Respiratory Care

Nasal CPAP is an established method to provide NIV support to spontaneously breathing infants. In infants, CPAP is commonly applied using bi-nasal short prongs. Recently, there has been increased interest in the use of next generation nasal cannulas, such as RAM cannula (Neotech), to delivery CPAP. However, due to inherent resistance concerns, some centers have reported the use Optiflow cannulas (Fisher & Paykel) as an alternative. The aim of this study was to quantify CPAP delivery through RAM and Optiflow cannulas and bi-nasal short prongs in a simulated infant lung model.

An infant manikin (AirSim Baby X, TruCorp), with an anatomically correct airway of a 6-month-old, was connected to a breathing simulator (ASL 5000, Ingmar Medical) with parameters set to simulate a 6-month-old weighing approximately 7 kg (36 breaths/min, Ti of 0.45 s, R of 40 cm H₂O/L/s, C of 10 mL/cm H₂O, and V_T of 43 mL). CPAP of 5 was provided by a Servo-i ventilator (Maquet) in nCPAP mode and delivered through four cannulas; RAM (N4903 Orange, N4904 Yellow) & Optiflow (OJR418 Jr XL, OPT942 SML Adult), and one size Fisher & Paykel (5040) bi-nasal short prong. Sizes were chosen to represent approximately 80-90% nares occlusion. The Jr XL and RAM cannulas bifurcate into two small tubes that supply gas flow to nasal cannula prongs, while the SML Adult cannula has a single larger tube. Simulations were performed with mouth closed. Outcome measures were MAP compared to set CPAP and ΔP_aw (difference between mean expiratory and inspiratory pressure). Data was collected over 36 breaths. Descriptive statistics are presented as mean values only and one-way ANOVA with Holm-Sidak method used for multiple comparison.

The bi-nasal short prongs delivered 96% of set CPAP (4.8 cm H₂O), significantly more than all tested cannulas and produced the least amount of ΔP_aw (1.4 cm H₂O) (P < .05). At similar occlusions, the SML Adult Optiflow cannula delivered 91% of set CPAP (4.5 cm H₂O) vs 75% (3.8 cm H₂O) with the RAM Yellow and had less ΔP_aw (2.0 vs 2.4 cm H₂O) (P < .05). At 80% occlusion, the Optiflow Jr XL and RAM Orange delivered 36% and 18% of set CPAP respectively, and the RAM Orange failed to maintain positive pressure during inhalation (Table 1).

The SML Adult Optiflow cannula and bi-nasal short prongs delivered > 90% of set CPAP level at similar nares occlusion. Cannula design and nares occlusion affect pressure transmission.

Cystic fibrosis (CF) is a genetic disease resulting in significant respiratory morbidity and mortality. Pulmonary exacerbations are detrimental to this populations’ lung function and quality of life. The rate of readmissions with respiratory therapist (RT) intervention via telehealth following hospitalization for pulmonary exacerbation is unknown. Telehealth can be a valuable tool to coordinate early intervention and education when needed. This study investigated the impact of telehealth intervention with CF specific education provided by the RT pulmonary navigator.

Patients admitted for CF pulmonary exacerbations were voluntarily enrolled in our UBreathe Readmissions program. Prior to discharge, patients received a specific CF action plan to assess symptom severity daily and an educational session of airway clearance therapy (ACT) focused on autogenic drainage and huff coughing. Participants were asked 16 questions from the respiratory section of the CF RISE questionnaire to assess baseline understanding of their disease. During post-discharge telehealth visits, RTs reviewed topics from the questionnaire and ACT training including intensive autogenic drainage and huff coughing. Patients completed surveys 30 d after discharge assessing symptoms and repeat CF RISE questions.

Six subjects (3 females, 3 males) admitted for pulmonary exacerbations were enrolled in the study. There were no readmissions for pulmonary exacerbation at 30 d for this cohort. Of the 6 participants, 3 responded at 30-d follow-up indicating no interval illness requiring urgent care or emergency department visits. Three participants did not respond to follow-up surveys but were seen in routine clinic follow-up at various times. Mean baseline score on CF RISE questionnaire from all participants was 80%. Re-assessment using CF RISE at 30 d yielded a mean score of 95.8% of respondents.

In this QI study cohort, findings suggest use of telehealth follow-up led to improvement in patient education relating to CF physiology and treatment while enhancing their performance using AD and huff coughing as part of their airway clearance routine. Further study utilizing short term telehealth visits following discharge assessing technique deficits while also providing education to prevent readmissions for CF pulmonary exacerbations is recommended and appears feasible from our initial study.

Data reporting patient safety attitudes of respiratory therapists (RTs) in the United States is limited. Positive patient safety attitudes have been associated with improved outcome measures such as employee retention, reduced medication errors, and decreased length of stay. This study reported patient safety attitudes of RTs to determine which attributes correlated with a greater safety score.

A non-experimental, cross-sectional study design using the safety attitudes questionnaire (SAQ) was employed. To be included in this IRB approved study, participants were required to be an RT and a member of the VA Society for Respiratory Care. Primary recruitment was through AARConnect with a link to the electronic survey. Variables were dichotomized by categorizing the attributes of having 10 or more years of experience, being 40 years old or older, having a baccalaureate or graduate degree in respiratory therapy, having a baccalaureate or graduate degree in any field, obtaining a specialty credential, or earning the RRT credential, and relating these to the SAQ score. A multiple regression model was deployed to determine which attributes lead to a more positive patient safety score. An alpha level was set to P < .05.

145 participants completed the survey resulting in a 13% response rate. The SAQ exhibited high internal consistency with Cronbach’s alpha of 0.93. The primary outcome was comparison of SAQ scores and the 6 study attributes. ANOVA indicated the predictors accounted for a significant proportion of the variance regarding patient safety attitude (F (8, 135) = 2.506, P = .014); R² was 0.129, representing almost 13% of variance for the SAQ scores. Obtaining a specialty credential was the only significant predictor; there is a nearly a 5-point higher safety score for those who have a specialty credential compared to those who do not have a specialty credential.

There is a significant difference in patient safety attitudes of RTs who have obtained a specialty credential. These results are similar to data reported from the nursing literature on the benefits of obtaining a specialty credential. Further research should be conducted to determine the importance of earning a specialty credential, earning a BSRT, and obtaining the RRT credential. Investigation into these attributes on a national level could help to provide evidence-based recommendation for education and credentials.

In contrast to the clear impact of previous lung cancer to the clinical course of the COVID-19, the impact of COVID-19 as serious infection to the development of lung cancer has not been found. We aimed to learn the risk factors for incidence of lung cancer in patients with history of the COVID-19 infection.

We have assessed the lung CT scan of the 1215 patients with COVID-19 timely: at the time of acute lung infection; 3 months after COVID-19 infection; and 6 months after COVID-19 infection. All patients with COVID-19 were assessed by severity of the disease course: mild, moderate, and severe.

In 59 patients of 1,215 have been evaluated and confirmed the diagnosis of lung cancer (4.9%). In surviving patients with ARDS, massive and non-resolving fibrosis was leading cause for lung cancer incidence and in 32 patients of 59 the cancer was developed after surviving ARDS (P < 0.001) and all ARDS cases were severe. In non-ARDS lung cancer patients (27 of 59) lung fibrosis together with smoking history also was leading factor for development of lung cancer after COVID-19 infection compared to non-cancer patients (P < 0.01). Commonly lung cancer developed at 3 months after COVID-19 infection and this incidence was significantly higher compared to the 6 months after lung infection (OR 2.58 [0.85--6.49] 95% CI; P < 0.002). At the time of acute lung infection in lung cancer patients, lymphopenia was significantly higher compared to non- lung cancer patients (OR 3.48 [0.92–8.94] 95% CI; P < 0.001). Comorbidity as COPD was associated most commonly with lung cancer compared to patients without lung cancer (OR 6.37 [1.21–13.35] 95% CI; P < 0.001). Most common histological type of lung cancer was squamous compared to adenocarcinoma (OR 2.43 [0.67--7.28] 95% CI; P < 0.006).

The incidence of lung cancer in patients with COVID-19 was most commonly associated with several risk factors including older age, male gender, lymphopenia at the time of acute lung infection, and COPD as comorbidity. Lung cancer most common was found at three months after lung infection, and most commonly incidence of lung cancer was observed in patients after surviving severe COVID-19 infection with severe ARDS in whom was developed massive and non-resolving fibrosis with history of cigarette smoking and most commonly type of the lung cancer was squamous cell lung cancer.

Respiratory therapy expertise is central to quality patient care in the neonatal intensive care unit (NICU). According to Benner’s Stages of Clinical Competence, healthcare providers pass through 5 level of proficiency: novice, advanced beginner, competent, proficient, and expert. Prior and during orientation, orientees are novice to the area they scheduled to orient in. This does not mean they do not have knowledge, but rather that they lack the fundamental competencies to work in that area. Staff that have completed a basic orientation progress from novice to advanced beginner during resourcing, advance to competent when resourcing in that area is complete, and grow in proficiency over time. The goal of this project was to determine the length of time is takes a NICU respiratory therapy orientee to reach self-proclaimed proficiency; defined as being confident in their ability to care for NICU patients, complete NICU tasks without assistance, and understand the pathophysiology of NICU diseases

All respiratory therapists with a minimum of 1 year respiratory therapy experience who began NICU orientation between May 2016 and May 2018 completed a voluntary online self-assessment regarding ability to perform skills and knowledge of disease processes directly before orientation, after orientation, one year after orientation and two years after orientation. Education included 12 h of didactic, 20 online learning modules, 4 h hands-on equipment, with competencies and checkoffs consistent throughout.

Voluntary online participants (N = 55) pre orientation self-professed ability to care for a neonate based on skills and knowledge ranged 1–3 (2.5 average) with 1 being limited ability and 5 being able to independently complete all tasks and understand the care required. Post orientation (n = 49) ability to care for a neonate ranged from 3.0–4.0 (3.50 average), one year post (n = 52) ability to care for a neonate ranged from 3.5–4.5 (4.0 average, and two years post orientation (n = 48) 4.0–5.0 (4.75 average).

While orientation consists of brief education, some didactic, equipment, and getting the competencies and checkoffs completed within a brief period of time, actually growing therapists’ knowledge takes time and effort. Before we can expect our therapists to be completely functional, and comfortable, in a unit we need to provide additional education, opportunities, and experiences with other trained professionals as resources until they can reach proficiency.

End of life care is difficult for all medical professionals, causing struggles with grief during and after the death. Very few respiratory therapists (RTs) perceive they are prepared to assist the dying process. These same RTs have to remove life support or stop life sustaining therapy. The objective of this project was to determine if a compassionate care RT support team trained with knowledge of end-of-life practices, brain death testing, religious and cultural requirements, and organ donation process including ventilator management would be a perceived benefit to our staff.

A compassionate care RT team was formed in April 2019. Staff were trained using End of Life Nursing Education Training Course (ELNEC), Life-sharing lectures, simulation lab scenario training, and lectures on spiritual, religious, and cultural aspects of end-of-life care. 16 months after training and implementation of the team, a convenience sample of 120 pediatric RTs were provided the opportunity to complete an online survey about end-of-life help. Participants were asked five questions, but each question was optional.

Voluntary online participants (N = 48), of the survey respondents, respiratory staff each cared for between 1–20 (mean 2.79) end of life patients between July 1, 2019 and June 30, 2020. Of these, 77.1% (37/48) would consult the compassionate care RT team as a resource for end-of-life care, and of those who would not call the team 22.9% (11/48) commented they felt they did not think they needed it, had been in the field a long time, or felt they would use other resources such as social worker, charge nurse, or respiratory director. 68.2% (30/48) knew the names of all the staff on the team. 95.8% (46/48) felt that having a compassionate care RT end of life team is beneficial to our staff. 4.2% (2/48) stated no benefit, but added the comment perhaps to newer therapists. When asked what the team could do better most 52% (25/48) stated there needed to be more team members on night shift, and 25% requested a better way to know whom to call on their shift if they have an end-of-life patient.

Implementation of an end-of-life compassionate care RT team has been beneficial to our staff who feel comfortable calling them as a resource, and know the names of the staff on our team. Additional needs were identified for more night shift resources and improvement of communication during the shift if an end-of-life situation arose quickly.

The National Healthcare Safety Network (NHSN) developed a new algorithm as an approach to improve monitoring for the physiologic changes contributory to ventilator-associated events (VAE), and identified subgroups of ventilator associated conditions (VAC), infection-related ventilator-associated conditions (IVAC) and possible ventilator-associated pneumonia (PVAP). After introduction of the new surveillance definition, we noted in our MICU the majority of PEEP changes triggering VAEs were unrelated to true ventilator-associated complications. It is known that mechanical ventilation is associated with reductions in functional residual capacity (FRC), which, can result in atelectasis. Given the FRC in ventilated patients is determined by PEEP, we hypothesized optimizing PEEP settings at higher starting levels would allow for better identification of clinically significant VAEs.

We initiated a pilot intervention across 25-beds in 2 MICUs at our urban tertiary care institution in March 2019. All newly ventilated patients were initiated at a starting PEEP of 8 cm H₂O rather than 5. Respiratory therapists, intensivists, and nursing staff were educated as to the protocol, and local champions were identified to ensure adherence. The new baseline PEEP allowed for minimal disruption in patient care, as spontaneous breathing trials and weaning could be conducted per usual practice. Other ventilator bundle components were maintained throughout both periods with a ≥ 75% compliance rate. We then compared pre- and post-intervention rates of VAEs.

There were 419 mechanically ventilated patients in the pre-intervention group, and 427 in the post-intervention group. After initiation of the higher baseline PEEP protocol, we found an approximate 50% reduction in rates of total VAE, along with reductions in IVAC and PVAP by 25-30% (Table 1). Comparative trends in VAC, IVAC and PVAP diagnoses between the two periods of interest are depicted in Figure 1.

Our data suggest optimizing baseline PEEP may help to reduce VAE in the MICU setting. As the intent of the new NHSN definition was to capture physiologic processes other than infectious pneumonia, the mechanism of our results may have been through reduction of atelectasis or other ventilator-induced lung injury. Further study will help to determine generalizability of this practice to non-MICU settings, and also measure its impact on outcomes such as antibiotic utilization.

High frequency chest compression (HFCC) is an airway clearance method used for treatment of cystic fibrosis (CF). It is frequently utilized in other diagnoses such as non-CF bronchiectasis, neuromuscular disease, severe neurological impairment, or other conditions with increased airway secretions. Consensus for HFCC session duration and device settings is available for CF but not other diagnoses. The aim of this study is to describe the use of HFCC in children’s hospitals.

Acute care children’s hospitals in the US who were members of the Children’s Hospital Association at the time of the study were invited to participate in a survey about HFCC practices used at their institution. Respiratory department directors, managers or supervisors were contacted by email to complete an electronic questionnaire. Responses were collected in the Research Electronic Data Capture database. Survey domains included diagnoses in which HFCC is used, session duration, device settings, frequency of therapy, and concomitant inhaled medication use. Descriptive statistics were used to analyze collected data.

Of the 198 invitations sent, 16% (31/198) were returned for unknown address, resulting in 167 invited institutions. The response rate was 19% (31/167). The regional location of participating institutions was Midwest (14), South (10), West (4) and Northeast (3). Three institutions (10%, 3/31) stated HFCC is not used and did not proceed to the survey. The majority of institutions that completed the survey were free-standing hospitals (71%, 20/28) and most did not have a pediatric pulmonary fellowship program (61%, 17/28). The median HFCC session duration for CF was 30 min and 20 min for all other diagnoses. The use of 10 and 15 Hz were the most common settings for all diagnoses. Short-acting bronchodilators were utilized by all institutions before or during HFCC for one or more diagnoses. Frequency of HFCC therapy for inpatient treatment of pulmonary exacerbation was 4 times a day for all diagnoses most of the time: CF 75% (21/28), non-CF bronchiectasis 71% (20/28), severe neurological impairment 64% (18/28), and NMD 61% (17/28).

Practices for HFCC use vary among US children’s hospitals. More research is needed to establish best practices and evidence-based guidelines for HFCC session duration, device settings, and concomitant inhaled medications, especially in non-CF diagnoses.

The optimal method for home ventilation in bronchopulmonary dysplasia (BPD) is not well defined. These patients have heterogeneous lung disease with increased alveolar dead space and airway resistance, varying time constants, malacia, and hyperinflation. A BPD collaborative suggested that ventilation strategies using larger tidal volumes, slower rates, and longer inspiratory times (Ti) have been successful.

Retrospective cohort study at a pediatric academic medical center including patients from 9/2016 to 2/2021 with a primary diagnosis of BPD and discharged with tracheostomy and home ventilation. PC or PS ventilation mode was chosen at the discretion of the ICU team. We sought to evaluate differences between allowing titrated PS (+/- volume guarantee) with varying rise time, % cycle time and Ti range vs PC with a set pressure, respiratory rate, and Ti. Data collected included gestational age (GA) at birth, birth weight (BW) and weight at time of trach (TW), respiratory support at 36-weeks postmenstrual age (PMA), PMA and respiratory support at time of trach and discharge, and days from trach to discharge. P-values were calculated using a 2-tailed unpaired t-test with a significance level of 5%.

Eighteen infants were included (PS n = 11, PC n = 7). There were no significant differences between the PS and PC groups for GA at birth, BW, support at 36-week PMA, age at trach, TW, FIO₂ at trach, or days from trach to discharge. Significant differences were found in FIO₂ at discharge (lower in PS group, P = 0.0002), PEEP at trach and discharge (lower in PS group, P = 0.019 and 0.003, respectively).

PSV can be safely applied in BPD patients for home ventilation with a lower oxygen requirement at discharge than those on PCV. The PEEP in the PS group was also lower at the time of discharge, however they started with a significantly lower PEEP at the time of trach and both groups had an equivalent decrease in PEEP from time of trach to discharge of ∼1.5 cm H₂O. PSV does not change the time from trach to discharge and may provide oxygen cost savings in the hospital and home.

Aerosolized bronchodilators (AB) are frequently administered via nebulizer (NEB) to treat episodes of bronchospasm. Lung model (LM) studies suggest that aerosol delivery during mechanical ventilation (MV) is suboptimal. Use of the Aerogen vibrating mesh nebulizer (VMN) allows administration of albuterol continuously through a syringe pump (SP) without the need of gas to power the NEB. We examined the interactions between electronic components to assess impact on rate of nebulization (RON) during MV.

Pharmacy downloaded programming for albuterol 0.5%, 5mg/mL continuous into the Medfusion 4000 SP drug library. A 60 mL syringe was filled with 20 mL of saline (0.9%) to simulate albuterol 0.5%, 20 mL solution, and attached to the SP. The SP was set to dispense 15 mg/h in the first round and 20 mg/h for the second round of 4h testing. Fluid from the syringe was used to prime the SP tubing and 1 mL injected into the VMN reservoir to start nebulization. The control timer was set to continuous. The Servo-i (SV) mechanical ventilator was used for the study with a VMN to deliver AB to a LM. The SV mechanics were monitored at 1 h and post 4 h nebulization at different mg/h doses; tidal volume (V_T) - 0.45 mL, volume control (VC) - 12 breaths/min, peak airway pressure (P_aw) - 22 cm H₂O, plateau pressure (Pplat) - 14 cm H₂O, PEEP +8 cm H₂O. The VMN was inserted on the dry side of the Fisher & Paykel humidifier chamber. Acceptable MV functionality was verified by observation of the SV on board monitoring systems.

After completion of the studies, there were no significant performance issues with regard to RON on MV mechanics; V_T - 0.45 mL ± 0.08, P_aw - 22 ± 2 cm H₂O, Pplat - 14 ± 2 cm H₂O, PEEP - +8 cm H₂O, with no auto-PEEP, auto-cycling or changes to waveform graphics detected. The RON equal aerosolized drug volume delivered in mL/h; 15 mg/h = 3 mL/h and 20 mg/h = 4 mL/h. This study confirmed that 12 mL ± 1 was nebulized at 15 mg/h and 16 mL ± 1 was nebulized at 20 mg/h in 4h.

This study demonstrated that continuous AB delivery via SP+MV is feasible. RON volume per hour were stable and drug dilution was not required which may improve effectiveness. Short term use of the SP (10–20 min) to administer AB may not be advantageous for delivering enough volume to optimize delivery. The interactions of different equipment did not have an undesirable effect on machinery functionality. Further study is needed to determine RON effect on deposition during MV.

SP+VMN connected to dry side of HC

Several devices exist today for high frequency percussive AWC for invasive and noninvasive patients. Despite several existing devices and some relatively new devices on the market, there were no current bench comparisons. This comparison used 10 mL of simulated mucous (SM) in a balloon, with a 7.5 endotracheal tube connected to Hill-Rom’s Volara and IPV-2C both with and without mechanical ventilation, to look at secretion removal.

We weighed the balloons with 10 mL of SM (95.5% water with 0.5% TIC Xanthan Gum Fastir) and the rubber band, using a Torbal AGCN200 scale. The Volara was set to Medium CHFO, Peak pressure (PIP) set to 30 cm and CPAP set to 5 cm H₂O. The Volara circuit was attached to the top of the endotracheal tube with the SM-filled balloon attached at the bottom, past the Murphy eye. A rubber band secured it in place. The endotracheal tube was upright and close to a 90 degree angle leading down to the balloon. 6 mL of NSS was nebulized during AWC. After 10 min, the balloon, rubber band, and remaining SM was removed and weighed for comparison on the 4 set-ups. This same process was followed for the IPV-2C. The IPV-2C was set to a high frequency rate of 230 breaths/min with PIP that ranged from 27–30 cm. This information was determined using the pressure line from Percussionaire VDR with measurements displayed on the monitor. We then repeated the steps above for Volara and IPV-2C in-line with the ventilator circuit. Both devices were on the inspiratory limb of an RT380 circuit directly before the Y-piece. Ventilator settings were AC pressure control, set RR 20, PEEP 8 cm H₂O, and total PIP 25 cm.

The SM-filled balloon and rubber band used for the Volara without ventilator weighed in at 11.9785 g. After therapy, it weighed 9.8765 g for a removal of 17.54% of total weight. The SM-filled balloon and rubber band used for the IPV-2C without ventilator weighed in at 11.8604 g. After therapy, it weighed 4.5131 g for a removal of 61.94% of total weight. The SM-filled balloon and rubber band used for the Volara with ventilator weighed in at 11.8067 g. After therapy, it weighed 11.2285 g for a removal of 4.89% of initial weight. The SM-filled balloon and rubber band used for the IPV-2C with ventilator weighed in at 12.2069 g. After therapy, it weighed 5.4525 g for a removal of 55.33% of initial weight.

The Volara with similar settings as the IPV-2C, did not removed as much SM as the IPV-2C did in this bench study. This was true with both invasive ventilation as well as no invasive ventilation.

Traditional education models for respiratory therapy (RT) programs require in-class attendance and laboratory experience. The COVID pandemic interrupted this model requiring RT programs to transition to virtual learning. The purpose of this study was to compare the 2020 mechanical ventilation I course test scores and overall final course grade to determine if modification to virtual instruction impacted mean scores compared to previous years of in-person instruction.

Data included two exam scores and final course grade for four years, from 2017-2020. Descriptive statistics and one-way ANOVA were used. Data from 2017-2019 was collected in a traditional course meeting in-person 200 min per week for seven weeks and seven laboratory meetings. Data from 2020 course utilized a virtual course design that included pre-recorded lectures on the same material as 2017-2019, including the same textbook and three in-person laboratory meetings. Online interaction via WebEx for 120 min was presented for students to identify material in which they did not understand. Additionally, students could converse via other communication sources outside of class as in previous years to discuss issues.

