Respiratory Care

Intrapulmonary percussive ventilation (IPV) provides benefits promoting pulmonary hygiene, treating secretion-related atelectasis, and potential alveolar recruitment in clinical practice. Similar to IPV, continuous high-frequency oscillation (CHFO) delivers high-frequency minibursts of gas during mechanical ventilation and benefits intubated patients from pulmonary hygiene and alveolar recruitment. The concerns of potential lung injury from higher volume or pressure delivery limit the application of IPV or CHFO in clinical practice. Thus, the purpose of this study is to compare patient-ventilation interaction and pressure delivery between IPV and CHFO superimposed on mechanical ventilation.

An Active Servo Lung 5000 (ASL 5000) simulator was programmed to simulate a pediatric patient (resistance of 60 L/min/s and compliance of 9 mL/cm H₂O) with maximal muscle pressure of 10 cm H₂O connected to a ventilator on pressure-controlled continuous mandatory ventilation with set-point targeting scheme (PC-CMVs) mode superimposed on IPV or CHFO device. Asynchrony index (AI) was calculated by total asynchrony events divided by total breaths over the 10-min experiments. Peak inspiratory pressure (PIP), mean airway pressure (MAP), auto-PEEP, inspiratory tidal volume (V_Ti), and expiratory tidal volume (V_Te) were recorded and analyzed.

348 breaths and 933 breaths were recorded in the IPV group and the CHFO group, respectively. PIP, MAP, auto-PEEP, V_Ti, and V_Te at baseline were 19.71 ± 0.05 cm H₂O, 9.73 ± 0.03 cm H₂O, 1.80 ± 0.04 cm H₂O, 66.13 ± 0.96 mL, and 66.13 ± 1.24 mL, respectively. Mean V_T errors ranged from -96% to 998% in two groups. Calculated AI in the IPV group and the CHFO group were 0.6% and 62.5% respectively. PIP, MAP, and autoPEEP in both groups were significantly higher than values at baseline. V_Ti, and V_Te in both groups were significantly lower than values at baseline. MAP and auto-PEEP were significantly higher in the IPV group than in the CHFO group.

High V_T errors were reported when applying high-frequency airway clearance techniques superimposed on mechanical ventilation. Compared to mechanical ventilation along, both IPV and CHFO superimposed on mechanical ventilation delivered higher MAP, and autoPEEP. Although CHFO led to more asynchrony events, IPV maintained higher MAP and autoPEEP than CHFO, which might be more beneficial in alveolar recruitment. Further investigation will be needed for the effects of secretion movements.

Identifying persons with COPD at high risk for hospital readmission allows for opportunities to provide efficient and appropriate care, which may lower readmission risk. This study examined the 30- and 60-day hospital readmission prediction of the COPD-readmission (CORE) score and added new predictors to comprise the CORE+ score. The relationship of CORE and CORE+ scores with ICU admission, endotracheal intubation, and in-hospital noninvasive ventilation (NIV) use were also investigated.

A retrospective cohort study evaluated participants with a spirometry confirmed COPD diagnosis from two academic hospitals in the Midwestern United States. CORE score included: eosinophil blood count, FEV/FVC ratio (< 0.70) and FEV (≤ 40% predicted), triple inhaler therapy, previous hospitalization, and presence of neuromuscular disease. Out-of-hospital NIV use and Charlson comorbidity index were added to comprise the CORE+ score. The association between covariates and outcomes was assessed using Chi square tests and Fisher’s exact tests. A Wilcoxon signed-rank test compared the mean ranks of CORE and CORE+ scores. CORE and CORE+ scores’ 30-and 60-day readmission predictive power was assessed using multiple logistic regression. Predictive accuracy was assessed by the area under the curve (AUC) of receiver operator characteristics (ROC) using P -value < .05 for statistical significance. Institutional review board (IRB) committee approvals were obtained.

A total of 391 participants were included in the study. The study found a 22% 30-day, all-cause readmission rate and a 16%, 60-day, all-cause readmission rate. CORE+ score had better predictive accuracy than the CORE score for 30-day readmission (AUC = 0.81, 95% CI (0.76-0.86), AUC = 0.73, 95% CI (0.66-0.79), P < .001) and 60-day readmission (AUC = 0.77, 95% CI (0.71-0.83), AUC = 0.75, 95% CI (0.69-0.81), P < .001). Participants who utilized in-hospital NIV had higher mean CORE and CORE+ scores ( P = .029, P = .003, respectively).

CORE and CORE+ scores offer accurate tools for 30- and- 60-day readmission prediction as they demonstrated moderate to excellent accuracy. Moreover, unique to this study is the discovery of a linear relationship between in-hospital NIV use and CORE and CORE+ scores. Future research could focus on validating the CORE and CORE+ scores in prospective clinical studies.

The SARS-CoV-2 virus known as the COVID-19 pandemic has been responsible for progressive pulmonary decompensation in many individuals that acquire the virus. Unfortunately, a percentage of these individuals require mechanical ventilation associated with a high degree of mortality. This was apparent during the early surges of the pandemic prior to vaccine availability. We assessed our patients that required mechanical ventilation secondary to COVID-19 in terms of mortality, demographics, and vaccine administration.

Patient population data was collected retrospective between March 20, 2020, through June 30, 2022, from chart reviews from the patients who were hospitalized with COVID-19. This data was based on patients who were tested positive with COVID-19 through PCR testing and then required mechanical ventilation during their hospitalization. These patients were admitted at various Lehigh Valley Heath Network Campuses during this time frame. Patient demographics and vaccine status were collected and recorded.

Data collection was obtained during the four major COVID-19 surges (Alpha, Alpha-Gamma, Delta-Omicron and Omicron variants) with a patient population of n = 975. The mean age of survivor group was 59 y and deceased group was 67 y. Assessment of gender revealed the total patients survived were 582 males and 393 females (Table 1). During the time when the vaccine was readily available, Sept 2021 through June 2022, our data showed 367 patients were eligible to be vaccinated out of which only 95 patients or 26% received a vaccination. 272 patients or 74% did not get vaccinated. From this subset of patient population, the survival rate was 44% in the vaccinated patients compared to 30% in those who were not vaccinated. The mortality rate was 56% in those who were vaccinated compared to 70% in those who were not vaccinated.

In our network, fewer women with COVID-19 required mechanical ventilation than men (393 women, 582 men) and the mortality rate for women was lower than men. After a vaccine was widely available, a large majority (74%) of the patients in our network that required mechanical ventilation were not vaccinated. Vaccinated patients were more likely to survive mechanical ventilation than non-vaccinated patients. Further analysis is needed to identify other factors that may have influenced outcomes.

Jobs for respiratory therapists (RTs) are projected to increase by 19% by 2029 which highlights the demand for educators in the field. Mentorship in higher education is vital among colleagues to aid in the professional development of new educators which can ultimately impact career success, growth, and confidence.

The professional development mentoring experience of adjunct faculty was qualitatively evaluated. The mentorship focused on altering course content to implement Transparency in Learning and Teaching (TILT) and a professional development opportunity. Correspondence between faculty included ensuring transparent assignments met learning outcomes and module learning objectives. End-of-course evaluations surveyed student satisfaction with the TILT framework and faculty reviewed the results. Adjunct faculty were mentored through reviewing publication guidelines and manuscript submission. The project aimed to provide adjunct faculty with the resources, knowledge, and feedback to influence their career development and self-confidence. The project was granted IRB approval on 12-12-2022.

Upon examination of the teaching and scholarly activity between the full-time faculty members and the adjunct instructors, many themes emerged relating to the professional development opportunity. The web-based meetings allowed for guidance and facilitation of the project. The meetings, set agenda, and professional interaction provided structure needed to navigate the process of performing instruction and conducting research. The INFUSE grant afforded faculty the dedicated time to explore strategies and implement into the course. Each faculty member maintained a focus on the student-centeredness of the project while understanding how instructor engagement and the presentation of instructional materials can impact student learning. Both faculty types reported a positive working/learning relationship. The beneficial relationship between faculty was contingent on the dependability and reliability of each member in meeting project goals.

Mentorship in academics is influential to new educators as it impacts satisfaction, organizational commitment, and career of the mentee. As the demand for RTs increases, the number of enrollees continues to decrease. Nurturing the relationship from provider to educator is critical in the evolution of the mentee's career. By investing in RT educators with positive mentorships, we are investing in the future of the profession.

Professional respiratory therapists (RTs) should possess and use critical thinking when caring for patients with cardiopulmonary disorders. Along with foundational respiratory care knowledge, RTs caring for neonatal-pediatric patients with congenital heart defects and acquired heart diseases require specific knowledge of complex anatomy, physiology, hemodynamic monitoring, and gas exchange capabilities. The purpose of this pilot study was to assess, measure, and compare the critical thinking skillset of professional RTs working in a neonatal-pediatric cardiac intensive care unit (CICU) using a validated critical thinking self-assessment questionnaire and the Health Professional Critical Thinking Assessment (HPCTA).

Forty-three RTs from a large pediatric hospital who work in a neonatal-pediatric CICU completed both critical thinking assessments over three months. Ordinal least square regression and Spearman’s rank correlations were used to assess the relationship between the therapists’ assessment results and demographic characteristics.

The RTs rated their self-assessed critical thinking skills as very well to quite well, whereas they had moderate critical thinking skills and positive critical thinking dispositions on the HPCTA. The RTs’ self-assessed critical thinking skills were not statistically significant predictors for their overall measured critical thinking score, and only select critical thinking constructs correlated with one another. Collectively, the RTs’ demographic characteristics were not statistically significant predictors of their measured critical thinking skills; however, male RTs had higher measured explanation (F _1,20 = - 4.22, P = .05) and evaluation (F _1,20 = 7.90, P = .01) skills.

Self-assessed critical thinking results should not substitute measured critical thinking results. There is a need to develop ongoing critical thinking learning activities and assessments for professional RTs that promote improvement of their critical thinking capabilities.

The COVID-19 vaccination significantly reduces the risk of SARS-CoV-2 infection. However, there are still uncertainties about the full protection against emerging variants. Breakthrough infections occur despite full vaccination.

This is a retrospective, cohort study performed at the University of Santo Tomas Hospital, a tertiary teaching hospital in Manila, Philippines. All USTH admitted COVID-19 confirmed patients referred to pulmonary team practice from March 2021 till March 2022 age ≥ 18 y were included. Descriptive statistics were used to summarize the socio-demographic data and vaccination status of the patients. Categorical variables were summarized using frequency and proportion, while non-normally distributed continuous variables were summarized using median and interquartile range, and normally distributed continuous variables were summarized using mean and standard deviation. Chi-square was used to test associations between categorical variables, and the t-test for independent samples was used to determine significant differences. A P -value < .05 was considered statistically significant. Data analysis was performed using SPSS version 23. The Research Ethics Committee (REC) of the USTH reviewed and approved the study protocol (Reference No. REC-2021-10-131-TF).

Out of 381 patients, 190 were above age of 65 and the majority were men. The two most common co-morbidities were hypertension and diabetes mellitus. The unvaccinated (53.2%) and partially vaccinated group (68.4%) had the highest incidence of severe COVID-19 cases. Most of the fully vaccinated patients had moderate infections (44.7%; P < .05). Mechanical ventilation (25.4%) and high flow nasal cannula (44.8%) were administered to the unvaccinated group. In contrast, fully vaccinated patients were mostly on high flow nasal cannula (35%) and not receiving oxygen support (32.5%; P < .05). Higher mean average of serum LDH (527.6 ± 394), ferritin (2,300 ± 3,781), C-reactive protein (207.7 ± 480.1), procalcitonin (10.1 ± 45.85), lymphocytes (0.220 ± 0.102), and interleukin-6 (215.6 ± 571.2) were seen among the unvaccinated group. They also had longer hospital stays and a higher mortality incidence (14.089.26, 29.1%). Most patients (72.2%) were discharged improved.

Full vaccination status was associated with lower mortality and required less invasive ventilation compared with unvaccinated group.

Table 1. Clinico-Demographic Characteristics of COVID 19 Patients, Section of Pulmonary and Critical Care, Department of Internal Medicine - University of Santo Tomas Hospital, Manila, March 2021 to March 2022

Table 2. Laboratory Parameters of COVID 19 Patients, Section of Pulmonary and Critical Care, Department of Internal Medicine - University of Santo Tomas Hospital, Manila, March 2021 to March 2022

Optimum mechanical ventilation requires determining which goal is most important (ie, safety, comfort, or liberation) and selecting a mode that best serves the goal. Ongoing adjustment of settings is then required. For liberation, a switch must be made from mandatory to spontaneous breaths, usually done manually. Staffing shortages and the increasing number of ventilated patients can delay needed mode changes and adversely affect patient outcomes. Automode, a feature included on Getinge Servo-I and Servo-U ventilators, automatically switches between mandatory and spontaneous breaths. Spontaneous breaths suppress mandatory breaths until an apnea occurs. The period from the last spontaneous breath to the reappearance of the first mandatory breath is determined by a calculated apnea time limit (ATL) which is based, in part, on a maximum apnea time (MAT) setting (7-12 s). However, unlike apnea settings on other modes, ATL is automatically adjusted based on the MAT setting, the mandatory breath rate setting (MBR) and the spontaneous breath count (SBC) since the last mandatory breath. This functionality is unusual and not explained clearly in the operator’s manual. Therefore, the purpose of this study was to describe and validate the (ATL) algorithm using simulated mechanical ventilation.

A SERVO-U ventilator was connected to an ASL 5000 breathing simulator (IngMar Medical). Ventilator settings: Automode (Pressure Control to Pressure Support), PC = 10 cm H₂O, PS = 5 cm H₂O, PEEP = 10 cm H₂O, MBR = 10, 12, 15, 20 breaths/min. MAT = 7 and 12 s. Simulator settings: resistance = 10 cm H₂O/L/s, compliance = 35 mL/cm H₂O, Simple Flow Trigger Model: rate = 20 breaths/min, trigger flow = 10 L/min, trigger duration = 800 ms. Script: SBC = 0-12 breaths. Flow waveforms were recorded and observed ATL was compared to the calculated ATL. Equation provided by Getinge: calculated ATL = (60/MBR) + (SBC × (MAT - (60/MBR))/10). The outcome variable was error (%) = 100% × (observed ATL – calculated ATL)/calculated ATL, averaged across the SBC range.

The graph shows expected performance according to equation (red is max ATL). The observed ATL for MAT = 7s ranged from 3s (MBR = 20, SBC = 0) to 7s (MBR = 10-20, SBC = 10-12). The observed ATL for MAT = 12s ranged from 3s (MBR = 20, SBC = 0) to 12s (MBR = 10-20, SBC = 10-12). Average error ranged from 0 to –2%.

The performance of the apnea time limit feature was as expected.

Increasing evidence suggests that hypocapnia is associated with brain injury on MRI and adverse neurodevelopmental outcome in infants treated with therapeutic hypothermia (TH) for neonatal encephalopathy (NE). Consequently, continuous carbon dioxide (CO₂) monitoring and avoiding extreme levels of CO₂ have the potential to improve neurologic outcome. Our aim was to compare changes in transcutaneous CO₂ levels during hypothermia and rewarming between infants with and without brain injury on MRI in a cohort of infants with neonatal encephalopathy.

This prospective observational trial enrolled infants, who received TH for mild to severe NE between October 2019 and June 2022.The pattern of brain injury was evaluated according to an MRI grading system. We identified 2 groups of patients with and without any brain injury based on the assessment of MRI after rewarming. Transcutaneous CO₂ (PtcCO₂) data were captured by a real-time integrated neuromonitoring system.

110 infants received TH during study period, out of those 37 infants were enrolled into this prospective study. Serial measurements from 31 patients were available for analysis. Sixteen (51.6%) infants had evidence of any brain injury on MRI. Integrated monitoring began at median 24 hours of life (min-max: 11-51) and ended at median 94 (min-max: 87-120) hours of life. Results from mixed models indicated a significant effect of phases/time on mean PtcCO₂ level (F = 4.4, P = 0.001), but no difference by brain injury status (F = 0.0, P = 0.304) or an interaction effect (F = 1.2, P = 0.304) (Figure 1). Mean levels of PtcCO₂ exhibited a significant decrease between the last phase of TH (> 60 hours of life) and post-rewarming phase: mean difference: -3.76, 95%CI -6.7; -0.8, P = 0.003

This novel longitudinal study of infants with NE showed relatively stable PtcCO₂ levels within the normal range during hypothermia and rewarming. Results from mixed models indicated a significant effect of time on transcutaneous CO₂ levels. Based on the results adjusted for multiple comparisons, the comparison that met statistical significance was the decline between the last phase of hypothermia (> 60 hours of life) and post-rewarming phase. The trajectories of PtcCO₂ did not differ between infants with and without brain injury. These pilot results are needed to be interpreted with caution given study limitations that include no adjustment for potential confounding or data collection during the early hours of life.

Carbon dioxide is one of the most potent regulators of cerebral blood flow. Near infrared spectroscopy has been used in neonatal encephalopathy during therapeutic hypothermia to monitor regional cerebral oxygen saturation that can be a proxy of CBF. Impaired cerebral autoregulation following severe hypoxic-ischemic brain injury has been associated with poor neurologic outcome. The aim of this study was to evaluate the correlation between transcutaneous CO₂ and markers of cerebral oxygenation including cerebral oxygen saturation and fractional tissue oxygen extraction among infants with neonatal encephalopathy.

This prospective observational trial enrolled infants, who received TH for mild to severe NE between October 2019 and June 2022. The pattern of brain injury was evaluated according to an MRI grading system developed by Weeke et al. We identified 2 groups of patients with and without any brain injury based on the assessment of MRI after rewarming. Transcutaneous CO₂, rSO₂ and bedside physiological data were captured simultaneously by a real-time integrated neuromonitoring system. Fractional tissue oxygen extraction was calculated as: FTOE = (SpO₂ – rSO₂)/SpO₂

110 infants received TH during study period, out of those 37 infants were enrolled into this prospective study. Serial measurements from 31 patients were available for analysis. Sixteen (51.6%) infants had evidence of any brain injury on MRI. Pearson’s r between PtcCO₂ and measures of oxygenation were calculated within each phase of hypothermia, rewarming and post-rewarming phase. Correlations between PtcCO₂ and measures of oxygenation were small throughout the phases of TH, with positive correlations with rSO₂ and negative with FTOE. Correlation between PtcCO₂ and oxygenation across the study period by brain injury status using repeated measures correlation to take into account intra-individual correlation among medians of the different phases. Though small in effect size, correlations were stronger among infants with brain injury, compared to those without brain injury on MRI.

Correlations detected between CO₂ and cerebral oxygenation were modest with a positive correlation with rSO₂ and negative correlation with FTOE across the study period. Though small in effect size, the correlation between PtcCO₂ and cerebral oxygenation (rSO₂ and FTOE) over the study period was greater in magnitude among infants with brain injury compared to those without, among whom the correlation was close to zero.

Pediatric patients who experience severe acute illness either at birth or secondary to acute or chronic disease can experience profound respiratory failure. Tracheostomy tubes provide a secure airway, assistance with ventilatory support and route to safe discharge home for recovering or chronically ill patients.

A needs assessment was performed at our tertiary care center involving all stakeholders. Several areas of improvement were quickly identified: improve communication with caregivers regarding discharge readiness, establish clearly defined roles for staff, and improve hands-on skills assessment with simulation. A roadmap was created at each patient’s bedside to allow for caregivers and team members to track the progress towards their child’s discharge. A revised CPR and new simulation curriculum were created to assess caregiver skill. A pre and post simulation surveys assessed caregiver comfort via five-point Likert scale. A preintervention population from 2019 to 2020 was used for outcome comparison.

Ten patients were enrolled and completed our updated education pathway including patient discharge roadmap and simulation scenarios between 2021 to 2022. Outcomes were compared with 7 patients who received new tracheostomies from 2019 to 2020 prior to intervention. Education documentation was completed for 50% of caregiver preintervention and 80% post. Readmission for respiratory complaint involving tracheostomy prior to intervention within three months of discharge was 43%, three patients with readmission and one death. Post intervention readmission for respiratory complaint was 30% with no deaths. Pre and post simulation surveys demonstrated 60% improvement in caregiver comfort for bedside skills following simulation, particularly tracheostomy tube replacement, rescue breathing and cardiopulmonary resuscitation.

Pediatric patients receiving tracheostomies are a medically fragile population with readmission or tracheostomy related complications and complaints accounting for 10% of their hospital evaluations and admissions. Incorporation of our tracheostomy education checklist into our electronic medical record improved documentation compliance. The addition of simulation education improved caregiver comfort regarding bedside skills particularly emergency skills. Overall, our interventions were associated with reduced readmission for respiratory complaints regarding tracheostomies.

Inhaled drug delivery during mechanical ventilation has been the topic of debate for years. There has been cross-examination when the nebulizer is placed on the dry side of the humidifier chamber regarding aerosol particle deposition. Lung morphology and length of the ventilator circuit are factors that may influence percent of deposition. Ari et al lung model studies demonstrated that aerosol deposition was 6.80% ± 1.55% with jet nebulizers and 23.16 ± 0.67% with vibrating mesh nebulizer (VMN) with a single dose 3 mL solution. With development of the VMN, this adds a novel chapter to continuously nebulized drug therapy (CNDT). The aim of this study was to demonstrate aerosol deposition with CNDT via syringe pump when a VMN is placed on the dry side of the humidifier.

A ventilator was set up with a dry adult ventilator circuit; no active humidity for the study. Two sterile filters were installed in the circuit. Filter labeled (A) was attached at the ventilator y-piece that was attached to a lung model. Another filter (B) was attached to the ventilator exhalation valve. Ventilator settings: tidal volume (V_T) 450 mL, VC-CMV 12 breaths/min, PEEP 8 cm H₂O, peak inspiratory flow 50 L/min. Albuterol 20 mL was mixed with a non-toxic red dye. The solution was drawn up into a syringe which was attached to the syringe pump and VMN, that was connected to the ventilator circuit on the dry side of the humidifier. The syringe pump was programmed to deliver 15 mg/h = 3 mL/h. The VMN timer was set for continuous. The dye represented aerosolized particles from the VMN collected in filters.

