Respiratory Care

Respiratory care (RC) students obtain a Bachelor of Science degree in respiratory care from Indiana University of Pennsylvania. The first two years of the program “pre-clinical phase”, requires science, math, liberal arts and elective courses, for a total of 62 of the 120 credits. The last two years are the “clinical phase” which requires 58 credits of respiratory care core curriculum. The purpose of this investigation was two-fold: To determine whether or not students truly understand what the RC major entailed during the first two years; and whether the preclinical science and math courses adequately prepared the students for the difficulty of the Respiratory curriculum during the last two years. The primary goal of this project was to attempt to reduce attrition in the program.

After obtaining IRB approval, third- and fourth-year respiratory care students answered a 10-question survey sent via Survey Monkey through university email. Fifty-seven students from 2018-2019 were surveyed with a return rate of 63% (n= 36). Fifty-three percent were juniors (n=19) and 47% were senior (n=17) RC students at the time of the surveys.

Survey results revealed that 75% of RC students felt prepared entering the clinical phase of the program. Moreover, 78% of RC students felt specifically the required math and science courses did adequately prepare them for the core courses. In fact, 61% of RC students report their QPA actually increased after entering the professional phase of the program. However, only 36% of these students admitted they knew exactly what the profession entailed when they were freshmen and sophomores.

Results indicate the current math and science curriculum during the first two years does appear to adequately prepare students for the clinical phase of the program. Student opinion shows that academic attrition during the clinical phase of the program appears to be due factors other than science preparedness. However, these results also indicate that students need more exposure to the major and/or a better understanding about the major during the preclinical years 1 and 2. The program currently offers RESP 101 “The Respiratory Care Profession”- a one credit introductory course for either freshman or sophomore students. While this course helps to explore the major and career paths in respiratory care, it may be helpful to consider providing additional information in this course in order to show more breadth and depth about RC which could reduce attrition.

Figure 1: Students Perceptions of Program Preparedness of Professional Phase

Figure 2: Results of Students Admitted Career Knowledge Prior to the Professional Phase of the Program.

Our 2019 Improving Staff Morale in the Respiratory Care Department QI project showed a 63% increase in overall staff morale. Due to the positive results the project warranted continuation. In an effort to make our department the best it can be, the study will continue. A re-survey showed an abrupt decrease in morale.

Surveys have been and will continue to be sent quarterly or post interventions to evaluate effectiveness. Since our post survey showed lower than anticipated results, we will continue the QI project. The goal is to implement interventions that effect long-term positive change in staff morale. After interventions are implemented throughout the year by the shared governance team and leadership team, we will re-survey and trend the date to see if the implementations increased morale.

After our post (third) survey the results showed a 23% percent decrease in overall staff morale. The decrease in staff morale correlated with critical care nurses receiving a $5.00 per hour bonus pay. Survey results also showed the therapists were not satisfied with their schedules. Neither of these influences are areas where shared governance can intervene. The results were presented to leadership, but changes to pay and schedules cannot be made. The decision was made by shared governance to continue the existing programs and created new interventions. As community out reach, a statement of support was sent to respiratory departments hardest hit by COVID-19. RT support began with our leadership team providing water bottles, meals, and words of encouragement. A t-shirt was also designed and sold. The largest overall positive impact was our Code Lavender day. This is a day where staff were able to unwind and de-stress. During the event, RTs had an opportunity to interact with a therapy dog, receive massages, speak with a chaplain, participate in various stress relieving activities, and food was provided. This day was welcomed with open arms from staff. A survey conducted after the Code Lavender day showed that morale was positively affected by 75%.

Programs will continue to be implemented that are within the scope of shared governance. The decrease in overall staff morale was influenced by factors that we cannot change. Shared governance will continue interventions that target mental health and overall employee support. We will continue to resurvey post interventions and make changes to our program. We will evolve with the needs of the department.

Chronic lung diseases, such as COPD and asthma, are associated with considerable morbidity and mortality and involve chronic inflammation and oxidative stress. However, the diseases are not diagnosed and treated efficiently in routine clinical practice because of the difficulties in monitoring inflammation. Consequently, it is often too late to alter respiratory dysfunction when patients’ referral for pulmonary function testing is delayed. The purpose of this study was to explore the possible associations between pulmonary function test (PFT) measurements and exhaled carbon monoxide (eCO) levels as an indicator of generalized inflammation. Data analysis was conducted to determine a potential level of eCO to use as an indicator for conducting PFT.

A sample of 343 subjects, who were referred by their physicians for a routine care PFT, were recruited from the Queen’s Medical Center Pulmonary Lab in Honolulu, Hawaii. A study-specific information sheet was provided to the subjects as part of the informed consent process, and the subjects’ data were collected through a Demographic Data Questionnaire. Exhaled carbon monoxide (eCO) levels were measured with a portable carbon monoxide analyzer (MicroCO Meter), and the maximum values from three successive measurements were used in all calculations.

FVC, FEV₁, FEV₁/FVC, and FEF25-75% decreased with elevated concentrations of eCO. In females, decreased lung volumes (TLC, FRC, and RV) were associated with increased eCO levels. In males, increased lung volumes were associated with increased eCO levels. Diffusion capacity of lungs for carbon monoxide (D_LCO) and eCO levels also showed the opposite correlation between females and males. D_LCO of female subjects markedly decreased with increased levels of eCO while D_LCO of male subjects mildly increased. Appropriate cut-off points of eCO levels also were examined to determine the most efficient use of eCO as an indicator for PFT. The present study found that a cut-off point for eCO of 6 ppm provided the best relationship between sensitivity and specificity in predicting the need for PFT.

eCO measurement, which is noninvasive, quick, inexpensive, and easily administered by primary care physicians, could serve as a useful biomarker for monitoring patients with pulmonary diseases. Therefore, eCO measurement may be clinically useful as a diagnostic tool to identify inflammation and to serve as an indicator of the need to conduct PFT.

Exhaled CO Levels and PFT Results of Female Participants

Exhaled CO Levels and PFT Results of Male Participants

The orientation of respiratory therapists to neonatal and pediatric intensive care units varies greatly among institutions. To date, there is scarce literature on current orientation practices or best practice in regards to training to these areas. Given the limited neonatal and pediatric education provided during respiratory programs, institutions must find efficient ways to prepare respiratory therapists to care for these patient populations.

The aims of this research project were to investigate how respiratory therapists are being trained, and how that training affects their preparedness to work independently in neonatal and pediatric intensive care units. A qualitative study was performed using one-on-one, semi-structured interviews with respiratory therapists trained to these areas to gain insight into current training practices, as well as training practices that respiratory therapists felt were important for preparing for independent practice. The recorded interviews were transcribed, and qualitative data analysis software was used to analyze the data. This research study qualified as exempt research and the study was approved by the A.T. Still University Institutional Review Board.

The results showed great variability in length of orientation and adjunct training, such as simulations and technology. In addition, most of the participants interviewed felt unprepared for independent practice at the completion of orientation. Participants felt orientation time was spent on equipment management, rather than patient management. The data showed that respiratory therapists with the RRT credential, a bachelor’s degree, and an orientation time of greater than four weeks reported being the most prepared for independent practice.

Orientation methods for training to neonatal and pediatric intensive care units varies greatly and leaves many respiratory therapists feeling unprepared to independently care for this patient population. This study demonstrates the need for further research in this area to help develop best orientation practices of respiratory therapists training to neonatal and pediatric intensive care units.

Respiratory devices are frequently implicated in the development of medical device related pressure injuries (MDRPI). Current risk assessment tools are not adequate to identify and prevent MDRPI. The purpose of this study was to evaluate whether the Braden Q or Braden QD scoring tool could reliably predict MDRPI in pediatric patients treated with noninvasive ventilation (NIV) using a mask

An IRB approved retrospective chart review was performed, reviewing all pediatric subjects who suffered from MDRPI while receiving NIV with a mask. The subjects’ demographics, as well as Braden Q and Braden QD scores were extracted from the Electronic Health Record (EHR) at time of admission, 48 hours prior to MDRPI, 24 hours before MDRPI, and at resolution. Braden Q and Braden QD scores were electronically binarized into "no risk" or "at risk" score ranges. McNemar test was used to assess if Braden Q and Braden QD have the same level of classification.

Forty-five unique subjects ages 1 months to 23 years with MDRPI were identified which included 24 female (53.3%) and 21 males (46.7%). Braden QD had a significant predictive value for MDRPI at admission (P<0.001), at 48 hours prior to injury (P<0.001), at 24 hours prior to injury (P<0.001), at time of injury (P<0.001), and at time of MDRPI resolution (P<0.001). By way of contrast, the Braden Q tool had no predictive value and scored all subjects at "no risk of MDRPI at admission, 24 hours prior to injury, and at the time of injury. The Braden Q scored 95.6% of subjects as no risk at 48 hours prior to injury.

Braden QD was able to predict risk for MDRPI in pediatric subjects using NIV masks. The Braden Q had no prognostic abilities within this same group during the same time intervals. The use of the Braden QD tool may enable the prospective identification of patients at risk for MDRPI related to the use of a NIV mask so that targeted interventions can be deployed.

The purpose of this study was to validate a new mathematical equation measuring the high frequency oscillatory ventilation index (HFOVI) against the ventilation index (VI). The ventilation index (VI) calculation has been used to determine the severity of lung injury in critically ill patients. There is no similar calculation for high frequency oscillatory ventilation (HFOVI). The equation using HFOVI is a measure of severity of lung injury which may provide an objective predictor for escalation and de-escalation of therapy. The first step toward this is validation of the HFOVI equation compared to the existing ventilation index. VI is not optimized to evaluate patients on HFOV. HFOVI is a newly developed formula to calculate the severity of lung disease in patients on HFOV.

This research project assessed the linearity of the HFOVI compared with the VI equation. Inclusion were all invasively ventilated patients who transitioned from pressure control ventilation to high frequency oscillatory ventilation and/or from high frequency to pressure control ventilation in the neonatal intensive care between 4/1/2019-9/1/2019. Each transition was collected as a separate event. HFOVI and VI were calculated from blood gas data acquired within one hour of transition. Underlying assumption was that the patient’s status was similar/same when they were measured. Subjects on specialty gas therapy were excluded.

22 unique subjects ages 0-38 days, mean 7.23 (SD=9.55) with 43 events were identified. 7 female (31.8%) and 15 males (68.2%). A linear mixed-effects model was used to analyze the relationship between HFOVI and VI. The result shows that HFOVI is a statistically significant predictor for VI (P < 0.001***). Based on the result, an increase by 1 unit in HFOVI corresponds to 4.177 increase in VI. Repeated measures correlation was used to analyze the correlation between VI and HFOVI. The output showed the repeated measures correlation coefficient of 0.552 (95% CI: 0.145, 0.799) and P-value of 0.008**.

HFOVI is a statistically significant predictor of VI, and may be a predictor of the severity of lung injury. Utilizing the HFOVI as a predictor of the severity of lung injury with neonatal patients on HFOV may be helpful in identifying patients who need alternate modalities of care.

Evidenced-based medicine is imperative to improving patient outcomes throughout the field of medicine. With respiratory care (RC) being such a technology-driven profession, advancing provider knowledge related to research skills is paramount.1,2 Our Respiratory Care Department (RCD) aimed to increase respiratory therapist (RT) involvement in research by creating an RC Research Task Force (RTF).

Bylaws were written for an RC RTF in November 2018, and an interest meeting was held in December 2018. Twenty-two RTs (department total 107 RTs) attended the interest meeting. Seventeen RTs joined the RTF in January 2019 and meetings began. All members were required to complete CITI Program training (for patient and animal research) and IRBNet training offered through our organization and become an American Association for Respiratory Care (AARC) and Delaware Society for Respiratory Care (DSRC) member. Initially, meetings were once monthly (for three months) and then transitioned to quarterly meetings. The first three months focused on education and included CITI training, IRB applications, literature searches, and research basics. Subsequent meetings were used to brainstorm research ideas, remove barriers, and continue education.

By using an RC RTF, our department was able to increase publications from four in 2018 to nine in 2019. The effect from these publications within our department resulted in two changes to patient care practices in 2018 and six changes in 2019. CITI Training increased from six RTs in 2018 to 19 in 2019. Additionally, the RCD RTF increased involvement in animal studies from zero to one in 2018 to 2019, respectively (Fig. 1). These results stemmed from the addition of approximately 250 hours of nonproductive time within our RCD in 2019.

Many RTs who study at an undergraduate level do not receive extensive research training even though the impact of such training is necessary to contribute to research within the field of RC. By creating and implementing an RC RTF within our RCD, we were able to increase research contributions, increase practice changes driven by original research, and capture RT staff interested in research to increase research engagement.

Figure 1. Comparison of RCD RTF impact from 2019 to the year prior.

Ventilator-associated pneumonia (VAP) is defined as a pneumonia that develops more than 48 to 72 hours after endotracheal intubation. VAP incidence and mortality rates can be reduced dramatically by following VAP bundles. Since there are no studies that focused exclusively on critical care respiratory therapists’ knowledge, this study was conducted. The aim of this study is to assess the critical care respiratory therapists’ knowledge regarding evidence-based guidelines for preventing VAP.

A descriptive cross-sectional study was conducted at King Abdulaziz Medical City (KAMC), Riyadh during June – August 2019. The participants were Respiratory Therapists working in the Critical Care area. To evaluate the level of critical care respiratory therapists’ knowledge regarding evidence-based guidelines for the prevention of VAP a valid and reliable questionnaire that consisted of 9 non-pharmacological strategies to prevent VAP was used. The data was analyzed using SPSS 22.

The study included 90 participants (72.2%) were males. Forty six percent were aged between 21-30 years and 53% had ≥ 7 years of experience. The results showed that the mean knowledge score of the participants was 4 questions out of 9 and the majority (56%) were below the average knowledge score. There was no significant relationship between gender and the knowledge score; however, statistical significance was observed between experience and the knowledge score (P =0.009). As the experience increases so does the knowledge score.

The study concludes that critical care respiratory therapists’ knowledge in KAMC was below the average. In order to increase their knowledge, they need to focus more on educational programs to help reduce the incidence of VAP.

An estimated 42% of laboratory testing performed in the hospital is considered wasteful or unnecessary. Unnecessary laboratory testing is associated with hospital-acquired anemia which in turn may cause significant morbidity, such as increased length of stay and increased frequency of blood transfusions. This project attempted to educate and provide feedback regarding inappropriate arterial blood gases (ABGs) on a medical intensive care unit (ICU), in order to reduce unnecessary testing.

Criteria for inappropriate ABG utilization were developed and are as follows: (1) Routine daily ABG measurements, (2) ABG after minor ventilator changes, and (3) Routine ABG after extubation. A preliminary retrospective chart analysis of all patients admitted to ICU in January 2018 who had an ABG performed revealed that 30% of ABG measurements were unnecessary based on these criteria. Pulmonary physicians and ICU nurses and respiratory therapists were provided education via lecture-format and emails regarding appropriate ABG utilization. The use of continuous capnography on ventilators was encouraged to guide therapy and prevent unnecessary ABG orders. Additional signs were posted on ventilators as a reminder to nurses and respiratory therapists that capnography measurement was ongoing and correlated to the most recent ABG to discourage unnecessary ABGs. The intervention start date was 11/4/2019.

The number of ABG measurements was recorded in the ICU for three months before the intervention start date (Aug 2019-Oct 2019) and three months after the intervention start date (Nov 2019-Jan 2020). Prior to the intervention start there were 664.88 ABGs per 1,000 patient days. During the intervention period there were 515.66 ABGs/1,000 patient days. This was a 22.4 percent reduction in ABG measurements during the intervention period. We also compared the intervention period to the same three months from one year prior. In Nov 2018 to Jan 2019 there were 879.63 ABGs per 1,000 patient days. The intervention period in Nov 2019 to Jan 2020 had 41.4 percent fewer ABG measurements.

Laboratory testing is often unnecessary and wasteful and ABG measurements in ICUs are no exception. A multifaceted intervention to decrease inappropriate ABGs was employed on a closed ICU unit and included: education, the use of end-tidal capnography, feedback and empowerment. The intervention was successful and resulted in 22 percent decline in ABGs.

Long-term adherence to bedside report (BSR) in the ICU is difficult to achieve for many respiratory departments. BSR has shown to improve: patient safety and staff accountability, prioritizing workload, communication with multidisciplinary team, opportunity to ask off going RCP questions while observing patients, and feeling more aware of patients’ issues. BSR studies are nursing-centric with a dearth of RCP focused research. The UC Davis Health, Respiratory Care leadership team set forth to create a positive culture change for BSR through administrative support, education, resolution of barriers, and sustained adherence.

An investigator-developed Quality Report Survey (QRS) was given to a convenience sample of n=34 RCP staff to determine the perception of need for BSR pre-pilot change. Literature review education, barriers addressed, and instructions on how to perform BSR was given by a shift supervisor following the QRS survey; standardized report elements established in current policy. BSR was initiated in two of nine ICUs: MICU and NICU. Portable EMR carts and clipboards provided to each ICU. RCP Leadership conducted shift-change rounding in pilot units to remind/support staff from initiation to the third month. Audit for adherence via anonymous surveillance with n=56 observations performed during the fourth month. Investigator-developed BSR Feedback Survey (FBS) given to a convenience sample of n=34 at month seven.

QRS with a four-point Likert scale determined a moderately-severe need for BSR. The anonymous adherence surveillance resulted in MICU performing BSR 50% of 30 observations; NICU resulted in 65% of 26 observations. BSR FBS questionnaire showed 80% of those that self-reported to have performed BSR ≥10 times found BSR beneficial. Forty-six percent found BSR beneficial of those that self-reported to have performed BSR 0-9 times. Fifty percent of staff had at least one instance of BSR helping to answer patient care questions from oncoming RCP. Sixty-two percent of staff experienced patient condition changed from previously visualizing patient at least once when performing BSR. Seventy-four percent of staff received or gave helpful information to other multidisciplinary team members during BSR.

Overall adherence of 57% in the pilot ICUs, as well as 63% of surveyed staff found BSR to be beneficial. Diligent administrative report, education, resolution of barriers, and surveillance of adherence provided improved outcomes in RCP staff performing BSR.

Mechanical ventilation, while used for many reasons, puts patients at risk for developing infections and complications. One of those complications is a Ventilator Associated Event (VAE). A VAE is defined by the CDC as “a period of deterioration in respiratory status after a period of stability or improvement on the ventilator” (CDC, January 2020). Criteria to be diagnosed with a VAE is mechanical ventilation of 4 days or more, an increased fraction of inspired oxygen (FIO₂) greater than or equal to 25% or an increase in mean airway pressure (MAP) of greater than or equal to 4 centimeters of water pressure (cm H₂O). This study sought to identify those patients who had a VAE using the CDC definition and then determine the epidemiology of those patients and compare to those patients who did not have a VAE.

IRB consent was obtained for a retrospective chart review of patients in the cardiovascular intensive care unit (CVICU) and pediatric intensive care unit (PICU) who were intubated and mechanically ventilated 4 or more days between January 1, 2017, and December 21, 2018, with day 1 of mechanical ventilation defined as the day the patient was intubated and initiated on mechanical ventilation. Data Warehouse was consulted and asked to gather the following information on patients during the defined timeframe: gender, age, admission and discharge dates, unit, ventilator days, consecutive vent days, vent mode, MAP, and FIO₂. Data analysis included Chi square and student t-tests.

There were 391 total patients included in the review. 76 VAEs were identified. CVICU had 154 patients, while PICU had 237 patients. 207 patients had noninvasive ventilation prior to or after extubation. When noninvasive support was used, 26.9% developed a VAE, and when noninvasive support was not used, 13% developed a VAE, which is statistically significant. Those who developed a VAE were intubated an average of 47.6 days compared to 11.9 days, which is statistically significant. LOS for those patients with VAE averaged 84.0 days compared to 33.3 days, which is statistically significant. The CVICU had 28.57% of their patients develop a VAE, and PICU had 13.5%, which is statistically significant. Unit admission to unit discharge time and patient age were not statistically significant.

The definition can be limited when used in a cardiac patient due to anatomy. Another limitation of the definition is the CDC states that this definition cannot be used to diagnose a patient; only monitor.

A research university located in the southeastern United States opened a state-of-the-art interdisciplinary medical simulation center intending to increase IPE among the health profession programs. This study proposed to develop, implement, and evaluate a faculty training program demonstrating how medical simulation could be utilized for IPE. IRB approval for this study was obtained.

The training course was developed in two sections: 1) a didactic section covering the definition, history, benefits of IPE and medical simulation, and an exercise in which participants created IPE activities using the Interprofessional Education Collaborative (IPEC) core competencies and 2) participation in a medical simulation conflict resolution case. The course was presented in four different sessions over two months. Each session concluded with a focus group using semi-structured questions probing participant’s pre/ post course IPE perceptions and knowledge. Data analysis included content analysis using deductive and inductive coding of focus groups responses into themes.

The IPE exercise resulted in the application of IPE competencies to create a variety of potential IPE activities including an IPE journal club, case studies, research and the development of patient education information. The participants found the course to be valuable in terms of clarifying and strengthening their understanding of IPE and simulation, and networking. Participants also expressed increased knowledge in the importance of debriefing exercises, the need to address role assumptions in IPE, the need for psychological safety in medical simulation, and the importance of communication, especially soft skills, with IPE.

The increased knowledge of IPE and medical simulation, the opportunity to network, the importance of communication, and the need to address role assumptions were consistent with the literature. Participants expanded on issues not addressed in the literature such as the need to incorporate debriefing and psychological safety in activities such as the use of animals and human cadavers, the importance of teaching soft skills in communication such as using layman’s terms with patients and families, and the need to incorporate non-patient caregivers such as pathologists, medical illustrators, and lab technicians as part of patient care teams in medical simulation. The faculty training course and the study will continue.

IPE and medical simulation are both used by health professionals to improve collaboration, communication, and safety in the health care environment. The lack of knowledge and perceptions about IPE can have a major impact on the implementation of IPE into the curricula of health professional programs. This study focused on how IPE knowledge and perceptions among health professions faculty at a research university changed as a result of a faculty training course that leveraged medical simulation to teach IPE.

IRB approval for this study was obtained. A pre/post-course survey was given consisting of the Interdisciplinary Education Perception Scale (IEPS), and five IPE knowledge multiple-choice questions based on the Interprofessional Education Collaborative competencies. Data analysis included a paired t-test of the pre/post survey data at an alpha level of 0.05. A focus group followed each training session and a thematic content analysis was performed using inductive and deductive coding. The 4-hour course was given four times over two months. Revisions to the course were made after each session based on participants’ feedback. 30 faculty from the medical, dental, graduate, nursing, and allied health colleges participated in the course.

The findings included statistically significant increases in questions regarding the definition of IPE (P = .043) and communication skills needed for IPE (P = .03), along with improved perceptions of the need to work together (P = .039) and seek advice from other professionals (P = .037). These results were corroborated by focus group responses in which participants reported misconceptions with the definition of IPE, a strong interest to implement IPE into their curricula, the use of simulation to teach communication skills, the importance of having multiple professions involved in patient care, the need to address professional role biases, and having a working knowledge of each other’s roles before IPE could occur.

