Respiratory Care

Bronchopulmonary dysplasia is a complex pulmonary complication of prematurity, with limited tools for understanding the underlying lung dz. While cutting-edge ¹H chest ultrashort echo time (UTE) MRI techs have overcome many of the challenges associated with x-ray and CT. These modalities depict lung parenchymal macrostructure, providing an incomplete pic of lung function. Hyperpolarized ¹²⁹Xe gas MRI is an established, non-ionizing tech in pediatrics and adults for sensitively measuring lung function, including ventilation, microstructure, and gas exchange, but has not yet been implemented in infants. Here, we demonstrate feasibility, challenges, and preliminary ¹²⁹Xe ventilation MRI findings with comparison to structural ¹H UTE MRI.

IRB approved chest MRI was acquired in 2 non-sedated preterm males (Sub A and Sub B) with severe BPD on a NC using a neo,1.5T scanner and home-built frequency-switch¹H/¹²⁹Xe coil. Coronal 2D ¹²⁹Xe ventilation slices were acquired via gradient-echo for Sub A and spiral for Sub B. ¹²⁹Xe gas (100% concentration, ∼40% polarization) was delivered via FM and Tedlar bag compression (3-sec breath-hold with O₂ suspended; ∼15 cm H₂O). HR and SpO₂ were monitored by a RT before, during, and 2 mins after delivery. Following coil-frequency switch without patient repositioning, 3D radial ¹H UTE images were acquired during tidal breathing.

HR and SpO₂ were within 40 beats/min and 8% of baseline after 2 min, with no safety concerns at follow-up. Maintaining pressure was challenging, with fluctuations throughout each breath-hold; this likely resulted in significantly improved spiral ¹²⁹Xe image-quality (Sub B) compared with Cartesian (Sub A), by virtue of repeated k₀ sampling (R lung SNR = 24.2 and 11.2, respectively). Comparisons in Sub B reveal a ventilation defect that may be attributable to an air-trapped region (yellow arrows), and 2 large ventilation defects that are less easily attributable to structural pathologies (red arrows).

We demonstrated preliminary feasibility of neonatal ¹²⁹Xe MRI, with tolerance consistent with older pediatric studies. Gas delivery and acquisition design are likely challenges for future consideration. Detection of focal ventilation defects via ¹²⁹Xe MRI that appear unassociated with structural pathologies may provide a new imaging biomarker of regionally impaired lung function, with strong potential value in management of BPD and other lung diseases in infancy, in both the neonatal period and beyond.

High-flow nasal cannula (HFNC) has been increasingly used to treat bronchiolitis, with a substantial increase at our institution over the past decade. Increased HFNC use has not reduced time on oxygen therapy, length of stay, or rate of intensive care unit transfers. Our objective was to reduce the frequency of HFNC use in patients admitted for bronchiolitis from 41% to 20% by March 1, 2022. This goal represented a 50% reduction that was closer to our institution’s HFNC use prior to acute care implementation.

Using quality improvement (QI) methods, our multidisciplinary team of MDs, NP, nurses, RTs, and family representatives formulated key drivers to design interventions (Figure 1). Interventions included: 1) development of standardized HFNC initiation criteria (Table 1), 2) staff education on appropriate HFNC use and high-value care, 3) real-time feedback to providers on their HFNC use, 4) a script for providers to talk with families about what to expect during admission, focusing on frequent suctioning and HFNC weaning for those patients on the therapy, 5) implementation of a team huddle for all patients admitted on HFNC to discuss necessity of the therapy, and 6) distribution of a bronchiolitis toolkit to staff, containing all institutional bronchiolitis protocols and evidence-based care recommendations. We identified patients using diagnosis codes for bronchiolitis and used a statistical process control chart to track the percentage of patients with bronchiolitis who received HFNC therapy.

Over the first 10 months of our improvement interventions, we decreased HFNC use for patients admitted with bronchiolitis from 41% to 22%, an improvement that has been sustained for 8 months. Additionally, we observed decreased variability in HFNC use, representing a reduction in unnecessary practice variation (Figure 2). Based on both temporal data and qualitative feedback from providers, the most impactful Plan-Do-Study-Act (PDSA) cycles were the development of standardized initiation criteria and HFNC overuse education.

We successfully used QI methods to reduce HFNC use in patients admitted with bronchiolitis. In addition to our interventions, the COVID-19 pandemic provided an opportunity to re-educate providers on appropriate HFNC use and evidence-based care in bronchiolitis. Next steps include a change to the electronic health record HFNC order and participation in the American Academy of Pediatrics Value in Inpatient Peds national project on HFNC overuse.

During the COVID-19 pandemic mortality outcome for mechanically ventilated patients can exceed 50%. Based on this data, aggressive attempts to prevent endotracheal intubation and thus mechanical ventilation have been instituted. Self-proning, noninvasive ventilation, and high-flow oxygen administration had been utilized. Even adding addition oxygen flow via a non-rebreathing mask when high-flow oxygen is maximized at 100% and 60 L/min. There are conflicting data that this additional oxygenation administration prevents intubation in a large percentage of patients who receive it. Another question that arises if the patients fail this hyper-oxygenation strategy and require mechanical ventilation is what is the morality of this subset of patients?

We retrospectively assessed 52 patients from February 1, 2021 to April 15, 2021 who either had additional flow (10-15 L/min) added to the high flow device or a non-rebreathing placed on the patient’s face for a minimum of 7 days who then went on to require mechanical ventilation

Thirty-two of the fifty-two patients who required mechanical ventilation (62%) expired during their ICU stay. Twenty patients were liberated from mechanical ventilation via extubation or post tracheostomy. The mean duration of high-flow oxygen was 7.2 days in the survivor group and 8.7 days in the expired group. Age, BMI, and existing comorbidities were similar in both groups. SpO₂ increased by 2-3% and respiratory rate reduced by 2-6 breaths/min in both groups after additional oxygen was placed, but these improvements were not universally sustained after 24-36 hours.

In our 52 patients who received additional oxygen administration when maximized on high flow settings, who then escalated to mechanical ventilation, had a mortality rate of 62%. This is little higher than our current mechanical ventilation mortality rate of COVID-19 patients of 52%. Further research needs to be conducted to determine the role of prolonged additional oxygen administration on the outcomes of the COVID-19 patient population.

Profound hypoxemia noted by an PaO₂/FIO₂ ratio <100 torr has been a common occurrence in COVID-19 ARDS. To address this severe hypoxemia common interventions included prone positioning, optimizing PEEP, administration of a neuromuscular paralytic, and the inhalation of nitric oxide at 20 ppm or a nebulized prostacyclin. The role of inhaled nitric oxide in ARDS is often utilized a bridge therapy until oxygenation is optimized or until another clinical interventions, example ECMO, are implemented. Rebound hypoxemia is a rare occurrence in the adult patient population occurring 2% of time. Sudden discontinuation of inhaled NO can cause severe rebound pulmonary hypertension, an increase in intrapulmonary right-to-left shunting, and a decreased PaO₂. It has been suggested that downregulation of endogenous NO synthesis and/or elevated endothelin-1 levels by inhaled NO is responsible in part for this rebound phenomenon.

At our institution this was often the role of inhaled nitric oxide administration, however in several patients its administration was continued beyond two weeks. Weaning of inhaled nitric oxide was performed via the institution’s established titration protocol. (Fig 1)

Ten (n = 20) developed profound desaturation, (reduction in baseline SpO₂ by 10%) when it was reduced below 5 ppm, requiring either an increase back to 10 ppm per protocol or increased of ventilator oxygen delivery by 20-30%. All patients were eventually weaned from nitric oxide within a 48-hour time frame. However, 4 patients required nitric oxide administration for an addition 7 days until discontinuation.

The mechanism of desaturation in the COVID-19 patient population is still being postulated, the precise underlying mechanisms remain to be elucidated, to avoid rebound pulmonary hypertension, a slow, stepwise reduction of the inhaled NO concentration is recommended based our intuition’s experiences. Clinicians should be aware of quick desaturations in prolonged nitric oxide administration of the COVID-19 patient population and the interventions needed to improve the patient’s oxygenation status quickly.

Over the last 4 years our respiratory department morale level has fluctuated. Working short staffed while opening a critical care tower placed a burden on our staff members. Several factors warranted a continuation on improving and maintaining staff morale at a level that will optimize care.

This ongoing QI project began in 2019 with a survey sent out quarterly. Results were becoming stagnate and a survey with specific questions needed to be sent. Results indicated we need to continue the QI project. The goal is to implement interventions that have long-term positive effect on staff morale. Surveys will continue to be sent quarterly to evaluate the effectiveness of interventions implemented throughout the year by shared governance and leadership team.

The results of our latest survey showed a 39% decrease in morale level and a 44% reduction in participation. This year presented as a challenge because staff viewed the overall morale as low however the perception of teamwork in their home unit and the division increased. A follow up survey with direct questions was sent to staff to help determine the root cause. Staff requested transparency in regards to base/incentive pay and productivity/staffing model. RTs often feel that our profession is equivalent to nursing and think we deserve equal pay. Face to face positivity from co-workers and managers had a positive effect on morale. The follow up survey showed that 53% percent of employees felt that money isn’t more important than morale. 74% of the RTs felt that they are positivity champions, yet morale remains low. The RTs fault constant toxic conversations surrounding money and staffing shortages as the root cause for low morale. Staff defined morale as a perceived level of the desire, hope, and willingness of employees to complete assignments without hesitation. Happiness comes from within and boosting self-worth produced more productive RTs. Our focus turned towards encouraging sharing raw emotion and transparency. The leadership team and others shared their personal stories on why they come to work every day. Managers began to round and gave face to face praise. A huge factor was getting pandemic pay for critical shifts.

Programs will continue to be implemented that are within the scope of the shared governance model. The decrease in overall staff morale was influenced by factors that we were a result of the COVID-19 pandemic. Shared governance will continue interventions that target mental health. We will continue to make a positive impact on staff that is willing to embrace our efforts.

Prolonged mechanical ventilation (PMV) is usually defined as the need for mechanical ventilation for longer than 21 days. It maybe come from some patients have unbalanced respiratory loading and muscle function because of their own disease and body states while weaning from the ventilator. Recently, it is an important issue to improve the success weaning rate and finding out the influencing factors. Unfortunately, various clinical studies are not clear about the prognosis and value of different indicators. It reminded us of using the various clinical values and indicators of PMV patients in our hospital to find out the weaning factors.

We collected the baseline characteristics of the patients in the first 3 days of admission. These characteristics included APACHE II score, age, and laboratory data and these characteristics were recorded by reviewing the hospital information system. In more detail, the laboratory data included complete blood count (CBC), electrolyte, liver function, inflammatory biomarkers, renal function, and thyroid function. Clinical outcomes, including weaning rate and analyzing the good weaning characteristics and indexes of PMV patients who successfully weaned from the ventilator in our hospital. We use Mann Whitney U test to analyze and compare the continuous variables between the two groups. A P value of < .05 using a 2-sided test was considered statistically significant. The Institutional Review Board of Show Chwan Memorial Hospital (1091002) approved the study. Since this was a retrospective study, the requirement for informed consent was remitted.

From the collected 65 patients, 45 were successful in weaning (69.2%) and 20 failed (30.8%). We found the successful weaning group at the time of admission had a higher Glasgow coma scale (GCS) (7.27 ± 2.73 vs. 5.22 ± 2.82, P = .01), a lower APACHE II (20.44 ± 3.47 vs. 26.3 ± 3.36, P < .001), the value of free thyroid was higher (0.97 ± 0.25 vs. 0.78 ± 0.17, P = .027), the value of albumin was higher (3.09 ± 0.44 vs. 2.6 ± 0.46, P = .001), higher calcium (8.67 ± 0.77 vs. 8.23 ± 0.81, P = .042), lower C-reactive protein values (3.57 ± 3.34 vs. 6.36 ± 4.25, P = .02), aspartate transaminase (40.63 ± 27.07 vs. 76 ± 41.28, P = .001) (Table 1).

In this study, we are finding that APACHE II, GCS, albumin, calcium, CRP, Free T4, GOT are the important weaning factors for PMV patients. This study allows us to focus precisely on the weaning of PMV patients. And identifying risk factors for successful weaning helps us optimizing weaning strategies.

Table 1 . Comparison factors of success and failure weaning

This quantitative, correlational study examined the relationship between artificial intelligence (AI) and intensive care nurses’ physiological and psychological well-being. Disruptive innovations in healthcare are generating technology advances that aim to improve patient outcomes and optimize patient data usability in nursing practice such as wearable devices for disease management and prevention, AI in clinical decision-making support systems with predictive analytics and smart devices using AI to enhance the ability to identify patient deterioration. Disruptive innovations provide traction in achieving organizational goals such as the three elements of the Quadruple Aim: better health care, better health, and lower costs.

Using the combined Wellbeing Index (WBI) and Unified Theory of Acceptance and Use of Technology (UTAUT) survey instruments, data were collected from 32 registered nurses working in an ICU. The survey results informed the study of two research questions: to what extent does the use of AI correlate with intensive care nurses’ physiological and psychological well-being, and to what extent does behavioral intent (BI) to use AI correlate with the UTAUT variables of performance expectancy (PE), effort expectancy (EE), social influence (SI) and facilitating conditions (FC). Nonparametric analysis was conducted using a Spearman correlation analysis, two-tailed test for 0.05 significance.

All variables revealed a positive correlation. A non-significant, positive, moderate relationship was demonstrated between WBI mean and the UTAUT mean. A significant, positive, moderate relationship was demonstrated between PE mean and the BI mean. A significant, positive, strong correlation was demonstrated between EE mean and the BI mean. A non-significant, positive, weak correlation was demonstrated between SI mean and the BI mean. A significant, positive, strong correlation was demonstrated between FC mean and the BI mean.

AI and nursing can lead enhancements in standard patient care processes and workflows to improve quality of care, impact cost and optimize the patient and provider experience. Understanding and addressing the UTAUT factors that influence future technology adoption and implementations can also support achieving the Quadruple Aim. This study contributes to the gap that exists in the lack of research with the relationship known between AI and intensive care nurses’ physiological and psychological well-being

The purpose and primary benefit of healthcare compliance is to improve patient care. Noncompliance leads to poor outcomes. Challenges to implementing a new process include education of staff, ability of staff to remember to implement the new process, and engaging staff to initiate process. Cuff inflation device education was provided in June and again in July for all patients with inflated cuffs in the PICU and CTICU. Despite repetitive education on the use and documentation of a cuff inflation device, respiratory therapists (RTs) continued to have poor compliance with implementation and documentation of the device with 23% compliance in June and 21% compliance in July. The purpose of this project was to determine if the use of real time follow-up through the electronic health record (EHR) chat feature would improve compliance with policy and documentation regarding cuff inflation device use.

Every Tuesday/Friday live chart review at 0500 and 0900 from 08/2021 through 12/2021 followed by secure chat with RTs through the EHR. Assigned staff noncompliant with use of cuff inflation device/documentation on eligible patients were followed up with in real time through secure chat in EHR. Number of cuffed endotracheal tubes was identified through EHR report.

253 cuffed endotracheal tubes in PICU/CTICU were identified between 7/1/2021 and 12/31/2021. Follow-ups required for non-compliance (n = 65). 95.4% (62/65) responded back via EHR secure chat within 20 min of receiving the chat message. 4.6% (3/65) responded back between 20 min and 2 hours (average = 1 hour). All situations requiring follow-ups were considered non-compliant. Compliance with use of cuff inflation device/documentation occurred during the same shift after return chat message. Average time to compliance was 1 hour from return chat message. Over the first few months the number compliant increased as follows: August = 23/56 (41.1% compliance), September = 36/58 (62.1% compliance), October = 39/46 (84.8% compliance), November = 49/52 (94.2% compliance), December = 41/41 (100% compliance). This represents an increase incompliance of 143.1% from August 2021 to December 2021 (P = .029)

Over time the compliance with cuff inflation device and documentation went from 41.1% in August to 100% in December, a 143.1% increase in compliance, and 100% compliance in January. Real time use of chat to remind staff of policy requirements can increase compliance with equipment and documentation.

I was asked to undertake an audit to determine: 1) the number of patients for whom hand-held nebulizer (HHN) therapy was initiated within a given month in our 348-bed acute-care hospital; and 2) the mean number of HHN treatments administered to each patient.

Our hospital’s accounting department employed a commercial electronic health record system (Sunrise Eclipsys, Atlanta, GA) which generated billing data as comma-delimited text files. In every row of such printouts, each therapeutic modality performed was assigned a unique numeric code. Each HHN initial was identified as an 8-digit code, while each HHN subsequent corresponded to a different code. I feared that I would need to sift through literally thousands of lines of computer code to ascertain the number of initial and subsequent HHN treatments that occurred over the course of the entire month. This would be an extremely tedious and time-consuming task and would elicit numerous errors. But I had already acquired considerable experience with Acrobat word processing software (Adobe, San Jose, CA). Acrobat’s portable document format (or PDF) files display the attribute of searchability: they identify any text/numeric string appearing within a voluminous document and generate a list of the location and frequency of that string. The accounting department readily agreed to convert the comma-delimited text files to PDF files, enabling me to generate a list of each initial HHN and every subsequent HHN at the stroke of a key. We could be confident that the flawless reliability of this computer process succeeded in capturing every instance in which the numeric codes of interest were generated.

Initially, we estimated that HHN therapy was administered to 300 patients per month, and that the average number of HHN procedures for each patient was approximately 12. When the audit was completed, we found that HHN therapy was initiated in 509 patients. On the other hand, our estimate of the number of HHN treatments received by each patient was found to be fairly accurate: 15.2 treatments.

Audits are often necessary in order to formulate sound reporting, staffing, and budgetary decisions. The reliability of such decisions necessitates audits be comprehensive, authoritative, and accurate. The availability of software that exploits the power of the digital computer can transform onerous, laborious, and error-prone operations to rapid and reliable analyses.

The purpose of this study was to compare indirect calorimetry to use of a body weight equation to determine nutrition needs of critically ill patients and whether one method leads to better outcomes. A secondary purpose was to determine what percent of the prescribed nutrition critical care subjects receive.

Approval from the Honor Health IRB was obtained. A quantitative design was used. Length of stay and ventilator days were compared between the groups who had indirect calorimetry used to calculate nutrition needs vs those who had nutrition needs determined by the standard body weight equation. In addition, the intervention group had both a body weight equation and indirect calorimetry to compare how close the two prescriptions were. The percentage of prescribed nutrition that a patient received was calculated by comparing total nutrition ordered to total nutrition received.

The intervention group and the control group were well matched by demographics and did not differ statistically on the key dependent variables: time on ventilator and length of stay in the ICU. The groups also did not differ on the percent of prescribed nutrition that they received, though in both groups it was only approximately 70% of what was prescribed. The COVID-19 pandemic may have contributed to the results. A shortage of rooms made it difficult to move ICU patients to a lower level of care and that may have contributed to the increased length of stay in the ICU. Staffing issues may have also impacted ventilator weaning because of the large number of ICU patients on ventilators

Since both groups only received roughly 70% of their nutrition, more work must be done to improve the processes used to meet the nutritional needs of our patients. More studies need to be done to determine if length of stay and ventilator days do decrease when patients receive their full prescribed nutrition amount. If this study were to be repeated it would be important to study the groups concurrently to ensure that they are subject to the same external forces. In this case, patients in the intervention group were hospitalized during the COVID-19 pandemic. That resulted in an increased census, higher acuity patients, a lack of beds, and staffing shortages. Generalizability of the study findings is limited by the non-probability convenience sample of the participants and retrospective nature of the control group. The study sample size was also small. A larger sample would increase statistical power.

St. Elizabeth Level 3 NICU (28-bed) in 2016 had a chronic lung disease incidence rate of 48% in our very low birth weight (VLBW) population, above the Vermont Oxford National (VON) average of 23%. To improve quality outcomes in our patient population we standardized our treatment protocols based on evidence-based literature, which is very limited to the NICU population. We also had a significant high incidence rate of device-related pressure injuries and unplanned extubations (UEs) in conjunction with our chronic lung disease rate. The NICU team needed to standardize our approach in care with our providers, nurses, pharmacy, and respiratory team to achieve quality improvement outcomes.

The RT NICU Team in collaboration with the NICU medical directors created a standard CPAP protocol that included specific criteria for any patient below 34 weeks’ gestation. The RT NICU team also created a skin safety score based on best practices to prevent hospital-acquired pressure injuries to prevent patients from being removed from CPAP. The team created a report through the electronic medical records (EMR) to be able to provide real time information to discuss CPAP and skin criteria for patients each shift at RT-led multidisciplinary rounds. The data were collected through the EMR and placed into statistical run charts to be discussed at each multidisciplinary team meeting.

The results since 2016, when the project began, impacted our quality metrics by decreasing our chronic lung disease to 18% by 2018 below the national benchmark per VON. In 2020, we had 0 UEs per 100 ventilator days, 0 hospital-acquired pressure injuries per 1,000 CPAP days, and significantly decreased chronic lung disease in our patients. We have sustained these results and have standardized our methodologies and processes in how we treat our VLBW population.

We approached this quality project as a multidisciplinary team, but it was led by passionate and dedicated RTs who truly made an impact on patient outcomes. Standardization of protocols, consistency in practice, and engagement of teams can lead to significant positive results.

CPAP Run Chart 2018

UPE events 2017-2021

Awake prone positioning (APP) is widely used in non-intubated patients with COVID-19 respiratory failure. The primary reported beneficial effects of APP are improving oxygenation, avoiding endotracheal intubation, and improving survival. However, the results are inconsistent.

We performed a systemic review and meta-analyses to quantify APP’s impacts on intubation rate and mortality on non-intubated respiratory failure patients with COVID-19 compared to usual care. We calculated and pooled the risk ratios (RRs) and 95% confidence intervals (CIs) using a random-effects model. Statistical heterogeneities were reported through the use of I² statistics.

We searched and retrieved all relevant randomized control trials and observational studies identified in Web of Science, PubMed, and EMBASE. The search cut-off date was March 18, 2022. Six studies involving 1,404 non-intubated patients receiving APP and 1,319 non-intubated patients receiving usual care that met our selection criteria were identified and analyzed. We found that in non-intubated patients receiving APP, intubation was 0.22-fold less likely to be intubated than patients receiving usual care. However, it did not reach a statistically significant level (RR = 0.78, 95% CI = 0.58-1.03, I² = 85%). We also found that the RR of mortality among non-intubated patients receiving APP was significantly lower than patients receiving usual care (RR = 0.68, 95% CI = 0.49-0.93, I² = 70%).

In non-intubated COVID-19 respiratory failure patients, APP was associated with a modestly lower risk of intubation and a moderately lower risk of mortality than usual care.

Smoking is a risk factor for unfavorable outcomes for other respiratory infections. This study attempts to show associations between tobacco smoking and the development of severe disease in positive SARS-CoV-2 patients. Besides determining the prevalence of smokers who are positive for SARS-CoV-2, another goal of this study was to raise awareness about the adverse effects caused by smoking on human health. We inferred that smokers with COVID-19 were at greater risk for hospitalization, ventilator requirement, oxygen requirement, and ICU admission as well as increased length of stay and duration in the mentioned therapies when compared to non-smokers.

