Respiratory Care

The Joint Commission definition of a pressure ulcer is a broader term that includes decubitus ulcers, but also includes any ulcerations associated with pressure. In 2015, over a 3-month period, the intensive care nursery at Thomas Jefferson University Hospital had 5 patients who developed pressure ulcers due to placement of an improper size nasal cannula being used for that patient. Infant nasal cannulas are typically classified as being for micro premature, premature, neonate, infant, and intermediate infant size patients. To this day, there is no instruction by most manufacturers for fitting a nasal cannula to the actual size of the patient in kilograms. Also, cannulas are not of a universal size from various manufacturers.

In October of 2015, using manufacturer specifications and measurements taken by our biomedical department, a sizing chart was developed to fit the proper size cannula based on a patient’s weight in kilograms. Four products from 4 different manufacturers were used in our nursery at that time. In January of 2018 a fifth product was added to our already existing products. (see table)

Since the implementation of the nasal cannula size chart in the intensive care nursery at Thomas Jefferson University Hospital, the incidence of pressure ulcers has remained zero. Thus far, from November 2015 through January 2024, a total of 983 patients have been followed. Surveillance of these patients has shown that 8 patients developed redness with no skin breakdown and 3 developed bruising. Of the 3 patients who developed bruising, 2 developed it from face planting, and none had any skin breakdown.

The implementation and use of a size chart based upon a patient’s weight has been proven to be a vital tool in our unit for reducing the incidence of pressure ulcers associated with nasal cannula use in the infant population. It may also be a vital tool that should be included in the manufacturer packaging material for use at other institutions. We will continue the use of this tool, along with continued patient surveillance to confirm that the use of a nasal cannula size chart is a vital method in reducing pressure ulcers associated with nasal cannula use in the neonatal/infant population.

Asthma is a chronic airway disease characterized by bronchoconstriction and inflammation and leads to symptoms such as coughing, wheezing, shortness of breath, and chest tightness. The Global Initiative for Asthma (GINA) updated the asthma guideline in 2019, now recommending regular or as-needed inhaled corticosteroid-containing treatment to control symptoms. Unfortunately, patients and even healthcare practitioners are still not knowledgeable about the recent change by GINA. Hence, there is an overreliance on short-acting beta-agonists and underuse of inhaled corticosteroid (ICS)-containing inhalers. There is also poor inhaler technique in 70-80% of patients. Two research questions were addressed. The first research question is: how does tailored asthma education affect adult participants’ knowledge about asthma? The second research question is how does tailored asthma education affect participants’ cognitive and psychomotor skills required in asthma self-management? Therefore, this study aimed to report the impact of tailored asthma education on asthma knowledge and skills.

This study was a pilot study with 6 participants aged 18-70 y, recruited between June and October 2023 in response to the recruitment flyer, and who attended one tailored asthma education session. Participants’ asthma knowledge was assessed using the Asthma Self-Management Knowledge Adult Questionnaire, and a standard inhaler checklist with the teach-back method was used to assess participants’ cognitive and psychomotor skills. The PI obtained IRB approval before any recruitment started.

Although 1 participant did not achieve a score that put her in the category of better asthma knowledge, all 6 participants showed improvement in asthma knowledge after tailored asthma education. Also, all 6 participants improved their inhaler skills and technique post-tailored asthma education. In addition, a discovery in this study shows that patients with asthma may have a false sense of confidence in disease management.

Although more research is needed to generalize the results, findings indicate that tailored asthma education can improve patients’ asthma knowledge and inhaler technique. In addition, findings suggest that tailored asthma education can improve patients’ confidence in asthma self-management.

While the impact asthma has on sleep disturbances is well-described, the impact that sleep can have on asthma is less understood. Therefore, the purpose of this review was to examine the evidence surrounding how sleep impacts asthma.