The study demonstrated medical simulation is an effective modality through which to develop faculty in interprofessional education. Limitations to our study including a small number of participants, the amount of time required for the course, previous knowledge of IPE by participants and the improvements made to the course after each session which could have impacted the participants’ perceptions and knowledge of IPE. Final revisions have been made to the training course and the study will continue.

Presenting research at the AARC Open Forum is an important aspect of the practice of respiratory care. Our department regularly presented abstracts but few projects were written up as manuscripts. We also noted that we had many respiratory therapists (RTs) doing research but no centralized strategy to evaluate individual projects and provide mentorship. To address these challenges, we formed a Respiratory Care Services Research Committee that meets monthly and includes the two co-chairs, departmental director, clinical research coordinator, adult/pediatric medical directors, educators and staff. We hypothesized that the formation of this committee would be associated with an increase in manuscripts.

We evaluated all original research abstracts authored or co-authored by Duke RTs presented at the AARC Open Forum between 2009 and 2019. Abstracts were grouped into two time periods; 1) 2009-2013 (before the formation of the research committee and 2) 2014-2019 (after the formation of the research committee. Abstracts were evaluated based on authors, type of study, patient population, and whether the abstract resulted in a manuscript. If part of an abstract was included in a manuscript, it was counted as a manuscript. Primary outcome was the percentage of abstracts published as manuscripts. Chi-squared and non-parametric testing were performed as appropriate. Statistical significance was set at ≤ 0.05 and data were analyzed using SPSS v25.

56 abstracts were presented by 18 different lead authors, with 15 (27%) published as manuscripts. Post research committee formation abstracts were more likely to be published as manuscripts (47% vs. 18%, P=0.02). The median (range) abstracts published per year decreased from 8 (5-10) to 3 (1-4), P=0.006. The senior author was most commonly a physician 40/56 (71%). There were no differences for the type of study (P=0.20), patient population (P=0.27), multi-center study (0.16), or senior author credentials (P=0.17) before and after committee formation.

The formation of a research committee was associated with an increase in abstracts accepted as manuscripts and a decrease in the number of abstracts presented yearly. A formal committee appeared to increase the quality of research in a respiratory care department.

At Sarah Bush Lincoln Health Center (SBLHC), respiratory Medical Device Related Pressure Injuries (MDRPI) accounted for 27% of all hospital acquired pressure injuries in FY19. As a result, a multidisciplinary team was created to develop a pressure injury prevention protocol. As part of the protocol, SBLHC utilizes thermographic imaging with WoundVision’s “Scout” camera for detection of suspected deep tissue injury (DTI) present at the time of admission. This study was initiated following review of a thermographic image taken of a home NIV dependent patient that indicated temperature abnormalities on the bridge of the nose consistent with signs/symptoms of suspected DTI present at the time of admission.

At admission, all patients are scored with the STOP BANG Questionnaire. A positive score triggers an OSA Assessment by RT. During the OSA screening, if it is determined the patient wears a NIV device at home and the patient was placed on NIV while in the ED, Wound Ostomy Care Nurses and other trained RNs take a thermographic image of the patients face. The area was imaged with a FDA-approved thermographic imaging device, clinically reliable for capturing thermal anomalies on localized pressure sites. Preventative measures including a skin barrier wipe and bordered foam dressing are also applied when NIV is initiated.

During the course of the evaluation a total of twenty-two thermal images were obtained. Six thermal images were excluded from interpretation due to poor image quality and laser position. Of the remaining sixteen thermal images, twelve demonstrated temperature anomalies representing signs/symptoms of suspected DTI over the bridge of the nose and/or cheek, which were likely present on admission. Four thermal images demonstrated a minimal temperature differential not indicative of signs/symptoms of suspected DTI. There have been no hospital acquired pressure injuries related to medical devices at Sarah Bush Lincoln in FY20 involving nasal cannulas, ET tube holders, or NIV devices.

Early detection and visual documentation of signs/symptoms of suspected DTI present at admission can trigger early intervention and prevent reimbursement loss. The implementation of a protocol including preventive measures and RT/RN education has significantly reduced MDRPI at SBLHC. Barriers to this data include inappropriate documentation, staff buy-in, and poor picture quality. This study was approved by the institutional IRB.

Emergency travel bags (ETB) for pediatric tracheostomy patients (TP) are imperative to reduce potential tracheostomy emergencies1,2. In our pediatric health system, our standard process is for every TP to have a stocked ETB available upon admission. Often times these ETB are left by patients at discharge or not used during the admission. We aimed to transition our single use, single patient (SP) ETB to a multi-patient (MP), reusable ETB to reduce waste and reduce costs.

A multi-disciplinary team (RT, MD, RN, SLP) was convened to assess the appropriateness of travel emergency bag supplies. After the contents of the ETB were evaluated we were able to remove 35 items from our standard SP ETB model (58 versus 43 items). This included 16 items at various quantities in the single patient model and 12 items at various quantities in the new multi-use model. 22 MP ETBs were created for use on tracheostomy units. Maintenance (ensuring locked, checking inventory, restocking as needed) for the MP ETB is done by RTs after use and on a weekly basis. MP ETB are readily accessible on all tracheostomy units for ease of use.

The cost of our SP ETB was $70.48 each. The new multi-use model had an initial startup cost of $352.00 to purchase the initial 22 bags ($16.00/each). Supplies for the MP ETB cost $44.54. Breakdown of cost based on bag type can be seen in Table 1. An IRB approved retrospective analysis showed that in 2019 our hospital saw 166 trach patients in 212 encounters. With a minimum savings in ETB of $25.94 per bag, minus initial bag cost, this equates to $5,147.28 of savings in 2019 when compared to the SP ETB model. In 2019, there were zero tracheostomy risk related events due to lack of available supplies related to the MP ETB.

MP ETB use in our institution was able to reduce cost without adverse effect to pediatric tracheostomy patients. Further studies must be done to evaluate possible increased cost savings when the ETB is unopened and does not need all items restocked, as well as the long-term safety of MP ETB.

There is a paucity of research on the prevalence of e-cigarette use among adults with chronic lung diseases. It is warranted to identify factors that contribute to the use of e-cigarettes among adults with chronic lung diseases. Some factors may include alcohol and marijuana use since previous research has shown positive correlations between these factors and e-cigarettes use. The aim of this study was to examine whether binge drinking and previous-month marijuana use will influence the relationship between chronic lung disease status and lifetime e-cigarette use in adults.

Data come from the 2017 Behavioral Risk Factor Surveillance System (BRFSS). A logistic regression was used to test the association between pulmonary status and e-cigarette use, controlling for demographic variables. We conducted moderation analyses to test our hypothesis that the association between chronic lung disease conditions and e-cigarettes was modified by binge drinking and previous-month marijuana use.

Lifetime e-cigarette use was higher among adults with chronic lung diseases than among those without (22.0% vs. 13.2%, P= < 0.001), as was the number of marijuana use days in the past 30 days (M [SD]: 15.9 [12.2] vs. 14.5 [12.1]). However, binge-drinking status was lower among those with chronic lung disease status (5.3% vs. 5.5%, P = .014). After controlling for covariates, binge drinking (β = – 0.31; P = < .001) but not previous-month marijuana use (β = – 0.002; P= .802) moderated the relationship between chronic lung disease status and lifetime use of e-cigarettes in adults.

We examined moderating effects of binge drinking and marijuana use on using e-cigarettes among adults with chronic lung diseases. Previous-month marijuana use was not a moderator that affected the use of e-cigarettes among adults with chronic lung diseases, but binge drinking did moderate this relationship. More extensive research is warranted to better understand e-cigarette behavior in people with chronic lung disease.

Although traditional rehabilitation exercise has been performed to improve respiratory muscle endurance and has been also applied to the weaning for the mechanical ventilation in patients with difficult weaning in ICU to refer RCC for dependent ventilator patients, practice is complicated. Elastic band resistance training easy to learn, not limited by space, but whether the affect to respiratory muscles will improve or how little is unclear. The study want to specific quantitative evidence-based training results and workups to support it in order to survey the strength, endurance of respiratory for short-term effectiveness, rather to increase the weaning rate in RCC.

We picked up RCC units in Taiwan middle medical center arbitrarily and recruited their residents under continuous mechanical ventilation. Nineteen subjects were randomly enrolled who exclusion criteria were as follows: GCS≤8 with unable to match a command, life-threatening hypoxemia when measured weaning profile or practice elastic band resistance exercise. Our patients sit in semi-sitting position and composed of 6 movements of upper with lower extremity joints (flexion and extension exercise). It is performed for 10th of every movement during 4 weeks by 7th for a week, with band pull-up for 15 min for every time. The training program lasted for 28th or until the weaning ventilator completed. On the first and 28th, the respiratory muscle strength (PI max and PEmax), RSI were collected. Furthermore, we measured weaning profile parameter and recorded at the pre and post elastic band resistance exercise.

After having completed the elastic band resistance training intervention in the enroll patients, we find characteristic is: There were 13 (68%) men and 6 (32%) women with a mean age of 74.6 y (SD ± 9.00). The success weaning ventilator were 15 patients and mean duration length of stay is 43.3 days (ICU plus RCC). Compared with pre and post exercise and measure weaning profile in Table 1.

Elastic band resistance exercise can extend respiratory muscle tolerance especially patients used mechanical ventilation and increase weaning rate (78%). Although pre and post are no difference in RSI, present patients accept well treatment in ICUs then refer RCC for further care for weaning program. This study need a large population should be carried out to confirm the favorable results cause it is still progress. By the way, if intervention in ICU perhaps increase weaning rate from mechanical ventilation.

Utilizing group education promotes problem solving, stimulates conversation, and provides shame free environments to decrease stigmas. Providing comprehensive education by an experienced certified asthma educator (AE-C) is an important step in supporting patients diagnosed with asthma.

Patients 2 to 17 years of age who were prescribed ≥2 systemic steroid courses, had ≥ 2 emergency department visits, and/or ≥1 hospitalization for asthma exacerbation the preceding 12 months were identified having poorly controlled asthma. These patients and their legal guardian/caregiver were recruited from pulmonary clinic or inpatient services to participate in classroom asthma education provided by a AE-C to address real life problem-solving and promote self-awareness regarding medication use. Post card consent was obtained for the patient and legal guardian to attend 1-2 classes over a four-month period; complete a pre/post asthma knowledge assessment; and receive text/phone call reminders prior to each class. The classroom education materials included audio and visual learning tools written at a fifth-grade reading level in both English and Spanish.

Our goal was to recruit 50-75 patients over a 9-month period. Only eight patients were recruited for the study, four of them with their caregivers participated in the classroom education. Patients and caregivers who attended the class coincided with a clinic visit. Two of the four families completed the pre and post asthma knowledge survey. Revisit/readmissions were reviewed as a part of our outcome measures. None of the patients who participated in the classroom education had a revisit/readmission for asthma within 90 days and 100% of them attended their pulmonary clinic visit. One of the four patients who did not attend the classroom education had a revisit within 90 days and none of them have a scheduled specialist visit since enrolling.

Due to the low enrollment and completion of the program we were not able to effectively evaluate the program. Caregivers felt the classroom education was well worth their time. Many families are not willing to participate in any educational sessions outside of scheduled clinic visits. Obtaining pre or post survey results was found to be successful only when provided in person rather than via phone call, email, or text. We believe convenience played a significant role in patient and caregivers’ engagement and participation.

The aim of the study on complex decision-making and quality of life for patients with life-threatening illness receiving prolonged mechanical ventilation (PMV) is an incontestable and crucial component to caring for these patients and their families. The family's mental pain and stress are no less than that of the patient. We used a questionnaire to conduct an investigation exploring the mental state of family members of patients on PMV in order to provide care and counseling in a timely manner.

This was a cross-cut design study. An open recruitment method was used. After a subject was explained the consent form and provided informed consent, they completed the questionnaire in an anonymous manner. A 6-point Likert scale was used, with higher scores indicating a better the mental health status. There were 4 parts to the questionnaire: Self-Worth or Controllable World, Just World, and Safe World. Analysis was performed using the chi-square, t-test, and mean ± SD. Institutional Review Board (IRB): TTMHH-107R0018.

Of the participants, 73% were between 45 and 54 years old (28%). According to Yi-Jen Su and Sue-Huei Chen’s Core Assumptions Scale (2012), the classification of family caregiver’s stress. Just World the mean ± SD was low (2.53±0.66), while the average Safe World of L score was higher (3.63±0.63). These results indicate that the respondents' stress needs are significant with respect to the Self-Worth or Controllable World, Just World, and Safe World. Family caregiver’s stress provides the caregiver value and meaning, and meaning to their own life, and this is very important for a primary caregiver.

The family caregiver’s stress (FCS) in this study was the greatest with respect to life objectives and meaning. Mao Xinchun (1997) found that patients with terminal diseases often understand the value of their existence, and the meaning of life, because of the care of others. Therefore, based on the results of this study and the experience gained from the process of collecting data, the recommendations for FCS education and practice are: (1) Proposal for FCS education (2) Suggestions for clinical practice.

Family Caregiver’s Stress Analysis (N = 40)

Asthma is the most common chronic illness in children. Poorly controlled asthma increases likelihood of an asthma exacerbation resulting in an emergency department visit or hospitalization. High-risk asthma patients are defined at Children’s Hospital Colorado as having frequent exacerbations that result in 2 or more emergency department/urgent care (ED/UC) visits or a hospital admission in the past 12 months. Bedside nurses and respiratory therapists are the primary educators. They often lack the time or knowledge to provide high level asthma education. High risk asthmatic patients and their caregivers may benefit from comprehensive face-to-face education and assessment of barriers from a certified asthma educator.

An Inpatient Asthma Education Consult (IAEC) service was created with team of certified asthma educators. Consults were requested by pulmonary consult and inpatient care teams on patients with a new or existing diagnosis of asthma who were admitted to PICU, had ≥2 hospitalizations or ED/UC visits the previous 12 months, and/or concerns for poor medication adherence. The IAEC included 30+minutes of face-to-face education with the patient and caregiver(s) reviewing what is asthma, asthma triggers, asthma medications, and review of the individualized asthma action plan. During the face-to-face education barriers to adherence and provider follow up were also addressed with resources provided based on the identified barrier. The IAEC also help facilitate follow up or referral for a follow up visit with a specialist (Pulmonary or Allergy) after discharge.

The IAEC service completed 55 consults from October 2018 to April 2019. Prior to the IAEC, 100% (95% CI: 93% to 100%) of 55 patients had at least one hospital and/or ED/UC visit the previous year. After the intervention, 38% (95% CI: 27% to 51%) of 55 patients revisited the hospital. McNemar’s test indicated a statistically significant difference in the paired proportions before and after intervention (S=21, df = 1, P<.001).

Providing comprehensive, one on one face-to-face asthma education and working with patients and their caregiver(s) to address barriers to medication adherence and follow up post discharge from the hospital can improve patient outcomes.

Patient Demographics

Patient Outcomes

Pediatric Emergency Departments treat large numbers of infants and children with respiratory illness. Several studies reported correct disposition and quality of care benefits associated with Respiratory Therapists (RTs) staffed in Emergency Departments. Despite this evidence, no data exists regarding their effect on throughput times and quality care measures associated with staffing a dedicated RT in a Pediatric Emergency Department. We hypothesized that staffing a dedicated RT will decrease ED throughput times and improve therapy specific quality of care measures in children with respiratory illness.

Prospective historically controlled cohort study evaluating throughput times and quality care measures for patients with respiratory illness. We compared July 2019 – January 2020 to July 2018 – January 2019 (control), evaluating ED LOS for patients either admitted or discharged home. Pre and post intervention quality measures were disease specific and included: ASTHMA - % albuterol administered within 60 minutes, % albuterol administered via MDI (vs. continuous Drug aerosol for mild/moderate exacerbation) CROUP - % racemic administered with in 60 minutes, BRONCHIOLITIS - % Racemic Administered. Seven-day return to the ED were also evaluated. Differences determined by Student T-Test for continuous variables presented as Mean ± standard deviation. The project was approved by the Quality Improvement Review Committee.

Seven thousand seven hundred sixty-eight patients were included for study, with 3,576 (46.1%) in the study group and 4,192 (53.9%) in the control group. Distribution of encounters included 45.9% asthma, 22.1% Croup, and 31.9% Bronchiolitis. All respiratory chief complaints had a decrease in ED admitted length of stay (261.4 vs. 207.9 minutes; P =.002) that was not witnessed in those patients discharged (P =.73). All LOS for asthma and admitted LOS bronchiolitis were significantly decreased. Quality measures illustrate improvement for use of MDI in mild to moderate asthma, and Racemic Epinephrine administered within 60 minutes (Table 1). No differences were found in 7-day return rates among groups.

Respiratory therapists bring a unique set of skills to the emergency room. This is the first study to demonstrate introducing respiratory therapist into the emergency room is associated with improved throughput times and quality of care. More specific study is needed to evaluate cost savings, patient/family satisfaction and age group specific outcomes.

Throughput Times (Admitted and Discharged Length of Stay) and Quality Measures Outcomes Pre Vs. Post Staffing a Dedicated Respiratory Therapist in an Academic Emergency Department.

High-flow nasal cannula (HFNC) is a noninvasive device that delivers heated and humidified gas at flows exceeding patient inspiratory demand. HFNC is used as an alternative to conventional oxygen therapy and noninvasive ventilation. HFNC’s value is not limited to ventilation and oxygenation, as it may also allow for oral feeding. At this time, HFNC’s impact on swallowing is unknown. One measure of swallowing function is spontaneous swallowing frequency (SSF), the rate at which individuals swallow their own saliva. This study investigated the impact of HFNC on SSF in healthy adults.

Heated (37°C) and humidified room air gas was delivered via the AIRVO 2 HFNC system. SSF was measured via the KayPentax Digital Swallowing Workstation (DSW) with integrated signals lab. To measure SSF, a submentally placed surface electromyography (sEMG) electrode captured swallowing muscle electrical activity. When a spontaneous swallow occurred, a large spike was recorded on the sEMG waveform. Visual confirmation of a swallow was also marked on the waveform. SSF was measured during baseline (no flow) and 3 experimental flow conditions: 30, 45, and 60 L/min. For each condition, participants sat quietly for 10 minutes while the DSW recorded all sEMG activity. Baseline rate was determined first followed by the experimental rates in randomized order. After each experimental session, HFNC was removed for 10 minutes. Summary statistics were used to describe participant characteristics; repeated measures ANOVA was used to analyze SSF among flow conditions.

Participants included 18 healthy adults aged 21-83 (SD=16.10) years. Since SSF is known to decline with age, the three older participants were analyzed separately. Among the younger participants, group mean SSF scores descriptively increased as flow increased [SSF baseline = 1.12 (SD=0.75); 30 L/min=1.13 (SD=0.79); 45 L/min=3.91 (SD=10.26) swallows/minute], until the 60 L/min flow. At 60 L/min, SSF decreased to lower than baseline [SSF=1.01 (SD=0.67) swallows/minute]. No statistically significant difference in SSF was found. SSF results for the three older adults (aged 55, 65, 83 respectively) showed the same pattern.

Among healthy adults, regardless of age, SSF was not significantly affected by HFNC at any flow. Future studies are warranted to determine if HFNC impacts other swallow function measures.

Exposure to environmental airborne pathogens may result in infections associated with significant morbidity and/or mortality. 1 Strategies to prevent hospital-acquired pneumonia is to avoid transmission of microorganisms with use of Venturi air entrainment devices. 2 Care for COVID-19 positive patients mechanically ventilated for prolonged periods of time eventually required tracheostomy tube placement. We managed these patients who successfully weaned from the ventilator with a traditional open-ended heated and humidified gas circuit. Clinician concerns led to a suggestion to protect escape of pathogens and we wanted to know if our intervention affected delivered flow, FIO₂ and flow resistance.

A Teleflex Neptune heater provided heated and humidified gas, (Teleflex, Inc., Morrisville, NC). To the ChonchaSmart column we connected a Teleflex 1605 bacterial/viral filter to protect the patient from environmental pathogens. The filter connected to an F&P RT008 adjustable air entrainer, (Fisher & Paykel Healthcare, Irvine CA). The entrainer connected to a 0-15 L/m O₂ flow meter using standard small-bore tubing. A Teleflex 870-19KIT single-limb adult ConchaSmart heated-wire circuit attached to the column outlet. Connected to the distal end of the circuit was a Teleflex 1648 tee piece for connecting to a tracheostomy tube. To this tee piece was a 6-inches standard aerosol tubing reservoir. The patient side of the tee piece occluded so that all flow was directed towards the exhalation side of the circuit. Baseline measurements were measured using a calibrated TSI-4080 FA-Plus analyzer, (TSI Inc., Shoreview, MN) for flow and FIO₂ at each setting of the diluter (28-90%). A Pall BB50-T hydrophobic filter, (PALL Corp., Parkland Court, IL) was added distal to the tubing extension. Repeat measurements were compared to baseline. Data were analyzed using two-sided Z-tests with P > 0.05 considered insignificant.

Baseline flow, FIO₂, and filter resistance were compared to the measurements after 72 hours of administration. Flow MD (±SD) was 4.12 L/m (± 13.6 L/m) (P > 0.05). FIO₂ MD (±SD) was 4.12 L/m (± 13.6 L/m) (P > 0.05). Filter resistance MD (±SD) comparing a filtered circuit to a non-filtered circuit was -0.17 cm H₂O/L/m (± 0.04 cm H₂O/L/m) (P > 0.05).

Addition of an inspiratory bacterial/viral and expiratory hydrophobic filters to a heated-humidified circuit did not significantly alter the flow, oxygen concentrations, or filter resistance.

The Centers for Medicare & Medicaid Services included COPD in the 30-day readmission penalty program starting in 2015. There has been intense interest in strategies to reduce readmissions. The Providence-St. Joseph Healthcare System is a large 51-hospital system across 7 states. The system utilizes a Respiratory Therapy Resource Council for system-wide initiatives, and in 2019 created a workgroup with the objective of reducing COPD readmissions. To understand the variety and effectiveness of different COPD related activities, the workgroup decided to survey the system to understand the effectiveness of local programs.

We created a 25-question survey on hospital practices aimed at reducing COPD readmissions. Survey was targeted towards respiratory therapy leadership, we reasoned this group would be the one most knowledgeable about their hospitals efforts. The draft of the survey was beta tested by 4 respiratory therapists with expertise in COPD and feedback was incorporated into final version. The survey was sent to RT leaders from April 1, 2019 to April 30, 2019 with weekly email reminders. After end of survey, outcomes data including COPD readmissions O/E, COPD readmission rates, Mortality O/E, and Length of stay was obtained from clinical analytics department via database search. Differences were determined by Mann-Whitney or Wilcoxon test where appropriate.

The response rate was 37% (n=20), however many questions only had 17 responses. Common tactics to reduce COPD readmissions included proactively identifying COPD patients (76%), reviewing COPD Readmission (93.8), screening for severity (58.8%), tools to assess risk for readmission (58.8%). Less common were COPD navigators (23.5%), bundled COPD order sets (5.9%) and conducting home visits (17.6%). There were no statistically significant results with the exception of facilities which demonstrated a longer LOS for those using a COPD navigator (1.7 vs. 5.6, P= 0.0227). Results in Table 1.

