Respiratory Care

There have been ongoing challenges with ensuring the appropriate utilization of supplemental oxygen in the acute care setting. Pre-intervention data showed that patients were not being weaned appropriately and oxygen orders were remaining active in patient’s charts for longer than clinically indicated. A recent meta-analysis study showed an increased risk of mortality in acutely ill adults treated with liberal versus conservative oxygen therapy [1]. The study concluded that there was a 21% increase in in-hospital mortality in patients who received liberal oxygen therapy.

A de-escalation pathway for nursing was created from the current oxygen therapy protocol with nursing, respiratory and physician input. Since implementation in August, we have seen improvement in all three metrics: weaning compliance, appropriate vital sign documentation, and order discontinuation. Initial scope included patients receiving oxygen via nasal cannula on the medicine service line floor units as well as the MIMU at Memorial Hermann Texas Medical Center. Project scope excluded patients receiving supplemental oxygen for pain related to sickle cell crisis, those on home oxygen, comfort measures patients, tracheostomy patients and those receiving oxygen to treat a pneumothorax.

Increased compliance was noted across all measured metrics following initial education. Oxygen de-escalation/weaning compliance improved from 56% to 63%. Order discontinuation for patients who were weaned improved from 6% to 18%. Vital sign charting with regards to oxygen therapy mode improved from 56% to 86%.

1) A PIL (PowerPoint and quiz) is being created to address the appropriate use of oxygen therapy which will be used for both nursing and respiratory therapy 2) Data collection is ongoing at the system level 3) Plan to continue data collection and re-evaluate/revise as necessary following PIL module implementation.

Compliance of de-escalation of chosen metrics

Nursing de-escalation pathway created to supplement respiratory oxygen de-escalation pathway

Acronyms in healthcare are used often but can present potential patient safety issues when staff are not familiar with the terminology. Previous studies regarding acronym use have demonstrated knowledge gaps for healthcare professionals. There are specific acronyms related to hospital-acquired conditions (HAC). The HAC workgroup at our institution collaborates with the national organization, Solutions for Patient Safety (SPS), to reduce and prevent these conditions. It was felt that many staff do not recognize some of the frequently used HAC acronyms. A staff survey to identify HAC acronyms was done to determine educational needs.

The aim of this quality improvement study was to assess staff knowledge of commonly used HAC related acronyms in a pediatric healthcare setting. The local institutional review board determined the project was not human subject research. Respiratory therapists (RTs), nurses, and physicians were provided with a list of 13 HAC acronyms to identify without assistance. It was not specified that the acronyms were HAC related. The acronyms were HAC, SPS, catheter associated urinary tract infection (CAUTI), unplanned extubation (UPE), pressure injury (PI), central line associated blood stream infection (CLABSI), ventilator associated event (VAE), venous thromboembolism (VTE), viral respiratory illness (VRI), ventilator associated pneumonia (VAP), surgical site infection (SSI), peripheral intravenous infiltration and extravasation (PIVIE) and adverse drug event (ADE). HAC workgroup members not involved in developing the survey also completed the survey for comparison. Results were analyzed using descriptive statistics.

There were 65 participants including 35 nurses, 25 RTs and 5 physicians. No one was able to correctly identify all 13 acronyms. Overall, VAP (74%), VRI (69%) and CAUTI (62%) had the largest percentage of correct responses while SSI (8%), ADE (5%) and SPS (2%) had the least. Physicians had the most correct responses (46%) followed by nurses (41%) and RTs (17%). SSI was commonly identified as social security income by all disciplines. No RT identified VTE as the HAC related acronym. From the HAC workgroup, 6 nurses completed the survey with 99% of correct responses.

Based on the survey results, education regarding HAC acronyms is warranted for all disciplines. VTE and SSI have additional definitions not related to HAC which could be easily confused. Disclosures: None

Mechanical ventilation with positive pressure ventilation, causes damage to surfactant deficient lungs. Administration of surfactant via aryngeal mask airway (LMA) offers a less invasive method of delivery without the need for intubation and mechanical ventilation. Early studies have shown that placement of the LMA is less difficult and less traumatic for the patient. The goal of surfactant administration via LMA is to remain off of mechanical ventilation and avoid the harmful effects of positive pressure ventilation, which can lead to long-term morbidity. Literature review supports the existing knowledge that the use of less invasive methods for the delivery of surfactant in the neonate is comparable to endotracheal administration, with a decrease in FIO₂, mechanical ventilator days, and overall length of stay. This study was designed to implement the existing evidence into our clinical practice to help improve the overall outcome of our patients.

To compare retrospective rates from 2015-2016 of surfactant therapy failure following in and out surfactant via intubation with a prospective Quality Study using alternative surfactant administration. The objective of this Quality Study is to avoid mechanical ventilation in neonates’ ≥ 25 weeks/≤1500 grams with mild to moderate RDS.(Institutional review board (IRB) approval was obtained for this project.) Inclusion Criteria: Gestational age (GA) 25 weeks and greater and ≤ 1500 grams Age < 48 hours RDS as defined by an FIO₂ requirement of 0.40 and greater on CPAP.

Retrospective Results: 2015- Average ventilator days (AVD)-14; 2016-AVD-15.5. Length of stay (LOS) 2015-65.2; 2016-59.3. CLD 2015-24%; 2016-14.3%. Prospective Results: AVD-2017-12.2; 2018-11.8. LOS-2017-55.8; 2018-54.0. CLD 2017-10.6%; 2018-9.8%.

Our results support the use of a less invasive method to deliver surfactant efficiently to decrease intubation and mechanical ventilation days. Data showed a decrease in the use of oxygen, LOS, AVD, and CLD rates. This is a 5-year study, initial results support the use of less invasive surfactant delivery and data will continue to be collected and reviewed.

Carilion Children's LMA Procedures FY 17 -FY 19

Treatment of bronchiolitis with high-flow nasal cannula (HFNC) may alleviate respiratory distress and reduce ICU utilization. However, HFNC use may prolong length of stay (LOS) if weaned more slowly than medically indicated. Using quality improvement methodology, we aimed to reduce HFNC length of treatment (LOT) and inpatient LOS each by 12 hours in 0-18 month old patients with bronchiolitis requiring HFNC on the pediatric hospital medicine service by April 1, 2019.

We recruited multidisciplinary representatives from key stakeholder groups to form a Wean Team. Key drivers of prolonged HFNC duration were communication difficulties between respiratory therapists (RTs) and physicians (MDs), overextended RTs and no prescribed weaning plan. Swim lane workflow analysis highlighted variations in weaning practices, which were used to inform PDSA cycles. We introduced an RT-driven weaning protocol, created standardized MD weaning orders, employed nursing and RT huddles, held education sessions, and posted reminders. The impact of interventions on HFNC duration and LOS were plotted over time in a statistical process control chart and compared to baseline rates using the Wilcoxon rank-sum test.

Mean HFNC duration decreased from a baseline of 41.9 hours to 28.9 hours during the intervention period (P < .001); mean LOS decreased from 75.4 hours to 57.2 hours (P < .01). The HFNC duration and LOS control charts (fig. 1) both demonstrate special cause variation with 7 consecutive points below the center line beginning in June 2018. Median-adjusted Levene test demonstrates a trend towards less variation in HFNC LOT (P = .06) and LOS (P = .053) during the intervention period. Balancing measure analyses revealed no post-wean PICU transfers and no change in 72-hour readmission rate.

This ongoing quality improvement project significantly decreased duration of both HFNC use and LOS for patients with bronchiolitis. Additionally, there was a concomitant reduction in variance, suggesting reduced practice variation. RT-driven HFNC weaning protocols with MD participation can reduce HFNC duration and LOS in bronchiolitis. Future work will focus on sustaining improvements and assessing the cost savings of this approach. “

In fiscal year 2015, CMS began reducing payments for patients readmitted within 30 days of hospital discharge with a diagnosis of acute exacerbation of COPD. GOLD guidelines suggest that while COPD should be considered in symptomatic patients, spirometry (PFT) is required to make the diagnosis. As part of a COPD hospital discharge review, we noticed there were instances where the patient’s diagnosis may not have been supported by available PFT data and thus may have had an impact on hospital readmissions.

Institutional IRB approval was obtained. Patients coded with a COPD hospital discharge in 2018 at Cleveland Clinic Main Campus were reviewed. PFT data (if available) was recorded to include kg/m² and FVC. The kg/m² /FVC ratio was calculated and compared with the predicted Lower Limits of Normal (LLN) values. Hospital discharge diagnosis and 30-day hospital readmission data was also available. One-tailed two-proportions z-test with continuity correction was used in R version 3.3.2 and all analysis were performed at a significance level of 0.05.

In 2018, there were 523 hospital admissions with a COPD diagnosis at Cleveland Clinic Main Campus. 109 of these patients (20.8%) had a 30-day hospital readmission. 99 of these patients had PFT data available at the time of this analysis. Of the 99 patients with data, 34 (34.3%) had a kg/m² /FVC ratio that was greater than their predicted LLN on PFT. Of the 414 patients that were not readmitted within 30 days, 318 had PFT data available and 85 (26.7%) had a ratio greater than LLN. If the 34 readmitted patients had not been coded with COPD, the 30-day readmission rate would have decreased significantly from 20.8 to 15.3% (109/523 vs. 75/489, P = .014). Even if all of the 119 patients that had PFT data greater than LLN had not been counted, the readmission rate would still have decreased from 20.8 to 18.6% but not significantly (109/523 to 75/404, P = .22). Those that were coded with a principal diagnosis of COPD exacerbation and had PFT data were significantly less in the group that did not support the diagnosis than in those that did (36/119 vs. 172/298, P < .001).

When available, providers should take into account PFT results to possibly prevent a COPD misdiagnosis. An accurate diagnosis may decrease the amount of COPD hospitalizations and readmissions. Limitations of this study include incomplete PFT data. Further studies are encouraged to examine this impact.

COPD is the second most common cause of hospital admission in the United States. Sleep Disordered Breathing is a highly prevalent and under-diagnosed condition which may impact the outcome of COPD. We hypothesized that the presence of unrecognized and untreated SDB will increase hospital readmissions in patients admitted for COPD exacerbation.

We reviewed consecutive patients admitted for COPD exacerbation from Nov 2016 - October 2017 who were also screened for SDB with sleep questionnaire, and who subsequently underwent a high-resolution pulse-oximetry (HRPO) or portable sleep monitoring (PM). We compared the rates of 30, 60 and 90-day readmission or death across SDB categories and compared overall survival in patients with and without SDB.

Of the total of 380 patients admitted for COPD exacerbation, 256 were screened for SDB with a sleep questionnaire (STOP). Of these, 238 underwent an overnight HRPO/PM. Out of the total of 238 patients, 111 (46.6%) were found to have SDB; 28.6% had mild, 9.7% moderate and 8.4% severe SDB. Baseline characteristics and demographics were compared for COPD- SDB and COPD- no SDB and were similar, except patients with SDB who had an increased mean BMI (33.9 vs 30.3) and increased co-morbidity of heart failure (19.8% vs 7.1%). Among patients with COPD-SDB the odds of 30-day readmission were 3.5 times as high as for COPD- no SDB patients (45% vs 19%, P < .001). Additionally, the odds of readmission were 3.3 as high for moderate SDB patients than mild SDB patients (61% vs 32%) and 1.5 times as high for severe SDB patients than moderate SDB patients (70% vs. 61%). The overall survival time was lower for patients with SDB than patients with no SDB (P = .001). The time to hospital readmission or death increased with increasing SDB severity (P < .001).

Patients admitted to the hospital for COPD exacerbations have significant burden of undiagnosed SDB, which may a significantly impact 30-day readmission rate. Longer term follow-up shows worse outcome with the composite endpoint of readmissions and death.

There is limited research on the effects of vaping with electronic nicotine delivery systems (ENDS). Inflammation markers and morphological lung changes have been shown within 24 hours of vaping in cell studies (doi:10.1016/j.tox.2016.07.020). There are several factors that could possibly contribute to decreased lung function and increased inflammation regarding vaping including the flavoring compounds. The aim of this pilot study was to determine if clinical measures could detect changes in lung function soon after vaping.

This IRB-approved study recruited healthy volunteers (no fever and self-reported health status, ages 21-28, 71% female). Baseline testing (prior to vaping) involved participants abstaining form vaping for 12 hours prior to measurement of forced expiratory volume in first second (kg/m²), forced vital capacity (FVC), peak expiratory flow rate (PEFR) and fractional exhaled nitric oxide (F_ENO). Participants then vaped for 10 minutes, waited 30 minutes, and then repeated testing. The participants were recruited based upon age and vaping at least 3 times per week. Manufacturer guidelines for F_ENO testing and American Thoracic Society guidelines for spirometry were followed.

Basic spirometry showed no significant change after vaping occurred. The peak flow had a modest decrease and F_ENO values increased but still remained within normal range for the seven subjects. The pre- and post F_ENO changes for three participants who vaped >5 times per week exhibited a 22.7% percent change increase.

There were no significant short-term effects, but these findings cannot be extrapolated to long-term effects of ENDS use. Study limitations include small sample size, a narrow age range and excluding those with lung conditions. It is unknown if 30 minutes post-vaping is adequate to observe the maximum effect on F_ENO. Also, each participant used their personal e-juice and ENDS device (the same flavor/brand/ingredients were not required). Some participants used e-juice with nicotine while others did not. It would be interesting to see if a nicotine component used by the entire sample group has an independent effect. Asthmatics and those with compromised airways may be more susceptible to lung function decline with e-cigarette use. Next steps for future investigation could explore the effect of ENDS on specific chronic lung disease groups. Disclosures: Loan of NIOX device and disposable patient filters provided by Circassia Inc.

Acute COPD patients utilize the hospital for inpatient admissions and ER visits. Pulmonary rehabilitation (PR) can reduce use of health care resources. The null hypothesis was that neither patient age nor PR have a significant effect on hospital utilization.

With IRB approval, discharge summaries from electronic medical records (EMR) were queried at a community hospital between January 1, 2016 and January 1, 2017. Inclusion criteria: inpatient status >1 day, >40 y of age, and primary admission ICD-10 code of COPD. Data collected: age (5 categories), combined encounters (ER visits without admission and inpatient re-admissions), PR referral/recommendation. Data analysis: P < .05 for descriptive statistics, t-test, two-way ANOVA, Pearson’s correlation for interval data.

See Table 1. For a P < .05 Pearson’s correlation found no significant association between age and combined encounters. A t-test found no significant difference in combined encounters based on PR status, PR (n = 13), No PR (n = 39) (P = .67). Two-way ANOVA found no significant differences in combined encounters between the 5 age categories and PR.

Patient age and participation in PR do not have a significant effect on hospital utilization for COPD patients. Results may be due to the variability in discharge planning given for COPD patients. More standardized discharge planning for COPD patients may decrease hospital utilization. Further study to determine specific factors affecting ER visits and re-admissions is needed. Sponsored Research: None.

Hyperinflation is routinely used to recruit lungs and prevent atelectasis in postoperative patients. This study evaluated the effectiveness of Continuous High-Frequency Oscillation Therapy (CHFO) on Cardiac Surgery (CV) patients before liberation from ventilator. We hypothesized that use of a CHFO device postoperatively (postop) would improve CV outcomes, including fewer pulmonary complications requiring antibiotics, reduced oxygen usage, and shorter ICU and hospital length-of-stay (LOS). There have been no previous studies conducted on adult CV subjects using CHFO prior to liberation from a vent.

Study sample consisted of CV patients with ASA scores of 3 or greater between Jan 2018 and Jan 2019 at Mayo Clinic-Eau Claire, WI. Prior to intervention, standard of care was to perform 4 hyperinflation treatments/day after patient was extubated. We developed a protocol incorporating CHFO. After ICU admission, and while patient was still intubated, one 10 minute CHFO treatment was performed inline with the vent. Once extubated, patients received CHFO treatments QID for 48 h. After 48 h, patients continued treatment or CHFO was discontinued. Outcomes included postop. hospital and ICU LOS, duration on vent, oxygen usage, and infections needing antibiotics. Postop. outcomes prior to intervention were compared to outcomes post intervention using linear regression for continuous outcomes, and logistic regression for dichotomous outcomes. This study was approved by Mayo Clinic’s IRB.

104 adult CV patients were studied with an ASA score ≥ 3 between Jan 2018 and Jan 2019, with 54 receiving standard of care and 50 receiving the CHFO Therapy. Standard of care patients tended to be older men (median age 70 yrs vs. 67; P = .009, 74% vs. 62%; P = .19). Compared to standard of care, CHFO Therapy patients had shorter vent days (0.6 days vs 1.1; P = .06), hospital LOS (6.2 days vs. 7.4; P = .04), ICU LOS (2.7 days vs. 3.4; P = .06), and oxygen usage (3.6 days vs. 4.2; P = .34). After multivariable adjustment, ICU LOS remained significant (0.85 fewer days; 95% CI = 0.06 to 1.65; P = .04). The CHFO Therapy group had fewer postop complications (10% vs. 20%; OR = 0.51; P = .26).

Use of CHFO Therapy for CV patients prior to liberation from MV significantly reduced ICU LOS. Other outcomes of vent days, hospital LOS, and complications were superior although ultimately not different in the protocol group. Larger studies are needed to confirm findings.

Jet nebulizers (JN) are commonly used in emergency departments to deliver bronchodilators in patients with acute asthma exacerbations. Vibrating mesh nebulizers (VMN) have been shown to be more efficient and deliver higher concentrations of medication compared to JN, but there have been no RCTs of VMN versus JN. The purpose of this study was to compare clinical outcomes related to using a VMN versus JN in the treatment of pediatric patients with acute moderate to severe asthma exacerbations.

We conducted a single-blinded randomized controlled trial of 217 children (2-18 years old) who had a known history of asthma and presented to the emergency department with an acute moderate to severe exacerbation. Assessment of severity was defined by our acute asthma score (AS), adapted from Pediatric Asthma Score (PAS), which rates severity based on respiratory rate, oxygen requirement, retractions and findings on auscultation (Mild; 1-4, Moderate; 5-8, Severe; 9-12). Patients were randomized to receive treatment via VMN and valved mask or mouthpiece or standard JN with aerosol mask or mouthpiece, and were treated until they received a mild AS and discharged or until decision to admit. Patients were treated per our Acute Asthma Clinical Pathway Algorithm for ED with modifications to allow for blinding and assessment of treatment/dose response.

108 patients were randomized to receive bronchodilator treatment via VMN and 109 via JN. There was significant difference in initial AS (P < .05) between the two study groups [VMN 9.0 (8.0 - 10.0) vs JN 8.0 (7.0 - 10.0)], but no other significant differences in demographics existed between groups. To adjust for the effect of initial AS, multiple logistic regression model was used to model admission. After adjustment of log-transformed AS and patient weight, patients treated with VMN had a higher probability to be discharged overall compared to patients treated with JN (P = 0.06), and in patients with mask interface, VMN significantly reduced the probability of admission (P = 0.03). The VMN group required significantly fewer treatments [2.0 (1.0 - 3.0) vs 3.0 (2.0 - 5.0), P < .001] and time to reach mild AS [58 mins (33 - 103) vs 81 mins (56 - 133), P = 0.004] compared to JN.

Patients treated with VMN required significantly fewer treatments and time to achieve mild AS, and in patients with mask interface, VMN significantly reduced the probability of admission compared to JN.

This study looks at the delivered amplitude (amp) and tidal volume (V_T) using an inspiratory percent (I%) of 30 at one hertz (Hz) vs the next greater Hz with an I% of 33 using a 3100A high frequency oscillatory ventilator (HFOV). Increasing HFOV Hz is a method of weaning the HFOV ventilated patient. Increasing the Hz decreases the inspiratory and the expiratory time. Despite the fact I:E remains the same, the changes increase the possibility of inadequate time for exhalation. The resulting consequence can be air trapping. The trapping can result in hyper-expansion of the lungs, which can impair gas exchange, increase shunting, and in some cases impair cardiac function if severe enough. This study looks at the delivered amps and V_Ts to understand if decreasing the I% is a choice in weaning the HFOV.

A calibrated HFOV was connected to one of the three test lungs using a full-length endotracheal tube. The lung compliances in cm H₂O and ETTs used were; 0.20cc with a 2.5 ETT, 0.39cc with a 3.0 ETT, and 0.59cc with a 3.5 ETT. The HFOV bias flow was maintained at 15 L/min. The MAP at 14 cm H₂O (+ - 0.1). The amps were measured in the test lungs using a TSI Certifier. The V_T monitor was a Dragger VN 500 BabyLog ventilator.

The HFOV frequencies tested; 6Hz thru 12Hz. The I% used; 30 and 33 for each frequency, except 12 Hz at 33 I%, only. The amps tested; 16, 18, 20, 22, 24, 26, 28, and 30. The data was collected and placed into a category consisting of the averaged measured values from all 8 amps and V_Ts from a single Hz at a given I%. The categories were then paired, so a Hz at 30 I% was matched with the category of the next higher Hz at 33 I%(see graphs 1 thru 6). The V_T categories were then stratified further using the DLCO2 equation [(f * VT²)/kg] (see graphs 7, 8, and 9). With using in vitro testing the weight aspect of the DLCO2 equation was not completed.

By decreasing the I% to 30 there is a demonstrated reduction in the delivered amps and V_Ts. The paired categories results are similar. The 30 I% values are slightly larger than the 33% measurements, except for a few examples. Where 30 I% values are larger you may expect that the change would be a lesser wean. However, when the V_T categories are stratified using the DLCO2 equation the data would suggest the Hz at 30 I% would be a marginally greater wean than increasing the Hz at 33 I%. Only clinical application/trial will determine if these assumptions are correct.

Graphs 1, 2, & 3 are the delivered amplitude to the lung model. Graphs 4, 5, & 6 are the delivered tidal volumes. Graphs 7, 8, & 9 are the calculted DLCO2s

Scoring systems are frequently used to assess the severity of pediatric asthma exacerbations. The modified pulmonary index score (MPIS) is used in our institution as part of our pediatric asthma pathway. Total MPIS has been found to be highly correlated with pediatric intensive care unit (PICU) length of stay (LOS); however, this was a single center study with a relatively small sample size. We sought to evaluate the use of the MPIS to predict hospital LOS for patients admitted to our PICU.

Following IRB approval, the medical records of all pediatric asthma subjects aged 2 to 17 years of age admitted to our PICU between June 2014 and November 2017 were retrospectively reviewed. Subjects were identified via ICD9 and ICD10 codes. We a priori divided subjects into three groups based upon each subject’s first MPIS documented in PICU, low (MPIS 0-5) medium (MPIS 6-9) and high (MPIS ≥10). Hospital LOS, PICU LOS, time on continuous albuterol, and need for increased respiratory support were compared between groups. Data were analyzed with SPSS v24 with nonparametric, chi-squared, and one-way ANOVA performed. Poisson regression analysis was performed to identify PICU admission factors associated with hospital length of stay.

A total of 143 subjects were included. There were no differences for age, gender, weight, home medications, medical history, cause of exacerbations, noninvasive ventilation use, or need for intubation between groups. There were significant differences between groups for mean heart rate (P < .001), respiratory rate (P < .001), SpO₂ (P = .01) and FIO₂ (P < .004). There were significant differences between groups for median hospital length of stay (1.2 vs. 2.3 vs. 3.4 days, P < .001), PICU length of stay (0.39 vs. 1.3 vs. 2 days, P < .001), and time on continuous albuterol (7.4 vs. 20.6 vs. 34.7 h, P < .001). There were significant differences between groups for route of admission (P = .03), high-flow nasal cannula use (P < .001), and heliox use (P < .001). After adjusting for demographics and medical history, the incidence risk ratio for hospital LOS was 2.47 for PICU admission MPIS of 7-10 and 3.25 for an MPIS >10 when compared to an MPIS ≤6.

The MPIS thresholds used in our pathway appear to differentiate exacerbation severity. A higher MPIS is associated with increased hospital LOS, PICU LOS, time on continuous albuterol, need for high-flow nasal cannula and need for heliox.

Retinopathy of prematurity (ROP) and bronchopulmonary dysplasia (BPD) are significant morbidities of the very low birth weight (VLBW) infant. Hyperoxia, hypoxia, and oxygen fluctuations have been implicated in these disease processes. The ideal target SpO₂ range has been the subject of discretion in literature; however, any target range within a larger recommended range is prudent for best practice. An individual unit must determine alarm limits and metrics for tracking compliance with oxygen supplementation.

“Save Our Lungs and Eyes” (SOLE) is an oxygen saturation protocol that was implemented to improve SpO₂ targeting in VLBW infants. Our unit targets 89 – 94%, and tracks compliance. Histograms for all VLBW patients receiving FIO₂ of 30% or more are reviewed every 12 hours and categorized into predetermined oxygen ranges. Using the Model for Improvement, we aim to improve our within range time from an average of 40% of the time to an average of 50% of the time over the next year.