We analyzed 2,990 EMRs from patients who tested positive to SARS-CoV-2 from HGPS evaluated in the ER. We identified n = 75 patients with a history of smoking (S = smokers) and n = 75 non-smokers (NS = non smokers) which were matched for age, sex, and comorbidities. The hospital length of stay, incidence of admission and duration in ICU, use and duration of oxygen therapy, use and duration of mechanical ventilation, and mortality rate were obtained. It was analyzed using JASP, SPSS for relative risk (RR) and t-tests. Ethics committee approval was obtained prior to the study.

Group S was associated with longer hospital stay [mean (x) = 8.87 days] compared to group NS (x = 6.49 days) P = .032. Smokers were not at higher risk for oxygen requirement [RR = 0.98 (95% CI: 0.7675—1.2492, P = 0.877)]. There was no significant difference between S (x = 7.34 days) and NS (x = 6.19 days) in the duration of oxygen therapy (P = .38). Smokers did not show a higher risk for ICU admission [RR = 0.92 (95% CI: 0.62-1.39 P = .61)] but there was an increase in length of stay in the ICU for the S (x = 10.96 days) compared to the NS (x = 5.47 days) (P = .002). Smokers were not at higher risk for requiring mechanical ventilation [RR = 1.25 (95% CI: 0.63-2.49 P = .52)]. An increase in duration of mechanical ventilation was found in S (x = 21.93 days) compared with NS (x = 3.92) (P = .016). There was no increased risk of mortality in S compared to NS [RR = 1.75 (95% CI: 0.93-3.29) P = .083].

The history of smoking significantly increased the total duration of hospitalization, ICU stay, and duration of mechanical ventilation. No significant difference was found in the risk of admission to the ICU, requirement of oxygen, ventilator requirement, or mortality. Studies with larger samples and multi-center settings are recommended.

Noninvasive ventilation (NIV) and CPAP are noninvasive respiratory support modalities commonly used in preterm infants. There is conflicting data on the superiority between these two modes of noninvasive respiratory support. The objective of this study was to determine if oxygen saturation is more within the target range on NIV compared to CPAP using the data from histograms.

Retrospective analysis of premature neonates (< 1,500 grams, gestational age < 30 weeks) admitted to the NICU for which oxygen saturation histogram data was available one day before and after the transition between NIV and CPAP. FIO₂ at the time of data collection was greater than 0.21. This histogram data and the percentage of time spent in certain SpO₂ ranges was compared before and after the de-escalation from NIV to CPAP or escalation from CPAP to NIV. FIO₂ was additionally compared between the two modes of respiratory support.

A total of 26 infants were included. The median gestational age was 25.5 weeks and the median weight of the infants was 792 g. Among the 26 infants, there were 34 episodes of transition between NIV and CPAP, 19 switches from NIV to CPAP, and 15 from CPAP to NIV. The percentage of time that oxygen saturation was within the target range (89-94 %) was not statistically significant between the two modes of respiratory support (CPAP 39.9% vs. NIV 43.9%, P = .09) (Table 1). The percentage of time that oxygen saturation was between 86-88% was higher on NIV and the percentage of time that oxygen saturation was >94% was higher on CPAP. There was a trend towards lower FIO₂ on NIV compared to CPAP. When switched from NIV to CPAP, there was a higher percentage of time spent above the target range (> 94%) while on CPAP (56% vs 49%, P = .001), and below the target range (86-88%) while on NIV (5.0% vs 1.4%, P = .02) (Table 3). When switched from CPAP to NIV, there was no difference in oxygen saturation ranges.

Target oxygen saturation ranges on histogram data were similar in premature infants when supported on CPAP and NIV. However, oxygen saturation below the target range was more frequent on NIV compared to CPAP. NIV was not superior to CPAP in maintaining oxygen saturation within the target range in premature infants on moderate noninvasive respiratory support. The potential risk of low oxygen saturation range while supported on NIV in preterm infants requires further research.

The palpation technique utilized when performing an arterial puncture is often not described or is illustrated as a technique in which two fingers perpendicular to the artery are utilized. A single-finger technique might be simpler to palpate and mentally visualize the artery. Aligning the finger linearly with the artery might provide a more precise target – the center of the fingernail. This single finger aligned linearly (SAL) palpation technique was compared to a multi-finger aligned perpendicular (MAP) palpation technique. The authors conducted this study to determine if palpation technique can affect the number of puncture attempts required to obtain an arterial blood sample.

Fifty volunteer participants were randomly assigned to one of two groups and taught either the MAP technique (n = 24) or SAL technique (n = 26). After instruction and practice each participant’s ABG sampling performance was evaluated utilizing an arterial puncture training simulator and each participant completed a perception survey. Exemption was granted by the Youngstown State University IRB.

The participants were predominantly female (88%), with a mean age of 23 years. All participants largely perceived that the training prepared them to obtain an arterial sample (MAP: agreed or strongly agreed (n = 23, 96%); SAL: agreed or strongly agreed (n = 25, 96%)). Linear regression and binary linear regression analysis were conducted (alpha = 0.5). The results of the linear regression model were significant, F (1,48) = 4.82, P = .033, R² = 0.09. The MAP technique significantly predicted attempts, B = 0.51, t (48) = 2.20, P = .033. Moving from the SAL to the MAP technique will increase the mean number of attempts needed to obtain a sample by an average of 0.51. The binary logistic regression model was also significant, χ² (1) = 4.76, P = .029. The effect of the MAP technique was significant, B = -1.53, OR = 0.22, P = .040, indicating that this technique decreases the odds of obtaining a sample on the first attempt by approximately 78.26% relative to the SAL technique.

The results of this study suggest that moving from the MAP to the SAL technique will decrease the number of attempts required to obtain a sample and increase the odds of obtaining a sample on the first attempt. Reference: Analysis conducted and reports/results drafted in part using Intellectus Statistics Online computer software 2021. Intellectus Statistics. https://analyze.intellectusstatistics.com/

Multi-finger Aligned Perpendicular (MAP) and Single-Finger Aligned Linearly (SAL) Palpation Techniques

Barplot of Attempt 1 by Technique

Although COVID-19 has contributed to more than 5 million deaths worldwide, the quality of life (QOL) for survivors should be addressed and managed. COVID-19 survivors that develop ARDS have been reported to experience impaired 6-min walk distance (6MWD) and severe fatigue, decreasing QOL. There are suggestions that exercise training significantly improves exercise capacity in COVID-19 patients, with pulmonary function testing (PFT) improving after 6 weeks of pulmonary rehabilitation (PR), contesting this QOL decline. PR has improved the QOL in other respiratory diseased patient populations. Our objective is to determine if PR benefits functional ability and quality of life for post-COVID-19 patients by increasing 6MWD and decreasing shortness of breath scores (UCSD). We hypothesize that completing 6 weeks of PR will decrease UCSD and increase 6MWD for patients with continuing dyspnea post-COVID-19 infection.

We performed a retrospective analysis of EMR (electronic medical record) data of 47 patients diagnosed with COVID-19 who completed 6 weeks of PR at UTMB’s (University of Texas Medical Branch at Galveston) Post-COVID-19 Clinic. We compared UCSD scores and 6MWD, as measured of QOL, before and after 6 weeks of PR. Inclusion criteria were patients with positively diagnosis for COVID-19, 18 years of age or older, who completed 6 weeks of PR at UTMB’s Post-COVID-19 Clinic. Measures included PR as independent variable, UCSD, and 6MWD as outcome variables and covariates (age, gender, BMI, race/ethnicity, and PFT status). Linear regression analysis was performed to estimate the effect of PR on the UCSD score and 6MWD difference (before and after PR) controlling for all covariates.

Among the patients included, 8 (59.6%) females and 19 (40.4%) males with an average of 56 ± 13 years old. There was a clinically significant improvement in QOL based on improved mean difference in UCSD -22 ± 19; and increased 6MWD mean difference 264 ± 237 m after PR. The linear regression analysis did not show any statistically significant variables associated with 6MWD. Non-Hispanic Blacks had 20.7 times higher UCSD score difference compared to non-Hispanic whites when controlling for all other variables.

Measures impacting QOL and physical function, UCSD, and 6MWD, clinically improved after 6 weeks of PR for patients with continuing dyspnea post-COVID-19 infection.

Patient-ventilator asynchrony (PVA) occurs frequently and can lead to complications, such as increased work of breathing and longer mechanical ventilation duration. Asynchrony can potentially be improved by adjusting ventilator settings specific to the type of PVA. Sedation is sometimes used even though it may worsen PVAs and increase mechanical ventilation duration when used in the absence of other ventilator adjustments. Identifying and correcting PVAs is essential for respiratory therapists (RTs) to improve the quality of ventilator care. RTs have varying levels of comfort and knowledge for assessing the patient-ventilator relationship and making appropriate changes. This study aimed to determine whether RTs can recognize PVA and, if so, whether the RT can offer appropriate corrective actions.

Twenty-one RTs from the Michigan Medicine Adult Respiratory Care Department volunteered. A Drager Evita Infinity V500 ventilator was attached to an Ingmar Medical ASL-5000. For each participant, four randomly assigned independent scenarios were simulated: control (synchronous), inspiratory PVA, cycle PVA, and trigger PVA. Each scenario included a patient history. The RT was instructed to ask for additional patient information as needed. During each scenario, the RT was asked to describe the patient’s breathing and to list interventions if needed. RTs were not able to physically change ventilator settings due to the model design. RTs' analysis of the scenario and suggested changes were recorded. During data analysis, interventions were classified as correct or incorrect for each PVA based on if it would improve the PVA. Sedation as a stand-alone intervention was marked as incorrect.

The control was correctly identified 100% (63/63) of the time. The presence of asynchrony was correctly identified 95.2% (60/63) of the time. RTs identified at least one correct intervention 76.2% (48/63) of the time. Sedation was included 39.7% (25/63) of the time as a possible intervention and as the only intervention 4.7% (3/63) of the time.

In this bench model, RTs accurately identified the presence of PVA most of the time and were able to offer at least one correct intervention. The study suggests RTs do not solely rely on sedation to improve asynchrony but may frequently request it as part of the decision-making process. This study suggests an opportunity to improve PVA corrective actions, potentially through education and standardization of interventions.

The purpose of this study was to ascertain whether the COVID-19 pandemic and the instructional changes implemented in response to it have affected student enrollment, retention, or success on the National Board for Respiratory Care (NBRC) credentialing examinations at an associate degree respiratory care program in the state of Texas.

A retrospective analysis of student enrollment and retention data and graduate success rates on the NBRC credentialing examinations were used in this study. The data was collected from an associate degree respiratory care program in Texas including all graduates (n = 69) for the 5-year study period. The three academic years leading up to the COVID-19 pandemic served as a pre-pandemic baseline for comparison. The cohort of 2019-20 was labeled early-pandemic, the cohort of 2020-21 was labeled mid-pandemic, and the cohort of 2021-22 was labeled late-pandemic for data comparison purposes. Kruskal-Wallis with multiple pairwise comparisons was used for data analysis and significance values were adjusted by the Bonferroni correction for multiple tests (P < .05). The research protocol was approved by the Institutional Review Boards at Texas State University and Dallas College.

As shown in Table 1 below, the number of program applicants significantly decreased between the pre-pandemic and late-pandemic groups (P = .001), but overall student enrollment (P = .42) and retention (P = .95) were not significantly affected by the COVID-19 pandemic. First-time pass rate on the Therapist Multiple-Choice (TMC) examination, low-cut score (P = .005), and high-cut score (P = .007) were significantly reduced in the mid-pandemic group when compared to previous cohorts (Table 2).

The COVID-19 pandemic and the instructional changes implemented in response to it decreased students’ first-time pass rate on the TMC examination in the mid-pandemic group compared to the pre- and early-pandemic groups.

The COVID-19 pandemic presented a significant challenge to higher education and could affect health care students to a greater degree due to the wide variety of restrictions those students faced in the classroom, laboratory, and clinical settings. For an associate degree respiratory care program in Texas, the abrupt change to online learning meant making significant changes to how these in-person experiences were delivered. The purpose of this study is to determine the impact of the COVID-19 pandemic on students’ perceptions of the abrupt change in a learning format.

To determine the respiratory care students’ perception of the change to online learning in response to the COVID-19 pandemic, an online questionnaire was distributed to all students (n = 29) who were directly affected, including academic years 2019-20 and 2020-21. The questionnaire was modified from the student’s perceived abrupt distance learning readiness model, which was evaluated for validity and reliability in the study entitled, Factors Affecting Student’s Perceived Readiness on Abrupt Distance Learning Adoption: Indonesian Higher-Education Perspectives. Permission to modify and use the questionnaire was obtained from the corresponding author. There were 28 questions divided into 7 sections: (1) self-competence/computer self-efficacy, (2) self-directed learning/self-management of learning, (3) motivation, (4) comfort with e-learning, (5) technology, (6) financial, and (7) perceived readiness. As shown in Table 1, demographic data was collected with 5 additional questions. Descriptive statistics and the Mann-Whitney U test were used for data analysis (P < .05).

The questionnaire received a 100% response rate from the 29 students (21 female and 8 male) and there were no statistically significant differences in the 7 categories between the two cohorts. However, the 2019-20 cohort responded they had more difficulty completing their work due to distractions in the home (42.8% vs 20%, P = .51). Additionally, this cohort was more likely to say that the online learning environment was not at least equal quality to traditional learning (64.3% vs. 33.3%, P = .11).

While there was no significant difference in the responses between the two cohorts, the 2019-20 cohort seemed to have a more negative perception of the abrupt change in the learning format. This may have been due to distractions at home or a perceived decline in the quality of instruction when compared to traditional learning.

Length of stay (LOS) is an indicator of efficiency of hospital management. Reducing LOS has been proven to decrease the risk of opportunistic infections, improve quality care, and lower mortality rates. An interdisciplinary team was implemented to initiate and evaluate strategic interventions that could facilitate discharge planning. Members included respiratory therapy (RT), nursing (RN), physicians, advanced practice providers, speech, physical, and occupational therapies, and case management. Goals included reducing LOS, coordinating care teams, and engaging clinicians by utilizing evidence-based protocols. Causes of increased LOS include weaning protocol not ordered or followed, inadequate RT documentation, and not progressing in therapies.

Metrics and data were collected retrospectively through chart review pre- and post- interventions after IRB approval. Interventions include utilization of an evidenced-based RT-driven protocol, daily rounding between RN, RT, and provider, and a weekly interdisciplinary meeting to discuss barriers and synchronize care from multiple disciplines. 32 patients were identified in the pre-intervention group and 31 patients were in the post intervention group. Inclusion criteria included >18 years of age, tracheostomy present, mechanically ventilated, and weaning patient. Exclusion criteria included no-wean patient, home ventilator patient, and deceased during hospital admission.

All data were analyzed through IBM SPSS software v25 (IBM, Armonk, New York) using chi-squared tests and independent samples t-test. Our study showed a clinically relevant reduction in mean LOS of 10.91 days (P = .084), this resulted in potential cost savings of approximately $216,455. In addition, there was also a 1.3-day reduction in ventilator days (P = .731), a significant reduction of 4 days from tracheostomy placement to protocol initiation (P <.02), and significantly more patients (40%, P <.001) on the weaning protocol. The number of patients weaned in hospital and decannulated was reduced in the post groups (both not significant).

Utilizing RT protocols, daily rounds, and a weekly interdisciplinary meeting can improve quality of care and coordinate care effectively. The pilot study resulted in an improved mean LOS but was not statistically significant. Other positive results noted were increased teamwork, communication, accountability, and staff empowerment. Future studies should investigate more rigorous quality improvement methodologies and include larger sample sizes.

Clinically ill COVID-19 intubated patients who require sedation are increasing. Medical institutions are experiencing shortage of propofol. The propofol preparation should be used more appropriately. If there was no clinical problem, the use of volatile inhalation anesthetics in maintaining anesthesia was recommended. The anesthetic conserving device (AnaConDa) is a disposable vaporizer that can deliver volatile inhalation anesthetic used in isoflurane. Recognized common problems with sedatives includes delirium. The purpose of this study was to determine whether sedation with isoflurane caused delirium more than with propofol.

The study population included adult patients who were diagnosed with COVID-19, admitted to the ICU, and who were intubated. A retrospective chart review was conducted which compared two groups of COVID-19 patients both with and without the use of isoflurane to explore delirium and determine whether sedation with isoflurane affected mortality rate and the duration of ventilation days compared to sedation with propofol. The study site was a 400-bed hospital in Osaka, Japan. Thirty-three ventilated patients identified the date preceding use of isoflurane (April 25-May 25, 2021) were enrolled in the control group. Thirty-three ventilated patients fitting the inclusion criteria with sedation with isoflurane (May 26, 2021-April 3, 2022) were enrolled in an intervention group. Institutional Review Board (IRB) approval was obtained.

There was no significant difference in delirium between the groups (81.8 % vs 72.7 %, P > .05). There was no significant difference in the mortality rates between the comparison group and the intervention group (24.24 % vs 27.27 %, P > .05). There was no significant difference in the length of ventilation days (11.3 days vs 9.0 days) between the two groups.

The use of isoflurane sedation did not differ in delirium, mortality, and ventilation days compared to propofol sedation.

COVID-19 is a highly contagious viral illness caused by SARS-CoV-2, which predominantly targets the respiratory system, infecting more than 435 million people and attributed to more than 5 million deaths worldwide. Studies show different clinical phenotypes associated with COVID-19 infection lung compliance changes. There are equivocal reports in the literature that describe the relationship between ARDS severity and COVID-19 mortality in mechanically ventilated patients. This retrospective study aims to determine a relationship between ARDS severity and COVID-19 survival. Our second aim is to analyze if declining lung function (dynamic compliance [Cdyn]) is associated with decreased chance of survival. Understanding the pattern of changes in Cdyn and severity of lung disease could provide diagnostic and therapeutic benefits in managing and treating COVID-19.

We retrospectively analyzed electronic medical record data of patients diagnosed with COVID-19 and invasively mechanically ventilated for at least 5 continuous days at University of Texas Medical Branch at Galveston. We calculated the odds ratios for main effects of interests' association with survival. Chi-square tests were performed for categorical variables, and t-tests for continuous variables. Bivariate logistic regression analysis of main effects (age, gender, race/ethnicity, number of comorbid conditions, use of antiviral medications, ARDS severity day 1 and day 5, Cdyn day 1 and day 5, and PaO₂/FIO₂ (P/F) ratio day 1 and day 5 as predictors influencing survival were performed. Significant variables were included in the final model. There is a 0.05 level of significance. All tests were performed in RStudio.

220 patients met the inclusion criteria for our study. Among the patients included, 123 (55.91 %) did not survive, and 97 (44.09 %) survived. Age, gender, race, ARDS severity on day 5, Cdyn on day 5, and P/F ratio on day 5 all showed significant association with survival within this population. Older patients showed a lower chance of survival compared to younger patients. Survival was less frequent for males than females. Cdyn and P/F ratio means trended in a positive direction in patients that survived.

ARDS severity, P/F ratio, and Cdyn should be considered for diagnostic and therapeutic benefits in management of mechanically ventilated COVID-19 patients.

Evidence on mortality indicates the importance of avoiding intubation too soon or too late. When to switch from noninvasive oxygen delivery systems to mechanical ventilation (MV) can be difficult to assess. The Respiratory rate-OXygen index (ROX) is a validated tool to assist clinicians in this decision process. This study evaluates independent variables for opportunities to improve mortality with the retrospective application of ROX.

This is a single center, observational, cross-sectional study with IRB approval from UC Davis Medical Center, IRBNet. From January 2020-December 2020, a consecutive patient population was received from an EMR data analyst if ≥18 yrs old, diagnosed with acute respiratory failure due to pneumonia, ARDS, and/or COVID-19, utilized high-flow nasal cannula (HFNC), and subsequently intubated. Data analyst's population included ROX metrics (SpO₂, FIO₂, RR) when charted into Epic EMR in the same date/time stamp between initiation of HFNC and MV start. ROX results measured with an Excel formula, SpO₂/FIO₂/RR; inclusion criteria of <4.88 and exclusion criteria of >4.88. Patients included when ROX result was <4.88 twice, consecutively. Authors collected date/time stamp of the second failed ROX (SFR) for extrapolation. Univariate analyses compared expired/hospice (E) to survived (S) population with independent variables. Excel t-Test: Two-Sample Assuming Unequal Variances used for statistical analyses. Cognizance of one-tail and skewness of data for P-value interpretation validity.

Authors included n = 76 patients for variable comparisons with a mortality rate of 56.6% (43). We found statistical significance in (mean, 95% CI): Age, P = .005 (E) 65.56 (70.16-61) vs (S) 55.3 (60.85-49.75); HFNC start to SFR in hours, P = .03 (E) 33.99 (50.35-17.62) vs (S) 15.18 (26.42-3.94); SFR to MV start in hours, P = .013 (E) 62.57 (86.12-38.02) vs (S) 28.57 (47.91-9.23). We found no statistical significance in: duration of MV in hours, P = .769 (E) 185.4 (230.91-139.88) vs (S) 222.44 (313.39-131.49); hospital LOS in in days, P = .957 (E) 18.74 (24.78-12.71) vs (S) 26.55 (33.35-19.74); ROX result, P = .507 (E) 3.83 (4.05-3.61) vs (S) 3.83 (4.04-3.61).

Opportunities to decrease mortality may exist within the periods from HFNC initiation to observed failed ROX and from observed failed ROX to MV start. UC Davis Medical Center will initiate ROX to auto calculate in Epic EMR to find ROX failure quicker and to potentially decrease the time from failed ROX to MV start.

A nationally qualified respiratory therapist is not established in Japan. Rather, respiratory care therapies are provided by a team of interdisciplinary healthcare providers. The purpose of this descriptive investigation was to examine the impact of the Respiratory Support Team (RST) at a facility by measuring the mortality rate, reintubation rate, and lengths of ventilation days since provide healthcare providers with the ventilatory guideline and education from RST.

A retrospective chart review was conducted which compared two groups of over 48-hours ventilated patients with bacterial pneumonia one year before and one year after the 2010 formation of the RST to explore the mortality rate, reintubation rate, and lengths of ventilated days and determine whether the utilization of a team-based approach to ventilatory management improved outcomes at this facility. The study site was a 341-bed hospital in Osaka, Japan. Twenty-one ventilated patients identified the year preceding formation of the RST (April 12, 2019- for a year before April 30, 2010) were enrolled in the comparison group. Twenty-one ventilated patients fitting the inclusion criteria and admitted the year immediately following the initiation of the RST (May 1, 2016-August 12, 2017) were enrolled in an intervention group. The study population included adult patients who were diagnosed with pneumonia, admitted to the ICU, and who were intubated for over 48 hours. A retrospective review of charts identified a sample of patients fitting the inclusion criteria.

There was a significant difference between the mortality rates (61.9 % vs 38.1 %) and survival rate (28.6 % vs 71.4 %) between the intervention group and the comparison group (P <.05). There was a significant difference in the reintubation rates (23.8% vs 0%) between the two groups. It was associated with a decrease in lengths of ventilation days for pneumonia patients.