PSJH utilizes a wide variety of COPD readmission reduction processes without clear evidence of a best practice. Further research and quality improvement indicatives will need to be conducted to establish best COPD readmission reduction strategies.

Intubated patients with stable vital sign, well weaning profile and spontaneous breathing test are the most important key points to be extubated. The aim of present study is to validate the influence factors of the successful extubation of patients in intensive care unit.

Thirty-eight intubated patients in the intensive care unit of Show Chwan Memorial Hospital, a regional hospital, were enrolled in this retrospective study from November, 2019 to February, 2020. All of them used mechanical ventilator support for more than 3 days. The patients’ characteristics, including age, body height, body weight, neck circumference and the weaning profile parameters were collected, and the length of intubation days. In addition, cuff leak test value was measured before extubation, by calculating the volume of air leakage after the endotracheal tube cuff was deflated while the ventilator was set as the volume-assist-control mode. Successful extubation was defined as no re-intubation in the following 28 days. Statistic t test and independent sample test were applied to assess the correlation between these parameters and the success rate of extubation.

The influence factors of better success rate for extubation include the neck circumference (P=0.005, 95% CI 34.8 to 37.2), and the cuff leak test (P=0.015,95% CI 174.7 to 340.5). In addition, we found that the patients with neck circumference more than 37.5 centimeters may have higher risk of extubation failure (Fisher exact test P <.001).

Patients with the smaller neck circumference, the higher cuff leak volume have a better extubation success rate.

Inspired oxygen fraction (FIO₂) of low-flow oxygen therapy devices is greatly affected by breathing patterns and parameters, such as tidal volume, respiratory rate and inspiratory to expiratory ratio (I:E). The impact of lung mechanics on FIO₂ delivered by low flow oxygen devices is not well explored.

A dual training/test lung (Michigan Instrument) was connected to an oxygen analyzer and then to an intubation training mannequin. Three breathing patterns were set with tidal volume 500 mL, and (1) a normal lung breath pattern with respiratory rate of 20 breaths/min, and I: E of 1:2, compliance 100 mL/cm H₂O, and airway resistance 1 cm H₂O/L/min; (2) a restrictive lung breath pattern with respiratory rate of 25 breaths/min, and I: E of 1:1.4, compliance 30 mL/cm H₂O, and airway resistance 1 cm H₂O/L/min; and (3) a obstructive lung breath pattern with respiratory rate of 14 breaths/min, and I: E of 1:4, compliance 100 mL/cm H₂O, and airway resistance 20 cm H₂O/L/min. A simple oxygen mask with oxygen flow 10 L/min, a non-rebreathing mask with oxygen flow 10 L/min, and a nasal cannula at 1-6 L/min were randomly placed on the face of the mannequin. The FIO₂ under each condition was recorded every 3 minutes for a total of 15 minutes, and measurement were repeated for 5 times (n = 5).

Figure 1 shows FIO₂ measured with oxygen devices and breath patterns, and Figure 2 illustrates the comparisons of FIO₂ using a nasal cannula with different flow and lung conditions. The FIO₂ with normal lung parameters were significant lower with a simple mask and a nasal cannula at each flow. The equations from linear regression (R2 = 0.962-0.968) showed Y = 4.28X+19.79 for normal lungs, Y = 6.16X+19.4 for restrictive lung disease, and Y = 7.36X+18.27 for obstructive lung disease.

Lung conditions with various breathing parameters and mechanics influence FIO₂ with low flow oxygen devices.

Comparisons of FiO₂ among devices under different lung conditions

FiO₂ measured with nasal cannula with different oxygen flow amont various breathing parameters

Aerosolized drug dose delivered to the lungs is affected by solution concentration and osmolality. Salinity of solution may alter aerosol particle size distribution as higher salinity may prompt aerosol aging during nebulization. The aim of this study was to evaluate aerosol delivery with various solution salinity via a jet nebulizer during mechanical ventilation.

A Drager V300 ventilator operated in volume control (500 mL, 12 breaths/min, PEEP 5 cm H₂O, T_I 1.0s) with heated humidification at 37°C was connected to an endotracheal tube (ETT, 7.5 mm), inline with a collecting filter connected to a lung model with compliance of 0.06 L/cm H₂O and resistance of 15 cm H₂O/L/s (Michigan Instrument). A small volume nebulizer was filled with a unit-dose of salbutamol (GlaxoSmithKline Corp.) and diluted with 2 mL of distilled water, 0.45% saline, or 0.9 % saline, placed at 15 cm from the Y piece in the inspiratory limb of the ventilator circuit. and the nebulizer was powered by external compressed oxygen at 8 L/min till 3 minutes after sputter. An Anderson Cascade impactor (Thermo Fisher Scientific Corp.) operated with a flow 28.3 L/min was used to determine particle size distribution, placed at outlet of the nebulizer and distal to the ETT. The collected drug was eluted from filter and impactor and analyzed by a spectrophotometer with wavelength 276 nm. Statistical analyses were performed with ANOVA with a significance level of P< 0.05.

Inhaled drug doses distal to the ETT were 4.9±0.8% with distilled water, 4.9±0.5% with 0.45% saline, and 5.4±0.8％ with 0.9% saline, with no statistical difference (P = 0.452). The mass median diameter (MMAD) were 1.37±0.01 um distal to the ETT for all solutions (P =1), yet varied at outlet of the nebulizer (2.2±0.1 um with distilled water, 1.8±0.1 um with 0.45% saline, and 2.23±0.2 um with 0.9% saline; P = 0.026). Figure 1 below demonstrated the comparisons of particle size measured at outlet of the nebulizer and through the mechanical ventilation system.

Salinity of dilution solution impacted MMAD emitted from a small volume jet nebulizer but did not affect drug dose and particle size delivered distal to the ETT. The MMAD of aerosols distal to ETT during mechanical ventilation with active heated humidification reduced, possibly due to a rainout effect from the contours of the system.

Experimental apparatus set-up. A ventilator was connected to a test lung via an endotracheal tube with an inline collecting filter or Andersen Cascade Impactor. A jet nebulzier was placed at 15 cm from the Y-piece of the inspiratory limb.

Comparisons of particle size measured at outlet of the nebulizer and through the mechanical ventilation system

Two counties in Utah had been reported as the nation’s highest e-cigarette users among youth. COPD continues to be the third largest cause of death in America. Education to youth is a vital tool that can help prevent youth vaping/tobacco use and emphasize health promotion in general. In 1995, the Breathe-zy Community Education program was created by an RT to teach youth about disease prevention, health promotion and raise awareness of RT as a profession. It has evolved as an annual student project to allow students to gain skills in community education, leadership and research.

Sixth-grade students started with a pre-test as a control that evaluates the knowledge of students before Breathe-zy. A PowerPoint presentation taught students basic anatomy and physiology of the lungs, basic pathophysiology of asthma, and the negative effects of smoking/vaping. Interactive activities were utilized for education retention. Activities included: 1) making models of lungs, 2) asthma exacerbation where students played the parts of inflammation, bronchoconstriction and secretions, 3) ventilating healthy and unhealthy pig lungs which resembled a smoker’s lung, and 4) porcine lung dissection. The students then took the post-test to evaluate learning retention.

A total of 431 students from four schools completed the course. The correct answers were totaled for both pre-/post-tests. The pre-/post-scores had a mean score of 69% and 92% respectively. This was an increase of 23% from pre- to post-testing. When broken down into individual questions, the post-test showed improvement in total correct answers for each question in varying degrees. Each school had an increase of at least 20% from the pre-/post-testing (see Figure 1). A P-value of 0.000000087 is clearly < 0.05 which suggests our data is statistically significant.

Based on the percent increase comparing pre-/post-testing, it is our impression the Breathe-zy Program increased health promotion, disease prevention and raised awareness of the RT profession. The RT student leads were granted an opportunity to learn the impact of community partnerships, leadership and research skills. We encourage anyone interested in starting this program to contact the authors who will provide all information and resources required to implement a program and support the course for RT students as an effective pulmonary community education program.

Figure One: Breathe-zy Pre/Post Testing Outcomes

There is an ever-present demand for increasing student enrollment in higher education institutions. Not surprisingly, respiratory care (RC) programs are under pressure to recruit and retain students in both undergraduate and graduate programs. The decision for an undergraduate student to continue their education into an advanced degree program is not fully appreciated. The purpose of this study is to determine students’ perceived self-efficacy, outcome expectations, barriers, and support to attend a Master of Science in Respiratory Care (MSRC) degree program.

The survey developed by Crede and Borrego was modified to use in this study and included questions on undergraduate student self-efficacy, outcome expectations, perceived barriers, and support to attend the MSRC. The perceived impact of the MSRC on career goals was also explored. After receiving IRB approval and informed consent from all participants, 89 undergraduate students in the bachelor’s degree program at Texas State University were surveyed on campus.

A total of 87 surveys were collected (42 juniors and 45 seniors) with a response rate of 97%. Participant demographic results demonstrate 90% are female and the average age is 22.54±3.50 years. Self-efficacy results indicate 88.5% believe they would be successful if enrolled in the MSRC program. Only 58.6% have an interest in pursuing the MSRC possibly because 51.7% do not think the MSRC is required for the job they want. However, 98.8% believe the MSRC will create more opportunities for them. Cost (34%), tired of schoolwork (20%), and marriage (10%) are the three main reasons not to attend the MSRC. Also, 71.3% of participants do not know if they can receive financial support for tuition and living expenses in graduate school. Most participants (71%) do not know who to ask about attending graduate school, and 89% of participants think it will be hard to make friends in graduate school.

RC students have self-efficacy to attend an MSRC program and believe it will provide more opportunities for them. However, the cost is the main barrier to enrolling in the graduate program and students do not know about resources available to them due to lack of support. This study highlights students’ perceived barriers and challenges in advancing their knowledge and continuing their education with an MSRC degree.

Respiratory therapists who work in the intensive care unit with patients who suffer from cardiopulmonary diseases are affected from compassion fatigue and burnout. The intensive care unit is a stressful environment, due to most patients being critically ill or unstable, as well as when the doctor has told the patient or patient family of a terminal illness prognosis. Respiratory therapists work in different areas in the hospital especially in the ICUs. Sometimes respiratory therapists and other staff are involved in traumatic events. After continuous exposure to traumatic events the respiratory therapists are more likely to develop compassion fatigue and burnout.

A cross-sectional study in KAMC in Riyadh among respiratory therapist. The Professional Quality of Life Scale (proQOL-5) questionnaire was used to collect data.

The prevalence of compassion fatigue, burnout and Compassion satisfaction were 68.7%, 60.6% and 54.5% respectively. The level of compassion satisfaction among the participants about 52% of participants had average level of CS. About the level of compassion fatigue 63% of the participants had average level of CF. A majority (60%) of participants had average level of burnout. The mean score of compassion satisfaction was found to be 40.13 + 6.41 while the mean score of burnout was 26.89 + 7.82 and that of compassion fatigue was found to be 24.22 + 5.57.

High level of compassion fatigue causes a lot of problems such as feeling of helplessness, lowered concentration, and work absenteeism. After this study our suggestion is to limit the development of compassion fatigue on the staff and find the solutions for them.

We sought to determine if the general population is prepared in regards to prescription medications (RXM) in the event of an emergency. Pharmacies, physicians and insurance companies contribute to the problem by limiting the availability and quantities. Recent disasters, quick evacuations and quarantine have contributed to RXM unpreparedness.

The questions on the Medical Preparedness Survey were created to gauge the preparedness of the general population of one Utah county. We sought to determine: 1) 3-day RX preparedness in general, 2) gender dependence on RXMs, 3) preparation by gender, 4) Utah County, UT preparedness with RX meds, 5) preparedness of home oxygen (O₂) where applicable, 6) the role of education in readiness with RXMs, and 7) age dependency and preparedness. Additional questions included: patient demographics including age, gender, zip code, ethnicity and highest level of education, 5-minute access to RXMs, pet dependency on RXMs, and if access could be accomplished in 5 minutes, and patient identification of emergency outside designated meeting spots. Data were collected via a Qualtrics template survey distributed via Facebook. Two hundred twenty-five surveys were returned and analyzed.

Survey results are reported in Table One. Other outcomes of note include: 1) 2.2 % of the respondents indicated they were dependent on RXMs but would not be able to access their medications in under 5 minutes, 2) 42% of respondents indicated they owned pets that rely on medications but did not have an available emergency supply, 3) 25% of respondents with RXMs would rely on their local pharmacy, and 4) 66% of respondents did not have a pre-designated emergency meeting spot.

It is our impression most are prepared with RXMs for 3 days but not beyond that. A gender gap in preparedness was noted. More respondents < 60 were dependent on RXMs than those > 60 despite comorbid conditions which emerge with advancing age. Higher levels of education did not equate with level of preparedness. This seems inversely related; however, this result warrants further investigation. Community education regarding the need for RXM preparedness and planned emergency meeting location may impact preparedness and decrease potential burdens. It is our impression community services, hospitals, medical supply and insurance companies should coordinate processes to assure oxygen dependent patients have adequate RXM and oxygen sources. The authors acknowledge Kira Zabriskie, Esau Jared Moreno Cordova, and Taylor Hale.

High velocity nasal insufflation (HiVNI) is used commonly in pediatric bronchiolitis patients in respiratory distress. The use of oxygen, of any kind, in this population can impact hospital length of stay (LOS). Our existing bronchiolitis pathway (BP), which promotes standardized care for these patients, was revised with the goal of more rapidly decreasing and discontinuing HiVNI while maintaining patient safety.

A multi-disciplinary work group was formed and focused on reducing length of stay (LOS) and readmission rates for BP patients. Changes were made to our HiVNI weaning guidelines to aid in more rapid decrease and succinct removal of therapy (Table 1 and Image 1) . For BP patients on HiVNI after a 4-hour period of stability on HiVNI, the flow was dropped to the initial flow for two hours. If the patient remained without severe distress for the two-hour trial period they were placed on room air. A retrospective chart analysis was completed comparing BP patients from 01/2019-03/2019 to 01/2020-03/2020, periods from before and after implementation of the revised BP. Variables for analysis included LOS, HiVNI use, and readmission rate (RA).

In the 2019 period, 233 patients were admitted on the BP. 52% (121/233) of these patients received HiVNI therapy. In the 2020 period, 190 patients were admitted on the BP and 32% (59/190) received HiVNI therapy. Hospital LOS decreased from 2.23 days in 2019 to 1.84 days in 2020 (P=0.027) for HiVNI BP patients. RA were unchanged from 21% in 2019 to 19% in 2020 (P=0.34). The use of HiVNI for patients on the BP decreased by 47.61% from 2019 to 2020.

Revising our BP with a focus on a more rapid decrease and succinct removal of HiVNI reduced hospital LOS by 39% without adverse effect in RA in our hospital’s pediatric bronchiolitis population. Further research must be done to evaluate the most effective weaning method from HiVNI in pediatric and other applicable populations.

HFNC Weaning Recommendations for BP Patients at Nemours Alfred I. duPont Hospital for Children

Transpulmonary pressure (PL) manometry is used to assess pulmonary mechanics and guide lung protective mechanical ventilation (LPV). PL manometry is recommended to individualize LPV settings for patients with increased chest wall elastance and hypoxemia. Our primary aim was to determine if non-PL guided LPV settings, pulmonary mechanics, and oxygenation differ 1-day after receiving PL guided LPV among obese mechanically ventilated (MV) patients. Secondary endpoints: Ventilator-free days (VFD), ICU length of stay (LOS), and overall ICU mortality..

This was an IRB approved retrospective analysis of prospectively collected quality improvement data from MV adult obese patients. All patients were MV for a period prior to placement of an esophageal balloon catheter. Ventilator settings, pulmonary mechanics, and oxygenation were recorded on the initial day of PL measurement (D1, non-PL guided LPV). PL guided LPV targeted Inspiratory PL < 20 cm H₂O and expiratory PL 0-6 cm H₂O. PEEP was adjusted according to a FIO₂/PL Table. Comparisons were made to repeat measurements done on day 2 (D2, PL guided LPV). Hypoxemia severity was also compared. Data reported as n (%) and median (IQR). Alpha set at .05.

19 patients (63% male) with median age 49 (40-65) y, BMI 46.3 (36.6-55.9) kg/m2, and SOFA score 8 (6-11) were included in our sample. 13 (68%) patients received care in the medical ICU and 6 (32%) in our surgical/trauma ICU. PL measurement occurred 16 (9-21) h after initiating non-PL guided LPV in an effort to optimize ventilator settings. PL guided LPV resulted in higher PEEP [14 (14-20) vs 18 (17-25)], P <.01), Expiratory PL [-3 (-5 to -1) vs 1 (0 to 3), P <.01], Crs [30 (26-42) vs 43 (37-51), P <.01], and PaO₂/FIO₂ [165 (106-193) vs 246 (204-286), P <.01] at D2. PL guided LPV resulted in lower FIO₂ [.60 (.40-.90) vs .30 (.30-.40), P <.01)] and lower Driving Pressure [14 (10-15) vs 10 (8-11), P =.01]. V_T [420 (360-457)] vs 435 (363-463) mL, P =.64) and Inspiratory PL [7 (2-11) vs 8 (5-10), P =.55) were similar. Hypoxemia was lower after PL guided ventilator setting adjustment (Table). VFD ranged from 2-28 [8 (6-12)] d and ICU LOS was 17 (11-27) d. ICU mortality was 11% (n=2/19).

PL guided LPV results in higher PEEP, lower FIO₂, improved pulmonary mechanics, and greater oxygenation when compared to non-PL guided LPV MV settings in adult obese patients. Future studies should evaluate early PL guided LPV among obese pts and the effect on VFD, ICU LOS, and ICU mortality.

Pediatric patients receiving chronic mechanical ventilation via tracheostomy have variable needs for oxygenation. Supplemental oxygen can be supplied either through the ventilator or at the tracheostomy site. In this study we compared tracheal FIO₂ achieved through 2 different methods in a model of pediatric mechanical ventilation via tracheostomy. We hypothesize that administering oxygen through the tracheostomy would provide a higher FIO₂.

An in-vitro model of pediatric ventilation via tracheostomy was utilized with a home ventilator (Breas Vivo 65) which was connected in series to a single-limb heated wire passive ventilator circuit (Fisher & Paykel RT219, internal diameter 30 mm), a tracheostomy ring (t-ring) adapter, 4.0 pediatric tracheostomy tube with cuff inflated (Bivona TTS), t-piece with oxygen analyzer (trachea), filter, and an infant test lung (20% leak, resistance Rp50 and compliance 2 mL/mbar). Ventilator settings were PC-SIMV, RR 30, PC 30, I-time 0.6, PEEP 5 and PS 15. Oxygen was administered through the ventilator’s designated oxygen inlet and through the t-ring at different flows and the resultant FIO₂ was measured at the tracheal level. Measurements were done in quadruplicate after 5 minutes of continuous operation. A T-test was used to compared tracheal FIO₂ obtained with different connections.

See Table.

In an in-vitro model of pediatric ventilation via tracheostomy, delivering supplemental oxygen through the t-ring provided a higher FIO₂ than using the ventilator port when oxygen flows were ≥ 3 L/min. However, the use of a t-ring could potentially affect the monitored tidal volume.

Heated tracheostomy collar (HTC) with different interfaces (direct connection or tracheostomy mask) is used to provide humidification of inspired air to spontaneously breathing tracheostomized children. At our hospital we use a HTC with a blender system (FIO₂ 0.21). If supplemental O₂ is needed, low flow O₂ (FIO₂ 1.0) is given through a tracheostomy ring (t-ring). This is done in the event the HTC circuit becomes disconnected. Sometimes, despite using a maximum flow, the desired O₂ saturation is not achieved. We hypothesized increasing the FIO₂from the blender, using a direct connection interface, and increasing t-ring flow would result in higher tracheal FIO₂s.

We used a model of a spontaneously breathing tracheostomized child consisting of a 4.0 pediatric tracheostomy tube with cuff inflated (Bivona TTS) inserted into a tracheal model connected in series to a t-piece with O₂ analyzer (tracheal FIO₂), a filter and a breathing simulator (RR 30, V_T 140 mL, I-time 0.7 seconds). Oxygen was delivered through a t-ring attached to the tracheostomy (0-4 L/min), the HTC (15 L/min) at different FIO₂s, or with both. We tested 2 different interfaces: a direct connection adapter and a tracheostomy mask. Tracheal FIO₂was recorded after 5 minutes and each experiment was repeated 4 times. Interfaces were compared with T-test, and effect of flows and FIO₂s were compared with ANOVA. A P < .05 was considered statistically significant.

The direct connect provided higher tracheal FIO₂s than trach mask in most occasions. Increasing t-ring O₂ flow and increasing HTC FIO₂ increased tracheal FIO₂.

The HTC used with blender FIO₂alone achieved higher tracheal Fi02s than the t-ring in a model of spontaneously breathing tracheostomized child. Increasing t-ring flow increased tracheal FIO₂ with HTC FIO₂ of 1. The addition of the t-ring O₂flow to blender FIO₂provided only minimal increases in FIO₂. When the blender was set to deliver 1.0 FIO₂, the addition of t-ring flow had no impact. In general, there were no significant differences in FIO₂between interfaces.

Various clinical parameters have been studied as predictors of successful weaning in patients in the ICU; however, the results appeared to be inconclusive.

In an ICU with 24 beds in a regional hospital, baseline demographic characteristics and clinical parameters from 336 continuous patients admitted to ICU were collected. These parameters include age, sex, body mass index, blood levels of albumin, hemoglobin, blood urea nitrogen, creatinine, sodium, potassium, Glasgow coma scale, arterial blood gas, and vasopressor use. Patients were divided into two groups: successful weaning (n = 175) and non-successful weaning (n = 161). Continuous data were summarized by mean and standard deviation (SD), categorical data were summarized by frequency and percentage. The continuous and categorical data between groups were compared using Student’s t test and chi-square test, respectively.

All demographic and clinical parameter were similar between two groups, except for Glasgow coma scale (10.15 ± 4.58 in the successful weaning group and 7.89 ± 4.35 in the non-successful weaning group, P < .001) and vasopressor use (29.7% in the successful weaning group and 62.1% in the non-successful weaning group).

Conscious level and vasopressor use appeared to be associated with successful weaning from mechanical ventilation in intubated ICU patients.

The novel coronavirus (COVID-19) is a highly contagious, public health emergency. COVID-19 creates risk for healthcare workers, especially those unfamiliar with utilizing personal protective equipment (PPE). In a large pediatric health care system, we aimed to reduce transmission from COVID-19 patients as well as transmission from clinical staff and patient/caregivers by creating the role of PPE coach (PPEC).

Our health system redeployed outpatient clinical staff (OCS) into the role of the PPECs, including registered respiratory therapists, registered nurses, nurse anesthetists, and surgical technicians. PPECs received training on PPE best practices, organizational standards, and coaching within the clinical environment. PPECs were introduced to our organization by utilizing mass email distribution and visible by assigning them as PPECs in the hospital communication tool (Voalte, Inc., FL). PPECs began supporting the health system on April 1st, 2020. PPECs were primarily responsible for observing and providing feedback on PPE donning and doffing. They were also able to answer PPE-related questions and escalate concerns or issues to our organizational COVID-19 incident command team. PPECs remained deployed throughout the COVID-19 pandemic. An IRB approved survey (Table 1) was sent out to associates via mass email distribution to review the PPEC role after 30 days on 5/1/20 and was open for 15 days.