A literature search was performed from August 17 to September 5, 2023, in four databases following the Preferred Reporting Items for Systematic Review and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. Inclusion criteria included cross-sectional, cohort, and observational studies published in English that evaluated adult populations with clear directionality of sleep impacting asthma. Two independent reviewers used an iterative process for abstract and full-text review. Study quality was assessed using the Joanna Briggs Institute (JBI) critical appraisal tool for each study type.

Of 919 studies, 13 met inclusion criteria and were analyzed. Sleep was assessed through the Pittsburgh Sleep Quality Index (no. = 6), the Epworth Sleepiness Scale (no. = 5), self-reported sleep duration (no. = 4), and actigraphy (no. = 2). Asthma was assessed through asthma control surveys (no. = 11), spirometry (no. = 7), inflammatory biomarkers (no. = 3), and a quality-of-life survey (no. = 1). Twelve studies (92%) determined that sleep quality and/or duration impacted asthma control, quality of life, and healthcare utilization. One study (8%) found no association between sleep parameters and asthma control in individuals with well-controlled asthma.

Poor sleep quality is associated with poorer asthma control, more frequent asthma exacerbations, and reduced quality of life. Further research using valid and reliable self-report and objective measures is needed to characterize sleep disturbances in individuals with asthma and to assess the impact that sleep disturbances have on asthma.

Brackett, Cohen, and Schwartz published a seminal research report (N Engl J Med 1965; 272: 6-12) describing the effects of escalating degrees of acute hypercapnia in man. Brackett, Wingo, Muren, and Solano subsequently published a classic monograph (N Engl J Med 1969; 280: 124-130) describing the effects of progressive degrees of chronic hypercapnia in the human organism. Because the clinical response to acute hypercapnia varies markedly from the therapeutic strategy employed to treat chronic hypercapnia, it is crucially important for clinicians to discriminate between the two presentations. We have generated a diagrammatic representation of the results of the authoritative and comprehensive studies cited above, and have posted that nomogram on the internet.

First, the steady-state (linear) regression line relating arterial carbon dioxide tension (PaCO₂; on the abscissa) versus arterial pH (pH_a; on the ordinate) pertaining to acute hypercapnia was plotted on a rectilinear co-ordinate axis system, together with the so-called 95% confidence band. Next, the linear regression line relating PaCO₂ versus pH_a pertaining to chronic hypercapnia was plotted on an identical X/Y grid, together with its 95% confidence band. Then, these regression lines/confidence bands were combined within a composite Figure (see below). Finally, this graphic was coded to run on a server as a computer application (app), the Chronicity Map, and posted to the internet.

Clinicians navigate to the app by means of the following Universal Resource Locator (URL): http://acidbaseclinimap.com and key in the patient’s prevailing PaCO₂ and bicarbonate ion concentration, which are retrieved from the patient’s arterial blood gas (ABG) Report. If the < PaCO₂ exceeds 49 torr (and metabolic acidemia is absent), the Chronicity app launches automatically. Under computer control, a vertical line is scribed coinciding with the PaCO₂, together with a horizontal line coinciding with the hydrogen ion concentration, in nanomoles per liter. The region within which those lines are observed to cross identifies the disorder as an acute, or chronic, or acute-on-chronic hypercapnia.

Practitioners cannot be expected to memorize large arrays of data, such as the detailed results of clinical research studies, but networked computers can enable us to gain immediate access to the results of seminal investigations.

Secretion-related atelectasis is a common complication in pediatric mechanical ventilation. Intrapulmonary percussive ventilation (IPV) delivers high-frequency small bursts of gas flow to facilitate pulmonary secretion mobilization and treat secretion-related atelectasis. Inhaled Nitric oxide (iNO) is used to reverse hypoxemia and pulmonary hypertension and potentially reduces ventilator days and use of extracorporeal membrane oxygenation in pediatric mechanical ventilation. A previous bench study demonstrated placement of the NO inject module in line with the sliding Venturi resulted in a ventilator failure and affecting the accuracy of NO delivery during different configurations. We hypothesized that affecting factors of NO delivery and fraction of inhaled oxygen (FIO₂) delivery during IPV superimposing mechanical ventilation are location of NO inject module compared to IPV adaptor and cap on the IPV adaptor.