The ventilatory guideline for a patient receiving mechanical ventilation and the education from RST were effective in reducing the rates of both reintubation and mortality.

Terminal extubation (TE) is defined as the planned extubation leading to death. During the COVID-19 pandemic, we perceived an increase in RTs performing TE alone, and were concerned about the mental health impact from this practice. We surveyed RTs to assess mental health impacts related to TE and access to available support.

Interior Health (IH) has 207 RTs working in community and small to tertiary hospitals. 64 out of 207 RTs participated in a 17-question survey. Logic branching was used, thus some respondents completed fewer than 17 questions. Representation was from a wide spectrum of career experience: 9% 0-2 years, 14% 2-5 years, 20% 5-10 years, 30% 10-20 years, and 30% > 20 years of experience. IH Privacy Impact department and ARECCI IRB approved this survey.

61% (n = 39) of RTs surveyed continue to carry thoughts of TE more than 3 months later. Of those 39 RTs, 59% think of a past TE at least once a month, 26% remember the extubation at least once year, and 18% continue to reflect on a TE 10 years or more after the event. 98% of respondents indicated their site either did not have a policy or they were unaware of a policy requiring a supervisor to check in after a TE. 75% of participants indicated that their supervisor never checks in following a TE, conversely only 2% of RTs always receive a check-in. This could be explained by the survey finding that only 4% of respondents in supervisory positions have received training on how to provide mental health support. 59% of the RTs said they never utilize support such as organized debriefings or a counselor. Since COVID-19 started, 53% of the RTs had an increase in the expectation to perform TE alone. 45% of RTs prefer having a second provider present to assist with medical care or liaise with family, while 45% were uncertain if a second provider is always required. 14% of RTs indicated that performing TE was a factor in leaving an area of practice. This may be an underestimate as the survey was not distributed to RTs working in the private sector, or who have left the profession.

Within the RT profession there is a culture of being strong despite emotionally difficult aspects of our role, such as TE. These survey results indicate that TE events can have a long-lasting impact on RTs. Not only might this affect their mental health, but also their career trajectory. This study revealed there are gaps in education, training and guidelines that could improve support and potentially reduce future harm to RTs’ mental health.

Ventilator mode selection and pulmonary rehabilitation are useful for improving prolonged mechanical ventilation patients’ respiratory status. However, integration of Chinese and Western medicine, especially acupuncture treatment for these patients is unknown. The present study aimed to determine the effect of acupuncture on respiratory indices in patients who underwent mechanical ventilation in Respiratory Care Center (RCC) after transfer from the ICU.

This randomized clinical trial was conducted in RCC of Taiwan middle medical center.Eighty patients were recruited and underwent hemodynamic stable.GCS>9 and eligible for more than 21 days mechanical ventilation.The following 8 standardised acupuncture points were selected according to previous research: lung meridian，LU5; large intestine meridian，LI4 ; conception vessel，CV4; stomach meridian，ST36.37.39;liver meridian.LR3;pericardium.PC6; and spleen meridian，SP6；sustain 20 minutes and six-a week for 2 weeks that before and immediately after acupuncture were extracted from the medical records.

This randomized clinical trial was conducted in RCC of Taiwan middle medical center. Eighty patients were recruited and underwent hemodynamic stable. GCS>9 and eligible for more than 21 days mechanical ventilation. The following 8 standardized acupuncture points were selected according to previous research: lung meridian，LU5; large intestine meridian，LI4 ; conception vessel，CV4; stomach meridian，ST36.37.39; liver meridian, LR3; pericardium, PC6; and spleen meridian，SP6 sustain 20 min and 6 times a week for 2 weeks that before and immediately after acupuncture were extracted from the medical records.

The mean age was 60.8 years and median number of days on MV before acupuncture initiation was 23.5 days. PI max and PE max were significantly increased immediately after acupuncture (all P < .001) whereas RSBI and Csta were significantly improved (all P < .05). 57 patients were successfully weaned (71 %) from MV after acupuncture initiation above weaning rate of RCC in Taiwan.

The purpose of this study was to determine the extent to which selected academic and non-academic variables can predict success or failure on the national boards for graduates who have matriculated through a required respiratory therapy curriculum. Based on the stated problem this study addressed the following research questions: 1. For graduates from two respiratory therapy associate degree programs in one Midwestern state, what is their profile in reference to the following variables: a) student demographics; b) prerequisite college course grades; c) required core program required course grades; d) clinical experience grade; and f) board exam preparation type? 2. To what extent do these variables predict passing of the TMC on the first attempt when holding contend student demographic variables?

The research design for this non-experimental quantitative study used a retrospective design with data analysis using correlations and stepwise regression to determine the strongest predictors of first-time pass success on the TMC.

A stepwise logistic regression procedure was performed, eliminating the explanatory variables to significantly predict success or failure on the TMC's first-time attempt. Key results included a positive relationship between 4 academic variables involving students’ grades within 4 courses and TMC first-time pass success. For every one-point change in the Pre-Program Biology grade, the log odds of pass vs. failure on the TMC increased by 8.42. For every one-point change in the Pharmacology, the log odds of pass vs. failure on the TMC increased by 3.55. For every one-point change in Cardiovascular Physiology grade, the log odds of pass vs. failure on the TMC increased by 7.20. For every one-point change in the Neonatal and Pediatrics grade, the log odds of pass vs. failure on the TMC increased by 6.65. The odds of accurately predicting TMC outcome was 91.9% of the time using the four significant variables.

Results can be used to enhance respiratory therapy programs' admission policies, remediation, mentoring, and curriculum development. Also, increasing the number of graduates who complete the TMC on the first attempt and promptly join the respiratory therapist workforce will demonstrate positive social changes by mitigating the respiratory therapist shortage promoting safe patient care. Importantly, it adds to the literature on these complex issues, in which no previous research had been found examined associate degree respiratory therapy programs.

Travel respiratory therapy has been a professional choice for a small cohort of respiratory therapists (RTs). Over the past two years a professional choice phenomenon occurred where more RTs chose to incorporate traveling in their career instead of traditional employment. Although higher pay is commonly assumed to be the main attraction, multiple factors motivate RTs to transition to a travel work assignment. What is causing this shift? What is it about traveling that attracts RTs? What is it that encourages RTs to extend their contracts?

An IRB approved study of travel RTs using online survey. We solicited responses through various social media channels from 2/1/2021 through 5/1/2021. We collected, age, years of RT experience, gender identity, and highest level of education. We used a 5-point Likert scale from 1 = agree to 5 = disagree for the following questions: I look after my personal wellbeing, I find travel work interesting. We asked travelers to rank what made them decide to be a travel RT, and what factors typically lead them to extend at a facility.

89 unique subjects age 20-68 years (mean = 42) with 1 year to more than 25 years of respiratory experience (mean = 12) were identified. More travel RTs identified as female (78.7%). Highest level of education was Master’s (14.6%), Bachelor’s (34.8%) and Associate’s (50.6%). Fifty-six (62.9%) travel RTs agree they look after their personal well-being, 18 (20.2% partly agree), 10 (11.2%) neither agree or disagree, and 5 (5.6%) partly disagree. Forty-five (50.6%) travel RTs agree their work is interesting, 28 (31.5%) partly agree, 10 (11.2%) neither agree nor disagree, 4 (4.5%) partly disagree, and 2 (2.2%) disagree. Categories ranked as most important when deciding to travel, in order, were: pay, new experiences/learn new things, travel/adventure, and avoiding job politics. Pay (47.2%), schedule (22.5%), and friendliness to travelers (18%) topped the reasons for accepting extensions.

Travel RTs age is consistent with average age of RTs in the United States. Most RTs taking the survey identify as female (78.7%) where 62.5% of all RTs employed are female. Almost half (49.4%) reported having a Bachelor’s or Master’s degree compared to only 30% of all employed RTs. These RTs prioritize pay, new experiences, adventure, and avoiding job politics. They focus on their well-being. Pay, schedule and traveler friendliness of the host facility are important factors in extension acceptance.

Palliative care is the relief of suffering which can be given with both curative therapies and treatment as well as when the care strategy consists of comfort measures only. The purpose of this study was to explore the RTs’ perception of their role as it pertains to palliative care and assess the type of training, degree of knowledge, experience, and comfort they have with palliative care.

A secure electronic survey was administered through REDCap in May 2022. The survey link was distributed through social media and reminders were posted twice over a 3-week period. Data collected included demographic information, education experience, comfort level, patient experience with palliative care, and the perceptions of the involvement of RTs during palliative care. Descriptive statistics were used to analyze results. This survey was declared exempt by the Rush University IRB.

One hundred fifty-one valid responses were received. Most respondents indicated that they had experience with palliative care at the end of life (90.7%), yet only 21.9% received formal instruction during their RT entry to practice education. Although formal training was not provided for most RTs during their entry to practice education, 56.3% reported participation in continuing education courses focused on palliative care. While most respondents (72.9%) reported a high comfort level with participating in their patient’s palliative care plan and with discussing palliative care with the health care team (64.3%), only 41.2% reported a high comfort level in talking about palliative care with patients. In addition, 45% of respondents reported that they do not feel included in their patient’s palliative care plan. Further analysis of the data revealed that those who work in a critical care setting care were more comfortable discussing palliative care with the care team (78.5%) and with the patient (62.1%) than those who work in other care settings, though this was not a statistically significant difference (P = .874).

As the role of the RT evolves, the opportunity for a more defined role in palliative care is clear. This survey revealed high percentage of RTs who participate in palliative care but lack foundational training for this role. Incorporating palliative care instruction in RT entry-to-practice education and through departmental continuing education could improve the RT’s comfort level with the topic and further the RT’s participation in the palliative care plan.

Physician orders for life-sustaining treatment (POLST) forms are commonly signed by seriously ill patients and those with terminal cancer in order to improve their end-of-life care by specifying the extent and type of life-sustaining treatments (LSTs) that they wish to receive, thus enabling an appropriate preparation for their end-of-life months ahead of time. In contrast, patients with chronic lung diseases (CLDs) are often unable to sign the POLST form themselves because CLDs are characterized by recurrent episodes of exacerbation and recovery, which hinders an accurate estimation of their end of life. As such, POLST forms for CLD patients are often signed by their caretakers while the patients have become unresponsive in ICUs, which is not in line with the primary purpose of the POLST form. We therefore examined the characteristics and outcomes of CLD patients whose POLST forms were signed in the ICU.

We retrospectively analyzed the medical records of 59 adult patients (male, 66%; mean age, 65.7 ± 12.2 years) with CLD whose POLST forms were signed at the ICU of our center between January 2019 and July 2021. Patients with cancer were excluded.

Of the 59 study patients, 58% had interstitial lung disease (ILD) and 27% had COPD. The main reasons for ICU admission were acute respiratory failure (58%), acute exacerbation (29%), and cardiac arrest (14%). At POLST decision, only 7% were fully alert and the POLST forms were signed by the caregivers in 97% of the cases. The rates of ICU mortality and in-hospital mortality were 90% and 93%, respectively; importantly, 58% died within 48 hours of the POLST decision. After the POLST decision, 98% of the patients still underwent blood tests and radiography. Antibiotics and mechanical ventilation were continued in 92% and 81% of patients. Inotropic drugs (24%), extracorporeal membrane oxygenation (20%), and mechanical ventilation (15%) were discontinued only in some patients after POLST.

Virtually all POLST forms for CLD patients were signed by caregivers, and more than half were signed within 48 hours before death. Despite the POLST decision, intensive care methods were continued or added in many patients. These results suggest that in the case of CLD patients, it is necessary to discuss the patient's life-sustaining treatment plan in advance.

Respiratory therapists (RTs) are integral members of multidisciplinary healthcare teams and work predominantly in ICUs to care for critically ill patients. Despite being an established profession in the United States, the growth of the profession globally has been subdued, especially in Asia where there are limited RT training programs. Without a formal RT training program in Singapore, the local RT workforce heavily depends on foreign RTs. This study was performed to examine the contextual background of the RT profession through the unique perspectives of the RTs on their experiences and perceptions to assess the current needs for professional growth and to examine the awareness of a need for a change of the RT supply through the Awareness, Desire, Knowledge, Abilities, and Reinforcement (ADKAR) Model in Singapore.

A qualitative case study approach with semi-structured interviews was conducted using an interview guide over a video-conferencing platform for 15 RTs who are currently working in Singapore.

This study identified major challenges for the profession, which include: (a) an unsustainable manpower supply, (b) an inadequate awareness and recognition of the profession, (c) an unregulated profession, and (d) antagonistic strategies threatening the future of the profession.

Challenges notwithstanding, most participants in this study remain optimistic since the identified challenges can also be regarded as opportunities for the development and growth of the profession through the continued use of the ADKAR model to inform policymaking in Singapore.

Acute asthma exacerbation is a leading cause of pediatric hospitalization and is associated with significant healthcare resource utilization and cost. Length of stay (LOS) is commonly used as a measure of efficiency, efficacy, and resource utilization, and even small reductions in LOS can substantially reduce the economic burden and impact on healthcare systems. To align with the top-10 Benchmark Hospitals among PHIS (pediatric health information system) for asthma LOS, we developed a multidisciplinary team consisting of pediatric hospital medicine providers and respiratory care leadership with the aim of decreasing asthma LOS by 4 hours in patients 2-18 years of age admitted to acute care services with uncomplicated asthma by the end of 2021.

Utilizing the Model for Improvement, we identified three primary drivers possibly contributing to increased LOS: 1) A drift in the number of recommended (per our asthma clinical practice guidelines) treatments given before discharge, (2) the lack of an efficient and timely method for respiratory therapists to communicate with providers once patients had reached discharge criteria, and (3) stringent SpO₂ goals within our asthma scoring tool. Adoption and implementation of interventions occurred in June 2020 and May 2021, which included: (1) provider education; (2) implementation of a chat feature within our EMR software system that allows respiratory therapists to send a message from the patient’s chart directly to the provider’s phone once a patient is ready to assess for discharge; and (3) lowering of SpO₂ goals within our asthma scoring tool. Baseline median LOS for the 18 months prior to interventions was 28.9 hours. 30-day same-cause readmissions were used as balancing metrics. Rank sum and two proportion Z-test were used for statistical analysis.

For the 18 months (July 2020 to December 31, 2021) post first intervention, median LOS significantly decreased by 5.5 hours compared to baseline [23.4 hours (16.8-35.0) (n = 780) vs 28.9 hours (20.7-40.7) (n = 795), P < .001], with no difference in 30-day same-cause readmissions [pre 9.9% (79/795), post 8.3% (65/780), P = .308].

Utilization of a multidisciplinary quality improvement initiative led to a significant decrease in asthma LOS without affecting 30-day readmissions. Next steps include protocolization of continuous short-acting beta-agonist (SABA) administration and evaluating frequency of SABA administration prior to discharge.

A time study within our electronic medical record (EPIC) demonstrated a no-show rate for methacholine challenge testing (MCT) of 23%, resulting in 16 hours of lost testing. In addition, the methacholine, prepared by onsite pharmacists, expired after two weeks resulting in $600 of wasted drug. Further, patients were inappropriately scheduled for MCT testing without compliance with our lab policy of having spirometry testing within the year prior to MCT. The previous scheduling process included patients being scheduled by a hospital-based call-center. This involved non-technically trained staff who would read prepared instructions but were unable to answer subsequent patient questions including information regarding withholding certain medications or other possible contraindications.

Consequent to the time study, several changes were made to the MCT scheduling process to address the no-show rate and better inform patients of the testing procedure. Trained technologists in the pulmonary function lab took over calling/scheduling patients for MCT, and no other departments/groups had access to scheduling. We developed a scheduling/mailing script to provide patients with consistent information prior to scheduling MCT. During the call, patients were provided a detailed review of the test, testing requirements, contraindications, as well as a call-back number if they have additional questions or needed to reschedule. Performance of baseline spirometry testing within one year was confirmed and if not available, the physician was contacted for clarification and to obtain an order. Once scheduled, the patient was mailed a copy of the MCT instructions.

After implementation of new MCT scheduling processes, no show rates decreased to 4%. This equated to only 4 hours of lost testing, an improvement of 12 hours and a decrease in wasted drug costs to $150, thus a cost savings of $450. Subjectively, on testing day, patients appeared less anxious and more prepared for testing.

Including trained technologists in scheduling MCT has streamlined scheduling, improved no show rates, added cost savings, improved PFT testing capacity, and improved patient understanding and anxiety. We have similarly implemented similar processes for other testing with high no show rates. Our results suggest that patients should be vetted and provided more detailed information regarding the testing prior to scheduling MCT.

COPD is a prevalent disease that is of monumental concern to patients, pulmonary providers, healthcare systems, and the Centers for Medicaid and Medicare Service. This study aims to evaluate hospital readmissions for subjects admitted for exacerbation of COPD who are given standard of care for COPD vs a respiratory therapist (RT)-led COPD hospital education program.

An institutional review board exempt retrospective chart review was completed with a pre/post-intervention study. This study compared readmissions for subjects with COPD exacerbation who received standard of care vs RT-led COPD hospital education program. Subjects ≥18 years old were included in the pre-intervention cohort if they had a diagnosis of exacerbation of COPD and were admitted to a medical center in Northeast New Jersey from February 2020 to January 2021. The RT-led hospital education program is a 1-hour education session, which included disease management, review of the COPD Action Plan, proper inhaler technique, completion of the COPD Assessment Test (CAT), sleep apnea screening, self-management aimed at early mobility, and coping with anxiety and depression. When required, subjects received education on home oxygen safety and smoking cessation counseling. Discharge strategies include talks on the Better Breathers Support Group and confirmation of outpatient pulmonologist follow-up within 7 days of discharge. All subjects received post hospital phone calls on days 1-3 and 7-9. Minitab statistical software was used to calculate the 30-day readmission rates for both cohorts. Categorical and continuous baseline data were analyzed using chi square tests and two sample t-tests or Mann-Whitney U tests, respectively.

A total of 235 subjects were included in the study, 112 in the pre-intervention cohort and 123 in the post-intervention cohort. Patient demographics between the two cohorts were similar, with subjects with mean age around 70 years old and majority of subjects were current or former smokers. Comorbidities were similar between the two cohorts. In the pre-intervention cohort, 15.18% (17) of subjects were readmitted within 30 days of discharge compared to 9.76% (12) in the post-intervention cohort (P = 0.209).

Although not statistically significant, there was a numerical decrease in readmission rates in the RT-led group compared to standard of care. Future research recommendations include enrolling more subjects into the study to meet power.

Recent publications document less than 5% of patients with a qualifying lung disease are enrolled into a pulmonary rehab program. Limitations such as access, transportation, and financial concerns effect patients attending center-focused pulmonary rehab (CFPR). The COVID-19 pandemic created additional barriers for the care of patients, further limiting access to CFPR. In spring of 2020, the Centers for Medicare and Medicaid Services (CMS) temporarily expanded its coverage to include telehealth services. We assessed the effectiveness of remote rehab compared to CFPR during the pandemic.

We developed a remote pulmonary rehab (RPR) program to safely monitor patients in their home while participating in remotely-guided pulmonary rehabilitation. From October 2020 through July 2021, 21 patients completed the program (11 RPR, 10 CFPR). Outcome measures in all patients on site included: Timed Up and Go (TUG), 6-min walk distance, Metabolic Equivalency Threshold (METS), and fragility measurement (grip strength) at baseline and upon program completion (9 to 12 weeks). RPR patients were provided Therabands, a pulse oximeter, video tablet, and educational booklet. Sixty-minute remote sessions including up to 4 patients were led by an exercise physiologist or respiratory therapist utilizing the Vidyo application. Like CFPR, RPR sessions included education, monitoring, and exercise, but only CFPR had access to aerobic exercise equipment.

RPR patients had a 79% attendance rate versus a 74% attendance rate in center-focused rehab. 73% of patients attending RPR and 70% of patients completing CFPR met minimum clinically important differences for 6-min walk functional capacity (98 feet). TUG measurements improved in 64% of the remote population and 90% in the CFPR. Grip strength measurements improved in 73% of the RPR group and 90% in the CFPR group. METS obtained from a recumbent cycle improved in 45% of the remote population and 70% in CFPR.

Telehealth allows accessibility for those needing pulmonary rehab, particularly during the pandemic. While objective testing demonstrated a greater proportion of improvers within the CFPR program, RPR patients exhibited improvements in objective outcomes justifying the continuation of telehealth service for pulmonary patients with limited accessibility.

Timely outpatient follow-up after initiating noninvasive ventilation (NIV) during an inpatient stay is essential to ensure the effectiveness, efficacy, and safety of the prescribed intervention. Connecting with outpatient providers soon after discharge provides access to care allowing proper troubleshooting, potentially decreasing morbidity and re-hospitalization. We aimed to improve timely follow-up of patients discharged from the hospital after initiation of NIV in our outpatient sleep or pulmonary clinics as defined by increasing the percentage of newly initiated NIV patients discharged from inpatient and scheduled for follow-up in the outpatient sleep/pulmonary clinic within 30 days from 33% to 50% by December 2020.

A driver diagram was created to identify barriers to timely outpatient follow-up. A shared EPIC list was created to identify new NIV patients slated for discharge. Patients on this list were identified for teaching by nursing and respiratory therapy and for tracking by our sleep center coordinator. Several new tools were created to assist with communication and workflow: A hand-off smart phrase for EPIC notes to facilitate the transition to outpatient care, including a summary of patient settings, new sleep consult order to facilitate follow-up scheduling. Workflow was developed and disseminated to pulmonary service/consult teams, durable medical equipment companies, inpatient nursing, case management, respiratory teams, outpatient nurses, respiratory therapists, and sleep coordinator. With IRB approval, data were collected from 8/2020 to 01/2022.

192 patients were initiated on NIV and discharged in the 18-month surveillance period. 89% had a specialty outpatient appointment following discharge; 56% were seen within 30 days, 81% were seen within 60 days. Mean ± SD time to follow up appointment was 29.8 ± 25.5 days. Of those that did not follow up, 10 (5%) followed up locally, one followed up with an adult provider, 6 passed away (3%), and 5 (3%) were unaccounted for. The percentage of patients readmitted for any reason was 11% with 3% for respiratory reasons. A Healthy Planet reporting tool was launched to automate tracking of patients’ long term.

A new standardized process to improve follow-up and interdisciplinary communication across the continuum was created to improve safety, effectiveness, efficiency, and outcomes reducing time to necessary care, reducing rehospitalization and disparities in care.

Does a bedside practitioner-led rounding format lead to an increase in interdisciplinary communication? We believe so, by allowing the RT and RN to present the appropriate patient system during daily rounds. This was a change from the current practice of NP and resident-led rounds.

An interdisciplinary taskforce was formed that developed a survey for the PICU. The survey used a Likert scale (0-5) to assess components of the rounding format (level of participation, efficiency, important and redundant data shared, level of comfort speaking, questions addressed, satisfaction, clarity of overall plan). The taskforce then met monthly to create a new rounding format with an accompanying rounding tool (patient data sheet organized by system updated q shift). After 6 months of planning and preparing, we trialed this new rounding format with RTs presenting the respiratory system and RNs presenting all other system reviews, concluded by a closed-loop recap led by the resident or NP. Members of the taskforce performed random audits for data collection over the next 6 months after implementation. The taskforce then sent out another, post-implementation, Likert scale survey to the PICU.