Since 2014, our within range time was tracked. We averaged 40% of time within range for 2014 and 2015. We increased our time within range in 2016 slightly, but have decreased in 2017.

Applying improvement science has led to standardization of practice, but high reliability has been difficult to achieve. Our small tests of change, which have included bedside triggers, monitor programming, and education bundles, have led to modest but questionably sustainable improvement. Future directions include peer conversation with other units, further monitor interrogation, and perhaps revisiting our alarms and targets for sustainability of improvement.

Device related pressure injuries cause pain, disfigurement, morbidity and mortality. Reducing respiratory device related pressure injuries is one of our hospitals operating plan goals. The rate of pressure injuries in January 2018 was 12.46 per 1,000 noninvasive days or 0.70 per 1,000 patient days. A recent study done at our facility revealed a correlation between NIV patient mask leak and pressure injury. Specifically our research identified that there was a correlation with higher patient leaks and pressure injuries. After placing the minimum and maximum patient leaks on the same graph it was noted that there was less pressure injuries in the group with patient leaks >25 L/min and max leaks <55 L/min.

An IRB approved prospective interventional design study was conducted on all noninvasively ventilated patients with mask from 02/01/18-2/1/19. We presented the results of our previous correlation study in May 2019. In August and September all respiratory and nursing staff in PICU, ACU, Medical, Hematology/Oncology, and Pulmonary were instructed on the use of leak guidelines for preventing mask device related pressure injuries. Following education, signs were placed on each machine reminding staff of guidelines and weekly audits were implemented to assess compliance. Compliance with flow guidelines reached more than 80% in December 2018.

Of the 1,932 noninvasive days since education was completed, only one pressure injury has occurred (0.52/1,000 vent days; a 96.79% reduction) or 0.05/1,000 patient days; a 92.86% reduction). Since we reached 80% compliance with maintaining leak guidelines in December 2018, 1,221 noninvasive days has resulted in 0 noninvasive mask related pressure injuries.

Utilizing flow guidelines to guide mask strap tension on noninvasively ventilated patients with a mask has led to 0 pressure injuries related to this respiratory device. This allowed us to successfully achieve our hospitals operating plan goal within this group.

Current Respiratory Therapy programs incorporate minimal palliative and hospice care education in their curriculum; palliative and hospice care is not included in the respiratory care department orientation process; participation in the Main Line Health (MLH) Palliative Care Fellowship highlighted the need to determine baseline RT knowledge and attitudes towards Palliative and Hospice Care and evaluate potential education and engagement opportunities. Literature Review: Much of the literature obtained focused on terminal extubation and end of life care in the critical care setting; Michaud-Young (2009) noted that patients with chronic lung disease require care by clinicians who will be in a position to support them as they approach end of life; an editorial in the September 2017 Lancet journal remarked that palliative care in chronic lung disease is an important and often neglected part of clinical practice.

Respiratory therapists at MLH were invited via email and department posted flyers to participate in a palliative and hospice care pre/post education survey; all RTs who completed the pre survey were sent a link to view a short palliative and hospice care video in-service; as well as, complete a post survey.

44 of 126 RTs (35%) invited to participate completed the pre-survey, while 32 of 44 RTs (73%) who completed the pre-survey viewed the video in-service and completed the post survey; 91% (40/44) of RTs believe there was not adequate Palliative and Hospice Care education provided during their student training; 98% (43/44) of RTs believe palliative and hospice care should be part of the department orientation process. Post survey/in-service data displayed in chart below.

Simple education initiatives related to palliative and hospice care may address RT knowledge gaps; as well as, positively impact attitudes related to this topic; incorporating palliative and hospice care into our department orientation process is warranted; with an aging chronic lung disease population there is opportunity for Respiratory Therapists to increase engagement in MLH Palliative and Hospice Care initiatives. Disclosures: None

Texas Children’s Hospital (TCH) is located in Houston, Texas. The TCH Newborn Center has 173 beds separated into three units. The Newborn Center is staffed with 480 registered nurses (RNs), 130 physicians and neonatal nurse practitioners (NNPs), and 50 respiratory therapists (RTs). The task of translating quality improvement (QI) projects related to reducing lung injury from teams to the providers at the bedside is a daunting prospect and one that we struggled with based on having three separate units and such a large staff.

The Respiratory Care Department made a commitment to pilot providing Team Leads (TLs) Monday through Friday on the day shift, and Monday through Thursday on the night shift. The TLs were then integrated into the Avoiding Lung Injury (ALI) QI Team which had a focus on minimizing time on the ventilator, a CPAP first strategy, placement of CPAP on in the delivery room, oxygen titration and performing room air trials on qualified infants. The TLs are also engaged with simulation related to decreasing unplanned extubations, performing skin rounds and providing respiratory education to the nursing staff, physicians and NNPs. The TLs attend the morning huddles and report out to the medical teams on infants that are on extubateable settings, infants that are on inhaled nitric oxide and infants that have not had their supplemental oxygen weaned in a week. Monthly educational topics are developed and the TLs will take the education to the bedside for nursing and medical staff.

Placement of CPAP in the delivery room is at 100%, there have been no serious hospital acquired skin injuries, and the unplanned extubation rate is at a new low of 0.4 events per 100 ventilator days. The culture is shifting in that there are now extubations occurring around the clock and not primarily on the day shift Monday through Friday as was the old routine. The TLs have been able to provide ventilator education to incoming classes of Graduate Nurses and to incoming Fellows and Residents.

The TLs have had a positive impact on the Newborn Center and are actively engaged in seeking out additional opportunities in which they can get involved. The next step will be to place a cost value to the role so that hospital administration can see the value in having a non-productive, meaning not generating revenue via therapy, positions in the Respiratory Care Department.

Texas Children’s Hospital (TCH) is located in Houston, Texas. The TCH Newborn Center has 173 beds in three units. TCH Newborn Center manages approximately 25 intubated infants per day with 480 Registered Nurses (RNs), 130 physicians/Neonatal Nurse Practitioners (NNPs), and 50 Respiratory Therapists (RTs). Ues are the fourth most common cause of harm in Neonatal Intensive Care Units in the United States, with approximately 20% resulting in cardiovascular collapse requiring CPR or epinephrine.

The Unplanned Extubation (UE) team is comprised of RNs, RTs, physicians, and NNPs that meet weekly to review any Ues from the preceding week and determine trends and potential interventions to help decrease the incidence. Each UE event has a debrief form completed, an in house safety event generated and is documented in the electronic medical record. In the weekly meetings all of the documentation is reviewed and events surrounding the UE are examined to determine a category in which to place the event. The primary categories are depth of the endotracheal tube (ETT), securement device failure, high risk activity (repositioning, weighing, bathing), agitation and unable to theme. The interventions developed and deployed to the units were, the WHERE Campaign, Weight Helps Ensure Right ETT depth, the NRP recommendation for ETT depth was used, weight in kg + 6 = approximate depth of the ETT at the lip. Utilization of an Airway Guardian to maintain the ETT during positioning, movement and invasive procedures. ETT securement was standardized to either tape or a commercial securement device. Rolling simulations were performed throughout the units on both shifts to facilitate comfort with standing transfers for Kangaroo Care. The last intervention looked at the standard ETT securement with tape and was more prescriptive over the amount of cheek coverage that should be attained, with a goal of at least 50% coverage of the area from the corner of the mouth to the ear.

The UE rate in the Newborn Center from October 2015 to September 2016 was at a high of 2.93 Ues per 100 ventilator days, this was reduced by 41% to a rate of 1.74 over the following year. The rate has continued to decline and in May 2019 has reached our lowest level with 0.4 Ues per 100 ventilator days.

Despite the challenges of separate units and a large number of people to educate, a concerted and dedicated team can affect sustainable improvement and effect a culture change.

Caregiver education and training for children with tracheostomies is multi-faceted and complex. The process can be lengthy as there are many aspects of care that must be learned, practiced and demonstrated proficiently before discharge home can occur. The process is generally longer for children requiring a home ventilator due to additional training needs. There are on average 20-25 new tracheostomies performed per year at our pediatric institution. The caregiver tracheostomy education process is managed by dedicated respiratory therapists. Changes in documentation and communication were made to the education process in efforts to improve efficiency and reduce the time to complete training as part of an institutional quality improvement program.

A tracheostomy list was created within the electronic medical record (EMR) system to identify all inpatients with a tracheostomy. Communication of training status was documented in the treatment team section of the EMR. Education record documentation was revised for tracheostomy teaching specific points. The length of time between the tracheostomy class and completed training was compared before and after the process changes. Inclusion criteria were children who had a tracheostomy placed during July 2017 – January 2019 and whose caregivers received training. Children who had not yet discharged were excluded.

There were 38 children for whom caregiver tracheostomy education was completed during the defined timeframe. Three were excluded due to ongoing hospitalization. Of the remaining 35 children, 21 (13 ventilated, 8 non-ventilated) received education before changes were implemented and 14 (9 ventilated, 5 non-ventilated) afterwards. The length of time to complete education was reduced for both ventilated and non-ventilated children. See table. Time from completed training to discharge was relatively unchanged.

Improvements in treatment team communication and EMR documentation were effective in reducing the time to complete caregiver tracheostomy education. Time to discharge can be influenced by many factors not related to the training process. However, completing the training sooner may allow the opportunity for more time to practice skills before discharge.

A score-based asthma pathway is utilized at Arkansas Children’s Hospital to manage and treat asthma exacerbation in children. The pathway is initiated by the physician and completed by the respiratory therapist (RT) who assesses and provides treatment based on the score. Frequency of treatments and reassessment is dependent upon the score. When admission from the Emergency Department (ED) for asthma exacerbation occurs, an inpatient RT coordinator evaluates the patient upon arrival to the medical-surgical ward. Delays in treatment and escalations of care have occurred due to waiting on bed placement. During this time, inpatient orders are held until arrival to the ward and the coordinator is unable to assess. We hypothesized that if the RT coordinator evaluated the patient before transferring to the inpatient ward, delays in care would be decreased.

The study was approved by the local Institutional Review Board. Several process changes were made including improved communication between the ED admitting nurse and the RT coordinator, patient assessment by the coordinator in the ED, and monitoring of the ED tracker board. A retrospective and prospective chart review was utilized to compare the length of time between rescoring in the ED and on the inpatient ward before and after process changes were made. Children with asthma admitted to the pediatric intensive care unit (PICU) were excluded as assessment is done by the RT assigned to the unit rather than the coordinator.

There were 261 children with asthma admitted from the ED between June 2018 and January 2019. Of those, 95 were treated before changes were made while 114 where managed with new process. Fifty-two were excluded due to transfer to the PICU. The baseline for time between rescoring in the ED and on the inpatient ward was 132 minutes. Under the new process, the time was reduced to 81.48 minutes which resulted in a 38% decrease in waiting time.

Implementing process changes for children with asthma admitted from the ED resulted in a significant reduction in the wait time for care.

Delivery efficiency of nebulizers has been described with noninvasive ventilation. However, albuterol delivery to patients with different airway resistance (Raw) and lung compliance (CL) has not been quantified. The purpose of this study is to compare albuterol delivery during noninvasive ventilation of a simulated pediatric with different levels of Raw and CL.

A collecting filter at the bronchi of a teaching manikin was attached to a passive test lung (QuickLung, Ingmar Medical) to simulate a spontaneously breathing pediatric. A ventilator (Trilogy 202, Philips) with a single limb circuit (S/T mode, inspiratory pressure: 6 cm H₂O, expiratory pressure 8 cm H₂O, respiratory rate: 30 breaths/min and I:E ratio 1:2) was connected to a pediatric upper airway manikin via the standard oronasal mask (AF541, Respironics). Albuterol sulfate (2.5 mg/3 mL) was delivered with jet (MistyMax10) and mesh (NIVO) nebulizers at Raw of 5 and 20 cm H₂O/L/s and CL of 10 and 20 L/cm H₂O during noninvasive ventilation (n = 5). Descriptive statistics and Mann Whitney U test were used for data analysis (P < .05).

The table below shows inhaled dose% delivered (mean ± SD) distal to the trachea. The mesh nebulizer delivered up to 3-fold more drug than the jet nebulizer in all conditions tested in this study. Regardless of the type of nebulizer used, no significant difference was found between Raw 5 and Raw 20 at CL of 10 L/cm H₂O while reducing Raw from 20 cm H₂O/L/s to 5 cm H₂O/L/s significantly improved aerosol delivery using jet (P = .030) and mesh (P = .040) nebulizers at CL of 20 L/cm H₂O. Although aerosol deposition obtained with the mesh nebulizer was not statistically different with CL 10 and 20 L/cm H₂O at Raw 20 (P = .55), its delivery efficiency increased with an improvement in lung compliance at Raw 5 (P = .041). Aerosol delivery with the jet nebulizer significantly increased with CL 20 L/cm H₂O compared to CL 10 L/cm H₂O at Raw 5 (P = .003) and Raw 20 (P = .031).

At low CL such as 10 L/cm H₂O, a significant increase in Raw does not impact aerosol delivery regardless of the type of nebulizer used during NIV while there is an inverse relationship between aerosol deposition and Raw at CL of 20 L/cm H₂O. Aerosol delivery with jet and mesh nebulizers improved with an increase in CL during pediatric noninvasive ventilation.

Objective measurements of asthma impairment could aid teens in recognition of changes in asthma status over time. Ready access to a conventional spirometer is not realistic outside of the clinical setting. In this proof-of-concept study, we compared the performance of the VitalFlo mobile spirometer to the nSpire KoKo sx1000 spirometer for accuracy in measuring Forced Expiratory Volume in one second (kg/m²) and Forced Vital Capacity (FVC) in adolescents with asthma.

Two hundred forty pulmonary function measurements were collected from 48 adolescents with persistent asthma from the University of North Carolina’s pediatric allergy and pulmonology subspecialty clinics. Participants performed spirometry with the nSpireKoKo sx1000 spirometer and the VitalFlo spirometer during their clinic visits. 119 simulated FVC maneuvers were conducted on both devices to standardize measurements. Pearson correlations, Bland-Altman analysis, and two-sample comparison tests were performed to assess the relationship between the two spirometers.

VitalFlo measurements were significantly highly correlated with nSpireKoKo spirometer values for kg/m², (r2 = 0.721, [95% CI, 0.749 ± 0.120], P < .001) and FVC (r2 = 0.617, [95% CI, 0.640 ± 0.130], P < .001) measurements. There were no statistically significant differences of the mean kg/m² (M = 0.00764, SD = 0.364, t(59) = 0.16, P = .87) and FVC measurements (M = 0.00261, SD = 0.565, t(59) = 0.036, P = .97) between the VitalFlo and nSpireKoKo systems. Both devices demonstrated significantly high correlation when comparing the automated FVC (r2 = 0.997, [ 95% CI, 1.00 ± 0.00974] P < .001) measurements. Bland-Altman plots did not demonstrate significant bias between devices for both kg/m² and FVC measurements.

Lung function measurements from the VitalFlo mobile spirometer were comparable to a commercially-available spirometer commonly used in clinical settings. This validated app-based spirometer for home use has the potential to improve asthma self-management.

Noninvasive ventilation (NIV) provides ventilatory support for spontaneously breathing patients without requiring an artificial airway. Questions remain regarding carbon dioxide (CO₂) clearance while using a conventional ventilator and dual limb circuit with various patient interfaces. The purpose of this study is to determine the PEEP level required to effectively washout CO₂ for full-face and oronasal masks, and assess their comfort.

This randomized crossover trial was conducted at an academic medical center in the Midwest. After obtaining informed consent, 8 healthy volunteers were placed on a 980 Puritan Bennett (Medtronic, Minneapolis, MN) ventilator operating in the NIV mode. All subjects performed 20 minutes of breathing on 4 levels of PEEP (0, 2, 4, and 5 cm H₂O) and pressure support of 5 cm H₂O. NIV settings were applied to 4 masks (2 oronasal and 2 full-face masks) that were randomly selected with a 5-minute wash out period between each mask. Fraction of inspired carbon dioxide (FICO₂) was sampled/monitored with a nasal cannula using a CapnostreamTM 20p monitor (Medtronic, Minneapolis, MN) and reported as percentages. Additionally, subjective mask comfort was assessed via visual analog scale (VAS). A Kruskal-Wallis test was used to reveal significance difference across PEEP levels. Pairwise comparisons of the groups were made using Mann-Whitney tests with a Bonferroni correction.

FICO₂ was significantly lower at PEEP of 5 (0.0%, IQR: 0, 0.92) compared to PEEP of 0 (1.83%, IQR 0.66, 4.0, P < .001) or PEEP of 2 (1.0%, IQR 0.33, 2.66, P = .002). FICO2 was significantly lower at PEEP of 4 (0.5%, IQR: 0, 1.92) compared to PEEP of 0 (P = .001). Comparison of masks’ level of comfort showed no significance differences.

A PEEP level of at least 5 cm H₂O was required to minimize the likelihood of CO₂ rebreathing while using a critical care ventilator with a double limb circuit and full-face or oronasal masks. Although masks comfort level was not significantly different, it should be assessed in a larger sample size.

Median Fraction of Inspired CO2 at Various PEEP Levels During NIV Using a Critical Care Ventilator with Full-Face and Oronasal Masks

While numerous factors influence employee engagement, communication is considered the cornerstone of an engaged workforce. When department operations run 24/7 and staff work 3 days a week, face to face communication can be limited compared to traditional workplace settings. The primary purpose of this study was to evaluate the effect new communication tools would have on the perception of communication in employee engagement scores, particularly communication drivers.

We conducted pre/post surveys of staff perceptions of communication and trend analysis of 2018/2019 employee engagement results. New communication tools included a smart phone app, department newsletter, communication board, start of shift check-ins. We hypothesized an improvement in post-implementation survey results and post-implementation employee engagement survey drivers in communication category, demonstrating improvement in both perception of communication and employee engagement.

The pre/post implementation surveys showed 68% of staff were satisfied with overall communication pre-implementation compared to 65% post-implementation. While there was a slight decrease in overall satisfaction with communication, the respondents were given an option to provide comments which revealed overall positive opinions about the new communication tools. For the employee engagement survey, two questions in the Communication and Input category were evaluated for positive agreement by answering either Strongly Agree or Agree. 51.3% agreed in 2019 “I am kept informed of the organization’s future plans and direction” compared to 50.6% in 2018, a 0.7% improvement. 72.7% agreed in 2019 “My manager communicates messages that my coworkers need to hear, even when the information is unpleasant” compared to 62.7% in 2018, a 10.1% improvement.

We did not demonstrate improvement in perception of communication by implementation of these communication tools. We did see improvement in employee engagement responses, however, we cannot conclude that the new communication tools specifically contributed. We identified factors which may have influenced results during this timeframe, including leadership changes, management of confidential HR matters, and general adjustment to change. Ongoing assessment and evaluation of communication methods are needed to determine best approaches as staff demographics change, department needs shift, and technology evolves. Disclosures: None

Delivery of albuterol in-line with heated high flow nasal cannula (HHFNC) using a vibrating mesh nebulizer is frequently used in the hospital setting. HHFNC systems are now available for home use, however efficacy of aerosol delivery with these devices is unknown.

An anatomically correct pediatric model of a spontaneously breathing 5-year old child was connected in series to a filter (lung dose), and to a breathing simulator (tidal volume 200 mL, breathing frequency 20, inspiratory time 0.9 s). An AIRVO 2 HHFNC system (Fisher & Paykel) was connected to an Optiflow Junior 2 XL cannula, and operated at 5 and 15 L/min. A Solo vibrating mesh nebulizer (Aerogen) was placed between the circuit and the cannula using a proprietary adapter or regular t-piece adapter. The heating chamber was modified to allow placement of the nebulizer in the dry or in the wet side of the humidifier. Four units of the nebulizers loaded with 10 mg/2 mL of albuterol were tested. Albuterol mass was measured via spectrophotometer, and reported as percentage of loading dose.

See table.

Aerosol delivery in-line with a heated high flow nasal cannula system designed for home use was inefficient except when a t-piece adapter was used between the circuit and the cannula. Lower flow improved aerosol delivery for the same system.

Endotracheal tube (ETT) cuff leak in intubated patients is one of the leading causes of aspiration pneumonia and ventilator-associated pneumonia. The primary functions of the ETT cuff are to prevent air leak and minimize aspiration. The recommended cuff pressure ranges from 20 to 30 cm H₂O. The purpose of this study was to evaluate the ETT cuff compliance change over time while maintaining the cuff pressure at 30 cm H₂O.

IRB approval was not required for this laboratory study. Under controlled conditions, the Laerdal Airway Management Trainer (Wappingers Falls, NY) was intubated with three different sizes of ETT (8.0,7.5, and 7.0) (Covidien/Medtronic, Minneapolis, MN). The depth of ETT was 22 cm at the incisors and the ETT was secured with regular ETT tape. A three-way stopcock was used with ports connected to the ETT pilot balloon, Posey Cufflator (Arcadia, CA), and 10 mL syringe. The cuff was inflated with the syringe until Cufflator reads 30 cm H₂O of pressure. Volume of air needed to reach 30 cm H₂O was recorded. The stopcock was removed and the Cufflator was subsequently used to check and maintain cuff pressure at 30 cm H₂O every 6 to 8 hours. Same steps were repeated for 14 days for each ETT tube. Confidence intervals (CI) for the mean were calculated with a significant level of <0.58 for all 3 sets of sample data.

After 14 days of maintaining the cuff pressure at 30 cm H₂O, all three ETT require more volume to maintain cuff pressure at 30 cm H₂O (Figure 1). The size 8.0 ETT shows an increase of volume from 3.3 mL (day 1) to 5.9 mL (day 14). The size 7.5 ETT shows an increase of volume from 3.9 mL (day 1) to 4.3 mL (day 14). The size 7.0 ETT shows an increase of volume from 4.0 mL (day 1) to 4.8 mL (day 14). The calculated CI for ETT sizes 8.0, 7.5, and 7.0 are 0.54, 0.08, and 0.13 respectively. All three data sets show a significant volume change from day 1 to day 14.

More cuff volume is needed to maintain the cuff pressure following sustained cuff inflation. Since compliance is determined by the volume and pressure, the volume increase at day 14 infers that the cuff compliance has increased over the course of 14 days. Routine use of the recommended cuff pressure should be done along with careful airway assessment in order to prevent inadvertent overinflation of the ETT cuff. A limitation of this study is that human subjects were not available due to IRB restrictions.

Figure 1 Volume of air needed to maintain cuff pressure at 30 cm H2O from day 1 to day 14

Middle East Respiratory Syndrome Coronavirus (MERS-CoV) is a novel betacoronavirus that was first reported in Saudi Arabia 2012. The majority of infected cases were reported in Saudi Arabia too. Extracorporeal membrane oxygenation (ECMO) is an option as a rescue therapy for patients with refractory hypoxemia and has been successfully used in young patients with severe ARDS secondary H1N1 influenza with refractory hypoxemia. Aim: We conducted a retrospective study to determine the mortality rate of severe ARDS secondary to MERS-CoV infection in response to ECMO therapy in our adult ICU.

A retrospective analysis of data from all patients admitted to our adult 23-bed mixed ICU with MERS-CoV infection who developed severe ARDS and been mechanically ventilated between March 1, 2013 and August 30, 2016.

During the period from March 1, 2013 and August 30, 2016, 32 patients were admitted with severe ARDS secondary to MERS-CoV infection (mean age 54 ± 21 years, 25 [78.1%] males). Bilateral pulmonary infiltrates were reported in all patients. Invasive mechanical ventilation and ECMO therapy was applied in all patients and vasopressor therapy in 26 (81.2%) patients during the ICU stay. Twenty-four (75%) patients died in the ICU. Non-survivors were older and/or had high APACHE II scores on admission.

Severe ARDS secondary to MERS-CoV infection is associated with high mortality. ECMO therapy was associated with better survival rates and outcomes in younger patients and the patients who had lower APACHE II scores.

Rural hospitals have a difficult time recruiting pulmonologists and intensivists; not every provider in the Sarah Bush Lincoln Health System (SBLHS) has ventilator privileges. Historically, challenges have been receiving timely orders, evaluating vent settings, and aggressive weaning. Current research suggests RT driven protocols are safe and efficient ways to manage ventilated patients.

An RT and RN driven protocol was co-developed and adopted to better facilitate a more consistent ventilator weaning process for patients. Beginning in January 2018, an algorithm was piloted at SBLHS. Patients were evaluated daily by nursing with a safety screen and subsequent spontaneous breathing trial (SBT) by RT if the patient qualified. During the vent weaning process, and upon completion of the SBT, patients are evaluated by a remote telemedicine multidisciplinary team comprised of RT, RN, and an intensivist. Upon successful completion of a SBT, even if a SBLHS provider is unavailable, a remote telemedicine intensivist can provide optimization or extubation orders. Examples of optimization orders may be changes such as sedation, vent settings, further blood gas analysis or a repeat wean trial later in the day. Continuous feedback and case reviews were evaluated along the way.