We compared iNO delivery using three configurations superimposing IPV with the Gentinge Servo-U ventilator, the Percussionaire IPV-2c, and INOmax DSIR Plus in a lung model. Set NO values were 5, 10, 20, 40, 60, 80 ppm for three configurations. Ventilator settings and lung model values remained consistent throughout the experiments. Delivered NO, NO₂, and FIO₂ were measured. The accuracy of NO delivery was calculated among configurations.

FIO₂ delivery was higher than set FIO₂ when delivering IPV superimposing conventional mechanical ventilation. When the IPV adaptor with cap was followed by the injector module, the accuracy of NO delivery ranged from –90 to –82%. When the injector module was followed by the IPV adaptor without cap, the accuracy of NO delivery ranged from –18 to 0%. When the injector module was followed by the IPV adaptor without cap, the accuracy of NO delivery ranged from –12.5 to 10%. Notably, the configurations with the IPV adaptor followed by the inject module and set NO dose of 80 ppm, the delivered NO values were out of accuracy suggested accuracy (± 10%).

The delivery of NO during IPV superimposing with mechanical ventilation was affected by the injector module and IPV adaptor location. The accuracy of NO delivery was within the suggested range when the injector module was followed by the IPV adaptor.

Unplanned extubations (UPEs) in the PICU can result in increased mortality, morbidity, and length of stay. Our rates (events per 100 patient ventilator days) were consistently above the benchmark from the Solutions for Patient Safety (SPS) national collaborative, and were on track to increase even further in early 2018. We aimed to reduce our annual UPE rate from FY 2018 baseline of 0.96 by 20% per year until we achieved an annual rate below the SPScenterline (0.59 at project initiation).

We reviewed 2 years of data, identified root causes, which included inadequate sedation or decreased sedation in anticipation of extubation, sudden agitation (spontaneous or with procedure), movement during procedures, improper tube securement or delayed retaping, inadequate medical immobilization, or excessive secretions. We quantified how often each root cause was the primary cause of an UPE and how often they contributed to an UPE to aid in prioritizing interventions. In planning interventions, we incorporated suggestions from our NICU colleagues who participated in the SPS Unplanned Extubation Pioneer Cohort, including their It Takes Two methodology for securing, repositioning, and/or manipulating endotracheal tubes. Interventions fell into three broad categories: (1) communication/documentation (eg, new procedures and education on escalating concerns, new post-event huddle, and updated event reporting), (2) inadequate sedation (eg, education and discussion around sedation goals, and updated rounding tool), and (3) inadequate endotracheal tube securement (eg, new product trials and adoption of a novel center upper lip taping procedure for children too small for a commercial securement device).

Compared with our preintervention baseline rate in FY2018, we reduced our average annual rate of unplanned extubations by over 50%, exceeding our goal and the national SPS benchmark.

A multidisciplinary team using continuous quality improvement can dramatically reduce UPEs in a PICU. Keys to success included collaboration within our interprofessional team, synergy across units/sister institutions and other initiatives (eg, delirium reduction, early mobility), and learning through multicenter collaboratives. Ongoing barriers to sustainability include human resource issues (ie, turnover, burnout, evolving unit culture, ineffective communication among team members and other services, and lack of resources to support ongoing education and auditing), data acquisition, and EMR optimization.

Long-term mechanical insufflation-exsufflation (MI-E) has been widely used to treat pediatric patients with ineffective cough from various conditions, such as neuromuscular diseases and chronic respiratory failure receiving mechanical ventilation. A previous bench study found the performance of MI-E devices extremely varied from manufacturers and even models of the same manufacturer and recommended individualized MI-E settings based on the specific machine utilized. We conducted a bench study to compare peak cough flow and insufflation volume delivery through two MI-E devices using a breathing simulator.

