the Sputum Color Evaluation Depends on the Category of Caregivers
Τρίτη, 5 Ιουλίου 2016, 1:30:07 μμ | Reychler, G., Andre, E., Couturiaux, L., Hohenwarter, K., Liistro, G., Pieters, T., Robert, A.
BACKGROUND:Sputum production and purulence were proposed as criteria for justifying the use of antimicrobial agents. The Sputum Color Chart was developed and validated to standardize purulence of sputum evaluation. The aim of this study was to observe the reproducibility of the Sputum Color Chart from different categories of health caregivers.METHODS:The color of 10 sputum samples was evaluated using photographs for intra- and inter-reliability. The observation was repeated 3 times. Eighteen volunteers from 6 categories of health caregivers (student in physiotherapy, senior chest physiotherapist, junior resident in pulmonology, medical microbiologist, pulmonologist, and general practitioner) were investigated.RESULTS:Poor inter-rater reliability was observed for all categories with the exception of senior chest physiotherapists. The best intra-rater reliability was observed for microbiologists and senior chest physiotherapists. We found a great proportion (>40%) of important discrepancies in 2 categories (junior pulmonologist and general practitioner). The proportion of non-discrepancy between evaluators varied between 10 and 40%, depending on the category.CONCLUSIONS:Even if the Sputum Color Chart is a useful tool for the clinician in the context of clinical deterioration, it presents non-uniform reliability regarding the caregivers and their category.
Socioeconomic Variations in Use of Prescription Medicines for COPD: A Register-Based Study
Τρίτη, 5 Ιουλίου 2016, 1:30:07 μμ | Jacobsen, R., Ekholm, O., Rasmussen, N. K., Hansen, E. H., Frolich, A.
BACKGROUND:The purpose of this study was to examine socioeconomic variations in the use of prescription medicines among elderly subjects with COPD.METHODS:Data from the Danish national administrative registers were used. The study population included 1,365 individuals >60 y old residing in the Municipality of Copenhagen and diagnosed with COPD in a hospital setting in 2007. Logistic regression analysis was applied to examine the associations between the use of all prescription medicines for obstructive pulmonary diseases and the use of long-acting bronchodilators, in subject groups of different socioeconomic position.RESULTS:The study demonstrated that approximately 90% of subjects with COPD purchased at least one prescription medicine for obstructive pulmonary diseases, whereas approximately 50% purchased a long-acting bronchodilator. Medicine use did not vary according to educational status or personal wealth.CONCLUSIONS:There were no systematic socioeconomic differences in the use of relevant prescription medicines in elderly subjects diagnosed with COPD in hospital settings in Copenhagen. However, our findings indicate a gap between guideline recommendations and observed use of long-acting bronchodilators and hence suboptimal quality of treatment in the elderly COPD population.
Cystatin C as a Predictor of In-Hospital Mortality After Exacerbation of COPD
Τρίτη, 5 Ιουλίου 2016, 1:30:07 μμ | Hu, G., Wu, Y., Zhou, Y., Yu, Y., Liang, W., Ran, P.
BACKGROUND:COPD is associated with cardiovascular and renal dysfunction. Cystatin C (CysC) is a biomarker of renal function and an independent risk factor for all-cause and cardiovascular mortality among elderly persons. The aim of the study was to examine the prognostic role of CysC for in-hospital mortality in subjects with a COPD exacerbation.METHODS:Upon admission, serum CysC levels and arterial blood gas analysis from 477 subjects with a COPD exacerbation were measured. Clinical characteristics were also recorded. A receiver operating characteristic curve analysis was used to determine the level of CysC that discriminated survivors from non-survivors. Univariate and multiple logistic regression analyses were used to identify the risk factors for in-hospital mortality. To reduce the influence of confounders, subgroup analyses were performed according to the comorbidities, including states of heart failure, renal dysfunction, and pH, PaCO2, and PaO2 levels.RESULTS:During the in-hospital period, 59 subjects died, and 418 subjects recovered. The decedent group showed lower pH (7.27 ± 0.17 vs 7.38 ± 0.06, P < .001), higher CysC (2.21 ± 1.05 mg/L vs 1.39 ± 0.54 mg/L, P < .001), higher PaCO2 (77 ± 39 mm Hg vs 48 ± 14 mm Hg, P < .001), and lower PaO2 (74 ± 32 mm Hg vs 84 ± 26 mm Hg, P < .001) levels. The area under the receiver operating characteristic curve for the CysC prediction of death was 0.77 (95% CI 0.70–0.84). CysC values ≥1.59 mg/L were associated with significantly higher in-hospital mortality (relative risk = 5.49, 95% CI 3.24–9.32, P < .001). Multiple logistic regression analysis showed that pH
Tracheostomy in Infants With Congenital Heart Disease: A Nationwide Population-Based Study in Taiwan
Τρίτη, 5 Ιουλίου 2016, 1:30:07 μμ | Lee, Y.-S., Jeng, M.-J., Tsao, P.-C., Soong, W.-J., Chou, P.