The results of our post-survey indicated an overall positive change in the way our staff felt about the rounding process. There was strong evidence (P = .01) that people were more comfortable speaking up, moderate evidence (P = .05) that the plan of care was clearer, and weak evidence (P < .1) that people participated more, and their questions/concerns were addressed more. When the results were looked at by role, RTs responded positively in all categories except for two - important or redundant data being shared.

By switching our rounding format to one with RT/RN-led discussions, we were able to measure a significant increase in the level of interdisciplinary communication. Our post-survey results indicated that staff were more likely to engage in the discussion as well as understand the plan afterward. This supports the hypothesis that a beside practitioner-led rounding format can lead to an increase in interdisciplinary communication.

Cuff pressure manometry is a standard of care in many health care facilities to ensure appropriate and safe cuff pressures of endotracheal and tracheostomy tubes. Anecdotal bedside experience using a commercially available product produced the thought that we were losing cuff pressure upon initial attachment to the pilot balloon. We sought to evaluate if there was a difference in cuff pressure loss with and without a stopcock attached to the syringe manometer.

IRB approval was obtained for this quality improvement study of subjects that were intubated with an oral endotracheal tube or subjects who had a tracheostomy. Exclusion criteria included any patient that was under the age of 18, was using a speaking valve, was not on a ventilator, or had a non-air-filled cuff. Using the Mallinckrodt Puritan-Bennett PTS 2000 Ventilator Analyzer (TSI Incorporated, St. Paul, MN) cuff pressures were recorded. Cuff pressure was set without a stopcock, the manometer was removed, then placed back on the pilot balloon. The difference between the two pressures was the without stopcock pressure gradient. A stopcock was then attached to the manometer, the cuff was pressurized, and the stopcock was turned off to the cuff. The manometer was removed from the pilot balloon and then reattached; the stopcock was then opened to the balloon. The difference between the two pressures was the with stopcock pressure gradient. Data was analyzed using IBM SPSS software v25 (IBM, Armonk, New York) using Wilcoxon signed rank test.

20 evaluations were included in the study: 14 endotracheal tubes and 6 tracheostomies. There was significantly more pressure loss without a stopcock (median 5.49 cm H₂O) compared to the pressure loss with a stopcock attached (median 0.78 cm H₂O; P = .011).

There is pressure loss when measuring cuff pressure with the commercial manometer. Utilizing a stopcock attached to the manometer and pre-pressurizing the manometer had less cuff pressure loss. While there is a significant difference, we are unsure of the clinical significance. Further studies could confirm our findings.

Alpha-1 antitrypsin (AAT) is a protein that protects the lungs by utilizing anti-inflammatory and anti-proteolytic functions. AAT deficiency is a hereditary disorder that clinically manifests in the lungs, liver, and skin. Pulmonary presentation is primarily displayed as COPD and bronchiectasis. Nationwide, only 5-8% of patients with AAT deficiency have been identified. Due to the lack of routine screening for AAT deficiency, 90% of patients with AAT are believed to be undiagnosed. The American Thoracic Society (ATS) and the European Respiratory Society (ERS) Clinical Practice Guidelines recommend screening patients with a spirometry value of FEV₁ less than 70% post bronchodilator, history of COPD, incompletely reversible asthma, chronic liver disease, a family history of pulmonary disease, or if patient prompts a request. This screening can be performed by a respiratory therapist in the pulmonary function testing (PFT) lab during a routine patient visit.

A respiratory therapist performs ordered PFT; if a patient is identified as meeting ATS/ERS criteria for AAT screening, the therapist obtains an additional consent and performs a free screening via a buccal mucosa swab. The sample is sent to an outsourced lab for genotype identification, results are reported directly back to the PFT lab as normal or abnormal (see graph below). The lab then performs a serum level to identify the severity of deficiency for abnormal results. Results are reported to the patient and ordering physician

The PFT lab implemented AAT screening in 2017. Of the 424 individuals screened to date, 61 patients showed one normal gene and one abnormal gene. 2 patients showed 2 abnormal genes. The patients identified with severe deficiency were offered treatment with augmentation therapy to boost protein in the blood and slow disease progression. Patients with AAT deficiency have shown improvement in quality of life with ongoing treatment.

Respiratory therapists performing pulmonary function tests play a vital role in providing access to screening, raising awareness about the importance of screening, and potentially identifying those patients that would otherwise go undiagnosed. Increased screening in PFT labs nationwide would improve patient outcomes

The proliferation of smart devices provides the possibility of early detection of the signs of pulmonary infection. The present study validates a smart device-based algorithm to monitor the risk of pulmonary infection.

An algorithm based on smart devices (Huawei Device Co, Shenzhen, China) has been developed among 87 patients with pulmonary infection and 458 healthy subjects, consisted of the heart rate variability, respiratory rate, oxygen saturation, body temperature, and cough sound. The algorithm embedded into the Respiratory Health Study application to detect the risk of pulmonary infection was further validated in hospital. The pulmonary infection was diagnosed by the doctors with the clinical evaluation, lab test, and imaging examination, as golden standard. The accuracy, sensitivity, and specificity of the algorithm predicting pulmonary infection were evaluated.

80 patients with pulmonary infection and 85 healthy volunteers were recruited. The area under the curve (AUC) of the algorithm in predicting pulmonary infection was 0.86 (95% confidence interval, CI: 0.82-0.91) (P < .001). The overall accuracy of the algorithm was 85.9%, the sensitivity was 81.4%, and the specificity was 90.4%, respectively, compared to accepted standard. The algorithm of heart rate, respiratory rate, oxygen saturation and body temperature demonstrated the accuracy of 68.2%, meanwhile, the accuracy of the algorithm with cough sound was 82.6%.

The wearable devices could facilitate the detection of the risk of pulmonary infection. Multi-source features were useful to enhance the performance of pulmonary infection screening algorithm.

Continuous nebulization (CN) of the bronchodilator albuterol is often administered to ameliorate R_aw associated with status asthmaticus (SA) during mechanical ventilation (MV). The morphology effect of SA is bronchoconstriction which may increase driving pressures (DP) and cause suboptimal inhaled drug delivery. In vitro investigation with the vibrating mesh nebulization (VMN) Aerogen demonstrated that CN during MV is feasible. Helium/oxygen (heliox) in conjunction with MV has been used to treat respiratory acidosis and persistent hypercapnia associated with SA.¹ Previous study demonstrated that MV with heliox and CN had a positive impact on alveolar-arterial (A-a) gradient during treatment for SA.² Bias flow needed to power jet nebulizers may be problematic during MV. The aim of this study was to determine whether rate of nebulization during CN with a VMN would negatively impact DP during MV with heliox.

A Servo-i ventilator equipped with heliox gas module was used for the study via lung model, high pressure gas lines were connected to a heliox G cylinder (80:20) and oxygen (1.0) source. Ventilator settings were: V_T 0.40 mL, VC-CMV 12 breaths/min, PEEP +8 cm H₂O, FIO₂ 0.40 oxygen equal heliox 60:40 ratio. Albuterol (0.5%) 20 mL was drawn up into a syringe that was attached to a syringe pump. Dose delivery on the syringe pump was programmed to administer 20 mg/h. The VMN was inserted on the dry side of the humidifier chamber and the control timer was set to continuous. The ventilator microprocessor monitored respiratory parameters; a 10% increase of measured values was considered undesirable.

Set delivery dose of 20 mg/h, was converted into a delivery volume of 4 mL/h, total rate of nebulization was 16 mL/h over 4h. Heliox+VMN+MV; expired V_T 0.40 mL ± 0.08, P_aw 22 cm H₂O ± 6, no auto-PEEP, breath stacking, or auto-cycling detected.

Rate of nebulization output from the VMN and heliox did not grossly affect MV functionality. Therefore, did not subversively impact DP. Clinical investigation is needed to determine whether MV+heliox+CN via VMN can enhance inhaled drug delivery and impact clinical outcomes associated with SA. This study has several limitations, as other CN agents (eg, epoprostenol) have an alkaline (sticky) base that over time could inadvertently impact DP. Close monitoring of MV mechanics is prudent during any CN procedure. </br>References: 1. Gluck EH, et al. Chest 1990. 2. Schaeffer EM, et al. Crit Care Med 1999;27.

Educators are tasked with preparing the next generation of professionals. The COVID-19 global pandemic added another dimension of responsibilities to the faculty in health-related fields. Educators in these areas may have experienced additional role strain as a result of impacts related to the pandemic in both the clinical and academic settings; however, very little is understood about the perceptions these faculty have regarding the extent to which this type of strain contributed to feelings of burnout or wellness imbalance. The purpose of this study was to investigate the potential reasons for perceived burnout and poor well-being among full-time health-science faculty at one institution.

This explanatory sequential design utilized qualitative data from a mixed-methods approach utilizing a validated survey tool. The survey was distributed via a web-based platform to 117 full-time faculty within the College of Health Sciences at a mid-sized, four-year institution. Qualitative data from two questions were categorized and analyzed to identify major themes regarding work-life imbalance which may have contributed to the occurrence of burnout.

Responses indicated that most faculty are experiencing moderate to high levels of burnout. Main themes identified included high levels of stress related to a mismatch of values regarding autonomy, displacement of community, and heightened workload requirements. These issues were compounded by increased demands from students, a lack of communication between colleagues and administration, and a perceived lack of support from the university. Institutions can allay feelings of burnout by increasing support; specifically, reduced workloads, time off from work with no communication, dedicated meeting-free days, and/or permanent flex or work-from-home options. Opportunities for institutional support of employee-wellness included confidential faculty support/therapy groups, time management tips, free access to the recreation center, increased hours for dedicated wellness activities each week, and available childcare.

Although the perceived mismatch in prioritized values between the institution and faculty is a multifaceted issue; the loss of autonomy due to the effects of the COVID-19 pandemic likely influenced feelings of both burnout and faculty wellness. It is clear that to address faculty burnout, institutions of higher education must allocate resources to support faculty wellness and retention.

In vitro assessment of trans-nasal aerosol delivery via HFNC has been conducted with anatomical models and intubation manikins that are facsimiles and may not be anatomically correct. As a precursor to planned bench studies, we have created and validated an open-source anatomical nasal model that can be 3D-printed using readily available materials and printers.

A nasal airway cast (solid) model, derived from a CT scan of the skull, was downloaded from NIH 3D Print Exchange as a STL (Standard Tessellation Language) computer file, widely used in 3D-printing. In Computer Aided Design (CAD) software (TinkerCAD, Autodesk), the solid nasal cast was converted to a negative space surrounded by a solid head and face structure. The nares of the nasal airway were aligned with the nares of the face/head and its hypopharynx was aligned to create an opening on the inferior posterior surface of the head. The new CAD was converted to an STL file, prepared for 3D-printing using slicer software, and printed with ultraviolet-curable polyurethane resin at a resolution of 0.05 mm. A 3D-printed 22-mm diameter tubing adaptor was glued over the orifice at the hypopharynx to allow a respiration simulator and aerosol collection filter for inhaled mass (IM) determination to be attached. The model was initially tested to ascertain trans-nasal aerosol transit by fitting a medium Fisher & Paykel Optiflow HFNC to it (Fig. 1) and administering a 3 mL bolus of radiolabeled saline via a nebulizer attached to the dry side of the heated humidifier at a HFNC gas flow of 30 L/min. The IM filter was placed after the hypopharynx and attached to a sinusoidal piston pump set to simulate a distressed breathing pattern (30 breaths/min, tidal volume 750 mL, I:E 1:1). After nebulization was complete, all components including the head model were imaged by gamma scintigraphy to assess deposition of radioactive aerosol throughout the system and determine the mass balance.

Figure 2 shows mass balance and distribution of radioaerosol deposition including 7.6% inhaled mass plus system losses of aerosol and loss (12.7%), by deduction (crosshatch), at the interface of cannula prongs and nares.

The initial experiment on the new open-source anatomically correct nasal airway model shows that aerosol delivered via HFNC can transit the model from the nares to the hypopharynx and that the model will be acceptable for conducting more comprehensive studies of HFNC aerosol delivery.

Fig. 1. 3D-printed head with complete nasal airway.

Fig. 2. Mass balance.

Several methods exist for determining optimum PEEP in ARDS patients. Chiumello’s study supports use of ARDSnet PEEP/FIO₂ tables over other methods (PMID: 24434443). A previous QI project uncovered an unexpected inherent ambiguity leading to errors in interpreting tables. This ambiguity creates a problem for two reasons. First without a true table interpretation to follow, tracking adherence to protocols is impossible. Secondly, it introduces unnecessary variability in study results. The purpose of this study was to transform the ambiguous ARDSnet tables into explicit PEEP/FIO₂ matrices showing acceptable setting pairs (ie, on the ARDSnet tables) and to determine error of respiratory therapists’ (RTs) interpretations using actual patient data. We hypothesized that RT error in determining acceptability of patient data pairs will be lower for explicit matrices.

We transformed the ARDSnet PEEP/FIO₂ tables into explicit high and low PEEP/FIO₂ matrices (Figure). Next, PEEP and FIO₂ data from patients with ARDS with orders to follow the PEEP/FIO₂ table were extracted from the hospital electronic medical record. Data pairs (both on and off the table) were used to create a survey. RTs were asked to use first the ARDSnet PEEP/FIO₂ tables and then the corresponding explicit matrices to designate whether each data pair was on or off the table/matrix. Surveys were scored according to the number of incorrect interpretations of paired data. Mean error values for table vs matrix were compared using t-test with P < .05 indicating significance.

We collected data from 43 RTs. For the low PEEP/FIO₂ data, mean error was 5% for the table version vs 4% for the matrix version (P = .539). For the high PEEP/FIO₂ data, mean error was 4% for the table version vs 2% for the matrix version (P = .011).

In general, the error we observed in interpreting PEEP/FIO₂ tables was no more than 5%. Expressing the ARDSnet PEEP/FIO₂ table as a matrix reduces interpretation errors. This effect was only significant for the high PEEP/FIO₂ matrix. We recommend using the matrix version of the ARDSnet PEEP/FIO₂ tables to potentially improve patient care and facilitate adherence to protocols.

Mechanical ventilation is a lifesaving intervention provided by most hospitals. Despite its wide usage, its application can vary significantly among institutions, and particularly between countries. There are many options when it comes to selecting a ventilator, its modes, and settings that may affect the quality of care and comfort of the patient. The purpose of this study was to determine the spectrum of use of mechanical ventilation in intensive care units in different parts of the world.

This cross-sectional survey was created using Google Forms and included 57 items examining demographic information and the implementation of mechanical ventilation. It was distributed internationally via social media to clinicians with mechanical ventilation responsibilities in adult ICUs between February and April 2022. The Google Forms responses were routed to Google Sheets to perform analyses. Descriptive statistics were used to report the results. IRB approval was obtained.

A total of 453 responses were received. Most respondents were RTs (97.13%) and from North America (80%), followed by Asia (10%). The most widely utilized ventilators were Puritan Bennett (25%), Servo (22.3%), Drager (19.2%), Hamilton (15%), Avea (7.5%), and General Electric (7%). VC/AC (39.3%) was most used to initiate mechanical ventilation, followed by PRVC/AC (33.6%) and PC/AC (20.5%). Most participants (85.9%) reported using IBW to determine initial V_T and common initial settings were PEEP 5-8 cwp, Ti 0.8-1.2 sec, V_T 6-8 mL/g IBW, and ARDS V_T 6 mL/kg IBW. Wide variations were seen in initial settings for FIO₂, (mean 0.57; range 0.21-1.0) PS (52% titrate to V_T exhaled and 39% initiate at 10 cwp), and RR (mean 16; range: 10-18). Flow was the most common method used for triggering (89.8%) and more than half (54%) reported routinely selecting tube compensation. The most common weaning criteria selected were RSBI (19.5%) and NIF (12.9%) and the most common weaning methods were CPAP/PS (67%) and T-piece (12%). When considering extubation, 19.4% of respondents used the cuff leak test.

The results of this international survey revealed that while initial selection of modes of ventilation varies, many of the primary ventilator parameters are set consistently across geographic areas.

Patient safety plays a vital role in health care. The AARC has recommended protocols to standardize patient care and improve outcomes. In the critical care setting, ventilator alarms are essential to ensure patient safety while undergoing mechanical ventilation. While there are not evidence-based standards for selecting ventilator alarms, some institutions have arbitrarily adopted a 50% higher and lower than patient’s recorded value on the patient-ventilator assessment. The goal of this study was to evaluate alarm parameter selection practices in one adult medical ICU at a large metropolitan city in Texas.

This prospective observational study was conducted at a university-affiliated hospital in San Antonio. Patients 18 years old and older who were mechanically ventilated in adult ICUs were included in this study. The respiratory rate (RR), peak inspiratory pressure (PIP), tidal volume (V_T), and minute ventilation (VE) documented in the patient-ventilator assessment were compared with the selected alarm parameters (high RR, high pressure alarm, high V_T, and high/low VE). Excel (Microsoft) was used to collect data. Descriptive statistics were used to report the results.

One-hundred and twenty-five subjects participated in this study. Most participants were male (61%) and their mean age was 53.6 years (± 14.9; range 18-100). The mean exhaled V_T for the subjects was 396.86 mL (± 139.93), while the mean high V_T alarm was set 99.7% higher (792.44 mL ± 214.5). The mean PIP was 22.76 cm H₂O (± 7.48 cm H₂O), whereas the mean high-pressure alarm was set 76.3% higher (40.12 ± 4.64 cm H₂O). While the mean VE was 7.92 L/min (± 3.00 L/min), the mean high VE alarm set was 113.9% higher (16.94 ± 4.03 L/min) and the mean low VE alarm was 43.5% below the patient recorded VE (2.86 ± 2.61 L/min). The mean RR by the patients was 21.90 breaths/min, while the mean high RR alarm set was 94.9% higher (42.69 breaths/min ± 9.04).

Based on these results, the ventilator alarms selected by respiratory therapists in this ICU, except for the low VE, were set well outside of recommended ranges. This practice needs further evaluation and standardization as it may compromise patient safety.

High-frequency percussive ventilation (HFPV) has been used in patients ranging from neonates to adults. There is little evidence to support protocol development for HFPV. This study aims to describe how practitioners initiate HFPV based on hospital protocols.

Protocols were identified in published literature, and voluntarily submitted after an email was sent via a listserve and posted on AARConnect. Settings were categorized based on the VDR-4 manual, recommendations from Forrest Bird, and feedback from subject matter experts. Categories were developed with expert interviews to establish low, moderate, high, and variable/match conventional settings. The category table was reviewed by subject matter experts for feedback based on clinical experiences. Demand and oscillatory PEEP categories were off, low (1-3 cm H₂O), moderate (4-6 cm H₂O), high (≥ 7 cm H₂O), and match conventional. Pulsatile flow categories were low (20-30 cm H₂O), moderate (31-40 cm H₂O), high (≥ 40 cm H₂O), and matched conventional/variable.

Eighteen protocols were identified. The low and moderate categories for demand PEEP each had 5 (28%) protocols, and 2 (11%) protocols were variable. Moderate oscillatory PEEP had 4 (22%) protocols, high had 7 (39%), and variable had 5 (28%) protocols. Pulsatile flow had 10 (56%) protocols in the low category and 5 (28%) were variable.

Setting variation among protocols indicates little agreement between hospitals on the appropriate initiation strategy for HFPV. Future studies are needed to develop evidence-based protocols and determine a systematic approach for HFPV settings in specific patient populations.

Increasing evidence has demonstrated that circular RNAs (circRNAs) are involved in a variety of human diseases. However, the functions of circRNAs in lung injury induced by obstructive sleep apnea (OSA) remain unknown. Here, we performed RNA sequencing to analyze the circRNA expression profile in a mouse model of OSA-induced lung damage and investigated the relevant mechanisms.

The mouse model of OSA treated by chronic intermittent hypoxia (CIH) was established. We assessed the expression profiles of circRNAs by RNA-sequencing. Bioinformatic analyses, including Gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis, were further performed by us to predict the potential roles of circRNAs. Meanwhile. we confirmed the changes in circRNAs by qRT-PCR. Finally, a circRNA-miRNA-mRNA competing endogenous RNA (ceRNA) regulatory network was constructed.

We found 31 upregulated and 53 downregulated circRNAs in CIH-induced lung injury. The qRT-PCR validated that the 7 selected circRNAs were identical to the results of RNA-seq. Both GO and KEGG analysis were further employed to annotate the potential functions of dysregulated circRNAs. Finally, we established a ceRNA network to predict the target genes of circRNAs.

In summary, the results of our study first revealed the expression profiles and potential functions of differentially expressed circRNAs in OSA-induced lung injury in mice. This may provide new clues for studying the mechanisms underlying this disease, and present novel molecular targets for clinical therapy of OSA-associated lung disease.

The COVID-19 pandemic emerged in 2019 as an aggressive respiratory disease. The highly contagious virus spread worldwide and affected millions of people. Due to the novelty of the virus, there was no consensus on effective treatment; consequently, many supportive therapies were commonly used. The primary goal of this study was to determine the use of alternative medicine products (AMP) commonly used during the COVID-19 pandemic and the user’s perception of benefit.

For this cross-sectional study, a 20-question survey was created using Google Forms. It was distributed via social media from March to May 2022 to subjects at least 18 years of age from different countries. The instrument explored participants’ demographics, general health condition, which alternative medicine products (AMP) were used and why, and COVID-19 infection and immunization history. Excel (Microsoft) was used to tabulate data and report descriptive statistics. IRB approval was obtained.

A total of 162 responses were obtained. The great majority of participants were from North America (n = 114; 70.4%), followed by Asia (n = 18; 11.11%) and South America (n = 15; 9.25%). The mean age was 35.55 years old (± 13.6) and 68.5% were female. Most participants hold a BS (41.4%) or MS (21%) degree. More than half (56.7%) had received 3 doses of the vaccine while only 9% had received none. Most participants use AMPs (n = 148; 91.4%) either always or regularly (51.2%) and to either prevent or lessen COVID-19 symptoms 116 (71.6%). The most common AMP used were Vitamin C (56.8%), Vitamin D (54.3%), Zinc (42.6%), and antioxidants (27.7%). Over 70% of subjects (n = 107) reported that the use of AMP let them achieve their desired results.

Despite the lack of scientific data supporting the use of alternative medicine products during the COVID-19 pandemic, the results from the survey indicate that they are often used even by fully vaccinated individuals. This use is due in part due to the belief that it would help prevent and/or lessen symptoms associated with the virus.

Respiratory therapy students received decreased clinical time due to the COVID-19 pandemic. We developed a pilot team-based learning simulation program to bridge the experience gap, support the new graduate employee, and achieve a successful orientation outcome.

Seven new graduates began employment in September 2021. 6 of the 7 graduated from the same respiratory care program. This presented a unique opportunity to partner with the program director of the school to place the new graduates into effective simulation teams based on her knowledge of their psycho-social characteristics and learning aptitude. Participants were divided into one team of 3 and two teams of 2 members. Each team completed a two-day simulation program scheduled at specified intervals during general floor care orientation. The first simulation day included 3 scenarios focused on basic respiratory care topics. The second day consisted of 2 simulations which progressed to more complicated critical patient care scenarios. Scripted pre-briefing, including key learning points and full scenario debriefings were provided. A checklist of expected actions was used to guide the debriefing and the learning experience. Each participant completed a four-point Likert scale evaluation of the sessions after each simulation day. Exemption was granted from local IRB.