PPECs observed, on average, 47.6 donning or doffing events each day. 64.80% of surveyed staff found that PPECs were able to improve their donning and doffing technique to remain in compliance with procedural standards (n=116). 78.63% of staff surveyed found the role of the PPEC to be effective (n=116). From 4/1/20-4/30/20 PPECs escalated 152 issues to incident command, which resulted in 43 changes to the standard practice during this global emergency. The role also appeared to aid in reducing anxiety related to PPE in our institution.

By redeploying staff within our health system as PPECs, we were able to increase safety practices and reduce potential contamination during PPE donning and doffing. Redeployment of OCS in the role of PPECs during the COVID-19 pandemic was paramount in our organizational success in this climate. Further studies must be done to assess temporary roles and re-deployment practices within the field of respiratory care and other disciplines as well as the overall impact.

Graph 1 shows the number of reported PPE Observations per day in the month of April.

Spirometry is a physiological test that measures how a patient inhales or exhales gas as a function of time. The American Thoracic Society (ATS) guides spirometry standards to ensure that spirometry results are accurately interpreted and influence care appropriately. Accuracy of pediatric spirometry ranges from 37-95%.1,2 In our health system, Registered Nurses (RNs) and Registered Respiratory Therapists perform pediatric spirometry. Audits of completed spirometry are reviewed by trained PFT staff for acceptability based on ATS Standards (Table 1). We reviewed audit results to evaluate for differences based on provider credential type.

In an IRB approved retrospective analysis, we reviewed and compared pediatric spirometry audits from 11/2019-03/2020. Audits were split into groups based on credentials of the spirometry technician (RPFT, RRT, CPFT, RN). We analyzed the spirometry audits for alignment with ATS standards based on spirometry technician user. 60 RN preformed spirometries and 60 RT preformed spirometries were randomly selected and compared.

In 120 pediatric spirometry audits, patients ages were 7-19 years (average 11.2 years). When comparing RN to RT spirometry audit compliance with ATS standards we found that RNs submitted spirometry that was compliant with ATS standards 63.08% of the time. In comparison, RTs submitted compliant spirometry results 79.24% of the time. In the 60 RT audited spirometry tests 42 were done by RRTs, 6 by CPFTs and 12 by RPFTs. When comparing RT specific credentials, those with RPFT had the greatest percentage of compliance with ATS standards, followed by CPFT, then RRT (graph 1).

In our pediatric hospital, compliance with ATS standards, as indicated by spirometry audits was demonstrated best by professionals with the RPFT credential. The need for extensive training and auditing should be mandated for all professionals preforming pediatric spirometry to ensure accuracy of results aligned with ATS standards. More research is needed to assess the potential impact of training and spirometry audits within the field of pediatrics. References: 1. Loeb J, et al. Acceptability and repeatability of spirometry in children using updated ATS/ERS criteria. Pediatr Pulmonol. 2008;43(10):doi:10.1002/ppul.20908 2. Pérez-Yarza E, et al. Forced spirometry in healthy preschool children. An Pediatr (Barc). 2009;70(1):doi:10.1016/j.anpedi.2008.10.003

Graph 1 shows the percentage of compliance with ATS standards for pediatric spirometry in our facility based on provider credential.

The COVID-19 pandemic presented an array of challenges across healthcare, notably critical care staffing models. The potential for mechanical ventilation (MV) to be managed in part by practitioners unaccustomed to doing so revealed the need for basic and applicable education. Detailed online modules and quick-reference document formats emerged to bridge knowledge gaps. A one-page primer for MV was developed and widely disseminated.

A panel of experts composed of respiratory care clinicians, educators, and managers developed a bedside MV reference intended to aid clinicians who were assisting in the MV management of COVID-19 patients. Mean respiratory care experience amongst the panel was 22 years (11-31). The panel developed the MV reference based on evidence-based practice, consensus guidelines, and ventilator platform configurations. The MV reference summarized initial ventilator settings and assessment-based adjustments as well as recommended ARDS guidelines. A glossary of commonly used terms and modes of ventilation was also included.

The MV reference was distributed via social media (Twitter, Facebook, LinkedIn). According to available analytics, social media posts were viewed 46,745 times and the MV reference attachment was opened 2,815 times. It is unclear from available analytics how many times it was downloaded. The MV reference was also posted to the AARC’s clinical resource page, AARC Connect, and SCCM Connect. The AARC’s “Mechanical Ventilation for COVID-19 Video Series” webpage, on which the MV reference was posted, showed 34,501 site visits, though data relevant to downloads of the MV reference specifically was not available. Data relevant to views associated with AARC Connect or SCCM Respiratory Care Section as well as institutional utilization were unavailable. Our data is inconclusive and limited since we could not analyze which specific information was accessed or if our document was downloaded; nor did we intend to collect outcomes.

Quick reference educational tools and just-in-time learning can be developed and disseminated rapidly in times of crisis. Attention to evidence-based practice and expert experience in the development of these tools ensures appropriate guidance. More research is needed to assess the effects these educational efforts have on outcomes.

Adequate hours of sleep in adults and college students has steadily decreased in the past 10 years (CDC). According to Dr. Kusida (2020), if students are routinely sleep deprived their ability to learn, memorize, and be attentive is diminished. There are few published studies that examine the use of experiential learning in sleep education. The question being posed is: What is the impact of using experiential learning as a theoretical framework for sleep education in the collegiate environment? Experiential learning is defined as, "the process whereby knowledge is created through the transformation of experience" (Kolb 1984, p.38). To follow the principles of this theory, students participated in four activities that focused on promoting pre-bedtime routines/healthy sleep habits. The four activities were drinking Sleeptime tea before bed, guided meditation, yoga, and nap sessions. A brief survey was used as a reflection tool.

This mixed-method pilot study used a survey and qualitative feedback from students enrolled in a Sleep education course. Data from 25 participants was used; 24 student-athletes; from seven different sports; one female non-athlete; 14 males and 11 females. The data collected from the survey was both quantitative and qualitative. Excel was used to calculate the percentages for the quantitative data and qualitative responses was coded and reviewed by peer briefing. Themes emerged as the students described their experiences and benefits for each activity.

The results from the tea activities showed, 92% of the student benefitted from the activity and would use this technique again. The result were identical for yoga and nap sessions; 92% positive responses. The results from the meditation session was higher, 100% benefitted, with 95% stating they would participate in meditation as a pre-bedtime activity. There was minimal to no prior experience with the activities. The qualitative feedback show that the students found all the activities to be relaxing, improved mood, soothing and increase concentration, while reducing stress. Limitations: 1. Small sample size; results cannot be generalized to a larger population or demographic 2. Surveys not validated and subjective.

The results of the study showed, students were able to increase their exposure to healthy sleep habits and learned techniques to improve pre-bed/sleep activities. The student enjoyed learning through experiential activities and would incorporate them into their pre-bed routines.

Telemonitoring (TM) with COPD patients has been shown to reduce hospitalization and exacerbations events. However, information about the most crucial parameters that constructed home-based rehabilitation programs still limited and conflicting. The objective was to summarize and report the most common TM parameters with COPD.

A systematic search was performed up to April 2020 included MEDLINE (Ovid), CINAHL, Cochrane library, and Embase databases. The Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) checklist tool was used to guide the selection process. Only randomized controlled trials (RCTs) that provided TM during home-based rehabilitation programs to individuals with COPD were included. Two independent reviewers retrieved titles, abstracts, full texts, and completed data extractions. TM parameters were extracted from the description of interventions found in the included studies. To summarize TM parameters, we used descriptive statistics as frequency and percentages.

Among 1,577 abstracts identified, 96 articles underwent full-text review, and 27 were eligible and included. Overall, TM parameters were variable within our included studies. The most commonly used TM parameters were oxygen saturation (21/27) 77% and heart rate (19/27) 70 %. Whereas the lowest frequent TM parameters were respiratory rate (5/27) 18% and weight (3/27) 11%. All included studies used at least two or more TM parameters to follow-up with COPD patients. Majority of included studies were transferred patient data to healthcare centers for health care professional review and feedback. The most common ways to deliver guidance and feedback were telephone calls and predesigned online platforms (21/27) 77% and (14/27) 51%, respectively. Daily-bases TM was reported more than weekly-bases TM among all included studies (25/27) 92% versus (2/27) 7%. Daily score of symptoms and medication diaries were only the subjective parameters included in TM packages.

Cardiorespiratory parameters are essential components of TM with COPD, but attention should be paid to further parameters such as cough and sputum production. The current review suggests optimizing the design of TM by considering more daily cardiorespiratory parameters to reflect patient status. Further research is needed to evaluate if using more TM parameters with COPD will increase the positive impact of home-based rehabilitation interventions.

School nurses are uniquely positioned to provide direct care, adherence counseling and education for children with asthma.1 However, standardized asthma education for Arkansas school nurses does not exist. Pediatric health systems that provide patient-centered care have a unique obligation to recognize and support school nurses as an important part of the health care team and provide education and resources to bolster their knowledge base and ability to managing asthma in the school setting.1 This study evaluated the effectiveness of an education program for nurses created to increase comfort with managing asthma in a school-based setting.

An asthma education program was developed and implemented in the Arkansas School Nurse Academy program. The program included both didactic and hands-on education for routine asthma management including social determinants of health, asthma triggers/avoidance strategies, inhaler technique, and utilization of the asthma action plan for treatment of acute asthma. Education content was prepared using best practice guidelines from both the Global Initiative for Asthma Management and the National Asthma Education and Prevention Program. Participants were asked to complete a pre and post survey for overall evaluation of the program. The evaluation included 5 asthma related questions regarding comfort for addressing social determinants of health that influence adherence, education of triggers and avoidance strategies, inhaler technique, use of an asthma action plan, and seeking asthma resources. Responses were based on a 5-point Likert scale for comfort with each topic. Strongly agree and agree responses were combined to evaluate change from pre to post survey. The asthma specific questions were analyzed separately using the Wilcoxon signed-ranks test.

There were 194 participants in the study. Respondents reported an increase in comfort from pre to post survey for each question. This increase was statistically significant for addressing social determinants (P = .003), use of an asthma action plan (P = .001) and seeking resources (P = .002).

An asthma education program for school-based nurses, utilizing both didactic and hands-on skills demonstration, led to improved comfort level in managing asthma. Reference 1. Lemanske RF, Kakumanu S, Shanovich K, Antos N, Cloutier MM, Mazyck D, et al. Creation and implementation of SAMPROTM: A school-based asthma management program. J Allergy Clin Immunol. 2016;138(3):711-723.

For patients with cystic fibrosis, thick secretions cause a need for bronchial hygiene therapy. We tested three percussive devices that are designed for secretion mobilization to determine the most efficient product: The IPV (Model IPV-1C, Percussionaire, Sandpoint, ID), MetaNeb (Hill-Rom, St. Paul, MN), and Vortran PercussiveNEB (Model 2.0, Vortran Medical Technology, Sacramento, CA). Our null hypothesis is that the three devices will show no significant difference in rate of mucus velocity when compared.

An ASL 5000 lung simulator (Ingmar Medical, Pittsburgh, PA) was set to simulate a cystic fibrosis patient with a Cstat of 45 cm H₂O, Raw of 17 cm H₂O/L/s, V_T 800 mL, f 15, and I:E ratio 1:2. To create the airway, a 10 mm I.D. x 30 cm clear plexiglass tube was attached to the ASL 5000 and each device was attached to the distal end of the tube. A hole was drilled in the center of the tube to accommodate a 10 mL syringe. For the mucus simulant, two parts of Aquasonic 100 Ultrasound Transmission Gel (Parker Laboratories Inc., USA) was mixed with three parts of water. This mixture’s viscosity has been documented to be in the same range of human sputum. For each run, 1 mL of mucus simulant was injected into the center of the leveled plexiglass tube and allowed to settle for one minute. Each device was set to run for 30 seconds at the highest and lowest frequency setting for 5 trials. The best three out of the five trials were used in the mean for the conclusion. A photograph was taken at the end of each trial using a 12 megapixel camera. We set the starting point for the measurement at the distal leading edge of mucus once settled and measured the amount of forward or backward movement after the trial was completed in centimeters via ruler and pixel measurement.

The IPV produced forward movement of +10.67 cm on the high frequency setting and +6.12 cm on its low frequency setting. The MetaNeb’s average was - 0.02 cm on low frequency and - 0.14 cm on high frequency. The Vortran PercussiveNEB’s average on the low frequency setting was - 0.79 cm and - 16.76 cm on the high setting.

We rejected our null hypothesis because there were significant differences between the three devices. The MetaNeb and Vortran PercussiveNEB both produced negative caudad movement on both high and low frequency settings. The IPV produced forward cephalad movement on both high and low frequency settings. During use of the IPV, secretion movement is best when set at its highest frequency.

Ventilators for invasive and non-invasive respiratory support have the ability to store and transmit data. Many outpatient clinics, long term care facilities, and home care agencies use the data download feature to retrieve ventilator data remotely and make changes as needed. In these environments, daily assessment of the ventilator by a respiratory therapist (RT) is not always feasible. In the hospital setting, RT assessment is the norm, with data downloads not utilized frequently to make ventilator changes. We evaluated concurrent stored Trilogy 202 ventilator data and RT documented ventilator checks to determine if differences were present.

After obtaining IRB approval, 10 patients were selected randomly if they met our inclusion criteria of Trilogy 202 ventilator use for >7 days and a minimum 12 hour per day ventilator use. Data from the ventilator’ SD card was analyzed and compared to concurrent RT documentation in the EMR. Variables for analysis included breaths/min, leak, minute volume (MV), tidal volume (V_T), and peak inspiratory pressure (PIP) .Averages for each parameter for each patient were recorded. Variable mean and standard deviations were determined and compared using paired T-tests.

The average patient age was 2.98 years. 5/10 patients had uncuffed tracheostomy tubes. 4 patients received SIMV PC PS, 3 CPAP/PS, 2 PC, and 1 CPAP. There was a statistically significant difference in SD card obtained data when compared to RT documentation 10% of the time for breaths/min, 40% of the time for leak, 20% of the time for MV, 30% of the time for V_T and 10% of the time for PIP (Table 1). Overall, in 22% of comparisons there was a statistically significant difference between SD card data and RT documentation for the measured parameters. For the 10 patients studied, 6 patients (60%) had a statistically significant change in one or more of the compared variables. See graph 1 and Table 2 for additional data.

In our practice, significant differences are present between Trilogy 202 ventilator SD card data and RT documentation. Based on the design of this study we are unable to conclude if Trilogy 202 recorded data or RT documented data is preferred. Further studies must be done to evaluate the significance of these differences as it is applied to ventilator adjustments and patient outcomes.

Graph 1 displays the variables for analysis comparing the Trilogy 202 SD Card data trends and the average RT electronic health record documentation.

The purpose of this study was to evaluate aerosol delivery efficiency through a tracheostomy interface attached to a jet nebulizer, vibrating mesh nebulizer (VMN) combined with an aerosol adapter, and VMN combined with a heated humidified breathing circuit in a simulated spontaneously breathing pediatric model with tracheostomy tube (TT). Aerosol delivery at different flow output levels was also investigated with VMN.

An in vitro model consisting of a pediatric manikin with an anatomically correct airway and uncuffed TT (5.0-mm inner diameter) was connected to a lung simulator via a collecting filter at the level of the carina to simulate a spontaneously breathing child weighing 20 kg (V_T 140 mL, RR 24, I:E ratio 1:2.5). Albuterol sulfate was administered using a jet nebulizer (AirLife Side-Stream, 2.5 mg/3.5 mL) and VMN (Aerogen Solo, 2.5 mg/1.5 mL). The jet nebulizer was attached to the TT via a tracheostomy interface (OPT970, Fisher & Paykel) and operated at 6 L/min with a resulting flow output of 13 L/min during nebulization. The VMN was attached to the TT via the tracheostomy interface with an aerosol adapter (Aerogen Ultra) or heated humidified breathing circuit (RT232, Fisher & Paykel) with VMN placed at inlet of humidifier (Fisher & Paykel 850) set at 37 C. In both VMN conditions, aerosol was delivered through the tracheostomy interface at flows of 2, 6, and 13 L/min. Prior to testing, flows were verified with a mass flow meter (TSI, Shoreview, MN). Flow was discontinued at the end of nebulization. Each device was tested in triplicate. Drug was analyzed by spectrophotometry (276 nm). ANOVA followed by Holm-Sidak multiple comparison was used for data analysis, P < .05.

There was no significant difference in the percent of inhaled albuterol between the jet nebulizer (2.88 ± 0.1%), VMN with aerosol adapter at 13 L/min (2.87 ± 0.3%) or VMN with heated humidified breathing circuit at 6 L/min (2.2 ± 0.3%). However, the VMN combined with aerosol adapter delivered significantly more medication than any other tested condition at output flows of 2 L/min (7.01 ± 0.7%) and 6 L/min (6.49 ± 0.5%)(P < .05). Aerosol delivery at 2 and 13 L/min with the VMN combined with a heated humidified breathing circuit was significantly less than any other tested condition.

In this pediatric tracheostomy model, the inhaled dose delivered through a tracheostomy interface was greatest when aerosol was generated with the VMN combined with aerosol adapter at output flows of 2 and 6 L/min.

Ventilator-associated lung injury is highly associated with the tidal volume (V_T) selection, which requires special attention and monitoring in an ICU. 1 The current guidelines recommend setting the V_T according to the ideal body weight (IBW).18-19 However, there is a lack of research that examines the adherence of clinical practitioners to the ideal method of setting the V_T for patients who require mechanical ventilation. The aim of this study is to explore whether the selection of V_T in mechanically ventilated patients is based on patients’ IBW.

Cross sectional study was conducted at King Abdulaziz Medical City during the period 2016-2018. Electronic medical records were used to extract the information on all intubated adult patients who had been admitted to the ICUs. From each medical record, demographic information, clinical diagnosis, and ventilator settings were extracted. We compared the set V_T that each patient received with the adjusted V_T based on IBW.

A total of 160 patients were admitted to the ICU and received mechanical ventilation during the study period. The mean age of the included patients was 66 (SD=18 years), and the majority were male patients (53%). One hundred thirty-five (84%) of the patients were diagnosed with restrictive pulmonary disease, and the average set V_T was 378 (SD=57 mL). Twenty-five patients (15%) were diagnosed with obstructive pulmonary disease with mean of set V_T 361 (SD=70 mL). After calculating the adjusted V_T, 59% of the patients received volume out of the appropriate range.

This study shows that set V_T by Respiratory Therapist (RT) for patients receiving mechanical ventilation is inconsistent with the predicted V_T based on ideal body weight with a P value < 0.001. This provides evidence to improve the current practices of setting V_T parameters.

Lung sound auscultation is important in the training course of respiratory therapists (RTs). Lung sound auscultation is a non-invasive and effective method to assist in the diagnosis of lung diseases. Take diagnosis of lung diseases as an important reference. Therefore, auscultation can find the dangers of the disease, and to make suggestions and adjust treatment strategies. The purpose of this study was to increase Self-confidence, Lung sound discrimination accuracy, and quality of clinical work on the respiratory therapists (RTs).

This study was conducted at a teaching hospital in the middle of Taiwan. Subjects included 6 RTs in the period from 2017 to 2019. We use a lung sounds training model (LSTM). The intervention was applying a web-film demonstrating. RTs were required to take a pre and post-course test and questionnaire.

This study collected 6 after-course test results and questionnaires. All RTs average age 26 years. They scored 75 points pre course test and 88 points post course test. Lung sound quality satisfaction was 6 to 7. Self-confidence (full makers 10) was mean 6 to 8. Lung sound discrimination accuracy is 83% to 86%.

The LSTM can affect the attention, learning, memory, and effectiveness of the RT. It can provide education and training for respiratory therapists on auscultation teaching and improve the quality of medical care.

course test

Course in progress

Infants born prematurely are at risk of developing chronic lung disease (CLD) due to their immature lungs and the use of invasive mechanical ventilation (MV). At Aurora Sinai Medical Center (ASMC), the rate of very low birth weight premature infants (<1,500 g) on oxygen at 36 weeks gestational age (GA) is above average when compared to the Vermont Oxford Network national database. Because CPAP at delivery has been recognized as an effective treatment to reduce intubation and invasive MV methods, we implemented a clinical guideline to provide a standard practice to reduce invasive MV for neonatal patients (26-32 weeks old) by using CPAP for the first 72 h of life.

Retrospective chart review of all infants born between GA of 26 to 32 weeks and admitted to ASMC’s Neonatal Intensive Care Unit in 2018 and 2019. Data from 02/2018 to 12/2018 was compared to data after clinical guideline implementation, 02/2019 to 12/2019. Effectiveness is determined as non-diagnosis of CLD. Noninvasive ventilation techniques (NIVTs) includes noninvasive ventilation, heated wire nasal cannula, and CPAP. Basic descriptive statistics were used to describe the population.

There were 46 patients enrolled in 2018 and 50 patients enrolled in 2019. GA (M=29 weeks) was similar for 2018 and 2019 groups. Initial respiratory support at delivery showed that for infants <1,500 g NIVTs was used similarly in 2018 (47%) vs 2019 (40%). By 24 h of life, these NIVTs increased in infants <1,500 g to 85% in 2019 when compared to 66% in 2018. Similarly, NIVTs showed a clinical increase at 48 and 72 h of life in 2019 vs 2018 for infants <1,500 g. However, for infants ≥1,500 g for 24, 48, and 72 h of life NIVTs remained unchanged. Intubation at birth for infants <1,500 g occurred 53% in 2018 compared to 55% in 2019, and the trend was similar for infants ≥1,500 g in 2018 (36%) vs 2019 (40%). In terms of CLD diagnosis, there was no difference for infants born <1,500 g in 2018 (34%) compared to 2019 (35%). The same was seen in infants born ≥1,500 g in 2018 (14%) compared to 2019 (10%).

Although the new guidelines did not reduce the rate of CLD, the team was able to decrease the use of invasive MV in the first 72 h of life. The need to further hardwire best practices in this area will lead to a reduction in CLD and other related complications from invasive MV.

Chronic lower respiratory tract disease has been the seventh most common cause of death in Taiwan for decades. Previous studies have revealed relationships between the stages of COPD and medical utilization and mortality. However, such research in Taiwan is lacking. Therefore, we investigated the association between the Global Initiative for Chronic Obstructive Lung Disease (GOLD) stages of COPD versions 2007 and 2011 and medical utilization and mortality among patients with COPD to compare the effectiveness of these two versions.

This retrospective study used the clinical database of a medical center in central Taiwan from 2011 to 2017. A total of 613 patients with COPD were identified. Independent variables comprised the 2007 and 2011 versions of the GOLD stages of COPD, demographic characteristics, health status, and physician seniority. Dependent variables included total medical expenses, average duration of hospitalization, and mortality. Statistical methods included binomial logistic regression and the general linear model (GLM).