A breathing simulator was set to simulate a pediatric patient (resistance of 50 L/min/s and compliance of 10 mL/cm H₂O) with spontaneous breathing efforts, connecting with two MI-E devices—CoughAssist T70 and Synclara. A flow analyzer Citrex H5 was connected between the MI-E devices and ASL 5000 to measure cough peak flow (CPF) and insufflation volume (Vi). Accuracies of the MI-E devices were calculated for CPF and Vi values. 10 consecutive CPF and Vi values measured by ASL 5000, MI-E devices, and the flow analyzer were recorded and analyzed.

The CPF values measured by CoughAssist T70 and Synclara were 97 [91-105] and 144 [121-157] L/min, respectively. The Vi values measured by CoughAssist T70 and Synclara were 344 [303-351] and 174 [165-187] mL, respectively. The median accuracy (%) of CPF for Cough Assist T70 and Synclara were -31 and -5%, respectively. The median accuracy (%) of Vi for CoughAssist T70 and Synclara were -38 and -56%, respectively. There were no significant differences on CPF and Vi delivery to the simulator (P = .21 and P = .98, respectively).

Although the accuracy of parameters varied by MI-E devices, there were no significant differences on CPF and Vi delivery. Future research may be needed to evaluate movement of secretion in pediatric population among different MI-E devices.

Accuracy of Peak Cough Flow and Insufflation Volume Measurement on Mechanical Insufflation-Exsufflation Devices

Singing is the production of musical tones with the voice. It involves the respiratory system, including respiratory muscles. This universal human behavior practiced for thousands of years in various cultural contexts including religious ceremonies, social gatherings, and artistic performances. Previous research suggests singing can improve various aspects of health in both healthy individuals and those with respiratory conditions. This study aims to explore perceptions regarding the use of singing to promote general and respiratory health in Makkah.

An observational, cross-sectional survey in Makkah to explore perceptions regarding the impact of traditional singing on general and respiratory health. Data was collected using a questionnaire including open and closed questions. Quantitative data was summarized as frequency and percentages, while qualitative data from open questions was summarized into themes. Ethical approval was obtained from Umm Al-Qura University in Makkah ID (HAPO-02-K-012-2023-12-1911).

The participants were 273 people from Makkah region, of which 153 (56%) were female, the majority aged 21 to 41 y (63%), 88 (32%) reported chronic respiratory diseases. Among all participants,158 (58%) engaged in daily singing, 161 (59%) believed that singing has a positive impact on general health and 117 (42%) were agreed that singing can improve lung health. Overall, 146 (54%) of the participants agreed that singing can improve quality of life. Perceived barriers to singing participation included absence of support from family and relative (113; 41%), singing is a tradition and has no effect on health at all (80; 29.3%), and singing has no health benefits (91; 33.3%).

People in Makkah believed that singing could have an impact on general and lung health. Further research assessing the impact of singing on clinically relevant parameters would be useful.

High-flow nasal cannula (HFNC) is a common respiratory support device utilized in the management of children hospitalized with bronchiolitis. Around 2010, early adoption of HFNC in many pediatric wards was developed using age-based flow limits, primarily based on limited neonatal literature of the time. However, age-based flow limits do not align with current evidence and potentially contribute to unnecessary ICU admissions. To align with current evidence and improve ICU bed allocation, we implemented new weight-based flow guidelines within our pediatric wards. The primary objective of this study was to evaluate the impact of HFNC weight-based flow guidelines on ICU admission rates and adverse respiratory events for bronchiolitis.

This retrospective study was conducted at Children’s Medical Center in Plano, Texas, a free-standing, community-based hospital affiliated with an academic quaternary center and UT Southwestern. Subjects were infants admitted for bronchiolitis and supported via HFNC in the 12 months before and after implementation of weight-based flow guidelines (March 22 – Feb 24). Primary outcomes were ED disposition and ICU transfer rates. Secondary outcomes were escalation of respiratory support (NIV or intubation), escalation within 1 h of ICU admission and hospital length of stay (LOS). Descriptive statistics, t-test, and z-test were used for statistical analysis. This study was designated as non-regulated research by our institutional review board.