7 new graduates completed 13 surveys (93% response rate). One participant did not complete the day two survey. Participants responded agree or strongly agree to every question. All 7 new graduates completed general floor care orientation. Additionally, 5 advanced and completed ICU orientation, one was terminated due to non-clinical issues, and one was not eligible to advance to the ICU due to work status reduction.

The pilot team-based learning simulation program was supportive of the new graduate employee and led to successful orientation outcomes. Team-based simulation is now used for all new graduate hires during general floor care orientation.

High-flow nasal cannula (HFNC) is a therapy that can be applied by many devices. Healthcare institutions may have several different devices that deliver HFNC. These devices may vary due to the interaction of flows, nasal cannula (NC) sizes, and obstruction. The aim of this comparative bench study was to evaluate the response of HFNC devices with predetermined flows, NC sizes, and obstruction.

Three aerosol T-pieces with two holes drilled at diameters twice the size of the prong inner diameters were used to simulate small, medium, and large nares. The Fisher & Paykel Optiflow small, medium, and large NC were used. The prongs occupied up to 50% of the corresponding simulated nares. The devices tested were a blender set-up, Hamilton T-1 (HT), Dräger V500 (DV), Respironics V60 (RV), and Fisher & Paykel Airvo 2 (FP). An Ingmar Medical ASL-5000 simulated mild adult respiratory distress. The HFNC devices were tested with each size NC attached to its corresponding aerosol T-piece and the ASL. The device flow was started at 10 L/min and increased by 10 L/min to the device maximum flow (DM). Device response was recorded. The devices were tested again with one prong of the NC clamped to simulate an obstruction. The flow was started at DM and decreased in increments of 10 L/min.

The blender set-up delivered flow with any NC size and obstruction up to a DM of 70 L/min. It does not have alarms. HT and DV alarmed and flow stopped when the flow was obstructed. RV and FP alarmed and delivered a lower flow than the set flow when the flow was obstructed. Without obstruction, HT and DV can deliver DM (60 L/min; 50 L/min) with any NC size. Without obstruction RV and FP can deliver DM (80 L/min; 60 L/min) with the medium and large NC; and a 50 L/min flow limit with the small NC. With obstruction, HT and DV can deliver DM with medium and large NC. HT and DV are limited to 40 L/min with an obstructed small NC. With obstruction, RV can deliver 60 L/min with the medium and large NC, and 40 L/min with the small NC. FP with obstruction can deliver DM with the large, 50 L/min with the medium, and 30 L/min with the small NC.

Devices that deliver HFNC respond differently depending on the interaction of the nasal NC size, flow, and obstruction of flow. Bedside clinicians should be aware of flow limitation and the device response. This information may be used clinically as part of a device troubleshooting algorithm, and to determine how an obstruction may affect patients.

During the current COVID-19 pandemic, healthcare workers (HCWs) have been more exposed to physical and mental exhaustion leading to burnout. This increased psychological pressure has led to many psychological issues, such as post-traumatic stress disorder, fear, depression, anxiety, and insomnia. The sudden onset of COVID-19 has brought new challenges to the clinical setting. The purpose of this study was to evaluate the effects of the COVID-19 pandemic on the mental health of HCWs.

For this cross-sectional study, a survey consisting of 33 items was created using Google Forms and distributed via social media between March and April 2022 to healthcare workers (HCWs) over the age of 18 caring for patients with COVID-19. The items were designed to evaluate psychological burnout in HCWs during the pandemic. Google Forms responses were routed to Google Sheets and Excel to perform descriptive statistical analyses. IRB approval was obtained.

A total of 320 participants completed the survey. The mean age was 39.8 years old ( ± 12, IQR 25-75 = 29-49), and most were women (n = 268, 83.8%). The majority of participants (92%) agreed that they were experiencing some degree of burnout at work. Participants identified increased patient workload (80.6%), increased patient mortality (71.3%), and increased emotional needs of patients (64.8%) as the most significant work or life stressors that have affected them since the beginning of the pandemic. Most participants (n = 229, 73.9%) stated they had feared for their personal and their family’s health and more than half (n = 180, 58.1%) stated they had been adversely affected by the loss of social contact. Of the participants who said they are thinking of leaving their current job or profession due to the pandemic, 49.7% of them said they are definitely considering doing so in the next 5 years, and 25% said they had considered doing so within the next 6 months.

The results of this study suggest that the COVID-19 pandemic has affected the mental health of HCWs to the point that burnout may lead to leaving their clinical job or even the profession. Further research is needed to understand, prevent, and reduce medical burnout.

From July 2019 to January 2020, four sentinel events occurred related to accidental tracheostomy tube decannulation within our 700-bed academic medical center. Evaluation of these events by an inter-professional team comprised of RTs, intensivists, anesthesiologists, and patient safety specialists found that there was no consistent approach for early recognition and intervention of this type of surgical airway emergency at our facility.

Following the inter-professional team review of the safety events, a literature review was conducted with focus on an evidence-based approach to prevent, identify, and provide timely interventions in patients with a suspected accidental tracheostomy decannulation. A tracheostomy surgical airway emergency workflow was developed and approved by the Safety Oversight Committee. Education consisting of computer-based learning and live presentations was provided to over 1,000 staff members including RTs, RNs, CNAs, and providers. RTs also participated in a high-fidelity simulation with focus on application of the emergency algorithm and team lead role demonstration. Implementation of the Surgical Airway Emergency Team (SAET) comprised of RTs, a rapid response RN, a medicine ICU resident, an ICU pharmacist, an ICU RN, an anesthesiologist, and a trauma surgeon was established to rapidly deploy trained clinicians for this type of emergency. Upon activation of the SAET, the RT will lead the stepwise algorithm interventions until the trauma surgeon assumes the role of team lead. The SAET went live January 1, 2021.

Since the introduction of the standardized approach for early recognition and emergency activation for suspected accidental tracheostomy decannulation in 2021, the SAET has been activated 10 times (1/1/2021-5/31/2022). No sentinel events have been associated with accidental tracheostomy tube decannulation since implementation. Data are collected and shared with the inter-professional Surgical Airway Practice Standardization workgroup, and Plan-Do-Study-Act (PDSA) cycles are used to identify and address opportunities for improvement in real time.

A standardized approach empowers clinicians to have heightened safety awareness, identify early warning flags, and escalate care when appropriate that leads to improved patient outcomes. A quality improvement process with inter-professional clinicians maximizes resources and strengthens practice change. Ongoing PDSA cycles allow for continued progress for positive outcomes.

Vaping has gained popularity globally. Touted as a better alternative to cigarettes, many questions remain regarding its safety. Of particular concern are the various chemicals and substances that may adversely affect the cardiopulmonary system. Undoubtedly, people have different opinions about vaping. The aim of the study was to determine the perception on vaping as better and safer alternative to cigarettes.

For this cross-sectional study, a survey (Google Forms) with 52 items was distributed via social media and other forms of digital communication to participants at least 12 years of age worldwide between February and April 2022. The survey included items to evaluate demographics, smoking history, vaping history, vaping opinions, and health history. Excel (Microsoft) was used to tabulate the information and report descriptive statistics. IRB approval was obtained.

Data was collected from 304 participants. Most respondents were female (71%; n = 216). While ages ranged from 12 to 74, the majority of participants were 18-24 (n = 110; 36.2%) and 25-34 (n = 113, 37.2%). Most respondents originated from North America (70.1%, n = 213) with most the remaining participants from either Europe (18.8%; n = 57) or Asia (7.9%; n = 24). Out of the 304 participants in the study, 20.4% (n = 62) reported vaping usage. Of the 62 participants who reported smoking, 46.7% had a great experience vaping, and were unlikely to smoke cigarettes again. In fact, 48.4% of vapers reported quitting cigarettes altogether (n = 30) while another 24.2% (n = 15) never smoked cigarettes in the past. Only 5% of vaping participants (n = 3) quit vaping and returned to cigarettes. When asked if they thought vaping is a better/healthier alternative to cigarettes, 54.5% answered no, 23.1% answered yes, and 22.4% answered unsure. Seventy-three percent of the vapers reported the following symptoms: chronic cough, recurrent respiratory infections, wheezing, shortness of breath, and/or chest tightness.

The results of this survey suggest that most participants believe that vaping is neither better nor a safer alternative to cigarettes. While the scientific evidence confirms this opinion, advertisement continues to portray vaping as a better and even a safer alternative to cigarettes.

Respiratory therapists (RTs) are allied healthcare professionals, responsible for cardiopulmonary care in healthcare settings, and RT students play a significant role in strengthening various aspects of healthcare in the future, with the evolving trends in inpatient care. There are no validated instruments to evaluate students’ perception of their careers and satisfaction with the learning resources. The primary objective of the current study is to develop and validate a structured questionnaire (SQ) for RT students encompassing all the components of their career development and satisfaction.

Proceeding from the literature review and content validation by RT experts through focused group discussions, a reliable SQ was generated with 48 items based on the Likert scale. After receiving ethical clearance from the institutional review board, the SQ was administered to 904 RT students across the country using an online survey platform. We performed Principal Component Analysis (PCA), Structural Equation Modeling (SEM), and Confirmatory Factor Analysis (CFA) for the global fit. Cronbach's alpha was performed to estimate the internal consistency.

The PCA generated a 4-factor model, and internal consistency for the total scale exceeded the standard criterion of >0.70. Satisfactory goodness of fit data was yielded from CFA. Average variances extracted were higher than the correlation coefficients of the factors, which show sufficient discriminant validity.

This study shows a clinically acceptable model, it fits and suggests the possibility of applying SQ to an RT student with relatively good construct validity and internal consistency, based on the results of CFA.

SEM results of the confirmatory factor analysis for the four-factor model

Mechanical ventilators are essential for survival of critical care patients. Although ventilator alarms promote patient safety, their importance is often overlooked and seldom studied. This is due in part to their very high rate of occurrence, leading to alarm fatigue, thus increasing burnout. The main goals of this study were to evaluate ventilator alarm parameter selection by healthcare providers, and to determine the healthcare provider’s perception of alarm fatigue in the adult ICU.

This cross-sectional study surveyed healthcare professionals (HCP) 18 years and older working in adult ICUs. A questionnaire created using Google Form consisted of 29 items that was distributed via social media to participants in North America. It included sections addressing the participants demographics, occupation, area of patient care, basic ventilator inquiries and scenarios, as well as covid related issues. Descriptive statistics were used to report means and standard deviations. IRB approval was obtained.

A total of 53 participants completed the survey; most were respiratory therapists (n = 47; 88.7%), and the HCP responsible for adjusting the ventilator setting and alarms in their facilities according to most respondents (84.9%). When selecting the alarm setting for the high peak pressures (PIP high), 56.6% agreed to setting the alarm 10 cwp above PIP, 43.4% of participants would set the low PEEP alarm 5 cwp below set, and 49.1% of participants would set the low minute volume (VE low) alarm 2 L/min below patient's VE. When simulated scenarios were presented to participants, selections for VE high alarm varied the most, with 42.3% of participants selecting 4-6L/min above the average VE and 40.4% selecting 2-4 L/min above. When asked about alarm nuisance, two-thirds of participants had experienced alarm fatigue and felt they addressed the PIP high alarm most frequently (66%). However, 34.6% of participants stated alarm fatigue was caused by a multitude of false-negative alarms. The remaining 65.4% believed alarm fatigue was caused due to a shortage of staff, heavy workloads, or loud environments. Most participants (71.2%) believed COVID-19 caused an excess of ventilator alarms.

The results of this study suggest that while most participants select alarm parameters that are consistent with recommendations, the majority of HCP report alarm fatigue. Reducing alarm fatigue should be a priority to ensure patient safety remains our number one concern.

Instillation via artificial airway is used to directly deliver medications into the trachea. Despite poor evidence, various medications have been reported as administrable via artificial airway. Different procedures are reported for administering medications via artificial airway but the efficacy of these methods has not been widely studied.

This bench study utilized 3.5 and 6.0 tracheostomy and endotracheal tubes. Four volumes of sterile water (0.1, 0.5, 1.0, and 3.0 mL) were instilled down each airway using three repetitions and methods of instillation in random order. Methods included direct administration of water down the airway via syringe, advancement of a closed suction catheter (8 and 12 French for 3.5 and 6.0 tubes respectively) into the hub followed by administration of water through the instillation port of the suction catheter, and advancement of a closed suction catheter just beyond the tip of the airway followed by administration of water through the instillation port of the suction catheter. After instillation the catheter was withdrawn when applicable and five positive pressure breaths delivered to simulate mechanically ventilated breaths. Administered volumes were weighed pre/post instillation on a laboratory scale. Descriptive statistics and one-way ANOVA were used to compare mean volume differences, or volume lost, within and between each instillation method.

Mean difference in volume lost was homogenous across four volumes and three instillation methods. There was no statistically significant difference between mean volume lost for each method using the 6.0 tracheostomy or endotracheal tube. However, the mean volume lost for the direct instillation method for the 3.5 tracheostomy (P = .04) and endotracheal (P = .03) tubes was statistically significant compared to the other instillation methods for these airway sizes (Table 1).

Instillation of sterile water down an artificial airway yields small volume differences between amount instilled versus amount recovered. Though direct instillation for the 3.5 tracheostomy and endotracheal tubes was significantly different statistically, the volume difference was not clinically significant. This data suggests that it may be more valuable for the clinician to weigh other considerations such as PEEP requirement, risk of infection, or overall patient tolerance when deciding which method is optimal for medication delivery to the trachea.

Table 1. Summary of mean volume lost (mL) by method and airway size and type.

Lung ultrasound (LUS) is a feasible and radiation-free diagnostic method to confirm the presence of pulmonary disease. As the role of healthcare professionals (HCP) has significantly expanded over the years, involving LUS in the assessment and care of patients not only benefits patients, but also HCPs themselves. Current evidence supports the use of LUS as a useful alternative to chest radiography in evaluating and diagnosing critically ill patients with possible pulmonary compromise. The main objective of this study was to evaluate HCPs perceptions on the advantages of the use of LUS within the ER and ICU and to assess their knowledge of this procedure.

For this cross-sectional study, a survey with 40 items was created using Google Forms and was distributed via email and social media to HCPs and trainees 18 years or older working in ICU and ER in different countries. The survey evaluated demographic information, level of education, clinical experience, and exposure, training, and knowledge of LUS. Google Forms data was exported to an Excel (Microsoft) file where descriptive statistics were used to report the results. IRB approval was obtained.

A total of 43 participants completed the survey. Most participants were female (65.1%), between ages 18 and 33 (65.1%), from North America (95.3%), and have earned a BS degree (62.8%). Almost half of responses were from RTs (47.6%), followed by healthcare students (21.4%), and nurses (14.3%) working in the ICU (82.1%) with 2 to 10 years of experience (41.9%). Most participants reported that LUS is not used in the ER/ICU setting (50%) or were not sure (23.8%). One-third considered LUS easy to use (35%) whereas no participant had ever performed a LUS in a clinical setting and did not feel comfortable performing it (95.3%) or interpreting it (100%). While most participants (92.7%) did not receive LUS training in school nor on the job, 87% of believed that LUS should be added as part of the healthcare training, and 73.2% believe that it should be a requirement for RTs working in the ICU or ER. Of the technical questions on using LUS, 90% of the participants self-identified as lacking the required knowledge on the application of LUS.

The results of this study indicate that HCPs working in the ICU or ER consider LUS a valuable diagnostic skill and tool. However, since most participants lack basic application and interpretative skills of this technique in the clinical setting, educational support may be granted.

In the past, our institution utilized 4 non-standardized carts to manage difficult airway situations. When specialty providers were called to assist with emergent airway needs, varying factors influenced timeliness of successful airway intubation. In reviewing serious safety events of difficult airway encounters it was documented that the lack of appropriately sized equipment and/or expired supplies substantially impacted outcomes. It was hypothesized that increasing the number of carts across the care continuum, standardizing the contents and placing them in strategic locations would reduce adverse outcomes. A multidisciplinary group of stakeholders determined the implementation strategy would be to align the cart structure with the Broselow Tape to reduce the challenges and facilitate equipment selection. Respiratory care took the project lead and maintained the monthly auditing process for expired supplies. Fifteen standardized carts were launched for bedside use in April 2021 following end user online training.

The project aim was to follow-up with end users on experiences with respect to the new carts. Staff were invited by email to complete a brief 5-question electronic survey to identify training, availability, equipment, and barriers with respect to use of the carts. Survey data was collected in REDCap.

The survey had a 43% (40/93) response rate with the following key findings. Among survey respondents, 75% reported completing the training. Staff who had used the cart found them available when needed for direct patient care. The primary equipment utilized was targeted for obtaining an emergent airway via endotracheal tube. Identified barriers included quantity and organization of contents and noted knowledge gaps with respect to cart structure and restocking. The most common issue expressed was the amount of time needed to obtain the various items during the restocking process.

Adjustments occurred based on results. Findings were presented to the educator council, which resulted in opportunities for in-person training, as well as inclusion of the airway carts during clinical emergency preparedness training that occurs quarterly during mock code simulations. Training modules were revised to address the identified barriers. A video overview was developed to compliment training. An electronic restocking form with a QR code was developed to assist with time management.

Pulmonary rehabilitation (PR) is a core component of COPD patients’ management strategy. PR is administered by multidisciplinary healthcare providers (HCPs), but their attitudes toward delivering PR to COPD patients, factors and barriers that might influence referral have not been studied. This study aims to assess HCPs attitudes toward delivering PR to COPD patients and identify factors and barriers that might influence referral.

A cross-sectional online survey consisting of 9 multiple-choice questions was distributed among HCPs in Saudi Arabia between September 2021 and January 2022. Descriptive statistics were used to describe the respondents’ characteristics. Categorical variables were reported as percentages and frequencies.

Overall, 980 HCPs, 520 of them male (53.1%), completed the online survey. Nurses accounted for 40.1% of the total sample size, while respiratory therapists and physiotherapists accounted for 32.1% and 16.5%, respectively. Most HCPs strongly agreed that PR would improve COPD patients’ exercise capacity 589 (60.1%), improve patients’ health-related quality of life 571 (58.3%), and improve disease self-management in COPD patients 589 (60.1%). Moreover, in-hospital supervised PR program was the preferred way to deliver PR for 748 (76.3%) HCPs, and 832 (84.9%) perceived information about COPD disease as an essential component of PR, followed by smoking cessation 787 (80.3%). The most common patient-related factor that strongly influenced referral decisions was mobility affected by breathlessness (64%), while availability of PR centers (61%), lack of trained HCPs (52%) and lack of authority to refer patients (44%) were the most common barriers for referring.

PR is an effective management strategy for COPD patients, but sufficient PR centers, trained staff, and the authority to refer patients are lacking. An in-hospital supervised PR program is the preferred method of delivering PR, with information about COPD disease and smoking cessation being considered essential components of PR.

Patient-related factors that influence referral decision to PR, using strong, some or no influence grading.

Barriers to referring COPD patients to PR from HCPs perspective, using strong, some or no influence grading.

The Glasgow coma scale (GCS) is a neurological assessment that is used to evaluate level of consciousness. A patient’s GCS score is taken into consideration when deciding whether placement of an advanced airway occurs. We aimed to evaluate and describe intubation rates among trauma patients based upon their GCS at the scene as well as the associated outcomes.

IRB approval was obtained for this retrospective chart review of subjects who presented to a level one trauma center in south central Pennsylvania from January through December 2021. Subjects with an artificial airway placed pre-hospital or upon admission to the ED/trauma bay were included. Data was queried from the trauma registry using ICD-10 codes that signify placement of an airway. Missing or incomplete data was manually abstracted from the electronic health record. IBM SPSS software v25 (IBM, Armonk, New York) was used for data analysis.

There were 157 trauma activations in which the subject received an advanced airway. Of the 95 subjects who met inclusion criteria, 8 (8.4%) were intubated pre-hospital and 87 (91.6%) were intubated upon admission. Subjects intubated pre-hospital had a median scene GCS score of 8 (IQR = 6, 12), while those intubated upon admission had a median scene GCS score of 10 (IQR = 3.75, 15). Median hospital length of stay (LOS), ICU LOS, and ventilator days for the pre-hospital group was 3 (IQR = 0.5, 19), 2 (IQR = 0.25, 12.5), and 1 (IQR = 0.25, 6.5), respectively. Subjects intubated upon admission had LOS, ICU LOS, and ventilator days of 5 (IQR = 1, 15), 2 (IQR = 0, 7), and 1 (IQR = 0, 5). Six (75%) subjects within the pre-hospital group and 55 (63.2%) within the upon admission group were discharged alive. Results of independent samples Mann-Whitney U tests showed no statistically significant difference in LOS (P = .96), ICU LOS (P = .89), or ventilator days (P = .95) between subjects intubated pre-hospital versus upon admission. A Fishers exact test (P = .71) showed no significant difference in rates of in-hospital mortality between groups.

Lower median on-scene GCS scores resulted in quicker advanced airway placement. There were no differences in mortality, LOS, ICU LOS, or ventilator days regardless of airway placement location. A larger study would be beneficial, as the smaller sample size may not have allowed for differences between groups to be detected statistically. We will continue to monitor factors and outcomes of intubation as part of our institution's trauma performance improvement program.

High impact practices (HIP) are course activities designed to include one or more of the following: service learning, e-portfolios, capstone, collaborative teaching, internships (clinical practicums), study abroad, writing intensive and research. When teaching strategies intentionally use HIPs, student engagement and academic accomplishments are increased.¹ The purpose of this project was to identify HIPs, assess evidence of student learning and consider student feedback in respiratory courses where HIPs are used. Northern Kentucky University IRB approved this project, #1828.

HIP principles were included in: Cardiopulmonary Pathophysiology, Respiratory Capstone, Introduction to Respiratory Critical Care, Pharmacology I. The variables observed were course organization, assignment development, summative scores, and student feedback.

In Cardiopulmonary Pathophysiology, the final average was B+ when HIPs were used (2022) compared to B when they were not (2017). The HIPs were chapter self-assessments, real world problem group research project, and daily student learning outcomes. In Respiratory Care Capstone, the final average was A when HIP strategies were used (2022), and the same when they were not (2019). In 2022, every Capstone abstract was accepted to NKU’s Celebration of Student Research/Creativity. Four of the top 12 ranking abstracts (n = 76) were by respiratory students. In Introduction to Respiratory Critical Care, the final average in 2022 was B+ when more HIPs were implemented. This was the same as 2019, 2020, and 2021, when HIP strategies were not used. Final exam grades increased 8% in 2022 when format was changed to essay, scenario-based instead of multiple choice. Feedback was very positive with more hands-on and clinical applications added to classroom activities. In Pharmacology I, the final average was B when HIPs were used (2020) compared to C when they were not (2019). Upon student request, a more comprehensive self-assessment study tool was implemented in 2020, StudyMate² games. Students felt it helped their learning and complemented in-class verbal quizzes, study guides, and recorded lectures.