The total medical costs during the observation period for patients with COPD averaged NT$292,455.60. The average duration of hospitalization was 9.7 days. The mortality rate was 9.6%. The adjusted logistic regression analysis indicated that compared with patients with Grade 1 disease as per the 2007 version, patients in 2007 Grade 4 had significantly higher odds of death (OR = 4.07, P = .02). The adjusted GLM analysis revealed that patients in 2011 Group D had a significantly longer duration of hospitalization than those in 2011 Group A version (P = .04). Regarding the total medical costs and accuracy of mortality prediction, no differences were found between the 2007 and 2011 versions. Complications were significantly associated with the total medical utilization and average duration of hospitalization.

Higher 2011 GOLD stages of COPD were associated with an increased average duration of hospitalization, whereas higher 2007 GOLD stages of COPD were associated with an increased risk of mortality. This study suggests that both versions of GOLD should be used together in the classification of patients with COPD to help clinicians better evaluate their prognosis, such as mortality and treatment. The findings serve a reference for medical institutions to prioritize high-risk patients with COPD and allocate resources appropriately for preventive interventions.

COPD is a common chronic respiratory disease that in the long term may develop into respiratory failure or even cause death and may coexist with other diseases. Over time, it may incur huge medical expenses, resulting in a heavy socio-economic burden. The ADO (age, dyspnea, and airflow obstruction) index is a predictor of the number and severity of acute exacerbations of COPD. This study focused on the correlation between the ADO index, comorbidity, and healthcare resource utilization in COPD.

This is a retrospective study of clinical outcomes of COPD patients with complete ADO index data in our hospital from January 2015 to December 2016. Based on the patients’ medical records in our hospital’s electronic database from January 1, 2015 to August 31, 2017, we analyzed the correlation between ADO index, Charlson comorbidity index (CCI), and medical resources.

Of the 396 patients with COPD who met the inclusion criteria, 382 (96.5%) were male, with an average age of 71.3 ± 8.4 years. Healthcare resource utilization was positively correlated with the ADO index during the 32 months of retrospective clinical outcomes. The study found a significant association between the ADO index and the CCI of COPD patients (P < .001)(Figure1). In-hospitalization expenses were positively correlated with CCI (P < .001) (Figure2). Under the same CCI, the higher the quartile, the higher the hospitalization expenses. ADO quartiles were positively correlated with number of hospitalizations (P < .001), hospitalization days (P < .001), hospitalization expenses (P = .03), and total medical expenses (P = .037).

This study demonstrates the value of examining the ADO index and comorbidities that can predict healthcare resource utilization in COPD.

Endotracheal tubes (ETT) must be properly placed to protect airways, avoid accidental dislodgment, and provide ventilatory support. Infants and small children have short tracheal length complicating proper initial ETT positioning. We sought to develop, internally validate and establish safety, and feasibility of a regression model to determine depth of ETT insertion. We hypothesized that the predictive equation will facilitate correct initial ETT placement compared to PALS guidelines.

We recorded height, weight, age, gender, ETT internal diameter (ID) and cm marking at lip from the electronic record from a random subset of 2,000 initial chest radiographs (CXR) obtained 01/01/09 - 05/05/12. A multivariable linear regression model was constructed, refined and validated by non-parametric bootstrapping technique using unrestricted random sampling methods. A prospective pilot study of subjects age 0 – 18 years admitted to pediatric intensive care unit, requiring invasive mechanical ventilatory support from 1/7/19 – 5/31/19 was conducted. Subjects with spinal and/or skeletal malformations, for whom a post-intubation CXR was not ordered, or whose CXR quality impaired visualizing the carina and ETT tip were excluded. The validated regression equation, Lip Mark ∼ 0.8636 * Height 0.6223 determined insertion depth. Initial CXR following intubation determined ETT position. Demographic data was summarized and a One Sided, One-Sample Binomial Test of Proportions was used to assess if proportion of correct position was greater by predicted lip mark calculation than by lip mark. Analyses completed using R and SAS for this IRB approved protocol.

450 subjects were included in the random subset for model construction. Unrestricted random sampling created 10,000 independent samples used for internal validation. Bias between the bootstrap coefficients and refined model estimates were negligible (< 0.01), indicating they are stable and appropriately reflect the original sample data structure. 11 subjects were included in safety and feasibility testing. When predicted lip mark was not strictly adhered to, 4 (36.4%) were malpositioned, subsequent repositioning to predicted lip mark resulted in 100% correct positioning (P = .01), Table 1.

Use of regression equation is safe, feasible and facilitated correct ETT placement. A larger, diverse sample is required to externally validate the model.

Premature infants are born with a lack of surfactant which requires replacement after birth by direct instillation into the lungs. Each brand recommends a different administration procedure. We initially utilized Brand A; it required patients to be rotated on each side and was administered in two aliquots. In October 2018, we switched to Brand B that did not require patients to be rotated on each side. Rotating patients increased the risk for unplanned extubation, aspiration, mainstem ETT (endotracheal tube) placement, and hemodynamic instability amongst other factors. These risks were associated with hypoxia, intraventricular hemorrhage, ventilator associated pneumonia, cardiopulmonary arrest, multiple intubations, bronchopulmonary dysplasia, and increased number of ventilator days.

A multidisciplinary team formed to evaluate risks and benefits of Brand B versus Brand A and the administration procedure. Administration via mechanical ventilation, via T-piece or manual ventilation with flow inflating resuscitation bag, slow instillation via medication administration catheter inserted to the tip of ETT or inserted to the end of patient wye and beginning of ETT (not directing inserting catheter into ETT), and division of dosage into 2 aliquots were evaluated. Based on a survey of other facilities and the manufacturing company’s recommendation, a standardized administration procedure was created. Procedure changes from Brand A to Brand B required the patient to maintain a supine position and deliver dose via one aliquot. Administration procedures maintained from Brand A to Brand B were manual ventilation with a flow inflating bag and quick installation of medication via administration catheter inserted to tip of ETT. Adverse events that occurred during surfactant administration were reviewed at weekly multidisciplinary meetings. The outcome measure was the number of events per administrations. Process measures were compliance with administration procedure and completion of administration checklist. Balancing measures were number of doses per patient and re-intubation rates.

Brand A had 9 adverse events out of 151 administrations in 19 months. Brand B had 1 adverse event out of 124 administrations in 19 months. P value .036, 3.6%.

Brand B removed the rotation of the patient during administration; significantly reduced the rate adverse events related to surfactant.

A substantial proportion of low-income children with asthma living in rural western North Carolina have suboptimal asthma care management. To address the needs of these underserved children and families, we developed and implemented the Regional Asthma Disease Management Program (RADMP). A multi-faceted approach is used to help families build skills in managing environmental triggers and connect them with community resources. The RADMP provides holistic care management, addressing social determinants of health in children with asthma who are at risk for lower school performance, decreased attendance, fragile nutritional status, and inadequate housing. Children and families are given care and education in their homes, childcare centers, and/or schools.

This retrospective study was conducted from October 1, 2018- April 30, 2019 in 15 rural counties and the Eastern Band of Cherokee Indian Reservation in western North Carolina. Community and individual components included holistic asthma disease management, asthma education in-services, and environmental assessments/remediation. The individual intervention also included clinical assessment and management. Mission Health System Institutional Review Board (IRB) approval was obtained.

All children had persistent asthma (mild, moderate and severe) and were all uncontrolled as per NIH criteria. Two hundred and one children received holistic asthma care management, resulting in 636 in-person consults and 1,018 telephone consults. Comprehensive environmental assessments and asthma education was provided to 63 individuals in 21 different homes. Home remediation primarily in the form of mold mitigation and integrated pest management was conducted to create an asthma-friendly home. Nine asthma educational in-services were provided to health care professional groups, community organizations and families to include a total of 1,384 people.

The Regional Asthma Disease Management Program provided holistic asthma care management to decrease environmental exposures, decrease exposure to irritants and provide asthma education for rural, impoverished asthmatic children as well as their families in western North Carolina. By creating an asthma friendly environment, this program resulted in improved asthma-related outcomes.

Immature lungs need surfactant administration due to lack of adequate production prior to 32 weeks gestation. Surfactant reduces the surface tension within the lungs, allowing the alveoli to remain open. We utilized Brand A of surfactant until October 2018, patients required multiple doses. We were changed to Brand B by our formulary. Brand B presented that their product had greater efficacy and patients rarely needed more than 1 dose and even more infrequently needed more than 2. While the initial dose of Brand B is more expensive than Brand A, there was an expected cost savings due to decreased amount of subsequent administrations. Patients that required more than one dose were more likely to have greater amount of days on mechanical ventilation and other risk factors.

A multidisciplinary team formed and evaluated risks and benefits of Brand A surfactant versus Brand B. Surfactant was administered to patients meeting the same criteria as Brand A; oxygen requirement above 30% while on mechanical ventilation and oxygen requirement above 40% on Bubble CPAP. We utilized our updated surfactant administration checklist to assure procedure was completed per policy and the number of doses documented. Subsequent doses of Brand B required half the initial dose, and Brand A required the same dose for initial and subsequent instillations. The outcome measure was the number of subsequent surfactant administrations and the overall cost to the patient. Process measures were compliance with audit completion for each administration and use of ventilator weaning protocol. Balancing measures were rate of patients that required reintubation and documented adverse events.

There were 84 patients administered Brand A (Bovine) and 50% required more than one dose. There were 86 patients administered Brand B (Porcine) and 66% of patients required one dose with no subsequent administrations. Patients that received Brand B that required more than one dose required a third dose less often than Brand A. The average cost for Brand A was $409.03 and Brand B average cost was $515.38 per administration.

Brand B supported a statistical difference; P = .045, in the need for one dose versus subsequent doses. While Brand B is more expensive upfront, we were still able to reduce cost because there was a significant difference in the number of patients requiring only one dose.

Mechanical ventilation (MV), while life-saving, can lead to significant morbidity, hospital cost, psychosocial and physical risk to a child including death. It is critical to minimize length of mechanical ventilation while also preventing sequelae of failed extubation. Protocols aim to safely and efficiently liberate patients from MV, reducing harmful variations in approach. After implementing a RT-driven spontaneous breathing trial (SBT) protocol in a pediatric intensive care unit (PICU), we examined its effect on MV days pre/post SBT protocol initiation.

A protocolized, RT-driven SBT was implemented in March 2017. We completed an IRB approved retrospective data review for all MV patients in the PICU between January 2015 and October 2019. We eliminated patients with or who received tracheostomies during their PICU course, those who died, and patients intubated less than 24 hours from analysis. Variables for analysis included; SBT/intubation course, demographics, extubation failure status, MV hours, time of SBT, SBT results, and, time of extubation.

1107 intubations were included (507 pre-SBT, 600 post-SBT) with a median length of MV of approximately 93 hours. With implementation of the protocol, median (IQR) length of MV was reduced from 111 hours to 81 hours (P= 0.00069). No difference was seen in the rate of reintubation within 24 hours. Despite performing SBTs twice daily, the average time between passed SBT and extubation was nearly 13 hours. See Table 1 and Graph 1 for detailed results.

After implementation of a fully-integrated RT-driven SBT protocol, length of MV in the PICU was reduced with no increase in extubation failure. Significant length of time between passed SBT and extubation suggest that with more immediate extubation, length of MV could be reduced even further. Additional studies to evaluate this relationship and the possible decrease in MV hours must be done.

Graph 1 displays the duration of intubation pre and post spontenour breathing trial implmentation.

Unplanned extubations (UE) can result in immediate airway management complications, hemodynamic instability, increased length of stay (LOS), and, increased ventilator days (VD). UEs in children contribute to significant morbidity and mortality, with an arbitrary benchmark target of less than 1 UE per 100 ventilator days.1 Risk factors, such as age, gender, increased salivary secretions, intubation duration, nursing attentiveness, endotracheal tube fixation method, and sedation have all been referenced in the literature. After reviewing our practices in 2019 with a UE rate of 0.56/100 VD, we created a multidisciplinary subgroup with a goal UE rate of 0/100 VD. We focused our efforts on standardizing a process for evaluating UE in our PICU using the Solutions for Patient Safety (SPS) workgroup as a source of information.

In an IRB approved retrospective analysis, data was analyzed from 1/1/2019 to 4/30/2020 for number of UEs per 100 VD. After review in 12/2019 changes to our UE bundle included three major changes that were implemented 1/1/2020. First an immediate swarm event post UE with the providing team (RN, RT and MD) using a standard Event Review Form. A visual bundle card was created and education to multidisciplinary teams regarding ETT management in the PICU was completed. Lastly, an ETT management education and elements included; standardized ETT securement process, 2 RT ETT securement process, “Two on the Tube” during patient mobility, and increased awareness for RNs on ETT securement verification.

UE rate from 2019 was compared to available data from 2020. The UE rate for the first 17 weeks in 2019 was 0.83/100 VD and in the same time in 2020, UE rate was 0.38/100 VD. For 2019 (1/1-12/31), PICU UE rate was 0.56/100 VD (7/1,257). The current PICU UE rate (17 weeks) is 0.36/100 VD (2/527). See Figure 1 for detailed week-to-week data.

By implementing UE swarms, adding visual bundle elements, and providing multidisciplinary education in our PICU the UE rate decreased 54.21% (Q1 2019 vs. Q1 2020). Our goal is still 0/100 VD and we will continue with continuous improvement initiatives and bundle modifications to achieve this standard in our PICU. Further studies must be done to evaluate the effectiveness of these types of interventions in other patient populations. 1. Klugman D, et al. Assessment of an Unplanned Extubation Bundle to Reduce Unplanned Extubations in Critically Ill Neonates, Infants, and Children. JAMA Pediatr 2020 Apr 13:e2DD268

Graph 1 displays the rate of unplanned extubations per 100 endotracheal tube days.

Ventilator-associated pneumonia (VAP) can prolong ventilator days, increase mortality rate, and directly influence patient outcomes. VAP prevention bundles have proven effective in decreasing the VAP rate, however VAP remains one of the most common causes of nosocomial infections and death in the ICU. Current challenges in the management of VAP involve complexity of, the absence of effective preventative strategies, and the rise in antibiotic resistance.1 From 1/1/2016 to 12/21/2017, our VAP rate in the PICU ranged from 6.5-1.4 per 1,000 ventilator days. In 2018, we implemented VAP bundle elements and saw a decline in our VAP rate to 0/1,000 vent days in 2018. With an increase in our rate to 1.4 at the end of first quarter 2019, our PICU set out to address patients with a high-risk of developing a VAP to maintain our rate of zero.

An IRB approved retrospective study showed that our VAP rate of 0 in 2018 was ended by a patient who had many difficulties completing elements of our VAP bundle. The interdisciplinary VAP Prevention Team (RT, MD, IP, RN) implemented a pre-swarm process on patients determined to be high-risk for developing a VAP. VAP pre-swarm screening were respiratory-driven and performed on every mechanically ventilated patient upon arrival to the ICU and once every shift by the bedside PICU RT. Patients identified by the RT as high risk during the VAP pre-swarm initiated the VAP Prevention Team to meet, discuss the patient case, highlight their risk and identify mitigation strategies. VAP rate was analyzed again from Q2 2019 to Q2 2020 after the pre-swarm process was in place for one year.

PICU 2018 rolling VAP rate was 0/1000 ventilator days with an increase to 1.4 after Q1 2019. After implementation of the RT-driven VAP pre-swarm identification process, the VAP rate in our PICU from 4/1/2019-4/1/2020 decreased to 0 and has been maintained in 2020 as of the time of publication. See Figure 1 for quarterly data.

A respiratory-driven pre-swarm identification process increased awareness and aided in a more proactive approach to decreasing VAP in our PICU. Further research must be done to evaluate ongoing effectiveness in conjunction with already-established prevention techniques.

Figure 1 displays the VAP rate per 1,000 ventilator days in our Pediatric Intensive Care Unit

Previous research has shown that providers consistently demonstrate poor technique with manual ventilation in all populations. Manual ventilation with high peak pressures and high tidal volumes is particularly concerning among patients susceptible to lung injury, including those infected with COVID-19. This study sought to examine manual ventilation performance among RTs in a simulation model.

Respiratory therapists (n=98) participated in a simulation model, which included a standard BVM and an IMT Analytics SL 2000 2L and an IMT Analytics Citrex H5 (IMT analytics, Switzerland). Participants were instructed to normally ventilate a manikin for 18 breaths following a preset variable frequency indicated by a flashing light for 90 seconds. A short survey was administered to participants while the study was in progress. Descriptive statistics were computed to determine the mean ventilation estimates. Multiple linear regression was utilized to determine associated provider predictors with the outcomes: delivered tidal volume, pressure and flow. The university institutional approval board approved this study.

Among all respiratory therapist participants, the mean ventilation parameters include a tidal volume of 599.70 mL, peak pressure of 26.35 cm H₂O, peak flow of 77.20 L/min, inspiratory time of 0.75 seconds and an inspiratory rise time of 0.49 seconds. Those who had greater than 10 years of experience and the highest self-rated confidence (n=28), ventilated the most unsafely with the highest mean values of volume (631.43 mL), peak pressure (30.55 cm H₂O) and peak flow (86.10 L/min). Confidence level was associated with higher mean pressure and higher flow delivered via bag valve mask.

The group with the greatest experience and highest confidence level delivered higher tidal volumes, pressures and flows compared to their peers. Our results emphasize the urgent need to create an intervention that allows providers to deliver safe and optimal manual ventilation, particularly in vulnerable patients such as those with COVID-19.

Critically ill neonates are particularly susceptible to medical errors. Previous research has shown a strong link between positive attitudes towards safety climate and a lower incidence of medical errors. However, no study to our knowledge has evaluated NICU safety climate in the context of registered nurse (RN) and respiratory therapist (RT) perceptions. This study aims to identify the overall safety perceptions of NICU staff and to examine differences in safety perceptions between NICU RNs and RTs.

This study utilized a convenience sample of 79 NICU staff members (38 Nurses and 41 Respiratory Therapists). Questionnaires consisted of demographic factors (years of experience, sex, education) and the Safety Attitudes Questionnaire (SAQ). Safety attitudes domains (management, job satisfaction, work conditions, safety, and stress) were evaluated among the total sample and between subgroups of RNs and RTs. The Wilcoxon Rank-Sum test was utilized to determine differences in the SAQ domains between RNs and RTs. The institutional review board approved this study.

Among those who completed the study, approximately 84.8% were female. The median SAQ domains for the total sample were 25 (range 6-30) for management perceptions, 24 (range 5-25) for job satisfaction, 32 (range 7-35) for teamwork perceptions, 16 for working conditions (range 4-20), 27 (range 6-30) for safety perceptions, and 11 (range 3-15) for stress management. Statistically significant differences were found between RNs and RTs for job satisfaction (934.5, P=0.01) and stress management (427, P<0.01). Specifically, RNs reported more positive attitudes towards stress management compared to RTs (12 vs. 9, respectively). RNs reported slightly lower job satisfaction scores compared to RTs (23 vs. 24, respectively).

Overall, safety perceptions among NICU RTs and RNs are positive. Differences between RTs and RNs existed for stress management and job satisfaction. Future studies should explore reasons for these differences in stress and job satisfaction between RTs and RNs. Additionally, interventions focused on reducing medical errors should consider tailoring domain-specific aspects to account for differences in RT and RN safety perceptions.

The recommended infection control procedure in medicated aerosol therapy is to rinse the small volume nebulizer (SVN) reservoir with sterile distilled water after each treatment and allowing it to air dry, to prevent bacterial growth. Studies involving this topic have yielded conflicting results regarding which reagent and rinsing method is effective. If infection control guidelines are not being followed during the patient’s length of stay, (e.g. 3-5 days), there is the potential for bacterial growth inside the nebulizer, which may be inhaled by the patient, leading to nosocomial infection. The research question is: does rinsing the SVN reservoir with sterile distilled water and air drying reduce bacterial contamination in SVN reservoirs?

Following IRB approval, swab samples were collected from SVN reservoirs in clinical use, before and after the recommended sterile distilled water rinsing protocol was performed. Equipment belonging to patients in isolation was excluded. Nebulizers were chosen based on ordered frequency of bronchodilator therapy. A control group consisted of samples from reservoirs that had not been rinsed. The experimental samples came from the same reservoirs that had been rinsed with sterile distilled water and allowed to air-dry (the recommended protocol). All samples were plated on 5% sheep blood agar using serial dilution, incubated at 37°C for 18-24 hours, and evaluated for bacterial colony growth. Colony forming units (CFUs) were counted and compared between the two groups to determine if there was a difference in CFUs between the control and experimental groups. The data were analyzed using a paired T test (Excel, Microsoft Corp, Redmond, WA) to compare pre and post sample colony forming units (CFUs).

Ten nebulizers in clinical use were chosen to be evaluated for this research. Each SVN had been used to nebulize bronchodilators at a frequency of every four hours for two days or more. There was a significantly lower number of CFUs in those nebulizers that had been rinsed (P= 0.01, 95% CI -11.69 to -0.3).

This study concludes that rinsing the SVN reservoir with sterile distilled water and allowing to air dry, reduces bacterial contamination in SVN reservoirs.

Nebulizer 7 control (pre rinse) and experimental (post rinse) cultures.

Several devices in the market have been used to measure physical activity, including but not limited to Fitbit and pedometers. However, pedometers are considered to be a low-cost measure of steps when compared with Fitbit. Studies have not compared the accuracy of a pedometer (Yamax Digi-walker SW-200) with Fitbit (Fitbit Altra HR, USA). The aim of this study is to evaluate the level of agreement between these devices on counting steps when worn by healthy subjects.

Eleven healthy subjects wore the pedometer (Yamax Digi-walker SW-200) and Fitbit (Fitbit Altra HR, USA) for 5 consecutive days and recorded their physical activity measured by steps on a diary card for both devices. Descriptive measures as a Mean (M) and Standard deviation (SD) were provided, and data were tested if normally distributed. Intraclass coefficient of correlation (ICCs) was used to examine the level of agreement between both devices. Verbal consent was obtained from all subjects.

Seven males and 4 females with age (M ±SD: 31.73 ± 4.98 years) participated. The steps counted for Yamax Digi-walker SW-200 group were (M ±SD: 11620.2 ±1107.4 steps), whereas the counted steps for Fitbit Altra HR group were (M± SD: 11893.5 ±1097 steps). There was an excellent agreement between both devices (ICC: 0.98, 95% CI 0.93 to 0.99).

The Yamax Digi-walker SW-200 and Fitbit Alta HR showed almost perfect agreement in counting steps in healthy subjects.

Little research has been done on individuals with major psychiatric illness and longer mechanical ventilation and hospital stays. The purpose of this study is to examine the mechanisms of association between major psychiatric illness and mechanical ventilation days, length of hospital stay, and total ICU days.

Data for this study consisted of subjects admitted to the intensive care unit in a level-1 trauma center after a motor vehicle accident from January 2011- September 2015 (n=2,802). Wilcoxon rank sum test and chi-square tests were used to determine differences between those with major psychiatric illness and without psychiatric illness for demographics, injury severity score (ISS), substance use, and clinical outcomes. Mediation models were computed for associations between psychiatric illness and clinical outcomes through alcohol and drug use. R 3.5.3 and Mplus (version 8) were used in this analysis. The university institutional review board approved this study.