The 2020 data group had the highest mean grade for exam one, exam two, and final grade at 88.92, 83.11, 87.59 respectively. Of the four groups, 2020 had the lowest number of students (N = 37). One-way ANOVA showed no statistical differences between the four years for exam one (P = .594), exam two (P = .626), or final course grade (P = .35).

Transitioning to virtual instruction for mechanical ventilation did produce higher mean averages for exam one, exam two, and final grade for the 2020 subject group compared to previous years, but this difference was not statistically significant. This could have been influenced for reasons other than the virtual classroom model. Students had opportunities to review lecture material multiple times and online/email access to the professor. Therefore, the COVID pandemic had no significant impact on RT student’s achievement in mechanical ventilation.

We have observed that clinicians believe there is a difference in oxygen delivery between a standard low-flow nasal cannula (LFNC) and one labeled for high-flow use (HFNC), independent of the oxygen flow setting. In particular, for cannulas made by Westmed, the LFNC is recommended (depending on distributor) for flows of 1–5 L/min, while the HFNC is recommended for flows of 6–15 L/min. Hence, clinicians have come to believe that you need to use different cannulas depending on the desired oxygen flow. The purpose of this study was to test this assumption by comparing FIO₂ delivery for LFNC and HFNC over the range of 1–15 L/min.

An adult mannequin head (Michigan Instruments) was attached to a breathing simulator (IngMar ASL 5000) which is capable of measuring lung FIO₂. The simulator was set to closed-loop volume control mode with V_T = 490 mL, C = 50 mL/cm H₂O, R = 4 cm H₂O/L/s, f = 15, increase = 25%, hold = 0%, release = 30%. LFNC (Westmed 0556) and HFNC (Westmed 0549) were attached to the nares of the mannequin (mouth opening blocked) and run at 5, 10, and 15 L/min (verified with a Citrix H4 flow meter). The experiment was repeated once.

The difference in FIO₂ (%) between LFNC and HFNC was clinically unimportant (see Table).

This study shows that the assumption of needing different types of cannulas depending on flow is false. FIO₂ depends only on source oxygen flow, not cannula design for this manufacturer.

A low-flow nasal cannula (LFNC) is a common device used in the administration of oxygen and has been traditionally used for flows up to 6 L/min. The heated high flow nasal cannula (HFNC) was designed for use with oxygen flow up to 60 L/min and heated humidifier. Recently, manufacturers have introduced a HFNC for use with a bubble humidifier up to 15 L/min. The ISO 80601-2-74:2017 standard for unheated humidification devices specifies that 12 mg/L is the minimum level of humidification for patients whose upper airways have not been bypassed. The purpose of this study was to determine if use of an unheated bubble humidifier for HFNC meets this standard.

A HFNC (Westmed 0549) was attached to the bubble humidifier supplied with it (Westmed 0795) and experiments run at flows of run at 5, 10, and 15 L/min. The humidifier was filled with sterile water. To verify flow, a Citrix H4 flow meter was used to set a medical grade oxygen flow meter and the setup was allowed to reach steady state temperature. Then the Citrix H4 was removed the humidifier was weighed. After 5 h of continuous flow, the humidifier was weighted again. The delivered absolute humidity (mg/L) was calculated as water weight difference divided by delivered volume (flow × time). Each experiment was repeated once.

The absolute humidity decreased as flow increased (see Table). At 5 L/min the bubble humidifier met ISO standards. However, at flows of 10 and 15 L/min the humidifier did not meet the ISO standards.

Humidity produced by an unheated bubble humidifier is only adequate at low flows but may not provide sufficient humidity at higher flows commonly used for HFNC.

Ventilation of two patients with one machine during a ventilator shortage became a popular topic during the COVID-19 pandemic. Our previous study indicated failure of a multiplex circuit to ventilate patients with different lung mechanics in 67% of simulations (PMID: 32345741). Prior studies attempted to solve this problem by manipulating the resistance of the circuit to the patient requiring less V_T. But this method affects the total resistance of the system and changes volume delivery to both patients. We designed an adjustable flow diverter valve (AFDV) to partition flow without affecting the system resistance. The purpose of this study was to evaluate the performance of the AFDV.

Two IngMar ASL 5000 breathing simulators were set to represent identical passive patients (same resistance and compliance). The mode of ventilation was pressure control continuous mandatory ventilation with set-point targeting (PC-CMVs) as in our previous study. The volume delivery to each lung simulator was recorded by the simulators. The AFDV was adjusted from equal V_T to full occlusion of one patient. The AFDV was considered successful in individualizing V_T if volume delivery to patient A did not change while volume delivery to patient B decreased, as the valve was adjusted toward occlusion for patient B. In the full occlusion position, patient B was disconnected from the simulator to determine if there was disrupted ventilation to the other patient.

The AFDV allowed precise control and nearly linear adjustments in volume delivery to one patient without impacting the other (see Figure). When the valve was adjusted for occlusion to patient B, this patient was successfully removed from the ventilator without affecting volume delivery to patient A and without ventilator alarms.

This simulation-based study shows that the AFDV allows individual control of the V_T to one patient without affecting ventilation to the other.

Studies have investigated multiplex ventilation during the COVID-19 pandemic. Our previous study indicated failure of a multiplex circuit to ventilate patients with different lung mechanics in 67% of simulations (PMID: 32345741). Of the four safety problems that must be solved to safely ventilate two patients with one ventilator, individual tidal volume monitoring may be the most important. IngMar Medical designed a prototype auxiliary volume display (AVD-19) to display tidal volume delivery to two patients during multiplex ventilation. The AVD-19 is not currently approved for patient use. The purpose of this study was to evaluate the accuracy of the AVD-19.

Two IngMar ASL 5000 breathing simulators were set to represent identical patients (same resistance and compliance). The mode of ventilation was pressure control continuous mandatory ventilation with set-point targeting (PC-CMVs) as in our previous study. The volume delivery was changed to each simulator with an adjustable flow diverter valve. As the volume distribution between patients was changed, the tidal volume to each lung simulator was recorded by the simulators and compared to the volumes displayed on the AVD-19. The volumes displayed on the AVD-19 were manually corrected to body temperature and pressure saturated conditions (BTPS).

The volume reading from the AVD-19 underestimates actual volume delivery with average error of -17%. However, ISO standard 80601-2-12 says that the accuracy of the delivered volume monitoring equipment shall be within ± 4.0 mL +15% for the actual delivered volume. Therefore, the accuracy range of the AVD-19 (-15 to -24%) was reasonable.

This simulation-based study shows that the AVD-19 can display individual tidal volumes during multiplex ventilation, but for best accuracy would require an adjustment to correct for the error: V_T dosage = desired (mL/kg) x ideal body weight x 0.83.

Ventilation of two patients with one machine during a ventilator shortage became a popular topic during the COVID-19 pandemic. Our previous study indicated failure of a multiplex circuit to ventilate patients with different lung mechanics in 67% of simulations (PMID: 32345741). Four safety problems must be solved to provide practical multiplex ventilation: 1) individual adjustment of tidal volume (V_T), 2) individual measurement of V_T, 3) individual adjustment of PEEP, 4) individual PEEP measurement. The purpose of this study was to evaluate potential solutions developed at our institution.

Two separate IngMar ASL 5000 breathing simulators were ventilated with a modified multiplex circuit using pressure control continuous mandatory ventilation set-point targeting (PC-CMVs). Parameters of the lung models used for simulations (resistance and compliance) were evidence-based from published studies. Individual circuit modification devices were first evaluated for accuracy. The modified circuit was designed to solve the four safety problems above by implementing an adjustable flow diverter valve (AFDV), prototype dual volume display, PEEP valve, and disposable PEEP display. The modified multiplex circuit was assessed by ventilating six pairs of simulated patients with different lung models. The AFDV and PEEP valves were adjusted until both lung simulators received equal ventilation. Ventilation was considered equalized when V_T and EELV were within 10% for each simulation.

The multiplex circuit allowed for adjustments that equalized ventilation to both simulators regardless of differences in resistance and/or compliance, reversing the failure modes of our previous study.

This study shows that our multiplex circuit modifications allow for individualization and monitoring of volume and PEEP to each patient. These modifications allow for safer ventilation of two patients with different lung mechanics in the event of a ventilator shortage.

Children requiring invasive mechanical ventilation are often administered aerosol and airway clearance therapies. Certain modalities require disconnection from the ventilator and some children may be unable to tolerate interruption of ventilation. Intrapulmonary percussive ventilation (IPV, Percussionaire) therapy is frequently used as it delivers both aerosol and airway clearance. A new in-line adapter (True IPV in-line adapter) that remains in the ventilator circuit allows for therapy during ventilation without disconnection. The aim of the study was to evaluate the effects of IPV used with the in-line adapter on respiratory pressures using an in-vitro pediatric lung model and ventilator.

A ventilator (Servo-i, Maquet) was connected in series to a dual limb circuit, 5.5 pediatric endotracheal tube with cuff inflated, flow analyzer, and test lung (ARDS conditions: resistance Rp20, compliance 10 mL/mbar). The adapter was placed in the inspiratory limb of the circuit at the Y-piece. Ventilator settings: RR 20 breaths/min, V_T 100, PEEP 10 cm H₂O, inspiratory time 1 in volume control (VC), pressure regulated volume control (PRVC), and pressure control (PC) modes. IPV settings: pressure 25, and easy or hard percussion. The adapter was closed or 50% open. Respiratory pressures (PIP, MAP, PEEP) were measured at baseline and during IPV. The manufacturer recommends opening the adapter during volume ventilation.

Mean PIP and MAP without IPV were 30 cm H₂O and 16 cm H₂O respectively (all modes). During PC ventilation, pressures were least affected. When the adapter was open, PIP and MAP decreased below baseline (all modes). PRVC and VC had greater changes than PC with a closed adapter. Easy settings resulted in higher PIP than hard settings (closed adapter) but the opposite occurred with MAP. PEEP increased with closed adapter by 1-2 cm H₂O and decreased by half when opened (all modes). Percussion setting did not affect PEEP (open/closed adapter). However, easy settings had a higher PIP than hard settings (closed adapter) but the opposite occurred with MAP.

The use of in-line IPV affects respiratory pressures (PIP, MAP, PEEP). These changes were more evident during PRVC and VC than in PC ventilation mode in a closed system. Keeping the adapter closed resulted in an increase in PIP, MAP and PEEP (VC > PRVC > PC). Opening the adapter 50% resulted in decreased PIP, MAP, and PEEP. The findings in this in-vitro model need to be validated in an animal model before clinical recommendations can be made.

Effect of percussion and adapter setting on PIP and MAP

Effect of percussion and adapter setting on PEEP

Portable oxygen concentrators (POCs) have shown efficacy in delivering adequate oxygen for various patient scenarios; however, there is a lack of research on POCs’ efficacy across different respiratory rates specifically among COPD patients.

This bench study was conducted using the IngMar Medical Active Servo Lung 5000 attached to flexible tubing, which simulated an adult patient’s nares. An oxygen analyzer (Maxtec Handi+) was connected to the tubing 6 inches below the nares to estimate the inspired oxygen concentration at the adult trachea. A standard nasal cannula was placed in the simulated patient nares, which was also attached to each POC. The IngMar Lung was programmed to simulate a COPD patient at the following respiratory rates: 15, 20, 30, and 40 breaths/min. POC devices were then compared to an oxygen wall outlet and a standard oxygen concentrator (non-portable CAIRE device). The POCs included the CAIRE FreeStyle Comfort (with Autosat), CAIRE FreeStyle Comfort (without Autosat), Inogen G4, Inogen G5, Phillips SimplyGo Mini, GCE Zen-O lite, Drive Medical iGo2, and Kingon POCs. Descriptive statistics and ANOVAs were computed to determine statistically significant differences between POCS and control devices (wall oxygen and standalone oxygen concentrator).

Across most respiratory rate scenarios, the wall oxygen and standalone oxygen concentrator (control group) resulted higher oxygen measurements compared to the POCs. Among the POCs on setting 2, the highest oxygen measurement for 15, 30, and 40 breaths/min was the CAIRE FreeStyle Comfort with AutoSat on sensitivity 5 (24.43%, 24.81%, and 25.0%, respectively). On setting 2, the 20 breaths/min highest oxygen measurement was the Inogen G4 (24.43%). For setting 5, the highest oxygen measurement for 15 breaths/min and 40 breaths/min was the CAIRE FreeStyle Comfort without AutoSat (31.56% and 26.13%, respectively), while the highest oxygen measurement for 20 breaths/min was the Inogen G5 (30.26%), and the highest oxygen measurement for 30 breaths/min was the CAIRE FreeStyle Comfort with AutoSat on sensitivity level 5 (27.89%).

The oxygen administered through the wall and the standalone CAIRE oxygen concentrator all delivered higher oxygen levels compared to the POCs (with the exception of the 40 breaths/min scenario on setting 2). However, among the POCs, the CAIRE Freestyle Comfort with AutoSat, CAIRE Freestyle Comfort without AutoSat, and the Inogen G4 all performed the best among the various breathing rate scenarios.

Lung compliance in patients with ventilator management affects the ventilatory status and mortality. However, there are few studies on permanent ventilation dependence (PVD) and time course studies on lung compliance have not been conducted. We aimed to clarify the longitudinal factors affecting lung compliance if there exist the time course deterioration during chronic period in PVD subjects.

A prospective cohort study was performed on 24 PVD subjects on ventilator for about 6 years evaluated twice between 2019 and 2020. We compared static (Cst) and dynamic (Cdyn) lung compliance and alveolar-arterial PO₂ difference (P (A-a)O₂) between the two measurements, and examined correlations in Cst and Cdyn over time with BMI, age, ventilator management days, and the incidence of pneumonia. Subjects were divided into two groups according to the presence of atelectasis, and Cst, Cdyn, and P (A-a)O₂ were compared between the two groups.

The primary diseases of the subjects were central nervous system disorders, such as spinal cord injury, hypoxic encephalopathy, head trauma, subarachnoid hemorrhage, and brainstem infarction, and neuromuscular diseases such as ALS and Parkinson's disease. The comparison of Cst and Cdyn between baseline and follow-up revealed no significant difference. Atelectasis was observed in 13 subjects at baseline, 4 of whom discontinued the study, and the remaining 9 subjects had atelectasis at follow-up without new atelectasis. One subject who had no atelectasis was excluded from the present study because of death. There was no difference in Cst and Cdyn between the groups in terms of atelectasis. In contrast, the values of both Cst and Cdyn slightly decreased in the group without atelectasis and increased in the group with atelectasis over the course of 1 year, and significant differences were noted between the two groups in the values (Table 1). No significant differences were found in the difference in P (A-a)O₂ between groups in terms of atelectasis. A decrease in Cst was related to an increased BMI (r = -0.41, P = 0.047), but P (A-a)O₂, age, ventilatory management days, and pneumonia incidence were not associated with the differences in Cst or Cdyn (Table 2).

Increased BMI affected lung compliance in PVD subjects during one year of chronic period. Regarding atelectasis, its relationship with differences in Cst and Cdyn was not clear and impaired lung compliance was thought to be almost settled in several years of PVD.

Table 1. Cst, Cdyn, and A-aDO₂ t-test by the presence of atelectasis

Table 2. Correlation coefficients for each item with differences in Cst and Cdyn

Respiratory therapists (RTs) perform terminal extubation without consistent preparation of end-of-life (EOL) competencies including assessment, symptom control, therapeutic communication, and multidisciplinary collaboration. High-fidelity simulation is an experiential tool to enhance technical skill and emotional development through learning. Working in the ICU, RTs participate in EOL care of neonates, pediatrics, victims of trauma, covid-19, and chronically ill patients. The aim of this project is to measure if a simulated learning experience can prepare RT students for competency development as well as process their feelings towards caring for EOL patients.

Simulated terminal extubation of a lung cancer patient was performed with 11 RT students. Approval was obtained through the Department of Accountability and Research. Qualitative data was collected immediately utilizing questions based on debriefing for meaningful learning with the program director, simulation coordinator and faculty playing the roles of family members. Psychological safety was monitored. Results were coded for similarity. Quantitative data was collected one week post simulation utilizing National League for Nursing effectiveness questionnaires.

Feeling uncomfortable, awkward, and uncertain as what to do post-extubation are the themes generated from this study. Symptoms and technical procedure were adequately managed. A quiet, dim environment felt supportive to the family. Collaboration happened in roles in which they were trained. 10 of the 11 participants (90.9%) responded to the design survey in the reflection phase. 100% agreed or strongly agreed that the simulation was designed to resemble a real-life situation. Students were able to independently solve problems, prioritize care, goal set, and analyze behavior and actions that build knowledge. Eight of the 11 participants (72.7%) responded to the satisfaction and self-confidence in learning survey in the reflection phase of the program. 100% strongly agreed or agreed that the simulation was helpful and effective, provided a variety of activities to learn, built confidence, and developed skills to perform in a clinical setting.

Clinical simulation was an effective training modality for students to learn EOL competencies prior to licensure. Participants safely discussed their feelings in an effort to process the awkwardness they expressed. Ultimately, this will help therapists cope while performing EOL care during their careers.

Pickens Technical College simulation lab set-up for a terminal extubation scenario.

Interprofessional collaborative practice requires effective teamwork in order to provide safe, patient-centered care. Health care teams are composed of various individuals with specific roles and responsibilities. To fully learn about, from, and with other professionals, exploring stereotypes of specific disciplines may help overcome the barriers these preconceived thoughts may have in providing quality health care.

A group of health science students participated in an online asynchronous interprofessional learning experience during the 2019-2020 academic year. As part of the experience, students were asked to complete a survey addressing stereotypes and implicit bias. Students from public health, nursing, dental hygiene, and pre-physician’s assistants identified stereotypes about respiratory therapists. The approach to the analysis was qualitative and responses were categorized as negative or positive. Data were not analyzed until greater than one year after the completion of the experience. Questions that required a narrative response by students were placed in NVivo 12 Pro software for text and content analysis. Student evaluations of the module were analyzed with descriptive statistics.

There were 47 independent responses for both positive and negative stereotypes. The negative could be classified into six separate themes. The majority of responses pertained to the perceived limited knowledge, education, and scope of practice of respiratory therapists. Additional negative notions were that RTs are frequently unavailable due to workload constraints which prevented meaningful interaction with patients and colleagues. Four main themes surfaced upon evaluating the positive stereotypes. Fifty-seven percent of students commented on the perceived expertise of the respiratory care provider and how the services they offer are essential to improving patient outcomes. Student evaluations of the Stereotypes in Healthcare and Community Health activity revealed that 80% of students felt the exercise was somewhat to very engaging and 92% agreed the exercise was somewhat to very informative.

An open and respectful dialogue among interprofessional learners can lead to better understanding of the roles and responsibilities of each team member, which may then impact the quality of care provided to patients and populations. The findings may also serve to better educate our community on what Respiratory Therapists actually do, being a lesser-known medical profession.

Burnout is a major challenge in health care. Burnout prevalence has not been evaluated in practicing respiratory therapist (RTs). The purpose of this study was to identify RT burnout prevalence and identify factors associated with RT burnout.

A survey was administered to 26 centers or healthcare systems and was administered between January 17, 2021 and March 15, 2021. Validated surveys were used to measure burnout and leadership domains, we developed our own questions for RT staffing and demographics. Data analysis was descriptive and logistic regression analysis was performed to evaluate risk factors, expressed as odds ratios (OR), for burnout.

There were 1114 responses. The response rate was 37%. Seventy-nine percent of individual respondents reported burnout, 10% with severe, 32% with moderate, and 37% with mild burnout. Univariate analysis revealed those with burnout worked more hours per week, worked more hours per week in the ICU, were more likely to primarily care for adult patients, primarily delivered care via RT protocols, did not have adequate RT staffing, were unable to complete assigned work, were frequently exposed to COVID-19, had a lower leadership score, and were less likely to have a positive view of leadership. Logistic regression revealed burnout climate (OR 9.38, P < 0.001), inadequate RT staffing (OR 2.08 to 3.19, P = 0.004 to 0.05), being unable to complete all work (OR 2.14 to 5.57, P = 0.003 to 0.20), and missing work for any reason were associated with increased risk of burnout (OR 1.96, P = 0.007). Not providing patient care (OR 0.18, P = 0.02) and a positive leadership score (0.55, P = 0.02) were associated with decreased risk of burnout.

Burnout was common among RTs in the midst of the COVID-19 pandemic. Good leadership was protective against burnout while inadequate staffing, inability to complete work, and burnout climate were associated with burnout.

ARDS is a most serious and fatal disease in ICUs throughout the world with high mortality rates. Airway pressure release ventilation (APRV) shows significant outcomes when used with ARDS patients resulting in mortality reduction. There are no studies test the knowledge and perception regarding APRV and ARDS besides the APRV prevalence in Saudi Arabia (SA). This study aimed to survey RTs to assess their knowledge and perception of using APRV on patients with ARDS, and to explore the prevalence of using APRV mode in the Eastern Province (EP) of SA. We hypothesized that not many RTs in SA have the knowledge to effectively utilize the APRV mode on ARDS patients.

A cross-sectional study was designed as a self-administered survey based on current literature and research. The population of this study was a non-probability convenience sample. Participants were limited to RTs only. An online link was sent to 116 RTs from 6 hospitals, divided equally into 3 government and 3 private hospitals. After collecting the data, statistical analysis, including the Chi-Square test and the Fisher Exact test were computed to examine differences in APRV knowledge and perceptions between the two types of hospitals. This study was approved by the Georgia State University Institutional Review Board.

A total of 52 returned surveys were received with a response rate of 44.8%. The majority of participants were bachelor’s degree holders (90.2%) who had less than 8 years of experience (78%). RTs had a general level of knowledge about ARDS and APRV mode (63%). Most hospitals in the EP use the APRV mode (96%) and used by more than 80% of the respondents, half of whom had positive outcomes. Patients with ARDS were the most common disease when APRV was applied (98%). Few significant differences were found between the two types of hospital therapists in terms of APRV usage (P = 0.0002 and P = 0.006). However, aspects like APRV-ARDS knowledge, perception, and ARDS protocol and practices showed no significant differences between participants in the two groups.

The vast majority of EP hospitals used ventilators with the APRV mode and most of their therapists have used the mode. This study identified a gap in literature which revealed limited data involving RTs knowledge and perceptions with APRV used as a treatment for ARDS. Further studies on RTs, involving APRV and ARDS in SA are needed with larger sample size and to include multiple regions of the country.

Prior to the COVID-19 pandemic, most patients were administered metered dose inhalers (MDI) using the common canister method at Sarah Bush Lincoln Health Center (SBLHC). During a quality review of processes, a multidisciplinary group estimated the cost of lost doses from budesonide/formoterol MDIs to be $50,255 annually. Despite concerns regarding aerosolized medication during a respiratory pandemic, it was decided SBLHC could safely administer nebulizers with filters and in-line, with proper personal protective equipment, and with negative pressure rooms.

At admission, pharmacy automatically substituted all medications to nebulizers unless the provider chose an exemption reason.

Pharmacy ran reports of the total number budesonide/formoterol MDIs purchased and doses administered in 2018. This information as well as the estimated on-hand inventory were used to determine the estimated number of lost doses for 2018. Lost doses occurred when inhalers were accidently sent home with patients or spacers were unable to be utilized. Our calculations indicated an estimated loss of $50,255 annually due to lost doses. After implementing nebulized medications, pharmacy reviewed the same metrics and the estimated loss dropped to $310 annualized. A cost savings was also realized with the decreased usage of spacers at approximately $12,000 annually. Although most nebulized medications cost more per unit dose, the cost avoidance of lost doses of MDIs was still greater in this case and SBLHC saved approximately $31,400 annualized.