Post study observation illustrated that at 15 mg/h, a total of 12 ± 2 mL/h was delivered over the 4 h study period. Filter A captured aerosol particles at the ventilator y-piece. Filter B captured aerosol particles in the expiratory circuit before the exhalation valve. Both filters demonstrated enhanced aerosol saturation (see figure). There were no abnormalities related to mechanical ventilator functionality. The red dye stained the inside walls of the (inspiratory, expiratory) ventilator circuit which may represent lost aerosol particle volume, no detectable red dye pre-humidifier.

This study has limitations, one is aerosol deposition was only evaluated down to the y-piece. More study is needed to validate performance with and without humidity. With emerging novel applications for inhaled drug delivery (eg, inhaled vasodilators, β₂-agonists, inhaled sedation), this study gives researchers conceivable insight into CNDT as this may impact aerosol delivery percent. An indirect observation demonstrated very minimal penetration of red dye past the protective median for both filters, which is propitious for infection control.

Filters labelled A & B

Purchasing capital equipment such as ventilators is an important decision for providing critical care, as ventilators come with not only significant initial costs, but continuing costs as well. As a result, we sought out more information about what factors are considered when purchasing a ventilator beyond the newest high-tech mode or feature.

A 29-question survey was distributed amongst RT department leaders in British Columbia, Canada, 21 leaders responded. Hospitals ranged in bed size: 14% ≤ 55, 19% 56-200, 48% 201-400, and 19% ≥ 400 funded beds. The ages of patients ventilated on a daily basis were: 14% birth-18 years, 38% birth-30 days AND ≥ 18 years old, and 48% ≥ 18 years old.

Feedback on ventilators from different professions was assessed with ‘very important’ being selected 91% of the time for the site’s own RTs, other hospital RTs 48%, biomed 19%, nursing 5%, medical directors 0%; feedback was considered ‘not important at all’ or ‘slightly important’ 0% of the time for the site’s own RTs, other hospital RTs 0%, biomed 14%, nursing 76%, and medical directors 62%. When assessing ventilator modes, 86% felt high quality noninvasive ventilation (NIV) was ‘fairly important’ or ‘very important’ and 81% felt neonatal invasive and NIV was ‘important or very important’. 62% felt high quality HFNC was ‘fairly important’ or ‘very important’. Capital funds are becoming tighter although 33% felt the purchase price was ‘not important at all’ or ‘slightly important’; while purchase price was ‘fairly important’ or ‘very important’ 29% of time. Ongoing costs were ‘fairly important’ or ‘very important’ for preventative maintenance 19%, proprietary supplies 29%, and warranty 14%. In regard to vendors, 67% of leaders reported both trust with the sales representative and the vendor’s ability to provide quality, in person, hands-on education as ‘very important’ to them. 48% said vendor technical knowledge is ‘very important’, and 52% reported history of support and response time as ‘very important’.

This study examined interdisciplinary feedback, ventilator capabilities, price and quality, plus relationships with vendors and how each plays a role in the decision-making process. Although financial pressures continue to increase, this study revealed that quality care is still the most important goal highlighted by the importance of frontline RT feedback and the ventilator's ability to provide high quality neonatal modes, NIV, and HFNC.

Pressure injuries associated with noninvasive ventilation (NIV) cause suffering, increased hospital duration, and even morbidity. During FY 2017-FY 2021 twelve facial pressure injuries, per 1,824 NIV days, associated with NIV were documented. To address this problem, we implemented proactive countermeasures.

Countermeasures included the use of a protective barrier placed between the patient’s face and mask, the rotation of the NIV mask every 4 hours from full face mask to regular BPAP mask, enhanced staff education germane to the recognition of pressure injuries, and QH4 hrs assessment for NIV liberation. Also, we implemented daily wound care assessment rounds to be conduct by a nurse wound specialist.

Post implementation of the countermeasures we saw a significant reduction in facial pressure injures. (Table 1)

With the implementation the above countermeasures, our hospital was able to reduce the occurrences of NIV-related pressure injures. It was a multiple pronged approach to address this problem. It is unclear if one measures was more effective than any other single one in reducing this issue. Enhanced staff educated increased both the awareness of pressure injuries and the criteria for NIV liberation contributed greatly. Daily wound round assessment was very beneficial in addressing potential patients who were at high risk with proactive protective measures. Based on our above data our countermeasures significantly reduced the number of NIV pressure injuries. We continue to conduct daily wound assessment rounds and search for additional countermeasures to maintain and even reduce these occurrences.

Simulation-based education is thought to be more effective than traditional teaching. Recent studies have described the benefits of simulation-based training on healthcare professional performance in several clinical areas, but not many studies have researched the benefits of simulation training in COPD and tracheostomy education. Therefore, this study was composed to assess the approach of mannequin simulation-based training education as a method to provide an interactive learning experience for RTs, which could in turn translate into better management performance.

This study was approved by the Institution Domain Specific Review Board (NHG DSRB 2020-01138). A pilot study of the COPD-TTP was implemented targeting RTs at a large tertiary hospital from March 2021 to July 2021. The study narrowed down on focusing simulation for tracheostomy care on COPD patients due to a high prevalence of tracheostomy in COPD patients; managing COPD and tracheostomy has shown to be a major concern to most clinicians after a pre-interview on respiratory education topic was performed. RTs were randomized into control and intervention groups and presented with the COPD clinical scenarios of patient assessment management and tracheostomy scenarios using the difficult airway high-fidelity mannequin. Before the simulation training, a 25-question theory test covering COPD and tracheostomy assessment principles was administered. Participants then underwent COPD-TTP simulation assessments, and a debrief was held at the end of the session.

26 RTs participated in the COPD-TTP program. As for demographics, a majority were female (n = 15 [57.7%]), and 8 (30.8%) RTs had less than five years of working experience. The median (range) of RTs’ experience was 6 (1-11) years. The intervention group has a significant difference in the mean for both theory test scores (82.3% vs 73.1%; P = .044) and overall psychomotor skills competency (74.5% vs 61.2%; P = .018) as compared to the control group. The results demonstrated a significant difference in scores in the intervention training group that underwent COPD-TTP, supporting the proposed hypothesis. Table 1 provides the full overview of the result and the curriculum of COPD-TTP.

This study demonstrated that using E-Learn is essential coupled with having hands-on and open communication experiences, enhances the educational value of web-based education in training psychomotor skills, and increases in knowledge and confidence.

Figure 1: Box-Plot of the median overall assessment in % for control and intervention group

Tracheostomy management is an established skill within the respiratory therapists’ scope of practice. For registered nurses (RN), tracheostomy management can be a rarely used skill that fosters a lack of confidence. Literature review shows a lack of confidence influences the ability of the RN to provide effective tracheostomy management. A practice gap was identified in the areas of tracheostomy care, suctioning, and response to accidental decannulation. A simulation-based workshop was developed to improve RN confidence when caring for a patient with a tracheostomy.

The workshop registration was limited to four RNs to allow each learner hands-on implementation of tracheostomy management. The Respiratory Care Educator provided a demonstration for proper suctioning technique, tracheostomy care, management of accidental decannulation and supplies available to the learners were reviewed including the patient-specific emergency tracheostomy kit. A two-part simulation was facilitated utilizing a tracheostomy manikin and all of the supplies needed to respond to the two scenarios were available for use. Scenario one was response to routine trach care and suctioning. Scenario two was response to accidental decannulation. After completion of the simulations, the facilitators debriefed utilizing the Plus/Delta method.

A pre/post survey utilizing a 5-point Likert scale was administered to each learner. The pre-survey showed 59% of participants (n = 22) reported somewhat disagree to strongly disagree to confidence replacing a tracheostomy after accidental decannulation and 27% of learners reported somewhat disagree to strongly disagree to familiarity of the contents of the emergency tracheostomy kit. 31% of learners reported low confidence providing routine tracheostomy care. The post-survey showed that 100% of participants felt confident replacing a tracheostomy after accidental decannulation and familiarity with the contents of the emergency tracheostomy kit. 94% of participants reported an increase in confidence when providing routine tracheostomy care. 87% of participants reported the ability to apply what they learned immediately on the job.

Simulation-based education increased RN confidence to care for a patient with a tracheostomy. The small class size allowed the participants to improve skills needed to provide routine tracheostomy care, manage decannulation, and increased familiarity with supplies available during an accidental tracheostomy decannulation situation.

Past research provides good evidence that having a competency assessment on an annual basis can improve the clinician's quality, safety, and confidence. Competency documentation, however, is not cost-effective and can consume a huge amount of administrative time in preparing and storing it. Furthermore, it is hard to keep all paper records for all staff in a secured area and higher risk of missing staff competency. Implementing digital solutions to replace paper filing can increase efficiency, better data access, accountability, and reliable backups. The study evaluates the perception of usability and satisfaction of developed competency documentation using the digital application that replaced paper-based records in the RT department.

To improve efficiency and ensure safekeeping, the RT department at JurongHealth Campus, Singapore, initiated the transition from paper-based competency documentation to digital competency documentation in November 2022. A questionnaire was conducted to the RTs on the transition to digital competency form using the technology model assessment (TMA) format six months post-transition in April 2023. Each item in the questionnaire used a 7-point Likert scale for item scoring the RTs' perception of digitalized competency. In total, 20 RTs answered the questionnaire. This study and TMA questionnaire are part of major research and approved by the Institution Review Board (NHG DSRB 2020/01138).

The initiative of digitalized competency has helped the department have an estimated savings of ∼800 papers for each RT per year. 100% of RTs reported (agree and strongly agree) that they could readily access materials and competency checklists; 90% agreed that there is easy access to track completed competencies. 65% decided that the new initiative improves document filing and prevents data loss. However, (n = 7, 35%) RTs were concerned about PDPA/IT issues due to recent cases of malware attacks in other countries/servers. Factor analysis was performed on the questionnaire, and two themes emerged, with 72.84% of variances explained. Cronbach’s alpha was used for internal consistency assessment, and Cronbach’s alpha shows 0.872 for the theme Acceptance of digitalized solution and 0.801 for the theme worries of PDPA/IT.

It is essential to have digitalized solutions in healthcare settings, as it ensures higher security in safeguard sensitive information, creating efficiency, on-the-go resources and creating a green environment at the workplace.

Figure 1 : Themes created based on eigenvalues >1 from factor analysis with n=20 and variances explained 72.84%

Figure 2 : Breakdown of the questions based on the theme “Acceptance of digitalised competency" and "Worries of PDPA/IT issues”

NIV is commonly utilized outside of the ICU for respiratory support. A novel remote monitoring NIV system (tele-NIV) consisting of streaming real-time NIV data and vital signs from Phillips Intellivue MX400 to assist in RTs streamlining the work processes and efficiently responding to NIV alarms. The workflow using tele-NIV aims to reduce ICU admission for respiratory patients and improve patient care and safety. The tele-NIV system has been implemented since April 2021 at JurongHealth Campus, Singapore, and this study evaluates RTs' perceptions (n = 25) of the tele-NIV system.

Using the technology model assessment (TMA) model, a 5-point Likert scale was used for item scoring in the respondents’ 25-question questionnaire. Before further data analysis, the quality and factorability of the data were assessed. Multivariate normality was tested by calculating the mean value of the Mahalanobis squared distances in the data distribution against the critical importance (number of items multiplied by the number of items plus 2). An inter-item correlation matrix was analyzed, and factor analysis was conducted using eigenvalue (>1) to determine the factors. 13 low and cross-loading (<0.65) items were removed from the questionnaire. This study was approved by Institution Ethics Review Board (NHG DSRB 2022/00455).

Factor analysis was performed, and the final factor models in the instruments represented three factors with a total of 12 items. The total variance explained by the three-factor model was 69.74%. Of the factor-specific percentages, the first factor (6 items), the feasibility of tele-NIV demonstrated at 25.55%; the second-factor perceptions of tele-NIV (3 items) at 23.65%; the third factor, tele-NIV resources and training (3 items) at 17.35%. Cronbach’s alpha was used for internal consistency assessment, and Cronbach’s alpha ranged from 0.820 to 0.935 in the factors. 100% of RTs reported (agree and strongly agree) that tele-NIV is feasible and has proven to help them in their clinical work outside ICU. However, (n = 16, 64%) RTs prefer that nurses and clinicians can be empowered and better trained in managing NIV patients. Coupled with the tele-NIV system, it will optimize efficiency at work and improve patient safety.

Tele-NIV is a novel approach well-liked by the RTs in terms of feasibility. However, ongoing study and training are being conducted to receive feedback from the nurses, patients, and their caregivers for a holistic review of the tele-NIV system.

Respiratory therapists are often exposed to the process of dying and dying of patients due to their work, and this process is prone to induce anxiety. Therefore, this study explores the effect of death education courses on clinical respiratory therapists' death anxiety, so as to understand whether death education courses can improve clinical respiratory therapists' death attitudes and reduce death anxiety.

This study was a prospective cross-sectional study design and selected respiratory therapists from Taiwan Beizhong Nandong Medical Center as subjects. The survey was conducted with a structured questionnaire, including the demographic data of the respiratory therapists and the situation of the Revised Death Anxiety Scale (RDAS) (Cronbach's α = 0.91, retest reliability 0.93). A total of 171 respiratory therapists were enrolled in this study, including 75 in the first group (without taking the death education course) and 96 in the second group (having taken the life and death education course).

The results of the study found that: In terms of death anxiety, the respiratory therapists in the first group had worse death anxiety scores than the respiratory therapists in the second group (P < .001). Items included: I was terrified at the thought of surgery (2.81 ± 0.71 vs. 2.45 ± 0.80, P < .002). I was terrified when it came to painful near-death (2.84 ± 0.72 vs. 2.56 ± 0.82, P < .019).I'm not particularly afraid of getting cancer (1.93 ± 0.74 vs. 2.20 ± 0.76, P < .024).I don't worry about being helpless (2.25 ± 0.66 vs. 2.78 ± 0.64, P < .010). I don't worry about being in control of my life. (2.45 ± .59 vs 2.67 ± .67, P < .033). What happens to the body after death doesn't bother me (2.64 ± .72 vs. 2.89 ± .71, P < .028) among other items. However, there was no significant difference between the two groups in the total score of death anxiety, fear of painful process, loss of autonomy, life after death, and helplessness (P > .05).

Accepting death education courses can enable clinical medical staff to gain more intelligence, reduce anxiety about patient death during the care process, and provide better care for dying patients.

Since 2014, The Joint Commission introduced use alarms safely as a National Patient Safety Goal. In 2019 published by AARC, ventilator alarms are ranked fourth. The biggest contributing factor to alarm-related adverse events is suggested to be the excessive number of alarms in a clinical environment, which can be as high as 942 alarms per day. This review utilizes the tele-NIV system, which is a telemetry system that continuously transmits live data, such as NIV readings and vital signs. Tele-NIV examines the factors that affect NIV alarm utility and provides recommendations to improve patient safety and clinician efficiency while reducing alarm fatigue.

A retrospective study was conducted from April to June 2021. A total of 113 NIV patients received additional telemonitoring during the study period during their stay at the hospital. All data were recorded and extracted from the tele-NIV server. Logistic regression was performed on the importance of tele-NIV and the frequent alarms in ensuring NIV alarms were resolved within 2 min. This study was approved by the Institution Domain Specific Review Board (NHG DSRB 2022/00455).

Among our 113 patients, there were a total of 5,146 alarm encounters during the period. 384 alarms were recorded by the respiratory therapists (RTs) as essential alarms, with a median of 3.5 (1.0 – 4.9) essential alarms per patient. The most common essential NIV alarms were low pressure or patient disconnect alarms (194 alarms [50.5%]), low SpO₂ alarms (101 [26.3%]), and low tidal volume alarms (42 [10.9%]). Out of the 384 essential alarms, 76 (19.8%) essential alarms were recorded simultaneously and are mostly linked to the disconnection from the patient. The median response time in resolving the alarm was 2.0 (2.0-8.0) min. Management responses to the telemonitoring of NIV events were that most of the alarm encounters (205 [53.4%]) were reported to be resolved remotely, and 179 [46.6%] of alarms required the support of the RTs to review the patient. 204 (53.1%) of the essential alarms responded and were resolved within 2 min. Of those, 135 (66.2%) were resolved through tele-NIV.

This review identified essential NIV alarms that will help clinicians respond appropriately and reduce alarm fatigue. Tele-NIV has made remote monitoring of alarms and provided clinicians with a better awareness of NIV alarms. Further research is needed to determine the alarms' priorities and expand the tele-NIV system to improve patient care.

It has been shown that utilizing order protocols can improve order accuracy in healthcare. An established ventilator protocol in place at BWH had greatly improved order accuracy following chart reviews. An erroneous noninvasive ventilation order was uncovered noninvasive ventilation per protocol and was being documented in patient charts. This discovery led to the implementation of a hospital wide algorithm and protocol for all noninvasive orders.

Multidisciplinary teams within the hospital collaborated to create a universal NIV algorithm and protocol for acute/non-acute BPAP, acute/non-acute CPAP, and for the use of a patient’s home NIV device. A smart phrase template was created to access the protocol. General safe parameter ranges were established so most patients’ settings were within the guidelines. Once approved by leadership, education was provided on how to correctly use the algorithm and protocol. Daily chart audits for all noninvasive ventilation patients were reviewed for order accuracy.

Overall order accuracy increased from 67% in March 2022 to 85% in March 2023

Mass General Brigham enterprise is currently in the process of adopting the protocol for use system-wide. The updated system-wide protocol will have a direct link to the protocol within the order. Even though the NIV order protocol and smart phrase are currently available to all staff, we found it to be underutilized.

COPD poses a significant burden on healthcare in the US, with inadequate patient education leading to delayed exacerbation recognition and increased hospitalizations. This study aims to incorporate technology, such as Bluetooth monitoring devices, to address early symptom detection and reduce medical utilization. Although Intermountain Healthcare’s Pulmonary Disease Navigator program provides education/monitoring after discharge, early exacerbation signs are not easily recognized or monitored.

This quality assurance study evaluated home-monitoring devices and Bluetooth technology for their effectiveness in early exacerbation recognition and reducing medical utilization. The Intermountain Healthcare and Boise State University Institutional Review Boards approved the study. Participants with Bluetooth-capable smartphones were recruited from various healthcare settings. Four devices were selected based on reliability and ease of use: MIR SmartOne, In-Check Dial, Pulse Oximeter, and a Data Journal. Weekly data on respiratory parameters were collected and analyzed to identify early exacerbation signs. Participants received education on COPD and device usage. Statistical analysis compared pre- and post-intervention medical utilization rates using a paired t-test to assess the impact of home-monitoring technology on reducing medical utilization. The statistical analysis assessed the medical utilization rate from the electronic medical record. A paired t-test compared pre- and post-intervention medical utilization rates to determine if the home-monitoring technology reduced medical utilization rates.

Forty-six participants diagnosed with COPD agreed to participate for 6 months, and 32 (70%) completed the study. Only 14 voluntarily withdrew from the study, did not complete it, or had more than 50% of their data missing. There was a significant difference in the medical utilization rate pre-intervention (M = 0.47, SD = 0.32) and post-intervention (M = 0.19, SD 0.33): t(32) = 4.06, P < .001, which suggests that the technology significantly decreased the medical utilization rate for those who completed the study.

The study observed that COPD patients effectively utilized home-monitoring technology to significantly reduce medical utilization rates by identifying early exacerbation warning signs. These findings emphasize the efficacy of technology in COPD management and stress the importance of patient and healthcare provider education on these home monitoring tools.

Baseline Subject Characteristics

Comparison of Pre-intervention and Post-intervention Medical Utilization Rate

Mechanical power (W) represents ventilator energy transferred to the lungs and chest wall (ie, W_RS) over time. W_RS is linked to both ventilator-induced lung injury and ARDS mortality. Estimating W_RS is complex and unwieldy as it encompasses minute ventilation, peak airway pressure, PEEP, and inspiratory flow.¹ A simplified, clinical equation for pressure control ventilation (PCV): W_RS = 0.098 x frequency x V_T x (PEEP + P_DR),¹ was used in this retrospective study to assess mortality risk, without distinguishing CMV modes (ie, P_DR = Pplat-PEEP vs. PIP-PEEP, and excluding inspiratory flow).

948 ARDS subjects were studied who: 1) met the Berlin definition, 2) were managed with ARDSNet protocols initiated ≤ 24 h after ARDS onset, and 3) survived ≥ 24 h after protocol initiation (allowing lung-protective ventilation optimization and censoring moribund cases). W_L and W_CW were estimated using subcomponents of ARDS elastance data:² E_L/E_RS (0.72), E_CW:/E_RS (0.28). Other calculations included ratio of measured W_RS to normal W_RS (∼4 J/min) and ΔW_RS ∼24 h after protocol initiation. Mortality risk was assessed by univariate logistic regression. Alpha was set at 0.05.

Hospital mortality was 35.6%. All W estimates predicted mortality risk (Table), having identical area under the receiver operating curve and P-values: AUC (95%CI) 0.65 (0.61-0.69), P < .001. W_RS was ∼ 6-fold higher than normal: median (IQR) 5.8 (4.4-7.8). W_CW, was associated with a higher mortality risk than W_L.

A simplified W_RS estimate of ARDS mortality risk suggests complex W equations may not be clinically necessary. Higher mortality risk with increasing W_CW might reflect the presence of intra-abdominal hypertension that may portend worse clinical outcomes in ARDS. 1. Chiumello D et al. Crit Care 2020;24:417. 2. Kallet RH et al. Respir Care 2007;52(8):989.

Mechanical power transferred to the lungs and chest wall (ie, W_RS) over time (J/min) is linked to both ventilator-induced lung injury and ARDS mortality. Berlin definition ARDS-related mortality increases from mild (27%), to moderate (32%), to severe (45%)¹ with relative increases of 119% and 167% respectively. This retrospective study examined whether W_RS intensity also increases across Berlin demarcations, and if it approximates that of the corresponding mortality rise.

948 ARDS subjects were studied who: 1) met the Berlin definition, 2) were managed with ARDSNet protocols initiated ≤ 24 h after ARDS onset, and 3) survived ≥ 24 h after protocol initiation (allowing lung-protective ventilation optimization and censoring moribund cases). A simplified W_RS calculation (0.098 x frequency x V_T x [PEEP + P_DR]),² was used whereby W_L and W_CW were estimated using fractional subcomponents respiratory system elastance: E_L/E_RS (0.72), E_CW/E_RS (0.28).³ Data were analyzed using the Kruskall-Wallis test and Dunn’s post-test. Alpha was set at 0.05.