BACKGROUND:This study aimed to use the National Health Insurance Research Database in Taiwan to examine the risk factors for tracheostomy in infants with congenital heart disease (CHD) and to evaluate the associated mortality risk in those who received a tracheostomy.METHODS:The study was conducted between 2000 and 2011 with infants assigned to either a CHD group (34,943 subjects) or an age- and sex-matched control group (136,600 subjects). We then performed descriptive, logistic regression, Kaplan-Meier, and Cox regression analyses for the investigation.RESULTS:Infants with CHD had an increased risk of tracheostomy (adjusted hazard ratio [HR], 6.67, 95% CI 4.40–10.10). Congenital airway anomaly (adjusted odds ratio [OR], 15.25, 95% CI 10.56–22.02), neuromuscular impairment (adjusted OR 6.24, 95% CI 4.35–8.94), and time (0–3 y) after CHD diagnosis (adjusted OR 3.27, 95% CI 2.19–4.89) were most highly correlated with tracheostomy placement. The mortality risk was increased in infants with CHD and a tracheostomy even after adjusting for confounders (adjusted HR 3.88, 95% CI 2.96–5.08). Mortality risk (adjusted HR and 95% CI) increased by 2.06 (1.56–2.71), 7.19 (2.42–21.38), and 14.76 (1.46–149.69) after 0–3, 4–7, and 8–11 y of follow-up, respectively.CONCLUSIONS:Infants with CHD had an increased risk of undergoing tracheostomy. The mortality risk is significantly increased in infants with CHD and tracheostomy, and the risk increases progressively with time. Further studies are warranted to clarify the mechanisms underlying the risks associated with tracheostomy.
Independent Prognostic Factors for Acute Organophosphorus Pesticide Poisoning
Τρίτη, 5 Ιουλίου 2016, 1:30:07 μμ | Tang, W., Ruan, F., Chen, Q., Chen, S., Shao, X., Gao, J., Zhang, M.
BACKGROUND:Acute organophosphorus pesticide poisoning (AOPP) is becoming a significant problem and a potential cause of human mortality because of the abuse of organophosphate compounds. This study aims to determine the independent prognostic factors of AOPP by using multivariate logistic regression analysis.METHODS:The clinical data for 71 subjects with AOPP admitted to our hospital were retrospectively analyzed. This information included the Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, 6-h post-admission blood lactate levels, post-admission 6-h lactate clearance rates, admission blood cholinesterase levels, 6-h post-admission blood cholinesterase levels, cholinesterase activity, blood pH, and other factors. Univariate analysis and multivariate logistic regression analyses were conducted to identify all prognostic factors and independent prognostic factors, respectively. A receiver operating characteristic curve was plotted to analyze the testing power of independent prognostic factors.RESULTS:Twelve of 71 subjects died. Admission blood lactate levels, 6-h post-admission blood lactate levels, post-admission 6-h lactate clearance rates, blood pH, and APACHE II scores were identified as prognostic factors for AOPP according to the univariate analysis, whereas only 6-h post-admission blood lactate levels, post-admission 6-h lactate clearance rates, and blood pH were independent prognostic factors identified by multivariate logistic regression analysis. The receiver operating characteristic analysis suggested that post-admission 6-h lactate clearance rates were of moderate diagnostic value.CONCLUSIONS:High 6-h post-admission blood lactate levels, low blood pH, and low post-admission 6-h lactate clearance rates were independent prognostic factors identified by multivariate logistic regression analysis.
Early Mobilization and Rehabilitation in the ICU: Moving Back to the Future
Τρίτη, 5 Ιουλίου 2016, 1:30:07 μμ | Hashem, M. D., Nelliot, A., Needham, D. M.