It is important to periodically review processes to determine if the initial values have changed and how to make improvements based on available treatment options and practices. In this study, transitioning to nebulized medications improved patient safety by eliminating the chances of a common canister MDI being administered to the incorrect patient prior to appropriate reprocessing, decreased pharmacy technician work spent reprocessing MDIs, and saved money on spacers. Overall, transitioning to nebulizers was a substantial cost savings to the SBLHC health system. This study only reviewed budesonide/formoterol MDI due to the high cost and use of this medication, but additional cost savings can be assumed with transition of other various MDI’s to nebulized solutions including anticholinergics and short acting bronchodilators. This study was approved by the institutional IRB.

Burnout within healthcare is prevalent and its effects are detrimental to patient outcomes, organizations, and individuals. These include increased prevalence of anxiety, depression, excessive alcohol and drug use, cardiovascular problems, and time off work. Prior data has suggested up to 50% of healthcare workers and up to 72% of respiratory therapists (RTs) experience burnout. Leadership has been cited as a key driver of burnout among RTs. We aimed to identify factors associated with a positive or negative leadership perception.

A post-hoc analysis of an IRB-approved survey to evaluate RT burnout, administered via REDCap by convenience sample to 26 respiratory care departments in healthcare centers from January 17– March 15, 2021, was performed to identify factors associated with a positive view of leadership. Survey questions included validated tools to measure leadership, burnout, staffing, COVID-19 exposure, and demographics. Data analysis was descriptive and logistic regression was performed to evaluate factors associated with leadership perception.

Of the 1,080 responses, 710 (66%) had a positive view of leadership. Univariate analysis revealed those with a positive view of leadership were less likely to be working without adequate staffing, rarely unable to complete all work, less likely to be burned out, disagree that people in this work environment were burned out, less likely to miss work for any reason, less likely to care for adult patients, more likely to be in a leadership position, working fewer hours in intensive care, working in a center affiliated with a medical school, working day shift, and more likely to be male. Logistic regression revealed providing care to COVID-19 patients (OR 5.8 to 10.5, P < 0.001 to 0.006) was the only factor associated with a positive view of leadership while working without adequate staffing (OR 0.27 to 0.28, P = 0.002 to 0.006), staff therapist (OR 0.33, P < 0.001), work environments (OR 0.42, P = 0.003), missing work for any reason (OR 0.69, P = 0.003), and burnout score (OR 0.98, P < 0.001) were associated with a negative view of leadership.

Most RTs had a positive view of their leadership. A negative leadership score was associated with higher burnout and missing work. This relationship requires further investigation to evaluate if changes in leadership practices can improve employee well-being and reduce burnout.

Figure 1 shows the responses to survey questions related to leadership positions and burnout.

The impact of moral distress, burn out, and compassion fatigue has been described in nurses and physicians, but limited data exist regarding respiratory therapists (RTs). We sought to investigate the prevalence of moral distress and burnout in pediatric RTs and extracorporeal membrane oxygenation (ECMO) specialists.

IRB approval was obtained and an anonymous survey was electronically distributed to the Respiratory Care and ECMO departments at Boston Children’s Hospital. The survey was conducted from August 5 - September 20, 2020. Demographic variables were collected and participants were asked about familiarity with compassion fatigue, moral distress, burn out, and self-care. Measurement of Moral Distress for Healthcare Providers (MMD-HP) and a Single Item Assessment for Burnout were collected for each participant. Additional questions included whether or not they felt supported by the department and leadership during traumatic patient care experiences, day to day activities, and if they performed adequate self-care. Categorical variables were summarized using frequencies, percents, or proportions and compared using chi-square or Fisher’s exact test as appropriate. The Kruskal-Wallis test was used to compare MMD-HP between grouping variables. Spearmen correlation was used to assess the relationship between variables.

A total of 57 (67%) of the respondents completed all forms and were included for analysis. Staff characteristics are displayed in (Table 1). Median scores for MMD-HP and burnout were 92 IQR (68.5-133.5) and 2 (2-3) respectfully. Moderate inverse correlations were observed between MMD-HP and perceived support from the department (correlation coefficient -.273; P = .04), leadership (correlation coefficient -.279; P = .036), and reported levels of self-care (correlation coefficient -.314; P = .017).

Pediatric RTs and ECMO Specialists reported moderate levels of moral distress and burnout. We identified that perceived lack of support from colleagues or department leadership and limited self-care practices may negatively influence moral distress. Further research evaluating the specific drivers of moral distress and the modification thereof are essential for designing interventions to mitigate the impact of moral distress within respiratory care departments.

Noninvasive ventilation (NIV) is a common respiratory modality used for patients with acute respiratory failure. It involves use of an oronasal mask, held in place with straps on patient’s face to provide ventilatory support without using artificial airways. NIV use for longer duration and mask strap tension are associated with increased risk of skin breakdown at the nose bridge as well as cheeks, leading to reportable medical device-related injuries. The development of medical device-related skin injuries among hospitalized patients is a growing concern. The primary aim of this quality improvement project was to reduce the incidence of NIV related reportable, pressure ulcers among adult patients with acute respiratory failure.

This was a collaborative, quality improvement (QI) project conducted at an academic medical center from July 2018–June 2020. All adult patients who received continuous NIV for acute respiratory failure were enrolled. The QI plan was devised to include key drivers of change: 1) prophylactic use of a foam dressing (Mepilex Lite) at the initiation of NIV; 2) Q4H skin assessment by bedside nurse and respiratory therapists, and 3) mask rotation for patients receiving NIV > 24 h. Mask rotation refers to sequential use of different masks (eg, oronasal to full face mask) to offload and redistribute the pressure on the underlying skin. The incidence of reportable, stage II and above, hospital acquired pressure injuries related to NIV mask occurred during pre-QI phase (July 2019–June 2019) were compared with the post- QI phase (July–June 2020).

During the pre-implementation phase, a total of 8 NIV mask-related, Stage II and above, skin injuries were reported (incidence rate 0.04 per 1,000 patient days). In the post implementation phase, there were total 2 NIV mask-related, Stage II and above, skin injuries identified (incidence rate 0.01 per 1,000 patient days). With the QI plan focused on the prophylactic measures and collaborative efforts between respiratory therapists and nurses, reportable NIV mask related injuries were reduced by 25%. The median Braden Score for pre-QI cohort was 14.5 (IQR 14.5–15) and 13 (13–13) for post-QI cohort representing moderate risk level for developing pressure sores in both the groups.

The bundle-based QI plan including prophylactic foam dressing, Q4H skin assessments, and mask rotation was beneficial in reducing the incidence of NIV mask-related, reportable skin injuries in an adult population.

Although there are more AS degree programs in the US, research into the academic success of respiratory care students has primarily focused on the baccalaureate level respiratory care programs. The purpose of this study is to determine the relationship between student age, academic performance, and the National Board for Respiratory Care Secure Self-Assessment Exam (NBRC SAE) scores in an accelerated associate degree respiratory care program.

This retrospective study used existing student records from the Department of Respiratory Therapy at Concorde Career College in San Antonio. Student records and demographics were collected from 37 students enrolled from 2016 through 2020. Age, student scores on RT 210, RT 250, and NBRC Secure SAE were collected from the student records to determine the relationship between student academic performance in the RT 210 and RT 250 courses as well as NBRC SAE. A Pearson product-moment correlation was performed to determine the relationship between age and academic performance. The P-value less than 0.05 was considered statistically significant.

There is no significant correlation between age and students’ academic performance in RT 210 (P = 0.43), RT 250 (P = 0.86), and the NBRC SAE (0.79). The results of this study reveal a positive correlation between the RT 210 and RT 250 course grades (r = 0.725, P < 0.001) as well as between the NBRC SAE and the students’ grades in RT 210 (r = 0.744, P < 0.001) and RT 250 (r = 0.789, P < 0.001). For example, the correlation between the RT 210 grade and RT 250 grade was 0.725 (P < 0.001) indicating that students’ grade in RT 210 (r = 0.725, P < 0.001) was responsible for 52% of the variation in the RT 250 grade. Similarly, the grade obtained in RT 210 (r = 0.744, P < 0.001) accounts for 55% of the variation in the NBRC SAE score. The findings of this study also revealed that 62% of the variation in students’ NBRC SAE scores can be explained by their grade in RT 250 (r = 0.789, P < 0.001).

There is a positive correlation between students’ performance in RT 210 and RT 250 as well as students’ grades in these courses and the NBRC Secure SAE. No relationship was found between student age and academic performance in an accelerated associate degree respiratory care program.

The COVID-19 pandemic stretched respiratory therapy resources as never before. It was identified early on that respiratory therapists (RTs) were the most valuable asset in the fight against this pandemic. But continued use of RTs performing non-value added (NVA) procedures would have a direct impact on the ability to care for the increase in COVID patient volume and acuity.

Using Lean methodology (A3, root cause analysis, and team huddles) select RT procedures were evaluated for value, effectiveness, and efficiency. NVA items were described as those that had no impact to patient outcomes, those that can be transferred to other departments, or waste in procedures that were considered value added. Once identified, collaborative action planning was used to eliminate or reduce waste. Procedures and processes that were eliminated or optimized included: nebulizer to MDI conversion, incentive spirometry, continuous pulse oximetry orders, positive expiratory pressure therapy, frequency of trach rounds, nocturnal CPAP, and medical record redundancies. The time reduced or eliminated was equated to RTs saved per shift, thus Full Time Equivalents (FTEs).

October–November 2020, ideas to reduce NVA work were elicited at tier 1 (clinician) and tier 2 (leadership) huddles. During this time, 32 ideas were submitted. General floor workload data was retrospectively collected and compared: November 2019–February 2020 (pre COVID) vs. November 2020–February 2021 (COVID). The COVID cohort observed a general floor volume decreased by 37.3%. NVA reduction time saved was 44.2 h per day which equated to 5.9 RTs per day (8.6 FTEs). This workload was reduced in spite of an 849% increase in acute high flow oxygen use on the general floors.

COVID-19 highlighted a problem that has plagued the respiratory care profession for many years. RTs delivering NVA procedures equates to poor outcomes, increased expense, and de-values respiratory therapists. The true value of an RT is not how many procedures can be completed, rather the impact they have on the patient's outcome. In the face of an unprecedented RT shortage, we hypothesize that if this philosophy is ignored by hospital leaders, we will continue to employ RTs in areas that they are not needed, thus continuous erosion of the respiratory care profession.

This novel approach to aerosolization of simulated viral spread allows for continued natural interactions and maneuverability within team-based respiratory and cardiopulmonary arrest scenarios. To mimic viral spread, our simulated model emanated GloGerm from the respiratory tract. Our unique model allowed for realistic team responses such as bag-mask ventilation, endotracheal intubation, and Cardiopulmonary Resuscitation (CPR) allowing for observation with a blacklight at simulation conclusion of particle containment or spread in true arrest scenarios.

We modified a Laerdal ResusciAnne QCPR mannequin (Stavenger, Norway) to emanate simulated virus particles (GloGerm, Moab, UT) from the oropharynx. A Vyaire Airlife Nebulizer was retrofitted to emulate the powdered GloGerm. This allowed the powder to emanate from the mannequin’s mouth, but remained ‘invisible’ to mimic viral shedding. Slow continuous emanation of simulated virus from the oro- and nasopharynx was used to replicate aerosolized respiratory particles without the need for a human subject.

Contamination outcomes include the number of contaminated protective equipment and distance of furthest contaminated object. Out of n = 43 respondents from 13 scenarios, the team and the room were evaluated for contamination there after using a blacklight to expose fluorescent simulated virus particles.

Our model was successful in visualizing particulate spread Pre & Post CPR. Unlike other models, our simulation allows for full team-based CPR simulations to occur creating a more realistic simulation during the COVID-19 pandemic. While some participants felt protected from the contamination due to their PPE, other participants focused on strategies to further minimize future contamination. Future innovations of a simulated virus could be replicated for further research studies and projects in a modified mannequin limiting live test subjects.

When tracheostomy-dependent pediatric patients are hospitalized due to tracheitis, pneumonia, or other respiratory infections, there is insufficient evidence to support tracheostomy tube replacement prior to obtaining a respiratory culture. The lack of evidence has led to inconsistent practice across the institution and may have implications regarding antibiotic exposure for these patients. The purpose of this study was to investigate differences in microbial growth between cultures obtained before and after changing the tracheostomy tube.

This quasi-experimental, IRB approved prospective cohort study enrolled 38 tracheostomy-dependent pediatric patients [between the ages 0-17.99] accompanied by a consenting caregiver presenting in the Emergency Department or acute medical-surgical unit. Pre-tracheostomy and post-tracheostomy tube change respiratory cultures were obtained and examined. Descriptive statistics were done to characterize the sample in terms of demographics, details of presenting signs and symptoms, and differences in the profile of microorganisms in the pre- and post-tracheostomy change cultures. Chi-Square analyses using a McNemar’s test were performed to analyze differences in gram stain results in the pre- and post-cultures.

Among 60 eligible patients screened, 11 were excluded due to lack of team member availability; of the 49 approached, 42 were enrolled, while seven declined. The total number of participants with complete data is 38, and four participants were withdrawn for the following reasons: failure to meet inclusion criteria after preliminary screening, loss of specimen sample by laboratory, and inability to perform study procedures due to lack of time and patient acuity. The WBC amount seen in the pre- and post-cultures was significantly different (P = 0.012). Specifically, 10 patients (26%) were noted to have moderate or many WBCs in their pre-tracheostomy change culture and subsequently rare to few WBCs observed in their post-culture. In the pre-cultures, 49 organisms were identified (35 gram negative, 13 gram positive, and one fungus), versus 34 in the post-cultures (25 gram negative, 9 gram positive, 0 fungus).

We observed differences in cell count and bacterial growth when pre- and post-trach change cultures were compared. Given these results, changing the tracheostomy tube prior to obtaining a respiratory culture should be considered. Future research is needed to confirm these findings with a larger sample size.

It is well known that patients with chronic respiratory diseases struggle in most activities, while they are sleeping, and in their daily life. While, these diseases cannot be cured, they can be managed, for example through pulmonary rehabilitation. Patients with chronic respiratory diseases suffer from sleep disturbance, but their sleep quality is still unclear. Therefore, this study aims to assess the quality of sleep among patients who attend pulmonary rehabilitation department in King Abdulaziz Medical City.

The study design was a descriptive, prospective, case series. Sample size was based on the medical files from 21 patients referred to pulmonary rehabilitation department between September 2019 to November 2019 were reviewed. Only 9 patients answered a sleep quality questionnaire (Pittsburgh Sleep Quality Index [PSQI]), and the Borg dyspnea scale.

In this initial analysis which included 9 female and male patients, all of whom responded to the questionnaire, with known underlying respiratory diseases who were enrolled in pulmonary rehabilitation. The finding suggested that the median age of the sample was 73 y (IQR 58–79 y). Additionally, we categorized the subjects according to their underlying respiratory disease, out of the 9 patients who answered the questionnaire. Therefore, participants who scored <5 were categorized as having good sleep quality. All participants scored above 5, which indicate overall poor sleep quality. Also, among all the enrolled patients, the score of the sleep quality was >13 for 3 of them, 2 of whom had interstitial lung disease.

In conclusion, this study emphasizes that most patients who suffer from pulmonary diseases have a poor quality of sleep.

Vyaire Medical has recently created an open-faced oxygen mask, Vyaire Open (VO) that is designed to direct flow towards the nares and mouth via multiple jet orifices. The manufacturer claims that this device is superior in tracheal FIO₂ delivery across a range of flow. This suggests that it eliminates the need for usage of multiple oxygen delivery devices as a patient’s FIO_{2 requirements change. The VO specifies flow (1–15 L/min and flush) and expected FIO2 from 0.25-0.85. The purpose of this study was to compare FIO2 performance between the VO and standard oxygen masks.}

The following oxygen masks were compared to VO: A simple mask (Vyaire), OxyMask (open design from Southmedic), partial rebreather (Vyaire), and non-rebreather (Vyaire). An adult mannequin head (Michigan Instruments) was attached to a breathing simulator (IngMar ASL 5000) which recorded FIO₂. Each mask was sealed to the mannequin head to prevent leaks. The simulator was set to closed-loop volume control mode with V_T = 320 mL, C = 50 mL/cm H₂O, R = 4 cm H₂O/L/s, f = 15, increase = 25%, hold = 0%, release = 30%. Each oxygen mask was run at the recommended flows: simple mask 5–10 L/min, OxyMask 1–15 L/min, flush, partial rebreather and non-rebreather mask 10–15 L/min, flush. Each flow was verified with a Citrex H4 flow analyzer (imt Medical) prior to attaching the mask for FIO₂ measurement. Each experiment was repeated once.

For VO: at low flows (1–6 L/min) the measured FIO₂ was higher than that specified by the manufacture, at flows 7–10 L/min the measured FIO₂ was within the specified range, and at flows >10 L/min the FIO₂ was below the specified range (see graph). The results for FIO₂ across all devices are shown in the table.

In this simulation study we found the measured FIO₂ for VO varied from the manufacture’s specifications in the package insert. As expected, performance varied greatly among devices. The FIO₂ was generally higher for the VO than the OxyMask. The simple mask outperformed both VO and OxyMask. Finally, both the partial and non-rebreather outperformed all the other devices. This study reinforces the notion that oxygen delivery cannot be reliably predicted and must be titrated using blood saturation measurements.

COVID-19 impacted respiratory care education and faculty were scrambling looking for new, innovative, and engaging teaching and learning strategies. Gamulation has been used in corporate America, business schools, and healthcare administration education, yet has not been studied in respiratory care leadership education. Gamulation is a type of avatar experience that places students in real life situations that must be dealt with in a timely manner using a logic model. This type of learning has been reported to be effective. This

IRB was submitted and determined exempt. Gamulation was developed to measure leadership characteristics using a logic model. After completing course content focused on leadership and management, this activity was last in the course schedule. Students were assigned the gamulation as a course activity and had 2 hours to complete the gamulation. Student perception questions were presented first to learn students experience with other avatar type gamulation. The gamulation placed students in three scenarios: Chief Operations Officer, Chief Financial Office,r and Director of Respiratory Care. After the gamulation, perception questions of the experience as an earning tool were asked. All data were deidentified and analyzed for descriptive analysis.

All students (n = 44) completed the gamulation. Of the 44 students, 13.6% n = 6) scored highest in caregiver category, while 6.8% (n = 3) scored highest in the patient focused category and 2.2% (n = 1) scored highest in strategic thinking category. More than half of the students (n = 30) felt that the gamulation was too long, while 75% of the students (n = 33) felt the gamulation was easy to use and understand.

Gamulation is an engaging tool capable of identifying leadership characteristics in BSRC students. The use of gamulation may be further researched across all BSRC programs.

Compassionate extubation (CE) is the process of removing mechanical ventilation and allowing a patient to die peacefully at the end of life. After conducting a 3-month review of our CE practices (baseline), we developed a CE protocol to address gaps in the clinical practice. The primary aim of this quality improvement (QI) project was to assess the use of a protocol-based approach to improve the process of CE among adult patients.

Based on the baseline data (n = 62), a CE protocol was designed to include key drivers of change: 1) identify patients at high risk of dyspnea associated respiratory distress, 2) improve ventilator weaning process and symptom management, and 3) increase chaplain and physician presence during ventilator withdrawal. The protocol was piloted in the medical intensive care unit from November 2020 to February 2021. All adult patients who underwent CE during the pilot period were enrolled. Manual chart review was performed to gather demographic data, ventilator settings, and symptomatology. A Likert scale was used to assess respiratory therapists’ (RT) level of emotional discomfort during CE. Our QI goals were to reduce the presence of agonal breathing by 12%, increase ventilator weaning by 39%, increase physician presence by 11% and increase chaplain presence by 31%. Results were analyzed using descriptive and Chi-square statistics.

In this pilot study, 15 patients underwent CE. As compared to the pre-cohort, physician presence increased by 7.3% (19.4% vs 26.7%), chaplain presence increased by 33.9% (19.4% vs 53.3%), ventilator weaning increased by 49% (11.3% vs 60%) and incidence of agonal breathing was reduced by 5.6% (32.2% vs 26.6%). Among RTs, level of emotional discomfort during CE increased by 31.2% (35.5% vs 66.7%). There were no statistical differences noted among these changes.

Utilizing a QI process to address variability in the practice of CE, we developed a CE protocol. Implementation of this protocol was shown to be feasible, and we made progress toward our goals of increasing ventilator weaning frequency and reducing agonal breathing and increasing physician and chaplain presence during CE. Next steps in the QI process include performing a root cause analysis to assess why physician presence did not meet desired goal, updating and re-evaluating the protocol. Further evaluation as to the cause for increase in RT emotional discomfort is also warranted.

In our health system, respiratory therapists (RTs) bill for services as they document within the electronic medical record (EMR). In the USA, hospitals lose millions of dollars in revenue annually because of documentation errors,¹ and this is true in our institution. After using LEAN principles to increase our EMR utility in 2019, RT errors remained plentiful and resulted in financial impact.

An RT auditor role was posted and filled internally as a trial. The RT was experienced in RT policies, procedures, and charting. Minimal training was performed prior to the start of the role. The RT auditor trial began 11/1/2019, and ended 1/31/2020, during which time, the auditor worked 3:00pm–11:00pm Monday through Friday and reviewed charting and charges for the prior 24 h for all inpatients in our facility with respiratory services. At the end of the trial period, an IRB approved survey was sent to staff within the respiratory care department to determine impact and perceptions related to the auditor role and overall trial effectiveness (Table 1).

The RT auditor was successful in reducing charge errors by 79% (January 2020 versus January 2021), translating to over $600,000 in increased gross billed revenue during the trial period. The staff survey received a response rate of 55.5% (n = 55). Overall, 87.3% of RTs surveyed had been contacted by the RT auditor for charge related documentation opportunities. 98.2% of staff had a positive perception of the RT auditor role and 92.2% reported that they felt the role was effective. 92.5% of staff reported that a non-clinical associate in this role would have been less effective. 67.92% of respondents reported that feedback obtained from the auditor changed their practice and 43.4% felt the auditor assisted in education of department policies and practices. On a Likert scale of 1–5, the staff rated the RT auditor’s overall effectiveness at 4.7.

An RT auditor successfully aided in reducing charge errors in real time while maintaining positive perceptions from RT staff providing clinical care. More studies must be done to evaluate the full-time impact of positions such as this in a variety of healthcare settings. Reference: Koshy S. Documentation tips for pulmonary medicine - implications for the inpatient setting. Chest 2012;142:1035-1038.

In 2018, our respiratory department noted large losses of revenue due to incorrect staff documentation. A continuous improvement project was completed in December 2018 in order to streamline documentation in an effort to increase revenue generation. While charge errors were reduced after documentation changes numerous opportunities were still missed that decreased gross revenue. We aimed to evaluate the impact of an auditor on gross billed charges within our department.

A trial position was created, where an internal RT candidate (fully oriented and experienced staff RT) transitioned into a full time RT auditor role (11/1/2020–1/31/2021). Minimal one-on-one training was completed with the clinical instructors of the respiratory department. The auditor worked 3pm–11pm, Monday- Friday, to capture both dayshift and nightshift documentation in real time. IRB approved retrospective financial analysis was completed to assess the financial impact of the RT auditor. Errors were categorized by total errors (TE) and not-billed errors (NB). TE included any charge related discrepancies (eg, no order, not documented, documentation frequency) and NB-included errors where only the charge was missing from documentation.