With one exception (W_CW: mild vs. moderate) all measures of W transfer increased significantly: moderate vs. mild (P = .019), severe vs. moderate (P < .001) and severe vs. mild (P < .001). The proportional increase in W transfer increased by 113% between mild and moderate ARDS, 116% between moderate and severe ARDS and 131% between mild and severe ARDS.

Estimated median W_RS transferred from the ventilator to the respiratory system and its lung and chest wall subcomponents increased steadily as ARDS severity increased from mild to moderate to severe acute lung injury, however it occurred at a rate substantially below that of mortality rise. 1. Berlin Taskforce. JAMA 2012;307:2526. 2. Chiumello D et al. Crit Care 2020;24:417. 3. Kallet RH et al. Respir Care 2007; 52(8):989.

Mechanical power (W) is ventilator energy transferred to the respiratory system (ie, W_RS) over time (J/min). W_RS > 12 J/min and > 25 J/min are associated with ventilator-induced lung injury (VILI) onset and severe VILI respectively.¹ Yet, baseline W_RS of ∼ 28 J/min previously was not found to differentiate ARDS survivors from non-survivors.² This retrospective study examined whether increasing W_RS and W_L intensity corresponds with increasing mortality as ARDS intensity worsens.

948 ARDS subjects were studied who: 1) met the Berlin definition, 2) were managed with ARDSNet protocols initiated ≤ 24 h after ARDS onset, 3) survived ≥ 24 h after protocol initiation. A simplified W_RS calculation (0.098 x frequency x V_T x [PEEP + P_DR]),² was used wherein W_L was estimated using fractional subcomponents respiratory system elastance: E_L/E_RS (0.72).³ Data were analyzed using the Mann-Whitney test. Alpha was set at 0.05.

Within ∼36-48 h of ARDS onset, significantly higher W_RS and W_L were observed in non-survivors with median W_RS approximating levels associated with severe VILI (ie, ∼25 J/min). Hospital mortality rates were similar to Berlin Taskforce findings (ie, 27%, 32%, and 45%).⁴ Lower estimates of W_L also reached the threshold wherein some degree of VILI appeared likely.

Contrary to previous findings,² W_RS ∼25 J/min was associated with increased mortality risk and, by extension, perhaps severe VILI risk.1. Silva PL et al. Anesthesiology 2020;132:949. 2. Wu H-P et al. Diagnostics 2023;13:1226. 3. Kallet RH et al. Respir Care 2007; 52(8):989. 4. Berlin Taskforce. JAMA 2012; 307:2526.

Mechanical power (W) is ventilator energy transferred to the respiratory system (ie, W_RS) over time (J/min). W_RS exceeding 12, 15, and 25 J/min are considered ventilator-induced lung injury (VILI) thresholds of increasing severity.¹ This study examined mortality risk associated with five W_RS thresholds.

948 ARDS subjects were studied who: 1) met the Berlin definition, 2) were managed with ARDSNet protocols initiated ≤ 24 h after ARDS onset, and 3) survived ≥ 24 h after protocol initiation. A simplified W_RS calculation was used: W_RS = 0.098 x frequency x V_T x (PEEP + P_DR).² Mortality risk was assessed at W_RS thresholds of > 12, > 15, > 20 > 25, and > 30 J/min using Fisher-exact tests. Alpha was set at 0.05.

Mortality steadily increased both below and above each threshold, with cumulative mortality increases 8% vs. 14% respectively: the relative increases being the same for each cohort (138%). Over 40% of cases had W_RS levels exceeding those associated with severe VILI risk.

Mild and severe ARDS mortality (27%, and 45% respectively)³ approximates that found between cohorts across the 25 J/min threshold (27% and 47% respectively): a threshold associated with severe ventilator-induced lung injury.¹ Given relative inexactness of the simplified clinical equation used, this particular finding only cautiously suggests a relatively high tolerance of W_RS ≤ 25 J/min.1. Silva PL et al. Anesthesiology 2020;132:949. 2. Chiumello D et al. Crit Care 2020;24:417. 3. Berlin Taskforce. JAMA 2012;307:2526.

Previous abstract (Part 4) compared mechanical power transferred to the respiratory system (W_RS), in which below/above the 20 J/min threshold revealed a widening mortality departure (ie, 24% vs. 42% respectively). Those whose W_RS > 20 J/min accounted for 65% of subjects. Thresholds in plateau pressure (Pplat) > 30 cm H₂O and driving pressure (P_DR) > 15 cm H₂O are also associated with increasing mortality risk in ARDS.^1,2 This study examined the relevance of all three thresholds on mortality risk when compared to prominent non-pulmonary factors that drive mortality in ARDS.³

948 ARDS subjects previously described (abstracts part 1-4) had threshold values for W_RS, Pplat and P_DR compared to non-pulmonary factors (ie, age, ARDSNet study comorbidity exclusion criteria,¹ and APACHE II scores) both in univariate and multivariate logistic regression modeling. Alpha was set at 0.05.

In univariate analyses all variables were associated with mortality risk (P < .001). Low collinearity was found between dichotomous expressions of the inter-related variables W_RS, Pplat and P_DR (R²:0.19, 0.19, 0.23 respectively). Multivariate modelling revealed Pplat and W_RS thresholds, but not P_DR threshold, remained strongly associated with mortality when controlled for non-pulmonary variables (Table). Area under receiver operative curve of 0.80 (95%CI: 0.77-0.83), P < .001.

When lung protective ventilation is initiated ≤ 24 h after ARDS onset, exceeding Pplat and W_RS thresholds influences mortality rather than P_DR threshold > 15 cm H₂O.1. ARDS Network. N Engl J Med 2000;342(18):1301. 2. Amato MB et al. N Engl J Med 2015;372(8):747. Kallet RH et al. Respir Care 2019;64(5):493.

Patients on prolonged invasive ventilation following early intubation and the associated mortality rate during the COVID-19 pandemic have triggered the utility of noninvasive respiratory supports such as high-flow nasal cannula and noninvasive ventilation as an initial approach. Nevertheless, the patient's self-inflicted lung injury with worsened lung mechanics remains a serious concern, while delaying intubation with noninvasive respiratory support. Early reports during the pandemic also stressed viral aerosolization with noninvasive support, thereby creating debates among healthcare professionals to justify their actions. It eventually proved that the utility of the right noninvasive respiratory support for the right patients with the right protective techniques for the healthcare professionals warrants beneficial outcomes. This systematic review and meta-analysis aimed to compare the utility of high-flow nasal cannula and noninvasive ventilation, in terms of clinical outcome.

A sequential systematic review via PubMed and Scopus was conducted and then was followed by a meta-analysis. The results and the risk of bias were assessed using RevMan 5.4. The primary aim was to measure and assess SpO₂ and PaO₂ of patients under noninvasive respiratory support. The secondary outcome was to compare the length of hospitalization of patients and the mortality rate between high-flow nasal cannula and noninvasive ventilation.

In total, 7 studies from 3,010 studies were included for meta-analysis. The mean difference (MD) pooled was -4.38 [-18.40, 8.74] units and I² = 79% was observed for the oxygenation index in the 4 studies. Three studies were used to evaluate the length of hospitalization and the pooled MD was -0.07 [-0.78, 0.63] units, and I² = 9% was noted. Assessment of mortality rate was done in 3 studies in the noninvasive ventilation group and high-flow nasal cannula group. The pooled MD was 32.32 [-31.95, 96.43] units and I² = 100% was noted.

The use of noninvasive ventilation and high-flow nasal cannula in acute hypoxemic respiratory failure were compared in terms of oxygenation index, mortality, and length of hospitalization. High-flow nasal cannula was better in terms of improvement of oxygenation index, but noninvasive ventilation fared better in terms of lesser mortality. There was no significant difference in terms of length of hospitalization.

Risk of Bias traffic light plot

Choosing data to use when selecting students for a respiratory therapy (RT) program can be a difficult task. Information such as program grade point average (PGPA), Test of Essential Academic Skills (TEAS), core curriculum grades, and essay composition can be used for this task. Can combining these data points into one composite score (CS) predict successful completion of a respiratory therapy program and success on national credentialing exams?

Georgia State University (GSU) data was used for this study. A retrospective analysis of data submitted by students as part of the application process to GSU Respiratory Therapy (RT) program for years 2018-2020 was used. Admission data used for this study was TEAS, GPA, and calculated CS. Also used in the analysis were the Therapist Multiple Choice (TMC) exam and the Clinical Simulation Exam (CSE) taken after graduation from the program. Descriptive statistics and correlational analysis were used with SPSS 25 to examine data.

A total of 101 students completed GSU RT program in the 2018, 2019, and 2020 cohorts. Descriptive statistics for these cohorts reveal 21.8% (22) male and 78.2% (79) female. Additionally, 87.1% (88) identified as minority and 12.9% (13) identified as Caucasian. Means for this study are as follows: CS 31.09 (SD = 7.55), TEAS 75.43 (SD = 6.92), and PGPA 3.41 (SD = 0.31). Pearson correlation coefficient was computed to assess the linear relationship between CS and TEAS and CS and PGPA. There was a positive correlation between CS and TEAS r(98) = 0.378, P = < .001 and CS and PGPA r(98) = 0.818, P = < .001. Pearson correlation coefficient was also computed to assess the linear relationship between CS and TMC and CS and CSE. There was a positive correlation between CS and TMC, r(96) = 0.290, P = .004 and CS and CSE, r(93) = 0.245, P = .018.

Georgia State University (GSU) RT program is diverse and substantially female. The GSU derived CS had a positive correlation and was statistically significant between TEAS, PGPA, TMC and CSE. These finds suggests that CS is useful in selecting prospective RT students.

West Virginia has the highest prevalence of obesity in the US, with approximately 38% of its adult population classified as obese based on BMI in 2020. Obesity is a major risk factor for OSA, a common sleep disorder characterized by repeated episodes of upper airway obstruction during sleep. CPAP is a commonly used therapy for OSA. Adherence to CPAP can be challenging for some patients, particularly during inpatient stays. Adherence to CPAP is defined per Medicare guidelines as usage of greater or equal to 240 min. This study aims to evaluate whether having a personal connection to someone who uses CPAP is associated with better inpatient CPAP adherence for patients with OSA in WV.

IRB 2009120369 This study retrospectively reviewed the medical charts of 52 patients who had received inpatient CPAP for sleep apnea. The study collected the following data from each patient: apnea-hypopnea index (AHI), oxygen desaturation index (ODI), and inpatient CPAP usage in min. Patients with an AHI or ODI less than 5 were excluded from the study to ensure that only patients with clinically significant sleep apnea were included. The patients were also divided into two groups based on whether they reported knowing someone who used CPAP.

A total of 52 patients with a mean BMI 40.4 were included in the analysis, with 30 patients reporting knowing someone who used CPAP, while 22 did not. The mean inpatient CPAP usage for patients who knew someone who used CPAP was 300.77 min (SD = 111.76), while the mean usage for patients who did not know someone who used CPAP was 314.72 min (SD = 104.37). The difference in mean usage between the two groups was not statistically significant (P = .64). Patients who did not know someone who used CPAP had a mean AHI of 28.63 or a mean ODI of 34.99, while patients who knew someone who used CPAP had a mean AHI of 25.14 or a mean ODI of 42.83.

This study suggests that prior knowledge of CPAP use, does not significantly affect inpatient CPAP usage. The mean inpatient CPAP usage was similar for both groups. However, given the complex relationship between prior knowledge of CPAP and inpatient CPAP usage, healthcare providers should take a comprehensive approach to addressing patient concerns and promoting the benefits of CPAP, regardless of the patient's prior knowledge or experiences with the treatment. This study highlights the need for further research to understand the impact of prior knowledge of CPAP on inpatient CPAP usage.

Pulmonary rehabilitation (PR) programs are an effective non-pharmacological intervention for COPD patients that aim to improve the quality of life and lung function. PR has been shown to reduce mortality and morbidity. To enhance COPD management strategies, it is essential to examine students' perceptions toward PR programs. This study would also be considered one of the initial steps in developing a pulmonary rehabilitation education course in the curriculum of all healthcare programs at Georgia State University.

The data used for this study were collected from three different healthcare programs at GSU using a convenience sample, including respiratory therapy n = 77, physical therapy n = 71, and occupational therapy n = 30. Data were collected through a self-administered survey consisting of 28 questions on a 5-point Likert-type scale evaluating the perceptions. The survey was examined for face validity by respiratory therapy educators from GSU. IRB permission was obtained. Statistical Package for the Social Sciences was used to analyze each variable to identify differences in the perceptions of healthcare students toward PR programs for COPD patients.

The study findings revealed statistically significant differences in students' perceptions towards PR programs between healthcare programs. There was a significant difference in positive perceptions was found between students who had experience attending in PR and those who did not (P = .043). The study also showed that there was no significant difference in familiarity with PR programs between respiratory therapy students and other healthcare students. Finally, there were no statistically significant differences in students' perceptions towards factors that could influence COPD patients' decisions not to participate in the PR between healthcare students.

Healthcare students value and have a positive perception toward PR. The results of this study support the idea of the implantation of pulmonary rehabilitation courses throughout the healthcare program curriculum. Healthcare students felt that they had an important role in PR programs, but barriers to participating and assisting in PR included their own lack of knowledge, time, and clinical experience. They considered that there should be more teaching on pulmonary rehabilitation and that these should feature in both the curriculum and clinical. Further studies with a higher number of participants and different institutions are recommended.

Quality clinical education is essential in respiratory therapy education. However, many respiratory therapists who serve as clinical instructors lack formal pedagogical training and most respiratory therapy students have not previously engaged in clinical learning. It is known that misaligned expectations may cause conflict, dissatisfaction, anxiety, and attrition. The purpose of this study was to examine the expectations of clinical instructors and students regarding the Cognitive Apprenticeship Theory’s (CAT) teaching methods. University of North Dakota IRB approval was obtained.

For this quantitative survey study, a modified version of the Maastricht Clinical Teaching Questionnaire (MCTQ), a survey based on CAT teaching methods created by Stalmeijer et al was used. An invitation to participate was sent to and disseminated by program directors of entry level respiratory therapy programs accredited by the Commission on Accreditation for Respiratory Care (CoARC) in June of 2021. A total of N = 248 responses from clinical instructors (n = 85) and students ( n = 163) were collected and analyzed using descriptive statistics, independent t-tests, and Pearson correlation coefficient.

Results indicate that clinical instructors and students expect the teaching methods of the CAT to be used (average percentage of agreement 98.8% and 95.9%, respectively). Clinical instructors had statistically significant (P < .05) higher expectations than students regarding the expectations for clinical instructors to demonstrate how to perform skills (P = .019), adjust their teaching activities to the level of the students’ experience (P = .001), and to ask students questions to increase the students’ understanding (P = .006). No significant differences were found when comparing gender and type of credential held by the clinical instructor. A statistically significant positive correlation was found between the program degree level and the level of education completed by the clinical instructor. Statistically significant negative correlations were found between clinical instructor experience and the expectations for them to encourage students to formulate and pursue learning goals.

The findings clarify the expectations of clinical instructors and students regarding clinical education in respiratory therapy. Furthermore, the results support the use of the CAT teaching methods in the field of respiratory therapy to meet clinical teaching and learning expectations.

This figure outlines the domains of the Cognitive Apprenticeship Theory and was created based on the publication of Collins et al.²

This figure displays the percentage of entry-level associate, baccalaureate, and master’s degree programs and study participants.

A tracheostomy tube (TT) has been the solution to free patients from ventilatory support and maximize scarce resources in ICU. Adverse events such as TT dislodgement or obstruction are not rare. An article by Hess (2014) stated that caregivers should ensure that humidifiers and suction are set up correctly and that spare TTs of the same size and smaller are at the bedside for emergencies. With the increased tracheostomized population, there is a need for references for the nurses and a box for keeping emergency accessories.

We audited tracheostomy emergency accessories in a 700-bed tertiary care adult hospital in Singapore. Data were obtained from the tracheostomy study between May 2022 and March 2023. Observations recorded were the incorrect set-up of humidification, and missing or inaccurate emergency accessories, including TTs at the bedside. The NHG Domain-Specific Review Board (DSRB) approved the study (DSRB 2020-01138).

Preliminary results found that preparing tracheostomy emergency accessories could be challenging for nurses who seldom care for tracheostomized patients. This has resulted in high incidences (42.1%) of standby emergency TTs at the bedside being incorrect and (63.8%) not having proper tracheostomy accessories at the bedside. This is because TTs have many sizes and types; some use the Jackson sizing system, while others use the ISO system. We have standardized and use Shiley 4FEN (OD: 9.4mm) and Shiley 6FEN (OD: 10.8 mm) as emergency TTs. As a study has shown that adult females can accommodate a TT with an outer diameter (OD) of 10 mm, whilst an OD of 11 mm for adult males. All our patients have a TT inserted with OD ≤11.5 mm. A tracheostomy box, notably Trachi-Case, has been used in healthcare institutions. The case allows for placing additional TTs and all essentials in a handy carrying case, which the nurses can bring with the patient for transport. We created a cost-effective box with a reference guide that can be placed at the patient's bedside and used for transport. The tracheostomy box with all required emergency accessories was implemented in all wards in December 2022. There were significant reductions of 47.3% from an average of 1.9 errors per tracheostomized patient (6 months pre) to 0.8 errors per tracheostomized patient (6 months post).

A standardized tracheostomy box with a reference guide is useful for keeping a patient’s tracheostomy requisites together while providing useful instruction for inexperienced caregivers and providing contacts for tracheostomy care support.

Elderly patients often have poor inhaler technique, resulting in ineffective deposition of medication in the lungs. Low motivation, a short attention span, and poor medication adherence pose substantial challenges for health educators when teaching inhaler techniques. Regarding a solution to these challenges, this study compared the effectiveness of a traditional training method with that of a tailored training program in enhancing the inhaler technique of elderly inpatients in Taiwan.

Participants were randomly assigned to the tailored training group (TG) or routine training group (RG). The TG received three-step training involving scenario simulation videos, a standardized guiding video, and verbal corrections after the recorded videos (patient demonstration) had been played. The RG group received only verbal corrections from a respiratory therapist following self-demonstration after watching the inhaler guiding video. Inhaler technique was assessed by reviewing the videos recorded on days 1, 3, and 7. Data were analyzed using JASP, with descriptive statistics for patient characteristics. An independent-samples t test was used to compare critical error ratios, with statistical significance set at P < .05.The study was approved by the Institutional Review Board of Chang Gung Medical Foundation (approval no.202001107B0) and the procedures of this study adhered to the Declaration of Helsinki.

Achieving adequate inhalation was a challenging process; the success rate was 58.0% and 51.7% in the TG and RG, respectively. Analysis of the learning effect revealed a significant intergroup difference on day 7. The proportion of participants with critical inhaler technique errors was significantly lower in the TG group (TG = 0.42 ± 0.50, RG = 0.69 ± 0.47, P = .03).

Compared with traditional methods, the proposed tailored training program was considerably more effective in improving the inhaler technique of elderly inpatients. Scenario simulations enhance patients’ understanding of asthma and chronic obstructive pulmonary disease resulting from inhaler misuse. Video observation also aids in rectifying errors and overcoming reluctance to acknowledge mistakes. These findings can serve as a reference educational model for healthcare providers in hospitals. However, studies on a larger scale are required.

Pulmonary hypertension may occur after cardiovascular surgery, and inhaled nitric oxide (iNO) is expected to reduce pulmonary artery pressure and improve oxygenation. Pulmonary hypertension can occur even after cardiopulmonary bypass because of microemboli, ischemia, sedimentation of blood cells or stress reaction. iNO is a pulmonary vasodilation therapy in which nitric oxide (NO) is administered directly into the alveoli via the airways. iNO is transported to the alveoli by both convection and diffusion and is rapidly absorbed into the tissues where it relaxes vascular smooth muscle. NO binds to Hb (hemoglobin) in blood vessels and is inactivated within seconds. Therefore, it does not act on systemic vasodilation and selectively dilates only pulmonary vessels. However, sudden weaning can pose the risk of causing serious hypoxia and rebound hypertension. The purpose of this study is to investigate oxygenation response to initiation and withdrawal of iNO.

The study population included intubated adult iNO patients who had pulmonary hypertension (mean PAP ≥ 20 mm Hg) after cardiac surgery, admitted to the ICU. A retrospective chart review was conducted to P/F ratio, weaning time, rebound, and mortality rate. The study site was a 400-bed hospital in Osaka, Japan. 12 ventilated patients identified the date of iNO use (April 1, 2022–March 31, 2023) were enrolled in the study group. AINOMAX (Mallinckrodt Pharma) was used as an NO inhaler for adults. Wilcoxon signed-rank test was used to analyze the data. Institutional Review Board (IRB) approval was obtained.

There was not significant difference in P/F ratio between pre and post initiation of iNO therapy (104.1 [81.9–174.3] vs. 155.5 [111.8– 220.8], P > .05). There was significant difference in P/F ratio between pre and post withdrawal of iNO therapy (234.5 [209.8–303.8] vs. 191.6 [153.8– 235.3], P < .05). Median of iNO therapy time, total weaning time, and 1 ppm to 0 ppm weaning time were 93 hours 24 min, 8 hours 38 min, and 48 min [30–127], respectively. Rebound occurred in one patient (8 %). 1 ppm to 0 ppm weaning time of the patient with rebound was 20 min. Mortality rate was 33.3%.

Oxygenation response to withdrawal of iNO differed in adult patients with pulmonary hypertension after cardiac surgery. Patients with pulmonary hypertension after cardiovascular surgery had a mortality rate of 33.3% and weaning must be performed carefully to avoid rebound.

There has been a push toward degree advancement by the respiratory care profession, with many academic institutions creating graduate-level degree advancement programs. However, many practitioners have been apprehensive to advance their degrees past the entry-to-practice level. Little research exists regarding the benefits of obtaining a graduate- level degree in respiratory care through degree advancement.

A descriptive survey was developed to identify perceived benefits of completing a MSRC program. Graduates from a single institution were asked to participate to identify how efficacious the program was in preparing graduates for new or expanded roles as well as other tangible benefits attribute to earning a degree advancement MSRC. 50 graduates were invited to complete the anonymous web-based survey. A total of 37 surveys were initiated (74%) and of those, 70 % were completed. A descriptive analysis was conducted, and a thematic review of open-ended questions was performed to identify themes related to graduates’ perceptions of the efficacy of the degree. The project received Institutional Review Board approval.