Two years of data was collected and evaluated. In 2017 and 2018, SBLHS had a total of 220 ventilated patients in our adult CCU. The top three diagnoses of patients who were maintained on ventilators were sepsis, surgery, and overdose, which account for nearly 63% of all intubated patients at SBLHS. One year after implementing the weaning process, our critical care unit saw a 24% reduction in median vent days.

The addition of telemedicine support allows for timely provider orders and supports the bedside CCU staff with the vent weaning process. Regardless of time of day, this weaning process has improved communication and collaboration at the bedside through telemedicine support. This support has optimized ventilated patient outcomes, by decreasing ventilator days. RT and RN led protocols with the support of telemedicine have decreased median vent days in a rural community hospital. This study helps to set the stage for other opportunities that might exists between RT/RN led quality metrics. Barriers to this data include staff and provider buy-in. This study was approved by the institutional IRB. Disclosures: None

The purpose of this study was to investigate if sleeping with a weighted blanket improves the quality of sleep for the user. Weighted blanket manufacturers claim that sleeping with a weighted blanket improves sleep quality by reducing anxiety, stress and insomnia. There is dearth research to support their claims besides user testimonies.

Participation in this study included having individuals wear an out of center sleep testing device (OCST) for two nights. This device measured total sleep time, sleep efficiency, sleep onset and snoring. After the participants slept the first night wearing the OCST without the weighted blanket, they were then asked to sleep with weighted blanket and repeat the study. An 8 question Epworth Scale was also used to evaluate participants predisposition to sleep disorders. Informed consent was obtained.

A total of 10 subjects participated in this study. Due to tight academic time constraints the total number of participants was limited. Comparison between sleeping with and without the weighted blanket yielded mixed results. An increase in total sleep time was found in 40% of the participants, a decrease in sleep onset in 60% of participants, a decrease in snoring episodes in 40%, and an increase in sleep efficiency in 50% of the participants.

There is an expanding market for consumers searching for easy solutions to poor sleep quality as well as a huge emphasis on the need for sleep education today. Dearth amount of data is available to prove or disprove the claims that weighted blankets improve the user’s sleep quality. With the mixed results from this study, and the lack of available research, more research needs to be done to determine the effects of weighted blankets on sleep quality.

The standard for administering aerosolized medication (AM) to infants and toddlers has been via jet nebulizer with face mask (FM). Continuous nebulization (CN) with a bronchodilator has been used to treat asthma symptoms. High flow nasal cannula (HNFC) is the treatment of choice for kids in respiratory distress. Globally, trans-nasal (TN) pulmonary AM delivery via HFNC has been receiving increasing clinical attention for comfort treatment, but, presents a challenge when used in conjunction with CN via FM. Several published in vitro studies demonstrated that AM deposition in infant lung models were vastly reduced when interfaced with a FM. Particularly, if applied on top of the HFNC appliance or if a pacifier is present or the baby is stressed. Furthermore, comfort levels for infant and parent may decrease and impact AM delivery.

This study examined the performance of a vibrating mesh nebulizer (VMN) (Aerogen nebulizer), HFNC in conjunction with an MedFusion 4000 syringe pump (SP) to measure AM output at varied mg/h. The HFNC equipment consisted of: (MR850 humidifier chamber (HC) with an RT329 infant heated wire circuit), products by Fisher & Paykel Healthcare. Our Pharmacy Department added 0.5% (albuterol - 5 mg/mL continuous) into the SP library program. NaCL solution was substituted for albuterol, 20 mL was drawn up into a 60 cc syringe was connected to the SP. The VMN was installed on the dry side of the HC. An RT329 circuit was used during the evaluation with gas flows set at 2 to 6 L/min. The SP was programmed in mg/h. The liquid solution was dropped onto the VMN for the creation of aerosol mist.

Infusion rate equal aerosol output rate mL/h; 5 mg/h = 1 mL/h, 7.5 mg/h = 1.5 mL/h, 10 mg/h = 2 mL/h, 15 mg/h = 3 mL/h, and 20 mg/h = 4 mL/h.

The SP performed up to manufactures specifications comparing set mL/h to total volume delivered in mL/h at different mg/h. The advantages of TN-AM via SP; precise drug concentration delivered in mg/h, no (NaCL) dilution required with less AM loss into the surrounding environment with more available for inhalation. The FM is not required and may improve comfort score and overall AM deposition. Liberation is achieved by modifying mg/h or frequency/h. More In vitro and in vivo investigations are needed to determine objective dose effectiveness of TN - AM delivery, or if different mg/h concentrations have an effect on clinical outcomes.

The role of mechanical ventilation is to improve gas exchange and reduce the patient’s work of breathing. Unfortunately, prolonged ventilation is associated with many negative sequelae. It is imperative when clinical stability is achieved that the goal of ventilator liberation is facilitated. Adaptive support ventilation (ASV) is a novel mode of ventilation that provides a closed loop assessment of mechanically ventilated patients. The mode will adjust delivered tidal volume and set respiratory rate based on feedback physiological data and patient interaction. If the patient starts breathing spontaneously, the mode adjusts from time-cycled ventilation to flow-cycled ventilation and may wean the patient without clinician ventilator interaction. This facilitation of weaning may decrease ventilator duration and facilitate ventilatory liberation. Mechanical ventilation in a neuro-science ICU (NSICU) is often utilized for patients with a normal respiratory status but an altered neurological function. The goal of mechanical ventilation in the majority of patients is to optimize gas exchange until the patient is neurologically stable and awake. Typically pedestrian ventilator parameters are required to achieve these clinical end-points. The standard practice to facilitate ventilator liberation was to transition the patient from volume target CMV ventilation to flow-cycle PSV and then perform a spontaneous breathing trial prior to extubation.

In attempt to facilitate ventilator liberation thus decrease ventilator duration we implemented ASV as the default ventilator mode in stable NSICU patients. An ASV ventilator protocol was developed and any patient meeting the inclusion criteria was placed on 100% MV via ASV mode (figure 1).

Over a 6-month time frame the utilization the ASV mode in the NICU reduced ventilator duration from the historical length of 5.6 days to 4.1 days. Re-intubation rates remained < 5% and ventilator-associated pneumonia< 1%.

Based on our clinic experience ASV can facilitate the weaning process and reduce ventilator duration in a NSICU. By automatically transitioning from time-cycle to flow cycle ventilation and titrating PSV levels to a desired tidal volume the ASV mode can expedite the weaning process in clinically stable patients.

The role of mechanical ventilation is to improve gas exchange and reduce the patient’s work of breathing. Unfortunately, prolonged ventilation is associated with many negative sequelae. It is imperative when clinical stability is achieved that the goal of ventilator liberation is facilitated. Adaptive support ventilation (ASV) is a novel mode of ventilation that provides a closed loop assessment of mechanically ventilated patients. The mode will adjust delivered tidal volume and set respiratory rate based on feedback physiological data and patient interaction. If the patient starts breathing spontaneously, the mode adjusts from time-cycled ventilation to flow-cycled ventilation and may wean the patient without clinician ventilator interaction. This facilitation of weaning may decrease ventilator duration and facilitate ventilatory liberation. Mechanical ventilation in a thoracic open heart unit (OHU) is often utilized for patients with a normal respiratory status but an altered neurological function secondary to post-operative sedation. The goal of mechanical ventilation in the majority of patients is to optimize gas exchange until the patient is awake and spontaneous breathing. Typically pedestrian ventilator parameters are required to achieve these clinical end-points. The standard practice to facilitate ventilator liberation was to transition the patient from volume target CMV ventilation to flow-cycle PSV and then perform a spontaneous breathing trial prior to extubation.

In attempt to facilitate ventilator liberation and thus decrease ventilator duration we implemented ASV as the default ventilator mode in stable OHU patients. An ASV OHU ventilator protocol was developed and any patient meeting the inclusion criteria was placed on 100% MV via ASV mode (figure 1).

Over a 6-month time frame the utilization the ASV mode in the OHU reduced ventilator duration in clinically stable OHU patients from the historical length of 11.1 h. to 5.5 h. Re-intubation rates remained< 1% and ventilator-associated pneumonia< 1%.

Based on our clinic experience ASV can facilitate the weaning process and reduce ventilator duration in OHU patients. By automatically transitioning from time-cycle to flow cycle ventilation and titrating PSV levels to a desired tidal volume the ASV mode can expedite the weaning process in clinically stable patients in a OHU.

Employee engagement is a hot topic in healthcare and a strategic focus in many high performing organizations. Engagement leads to improved performance, higher productivity, and less turnover yet, according to a Gallup poll, 68% of the U.S. workforce is disengaged. The Studer Group, an authority on this topic, believes eliciting employee feedback through rounding is a foundation tactic to improve engagement. But, gathering feedback without mining for solutions delivers no opportunity for improving operational results.

In 2018, the Penn Medicine Lancaster General Hospital's Pulmonary department enhanced their rounding strategy to include focused solution finding. Termed Purposeful Rounding", the department's leadership team added questions to their rounding that focused on lower scoring items from their previous year's organizational employee engagement survey which included: workload, recognition, ideas and suggestions, training opportunities, and safe care (AHRQ question). Using a Likert scale, therapists were asked to rate their feelings on these topics and offer solutions to improve them. The team was continually asked for feedback to measure the impact of improvements made in the department.

The experiment was measured over 7 months where all therapists were rounded on at least once with a total of 135 individual rounds. The average score of the lowest scoring items of the 2017 survey was 19.3% favorable. As improvements were made and feedback was re-measured, favorable scores improved to 68.8%. Therapist retention rate was measured at 92.8% during the same time period.

Eliciting feedback, mining for solutions, and idea execution resulted positive changes in the pulmonary department. The use of purposeful rounding provided the department the insight to identify these opportunities while providing an objective measure to the subjective metric of engagement. We hypothesize that these results will predict the results of our next formal engagement survey and improve the overall score by focusing on the lowest scoring items. "

The therapeutic use of respiratory (RT) devices in the ICU places patients at increased risk for the development of device related pressure injuries (PI). After a sustained elevation in RT device-related PI in the ICUs of a large academic children’s hospital, a quality improvement project was initiated. Goal: To decrease the incidence of RT device-related PI by 20% from baseline over a 9-month period.

Patients admitted to the ICU of a pediatric academic medical center were evaluated for the outcome of RT device-related PI. Each PI was staged in accordance with the National Pressure Ulcer Advisory Panel. Data for hospital acquired PI was examined, and PI from RT devices were extrapolated and reported per 1000 inpatient days. Only stage 2 or worse PI were included in this evaluation (Stage 2, 3, 4, unstageable, and deep tissue injury). Interventions included: 1) Multi-disciplinary group assembly to focus on RT device-related PI 2) Skin care bundle recommendations during noninvasive ventilation (NIV) for both neonatal and pediatric applications 3) Education to clinicians for proper securement of endotracheal tubes (ETT) 4) Increased surveillance and documentation of skin assessments in the electronic medical record every 3-4 hours. Outcomes over a 9-month baseline were compared to a 9 month intervention period followed by evaluation of a 9 month sustainability period. Sustainability measures included frequent process measure audits and ongoing education to providers on service in the ICUs.

During the baseline period, RT device-related PI were associated with ETT (n = 9), pediatric NIV (n = 3), neonatal NIV (n = 5) and trach tube (n = 1). Baseline incidence rate for RT device-related PI was 0.4/1000 patient days, which decreased during the subsequent 9-month period (Figure 1). The skin protective strategies implemented resulted in a 55% reduction in the incidence of RT device related PI, and results were sustained for a 9-month period.

A collaborative and multi-faceted pressure injury prevention strategy contributed to reducing skin harm, while allowing for the continued use of critical respiratory support devices. Acknowledgement: Our thanks to the JHACH department of Respiratory Care and the Save our Skin workgroup for their commitment to reducing patient harm.

Low tidal volume targeted ventilation (LTVV) has been recommended as a standard strategy for adult mechanically ventilated patients and is associated with reduced mortality. Adoption of LTVV has been reported to range between 19% – 75%. All cause hospital mortality for adult mechanically ventilated patients has been reported at 28%. We sought to evaluate how a respiratory therapist directed LTVV model applied at the onset of mechanical ventilation would compare to previously reported LTVV practices. We also compared all cause hospital mortality.

This IRB approved retrospective analysis included electronic medical record review of adult mechanically ventilated (MV) patients managed between March 2018 and March 2019. 1,425 subjects required MV for > 24 hours. The primary outcome was the percentage of subjects receiving set V_T < 8 mL/kg of predicted body weight at onset of MV when compared to a reported average of 75%. Secondary outcome was all cause hospital mortality compared to a reported average of 28%. Categorical data is reported as frequency (%) and continuous data is reported as median (IQR). Chi-Square goodness-of-fit test was applied to compare outcomes. Alpha (2-tailed) < .05.

At initiation of MV, V_T was < 8 mL/kg in 96.8% of subjects when compared to reported average of 75% (P < .001). Median V_T at initiation of MV was 6.0 mL/kg (IQR 5.9-6.3) whereas median V_T for the duration of all days of MV was 5.9 mL/kg (IQR 5.8-6.0). All cause hospital mortality was significantly lower among our subjects (18.4%) when compared to previously reported values (28%; P < .001). Median age was 61 y (60% male). Cardiac (32%), Medical (21%), and Surgical (12%) subjects accounted for the majority of the cohort. Refer to Table for additional descriptive characteristics.

A respiratory therapist-directed LTVV strategy initiated at the onset of adult MV resulted in high adherence when compared to previous publications. The overall mortality observed in these subjects was significantly less than previously reported.

Health care facilities that choose not to utilize 24-hour on-site respiratory therapist coverage, such as some freestanding emergency departments, critical access hospitals, and skilled nursing facilities, rely on other licensed health care professionals to assume such clinical responsibilities. The use of a virtual respiratory therapist via a telehealth cart provides another alternative. The current evaluation investigates the accuracy and efficiency of registered nurses (RNs) utilizing a remote virtual respiratory therapist in the absence of an on-site respiratory therapist.

Institutional review board was consulted, and determined that this evaluation was exempt. In a simulated patient room, 20 emergency room RNs were guided by a virtual respiratory therapist via a telehealth cart in the following procedures: 1) initial starting up and entering initial ventilator settings on an acute care ventilator and a transport ventilator, 2) changing ventilator settings, 3) starting up and entering initial BIPAP settings, and 4) changing BIPAP settings. The accuracy was calculated based on the number of tasks completed correctly divided by the total number of tasks assigned in each procedure. Efficiency was measured based on the time taken for completing each procedure. For comparison, the same procedures were performed independently by 10 respiratory care practitioners (RCPs) and were evaluated using the same parameters.

As shown in Table 1, RNs utilizing a virtual respiratory therapist took longer to perform all procedures. A two-sided, two-sample t-test with equal variance assumption showed that this difference was statistically significant. The RNs exhibited 100% accuracy, as did the RCPs, in changing ventilator and BIPAP settings and in initial starting up of the transport ventilator. However, the accuracy of initial starting up and entering initial settings on the acute care ventilator (97.8%) and BIPAP (99.0%) were slightly less in the RN group than in the RCP group (100%).

Although it was possible for a virtual respiratory therapist to assist RNs in completing tasks remotely via a telehealth cart, facilities interested in pursuing this staffing model will need to consider the extra time needed to perform these tasks and the potential for decreased accuracy in completing tasks as compared to staffing a respiratory therapist on-site at all times. Disclosures: No potential conflict of interest.

Prevalence of tobacco smoking is poorly declining especially in low and middle-income countries. There are numerous studies on effect of cigarette smoking on tuberculosis treatment outcomes but with dissimilar conclusion. Objective: to determine the effect of cigarette smoking on tuberculosis treatment outcomes Methods: PubMed, Cochrane library and Google Scholar databases were searched last on February 27, 2019. Stata version 14 with meta-extension and Comprehensive Meta-analysis (CMA) software were used to analyze the dataset. Random effects model was applied for the analysis and forest plot was displayed together with the effect sizes (odds ratios) and the 95% confidence intervals of the studies. Sub-group analysis and meta-regression were also run to identify reasons for heterogeneity. Publication bias was assessed using funnel plot with superimposed Egger’s regression line and its test of significance. Furthermore, contour enhanced funnel plot, Orwin’s Fail-Safe N, cumulative meta-analysis were performed to check for small study effects.

Twenty-two studies were included in the qualitative synthesis. Eight studies reported P -values (< .05) that show smoking significantly increases risk. Four studies also report the same effect albeit they indicated the effect was dependent on dose of the cigarette smoked per day. However, 10 studies reported non-significant P-value (> .05). From the meta-analysis, smoking was found to increase risk of poor tuberculosis treatment outcomes by 51% (OR = 1.51; 95% CI = 1.30 to 1.75 and I-square = 75.1%). The effect is higher for countries with lower-middle income (OR = 1.74; 95% CI = 1.31 to 2.30) and upper-middle income economies (OR = 1.52; 95% CI = 1.16 to 1.98) than for high income ones (OR = 1.34; 95% CI = 1.03 to 1.75) though not statistically significant. The effect of smoking doesn’t show significant improvement over years (P = 0.82). Test of publication bias reported publication bias is unlikely (P = .403) and the Orwin’s Fail-Safe N analysis indicated at least 50 small missing studies are required to bring the computed combined effect to 1.10 trivial odds ratio. The effect of small studies was negligible.

Cigarette smoking increases risk of poor tuberculosis treatment outcomes

No nebulized form of a long-acting dual bronchodilator exists for patients with chronic obstructive pulmonary disease (COPD). With the approval of once-daily, long-acting muscarinic antagonist (LAMA) revefenacin (REV), it may be possible to deliver a LAMA and a long-acting _-agonist via a standard jet nebulizer. These prespecified and post hoc analyses assessed the safety and efficacy of REV 175 µg administered sequentially before or combined with formoterol (FOR) 20 µg via a standard jet nebulizer, in subgroups of patients with COPD defined by certain demographic and clinical characteristics.

In Study 0167, a randomized, double-blind, phase 3, 42-day trial (NCT03573817), 122 patients with moderate to very severe COPD were randomized to receive REV (n = 63) or placebo (PBO) (n = 59), then FOR in the morning and evening for 21 days (sequential administration), all via a standard jet nebulizer. Patients continued treatment for an additional 21 days. However, the morning treatments, REV or PBO, and FOR, were given as mixed solutions via a single nebulization (combined administration), and FOR was given alone in the evening. Adverse events (AEs), serious AEs (SAEs), discontinuations, deaths, and trough forced expiratory volume in 1 second (kg/m²) changes vs baseline were assessed in the following subgroups: smoking status, age, current inhaled corticosteroids (ICS) use, reversibility to a short-acting bronchodilator, sex, and Global Obstructive Lung Disease 3 and 4 patients. Approval for this trial was obtained from an Institutional Review Board.

Patients (mean age 64 y; 57% men; 57% smokers) had an kg/m² of 55% predicted; 24% were on ICS. The proportion of AEs by subgroups are shown in the Table. Across all subgroups, exacerbation/worsening of COPD, cough, and dizziness were the most common AEs, with more AEs reported in the PBO-treated subgroups. No AEs led to discontinuation in the REV-treated subgroups and there were no SAEs or deaths in any subgroup. Trough kg/m² vs baseline over each 3-week treatment period by subgroups are shown in the Table. For former smokers and patients who were not reversible to ipratropium, the least squares mean differences were smaller vs the other subgroups.

Across all subgroups, REV, administered sequentially before or combined with FOR via a standard jet nebulizer, had a tolerability profile similar to FOR alone. Trough kg/m² response was greater in patients treated with REV + FOR, vs FOR alone.

The American Thoracic Society and European Respiratory Society 2005 guidelines recommend weekly spirometry linearity checks for flow sensing devices and weekly syringe D_LCO checks using a calibrated 3-L syringe. The expected failure rate for these checks is unknown. One abstract from a multi-center study suggests < 10% failure rate. This study identified the current frequency and source of failures with syringe linearity and syringe D_LCO checks. Quality control (QC) failure reasons were also categorized.

A mechanical QC program for an inhaled medication study included biweekly syringe linearity and syringe D_LCO checks to ensure reliable equipment function for subject testing. Results were sent to a central repository for expert review. Onsite training was provided to 114 pulmonary function labs (PFLs) from North America, Europe, and Israel. Over 42 months ending in 2018, 108 PFLs continued with the study. The syringe linearity checks used peak flows < 2 L/s, 3 to 7 L/s, and > 8 L/s. Acceptable linearity data were within the expected flow range and had FVC variance ≤ .09 L. Syringe D_LCO checks were accepted when 2 trials fell within pre-established ranges for D_LCO, IVC and VA. Percentage failure rates for onsite training checks and subsequent study period were calculated. The reasons for failure were categorized.

Of 114 PFLs, onsite training syringe linearity failure occurred in 2 (1.8%) sites, syringe D_LCO check failures occurred at 6 (5.3%) sites. Syringe linearity failures during training were related to inadequate 3-L calibration syringe equipment. Of the 6 syringe D_LCO failures, 3 were due to inadequate calibration equipment and 3 required service calls for hardware repairs. During the study period, 108 sites completed 5083 syringe linearity and 4992 syringe D_LCO checks. Of the 5083 syringe linearity checks, 496 (9.76%) failed and of the 4992 syringe D_LCO checks 311 (6.23%) failed. Reasons for QC failure are shown in Figure 1.

The failure rates for both syringe linearity and syringe D_LCO checks were < 10%. Over 40% of syringe linearity checks failed due to technologist errors. In contrast, equipment errors accounted for 86% of syringe D_LCO failures. The QC failure reasons define and target areas for corrective action and education for PFL staff. Assuring that equipment is within established QC limits is essential for accurate subject test results.

In 2016 alone, 490,000 multidrug-resistant TB (MDR-TB) cases reported worldwide. The failure to control the disease in the presence of effective drugs to cure it implies that psychosocial and economic factors of the cases need to be addressed and such studies are uncommon in Ethiopia. Objective: To understand psycho-social challenges patients with multi drug resistant tuberculosis face and the perception of patients with multi drug resistant tuberculosis as a threat to community Methods: A hermeneutic phenomenological study design was used to explore the lived experience of patients with MDR/XDR-TB at ALERT hospital during December 28, 2017. Purposive sampling technique was employed to recruit the study participants. A semi-structured interview guide which had main questions and probing question was developed to undertake in-depth face-to-face interview. Open Code software version 4.02 was employed to make the analysis. Emergent codes were assigned to segments of the transcript that were relevant to the study objective. Finally, themes were developed from the categories. In reporting the findings, the consolidated criteria for reporting qualitative research (CORE-Q) which is a 32-items checklist was followed. Lastly, the inter-relationship among codes, categories and themes was displayed using a diagram.

From the analysis, 6 categories were identified from the codes as contributors of psychosocial problems in MDR-TB patients. Those were; Apprehension about economy for survival of dependent family or self, phobia development against risk factors of TB disease, regretting of handling previous life condition to protect self from TB, feeling hated or stigmatized, hopelessness and harm to mind. These categories in turn used to develop two major themes, namely anxiety/depression and intending revenge to transmit the disease to others.

Control of MDR-TB spread demands beyond therapeutic treatment of the patients Recommendation Psychological therapy and designing income generation mechanism for MDR-TB patients while they are at treatment center are commendable.

Bullying is a well-documented issue for healthcare workers, and can have a significant impact on an institution in regards to employee retention. Retention of healthcare workers is an important concern, as turnover is costly to the healthcare system. The retention problem has become even more complex as managers have had to adopt individualized strategies to account for the multigenerational workforce. Intent to leave has been described in the literature to be an accurate predictor of actual turnover. This study explores the relationship between bullying experienced in the workplace and an individual’s intention to leave, stratified by generational cohorts.

This study was approved by the IRB. A multi-institution electronic survey was conducted of registered nurses and respiratory therapists working in hospitals throughout central Ohio using the 22-item Negative Acts Questionnaire Revised (NAQ-R) and the Turnover Intention Scale (TIS-6).

Over 23% of respondents indicated they experienced bullying in the workplace. Respondents indicated they were exposed to unmanageable workloads, had their views and opinions ignored, and felt excluded in the workplace. Baby Boomers had the highest mean score on both the NAQ-R and TIS-6, indicating they experienced the most negative acts in the workplace and had the highest intention to leave of the three cohorts. Millennials had the lowest mean score on the NAQ-R, and the second highest score on the TIS-6. A Pearson Product moment correlation was used to examine relationships in sum scores between the TIS-6 and NAQ-R. Results indicate a somewhat low-moderate positive relationship between the two measures (r = 0.30; P < .001).

Bullying is still a problem facing healthcare professionals. Baby Boomers are likely to leave their positions to retire, which may account for their high intent to leave scores. Millennials had the second highest scores on the TIS-6. Millennials, who have previously been described in the literature as having the highest rates of turnover, are starting to show more loyalty to their current employers, compared to previous years. Higher scores on the TIS-6 did correlate with high scores on NAQ-R, but the correlations were low-moderate, suggesting that a relationship exists between workplace bullying and intention to leave. Future studies in various settings will need conducted to confirm these preliminary findings, and to account for the next cohort, Generation Z.