In comparison to the same months in 2019, the hospital claims audit team found 43% less TE and 53% less NB in the 2020 trial months. January 2021 had 53% fewer TE with 79% fewer NB than January 2020 (Figure 1). Of note, the workload units were 8% less in Nov–Dec 2020 versus 2019 and 20% less in January 2021 versus 2020. After trial completion, we analyzed documentation errors and revenue generation for the following month. In the month following the trial (no RT auditor), there was a 48% increase in NB. The real time RT auditor was able to produce an increased gross billed revenue from chart auditing by $341,000 in 3 months.

The real time RT auditor was able to produce increased gross billed revenue from chart auditing. The position required minimal training, and revenue gains well outpaced expected clinical productivity of the RT auditor. Aside from increased revenue, there was a decrease in documentation errors, increased quality of RT documentation and recognition of improvement by our hospital’s claim auditor manager. The utility of this position and high benefit of a fully trained RT auditor, raises a potential new career opportunity for respiratory therapists.

Figure 1 shows the number of audit findings by the claim anaysts (reviewed after patient discharge and prior to insurance billing) during the real-time RT auditor trial period.

Pressure injuries (PI) occur often in healthcare and cost billions of dollars annually in the U.S. Device-related PIs (DRPI) occur in up to 41% of hospital admissions. Up to 35% of DRPIs are caused by respiratory equipment. In our pediatric institution, we saw numerous respiratory related DRPIs that were not reported but required intervention. We aimed to increase early reporting of respiratory DRPIs.

A Pressure Injury Prevention Task Force (PIPTF) was formed in Q3 of 2019. The PIPTF included multi-disciplinary team members including RNs, RTs, MDs, and wound care. The task force utilized existing tools to provide re-education related to pressure injury reporting, prevention, and notification. These tools included our NIV Skin Assessment Algorithm (Figure 1) and electronic health record notification for wound care referral and documentation. The PIPTF also reviewed pressure injuries as they were reported in real-time in order to offer expert insight and evaluate our processes from a continuous improvement perspective. In an IRB approved, retrospective analysis, from 1/1/2018 to 4/30/2021, we reviewed the incidence and prevalence of respiratory related DRPIs, and initial PI stage to evaluate the effectiveness of our processes and re-education efforts.

In 2018, we had 1 reported respiratory-related DRPI that was stage 2. In 2019, there were 13 reported respiratory-related DRPIs, 61.5% of these reported injuries occurred in Q3 and Q4 of 2019 which coincides with the PIPTF re-education efforts. In 2019, the number of reported respiratory-related DRPIs in 2020 increased to 26 (66% increase when compared to 2019). In 2021 (1/1-4/30), there has been 1 reported respiratory-related DRPI. A reduction in unstageable pressure injuries was also noted when comparing 2019 to 2020/2021. Contributing device and PI stage information for reported events is shown in Table 1.

A multidisciplinary PIPTF can influence pressure injury prevention. While an increase in reportable DRPIs is not ideal on the surface, many of these injuries would have been unreported previously. The reduction in unstageable DRPIs could align with earlier detection of PIs and will be explored. Further studies must be done to evaluate the effectiveness of this model in other patient populations.

Figure 1 shows the skin algortithm used for patients with non-invasive orders in our facility.

Unplanned extubations (UE) affect respiratory gas exchange, length of stay (LOS), and ventilator days (VD) unfavorably. UEs in children contribute to consequential morbidity and mortality, with an arbitrary benchmark target of less than 1 UE per 100 VD. Age, gender, increased salivary secretions, intubation duration, nursing attentiveness, endotracheal tube fixation method, and sedation are all contributing factors referenced in the literature. After reviewing our practices in 2018 with a rising UE rate of 0.20/100 VD and in 2019 with a UE rate of 0.22/100 VD, we created a multidisciplinary team to reduce UE in the cardiac intensive care unit (CICU). We focused our efforts on standardizing a process for preventing UE in the CICU using a UE prevention bundle that included multidisciplinary elements. A secondary target was to maintain the decrease in UE rates through continuous improvement processes.

In an IRB approved retrospective analysis, data was analyzed from 1/1/2018 to 4/30/2021 for number of UEs per 100 VD. After review in 11/2019, a UE bundle was implemented in 2/1/2020. We placed emphasis on patients ≤ 5 kg, as their UE rate was higher than the unit average (0.44/100 VD). An identification system for high-risk patients was created and included patients with oral endotracheal tubes, < 2 kg, and any barriers to tube securement. The UE bundle components are included in Figure 1 and this was posted at the patient bedside. Nasotracheal intubation was defined as the preferred method for all intubations unless contraindicated. High risk patients were identified with a red bedside sign. Audits were completed twice weekly by RTs to verify compliance to the UE bundle elements. Data and barriers were reported at daily CICU huddles and at the monthly CICU Quality and Safety meeting.

UE rate from 2018 and 2019 was compared to 2020 and 2021 (Table 1). The UE rate for 2018 and 2019 was 0.21/100 VD. In 2020, the CICU UE rate was 0.00/100 VD. The current CICU UE rate (1/1–4/30) for 2021 is 0.037/100 VD.

By utilizing a multi-disciplinary work group and UE bundle in the CICU, UE rate decreased 82.38% (2018/2019 vs. 2020/2021). We continue to use a continuous improvement process to enhance our UE bundle to maintain a goal UE rate of 0.00/100 VD. Further studies must be done to evaluate the effectiveness of these types of interventions in other patient populations.

Figure 1 shows the UE bundle card that is placed at the bedside.

There are limited pediatric data evaluating the use PEEP/FIO₂ combinations. We aimed to describe PEEP/FIO₂ use in pediatric ARDS (PARDS) patients in relation to a PEEP/FIO₂ table modified from the ARDSNet protocol in the first 7 days of PARDS.

Data was utilized post-hoc from a before-and-after comparison study of lung protective mechanical ventilation (MV) strategy in children with PARDS. Time-matched PEEP and FIO₂ combinations for the first 7 days of ARDS were described in relation to the protocol. We calculated how far the set PEEP for a given FIO₂ was from the protocol recommended PEEP. We took the summative score over the 7 days of PARDS diagnosis for analysis. Logistic regression was used for the main outcome of PICU mortality adjusting for low tidal volume ventilation (3–6mL/kg).

We identified 138 children with PARDS who required MV from January 2016 to June 2019. Median OI on day 1 was 10.7 (IQR 7.6–16.6). Patients were on conventional MV on 507/808 (62.8%) of PARDS days. PEEP/FIO₂ was within protocol limits for 283/507 (55.8%) days, too low on 150/507 (29.6%) days and too high on 74/507 (14.6%) days. 60/133 (45.1%) patients had a summative PEEP/FIO₂ score below that recommended by the modified protocol. A summative score below recommendation was associated with increased PICU mortality [15/60 (25.0%) vs. 13/73 (17.8%); P = 0.311], though this was not statistically significant. After adjustment for low tidal volume ventilation, the summative score was not significantly associated with mortality [odds ratio 0.97 (95% CI 0.90–1.03)].

A PEEP/FIO₂ combination table adapted from the ARDSNet protocol in patients with PARDS was adhered to on roughly half of ventilation days, but this was not associated with improved survival.

Rheumatoid arthritis (RA) is a systemic autoimmune disease affecting the joints with extra-articular manifestation. The current literature has suggested an increased risk of RA among patients with obstructive pulmonary disease; thus, both conditions have common risk factors, including tobacco use and obesity. Describing this relationship would help to assess obstructive pulmonary disease risk among patients with RA for early intervention and establish pulmonary rehabilitation and self-management education programs. However, the evidence regarding this association is still obscure. The current study aimed to assess the association between obstructive pulmonary disease and RA in a hospital-based case-control study.

A matched case-control study was performed utilizing the electronic database from tertiary care center in Saudi Arabia between 2016 and 2020. Adult patients who have been diagnosed with RA were matched on age and gender to control patients without RA. Data on the obstructive pulmonary disease were assessed before the date of RA diagnosis, including asthma, chronic obstructive pulmonary disease, chronic bronchitis, emphysema, and bronchiectasis. In addition to other data related to lifestyles and other comorbidities were collected. Logistic regression models were used to compare study groups.

The study included 304 RA cases and 1,182 controls. The mean age was 48 ± 16 for both cases and controls, with 50% female patients. The prevalence of obstructive pulmonary disease was higher in cases compared to control [11.8% vs. 7.4% %, P< 0.013, odds ratio (OR) 1.67, 95% CI 1.11-2.52]. After controlling for confounders, including smoking, obesity, and comorbidities, the adjusted OR was 1.37 (95% CI 0.83–2.27).

In this case-control study, RA was found to be associated with obstructive pulmonary disease. From a clinical point, both obstructive pulmonary disease and RA reduce mobility; therefore, respiratory therapists need to be aware of their concurrence to start early management programs such as pulmonary rehabilitation and smoking cessation.

In 2016, our institution developed an outreach education program (OEP) that provides pediatric medical education to hospitals in the region (Pennsylvania, Delaware, New Jersey, and Maryland). The OEP goal was to increase pediatric critical thinking skills in a fully interdisciplinary, non-judgmental, hands-on fashion by providing pediatric education, pediatric mock codes, and debriefings. After noticing a growing need to include a respiratory-focused critical care scenario, respiratory therapists (RTs) were asked to join the OEP to perform respiratory education and pediatric mock codes. RTs began providing education as part of the OEP in 2017. We aimed to evaluate the impact of RT involvement on the program by reviewing number of RTs in attendance at OEP external pediatric mock codes and overall satisfaction of offerings.

RTs began accompanying intensive care physicians to outside facilities for outreach education in 2017. In addition, RTs were involved in scenario planning, education, and debriefing in relation to all OEP activities. The OEP coordinator marketed RT involvement to partner facilities in 2017. The OEP began tracking attendance by discipline in 2018. In 2021, an IRB approved, retrospective review of surveys and data collected from the Nemours OEP was completed.

RTs provided mock code simulations with the OEP in 8 different facilities, with over 14 offerings from 2018-2020. Post OEP event survey responses (n = 2,916) indicated that all participants (RNs, RTs, MDs), felt the activity was appropriately challenging, was fit for their level of training, that they would participate in the program again and they plan to incorporate learnings into practice. RT attendance increased 900% from 2018-2019. All offsite, in person, OEP activities were halted as of March 31, 2020 secondary to the COVID-19 pandemic.

RT involvement in the OEP significantly increased RT attendance at educational offerings from 2018 to 2019. There was no statistically significance difference in OEP satisfaction. COVID-19 impacted the number of OEP offerings available in 2020. Virtual education was provided for lectures, but we were unable to successfully complete full pediatric mock-codes in a virtual atmosphere. Further research must be completed to fully understand RT impact in outreach education.

Figure 1 shows the attendance and survey response rates from participants, by dsicipline from 2016-2020.

The incorporation of clinical simulation (CS) in healthcare curriculum is relatively new, more specifically to respiratory care (RC). CS and standardized patient (SP) encounters are increasingly utilized to assess and prepare students for patient care in programs such as nursing, dental and medical schools. Preparation for this simulated experience has been offered in person for several years in our Division of RC. During the global COVID-19 pandemic, much of education has shifted virtually and daily human interactions are complicated by safety protocols and fear of viral exposure. The aim of this study was to determine if the COVID-19 pandemic impacted the UT Health San Antonio Respiratory Care’s first-year students' SP encounter performance when compared to pre-pandemic groups.

This was a retrospective review of faculty evaluations of respiratory therapy student (RTS) performance from a patient-encounter database. RTS (Bachelor's and Master's degree) engaged in an encounter with a SP presenting with cough and shortness of breath. The evaluations included 2018-2019 (pre-COVID group) and 2020 (COVID group). Faculty graded 54 different tasks (scale 1-100) to comprehensively assess interviewing skills during the simulated encounter. IRB approval was obtained.

Scores from 142 students were included in the study. The COVID group scored lower on 28 (51.9%) of the 54 areas evaluated compared to pre-COVID group and in 19 (73.1%) of those areas there was a ≥15% decrease in scores. A significant decrease (P< 0.05) was found in areas such identifying themselves or their role (96.9% vs. 15%); offering water/tissue to SP when coughing (71.6% vs. 39.4%); asking for onset of symptom (69.3% vs. 33.3%); asking about health screening (65.85 vs. 46.9%), sleep quality (60.4% vs. 28.8%), diet (74.3% vs. 50%), weight changes (44.7% vs. 13.6%), and hobbies (47.7% vs. 21.2%).

This study demonstrated that RTS performance in this preclinical simulated encounter was negatively impacted by the COVID-19 virtual learning. Decreased in the face-to-face learning experience during the COVID-19 pandemic can negatively impact teaching of other academic areas of respiratory care programs and student performance.

Tidal volume (V_T) selection for adult patients should be based on ideal body weight (IBW); however, this method is not routinely practiced. Instead, the V_T is often set arbitrarily or calculated based on actual body weight (ABW). Inappropriate selection of V_T may result in hypoventilation and patient-ventilator asynchrony (V_T ≤ 6 mL/kg) or can induce lung injury (V_T ≥10 mL/kg). A low tidal volume ventilation (LTVV) or lung protective strategy has been defined as V_T 6-8 mL/kg based on IBW. The aim of this study was to evaluate if selection of V_T in a group of mechanically ventilated subjects was based on a LTVV strategy. The secondary aim was to determine if there was a correlation between V_T selected and higher oxygen requirement.

This was a retrospective cohort study performed on subjects admitted to a medical ICU at a level-1 trauma center in San Antonio, Texas during the month of March of 2021. The study evaluated subjects ≥18 years of age, intubated, and mechanically ventilated ≥ 48 h. Ventilator parameters recorded included: V_T, respiratory rate (RR), fraction of inspired oxygen (FIO₂), minute volume (MV), PEEP, and IBW. Higher oxygen requirement was arbitrarily defined as PEEP ≥ 5 cm H₂O and FIO₂ ≥ 0.5. Descriptive statistics (mean/SD) were used to report results and a Pearson test to report correlation. IRB approval was obtained.

A total of 50 subjects meeting criteria were selected for analysis. Using IBW, the V_T selected was 7.2 ± 1.6 mL/kg (range: 5.3 - 9.8). Eight subjects (16%) received a V_T < 6 mL/kg (5.71 ± 0.2) while 13 patients (26%) received a V_T > 8 mL/kg (8.94 ± 0.58). The mean V_T selected for these patients based on ABW was 5.6 mL/kg (± 1.86). The single most often selected V_T ranged from 450 and 500 mL (n = 36; 72%). Fifteen patients (30%) had a PEEP > 5 cm H₂O while 38 patients (76%) required FIO₂ > 0.5. Patients on high oxygen requirement represented 28% (n = 14) of the study population. There was no correlation between high-oxygen requirement and V_T selected (r = 0.08).

This study suggests that a LTVV-strategy was routinely used to select the V_T in patients admitted to the medical ICU. This probably explains why patients with high oxygen requirements did not require additional adjustments on V_T. Although utilizing LTVV in lungs without injury appears theoretically attractive, more support from large-scale trials is necessary.

Albuterol (ALB) is the most commonly prescribed aerosolized medication worldwide. Although a relatively safe medication, its use without a clear indication could be associated with unwanted side effects, addition of unnecessary time to therapy and overall cost to the respiratory care department. The aim of this study was to evaluate if ALB utilization was associated with documented indications including diagnosis and physical exam.

This was a retrospective review of electronic medical records (EMR) of subjects ≥18 y admitted to an adult floor unit who received at least one dose of ALB at a Level-1 Trauma Center in San Antonio, Texas. Demographic information, history of COPD and asthma, admission diagnosis, use of bronchodilators, frequency of administration, and bilateral breath sounds (BBS) via auscultation were recorded for analysis. Descriptive statistics were used to report data. IRB approval was obtained.

A total of 50 EMR from subjects with a mean age of 60 y (± 18; range: 18–88) were reviewed for the study. A small percent of subjects who received ALB had a diagnosis or history of asthma (16%) or COPD (22%) while 46% reported history of allergies. Shortness of breath was the most common diagnosis for subjects receiving ALB (26%), followed by hypoxemia (14%), COVID-19 (12%), stroke (12%). Only 2% of subjects had a diagnosis of asthma and 4% of COPD exacerbation. The most commonly documented BBS prior to ALB were clear (60%) or diminished (42%). Only 4 subjects (17%) while 20% reported coarse breath sounds. ALB plus ipratropium was ordered for 26 patients (51%). Some other subjects received Symbicort (8%), Pulmicort (6%), and Mucomyst (2%). ALB 2.5 mg was administered Q6H in most subjects (98%).

According to the results of this study, the great majority of patients admitted to this hospital area received frequent doses of albuterol despite not having a history of obstructive airway disease or auscultation to support its use. A stricter protocol for ALB administration may dramatically decrease the misuse of this important medication.

Vaping is a new form of smoking introduced and marketed as a safer and healthier alternative than traditional cigarettes. As more additives and flavors are added, the less is understood regarding long-term side effects, particularly in the respiratory system. The aim of this study was to evaluate the general population’s perception about vaping and its knowledge about vaping-related lung injuries.

A survey consisting of 29 items was created using Google Forms and distributed via email and social media platforms to volunteer participants at least 18 years of age. Data collected included demographic information, use of vaping, and perceptions about vaping-related side effects. Descriptive statistics were used to report results. IRB approval was obtained.

Data was obtained from 309 participants. The majority of participants were female (n = 186; 60.2%), Hispanic/Latino (n = 170; 55.0%), between the ages of 25 to 39 years of age (n = 124; 40.1%), spoke primarily English (n = 193; 62.5%), worked in healthcare (n = 128; 41.4%), were married (n = 202; 65.4%), and had at least a bachelor’s degree (n = 115; 37.2%). Overall (76.7%) of participants reported never using tobacco or vaping products, and almost double of those who smoked or had smoked reported using tobacco products more than vaping products (11.0% and 5.8%, respectively). When asked if vaping can be used as a means to quitting smoking, 56.6% answered NO, only 14.2% answered YES, and 29.1% answered MAYBE. Among those who vaped (12.3%), only 5.2% believed it was a healthier option, and (22.0%) remained undecided that vaping could lead to negative health effects. Majority of participants believed that it is unsafe to use tobacco products and that vaping products are unsafe (98.7% and 97.4%, respectively). Most participants considered that vaping can cause lung disease (64.1%), but almost a third (31.7%) were undecided.

The results of this study suggest that a significant portion of participants evaluated poorly understood the adverse effects of vaping. Additional research in this area and public awareness may be necessary to change the overall perception of vaping and its effects on the pulmonary system.

Burnout has been identified as a major challenge in health care and is significantly associated with increased medical errors and poor job satisfaction. There is scant literature focused on the respiratory therapist (RT) experience of burnout and a thorough exploration of RTs’ perception of the factors associated with burnout has not been reported. The aim of this qualitative study was to understand the factors associated with burnout as experienced by RTs amidst the COVID-19 pandemic.

We performed a post-hoc, qualitative analysis of free text responses to a survey of 26 centers that assessed the prevalence of burnout in RTs. The analysis used an inductive approach to identify themes within the unstructured comments provided by the subjects in the context of their experiences of burnout. Three of the authors triangulated the emerged themes. The survey was declared exempt by the Duke University Medical Center Institutional Review Board.

There were 220 free text responses. Five overarching themes emerged from the analysis: staffing, workload, physical/emotional consequences, lack of or ineffective leadership, and lack of respect. Subjects discussed feelings of anxiety, depression, and compassion fatigue, as well as concerns that lack of adequate staffing, high workload assignments, and inadequate support from leadership contributed to feelings of burnout. Specific instances of higher patient acuity, surge in critically ill patients, rapidly evolving changes in treatment recommendations, and minimal training and preparation for an extended scope of practice were reported as stressors that led to burnout. Some subjects stated that they felt a lack of respect for both the RT profession and the contribution of RTs to patient care.

Factors associated with burnout in RTs included staffing, workload, physical/emotional exhaustion, lack of or ineffective leadership, and lack of respect. These results provide targets for interventions to combat burnout among RTs.

Respiratory therapy is moving toward baccalaureate degree as the standard for new graduates to enter the profession. Differences have been noted in the curriculums within associate and bachelor’s degree programs. To our knowledge, there is currently no data comparing orientation outcomes in associate degree versus bachelor’s degree graduates. We sought to compare new graduate orientations in hospital settings.

After approval from IRB, a request to participate in data collection was sent to 181 RT managers Pennsylvania. Each center was asked to complete a survey on their orientation process, attend a call on the study to learn operational definitions and data collection methods for new graduates completing orientation. A data entry log was provided to collect the required information until each individual completed orientation for entry into the database. For comparison between groups we included only the extra hours spent on general care orientation beyond institutional standard as it was anticipated that dedicated orientation time would vary.

Fourteen hospitals agreed to participate. Of those, 8 (57%) returned data on 55 new graduate RTs from May 2019–September 2020. Five individuals terminated before the end of the orientation process were not included in the analysis. Twenty-six RTs earned an associate degree and 24 earned a baccalaureate degree. RTs with an associate degree spent a total 340 extra hours on general care orientation versus those with a bachelor’s degree, who spent a total of 656 extra hours. A combined mean of 216 extra hours was spent on general care orientation. Individuals with associate degrees spent a mean 34 ± 21.44 extra hours. Bachelor’s degree earners spent a mean 51.2 ± 21.33 extra hours orienting to general care. The mean difference between groups was 17.2 h (P = 0.178). Thirty-two individuals included (64%) were new hires from a free-standing children’s hospital in an urban center and likely heavily skews the data as their educational needs may greatly differ from the other institutions.

Differences in extra hours spent in orientation between newly hired associate degree and bachelor’s degree RTs did not differ statistically. However, differences in orientation programs likely contribute and should be unified for future investigations.

During the COVID-19 pandemic, respiratory therapists (RTs) were faced with many unpredicted challenges and exposed to higher levels of stress, including risk for their own safety while managing critically ill patients with COVID-19. The primary objective of this study was to evaluate the compassion satisfaction and compassion fatigue among RTs in the United States during the COVID-19 pandemic.

This was a cross sectional, descriptive, survey-based study conducted from July 2020- August 2020. A survey was administered to all active members of the American Association of Respiratory Care (AARC) via AARConnect. RT characteristics including personal factors, job specific factors and organization factors were collected. Professional Quality of Life Scale (ProQOL Version V) was used to assess compassion satisfaction, burnout, and secondary traumatic stress (STS). The survey results were analyzed using descriptive, Chi-square and Kruskal Wallis statistics.

A total 218 participants fully completed the survey, 142 (65.1%) were females and 39 (17.9%) were < 34 y old, 107 (49%) were 35–54 y old, and 72 (33%) were > 55 y old. Work experience was >12 y for 144 (66%) RTs. Burnout score was low in 90 (41.3%), moderate in 127 (58.3%), and high in 1 (0.5%) RTs. Secondary traumatic stress (STS) was low in 106 (48.6%) and moderate in 112 (51.4%) RTs. Compassion satisfaction was low in 2 (0.9%), moderate in 123 (56.4%) and high in 93 (42.7%) RTs. Higher burnout was found among RTs with <2 years of experience (P = .001), and lower salary (P = .001). Higher STS level was noted in younger RTs (P = .001), females (P = .001), and RTs with a lower education (P = 0.008). Higher compassion satisfaction was found in RTs that work days (P = 0.005), work overtime (P = 0.006), leadership (P = 0.004) or education/research roles (P = 0.001), those that work in departments where they receive help in managing burnout and stress (P < .001) and overall promote positive work environment where employees feel appreciated (P = .001).