71.4% of respondents indicated that the motivation for pursuing a graduate-level degree was entirely personal. 44.4% of respondents did not receive any type of tuition reimbursement for degree advancement and 97.14% indicated that they did not receive any type of scholarship towards the completion of the degree. 85.7% of respondents indicated that the program prepared them to assume new or expanded roles. Additionally, respondents reported that the degree contributed to approximately an 11% increase in annual salary. Thematic analysis of the responses indicated primary themes of invigoration, preparedness, and general concern for the support of degree advancement within the field.

Attainment of a graduate-level respiratory care degree through degree advancement is heavily reliant on intrinsic motivation of practitioners. There remains little financial support from employers for practitioners to advance education beyond the clinical requirements of either licensure or scope of practice. However, graduates of a single institution’s MSRC degree advancement program indicated that earning a MSRC degree supported educational development, contributed to new or advanced roles, and contributed to a tangible increase in annual salary. Additional research is needed to investigate the extent to which these findings are consistent across academic institutions.

Interventional pulmonology is an evolving specialty with a board certification for physicians. The specialty is technology-dependent. Respiratory therapists play a crucial role in assisting interventional pulmonary programs throughout the country. It is of paramount importance to have a structured curriculum for respiratory therapists to understand the various devices and disease processes to enable them to be efficient team members. We formalized a structural process of training with an introductory course in interventional pulmonology to assess and evaluate the competency gained before and after the administration of the training.

The curriculum consisted of a preliminary evaluation of knowledge base in interventional pulmonology followed by a structured lecture on various parenchymal, airway, and pleural diseases. The devices that are used in procedures related to each part of the lung, device-tissue interaction, and performance were emphasized. Subsequently, a post-instruction evaluation was conducted in a multiple-question format with a single best answer. Knowledge before and after the instructional course was evaluated. The study was exempted by the Institutional Review Board (186-SB23-045).

The class average on the pre-test was 62.8% ± 9% (mean ± 95% CI). A total of 6 out of 15 students (40%) met or exceeded the criterion of success for the pre-test. The difference between the pre-test score and the criterion of success was not statistically significant: t(14) = - 1.55, P > .05. The difference between these scores had a small effect size (Cohen’s d = - 0.4). The class scores on this test approached the criterion of success for this assessment. The class average on the post-test was 85.9% ± 8.4% (mean ± 95% CI). A total of 12 out of 15 students (80%) met or exceeded the criterion of success for the post-test. The difference between the post-test score and the criterion of success was statistically significant: t(14) = 3.73, P < .005. The difference between these scores had a large effect size (Cohen’s d = 0.96). The class scores on this test greatly exceeded the criterion of success for this assessment.

Our study demonstrates that an introductory course in interventional pulmonology enhances the knowledge base of respiratory therapists in the field. Larger studies are needed to further validate this data.

Tracheostomy is a common procedure in critical care units. Many of those patients are breathing spontaneously and require nebulization to treat their underlying conditions. However, optimal aerosol delivery methods for these patients remain unclear. Thus, we aim to assess the impact of various factors on aerosol delivery, including nebulizer placements, flow settings, and interfaces, using vibrating mesh nebulizer (VMN) in-line with unheated humidification via large-volume nebulizer (LVN) for tracheostomized patients with spontaneous breathing, and compare it to conventional nebulization using jet nebulizer (JN) or VMN.

An adult tracheostomized spontaneous breathing model driven by a critical care ventilator was utilized, an 8.0 mm tracheostomy tube was connected to the lung model through a collecting filter. An Albuterol sulfate of 2.5mg/3mL was delivered via a VMN, which was placed in-line with LVN with FIO₂ set at 0.28, in comparison to conventional nebulization using JN and VMN. The in-line aerosol delivery was compared at nebulizer placements of distal versus proximal to the lung model, using trach collar versus T-piece, and gas flows of 2 versus 6 L/min. Each condition was tested five times. The drug was eluted from the collecting filter and assayed with ultraviolet spectrophotometry (276 nm).

When VMN was placed in-line with LVN, the inhaled dose with the gas flow set at 2 L/min was 2-4 times higher than that with 6 L/min, regardless of the nebulizer placements and interfaces (all P < .01). The inhaled dose with VMN placed proximal to the lung model was higher than distal placement with both interfaces at 6 L/min (both P < .05), but lower at 2 L/min using tracheostomy collar (23.0 ± 1.6 vs 19.9 ± 1.1%, P = .016). Compared to the tracheostomy collar, T-piece had a higher inhaled dose at 6 L/min but a lower inhaled dose with VMN placed distal at 2 L/min (all P < .05). Regardless of the nebulizer placement and interfaces, the inhaled dose with VMN placed in-line with LVN at 2 L/min was comparable to that with conventional nebulization using VMN but higher than JN.

Aerosol delivery via the in-line placement of VMN with an LVN was significantly affected by nebulizer placement, interface, and gas flow settings. The inhaled dose increased as the flow decreased. At low gas flow settings (2 L/min), the inhaled dose was similar to that with conventional nebulization using VMN and tracheostomy collar.

A) Study set-up, B) Proximal in-line placement with T-piece, C) Proximal in-line placement with tracheostomy collar, D) Distal in-line placement.

Several studies described the relationship between stress and asthma. However, there is a shortage of literature that explains this relationship in the Arab region. This research aimed to investigate the association between psychological stress level and bronchial asthma among adult asthmatic individuals in Saudi Arabia, and to analyze the mechanism of the effect of psychological stress on asthma.

The study was conducted among adult with asthma age ≥18 y in Saudi Arabia. The collected sample size was 733 participants, and data collection tool was an online questionnaire on asthma and stress scales.

The internal consistency for stress scale was (0.728) and asthma (0.819), out of total participants, 52% were female and 48% were male. The majority of participants were 18–26 y old (48.7)%. The low and high levels of asthma were found to be 20.3% and 54.6% respectively. The majority of participants had a high level of stress (85.4%). The Pearson correlation coefficient was calculated at (-0.216, P < .05) which indicated that high level of stress lead to poor asthma control.

Psychological stress was significantly associated with asthma exacerbation and pathogenesis. Therefore, asthma patients must control their stress level in order to manage their asthma symptoms.

Plot box shows the difference in the extent of asthma control between male and female using asthma control scale.

Perceived organizational support (POS) has been linked to employee commitment, and job satisfaction. Understanding the effects of POS on employees allows leaders to improve employees’ performance and institutions’ success. This study aims to identify the POS across different respiratory care education (RCE) programs in the U.S. and determine the impact of program components on POS in RCE.

After obtaining approval from the institutional review board (IRB), all chairs and program directors of the bachelor’s (B.S.) and master's (M.S.) degree RCE programs in the U.S. were surveyed (n = 97). The Survey of Perceived Organizational Support, developed by Eisenberger et al, was modified after written approval. The final instrument included 31 items, including student-, program- and participant-related components, with a Likert scale (1 = strongly disagree, 7 = strongly agree). Descriptive statistics, multiple regression, and topic modeling (machine learning) were used for data analysis (P < .05).

A total of 67 participants responded to the survey with a 69% response rate. They are satisfied with their job and committed to their institutions. They also reported that faculty salaries are equitable relative to the national average, and their institutions encourage teamwork among faculty. The participants’ titles (P = .023,) total years of administrative experience (P < .001), students’ scores (P = .001) on the national credentialing exam (TMC), and institutions offering both B.S. and M.S. degree programs have a direct relationship with POS in RCE programs (P = .005). Age (P = .001) and gender (P = .029) were inversely related to POS. A topic modeling analysis (Figure 1) based on the participants’ opinions about POS showed that the words frequently mentioned by the participants included support, institution, budget, year, nursing, and experience. Participants emphasized the importance of support, institution marketing, their years of experience, and the program budget. They also mentioned that nursing programs overshadow RCE programs at their institutions.

Age, gender, job title, years of administrative experience, TMC scores of students, and the type of programs offered impact POS by respiratory care directors. Student-, program- and participant-related components can be used to improve POS in RCE.

Respiratory therapists (RTs) now face both problems and possibilities as a result of the profound changes in healthcare over the decade that has passed. In order to determine RT recruitment and retention, it will be crucial to consider how they perceive their career prospects and level of job satisfaction. However, no research has been published that thoroughly evaluated these factors using a valid and accurate RT-specific metric. The creation and psychometric testing of a standardized questionnaire for assessing RTs’ general job satisfaction was our goal.

A primary questionnaire for exploratory factor analysis was prepared following expert consultation and RT interviews. A confirmatory factor analysis was performed on the 49 items of the structured questionnaire to corroborate the theorized factor structure and content validity. Confirmatory factor analysis, structural equation modeling (SEM), and principal component analysis were performed for the global fit. The internal consistency was estimated using Cronbach's alpha. In India, RT samples were collected between August 2021 and January 2022.

409 RTs who work in India participated in the survey between June 2021 and January 2022 as a convenience sample. Three variables were found by the exploratory factor analysis to account for 61.2% of the total variance. (X2/df = 4.4, P = .02, standardized root-mean-square residual = 0.05, goodness of fit index = 0.94, comparative fit index = 0.98) The confirmatory factor analysis produced a 3-component structure. The whole scale's Cronbach's alpha was 0.94.

Exploratory factor analysis and confirmatory factor analysis are statistical methods that are commonly used in the development and validation of measurement instruments. These methods are particularly useful for evaluating the reliability and validity of questionnaires that assess the perceptions, satisfaction, and attitudes of individuals. The structured questionnaire, which has been developed using exploratory factor analysis and confirmatory factor analysis, is a reliable and valid tool that can be used to assess the perceptions, satisfaction, and attitudes of respiratory therapists. The questionnaire can also be used to compare similar psychometric measures across different groups or settings. Overall, these methods and the resulting questionnaire provide a rigorous and robust approach to measuring complex constructs and can help to ensure that researchers and practitioners have access to high-quality assessment tools.

Structural Equation Modelling (SEM) results of the confirmatory factor analysis for the three-factor model (Standardized estimates)

Pressure injuries (PI) are serious, reportable adverse events that cause pain, infection, and prolonged hospitalization. They are defined as an injury to the skin caused by pressure or shear. Some of the most serious PIs can even necessitate surgery. Many PIs in neonates are caused by respiratory devices. This can prevent the use of noninvasive ventilation (NIV), necessitating invasive ventilation. As such, prevention of device-related injury, early detection, and management are essential to decrease the severity of PIs. A PI prevention program may result in increased reporting of injuries as caregivers become more diligent in documenting and investigating potential injuries. Staff trained in device selection, application, and use of barriers can improve the success of NIV in the neonatal population.

A multidisciplinary approach using evidenced-based practices to evaluate the impact of implementing a bundle for skin care practices was applied. PI data specific to respiratory devices was evaluated and shared. A pareto chart of causes identified the areas of focus for the improvement plan. A team of bedside champions was provided detailed education and tools for NIV device choice and maintenance while also identifying early possible pressure injuries at the bedside. This workshop presentation with videos and graphics reviewed the selection and application of various NIV interfaces and appropriate pressure redistribution devices and nuances of each. The training culminated with learners being evaluated on conducting skin assessments, identifying, and preventing issues that contribute to NIV-related PIs using a standardized checklist, and a discussion on the importance of frequent and thorough skin assessments. IRB approval obtained.

Following the implementation of these prevention strategies, the total number of PIs was unchanged, but severity decreased. Data showed that the number of stage 1 pressure injuries increased by 70% (pre n = 14, post n = 20) and after implementation no stage 4 pressure injuries were recorded (Figure 1). This positive change represents an awareness of staff to monitor and report potential PIs before the severity worsens.

The adoption of clinical practices supported by evidence aiming for the best long-term outcomes for these patients was challenging. A multidisciplinary team approach and the implementation of a prevention bundle contributed to reducing harm, while allowing for continued use of the appropriate NIV support for these patients.

Figure 1

Varying levels of experience and skill pose challenges when orienting new respiratory therapist (RT) graduates. Many orientation processes lack standardization and make verification of the orientee’s readiness for independent patient care assignments difficult. Hypothesis implementation of a standardized simulation-based ICU orientation course for new RT graduates will improve their critical thinking skills, communication, troubleshooting, and confidence.

IRB exempt status was granted. Scored ICU orientation preceptor evaluations were obtained for both RTs completing our traditional orientation (control group) and RTs completing our novel simulation-based orientation (intervention group). RTs that attended the intervention were asked to complete pre- and post-course self-assessment evaluations which were used to measure confidence levels. Ordinal ICU orientation preceptor evaluation scores were compared across the orientation styles with Wilcoxon rank-sum tests. Stewart Maxwell and McNemar tests were used to assess changes in self-reported confidence levels among the intervention group. P values ≤ .05 were considered to indicate statistical significance.

There was a significant shift toward higher RT confidence in 9 out of 15 competencies and 3 of 7 course objectives (P < .05). There was not a significant difference in the minimum or maximum overall preceptor evaluation scores when comparing the orientation styles (P = .33 and P = .13, respectively). For individual evaluation subscales, the intervention group achieved significantly better clinical decision-making subscale scores than the control group (P = .05) when considering their best score.

Utilizing a simulation-based orientation course led to improvement in self-confidence and critical thinking skills among new RT graduates beginning their ICU orientation. It has also resulted in improved productivity as it is no longer necessary to pull preceptors from patient assignments to complete competencies with their RT orientees. Most importantly, this new orientation course has resulted in the standardization of ICU orientation across multiple hospitals in the Cleveland Clinic Health System. The use of facilitators trained in simulation education has strengthened our ability to provide standardized training and assessment of competence throughout the course. Further investigations and literature are imperative to develop new RT orientation best practices.

Bag suction, a variant of manual hyperinflation, is frequently employed as a pulmonary hygiene technique in our pediatric intensive care unit (PICU). This practice involves scheduled disconnection from the ventilator, attaching a patient to a flow-inflating bag, manual ventilation, instilling normal saline, and suctioning the airway. Bag suction lacks standardized guidelines and uniform definitions, leading to variability. We undertook a quality improvement project aimed at evaluating the necessity and effectiveness of bag suction and examining the possibility of discontinuation.

We conducted an audit of bag suction utilization at our institution, comparing its use to other pulmonary hygiene practices used in our PICU. We used workload tracking to gather metrics related to patients receiving invasive ventilation and bag suction, or other therapies. Stakeholders identified the reason for use, the most important components, and perceptions surrounding the practice. A survey composed of open and closed-ended questions, was disseminated to the PICU primary team and members of the PICU intensivist team. Education was implemented to reduce or eliminate bag suction in alignment with evidence-based recommendations derived from the audit and literature review. The findings were presented to stakeholder groups at several presentation sessions.

Stakeholder engagement demonstrated significant variation in reported perceptions, indications, goals, and methods. Consisting of 22 responses from respiratory therapists and physicians, the survey identified highly variable pressure targets. The audit revealed a high rate of bag suction utilization prior to education, with a reduction from an average of 29.3% for patients receiving invasive ventilation to an average of 9.9% following the presentation of our findings. After providing education, the decision was made to discontinue workload point allocation for this practice.

Bag suction presents certain risks and does not show superiority over other available techniques. The use of a mechanical ventilator for lung expansion and minimizing saline instillation aligns more with evidence-based practice standards. Suction application should be driven by patient needs rather than a rigid schedule. The substantial reduction in bag suction following education interventions signals the potential for a phased-out discontinuation. This change necessitates sustained education and evidence-based policy adoption.

Mechanically Ventilated with Bag Suction orders

Endotracheal intubation is an invasive procedure commonly performed in the NICU. Direct laryngoscopy (DL) is the standard technique, while video laryngoscopy (VL) is a newer tool developed in the last 15 years. VL has been shown to increase the success rate of first-attempt intubations and potentially decrease complications such as trauma to the airway, hypoxemia, and esophageal intubation. VL technology was introduced to this NICU in May 2022.

A survey was administered to the respiratory therapy staff in March 2023, ten months after VL implementation. The survey collected both qualitative and quantitative data using open-ended questioning and the Likert scale. All full-time, part-time, and per diem staff who had used the VL were eligible to participate. The survey response rate was 66%.

RT staff were asked to recall their most recent intubation assists in the NICU and whether the intubating physician or nurse practitioner used VL or DL. Those who used DL most recently stated that VL was not used due to physician/NP preference or lack of immediate availability of VL equipment in the unit. RTs reported similar comfort levels in assisting with VL intubations compared to DL; however, RTs had a low level of confidence in providers' ability to successfully intubate with VL.

Two barriers to VL use were identified: training/education, and physical availability. RTs reported that more education is needed for providers. All RTs responded they would attend additional training sessions for the VL. The RT department had varying practices when preparing for an intubation; some RTs would bring the VL, while others would wait for the intubating provider to request the VL. In an open-ended survey question, multiple RTs described the location of the VL, stored in the RT office, as an impediment to its usage. Limitations: The NICU is within a teaching hospital, therefore trainees are able to practice their intubation skills regularly. RT confidence in provider ability may vary depending on the experience of the provider and is not necessarily VL- or DL-dependent. Recommendations: Two educator roles have been established in the RT department to assist with training and implementation of new technologies and best practices. Additionally, there is a plan to relocate VL equipment to the in-unit airway carts to improve accessibility. Further study is needed to determine if VL has decreased intubation attempts and the associated negative sequelae in this department.

Respiratory therapists (RTs) are specialized healthcare professionals who play a critical role in managing patients with respiratory diseases. The prevalence of respiratory illnesses is significant in India, and there is a rising need for proficient RTs. However, there is a shortage of qualified RTs in the country, and retaining qualified RTs is a significant challenge for healthcare organizations. This cross-sectional study aims to address the gap in the literature by assessing the perceptions and attitudes of RTs toward career progression and job satisfaction in India.

A convenience sampling technique was used to perform this study among RTs all over India. Prior to participating in the survey, informed consent was obtained, and the host institution granted institutional ethical clearance. Data were gathered using a self-administered questionnaire with a 0.94 Cronbach alpha score. The data were summarized using descriptive statistics including frequencies, percentages, averages, and standard deviations. To evaluate the association between variables, inferential statistics including chi-square tests, t-tests, and regression analysis will be employed. The Declaration of Helsinki's ethical guidelines were followed when conducting the study.

The survey had been completed by 388 RTs in total, and the results were analyzed. The majority of them were from Karnataka (27%; n = 106), Kerala (19%; n = 72), and Tamilnadu (16%; n = 64). 79% (n = 307/388) of the respondents had a bachelor's degree in RT, and 93% (n = 361/388) of the respondents were employed full-time. RTs with less experience and lower incomes were both 5.77 and 4.55 times more dissatisfied with their profession and type of job, respectively. Half of the respondents (52%) disagree that they were frustrated with their profession, while only 40% of the participants agreed that RTs were paid a fair amount for their work. However, 78% of the participants were happy with their work profile as an RT.

In conclusion, this cross-sectional study sheds light on the perceptions and attitudes of respiratory therapists (RTs) in India toward career advancement and job satisfaction. The study revealed that there is a high level of job satisfaction among RTs in India, with a majority of participants reporting satisfaction with their work profile. The findings of this study may be useful to healthcare organizations and policymakers in developing strategies to attract and retain qualified RTs in India.

The pediatric population has a long history with trach-dependent patients. Families often need education before taking their trach-dependent child home. The bedside respiratory therapists (RTs) have been responsible for educating families about their child’s trach. This process was not streamlined. Trach education was inconsistent. A house-wide trach collaborative committee (TCC) was formed, and consistent educational resources have been made available with easier access. The TCC and the RT dept determined the next step would be to create a position for a trach education specialist (TES). This position is full-time and duties for this position include teaching trach families about the trach so they will be prepared to take their child home. The TES serves as a clinical expert to help the bedside RTs answer questions and assist families with their child’s trach needs.

The purpose of the study is to compare pre and post implementation of the TES position. A Likert scale survey was sent out to the RT dept prior to the TES position to understand the baseline knowledge and what areas of concern could be improved, if any. Once the areas of concern are identified then interventions would be implemented to target the needs. The objective was to compare if the TES is beneficial to the RT department and, more specifically, to the clinical RTs who encounter trachs frequently. After the TES position was established and fully functioning another survey was sent out to the clinical RTs to measure the impact of the TES.

The areas of concern included the comfort level of the bedside RTs, locating reference materials, caring for a fresh trach and mature trach, and educating family on trach care. We also focused on increasing awareness on how to contact the TES and TCC. The interventions implemented to increase awareness of the TES were an email introduction to staff, TES on volate, and contact information listed on TCC webpage. The TES engages with staff and self-promotes the role.

The RTs have tremendously benefited from the TES. There was a 16% increase in the awareness of where to locate reference materials. When caring for a fresh trach we noticed a 27% increase in knowledge and comfort level of teaching. RTs’ comfort level in teaching families about a mature trach increased by 23%. Discharge education comfort level increased by 27%. Awareness of how to contact the TES increased by 16%. An increase of 42% on how to find the TCC webpage. Well over half of our clinical staff now use the TES during their shifts.

The use of ultrasound (US) has become a mainstay for a variety of vascular procedures, but there is little research on the efficacy of using ultrasound for arterial blood gas (ABG) sampling. Obtaining an ABG sample is a task frequently performed by respiratory therapists (RTs) under scope of practice, however, little is understood about how much time is dedicated to the procedure in many entry-to-practice respiratory therapy education programs. In order for RTs to perform this procedure effectively in the clinical setting, it is essential to introduce theoretical, application, and practice-based opportunities in a low-stakes educational setting. The purpose of this study was to establish a baseline understanding of ABG draws under US guidance and compare it with post-education module performance using a web-based assessment in a sample of RT students at one institution.

13 entry-to-practice students enrolled in a baccalaureate respiratory care program at a four-year institution consented and participated in this study. All had met previously established competency requirements to obtain ABGs and all had successfully obtained an ABG sample on at least one patient in clinical practice. Participants were first asked to complete a web-based assessment to identify their experience with US-obtained ABGs, comfort level with US, and questions related to US technology and the use of US to obtain an ABG. Following this, students attended a 40-minute lecture which covered an overview of US technology, use of US equipment, how to identify an artery under US, and how to guide a needle tip into the arterial lumen. Participants were then afforded time to practice identifying their own arteries under US and to practice guiding a needle tip into latex tubing which had been submerged in phantom gel. Participants were then asked to complete a post-assessment to ascertain whether there was growth in understanding of the procedure. This project received IRB approval from the educational facility.