More data is needed to confirm academic improvement when HIPs are implemented in respiratory courses. In the courses listed, there was evidence of positive feedback, improved engagement, and increased scores when HIPs were used. </br> References 1. HIP (High Impact Practices) 2021. Salem Press Encyclopedia. 2. StudyMate https://web.respondus.com/he/studymate/

At our institution, in the outpatient primary care settings, orders for a written asthma action plan (AAP) with education and pulmonary function testing (PFT) are currently entered at the discretion of the licensed independent practitioner (LIP). A chart review revealed that AAPs and PFTs were not consistently ordered based on the recommendations from the Global Initiative for Asthma Management and the National Heart, Lung, and Blood Institute Expert Panel Report 3 asthma management guidelines. A respiratory therapist (RT)-driven protocol was developed as a quality improvement study aimed to increase frequency of PFTs and AAPs in primary care clinics. This protocol allows the RT to order PFTs and AAPs for children with asthma who meet specific criteria. The aim of this study was to evaluate provider acceptance of an RT-driven protocol and to assess barriers regarding protocol implementation.

A survey was created and sent electronically to LIPs prior to implementation of the RT-driven protocol. Survey questions focused on RT availability, barriers to ordering PFTs and AAPs, comfort with utilizing PFT results, and importance of asthma education. The survey was repeated 6 months post protocol implementation with additional questions regarding LIP satisfaction with the RT-driven protocol. Responses were collected in REDCap.

The survey was sent to 115 LIPs. The survey was completed by 29 (25%) and 22 (19%) LIPs pre and post protocol respectively. The pre protocol survey identified interruption to clinic flow as the main barrier to ordering PFTs (17, 58.6%). The majority (28, 96.6%) were comfortable utilizing PFT data for clinical decision-making. All respondents indicated asthma education is important for self-management of asthma. In the post protocol survey, half of all respondents identified interruption to clinic flow as a barrier to LIP ordering PFTs (11, 50%). Most (21, 95.5%) LIPs felt comfortable utilizing PFT data for clinical decision-making, and all continued to report asthma education is an important part of asthma self-management. The majority (19, 86%) were satisfied with the RT-driven protocol.

Interruption to clinic flow was the main barrier identified by LIPs for ordering PFTs. All LIP respondents felt that asthma education is important for self-management. Providers were satisfied with an RT-driven protocol for ordering PFTs and AAPs in the primary care setting.

Bronchial asthma is a chronic inflammatory disorder of the airways associated with reversible airway obstruction and increased airway responsiveness to a variety of stimuli. The present study aimed to evaluate the ethanolic extract of Achillea millefolium flower for antitussive and anti-asthmatic potential through experimental models.

Antitussive activity was carried out against SO₂ induced cough reflex in mice. Swiss albino mice of either sex weighing 30 ± 5 g were selected and divided into five groups of 6 animals each. Test drugs were administered orally at a dose of 200,400 and 800 mg/kg. Codeine sulphate was used as standard drug. The sensitized guinea pigs were screened out and divided into control, standard, and AMEE treated groups. Antiasthmatic activity of AMEE was assessed by in vitro guinea pig tracheal chain method and in vivo bronchoprotective test method using aminophylline as a standard drug.

AMEE showed significant (P < .001) antitussive activity against SO2 induced cough reflex. AMEE significantly reduced the number of cough reflexes by 43.82%. AMEE exhibits maximum bronchi relaxation of 82.46% and 89.22% against acetylcholine and histamine induced contraction, respectively. AMEE exhibited maximum and significant (P < .001) bronchoprotection of 40.16%. The histopathological studies, in AMEE treated groups showed reduced inflammation of cells when compare with control group.

The results of the study revealed the potent antitussive and antiasthmatic activities of Achillea millefolium flower extracts, which support the Achillea millefolium to be used as an antitussive and antiasthmatic in Indian folk medicine and its further implication for the treatment of cough associated complications.

Histopathological section of lung of guinea pig AMEE (400mg) treated.

Small airways dysfunction (SAD) and airflow obstruction (AO) are prevalent in asthma and lung volumes are also commonly affected due to gas trapping. This study assessed relationships between SAD and AO on lung volumes in patients with asthma.

Adults with asthma who had a set of full lung function measurements between (January 2016 to April 2021) were included from a tertiary hospital in the West Midlands, United Kingdom. Predicted values were calculated using the 2012 Global Lung Initiative equations. AO was defined as a standardized residuals (SR) of < -1.645 in FEV₁/FVC. (1). SAD was defined as a SR of < -1.645 in MMEF. Rstudio software was used for statistical analysis. Wilcoxon rank test was used to analyze the differences between the groups. The study was approved by the Research Ethics Committee and the Health Research Authority of the NHS (20/WM/0024).

208 patients were included, of which 36 (17.3%) and 46 (22.1%) had physiological evidence of AO and SAD, respectively. Residual volume (RV) % predicted was higher in asthma patients with AO (n = 36) compared to patients without AO (n = 172), (median [IQR]: 102 [95.8-108] vs. 92.3 [84.6-101], (P < .001). The total lung capacity (TLC) was also higher in those with AO compared to without AO (median [IQR]: 102 [95.8-108] vs. 92.3 [84.6-101], P < .001). RV was higher in patients with SAD compared to those without SAD, (median [IQR]: 109 [88.6-125] vs. 85.7 [74.6-98.0], (P < .001). TLC was not different between groups (SAD: 97.7 [87.8-103] vs. non-SAD 93.9 [86.3-103], P = .35), see Figure 1. In a univariate analysis of SAD on the total group (n = 208), RV was associated with SAD (OR 1.05, 95% CI: 1.03-1.06, P < .001).

In patients with asthma, SAD and AO are both associated with a higher RV and RV/TLC, which are suggestive of gas trapping. This may be contributing to the symptomatic burden in these patients and MMEF may be a useful parameter to measure.

Figure 1. % predicted of the lung volumes in SAD and AO in the whole population. It shows that there was an increase of RV in those with SAD similar to those with AO, although TLC was maintained in the SAD group. All values are median (IQR).

The goal of this bench study was to simulate continuous infusion nebulization of short-acting drugs (albuterol/epoprostenol) during HFNC therapy to test the real-time gamma ratemeter technique with trans-nasal aerosol delivery to detect and measure inhaled mass (IM) dynamically during experiments.

A breath-enhanced jet nebulizer (BEJN) operated in a heated Fisher & Paykel Optiflow HFNC system with a medium cannula fitted to a 3D-printed head model with nasal airway (described in poster by McPeck and Smaldone) was tested during continuous infusion aerosol delivery (10 mL/h). A sine-wave piston ventilator provided a distressed breathing pattern (f 30 breaths/min, V_T 750 mL, DC 0.50). Gas flows to the HFNC were deliberately changed between 30 and 60 L/min at 30-min intervals. Radioactive (99m-Tc) saline was infused continuously by 60-mL syringe pump or 500-mL IV bag pump into the BEJN. A shielded gamma ratemeter was oriented to measure radioaerosol accumulating on an IM filter 18-in distal to the hypopharynx of the head model. Radioactivity measured at 5-min intervals, expressed as gamma counts/min, was graphed in real time in Microsoft Excel to allow visualization of aerosol delivery rate against time.

The effect of changing gas flow through the BEJN to the cannula every 30-min was immediately visualized in real time. Radioactivity delivered by syringe pump, measured by the ratemeter, and graphed against time quantitatively reflected accumulation of trans-nasal radioaerosol on the IM filter (Figure) as evidenced by different slopes for each condition (colored lines). Another test with a 500-mL IV bag/peristaltic pump showed no difference between infusing the nebulizer with an IV pump vs a syringe pump. A similar test run with different nebulizer infusion flows also demonstrated ability of the ratemeter to detect dynamic changes in aerosol delivery to the IM filter.

Real-time ratemeter monitoring and measurement of radioactivity accumulating on an IM filter provides instantaneous updates of inhaled drug delivery during in vitro testing procedures. The ratemeter also provides detailed analysis of the impact of total gas flow to the cannula and/or the infusion flow to the nebulizer that influence continuous infusion drug delivery during HFNC therapy. This method of analysis facilitates appraisal of nebulizer output and enables assessment of HFNC drug delivery dynamically under changing conditions.

Ratemeter gamma counts vs time with changes in HFNC gas flow.

HFNC oxygen therapy is routinely used to treat patients with gas flows of 30–60 L/min. Trans-nasal aerosol delivery is reduced at higher cannula gas flow. A new application of breath-enhanced jet nebulizer (BEJN) technology may reverse this occurrence. To test this hypothesis, the present study measured aerosol outputs during continuous infusion by applying a humidified gas flow of 60 L/min directly to a prototype BEJN. Results were compared to conventional vibrating mesh nebulizer (VMN) technology.

In principle, BEJN uses the high flow gas to the cannula passing through it, combined with the high-pressure flow to the nebulizer jet orifice (5 L/min) to generate aerosol. BEJN output, therefore, should increase with increases in total gas flow to the cannula. The limitations of BEJN were first defined using visual assessment, and then confirmed by sampling radiolabeled aerosol. At a given combination of gas flow and infusion pump flow, the nebulizer residual volume was observed after 20 min of operation to define maximal infusion pump rates that generated a visual aerosol cloud without solution accumulating in the nebulizer. Then, using the clinical maximum gas flow of 60 L/min, radiolabeled saline was infused at 5, 12, 20, 30, 40, 50 and 60 mL/h for the BEJN and 5, 12, 20, and 30 mL/h for the VMN. Inhaled mass (IM) was measured for each infusion pump flow in real time using a ratemeter and output was defined as IM (% of syringe charge) per min.

At 60 L/min gas flow, VMN aerosol output (IM) ranged from 0.06 to 0.29 %/min and reached maximum output (started to fill) at an infusion rate of 20 mL/h (Figure). For the same gas flow, the maximum output of the BEJN was visualized at an infusion rate of 60 mL/h. Radiolabeled aerosol experiments confirmed the visual observations. For the BEJN, IM increased from 0.01 to 0.62 %/min as infusion rate was increased (Figure).

HFNC drug delivery is limited by aerosol loss in the circuit and at the nasal interface. These limitations can be overcome by increasing nebulizer output. For conventional jet nebulizers and VMNs, aerosol delivery is constrained by limitations in nebulizer output. Breath enhancement increases drug output by several fold over conventional technology. BEJN potentially can deliver drug at all relevant HFNC gas flows, facilitating a dose response assessment based on clinical needs at the highest HFNC gas flows by simply adjusting the infusion rate during therapy.

Rate of drug delivery for VMN and BEJN at 5 to 60 L/min. VMN not shown at >20 L/min due to overfilling.

For HFNC continuous infusion aerosol therapy, infusion rates for vasodilators are calculated by body weight-based protocol. Clinical response may be limited by aerosol losses and limitations of nebulizer output. Conventional nebulizers generate aerosol separate from high gas flow. Breath enhanced jet nebulization (BEJN) combines the energies of nebulizer jet flow plus cannula high flow to generate aerosol and overcome these limitations. BEJN may therefore increase drug delivery beyond typical levels at the highest flows to the cannula. To test this hypothesis, we used real time measurement of radiolabeled aerosol delivery to compare BEJN to a conventional vibrating mesh (VMN) system.

The experimental in vitro setup is detailed in posters by McPeck et al. The heated Fisher & Paykel Optiflow circuit and cannula was interfaced to a 3D-printed nasal/head model. An inhaled mass (IM) filter placed distal to the model’s hypopharynx was connected to a Harvard pump for distressed ventilation (f 30 breaths/min, V_T 750 mL, DC 0.5). A shielded ratemeter was positioned over the IM filter for real-time measurement of radioaerosol activity accumulating on the filter. Tc-99m radiolabeled 0.9% saline as a tracer was infused at rates of 5 to 60 mL/h for the BEJN and 5 to 20 mL/h for the VMN. HFNC gas flows of 10, 20, 30, 40, 50, and 60 L/min were used. IM data/min was converted to µg of salt (NaCl) and plotted versus time. The slope of each experimental condition represented the drug delivery rate (µg NaCl/min).

For each gas flow, aerosol delivery was a function of infusion rate and gas flow. Delivery that would have decreased with increasing gas flow was balanced by increases in infusion rate. Maximum infusion rate for VMN was 20 mL/h and 60 mL/h for BEJN, resulting in greater delivery for BEJN. For example, for the high flow of 60 L/min (Figure), rates of delivery ranged from 3.2 to 330.2 µg NaCl/min (BEJN) vs 23.6 to 104.5 µg NaCl/min (VMN). Overall, for all gas flows, BEJN maximal dosing ranged from about 2 to 4 times the VMN rates.

BEJN utilized the high gas flow passing through the nebulizer to increase nebulizer output significantly beyond conventional technology. For clinically relevant high gas flows, the wide range in BEJN delivery may allow individualized treatment of critically ill patients by titrating delivery to clinical response, and by employing a wider range of infusion rates, rather than a weight-based dosing protocol.

Rates of HFNC drug delivery for combinations of nebulizer infusion flow and HFNC gas flow for VMN and BEJN.

There is a lack of consensus regarding the use of transpulmonary pressure (P_L) monitoring in the treatment of patients with ARDS. The purpose of this study was to evaluate if patients with a diagnosis of ARDS had better outcomes when P_L was monitored. Outcomes included the number of days on a ventilator and in the ICU, the hospital length of stay, and mortality. A comparison was made between two groups of patients with and without P_L monitoring.

A retrospective analysis was conducted of adult patients with ARDS admitted to Santa Barbara Cottage Hospital between January 2018 and May 2021, with and without P_L monitoring. A total of 40 patients (n = 40) were included in this study: 20 patients with P_L monitoring and 20 patients without P_L monitoring.

There were significant differences in the mean of variables between the group with P_L monitoring and the group without P_L monitoring: LOS: (t ₍₃₈₎) = -2.88, P <.05); ventilator days: (t ₍₃₈₎ = -4.53, P <.001); ICU length of stay: (t ₍₃₈₎ = -3.68, P <.001). There was no significant difference in the mean ages of patients between the groups (t ₍₃₈₎ = -.306, P = .766) or between the use of P_L monitoring and mortality in this sample of patients, as identified via chi square analysis (x² (1, N = 40) = 0.900, P = .343).

The results may indicate the conditional use of P_L monitoring, meaning that benefit cannot be inferred. The data indicated that P_L monitoring was more likely to be implemented on patients who were deemed ‘sicker’, who required longer lengths of stays in both the ICU and hospital, as well as more days on the ventilator.

Frequent flyer hospital visits account for a disproportionately large share of overall visits and costs. A 2011-2012 Intermountain Healthcare study investigated factors driving high hospitalization rates of COPD frequent flyers. We repeated this study on new subjects for 2019-2021 to detect changes in demographics, treatment, comorbidities, and non-compliance. Following the original study, initiatives were implemented to improve COPD patient care. Also, in 2017, the Pulmonary Disease Navigator (PDN) scope was expanded to include COPD.

For 2019, 2020, and 2021, we extracted adult subjects (≥ 18 y) assigned a COPD exacerbation diagnosis associated with ≥ 5 visits (ER or admission) per year at all Intermountain hospitals. We performed retrospective electronic medical record reviews on these subjects, including all variables from the original study. To assess differences between cohorts in comorbidities, each variable was compared with a z-test. For cohort differences in housing, chi-square analysis was used.

We identified 33 subjects with ≥ 5 visits per year during the 2020-2021 period. There was a significant difference between cohorts in proportions of non-compliance with medication and clinic appointments. 61% of the subjects in the current cohort are followed by a PDN. Additionally, since 2012, 62% of subjects in the current cohort quit smoking and 31% reduced to half a pack a day or less. Other results are reported in accompanying abstracts.

Compared to the previous cohort, a larger proportion of subjects in the current cohort exhibit medication and clinic appointment non-compliance, suggesting COPD frequent flyer care has not improved. However, we extracted fewer total subjects, and a larger proportion of these subjects may be homeless. This suggests that there are fewer frequent flyer COPD patients overall, and that the current cohort consists of more subjects with behavioral issues and lack of resources. We attribute smoking cessation success and the reduction in total COPD frequent flyers to PDN involvement and initiatives implemented after the original study. We commend the improvements and recommend increased efforts to assist and educate homeless COPD patients. This study was limited by a small patient population and no access to the original dataset. Overall, we found a reduction in COPD frequent flyers and that medication and clinic appointment non-compliance have increased, possibly due to an increase in homelessness.

Frequent flyer hospital visits account for a disproportionately large share of overall visits and costs. A 2011-2012 Intermountain Healthcare study investigated factors driving high hospitalization rates of COPD frequent flyers. We repeated this study on new subjects for 2019-2021 to detect changes in demographics, treatment, comorbidities, and non-compliance. Following the original study, initiatives were implemented to improve COPD patient care. Additionally, in 2017, the Pulmonary Disease Navigator (PDN) scope was expanded to include COPD.

For 2019, 2020, and 2021, we extracted adult subjects assigned a COPD exacerbation diagnosis associated with ≥ 5 visits (ER or admission) per year at all Intermountain hospitals. We performed retrospective electronic medical record reviews on these subjects, including all variables from the original study. To assess differences between cohorts in PFTs, pulmonology consults, and code status, each variable was compared with a z-test.

We identified 33 subjects with ≥ 5 visits per year during 2020-2021. There was a significant difference between cohorts in proportions of pulmonology consults and PFTs. For the current cohort, 30% of PFTs were ordered by PCPs and 60% by pulmonologists. 61% of the subjects in the current cohort are followed by a PDN. Other results are reported in accompanying abstracts.

Compared to the original cohort, a larger proportion of subjects in the current cohort were seen by a pulmonologist and received a PFT during the pandemic where PFTs were considered high-risk elective procedures. This is an indicator that COPD patients are receiving more comprehensive care, potentially due to initiatives implemented after the original study, as well as PDN involvement. Another indicator is a reduction in total subjects extracted with the same inclusion criteria. As reported in accompanying abstracts, these 33 subjects may be more medically complex and older in age, which aligns with the possible increased proportions of DNR and palliative/hospice status. We recommend that COPD patients receive more pulmonology referrals and that providers other than pulmonologists be more inclined to order PFTs. This study was limited by a small sample size and no access to the original dataset. We conclude that progress in COPD frequent flyer care is evidenced by increased utilization of PFTs, pulmonology consults, and PDNs.

Respiratory Care is a platform for respiratory therapists (RT) to engage in scholarly activity. Understanding the progression of RT authorship through Respiratory Care may provide insight related to the direction of research in the profession and how the Journal has evolved to support RTs in research. This investigation aims to illustrate RT scholarly activity through Respiratory Care over 10 years.

Publications in Respiratory Care from 2011 and 2021 were included. Search queries were conducted through a tool provided on the Respiratory Care journal webpage and manuscript management system. Search results were verified by a second party for consistency. Papers were included in the analysis if the work had at least one RT author credentialed in the United States and were listed as an author regardless of the type of publication. Practitioner credentials were confirmed via the National Board of Respiratory Care’s credential verification tool. Descriptive statistics were used to express the frequency and percentage of RT authorship by type of publication and authorship status. Institutional Review Board (IRB) approval was not required for this investigation.

There were 242 and 264 published papers in 2011 and 2021, respectively. Of the 506 papers, there were 168 (33.2%) original research, 37 (7.3%) review, 14 (2.8%) clinical practice guideline (CPG), and 34 (6.7%) editorial papers with at least one RT author. In 2021, 159 (60.2%) papers had at least one RT author; 2011 had fewer papers with RT authorship (n = 115, 47.5%). Original research RT authorship increased from 2011 to 2021 (n = 49, 20.2%; n = 119, 45.1%). A greater number of review papers were published with an RT author in 2011 when compared to 2021 (n = 26, 10.7%; n = 11, 4.2%). There were fewer CPG publications with RT authorship in 2011 than 2021 (n = 4, 1.7%; n = 10, 3.8%). RT authorship in editorials decreased from 2011 to 2021 (n = 19, 7.9%; n = 15, 5.7%). For original research publications, first authorship, co-authorship, and senior co-authorship increased from 2011 to 2021. This change was the greatest in the co-authorship domain between 2011 to 2021 with an 84.6% increase in RT authorship.

A global increase in RT authorship is noted in Respiratory Care between 2011 and 2021. There is a distinct shift in RT authorship in original research in Respiratory Care from 2011 to 2021. This relationship requires further investigation to illustrate a clear trend related to RT authorship in Respiratory Care.

Unplanned extubation (UE), defined as unexpected dislodgement, accidental or patient-induced, of an ETT, is a significant patient safety concern, including risk of aspiration, O₂ desaturation, and cardiopulmonary decompensation. In 2016, UE rates exceeded the Solutions for Patient Safety (SPS) national benchmark of 0.68 and 1.48 events per 100-patient-ventilator-days (PVD), respectively, in our PICU and NICU.

Preventative strategy bundles were developed through PDSA cycles to decrease UE including standardized anatomical reference points; ETT securement methods; airway care practices; extubation readiness; and analysis of each UE. Staff received education on key interventions through electronic learning modules, skills labs, and education at the bedside. New product trials led to adopting a standardized taping method and securement devices for all ETTs ≥ 5.0 mm ID. Protective airway practices include visualization of ETT placement and securement at each hand-off. Two licensed practitioners are required during patient movement; one dedicated to hold the ETT. Ventilated patients are assessed each shift for extubation readiness. If criteria met, a spontaneous breathing trial is conducted. Results are discussed and documented during hand-off and daily rounds. A multidisciplinary apparent cause analysis form was developed and utilized for every UE, followed by a bedside huddle, where the team identifies contributing factors, morbidities, and processes and interventions to promote patient safety.

Both ICUs continue to demonstrate improvements over time compared to our baseline UE rate and the SPS benchmark. In the NICU, UE rates were significantly better than the 2016 baseline every year after 2018 (P < .001), to a low of 0.52 (95% confidence interval 0.31-0.87) in 2021. In PICU, progressive improvement occurred over time with UE rates dropping to 0.10 (95% confidence interval 0.03-0.38) by 2020, statistically significantly better than our 2016 baseline (P = .02) and the 2020 SPS benchmark (P = .03). No UE serious harm events have occurred in the last 29 consecutive months.

Interdisciplinary collaboration significantly reduced our UE rates and serious patient harm by developing a culture of safety around artificial airway protection using an evidence-based airway protection bundle, standardized ETT securement practices and extubation readiness evaluation aided in UE reduction rates. Intervention compliance monitored through data collection monthly.

Past studies have supported the superiority of flow triggering during mechanical ventilation. Pneumotachometers that are placed proximally to the patient have shown to provide more accurate measurements for the changes in volume, airway pressure, and gas flow. Therefore, a ventilator system such as the Hamilton G5 with an external flow sensor that is proximal to the patient will be more sensitive in responding to a patient's efforts.

The ASL 5000 high fidelity lung simulator (IngMar Medical) was used to simulate a breathing pattern on the Hamilton and Avea ventilator systems. Both ventilators were set with the same ventilator settings, which included a flow trigger setting of 2.5 L/min and a bias flow of 5 L/min. The same ventilator circuit and flow sensor (Hamilton G5) was used in all of the trials. The same lung characteristics on the ASL 5000 were used in all of the trials. The ASL 5000 was run for 10 breaths on three different Hamilton G5 and Avea ventilators. The average time-to-trigger was calculated for each of the six trials using the ASL software.