Heated high-flow nasal cannula (HHFNC) systems are used to treat children with hypoxemia and respiratory distress. These devices allow modification of flow and FIO₂. We evaluated the effect of different FIO₂ settings and the relationship between inspiratory and cannula flows on tracheal FIO₂.

An anatomically correct orotracheal model of a 5 y old child was connected to a breathing simulator (frequency = 20 breaths/minute, tidal 180 mL, T_I 0.9 s, inspiratory flow 12 L/min), and an oxygen analyzer was interposed. A Fisher Paykel (FP) Optiflow Junior 2 XL cannula was used with the Fisher Paykel HHFNC system with a blender and the AIRVO 2 device with cannula flows of 6, and 12 L/min. Another oxygen analyzer was placed in-line with the circuit at the cannula connection. FIO₂ was set at 0.95, 0.70, 0.50 and 0.35. Circuit and tracheal FIO₂ was measured. Absolute difference between device and tracheal FIO₂ (Delta FIO₂) at different FIO₂ s, and Delta FIO₂ at 6 and 12 L/min were analyzed. Measurements were done in quadruplicate after 7 minutes of continuous operation.

See table.

Delta FIO₂ was greater at higher FIO₂ settings. The effect of air entrainment was more evident at higher FIO₂ settings. The AIRVO 2 device was more effective than the FP device when cannula flow matched inspiratory flow.

The primary objective of the study was to determine whether home usage of warm humidification can potentially reduce the number of exacerbations in patients with a diagnosis of chronic obstructive pulmonary disease (COPD) stage II-IV. There have only been a few small studies evaluating the efficacy of warm air humidification in reducing the number of hospitalizations in this population.

The study was conducted as an open label, non-randomized prospective trial, with use of a retrospective comparable control group. Patients with stage II to IV COPD were asked to participate in the study. A warm air humidifier was provided for home use as either a stand-alone unit, or in addition to their current long-term oxygen therapy (LTOT). Patients were followed for 1 year. Measurements taken at base, 1 month 3 month, 6month, 9 month, and 1 year time periods, included pulmonary function testing, hospitalizations, Steroid or antibiotic therapy, six minute walk test, and Quality of Life questionnaire. The study was reviewed and approved by a local IRB. All patients were consented and provisions of HIPAA were followed. Student's T test was applied for all continuous variables, Bonferroni adjustment not applied.

A total of 22 patients were enrolled into the study with a 45.5% (10 of 22) completion rate at 12 months. Pulmonary function test change after 12 months for kg/m² and kg/m²/FVC were -0.035 L/s (P = .53) and -0.501 L/s (P = .043) respectively. Quality of life (QOL) measures differed at 6 months with an improved mean of 4.06 (P = .0005), to a worsened value of 1.79 (P = .07) at 1 year. Compared to a separate control group, annual hospitalizations decreased from 12 to 8 in the treatment group (P = -0.534), with yearly use of antibiotics, steroids, and self-treatments decreasing from 48 vs. 25 (P = .10), 40 vs. 23 (P = .13), 41 vs. 17 (P = .07) respectively. When the year prior to enrollment hospitalization rates and use of antibiotics and steroids were analyzed, the statistics yielded similar results.

In this study, the daily use of warm humidification, statistically did not improve lung function or quality of life in those with stage II-IV COPD at 12 months. The device also lacked statistical significance in decreasing hospitalization, antibiotics, steroids, or use of self-treatments. Device or treatment tolerance was an issue and lead to a high dropout rate. Disclosures: None of the authors have any disclosures to report.

Respiratory therapists (RTs), nurses (RNs), nurse aide (NAs), and emergency medical services (EMS), are required to work together to provide care. Shared learning through interprofessional education (IPE) enhances education, and patient outcomes. The objectives are to understand student and faculty readiness for IPE and to ascertain if it is an effective teaching strategy in conjunction with the use of high-fidelity simulation for Advanced Cardiac Life Support (ACLS) instruction. A secondary goal is to explore student and faculty perceptions and attitudes toward IPE.

60 students and 10 faculty from 4 health science programs attended a code blue simulation in the Sim Lab at Southwestern Community College (SCC). The Readiness for Interprofessional Learning Scale (RIPLS) was completed by all participants pre/post to measure readiness for and attitudes toward IPE. Data were collected using a pre-post quiz pertaining to ACLS as well as a video to assess knowledge and perceptions. Data were analyzed using descriptive statistics. Approval to undergo this study was given from the Institutional Review Board (IRB) at SCC and from the IRB at the University of North Carolina at Charlotte.

The average score on the pre quiz (67%) increased to 89%, indicating improved learning. NA and first year RT students combined saw the most improvement (54% pre, 85% post). Results demonstrated a higher degree of readiness at SCC for IPE than average. The overall mean scores of students’ readiness (79) and faculty (90) was higher than the average score on the RIPLS survey (48). Results suggest that participation in the study enhances attitudes toward IPE, collaboration, understanding of others’ roles, and confidence.

The study exposed an exceptional degree of readiness and a positive attitude among participants toward IPE and the value of collaboration. The research suggests that incorporating IPE in community college health science programs using ACLS simulation yields several benefits. These include improved student learning outcomes, confidence, and knowledge as it relates to the curriculum. Faculty and student attitudes and readiness for IPE is positive. Learning using IPE increases understanding of the roles of other healthcare professions, improves confidence, enhances clinical preparation, improves communication, and promotes teamwork.

Respiratory therapists are an integral part of the critical care team as they are specialist in airway and ventilator management. Currently newly graduated respiratory therapists have limited exposure to advanced critical care technologies and critical training. Once the allotted orientation period is over, the expectation is for recent graduates to master equipment and procedures in a high stress environment. The post orientation period is when recent graduates would benefit from practicing skills and reviewing policies. The Respiratory Care Department at Boston Children’s Hospital adopted a high fidelity simulation for new RTs to become proficient with low volume high risk procedures, skills and knowledge. The SIMPeds center at Boston Children’s Hospital offers 2 simulation sites on campus and also an entire SIM center across the street from the hospital Methods: While the respiratory care department was involved with numerous multidisciplinary simulations throughout the hospital but they were not fulfilling the needs of the post orientation periods of our new therapists. We decided to offer a safe environment fostering communication skills as they practice these identified high risk skills. The course consists of didactic skills sessions; two simulations and debriefings, lasting in total five hours. Participants employed six months to a year and a resource therapist. To enhance the dynamic of the simulations, we have recruited an RN and MD to make the experience more realistic. The didactic concentrates on communication and other principals of crisis resource management. The simulation scenarios combine both the skill sets reviewed and didactic portion for a cohesive curriculum.

There were 57 RTs, (73% of the department) who completed this course. We have held 12 courses in the past 3.5 years. Participants are asked to complete a Likert scale survey at the end of the course, with IRB approval. Of the 57 responses: Conclusions: After reviewing the results from the Likert survey and the answers to some of the open ended questions, it was evident that not only was there a need for the course, but also a request for more simulations in the future. There were 12 requests for more simulations and among those requests were 8 for simulations twice a year for all staff members

Working in collaboration with the NICU Skin team to evaluate pressure injury rates (HAPI Healthcare acquired pressure injury) it was discovered that a large amount of the injuries was related to respiratory therapy devices. With these results, a literature review was conducted to evaluate the findings compared to published results. The Journal of Neonatal Nursing found 247 neonatal patients were reviewed, of these infants 77 were identified as having a skin injury (a prevalence rate of 31.2%). The Respiratory therapy noninvasive CPAP delivery devices were associated with 14.0% of those HAPI. The mean gestational age was 28 weeks. A Literature review on prevention of HAPI found the use Hydrocolloid dressing to be beneficial in the preventing nasal trauma secondary to nasal CPAP in preterm infants. (2) Along with continuous education to nursing and respiratory therapy were found to be beneficial to decreasing the rate of HAPI events (3).

Continue to perform NICU skin assessments and collect data starting January 1st 2017 till April 2019 with a total of 812 babies assessed. Starting January 2017 event reports were completed for all issues including redness. Prior to 2017 multiple changes were implemented to include standardizing equipment to use only Fisher & Paykel Flexi trunk CPAP system. Starting simultaneous RN and RT skin assessment along with nasal prong and mask sizing any changes occurred at this time. The team instituted the use of Septal H, a hydrocolloid barrier device.

The NICU HAPI rate was < 2% of annual admissions and assessments (15/812). The Respiratory Therapy related injuries were 1.3% (9/812) of the HAPI. The mean gestational age was 26 weeks. The HAPI rate remained stable at < 2% of NICU admissions. In 2017, with the introduction of Septal H there was 5 HAPI in a 2 month time frame. This was analyzed and found not to be the product itself, but due to a deviation from traditional skin assessment technique. From September 2017 till March 2019 the HAPI rate remained less than 2%.

Strong nursing and respiratory therapy relationship can achieve a significant reduction in Neonatal HAPI. While there are many CPAP interfaces available, mastering proper fit and sizing along with attentive skin assessment will lead to reduction in HAPI. . While being successful in all of the previously mentioned changes, continuing education for RT and RNs had the largest impact on the reduction of HAPI.

Reported HAPI VS published national average

Extubation failure considers a common issue in intensive care units (ICUs) and leads to increased associated complications, mortality, and costs. Many factors have been identified as predictors for failed extubation, but the role of electrolytes and glucose were not fully examined in the previous research. The aim of this study, therefore, was to investigate the impact of electrolytes disturbance and glucose level on extubation outcomes among adult patients in ICU.

A cross-sectional study was conducted using data from electronic medical records at King Abdulaziz Medical City (KAMC) between 2016 and 2017. Adult patients who were admitted to ICU and intubated for at least 72 hours were included in this study. Glucose and electrolytes levels were obtained 72 hours before and after extubation attempt. We used unpaired t-test to compare the mean of electrolytes and glucose level between patients with successful extubation and patients with failed extubation. This study has been approved by the King Abdullah International Medical Research Centre IRB committee (protocol number SP18/225/R).

A total of 2,385 patients were screened for inclusion and 82 of them met inclusion criteria A total of 82 patients were included in this study. 88% of the populations were male with a mean age of 40 years (± 14). The mean of glucose was 7.88 mmol/L for those patients who had successful extubation, where this was higher in those with failed extubation 10.2 mmol/L. The mean level of sodium was statistically different between patients who had successful extubation compared to patients with failed extubation 140.4 mmol/L vs 145 mmol.L) Conclusions: Hyperglycemia before extubation and hypernatremia after extubation may be considered predictor factors for extubation failure. The finding of this study provides insight on the possible association of glucose and sodium one the risk of extubation failure. Further epidemiological studies with the rigorous methodological design are needed to examine this association in more depth. Disclosures: All authors have nothing to disclose.

Obesity (defined as body mass index (BMI) of ≥30 kg/m²) considers a rising health problem around the world. Currently, the influence of obesity on acute illness has been explored in the literature. However, the effect of obesity on the duration of mechanical ventilation among patients who admitted to the intensive care unit (ICU) remains unclear. The current study; therefore, examined the effect of the obesity on the duration of mechanical ventilation among injured patients who admitted to the ICU and were involved in road traffic accidents.

An analytic cross-sectional study was conducted using data from electronic medical records at King Abdulaziz Medical City in Riyadh, Saudi Arabia between 2016-2018. Adult ICU patients receiving mechanical ventilation who were involved in road traffic accidents were included in this study. Patient’s demographic and clinical information were extracted from the medical files. The association between BMI categories (normal BMI (18.5-24.9 kg/m²), overweight (25-29.9 kg/m²), obese (≥30 kg/m²), and underweight (<18.5 kg/m²) and the duration of mechanical ventilation (in days) were examined using ANOVA test. This study has been approved by King Abdullah International Medical Research centre IRB approval committee (protocol number SP18/060/R) Results: Total of 128 patients were included in this study. Majority of the study population were male (94%) with a mean age of 29 ± 12 years. The average duration of mechanical ventilation among the study population was 8 days (SD ± 6). 46.9% of the patients had normal BMI, 27.3% were overweight, 13.3% were obese, and 12.5% were underweight. The mean duration of mechanical ventilation were longer among underweight patients (10 ± 7 days) compared to overweight patients (mean duration was 8 ± 6days). There was no statistical significant difference in the mean duration of mechanical ventilation between BMI categories by one-way ANOVA (F = 1.49.7, P = .22).

The current study provides insight for a possible influence of BMI level on the duration of mechanical ventilation in acute illness. This can add new evidence to support the obesity paradox that refers to a lower mortality rate among obese patients with many daises. ICU physician and respiratory therapists have to consider the impact of BMI in the management of patients who involved in a road traffic accident. Disclosures: All authors have nothing to disclose.

Unplanned extubation (UE) is a preventable adverse event and may lead to additional complications such as cardiovascular resuscitation or respiratory compromise in a critically ill neonate during an emergent reintubation. A quality improvement project to reduce unplanned endotracheal tube dislodgement would reduce these morbidities. Aim: To reduce unplanned extubations in the NICU to 1 UE/100 ventilator days by October 2018. Setting: A level 4 NICU with 950 annual admissions and a baseline rate of 9.9 unplanned extubations/100 ventilator days Culturally, our NICU clinical team accepted unplanned extubation as a normal risk factor in the patient population and did little to challenge this status –quo. We felt we could decrease our UE rate through the use of standardized securement equipment, standardized care delivery models and a re-education program for all NICU staff.

We formed an inter-professional task force consisting of a Neonatologist, two Respiratory Therapists and the NICU Nurse Educator. We tracked all of our unplanned extubations as well as required the staff involved to file an electronic safety report. PDSA cycles consisted of: staff attitude survey, development of data collection tool, protocol of 2 staff members for all transfers of intubated patient, staff education around securement device and daily retaping of ETT to securement device. UE and ventilator days were extracted from a respiratory database and electronic medical record. Control charts (u-chart) were created using QI Macrosã and IHI-Healthcare control chart rules used to determine special cause variations. The Maine Medical Center Institutional Review Board determined that this was quality improvement and did not qualify as research.

A special cause variation was noted via control chart rules for the mean UE rate from baseline of 9.9 UE/100 ventilator days (8/2017-11/2017) compared to post-intervention mean of 1.6 UE/100 ventilator days (8/2018-3/2019). In addition, during the intervention phase of the project (12/2018-7-2018), a special cause variation was noted with an UE rate of 5 UE/100 ventilator days (Figure 1).

Development of a QI project by a multidisciplinary taskforce, along with several PDSA cycles including education and staff awareness, reduced UE rate by 84% in a level 4 NICU. Ongoing surveillance, education and review of UE cases will be key to maintaining UE at a goal of 1 UE/100 ventilator days.

Opioid related deaths are rapidly increasing and are a national focus1. Uintah Basin Medical Center is a 49-bed hospital located in eastern Utah. Following 3 unplanned home deaths in patients taking opioids as prescribed post-operatively who had undergone Ear, Nose and Throat (ENT) procedures, we piloted an initial study of a home monitoring protocol to earlier identify and intervene with pts most at risk for opioid induced respiratory depression (OIRD). This is our second study.

From July 2017-June 2018, all pediatric and adult ENT post-op pts prescribed opiates were discharged with a Masimo RAD 8 or Masimo Rad 97 monitor for 7 days. Data was recorded during sleep/naps and analyzed after device return. Pts were educated on risks of opioid use, the relation between OIRD and falling blood oxygen levels. They were instructed to call/come to the hospital if oxygen saturation (SpO₂) alarmed and read < 85%.

Two-hundred fifteen pts were monitored. Results are reported in Table One.

It was our impression that using the Masimo technology would diminish false alerting since it differentiates between artifact and actual out-of-range alerting. Our collaborating hospital is conducting a side-by-side study comparing SpO₂ and end-tidal carbon dioxide in home monitoring of pts. With 210 (98%) of the patients studied being opioid naive, we agree with guidelines from the CDC which recommends short-acting opioids rather than long-acting or extended release opioids for the treatment for acute pain in opioid naïve patients. Other factors such as age, gender, hepatic/renal impairment, comorbidities, polypharmacology and drug metabolism should also be considered. We have identified the need for more education to ED staff regarding protocol compliance and recognize that relying on patients/caregivers to identify and respond to out of range parameters is not ideal. We are considering remote monitoring in the home via Telemedicine for our higher risk pts. It is our impression that opioid related deaths are under diagnosed and reported and are often reported as “pneumonia” by medical examiners. We are pursuing validation of this impression. Our initial work facilitated Utah SCR004 being signed into law March 2018. Utah legislators requested more studies regarding home monitoring of high-risk opioid patients, and our goal is to meet that request. RTs are in a unique position to further this work. Reference: https://www.cdc.gov/drugoverdose/epidemic/index.html

The FY2016 Agency for Healthcare Research and Quality (AHRQ) Quality Indicators report indicated our hospital had a performance worse than expected O/E ratio for PSI 03 Pressure Ulcer Rate. We have had a Pressure Ulcer Prevention (PUP) team in place actively working to manage and reduce hospital acquired pressure ulcers (HAPU) within the Department of Nursing. Data routinely compiled by our Wound Ostomy Care Department provided detailed information on pressure injuries by type and location occurring in the hospital. In FY16, 40% of all HAPU were medical device related pressure ulcers (MDRPU); 37% of all MDRPU were respiratory device related. An opportunity existed to reduce respiratory device related HAPU with a collaborative effort between Respiratory and Nursing Departments.

Initially, we developed a Pareto chart to identify what devices caused the most respiratory related injuries. OETT and NIV masks accounted for 57% of respiratory device related injuries in FY 16. We focused on two goals in adult ICU patient population. Our first goal was to decrease pressure injuries related to OETT devices in the ICU by 30% for FY2017. Our second goal was to decrease pressure injuries related to NIV masks by 15% for FY2017. Using brainstorming, our group identified possible causes and solutions related to OETT and NIV pressure injuries. With this data, we created an effort/yield matrix and a focused action plan on reducing pressure injuries which included standardization of OETT and NIV maintenance and rotation processes, education of RT and nursing staff on these protocols, concurrent rounding audits of adherence to the protocols with immediate feedback to caregivers, and proper ventilator arm positioning, repair or replacement as necessary.

Our results exceeded both of the goals. On our goal to decrease pressure injuries related to OETT/securement devices in the ICU by 30%, we attained a decrease of 57% from 21 in FY2016 to 9 in FY2017. The second goal was to decrease pressure injuries related to NIV masks in the intensive care units by 15%, and we attained a decrease of 31%.

In conclusion, the collaboration of both respiratory staff, nursing staff and Wound Ostomy Care Department to reduce respiratory device related injuries proved successful. We continue to show improvement and meet quarterly to review data and ensure that identified reduction strategies continue to prevent respiratory device related injuries.

Endotracheal intubation by respiratory therapists (RTs) is a well-established practice and has been described primarily in adult and neonatal patients. However, minimal data exist regarding RT intubation practice in pediatric intensive care units (ICUs). The purpose of this study was to describe the current landscape of RT intubation in pediatric ICUs.

A multi-center quality improvement database, the National Emergency Airway Registry for Children (NEAR4KIDs) was queried from 2015-2018. Data were prospectively collected on patient demographics, indication for intubation, difficult airway history and feature presence, provider discipline, medications and device. Intubation outcomes included first attempt and overall success rates, and tracheal intubation adverse events (TIAEs). One attempt was defined as an insertion of a device (e.g., laryngoscope) into the oropharynx. Overall intubation success was defined as tracheal intubation achieved in ≤ 2 attempts. Statistics were descriptive with Chi-squared test to compare proportions with statistical significance set at 0.05.

There were 12,056 initial intubation encounters analyzed, with 109 (0.9%) by RTs. Nine centers reported at least one intubation encounter by RTs. The number of RT intubation attempts per center ranged from 1 to 46 (RT attempt rate per center: 0% to 19.6%). Overall RT success rate was 76.1%, with first attempt success rate 60.6%, and adverse TIAE rate 22.9%. First attempt success rate (range 0% to 73.3%, P = .03), overall success rate (0% to 100% range P = .004), any TIAE rate (0% to 100%, P = .02) and severe TIAE rate (0 to 42.9%, P = .006) varied across centers. Three centers reported a minimum of 10 intubation attempts by RTs, with first attempt success rates of (56.0%, 71.7%, and 73.3%), overall success rates of (80.0%, 82.6%, 86.7%), and adverse TIAE rates of (36.0%, 10.9%, 33.3%). When RT attempts were compared to other providers, airway characteristics were similar except RTs were more likely to intubate children due to a neurologic indication (RT 1.9% vs. 0.8%, P < .001). Results are summarized in Table 1.

RTs infrequently intubate in pediatric intensive care units, with success rates similar to other providers, although adverse events were higher overall. RTs were more likely to use video laryngoscopy. RT intubation success and complication rates varied greatly across centers.

Endotracheal intubation is a common procedure performed by respiratory therapists (RTs). The purpose of this study is to describe current RT intubation practices in North Carolina through the use of survey instrument.

A survey was developed by the authors and sent via email to all licensed RTs in North Carolina. An exemption was granted by the Duke Institutional Review Board. Questions included: respondent demographics, intubation practices (including training and skill maintenance) and attitudes about RT intubation practices. Data are presented as percentages or medians with interquartile range (IQR).

The survey was sent to 4,817 licensed RTs, with 411 responses from 133 unique institutions and 81 (61%) intubated at their facility. RTs who performed intubation were more likely to be from community hospitals and less likely to be from level one trauma centers. 60% of respondents defined an intubation attempt as an endotracheal tube passed through the oropharynx with 34% defining an attempt as a laryngoscope in the mouth. Respondents reported intubating adults (91%), pediatric (61%), and (65%) neonatal patients. The most common areas RTs reported performing intubation were the adult ICU (80%), ED (76%), outside the OR for emergencies (76%), neonatal ICU (43%), the delivery room (45%), and pediatric ICU (25%). Training for intubation varied among respondents with classroom training (51%), written materials (38%), written test (27%), skill demonstration in a simulation setting (85%), and supervised intubations (71%) reported as training methods. Supervised intubations were performed in the operating room (54%), ICU (68%), ED (59%), delivery room (29%), and other (23%). 84% respondents reported there was no minimum amount of experience before intubation training. The reported number of supervised intubations required to be competent was 5 (3-5). Less than 10 intubations were required by 81% of respondents. The perceived number of intubations to gain competence was 6 (range 5-10) and did not differ based on years of experience. Most respondents believed their RT intubation program was safe (93%), effective (91%), RTs were well-trained (81%), their intubation skills objectively evaluated (66%), and receive sufficient feedback on performance (68%).

RTs in North Carolina frequently provided intubation and had high confidence in their programs. Training methods and clinical practice varied throughout the state.

High-frequency jet ventilation (HFJV) has been utilized as a modality in infants with respiratory distress syndrome who are refractory to conventional ventilation. There is a paucity of data informing initial PEEP selection during HFJV. Therefore, we sought to describe parameters that were associated with PEEP levels following conversion to HFJV.

An IRB approved single-center retrospective review was conducted on subjects who underwent HFJV between 01/2015-01/2019. Subjects were enrolled if birth weight ≤ 2,000 grams and ≤ 34 weeks gestational age. Subjects were excluded if they received HFJV as a first line therapy upon admission. Ventilator parameters and laboratory data were extracted and analyzed prior to HFJV transition and at hours 1, 4, 6 and 12 following conversion. Data included: PEEP, mean airway pressure, FIO₂, peak inspiratory pressure (PIP), pH, capillary carbon dioxide level and sigh-breaths. Since the data were not normally distributed, they are reported as median (interquartile range). The Kruskal-Wallis test with Dunn posttest were used in order to evaluate differences in parameters over time.

Fifty-three premature subjects (n = 37 male) were studied. Median gestational age was 25.5 weeks (24.1 – 27.8) and birthweight of 900g (695 – 1,555). Subjects received conventional ventilation for a median of 50 hours (13.8 – 218) prior to HFJV; with PIP 20 cm H₂O (18 – 24) and frequency 40 breaths/min (38 – 44) respectively. A HFJV frequency of 420 breaths/min and on-time of 0.02 seconds were used for all subjects. A target pH ≥ 7.25 and FIO₂ ≤ 0.4 was achieved in 54% and 60% of subjects at four hours, respectively. Ventilator parameters and laboratory data are displayed in Table 1.

We observed a statistically significant increase in PEEP, PIP, pH and decrease in PcCO2 compared with baseline. Our findings may inform initial PEEP during conversion to HFJV.

Results are presented as median (interquartile range)* PEEP significantly higher than baseline † PIP significantly higher than baseline ‡ pH significantly higher than baseline§ PcCO₂ significantly lower than baseline

High-frequency jet ventilation (HFJV) has been used in conjunction with conventional ventilation (CV) for premature infants with respiratory failure. We sought to identify parameters that were associated with mortality in subjects who underwent HFJV.