A paired t-test was used to evaluate the data. There were significant differences in the mean self-reported comfort level (1.58 vs 3.75, P < .001) and number of correct answers (2.77 vs 5.83, P < .001).

An educational module consisting of lecture and hands-on practice was effective in increasing the comfort levels associated with the basic understanding and application of US as a method of ABG sampling in the clinical environment.

Retention of respiratory therapists (RTs) has been a major challenge across the nation. The prevailing approach is to apply linear thinking which reduces the problem and its solution to additive parts, such as increasing pay rates. This mode of thinking does not adequately consider the characteristics and influences of the containing system, the many elements within the problematic organizational system or their interdependencies and interactions. Retention may be better framed as a complex system problem wherein organizations are social systems which include members and groups who collaborate within and between social sub-systems (Figure 1). In this project, retention of RTs is framed as a complex system problem that requires a complex system thinking approach to frame, navigate, and solve.

Navigating complex systems problems requires systems-informed methodologies and tools. This project utilized the Cynefin Framework to frame the problem and interactive planning and idealize design to develop a prototype to solve or dissolve the problem. Interactive planning is a methodology where the problem’s stakeholders creatively design a new system for RT retention based on what is viable, feasible, and desirable. The process generates elements of a prototype design in which current and future challenges of RT retention would not occur. Using an influence-interest matrix, 70 stakeholders from Thomas Jefferson University Hospital were identified and invited to participate in a volunteer workshop. The research was considered exempt by Jefferson IRB.

Of those contacted, 24 responded positively, and 14 attended a workshop facilitated by three systems-educated practitioners. The data that emerged from the design session were collected and coded which created 27 codes and 8 code. Data were categorized into the following: Mission Statements, Value Propositions, Functions/Outputs, Processes, Structure, and Financial.

An iterative model for the ideal RT retention system emerged (Figure 2). The system was designed to evolve and adapt in cycles based on the changing environment which will influence subsequent iterations of the system. The components are interconnected and interdependent rather than linear and additive. Critical elements of culture, professional development and educational partnership rarely part of a traditional retention system were identified and integrated.

The abuse of nicotine through cigarette smoking is the prime cause of preventable death in the United States. Globally 8.7 million people succumb every year from tobacco-associated issues. There are a multitude of performed and investigated interventions for smoking cessation including pharmacologic, non-pharmacologic, and combination interventions with the goal of achieving tobacco abstinence. In our investigation, we sought the answer to: Does the delivery of current and emerging smoking cessation interventions have an impact on the effectiveness and success of becoming a non-smoker?

After obtaining IRB approval an extensive literature review was performed utilizing CINAHL, PubMed, Google Scholar, Health Reference Center-Academic, databases. Inclusion criteria for this study focused on smoking cessation interventions and their impact on the success of becoming a non-smoker, utilizing a systematic review to define Populations, Intervention, Comparison, and Outcomes (PICO) parameters. A meta-analysis consisting of the statistical evaluation of smoking cessation research studies was performed to combine the results of comparable studies and clinical trials.

Of the studies examined, (117,215), 26 were defined as appropriate for inclusion, with 14 studies initially selected (12 randomized controlled trials and 3 observational studies) met the inclusion criteria. A total of 265,874 participants were included within this meta-analysis. The reviewed interventions consisted of pharmacological, non-pharmacological, and combination interventions. Of the reviewed studies, combination intervention success rates for abstinence were 25%, (>1 year), Although success rates for pharmacological interventions revealed a statistical significance with an abstinence success rate of 27.3%, our meta-analysis revealed an impressive 32.8% abstinence success rate for non-pharmacological interventions.

This investigation sought the answer to current smoking cessation interventions and if the method of delivery and experiences had an impact on the effectiveness and success of becoming a non-smoker. This investigation revealed the dominance of non-pharmacological interventions over other individual smoking cessation interventions to have the most impact on smoking abstinence. Since this is a pilot investigation, more research may be needed to yield a higher understanding of emerging interventions.

Intrapulmonary percussive ventilation (IPV) facilitates airway clearance in small to mid-sized airways and promotes alveolar recruitment in diseases such as bronchiolitis, characterized by inflammation of lower airways, increased mucus production and increased airway resistance (R_aw). However, in a recent adult model, excessive PIP was reported with IPV during instances of high R_aw. The purpose of this study was to investigate pressure delivery between two IPV models in a simulated spontaneously breathing infant intubated for bronchiolitis.

Six IPV devices, (3 IPV-1C and 3 IPV-2C, Percussionaire) using the same sliding venturi (Phasitron 5, Percussionaire) were connected to a lung simulator (ASL 5000, Ingmar Medical) via a 3.5 ETT and set to simulate a 5 kg 3 month old infant intubated for bronchiolitis (inspiratory and expiratory R_aw of 142 and 158 cm H₂O/L/s, respectively, C_L of 4 mL/cm H₂O, frequency 40 breaths/min, Ti 0.5, P_mus was set to achieve V_T of 5 mL/kg). Settings based on previously published data of infants intubated for bronchiolitis. All IPV devices were tested at 30, 35, and 40 psi with frequency set at easy, mid, and hard. For the IPV-2C; demand valve, Ti, and inspiratory flow were set in 12 o’clock position. Tracheal (distal to ETT) and alveolar (distal to R_aw) MAP and peak airway pressures (P_aw) were obtained over four spontaneous breaths for each scenario. Values above 95th percentile were used to calculate Paw. Overall results for IPV models were based on average of each device (no. = 3). Descriptive statistics, T-test, and one-way ANOVA with Holm-Sidak were used for comparison between IPV models and intra-device variability.

As shown in Table 1, the IPV-1C delivered significantly higher MAP (∼30%) and P_aw (∼31%) in all tested scenarios compared to the IPV-2C (P < .001). Alveolar P_aw was significantly less (P < .001) than tracheal P_aw in all scenarios. The highest alveolar P_aw value (43.40 cm H₂O) was observed at 40 psi and mid setting with the IPV-1C. Significant intra-device variation was found in 25/27 comparisons with the IPV-1C, and 23/27 with the IPV-2C (P < .05).

In this simulated infant model with high R_aw, significant differences in pressure delivery were observed between IPV devices and models. While attenuation of tracheal to alveolar P_aw was observed, clinicians should be aware of potentially elevated MAP and P_aw when using operating pressures above 30 psi and/or at lower frequencies.

Healthcare practitioners' daily practices may be enhanced by incorporating evidence-based practice (EBP), which could potentially contribute to better patient outcomes. It is essential for respiratory therapists (RTs) to build their body of knowledge, standardize practice, and improve patient outcomes. This study intends to investigate the EBP beliefs and practices of RT students, as well as the changes in these views and practices caused by earlier EBP training and the implied relationships between them.

A cross-sectional survey design was used with a convenience sample of 171 RT students from two public universities in the Kingdom of Saudi Arabia. Students were asked to answer the questions in the Evidence-Based Practice Belief and Implementation scales. The Declaration of Helsinki's ethical guidelines were followed when conducting the study.

This study revealed that the mean total belief score among the students were 62.04 out of 80 (SD = 11.94). They did, however, observe an implementation score of 29.74 out of 72 (SD = 12.05), which is substantially lower. Students who received EBP training or received neither reported that their overall belief score did not differ much. However, there was a considerable difference in between both groups' total implementation scores. Finally, even though there was no significant correlation between the two groups' belief ratings (P > .05), there was a substantial correlation between their implementation scores (P < .05).

Teaching RT students how to access, evaluate, and appropriately apply evidence-based knowledge is crucial for advancing the science of respiratory therapy, improving practice for aspiring RTs, and improving patient outcomes.

Demographic Characters

Pulsed oxygen sources rely on pressure triggering to detect inhalation: during inhalation, room air entrainment creates a small drop in pressure monitored through the cannula tubing, referred to herein as the signal pressure. When the signal pressure exceeds the triggering threshold of a pulsed-flow oxygen device, a pulse of oxygen is released. Patients may struggle to trigger oxygen delivery during sleep, oral breathing, or other circumstances characterized by low nasal inhalation flows. To address this issue, a new nasal interface that can provide higher and more consistent signal pressures is being developed.

Eight volunteers ranging from 22-47 years old participated in the study. Each volunteer was asked to breathe at different flows through their nose while connected to an oxygen tank with a Philips SimplyGo Mini POC, an OxyGo Next POC via standard nasal cannula, or the new nasal interface. A Precision Medical Easy Pulse 5+6 oxygen conserving device was used with the tank. To monitor flows, a respiratory belt (Respiration Sensor, TTLP2HRVSYS, Bio-medical Instruments, MI) was strapped around each participant’s chest. The respiratory belt was calibrated using spirometer data (MicroLoop Spirometer, #ML3535-S, Micro Medical, ME). Tests were repeated while participants breathed through their mouths. Video recordings with a close-up view of the oxygen sources were used to detect pulse triggering. Each participant breath was retroactively matched with a pulse/no pulse response, and the number of pulses was divided by the number of breaths to calculate triggering success rates. A two-tailed t-test (P <.05) was conducted with triggering success rate as the dependent variable and cannula type as the independent variable. Ethics approval was granted by the NAIT Research Ethics Board.

Pooled across all study conditions, triggering success rates were significantly higher (P = .03) when using the new nasal interface (78.9%) compared to the standard nasal cannula (65.2%). When using a standard nasal cannula during oral breathing, mean triggering success rates were below 40% for all oxygen sources. Using the new nasal interface approximately doubled oral breathing triggering success rates.

Reliable breath detection is an issue when using pulsed-flow oxygen sources, especially during oral breathing. Significantly improved breath detection was observed when healthy participants used the new nasal interface versus a standard nasal cannula.

Figure 1: Average triggering success rates (%) when using a Standard Cannula and the New Nasal Interface. Error bars represent standard deviations. Data is pooled across all breathing patterns and oxygen sources.

Figure 2: Triggering Success Rates during Oral Breathing sorted based on Cannula Type and Oxygen Source. Error bars represent standard errors.

Game-based learning is considered a best practice in education. Learners are motivated when using games and they have been successfully introduced in many healthcare topics, such as medicine. The aim of this study was to increase along with evaluation of their effect in terms of engagement, learning, classroom dynamics, concentration, motivation and enjoyment on the respiratory therapists (RTs).

This study was conducted at a teaching hospital in central Taiwan. Subjects included 16 RTs in the period 13th April 2022. Each team was composed of 8 RTs. There were two groups: Full Kahoot! and no music or points. First, the teacher introduced the lecture by presenting the agenda and the current topic. Second, the teacher taught the topic software engineering using Kahoot! The procedure was that first the RTs were asked a question in Kahoot! and got their chance to respond. In the experiment we made variations in the use music and points for the two parallel lectures. A Kahoot! Jumble consisting of the same 10 questions on software engineering was used in all parallels. The RTs were observed during lecture from the perspective of classroom dynamics. Third, the RTs filled in a questionnaire electronically using Kahoot!.

In the analysis we looked at differences in RTs’ motivation, enjoyment, engagement, and concentration in regards to the used jumble method. This section also reports on differences in the learning outcome. Table 1 showed the descriptive statistics and the results from the Kruskal-Wallis test for statements related to concentration, engagement, enjoyment, perceived learning, and motivation. Among the Concentration (statement 2, P = .001), Engagement (statement 4, P = .002), Enjoyment (statement 5, P = .03), and Motivation (statement 9, P = .009) were statistically significant.

The majority of these papers show that game-based learning has a positive effect compared to more traditional learning methods. However, Kahoot! can encourage RTs in engagement, learning, increased to classroom dynamics, concentration, motivation and enjoyment.

In critical cannot intubate cannot oxygenate situations, cricothyrotomies are an option for an emergent airway; however, many people practice for years without performing or assisting with one. This survey set out to discover what equipment and education would enable familiarity and competency with performing/assisting with this procedure based on experience.

Interior Health comprises community to tertiary hospitals. 62 individuals within IH responded to an 18-question survey: 3% anesthesia assistant (AA), 7% anesthesiologist, 24% emergency physician, 2% ENT physician, 14% internist/intensivist, and 50% RT. Representation was from a wide spectrum of career experience: 15% 0-2 years, 11% 3-5 years, 36% 6-10 years, 19% 11-20 years, and 19% greater than 20 years. IH Privacy Impact department and ARECCI IRB approved this survey.

75% of the physicians, RTs, and AAs felt that scalpel bougie procedure is the easiest method of performing a cricothyrotomy to maintain competency. Currently only 70% of RTs and AAs agree or strongly agree they are familiar with their role during an emergent cricothyrotomy and 53% agree or strongly agree they are competent assisting. 65% of all participants stated that their workplace had more than one type of emergent cricothyrotomy kit and 30% strongly disagreed, disagreed, or were neutral to being familiar with emergent cricothyrotomy equipment at their hospital. 69% of participants were agreeable to having only one emergent cricothyrotomy procedure and set of equipment even if this meant it was not their preferred method. 61% of participants have never performed or assisted with an emergent cricothyrotomy. 52% of participants would like hands-on cricothyrotomy education simulations every year.

Standardization of equipment and procedure may improve competency but there is some initial opposition to this option. Best success for positive patient outcomes as well as ease of performing and assisting is by using the scalpel bougie method. Yearly hands-on education is desired for familiarity and competency with the cricothyrotomy procedure as this study revealed that many participants of this survey have not yet had to perform/assist with this skill throughout their career, and those that have, have done so quite infrequently. This provides us with an opportunity to develop multidisciplinary education/simulation days to support overall success for both patients and the professionals involved in emergent cricothyrotomies.

COPD is a debilitating condition and projected to be the third leading cause of death worldwide by 2030. DRIVE4COPD is one of instrument used to assess COPD risk in population and original version of DRIVE4COPD (English) is valid and reliable. In this study we aimed to assess reliability and validated Arabic version of DRIVE4COPD questionnaire. The study was approved by the institutional ethical committee at Batterjee Medical College (BMC) (RES 2022-42.)

The DERIVE4COPD questionnaire contains 5 items of total score 10 which indicted to high risk of COPD and 0 low risk. This questionnaire was translated into Arabic version and reviewed by an expert panel before being back-translated into English. The Arabic version was administered to 6 Arabic participants to test whether it was easily understood after which a final Arabic version was produced. Thereafter, 30 participants with average age of 40 years (63% male) conducted spirometry and completed the Arabic version of DRIVE4COPD, COPD Assessment Test (CAT) and The Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F). The DRIVE4COPD was re-administered two week later to same participants.

The Arabic version of the DRIVE4COPD questionnaire demonstrated excellent reliability over the two-period administration (intraclass correlation coefficient = 0.979, P = .004. The DRIVE4COPD consisted of 5 items and the value for Cronbach’s alpha for the survey was α = 0.979. the test-retest correlation between each question over the two times were (Q1, r = 0.90. Q2, r = 0.49. Q3, r = 0.76. Q4, r = 1.0. Q5 r = 0.90), respectively. Additionally, to assess the validity of the Arabic version of the DRIVE4COPD questionnaire, Cohen's κ was run to determine if there was agreement between DRIVE4COPD result and spirometry for the 30 participants. The results indicated moderate agreement between the translated tool and the spirometry result, κ = .50 (95% CI 0.331 to 0.669), P = .004. Moreover, the DRIVE4COPD indicated a sensitivity 50% and specificity 95%. Finally, strong associations were demonstrated between the total score of DRIVE4COPD, and FACIT-F score (r = 0.61; P ≤ .001) and with CAT score (roh = 0.71; P ≤ .001).

The Arabic version of the DRIVE4COPD is a reliable and valid instrument to assess risk of COPD among Arab society.

Children with a tracheostomy require a variety of different supplies and equipment to be safely managed at home. At our institution, several caregivers reported running out of monthly supplies and difficulty obtaining additional supplies. The aim of this study was to determine how often children with a tracheostomy run out of supplies at home and to identify the types of supplies most commonly affected.

Caregivers of children with a tracheostomy were invited to anonymously complete a survey regarding home tracheostomy supplies. The survey was administered from September 2022 – April 2023. Inclusion criteria were children with a tracheostomy who had been home for at least 3 months following initial hospital discharge. Children who were residents of a long-term care facility were excluded.

Caregivers of 28 children completed the survey. The majority of children, 82%, were ventilator-dependent. Only 14% of all respondents reported never running out of tracheostomy supplies. Tracheostomy ties (43%) were the most common supply to run out followed by heat and moisture exchangers (39%). Most caregivers (86%) identified the hospital as the place to obtain new tracheostomy tubes and 46% reported using a tube for longer than recommended due to difficulty obtaining a new tube. The durable medical equipment company was the most common place to obtain all other tracheostomy supplies. Half of all caregivers (50%) noted they had paid out of pocket for supplies. For ventilator-dependent children, few caregivers (17%) reported running out of ventilator supplies, with filters being most common. In the open response, other identified supply issues were pulse oximetry probes, tracheostomy cleaning kits, lubrication, syringes for inflating the cuff, and ventilator circuit attachments. Several caregivers noted obtaining supplies from other families or support groups. Medicaid was the primary health insurance for the majority of children (75%).

The majority of caregivers who completed the survey reported running out of home tracheostomy supplies. Some supplies were used longer than recommended due to difficulty obtaining them. Many caregivers paid out of pocket for supplies they are unable to obtain through health insurance coverage. It was less common to run out of ventilator supplies than tracheostomy supplies.

At UPMC Presbyterian, impediments to referral for outpatient pulmonary rehab (OPR) following lung transplantation include extended length of stay, financial limitations, transportation issues, etc, particularly in patients who were being accommodated remotely from their homes. The pulmonary rehab staff collaborated with the lung transplant department to establish a rehabilitation protocol that would optimize therapeutic response in in a more efficient and shorter time frame than a traditional OPR program which consists of 2-3 days per week for up to 36 sessions. The goal of this new initiative was to allow participants to be discharged home faster post lung transplantation without compromising strength and endurance training goals.

Upon discharge from the hospital after lung transplantation, the patient is scheduled within 2-3 days for OPR for 4 days per week for a total of 3-6 weeks. The patients are assessed weekly for grip strength, balance, frailty, and functional capacity to determine if they have met all criteria for discharge to a pulmonary rehab facility local to their home based on observation of a plateau in the patients’ weekly physical assessments. The OPR staff communicates with the transplant team on the patients’ progress throughout their program.

23 patients were evaluated. Average duration in our program was 4.6 ± 1.1 weeks and 15.2 ± 5.2 sessions. 96% of patients met clinically important differences for 6-minute walk functional capacity (98 feet) with an average improvement of 412 ± 208 feet. Timed Up and Go (TUG) measurements improved in 87%, average 4.2 ± 4.3 s. METS obtained from a recumbent cycle improved in 87%, average 0.75 ± 0.72 METS. Frailty measurements which include grip strength improved in 74%, average 7 ± 7.6 kg; 5 chair stands improved in 83%, average 9.55 ± 9 s, and balance test improved in 100%.

A modified more intensive OPR program was beneficial for the post-lung transplant population as evidenced by meaningful functional and frailty outcome measurements. Since implementation of the post-transplant initiative, patients are discharged home within 3-6 weeks. Post-lung transplant patients exhibited improvements in objective outcomes justifying the continuation of an intensive pulmonary rehab program.

Enrollment in respiratory care (RC) programs continues to be a concern with entry-to-practice programs. Enrollment in RC programs was down 4.5% in spring 2021 and has declined by 27% since 2010. Additionally, there has been a 3.29% decrease in enrollment at the undergraduate level. Combined with the projected loss of 92,474 RTs by 2030, the need for targeted recruitment is important.

During the spring 2023 application period for the on-campus entry-to-practice program at Boise State University, data were gathered about where and how students had heard about the field and the program. After IRB approval, the data were retrospectively analyzed to identify where and how students were learning about the program.

The responses for 46 student applications were reviewed. 22 (48.9%) applicants only followed the department on Instagram, 2 (4.4%) applicants only followed the department on Facebook, 8 (17.8%) applicants followed the department on Instagram and Facebook, 8 (17.8%) applicants do not follow the department on social media, and 5 (11.1%) applicants were not on social media. In 2022-2023, marketing ads were run on Facebook and Instagram. 60.9% of applicants recalled seeing a social media ad on Instagram (48%), Facebook (2%) and both Instagram and Facebook (11%) within the last 12 months. 39% of applicants did not recall seeing an ad on social media. When applicants were asked where they heard about the Boise State RC program, 78% stated their advisor through the College of Health Sciences, 37% medical terminology course, 30% on Google, 15% experience with respiratory therapists in the hospital, 18% on Instagram, and 30% through community outreach opportunities that included program visits to high schools and a program open house. On average, applicants were exposed to the program from one to nine sources with an average of 2.8.

Academic advisors play a large role in student recruitment into the entry-to-practice respiratory care program. We need to continue to build strong relationships with our academic advisors. Social media continues to play a large role in capturing students interested in respiratory care, with Instagram being the most popular platform in this set of applicants. Priority should be placed on creating more of a presence on Instagram for individual programs and the profession. Additional research needs to be done to identify ways to recruit respiratory care students.

Where are applicants hearing/seeing Boise State Respiratory Care?

What Social Media Platforms are Most Popular for Boise State Respiratory Care?

The measurement of maximal inspiratory pressure during airway occlusion (P_Imax) is recommended for extubation readiness testing by the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network. The gold standard for performing P_Imax is to place a pressure manometer at the patient y-piece and perform a sustained end expiratory occlusion. P_Imax is also available as a built-in ventilator maneuver for newer ventilators, but the circuit remains connected to the patient and the pressure is measured at the ventilator instead of proximal to the patient. We sought to compare the accuracy of ventilator P_Imax to P_Imax gold standard across a variety of simulated conditions.

A ventilator (NKV-550) with P_Imax ventilator capabilities was connected to a lung simulator (ASL 5000) via an age-appropriate ETT. P_Imax ventilator was obtained by performing the built-in maneuver on the ventilator during an expiratory hold, and P_Imax gold standard was obtained by disconnecting the circuit at the patient y-piece and placing a pressure adapter connected to a standalone pressure manometer and manually occluding the airway with a gloved hand. A range of simulated patient inspiratory muscle effort (P_mus) was tested across various adult and neonatal models with varying compliance and resistance to simulate normal conditions, ARDS, and asthma of various severities. Each experimental condition was repeated in triplicate.