The average time-to-trigger in the Hamilton ventilators was 162.4 ms compared to 216 ms in the Avea ventilators. However, there was a wide, unexpected variance in samples within each device. Within the Avea ventilators the analysis of variance shows an F Ratio of 499.9 (P < .001). In the interval plot, AVEA ventilator #1 had the fastest time to trigger response, and the least amount of variance. The AVEA ventilators #2 and #3 had a slower time to trigger response but had a wide variance in values. The Hamilton G5 ventilators #1 and #3 were significantly quicker to respond to triggers than Hamilton ventilator #2, but there was a significant variance between the three devices. A 2-sample t-test shows that the data is significant.

The test runs show that there is a significant variance between the time-to-trigger within both devices. However, 2 of the 3 Hamilton ventilators demonstrated a faster time-to-trigger response than the Avea ventilators with the same flow trigger setting and bias flow. Further research is needed to address the wide variation in values in both devices. For example, the Hamilton G5 ventilators that were used had over 1,000 hours of usage and had not been serviced or calibrated. Only one flow trigger and bias flow setting was used during testing. Adjusting the bias flow and flow trigger could have significant effects on how quickly the ventilator will respond to the ASL 5000.

SARS-CoV-2, a novel coronavirus from the same family as SARS-CoV and Middle East Respiratory Syndrome coronavirus, has overrun worldwide leading the World Health Organization to declare a pandemic. The aim of study was to clarify high-risk factors for COVID-19 with multivariate analysis and establish a predictive model of disease progression to help clinicians better choose a therapeutic strategy. With the latest in technology and research, and further studies into the pathogenesis Evaluate, clinical implications, identification, diagnosis, and treatment of COVID-19 will push society past this pandemic.

A comprehensive search of PubMed, MEDLINE, UptoDate, Natural MEDLINE, Embase, and Web of Science electronic databases was made, using the following search terms: COVID-19，COVID-19 SCORE，COVID-19 diagnosis，COVID-19 management, coronavirus, and SARS-CoV-2 as keywords for our search. We included scientific publications from December 1, 2019 to April 30, 2021 which focused on clinical characteristics of and treatments for SARS-CoV-2 were eligible for inclusion. We screened all reference lists of relevant studies in order to identify any missing publications.

A total of 31 articles. We found that the main symptoms of COVID-19 are fever, cough, fatigue, dyspnea, sore throat, headache, diarrhea, and gastrointestinal issues. Realtime PCR is used as a diagnostic tool using nasal swab, tracheal aspirate or bronchoalveolar lavage samples. Computed tomography findings are important for both diagnosis and follow-up. To date, there is no evidence of any effective treatment for COVID-19.

Prognosis scores routinely using the COVID score model, this guideline is not to replace clinical professional judgment or expert advice. Even in countries with adequate levels of vaccination, the epidemic could recur if indoor ventilation is not properly addressed. Governments should acknowledge scientific evidence and take steps to develop official regulations and guidelines for indoor space ventilation to reduce the spread of COVID-19.

Symptoms observed in various cohorts of patient

Aerosol and airway clearance are simultaneously delivered with intrapulmonary percussive ventilation (Percussionaire, IPV). The device can be used during mechanical ventilation with an in-line adapter with adjustable pressure relief port that remains in the ventilator circuit, reducing the need for disconnection. Previous evaluations of in-line albuterol via IPV using a cone adapter reported low aerosol delivery. We hypothesized that opening the adapter will decrease aerosol delivery.

The aim was to evaluate albuterol delivery via IPV using an in-line adjustable adapter during invasive mechanical ventilation with a pediatric lung model. A ventilator (Maquet, Servo-i) was connected in series to a dual limb circuit, 5.5 pediatric endotracheal tube with cuff inflated, filter (lung dose), and test lung set as ARDS (resistance Rp20, compliance 10 mL/mbar) or normal (Rp20, 30 mL/mbar). The adapter was placed in the inspiratory limb of the circuit at the wye. Pressure control ventilation was set to obtain V_T 100 with RR 20, PEEP 10, and I-time 0.8. Variables were IPV pressure (25 or 40), percussion (easy or hard), and adapter opening (closed, 25% or 50% open). Three different IPV nebulizers were loaded with albuterol 7.5 mg/9 mL and operated 15 min. Albuterol mass was measured via spectrophotometer and reported as percentage of loading dose. Bivariate analysis was performed to evaluate the different variables. Non-parametric tests Kruskal-Wallis (adapter opening) and Mann Whitney (IPV settings) were used.

Aerosol delivery ranged between 0.3 and 1.2% of the loading dose. The adapter setting had a significant effect on aerosol deposition in the ARDS model (P = .006). Opening the adapter 50% reduced aerosol delivery in both lung models but more on ARDS (P = .02). No statistical differences were found between pressures or percussion settings. This could be due in part to large variance of the measurements.

In a pediatric model of mechanical ventilation, IPV with an in-line adapter results in very low deposition of albuterol. Opening the IPV adapter results in decreased lung deposition in an ARDS model. IPV settings (pressure and percussion) do not seem to affect lung deposition.

A common concern with using masks to provide supplemental oxygen is claustrophobia experienced by the patient. The mask covers the nose and mouth limiting oral intake and speaking. An open concept mask (OCM) has been developed which has been suggested to address this issue while still maintaining sufficient delivered oxygen concentrations (FDO₂).

Four types of oxygen masks were evaluated, a simple mask, the OCM, a Venturi mask, and a non-rebreather (NRB). Each mask was mounted onto a piece of card stock with the sides of the masks sealed to the card stock. Each mask was connected to an oxygen flowmeter set at one of four flows (3, 6, 8, and 15 L/min). In addition, to simulate flow demand, tubing connected to suction was inserted into the volume of the mask with flows of -2, -4, -6, and -8 L/min. FDO₂ was determined by inserting an oxygen analyzer through a port cut into the card stock. FDO₂ was recorded once the measurement stabilized. Data was analyzed using ANOVA with P < .05 as significance.

Overall mean FDO₂ for the OCM was 0.66 ± 0.11 and 0.64 ± 0.10 for the simple mask, P < 0.01. The demand flow had no effect on FDO₂ between the simple mask and the OCM P = .46. When compared to the NRB, mean FDO₂ 0.78 ± 0.17, P < .01

The OCM has similar function to the standard simple mask. When compared with the NRB, the FDO₂ was higher for the NRB, but less affected with increases in demand flow. The difference between the simple mask and the OCM is unlikely to be clinically significant. The non-rebreather and Venturi mask were able to supply consistent FDO₂ regardless of the draw flow or the mask flow. Further investigation of this mask should be considered.

Smoking is a public health threat and a leading cause of premature death. Eight million individuals die around the world yearly. In order to minimize tobacco consumption, tobacco control programs established to change behaviors. The aim of these programs is to protect non- smokers in society and reduce prevalence. The initiatives are done by the country such as plain packaging, taxation, health messaging, and pictorial warning are important measures. All of these initiatives are expected to help smokers quit; however, there are lack of studies to support this assumption in the country.

A cross-sectional study collected a sample of 793 adult Saudi smokers and former smokers. A self-administrated questionnaire was used to determine the effects of tobacco control initiatives on smokers in Saudi Arabia.

After applying the new form of plain packaging, 15.6% of participants felt they were smoking the usual tobacco yet 29.8% completely disagreed. Moreover, 43% of the participants did not fully agree that the quality of tobacco is good but 7.1% completely agreed. In addition, 35.7% of participants were aware of the dangers of tobacco due to the effectiveness of health warnings yet 16.3% completely disagreed. On the other hand, regarding the price of pack, 66.4% found the pack expensive/very expensive yet 5.8% found it cheap/very cheap. In addition, 29.5% did not have intentions to quit smoking due to increasing of the price of pack yet 29.1% had no intention to quit smoking.

The effects of tobacco control initiatives on the smoking behavior of Saudi smokers were effective in reducing tobacco consumption. The most effective approach in reducing tobacco consumption and increased the smokers’ intent to quit smoking was taxation. In addition, plain packaging which has been effective worldwide, turned out to be also effective approach in Saudi Arabia. In our opinion, in the near future we can reduce the number of cigarettes in a pack as an approach to tobacco control.

Heated tobacco products (HTPs) were promoted as an alternative and less harmful method of nicotine delivery. Harm reduction of tobacco refers to moving to a less toxic nicotine product for those who are unable to avoid using nicotine or smoking. Therefore, our study purpose is to assess the susceptibility of smokers to switch from smoking cigarettes to heated tobacco products based on the theory of harm reduction. The future goal is to inform prevention and treatment programs of tobacco use about the new emerging products – HTPs.

This cross-sectional descriptive study collected a sample of 558 adult cigarette smokers. A self-administered questionnaire was used to examine several variables, including descriptive, smoking behavior, Fagerstrom Test for Nicotine Dependence (FTND), and harm reduction questionnaire. Using Rao software, and we estimated that we will collect approximately 377 with a margin of error 5% and 95% confidence level. Data analysis using SPSS was used to answer the research question.

A total of 558 smokers completed the questionnaire. The overall percentage of the smokers that are willing to quit smoking, but continue to use nicotine, by switching to HTPs for the sample was 41.6%. Based on the harm reduction theory the percentage of the participants that would consider switching to a new product with reduced health risk by 50% or 99% were 74.2% and 83.1%, respectively.

HTP prevalence and the susceptibility of smokers to switch from smoking tobacco products to HTPs based on the theory of harm reduction among adult Saudi smokers were identified. Although future studies are required to address the same research problem in a different Arab country to assess the prevalence of HTPs among Arab countries.

Fugitive aerosols from nebulizers are a great concern for health care workers as they administer aerosol therapy in a close distance, as well as for patients in a shared hospital room during the COVID pandemic. With a distressed respiratory pattern, patients tend to breathe forcefully which might distribute fugitive aerosol to a further distance. We aimed to evaluate the concentrations of fugitive aerosol with normal and distressed breath patterns with different interface at various distances.

A breath simulator (Michigan Instrument) was connected to an adult intubation mannequin with a normal breath pattern (V_T 500 mL, rate 15 breath/min, and inspiratory time to inspiration time (I/E) 1:3) and a distressed breath pattern (V_T 500 mL, rate 30 breath/min, and I/E 1:1). A jet nebulizer filled with a united-dose salbutamol (5 mg/2.5 mL, GSK Inc.) and powered by compressed gas at 8 L/min was connected to three commercially available face masks: an aerosol mask with open side-holes, aerosol masks with the closed feature of a non-rebreathing mask, and an AerosoLess mask. Fugitive aerosol was measured by an aerodynamic particle sizer (GRIMM Corp) with measurement ranged 0.225 - 34 µm for aerosol concentrations, and the sizer was placed at 0.8 m (where a care provider stands), 1.8 m (the end of a bed), and 2.2 (distance between two hospital beds) from the face of the mannequin. Aerosol particle counts were sampled for a total of 30 min, including 5 min for baseline detection, 6 min for nebulization, and 19 min for the aerosol count returned to baseline. Experiments were repeated five times.

The figure below illustrates the aerosol concentrations with particle sizes of 2.5 µm and 1.0 µm with three masks at different distances. The aerosol concentrations during normal and distress breathing patterns were different at the three distances. Use of a standard aerosol mask with side-holes at a close distance under distressed breathing pattern yielded a 4-fold greater aerosol concentration at 0.8 m and 2-fold greater at 2.2 m.

Breath patterns and mask features influence fugitive aerosol concentration during nebulization. The masks with closed features can eliminate fugitive aerosol at any distance.

Comparisons of aerosol concentrations with particle size of 2.5 µm with three masks at different distances.

Comparisons of aerosol concentrations with particle size of 1.0 µm with three masks at different distances.

Aerosol delivery via high-flow nasal cannula (HFNC) has gained popularity, due to the nasal interface's comfort and continuous trans-nasal pulmonary delivery of aerosolized medication. Various HFNC devices are available in the US, however, the aerosol delivery with different HFNC devices remains unclear. Thus, this study aimed to investigate the impact of different devices on trans-nasal aerosol delivery.

A two-chamber model lung was connected to one chamber of an adult manikin with anatomically correct upper airway proportions, while the other chamber was connected to a critical care ventilator to simulate spontaneous breathing. A large-size nasal cannula was placed at the nasal prongs of the manikin, four HFNC devices (Vapotherm, Respironics V60, Hamilton C-1, Airvo2) with four flow settings were compared, with a vibrating mesh nebulizer (Solo, Aerogen) placed at the humidifier. 3 mL of albuterol (2.5mg/3mL) was used in each run (n = 5). The collection filter was placed between the manikin and the model lung. The drug was eluted from the filter and assayed with UV spectrophotometry (276 nm). Statistical test used was Kruskal Wallis.

Among the four HFNC devices, the Hamilton C1 delivered the highest inhaled dose, regardless of the flow settings. At low flow settings (10-20 L/min), the inhaled dose between Hamilton C1 and Airvo2 were comparable, while at high flow settings (40-60 L/min), inhaled dose with Hamilton C1 was 2-3 times of Airvo2 and V60. Aerosol delivery with Vapotherm was negligible (1-2.5%). In all devices, the inhaled dose decreases as the flow increases.

Hamilton C1 and Airvo2 had similar inhaled doses with flow at 10-20 L/min, Hamilton C1 generated 2-3 times higher inhaled dose than Airvo2 and V60 with flow at 40-60 L/min, and aerosol delivery via Vapotherm should be avoided.

Figure 1. experiment set-up

Mechanical ventilation (MV) is a life-saving intervention in critically ill patients. MV has side effects such as ventilator-induced diaphragm dysfunction (VIDD), with 80% prevalence in critically ill patients.¹ VIDD results in longer ICU and hospital length of stay.² Diaphragmatic training by repetitive noninvasive bilateral electromagnetic phrenic nerve stimulation could prevent or ameliorate VIDD.³ We have demonstrated that magnetic stimulation technology can be safely used in an ICU setting.⁴ We hypothesized that noninvasive stimulation of the phrenic nerves is feasible in anesthetized obese patients and results in a diaphragm contraction generating adequate tidal volume. The primary endpoint was the mean tidal volumes of at least 10 stimulations with the same intensity.

This single center, proof-of-concept study was performed in five ASA I/II obese patients scheduled for elective surgery with general anesthesia and planned intubation after IRB approval and informed consent of each patient. After RSI induction anesthesia and intubation, patients received noninvasive electromagnetic stimulation of the phrenic nerves, while the mechanical ventilator was set on spontaneous breathing mode. For the stimulation, the STIMIT-exclusive PMR35 dual coils in combination with a standard clinical magnetic stimulator were used bilaterally with different stimulation intensities (30%, 40%, 50%).

Patients were 34 [IQR 24-41] years old, 80% (n = 4) females, with a BMI of 42.7 [IQR 38.0-46.6] undergoing elective surgery. The mean tidal volume was 0.00 ± 0.00 mL/kg ideal body weight (IBW), 1.97 ± 1.02 mL/kg IBW and 3.73 ± 0.45 mL/kg IBW for 30%, 40% and 50% stimulation intensity, respectively (Figure 1). There was a linear relationship between dosage (stimulation intensity) and effect (tidal volume) (P < .001; r² = 0.87). The stimulation intensity to induce 3-6 mL/kg IBW was 50% intensity in most cases (Figure 2).

Noninvasive bilateral phrenic nerve stimulation can effectively generate diaphragm contraction. A stimulation intensity of 50% generated diaphragm contraction induced tidal volumes of 3-6 mL/kg IBW in pulmonary healthy, obese anesthetized patients. Whether this non-invasive technique can prevent or attenuate VIDD should be assessed in critically ill patients. References: 1. Jung B, et al. ICM. 2016; 42: 853-861. 2. Goligher EC, et al. Am J Respir Crit Care Med 2018;197:204-213. 3. Reardon PM, et al. Curr Opin Crit Care 2021;27:282-289. 4. Kuhn KF, et al. SciRep 2021;11:16317.

Figure 1 – Tidal volume generated by bilateral non-invasive electromagnetic phrenic nerve stimulation in ml per ideal body weight with different intensities (30%, 40%, 50%) of the magnetic stimulator in anesthetized obese patients. Linear correlation with 95% CI (p < 0.0001; r² = 0,87).

Figure 2 – Averaged pressure, flow, volume curves for all patients, during stimulated breaths with 40% and 50% intensities with 95% confidence interval. At 30% intensity no tidal volumes were generated. Each graph includes 10 stimulations per patient.

During aerosol delivery via high-flow nasal cannula (HFNC), our previous in vitro study reported a higher inhaled dose with inspiration-synchronized vibrating mesh nebulizer (VMN) than continuous VMN. Recently, a prototype of VMN that generated aerosol particles < 3mm was reported to improve aerosol delivery during invasive ventilation in a porcine model, compared to the commercially available VMN (Solo, Aerogen). Its use during HFNC remains unknown.

An adult manikin was connected to a dual-chamber model lung, which was driven by a ventilator to simulate spontaneous breathing (V_T of 470 mL, RR 21 breaths/min, and Ti of 1.2 s) (Figure 1). An HFNC system was utilized with the temperature at 37°C with gas flows at 15, 30, and 60 L/min. Inspiration synchronized and continuous VMNs were compared at different positions (the inlet of the humidifier vs close to the nasal cannula), and small-particle VMN was compared to the commercially available VMN. 1 mL of albuterol (2.5 mg/mL) was used in each run (n = 5). The collecting filter was placed at the trachea and was removed after each run. The drug was eluted from the filter and assayed with UV spectrophotometry (276 nm).

When small-particle VMN was placed close to nasal cannula, inspiration synchronized VMN had a greater inhaled dose than continuous VMN, regardless of HFNC flows (all P < .05) (Table 1). When small-particle VMN was placed at the inlet of the humidifier, continuous VMN had a higher inhaled dose than inspiration synchronized VMN at HFNC flows of 30 and 60 L/min but not 15 L/min. Compared to inspiration synchronized VMN Solo, small-particle VMN had a greater inhaled dose at HFNC flows of 15 and 30 L/min, regardless of the nebulizer placements. The inhaled dose was higher with inspiration synchronized VMN placed close to the nasal cannula than at the inlet of the humidifier, while it was higher with continuous VMN placed at the inlet of the humidifier than close to the nasal cannula.

During trans-nasal aerosol delivery, inspiration synchronized VMN delivered a greater inhaled dose than continuous VMN, and it should be placed close to the nasal cannula. The prototype of VMN that generated smaller aerosol particles could further improve aerosol delivery via HFNC.

Frequent flyer hospital visits account for a disproportionately large share of overall visits and costs. A 2011-2012 Intermountain Healthcare study investigated factors driving high hospitalization rates of COPD frequent flyers. We repeated this study on new subjects for 2019-2021 to detect changes in demographics, treatment, comorbidities, and non-compliance. Following the original study, initiatives were implemented to improve COPD patient care. Additionally, in 2017, the Pulmonary Disease Navigator (PDN) scope was expanded to include COPD.

For 2019, 2020, and 2021, we extracted adult subjects assigned a COPD exacerbation diagnosis associated with ≥ 5 visits (ER or admission) per year at all Intermountain hospitals. We performed retrospective electronic medical record reviews on these subjects, including all variables from the original study. To assess differences between cohorts in age, ages were grouped into 30-60 and >60 due to limited data, then compared with a chi-square test. For cohort differences in comorbidities, each variable was compared with a z-test. Pearson correlation was used to identify relationships between comorbidities in the 2020-2021 cohort.

We identified 33 subjects with ≥ 5 visits per year during 2020-2021. There was a significant difference between cohorts in proportions of cardiac, chronic pain, anxiety and/or depression, and OSA comorbidities. For the 2020-2021 cohort, OSA and diabetes were significantly positively correlated (P = .05). 61% of the 33 subjects are followed by a PDN. Other results are reported in accompanying abstracts.

Compared to the previous cohort, a larger proportion of subjects in the current cohort have cardiac, chronic pain, anxiety and/or depression, and OSA comorbidities. At the same time, we extracted fewer subjects, which may conclude that COPD patient care has improved, and remaining frequent flyers have more complex health conditions. The current cohort may also have a smaller proportion of young subjects and larger proportion of old subjects, contributing to comorbidities. Possibly influenced by a rising national BMI, OSA is the most significant change and will be addressed by the OSA navigator role being developed. This study was limited by a small sample size and no access to the original dataset. We conclude a reduction in COPD frequent flyers and that these subjects have increased comorbidities, possibly due to a concentration of medically complex subjects and a possible shift toward older age.

Frequent flyer hospital visits account for a disproportionately large share of overall visits and costs. A 2011-2012 Intermountain Healthcare study investigated factors driving high hospitalization rates of asthma frequent flyers. We repeated this study on new subjects for 2019-2021 to detect changes in demographics, treatment, comorbidities, and non-compliance. No initiatives were implemented following the original study, except for the Pulmonary Disease Navigator (PDN) scope being expanded in 2019 to include asthma.

For 2019, 2020, and 2021, we extracted adult subjects assigned an asthma exacerbation diagnosis associated with ≥ 4 visits (ER or admission) per year at all Intermountain hospitals. We performed retrospective electronic medical record reviews on these subjects, including all variables from the original study. Chi-square analysis was used to assess differences between cohorts in age and access to healthcare. For cohort differences in comorbidities, each variable was compared with a z-test. We collected an additional year of data for insight prior to the COVID-19 pandemic. We excluded pediatric subjects as the original study found that outcomes were better than for adults.

We identified 112 subjects with ≥ 4 visits per year during 2019-2021. There was a significant difference between cohorts in proportions of obesity and access to healthcare. 12% of the subjects in the current cohort are followed by a PDN. For 2019-2021, we noted a downward trend in admissions, ER visits, and 30-day readmissions per year. Other results are reported in accompanying abstracts.

Compared to the original cohort, a larger proportion of subjects in the current cohort is obese, aligning with increased national BMI over the past decade. There is also an increased proportion of subjects with Medicaid and decreased self-pay, likely due to the Affordable Care Act. As a result, subjects may be more likely to seek and receive care. The minimal change in the remaining comorbidities, age, and variables in accompanying abstracts suggests that asthma frequent flyer management has made little progress since the original study, possibly due to a lack of initiatives implemented and minimal subjects being followed by a PDN. This study was limited by having no access to the original dataset. We conclude that there has been an increase in obesity, and, due to no clear adjustments in the management of asthma frequent flyers, we recommend increased utilization of PDNs.

Frequent flyer hospital visits account for a disproportionately large share of overall visits and costs. A 2011-2012 Intermountain Healthcare study investigated factors driving high hospitalization rates of asthma frequent flyers. We repeated this study on new subjects for 2019-2021 to detect changes in demographics, treatment, comorbidities, and non-compliance. No initiatives were implemented following the original study, except for the Pulmonary Disease Navigator (PDN) scope being expanded in 2019 to include asthma.