An IRB approved single-center retrospective review was conducted on subjects who received HFJV between 01/2015-01/2019. Subjects were enrolled if birth weight ≤ 2,000 grams and ≤ 34 weeks gestational age. Subjects were excluded if they received HFJV at time of admission with the aim of studying subjects who failed conventional ventilation. Ventilator parameters and laboratory data were extracted and analyzed prior to HFJV and at hours 1, 4, 6 and 12 following conversion. Subject demographics, including duration of ventilation, infection status, and inhaled nitric oxide usage were analyzed. Since the data were not normally distributed, they are presented as median (interquartile range). Mann-Whitney un-paired t-test was used to assess differences in continuous variables and the chi-square and Fisher exact test were used for categorical variables between the groups.

Fifty-three premature subjects, (n = 37 male) were studied. Prior to HFJV, PEEP was lower in non-survivors (5 cm H₂O vs. 6 cm H₂O, P = .18) and FIO₂ (.50 vs. .35, P = .049) was higher. Initial HFJV PIP (29 cm H₂O vs. 26 cm H₂O, P = .02); inhaled nitric oxide use (∼8% vs. 4%, P = .04) and FIO₂ (.50 vs .34, P = .03) at 4-hours were higher in non-survivors. Non-survivors were more likely to be female (50% vs. 16%, P = .02); larger (1,200 grams vs. 800 grams, P = .04); and transitioned to HFJV at later postmenstrual age (29.5 weeks vs. 27.7 weeks, P = .04). Subject demographics and characteristics are displayed in Table 1.

We identified that PMA, weight, initial HFJV PIP, FIO₂ and nitric oxide use were higher in non-survivors, and baseline PEEP was lower. These data may help to inform ventilation strategy and identify patients who are most likely to benefit from HFJV in the neonatal intensive care unit.

* Postmenstrual age at time of HFJV† Duration of conventional ventilation prior to HFJV NEC = necrotizing entercolitis PDA = patent ductus arteriosus

The Virtual Critical Care Respiratory program collaborated with a fourteen bed ICU, Atrium Health Union, to establish a target time for the daily Spontaneous Awakening and Breathing Trials (SAT/SBT). Once the targeted time was in place, the Virtual Respiratory Therapists (VRTs) would implement the idea of SBT re-trials on patients who meet criteria to decrease VLOS to a higher degree. Re-trials are defined as a second trial for those meeting the criteria per protocol, who failed the initial daily trial, or did not meet criteria previously but have been managed up. This program can positively impact overall VLOS by encouraging re-trials resulting in earlier extubations and decreased ventilator days.

IRB approval was received, and the project was deemed quality improvement. A cohort study was performed. All vented subjects during quarter 1 2019 at a comparable facility, Atrium Health Cleveland, were identified. Encounters were analyzed for re-trial opportunities in addition to the daily SBT. The VCC teams collaborated with bedside teams to set a specific time for daily SBTs at AH Union. VRTs assessed remaining vented patients after the daily trails to make suggestions for optimization and re-trials.

330 encounters were analyzed at AH Union during quarter 1. 303 encounters remained vented after the daily SBT. 48 of 57 re-trials were scheduled and completed. 32 of 48 re-trials were done and passed resulting in 31 encounters liberated from the vent with the VRT initiative. The total vent days, average vent days, and vent days/patient days (%) were compared between AH Cleveland, with no VRT intervention, and AH Union, with VRT intervention. The total vent days at AH Cleveland for 2019 quarter 1 were 300.5, with the average being 4.4 days. The total vent days at AH Union for 2019 quarter 1 were 326.2 days, average 3.8 days yielding a vent days/patient days 44%. In comparison to AH Union’s 2018 quarter 1 total vent days of 370.1, average of 4.4 days yielding a vent days/patient days 49.3%. A significant reduction in ventilator days was identified with the VRT re-trial initiative.

Virtual Respiratory Therapists implemented the process of ventilator liberation re-trails that positively affected VLOS as the Power BI, Atrium Health’s system data base, vent days for January 2018 were 3.75 and decreased for January 2019 to 3.31 days for AH Union. AH Cleveland’s VLOS for Jan 2019 was 4.39 days without any VRT interventions.

Atrium Health Union Ventilator Length of Stay O/E trends from before and after VRT SBT re-trial iniative.

The Center for Disease Control (CDC) and National Health Safety Network (NHSN) have defined VAE as a deterioration in respiratory status following a period of stability-determined by PEEP or FIO₂, evidence of inflammation or infection-determined by patient temperature and white blood cell count or lab evidence of a respiratory infection. VAE rate is defined as the number of events per 1000 ventilator days. The VAE rate had been higher than expected in our adult Surgical/Trauma and Neuro ICUs. We wanted to determine if a performance improvement process could reduce that rate. METHOD: This is a retrospective review of all ventilator patients in our Surgical/Trauma and Neuro ICUs during the baseline (January 2013 to September 2018) and pilot (September 2018 to present) periods. We employed a PDCA performance improvement process. The main performance improvement implementations that occurred were caregiver education on the VAE criteria and initiating a new standard baseline PEEP setting of 6 cm H₂O for all ventilator patients instead of 8 cm H₂O.

Mean VAE rates for the Surgical/Trauma and Neuro ICUs were 18.9 and 15.7, respectively, prior to project implementation. After implementation, VAE rates fell to 3.7 and 2.6, yielding an 80% and 83% reduction in the VAE rate. The reduction is statistically significant for both ICUs (P < .05). See image for control chart of VAE rate in the Surgical/Trauma ICU over time with baseline and pilot periods Conclusions: Changing the standard baseline PEEP level for adult ventilator patients and improving understanding of how PEEP management can trigger a VAE resulted in a significant reduction in the VAE rates. Since the success of the project, the new standard baseline PEEP has been implemented system-wide and VAE rates will continue to be monitored for ongoing success.

Inhaled albuterol and prostacyclin continuous infusion aerosol delivery during mechanical ventilation (MV) evolved as a popular off-label treatment for refractory asthma and severe respiratory failure with pulmonary arterial hypertension and arterial hypoxemia. Initial protocols used a sidestream jet nebulizer (JN) and, more recently, a vibrating mesh nebulizer (VMN). Breath-enhanced (BE) JN has potential advantages. This study compared aerosol delivery of BEJN to VMN during continuous infusion.

4 samples of BEJN i-VENT (InspiRx, Somerset NJ) and VMN Solo (Aerogen, Galway Ireland) were used in rotation during testing. Using infusion pump flows between 1.5 - 12 mL/h, radiolabeled saline was infused into nebulizers during MV of a test lung. Four breathing patterns with 2 L/min bias flow, 5 cm H₂O PEEP and duty cycles (DC, % inspiratory time) ranging from 0.12 - 0.33 were tested. The VMN was placed on the dry (inlet) side of an F&P MR850 heated humidifier (run at 37°C to achieve temperature prior to all tests). The BEJN, placed on the wet (outlet) side, was operated by an air flow meter at 3.5 L/min. Test runs for each DC and humidifier placement were conducted for 1 h, after which radioactivity collected on a filter (Inhaled Mass, IM) at the test lung’s airway opening was measured by gamma scintigraphy and expressed as a percentage delivery rate of the radioactivity initially placed in the infusion syringe per hour (IM%/h). Humidifier retention of aerosol was also measured.

IM%/h vs infusion pump flow regression for VMN (y = 0.45x, R2 = 0.29) and BEJN (y = 0.61x, R2 = 0.93) showed greater scatter for VMN due to failures (Figure). At 10-12 mL/h, some VMNs did not keep pace with infusion rate, accumulated excess solution and failed to nebulize. Otherwise, IM%/h for both BEJN and VMN tended to plateau between 10-12 mL/h. The VMN dry side placement deposited 14.7%/h in the humidifier versus 0.2%/h for BEJN wet side placement.

Our data demonstrate that continuous infusion aerosol delivery rate, IM%/h of the i-VENT breath-enhanced JN, which can be utilized for continuous albuterol and prostacyclin aerosol delivery during MV, is more consistent than VMN, suggesting that: (1) predictable dose delivery can be achieved with a breath-enhanced JN, (2) BEJN is more reliable than VMN, (3) 10 mL/h infusion flow is a practical maximum for both devices, and (4) BEJN avoids humidifier contamination.

Nishimura reported in his article regarding respiratory care in 2016 that high-flow nasal cannula (HFNC) was a reliable therapy device for respiratory failure patients with hypercapnia. However, we often experienced carbon dioxide narcosis in patients using Venturi-effect typed HFNC (HFNC/Venturi). PURPOSE We hypothesized that oxygen concentration was increased by back pressure in the circuit of HFNC/Venturi which was produced during breathing.

FIO₂ on HFNC/Ventrui was adjusted to 32%, which is the minimum concentration (MaxVenturi, Maxtec, US). Three volunteers using the Venturi-effect typed HFNC maintained stable breathing for 30 seconds. Then, the back pressure and the oxygen concentration in the circuit during their stable breathing were measured three times for each examinee. The experimental conditions used are shown as below. Total flow: 20 to 60 L/min. Breathing style: mouth and nose.

Back pressure in the mouth breathing when the total flow was 60 L/min reached a median of 14.2 cm H₂O (interquartile range [25th to 75th percentile], 14.0 to 14.2), as compared with 1.65 cm H₂O (IQR, 1.60 to 1.80) in that of the total flow 20 L/min (P < .001). In the nose breathing, back pressure of the total flow 60 L/min reached a median of 15.9 cm H₂O (IQR, 15.4 to 16.3), as compared with 1.90 cm H₂O (IQR, 1.63 to 2.18) in the total flow 20 L/min (P < .001). Similarly, the oxygen concentration in the circuit increased significantly in proportion to the increase of the total flow (figure).

The results support the hypothesis that FIO₂ in the circuit of the Venturi-effect typed HFNC would increase in proportion to the back pressure produced during breathing. Therefore, the use of the Venturi-effect typed HFNC in COPD is recommended to be avoided in clinical situations.

Oxygen concentration in the circuit of the Venturi-effect typed HFNC on the setting: F_IO2 32%: It increased in proportion to total flow in both breathing styles. Especially, the measured oxygen concentration of nasal breathing was significantly higher than that of mouth breathing.

In the fall of 2016 as we aligned with Cleveland Clinic Alliance Network, it became clear that we had a significantly larger cardiac bypass and graft (CABG) patient population experiencing prolonged mechanical ventilation versus the national STS data. From January through September 2016, we had 11 patients (9.7%) receiving mechanical ventilation for >24 hours post-operatively versus the national Society of Thoracic Surgery database at 7.9%.

Using the Plan-Do-Study-Act (PDSA) approach, an interdisciplinary team was formed comprised of RNs, providers, RTs, physical therapy and pharmacy. An early extubation protocol was developed to guide all disciplines within all phases of care from pre-operative to post-extubation. Once implemented, ongoing evaluation of patient outcomes and caregiver feedback supported a continued PDSA cycle.

In fiscal year 2018 an increase of prolonged ventilation occurred. Interdisciplinary quarterly meetings were established to review cardiac surgery prolonged ventilation cases and determine trends. Challenges were also identified: three new cardiac surgeons joined our hospital in 2017, case volume increased by 21% (311 procedures in FY2017 to 376 in FY2018). We experienced an increase in high acuity cases such as ventricular assist devices (VADs), heart transplants, etc. that made up almost 33% of the total cardiac cases. After identifying the obstacles, changes were made utilizing the PDSA model. Changes made included new approach to identifying patient trends, broadened eligibility criteria and a 20-hour bedside huddle with RT, RN and provider if patient was still intubated. Once the protocol was established, the process saw impressive results regarding the percentage of CABG patients with prolonged ventilator times during our fiscal year 2017: Q1 8%, Q2 14.3%, Q3 (roll out of early extubation protocol) 3.7% and Q4 0%. In fiscal year 2018, a resurgence of prolonged mechanical ventilation after the success in fiscal year 2017: FY2018: Q1 11.1%, Q2 6.3%, Q3 14.3%. After the interdisciplinary workgroup made modifications using the PDSA model which led to a reduction of prolonged ventilation in Q4 to 4.5%.

An interdisciplinary approach is necessary to facilitate and maintain the process of striving for early extubation in cardiac surgery patients. We incorporated this process for all cardiac surgery types in our CVICU and continue to meet as a team on a quarterly basis to review and adjust our protocol as needed utilizing the PDSA model.

Patients admitted to emergency departments (ED) with breathlessness are often ordered on bronchodilator therapy. Due to limited clinical response, dosing of these short acting bronchodilators has necessitated the use of hour-long aerosol therapy with jet nebulizers (JN) to accommodate the required high dosages for asthma and COPD patients admitted to our ED. Our aim was to determine whether treatment with vibrating mesh nebulizer (VMN) compared to (JN) would result in less total amount of albuterol (mg) required for adult asthma and COPD patients.

We designed a prospective, single center, non-randomized chart review study of adult asthma and COPD patients in the ED with breathlessness requiring bronchodilator therapy (at the treating physician’s discretion). They were treated according to current standards with JN during period 1 or VMN during period 2 (sample size calculation, 80% power). At the end of the two treatment periods, demographic and endpoint data were extracted from the electronic medical record (EMR) for patients meeting inclusion and exclusion criteria. This study was IRB approved.

A total of 199 patients (118 JN, 81 VMN) were extracted from the EMR between December 10, 2018 and April 5, 2019. The total mean amount of albuterol (mg) required was significantly less in asthma patients treated with VMN compared to JN (7.9 ± 5.4 vs. 13.8 ± 9.6. respectively) (P = .0003) but it was not significant in the COPD patients (7.6 ± 4.4 vs. 8.8 ± 6.5. respectively) (P = .84). Patients treated for asthma and COPD combined with VMN required significantly fewer treatments compared to JN (2.1 ± 1.6 vs. 2.7 ± 1.6. respectively) (P = .009). Total treatment time (minutes) for asthma patients treated with the VMN was significantly less than the JN (40.7 ± 24.9 vs. 63.1 ± 40.4. respectively) (P = .002) but for COPD it was not significant (40.4 ± 23.1 vs. 42.6 ± 26.3. respectively) (P = .99). In asthma patients, 1 in 42 (2.4%) VMN required an hour-long treatment compared to 30 in 63 (47.6%) in the JN group (P < .001). In COPD patients 0 of the 39 VMN required hour-long treatments compared to 9 in 55 (16.4%) in the JN group (P < .001).

Asthma patients treated with the VMN required significantly less total albuterol and shorter treatment times. Combined COPD and asthma patients treated with VMN required significantly fewer treatments. Both diagnoses required significantly fewer hour-long treatments with VMN vs JN.

Bubble continuous positive airway pressure (bCPAP) in preterm infants has been associated with fewer doses of surfactant, fewer days on mechanical ventilation, and lower fraction of inspired oxygen (FIO₂). Most bCPAP evidence focuses on delivery room initiation and extubation of low birth weight preterm neonates. We sought to evaluate outcomes associated with bCPAP in a diverse population admitted to a quaternary-academic neonatal intensive care unit. We hypothesize application of bCPAP is associated with decreased ventilator days, fewer surfactant doses, and shorter length of stay (LOS) in a diverse patient population.

A respective analysis of neonates supported via bCPAP between July 2018 and April 2019, comparing pre- vs. post-implementation outcomes. Differences determined by student T-Test for continuous variables presented as mean ± standard deviation. Demographics, bCPAP measures, and failure rates (need for intubation) were evaluated. Outcomes included average monthly ventilator days, surfactant doses administered per month, and NICU LOS. The project was approved by the Quality Improvement Review Committee.

One hundred twenty-five patients were included in the study. Gestational age were 36.9 ± 7.2weeks, weight 2.4 ± 0.9 kilograms, 63 (50.4%) were male, and 28 (22.4%) had surgical intervention. Diagnostic categories illustrated in Figure 1. Duration of bCPAP support was 7.3 ± 8.7 days with an initial FIO₂ of 0.32 ± 0.13 and FIO₂ of 0.27 ± 0.13 at cessation of support. Fourteen (11.2%) patients failed bCPAP. Of infants successfully weaned from bCPAP, 52.8% were on room air, 26.4% were supported by low-flow nasal cannula, and 9.6% received high-flow nasal cannula. We found a significant decrease in surfactant doses per month (7.0 ± 1.0 vs. 1.3 ± 0.6; P < .001) when comparing pre- vs. post-implementation groups. No difference was found between ventilator days or NICU LOS.

We describe the use of bCPAP in a diverse NICU population with low rates of bCPAP failure. Greater than 50% of the cohort did not require supplemental oxygen support post therapy. A significant decrease in surfactant administration following bCPAP adoption was found, having workflow and financial implications. No difference in ventilator days or NICU LOS was found.

The National Board of Respiratory Care (NBRC) reports that the national first-time pass rate for the Clinical Simulation Exam (CSE) is < 65%. This relatively low performance coincides with the results of the closed CSE given to Middle Georgia State University students within the respiratory therapy (RT) program. The purpose of this study is to compare student performance on the CSE before and after implementation of high-fidelity simulation in the respiratory curriculum. The secondary purpose is to determine the progression of students’ performance with high-fidelity simulation exposure over time.

The RT program implemented a high-fidelity simulation program into the curriculum in 2016. The program utilizes certified patient case scenarios based on the NBRC matrix. Each simulation involves pre-brief, simulation, debrief and post-debrief questions written for NBRC Board preparation. Data was collected over a 2-year period (2016-2018) over the course of two semesters for each cohort increasing the number of simulations completed between groups (none, 3, and 8 simulations) including grade point averages (GPA). GPAs were compared between each group using one-way ANOVA with Tukey HSD analysis via 95% confidence intervals (N = 58 students).

There is no statistical difference between students’ first time CSE pass rate (.625) and the national pass rate (.579) for students completing three high fidelity simulations (z = .37, P = .36). Respiratory therapy students’ first time CSE pass rate for students completing eight high fidelity simulations (.937) is significantly greater than the national pass rate (.712), (z = 1.99, P = .023).

The use of eight high-fidelity simulations improved the performance of MGA students on the closed CSE and national board exam, whereas the use of three simulations did not. Therefore, increased exposure to high-fidelity simulation improves student performance on the National CSE.

Bronchoscopy is a common procedure in the ICU setting (1). It is often performed for airway inspection/visualization and secretion removal. While the procedure is among those of low to moderate risk, the question of cross contamination of patients by use of fiber optic scopes remains, with some reports of cross contamination as high as 20%(2). Single patient use disposable bronchoscopes have recently become available, but have received mixed reviews by users. Our study sought to determine the functional ability of a disposable versus a flexible fiber optic bronchoscope.

A bench study involving direct comparison of two commercially available bronchoscopes (Olympus America, Southborough MA; Ambu Inc., Colombia MD). Each manufacturer offers a scope with a channel size of slim, standard, and therapeutic. Picture quality was not directly addressed, but was deemed adequate for routine work in the ICU. Suction capability was assessed by attempting aspiration of three solutions. 0.9% Saline was used to simulate thin liquids, Clorhexadine Gluconate 2% solution represented a medium thickness secretion, and “honey” consistency barium sulfate suspension (29% w/w) comprised a thick/tenacious secretion. Suction was applied at two settings (150 mm Hg and Full) for either 10 or 20 seconds. Solution(s) acquired were weighed on a scientific scale to an accuracy of 0.1 g (Tree Instruments, China). Findings of mass were converted to liquid volume by weighing a measured quantity (1 mL) in a 10 mL syringe. Scope choice and solution tested were randomized throughout.

Table 1 details our findings. There was no statistical difference in terms of scope tested against the same solution. There was statistical significance between solutions (P < .0005), and time of suction applied (P < .05) when results were placed in a predictive multiple regression model.

In instances where the enhanced picture quality of a flexible fiber optic scope is not required, the functional ability of single patient use bronchoscopes is equal to that of the flexible fiber optic. The eliminated risk of cross contamination and the reduced cost of acquisition/maintenance of single patient use scopes should be among the deciding factors for ICU bronchoscopic procedures. References: (1) BJA Education 17;2:48-56. (2) Infect Control Today, August 10, 2018 Disclosures: The authors claim no conflict(s) of interest in this research.

Bland aerosol therapy via large volume nebulizer remains a standard of care in tracheostomy patients (1). Our facility routinely provides care for > 20 tracheostomy patients on a daily basis, and respiratory care is solely responsible for all aspects of their tracheostomy care needs. After a recent product substitution, staff began to anecdotally report a negative quantitative and qualitative change in the sputum characteristics of their tracheostomy patients. Given the timing of these reports, the new product became immediately suspect. It was felt that the new large volume nebulizer was inferior to the old one, with reduced aerosol output being the cause of thicker and more tenacious secretions. Aerosol characteristics of both the old and new large volume nebulizer were not readily available. Our study set out to objectively evaluate both products.

A bench study utilizing a hygrometer placed in line at the distal end of an aerosol circuit via a tee piece. This placement would evaluate function as aerosol was delivered. Standard large bore aerosol tubing was utilized. Outputs from the two nebulizers (Teleflex, Temecula, CA; AirLife, San Diego, CA) were sampled at varying flows and FIO₂ illustrated in Table 1. The minimal FIO₂ (0.28) was sampled, as was a 1:1 entrainment ratio at a FIO₂ of .60 and a maximal FIO₂ (no entrainment) for each device.

There was no statistically significant difference noted in the humidity level provided by either device again as noted in Table 1. Readily visible mist output was noted on all but one FIO₂/flow combination on one device. Ambient temperature (22.8 C) and RH (59%) were constant throughout the study.

The product change occurred during the winter season, and ambient conditions from that time are not known and are thus unable to be duplicated. It is possible that the ambient conditions were the cause of the clinical concern and that the product substitution had no effect. It should be noted that the finer mist from the low flow/low FIO₂ combination more than likely contributed to the cause of the complaint(s). Reference: Egan’s Fundamentals of Respiratory Care, 9th Edition Disclosures: The authors claim no conflicts of interest in this research.

Utilization of high-flow oxygen is an expanding clinical intervention in adult and pediatric patients. Clinical indications for adult high-flow oxygen via a nasal cannula or tracheostomy aim to improve oxygenation, meet ventilatory demand, provide mucokinetic therapy, provide post-extubation humidification, and enhance work of breathing comfort at the end of life. With this continually expanding indication list, clearly defined resource allocation is imperative. Unfortunately, the therapy popularity often times results in the clinical needs exceeding device availability.

To facilitate optimal resource allocation for high-flow oxygen, a multi-disciplinary team at Lehigh Valley Hospital Cedar Crest developed a clinical management protocol focusing on high-flow oxygen (Fig. 1). Providers’ requirements of clinical indication for use and SpO₂ target were imbedded in the protocol and in the electronic order set. Based on these clinical goals, the bedside nurse and registered respiratory therapists followed the designed protocol to escalate, reduce or liberate the high-flow oxygen delivery. Time restrictions were also placed on the post- extubation and enhanced work of breathing comfort indications to facilitate high-flow oxygen termination.

Post protocol implementation of the high-flow delivery treatment strategy resulted in an average time duration of high flow use reduction from a historical mean of 18.3 hours to 11.7 hours. Return to high flow oxygen post- termination remained similar between 20 and 25 percent.

Based on this experience, care giver collaboration and compliance to the developed high-flow protocol assists to define clear clinical end-points and optimize resource allocation. Reducing high flow oxygen device duration allows the equipment to be used more appropriately on patients in acute distress.

As a follow up report on last year’s abstract, we continued to monitor and adjust our High Flow Nasal Cannula (HFNC) use in all areas. Our previous success of HFNC use outside of the critical care areas on our medical floors resulted in decreased ICU days and decreased noninvasive ventilation (NIV) use. This study was to evaluate our continued success of appropriate HFNC use, including where to care for the patient, as well as whether we continued to decrease NIV cases. Prior to our initiation of HFNC use on the medical floors, all patients on HFNC would have gone to the ICU on NIV.

We evaluated all patients on HFNC from 5/1/18-1/31/19. We looked at where HFNC was initiated, whether it was used on the medical floors or whether an ICU admission was needed. If an ICU transfer occurred, we then reviewed each case to determine if that patient required an escalation to NIV once in ICU. We stretched the limits of our current policy on HFNC on the medical floors, on a case-by-case basis, as our comfort with HFNC increased.

There were 99 HFNC treatments on 95 patients admitted through the Emergency Department. Fifty-one treated patients were admitted directly to the medical floor on HFNC. Two of these patients required a transfer to the ICU, where only one required NIV. Thirty-five of the 48 patients admitted directly to the ICU were managed with HFNC alone. Three of these patients transitioned to the floor on HFNC successfully, not requiring NIV. Eight of these ICU patients required escalation of respiratory support to NIV. Three patients admitted to the ICU on NIV were transitioned to HFNC successfully. Two patients were treated with NIV at night and HFNC during the day by schedule. HFNC patients treated on the medical floors were managed successfully without NIV 98% of the time. Eighty-eight of the ninety-five patients never required NIV. Forty-nine ICU admissions were avoided and many ICU days were decreased using HFNC.