300 experiments were performed and the difference between P_Imax ventilator and P_Imax gold standard stratified by P_mus and model type are reported in the Figure. P_Imax ventilator was lower than P_Imax gold standard for almost every condition. Simulating normal conditions for adult and neonatal models resulted in a low mean difference, 3.4 ± 1.2 and 0.7 ± 0.8 cm H₂O respectively. Differences increased when simulating ARDS (6.8 ± 3.8 and 5.7 ± 2.6) and asthma (7.8 ± 3.6 and 5.2 ± 2.2). In ARDS and asthma models the P_Imax ventilator underestimated P_Imax gold standard in increasing amounts as a function of increasing P_mus.

The P_Imax ventilator is simple to perform as it does not require circuit disconnection however it results in a lower value than P_Imax gold standard and may be significantly lower when there is derangement in respiratory system compliance and resistance. If the P_Imax ventilator results in a low value that affects clinical decision-making it may be valuable to perform P_Imax gold standard to verify the result.

The apnea test is routinely performed for brain death assessment. During mechanical ventilation cessation, provision of oxygen is required to attenuate oxygen desaturation. Apneic CPAP is associated with the lowest PaO₂ rate of decrease and a similar PaCO₂ rate of increase compared to oxygen delivered via intratracheal insufflation and T-piece and reduces the frequency of complications leading to test termination. Weingart introduced a novel method using a bag valve mask (BVM) for CPAP delivery in the emergency department. This study aims to evaluate the efficacy of this method in simulated apneic conditions during apnea testing.

The proposed method converts a BVM to a CPAP system using a PEEP valve and continuous gas bias flow. A digital manometer (HT-1890, China) was connected to the manometer port and an O₂ catheter was connected to the M-port of a disposable resuscitator (Ambu SPUR II, Denmark). A fixed-value PEEP valve (Intersurgical, UK) was attached to the BVM expiratory port. Oxygen flow was measured using a flow analyzer (5310-2, TSI). Experiments were conducted with different oxygen flows (1, 4, 8, 12, and 15 L/min^-1) and PEEP valve pressures (10 and 20 cm H₂O). Each configuration was measured three times, observing the sustained positive pressure over time. The BVM was connected to a 1-L adult test lung (Maquet, Germany), and data were recorded and analyzed using Microsoft Excel 360 v 2304.

Thirty experiments were performed. Table 1 presents the CPAP levels measured using several flows and PEEP valves. Figure 1 depicts the mean duration required to establish the CPAP pressures from a completely deflated test lung.

This novel method achieves consistent CPAP levels even at low flows of 1 L/min^-1. The time required to reach a certain pressure level depends on the PEEP valve level and flow. This method offers several advantages as an apneic oxygenation technique. It increases oxygenation thus extending safe apnea time and is noninvasive thus reducing the risk of infection and barotrauma compared to intratracheal O₂ insufflation. It uses simple, small, inexpensive, and readily available equipment (BVM and PEEP valves), avoids false triggers, and allows for prolonged periods of apnea. Further studies are needed to explore its efficacy in various patterns of spontaneous ventilation with and without gas leak.

Figure 1. The mean time (sec) taken to establish a PEEP valve level of 10 cm H₂O, left panel (A), and 20 cm H₂O, right panel (B), from a complete test lung deflation.

Table 1. The CPAP levels measured while using different flow rates and PEEP valves.

Our objective was to increase patient and medication scanning compliance to > 90% for all respiratory care staff at UCSD (University of California, San Diego) Health’s Hillcrest Medical Center in alignment with National Patient Safety Goals and UCSD Safe Medication Practices Committee.

We analyzed metrics provided by the pharmacy gathered from the medication management dispensing software and the electronic medical record (EMR) monthly. We then identified constraints and areas of impedance to scanning and worked to incorporate solutions. Finally, the team compared initial data collected in January 2019 to endpoint data collected in April 2023.

Multiple barriers to scanning were discovered with the primary contributing factors being (A) staff education and (B) availability of technology. In addressing these issues, we began with introducing scanning compliance data into our daily huddles with staff, incorporated emphasis on scanning compliance as a patient safety tool into our new employee orientation program, provided monthly compliance feedback to staff paying specific attention to those under the 90% requirement and finally late in the process we replaced our staff cell phones with smart phones equipped with EMR scanning capabilities. Scanning compliance rose steadily from a baseline of only 80.8% of users achieving greater than the 90% compliance with a total patient/medication scanning compliance of 90.93% and 91.19% respectively in January 2019 to April 2023 with 95% of users achieving a greater than 90% compliance with a total patient/medication scanning compliance of 97.9% and 97.6% respectively.

Our findings indicated that staff education and training, adherence to policy and procedures, and increased staff knowledge of scanning requirements contributed to these results. We will continue to monitor scanning compliance as it relates to patient safety and evaluate the effectiveness of the newly introduced technology.

Figure 1. Patient Scanning Compliance, Hillcrest Respiratory Care Inpatient.

Figure 2. Medication Scanning Compliance, Hillcrest Respiratory Care Inpatient

High-frequency jet ventilation (HFVJ) delivers very small tidal volumes at supra-physiologic frequencies. Advantages of HFJV include minimizing lung trauma and allowing spontaneous breathing. The objective of this study was to examine whether elective (first-intention mechanical ventilation mode) use of HFJV, compared to conventional volume-targeted ventilation (VTV) in extremely preterm infants with respiratory distress syndrome (RDS), would be associated with lower incidence of bronchopulmonary dysplasia (BPD) and other adverse outcomes.

We conducted a retrospective cohort study of all extremely preterm neonates with gestational age (GA) ≤28 weeks admitted to the neonatal intensive care unit between 2020-2023. Neonates intubated and receiving mechanical ventilation with either first intention HFJV or VTV were included in the analysis. We evaluated the perinatal and clinical characteristics between neonates of the HFJV and VTV groups, with a subgroup analysis including only neonates with mild/moderate RDS, defined by an oxygenation index > 5.

117 neonates, 24 neonates with a mean GA of 25.2 ± 1.6 weeks were started on HFJV, whereas 93 neonates with a mean GA of 26.4 ± 1.5 weeks (P = .001) were started on VTV. Neonates in the HFJV group had significantly higher rates of mild/moderate RDS, higher oxygenation indices on admission, higher inotrope use, and remained intubated for a significantly longer period of time. Despite these differences, there were no statistical differences in rates of BPD, survival, or the combined outcome of BPD or death between the two groups. When only neonates with mild/moderate RDS were analyzed, 22 neonates on first-intention HFJV (mean GA 25.3 ± 1.6 weeks) and 66 neonates on first-intention VTV (mean GA 26.3 ± 1.5 weeks), no differences were recorded in the duration of mechanical ventilation, although the oxygenation indices on admission were higher in the HFJV group. Neonates of the HFJV group had significantly lower rates of BPD, or combined BPD or death, compared to the VTV group. In multivariate regression analysis, HFJV mode was significantly associated with lower rates for BPD (OR 0.14, 95% CI 0.03-0.75), and combined BPD or death (OR 0.15, 95% CI 0.03-0.79).

In extremely preterm neonates with mild/moderate RDS, first-intention HFJV was associated with lower rates of BPD or combined BPD or death, in comparison to VTV mode.

Many pediatric ICU (PICU) patients treated with noninvasive ventilation (NIV) for respiratory failure also receive aerosolized medications. There are concerns that aerosolized medications delivered via full-face mask could inadvertently deposit onto the eye, resulting in irritation or injury. Despite this concern, aerosolized medications via full-face and nasal interfaces are often administered to children. We hypothesized that aerosol medication delivery during NIV would not be associated with the development of ocular complications.

We retrospectively reviewed the medical records of children < 10 kg who received aerosolized medications during NIV or CPAP admitted to our PICU. We collected demographics, support modality, interface used, medications delivered, treatment tolerance, and any noted ocular complications upon hospital discharge. Respiratory therapist (RT) documentation was used to determine treatment tolerance (tolerated well, fairly well, poorly, or other). The occurrence of ocular complications was assessed through review of physical exam findings and discharge summaries.

We included 36 children: 21 (58%) who received NIV or CPAP via full-face mask and 15 (42%) via nasal mask. A total of 299 aerosol treatments were delivered, including 84 treatments during NIV via full-face mask. Albuterol was the most commonly delivered medication, given to 15 (71%) children; 4 (19%) subjects received hypertonic saline, 4 (19%) received racemic epinephrine, 2 (10%) received dornase alfa, 2 (10%) received budesonide and 1 (5%) received acetylcysteine. Children received a median of 2.5 (1-6) treatments. No treatments were documented as having been poorly tolerated and no treatment-related ocular complications were noted. A total of 4 ocular abnormalities (nystagmoid jerks and cataracts) were noted upon hospital discharge, with 1 (5%) in a child receiving NIV through a full-face mask, and none were attributable to aerosolized medication delivery.

Aerosolized medications delivered through full-face mask were not associated with ocular complications at hospital discharge.

Bronchial asthma is a major worldwide health problem. The prevalence of bronchial asthma in Saudi children ranges from 8 to 25% depends on the region. Arabian incense (bakhour) burning is a very popular activity in religious ceremonies and aromatizing homes. It’s slow and partial combustion, continuous smoke contains high concentrations of fine and ultrafine airborne particulates and gaseous pollutants such as carbon monoxide, nitric oxide, and volatile organic compounds. Children spend most of their time indoors and exposure to smoking incense can cause several health effects. The aim of this study was to determine whether exposure to bakhour increases the risk of developing asthma and/or exacerbates its symptoms in children from various regions of Saudi Arabia.

A cross-sectional survey was conducted among parents who have children of age between 3 to 16 years. The survey used Arabic version of ISAAC Phase II questionnaires with the addition of questions concerning the use and effect of Arabian incense on asthma symptoms. Current asthma was defined as positive response to wheeze in the past 12 months or positive response to "ever had asthma" together with a positive response to exercise wheeze or night cough in the past 12 months. Simple and multivariable logistic regression analyses were performed to estimate the effect of bakhour exposure and other variables on current asthma diagnosis and parents' response to the question.

A cross-sectional survey was conducted among parents who have children of age between 3 to 16 years. The survey used Arabic version of ISAAC Phase II questionnaires with the addition of questions concerning the use and effect of Arabian incense on asthma symptoms. Current asthma was defined as positive response to wheeze in the past 12 months or positive response to ever had asthma together with a positive response to exercise wheeze or night cough in the past 12 months. Simple and multivariable logistic regression analyses were performed to estimate the effect of bakhour exposure and other variables on current asthma diagnosis and parents' response to the question.

Out of 821 attended the survey, 26.1 % had current asthma with regional distribution of 28.5% southern, 27.4% western, 20.5% central,13% eastern, 10.6% northern. Bakhour use more than two times per week had increased effect on asthma symptoms compared to no bakhour use (adjusted OD 1.89;95% CI 1.03-2.01). There was no significant association between bakhour use and the prevalence of current asthma. The use of bakhour was at home was equally common in all regions of Saudi Arabia. However, its use more than twice per week was significantly higher in northern region.

Bronchospasm is one of the most common perioperative respiratory events. Standard treatment includes administration of albuterol via a pressurized metered dose inhaler (pMDI). A laryngeal mask airway (LMA) is a supraglottic airway device used to maintain an open airway and to provide support during anesthesia. The aim of this study was to evaluate delivery of albuterol administered through an LMA using a model of a spontaneously breathing adolescent.

The experimental set-up included a ventilator (breathing frequency 15 breaths/min, tidal volume 200 or 300 mL, PEEP 5 cm H₂O, FIO₂ 0.21) connected in series to an unheated ventilator circuit, pMDI delivery device (valved holding chamber [VHC] or adapter), LMA (size 2.5 or 3.5 modified to create a seal), filter, and test lung (Rp20, 30 mL/mbar). Tidal volume (V_T) was measured with a flow analyzer placed between the LMA and filter prior to aerosol delivery. Four actuations of albuterol 90 µg were delivered during inspiration or expiration either as a single actuation, waiting at least 30 s (allowing 7 breaths) and shaking the pMDI between actuations, or multiple actuations without waiting or shaking. Albuterol mass was measured via spectrophotometer. Each condition was repeated in triplicate. The dependent variable was delivery efficiency (mass captured in the filter expressed as percentage of nominal dose). General linear regression (LMA size, V_T, device, single vs. multiple actuations, and timing of actuation) and descriptive statistics were performed. Comparison between otherwise similar variables but different device, different V_T, use of single and multiple actuations, timing of pMDI actuation, and LMA size were made with T-test.

The VHC had higher delivery efficiency than the adapter. Larger LMA size did not improve delivery efficiency (P > .06). R² was 0.329 with the device and mode of actuation (single vs. multiple) explaining 22% and 5% of the observed variation respectively.

In general, delivery efficiency of albuterol pMDI through LMAs in a model of a spontaneously breathing adolescent increased when using a VHC and using single actuations.

Bronchospasm occurring during anesthesia is commonly treated with albuterol via a pressurized metered dose inhaler (pMDI). A laryngeal mask airway (LMA) during anesthesia is frequently used to maintain an open airway and provide support during anesthesia. The aim of this study was to evaluate delivery of albuterol administered through an LMA using a model of a spontaneously breathing infant and child.

A ventilator (breathing frequency 30 breaths/min, tidal volume 50 or 100 mL, PEEP 5 cm H₂O, FIO₂ 0.21) was connected in series to an unheated ventilator circuit, pMDI delivery device (valved holding chamber [VHC] or adapter), LMA (size 1, 1.5 or 2 modified to create a seal), filter, and test lung (Rp20, 5 mL/mbar). Tidal volume (V_T) was measured with a flow analyzer placed between the LMA and filter prior to aerosol delivery. Four actuations of albuterol 90 µg were delivered during inspiration or expiration either as a single actuation, waiting at least 30 s (allowing 15 breaths) and shaking between actuations, or multiple actuations without waiting/shaking. Albuterol mass was measured via spectrophotometer. Each condition was repeated in triplicate. The dependent variable was delivery efficiency (mass captured in the filter expressed as percentage of nominal dose). General linear regression (LMA size, V_T, device, single vs. multiple actuations, and timing of actuation) and descriptive statistics were performed. Comparison between otherwise similar variables but different device, different tidal volume, use of single and multiple actuations, timing of pMDI actuation, and LMA size were made with T-test.

VHC had higher delivery efficiency than adapter (P < .05). Larger LMA size did not improve delivery efficiency except when for VHC/V_T 100 mL/both actuation timing (P < .036). No differences were found between different tidal volumes or single vs. multiple actuations (P > .05). There was a 3-fold increase when actuation occurred during expiration while using VHC (P < .04). R² was 0.623 with the type of device, timing of actuation, and tidal volume explaining 33%, 17% and 8% of the observed variation respectively.

Delivery efficiency of albuterol pMDI through small size LMAs in a model of a spontaneously breathing infant and child increased with use of a VHC, actuation during expiration, and with small tidal volumes.

Inhaled nitric oxide (iNO) delivered with a high-flow nasal cannula (HFNC) system is frequently utilized at our institution in children with congenital heart disease. An in vitro study of noninvasive iNO in a neonatal model identified differences between dialed and delivered iNO dose. Although the dialed iNO is known, the amount delivered to the trachea is unknown. Moreover, the effect of dialed iNO and HFNC flow on the amount delivered to the trachea is also unknown. The aim of this study was to evaluate iNO delivered dose at the tracheal level using a HFNC system in a spontaneously breathing pediatric model.

An anatomically correct 3D airway model of a 5-year-old child was connected in series to a scavenger filter and breathing simulator using normal and ARDS lung models (frequency 20 breaths/min, V_T 125 mL, I:E 1:2, and frequency 30 breaths/min, V_T 100 mL, I:E 1:1, respectively). An XL Optiflow Jr 2 nasal cannula (Fisher & Paykel) was used with flows 2, 3.5, 5, 7.5 10, and 25 L/min. The iNO delivery system (INOMax, Mallinckrodt) included an injector module placed at the humidifier chamber of the HFNC system (dry with heater off), a sampling line, and 2 sampling ports. One port was placed between the cannula and the circuit to monitor delivered iNO and the second was placed between the airway model and the scavenging filter to measure tracheal iNO concentrations. (Figure 1) The second port remained closed until the delivered iNO measurement was obtained. The sampling line was then switched to the second port and the first port was closed. Delivered and tracheal iNO measurements were recorded after 3 min for dialed concentrations of 5, 20, and 40 ppm. Experiments were performed in quadruplicate. Delta dialed iNO - delivered iNO, and tracheal iNO/dialed iNO (%) were calculated. General linear regression (lung model, dialed iNO, and flow) and descriptive statistics were performed.

Median (IQR)/95%CI for delta (dialed - delivered iNO) and for tracheal/dialed iNO were 1 ppm (0-2 ppm)/0.4-2 ppm and 84.5% (56.8-92.4%)/76-90% (Figure 2). Linear regression analysis showed R² of 0.49 (0.48 for the flow variable for flows 2-25 L/min) (P < .001) and R² 0.79 (0.67 for the flow variable for flows 2-10 L/min) (P < .001). The contribution of dialed iNO was minimal (R² = 0.01).

iNO was efficiently delivered to the trachea of a spontaneously breathing pediatric model using a nasal cannula and HFNC system (2-25 L/min). Efficiency was mainly affected by the flow but not by dialed iNO (5-40 ppm).

Early in the COVID-19 pandemic, children overall seemed less affected by severe illness. Older individuals and those with underlying medical conditions were thought to be at higher risk for severe disease. The purpose of this study was to describe the outcomes of children hospitalized with COVID-19 from the start of the pandemic through the surge of the Delta variant.

This was an observational study of children and young adults aged 0-20 years admitted March 2020 - November 2021 with a positive test for COVID-19. Exclusion criteria were patients who required respiratory support unrelated to COVID-19 (eg, trauma, burn injury, drowning). Retrospective data included demographics, underlying medical conditions, vaccination status, respiratory support, multisystem inflammatory syndrome, and length of stay. Early pandemic was considered March 2020-June 2021 and the Delta variant July-November 2021. Descriptive statistics, Fisher exact, Chi-square, or Mann Whitney U test were used to analyze results.

There were 762 admissions analyzed representing 735 unique subjects. The median age and length of stay was 7.4 years and 2 days respectively. The majority were white (52%), non-Hispanic (83%), and not eligible for vaccination at time of admission (78%). Respiratory support was required by 34%, and oxygen was the most common form of support. Some subjects required readmission (27, 4%). There were 3 deaths overall, all of which occurred during the surge of the Delta variant. There were significant differences between early pandemic and the Delta variant for ethnicity (P = .004), vaccination status (P < .001) respiratory support (P < .001), and length of stay (P <.001).

The majority of children were not eligible for the COVID-19 vaccine but there were more unvaccinated during the Delta variant. Most subjects did not have an underlying condition and less than half required respiratory support. Multisystem inflammatory syndrome was rare. During the surge of the Delta variant, more subjects were unvaccinated, required respiratory support, and had a longer length of stay.

Lung transplantation (LT) is considered for patients with advanced lung disease who failed to improve symptoms with medical interventions. In post-LT patients who develop respiratory failure requiring prolonged mechanical ventilation, early tracheostomy (ET) (<72 h) is performed to facilitate weaning from ventilation. This study evaluated the effect of ET by comparing the outcomes of LT patients receiving ET to those who did not receive tracheostomy (DNRT) in a cardiothoracic intensive care unit (CTICU) from an academic medical center.

A retrospective electronic health record review compared LT patients' outcomes with a matched sample of DNRT patients on age, gender, type of transplant, ECMO support (pre and post), and other concomitant surgeries. From January 2018 to December 2022, all LT recipients were considered. Data were collected on demographics (age, race, sex), single or double LT, and clinical outcomes. The primary outcomes were mechanical ventilator days, days to first oral intake, days to first ambulation, hospital and ICU length of stay (LOS), and primary graft dysfunction (PGD). Secondary outcomes were one-year and 30-day survival rates. Mean, SD, frequency, and percentage were used to describe the patient population. The outcomes of ET and DNRT groups were compared using independent t-tests and considered P < .05 to be significant. The Anesthesia and Perioperative Outcomes for ICU Patients IRB protocol supported the data extraction.

Between January 2018 and December 2022, 436 patients underwent LT; 46 patients had tracheostomy within 72 h. After 1:1 matching, the total sample size was 35 pairs ET-DNRT. There was a statistically significant difference between ET and DNRT groups on ICU LOS (22.5 ± 20.1 vs. 6.6 ± 3.7), hospital LOS (33 ± 22.3 vs. 16.1 ± 9.4), ventilator days (20.2 ± 24.7 vs. 1.8 ± 11.8), days to first oral intake (23.8 ± 23.5 vs. 4.9 ± 4.8), days to first ambulation (5.6 ± 4.9 vs. 2.5 ( ± 3.3). PGD grades 0 and 1 were more frequent in DNRT (29) than in ET (21). PGD grades 2 and 3 were more frequent in ET (12) than in DNRT (6). One-year and 30-day survival rates were similar for ET and DNRT.

This single-center report provides insight into the impact of ET in post-LT patients. The outcomes showed ET in post-LT with PGD>1, consistent with the institution's practice. In addition, ET and DNTR groups showed similar survival rates; therefore, ET can be safely performed for high-risk LT patients to promote early liberation from mechanical ventilation.

Management of spinal cord injury ventilator-dependent patients in acute care rehabilitation has significant challenges. Acute care rehabilitation is a short-term setting for patients to meet goals that will impact long-term recovery. Mechanically ventilated patients, along with the goal of being liberated from the ventilator, also have several other functional goals to meet. Spinal cord injury brings significant challenges to these patients, especially in the management of secretions, often causing atelectasis and lung infections, which could impact patient progression and even mortality.

We reviewed data during 2018-22 timeframe of spinal cord injury ventilator-dependent patients admitted at Magee Rehabilitation. The patient dataset had more than 30 data fields. Patients with ventilator weaning not as a goal were excluded. The following data fields were extracted for this review: mucolytic protocol (yes/no); history of pneumonia (yes/no); off vent at discharge (yes/no). Patient data were stored in a password-protected drive. The project is exempt according to Jefferson IRB.

A total of 71 patients were reviewed. Of these patients, 57 (80%) were placed on the bronchial hygiene pathway upon admission, and 14 (20%) were not placed on the pathway. 50 (70%) of the total patients reviewed had a recent history of pneumonia. Of these, 40 (70%) patients placed on the bronchial hygiene pathway had a recent history of pneumonia. 10 (71%) patients who were not placed on the bronchial hygiene pathway also had a recent history of pneumonia. 57 (80%) patients were discharged after being liberated from the ventilator. Out of this, 46 (81%) patients on the bronchial hygiene pathway were discharged without the ventilator, and 11 (79%) patients not on the bronchial hygiene pathway were discharged without the ventilator.