The study identified various factors associated with increased compassion satisfaction such as working daytime shifts, overtime, advanced roles, and departmental environment. Factors associated with compassion fatigue were less job experience, lower salary, female sex, and education level. This knowledge may help guide future strategies and interventions to improve respiratory therapists’ professional quality of life.

Aerosol delivery to infants and children is a challenge due to their intolerance of the interface of a jet nebulizer. The effectiveness of aerosol delivery through an oxygen hood to infants has been proven. Yet, the influence of hood design and breath pattern on the aerosolized drug dose is not well explored. This study aimed to evaluated nebulized drug delivered through a facemask vs. a hood with infant and toddler breath pattern.

A breathing simulation (ASL 5000, Ingmar Medical Inc.) was used to generate infant (V_T 50 mL, respiratory rate 33 b/min, flow 13.1 L/min) and toddler (V_T 100 mL, respiratory rate 24 b/min, flow 14.5 L/min) breath patterns, and connected to either an infant or a child intubation mannequin. A bacterial filter was placed between the ASL 5000 and the bronchi of the mannequin to collect aerosolized drug particles. A united-dose of salbutamol (5 mg/2.5 mL) was placed in a small volume nebulizer (Galmed Inc., Taiwan) and diluted to 4 mL. The nebulizer was connected either to a pediatric facemask or a customized infant oxygen hood (22 x 25.5 x 20 cm), or a child oxygen hood (36 x 33 x 27 cm) with and without a cover, and a hole with 2.5 cm diameter at the center of the top, back, and side. Drug mass deposited in the filter and on the face of the mannequin was analyzed by UV spectrophotometry at 276 nm wavelength (n = 5). Statistical analyses were performed with ANOVA and Scheffe post hoc test, with a significance level of P < 0.05.

Table 1 below illustrates comparisons between the inhaled drug dose and face dose between infant and child breath patterns. The inhaled dose was significantly greater with an oxygen hood and the nebulizer at the back for infant breath pattern, and with a facemask for toddler breath pattern (P < 0.001).

Aerosol delivery through an oxygen hood, with the nebulizer placed at the center of the back of the hood, is effective in the infant model. A facemask was more effective for toddler breath patterns.

Atelectasis results when alveoli collapse and is prevalent in approximately 90% of patients undergoing some period of anesthesia. (1-4) The pathophysiological effects of atelectasis include decreased lung compliance and decreased gas exchange capacity, leading to lung injury. (5) Current strategies to minimize atelectasis in these patients are centered around an ‘open lung’ approach that relies on PEEP to maximize alveolar patency. (6) Our research group is investigating the use of transvenous phrenic nerve stimulation to provide controlled diaphragm contractions to maximize alveolar patency. Compliance is a measure of the elastic resistance of a system and correlates with the number of patent alveoli. (7) It can be measured dynamically, while flow is occurring, reflecting the pressure exposure of the alveoli as they are stretching. (7, 8) This describes pathological changes indicating the potential risk for ventilator-induced lung injury in sedated patients.

A preclinical, semi-blinded study was conducted using large pigs, mechanically ventilated for 12 h post oleic acid-induced lung injury. This is an accepted preclinical model of ARDS. (9) The MV group received lung-protective volume control ventilation at 8 mL/kg (n = 6). Transvenous diaphragm neurostimulation (TTDN), delivered on every breath in synchrony with volume control ventilation at 8 mL/kg was delivered to the MV+TTDN group. The strength of diaphragm contraction targeted a reduction in ventilator pressure-time product of 15-20% during inspiration (n = 6) as previously published. (10) Dynamic compliance was measured by electrical impedance tomography at baseline, post achievement of lung injury, and hourly for 12 h. Statistical analysis of the repeated measures over time used a linear mixed model. Fixed effects were time, TTDN dose and TTDN dose interaction with time. Random effect was subjects. Data is reported as median with interquartile ranges. Ethics approval was obtained from the local REB.

The dynamic compliance was significantly higher after 12 h post oleic-acid-induced lung injury in the MV+TTDN group compared to the MV group (75 mL/cm H₂O (51-90) vs. 31 mL/cm H₂O (25-36). The dynamic compliance was significantly affected by both TTDN (P = 0.002) and TTDN over time (P = 0.002).

Negative-pressure-assisted ventilation, comprised of transvenous diaphragm neurostimulation during inspiration in volume control ventilation, improves dynamic compliance in a preclinical model of ARDS.

Dynamic Compliance as Measured by EIT over Time

Specimen transport is a pre-analytical factor that can influence the accuracy of blood gas results as gas exchange can occur between an air bubble and the sample. A literature review determined that there is no uniform consensus as to whether pneumatic tube transport is appropriate for blood gas specimens. Our study was designed to determine acceptability of pH, PCO₂ and PO₂ results for specimens transported via a pneumatic tube

Blood gas measurements were conducted on performance comparable Siemens Rapidpoint 500 analyzers. Blood gas samples were analyzed at point-of-care then sent through the pneumatic tube system for repeat analysis. Sample integrity was evaluated prior to tube transport. All sample analysis was performed by two experienced respiratory therapists. All point of care testing was performed by one therapist and the second therapist performed the post tube transport analysis. CLIA/CAP total allowable error limits were utilized to establish acceptable limits for pH, PCO_2, and PO₂. Phase two testing introduced a rubber stopper and immobilization padding prior to specimen tube transport.

Sixty blood gas specimens were analyzed pre and post-tube transport. 96.7% of pH results, 88.3% of PCO₂ results, and 50.0% of PO₂ results were within the acceptable range. The average biases between pre and post pneumatic tube specimens were -0.0048 for pH, 1.25 mm Hg for PCO₂, and 0.99 mm Hg for PO₂. In phase two, 54 blood gas samples were measured pre- and post-tube transport utilizing the mitigation interventions, 74.1% of PO₂ results (average bias of -0.59 mm Hg). 92.6% of PCO₂ results and 100% of pH measurements were within acceptable limits. To determine the clinical significance of the PO₂ differences, data with PO₂ values outside of the reference interval (70–100 mm Hg) with the potential to impact patient management were examined. Ten specimens were <70.0 mm Hg pre-transport, all of which had a higher post transport PO₂ (average increase of 7.4 mm Hg). Importantly, 100% of these specimens remained at < 70.0 mm Hg PO₂ post transport. All samples within the normal reference range remained in range post transport. The largest variation occurred in samples with high PO₂ values.

The study confirmed measurable variation in PO₂ values post tube transport. The PO₂ variability was reduced to an acceptable level by immobilizing the sample and capping the syringe with a rubber stopper. Findings support tube transport of blood gas specimens under these conditions.

Burnout among respiratory therapists (RTs) has been reported as high as 72% during the COVID-19 pandemic. Limited data are available regarding wellness and fulfillment among RTs. The purpose of this study was to conduct interviews to explore burnout, wellness, and fulfillment among RTs working in critical care during the COVID-19 pandemic and to inform future decisions for potential interventions to reduce burnout and increase feelings of fulfillment.

We conducted semi-structured interviews to learn about RTs experience of burnout, wellness, and job fulfillment during the pandemic. Recruitment occurred from April – May 2021 in a single academic, tertiary care medical center. We recruited staff RTs by including study information in a biweekly email and on flyers posted throughout workspaces. A single research coordinator conducted all interviews via videoconference or telephone. Participants received a $50 gift card in compensation for their time. All interviews were recorded and transcribed for analysis. Two of the authors identified themes using open coding. The study was approved by the University of Pennsylvania IRB.

Seven RTs participated in interviews. Median experience in the field was 16 (4.5-27) years. Respondents felt that burnout was driven by lack of staffing, challenges of working during the COVID-19 pandemic, and the emotional toll of caring for patients who were extremely ill. Factors reported to improve wellness included: working consistently in the same units, participating in committees, and professionalism among colleagues. Respondents felt fulfilled by building relationships with colleagues, having the ability to teach new colleagues and learn new skills, caring for patients and seeing them progress, and being appreciated by MDs, other staff, and patients. Regarding interventions to reduce burnout and improve wellness, respondents reported that they appreciated interactions with colleagues and camaraderie of celebrations, which were limited during the pandemic. However, the most consistent recommended intervention was to reduce staff shortages.

RTs experienced high levels of burnout during the COVID-19 pandemic. Coping mechanisms, such as interactions and celebrations with their colleagues, were interrupted due to pandemic policies. Interventions to provide more staffing and increased peer interactions may mitigate the severe burnout experienced by this group.

Asthma is one of the prime diseases of public health interest in the world, affecting around 330 million people globally. Rhinosinusitis disease is a common inflammatory disorder associated with asthma. Asthma and rhinosinusitis share the same pathophysiological mechanism and often occur together. There is no treatment for the root of asthma, but the symptoms can be relieved for a prolonged period. The root of chronic rhinosinusitis is still a challenge to be cured but the clinical symptoms can be improved by symptomatic treatment like topical steroids and nasal saline which are also considered asthma symptoms relievers. Untreated rhinosinusitis may worsen asthma patients' condition. There were limited studies that assessed the prevalence of asthma with rhinosinusitis among adult and pediatric patients in Saudi Arabia.

This study is a retrospective cross-sectional. The data withdrew from the King Abdulaziz Medical City Best Care system from 2016 to 2020. Inclusion criteria were patients with a confirmed diagnosis of asthma and rhinosinusitis, age 18 years and above. A data collection sheet was used, and it included two sections. The first section was the demographical data such as age, gender, diagnosis, smoking status, medical history, date of admission, medications, and allergic status. The second section was the disease history, signs, and symptoms. The data was being analyzed using SPSS.

The prevalence of rhinosinusitis among asthma patients was 0.45% (95% CI 0.3–0.6) which were 5 patients out of 1,688 asthmatic patients, and 1683 patients had asthma without rhinosinusitis (99.7%). Females were 1,139 (67.7%) while males were 544 (32.3%). The number of asthma patients with rhinosinusitis was 3 females and 2 males. The development of rhinosinusitis in asthma patients was less common. Most of the asthma patients 945 (56%) were 60 years old or older, and 740 (44%) were 18–59 years old. Asthma patients with a past medical history of COPD were 40 (2.3%). Moreover, 33 (1.9%) of asthma patients had bronchiectasis. The majority of asthma patients 1,334 (79%) had unknown allergic status while 349 (21%) were allergic. Patients who had asthma with rhinosinusitis had unknown allergy status 5 (100%). The smoking status revealed that 54 (3.1%) of asthma patients were smokers, but none of them had rhinosinusitis. However, 1634 (96.9%) were non-smokers.

The prevalence of rhinosinusitis among asthma patients was considered low.

Students frequently comment how they feel underprepared to deal with difficult situations in the healthcare setting. To address this issue, respiratory faculty from St. Paul’s College, MN and Northern Kentucky University, KY, developed a workshop for their students on the PEEER Communication Model for interacting in difficult situations. The elements of the model are P-Plain Language; E-Engagement; E-Empathy; E-Empowerment; and R-Respect.

Using Zoom, faculty (n = 2) and students from both programs (n = 29) introduced themselves. Student learning objectives were: 1) compare effective and ineffective communication; 2) define and discuss the PEEER model; 3) participate in meaningful discussion with respiratory students outside of their own university and geographical region. Faculty gave descriptions and applications of the PEEER elements. Scenario 1 was a video of healthcare providers gathering outside a patient’s room talking about his medication compliance; the patient’s wife walked past the group while entering the room. After the video, students were arranged in breakout rooms and discussed effective and ineffective communications exhibited; student groups were mixed from both programs. Afterwards the large group gathered for debriefing. Scenario 2 was an in-patient sudden cardiac arrest. Two RTs, two RNs, a physician, and the patient’s wife were in the room. Students evaluated the interactions between healthcare providers and wife during this difficult situation. After the video, everyone gathered in the large group for debriefing. Students were invited to complete a post workshop survey. The survey consisted of 7 questions using a 5-point Likert scale. NKU IRB gave exempt approval # 1318.

19 students participated in the survey (66%). The majority said the workshop was valuable (78.95%), they successfully interacted with students outside of their own college (89.47%), and they gained foundational skills in the PEEER model (94.74%). 84.2% reported there was an appropriate variety of learning formats for the activities (pre-work reading, class discussion, videos, patient simulation). When asked if they believed they gained a deeper understanding of all 5 PEEER elements, the mean score was 4.4. 90% said they were confident in their ability to use PEEER skills. 95% believed they’ll use these skills.

The PEEER Communication Model was an effective method for students to gain confidence and skill in communication in the healthcare setting.

Clinical rotations are foundational to student learning in respiratory therapy (RT) school. Telemedicine emerged as a means for managing critical care patients during the COVID-19 pandemic. We hypothesized that a clinical rotation at a tele-ICU would increase student knowledge of mechanical ventilation, telemedicine, and COVID-19.

Students from two universities completed clinical rotations in a tele-ICU as a part of an IRB-approved observational study. Two, four-hour shifts were spent with an RT preceptor. RTs rounded on 320 ICU beds at 5 hospitals. Patient assessments were completed at the request of RTs in the ICUs and clinical emergencies were addressed in real time via remote monitoring. Students completed a pre-rotation survey assessing their confidence evaluating and managing mechanical ventilation, experience with telemedicine and technology, ARDS and COVID-19 patients. At the end of the rotation, students completed a second survey assessing knowledge of the same concepts. Wilcoxon signed ranks was applied to compare pre- and post-clinical rotation self-confidence surveys (Likert scale 1 – 10). Data are reported as median (IQR). P < 0.05 was significant. Data was analyzed with SPSS 26 (IBM, Armonk, NY).

Thirty-three out of 37 students (89%) completed surveys pre- and post-clinical rotations. Of those, 67% (n = 22) were female. Fifty-five percent of students reported prior knowledge of telemedicine, while 52% had observed interactions with the tele-ICU in previous clinical rotations. Mean self-confidence in mechanical ventilation, assessing waveforms, and knowledge of ARDS increased after the clinical rotation (pre-rotation 7.0–8.0 [5.0–9.0], post-rotation 8.7–9.5 [8.0–10]; P = 0.001). Similarly, reported knowledge related to spontaneous breathing protocols, lung protective ventilation, patient care planning, and use of data collection tools increased from the beginning to the end of the clinical rotation (pre-rotation 6.5– 8.3 [5–9.5], post-rotation 8.8–9.9 [7.5–10]; P = 0.001– 0.009). Student confidence in interprofessional communication increased from 8.5 [6.9–9.8] to 9.5 [7.8–10] (P = 0.03). Overall, the largest change was students’ ability to assess COVID-19 patients (pre-rotation 5 [1.2–6.8], post-rotation 8 [5.9–10]; P = 0.001).

Students’ knowledge and skills in assessing patients via remote monitoring increased in a tele-ICU clinical rotation. Knowledge related to COVID-19 also increased statistically significantly.

Simulation techniques are considered an integral part of Applied Medical Science programs (AMS) education, and it continues to be an essential contribution to clinical practices. A few studies have examined the satisfaction of simulation experience among students from AMS specialties. This study aims to evaluate the AMS student’s satisfaction with simulation-based learning.

A cross-sectional study was conducted among undergraduate students in the College of Applied Medical Science at King Saud bin Abdulaziz University for Health Sciences - Saudi Arabia during the academic year 2019-2020. Third and fourth-year students from Respiratory Therapy, Emergency Medical Services, and Anaesthesia Technology programs completed the Satisfaction with Simulation Experience Scale (SSE). The SSE includes 18 items for which the response is measured using a 5-point Likert- scale. Informed consent was obtained from each student before completing the questionnaire.

A total of 255 students participated in this study from the three campuses. The majority of students were male (59%) and from the Riyadh campus (77%). The overall mean scores for the SSE were 69 ± 16 for study participants. There was a statistically significant difference in the overall mean score of the SSE scale between the three groups, and it was higher in the anesthesia group compared to the respiratory therapy control group (8.4 ± 2.4, P = 0.002). Similarly, this was observed in the three subscales of the questionnaire.

The finding from this study suggests that students were satisfied with simulation-based learning, although there was a difference in the satisfaction level between the three programs. Further efforts have to be directed to investigate the challenges of conducting and improving simulation sessions in AMS education.

Clinical rotations are essential to respiratory therapy students (RTS) learning objectives. The COVID-19 pandemic profoundly affected RTS education by limiting their bedside exposure, as they were prohibited from caring for COVID-19 patients. Here we describe a clinical rotation at a tele-ICU (eICU) which gave RTS access to COVID-19 patients. Our goal was to increase their knowledge of the disease process to better prepare them for the workforce.

Students from two universities completed clinical rotations in a tele-ICU as a part of an IRB-approved observational study. They completed two, four-hour rotations with an experienced telemedicine RT preceptor (eRT) in the eICU. Data collection occurred from February 2021 – May 2021. Along with their preceptors, RTS rounded on 320 ICU beds across five hospitals. Primary objectives of the clinical rotation included performing remote patient assessments, interpreting ventilator waveforms, arterial blood gases, and chest x-rays. RTS received education on lung protective ventilation and spontaneous breathing protocols. During ventilator rounds, RTS filled out demographic surveys to identify the complexity and diversity of the patient population.

Thirty-three RTS included in the study rounded on 370 patients during their remote clinical rotations. Of the patients RTS interacted with, 57% (n = 211) identified as male. Mean age of the population was 52.5 ± 18. Racial make-up closely resembled the diversity in the region with 39% (n = 145) Black and 50% (n = 183) white patients. Ninety-two percent of the patients were mechanically ventilated and RTS completed 239 patient-ventilator assessments. The primary disease processes of patients seen were ARDS (n = 178) and COVID-19 (n = 145). In patients with ARDS, 36% (n = 65) required follow-up due to issues related to adherence to protocol. Volume-targeted modes of ventilation were most commonly used, 47% (n = 175). Patient interventions included 73 instances of worsening symptoms on mechanically ventilated patients. Twenty-eight patients were deemed high risk airways which required increased surveillance.

During this remote clinical rotation, RTS had the opportunity to interact with and complete assessments on patients diagnosed with COVID-19. This rotation prepared RTS to care for a diverse patient population via the eICU and increase their knowledge and experience with COVID-19 patients despite a lack of traditional hands-on experience.

During the COVID-19 pandemic, we initiated a new clinical rotation for respiratory care students in a virtual ICU (eICU). During this rotation, students experienced an increase in their baseline knowledge of telemedicine and mechanical ventilation. We hypothesized that qualitative feedback of the clinical rotations would reflect a positive learning experience.

Students from two universities completed clinical rotations in a tele-ICU as a part of an IRB-approved observational study. They completed two, four-hour rotations with a telemedicine RT preceptor (eRT) with experience in the eICU. Students were involved in remote patient assessment, review and interpretation of ventilator waveforms, blood gases, and chest x-rays. Students received an introduction to lung protective ventilation, spontaneous breathing, and broncho-pulmonary hygiene protocols. At the end of the second day of the clinical rotation, students completed a survey which included qualitative questions regarding their experience.

In their comments, students stated eRTs provided guidance and created a comfortable learning environment that students would recommend to others. Interaction with tele-ICU RNs (eRN) was described as friendly, knowledgeable, and helpful. Students noted the high level of teamwork in the eICU and that they observed quality patient care provided. Students stated that interactions with tele-ICU MDs were educational; however, forty percent of students reported not interacting with eMDs. While some of the students did not interact with staff in the physical ICU, others noted that interactions via telecommunication platforms were positive and friendly. The biggest difference noted between this rotation and in-person rotations was that it is not hands on; however, students stated they were able to focus on technology and learning about ventilator waveforms and mechanics. When asked what it takes to be an effective eRT, a willingness to learn and be involved was described. Students felt it was important to be knowledgeable about technology, modes of mechanical ventilation, and waveforms. Additionally, the students noted it was important to be knowledgeable about diseases and patient-ventilator synchrony.

Students’ experience in a virtual ICU was overwhelmingly positive, providing new perspectives on patient care.

COPD is associated with substantial functional morbidity including activity-limiting symptoms such as dyspnea and fatigue. Self-management interventions aid in symptomatic management of COPD and have been shown to produce positive outcomes on quality of life (QOL) and hospital admissions. The purpose of this study was to evaluate the feasibility and acceptability of our team’s innovative, technology-enhanced COPD self-management application (PulManage) that integrates real-time spirometry, symptom tracking, and bidirectional provider communication within one platform.

A total of 20 participants were recruited for this mixed methods feasibility trial. Participants received remote spirometry devices and downloaded PulManage software on their phones. Participants tracked symptoms, temperature, and respiratory rate, and completed a minimum of two spirometry sessions (defined as three efforts) daily for 2 weeks. A total of 18 participants (90%) completed the 2-week trial. Acceptability was evaluated with the Technology Acceptance Model. Following the trial, system usability was evaluated with multiple choice questions and qualitative interviews explored perceptions of usability, acceptability, and satisfaction amongst participants.

Of the 11 participants who responded to feedback surveys, 100% indicated that they had the necessary knowledge and resources to use the PulManage system. 81.8% found the system useful and 90.9% indicated that it was easy to use. When evaluating overall reaction to the system construct (usefulness, ease of use, attitude toward system, intent to use), a total of 90.9% of the respondents had a positive attitude towards the system. Feedback included the desire for personalized feedback of spirometry performance and educational tools.

The remote patient monitoring app with integrated spirometry is feasible and acceptable. Continuing efforts are focused on developing personalized feedback mechanisms and educational modules.

Although the use of a high-flow nasal cannula in oxygen therapy has gained great interest in the last decade, oxygen therapy through a large-volume nebulizer (LVN) is most commonly used. The effect of high flow provided by LVN on nebulized bronchodilator delivery has not been investigated thoroughly. This study aimed to quantify aerosol delivery with a high flow oxygen system through LVN in a simulated, adult, spontaneously breathing lung model.

An adult intubation mannequin was connected to a dual-chamber test lung to simulate adult healthy (tidal volume [V_T], 500 mL; breathing frequency 15 breaths/min; inspiratory to expiratory ratio [I:E], 1:2) and distressed (V_T, 450 mL; breathing frequency, 30 breaths/min; I:E, 1:2) spontaneous breathing patterns. A small-volume nebulizer (SVN, BesMed Cooperation, Taiwan) was connected to an adult aerosol mask placed on the mannequin. The other end of the T-adaptor for the SVN was connected to an LVN to deliver oxygen at a concentration of 40% generated at oxygen gas flows of 9, 12, and 15 L/min. The total flow was verified using a flow meter (TSI Inc). The SVN was filled with a unit dose of salbutamol (5.0 mg/2.5 mL, GlaxoSmithKline, Australia) and diluted with 0.9% saline to 4 mL. Nebulization was performed until no aerosol was visible, and the process was conducted 10 time. The drug dose delivered distal to the bronchus was collected in a filter, which represented the inhaled drug dose. The drug mass deposited in the filter was determined by UV spectrophotometry at a wavelength of 276 nm.

The mean inhaled drug doses with the nebulizer alone were 7.57 ± 0.52% and 5.99 ± 0.16% (P = 0.006) for the healthy and distressed breathing patterns, respectively. Table 1 compares the inhaled drug doses for the three flows of the LVN and the two breathing patterns. The inhaled dose was significantly low when the gas flow increased from 9 to 12 L/min for the healthy breathing pattern (P < 0.001), but increased at a flow of 12 L/min for the distressed breathing pattern.