Patients requiring HFNC can be safely managed on the medical floor. This can free up ICU resources and decrease NIV use. Disclosures: Acevedo - consultant for Monaghan Medical and Sunovion.

Tiotropium HandiHaler posed significant issues to respiratory care and pharmacy even with our common canister approach. We looked for alternatives to improve respiratory therapist (RT) workflow and to manage cost. We piloted the non-institutional size tiotropium Respimat due to the increase use in the outpatient settings. At the time of the initial trial Respimat was not available in an institutional size. Our findings showed that the non-institutional size was cost prohibitive, however improved RT workflow. In July of 2018 the institutional size was made available. For the above reasons we evaluated the institutional size Respimat using common canister.

All patients receiving tiotropium by Handihaler from 1/18 onwards were converted to the non-institutional size Respimat and administered by common canister. On 7/18 Respimat was converted to the institutional size and administered by common canister. We compared the actual pharmacy costs of non-institutional and institutional size Respimat, both administered with common canister. Costs with 100% or no common canister delivery were estimated.

Costs: HandiHaler (5 capsules) $37.22, $7.44 per day; non-institutional size Respimat (30 doses) $333.02, $11.10 per day; institutional size Respimat (14 doses) $36.29, $2.59 per day. Pre-intervention monthly HandiHaler cost was $3,481. Average non-institutional size Respimat monthly cost using common canister was $11,375, a 3.27 fold increase in cost. Common canister was used 72% of the administrations. Average Institutional size Respimat monthly cost using common canister was $1,641, a 53% reduction in HandiHaler cost. Common canister was used 76% of the administrations. Treatments on influenza and isolation patients were done without common canister. Estimated average monthly cost of institutional size Respimat without common canister would be $1,212, a 14% reduction in HandiHaler cost.

Tiotropium delivered by institutional size Respimat is cost effective compared with HandiHaler. Significant additional cost savings can be achieved with common canister. Delivery with the HandiHaler can be eliminated. Disclosures: Acevedo - consultant for Monaghan Medical and Sunovion.

Aerosol delivery during mechanical ventilation is uncontrolled and a function of duty cycle, bias flow, nebulizer position and methods of humidification. The present study tested a novel nebulizer and circuit (i-VENT, InspiRx, Somerset, NJ) that utilizes the energy of ventilator flow to generate aerosol (breath enhancement) combined with stand-alone breath actuation to minimize ventilator influences. The unique circuit design incorporates ‘wet side’ jet nebulization at the humidifier outlet designed to prevent unpredictable tube losses of generated aerosol with active humidification. The system was studied using several ventilator brands over a wide range of settings, with and without humidification.

During a treatment, a 3-way valve directed all ventilator flow to the nebulizer. Aerosol was generated during inspiration by activation of a pressure sensitive breath-actuated circuit. O₂/air at 50 PSIG powered the nebulizer at a flow of 3.5 L/min. In vitro testing was performed using a heated wire circuit with humidification or by-passable/valved HME (BP-HME) on several ventilator brands over a range of breathing patterns, ventilator modes and bias flows (0.5-5 L/min). The nebulizer was charged with 6 mL of radiolabeled saline. Mass balance was performed using a gamma camera. Mann-Whitney test was used.

IM (% neb charge): mean ± SD [all data] 31.1 ± 6.33, n = 82; humidified 35.6 ± 5.47, n = 30; BP-HME 28.6 ± 5.31, n = 52. There was a significant difference in IM between humidification type (BP-HME and active humidification) for all data (P < .001), CMV modes (P < .001), and pressure support/APRV modes (P < .001). Bias flow had no effect, MMAD: Humidified 1.1 µm, BP-HME 0.9 µm.

Breath enhancement with breath actuation overcomes much of the variability in aerosol delivery providing a predictable dose at any ventilator setting or type of humidification. Preservation of drug delivery during heated humidification is a new finding, compared to previous studies, with clinically minimal effects of humidification method. The use of wall gases and stand-alone breath actuation standardizes conditions driving the nebulizer independent of ventilator design. ‘Wet side’ nebulizer placement at the humidifier outlet allows delivery without introducing aerosol into the humidification chamber and circuit design allows nebulizer servicing without circuit interruption.

Aerosol technology during modern mechanical ventilation is constantly evolving. This in vitro study compared 3 nebulizer designs: a new breath-enhanced jet nebulizer (BEJN), i-VENT (InspiRx, Somerset NJ); vibrating mesh (VMN), Solo (Aerogen, Galway Ireland); and jet nebulizer (JN), Hudson MicroMist (Teleflex Medical, Morrisville NC) during mechanical ventilation. Aerosol delivery (Inhaled Mass, IM) was measured using multiple ventilator settings (T_I = 0.45 to 1.01). Device reproducibility, humidification effects and fill volume were assessed. Measurements included mass balance across the ventilator circuit and particle size distribution.

Using radiolabeled saline and gamma scintigraphy, bench studies were performed using 2 ventilators, 4 breathing patterns. Four examples of each nebulizer type were randomly rotated during testing to assess reproducibility. 3- and 6-mL fill volumes were tested wet and dry [with and without heated wire humidification (Hudson Neptune Heated Humidifier, Teleflex Medical)]. Measurements of IM, nebulizer residual and exhaled mass, plus circuit losses were made to account for the total mass balance. Aerosol particle size distribution (APSD) at the distal ETT tip was made with a Marple cascade impactor. Statistical analysis was performed using Mann-Whitney.

Mean ± SD IM (% of nebulizer charge) averaged 17.5 ± 4.99%, 17.2 ± 7.81%, and 6.43 ± 6.43%, for BEJN, VMN and JN respectively (Figure). IM for VMN varied widely due to random failures to complete nebulization. For all ventilator settings, IM for JN was significantly affected by combined effects of fill volume and humidification compared to the BEJN (P = .002) and VMN (P = .02). BEJN and VMN were not different (P = .74). Mass balance indicated that large particles were lost in ventilator tubing for all devices and, for VMN, also in the humidifier (17%), resulting in similar APSD measurements (MMAD = 1.05, 1.05, 1.2µm for BEJN, VMN, and JN). Humidity effects were significant only for JN using 3 mL volume fill (P = .002).

Aerosol delivery during BEJN nebulization was less sensitive to fill volume, humidification and ventilator settings than VMN or JN. VMN delivery was not predictable over the range of individual devices and settings. All devices delivered similar particle size distributions to the distal ETT. Breath-enhanced nebulizer technology can ensure better control of drug delivery during mechanical ventilation.

Continuous positive airway pressure (CPAP) is a noninvasive method to deliver positive pressure with the goal of increasing the preterm infant’s functional residual capacity (FRC) and improving gas exchange. Use of CPAP has been shown to aid in the prevention of atelectasis while reducing the number of obstructive and central apnea events for preterm infants. Bubble CPAP (BCPAP) is one modality to provide CPAP to infants. Some preterm infants suffer from Bronchopulmonary Dysplasia (BPD), which is a form of chronic lung disease. Due to the immaturity of the lungs, infants born prematurely, less than 33 weeks and of low birth weight are at a greater likelihood to develop the disease. BPD is associated with inflammation and scarring in the lungs, caused by mechanical ventilation and long-term use of oxygen. The amount of oxygen or respiratory support an infant requires at a corrected gestational age of 36 weeks determines the severity of BPD.

Data and criteria presented at a major institution with notably low BPD rates prompted the development of practice guidelines. A multidisciplinary team of Nursing, Respiratory Care, Nurse Practitioners and Neonatology assessed the BPD rates of the Vermont Oxford Network (VON) and compared our institutional BPD rate. Based on our data and the guidelines of another institution, the practice guidelines include the level of CPAP at initiation, increasing or decreasing CPAP level based on oxygen requirements, and criteria to trial off. Because infants less than 30 weeks are generally in a low birth weight category, they were the group of patients concentrated on for the guidelines. The data collected in regards to the BPD rate included the number of ventilation days and number of CPAP days. Modification to the trail off criteria evolved after review of other facilities trialing off CPAP at an earlier state and maintaining low BPD rates.

Implementation of BCPAP guidelines decreased our BPD rate to 26% from 36-41% in previous years 2014-2017; respectively, intubation rates for very low birth weight, and improved consistency of CPAP therapy utilization.

Guideline implementation for initiation, maintenance, and weaning BCPAP decreases BPD in the preterm infant.

Interprofessional education (IPE) is recognized by the World Health Organization (WHO) and Institute of Medicine (IOM) as foundational to achieving safe, high quality, accessible, patient-centered care (Buring et al., 2009). Interprofessional (IP) teams provide opportunities to exchange knowledge and appreciate the scope of practice among healthcare professions. Hospitals utilize a variety of IP teams. IP early mobility (EM) teams are common among the regionÍs hospital systems; however, occupational therapy students (OTS) and respiratory therapy students (RTS) have minimal opportunity to participate. The purpose of the study is to describe this IP activity and evaluate and summarize student perceptions of this peer-teaching and learning activity.

The study was approved by the IRB. Participants included graduate OTS and undergraduate RTS. To provide students with realistic patient interactions and optimal feedback during the simulation, volunteers were recruited from the local OT and RT network to role-play mechanically ventilated patients and patients on bland aerosol therapy via tracheostomy tube. Prior to the simulation, OTS and RTS presented on various components of their profession (scope of practice, importance of functional and EM, how to perform a stand-pivot transfer, overview of oxygen modalities and assessment parameters). Next, students were required to safely transfer the patient while maintaining equipment, monitoring vital signs, and appropriately assessing the patient. Finally, students were debriefed and asked to participate in a 4-point Likert scale survey consisting of 6 questions focused on the peer-teaching experience. Results were summarized by ni and fi.

47 students participated; 31 OTS and 16 RTS. The ni and fi of students responding ñStrongly Agreeî to the 6 survey questions (Q) are: Q1 (n = 39) 83%, Q2 (n = 37) 79%, Q3 (n = 32) 68%, Q4 (n = 35) 74%, Q5 (n = 34) 72%, and Q6 (n = 46) 98%. Majority of students strongly agree with each survey question.

Overall, student perceptions of this IP peer-teaching and learning activity and working in an IP environment were positive. Faculty plan to continue this IP activity. Reference: Buring SM, Bhushan A, Broeseker A, Conway S, Duncan-Hewitt W, Hansen L, Westberg S. Interprofessional education: definitions, student competencies, and guidelines for implementation. Am J Pharma Educ 2009;73(4). Disclosures: None

Traditionally, the role of the respiratory therapist (RT) has been patient care delivery in the hospital setting. That has evolved over the last few decades to include patient education not only in the hospital but also outpatient clinics. However, formal training for patient education may not be part of the curriculum in all RT school programs. There are many RTs providing patient education that may not have received training regarding effective learning strategies in their RT school program.

This study was not deemed human subject research by the local Institutional Review Board. RT staff at our institution were invited to complete an anonymous survey about their training and experiences with patient education. Data was collected electronically in the Research Electronic Data Capture application.

The response rate was 39% (64/164) with 81% (52/64) females, and 80% (51/64) white non-Hispanic. Most respondents (73%, 47/64) held a bachelors or higher degree. The RRT, CRT, and NPS credentials were reported by 98% (63/64), 2% (1/64), and 47% (30/64) of respondents respectively. The mean ± SD years of experience was 16.4 ± 10.8. The primary work area reported by most participants was inpatient (78%, 50/64). Sixty-six percent (42/64) graduated from RT school 10 or more years ago. Many respondents, 44% (28/64) felt that the RT school program they attended provided courses and training in patient education while 42% (27/64) did not and 14% (9/64) were neutral. The majority of respondents (58%, 37/64) would have liked more training for patient education while in RT school. RTs who graduated 10 or more years ago were less likely to have received training for patient education when compared with those who graduated less than 10 years ago (50% vs. 27%, P = 0.024). Respondents reported having been trained in the following strategies: teach back (61%, 39/64), teach to goal (40%, 25/64), and motivational interviewing (44%, 28/64). Most respondents (66%, 42/64) indicated they would like to receive additional training regarding effective learning strategies.

This survey identified an educational need regarding proficiency in patient education teaching strategies. We plan to implement an educational intervention. Respiratory therapists who graduated RT school 10 or more years ago are less likely to have had patient education teaching strategies as part of their curriculum.

In our pediatric institution, a dedicated respiratory therapist (RT) discharge planner coordinates the inpatient acquisition of home respiratory equipment, while multiple RTs assist with outpatient orders. Lengthy delays in receiving equipment have occurred, including cases with significant delays not discovered until hospital readmission. With no process in place to ensure that ordered equipment was provided, delays and associated obstacles were unknown or inconsistently reported.

We conducted a quality improvement study in which a follow-up process was implemented to confirm delivery of home equipment ordered through inpatient discharges and the outpatient pulmonary clinic. The process consisted of the RT who assisted with the order placing a follow-up call to the caregivers, intervening when necessary, confirming receipt of equipment. To evaluate the process, a retrospective and prospective chart review was done from November 2017-April 2019. The length of time to obtain equipment and reasons for delay were monitored before and after process implementation. Orders for oxygen, pulse oximeter, suction, airway clearance devices, CPAP, and bi-level devices were included. Home ventilators were excluded because they must be utilized prior to discharge.

Records were reviewed for 257 orders for home respiratory equipment. Of 182 inpatient orders (92 pre/90 post), there was no change in the mean number of days to obtain the equipment after process implementation. Delays were due to late notification to the discharge planner, orders placed after discharge or on a holiday, and difficulty contacting caregivers for delivery. For the 75 orders originating in the pulmonary clinic (35 pre/40 post), the mean number of days to obtain equipment decreased from 24 days to 12 days post implementation. Outpatient delays were due to the equipment provider not receiving faxed orders, difficulty in obtaining a provider of pediatric-specific equipment, insurance verification, and the need for additional documentation of medical justification. See table.

As equipment ordered during an inpatient hospitalization is generally delivered prior to discharge, the follow-up process had minimal effect on equipment delays. By providing early problem identification and timely intervention, the outpatient RTs role is valuable in reducing delays in equipment acquisition.

Continuous high-frequency oscillation (CHFO) of the airway is a therapeutic mode for secretions mobilization. The device also incorporates aerosol administration using an integrated jet nebulizer. However, the effectiveness of aerosol delivery and influential factors remain largely unreported.

A collecting filter was placed between an adult manikin with representative upper airway and a breath simulator, set to represent quiet and distressed patterns of adult spontaneous breathing. The CHFO device (Metaneb, Hill Rom) was attached to the manikin via a mask. Two jet nebulizers (JN) were tested with placement in the manifold and between manifold and mask. A vibrating mesh nebulizer (VMN, Aerogen) was placed between the manifold and mask with and without extension tubing. Aerosol administration was compared during CHFO and nebulization mode alone. Albuterol (2.5mg in 3mL) was nebulized for each condition (n = 3). Drug was eluted from the filter and assayed with UV spectrophotometry (276 nm).

During CHFO, inhaled dose with JN were low (∼2%), regardless of nebulizer placement. Inhaled dose was improved with VMN placed between manifold and mask (12.48 ± 2.24 vs 2.58 ± 0.48 %, P = .004). Inhaled dose of JN in manifold with nebulization mode alone was lower than JN with aerosol mask (4.03 ± 1.82 vs 10.39 ± 2.79 %, P = .004). Inhaled dose was greater with distressed breathing than quiet breathing. VMN (P < .001) and distressed breathing (P = .001) were identified as predictors of increased inhaled dose.

Inhaled dose with JN via Metaneb was lower than JN alone. Placement of VMN at airway and distressed breathing increased inhaled dose.

Continuous high-frequency oscillation (CHFO) of the airway has been reported to improve secretion clearance and lung expansion. The device also provides continuous aerosol using a jet nebulizer (JN). Concomitant aerosol therapy during CHFO is appealing during invasive ventilation. However, evidence on the efficiency of aerosol delivery is rare. We investigated the aerosol delivery efficiency with Metaneb during invasive ventilation in both adult and pediatric settings, and explored methods to improve efficiency.

A model lung (TTL, Michigan Instruments) was connected to an ICU ventilator (PB840, Medtronic) via endotracheal tubes (ETT) of 8.0mm, 6.0mm, and 5.0mm respectively to simulate adult (COPD and healthy), and pediatric (5 and 10 y old) patients. Tidal volume was set at 6 mL/kg for all scenarios and frequencies were 16 breaths/min, except the 5 y-old patient (20 breaths/min). A collecting filter was placed between ETT and the model lung. Metaneb was set at high frequency oscillation with low flow. A vibrating mesh nebulizer (VMN, Aerogen) was placed at the inlet of humidifier vs between ETT and Y-piece. Albuterol (2.5mg in 3mL) was nebulized for each condition (n = 3). Drug was eluted from the filter and assayed with UV spectrophotometry (276 nm).

With CHFO during invasive ventilation, inhaled dose with JN at its manifold position was low in both adult (1.52 ± 0.44 %) and pediatric (0.86 ± 0.05 %) patients; substituting VMN for JN increased inhaled dose: VMN placed at the inlet of humidifier vs between ETT and Y-piece in adult (13.35 ± 1.01 vs 7.17 ± 0.23%, P = .004) and pediatric patients (7.79 ± 2.46 vs 4.21 ± 0.70 %, P = .004). Regardless of VMN placement, inhaled dose with CHFO was lower than inhaled dose with VMN without CHFO [22.66 (19.54, 25.44) vs 7.19 (5.11, 11.61) %, P < .001].

Using Metaneb per label to deliver aerosolized medication during invasive ventilation was inefficient for both adult and pediatric patients. Vibrating mesh nebulizer during CHFO improved inhaled dose, but still lower than standard practice without CHFO.

To assess the benefits of telehealth (TH) on decreasing exacerbations and emergency room visits with COPD, it is important to explore the Behaviour Change Techniques (BCTs) associated with TH interventions. BCTs are important strategies which could help to generate and implement effective TH interventions with COPD. This study describes the most common BCTs demonstrated to COPD invited to TH.

Included studies were randomized controlled trials (RCTs) and observational single arm pre-post trials that evaluated TH with COPD. A systematic search was performed from the earliest records to May 2019 in CINAHL, MEDLINE (Ovid), Cochrane library, and Embase databases. The Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) guidelines was used to guide the selection process. Two independent reviewers retrieved titles, abstracts, full texts, and completed data extractions. BCTs were extracted from the description of TH found in the included studies. To categorize and summarize BCTs, we used the taxonomy of Abraham and Michie that published in 2008. This taxonomy details 26 BCTs that can be combined in interventions, ranging from the simple provision of information on consequences of one’s behavior to more complex techniques.

Among 1480 abstracts identified, 93 articles underwent full-text review, and 33 were eligible and included. Twenty-seven were RCTs, and six were pre-post studies. Overall, 16 of BCTs were used within our included studies, out of the 26 possibilities of Abraham and Michie’s taxonomy. The most commonly used technique was to provide information about the consequences. It has been reported in 30/33 studies. The lowest frequent BCTs was prompt barrier identification. It was used only in 6/33 studies. All included articles used four or more BCTs combinations. 27/33 of the studies have the combinations between four BCTs which are provide information about behavior, provide information about consequences, prompt self-monitoring, and provide feedback. All BCTs delivered using video calls, online education martials, online activities and healthcare professional supports.

TH intervention with COPD used a combination of BCTs. BCTs are essential features of TH interventions with COPD. The current review suggests optimizing the design of TH studies by considering BCTs. The next step will be to evaluate if using more BCTs in TH intervention with COPD will increase the positive impact of TH interventions.

For years there has been a belief that the Percussionaire Turbohub delivers rebreathed CO₂ to patients. Primary Children’s Hospital uses the VDR with Turbohub in our NICU and PICU, so we wondered just how much CO₂ was being rebreathed and if there was a way to eliminate it.

The Percussionaire VDR with Turbohub was set up with an F&P Evaqua 2 infant ventilator circuit and attached to a 0.59 cc/cm H₂O compliant ridged test lung. CO₂ analyzers from the Drager Evita XL were attached at the test lung to read exhaled CO₂, and at the inspiratory side of the Turbohub to measure the amount of CO₂ being rebreathed. CO₂ was injected into the test lung via blended air/CO₂ mixture at 0.3 L/min to achieve an ETCO2 of approximately 35 torr. O₂ tubing for external flow was attached to the inspiratory relief valve on the Turbohub and to a flow meter. External flows up to 6 L/min were used during testing. The VDR was set at a working pressure of 40 psi, 1 second convective rate I time and high frequency I:E ratio at 1:1. Various peak pressures, peeps as well as some different convective rates and percussive rates were used to see how much CO₂ was rebreathed at each setting and if it changed using different settings. CO₂ measurements were obtained after settings had 5 minutes to stabilize. External flow ranging from 1 to 6 L/min was added at each setting after initial measurements were taken, and CO₂ was measured again.

Thru all ranges of settings rebreathed CO₂ was 3 to 6t orr without added external flow. Upon adding external flow to the Turbohub the CO₂ gradually decreased until it reached 0 at 6 L/min of flow in all test settings.

According to the data collected, it appears that patients do in fact rebreathe CO₂ on the VDR with Turbohub. Adding 6 L/min of flow to the inspiratory side of the Turbohub would likely be beneficial to eliminating CO₂. We also found that adding the additional flow required us to decrease the pulsatile flow and oscillatory CPAP/PEEP to maintain the PIP and PEEP test setting. Further testing may be indicated to change clinical practice.

The basis for the knowledge of a patient’s condition begins with verbal handover from another respiratory therapist (RT). This handover includes vital information that plays an integral role in patient safety and outcomes. Despite including the Situation-Background:-Assessment-Recommendation (SBAR) communication technique in courses and classroom labs, often students lack confidence and struggle to give thorough handovers. High-fidelity simulations have been found to be an effective technique in training health care providers in targeted skills. Reflective practice is also recognized as core to professionalism and skill development. The purpose of this study was to develop and analyze the effectiveness of a high-fidelity simulation experience with self-reflection on SBAR handover skill development.

Eighteen first-year RT students participated in this IRB approved pilot study. The simulation experience was an endotracheal intubation scenario in the operating room where students gathered clinical information throughout the experience. SBAR handover was video recorded and both an expert (faculty) and students used a rubric to rate SBAR and communication effectiveness post-simulation and post-skill check-off. An online survey instrument also measured pre and post-simulation self-efficacy and student satisfaction. Data analysis included descriptive statistics and paired t-tests.

Expert ratings showed a statistically significant improvement in all SBAR categories, along with communication and mean total handover score (P <.001) from post-simulation to post-checkoff. Students’ self-ratings also demonstrated a statistically significant increase in the “Situation” (P = .048), “Recommendations” (P = .009) categories, as well as communication ratings (P = .02), and mean overall score (P = .005). Self-efficacy for identifying landmarks for intubation improved and students rated the simulation environment to be more realistic than the low-fidelity lab.

Participation in a simulation-based experience with self-reflection requirements gives students the opportunity to enhance SBAR communication skills before entering the clinical environment. Significant improvements were made in handover skills including student self-efficacy. The simulation structure developed in this study could be adopted to enhance interpersonal communication competence in RT students.

New generation ICU ventilators frequently enter the market. To determine the performance of these ventilators they need to be compared to established ICU ventilators. In this study we compared the gas delivery capabilities of the new Nihon Kohden 550 ventilator (NKV 550) to that of the Medtronic PB980 and the Drager V500 ventilators. We hypothesized that if these ventilators were optimally set in pressure support ventilation there would be no differences in trigger response, pressurization time and volume delivery.

Evaluations were performed with the IngMar ASL 5000 computerized lung simulator using a dry circuit and the Fisher & Paykel RT380 adult ventilator circuit. The ASL 5000 was set to simulate normal, COPD and ARDS lung mechanics with two ventilatory drives 1.7 and 6.7 cm H₂O and inspiratory times varying from 500 to 900 milliseconds, ms. Ventilator trigger sensitivity, rise time and termination criteria were optimally set. Each ventilator was set to deliver 5/5, 10/5 and 15/10 cm H₂O pressure support above PEEP. A total of 18 trials were conducted on each ventilator. Each trial lasted 2 min. The last 10 breath of each trial were analyzed. Trigger time (TT, ms), max pressure to trigger (MaxTrigP, cm H₂O), time to max trigger pressure (T-Tpress, ms), trigger pressure time product (PTP, cm H₂O -ms) time to 90% of peak pressure (T90, ms), and tidal volume (V_T, mL) were compared among ventilators using ANOVA for repeated measures. Potentially important clinical differences were defined as a P < .001 and >10% difference among ventilators.

Potentially clinically important differences were identified among all variables except tidal volume(see table). Variables differed among ventilators with a P < .001 and >10% difference except for tidal volume. These differences were a result of increased time to trigger during COPD lung mechanics and a low ventilatory drive. Both independently increased time to trigger (data not shown).