The results of the retrospective review suggest that even though no significant differences in ventilator liberation among patients on or not on the bronchial hygiene pathway were identified. The majority (80%) of the admitted mechanically ventilated patients were placed on the bronchial hygiene pathway, with significant success in meeting ventilator liberation goals of 81%. A standardized approach to secretion management and bronchial hygiene is extremely important for patients with spinal cord injuries. Further research is required to identify the benefits of standardized respiratory pathways for ventilator-dependent spinal cord rehabilitation patients.

Unplanned extubations (UEs) are the 4th most common adverse event in NICUs. 10% of NICU patients require CPR after UEs. UEs in neonates increase oxygen requirements, ventilator days, and chronic lung disease of prematurity rates. Neonates are at increased risk for UEs because of immature skin, morbidities associated with sedation, and a narrow zone of acceptable endotracheal tube (ETT) placement. National goals for neonatal UEs are less than 1 per 100 ventilator days.

We utilized previous PDSA cycles, fishbone diagrams, Solutions for Patient Safety QI initiative, and instituted reliability bundles to ensure we were meeting our UE standards. Actions taken included educating NICU providers, RNs, and RTs on the Kempley chart and encouraged them to discuss ETT depth in multidisciplinary rounds as the patients reached set gestational milestones.

In the 6 months after implementation of the Kempley chart, the absolute number of UEs were reduced by 50%. One-third of the UEs in that period still had a prescribed depth less than that predicted by the Kempley chart, indicating challenges with compliance. We have noticed decreased variability in the frequency of UEs but have not seen a center line shift yet.

This suggests that compliance with the Kempley chart prediction could still be improved. In our next PDSA cycle, NICU providers will document a real-time assessment of Kempley chart compliance with any UE and nurses will audit compliance daily. Lessons learned: Precise, prescribed ETT depth is an important component of NICU UE prevention. Approximately 80% of our NICU UEs occurred in patients born at 28 weeks’ gestation or less. The UE frequency was low in the first days after birth, when skin is most immature. When these patients require chronic ventilation, timely ETT adjustments (by 0.5 cm increments based on advancing age) can prevent UEs.

Research is a critical for the advancement of respiratory care. Fellows of the American Association for Respiratory Care (FAARC) are nominated due to their significant contributions to the respiratory care profession. Research output is potentially an important component of qualification for FAARC. The purpose of this study is to report the academic output of respiratory therapists (RTs) with the FAARC designation.

We identified FAARCs from the AARC website. Research output was assessed by searching the SCOPUS database between May 2022 and May 2023. We collected total research documents, citations, H-index, co-authors, and type of document from each database. For FAARCs, we included gender, highest degree earned, and year inducted. We compared FAARC with RTs who are Fellows in the Society of Critical Care Medicine (FCCM). Results are descriptive and we compared those with only the FAARC designation to those with both FAARC and FCCM designations using chi square or Mann-Whitney test as appropriate.

We identified 381 RT FAARCs, 14 RT FCCMs, and 10 with both designations. FAARCs were predominantly male (261, 70%), 81 (22%) had a doctorate, 137 (37%) had a master, 50 (13%) a bachelor, and 107 (29%) did not have a degree reported. There were no differences for gender or highest degree between FAARC and FCCM. FAARCs had a total of 3,724 publications and 110,207 citations and those with both designations had 1,304 publications and 43,181 citations. In SCOPUS, 169 (46%) FAARCs had no publications and 27% had ≥ 10 publications. Among those with both credentials, 1 (10%) had no publications, and 7 (70%) had ≥ 10 publications. FAARCs inducted in 1998 and 1999 had significantly (P < .001) more publications than other eras, Figures 1 and 2. The median publications for FAARCs were 1 (0-10), H-index 1 (0-4), co-authors 0 (0-29), and citations 1 (0-112). Compared to those with both credentials, FAARCs had significantly fewer publications (1 [0-10] vs 50 [11-332], P < .001), lower H-index (1 [0-4] vs 18 [5-45], P < .001), fewer co-authors (0 [0-29] vs 233 [32-765], P < =.001), and fewer citations (1 [0-112] vs 1,486 [114-7,702]).

RT FAARCs had a large number of publications and citations; however, nearly half did not have any publications. Those with both FAARC and FCCM had significantly more academic output per fellow, although there are only 10 with both credentials.

Fellows of the American Association for Respiratory Care without any peer reviewed publications in SCOPUS.

Fellows of the American Association for Respiratory Care with at least 10 peer reviewed publications in SCOPUS.

Severe traumatic brain injury (TBI) is a major cause of morbidity and mortality. It can result from various causes, including traffic accidents, particularly motorcycle accidents, which are common in Taiwan; falls on stairs or from buildings; and sports or leisure activities. This study investigated the factors contributing to mortality after TBI in a multidisciplinary tertiary hospital.

A retrospective study was conducted from January 2020 to December 2022 at E-DA Hospital, Kaohsiung city, Taiwan. Severe TBI was defined as a Glasgow coma scale score < 9. The data collection followed the guidelines of the disease-specific care certification program of the Joint Commission of Taiwan. The study excluded patients younger than 20 years. Data on relevant factors were collected, including APACHE II scores, age, causes of TBI, body mass index (BMI), duration of mechanical ventilation, hospital length of stay, and the results of disengagement. The data were analyzed using an independent sample t-test and logistic regression.

The study included a total of 136 patients with severe TBI who were admitted to the ICU through the emergency department. All of these patients received endotracheal intubation. The average age of the patients was 53.9 years, and the mortality rate was 30.88%; n = 43). The majority of patients were male (men:women = 92:44). Mortality in the ICU was significantly associated with mean APACHE II scores (28.55; P < .001) but not with initial BMI, cause of TBI, or age. Regarding brain decompression craniectomy or craniotomy, 97 patients (71.32%) underwent the procedure, and 39 (28.68%) did not. Those who underwent decompression craniectomy or craniotomy had a longer mean duration of mechanical ventilation (11.76 vs. 6.95 days; P < .015) and length of hospital stay (29.28 vs. 15.95 days; P < .001).

The study explored factors associated with mortality after severe TBI. Higher APACHE II scores were correlated with higher mortality rates, as was expected. Clinical decision-making, particularly related to limiting decompression craniectomy and craniotomy, should not be based on APACHE II alone. Decisions regarding surgical interventions must be made in consideration of the difficulties of weaning patients off mechanical ventilation and the potential for prolonged mechanical ventilation and hospital stay.

The interpretation of ventilator waveforms is essential for effective and safe mechanical ventilation but requires specialized training and expertise. This study aimed to investigate the ability of ICU clinicians to interpret ventilator waveforms, identify areas requiring further education and training, and explore the factors influencing their interpretation skills.

An international online anonymous survey was conducted upon approval by the Institutional Review Board. ICU clinicians (physicians, nurses, and respiratory therapists) with at least one year of experience were invited to participate. The survey consisted of demographic information and 15 multiple-choice questions related to ventilator waveforms. Results were compared between professions using descriptive statistics and logistic regression (expressed as odds ratios [OR, 95% confidence interval]) was performed to identify factors associated with >60% correct answers.

2,067 ICU clinicians from 31 countries participated, yielding 1,832 valid questionnaires with responses to all 15 waveform questions. 53% of respondents answered at least 60% of the questions correctly. The three questions with the highest correct responses were condensation (90%), pressure overshot (79%), and bronchospasm (75%). Conversely, the three questions with the lowest correct responses were early cycle with double trigger (43%), patient inspiratory effort (37%), and early (reverse) trigger (31%). Comparison across professions is included in Figure 1. Factors significantly associated with >60% correct answers included years of working experience (≥ 10 years, OR = 1.1.554 [1.218-1.983], P < .001), profession (respiratory therapist, OR = 2.814 [2.142-3.697], P < .001), highest degree earned (graduate, OR = 1.705 [1.326-2.192], P < .001), workplace (teaching hospital, OR = 1.376 [1.085-1.744], P = .008), and mechanical ventilation training (OR = 1.698 [1.299-2.219], P < .001) (see Table 1).

Slightly over half respondents correctly identified at least 60% of waveform questions. Years of working experience, profession, highest degree earned, workplace, and mechanical ventilation training were significantly associated with improved interpretation skills. To enhance clinicians’ ability to interpret ventilator waveform, targeted education and training programs should be implemented.

Figure 1. Percentages of participants who answered correctly

This study aimed to determine the prevalence of cigarette smoking and secondhand smoke exposure among respiratory therapy students in the western region of Saudi Arabia, as well as to explore their perceptions regarding smoking cessation and the need for further education. The implications of these findings for respiratory care education and practice were also examined.

A cross-sectional study was conducted among respiratory therapy students (n = 159) in the selected region. Data on smoking prevalence, secondhand smoke exposure in public settings and at home, as well as students' perceptions of smoking cessation, were collected using a Global Health Professions Student Survey. Descriptive statistics and the Chi-square test were utilized to analyze the data.

The study revealed a prevalence of 6.66% for cigarette smoking among male respiratory therapy students, while female students had a lower prevalence of 3.7%. Exposure to secondhand smoke in public settings was high, affecting 52% of the participants, while exposure at home was comparatively low at 28%. Notably, respiratory therapy students expressed positive perceptions regarding smoking cessation, with the majority agreeing on the necessity of specific training in smoking cessation for respiratory therapists and routine counseling for smoking patients. The chi-square test showed a P -value < 0.05, suggesting that the smoking status differences between male and female students were not random. Cramer's V indicates a moderate correlation between smoking status and gender, suggesting that gender influences Saudi Arabian students' smoking behavior. Most respiratory therapy students in Western Saudi Arabia did not smoke, and those who did have positive things to say about quitting.

The findings indicate a need for further training and education in smoking cessation for respiratory therapy students and practitioners in the region. Integrating smoking cessation interventions into respiratory care practice can improve patient outcomes and promote healthier behaviors. Moreover, efforts to enforce and promote smoking bans in public spaces should be continued to safeguard individuals from the harmful effects of secondhand smoke. These implications highlight the significance of addressing smoking-related issues within respiratory care education and practice, contributing to reduced smoking rates, improved respiratory health, and enhanced patient care.

Invasive mechanical ventilation is necessary for many infants in the neonatal intensive care unit (NICU). Although it is a lifesaving intervention, it has potential adverse effects, including UE. UE can lead to significant cardiovascular and respiratory compromise. In 2018, our UE rate was 1.724/100 ventilator days. Due to the UE rate, the NICU developed an interdisciplinary UE committee to assess potential gaps in practice.

Our interdisciplinary UE committee meets monthly to complete an apparent cause analysis of each UE event. After the investigation is complete, the committee trends data on a dashboard and identifies countermeasures based on trends. The UE committee utilizes the IHI Model for Improvement and completes PDSA cycles. Our PDSA cycles include: 1. Developing standardized practices (ETT placement, 2-person positioning). 2. Increased situational awareness through an ETT card and order set. 3. Standardizing ETT securement method. 4. Developing an annual awareness month to promote bundle compliance and discuss new trends from ACAs. 5. Interdisciplinary UE debriefing led by a physician. 6. Chest radiograph standardization including optimal patient positioning and annotation of ETT position.

Our NICU had two centerline shifts: in June 2018 (decrease from 1.724 to 1.089) and in July 2021 (1.089 to 0.56). We increased compliance with UE debriefing from 45% to 53% of all events. We were to maintain 100% reliability to our UE prevention bundle (2 people for retaping, standardized landmark and standardized securement method). Our longest record between events is 72 days. We promoted intervention and data transparency through quarterly emails, nursing/respiratory updates, daily management system, and celebrations of milestones.

Reducing UE remains a top priority for our NICU with an engaged committee and increased staff awareness. The culture of safety has shifted towards increased escalation of concerns and proactive discussions of high-risk patients. With the support of key stakeholders and sponsors, we were able to remove barriers and promote accountability of compliance of targeted interventions. Staff are empowered to escalate concerns through use of error prevention tools and a collaboration algorithm that proactively address securement concerns. We also identified that continuous assessment of previous interventions is necessary as they may cause unanticipated consequences.

The purpose of this study was to identify the perceptions and barriers to degree advancement among active respiratory therapists. The primary objective of this work is to highlight common perceptions, or misconceptions, about the incentives related to pursuing a higher degree. The data may help professional organizations and academic programs align to best address perceived barriers to degree advancement with the overarching goal of propelling the profession forward.

This cross-sectional study utilized a web-based survey to glean descriptive and qualitative information related to the study questions. The survey was conducted using Qualtrics software and released via a social media platform with a specific audience of over 60,000 practicing respiratory therapists.

Due to the use of social media, the response rate to this survey is unknown. However, responses from 785 respiratory therapists were included in the final r analysis. Relevant findings identify that variables such as age, time in the field, likelihood and rate of tuition reimbursement, and compensation post-completion of degree advancement all represented perceived barriers to degree advancement. Qualitative analysis of open-ended questions revealed 4 predominant themes in the perception of degree advancement in respiratory care. These themes included the perception of irrelevance, insurmountable alterations to lifestyle, cost of degree advancement, and age in the context of benefits to degree advancement.

Findings support the need for institutions to encourage therapists who are concerned about the cost to return for degree advancement. Other factors such as age, and years of experience also play large roles in an individual's choice to return for degree advancement. However, individuals that found financial barriers were more likely to indicate a positive indication to return for degree advancement; therefore, it is vital to provide a level of tuition reimbursement to minimize this barrier.

O₂ flow guidelines for simple masks (SM) are restricted (≤10 L/min), but open-ended for non-rebreather masks (NRM) (≥ 10 L/min),^1,2 despite having uniform mask dimensions (5 x 3.3). Estimated maximum FIO₂ with these flows are 0.50 and 0.60-0.80, respectively. However, these guidelines conspicuously lack supportive data. Therefore, constraining SM to 10 L/min is unreasonable and unnecessarily restricts the flexibility for O₂ delivery, particularly in resource-deprived countries. We explored FIO₂ delivery by SM and NRM at 4 flow settings (10, 12, 15, and 20 L/min) under 3 breathing patterns with increasing minute ventilation (V_E) demand: normal-rest (6 L/min), unassisted breathing in ARDS (8 L/min) and hyperpnea (14 L/min).

A custom-designed adult manikin face was attached to an ASL-5000 lung simulator (Ing Mar Medical, Pittsburgh, PA) with an O₂ analyzer placed between the face piece and simulator. Masks were tightly fitted to the face-piece. A 2-point O₂ calibration was done prior to study, and 1-point calibration was repeated prior to each test run. Breathing patterns for each V_E were: 6 L/min (V_T 350 mL x 17), 8 L/min (V_T 350 mL x 24), and 14 L/min (V_T 550 mL x 26). All settings and conditions were repeated. FIO₂ variability with each paired-run was ≤ 0.005.

At all O₂ flows and breathing patterns SM was able to deliver an FIO₂ ≥ 0.50; often reaching an FIO₂ ≥ 0.60. The FIO₂ generated with NRM met guideline estimations except for O₂ flows < 15 L/min during hyperpnea.

SM O₂ flows of 12-20 L/min produced consistent FIO₂ > 0.50.1. AARC Clinical Practice Guidelines 2002:718. 2. Egan’s Fundamentals, 12th edition 2021:912.

In an accompanying abstract we reported FIO₂ achieved with a simple O₂ mask (SM) or non-rebreather O₂ mask (NRM) varied according to O₂ flow and level of minute ventilation (V_E). Here we test the premise that air entrainment signified by mismatching of O₂ flows with both peak and mean inspiratory flows (VI-peak and VI-mean) result in lower FIO₂ values.

As a brief review, our model consisted of 3 V_E levels: normal (6 L/min: V_T 350 mL x 17), ARDS spontaneous breathing (8 L/min: V_T 350 mL x 24), and hyperpnea (14 L/min: V_T 550 mL x 26). O₂ flows were 10, 12, 15, and 20 L/min. Twelve paired measurements each were made between FIO₂ and corresponding measures of: 1) O₂ flow, 2) VI-peak, 3) VI-mean, and 4) differences between O₂ flow and both VI-peak and mean. Paired data were analyzed by linear regression. Alpha was set at 0.05.

Relationships between O₂ flow and FIO₂ differed markedly between SM (R²: 0.48, P = .013) and NRM (R²:0.28, P = .08), that was reflected in how FIO₂ corresponded with differences between O₂ flow and both VI-peak and VI-mean (Table). Using a cut-off difference of ≤ 10 L/min for both devices, 67% of SM pairings had a FIO₂ ≥ 0.60, whereas 100% of NRM pairings had a FIO₂ ≥ 0.70.

With SM the association between FIO₂ and either O₂ flow or mismatches between VI-peak or VI-mean differed little; whereas with NRM the mismatch between VI-peak or mean with O₂ flow had a marked impact on FIO₂. The stronger association with VI-mean reflects the influence of V_T and mismatch duration (ie, VI-mean = V_T ÷ T_I). The weak association between O₂ flow and FIO₂ with NRM (and its strong relationship with flow differences) underscores the importance of an O₂ reservoir in reducing the impact of air entrainment.

The COVID-19 pandemic created massive amounts of stress for frontline healthcare providers. The purpose of this study was to examine perspectives of respiratory therapists, student respiratory therapists, and respiratory therapy managers on trust in leadership during the COVID-19 pandemic. The United States’ healthcare and government systems were not prepared for burden caused by the SARS-CoV-2 virus. High levels of prolonged stress along with significant amounts of death can cause burnout and moral injury for frontline healthcare providers. Healthcare leaders must provide effective communication, support, and proper amounts of personal protective equipment to help diminish the effects of burnout and moral injury.

This study used Q-methodology, which is a mixed-methods research design. The study included 203 staff respiratory therapists, student respiratory therapists, and respiratory therapy managers in the state of Ohio who worked the frontlines, or managed respiratory therapists working the frontlines, during the COVID-19 pandemic.

Five distinct groups emerged from perspectives of participants: I’ll be There for You, Won’t You Please, Please Help Me?, I’ll Get You There, What’s Going On?, and Show Must Go On. The quality of the leader has profound effect on participants’ perspective of how their institution handled the COVID-19 pandemic. The more daily contact and communication with their leaders, the less guilt the participants felt during the COVID-19 pandemic. Harold Kelley’s covariation model conceptualizes the entity and circumstance of the COVID-19 pandemic by sharing perceptions of frontline respiratory therapists.

Though the United States government considers the COVID-19 pandemic over, frontline respiratory therapists will endure the effects of the COVID-19 virus for years to come.

Q-sort grid

This study aimed to assess the feasibility of localizing the competencies for entry-level respiratory care professionals from the American Association of Respiratory Care (AARC) in Taiwan.

The researchers translated the AARC competencies into a questionnaire and distributed it to respiratory therapists, supervisors, and medical directors in Taiwan. The questionnaire measured the importance, feasibility, suitability for local culture, and timing of implementation for each competency using a 4-point Likert scale.

A total of 41 experts participated in the study, including 29 respiratory therapists and 12 medical consultants or physicians. The results showed that the respondents considered the AARC competencies important and feasible, with high agreement rates. The median agreement rate for importance was 98%, and for feasibility, it was 97%. However, the localization of performing tracheal intubation received lower agreement at 56%, indicating the need for further consideration for this specific competency. Additionally, the study found that while most respiratory therapy majors were completed in school, 13% of majors required additional training after employment to acquire advanced abilities.

Overall, the findings suggest that the majority of experts in Taiwan agree with following the AARC competencies for entry-level respiratory care professionals. However, the competency of performing tracheal intubation requires further attention. These insights are valuable for establishing competency-based education in respiratory care in Taiwan.

Importance, Feasibility, and Suitability in Taiwan of AARC Competences of Entry-level

Care for advanced lung diseases like COPD requires a customized care plan for best outcomes. Disease management care planning and education between providers and patients is essential. The purpose of this study was to assess COPD patients’ interest in receiving lung disease education and advance care planning.

We conducted an IRB-approved cross-sectional study. Subjects were invited to complete a form at the beginning of their COPD clinic appointment between 02/24/2021 to 05/10/2023. The form included 11 education categories. Subjects were instructed to select as many education categories as they felt would be helpful to them. Demographic and clinical data was extracted retrospectively from subjects’ electronic health record (EHR). FEV₁% predicted was used to stratify into one of two groups by COPD GOLD disease severity: mild/moderate COPD and severe/very severe COPD. Data are reported as n (%) and median (IQR). The Chi-Square of independence test and Fisher’s exact test were used to compare categorical variables. P < .05 was considered significant.

179 subjects (56% female) with a median age of 67 (59-74) were included in the study. 62% (111/179) had mild/moderate COPD and 38% (68/179) had severe/very severe COPD. 59% (105/179) indicated no need for education resources (P = .13). The top 3 education categories selected by both groups were Techniques to Help Shortness of Breath (20% vs 34%, P = .036), COPD Self-Management Plan (12% vs 21%, P = .11), and Advance Directive [AD] (12% vs 16%, P = .40). Subjects with severe/very severe COPD were 5.5 times more likely to want education on Tips for Energy Conservation (P = .006). While 35% of subjects had an AD in their EHR at the time of form completion (P = .21), 60% with mild/moderate COPD and 66% with severe/very severe COPD did not have an AD in their EHR at the time of data analysis (P = .44). Overall mortality was 5% (9/179). Six of 9 deaths occurred in the severe/very severe COPD group P = .09). Five deceased subjects had no AD in their EHR upon death. One of those subjects expressed a desire for an AD form.

COPD subjects were interested in receiving lung disease education and advance care planning regardless of disease severity. A disproportionate number of subjects thought they had an AD but did not have it filed in their EHR. Clinical practice should focus on repeated discussions about advance care planning and verifying AD transfer to the EHR. The gap in this practice could result in suboptimal care.

Setting and maintaining adequate endotracheal tube and tracheostomy tube cuff pressures is an important step in providing safe respiratory care. Airway cuffs, when properly inflated, provide protection against aspiration of fluids into the lungs and help maintain airway pressures while using mechanical ventilation. Conversely, over-inflation of airway cuffs can cause an array of issues, from irritation to injury and necrosis of the tracheal wall. We tested the Vortran Cuff Inflator (Vortran Medical Technology, Sacramento, California), to determine if it accurately set pressures. The null hypothesis is that there will be no difference between the measured pressures and the control.

