Associate degree in counseling

Helping smokers quit: Can counseling by phone work?

How effective are telephonic counseling strategies for smoking cessation? What specific approach would you recommend?

* Smoking is the most important modifiable risk factor for premature mortality.' Approximately 70% of smokers visit a physician each year; however, only half report being advised to quit smoking by their physician. (2) The Agency for Health Care Policy and Research (now known as the Agency for Healthcare Research and Quality) introduced the 5-step protocol for smoking cessation known as the 5 A's (3):

* Ask every patient on every office visit about their current smoking behavior.

* Advise all smokers to quit and tailor advice to each patient's clinical situation.

* Assess every patient's willingness to make a quit attempt.

* Assist patients in their efforts to quit, with pharmacotherapy and counseling if necessary.

* Arrange close follow-up around the quit date either by phone or in the clinic.

The first task of the physician is to become familiar with the smoker's history, including current smoking behavior and previous quit attempts. Use of the brief Fagerstrom test for nicotine dependence is helpful. (4) The 2 simple questions, about the time to the first cigarette of the day and number of cigarettes smoked per day, can help establish the degree of nicotine dependence. Smokers should be advised to quit, and the advice should be tailored to each patient's clinical situation.

Once it is determined that a smoker is ready to quit, assistance in the cessation process should be provided in the form of pharmacotherapy and counseling. Setting a quit date allows the physician to plan follow-up telephonic-counseling sessions. These follow-up sessions are geared toward relapse prevention. Nurses and counselors can conduct these sessions as well. (5)

Telephonic counseling for smoking cessation has been shown to be effective. In one study smoking cessation rates were 21% for smokers who had 6 telephonic-counseling sessions compared with 8% for those in the nonintervention group. (5) The probability of relapse is greatest during the first 7 days after cessation. (6) Therefore, proactive telephonic counseling should be designed to help reduce the risk of relapse. One study demonstrated the effectiveness of proactive follow-up telephonic sessions scheduled on days 1,3, 5, 7, 14, and 30 after the quit attempt. (6)

The main objectives of the follow-up telephonic-counseling sessions include:

* Assess current status: Use open-ended questions (for example, How are you doing? Are you having any problems?) to gauge the patient's well-being.

* Discuss withdrawal symptoms:

The symptoms of withdrawal are strongest during the first few days after the quit date. The signs and symptoms of tobacco withdrawal include craving for tobacco, irritability, anxiety, difficulty in concentrating, restlessness, insomnia, and increased hunger. (7) Emphasize that the craving for nicotine will subside, and encourage the use of nicotine replacement products.

* Assess risk of relapse: Reassess the degree of support at home. The presence of other smokers in the household can present a problem during the cessation process. Not only is the availability of cigarettes from other smokers a problem, but also their continued smoking discourages the quitter's continued abstinence. Household members who smoke should try to stop as well. Inquire about the characteristics of previous failed attempts at smoking cessation and design strategies to avoid the same barriers.

* Provide motivation: Remind the patient of the motivational factors that triggered the most recent decision to quit. Reemphasize the health benefits of smoking cessation. Remember to tailor the advice to the patients' clinical situation.

* Improve self-image: Smokers who have not been able to quit in the past may consider themselves failures. Inquire about their longest abstinence period and ask about the characteristics of that period that led to their success. Encourage the use of social support, such as that from family members and other successful quitters.

By following these 5 simple steps in the telephonic-counseling sessions, one can expect an enhancement of the success rate for smoking cessation.

BERNARD KARNATH, MD

Assistant professor of medicine, department of internal medicine, the University of Texas Medical Branch at Galveston.

(1.) cigarette smoking among adults--United States, 1998, MMWR. 2000;49;881-884.

(2.) Frank E, Winkleby MA, Altman DG, et al. Predictors of physician's smoking cessation advice. JAMA. 1991;266:3139-3144.

(3.) The Smoking Cessation Clinical Practice Panel and Staff. The Agency for Health Care Policy and Research Smoking Cessation Clinical Practice Guideline. JAMA. 1996:275:1270-1280.