Despite the historical precedent of mobilizing critically ill patients, bed rest is common practice in ICUs worldwide, especially for mechanically ventilated patients. ICU-acquired weakness is an increasingly recognized problem, with sequelae that may last for months and years following ICU discharge. The combination of critical illness and bed rest results in substantial muscle wasting during an ICU stay. When initiated shortly after the start of mechanical ventilation, mobilization and rehabilitation can play an important role in decreasing the duration of mechanical ventilation and hospital stay and improving patients' return to functional independence. This review summarizes recent evidence supporting the safety, feasibility, and benefits of early mobilization and rehabilitation of mechanically ventilated patients and presents a brief summary of future directions for this field.
Year in Review 2015: Pediatric ARDS
Τρίτη, 5 Ιουλίου 2016, 1:30:07 μμ | Cheifetz, I. M.
Led by the work of the Pediatric Acute Lung Injury Consensus Conference, much was published on the topic of pediatric ARDS in 2015. Although the availability of definitive data to the pediatric practitioner for the management of infants and children with pediatric ARDS continues to lag behind that for the adult clinician, 2015 augmented the available medical literature with more information than had been seen for years. This article will review key pediatric ARDS publications with a focus on the Pediatric Acute Lung Injury Consensus Conference consensus definition, sedation management, use of high-frequency oscillatory ventilation, diagnosis of delirium, noninvasive respiratory support, lung-protective ventilation, and adjunct management therapies. Despite the recent progress, additional investigation in each of these areas is essential to the continued advancement of our knowledge and, more importantly, improvements in the outcome for pediatric patients with ARDS.
Year in Review 2015: Extracorporeal Membrane Oxygenation
Τρίτη, 5 Ιουλίου 2016, 1:30:07 μμ | Raman, L., Dalton, H. J.
Extracorporeal membrane oxygenation (ECMO) is a modified form of cardiopulmonary bypass. Although early trials were plagued by severe bleeding and high rates of death, subsequent experience with neonates found good survival, and ECMO became an important tool in the care of critically ill infants with respiratory failure. Since the 1980s, expansion to other groups (children, patients with cardiac disease, etc) followed as experience was obtained. Today, there is a rapid growth of ECMO, especially in the adult population. To date, >73,000 patients receiving ECMO have been reported to the international Extracorporeal Life Support Organization registry. This rapid growth in the usage of ECMO has made it possible for it to be included in the management algorithm of certain disease processes, such as ARDS, cardiopulmonary arrest, and septic shock. Significant advances in technology have made it possible to support patients on ECMO for weeks or months with success. Reduction in sedative use and experience with “awake” patients has led to ambulatory and mobile ECMO. Changes in ventilator support while on ECMO, even to the point of extubation, are also occurring. This article will review briefly some of the literature related to criteria for severity of illness before ECMO and related to ECMO care and practice. Issues relating to the use of ECMO as a resuscitative tool in cardiac arrest as well as the controversial topic of volume and outcome will also be presented.
Respiratory Therapists' Involvement in End-of-Life Discussions: Stepping Up to the Plate
Τρίτη, 5 Ιουλίου 2016, 1:30:07 μμ | Strickland, S. L.
Exercise-Induced Bronchoconstriction in College Athletes: Are We Doing Enough?
Τρίτη, 5 Ιουλίου 2016, 1:30:07 μμ | DeJuilio, P.
When Things Don't Go as Planned: The Inherent Difficulties and Potential Insights During Quality Improvement
Τρίτη, 5 Ιουλίου 2016, 1:30:07 μμ | Poon, T., Kritek, P. A.
Comparison of Approaches to Spontaneous Breathing Trial for Extubation: Is PAV+ Better Than Other Methods?
Τρίτη, 5 Ιουλίου 2016, 1:30:07 μμ | Mathews, C. E., Kamath, A., Unnikrishnan, R.
Comparison of Proportional Assist Ventilation plus, T-Tube Ventilation, and Pressure Support Ventilation as Spontaneous Breathing Trials for Extubation: A Randomized Study-Reply
Τρίτη, 5 Ιουλίου 2016, 1:30:07 μμ | Osaku, E. F., Costa, C. R., Teixeira, S. N., Duarte, P. A.
FEV1/FEV6 May Misdiagnose Patients With COPD
Τρίτη, 5 Ιουλίου 2016, 1:30:07 μμ | Ruppel, G. L., Haynes, J. M., Kaminsky, D. A.
FEV1/FEV6 May Misdiagnose Patients With COPD—Reply
Τρίτη, 5 Ιουλίου 2016, 1:30:07 μμ | Wang, S., Zhou, J., Diao, X.
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