Among all participants (n=2,802), 5.5% (n=155) were classified as having a major psychiatric illness. Mechanical ventilation days were higher among those with psychiatric illness (4.90) compared to those without (4.86). A higher percentage of those with major psychiatric illness had an alcohol use disorder (14.7%) compared to those without psychiatric illness (5.1%) (P<0.001). Additionally, a higher percentage of those with major psychiatric illness had a drug use disorder (16.1%) compared to those without (4.4%) (P<0.001). Individuals with a major psychiatric illness had a higher length of hospital stay (16.41) compared to those without (13.61) (P<0.001); additionally, major psychiatric illness was associated with a higher number of ICU days compared to those without a major psychiatric illness (8.49 vs. 8.21, respectively, P=0.004). The association between psychiatric illness and length of stay was partially explained by drug use and alcohol use in the mediation models (45.4% mediated through drug use and 22.5% mediated through alcohol use). The association between psychiatric illness and ICU days was partially mediated through alcohol use (15.2% mediated); however, psychiatric illness and ICU days was not statistically significantly mediated through drug use.

Appropriate measures should be used to reduce length of stay, ICU stay, and mechanical ventilation days among those with major psychiatric illnesses.

The University of Kentucky (UK) Medical School at Northern Kentucky University (NKU) campus invited students from College of Health and Human Services (CHHS), (Respiratory Care, Radiography and Nursing) to participate in their IPE core curriculum, iCATS, (Interprofessional Collaboration and Team Skills), approved by UK Office of Research Integrity. Students were placed in interprofessional teams, participated in discussions on simulated patient scenarios and were introduced to the communication PEEER2 model (Conigliaro R, Kuperstein J, Dupuis J, et al, 2013). The purpose of this review is to evaluate CHHS students’ iCATS experiences and perceptions.

Quantitative and qualitative data was collected via pre and post surveys using a Likert Scale and student comments. The results of the surveys were evaluated by Respiratory, Radiography and Nursing faculty. Quantitative data included general experience, PEEER model, specific activities, knowledge of scope of practice, and Interprofessional Education Collaborative (IPEC) core competencies of values/ethics, roles/responsibilities, interprofessional communication and interprofessional teams/teamwork. Qualitative data was collected via students’ feedback regarding most valuable component and suggestions for improvement of iCATS.

CHHS students reported high satisfaction to the iCATS experience on a 5 point Likert scale: Respiratory Care (n=11, M=4.27), Radiography (n=19, M=4.56), Nursing (n=65, M=4.35). Students believed the PEEER model improved communication skills: Respiratory Care (n=11, M=4.18), Radiography (n=19, M=4.35), Nursing (n=65, M=4.29). Overall students indicated an increase in knowledge of scope of practice for most professions represented. For all three disciplines students reported a deeper understanding of the IPEC core competencies.

Students reported significant positive responses (P-value < 0.001) to iCATS .The students most valued the opportunity to collaborate with other professions and reported a greater appreciation for IPE. Although there was high satisfaction with the iCATS experience Respiratory Care and Radiography students identified a lack of representation of their profession in simulated patient scenarios. Changes to the patient scenario to include a more active role for Respiratory and Radiography students will increase student engagement and team interactions. Nursing students expressed concerns with time, clarity of activities, and the desire for more disciplines to participate.

The risk of developing atelectasis, lung derecruitment, and lung inflammation following postoperative cardiac surgery is heightened. These complications are not only associated with increasing financial cost but also with increase hospital length of stay, which is amplified in children with heart disease. The purpose of this study is to determine the safety of intrapulmonary percussive ventilation (IPV) in postoperative neonates with cardiovascular surgery.

After obtaining the IRB approval and informed consent from the parents, 10 patients were enrolled in this pilot study. They were postoperatively mechanically ventilated patients with both single ventricle and two-ventricle physiology and receiving pulmonary clearance via the IPV (Percussionaire) within the first 4 days of congenital heart surgery. Patients who required extracorporeal membrane oxygenation (ECMO) and patients with obstructive sleep apnea, macroglossia, difficult airway, increased intracranial pressure, increased intraocular pressure, or those weighing less than 2.0 kg were excluded. Heart rate (HR), systolic and diastolic blood pressure (SBP and DBP, respectively), mean airway pressure (MAP), oxygen saturation (SpO₂), bleeding from the endotracheal tube, and/or any other unanticipated complications were noted. Information was collected from the monitoring system 10 minutes, 5 minutes, 2 minutes, 1 minute before IPV followed by a 10 minute IPV treatment. Data was then collected 1 minute, 2 minutes, 5 minutes, and 10 minutes after IPV. Data was collected from each patient one time within a 24-hour period, following surgery. Descriptive statistics and the dependent t-test was used for data analysis (P-value<0.05).

Table below shows means (± standard deviations) measured 5 minutes pre- and post- IPV on post-operative cardiovascular pediatrics. 60% of subjects were male while the remaining 40% of the study population was female with patients ranging from 1 to 4 months with a median age of 1.5 months. Comparisons of the pre- and post-IPV variables showed no significant difference in HR (P= 0.196), SBP (P= 0.370), DBP (P= 0.894), MAP (P=0.905), and SpO₂ (P= 0.220). No bleeding from the endotracheal tube occurred in this study. There were no unanticipated complications that occurred in this study.

The use of IPV in postoperative neonates with cardiovascular surgery is a safe practice because it did not cause any unanticipated complications and impact the patient’s vital signs, MAP and SpO₂.

The cannula and mask have been used as an interface device to deliver oxygen in consideration of applying direct pressure on the face. However, due to its contact site, the interface device may cause the patient to experience stress. The purpose of this study was to compare the salivary amylase activity (SAA) with three types of interface devices in oxygen therapy.

We evaluated the Ecolite mask (Intersurgical, Wokingham, UK) and the Satelinn mask (GaleMed, Taipei, TW), and used a conventional nasal cannula (Intersurgical, Wokingham, UK) as the control. The conventional nasal cannula was used as the control due to the fact that it was assumed to have the lowest SAA. The subjects were 7 healthy faculty members of our university. The SAA was measured by a Saliva Amylase Monitor (Nipro Corporation, Osaka, Japan), and a saliva collection sheet and holder both before and after fitting the cannula and masks. A comparison between the SAAs was done using the Mann–Whitney U test with a statistical significance of P < .05. Mean ± SD are displayed in the Table below.

As thought, the control exhibited the lowest mean values (and SD). In comparison, the Satelinn mask exhibited the highest mean values (and SD), while the mean values (and SD) of the Ecolite mask were similar to those of the control.

Although the nasal cannula exhibited the lowest mean values (and SD), there are cases where a mask is required. The lower SAA of the Ecolite mask suggests that the Ecolite mask causes less stress than the Satelinn mask. The Ecolite mask is lighter, contains no PVC, has soft face seals, and has a strap that secures below the ears rather than over the ears, thereby providing improved patient comfort. For these reasons, the Ecolite mask is preferred.

Our Respiratory Quality Team identified five quality areas that offered the most opportunities for improvement in our respiratory department, based on monthly quality data, chart audits, staff survey, and incident reports (ONS). Our "fab five" areas needing improvement were the following: VAP/VAE (Ventilator Associated Pneumonia/Ventilator Associated Events), UE (Unplanned Extubations), TOC (Transfer of Care), PUP (Pressure Ulcer Prevention), and Trach cleaning/processing.

The Carnival station learning opportunities were completed, followed by an interactive game for the staff member to participate in for a small prize: 1. Trach journey: steps for trach cleaning and returning trachs to patient bedside were reviewed due to several gaps in processing steps by respiratory therapist. 2. UE: focused on evidence-based practice to collaborate with nursing to focus on ETT placement. 3. PUP: an increase in pressure ulcers was identified this station focused on how to identify the different stages of pressure ulcers, documentation of pressure ulcers, and how to support the patient post ulcer acknowledgement. We also displayed the different devices and options for patients with pressure ulcers. 4. VAP/VAE: several gaps in RT EPIC documentation were identified and these learning opportunities were reviewed as well as a review of the definition of VAP/VAE. 5. TOC: Gaps in transfer of care were identified and were focus points at this carnival station, as well as a comprehensive review of TOC expectations for all RTs.

Per our quality data, chart audits, and ONS reports, our department improved in all five quality areas by the end of 2019. More importantly, we saw a decrease in our UE rates. Our UE rate per 100 vent days for 2019 was the best in Children's Healthcare of Atlanta history. In 2018, our UE rates in the NICU was 1.10, in 2019 it decreased to 0.77.

This event was a huge success, with over 100 RTs (from all CHOA campuses), more than 20 SR RNs and 10 SR RN leaders in attendance. The decrease in UE was the best in CHOA history. There were vast improvements in PUP EPIC documentation. Additionally, the station that won "voted best station" was PUP. Our RT Quality committee plans to host this event again this summer, during our "down season", in an effort to gear up for "busy respiratory season" that typically starts at the end of August until the following spring.

Patients receiving opioids are at risk of morbidity and death due to opioid-induced respiratory depression (OIRD). Time to discharge is decreasing, pushing these risks into the home setting. Monitoring systems with alarms may avert post-discharge OIRD. The feasibility of such systems for home monitoring has had limited study. It is our impression that, rather than just OSA, an inadequate minute ventilation induced by opioids and/or polypharmacy of central nervous system depressing drugs may be contributing factors to OIRD.

The Orthopedic Specialty Hospital is the only stand-alone hospital for orthopedic care within Intermountain Healthcare. Opioids can: 1) directly inhibit respiratory musculature function from the upper airway to the diaphragm, 2) impair hypoxic/hypercapnic ventilatory response, 3) alter control of breathing at the medulla and pons, and 4) impair arousal response. With an Intermountain Research & Medical Foundation grant, we began a quantitative, prospective, non-randomized, single cohort study using Masimo RAD 97 monitoring devices to test the feasibility of 4-day, home monitoring. Pulse oximetry (SpO₂), HR, RR and capnography (ETCO₂) were recorded. Patients meeting high-risk opioid inclusion criteria and prescribed opioids were included. Patients were educated about opioid risks of OIRD and other CNS depressing medications, alarm response, Narcan administration and when to call emergency response. They were given a 24/7 number to call with questions/concerns. Upon device return, all recorded data were analyzed. Pre-study and post-study surveys were given to patients.

The study target was 500 enrolled patients or 6 months, whichever came first. As of May 13, 2020, 235 patients were enrolled in the study. Detailed pre-study patient survey results are reported in Table One.

We found 4 patients never received the Naloxone or education from pharmacy; however, none had any adverse outcomes. This was a significant finding, as receiving education and Narcan is an essential component of patient safety and imperative part of the study. When Utah’s 2018 SCR004 resolution (Parker’s Bill) was signed into law, legislators requested more studies to increase awareness of opioids and to identify and monitor high risk opioid patients at home post-surgery. Preliminary study data will be reported to internal stakeholders and legislators. A manuscript will be created upon study completion. It is our impression this study will address legislative requests.

Bronchiolitis is the leading cause of hospital admission for infants in the US and is commonly treated with HFNC. HFNC was not previously utilized in non-ICU wards at UC Davis Children’s Hospital. As part of an ongoing quality improvement (QI) effort, we identified the need to transition infants requiring HFNC for bronchiolitis out of the PICU.

In our single center QI project, we extended protocolized HFNC use to the acute care wards. A multidisciplinary team of physicians, nurses, respiratory therapists, and QI experts developed a HFNC protocol with an assessment tool; the Respiratory Assessment Classification (RAC). Preparing for safe deployment of protocolized HFNC in the non-ICU setting, we provided education for nurses, respiratory therapists, and physicians. QI meetings were held monthly and QI rounds daily to monitor adherence, implementation, outcomes, and adverse events. The pre-implementation period was December 2017 to March 2019, excluding December 2018 due to a short pilot program. The post-implementation period was March 2019 to February 2020. Analysis: Comparing pre and post groups, continuous variables (means or medians) were compared with t-test or STATA median test and categorical data (frequencies) were compared with X2 or Fisher’s exact test. IRB exemption was obtained through UC Davis.

Patients were similar in both groups, however post implementation patients were older (10 vs 12 months mean, P=0.01). Following implementation, 73% of patients meeting out of ICU criteria were discharged home or transferred to the ward within 2 hours of meeting the criteria. Transferring to the ward while still receiving HFNC increased from 12% to 33% (P<0.001) in the post period. Patients in the post period had shorter ICU and hospital length of stay (LOS) than those in the pre period, by 12 hours and 1 day respectively (P < 0.001). Patients in the post period received oral feeds at higher HFNC flows than in the pre-period. Direct discharge from the PICU increased by 13% in our post-implementation group (P=0.05).

HFNC can be safely utilized outside of the ICU setting for the management of bronchiolitis. Standardization in care, education, and daily rounding leads to an increased focus in HFNC management in moderate to severe bronchiolitis. This may explain the increase in direct discharge from the ICU, as well as decreased hospital and ICU LOS. Our findings are encouraging and warrant future exploration in use of HFNC outside of the ICU setting.

ARDS affects nearly 10% of mechanically ventilated postoperative cardiac surgery patients. Driving pressure (∆P) is defined as the difference in static airway pressure at end inspiration (Pplat) and end expiration (intrinsic PEEP) during controlled mechanical ventilation with a passive patient expressed in cm H₂O. Is driving pressure significantly associated with mortality after cardiac surgery? We hypothesized that driving pressure is not significantly associated with mortality after cardiac surgery.

This was an IRB-approved, single center, retrospective analysis. Data from 960 subjects was extracted from electronic medical records and analyzed from January 1, 2017-October 1, 2019. Data collected included initial driving pressure upon admission to the ICU from the OR and all-cause mortality to hospital discharge. Inclusion criteria for our study included patients over 18 years of age who had cardiac surgery during the data collection period and were not actively breathing upon admission to the ICU. Chi square of independence was applied to compare group mortality association. Data are reported as mean (SD). Alpha was set at 0.05. Data was analyzed with SPSS v25 (IBM, Armonk, NY).

Our sample included 960 subjects, of which 9% (n=94) died. Mortality was 29% (n=27) for subjects who had a ∆P > 13 cm H₂O whereas only 13% (n=116) of the surviving 900 subjects had a ∆P of > 13 cm H₂O (P < .001). The mean (SD) ∆P for subjects who died was 11 (3.8) cm H₂O whereas ∆P for those who survived was 9 (2.9) cm H₂O.

∆P > 13 cm H₂O is significantly associated with increased all-cause mortality among adult mechanically ventilated postoperative cardiac surgery patients. All-cause mortality may overestimate the number of deaths related to increased driving pressure. Future studies should include respiratory-related mortalities.

The COVID-19 pandemic led to extensive numbers of patients requiring mechanical ventilation. Partners Healthcare System, Boston, MA, includes two academic medical centers, 7 community hospitals, and two rehabilitation centers. To ensure appropriate ventilator distribution across this system, the system’s Incident Command assembled a Ventilator Crisis Team (VCT).

The VCT includes a critical care physician, the assistant director of respiratory care, medical director of biomedical engineering, director of anesthesia biomedical engineering, manager of the supply chain, and a project specialist. Data was collected from each institution within the system, detailing number and type of mechanical ventilators as well as current and potential ICU bed space. The VCT met twice daily to address long-term strategies for acquisition of additional mechanical ventilators. A database was created matching unique disposables to ventilators, for easy allocation. Daily census information from each site was analyzed by the MD and RRT team members and included current and available usage of ventilators and beds. If a hospital was identified as needing more devices, the MD and RRT team members devised an allocation plan with focus on maintaining the greatest number of patients on ICU ventilators, allocating the same brand of devices already employed at that site, and distributing ventilators ahead of a surge.

From March 23rd to May 11th, 2020 at peak, 375 patients requiring mechanical ventilation were cared for across the system. To accomplish this, 345 ventilators were allocated. This includes 108 newly acquired ventilators, 132 ventilators relocated from an area of low use to an area of high need, 95 ventilators loaned from the Strategic National Stockpile and other regional hospitals, and 10 ventilators received through donation. No patient transfers occurred due to lack of durable equipment or consumable materials.

The projected number of patients requiring mechanical ventilation during the COVID-19 pandemic exceeded the number of available ventilators at each hospital within our system. Understanding the types of mechanical ventilators used at each institution allowed for allocation of like devices, reducing the need for significant education during times of high workload and stress. Equipment transfers to institution of patient admission reduced the need for transport of patients, as well as avoided strain on any one part of the hospital system.

Measurement of arm span has been used as a predictor of height in pulmonary function testing and ulnar length measurement is used by nutritional experts. Can these measurements be used to predict height in patients that are admitted inpatient that do not have a documented standing height? We sought to find correlation between measured height standing and the measurement of arm span and measured ulnar lengths.

IRB approval was obtained for this prospective study of patients receiving outpatient pulmonary function testing (PFT). Patients presenting to the pulmonary physiology lab for PFT’s that could stand to have accurate height measured were included. Exclusion selection criteria included those that were unable to stand for measurements, or those that did not consent. The respiratory therapist would measure the patient’s height standing, followed by arm span, and the left and right ulnar lengths. Age, sex, race, and perceived conditions that could affect measurements were also recorded.

601 patients were recruited with 50 being excluded during data analysis. Data was analyzed using IBM SPSS software v25 (IBM, Armonk, New York). The measurements were as follows: mean height standing was 166.53 ± 9.97 cm, mean arm span was 171.08 ± 12.57 cm, predicted height based on ulnar length was 170.79 ± 9.15 cm for the right arm and 171.02 ± 9.36 cm for the left arm. Bivariate correlation was used to compare height standing to arm span and predicted height from ulnar length for the right and left arms which produced Pearson coefficients of 0.851, 0.759 and 0.752 respectively and all significant (P <.001).

Arm span measurements strongly correlated to measured height while ulnar length produced a moderate correlation. In the absence of measured height standing; arm span and ulnar length may be viable to predict a patient’s height.

Demographics Table

Correlations Table

The COVID-19 pandemic of 2020 placed enormous stress on the national and individual state health care systems but especially on individual healthcare institutions, with relation to a number of areas; insufficient staffing, ICU beds, and mechanical ventilators. In this abstract we describe the initial experiences at the Massachusetts General Hospital from March 23, to May 25, 2020.

This retrospective study was done with local IRB approval. Staffing was addressed by voluntarily suspending vacation time and working overtime, hiring traveling therapists, and the temporary movement of staff from other institutions not experiencing a surge to the MGH. Workflow was also adjusted. ICU beds were increased by conversion of many general care floors. Number of mechanical ventilators was increased by purchasing new ICU ventilators, borrowing from other hospitals not experiencing a surge and the rental of ventilators.

Minimal staff took vacation and most worked at least one overtime shift a week. A total of 24 travelers were hired, 8 staff temporarily reassigned from other institutions and 8 staff employed on a provisional basis. As the surge increased the number of routine patient/ventilator assessments decreased from every 4 hours to every 6 hours then to every 12 hours. The conversion of general care floors increased adult ICU beds from 119 to 256. The number of available ventilators increased from 167 (121 ICU, 30 transport, 16 NIV) to 321 (186 ICU, 63 transport, 72 NIV). At the peak, 156 COVID-19 patients were ventilated. During this period a total of 394 COVID-19 patients were ventilated with a median length of 16.3 days. Of these patients 263 (66.8%) were successfully liberated from the ventilator, 42 (10.7%) remained intubated and 89 (22.6%) died. In addition, 19 patients were maintained on ECMO at a median length of 12.5 days. A total of 8 patients were successfully decannulated (4 survived to hospital discharge to date), 4 died, and 7 remain on ECMO.

We were able to successfully negotiate the COVID-19 surge first as a result of the unselfish dedication and professionalism of the Massachusetts General Hospital Respiratory Care staff. Second, the ability to cooperate with other institutions regarding temporary transfer of ventilators and staff. Third, willingness to innovate by all involved. Fourth, the Massachusetts General Hospital and the Partners Healthcare System’s willingness to ensure that resources were available to meet the needs of all of our patients.

Patients receiving opioids are at risk of morbidity and death due to opioid-induced respiratory depression (OIRD). Time to discharge is decreasing, pushing these risks into the home setting. Monitoring systems with alarms may avert post-discharge OIRD. The feasibility of such systems for home monitoring has limited study. It is our impression rather than just OSA, an inadequate minute ventilation induced by opioids and /or polypharmacy of central nervous system depressing drugs, may be contributing factors to OIRD.

TOSH is the stand-alone hospital for orthopedic care within Intermountain Healthcare. Opioids can: 1) directly inhibit respiratory musculature function from the upper airway to the diaphragm, 2) impair hypoxic/hypercapnic ventilatory response, 3) alter control of breathing at the medulla and pons, and 4) impair arousal response. With an Intermountain Research and Medical Foundation grant, we began a quantitative, prospective, non-randomized, single cohort study using Masimo RAD 97 monitoring devices to test the feasibility of 4-day, home monitoring. Oxygen saturation (SpO₂), HR, RR and capnography (ETCO₂) were recorded. Patients meeting high-risk opioid inclusion criteria and prescribed opioids were included. Patients were educated about risks of OIRD and other CNS depressing medications, alarm response, Narcan administration and when to call 911. They were given a 24/7 number to call with questions/concerns. Upon device return, all recorded data were analyzed including pre-/post-study surveys given to patients.

The study target was 500 enrolled patients or 6-months, whichever comes first. As of May 13, 2020, 235 patients have been enrolled in the study. Detailed post-study patient survey results are reported in Table One.

The majority of patients were willing to participate in additional studies but were split on allowing camera/video for communication in homes. Patients reported ETCO₂ over-alarming. Masimo coordinated with researchers to identify a software issue and adjusted to allow for actionable alarming. One patient used Narcan after discharge, was aroused and caregivers called 911. Two patients with frequent alarms sounding during the night were admitted to the hospital and diagnosed with “opioid induced non-ST elevated myocardial infarction” and “opioid induced renal hypoxia/failure” respectively. It is our impression without this study raising the awareness of opioid risks and alarms alerting, these patient conditions may have gone unalerted, unrecognized, and delayed treatment.

At last year's Open Forum, we reported on different lung mechanics, driving pressure, ventilation mode, presence / absence of PEEP, and migration distance of mucus stimulants (MS) with different viscoelasticity, using the cough assist function of VOCSN ventilator. In this study, we also compared and examined the migration distance of MS with different viscoelasticity due to changes in different lung mechanics, driving pressure, and rise time.

We measured the movement distance of the MS in PCV A/C mode under the following conditions. 1) Four types of lung mechanics: compliance (Cst) 50mL/cm H₂O and airway resistance (Raw) 5cm H₂O/L/s in normal lung, restrictive lung (Cst 30 and Raw 5), obstructive lung (Cst 50 and Raw 20) and mixed lung (Cst 30 and Raw 20). 2) 4 types of driving pressure were insufflation/exsufflation 30/-30, 30/-40, 30/-50 and 30/-60cm H₂O. 3) The two types of inspiratory rise times were 1 (fast) and 6 (slow). Under the above conditions, the movement distance was measured using two types of MS. A 1% lysis of MS is potage-like, corresponding to the secretion of chronic bronchitis, and a 4% lysis MS is jelly-like, close to the viscoelasticity of a mucus plug during an asthmatic attack. The analysis of the ventilatory dynamics was measured 5 times under each condition using flow analyzer PF300, and the average value was compared. This research is conducted after obtaining approval from Showa University Ethics Review Board.