For 2019, 2020, and 2021, we extracted adult subjects assigned an asthma exacerbation diagnosis associated with ≥ 4 visits (ER or admission) per year at all Intermountain hospitals. We performed retrospective electronic medical record reviews on these subjects, including all variables from the original study. To assess differences between cohorts in non-compliance issues, each variable was compared with a z-test. We collected an additional year of data for insight prior to COVID-19. We excluded pediatric subjects as the original study found that outcomes were better than for adults.

We identified 112 subjects with ≥ 4 visits per year during 2019-2021. There was a significant difference between cohorts in proportions of medication non-compliance. For the 2019-2021 cohort, 12% of the subjects were followed by a PDN, and 39% had both behavioral health issues and medication non-compliance. For 2019-2021, we noted a downward trend in admissions, ER visits, and 30-day readmissions per year. Other results are reported in accompanying abstracts.

Compared to the previous cohort, a smaller proportion of subjects in the current cohort have at least one non-compliance issue. However, a greater proportion of the non-compliant subjects exhibited medication (and possibly clinic visit) non-compliance, potentially due to a lack of initiatives implemented after the original study. We believe PDN involvement has had little impact as few subjects are followed by a PDN, but perhaps this small amount contributes to the reduction in subjects with at least one issue. Clinic visits and total visit trends may have been influenced by the COVID-19 pandemic. This study was limited by having no access to the original dataset. We conclude that the number of asthma frequent flyers with non-compliance has decreased, but that the issues are magnified among those who are non-compliant. We recommend further involvement of PDNs to identify causes of and solutions to non-compliance.

Frequent flyer hospital visits account for a disproportionately large share of overall visits and costs. A 2011-2012 Intermountain Healthcare study investigated factors driving high hospitalization rates of asthma frequent flyers. We repeated this study on new subjects for 2019-2021 to detect changes in demographics, treatment, comorbidities, and non-compliance. No initiatives were implemented following the original study, except for the Pulmonary Disease Navigator (PDN) scope being expanded in 2019 to include asthma.

For 2019, 2020, and 2021, we extracted adult subjects assigned an asthma exacerbation diagnosis associated with ≥ 4 visits (ER or admission) per year at all Intermountain hospitals. We performed retrospective electronic medical record reviews on these subjects, including all variables from the original study. To assess differences between cohorts in PFTs and pulmonology consults, each variable was compared with a z-test. We collected an additional year of data for insight prior to the COVID-19 pandemic. We excluded pediatric subjects as the original study found that outcomes were better than for adults.

We identified 112 subjects with ≥ 4 visits per year during 2019-2021. No significant differences between cohorts were detected. For the 2019-2021 cohort, we found that 12% of subjects are followed by a PDN, and 75% of PFTs were ordered by a pulmonologist. For 2019-2021, we noted a downward trend in admissions, ER visits, and 30-day readmissions. Other results are reported in accompanying abstracts.

Compared to the original cohort, the proportion of subjects that received PFTs and pulmonology consults did not change significantly. There may have been a reduction in PFTs and an increase in consults, but further research would be required to verify this. This lack of change aligns with few subjects in the current cohort being followed by a PDN. Additionally, results in accompanying abstracts demonstrate that although some variables have shifted, the 2019-2021 asthma frequent flyers are considerably similar compared to the original cohort, suggesting that educating and treating these patients has made little to no progress since the original study. Reduction in total visits per year and the possible reduction in PFTs may be attributed to COVID-19. This study was limited by having no access to the original dataset. Due to a plausible lack of progress, we advocate increased involvement of PDNs in the management of frequent flyer asthma patients.

During nebulization via aerosol face mask, our previous in vivo study found fugitive aerosol concentrations could be reduced by using a face tent scavenger or a filter face mask. However, concerns were raised regarding the influence of these mitigations on aerosol delivery. This in vitro study was aimed to evaluate aerosol delivery efficiency with the use of scavenger and filter face mask during nebulization treatments.

An adult manikin connected to a dual-chamber model lung, driven by a ventilator to simulate spontaneous breathing of V_T of 470 mL, RR 21 breaths/min, and Ti of 1.2 s, with a collecting filter placed between the manikin’s trachea and the model lung. Albuterol (2.5mg in 3 mL) was administered via vibrating mesh nebulizer (VMN) and small volume jet nebulizer (SVN) with an aerosol face mask (n = 5). A face tent scavenger connected to negative pressure (-100 mm Hg), filter face mask, and standard face mask were compared, with tight and loose connection (fit to model) compared with VMN. After each run, the collecting filter was removed, with drug eluted and assayed with UV spectrophotometry (276 nm)

Inhaled dose was similar with and without scavenger, regardless of the nebulizer type (Table 1). The inhaled dose was also similar with standard and filter aerosol face mask for both VMN and SVN (Table 2). In contrast, a loose connection (fit) of the face mask significantly reduced inhaled dose, regardless of mask type (all P < .05).

Mitigation devices (scavengers and filter masks) did not affect aerosol delivery during nebulization treatments. Facemask needs to be tightly connected to the subject’s face.

Aerosol delivery may be enhanced by utilizing an inspiration-synchronized nebulization mode, in which nebulization occurs only during inspiration. This study aimed to compare aerosol delivery of albuterol via a prototype of an inspiration-synchronized vibrating mesh nebulizer (VMN) with continuous VMN during invasive mechanical ventilation.

A critical care ventilator with a heated ventilator circuit was utilized to deliver parameters of V_T 420 mL, RR 16 breaths/min, PEEP 8 cm H₂O, Ti 1 s, and bias flow 3.5 L/min, with humidifier temperature set at 37°C (Figure 1). The nebulizer was placed at different positions in the ventilator circuit (inlet of the humidifier vs inspiratory limb at y-piece vs between the y-piece and endotracheal tube [ETT, size 8.0 mm]). Two aerosol generation modes (inspiration-synchronized vs continuous) were compared, and a prototype VMN that generated aerosol particles < 3 µm was compared to a > 4 µm commercially available VMN (Solo, Aerogen). 1 mL of albuterol (2.5mg/mL) was used in each run (n = 5). The collection filter was placed between ETT and the model lung and removed after each run. The drug was eluted from the filter and assayed with UV spectrophotometry (276 nm).

When the VMN (Solo) was utilized, the inhaled dose was greater with inspiration-synchronized than continuous VMN, regardless of the nebulizer positions (at the inlet of the humidifier: 46.6 ± 1.9 vs 21.8 ± 2.3 %, P < .001; in the inspiratory limb close to the y-piece: 49.6 ± 2.3 vs 13.7 ± 1.7 %, P < .001; between the y-piece and ETT: 49.4 ± 1.6 vs 14.8 ± 1.9 %, P < .001) (Table 1). Regardless of the nebulizer placement and the aerosol generation mode, the new prototype of VMN (small particle) had a greater inhaled dose than VMN (Solo) (all P < .05). The inhaled dose was greater with the inspiration-synchronized VMN placed close to the endotracheal tube (all P < .001), while with continuous VMN, the inhaled dose was greater with VMN placed close to the humidifier (all P < .001).

Inspiration-synchronized VMN generated 2-3 times greater inhaled dose than continuous VMN, regardless of nebulizer placement. The prototype of VMN that generated smaller particle aerosols had a greater inhaled dose than VMN (Solo), regardless of nebulizer placement and aerosol generation modes. To achieve the greatest inhaled dose with bias flow, the inspiration-synchronized VMN should be placed close to ETT and continuous VMN should be placed at the inlet of the humidifier.

Figure 1. Experiment Set-Up. A PB980 ventilator with a heated circuit was utilized to deliver parameters of V_T 420 mL, RR 16 bpm, PEEP 8 cm H₂O, Ti 1 sec, and bias flow 3.5 L/min, with humidifier temperature set at 37 °C. The vibrating mesh nebulizer (VMN) was placed at different locations in the ventilator circuit (inlet of humidifier, inspiratory limb at y-piece, and between y-piece and endotracheal tube [ETT, 8.0 mm]). The collection filter was placed between the ETT and model lung.

Aerosol delivery may be improved during noninvasive ventilation (NIV) with an inspiration-synchronized nebulizer by reducing the medication lost during exhalation. This study aimed to compare aerosol delivery via a prototype of an inspiration-synchronized vibrating mesh nebulizer (VMN) with continuous VMN during NIV with a single limb circuit.

An adult manikin was connected to a dual-chamber model lung that was driven by a critical care ventilator to simulate spontaneous breathing (Figure 1). An NIV ventilator (V60, Respironics) was connected to the manikin with a single limb circuit and with settings of 12/5 cm H₂O. The nebulizer was compared at two positions in the circuit (inlet of humidifier vs between mask and exhalation valve) with mask leak of 35 – 40 L/min and without mask leak. Two aerosol generation modes (inspiration-synchronized vs continuous) of VMN were compared, and a prototype VMN that generated aerosol particles < 3 µm was compared to a > 4 µm commercially available VMN (Solo, Aerogen). 1 mL of albuterol (2.5mg/mL) was used in each run (n = 5). The collection filter was placed between the manikin and the model lung. The drug was eluted from the filter and assayed with UV spectrophotometry (276 nm).

The inhaled dose was greater with inspiration-synchronized than continuous aerosol generation, regardless of the nebulizer type, placement, and leak conditions (Table 1). When the nebulizer was placed between the mask and the exhalation valve, the inhaled dose was higher than that with the nebulizer placed at the inlet of the humidifier, regardless of the nebulizer type, aerosol generation modes, and leak conditions. The prototype VMN (small particle) had a greater inhaled dose than VMN (Solo) only when inspiration-synchronized nebulizer was placed between the mask and exhalation valve with a leak (18.05 ± 0 .75 vs 13.63 ± 0.45%, P = .008) and when continuous VMN was placed at the inlet of the humidifier with no leak (7.28 ± 0.29 vs 5.43 ± 1.04%, P = .009).

During aerosol delivery via NIV with a single limb circuit using a VMN, the inhaled dose was greater with inspiration-synchronized VMN than continuous VMN with nebulizer placed between the mask and exhalation valve, regardless of nebulizer types and leak conditions. At that position, smaller particles improved inhaled dose during leak.

Figure 1. Experiment Set-Up. An NIV ventilator was connected to the manikin with a single limb circuit and parameters were set to deliver 12/5 cm H₂O. The manikin was connected to a dual-chamber lung model that was driven by a critical care ventilator to simulate spontaneous breathing. The vibrating mesh nebulizer (VMN) was compared at two positions in the circuit (inlet of humidifier vs between mask and exhalation valve) with mask leak of 35 – 40 L/min and without mask leak.

The COVID pandemic not only stressed the healthcare system, it also compromised all forms of medical education. Our department provides the bulk of our care in the ICU. All respiratory therapists (RTs) need to be proficient critical care providers. Our department recruits newly graduated RTs. As pandemic restrictions provided far less clinical instruction, we noticed new graduates were less prepared and less clinically exposed. We realized our prior orientation would be woefully inadequate to address this – therefore, we chose to enhance simulation-based learning (SBL).

Our hospital has a fully equipped simulation center. With ten RTs who have been trained as simulation educators, we chose to enhance SBL. We segregated sessions into 3 categories: equipment, procedures, and clinical management. The equipment session entailed one-on-one training before the orientee managed the equipment in the hospital. The procedure session entailed one-on-one training to specific procedures (eg, mini-BALS.) Clinical management scenarios replicated high risk – low volume events that required advanced critical thinking (eg, airway emergencies). Each session was conducted by RT simulation instructors. The continuity of instructors and consistency of educational objectives was greatly enhanced. SBL time expanded from 8 hours to 40 hours.

We surveyed existing RTs and new orientees as to the effectiveness of expanded SBL. All indicators showed improvement. Whenever we surveyed new orientees with expanded SBL, 75% felt SBL prepared them considerably. When asked if the amount of SBL should be changed, 46% felt SBL should be increased. No one felt SBL time should be decreased. Whenever we surveyed RT staff employed prior to enhanced SBL, 63% felt new employees’ skills and ventilator management improved considerably over employees without enhanced SBL. Whenever asked if they had seen an improvement in the way new employees managed emergencies, 56% saw significant improvement.

Based upon results, an overwhelming majority felt expanded SBL proved beneficial. SBL consisted of highly trained instructors in a controlled and safe learning environment and repetitive practice. This proved far superior to random preceptors who rely upon chance opportunities to gain clinical practice for the orientee. Our traditional method of orientation exceeded $20,000 over a span of 14 weeks. Our future intention is to calculate the cost benefit of enhanced SBL orientation to traditional orientation.

Aerosol delivery may be improved during noninvasive ventilation (NIV) with an inspiration-synchronized nebulizer by reducing the amount of medication lost during exhalation. This study aimed to compare aerosol delivery via a prototype of an inspiration-synchronized vibrating mesh nebulizer (VMN) during NIV with a dual limb circuit.

An adult manikin was connected to a dual-chamber model lung that was driven by a ventilator to simulate spontaneous breathing (Figure 1). A ventilator (PB980, Medtronic) with a dual limb circuit was connected to the manikin via a full face mask, and NIV mode was used with △ pressure of 7 cm H₂O and PEEP of 5 cm H₂O. The nebulizer was compared at two positions (inlet of humidifier vs between mask and y-piece) with and without mask leak of 35–40 L/min. Two aerosol generation modes (inspiration-synchronized vs continuous) were compared, and a prototype VMN that generated aerosol particles < 3 µm was compared to a > 4 µm commercially available VMN (Solo, Aerogen). 1 mL of albuterol (2.5mg/mL) was used in each run (n = 5). The collection filter was placed between the manikin and the model lung and removed after each run. The drug was eluted from the filter and assayed with UV spectrophotometry (276 nm).

When inspiration-synchronized VMN was used, inhaled dose was greater with the nebulizer placed between the mask and y-piece than placed at the inlet of humidifier, regardless of nebulizer types and leak conditions (Table 1). However, no significant differences were found between placements with continuous VMN. When the nebulizer was placed between the mask and y-piece, the inhaled dose was greater with inspiration-synchronized than continuous aerosol generation (all P < .05), regardless of nebulizer types and leak conditions. However, when the nebulizer was placed at the inlet of the humidifier, the inhaled dose was greater with continuous than inspiration-synchronized aerosol generation when a leak was present (all P < .05). Leak reduced the inhaled dose with inspiration-synchronized VMN, regardless of the nebulizer types or placements (all P < .05). However, leak improved the inhaled dose with continuous VMN, except when VMN Solo was placed at the inlet of the humidifier.

During NIV with a dual limb circuit, the optimal inhaled dose can be achieved with an inspiration-synchronized VMN placed between the mask and y-piece without mask leak. A prototype VMN that generated smaller aerosol particles can improve inhaled dose by 1/4 - 1/3.

Figure 1. Experiment Set-Up. A ventilator with a dual limb circuit was connected to the manikin via a full face mask. An NIV mode was used to deliver a delta pressure of 7 cm H₂O and PEEP of 5 cm H₂O. The manikin was connected to a dual-chamber lung model that was driven by a critical care ventilator to simulate spontaneous breathing. The vibrating mesh nebulizer (VMN) was compared at the inlet of humidifier vs between mask and exhalation valve with and without mask leak of 35 – 40 L/min.

It is estimated that 16.5 million patients worldwide per year undergo mechanical ventilation (MV) as a life-saving intervention in the ICU [1]. Nevertheless, MV leads to complications such as ventilator-induced diaphragm dysfunction (VIDD) [2-3]. Techniques preventing or attenuating VIDD through diaphragm stimulation and activation should be further investigated. We hypothesized that time from start of stimulation to onset of diaphragmatic contraction (latency) is independent from stimulation intensity using bilateral noninvasive phrenic nerve electromagnetic stimulation. Primary endpoint was time from start of electromagnetic stimulation to effective stimulated inspiration (defined as time point of negative peak pressure) in anesthetized patient.

To gather the data necessary, we performed bilateral noninvasive electromagnetic phrenic nerve stimulation on 5 ASA I/II obese patients scheduled for elective surgery with general anesthesia and RSI induction. The pulsed electromagnetic field (inter-pulse frequency 25 Hz) was applied at different intensities (30%, 40%, 50%) with 2 seconds duration without ramp. Ventilator setting was CPAP with PEEP according to transpulmonary pressure measurement during the stimulation period.

Based on all patients the mean time from stimulation to inspiration (negative peak pressure) was 250.0 ± 116.7 ms, 238.5 ± 123.2 ms and 243.5 ± 136.2 ms at 30%, 40% and 50% intensity, respectively (Figure 1). There was no linear relationship between stimulation intensity and contraction latency; the diaphragm contraction lag was independent of the stimulation intensity (P = 0.9745, r² = 0.0001075; Figure 2). The overall contraction lag (all intensities combined) was 242.5 ± 116.3 ms.

Time to inspiration after bilateral noninvasive stimulation of the phrenic nerve was independent of the used stimulation intensities (30%, 40%, 50%). Stimulation intensity does not seem to need to be adjusted to ensure adequate conduction time but can be adjusted according to other necessary parameters (e.g., diaphragm contraction and tidal volume). </br> References 1. Adhikari et al. Critical care and the global burden of critical illness in adults. Lancet 2010. 2. Goligher et al. Mechanical ventilation–induced diaphragm atrophy strongly impacts clinical outcomes. Am J Respir Crit Care Med 2018. 3. Dres et al. Critical illness-associated diaphragm weakness. Intensive Care Med 2017.

Figure 1. Latency between start of stimulation and start of diaphragm contraction (negative peak pressure)

Figure 2. Linear regression of latency for 30%, 40% and 50% intensity. 95% CI is depicted.

In 2011, Taiwan's legislation was implemented to include ventilator-dependent patients who cannot be admitted to hospice wards due to terminal illness, so that hospice care is not limited to specific hospice wards. This study aimed to research the impact of Charlson comorbidity index (CCI) in ventilator-dependent patients on the inclusion of palliative care.

This study uses the entire population profile of the National Health Insurance to research the influence of CCI in ventilator-dependent patients (age ≥ 18 y who used ventilators for more than 21 d during the period 2009–2017) whether they join palliative care or not. CCI is divided into 4 grades, which are ≤3, 4–6, 7–9, ≥10. The statistical software package SAS 9.4 (SAS Institute, Cary, NC,) was used as the analysis tool. This study was approved by the Clinical Trials/Human Research Board (IRB) of the Research Ethics Committee of China Medical University and Affiliated Hospitals. This study was grants supported by the China Medical University Hospital (grant numbers DMR-109-015)

From 2009 to 2017, there were 186,533 new ventilator-dependent patients, 35,565 people joined palliative care, and the rate of joining palliative care was 19.07%. All 186,533 ventilator-dependent patients were analyzed for characteristics of CCI whether or not they received palliative care. The rate of adding tranquility and palliative care to CCI grade 4 was (CCI ≤ 3: 18.09%; CCI 4–6: 20.73%, CCI 7–9: 26.32%, CCI ≥ 10: 33.74%), of which CCI ≥ 10 points were added to tranquility and palliative care treatment was the highest, which was 1.37 times higher than that of patients with CCI ≤ 3 points who joined palliative care (95%CI: 0.90-0.96).

The higher the CCI, the higher the rate of receiving palliative care.

Respiratory therapists (RTs) provide a variety of patients care in different clinical settings. Burnout can have an undesirable effect on RTs and their patients. The involvement of managing COVID-19 pandemic, specifically in hospital, could stress RTs and increase the likelihood of burnout. Therefore, this study measures the level of burnout among RTs during the COVID-19 pandemic.

A validated cross-sectional questionnaire was used to identify prevalence and characteristics of burnout among RTs. Maslach burnout inventory was administered at a tertiary healthcare center in Riyadh, Saudi Arabia and it was administered by the hospital’s respiratory care department. Data analysis included descriptive, inferential, and correlational tests. Institutional review board (IRB) approval was acquired prior to study conduction.

The survey was distributed to 100 RTs, and the response rate was 66%. Most respondents reported high burnout levels according to the three burnout domains: 77% reported emotional exhaustion, 98% reported depersonalization, and 73% reported low personal achievement. Univariate analysis revealed that emotional exhaustion is significantly higher in RTs who are male, married, or working in critical care settings. Additionally, female RTs and those working in general care settings had significantly reduced personal achievement. Furthermore, analysis revealed a moderate positive correlation between the RTs’ years of experience and their emotional exhaustion (r = 0.6, P < .001) Figure 1.

There is a high prevalence of burnout among RTs during the COVID-19 pandemic in Saudi Arabia. Hospital management should develop comprehensive plans to support RTs, improve their working conditions, and promote their occupational health. The long-term impacts of burnout among RTs need further investigation.

Figure 1 Correlation between emotional exhaustion score and years of experience

In 2011, the Taiwan government promoted National Health Insurance Palliative Common Care Pilot Program to include non-cancer terminally ill patients. The program provided hospice palliative care outside the hospice ward, including prolonged mechanical ventilation patients. The number of prolonged mechanical ventilation patients are increasing year by year. This study would like to investigate the difference between the level of urbanization and patients received hospice palliative care rate.

This was a retrospective cohort study using the Taiwan Health Insurance Research Database from 2009 to 2017. The study population included patients aged ≥18 years old who used ventilation for ≥21 days (interruption ≤5 days) and analyzes the level of urbanization. With a total of 359 townships, cities, and districts across Taiwan, the region of residence was divided into one to seven levels based on urbanization, from the highest level 1 to the lowest level 7. This study has been approved by the Clinical Trials/Human Research Board (IRB) of the Research Ethics Committee of China Medical University and Affiliated Hospitals. This study was grants supported by the China Medical University Hospital (grant numbers DMR-109-015)

From 2009 to 2017, a total of 186,533 prolonged mechanical ventilation patients were included in the study and 19.7% (n = 35,565) received palliative care. Taking the urbanization degree 1 as the reference value, there was no significant difference between the urbanization degree level 1, and level 2 and 3. Compared with level 1, the odds ratio in level 4 to level 7 were 0.86, 0.8, 0.77, and 0.77.

The higher the level of urbanization, the higher the rate of receiving palliative care.

The Taiwan government held National Health Insurance Palliative Common Care Pilot Program to provide hospice palliative care for patients in the hospice ward and also outside the hospice ward. Prolonged mechanical ventilation patients have been included in the program since 2013. The prevalence of prolonged mechanical ventilation patients is increasing every year. This study would like to investigate the association of socioeconomic status and hospice palliative care on prolonged mechanical ventilation patients.

A retrospective cohort study was adopted to selected patients aged 18 or above who used ventilation for ≥21 days (interruption ≤5 days) from 2009 to 2017. Data were obtained from Taiwan Health Insurance Research Database. The education level was stratified into four groups: elementary school or lower; junior high school; senior high school and vocational school; and college, university, or higher education. This study was approved by the Clinical Trials/Human Research Board (IRB) of the Research Ethics Committee of China Medical University and Affiliated Hospitals. This study was grants supported by the China Medical University Hospital (grant numbers DMR-109-015)

A total of 186,533 prolonged mechanical ventilation patients were included in the study and there were 19.7% (n = 35,565) patients received hospice palliative care. Compared with elementary school or lower education, all other levels had higher ratio of hospice palliative care including junior high school (OR = 1.17); senior high school and vocational school (OR = 1.16); college, university, or higher education (OR = 1.17).

The higher the education level the higher the rate of receiving palliative care.