There are clinically important difference in the performance of the NKV 500, PB 980 and V500 ventilators during adult pressure support ventilation. Disclosures: Robert Kacmarek is a consultant for Medtronic’s and Orange Medical and has received research grants from Medtronic’s and Venner Medical. All other authors report no conflict of interest

Essentially all new generation adult ICU ventilators are designed to provide ventilation of neonates to adults. Nihon Kohden recently introduced a new ventilator to the market the NKV 500. To determine the performance of this ventilator during neonatal pressure support it needs to be compared to established ICU ventilators. In this study we compared the gas delivery capabilities of the new Nihon Kohden 550 ventilator (NKV 550) to that of the Medtronic PB980 and the Drager V500 ventilators. We hypothesized that if these ventilators were optimally set in pressure support ventilation there would be no differences in trigger response, pressurization time and volume delivery.

Evaluations were performed with the IngMar ASL 5000 computerized lung simulator using a dry circuit and the Fisher & Paykel RT260 neonatal ventilator circuit. The ASL 5000 was set to simulate neonatal lung mechanics with a weak, normal and strong ventilatory drive (P0.1 1, 4.2 and 7.3 cm H₂O) and inspiratory time varying from 250 to 400 milliseconds (ms). Evaluations were performed without a leak and with a leak (1 to 1.5 L/min). Ventilator trigger sensitivity, rise time and termination criteria were optimally set. Each ventilator was set to deliver 5/5, 10/5 and 15/10 cm H₂O pressure support above PEEP. A total of 18 trials were conducted on each ventilator. Each trial lasted 2 min. The last 10 breath of each trial were analyzed. Trigger time (TT, ms), max pressure to trigger (MaxTrigP, cm H₂O), time to max trigger pressure (T-Tpress, ms), trigger pressure time product (PTP, cm H₂O -ms), time to 90% of peak pressure (T90, ms), and tidal volume (V_T, mL) were compared among ventilators using ANOVA for repeated measures. Potentially important clinical differences were defined as a P < .001 and >10% difference among ventilators.

The only potentially clinically important difference identified among variables evaluated was maximum trigger pressure(see table). Even this difference, although it met our criteria (P < .001 and >10%), is small (-0.23 vs -0.28 cm H₂O across ventilators) and unlikely clinically important.

The NKV500, PB980 and V500 all performed similarly during this evaluation. The only potentially important difference was maximum trigger pressure. Disclosures: Robert Kacmarek is a consultant for Medtronic’s and Orange Medical and has received research grants from Medtronic’s and Venner Medical. All other authors report no conflict of interest

Chronic Obstructive Pulmonary Disease (COPD) is one of the leading causes of morbidity and mortality. COPD is included in the Hospital Readmissions Reduction Program (HRRP), a Medicare value-based purchasing program that penalizes hospitals for 30-day readmissions. Implementation of cost effective care methods to prevent readmissions has become a greater challenge for many health care systems. Such challenges include identification of gaps between the inpatient and outpatient care settings; that would allow for continuity in respiratory care and other pulmonary rehabilitation modalities. In fiscal year 2018, the overall 30-day readmission rate for Medicare Fee-For-Service (FFS) patients with COPD was 26.4% with 52% of these readmissions being within 7 days of discharge. Continuity of care between the inpatient and outpatient care areas is imperative to achieving a successful HRRP, while improving quality of life for the patient.

We implemented COPD Transitional Care Coordination (TCC) as a strategic model of promoting efficient collaboration between the inpatient and outpatient care settings. For in-patient care, the model includes, a COPD Action Plan and interdisciplinary collaboration to formulate efficient care, with appropriate outpatient referrals (i.e., smoking cessation, pulmonary rehabilitation). For out-patient care we established post-discharge follow up telephone calls, via a health care navigator (HCN), per inpatient respiratory care practitioners (RCPs) assessments and recommendations. The HCN provided continual information sharing between outpatient practitioners to allow for further referrals and collaboration of care; reinforcement of the COPD Action plan and inhaler reconciliation.

A total of 177 patients were seen for COPD Action Plan as part of our COPD TCC model. Between August 2018 and May 2019, 13% of the COPD TCC patients seen were successfully enrolled with the ambulatory palliative care program for additional layer support, 8% of patients were referred for pulmonary rehabilitation.

Active collaboration between all patient care areas plays an important role in promoting efficient patient care. Utilization of tools such as a COPD Action Plan allows for better patient engagement, leading to a better patient outcome.

Pressure injuries from medical devices have become a key quality initiative for patient care. Endotracheal tubes (ETT) are a lifesaving medical device yet the risk of a medical device-related pressure injury (MDRPI) associated with ETTs can be life threatening if not managed appropriately. From July 1, 2017 to June 30, 2018, the Neuroscience Critical Care Unit (NCCU) fell in third place out of all other clinical units for MDRPIs with a leading cause due to ETT-related pressure injuries. An ETT Repositioning Schedule was created to reposition the medical device every two hours. This responsibility is shared between Nursing and Respiratory Therapy (RT) to enhance collaborative practice and increase awareness of skin breakdown.

A trial was instituted in the NCCU for three months, July 1, 2018 to September 30, 2018, to evaluate a decrease in MDRPIs specific to ETTs by 50%. Current practice for ETT repositioning is completed by staff nurses every two hours. A laminated Endotracheal Tube Repositioning Schedule was created for both Nursing and RT. RTs reposition the ETT at 0800, 1200, 1600, 2000, 0000 and 0400. Nurses reposition the ETT at 0600, 1000, 1400, 1800, 2200 and 0200. The schedule was hung at the patient’s head of bed as a visual reminder. Education was provided to all nursing and RT staff.

Data collection occurred from July 1, 2018 to February 28, 2019. The initial three month trial was continued and established in the NCCU. From fiscal year 2018 (FY 2018) to fiscal year 2019 (FY 2019), all medical device-related hospital acquired pressure injuries (HAPI) in the NCCU decreased 10%, from 24 to 13. ETT-related HAPI in the NCCU decreased 50%, 11 to 6. In addition to respiratory device-related HAPI, all categories of medical device related HAPI have decreased in the current FY 2019 as compared to FY 2018.

The overall goal of the trial was achieved and an unintended benefit resulted in an overall decrease in all categories of MDRPIs. This trial helped to establish a need for collaborative ETT repositioning and visualization of skin in all adult intensive care units in pursing best practice and further reduction in MDRPIs. The success of the intervention was shared throughout the institution and was recently implemented as a standard of care in all adult ICU’s of the hospital. This change has been identified as an opportunity to enhance collaboration between RT and nursing in providing quality care.

One step for assuring accuracy of pulmonary function laboratory (PFL) equipment is performing a biologic quality control (BioQC). The American Thoracic Society (ATS) and European Respiratory Society’s (ERS) 2017 standard for D_LCO BioQC requires weekly performance with a coefficient of variation (CV) of 12% based upon a study using 8 individuals. The aim of this study was to assess the D_LCO BioQC %CV results from a large clinical trial.

This study received institutional review board approval from Rush University Medical Center, ORA# 19032007. A D_LCO BioQC program was developed for an inhaled medication study that spanned over 42 months ending in 2018. Onsite training was provided to 114 PFLs from North America, Europe, and Israel using equipment from five different manufacturers. Results were sent to a central repository for expert review. The annual D_LCO %CV was based upon a minimum of 10 D_LCO values separated by at least 5 days with no control for diurnal variation. Each BioQC had to be technically satisfactory according to ATS/ERS 2005 D_LCO standards without failure of other mechanical quality control tests. Descriptive statistics were computed. Paired t-tests were conducted to compare the rate of %CV changes between years and tested at α = .05 using SPSS.

Of 217 BioQCs, 168 participants met the inclusion criteria for D_LCO BioQC tests the first year of the study with fewer in subsequent years. As indicated in Table 1, over 90% of %CV values were < 8% and the %CV decreased with experience. There was < 1% change in %CV across the 2-year time span.

The D_LCO BioQC %CV standard could be reduced to < 8%. This could improve precision of this important diagnostic test by 33% without impairing the function of PFLs. The PFL BioQC staff do not need to recalculate their %CV more frequently than every two years based upon the low variation of < 1%.

The American College Health Association reported in 2016 that 8.9% of college students indicated having an asthma diagnosis. When asthmatic students transition to a college campus, they may be ill-equipped to self-manage their asthma due to a lack of proper education, misinformation from their physician, or lack of acceptance of the chronicity of their disease. The research questions are: (1) How do students with asthma learn from their experiences in the self-management of their asthma during their college years? (2) How do these students cope with their asthma on the college campus? Methods: This qualitative case study recruited five college students with partially controlled asthma through the student health center (SHC) of a large public university. Approval for this study was granted from the university’s IRB (#5359). The students were interviewed individually and in a focus group session. Data collected from the interviews underwent coding and analysis to include: (1) initial coding, (2) focused coding, and (3) axial coding. Once codes emerged, they were assembled into themes and the data was subjected to the constant comparative data analysis.

Qualitative coding and analysis of the data revealed the following themes: (a) students have learned from lived experiences to adapt to weather conditions and campus terrain to avoid asthma triggers, (b) students want to establish an educative, meaningful relationship with healthcare providers at the SHC, (c) students have acquired coping strategies from learned behaviors of living with asthma on campus, and (d) as students transition to an adult role they become more autonomous with healthcare decision-making.

Based on the findings of this study there is a need for well-written asthma literature that is tailor-made for college students. The need for access to affordable medications is necessary for the overall health and well-being of students with asthma. Study findings reveal there is a need for training of students in the proper use of medication delivery devices and the role of inhaled medications in controlling asthma symptoms. Students prefer a working relationship with healthcare providers at the SHC that utilize a patient-centered approach in the delivery of asthma care. Disclosures: All authors have no conflicts of interest or industry relationships to disclose. This research project was partially funded by a doctoral stipend through Texas State University.

Students entering different Health and Human Service majors (HHSM) have been on a steady decline. This issue can be related to whether or not high school students are being given up to date information regarding HHSM. If counselors do not have a full understanding of all HHSM, high school students may not have the ability to make career/major choices in these areas. In this study, we will attempt to explore the perceptions and needs of high school guidance counselors related to HHSM. The hypothesis of this study is that fifty percent of high school guidance counselors lack knowledge and feel uncomfortable providing students with information about HHSM.

The Institutional Review Board of Youngstown State University (YSU) approved this study. A survey instrument was developed to evaluate high school guidance counselor's perceptions and needs regarding HHSM. The survey was sent to the regions surrounding YSU.

Of the 88 local high school guidance counselors that were emailed the survey, 29 responded (32.9%). When asked if they felt as if they see a need to improve their resources and understanding of HHSM, 22 of the 29 (75.9%) said yes. Of the HHSM that are offered at YSU, the top 3 that counselors felt most knowledgeable about, (strong and very strong ratings), were nursing, 25 (86.21%), physical therapy, 24 (82.76%), and social work, 23 (79.31%). The counselors were also asked to rate their level of comfort in discussing each HHSM that are offered at YSU. The top 3 majors that counselors felt more, and very comfortable discussing, were nursing, 21 (72.41%), social work, 20 (68.97%), and physical therapy, 20 (68.97%). When asked what methods they prefer in gaining information to the HHSM, web based format and written handouts were the preferred methods. They were then asked what methods in educating their students about HHSM would best suit their needs, campus program visit and web based format were the preferred methods.

The hypothesis for this study is rejected. However the results of the survey showed that 75.9% of the high school guidance counselors felt as though they needed to improve their resources and understandings of HHSM. A limitation to this study is the sample size and that it only pertains to the regions surrounding YSU. Further research could investigate high school guidance counselors nationally.

Patients with acute rib fractures have significantly higher rates of pulmonary related complications and increased ICU readmissions from acute care units. A Respiratory Therapy Assess and Treat protocol (RTAT) was developed to assess and manage respiratory care interventions based off a scored patient assessment algorithm. We sought to determine if an RTAT Protocol impacted outcomes when compared to a physician directed approach. Null hypothesis: Among adult subjects with > 3 rib fractures, there is no association in pulmonary related ICU readmissions when comparing a RTAT Protocol Group to a Physician-ordered Respiratory Care Treatment Group (Physician Group).

This was an IRB approved single-center retrospective and prospective analysis. Data from 626 subjects was evaluated. The Physician Group (n = 254) was evaluated from January 2016-December 2016. RTAT Protocol Group (n = 372) was evaluated from June 2017-December 2018. The primary outcome was pulmonary related ICU readmissions between Groups. Secondary outcomes were age, presence of lung disease, prevalence of polytrauma, hospital length of stay and number of rib fractures. Descriptive characteristics are reported as median (IQR) and frequency count (%). Chi-square of independence and Mann-Whitney U tests were applied as appropriate. Alpha (2-tailed) < 0.05. Factors independently associated with pulmonary related ICU readmissions were assessed by multivariate logistic regression modeling.

There was no difference in pulmonary related ICU readmissions when comparing the RTAT Group (1.9% [n = 7/372]) to the Physician Group (3.1% [n = 8/254]); P = 0.31. Multivariate logistic regression modeling revealed the following variables were independent predictors of respiratory related ICU readmission: Presence of lung disease (OR 5.3 [1.7-16.4], P <0.01) and Group assignment (OR 0.31 [0.09-0.96], P = 0.04). There was a difference in age (P = 0.02), Presence of lung disease (P < .01), polytrauma (P = .01) and number of rib fractures (P < .01) in the RTAT managed Group (Table).

There was no difference in the relationship between pulmonary related ICU readmissions when comparing a RTAT Protocol to physician ordered therapy. The RTAT Group had greater age, higher prevalence of lung disease, polytrauma and number of rib fractures compared to the Physician Group. In a predictive model, the RTAT Group was found to have less likelihood of a pulmonary related ICU readmission.

A patient’s ability to follow recommendations and manage their medical condition is related to the respiratory therapists’ (RTs) communication skills. Teach-Back is a health-literate communication technique that allows RTs to confirm patient understanding, and enhances patient-centered care by improving RT communication skills.

After obtaining IRB approval, first-year undergraduate RT students’ completed a Health Literacy Knowledge and Belief Survey Pre (n = 20) and Post (n = 18) intervention. Students attended a one-hour Health Literacy and Teach-Back skills training intervention. Simulated patients assessed RT students for teach-back use during a regularly scheduled simulation center experience. RT students’ perceptions were documented in a semi-structured interview immediately after the simulation center experience.

Facilitators to Use of Teach-Back 1. Confirm patient understanding “… [I] wanted to make sure they understood the reason behind it [the medication] since I’m not going to be supervising them all the time when they are doing it.” 2. Confirm proper use of medical devices “[I] wanted to make sure the patient knew how to properly use the device before I gave it to him. To make sure there weren’t any mishaps pretty much.” Barriers to Use of Teach-Back 1. Discharge scenario used in the simulation I had a mental health patient scenario and I didn’t get that far. It was hard to bring up and incorporate many things because of the scenario.” 2. Forgot/Nervous The patient was paraplegic so I was thinking about other things I was overwhelmed by the setting and forgot about it.” 3. Engagement level of the patient “She [the patient] didn’t really ask anything. While I was observing her it seemed like she was doing it right.” 4. Individual communication style “I’m not the type of person [to use Teach-Back]. I want to use it, but because I don’t have much communication with other people- so I didn’t use it.” Conclusions: Results indicate that RT students benefited from a one-hour Health Literacy and Teach-Back skills training. There was a moderate effect size for both Knowledge (d = 0.539) and Beliefs (r = 0.489) which indicates they are both clinically and statistically significant. Findings show that adding health literacy skills training into the RT curriculum improved RT students understanding and use of patient-centered communication skills when working with simulated patients.

Respiratory care students spend hundreds of hours in clinical practica. University faculty orients and prepares the students for these essential learning experiences; however they typically are not the primary instructor in the clinical setting. The RT employee who precepts/mentors/takes the student assumes the primary role of teaching in the clinical setting. Discovering perceptions of students regarding learning experiences in the clinical setting will assist RT preceptors and faculty to develop favorable clinical teaching practices that enhance student learning.

With IRB approval, students enrolled in respiratory care programs in the Greater Cincinnati-Northern Kentucky area were invited to participate in a survey describing their perceptions of clinical practicum experiences. The survey (used with permission) consisted of 10 open-ended questions and had been used previously (Dunlevy and Wolf, 1994; Wolf and Dunlevy, 1996). Survey was distributed in the spring 2019 semester. Qualitative responses were categorized by themes.

89 students were invited to participate; response was 30%. The vast majority of participants identified the most rewarding experiences occurred when they had opportunities to do hands on care. The most frustrating experiences were when they were not allowed to do anything or when it was obvious the RT preceptor did not want to have the students with them. Characteristics of preceptors who were most helpful to their learning were those who asked questions, were kind, nice, respectful, and friendly. Characteristics of preceptors that hindered the students’ learning included a bad attitude, complaining, rude and lazy. Students felt their opinion was valued when the RT preceptor asked questions and invited their input. Advice students would give a new preceptor included: letting them fumble, do hands on care, and ask questions. The most fun ways to learn in the clinical setting was by doing hands on care. The most boring learning activity was downtime. Results were very similar to previous surveys in the literature.

Students shared that they learn the most in the clinical setting when they are with RTs who allow them to ‘DO’, asked them questions, and had an overall positive attitude.

Developing a useful and effective survey tool can be difficult. Developing a valid survey tool that can be utilized without geographical bias can present even more challenges. Can the Delphi Process of anonymous group consensus be utilized to develop a survey tool that does not possess geographical bias? Methods: IRB approval was granted before any research began. The Delphi Process can be utilized to allow all participants equal voice in the creation process. The members of the Delphi panel should consist of experts in the field for which the Delphi was convened. Through anonymous feedback the end product or tool of the Delphi process is considered to possess validity and reliability. A survey tool was developed and then distributed to the stakeholders. The stakeholders then provided feedback and face validity was obtained. An invitation was then sent to the state representative of the National Association of School Nurses (NASN) inquiring if they would agree to participate in a survey validation process. The NASN was chosen as they were considered the experts on the topics of this survey. In addition, efforts were made to have equal representation from all sections of United States. The participants were asked to evaluate each question on question clarity, comprehensiveness, and ease of answering. A Likert scale of 0 to 3 was utilized to rate the approval rating of the question as well as a comment box for feed back. As a question received 75% approval, it was then removed from the evaluation process and considered approved by the committee.

Over the course of 4 rounds, all questions received approval. Questions were modified based upon feedback of the Delphi Panel and then resubmitted for approval. The resultant survey received approval by the Delphi members and was considered to possess reliability and validity.

As a result of this study, a research tool can be utilized to create a tool that does not possess geographical bias. This process was used to develop and validate a survey. This same process could also be utilized to develop other tools and/or processes. Disclosures: None.

End of life care is difficult for all medical professionals, causing struggles with grief during and after the death. Caregivers with higher mastery of care situations have more positive responses to providing care because they perceive themselves as able to meet care demands which can reduce caregiver distress and increase their coping strategies. Very few respiratory therapists (RTs) perceive they are prepared to assist the dying process. These same RTs have to remove life support or stop life sustaining therapy. Objective: To determine if a one hour course on end of life education to RT staff was effective in increasing staff perception of; their knowledge of end of life practices, value to their care of end of life patients, comfort with providing end of life care, and knowledge of long and short term ways to deal with their own grief.

A convenience sample of 130 pediatric RTs were provided a one hour end of life education course on the technical and emotional/spiritual aspects of end of life care which served as the intervention for this study. After the education a voluntary online survey was used to collect data. Participants were asked four questions, but each question was optional. Statistical analysis included percent change.

Voluntary online participants (N = 63), 68.3% (n = 41) strongly agreed their knowledge of end of life care increased after this course, 26.7% (n = 16)) agreed, 5% (n = 3) disagreed, and 0% (n = 0) strongly disagreed. 67.7% (n = 42) strongly agreed that this course would add value to their care of end of life patients, 30.7% (n = 19) agreed, 1.6% (n = 1) disagreed, and 0% (n = 0) strongly disagreed. 66.6% (n = 42) strongly agreed that this course made them more comfortable with providing end of life care, 27% (n = 17) agreed, 6.4% (n = 4) disagreed, and 0% (n = 0) strongly disagreed. 65.1% (n = 41) strongly agreed that this course increased their knowledge of long- and short-term ways to deal with grief, 31.7% (n = 20) agreed, 3.2% (n = 2) disagreed, and 0% (n = 0) strongly disagreed.

RTs perceived an increase in: knowledge of end of life practices, the feeling of value added to the care of end of life patients, increased comfort with providing end of life care, and increased knowledge of long and short term ways to deal with their own grief after the course. End of life care should be included as part of continuing education for RTs. Disclosures: None

Preterm neonates (gestational age< 32 weeks) often need respiratory assistance in the delivery room (DR) and during transport to the Neonatal Intensive Care Unit (NICU). As part of a quality improvement (QI) project evaluating initial interventions for preterm infants, it was identified that the time to establish respiratory support upon arrival to the NICU was a barrier to completing the required care within the first hour of life. The DR team was challenged to improve team workflow and develop an apparatus that allowed for resuscitation and initiation of invasive or nasal noninvasive (NIV) respiratory support in the DR, thus decreasing time spent initiating such support in the NICU. Given that respiratory support is always placed prior to umbilical line (UL) placement, the start time of UL placement was used as a measure of completion of respiratory support establishment in the NICU. Goal: To decrease the time from NICU arrival to start of UL placement by 20% over a period of 5 months.

QI data collected for preterm deliveries was examined at two points: 1.) Time in minutes from birth to arrival in the NICU 2.) Time in minutes from arrival in the NICU to start of UL placement. Plan-do-study-act (PDSA) cycles included: #1 Role clarification and work flow improvement for DR team. #2 Application of skin barrier for nasal NIV in DR prior to transport to NICU. #3 Development of a mobile stand outfitted with a t-piece resuscitator, oxygen blender, transport ventilator, intubation and NIV supply bags, and cylinder holders for air and oxygen tanks. #4 Education and simulation for DR team prior to roll out. #5 Implementation of mobile system and ongoing feedback collected to improve device performance.

Base line data collected over 3 months showed the average time from NICU arrival to UL placement was 20 minutes (n = 12). After all PDSA cycles, this time decreased to 7 minutes (n = 13), a 65% reduction over a 5-month period. (Figure 1). As a balancing measure, data showed the average time from birth to NICU arrival was 24 minutes (baseline) and 23 minutes (post-intervention).

Improvements in team workflow and implementation of a standalone mobile respiratory support unit demonstrated success in improving key time measurements in the first hour of life for preterm infants without increasing time spent in the delivery room or delaying arrival to the NICU.

An advance in medical technology and increase of old patients with chronic respiratory failure are increasing the prevalence on noninvasive ventilation. This study was done to evaluate the clinic characteristics, outcomes, and prognostic factors of adult patients requiring noninvasive ventilation in a regional hospital.

Retrospective chart review was performed on ICU adult patients, who received noninvasive ventilation at Taiwan middle medical center hospital with approximately 200 beds from April, 2017 to March, 2018. We analyzed the characteristics between the weaning success and the weaning failure group. Data were expressed as the number or median. This study was approved by the ethic committee of Canghua Christian Hospital.

The median age of patients was 60.91 years and 67% were male. The cause of noninvasive ventilation were acute respiratory failure 59.4%, acute exacerbation of chronic respiratory failure 20.6%, and neuromuscular disease 7.3%. Mortality was 10.3% and the patients requiring home BiPAP at discharge were 5.7%. The overall weaning rate from noninvasive ventilation was 73.8% . The weaning success group had a higher heart failure 48.5% and a lower total duration of noninvasive ventilation, median 7.8 days vs 3.2 days, compare to weaning failure group. Total duration on noninvasive ventilation above 5 days, chronic lung disease,and heart failure were independently associated with successful noninvasive ventilation weaning.

Chronic lung disease, heart failure and duration of noninvasive ventilation appeared to be significantly associated with successful weaning from noninvasive ventilation.

The Comprehensive Center for Bronchopulmonary Dysplasia (CCBPD) at Nationwide Children’s Hospital is a referral center for term and post-term patients with severe BPD. The CCBPD strongly promotes family centered care. There is very little data regarding the optimal criteria and timing for the decision of a tracheostomy in this patient population. Risks of tracheostomy long-term are poorly understood and followed. An objective scoring tool of important factors were created for infants with severe BPD with need for mechanical ventilation and prolonged positive pressure in 2015.

Infants at 44 weeks corrected gestational age and beyond were scored monthly by the interdisciplinary team. Identified 16 clinical triggers based on disease physiology and past clinical decision making developed an objective scoring tool that assigned numerical values within each category. The total score was evaluated by zones: green for low risk, yellow for caution for need for tracheostomy and red reflecting likely need unless progress occurs soon. Infants scoring high in the high yellow zone or low red zone, triggered a care conference with family to discuss the score. We reviewed the percentage of parents with resistance to accept and consent to tracheotomy for 2 years before implementing the scoring tool and for 2 years after, as measured by the number of repeat care conferences. Also, rates and scores of tracheostomies before and after implementation were reviewed.