1) Regarding sputum viscoelasticity, as we have previously reported, the greater the negative pressure of cuff assist, the greater the movement distance of MS (P <0.05). 2) In 1% MS, the movement distance increased with rise time 6 in obstructive and mixed lungs, but the rise time difference did not affect as negative pressure increased. 3) With 4% MS, the shorter the rise time, the longer the movement distance, but if negative pressure became stronger, the rise time will not affect. 4) Rise time did not affect the peak inspiratory flow. 5) The peak expiratory flow increased with increasing negative pressure (P <0.05).

From these results, it seemed that the effective setting method was to set the rise time slow and increase the negative pressure in the case of obstructive lung and low viscoelasticity sputum. For sputum with high viscoelasticity, it was more effective to set the rise time faster and the negative pressure stronger.

High-frequency jet ventilation (HFJV) is commonly used for premature infants with respiratory failure. However, pressure attenuation across different HFJV settings and endotracheal tubes (ETT) has not been adequately described. Therefore, we sought to investigate and quantify pressure attenuation utilizing an in vitro model.

The HFJV ventilator was configured in tandem with the conventional ventilator and connected to an ASL 5000 lung model. The lung model was used to simulate four infant scenarios (weight 0.5, 1, 2, and 4kg) with corresponding ETT ID (2.5, 3.0, 3.5 and 4.0 mm), respiratory compliance (0.5, 1, 2 and 5 mL/cm H₂O/kg) and resistance (50 to 200 cm H₂O/L/s). The conventional ventilator was controlled throughout experiment on PC-IMV, PIP 20 cm H₂O, PEEP 10 cm H₂O, frequency 2 (breaths/min), T_I 0.5 seconds and FIO₂ 0.21. Measurements were taken at combinations of HFJV PIP (20, 30 and 40 cm H₂O) inspiratory time (0.02, 0.026 and 0.034 ms), frequency (360 and 420 breaths/min) which were applied to all lung model and corresponding ETTs. Pproximal was measured at the LifePort ETT adapter and Pdistal via the pressure sensor embedded within 3-D printed neonatal trachea model, precisely at the ETT outlet. For each combination of settings 1-minute of pressure samples were recorded at 100 Hz. Pressure attenuation (Patt%) was calculated as: Patt% = [(Pproximal - Pdistal)/ Pproximal] x100. Patt% was quantified for each simulated infant scenario. Linear regression analysis was utilized to quantify the relationship between Patt% and Pproximal.

Patt% was linearly related to Pproximal (y = 1.285 + 27.249; R2 = 0.950, P <0.001) for all combinations of HFJV PIP. Mean Patt % at HFJV PIP of 20, 30 and 40 cm H₂O was 45.66 ± 15.24%, 62.73 ± 11.97% and 71.36 ± 14.56%, respectively.

In an in vitro model, pressure attenuation was linearly related to Pproximal, with attenuation increasing as the HFJV PIP was increased.

Figure 1. Linear regression analysis of P_att % versus P_proximal, stratified by ETT ID.

Unplanned extubations are serious harm. Serious harm is directly related to increased length of stay, increased time on the ventilator, increased ICU time and increased risk of cardiovascular collapse and death. Over the past few years we worked to change the culture, create buy in, and engage all disciplines to decrease the amount of serious harm. This past year we have focused on specific pieces of an UE bundle, the key drivers, and interventions. Each ICU determined and development a protocol for a standardized approach for securement and placement of the ETT. The bedside providing team works collaboratively to hold each other accountable. We use a high-risk protocol, ensuring that we have a plan in place for any movement of the patient or manipulation of the ETT. The development of a "knowing note" to share with the caregivers explaining safe kangaroo care, providers at bedside during this time, and kangaroo hold simulations. The care provided is a team driven approach with real time bedside huddles, plans of care and consistent messaging. Everyone has a chance and is supported to speak up around safety. The Leadership team and the members are multi-disciplinary, and they meet monthly to review the cases and data. This has created engagement of everyone and aids in proving the safest care for our patients. Each unit has developed an extubation readiness tool that is utilized for planning and rounding on the patient. Many of the approaches we implemented are evaluated with our K-Card rounding tool.

We used the Solutions for Patient Safety Unplanned Extubation Bundle. The inclusion of a multidisciplinary team and culture change was needed to create buy in for participation, and to decrease serious harm. We evaluated some key metrics to strategize how to overcome barriers, and measure accomplishments. These were used to determine outcomes. Our goal was to decrease the UE rate from 0.66 to 0.63 per 100 vent days (w/o trach) by June 30th, 2020. Every event had a real time huddle, information was gathered and entered into a Red Cap data base. The data was evaluated on a month to month bases and entered into run charts.

All the initiative have shown a 60% decrease in our overall numbers of UE and have saved over 1.2 million potential dollars that would have been used to care for patients.

Our measured success related to decreasing unplanned extubations and working towards elimination of serious harm was attributed to the engagement of a multi-disciplinary team.

Efforts to address the shortage of mechanical ventilators during the 2020 COVID-19 pandemic are well known. However, little is known of the behind the scenes efforts to provide the supplies, without which these devices would have been inoperable. In the final analysis, availability of these supplies was subject to the fundamental, economic forces of supply and demand. A sluggish production system coupled with an exponential increase in the number of severely ill patients resulted in an imbalance between ventilator related supplies and the unprecedented demand for them. As manufacturers struggled to fill orders many went partially or even completely unfilled. Simultaneously, the federal government replenished its ventilator reserve including circuits further increasing the demand. In addition to the increased volume of patients, demand was influenced by the rapid influx of additional ventilators, the need to filter inspired and expired gasses, and the use of transport ventilators in the ICU. Furthermore, use of transport ventilators in the ICUs necessitated manual ventilation of patients during transport increasing the demand for bag-valve resuscitators and PEEP valves. MGH utilizes 1 primary vendor to order supplies from a variety of manufacturers. We describe a pro-active, multifaceted plan to maintain a constant supply of ventilator-associated consumables for the Respiratory Care Department at the Massachusetts General Hospital for the period March 23 – May 11, 2020.

Access strategic reserve to provide an early buffer for diminished receipt of supplies. Alternate use of heated humidifiers, HEPA filters, standard HMEs, and combination HEPA filter/HME without ventilator filters. Identify additional supply chains including acceptable alternative devices, normal third-party supplier and order directly from some manufacturers to promote a steady inflow of supplies.

We placed 93 orders with 10 vendors for 600 PEEP valves, 1,850 ICU ventilator circuits, 855 transport ventilator circuits, 4,450 HEPA filters, 1,120 HMEs, and 2,800 HEPA/HMEs, to equip 248 ventilators. Frequently we placed 2 orders to the same manufacturer simultaneously utilizing our primary distributer and ordering directly from the manufacturer.

By employing several humidification and filtering techniques and creative purchasing procedures we maintained enough supplies to ventilate 394 patients utilizing 248 ventilators.

High-flow nasal cannula (HFNC) has been increasingly utilized in PICUs for asthma, yet studies comparing it to mask nebulizer are lacking. We hypothesized that HFNC would perform similarly to the aerosol mask for meaningful clinical outcomes in children with critical asthma.

We retrospectively reviewed the medical records of children with critical asthma (age 2 to 17 years) with a modified pulmonary index score (MPIS) ≥ 8 admitted to our PICU between June 2014 and March 2020 as part of an IRB-approved quality improvement project. Patients were managed with our MPIS-based respiratory therapist-driven protocol. We divided subjects into 2 cohorts by initial respiratory support (HFNC or aerosol mask). Data included demographics, baseline asthma severity, initial respiratory support, and MPIS over time. Primary outcome was hospital length of stay (LOS). Secondary outcomes were: MPIS at 6 hours, PICU LOS, time on continuous albuterol, change in MPIS over time, and need for non-invasive ventilation (NIV) or helium-oxygen mixture. We used nonparametric and chi-squared testing to compare continuous, presented as median (IQR), and categorical data, respectively. P <0.05 was considered statistically significant.

We included 171 subjects; 104 in the HFNC group and 67 in the aerosol mask group. HFNC subjects were younger [5 (4-9) vs. 7 (5-10) years; respectively. P = 0.006)] while other demographic data were similar. Initial MPIS was similar between HFNC and aerosol mask groups [11 (9-12) vs 10 (9-12); P = 0.15]. There were no significant differences between groups for hospital LOS [2.9 (2.1-3.9) vs 3.0 (2.3-4.4) days; P = 0.47], PICU LOS [1.9 (1.4-2.8) vs 1.8 (1.5-3.0) days; P = 0.92], or time to MPIS < 6 [1.0 (0.6-1.6) vs 1.3 (0.8-1.9) days; P = 0.093]. Median time on continuous albuterol was shorter in the HFNC group compared to the aerosol mask group [1.0 (0.7-1.8) vs 1.5 (0.9-2.3) days; P = 0.048]. Of note, 16 (24%) patients in the aerosol mask group were eventually treated with HFNC. Heliox and NIV use was similar between groups. The progression of MPIS over time for both groups is shown in Figure 1.

Hospital LOS and change in MPIS were similar between HFNC and aerosol mask. HFNC use was associated with a shorter time on continuous albuterol.

Patients that wear non-invasive ventilation devices at home for chronic respiratory failure are admitted the hospital and continue non-invasive therapy as an inpatient in the acute care setting. These patients sometimes require oxygen. Per the user manual, oxygen may be added at either the mask or device. This study aimed to find optimal placement of the oxygen "bleed-in" adaptor. We wanted to find out which place gave the highest delivered amount of oxygen in the most consistent manner.

We used a DreamStation BiPAP machine (Respironics Inc., Murrysville, PA) with the standard 15mm circuit connected to a Michigan Instruments (Kentwood, MI) test lung via mannequin head with a small full face mask. A V500 ventilator (Dräger Medical, Lübeck, Germany) was used to simulate breathing. FIO₂ was measured via an oxygen analyzer placed into the top port of the test lung. Continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP) modes were tested. CPAP pressures were set at common end positive airway pressures (EPAP) of 5, 8, 10, 12, 15, and 20 cm H₂O. The same EPAP levels were used with BiPAP with the inspiratory positive airway pressure (IPAP) was set at 5 cm H₂O above EPAP. The oxygen adaptor was placed in-line at the mask and the device for all pressure settings. Oxygen flow was set in 2 L/min increments from 2 – 12 L/min for two minutes or until equilibration occurred. Flow was turned off and the next test was not started until the oxygen analyzer returned to room air.

All data was analyzed through IBM SPSS software v25 (IBM, Armonk, New York). The mean change of FIO₂ (%) for every 2 L/min increase while on CPAP averaged 2.84 ± 0.55 at the mask and 3.73 ± 0.41 at the device. The mean change of FIO₂ (%) for every 2 L/min increase while on BiPAP averaged 5.78 ± 2.95 at the mask and 5.73 ± 0.96 at the device. Changes in FIO₂ were significant when on CPAP and when the oxygen adaptor was at the device, P = .01. There were no significant changes (P = .97) in FIO₂ between oxygen adaptor placement when the mode was BiPAP.

Placement of the oxygen adaptor at the device appears to give a higher FIO₂ with CPAP. FIO₂ on BiPAP is higher when the oxygen adaptor is at the mask, however it is not significant. Oxygen placement at the device does offer less variation on both modes. The results of this study were based on one device; further studies could be done to confirm findings.

Data Table

Data Analysis Table

The use of planned peer tutoring (PPT) in education has been shown to enhance and expand the knowledge of both the learner and the tutor. These benefits have been shown in other higher education programs, but very little has been documented on the use of PPT in RT education. The purpose of this study was to evaluate the effectiveness of PPT in undergraduate RT students.

Previously established PPT sessions were provided by 2nd year RT students for 1st year RT students at various points during one semester within the curriculum. All students completed an evaluation at the end of the semester, assessing their opinions on the effectiveness of the PPT sessions from their perspective as tutor or learner. Grades on 4 different assessments were compared between treatment and control groups to determine the efficacy of the tutoring sessions. This study was IRB approved.

Of 22 1st year participants, 13 attended at least half of the PPT sessions and became the treatment group. The remaining 1st year students and all 2nd year students became the control group. There were no significant differences between treatment and control groups for mean age (P =0.178), admission cumulative GPA (P =0.103), or admission science/math GPA (P =0.728). According to the evaluations, 1st and 2nd year students reported that PPT improved their confidence, content mastery and communication skills (range 70% - 100% agree or strongly agree). Two of the 4 assessment grades were not statistically significantly different between treatment and control groups. The laboratory practical assessment (P =0.041) and the clinical simulation assessment (P =0.022) showed a significantly higher mean score on the assessment for the treatment group.

This study suggests that tutors and learners alike are supportive of a PPT experience in a RT program curriculum. PPT appears to be effective in enhancing student performance and is perceived as beneficial by the students. Disclosures: None.

Burnout, defined as emotional exhaustion, depersonalization, and lack of efficacy, is major problem in healthcare, with pre-COVID-19 rates approximately 50% in nurses and physicians. Available data on RTs demonstrate similar levels of for the individual components of burnout (emotional exhaustion, depersonalization, and moral distress) but RT burnout rates and drivers have not been specifically examined. The purpose of this project is to determine resilience and burnout resources available within RT departments and provide an estimate of pre- and post- COVID-19 burnout rates.

A survey was developed to evaluate resilience and burnout resources in respiratory care departments. The survey was posted online to the AARConnect management, education, adult acute care, neonatal/pediatrics, COVID-19, and help line communities. Data analysis was descriptive. Key drivers of burnout among RTs were identified from qualitative answers and a priori classified by the authors.

There were 164 respondents representing 42 states and 164 unique centers. Respondents were primarily from hospitals. 73% had personally experienced burnout, 67% within the last year. 9% of departments measured burnout, 34% used resilience tools, 84% free employee assistance, and 74% wellness programs. There was a significant difference in departments with an estimated burnout rate > 40% before and after the COVID-19 crisis (22% vs. 33%, P=0.04). The five most commonly mentioned drivers of burnout were: staffing 34%, poor leadership 23%, lack of recognition 17%, COVID-19 13%, and lack of respect 12%. 93% agreed that burnout is a major problem in health care, 32% that burnout is primarily driven by external factors, 92% that RTs have similar risk of burnout as other health care providers, 70% felt comfortable discussing emotionally challenging situations at work, 31% agreed leadership provides adequate support for those suffering from burnout, and 76% were open to using tools from the AARC or other professional organization.

Most respondents reported experiencing burnout. Thirty-four percent of departments used burnout resources and 76% were open to utilizing resilience tools. Key drivers were staffing, leadership, lack of recognition, COVID-19, and lack of respect. Most departments estimated their burnout rates to be greater than 40% but burnout appears to have increased modestly post COVID-19.

In clinical acute settings, healthcare providers work in stressful environments interfering with morale and quality of work including patient care. According to Porath et al. (2015), over half of people demonstrate incivility when they are work overloaded and do not have time to be nice. Porath et al. (2015) goes on to state that 71% of healthcare personnel connected disruptive behaviors (abusive, condescending or insulting conduct) to medical errors and 27% related to patient deaths. Current literature regarding respiratory care practitioners and incivility is minimal to non-existent which warranted the need to conduct an initial assessment in one particular pediatric respiratory care department. The PICO question for this project is among respiratory care practitioners, does workplace incivility decrease employee morale, retention, and productivity?: Description of the research design in sufficient detail to permit judgment of its validity. Must indicate statistical tests used. For studies involving human subjects, must indicate that Institutional Review Board (IRB) approval was obtained.

A 15-item questionnaire (Healthy Workforce Institute’s (2018) Disruptive Behavior Assessment) was sent to 172 RCPs through the use of a paper survey.

There was a 41% (n=73) return rate of surveys which showed mild incivility with 38% rarely experienced; 34% rarely witnessed. Top behaviors of incivility co-worker eye rolling, uneven work assignments based on favoritism, and co-workers being mocked or insulted indirectly. Data was analyzed using a Pearson Chi-Square method which yielded t-tests and P-values for significance.

Despite these mild levels, this contributes low department morale, lack of trust, and incivility among individuals warranting the need for further investigations. This needs assessment project has served to be pioneering work in the area of RCP incivility.

A regional understanding of mechanical ventilator utilization to support COVID-19 induced respiratory failure was developed to inform healthcare system decision makers about resource distribution, and potentially redistribution during the coronavirus pandemic. This resource could support the planning, procurement, and staffing needs of respiratory therapists, nurses, and physicians.

With permission, an E-mail solicitation was sent through the Maryland/District of Columbia (MD/DC) Society for Respiratory Care’s managers listserv with a request to participate in mechanical ventilator utilization data collection. Following coordinating center Institutional Research Board approval, participating sites signed a Letter of Commitment. Three questions were answered by participating sites on a daily basis: 1) How many spontaneously breathing (i.e., non-intubated) COVID(+) patients are in your hospital?; 2) How many intubated COVID(+) patients are in your ICUs?; and 3) What is the total number of ventilators your institution has on hand? Following completion of all daily surveys, data was regionally aggregated automatically to include 3 or more hospitals in any one region. If there was an instance when a region had less than 3 hospitals participating, the data was aggregated with the next closest region. Once data aggregation was complete it was made available through the web-based dashboard. The process eliminated any potential for personally identifiable information.

The Eastern Shore Regional Graphical Information Systems Collaborative (ESRGC) provided a dashboard displaying anonymized data in aggregate as well as calculated variables (e.g., utilization and estimates of reserve per region and as a state). Approximately 20% of hospitals in the state of Maryland and 17% of hospitals in the District of Columbia provided data on a daily basis for this study. The need for mechanical ventilation in Maryland and D.C. did not rise to the same levels as seen in New York City or some countries in Europe.

Hospital and managers were commonly reluctant to participate because of workload and concern for liability for the data. Natural and man-made disasters happen periodically. Countries with the most technological advancements and widely available resources can be severely impacted. Developing data sharing processes during disasters is difficult and should be prioritized in times of relative calm.

Screen shot of the pubically available COVID-19 Ventilator Dashboard

The COVID-19 pandemic of 2020 created concern regarding the preparedness of the US Health Care System. One major concern was the availability of mechanical ventilators. Consequently, the US government and many state and local health care systems called upon manufacturers of existing mechanical ventilators as well as entrepreneurs, innovators, and scientists to rapidly manufacture or develop devices to provide assisted ventilation. The Partners HealthCare System developed an Innovation center with one group devoted to ventilator innovation that met regularly. We present here the results of our evaluation of 2 of two “bag squeezer” types ventilators.

We evaluated the performance of near final prototypes of the RISE and a version of the MIT “bag Squeezer” type ventilators using the Michigan Instruments TTL adult patient lung simulator. A NICO respiratory monitor (Philips) was used to assess the difference between ventilator settings and actual delivered gas volume. The primary outcome was the ability of each ventilator to perform to its specification, and secondary outcomes included alarm system response. Each device was tested through the same range of specified ventilation and lung simulator conditions. A greater than 10% deviation of actual delivered from device set parameter in a given setting was considered unacceptable.

Neither the MIT nor RISE ventilator were able to perform to their specification. Both were unable to maintain delivery of set tidal volume as respiratory rate and inspiratory time were varied (Figure 1a and 1b). However, both performed best when the compliance was 50 mL/cm H₂O and the resistance 5 cm H₂O/ L/s. Specifically, the MIT ventilator was unable to provide the set tidal volume in 86% of the respiratory rate trials (1a) while the RISE ventilator was unable to provide the set tidal volume 75% of the time (1b). Similar finding occurred with inspiratory time variation vs. set tidal (79% vs, 82% respectively MIT then RISE). Alarms inappropriately sounded in 100% of trials with MIT ventilators and 66% of trials with the RISE ventilator, with numerous alarms sounding unrelated to the clinical condition tested. However, it should be remembered that these ventilators were developed over 4 to 6 weeks.

These ventilators were unable to meet specification. This data was provided to the manufacturers. Before these type ventilators are put into use their performance should be carefully evaluated.

The red dotted line represents a 1.0 ratio between set and measured tidal volume

The red dotted line represents a 1.0 ratio between set and measured tidal volume

In Taiwan, the prevalence of prolonged mechanical ventilation (PMV) patients was 35,143 to 37,043 per year from 2005 to 2010. Since 2000, non-cancer patients also can receive the hospice palliative care in Taiwan. The acceptance rate of the hospice palliative care with the PMV patients, the family member of patients were 66.2%-79.3% and patients themselves were 67.55%. We assume that with the hospice palliative care intervention on the PMV patients, the unnecessary examination and treatment can be prevented and final cost down the medical cost. We use secondary database to investigate the medical cost within 30 days before death, the difference between PMV patients who received hospice palliative care or not.

We use Taiwan National Health Insurance Research Database from year 2005 to 2010. The study population was patients on PMV that ventilator had using at least 21 days, and didn’t discontinue ventilator use over five days. Patients under 18 years old were excluded. The Chi-Squared test and T-test were used to estimate the difference between two groups. The SAS 9.4 version was used to investigate the relation.

There were 45,140 PMV patients included in the study. There were 276 patients received hospice palliative care within 30 days before death and 44,864 patients were in the control group. The medical cost between case group (USD $16,452 ± $12,045) and control group (USD $18,719 ± $11,693) were significant difference, the P value was .0013.

The hospice palliative care not only provide mental support but also decrease the medical cost within the 30 days before death in patients on prolonged mechanical ventilation.

In 2015, the Centers for Medicare and Medicaid Services (CMS) limit payments to hospitals with high readmission rates for patients admitted with acute exacerbation of COPD (AECOPD). Decreasing readmissions in this patient population improves patient health and decreases healthcare utilization of resources. We hypothesized a COPD Management Program (COPD-MP), delivered by a respiratory care practitioner (RCP) in the patient’s home would reduce readmission rates for AECOPD.

We performed a pre/post-intervention design study, comparing hospital readmissions for AECOPD patients who received standard of care in the home versus a RCP-led COPD-MP. From January 2016 to March 2017, patients discharged home from Atlantic Health System (AHS) with AECOPD were enrolled in the pre-intervention group. Subsequently, an evidence-based COPD-MP was implemented by an RCP from At Home Medical (AHM) in the home. The COPD-MP was implemented in the patient’s home from April 2017 until September 2019 and this served as the post-intervention group.

A total of 835 patients were included in the pre-intervention cohort and 576 patients in the COPD-MP. There was a reduction in 30-day all cause readmission between the pre-intervention cohort and the COPD-MP cohort (17.6% vs. 11.3%, P=0.001). There was also a reduction in 60-day all cause readmissions (26% vs. 12.5%, P<0.001) and 90-day all cause readmissions (33% vs. 12.5%, P<0.001).