The aerosol delivery significantly decreased with an LVN inline. Thus, changes in drug doses depend on the flow and breathing pattern.

COPD is the third-leading cause of death in the United States and 20% of patients readmit within 30 d; many of these readmissions are preventable. The current paradigm only allows patients to see providers when appointments are available, not when they need us. BBT is an innovative transition-to-home program that connects patients to a pulmonary navigator (PN) who helps identify early onset of symptoms and implement proactive interventions. Developed by our partners at Penn Medicine Hospital of the University of Pennsylvania (HUP), the program significantly decreased readmissions. Penn Medicine Lancaster General Health (LGH) adapted BBT in a new context to duplicate the results seen at HUP, launching a 6-month pilot program beginning January 2021.

The PN identifies eligible, hospitalized patients with a COPD diagnosis. During the admission, the PN educates and prepares the patient for successful discharge and follows up with a phone call at 48 hours. Post discharge, enrolled patients receive a daily text at 10:00 am Monday–Friday to evaluate their breathing and identify early clinical decline. Patients respond either A (breathing is better than usual), B (breathing is same as usual) or C (breathing is worse than usual). A worse response (C or Call) triggers an immediate alert to the PN who conducts a phone evaluation within 30 min to assess symptoms, provide treatment guidance, and/or triage care based on the escalation algorithm.

Since the beginning of the pilot, the PNs have reviewed 234 COPD patients for BBT eligibility. BBT enrollment rate was 55.4% (36 enrolled/65 offered). All patients who responded worse received a return call within the 30-min goal and were thoroughly assessed by the PN. Thirty day readmissions in the pilot group occurred at a rate of 11.1% due to breathing difficulties, compared to pre-BBT intervention rate of 11.7%. It was estimated that 17 emergency department visits were mitigated by the BBT escalation algorithm.

Although readmission rates did not significantly decline for those with breathing difficulties, the BBT program at LGH represents the evolution of an innovative, evidence-based intervention that is effective and scalable. It is an easy application that allows patients to interact with a PN when services are needed, not when they are available. Continued research is needed to identify how telemedicine interventions can affect the overall health of this vulnerable population.

The American Thoracic Society (ATS) guides spirometry standards to ensure that results are accurately interpreted and influence care appropriately. In 2019, ATS/ERS standards replaced the 2005 ATS standards and redefined criteria by removing the time requirement and implementing a grading system to allow more acceptable spirometry tests (Table 1). A study of 1,631 children found that only 18% were able to meet the end of test time requirement set by the 2005 ATS standards.¹ We hypothesized that there would be an increase in acceptable spirometry for pediatric patients in our facility when using the 2019 ATS guidelines for spirometry compliance.

In an IRB approved retrospective analysis, we reviewed and compared pediatric spirometry (n = 5,400) from 1/2019–12/2020. 20% (n = 1,080) of spirometry tests were chosen at random, audited, and then categorized based on patient age. Spirometry audits were analyzed for compliance based on 2005 and 2019 ATS standards criteria. Results were analyzed and the Student’s t-test was used to determine statistical significance.

1,080 pediatric spirometry audits were reviewed; the age range of patients was 6–18 y (median 11.3 y). When comparing spirometry compliance with 2005 and 2019 ATS Standards, compliance was increased by 15.3% when using the 2019 ATS Standards (P <0.001) (Figure 1).

In our pediatric hospital, introduction of the 2019 ATS Standards has led to a significant increase in acceptable spirometry. By eliminating the required minimum time for each maneuver and implementing a grading system to represent confidence level of each spirometry test performed by the patient, more acceptable and valid data can be used by the clinician to appropriately treat patients who may not have been able to produce acceptable spirometry in the past. Further studies must be done to evaluate the impact to patient care decisions that occur after spirometry is completed. Reference: Graham BL, et al. Standardization of spirometry 2019 update. An official American Thoracic Society and European Respiratory Society technical statement. Am J Respir Crit Care Med 2019;200 (8):e70-e88.

Figure 1 shows details the 2005 and 2015 ATS standards for acceptable spirometry.

During the COVID-19 pandemic, we frequently were able to support patients with singular, severe COVID-19 pneumonia with high-flow nasal cannula (HFNC) with settings of FIO₂ 0.90 and flows of 60 L/m. When the O₂ saturation dropped into the 80s, our respiratory therapist placed non-rebreather masks (NRB) to increase the O₂ saturations. Of note, these patients with exceptionally low O₂ saturations were surprisingly asymptomatic. In absence of data to support this practice, we collected data on our patients to document the benefit.

Consecutive patients with uncomplicated COVID-19 pneumonia requiring HFNC with settings of FIO₂ 0.90 and flows of 60 L/m and have not been previously placed on a NRB were eligible for the study. An oximetry recorder was placed on the patient and oximetries were recorded for one hour. A NRB was placed on the patient and oximetries were recorded for another hour. There was an average of 2,000 data points per hour. The oximetry data was downloaded into a database and the average oximetry before and after NRB was calculated. Respiratory rates, heart rates, and perfusion indexes were collected before, at the time, and after the placement of the NRB.

For individual patients, there were 8 that had significant differences comparing before vs after. Of these 8, 6 had higher readings after, and 2 had higher readings before. Of the 3 differences that were not significant, all were slightly higher before (see table). The differences of the averages of all before and after patients was 1.79% (P = NS). The figure below shows each patient listed in order with before then after distributions. P-values were calculated using a Wilcoxon two-sample test. Only patient 10 had a dramatic difference. At trial start, his O₂ saturation was 92% and his respiratory rate was 24. At NRB placement, his O₂ saturation was 88% and at the end the O₂ saturation returned to 92% and his respiratory rate was 24. He received appropriate respiratory interventions during his low saturation episodes. The perfusion index did not explain the difference.

The addition of a NRB to HFNC did not make a difference from a statistical standpoint, even with the dramatic improvement with patient 10. The improvement in patient 10 was mostly due to appropriate respiratory care interventions, with the NRB having a small role. The overall increase of 1.79 percentage points in O₂ saturation is also not clinically important.

Ventilator alarms are a critical built-in safety feature designed to detect changes that may require immediate attention to the patient and/or ventilator. Alarms are capable of identifying faulty equipment, leakage, patient disconnection, and alerting a trained clinician when important changes such as compliance or airway resistance occur. The goal of this study was to evaluate the selection of ventilator alarm settings, determine agreement to current recommendations, and measure percent discrepancy between patients recorded values and the alarm limits selected.

This was a retrospective review of electronic medical records (EMR) of subjects admitted to the adult medical ICU and placed on a mechanical ventilator during the month of April 2021 at a level-1 trauma center in San Antonio, TX. Patient recorded values and alarm parameter selection were obtained for each patient meeting criteria. The measured values recorded were peak inspiratory pressure (PIP), respiratory rate (RR), and exhaled minute ventilation (MV). The alarm settings selected for analysis were high peak inspiratory pressure (HI PIP), high respiratory rate (HI RR), and high and low minute volume (HI MV, LOW MV). Descriptive statistics (mean, SD, IQR) were used to report data. IRB approved this study.

Data was collected from 50 subjects. The mean recorded measured values were: RR 19.54 (± 4.63), PIP 22.70 (± 6.45), MV 9.18 (± 2.00). Discrepancies between recorded patient parameter and alarm limits ranged ranging from 63% to 114%. The mean percentage change between measured PIP and the high-pressure alarm was 93.52 ± 55.26%; range (14.29%–280.43%); IQR 25-75 (52.59%–117.80%); while between measured total respiratory rate and the high-rate alarm was 110.82 ± 43.67%; range (33.33%–233.33%); IQR 25-75 (81.81%–143.75%). The difference between mean measured minute ventilation and low minute ventilation alarm was 63.18 ± 8.59 %; range (36.51%–79.45%); IQR 25-75 (57.14%–69.62%), and between measured minute ventilation and high minute ventilation alarm was 113.92 ± 40.56%; range (23.29%–198.51%); IQR 25-75 (85.83%–145.61%) (Table 1).

The results of this study suggest that ventilator alarm limits in the adult medical ICU were not selected in accordance with current recommendations and appear to be poorly individualized. There is a clear need to review the practice of ventilator alarm selection in the ICU and to evaluate the potential impact of alarm selection on clinical outcomes.

Many patients who are mechanically ventilated are often extubated long after being clinically ready. Extended and unnecessary mechanical ventilation time can lead to several negative outcomes, such as increased risk of infection, ventilator-induced lung injury (VILI), ventilator-associated events (VAE) and increased length of stay (LOS). At our medical center, patients’ extubations were found to be delayed (after meeting criteria) for several reasons, including resident physician hesitancy, lack of attending physician presence, or proximity to end of shift. Our goal was to define and implement a protocol with a set of objective criteria for weaning and extubation. Using this protocol, the respiratory therapist (RT) would extubate the patient without a physician evaluation – eliminating delay and shortening course of mechanical ventilation without any unplanned reintubations.

Every evening during rounds, weaning and extubation evaluation for every ventilated patient would be discussed between the RT and resident provider. If weaning readiness criteria was met, a daily 1-h weaning trial would be performed between the hours of 04:00 am – 06:00 am. If a successful trial was completed, the RT would perform pulmonary mechanics and Rapid Shallow Breathing Index (RSBI) to assess extubation readiness (per protocol). If the patient met extubation criteria, they would be extubated by the RT. Success was defined as remaining ventilator free for 72 h post-extubation.

There were a total of 34 patients during the evaluation period who met criteria for weaning and completed a successful 1 hour weaning trial. Of these, 12 (35.3%) were successfully extubated by an RT following the protocol. Poor neurological status, provider declined, planned procedures, and other (12, 5, 2, 4 respectively), were given as reasons for not extubating the other 22 patients. None of the RT driven protocol extubations required reintubation within the 72-h window.

Implementing a respiratory therapy driven weaning and extubation protocol can help successfully facilitate and expedite extubation by RTs. With clearly defined criteria and a care plan in place, the RT can successfully evaluate, assess, and perform extubation without direct physician guidance.

Use of RT-driven protocols allows for standardization and improves quality of care. At our institution, inpatient treatment of acute asthma exacerbation in children ≥ 2 y old is managed with a score-based pathway that uses a modified Pediatric Asthma Score (PAS) [Qureshi et al. Effect of nebulized ipratropium on the hospitalization rates of children with asthma. N Engl J Med 1998;339(15):1030-1035]. The pathway is RT-driven and provides score-based guidance for initiation (PAS ≥ 8) and discontinuation (PAS ≤ 11) of continuous albuterol (CA). We use a vibrating mesh nebulizer (VMN) to deliver CA when patients are receiving respiratory support (HFNC, NIV), and a large volume nebulizer (LVN) otherwise. We evaluated the use of CA during asthma exacerbation treatment with the asthma pathway as part of a quality improvement process.

First hospitalization of children ≥ 2 y old admitted to PICU or step down unit for acute asthma exacerbation between 11/2017–12/2019 who were prescribed CA as part of the asthma pathway were included in a retrospective chart review. Data collected included: age, sex, asthma severity, CA dose/duration, nebulizer type, PAS (before, during, after CA), and length of stay. Need to restart CA, transfer to PICU, and death were recorded.

We identified 412 subjects with median age of 6 years (IQR 4–10). The majority were male (61%) and admitted from the emergency department to the step down unit (71%). Asthma severity was classified as mild, moderate, severe, and unspecified in 10%, 45%, 24%, and 20% of subjects respectively. Median initial dose and time on CA were 15 mg/h (IQR 10–20) and 9 h 20 min (IQR 5 h 55 min–16 h 38 min). PAS before, during, and after CA was 11 (IQR 10–12), 11 (IQR 9–12) and 6 (IQR 5–8) respectively. One type of device was used in 85% (LVN 71%, VMN 14%). PAS documentation was missing in 16%, 2%, and 2% before, during, and after CA respectively. 28% received respiratory support (HFNC or NIV). Median length of stay was 1.4 d (IQR 0.8–2.3). CA was restarted in 3% of subjects, and 2% required transfer to PICU due to escalation of care. No deaths were reported.

The use of a score-based pathway for initiation/discontinuation of CA for treatment of pediatric asthma exacerbation was safe with low complication rates at our institution. Efforts towards increasing documentation before starting CA are warranted.

Craniopagus twins joined at the head are an uncommon malformation found once in 2.5 million live births. Beyond findings from the Joint Commission on Accreditation of Health Organizations (JCAHO), there is limited evidence to inform best practices for successful preparation for delivery and management of craniopagus twins. JCAHO identified several root causes related to perinatal death; including poor communication, failure to function as a team, and poor training processes. UC Davis Children’s Hospital successfully delivered and managed craniopagus twins.

Anonymous surveys were distributed post-delivery to a multi-disciplinary team. Ten of the 13-team members had previously participated in mock deliveries. In preparation for the delivery of craniopagus twins fetal MRI imaging was reviewed to understand and produce anatomically correct positioning. Neonatal training mannequins were fabricated utilizing existing mannequins and the findings of fetal MRI imaging. Preparation required proper identification of each baby. Babies were designated to indicate the location of skull fusion. Baby Orange being fused along its occipital bone and baby Purple fused along its parietal bone. Multidisciplinary delivery team members participated in mock deliveries lasting 2 hours each; completed 3 weeks prior to delivery. Teams were configured utilizing color coding to facilitate closed loop communication. Anticipated requirement of cardiorespiratory support including CPAP and intubation were included. Babies were born at 36 weeks gestation and transitioned to the NICU; Baby Orange, utilizing customized headgear required bubble CPAP and Baby Purple on room air. Post-delivery surveys and team debriefing were conducted. IRB exemption as well as family consent was obtained.

Thirteen surveys were returned. Ten of the 13 (77%) team members participated in simulated deliveries. 100% of respondents agreed that color coding of teams was helpful to distinguish team members during resuscitation of the infants and helped facilitate good communication with less confusion. 100% of respondents agreed mock mannequins created for simulated delivery were accurate.

Multidisciplinary planning and simulation training for the delivery of craniopagus conjoined twins including mannequin representation was beneficial for preparation of the delivery team. The experience of UC Davis Children’s Hospital will serve as a guide for future craniopagus twin delivery preparation worldwide.

An abundance of misinformation spread during the COVID-19 pandemic. Contradictory public health policies only added to gaps in knowledge about this new virus. As a result, public attitudes towards CDC recommendations, health guidelines, and basic disease prevention techniques varied. The goal of this study was to examine public attitudes regarding the COVID-19 pandemic.

This cross-sectional study collected data about public perceptions and attitudes regarding COVID-19 from individuals 18 y old between in March of 2021. A questionnaire with 18 items evaluated perceptions about COVID-19, its vaccines, and adherence to public health and CDC guidelines. The survey was designed using Google Forms and distributed via social media platforms. Participants and their responses remained anonymous. IRB approval was obtained. Descriptive statistics were used to present data.

Data from 246 participants was used for analysis. Most participants were female (69.5%), 18–40 y old (61.8%), Hispanic (80.9%), had tested positive for COVID-19 (79.3%) and knew someone who had tested positive for COVID-19 (98.8%) or had received the vaccine (99.6%). Most respondents trusted the vaccine (80.5%). However, only 58.1% had been fully vaccinated, 17.9% received only a first dose, and 24% had not been vaccinated at all. Of those not vaccinated yet, 16.3% reported not planning on receiving it. Regarding public safety guidelines, most trusted masks to prevent COVID-19 transmission (89%) wore a mask in public (94.7%), and in most cases either a surgical mask (46.7%) or cloth mask (43.1%). Few wore any additional PPE such as gloves (15.4%) or face shield (11%). Most participants only left home for work or essential errands (48.4%) while some left home for leisure 1 to 3 times a week (28.5%), or even more than 3 times a week (11.4%). No participant was in complete isolation and 11.8% left home as much as they were used to. When visiting people (71.1%), only half of them wore a mask (52%), maintained a 6ft distance (42.7%). While 71.1% reported frequent hand washing during visits, 16.7% were not following any of the CDC guidelines during their visits.

This study indicates that the COVID-19 pandemic affected the public’s perceptions and attitudes toward CDC guidelines, vaccination, and general public health mandates. In the face of uncertainty, reliable literature tempered by transparency, expertise, and collaboration should be trusted when making decisions about public health safety.

Evidenced-based medicine is essential to improving patient outcomes and enhancing medical practice throughout the healthcare industry. Respiratory care (RC) is a technology-driven profession that is constantly evolving with provider knowledge related to research skills becoming imperative.^1,2 By creating a Research Task Force (RTF), our respiratory care department (RCD) intended to involve more respiratory therapists in research. We aimed to assess productivity of the RTF since inception at our institution.

An IRB approved retrospective review was completed to assess research productivity from 2018–2020. Variables for analysis included the number of; CITI/IRB trained members, animal studies, publications, practice changes from research, unique authors, and non-productive hours.

By utilizing a RC RTF, our department saw an increase in CITI/IRB trained members, involvement in animal studies, total accepted publications, practice changes driven by research and unique authors (Figure 1). These results stemmed from the addition of approximately 20 non-productive hours in 2018, 250 non-productive hours in 2019, and 115 non-productive hours in 2020. Despite a 54% decrease in non-productive hours due to COVID-19 in 2020, our RCD saw an increase in research productivity.

Many RTs who study at an undergraduate level receive little to no training in research, even though this is an essential aspect of our ever-evolving field. By establishing a RTF within our RCD, we were able to improve research related productivity. Further research must be done to evaluate the impact of staff-based research programs and the impact on career development, engagement, and patient outcomes within respiratory care. References: 1. Kallet RH. Developing a research program within a respiratory care department. Respir Care 2020;65 (3):388-399. 2. Hess DR. What is evidenced-based medicine and why should I care? Respir Care 2004;49(7):730-741.

Figure 1 details the Research Task Force productivity metrics and non-productive time from 2018 to 2020.

High frequency jet ventilation (HFJV), conventional ventilation (CV), and inhaled nitric oxide (INO) are therapies that are often used simultaneously. In our Level IV NICU, we noticed a discrepancy between CV set PEEP (actual PEEP), Pmin, and measured PEEP on HFJV when CV modes were changed. We aimed to evaluate the effect of this discrepancy on the delivery of INO.

A Drager Babylog equipped with a F&P Evaqua 2 circuit interfaced a Bunnell LifePulse HFJV, INO was placed in-line (between gas outlet and heater) on the HFJV from a Mallinckrodt INOmax DSIR system to a Drager neonate test lung. Two models were evaluated, Model 1 included CV-PC CMV, PIP 25, Ti 0.35, RR 5, PEEP 6, HFJV- PIP 30, RR 420, Ti 0.02 and INO at 20 ppm (sampling post ETT and within the test lung). Model 2 included CV- SPN CPAP, PEEP 6, PS 6, with the HFJV and INO unchanged. Variables for analysis included: CV measured PEEP/Pmin, HFJV measured PEEP/ΔP and INO sampling on DSIR. Due to an observed decrease in PEEP and increase in ΔP on the HFJV when switching between models slightly larger V_Ts would be expected. INO sampling was obtained from within the test lung to evaluate INO delivery and values were obtained three times in each model after stabilization and averaged. Student’s t-test was used to determine statistical significance.

Average values in CMV PC mode were CV PEEP 6.2, Pmin 5.9, HFJV PEEP 6.1, HFJV ΔP 23.9, INO 19 ppm. Average values in SPN CPAP mode were CV PEEP 5.8, Pmin 5.2, HFJV PEEP 5.3, HFJV ΔP 24.7, INO 19 ppm. Pmin/HFJV PEEP is decreased and HFJV ΔP is increased when CV mode is changed from CMV PC to SPN CPAP. As PEEP decreases and ΔP increases, larger V_Ts are expected. All reported pressure fluctuations were determined not significant (Table 1) and fall within manufacturer's specifications. INO delivery was not affected when CV mode changes were made when used in conjunction with HFJV.

Despite variability in CV Set PEEP, Pmin, and measured PEEP between CV and HFJV, when CV modes were changed INO delivery remained stable in our bench model. Further research must be done to evaluate expected volume increases and the potential impact to neonatal patients on these therapies.

Training caregivers to care for technology-dependent children after discharge is comprehensive and challenging. In our facility, initial hospital discharge to home of ventilator-dependent children with a tracheostomy requires education of 2 caregivers. Our comprehensive education program (EP) is offered to caregivers of all patients with tracheostomy placement. The EP involves interactive sessions with patient and caregivers to facilitate the knowledge of all aspects of medical care competently and independently (Figure 1). In March of 2020, COVID-19 placed challenges on the EP due to visitor limitations and social distancing guidelines (limited to 1 visitor). We aimed to evaluate the effect of these restrictions on education and discharge of ventilator-dependent children with tracheostomy in our facility.

We performed an IRB-approved retrospective data analysis of patients receiving a tracheostomy with caregivers opting for the goal of discharge home from 1/1/2019–12/31/2020. We examined tracheostomy indication, average length of stay (LOS), EP completion time, discharge delays, and visitation policy exemptions granted. Discharge delays were classified as medical or non-medical, with non-medical delays occurring when patients were stable on a home ventilator for ≥7 d.

In 2019 and 2020, patient age ranged from 3 weeks to 18 years and the most common indication for tracheostomy was bronchopulmonary dysplasia. In 2019, there were 21 patients who received tracheostomy enrolled in our EP. 76.2% (n = 16) were discharged home and 23.8% (n = 5) were discharged to a facility. 76.2% (n = 16) completed the EP. Those who did not complete the EP reported difficulty obtaining a second caregivers or travel difficulties. Total median LOS was 77 d, median EP completion time was 50 d, and median non-medical delay was 42 d. In 2020, there were 19 patients who received tracheostomy enrolled in our EP. 84.2% (n = 16) were discharged home and 15.8% (n = 3) remained admitted. 100% (n = 19) completed the EP. Total median LOS was 79 d, median EP completion time was 48 d, and median non-medical delay was 22 d, not including the 3 patients who remained admitted. Visitor exceptions (to allow 2 caregivers for EP) were granted by administrative leaders 100% of the time. All non-medical delays were secondary to difficulties with obtaining private duty nursing.

Caregiver training for ventilator-dependent children after tracheostomy placement in our facility was not negatively impacted by COVID-19 visitor restrictions. NMD did not significantly increase from 2019 to 2020. Further studies must be done in order to review the impact of COVID-19 on technology dependent patients more globally.

Figure 1 displays the technology dependent EP structure and components.

The utilization of tracheostomies in pediatric patients for the management of chronic disease has increased in recent years. Little prevalence data exists to describe this population and the adverse events related to tracheostomy care.

A retrospective observational trial was performed of all inpatient tracheostomy patients between January 1 and June 30, 2020. Patients remaining admitted were followed to discharge or to December 31, 2020, whichever came sooner. Descriptive statistics were conducted to describe trends in prevalence data. The IRB granted an exemption for the study.

A total of 241 tracheostomy patients were admitted, median age 5 y old (IQR 3–11). Number of admissions per patient averaged 1.44, while median length of stay was 7 d (IQR 3–62). Admission diagnoses were grouped as upper and lower respiratory, home medical emergency, sepsis/shock, cardiology, neurology, planned, or other (Table 1). 83.8% were discharged on home respiratory support, with 68.5% requiring positive pressure ventilation. 43.2% patients were discharged on either or both pharmacologic and/or mechanical airway clearance. The majority of patients received routine tracheostomy tube changes on a weekly basis (78.9%), while others received them every 2 weeks or 4 weeks, 11.7% and 8.6% respectively. Adverse events (Table 2) were characterized as skin breakdown (29.3%), granulation tissue (24.1%), tracheitis (4.1%), pneumonia (0.6%), cellulitis (0.6%), tracheostomy site bleeding (3.2%), and emergency tracheostomy change (5.8%). Unplanned decannulations (one event or more per patient) were tracked with an incidence of 10.4%.