Parental resistance to tracheostomy placement decreased from 62% to 10%. Scoring resulted in high reliability separately amongst disciplines and within 2 points. All patients scored higher than 15 on scoring tool and all but 1 scored >20 at time of trach insertion. Tracheostomy rates remained stable before and after scoring tool implementation. 6 patients received a trach out of 13 scored in 2016. 4 patients received a trach out of 11 scored in 2017. 6 patients received a trach out of 15 scored in 2018.

The tool provides an objective assessment determining the best timing for the decision of tracheostomy placement that provides a standardized approach to help parents understand why a tracheostomy might be recommended. Utilization of this scoring tool has helped decrease variability of decision making, anticipate discussions with family, and follow our outcomes over time for the severe BPD population.

Bronchopulmonary dysplasia (BPD) is the most common complication of prematurity. Despite advances that have significantly improved extremely low birthweight (ELBW) survival, BPD rates have not made any significant improvement within our institution. While several potentially better practices have been proposed to prevent BPD, none of these have individually shown to affect the prevalence of BPD. Bedside staff engagement, revealed significant knowledge deficits, and workflow barriers to meaningful bedside assessment and effective application of supplemental oxygen. A recurring theme in these interviews led to the conclusion that there was a significant gap in understanding of neonatal physiology. Bedside education was needed on neonatal lung development, physiological drivers of BPD, target SpO₂ ranges per gestational age, SpO₂ alarm limits, and how to read and use histograms on the monitors. It was then decided to start weekly BPD Prevention rounds.

The weekly BPD prevention rounds were led by a respiratory therapist and registered nurse. The goals for these rounds were to provide education to the bedside staff about neonatal lung development, physiological drivers of BPD, target SpO₂ and alarm limits per gestational age, how to read and use histograms, and proper oxygen utilization. By providing this education the hope was to give the bedside provider the tools to help prevent BPD and ultimately, decrease our BPD rates.

87.50% of the team agreed that the BPD prevention rounds have been beneficial. 83.33% agreed that the BPD prevention rounds have taught them how to help prevent BPD as a bedside provider. 91.67% agreed the BPD prevention rounds have taught them to utilize histograms. 83.33% agreed the BPD prevention rounds have helped encourage them to use less oxygen.

The weekly BPD prevention rounds have been instrumental in educating all of our bedside providers on BPD prevention and oxygen utilization in our level IV NICU.

Evidence-based practice (EBP) is considered a major respiratory therapy competency established by the profession and essential to the clinical decision-making process. Currently, there is a limited understanding of what factors influence the use of EBP among respiratory therapists. The purpose of this study was to assess the factors associated with the use of EBP among respiratory therapy faculty teaching in a large community college system and post-professional students enrolled in a university-based, respiratory therapy baccalaureate degree completion program.

An online self-administered questionnaire was developed and administered to assess EBP knowledge, self-efficacy, learning experiences, and use in practice. Binary logistic regression was conducted to determine which independent variables were predictors of EBP use in clinical decisions. IRB approval was obtained prior to initiation of this study.

A total of 25 faculty and 58 post-professional students responded to the survey. Faculty and students demonstrated sufficient knowledge and understanding of introductory concepts of EBP but knowledge of specific components of the EBP process was not as strong. Self-efficacy in knowledge and use of EBP among faculty and students was varied. Faculty and students rated their self-efficacy high in assessing patients’ needs, values and treatment preferences but were less confident using the PICO technique and interpreting common statistical tests. Students viewed their previous EBP learning experiences more favorably compared to faculty. Descriptive statistics for EBP knowledge, self-efficacy, and learning experiences are presented in the table. Faculty and students searched and read the research literature more often compared to critically appraising and using the research literature. Logistic regression analysis indicated no statistcally significant relationship of knowledge, self-efficacy, and learning experiences to the use of EBP, X2 (4, N = 54) = 7.73, P = .10.

Results of this study suggested faculty and post-professional students in this study were knowledgeable and confident regarding EBP but the frequency of using EBP in clinical decisions was limited. While the EBP knowledge, self-efficacy, and learning experiences had minimal influence on the use of EBP, the results of the study provided the foundation for future research in this area.

The VOCSN (Ventec Life Systems, Bothell, WA) device integrates up to five therapies (ventilation, oxygen concentrator, cough assist, suction, and nebulization) and can operate using two low flow oxygen sources: internal concentrator or bleed-in from an external gas source. We evaluated the oxygen flow requirements using the VOCSN pulse dose internal concentrator (PDIC) vs the VOCSN and Trilogy 100 ventilator (Philips Respironics, Murrysville, PA) using an external oxygen concentrator (EC). We hypothesized the flow necessary to achieve a specified FIO₂ would be lower when using the pulse dose internal concentrator.

The VOCSN and Trilogy 100 were compared using passive and active circuits connected to a TTL test lung (Michigan Instruments, Grand Rapids, MI). Three simulated lung models using different TTL test lung parameters included: normal – Cst 60 mL/cm H₂O and Raw 5 cm H₂O/L/s, restrictive – Cst 30 mL/cm H₂O and Raw 5 cm H₂O/L/s, and obstructive – Cst 60 mL/cm H₂O, Raw 20 cm H₂O/L/s. Using pressure ventilation, the peak pressure and rise time were titrated to achieve V_T of 500mL as measured by a Certifier FA Plus (TSI Inc, Shoreview MN). Additional settings include: 12 breaths/min, PEEP 5 cm H₂O, and IT 1.0 second. VOCSN PDIC and a Millennium M10 (Respironics, Murrysville, PA) EC flow were adjusted to achieve a measured FIO₂ of approximately 0.40. Flow from the EC was measured by the Certifier FA Plus and FIO₂ was measured by the Handi + oxygen analyzer (Maxtec, Salt Lake City, UT) at the inlet of the test lung. At least three measurements were done for each ventilator, circuit type, lung model, and oxygen concentrator combination. Data for the three lung models were averaged for each test configuration and reported as the mean ± SD for each circuit type.

The oxygen flow in L/min required to maintain a FIO₂ of 0.40 (mean ± SD) with passive and active circuits respectively was: VOCSN-PDIC 2.61 ± 0.02 and 2.68 ± 0.12, VOCSN-EC 3.05 ± 0.16 and 5.59 ± 0.36, Trilogy-EC 4.78 ± 0.70 and 8.28 ± 1.31. Measured V_T and FIO₂ for all lung models, test configurations, and circuit types averaged 502 ± 8 mL and 0.397 ± 0.006 respectively.

Oxygen flow requirement was lowest with the VOCSN ventilator using pulse dose internal oxygen concentrator with both the passive and active circuits, and with VOCSN using an external oxygen concentrator with the passive circuit compared to the Trilogy 100 ventilator.

A significant and unexplainable increase in ventilator-associated events (VAE) was noted in the ICU’s of Penn Medicine Lancaster General Hospital. An interdisciplinary team was formed, and LEAN A3 problem solving techniques were used to try and reduce VAEs. Multiple PDCA cycles were used to improve compliance with ventilator bundles. After compliance was verified, it was discovered that many VAEs were potentially avoidable and could be attributed to PEEP and/or FIO₂ not being returned to baseline after a hypoxic event had resolved. We hypothesized that daily monitoring of ventilator settings could help to reduce unnecessary Ventilator-Associated Conditions (VAC); therefore, reducing Infection-Related Ventilator-Associated Complications (IVAC) and Possible Ventilator Associated Pneumonia (PVAP) as well.

In December 2018, a standardized approach to monitor for VAE was implemented, and used a tool in the EMR that recorded the daily minimum settings for PEEP and FIO₂. Frequent, preferably daily, audits of the ventilator settings compared baseline settings to current settings. If patients were at risk for “flagging” as a VAC, discussions of the current ventilator settings and plan of care occurred with the ICU care team at the bedside. Attempts to wean the PEEP and/or FIO₂ back to baseline occurred if it was clinically indicated and appropriate for the patient.

In the 5 months prior to auditing, 23 VAE (14.17 VAE/1000 vent days) were observed. During the five months after auditing implementation, 6 VAE (4.04 VAE/1000 vent days) were observed. Infections (IVAC + PVAP) decreased from 16 (9.86/1000 vent days) without audits to 2 (1.34/1000 vent days) with audits during the same respective time periods. During the experimental period, a significant reduction in overall VAE were noted [P = .001].

Standardized monitoring of ventilator settings can play a role in reducing overall VAE. Referred to as weaning with a goal, weaning of the PEEP and FIO₂ contributed to this reduction due to known preferable/baseline ventilator settings. Patient safety and appropriate treatment must still remain a priority in this process. Lack of knowledge about VAE guidelines was a barrier that was overcome through real-time education at the bedside. Our next step will be to continue this process to determine if these results are sustainable.

It is believed that underlying the current state of health (HRQL) is the lifestyle status of the patient. However, other factors such as spiritual well being and psychological, mental and motivational status may be at least as important as others but understudied. This research describes an attempt to validate a new wellness assessment questionnaire and to identify and investigate the status of several wellness domains in patients with COPD.

The study consisted of two phases: first, the development of a new Wellness Questionnaire with the help of focus groups and then the validation and use of the questionnaire in a cohort of COPD patients.

Thematic analysis of findings from focus groups and original cohort respondents highlighted some factors that appear to influence wellness status. Five domains were explored as potential markers of wellness in patients with COPD, including spirituality. Quantitative analysis with Spearman correlation demonstrated a significant correlation between Physical/Personal Wellness as recorded by the questionnaire and other markers of COPD progression such as GOLD (0.006), kg/m² % (0.01), health-related quality of life (0.009), multidimensional BOD score and quartile (0.003 and 0.02).

This study led to the development of a new (Sunderland) Wellness Respiratory Questionnaire (SWRQ) to assess wellness status in patients with COPD and the observation that wellness status may have an influence on disease progression.

More cystic fibrosis (CF) patients are living longer, and lifestyle-related behavior is becoming increasingly important for improving morbidity and mortality. Declining levels of exercise leads to a low cardiorespiratory fitness, which is a strong, independent predictor of mortality in CF. As a result, exercise training has become a regularly accepted form of treatment for CF patients. The purpose of this study was to determine the volume of physical activity (PA) and perception of exercise in adult CF patients.

Adult patients from an in-patient CF clinic were recruited to participate. A structured interview and self-report questionnaires were used to collect information on volume (time and intensity level) of PA and exercise perception including preferences, readiness, and barriers.

Forty-six adult CF patients consented to participate in the interview and completed self-report questionnaires. The majority (76%) of participants self-reported performing PA at a moderate level or above. Mean (+ SD) hours per week of physical activity levels by category were as follows; moderate 11.8 + 12.2 (76.4%), hard 1.8 + 4.6 (17.4%), and very hard 0.4 + 1.6 (6.2 %). Most of the adult CF patients preferred walking and 65% of the participants felt exercise was very important. Lack of energy, good health, self-discipline, and time were noted as the most frequent barriers to exercise. Moderate PA was associated with both physiological and psychological factors.

Based on this study, adult CF patients self-report performing an adequate amount of moderate PA. However, a small proportion of time is spent at a vigorous PA level. Clinicians providing individualized care during rehabilitation have an opportunity for improving adherence to prescribed exercise that may positively impact both physiological and psychological factors. Further, motivating CF patients to engage in more vigorous PA may provide a stimulus that improves clinical outcomes and potentially survival. Key words: cystic fibrosis; physical activity; exercise; aerobic fitness; exercise barriers; cystic fibrosis survival.

The air entrainment jet nebulizer (AEJN) is a type of jet nebulizer designed to deliver similar aerosol dose in less time and are marketed as a faster delivery device. Although time to deliver a dose may be a consideration in the selection of a device, more important factors include; delivered lung dose and patient clinical response. In vitro bench, imaging and clinical studies comparing jet nebulizer to vibrating mesh nebulizer (VMN) consistently demonstrate superior performance of VMN. We hypothesized that VMN would provide greater % tracheal dose compared to AEJN.

Mask-mediated aerosol delivery with VMN (Aerogen Solo with Ultra, Aerogen Ltd., Galway, Ireland) and AEJN (Airlife Misty Fast, Carefusion Inc., Yorba Linda, CA) were compared in adult and pediatric models connected to a sinusoidal pump via a collecting filter at the level of the trachea. The following settings were used to simulate a spontaneously breathing adult (V_T 500 mL, 15 breaths/min, I:E ratio 1:1) and pediatric model (V_T 300 mL, 20 breaths/min, I:E ratio 1:2. The infant model utilized a blow-by interface held ½ inch from the upper airway of the spontaneously breathing lung model (V_T 50 mL, 30 breaths/min, I:E 1:3). The VMN was powered by the Pro-X controller with a driving gas flow of 2L/min from a 30 psi source (Aerogen, Galway, Ireland) and the AEJN powered by 8 L/min gas flow from a 30 psi source. The AEJN was loaded with a (2.5 mg/3 mL) solution of albuterol and aerosolized to sputter plus one minute and the VMN was run until aerosol was no longer produced (n = 4). Drug eluted from the filter was assayed with UV spectrophotometry (276 nm). Descriptive statistics and t-test were used for data analysis using SPSS. P < .05 was considered statistically significant.

The VMN resulted in significantly higher % tracheal dose compared to AEJN in adult and pediatric models (28.30 ± 0.62, vs 7.20 ± 0.22, P < .001 and 30.75 ± 2.18 vs 6.45 ± 0.59, P < .001, respectively). Percent tracheal dose with the blow by infant model was low with both VMN and JN (1.65 ± 0.79 vs 0.27 ± 0.10, respectively, P = .013). There was significantly less residual weight retained in the reservoir of the VMN (1.3%) compared to AEJN (43.6%) in all models tested, (P < .001).

The VMN provided significantly greater % tracheal dose in the adult and pediatric models, 4-5-fold higher and significantly lower residual waste retained in the reservoir in all models tested when compared to AEJN.

In 2017, I attended a seminar educating respiratory therapists on how to implement a vascular access program. The workshop introduced me to the benefits of using Point of Care Ultrasound (POCUS) for needle puncture procedures. I returned to my home hospital with aspirations of diving into developing a vascular access team of Respiratory Therapists. Unfortunately, when I brought the idea to my leadership team I was stopped in my tracks with a hard, No." My inherent persistence would not allow me to let go of the concept altogether. Respecting the boundaries set forth by my profession’s scope of practice and my hospital’s policies I conducted a pilot study comparing POCUS-guided arterial punctures with the traditional blind-stick palpation method.

Data was collected from 100 adult patients to include 50 POCUS-guided and 50 blind-stick arterial punctures. The POCUS-guided team performed 35 successful POCUS-guided punctures before data collection to gain competency for the procedure. The study group included data from both radial and brachial puncture sites, using both transverse and longitudinal ultrasound views.

Average time for the blind-stick method in 50 patients was 31.68 minutes versus 12.14 minutes for the POCUS-guided method. For the blind-stick method, 18 of the 50 ABG’s (36%) were resulted in <20 minutes versus 43 of the 50 (88%) for the POCUS-guided method. Average puncture attempts required to successfully obtain a sample using the blind-stick method was 1.36 (35 successful on first attempt, 12 successful on second attempt and 3 successful on third attempt.) With 35 of 50 procedures being successful on first attempt, that gives a 70% first attempt success rate for the blind-stick method. Average puncture attempts required for the POCUS-guided method was 1.01, a first attempt success rate of 96% (48 successful on first attempt, 2 successful on second attempt.) Conclusions: POCUS was recognized as a best practice for deep needle puncture procedures in 2001. The technology is constantly evolving in terms of affordability, portability, miniaturization and ease of use. Drawing blood is the single most frequently performed medical procedure, with roughly 760 inpatient blood draws performed in the United States every minute. POCUS is a billable procedure that improves success rate, decreases complications and enhances the patient experience. POCUS should be considered the standard of practice for all needle puncture procedures including venous and arterial punctures. "

Noninvasive ventilation (NIV) and high-flow nasal cannula (HFNC) are extensively applied to prevent extubation failure. The advantages of HFNC include stable oxygen supply and positive end expiratory pressure effect have been demonstrated in patients with heart failure to reduce right heart preload and relieve dyspnea. We aimed to compare the effectiveness of HFNC with NIV for preventing extubation failure in critical ill patients with heart failure.

This was a three-year retrospective and single-center study approved by the ethics committee of Taipei Medical University. A total of 104 patients with heart failure (Left ventricular ejection fraction less than 50%) who were treated with prophylactic HFNC and NIV after extubation were included. Patients who refused reintubation were excluded. Clinical data including demographics, comorbidities, echocardiographic data and weaning parameters were collected. The primary outcome was treatment failure within 72 hours. Treatment failure was defined in the HFNC cohort as escalation to NIV or reintubation, and it was defined in the NIV cohort as requiring reintubation. Secondary outcomes were reintubation, intensive care unit (ICU) and hospital lengths of stay (LOS), and hospital mortality. Chi-square, Fisher exact and Mann-Whitney U test were used to compare variables between two cohorts. We performed two multivariate logistic regression analyses including clinical variables associated treatment failure and hospital mortality, with a P value < .2 using univariate analysis.

Treatment failure within 72 hours was no significant difference between the two cohorts (P = .106). Hypoxemia respiratory failure was significantly lower in NIV (P = .031). Hospital mortality was significantly lower in HFNC cohort (P = .044). No significant differences were found in reintubation, ICU and hospital LOS. The multivariate logistic regression model revealed that NIV as prophylactic treatment and reintubation were independently associated with hospital mortality.

In patients with heart failure, the effectiveness of prophylactic HFNC in preventing extubation failure is similar to NIV. However, prophylactic HFNC resulted in lower hospital mortality. We suggest that HFNC can be routinely applied after extubation, but selective patients may need NIV. Disclosures: All authors conflict of interest: none. All research funding, sponsorships, provision of equipment, or other financial support: none

Recent advanced ventilation modes (AVMs) of mechanical ventilation are closed-loop modes that have the ability to automatically adjust some respiratory settings. Despite their effectiveness in several clinical trials, it is unclear to what extent these modes are actually used in daily clinical practice. The aim of this study is to define the practice of AVMs in intensive care units (ICUs) in the Eastern Province of Saudi Arabia, and to explore reasons for not applying AVMs.

A cross sectional survey was conducted among all adult ICUs in the Eastern Province of Saudi Arabia. ICU respiratory therapists were identified for each ICU and were asked to participate in the survey. We have divided the ICUs into three levels depending on the number of beds. Use of closed-loop modes was classified as frequently, occasionally or never. From (1 to 10) as level 1, (11 to 20) as level 2, and more than 20 as level 3. Institutional Review Board (IRB) approval was obtained.

A total of 100 ICU respiratory therapists were approached, only 83 including 60 male were completed the survey. Of those 83, 70 were holding bachelor degree, 13 were diploma, and only 40 of 83 have more than 5 years’ experience. The percentage of ICUs that had access to AVMs was 73.5%, which 62.7% were occasionally or never use them. Table 1 shows the frequency of use (frequently or occasionally/never) per ICU levels (1, 2 and 3). The most frequent used modes were neurally-adjusted ventilatory assistance (NAVA) (35.34%), airway pressure release ventilation (APRV) (19.83%), proportional assist ventilation (PAV) (17.25%), while INTELLiVENT-ASV mode was rarely used with only (0.86%). Reported reasons for not using AVMs were lack of knowledge (50.8%), no enough trust in these systems (23.4%), lack of value (20.5%) and no AVMs in the ICUs (5.3%).

The results showed that AVMs were clinically underused and their value seems to be underestimated in the adult critical care areas. Further investigations are needed to overcome possible barriers that may hinder the utilization of the newer ventilation modes, which would improve patients’ outcome.

The frequency of use (frequently or occasionally/never) per ICU levels

Lung disease compromises breathing, decreases activity and decreases quality of life. The purpose of this study is to investigate innovative strategies used by pulmonary rehabilitation leaders to keep patients motivated and engaged in completing pulmonary rehabilitation, thus increasing quality of life.

This study, approved by the International review board, utilizes a descriptive design gathering information through the eyes of pulmonary rehabilitation leaders. To gain a better understanding of the ways that leaders keep patients motivated to complete pulmonary rehabilitation, this researcher administered an questionnaire asking participants the various strategies they use to keep patients motivated in completing pulmonary rehabilitation.

A summary of the responses from completed surveys shows that constant positive reinforcement, maintaining flexibility, giving individualized attention, placing patients in social networks that work for them, and providing healthy foods helped keep patients engaged. Keeping the environment fun and offering any needed assistance including psychosocial, resolving home care and medication issues also kept patients motivated. Survey participants believed that patient success and motivation could be enhanced through the pulmonary rehabilitation leader. Paying attention to the patient’s needs, helping them resolve problems as well as creating an environment that is positive and supportive helped keep patients motivated. Respondents wrote that PR leader possess the skills and knowledge to engage the patient and learn patient interests. Improvements in QOL, depression, and functioning are a few indicators of patient motivation and success noted by the respondents. Leaders were motivated by seeing the disease process and its effects on both the patient and family as well as by improvements in patient’s overall status.

Pulmonary rehabilitation has become an important treatment modality prescribed by doctors for those with lung disease that increases quality of life. Information gained from literature of reasons why patients don’t comply as well as responses gained from leaders in PR to enhance patient compliance can be utilized to keep patients motivated. Survey results show listening, support, socialization, comfort, and education all increase QOL for patients and all help increase the likelihood that patients will be motivated to complete pulmonary rehabilitation. Thus, increasing quality of life.

Prolonged mechanical Ventilation patient (PMV), who used the ventilator equal or over 21days need caregivers (most are family members) to 24-hour care. Studies have shown that the physical and psychological stress on the caregivers of PMV patients, but no one compares the physical and psychological stress among caregivers of the intensive care unit, respiratory care center (RCC), respiratory care ward (RCW) and home care (HC) patient.

We conducted a cross-sectional study from November 2013 to April 2014. We used a structured questionnaire to survey main caregivers on a 5-point Likert scale. The survey was conducted in 64 Cooperative institutions (6 medical centers, 11 regional hospitals, 23 local hospitals, 15 nursing homes, and 9 home care centers) conducted questionnaire surveys and collected 687 questionnaires.

A total of 601 questionnaires were included (effective rate 87%), including 150 ICU stages, 150 RCC stages, 150 RCW stages, and 151 HC stages. There were no significant differences in caregivers, social, and economic performance among the four groups of respondents. Physical stress, compared with ICU caregivers, RCC is 1.94 times, RCW is 1.22 times, HC is as high as 3.67 times; psychological stress, compared with ICU caregivers, RCC is 1.20 times, HC is as high as 2.39 times Conclusions: The caregivers of PMV patients at Home were under high physical and psychological stress compared to ICU, RCC and RCW. It is recommended that more support to them were needed.

The aim of this study was to investigate the predictors of mortality after planned extubation in the nonagenarian pneumonia patients with acute respiratory failure.

A retrospective review from medical records was conducted for the nonagenarian patients with acute respiratory failure. All of these patients were under endotracheal tube intubation with mechanical ventilation support in intensive care units (ICUs) of Chi-Mei Medical Center, Taiwan from 1 Jan 2010 to 31 Dec 2017. Patient characters, such as disease severity (APACHE II, and TISS scores), body mass index (BMI), vital signs, laboratory data were collected. Reintubation was defined as intubation again due to acute respiratory failure after the first planned extubation in the hospital. The stay time in hospital and their medical costs were measured also. Statistical analysis of the data was done by SPSS version 18.0. Logistic regression statistical analysis was done. Statistical significance was set at P ＜ .05.

114 nonagenarian patients over 24 hours MV support were enrolled in this study. The average age of all patients was 92.5 ± 3.0. The hospital survival rate was 71.1% (81 over 114 cases) of these patients. Compared with the hospital survival cohort, high APACHE II (23.5 VS 21.5), high blood urea nitrogen(BUN) level (42.4 VS 31.4 mg/dL) and low hemoglobin (Hb) before extubation (9.3 vs. 10.3 mg/dL) were found in the hospital death patients. Compared with the hospital deaths cohort, higher rate of beginning weaning over 3days after intubation (29.6% VS 60.6%),lower reintubation rate during hospital (13.6% VS 33.3%) and lower prolonged weaning rate (45.7% VS 66.7%) were found in the hospital survival patients. Moreover, prolonged ICU (17.1 VS. 13.2days) with higher costs of medical care (33.8 vs 27.7 thousands in New Taiwan dollars) were also found in this cohort. The higher reintubation rate during hospital, lower Hb (Hb<10.3 mg/dL) and higher rate of beginning weaning over 3days after intubation,revealed the independent risk factors of hospital mortality (P < .05) for the cohort.

Reintubation was one of the three independent predictors of mortality in acute respiratory failure after planned extubation in nonagenarian patients with pneumonia. The hospital death patients exhibited a prolonged ICU with higher costs of medical care. Keywords: reintubation, planned extubation, nonagenarian, respiratory failure, pneumonia.