Utilizing an evidence-based RCP-led COPD-MP approach, in the post discharge period is crucial in preventing recurrent hospitalizations. This quality improvement project in COPD-MP established an innovative strategy implemented by an RCP in the discharge period to reduce readmission rates. A review of the data demonstrated a 35% reduction in 30-day readmissions when a COPD-MP was implemented in the patient’s home. There was also a reduction in 60-day and 90-day readmission by 52% and 62% respectively.

To investigate the satisfaction of pre-hospital medical staff after mechanical ventilation training at different times to solve the problems related to mechanical ventilation and the willingness to receive further training, so as to provide a reference for the design of respiratory therapy education.

In August 2019, 436 medical personnel were surveyed on 41 emergency websites in Wuhan, and a total of 389 were responded, with a response rate of 89.2%. We divided 311 trained of them into three groups according to the number of training days [within 3 days (Group A), 3-7 days (Group B) and more than 7 days (Group C)]. Among them, further analysis of occupation, education, work experience, and training methods. Satisfaction analysis for solving mechanical ventilation related problems and willingness to receive further training. For the statistical analysis using SPSS 12.0 and descriptive statistical analysis, Chi-Square test was also used for analysis and comparison. When P <0.05 was considered a significant difference.

71.3% (311/436) of the medical staff received mechanical ventilation training, and their satisfaction with solving mechanical ventilation-related problems after training. Reaching 100% satisfaction include, bachelor degree in group A, physician in group B, less than five years and more than 10 years of work experience and one or three types of training methods, and group C has 5 to 10 years of work experience. In terms of willingness to receive 100% retraining include, Group A is for those who have worked for 5 to 10 years, Group B is for those with more than 10 years of work experience and two training methods, and group C is for nursing staff, bachelor degree, more than 10 years of work experience and those with two training methods (Table 1). With chi-square analysis of relevant variables, the training method and the length of training time have significance for satisfaction (P <0.05). (Table 2-3).

At present, the pre-hospital ambulance staff in Wuhan is responsible for the formation of physicians and nursing staff. With the improvement of medical quality value, respiratory therapy related technologies and equipment are gradually being equipped within ambulances. This survey shows that the training methods and the length of time are satisfaction with issues related to mechanical ventilation is important.

The long-term health risks associated with the use of electronic nicotine delivery systems (ENDS) is still a topic of concern in public health. The use of these devices has been linked to the inhalation of many harmful chemicals, carcinogens, heavy metals, nicotine, and irritants that can trigger the inflammation of an asthmatic user’s airways. Our study sought to assess influencers of use with asthmatic students.

An online survey was administered in 2019 via Qualtrics to undergraduates attending the University of Tampa. The data was analyzed using SPSS version 25.0 to evaluate behaviors, demographics, and attitudes pertaining to vaping/JUULing among students who have been diagnosed with asthma.

Our sample size consisted of 315 participants who self-reported having asthma (N=315). Most participants were White/Caucasian females of ages 18 and 19 years. Of these, 33.3% said that their friend influenced them to vape (n=105). Students responded that their preferred ENDS was the JUUL and that they had primarily vaped nicotine and THC. There was a positive correlation between how many times a student vapes in a day and their attitude about vaping (r= 0.289; P-value < 0.01).

Students who vape more frequently during the day are more likely to find vaping favorable. Programs should focus on changing behaviors early in the experimentation phase to deter vaping.

Intensive care unit patients that require mechanical ventilator support can develop pulmonary complications which substantially alter their outcome. The benefits of mechanical ventilation are well documented however, there is evidence from randomized clinical trials that establishes risk factors of mechanical ventilation. These risk factors have the potential to injure the lung. Risk factors include managing oxygen, pressure and volume delivery to avoid injurious conditions that have been linked to acute lung injury and acute respiratory distress syndrome. The application of a virtual respiratory therapist (VRT) assists in the monitoring and maintenance of safe mechanical ventilation.

IRB approval was received from Atrium Health. Our facility implemented a program in which a VRT assesses all newly mechanically ventilated patients for delivered volume compliance of 6-8 mL/kg of ideal body weight (IBW) for the systems mechanical ventilation protocol. Data was collected by the VRT team for 6831 ventilator patient assessments and interventions from January 2018 through December 2019. VRTs also modify all protocol initiated mechanical ventilation physician orders with the patient’s IBW and tidal volume range per the system’s mechanical ventilation protocol to continue to improve compliance.

Patients without VRT intervention were found to be out of protocol compliance in 2018 and 2019 of 14.92% and 13.98%, but after VRT intervention, out of protocol compliance improved to 8.46% in 2018 and 8.48% in 2019. Therefore, 377 more patients were then within tidal volume protocol compliance. After the VRT interventions, the total compliance for 2018 and 2019 increased to 91.5% each year.

VRT intervention on mechanical ventilation tidal volume protocol compliance reveals a positive impact to improve patient care through evidence-based practice.

Flexible bronchoscopy (FB) is a well-established tool for the diagnosis and treatment of pulmonary disorders in children. For children receiving Extracorporeal Membrane Oxygenation (ECMO) and systemic anticoagulation, bleeding has been reported as an adverse event following FB. Therefore, we sought describe the safety profile of FB during ECMO.

An IRB approved retrospective review was conducted on subjects who received FB while on ECMO between 2015-2018. Demographic, clinical findings, laboratory, mechanical ventilation, anticoagulation profiles, ECMO and mechanical ventilation data were evaluated prior to and following FB. Descriptive statistics and Wilcoxon matched-pairs signed rank test were used for pre and post intervention comparisons. Data are presented as median and interquartile range.

18 Subjects (male=7); weight 13.67 kg (2.5-77 kg) underwent FB on ECMO (4 veno-venous) and (14 veno-arterial). ECMO duration was 22 days (2-42 days) and FB was performed 12 (0.29-30.37 days) from the initiation of ECMO support. Indications for FB included 56% therapeutic and 44% diagnostic. Four subjects (22%) required a red blood cell transfusion for hematocrit <30% within 6-hours of FB. No statistically significant differences were observed for included variables pre and post FB (Table 1.) and no additional adverse events were reported.

In our limited cohort, FB was not associated with major bleeding, titration of heparin dose, adjustment of mechanical ventilation and ECMO support. These data suggest that FB is a safe bedside procedure during ECMO support of critically ill children that may yield both therapeutic and diagnostic benefits.

In the United States, limited understanding of COVID-19 pathophysiology and disease trajectory, along with fear of transmission to healthcare workers, has led to an “intubate early” approach. High flow nasal cannula (HFNC) therapy is an alternative respiratory support modality for patients with acute hypoxic respiratory failure (AHRF), and this device has been standard of care for management of AHRF in both the Intensive Care Unit (ICU) and on all general inpatient wards of the study hospital since 2017. The purpose of this study is to describe our recent experience using HFNC as the escalation of care support device for adults with confirmed COVID-19.

This study is a retrospective chart review of adult patients consecutively admitted to hospitals in a regional health system in the Midwest. All patients had SARS-CoV2 confirmed by lab testing, required escalation of care due to AHRF demanding > 4 L/min oxygen to maintain saturations above 90%, and were managed with HFNC in the ICU or on the ward. The study was approved by the Institutional Review Board at the study hospital. Descriptive statistics were reported for continuous data as means and standard deviations (SD); categorical data were reported as counts and percentages.

At the time of writing, 116 of 321 (36%) of hospitalized COVID-19 patients required escalation of care due to AHRF and 96 (83%) patients received HFNC as the escalation support modality. Sixty-one percent of patients (n=58) were male, mean age was 64 years (SD=18), and mean BMI was 32 (SD=9). Of patients dispositioned at the time of writing (n=70), 49 (70%) did not require invasive mechanical ventilation at any time during hospitalization and 61% (n=43) discharged to home or a skilled nursing or rehabilitation facility. HFNC patients averaged 5 total days in the ICU, however 23 (33%) patients avoided the ICU altogether. For patients who were intubated after HFNC, average ROX score at the time of intubation was 3.81 and they averaged 25 hours (SD=1.5) of HFNC therapy prior to intubation.

Use of HFNC in the ICU and on general wards has been a safe, resource-sparing, and lifesaving option for patients who would have otherwise required invasive ventilation. During the COVID-19 pandemic, the study hospital has not experienced an overwhelmed ICU or depleted the supply of mechanical ventilators. There are no known cases of virus transmission to healthcare workers caring for patients using the therapy.

ARDS is a severe condition that necessitates immediate medical intervention. Airway pressure release ventilation mode (APRV) has been an increasingly accepted means of supporting ARDS patients. However, recent data from randomized clinical trials (RCTs) regarding the effectiveness of using APRV among patients with ARDS is still conflicting. The purpose of this study, therefore, was to determine whether APRV mode is more effective in improving oxygenation and reducing hospital mortality compared to conventional ventilation (CV) among ARDS adult patients.

We conducted this study following PRISMA guidelines. We searched for RCTs in PubMed, Embase, Web of Science, and the Cochrane library until April 2019. We considered for inclusion all studies that compared APRV and other CV modes among adult ARDS patients. Our primary outcomes were oxygenation status (defined as PaO₂/FIO₂ ratio) and hospital mortality. Risk of bias was assessed independently using appropriate tools.

In the initial search, we identified 118 potentially eligible studies in which 6 RCTs studies met our inclusion criteria with total of 375 patients. In all studies the effect of using APRV on oxygenation and mortality was assessed. PaO₂/FIO₂ ratio was similar between patients treated with ARPV and CV, mean difference = 0.62 mm Hg, (95%CI 0.05-1.3,I2=86%,P = 0.07). Mortality was lower among patients who received ARPV than patients who treated with CV (risk difference -0.05 days(95%CI -.13-0.03 days, P=0.02).

In this study, using APRV mode was associated with reducing mortality among ARDS patients, without any improvement in oxygenation status. However, there is still a need for well-planned RCT to address the issue of improving oxygenation and safety of using APRV in clinical practice.

By establishing a mentor program we hope to improve the process of onboarding new respiratory therapist to the RT Division at Cincinnati Children’s. We hope the program will enhance clinical competency, educational advancement, professionalism and leadership skills by providing a qualified and trained mentor to those therapist who wish to achieve their highest potential. It was decided to create a program that encompasses clinical and personal growth is essential to the success of new RTs.

A survey was sent to staff before the project began. The results showed a need and we took this opportunity to develop a QI project. Multiple mentoring tools will be implemented throughout the year by the mentor co-chairs, RT leadership, and those RTs serving as a mentor. All participants accepted are required to take a NERIS Type Explore personality test. Participants will be paired based on personalities. Mentors were required to attend a training class. We will re-survey and trend the data to see if there was improvement in the onboarding process. Changes will be made to the program if needed.

The results of the post survey showed the program was successful. 75% of mentors stated they would highly recommend becoming a mentor to their peers. One mentor stated they would not want to be a mentor in the future. They felt they couldn't support the mentee due to being on opposite shifts. Mentors preferred to be paired with a mentee on same shift. Mentors thought the program was beneficial to the mentee by making them feel welcome and comfortable with their peers. Their clinical confidence and skills were enhanced. We found communication issues between mentor/mentee if they worked opposite shifts.

Our first respiratory care mentor program exceeded all expectations. The post survey results showed all participants felt the program helped improve the onboarding process. Both the mentor and mentee grew as members of our team. The program was designed to help the success of the mentee. However, we noticed the mentor enjoyed helping! Success of the support system created optimized the division performance by retaining new hires. In turn, the division was able to maintain optimal staff levels. Communication is key to the success of onboarding. The program generated positive feedback. Our 2nd program opened up and participation increased. The mentors proved success by the mentees exhibiting their clinical competency and confidence. We will continue to improve our training program to support successful growth.

Aerosol transport during non-invasive positive pressure ventilation (NIV) follows the flow of pressurized gas through the NIV circuit, vented via leak port and face mask, and inhaled by the patient. Recommendations for nebulizer placement are based on in vitro models that have focused primarily on aerosol losses via the leak port; face mask leaks have been avoided. The present study tested aerosol delivery in the setting of controlled face mask leak.

Three nebulizer technologies (Aerogen Solo, Aerogen, Galway Ireland; i-AIRE, InspiRx, Somerset NJ; and Hudson MicroMist, Teleflex Medical, Morrisville NC) were studied on a bench model using a lung simulator with a face mask placed onto a manikin head. Radiolabeled aerosol delivery (Inhaled Mass, IM) was determined by mass balance using filters and a gamma camera; testing effects of nebulizer location and face mask leak. Low (15-20 L/min) and high (55-60 L/min) mask leaks were used to mimic realistic clinical conditions.

IM (% nebulizer charge) was a function of nebulizer technology (with nebulizer at ventilator outlet position: Aerogen 22.8%, InspiRx 11.1%, and Hudson 8.1%, P = .001). Location of the nebulizer before or after the leak port was not important (P > .99). Aerosol delivery was minimal with high mask leak (IM 1.5-7.0%). Aerosol losses at the leak port at low mask leak were 28-36% vs 9-24% at high mask leak. Aerosol losses via the mask leak were16-20% at low mask leak vs 46-72% at high mask leak. Furthermore, high face mask leak led to significant deposition on the mask and face, up to 50% of nebulizer charge with Aerogen.

During NIV, nebulizer placement at the ventilator outlet, a more practical position, is effective and minimizes deposition on face and mask. Aerosol therapy during high face mask leak should be avoided.

Experimental Set-up

The measurement of respiratory muscle strength is assessed using the maximal inspiratory pressure (MIP), the maximal expiratory pressure (MEP), and sniff nasal inspiratory pressure (SNIP). Presently, no guidelines specify the minimum number of SNIP attempts needed to achieve repeatability of this measure. Thus, the purpose of this study was to determine the minimum numbers of attempts of SNIP measures to achieve repeatability.

This was a secondary analysis of data from a cross-sectional study of 85 subjects free of acute cardiopulmonary disease who were admitted to general medical and surgical floors of an acute care hospital. Up to 10 SNIP attempts using the MicroRPM were made by each subject to achieve acceptable and repeatable results. Demographic information and the number of attempts it took to achieve the highest SNIP and repeatable SNIP measures within 10% were recorded. Frequency and median values of attempts were computed.

Of the 70 (82%) subjects who achieved repeatable SNIP values, slightly more were female (57.1%) and from minority backgrounds: African American (48.6%), Hispanic (18.6%). The mean (SD) age was 51.1 y (15.9) with a range of 19-86. The mean peak SNIP value was 61.8 cm H₂O (28) with a range of 3-129. The median (IQR) number of attempts to achieve the highest SNIP value was 6 (4-8) and the earliest median repeatability attempt was a 7 (6-8).

It appears that many hospitalized general medical and surgical patients can achieve repeatable SNIP maneuvers. A total of 8 attempts may be needed to allow most subjects to achieve their highest value. Publishing a standard specifying the minimum number of SNIP attempts could improve the precision of SNIP measurements.

The scientific literature supports that use of e-cigarettes does have associated safety and health concerns. E-cigarette or Vaping Product Use-Associated Lung Injury has resulted in a rise in hospital admissions and focused media attention on the nicotine delivery devices. Despite this increased attention, the use of e-cigarettes amongst college students has been increasing. Therefore, the aim of this study was to identify perceptions regarding the safety and usefulness of e-cigarettes among college-aged students from a large Midwestern University. In addition, comparison of perceptions between program of study and e-cigarette frequency of use was also examined.

This IRB approved study was a convenience sample of 291 undergraduate students from The Ohio State University’s School of Health and Rehabilitation Sciences and the Fisher College of Business responded to the voluntary online survey sent to them via college email. The Risks and Benefits of E-cigarettes questionnaire was used to measure perception of e-cigarette usage. The results from the usage of e-cigarettes were measured using items from the Electronic Cigarette Smoking History Questionnaire. SPSS was used for analysis.

Out of the total population (n=291), participants had a lower mean risk score (40.33) and a higher mean benefit score (95.24). This shows that participants were more likely to agree with the risks associated with e-cigarettes and more likely to disagree with benefits. There was a significant difference in benefit score between the two college programs (P=.005), but not in risk score (P=.246). In post-hoc analysis, there were significant differences between those who have never tried, tried at least once, and daily users of e-cigarettes.

This study was able to observe the perceptions of health risks and benefits regarding e-cigarette use from students at a large Midwestern University. The students’ educational program did not affect their perceived risks, but did affect their perceived benefits. It is apparent that higher perceived benefits have an influence on likelihood to try and use e-cigarettes regularly. Future research is needed to inform and develop educational programs for college students as e-cigarette use persists in this population.

Annually there are approximately 100,000 tracheostomies performed nationwide. While a common practice with critically ill patients, tracheostomy placement does not come without significant potential for risk. This retrospective data analysis was developed to analyze the practice of bedside versus operating room (OR) with respect to cost effectiveness and progression to potential decannulation

This study received IRB approval from Atrium Health. Data was analyzed for 75 patients that were admitted to Atrium Health Main with either the diagnosis of traumatic brain injury (TBI) or spinal cord injury (SCI) and had received a tracheostomy. Demographics, mechanical ventilation support, and surgical history were assessed to determine if there were any barriers to performing a bedside percutaneous tracheostomy. A #6 tracheostomy tube was used on all patients unless otherwise specified by referring physician. Age, tracheostomy size, and time-to-tracheostomy were compared to initial pass rates of a swallow test via Mann-Whitney U analysis.

From 2016-2017, 82 tracheostomies were performed; 36 of which were placed at bedside with 11 placed in the OR. In 2017, 35 tracheostomies were performed; 26 were placed at bedside and 9 in the OR; all were size #6. There was not a statistically significant finding within the analyzed domains regarding impact on swallow test pass/fail (P >0.05 for all domains). On average the cost for an OR tracheostomy is $4,600.00 and bedside approximate cost is $500.00. We had a total cost savings of $354,200.00.

After comparing the cost of bedside versus OR tracheostomy procedure, it was concluded that it is more cost effective to perform bedside tracheostomies. Age, time-to-tracheostomy and tracheostomy size did not have a significant impact on passing a swallow test.

Aerosol drug delivery by devices positioned on the “wet” side of the humidifier is significantly affected by humidification, with reported aerosol losses of 50 to 75% for nebulizers and 40% for MDIs. The unpredictable losses in these circuits led some investigators to advocate avoidance of active humidification during aerosol therapy. However, humidification is required for prolonged delivery of controlled doses of drugs (eg, vasodilators). Recently, we tested wet-side nebulization using a prototype breath-enhanced nebulizer and achieved good control of drug delivery. However, short term aerosol studies do not assess the stability of ventilator circuit humidification over time when devices are left in the circuit. To test this stability, we studied the humidified ventilator circuit over 24-48 hours using wet-side nebulizer placement on the humidifier.

A standard F&P humidifier/heated wire circuit was operated continuously during mechanical ventilation of test lungs over several days with a prototype i-AIRE breath-enhanced nebulizer or Aerogen Solo positioned at the humidifier outlet. The humidifier outlet thermistor was located either at the inlet cuff of the inspiratory limb or the humidifier outlet. Room temperature was controlled at 22 C. Periodically, the devices and inspiratory limb tubing were assessed for water accumulation, and the ventilator for alarm conditions.

Within 24-48 h, enough condensation formed within all devices and/or the inspiratory limb to trigger an occlusion alarm on the ventilator. By applying insulating materials, condensation was shown to be a function of heat loss caused by interposing devices between the humidifier outlet and the inspiratory limb (where the heated wire begins). This phenomenon could not be avoided by moving the thermistor to different locations.

Positioning nebulizing devices on the wet side of the humidifier with a heated wire circuit is not feasible. Nebulizing systems left in the circuit should be located on the dry side of the humidifier.

Drug delivery on ventilator circuits is difficult to control. In recent studies, our group has compared modern commercial nebulizers to breath enhanced technology (BET) with the goal of controlled drug delivery at all ventilator settings with and without humidification. Published studies revealed that BET successfully delivered controlled doses of drug with and without humidification. However, previous humidified experiments were performed with the nebulizer located on the “wet” side of the humidifier. A recent report found that this location is not tenable for any nebulizer because of excess condensation. The present study tested BET with the device located on the “dry” side of the humidifier.

Using radiolabeled saline, in vitro inhaled mass (IM) and mass balance were measured in a conventional ventilator circuit (Vyaire Avea connected to 2 1-L test lungs) and humidified with an F&P MR-850 humidifier. An InspiRx i-AIRE prototype nebulizer was connected to the inspiratory port of the ventilator. This nebulizer is designed to remain in place between treatments with drug added via a capped side port. All ventilator gas passed through the nebulizer (breath-enhancement) and the nebulizer was powered by medical air at 3.5 and 5 L/min. Low (0.13) and high (0.34) duty cycles were tested at fill volumes of 3 and 6 mL.

IM ranged from 12-26% of nebulizer charge. Humidifier losses were negligible (3-5%). Circuit and ET tube losses totaled 15%. The major factor affecting delivery was nebulizer residual (30-50%) which was reduced to 30% with 5 L/min flow and 6 mL fill volume. Delivery data were similar to previously reported non-humidified BET nebulization.

For breath-enhanced nebulization, the dry side location allows controlled drug delivery defined by nebulizer flow and fill volume during humidification with heated wire circuits. Condensation and humidifier losses were not observed.

Misunderstanding and incorrect inhaler technique is prevalent in COPD. Incorrect device usage of DPI’s and MDI’s include failure to exhale fully before inhaling, incorrect preparation, and lack of breath hold after inhalation. Several DPI’s require a minimum PIFR of 30 L/min causing inability of patients to meet requirements. Limited studies have compared SMI’s with alternative like medication in DPI form warranting further research. Additionally, recommendations for regular inhaler technique checks have been published, however not all outpatient centers have resources to complete assessments. UC Davis Comprehensive COPD Clinic integrates RCP assessment and education of inhaled medication and delivery devices to see if patients need further education, meet PIFR requirements, and/or require an alternative device. We hypothesize that changing MDI/ DPI regimens to SMI and/or nebulized regimens made an improvement in CAT scores.

Retrospective analysis of 241 patients enrolled in the COPD Clinic QI registry with IRB approval. Sixty-four patients had a follow up appointment with pre and post CAT scores, 131 patients had either no follow up CAT score, did not have or follow up with an appointment, or have a future appointment scheduled. The 64 patients were all assessed and had education on their current inhaled regimens and/or education to their changes that were made to their inhaled medication regimen during their clinic visit. A limited number of five patients had MDI and/or DPI regimens to SMI and/or nebulized regimens made with no changes in their baseline inhaled medication classification. Descriptive statistical analysis was performed with Chi square, Student t-test, and 95% confidence intervals when appropriate.

All 64 patients had a mean CAT score of 20.9 (±2.1, 95% CI) with a follow up CAT of 18.9 (±2.1, 95% CI), an improvement of 2.04. The five patients that had MDI and/or DPI regimens to SMI and/or nebulized regimens had a baseline CAT of mean 29 (±6.7, 95% CI) with a CAT mean at follow up change of 23.4 (±5, 95% CI).

This under-powered limited exploratory study demonstrates that further research is necessary to demonstrate overall symptom improvement when changing maintenance medication regimens from MDI and/or DPI to SMI and/or nebulized regimens. Continued outpatient assessments, education, regimen changes when warranted, and individualized patient care attributes to improvements in CAT scores with appropriate outpatient management of COPD patients.