We used an airway model (Laerdal Airway Management Trainer, Wappingers Falls, New York) to simulate an intubated patient and intubated it with an 8.0 mm ID endotracheal tube (Covidien, Dublin, Ireland). The cuff was inflated using the Vortran inflator. Using a stopcock, the cuff inflator was used to fill the ETT cuff to meet the pressure of 20, 30, and 40 cm H₂O on the analog manometer. Once the needle on the Vortran Cuff Inflator reached the center of the desired number on the manometer, the stopcock was turned off to the inflator and the pressure was measured via a SmartLab Series 1140 (Hans Rudolph, Shawnee, KS). The process was repeated five times at each pressure on two devices, and data recorded. After each trial, the cuff was deflated and disconnected and the SmartLab sensor was zeroed.

The measured pressure readings at 20, 30, and 40 cm H₂O were different than the control (P < .001). Mean pressure readings at each of the three inflation points were: 25.68 cm H₂O, 34.89 cm H₂O, and 47.48 cm H₂O.

The Vortran Cuff Inflator exhibited statistical differences between control and measured values at 20, 30, and 40 cm H₂O. More research is needed to determine if our findings are clinically significant. With these findings, the null hypothesis is rejected.

Securing an artificial airway in an intubated patient is of the utmost importance to avoid accidental extubations. Endotracheal tube (ETT) securing devices are associated with medical device-induced pressure ulcers (MDIPUs) and rates range between 7%-45%. MDIPUs have severe consequences for patients, clinicians, and facilities. This educational pre and post design study examined the knowledge of MDIPUs in a senior respiratory therapy program.

A 10-item pre-test based on a thorough literature review targeting pathophysiology, prevention, and treatment of MDIPUs related to ETT retaining devices was administered immediately before an in-person lecture and hands on exercise to entry level respiratory students. The same test was administered immediately after the education program to compare information retention and understanding.

The class average on the pre-test was 51.9% ± 9.2% (mean ± 95% CI). Out of 14 students (7.1%) met or exceeded the criterion of success (70%) for the pre-test. The difference between the pre-test score and the criterion of success was statistically significant: t(13) = -3.85, P < .005. The difference between these scores had a large effect size (Cohen's d = -1.03). The class scores on this test fell short of meeting the criterion of success for this assessment. The class average on the post-test was 81.9% ± 10.9% (mean ± 95% CI). A total of 11 out of 14 students (78.6%) met or exceeded the criterion of success for the post-test. The difference between the post-test score and the criterion of success was not statistically significant: t(13) = 2.14, P > .05. The difference between these scores had a medium effect size (Cohen's d = 0.57). The difference between the pre-test and post-test scores (30%) was statistically significant using a two-tailed paired t-test: t(13), P < .001. The magnitude of this difference has a very large effect size (Cohen's d = 1.62).

Entry level students' knowledge about avoiding MDIPU caused by airway securing devices increased after a lecture and hands-on exercise. Future research needs to be done across more respiratory care programs.

Infants with a high risk of extubation failure are often treated with noninvasive ventilation (NIV) or CPAP, but data on the role of these support modalities following extubation are sparse. This report describes our experience using NIV or CPAP to support infants following extubation in our pediatric ICUs.

We performed a retrospective study of children < 10 kg receiving post-extubation NIV or CPAP in our pediatric ICUs. Data on demographics, medical history, type of support, vital signs, pulse oximetry, near-infrared spectroscopy (NIRS), gas exchange, support settings, and reintubation were extracted from the electronic medical record. Support was classified as prophylactic if planned before extubation and rescue if initiated within 24 hours of extubation. We compared successfully extubated and reintubated subjects using Chi-square for categorical variables and Mann-Whitney test for continuous variables.

We studied 51 subjects, median age 44 (IQR 0.5-242) days and weight 3.7 (3.0-4.9) kg. There were no demographic differences between groups, except those reintubated were more likely to have had cardiac surgery prior to admission (0% vs 14% P = .04). NIV was used in 31 (61%) and CPAP in 20 (39%) subjects. Prophylactic support was initiated in 25 subjects (49%) while rescue support was needed in 26 subjects (51%). Twenty-two subjects (43%) required reintubation. Reintubation rate was higher for rescue support (58% vs. 28%, P = .03). Subjects with a pH < 7.35 (4.3% vs 42%, P = .003) and lower somatic NIRS (39 [24-56] vs. 62 [46-72], P = .02) were more likely to be reintubated. The IPAP, EPAP, and FIO₂ were higher in subjects who required reintubation.

NIV or CPAP use was associated with a reintubation rate of 43% in a heterogeneous sample of high-risk infants. Acidosis, cardiac surgery, higher FIO₂, lower somatic NIRS, higher support settings, and application of rescue support were associated with the need for reintubation.

Accurate ETCO₂ and PtcCO₂ readings provide healthcare practitioners with data they need to determine the efficacy of medications, therapies, and the necessity of interventions. We tested the Procedural Oxygen Mask (POM) (POM Medical, Moorpark, California) to determine if there were differences between ETCO₂ and PtcCO₂ readings. We hypothesize there is no difference in ETCO₂ and PtcCO₂ readings on live participants while wearing the POM.

First, a transcutaneous monitor (TCM) (Sentec, Lincoln, Rhode Island) was placed just below the left clavicle at the midclavicular line on each of the participants after prescreening and IRB approval. Then the POM was attached to a Medtronic Capnostream 35 ETCO₂ Monitor (Medtronic, Minneapolis, Minnesota) and was placed on a participant’s face with medical air running through the mask at 10 L/min. After calibration, the PtcCO₂ and the ETCO₂ were recorded at 1 and 2 min. After 2 min, a Pentax Medical Video Bronchoscope VB-1530t2 (Pentax Medical, Montvale, New Jersey) was placed through the POM membrane. PtcCO₂ and ETCO₂ readings were measured at 1 and 2 min and the bronchoscope was removed. The participant then kept the mask on for 2 additional min and data were recorded. This process was repeated at flows of 12 and 15 L/min of medical air.

The average ETCO₂ at 10, 12, and 15 L/min of air flow pre-procedurally was 23.93 mm Hg, 22.6 mm Hg, and 20.7 mm Hg. During the procedure at 10, 12, and 15 L the average ETCO₂ was 22.73 mm Hg, 22.06 mm Hg, and 20.53 mm Hg. Post-procedurally, at 10, 12, and 15 L the average ETCO₂ was 23 mm Hg, 22.37 mm Hg, and 20.23 mm Hg. See Figure 1. The average PtcCO₂ at 10, 12, and 15 L of air flow pre-procedural was 31.73 mm Hg, 32.39 mm Hg, and 32.43 mm Hg. During the procedure at 10, 12, and 15 L, the average PtcCO₂ was 31.93 mm Hg, 32.52 mm Hg, and 32.38 mm Hg. Post-procedural at 10, 12, and 15 L the average PtcCO₂ was 32.16 mm Hg, 32.39 mm Hg, and 32.53 mm Hg. See Figure 1.

It appears that with increases in flows via the POM, the measured ETCO₂ decreases while PtcCO₂ readings do not show much correlation with flows and less variance. Further research is required to determine if this is clinically significant. With these findings, the null hypothesis is rejected.

The partial pressure of end-tidal CO₂ (PETCO ₂) is sometimes measured during a code situation to determine the effectiveness of chest compressions via bag-endotracheal tube ventilation. We sought to determine if the supplemental oxygen delivered to the bag during manual ventilation affected the capnometer reading. Secondarily we evaluated whether the application of PEEP had any effect on PETCO₂. The null hypothesis is that neither high oxygen flow nor PEEP skew the capnometry reading during manual ventilation.

A simulation model was created using a Michigan Instruments TTL test lung connected to either an Ambu Spur II or Mercury Medical CPR-2 bag. Compliance was set for 60 mL/cm H₂O and resistance set for 5 cm H₂O/L/s. A Hamilton Medical C6 Capnostat monitor was attached between the resuscitation bag and the test lung. CO₂/air mixtures were introduced into the test lung to obtain a target PETCO₂ of 20 mm Hg and 40 mm Hg. The patient was bagged by the same person delivering 20 cm H₂O of pressure each time. Continuous bagging was performed for one minute, then a reading was recorded. Trials consisted of two flows (15 L/min and flush) and three PEEP levels (0, 10, and 20 cm H₂O). All trials were performed three times, the average was taken, and the difference from target was recorded.

Ambu Spur II values at 15 L/min and flush were within ± 3 mm Hg of both PETCO₂ targets and all PEEP levels except when the flow was set to flush with zero PEEP and the target was set to 40 mm Hg. In this scenario the measured value was 72.67 mm Hg, a 58% difference. Mercury Medical CPR-2 values at 15 L/min and flush were within ± 3 mm Hg of both PETCO₂ targets only when PEEP was set to 20 cm H₂O and when PEEP was set for 10 cm H₂O and the target was 40 mm Hg. All other values ranged from 7-13 mm Hg of target with the highest variability occurring when the flow was set to flush, zero PEEP, and a target of 20 mm Hg. In this case the measured value was 33 mm Hg, a 49% difference.

PETCO₂ values tended to be more consistent when oxygen flow was set for 15 L/min regardless of the presence or absence of PEEP. However, when the flow was increased to flush and PEEP set to zero we found that there was a significant difference between the target and PETCO₂ in both resuscitation bags but particularly in the Ambu Spur II bag when the target was 40 mm Hg. When bagging with high oxygen flow and zero PEEP, the capnometer may not reflect an accurate PETCO₂.

Endotracheal suctioning (ETS) is essential to maintain the patency of the artificial airway. Mastering this skill is a core competency of respiratory therapists (RTs). There have been no research studies on the practice of ETS among RTs in Saudi Arabia; therefore, this study aimed to assess their practice based on the latest (ie, 2022) American Association for Respiratory Care (AARC) evidence-based guidelines.

This study utilized a self-administered questionnaire to survey RTs working in critical care units in Saudi Arabia who hold at least one respiratory care degree. The aim was to compare their actual ETS practice with the recommended guidelines set by the AARC. The questionnaire consisted of 22 multiple-choice questions categorized into three domains: demographic data, RTs’ awareness, and adherence to the AARC guidelines. A scoring system was implemented to measure the level of adherence to the AARC recommendations, with answer choices graded on a scale of 0 to 4, as shown in Table 1. The maximum score attainable for complete adherence to the AARC guidelines was 32. The remaining questions were analyzed using summary statistics, presented as mean, standard deviations, and percentages. This study received approval from the Research Ethics Committee of the Faculty of Medicine, King Abdulaziz University (Reference No 259-22).

Of the 126 individuals who accessed the survey, data from 120 RTs were included in the analysis. The mean score and standard deviation were 21 and 4, respectively, representing a 67% compliance rate (SD 11%). The majority of participants (n = 74, 62%) achieved adherence rates between 60% and 80%. A small number of RTs (n = 8, 7%) had a concerning compliance level of less than 50%, whereas 16 subjects (14%) demonstrated adherence greater than 80%. Figure 1 depicts the RTs’ adherence level to each AARC recommendation.

The present study found that RTs demonstrated a moderate level of adherence to the AARC's latest ETS guidelines. The recommendations with the lowest compliance were normal saline instillation and ETS performance based on the time intervals. As these procedures are assessment-based, we recommend developing educational and training programs that highlight the significance of assessments in determining the clinical need for ETS.

Figure 1. The absolute degree of adherence to each ETS AARC recommendation.

Table 1. The questions and their answer choices score surveyed.

Many spontaneous breathing tracheostomized children receive inhaled medications, but the optimal aerosol delivery methods for them remain unclear. We aimed to assess the impact of different humidification devices and flow settings on aerosol delivery for spontaneously breathing tracheostomized infants and toddlers.

Spontaneous breathing models of trached infant (5 kg) (tidal volume [V_T] 30 mL, breathing frequency 30 breaths/min, inspiratory:expiratory [I:E] 1:2.3, and trach size 4.5 mm) and toddler (15 kg) [V_T 100 mL, frequency 20 breaths/min, I:E 1:2.3, and trach size 5.5 mm) with a collecting filter placed distal to the airway. Albuterol sulfate (2.5 mg/3 mL) was administered via a vibrating mesh nebulizer (VMN) in all conditions with heated and unheated humidification. VMN was placed near the humidification device and compared in different settings: 1) Optiflow set at 37°C and flows of 5 vs. 10 L/min for infant and 7.5 vs. 15 vs. 30 L/min for toddler; 2) Airvo2 set at 37°C and flows of 15 vs. 30 L/min for toddler; 3) large volume nebulizer (LVN) at flows of 1 vs. 2 L/min for infant and 1 vs. 2 vs. 4 L/min for toddler. Lastly, conventional nebulization was VMN with ultra via trach mask with O₂ at 2 L/min and JN with T-piece attached to the airway for both models. The collected drug was eluted and assayed with ultraviolet spectrophotometry (276 nm).

Inhaled dose increased as the setting flows decreased for infant and toddler modes, regardless of the humidification devices (all P <.05) (Table 1). In-line placement of VMN with Optiflow and Airvo2 had a higher inhaled dose than LVN for toddler at all flow settings and for infant at moderate flow (all P < .05). Inhaled dose was higher with conventional VMN than in-line placement of VMN with humidification devices at all flow settings for both models tested (all P < .05). When conventional JN was utilized, the inhaled dose was higher than in-line placement of VMN with all humidification devices for toddler (all P < .05), except at low flow settings with Optiflow (13.9 ± 0.5 vs. 12.5 ± 1.3%, P = .016). In contrast, in-line VMN with Optiflow and LVN generated a higher inhaled dose than conventional JN at moderate flows for infant (both P < .05).

During in-line placement of VMN with humidification devices, aerosol delivery increased as flow settings decreased, but the inhaled dose was lower than conventional VMN in both infant and toddler models. Nebulizer setups should be chosen based on patient oxygen and humidification needs.

Graphic representation of the study design

Physical activity and sufficient sleep are associated with individuals’ overall health. Studies have further shown using wearable devices for self-monitoring can aid in modification of health behavior. This investigation tested the utility of a wearable device and short message prompts to increase physical activity. The objective of this study was to explore the feasibility of using wearable fitness devices to quantitatively measure daily physical activity and sleep levels. This project explored approaches for designing activities to incorporate physical activity to help participants self-interpret to develop healthier sleep patterns.

This study comprised of participants (n = 38) from public health gerontology and respiratory care with qualitative data, from wearable fitness trackers and quantitative data through key informant interviews.The wearable fitness trackers were provided to each participant with necessary instructions. The data was collected weekly for up to 3 months. Key informant interviews were conducted to ascertain the usefulness of wearable fitness in physical activity. 80% of participants were female with all participants above 18 years of age.

Regression analysis was conducted to assess if 28 of the independent variables had statistical significance on the odds of observing effects by the dependent variables of race gender or level of education. The results of the analysis were not statistically significant with the exception of ‘I like to exercise because it reduces my stress’, revealing F (4,15) = 0.69, P = .611, R ² = 0.001. the remaining variables did not explain a significant proportion of variation in gender, race nor level of education. Table 2 summarizes the results of the regression model. Variance inflation factors (VIFs) were calculated to detect the presence of multicollinearity between predictors. All predictors in the regression model had VIFs less than 5. Table 1 presents the VIF for each predictor in the model.

The objective of this study was to explore the feasibility of wearable devices to quantitatively measure daily physical activity, and sleep levels. The project was exploring approaches for designing activities to incorporate to help participants learn how to interpret data. It was found that the participants' sleep hours increased for the first month (6.39 hours), third month (8.5 hours) approximately 2 hours. The findings reveal there was an increase from 45.5 % in the first month maintaining 33% respectively by the third month of the study.

The Hamilton G5 Ventilator (Hamilton Medical, Switzerland) displays automated measures of respiratory mechanics such as static compliance (C_RS) and airway resistance (R_aw) using the least squares fitting method. The manual calculation for constant flow resistance is commonly recognized, while the manual calculation for decelerating flow is not readily known. This bench study was conducted to determine the reliability and accuracy of the displayed values for R_awwith a decelerating flow pattern.

A bench test was conducted using the ASL 5000 Breathing Simulator (IngMar Medical, Pennsylvania) to compare the displayed calculations with manual calculations in passive conditions. Two clinical scenarios were created using compliance and resistance values (C_RS 50 mL/cm H₂O, R_aw 8 cm H₂O/L/s) and (C_RS 40 mL/cm H₂O, R_aw 15 cm H₂O/L/s). Two different flow patterns were assessed: constant and 50% decelerating. The tests were done using synchronized controlled mandatory ventilation, (S)CMV. Statistics were calculated in RStudio (Posit, MA) using the Bland-Altman analysis. The mean bias, limits of agreement (LoA), and concordance coefficient (CCC) are reported. The automated calculations of C_RS and R_aw were then compared based on the clinical scenarios.

The R_aw mean bias -7.26 (95% CI -8.01 to -6.52), LoA -9.83 and -4.70 (95% CI -10.67 to -8.98 and -5.54 to -3.86) with a CCC of 0.13 (95% CI 0.07 to 0.19) for difference between calculated and displayed values for decelerating flow were not favorable. Using the ASL 5000 as a reference value compared to displayed values of the Hamilton G5 yielded a bias of -0.73 (95% CI -0.90 to -0.55), LoA -1.31 and -0.16 (95% CI -1.59 to -1.12 and -0.35 to 0.03) with a CCC 0.97 (95% CI 0.94 to 0.98).

The automated calculations from the Hamilton G5 ventilator based on the least squares fitting model were dependable for both C_RS and R_aw measurements. As there are no defined calculations for bedside calculation of R_aw for a decelerating flow pattern, using the manual calculation for the constant flow pattern was not accurate. Using the ASL 5000 values as the reference measurement, the Hamilton G5 R_aw was reliable and accurate for flow pattern irrespective of the type described by low bias, Bland-Altman LoA, and CCC. The LoA show that the values cannot be used interchangeably for a decelerating flow pattern. These were in passive conditions and from previous studies would not be as reliable with a patient actively breathing.

Leak compensation algorithm is a key success element in patient-triggered ventilation. However, the effect of leak compensation on ventilator-triggered performance in the absence of leak has not been fully investigated. This bench study aimed to test the hypothesis that a change in the breathing pattern of certain lung mechanics incorrectly compensates for trigger sensitivity, causing ineffective efforts (IEs).

Two ICU ventilators (PB840 and PB980, Covidien) with activated leak compensation were compared in a leak-free setting using a lung simulator (ASL 5000, IngMar Medical). The default disconnect sensitivity was set to 40 L/min. Three adult lung models with different lung mechanics (normal, ARDS, and COPD) were tested using a combination of low and high muscle pressures (P_mus) and breathing frequency. The ventilators in a pressure support mode were connected to the ASL 5000. Pressure support was set at 5 or 10 cm H₂O; PEEP was set at 5 cm H₂O; apnea time was set at 20 s; flow trigger sensitivity was set at 3 L/min; and termination criteria were set at 5%, 25%, and 40% for ARDS, normal, and COPD mechanics, respectively. All combinations of frequency and P_mus were sequentially changed in the lung model, and the incidence of IEs diagnosed on the ASL 5000 waveforms and activation of apnea backup ventilation was observed for 60 s after each change. Three trials were run for each model. The influence of lung mechanics, breathing pattern, and the direction of change in the breathing pattern was examined on the outcomes.

The incidence of IEs was significantly higher with PB840 than with PB980 for pressure supports of 5 and 10 cm H₂O (21% vs. 2% and 7% vs. 2%, respectively; P < .05 for both comparisons). All IEs resulted in apnea backup ventilation with PB840 but not with PB980. With PB840, 35% and 65% of the IEs were observed in ARDS and COPD, respectively. Conversely, with PB980, all IEs were observed in COPD. Although most IEs (91%) occurred during reduced frequency, the incidence of IEs was not associated with the magnitude of P_mus or the direction of change in P_mus or frequency.

The activation of leak compensation in a leak-free setting resulted in IEs and the eventual backup ventilation with both PB840 and PB980. This was suggested to be accompanied by high airway resistance and low frequency. Thus, PB980 was superior to PB840 in ameliorating this problem. Further clinical investigation is needed.

Awake prone positioning (APP) has been reported to improve oxygenation and reduce the need for intubation in patients with acute hypoxemic respiratory failure (AHRF). However, the impact of APP on ventilation distribution during various forms of respiratory support remains uncertain.

Thirty-four patients were consented and included in this study after obtaining IRB approval (No. B2022-359R). The patients underwent 30-min phases of each respiratory support device in both supine position (SP) and APP in a random sequence. The respiratory support devices included high-flow oxygen mask (HFOM) at 60 L/min, high-flow nasal cannula (HFNC) at 60 L/min, and CPAP at 8 cm H₂O. FIO₂ was adjusted to maintain SpO₂ at 90-95%. Ventilation parameters including global inhomogeneity (GI) index, center of ventilation (COV), ROI (region of interest), and dorsal fraction of ventilation were continuously assessed using electrical impedance tomography (EIT).

Among the 34 patients, 24 were male, age 73 ± 10 years, with an average body mass index (BMI) of 25 kg/m². The average APACHE II score at enrollment was 13 ± 4. The SpO₂/FIO₂ ratio, ROX index (SpO₂/FIO₂ ratio/breathing frequency), and GI index were higher in APP compared to SP, regardless of respiratory support devices used (all P < .05). Similarly, these variables were higher with CPAP than HFOM and HFNC, regardless of patient positions (all P < .05). There was no significant interaction observed between body position and respiratory support. In the supine position, the COV with CPAP (53.4 ± 8.1%) was higher than that with HFOM (47.8 ± 6.0%, P = .015) and HFNC (48.1 ± 7.2%, P = .030). However, the COV with CPAP decreased to 46.7 ± 7.1% during PP (P = .001). With the use of CPAP, the ventral ventilation significantly increased during APP (44.9 ± 15.0 vs 55.0 ± 19.9%, P = .017), predominantly in layer ROI 1(6.9 ± 6.2 vs 11.5 ± 9.9%, P = .022), while a significant decrease was observed in layer ROI 3(48.0 ± 12.2 vs 39.6 ± 16.3%, P = .020). Additionally, significant discomfort was reported in both APP and with the use of CPAP.