Pediatric tracheostomy patients are hospitalized for a broad range of chronic and acute conditions. Skin breakdown and granulation tissue were the most frequent adverse events associated with pediatric tracheostomy, while respiratory infections, cellulitis, bleeding, and need for emergency tracheostomy change were infrequent. Routine tracheostomy tube changes most often occur weekly.

COVID-19 brought rapid changes in practice due to the early uncertainty of transmission of the virus during aerosol-generating procedures (AGPs). During a season when bronchiolitis is frequently seen in the pediatric population, alternative therapies to AGPs were preferred to decrease risk of viral transmission. Preference to treatments not considered AGPs was communicated via enterprise-wide email communication to all health care providers. In our facility, care of bronchiolitis patients is guided by a pathway (Figure 1). We aimed to assess the impact of COVID-19 with regards to AGPs in our pediatric bronchiolitis population.

After IRB approval was obtained, a retrospective chart review was completed comparing bronchiolitis pathway patients’ therapies (HiVNi use, respiratory treatments, and viral testing) and outcomes (LOS, RRT/code prevalence, and readmission rate). For the purpose of this study, only patients admitted to the limited stay unit (LSU) with bronchiolitis diagnosis were included. Descriptive statistics and the student’s t-test were used for data analysis. See Figure 1 for pathway details.

Bronchiolitis patients admitted to the LSU in 2019 (n = 638) were compared to 2020 (n = 217) before and during the COVID-19 pandemic (Table 1). Average age of patients in 2019 was 8 months (4 wks–23 mo) and 8 months in 2020 (4 wks–22 mo). Prevalence of viral testing increased from 2019 (81%) to 2020 (84%) by 3%. In 2019 36% (n = 227) of patients on the pathway received respiratory treatments. Of those 88% (n = 200) were delivered via small volume nebulizer (SVN) and 14% (n = 27) were delivered by metered dose inhaler (MDI). In 2020, 27% (n = 59) of patients received respiratory treatments, 7% n = (4) via SVN and 93% (n = 55) via MDI. Use of HiVNI decreased from 2019 (52%/n = 330) when compared to 2020 (29%/n = 64) by 23%. Mean LOS was 48.73 h (20.3 d) in 2019 and 41.85 h (1.74 d) (P < 0.03). Readmission rates for bronchiolitis patients was 6% in 2019 (n = 39) and 3% in 2020 (n = 6). The prevalence of RRTs/code response when compared year to year was not statistically significant.

The COVID-19 pandemic brought rapid changes in practice due to the uncertainty of transmission during AGPs. Our institution was able to reduce AGPs by 52% for pediatric bronchiolitis patients. LOS was also reduced while readmission rates for this population were not affected. Further research must be done to examine impact outside of a pandemic related response.

Figure 1 shows the Bronchiolitis Pathway for inpatients in our facility.

Our pediatric hospital utilizes 12 respiratory therapists (RTs) to perform spirometry studies in outpatient environments. The National Board of Respiratory Care (NBRC) offers the Pulmonary Function Technologist (PFT) credential for RTs to highlight specialized skills and excellence for those who obtain it. In our facility, 5 RTs were PFT certified (C/RPFT) prior to 2020 and 7 RTs became PFT certified in 2020 (2 CPFT and 5 RPFT). The quality of spirometry is guided by the American Thoracic Society (ATS) standards to ensure that spirometry results are accurately interpreted and influence care appropriately. Audits pre and post PFT credential were reviewed for acceptability based on ATS standards (Table 1). We aimed to evaluate if PFT credential achievement would translate into increased ATS compliance for spirometries performed in our pediatric hospital.

In an IRB approved retrospective analysis, we reviewed and compared spirometry audits from 01/2019–05/2021 for compliance to ATS Standards. As part of our standard quality assurance process a minimum 30% of spirometries are randomly selected and audited by trained PFT staff for compliance based. We evaluated compliance results pre and post PFT credential achievement for the 7 RTs who obtained certification in 2020 and analyzed for differences.

670 spirometry audits were included for analysis for the seven RTs who achieved a PFT credential in 2020 (514 pre credential and 156 post credential). Prior to PFT credential obtainment, RTs performed spirometry that met ATS standards 92.45% of the time. After obtaining PFT credential RTs performed spirometry that met ATS standards 97.72% of the time (Figure 1). This resulted in a 5.27% (P >0.05) increase in compliance with ATS standards post PFT credential achievement.

In our pediatric health system, we found that spirometry compliance to ATS standards increased after RTs obtained their PFT credential. This translates into increased spirometry accuracy and could influence appropriate treatment. More research is needed to assess further implications from possible increased spirometry accuracy and the subsequent care provided.

Figure 1 shows the individual percentage of compliance with ATS standards for pediatric spirometry in our facility based on pre & post PFT credential achievement.

Overnight oximetry studies along with pulmonary function tests are used to determine the need for nocturnal noninvasive ventilation needs for the ALS patient population. As an ALS research center, many patients travel great distances to attend our ALS clinic. Overnight oximetry studies are usually performed the night before the quarterly ALS visit. During the COVID-19 pandemic many visits were performed virtually. This led our team to explore alternatives to our traditional testing methods. We needed to be able to provide overnight oximetry tests remotely. We found local DME companies to be inconsistent with services provided.

A multidisciplinary team reviewed our institutional overnight oximetry study process for our ALS patient population. Currently, many of our ALS patients are performing overnight oximetry studies the night before their scheduled quarterly ALS clinic appointment. Patients pick up the overnight oximeter, perform the overnight test, and then drop off the oximeter prior to their appointment. During the COVID-19 pandemic many visits were done virtually, leaving us many times with no overnight oximetry study. We sought to investigate ways to improve this process. We developed a process whereby portable overnight oximeters are mailed to ALS patients (one week) prior to their scheduled quarterly multidisciplinary appointment. If patients were scheduled for a virtual visit, a Fed-Ex return label was included. If they were scheduled for a face-to-face visit, the oximeters were downloaded during their appointment. A six question Likert type survey was developed as tool to measure things like patient satisfaction, test process, quality of sleep, and patient convenience. Patients filled out surveys of the overnight oximetry process pre and post implementation.

Results show improved sleep and increased patient satisfaction. 82% of patients also rated the process as easy and 93% preferred to have the oximeter mailed to them rather than having to pick it up at our clinic.

As ALS progresses, making tests like overnight oximetry studies more convenient for those with ALS increases patient satisfaction. As a result of the COVID-19 pandemic, virtual visits are becoming more popular. Remote patient testing and monitoring is a must.

The Philips Trilogy 202 ventilator is often used as a home ventilator for ventilator dependent patients. In preparation for its discontinuation, we evaluated the Trilogy EV300 (EV300) as its manufacturer replacement. The EV300 is equipped with permanent tubing compliance (TC) which results in higher volumes delivered than the 202 and restricts use to larger pediatric patients. We aimed to determine if the humification feature on the EV300 had an effect on volumes delivered in consistent and reproduceable way that could expand use in patients who require tidal volumes below the minimum 50 mL setting.

A Philips EV300 equipped with a F&P 114 circuit and MR850 heater with a Philips Respironics whisper swivel valve which was interfaced with a Philips NM3 (pediatric adapter) and connected to a Michigan Test Lung (TL). TL compliance (CL) was set at 0.005 & 0.002 L/cm H₂O in two models to simulate CL of a normal infant and decreased CL. The EV300 settings included: pediatric category, adult circuit (20-22 mm), AC/VC, RR 15, Ti 0.6 s, PEEP 5. At each CL, 6 trials were performed with 3 V_Ts (50 mL, 100 mL, 150 mL) with the humidification feature either ON or OFF. After stabilization, pressure and volumes were recorded as displayed from the EV300 and NM3 3 times, 1-min apart and then reported as averages.

With the humidification feature OFF volumes delivered by the EV300 were decreased by an average of 10% from set V_T (Figure 1 and Table 1). This phenomenon is enhanced (up to 18% difference) in the decreased CL model. Differences in volume loss with the humidification feature ON and OFF is not consistent between models and is dependent on a variety of other factors such as: set volume, ΔP, and patient lung compliance and resistance.

Volume reduction from the humidification feature ON/OFF on the EV300 are present but not independently predicable. The changes in functionality between the 202 and EV300 impact the use and flexibility within pediatrics. Further studies must be performed to access outcomes in pediatrics related to transitions from critical care ventilator to EV300. Data with other CL and/or resistance models would be beneficial to reveal possible patterned correlations.

Figure 1 shows the percentage difference in volumes and pressure when the humidification feature is OFF on the EV300 ventilator.

Invasive mechanical ventilation is associated with costly complications such as ventilator-associated pneumonia, muscle atrophy, and line sepsis.¹ For patients with persistent need for inhaled nitric oxide (INO), extubation may be delayed by limited options for noninvasive ventilation (NIV) compatibility with INO. Studies suggest that NIV with INO may be appropriate and effective.² There is insufficient data on NIV INO delivery via systems with leaks. Our current standard of practice is to utilize a non-vented mask (NVM) in conjunction with F&P Evaqua dual-limb circuit on a Maquet Servo-U ventilator in NIV mode to accommodate Mallinckrodt INOMax DSIR recommendations. The need for a leakless system enhances restrictions for appropriate mask options in pediatrics. We aimed to evaluate INO delivery in a NIV bench model with a single limb circuit and leak to assess feasibility of INO delivery for our pediatric population.

INO delivery was evaluated using three NIV models. In all models a Michigan test lung (infant 0.005 compliance) was interfaced with the pediatric head mannikin (open nostrils) via Philips PerforMax XS mask and spontaneous breathing was simulated via ventilator (RR 30). INO injector module was placed immediately after the NIV outlet filter and INO was sampled proximal and distal to the patient interface. Both a Philips Respironics V60 and the EV300 were trialed with three models: the mask with non-vented adapter (NV) and distal exhalation port (DEP), the mask with NV and Respironics Whisper Swivel, and the mask with the Philips vented port. NIV settings were S/T, IPAP 20, EPAP 10, RR 10, Ti 0.7, % FIO₂ 1.0. NIV leak was maintained at <60 L/min and NIV pressures were allowed to stabilize and verified prior to trials. Each trial was 30 min, with recordings every 10 min.

In all models evaluated NO and NO₂ showed no statistical significance in set, delivered, or measured values (Table 1). INO PSI showed no change over the trial period in a system with leaks.

In our bench analysis of INO and a NIV system with leaks INO delivery remained consistent and reliable. More studies should be done to assess implications related to INO D-cylinder tank duration, patient response, and potential caregiver exposure. References: 1. Cooke C. Economics of mechanical ventilation and respiratory failure. 2021;28(1):39-55. 2. Priyanka Patel, et al. Safety and efficacy of noninvasive inhaled nitric oxide in pediatric cardiac intensive care unit. Pediatrics 2019;144:403.

A key element of lung-protective ventilation is to control tidal volume within 4–8 mL/kg of predicted body weight. In volume-targeted modes, a portion of tidal volume is lost due to compression in the patient circuit. The automatic compensation for compressible volume by the ventilator is important. Many critical care ventilators provide patient circuit compensation to counteract the loss of volume in ventilator circuits based on circuit compliance (C_circuit) and airway pressure (P_aw). The purpose of the study was to assess how inspiratory effort affects volume delivery with or without circuit compensation.

This study was conducted using the IngMar Active Servo Lung 5000 (ASL 5000), programmed to simulate an adult patient with moderate ARDS (compliance = 40 mL/cm H₂O and resistance = 10 cm H₂O/L/s) and different inspiratory efforts. The effort models were set to maximum muscle pressure, Pmax = 0, 5, 10, 15 cm H₂O. The experiment was performed with a heated humidifier in the patient circuit, filled with water, but not turned on. Two modes were used on a Servo-U ventilator: volume-controlled continuous mandatory ventilation with set-point targeting scheme (VC-CMVs) and pressure-controlled continuous mandatory ventilation with adaptive targeting scheme (PC-CMVa). The outcome variable was the difference between tidal volume with and without circuit compensation for passive and active breathing (ΔV_T). ΔV_T = (P_aw-PEEP)/C_circuit. We recorded the mean of inspired tidal volume as measured and analyzed by the ASL 5000 for 10 breaths after stabilization.

Data are shown in the graph below. ΔV_{T decreases as Pmax increases.}

The effects of circuit compensation are affected by the simulated inspiratory effort, as expected. For volume-targeted modes, increasing effort decreases P_aw. Decreasing P_aw decreases ΔV_T.

Transcutaneous CO₂ (TCM) monitoring is the accepted standard in assessing carbon dioxide pressure (CO₂) in the tissue and can be helpful in the management of newborns requiring ventilatory support. Infants with hypoxic ischemic encephalopathy (HIE) are routinely treated with therapeutic hypothermia (TH) to 33.5°C. It is well established that fluctuations in the partial pressure of CO₂ in arterial blood (PaCO₂) during TH is associated with poor neurodevelopmental outcomes, thus close monitoring of PaCO₂ is key to good outcomes. TCM correlation is perfusion dependent. TCM heats the skin at the sensor site to arterialize the sample. The non-invasive device produces a PCO₂ value corrected to 37°C (TcPCO₂). The TCM is mostly regarded as a reliable noninvasive manner to continuously monitor tissue CO₂. Our objective was to determine the accuracy and precision of TcPCO₂values in newborns undergoing TH.

We conducted a retrospective chart review of 10 neonates (3F/7M) undergoing TH for HIE requiring respiratory support. The weight of the neonates ranged from 2,230 to 3,810 g. We compared TcPCO₂to PaCO₂ values (all at 37°C) using a Bland-Altman plot for multiple measurements per patient. A Wilcoxon test for paired samples (non-normally distributed data), and a repeated measures ANOVA (rmANOVA: two types of measurements; five measurements per subject, eight subjects) was also used to aid in the analysis. IRB exempt status was gained through UC Davis.

Ninety paired samples were collected in 10 patients with a range of PaCO₂ 28–94 mm Hg. Median difference was 2 mm Hg higher in TcPCO₂ (Wilcoxon test for paired samples P < 0.01). However, the precision was poor (95% CI was -13 to +18 mm Hg). The rmANOVA showed no main effect on measurement number (P = 0.38), method of comparison (P = 0.78), or the interaction (P = 0.67).

TcPCO₂ showed a strong median correlation to PaCO₂ values at 37°C but lacked precision. TcPCO₂may not be appropriate for estimating PaCO₂ in patients undergoing TH. Care should be taken when utilizing TCM in these patients. TCM may prove to be a reliable trending tool but acute changes in values should be confirmed with PaCO₂. Given our small sample size (N = 10) and the retrospective nature of our study, more investigation into the usefulness of TCM during TH is warranted. Discrepancy in TcPCO₂and PaCO₂ values during TH justifies further exploration in transcutaneous monitoring.

Continuous nebulization of pulmonary vasodilators is an off-label therapy for hypoxemia. Patients may require additional aerosol therapies such as bronchodilators and antibiotics. This study evaluates delivery of concurrent therapy of multiple medications during continuous nebulization without interruption or circuit disconnection.

One i-AIRE dual-port breath-enhanced jet nebulizer (BEJN) or two Aerogen Solo vibrating mesh nebulizers (VMN) were installed on the dry side of the humidifier. VMN were stacked; one for infusion, the second for bolus drug delivery. The BEJN was powered by air at 3.5 L/min, 50 psig. Radiolabeled saline was infused at 5 & 10 mL/h with radiolabeled 3 mL and 6 mL bolus injections at 30 and 120 min respectively. Two adult breathing patterns (duty cycle 0.13 and 0.34) were tested with an infusion time of 4 h. Inhaled Mass expressed as % of initial syringe activity (IM %/min) was monitored in real time with a ratemeter. All delivered radioaerosol was collected on a filter at the airway opening. Transients in aerosol delivery were documented.

IM %/h during continuous infusion was linear and predictable, mean ± SD: 3.63 ± 2.02%, 3.54 ± 2.78% for BEJN and VMN, respectively. BEJN functioned without incident. VMN continuous aerosol delivery stopped spontaneously in 4 of 8 runs (50%); bolus delivery stopped spontaneously in 9 of 16 runs (56%). Tapping restarted VMN function during 3 of 4 continuous runs and 7 of 9 bolus delivery runs. Bolus delivery IM% (mean ± SD): 22.17 ± 7.65%, 14.37 ± 10.62% for BEJN and VMN, respectively.

Simultaneous continuous and bolus nebulization without circuit disconnection is possible for both jet and mesh technology. Monitoring of VMN devices may be necessary in case of spontaneous interruption of nebulization.

Previous work measured aerosol delivery for i-AIRE, a prototype inline breath-enhanced jet nebulizer (BEJN) located on the wet/outlet of the humidifier. Recent observations reported that placement of single-patient-use nebulizers in this location results in excess condensation in the inspiratory limb and nebulizer flooding. The present study tested i-AIRE in vitro compared to Solo, a vibrating mesh nebulizer (VMN) on the humidifier dry/inlet side of the ventilator circuit during continuous and bolus treatment nebulization.

Two adult duty cycle (DC) breathing patterns were tested during continuous infusion (5 or 10 mL/h) with and without dynamic changes in infusion rate and DC, or bolus delivery (3 or 6 mL) of radiolabeled saline. Inhaled mass (IM) reported as a function of time was measured in real-time using a gamma ratemeter (µCi/min) and analyzed by multiple linear regression. Expiratory losses (EXP) were measured and reported as the IM:EXP ratio.

During simple continuous infusion, IM increased linearly for both nebulizer types. IM variability was attributable to DC (P < 0.001, 34%) and infusion flow (P < 0.001, 32%), but independent of nebulizer technology (P = 0.381, 7%). Dynamic continuous infusion studies mimicking clinical scenarios with ventilator and pump flow changes demonstrated a linear increase in the rate of aerosol that was dependent on pump flow (P < 0.01, 63%) and was minimally dependent on duty cycle (P = 0.03, 8%). During bolus treatments, IM increased linearly to plateau. IM variability was attributable to DC (P < 0.001, 40%) and residual nebulizer volume (P < 0.001, 20%). Separate analysis revealed VMN residual volume contributing 16% of the variability and BEJN 5%. IM variability was independent of bolus volume (P = 0.82, 1%). System losses were similar (BEJN: 32% residual in nebulizer; VMN: 34% in circuitry). IM:EXP ratio was approximately 10 times greater than predicted by the ventilator DC for both nebulizer types during bolus and continuous infusion.

Aerosol delivery during continuous infusion and bolus delivery is comparable between the BEJN and VMN and determined by pump flow and initial ventilator settings. Once treatment is initiated, further adjustments in ventilator settings did not significantly affect drug delivery. Furthermore, placement of the nebulizer on the humidifier dry-side allows for a greater inhaled mass-to-expiratory loss ratio than predicted by ventilator DC.

In 2016, the CDC announced the pediatric ventilator-associated events (VAE) definition that would replace the ventilator-associated pneumonia (VAP) events beginning in 2017. The internal interdisciplinary VAP committee began work for surveillance and case reviews for this new metric alongside VAP surveillance and sought to estimate the burden of VAE compared to VAP.

A surveillance report was developed through EPIC in accordance with the CDC definitions for qualifying changes in P_aw or FIO₂ for all invasively ventilated patient. This query runs at midnight each day and sends the report to the respiratory therapy department clinical specialists for review and final determination. When a VAE occurs, an interdisciplinary case review occurs. Exemption was provided from local IRB.

From January 2017–April 2021, 112 VAEs occurred compared to 17 VAPs over the same time period (X², P = 0.22). Median age in months at the time of event as 8.85 (IQR 5.15-43.42). Forty-two percent occurred in the pediatric ICU, 31% neonatal ICU, 16% cardiac ICU, and 11% progressive care unit. Eighty-four percent were triggered for change in P_aw. Events deemed associated with the VAE were categorized with the highest three associations as: 29% severe bronchopulmonary dysplasia, 12% infectious cause, 12% progressive lung disease. All categories shown in table. Of note, none of the VAEs had a concurrent VAP and only 6 (5%) of the events were thought to have been preventable by the clinical team.

The occurrence of pediatric VAE in a quaternary children’s hospital is six-fold higher than the occurrence of VAP, with 100% discordance between the events. The pediatric VAE definition does not appear to trigger events of error or harm as the clinical teams perceived them to be non-preventable or predictable but were part of the anticipated clinical disease progression in our patient population.

Adults with COPD are predisposed to frequent complications related to their progressive disease which increases their hospitalizations. As elderly with COPD ages, the risk of hospital readmission increases; however, it is not clear what is the effect of body mass index (BMI) among elderly Saudi with COPD. Especially, within a cultural framework as the older tends to be served and less physically active to indirectly predispose him/her to abnormally high BMI.

Data from a random represented sample of 300 Saudi adults with COPD were retrieved from the medical record of a tertiary care hospital in Saudi Arabia after the approval of the institutional review board. Several variables were collected including demographics, hospital readmission, comorbidities, and BMIs. Logistic regression and Andrew Hayes’ moderation analysis were used to predict hospital readmission and test the moderation (interaction) effect of BMI with hospital readmission predictors among adults with COPD.

Among our hypothesized predictors, we have found that age and cardiovascular disease with COPD increases the odds of hospital readmissions (aOR = 1.025, 95% CI [1.004–1.046], and aOR = 2.374, 95% CI [1.092–5.164], respectively). However, those with COPD and musculoskeletal disorders were less likely to be readmitted into hospitals (aOR = 0.496, 95% CI [0.247–0.997]. Among the significant predictors, BMI significantly moderated the relation of age with hospital readmission (B = 0.002, SE = 0.001, P = 0.041).

The burden of COPD-related complications remains public health and clinical dilemmas; one of which is the hospital readmission of COPD. We revealed, however, that the older and higher BMI those with COPD, the greater the risk of hospital readmission. This moderation finding signifies the necessity of dietary and exercise prescriptions to elderly with COPD in their action and discharge plans to avoid abnormally high BMI and sedentary behaviors they may increase the risk of hospital readmission.

New graduate respiratory therapists (NG), regardless of degree program, receive limited preparation in neonatal/pediatric diseases and management. Experienced therapists (Exp) typically have adult knowledge, but limited exposure to pediatrics. We implemented a competence-based simulation program to help improve successful completion of orientation.

A 9-week orientation program curriculum with simulation-based competence assessment was developed to assure all new hires gain foundational knowledge and skills to perform pediatric clinical tasks. Each new hire individually completed the same simulation scenarios during the first week (pre) and last week of orientation (post). Curriculum changes were made based on the performance in the simulations as well as their on-the-job training knowledge and skills during and after orientation. The scoring system changed at the time of curriculum update (between period 1 and 2). Paired and unpaired t-tests with P < 0.05 as significant. Exemption was granted from local IRB.