(4.) Heatherton TF, Kozlowaki LT, Frecker RC, Pagerstrom KO. The Fageratrom rest for Nicotine Dependence: a revision of the Fageratrom Tolerance Questionnaire. Br J Addict. 1991:86:1119-1127.

(5.) Wadland WC, Soffelmayr B, Ives K. Enhancing smoking cessation of low-income smokers in managed care. J Fam Pract. 2001;50:138-144.

(6.) Zhu SH, Stretch V. Balabanis M, et al. Telephone counseling for smoking cessation: effects of single-sessions and multiple-session interventions. J Consult Clin Psychol. 1996:64:202-211.

(7.) Hughes JR. Hatsukami D. Signs and symptoms of tobacco withdrawal. Arch Gen Psychiatry. 1986;43:289-294.

Eyeing the usefulness of nonbronchoscopic BAL in evaluating pneumonia

How effective is nonbronchoscopic bronchoalveolar lavage (BAL) in identifying the cause of pneumonia? When is it appropriate to use this method?

* Nonbronchoscopic BAL is used primarily for diagnosis of ventilator-associated pneumonia (VAP). The diagnosis of VAP is difficult; there is still no "gold standard." In fact, much controversy surrounds its definition and diagnosis. Most clinicians accept a definition of VAP that consists of 4 major clinical criteria in addition to bacteriologic evidence of pulmonary parenchymal infection. These criteria include:

* A temperature greater than 38.5[degrees]C (101.2[degrees]F) or less than 35[degrees]C (95[degrees]F).

* Leukocytosis or leukopenia.

* Purulent pulmonary secretions.

* A persistent infiltrate or a new or changing infiltrate on the chest film.

Although the clinical criteria are defined, the optimal method for sampling pulmonary secretions to determine bacterial infection remains controversial. During the past 10 to 15 years, numerous studies have been published on the best methods of obtaining samples in the diagnosis of VAP. These techniques can be divided into 2 groups: invasive and noninvasive.

The invasive method involves the use of a bronchoscope with a protected specimen brush (PSB) and BAL. This has the benefit of allowing visual inspection of the airways while obtaining samples, although it does require proficiency in the use of a bronchoscope. (1)

The noninvasive techniques do not require the use of a bronchoscope and include the mini-BAL (blind insertion of a small, protected telescoping catheter) and endotracheal aspirates. Noninvasive techniques are appropriate for most patients who do not require visual inspection of the airways or site-specific sampling.

Recent studies have demonstrated that regardless of the sampling method, bacteriologic evidence for pneumonia can be based on growth of bacteria in culture media (quantitative culture). Specifically, for PSB samples, bacterial growth must be greater than [10.sup.3] colony-forming units (CFU)/mL, and for BAL/mini-BAL, bacterial growth should be greater than [10.sup.4] CFU/mL. For endotracheal aspirates, bacterial growth should be greater than [10.sup.6] CFU/mL.

These values have comparable sensitivities (greater than 60%) and specificities (greater than 80%) with each of the techniques. Therefore, according to the available published data, quantitative culturing of samples allows for the effective use of nonbronchoscopic techniques in identifying microbial pathogens in VAR. (2)

We find that quantitative mini-BAL is as effective as bronchoscopic-guided BAL in identifying a bacterial pathogen in patients who have VAR In addition, noninvasive techniques can be performed by ancillary personnel, such as respiratory therapists.

DAVID W. SIUMABUKURO, MDCM

Assistant professor of anesthesia and perioperative care, University of California, San Francisco, School of Medicine.

MICHAEL A. GROPPER, MD, PhD

Associate professor of anesthesia and physiology and director, critical care medicine, department of anesthesia and perioperative care, University of California, San Francisco, School of Medicine.

(1.) Chastre J, Fagon JY. Ventilator-associated pneumonia. Am J Respir Crit Care Med. 2002:165:867-903.

(2.) Ruiz M, Torres A, Ewig S, et al. Noninvasive versus invasive microbial investigation in ventilator-associated pneumonia: evaluation of outcome. Am J Respir Crit Care Med. 2000:162:119-125.