From Jan 2017–Feb 2020, the program had two curriculum updates (Period 1-3). Period 2 introduced weighted checklists for both simulations and Period 3 introduced 7 weekly didactic sessions. Noninvasive ventilation and decompensating patient scenarios were completed for all periods. Ninety-three new staff were oriented [period 1 = 29 (NG 20, Exp 9); period 2 = 42 (NG 31, Exp 11), period 3 = 22 (NG 22)]. Mitigation during orientation occurred in 16% of the staff. 67% successfully advanced on to ICU orientation after completion of the program. All staff improved scores between pre vs. post simulations in all periods: mean difference ± standard deviation [Period 1: NG 32.1 ± 17.0 P < 0.001; Exp 28.1 ± 18.9, P < 0.001; Period 2: NG 27.2 ± 19.9, P < 0.001; Exp 28.8 ± 12.8, P < 0.001; Period 3: NG 19.6 ± 14.5,P < 0.001, paired t-test]. The scores between NG and Exp during post-simulation were not significantly different for Period 1 (P = 0.346), however was significantly different for Period 2 and 3 (P = 0.040, unpaired t-test).

Use of a competence-based orientation program effectively shows educational advancements from orientation and assists with analysis of readiness for orientation completion.

Asthma is a persistent dreaded health condition that affects a vast population globally whether in developing or developed countries. Improper usage and incorrect inhalation methods result in reduced deposition of the medicine and thus the disease flares-up. Since there is a paucity of evidence about the knowledge of the Saudi population especially pediatrics caregivers regarding the use of metered-dose inhalers, this study aims to evaluate the level of knowledge among caregivers of pediatric asthma patients to administer metered-dose inhaler at King Abdul-Aziz Medical City, Riyadh, Saudi Arabia.

The study was conducted in the pediatric outpatient department at King Abdul-Aziz Medical City, Riyadh, Saudi Arabia. The design of the study was cross-sectional. The sampling technique was convenience sampling. Data was collected in the form of a questionnaire which contains 10 questions, and they were close-ended questions. A printed questionnaire was distributed to all the parents or the caregivers who had used a metered-dose inhaler or were use it at the same time as the study. Institutional Review Board (IRB) approval was obtained before starting the data collection and the confidentiality of the participants was maintained throughout the study.

A total of 90 patient caregivers after proper inclusion & exclusion criteria were included in this study. The majority (92.2%) of the patients were > 2 y old and (57.8%) of them were diagnosed with asthma or an asthma exacerbation episode. (56.7%) of the patients had an emergency department visit in the previous year. The common trigger for asthma attack was common cold (81.1%). (54.4%) of patients started using MDI in age < 2 y. 69 patients have used a spacer with MDI and 38 of them know how to use it properly. 62 (68.9%) patients were instructed to use MDI by physicians while 11 (12.2%) patients were instructed by RTs. Out of the total number of patients, the most common medication used was Ventolin (86 patients) used it and they constitute (95.6%) of the total population.

The study concluded that caregivers of pediatric asthma patients had a better knowledge of using MDI with spacer than using MDI without the spacer.

Endotracheal intubation is a routinely performed procedure in the ICU that can result in laryngeal injury. Many injuries from intubations occur at the posterior vocal cords (PVC) and present as superficial ulcers that can progress to involve deeper mucosal layers. Posterior vocal cord ulcers (PVCU) can lead to the development of granulomas and vocal cord dysfunction, which can increase the risk of aspiration in ICU patients. There is currently no consensus in the literature on the incidence of PVCU. One method to determine the occurrence of PVCU is during a tracheostomy. This study investigated the length of time ICU patients can be on a ventilator before the development of PVCU by determining the presence of PVCU at the time of tracheostomy placement.

This was an IRB approved retrospective analysis of 1,355 patients from 2002–2018 who received a tracheostomy. Post tracheostomy operative notes were reviewed and considered only if proper visualization of the vocal cords was documented. Demographic data was ascertained. Primary outcome measures included the presence of PVCU, length of time on a ventilator until a tracheostomy, length of hospitalization, and mortality. Ulcers were stratified by severity (mild, moderate, and severe) and were analyzed using ANOVA with an alpha of 0.05. Data was reported as n (%) and median (IQR).

192 patients were included in the study and divided into two groups: patients who developed PVCU (n = 153) and patients who did not develop PVCU (n = 39). Comparisons were calculated between patients with and without PVCU. On average, PVCU subjects were significantly older [56 vs 44, P = 0.002] and had similar hospitalization stays [29 vs 34, P = 0.743]. PVCU patients were intubated for significantly longer [10 vs 6, P <0.001). There was no statistically significant difference between gender, BMI, and mortality between groups. Most notably, there was a statistically significant difference (P < 0.001) between the length of time on a ventilator before tracheostomy and the severity of the PVCU seen (Table 1).

Patients with PVCU were on average older and intubated for longer. Longer intubation before tracheostomy correlated with more severe ulceration of the PVC suggesting earlier conversion to tracheostomy may decrease the incidence of severe PVCU. Further development of improved endotracheal tube designs can aim to reduce pressure on the posterior vocal cord and improve outcomes.

Emergency department (ED) re-visit and hospital readmission are critical issues affecting many healthcare systems. Current studies have investigated the effect of the obesity paradox on readmission rate, however, data are scarce in relation to the impact of body mass index (BMI) and ED re-visit after discharge for respiratory disease. This study aimed to examine the effect of BMI on the rate of ED visits within 30 d following hospital discharge for respiratory disease.

Institutional review board (IRB) approval was obtained. A retrospective chart review was carried out of randomly selected adult patients admitted with respiratory disease to the tertiary care center in Saudi Arabia between 2018-2020. The date of admission of those patients was considered the index date. Each medical file was reviewed for all-cause ED re-visit, excluding trauma and mortality, within 30 d of discharge from the index date. The BMI were classified using BMI categories into underweight (BMI <18.5 kg/m²), normal (BMI 18.5–24.9 kg/m², overweight (BMI ≥ 25–29.9 kg/m²), and obese (BMI ≥ 30 kg/m²). Additionally, demographic, and clinical information for each patient were retrieved from their electronic medical file.

A total of 600 patients admitted with respiratory disease were identified in which the most common respiratory disease for the initial admission for the index date was respiratory tract infections (47%). The mean age of the study population was 55 ± 21 y old. 372 (60%) of the study population had ED readmission post-hospital discharge within 30 d. 30% of the study population were overweight (BMI ≥ 25-29.9 kg/m²) and 38% were obese (BMI ≥ 30 kg/m²). Overweight-obese BMI had a higher prevalence of comorbidities compared with a normal BMI (71% vs. 21%, P = 0.036). No difference in percentages of readmissions within 30-day (69%) existed between overweight-obese and normal BMI groups.

ED re-visit and hospital readmission for patient with respiratory diseases are critical issues. We found that overweight-obese BMI had a higher prevalence of comorbidities compared with a normal BMI. There is no significant difference between ED visits and BMI. Similarly, gender factor and ED visits show no relation.

Tracheostomy is usually performed for patients who can’t maintain patent airway for breathing. In addition, it has benefits in terms of reducing the incidence of ventilator associated events (VAE), faster weaning from MV, and help patients to speak, eat, and communicate. However, infection and colonization after tracheostomy is a major complication that may increase the mortality rate. The aim is to describe the microbiology of adult patients and the prevalence of infection among tracheostomy patients in tertiary care center in Saudi Arabia.

Institutional review board (IRB) approval was obtained. The study was observational cross-sectional that is conducted in King Abdulaziz Medical City (KAMC) between 2016-2020. A total of 712 patients had tracheostomy during the study period, and the calculated sample size was 400 patients. Each medical file was reviewed for patients who had tracheostomy associated infections. Additionally, demographic, and clinical information for each patient were retrieved from their electronic medical file.

The study included 58 patients out of 400 sample size from 2016 until 2020 and we excluded 6 patients due to missing data in medical record of the patient. There were 8 types of bacteria obtained from 52 tracheostomized patient. The results showed that the commonest type of bacteria is Pseudomonas Aeruginosa 15 (39%) and next is Klebsiella Pneumoniae 7 (18%). The least common type was Enterobacter Aerogenes 1 (3%) and Stenotrophomonas Maltophilia 1 (3%).

Tracheostomy is associated with growth of certain microbiology on the respiratory tract. As a result in our study group, we have found eight types of bacteria obtained from 52 tracheostomized patient. Pseudomonas Aeruginosa and Klebsiella Pneumoniae have shown the commonest types of bacteria and Enterobacter Aerogenes and Stenotrophomonas Maltophilia least common.

20-25% of patients with acute respiratory failure in Taiwan who use ventilators cannot successfully liberty the ventilator within 21 d. Their average age is about 70–78 y old, 61-77% are unconscious, and so far, few studies have explored hospice palliative care (HPC) is dependent on the utilization of ventilators. Therefore, the main purpose of this study is to explore the current situation of ventilator-dependent patients in Taiwan receiving HPC.

This study uses the data of the entire population profile of the National Health Insurance to explore the current situation of ventilator-dependent patients to join the HPC with the population-based retrospective matched cohort study. Analyze the ventilator-dependent patients age ≥ 18 y who used ventilators for more than 21 d during the period 2009–2017, and analyze the current status of ventilator-dependent patients who have joined the HPC.

From 2009 to 2017, a total of 186,533 long-term ventilator dependent patients, a total of 28,607 (15.34%) were enrolled in HPC, and the utilization rate of HPC increased year by year.

The rate of patients who are dependent on ventilator in Taiwan who receive HPC is 15.34%, and it is increasing year by year.

The average medical cost in ventilator-dependent patients is higher than other inpatients. Previous studies have shown that hospice palliative care intervention in end stage cancer patients can reduce medical cost. The Taiwan National Health Insurance Administration offers many different payment plans for palliative care patients. The objective of this study is to investigate the medical cost in ventilator-dependent patients with and without hospice palliative care.

This study is a retrospective cohort study. The National Health Insurance Research Database was used to collect ventilator-dependent patients age ≥18 y who used ventilators for > 21 d from 2009–2017. We excluded patients who participated in palliative care > 181 d or < 15 d. A ratio of 1:1 matching is performed to collect patients whether they received hospice palliative care or not. The conditional multiple regression analysis was used to explore the impact of medical cost during 14 d before death after control other related factors.

The medical cost was lower (mean ± SD: 39,597 ± 54,650 vs. 46,331 ± 69,278, P < 0.05) in ventilator-dependent patients with hospice palliative care group than patients without hospice palliative care in 14 d before death. After controlling other factors, the medical cost was lower in patient with hospice palliative care in 14 d before death (Ratio:0.88 95% CI: 0.81–0.96).

Ventilator-dependent patients receive hospice palliative care can significantly reduce medical cost than patient without hospice palliative care in 14 days before death.

In the intensive care unit, therapists utilize various tools to assess and monitor respiratory illness; those tools are mathematical models such as the ratio of arterial oxygen tension to inspired oxygen fraction, arterial/alveolar oxygen tension ratio, alveolar-arterial oxygen tension difference, respiratory index, oxygen index and oxygen saturation index. However, evidence reported that some pulmonary physiological factors were not integrated into the calculation of those models. Therefore, this research aimed to demonstrate the variation in those models within a short period within critical care settings.

A retrospective cohort study was carried out in ICU at tertiary care center in Saudi Arabia between 2017–2019. Adult patients who have been admitted to the ICU and placed on the mechanical ventilation > 24 h were included. From the medical file of each patient, data on the mechanical ventilator setting and ABG results were extracted. Then, two different arterial blood gas samples were selected within a mean of 120 min based on patient-specific needs for one day. Continuous variables were presented as mean and standard deviation (SD), categorical variables as frequencies and percentages. The coefficient of variation percent [(CV%) = SD/mean] was calculated and Institutional Review Board approval was obtained (IRB:SP20089R).

A total of 211 intubated ICU patients were included in this study. The mean (SD) age of the study population was 57 (19.62), and 33% were female. The average CV% for all mathematical models report a degree of variation between (14%–30%). The mean CV% for PaO₂/FIO₂ and PaO₂/ PaO₂ was 14% which consider a low variation compared to the RI in which the mean CV% was 30%.

the finding of this study indicates the need to adopt a new model that integrate pulmonary physiological factors mathematically to represent a real lung condition. This will help alongside with the other oxygen indices in assessing the severity of respiratory illness.

Coronavirus disease 2019-associated ARDS (or CARDS) often requires invasive mechanical ventilation. Early on during the pandemic there was a perception that CARDS was associated with prolonged mechanical ventilation. This retrospective study assessed the characteristics and outcomes of both ARDS and CARDS subjects during the first 6 months of the COVID-19 pandemic. The primary objective was to ascertain whether subjects with CARDS had a longer mechanical ventilation duration than other forms of ARDS.

Between March 1st and August 12th, 2020, we identified a total of 73 subjects for inclusion with either CARDS (37) or ARDS (36) who were managed with the ARDSnet ventilator protocol. Exclusion criteria were: <18 years of age, required tracheostomy, ECMO or failed extubation < 48 h. IRB approval was obtained with a waiver of consent. Demographic and baseline clinical data were collected at ARDS onset (ARDS day 0), with subsequent longitudinal data collected on ARDS days 1–3, 5, 7, 10, 14, and 21. Comparisons were made using Wilcoxon rank sum test (continuous variables), Chi squared test (categorical variables) stratified by COVID-19 status. A Kaplan Meier plot was used for extubation, and the log rank test used to assess significance. A Cox proportional hazards model was used to estimate the adjusted hazard ratio for extubation. Alpha was set at 0.05.

At ARDS onset, those meeting severe criteria (Berlin definition) was similar between CARDS (24%) vs. ARDS (27%), P = 0.81. Median [IQR] mechanical ventilation duration was longer in CARDS vs. ARDS: 10 [6–20] vs. 4 [2–8] d, P <0.001) (Figure 1). In the Cox proportional hazard analysis COVID-19 pneumonia was independently associated with a 30% decrease in the rate of achieving unassisted breathing, but this was not statistically significant (P = 0.36, 95% CI -68% to 51%). However, the rate of achieving unassisted breathing significantly increased by 31% per 10 mL/H₂O increase in C_RS (P = 0.04, 95% CI 1% to 68%).

MV days is prolonged in CARDS when compared to ARDS, and may be independently associated with changes in C_RS.

Respiratory therapists (RTs) are health care practitioners trained to use scientific concepts to identify, manage, prevent, and treat acute or chronic dysfunction of the cardiopulmonary system. This study was conducted to measure the level of awareness about the role of RTs among intensive care unit doctors and nurses.

A cross-sectional study was conducted in the ICUs of King Abdulaziz Medical City (KAMC) in Riyadh from June to July 2019. A total of 107 health care providers including doctors and nurses were the participants. The data was collected using a valid and reliable questionnaire which consists of closed-ended questions. The data was entered in Microsoft Excel and analyzed using SPSS 22. Institutional Review Board approval was obtained before staring the data collection. Name of the participant and ID were not collected. Data access was restricted only to the investigators where the data was saved securely.

A total of 107 health care providers working in ICU at KAMC (78.5% of nurses, 21.5% of doctors) participated in this research. A majority of health care providers significantly agreed that RTs were able to assess cardiopulmonary status and review chest radiograph to determine abnormalities (P = 0.001). Also, they confirmed that RTs were able to perform intubation and extubation beside their abilities to interpret hemodynamic monitoring data. They agreed that RTs were capable to manage mechanical ventilator settings for different ventilators, including disease-specific ventilator protocols and weaning procedures (>95%). RTs were supported for their abilities to observe for signs of patient-ventilator dyssynchrony (80.4%). The majority of the participants (>90%) were agreed that RTs can interpret ventilator graphics and spirometric data.

The majority of health care providers were trusting RTs’ ability to assess ICU patients, manage mechanical ventilator settings, and measure spirometric data.

There are many studies showing that some nurses have anxiety while providing care to tracheostomy patients, and this anxiety reduces the confidence and skills needed for providing the best care for tracheostomy patients.

A cross-sectional study was conducted to the 188-medical staff in a form of a questionnaire (survey) contains closed-ended questions using convenience sampling technique. It was delivered to the respiratory therapists and nurses to know what their confidence level in management of patients with tracheostomy.

A total of 188 participants with 94 RTs and 94 nurses were included in the study. Majority (56.4%) had more than 5 years of work experience. A greater part (64%) of the participants were working in wards. Ninety five percent opined that they feel confident in managing the tracheostomy patients (RTs = 94.7%, nurses = 94.7% ). The confidence level of participants in managing tracheostomy patients with a ventilator was observed to be 78% (RTs = 96%, nurses = 60%, P value = 0.001). The median (IQR) knowledge score was higher in nurses 6 (2) as compared to RTs 5 (1.5) and was statistically insignificant with P value as 0.087.

The study concluded that the RTs were more confident in managing patients with both tracheostomy and ventilator than those with nurses.

Nebulization has been described as an aerosol generating procedure (AGP). AGPs may place health care workers at an increased risk of contracting viruses, such as COVID-19. No in vivo data are available on the fugitive aerosols generated by different nebulizers and interfaces, and the efficient modality to reduce the concentrations. This study aimed to explore the most effective method to reduce fugitive aerosol concentrations during nebulization.

This study was approved by the ethics committee in Rush University (20121804-IRB01). After signing consent, healthy volunteers were given treatments of 3mL saline using a small volume nebulizer (SVN) and vibrating mesh nebulizer (VMN) with a mouthpiece, a mouthpiece with filter, a mask, and a mask with scavenger in a random order for the 9 participants. An extra study was performed to compare the two scavengers (Exhalo vs Vapotherm) and a filter mask in a random order among 5 subjects. This study was implemented in an ICU room, with 2 particle sizers placed at 1 and 3 feet away from subjects. The aerosol concentrations at sizes of 0.3 to 10 µm were taken at baseline, before, during and after each treatment.

Aerosol concentrations were higher with SVN than VMN. Regardless of nebulizer type, mask generated higher fugitive aerosol concentrations than mouthpiece. Adding a filter to mouthpiece reduced aerosol concentrations at particle sizes of 0.3 to 1.0 µm at 1 foot (all P <0.05) for VMN and at particle sizes of 0.3 to 3.0 µm (all P < 0.05) for SVN (Fig 1). Adding a scavenger over mask during nebulization reduced fugitive aerosol concentrations at particle sizes of 0.3 to 3 µm for both nebulizers. Regardless of the nebulizer type, both Vapotherm scavenger and filter mask had similar efficacy to reduce fugitive aerosol concentrations generated by nebulizer with mask (Fig 2).

SVN produced higher fugitive aerosol concentrations than VMN, while masks generated higher fugitive aerosol concentrations than mouthpiece. Adding a filter to mouthpiece or a scavenger to mask reduced fugitive aerosol concentrations for both SVN and VMN. Vapotherm scavenger and filter mask had similar effectiveness in reducing fugitive aerosol as mouthpiece with filter.

Figure 1. Mean aerosol concentrations of SVN vs VMN with mouthpiece and mask at 1 foot

Figure 2. Mean aerosol concentrations of SVN vs VMN with scavengers and filter mask at 1 foot

Asthma is a common, chronic heterogeneous disease. Tests of large airways function (FEV₁) are commonly used to diagnose/monitor disease and bronchodilator responsiveness (BDR: measured by a change in FEV₁) is considered the hallmark of asthma. Small airways (<2 mm in diameter) dysfunction (SAD) has been described in asthma, but it is unclear how common BDR in the small airways is in asthma. The aim of this study was to compare BDR in the small airways compared to FEV₁.

A retrospective analysis of patients attending a secondary referral hospital in the Midlands, United Kingdom, including non-smoking adults (>18 y) referred to the pulmonary function laboratory as part of an asthma assessment between January 2016 and April 2021. BDR was assessed 20 min after the administration of 2.5 mg of salbutamol using a jet nebulizer. Changes in FEV₁ and FEF_25-75 were assessed. The study was approved by the Research Ethics Committee and the Health Research Authority of the NHS (20/WM/0024).

219 patients were identified for this initial analysis. The population consisted of 104 (47.5%) males and the mean age was 44.7 y ± 18.9 with a BMI of 28.2 ± 6.5. 28 (12.8%) demonstrated airflow limitation in pre-BDR tests. The mean difference in pre and post bronchodilator %predicted FEV₁was 9.7 (95% CI = 8.7-10.8) and 22.3 (95% CI = 19.7-24.9) %predicted FEF_25-75; (P < 0.01 for both). In total 73 (33.3%) demonstrated BDR in FEV₁, 101 (46.1%) in FEF_25-75. All of those with significant BDR response in FEV₁ had a significant response in FEF_25-75. The BDR in FEF_25-75 was noted to be the lowest in severe cases, with no distinctive differences in other patients' characteristics.

This study confirms the presence of BDR in more adults with asthma using measures of small airways function than FEV₁. It is unclear whether this represents a separate phenotype of asthma.

Patients with spinal muscular atrophy (SMA) have compromised respiratory muscle function which results in impaired cough, hypoventilation during sleep, and chest wall deformity. We hypothesized that a multidisciplinary pathway to standardize the management of SMA patients with acute respiratory failure would assist in standardizing care and reduce length of stay.

In 2017, a multidisciplinary team consisting of respiratory therapists, nurses, critical care physicians, and pulmonologists developed a pathway for the management of SMA patients with acute respiratory failure admitted to the pediatric intensive care unit (PICU). This comprehensive pathway included ventilator strategies, weaning practices, airway clearance regimens, nutrition guidance, and sedation recommendations. Interventions and clinical supports were utilized to increase pathway use including thorough formal pathway training, order set deployment, newsletter updates, and presentations at meetings held by all disciplines. Chart review of patients admitted with SMA to the PICU was completed from 2016-2021, including length of stay. The pathway was reviewed, and minimal updates were added in 2019. The project was exempt by the local Institutional Review Board.

Since pathway initiation, 90 patients with SMA were admitted to the PICU. 47/90 (52%) were treated via the pathway as determined by order set usage. Time periods for PICU length of stay pre and post pathway initiation were compared for patients who qualified for the pathway due to respiratory failure. The pathway did reduce LOS by 1.157 d (P = 0.853) but the difference was not significantly significant.

Utilization of a pathway to standardize and streamline the management of patients with SMA in the PICU minimally reduces length of stay. The PICU will need to increase utilization of the pathway and need a larger patient pool to determine if there is a significant impact of pathway utilization on LOS.

A number of studies have shown that hospice palliative care intervention in the cancer patients can reduce medical utilization. In Taiwan we have 20-25% prolonged mechanical ventilation population, only little research discussing the effectiveness of hospice palliative care in patients who prolonged mechanical ventilation. The purpose of this study was to explore the interest of patients undergoing PMV in hospice palliative care as the effectiveness on medical utilization.

This was a population-based retrospective matched cohort study. This study used the Taiwan Health Insurance whole population database to analyze data of patients undergoing PMV whose ages were ≥ 18 y from 2009 to 2017. Our aim was to analyze the rate at which patients undergoing PMV elected to join the hospice Palliative Care Program of the National Health Insurance and the impact of the program on related factors. The control group was obtained by 1:1 matching using propensity scoring after excluding patients who participated in palliative care > 181 d or < 15 d. We also sought to compare utilization of intensive care and emergency care before 14 days of death between those who accepted hospice palliative care and those who did not. Furthermore, we used conditional logistic regression analysis to explore ICU readmission, emergency department presentation, and cardiopulmonary resuscitation incidence.

The number of prolonged mechanical ventilation of the emergency visits (odds ratio [OR] = 0.68, 95% CI: 0.63–0.74), ICU hospitalization (OR = 0.59, 95% CI: 0.53–0.46), and cardiopulmonary resuscitation (OR = 0.40, 95% CI: 0.35–0.46) was lower in the palliative care group.

Patients undergoing PMV participating in hospice palliative care can significantly reduce ICU admittance, cardiopulmonary resuscitation utilization, and medical expenses at ≤14 d before death.