A total of 1,409 patients met inclusion criteria; 652 were admitted pre- and 757 post-implementation of weight-based flow guidelines. There were no differences between groups in age, weight, or gender. Compared to the pre-implementation group, we observed a 53% decrease in ICU admissions [111 (17%) vs 63 (8%); P < .001] and a 38% decrease in ICU transfers [44 (8%) vs 34 (5%); P = .03] with no difference in escalation of respiratory support [3 (7%) vs 5 (15%); P = .25] or escalation within 1 h of ICU admission [0 (0%) vs 2 (40%); P = .21]. Mean LOS decreased by 17.3 h in the post-implementation group, [73.0 (52.2) vs 55.7 (39.9); P < .001]. Full demographics, results, and subgroup analysis shown in Table 1.

Implementation of weight-based flow guidelines resulted in fewer low-acuity bronchiolitis patients admitted to the ICU. This was associated with higher ICU patient complexity, requiring increased provider coverage. Other hospitals should plan for a similar ICU acuity pattern.

Aerosol delivery during invasive mechanical ventilation is significantly affected by multiple factors related to the patient, device, and ventilator settings. Thus, we aimed to assess the impact of different ventilator settings, nebulizer positions, bias flows, circuit adaptors, and humidification on aerosol delivery during invasive ventilation.

An experimental setup was used to evaluate aerosol delivery using a vibrating mesh nebulizer (VMN) during invasive ventilation (Figure 1). Albuterol at 2.5 mg/3 mL was used under different ventilator settings, nebulizer placements, bias flows, and circuit connectors in the dry circuit. The exhaled humidity and the use of heated humidified circuits were only used in some settings. Each condition was repeated five times. The drug was eluted from the collecting filter and assayed using ultraviolet spectrophotometry at 276 nm.

The inhaled dose was higher with high settings compared to low settings regardless of nebulizer position, bias flow, heated humidification, and presence or absence of exhaled humidity (Table 1) (all P < .05) except at 2 L/min bias flow with exhaled humidity and VMN placed proximal to the endotracheal tube in dry circuits. The presence of exhaled humidity or heated humidification tended to diminish the differences between high and low settings in the inhaled dose. In dry circuits, no significant differences were observed in the inhaled dose when comparing Y-shaped and V-shaped connectors, except when the nebulizer was placed proximally at a bias flow of 2 L/min. Also, in dry circuits, proximal placement of the nebulizer at high settings generated higher inhaled doses than distal placement, regardless of the bias flow and connector type used. At low settings, with a Y-connector, no significant differences in the inhaled dose were observed between the two nebulizer placements.

In dry circuits, high ventilator settings generated a greater inhaled dose than low settings, with the nebulizer placed 30 cm proximal to the circuit connector showing higher inhaled doses at high settings. Exhaled humidity or the use of heated humidified circuits reduced the differences between high and low settings.

A) The study set up of a simulated adult intubated with an endotracheal tube (ETT) and mechanically ventilated while receiving invasive aerosol delivery using a vibrating mesh nebulizer (VMN). B) proximal VMN position placed 30 cm away from the circuit connection. C) distal VMN position placed at the humidifier inlet with the heated and humidified circuit. D) distal VMN position placed at the ventilator outlet with the dry circuit. E) Y-shaped connector. F) V-shaped connector.

The DOSE index is an invaluable instrument for evaluating both the severity and prognosis of COPD, encompassing elements such as dyspnea, obstruction, smoking, and exacerbations (DOSE) within a thorough patient assessment. In addition to its conventional role in assessing risks, the DOSE index demonstrates significant clinical value by predicting healthcare costs. Given the absence of specialized indices for forecasting medical expenditures, our research focused on examining the correlation between the DOSE index and medical expenses as measured by the Charlson Comorbidity Index (CCI) in COPD.

This retrospective study analyzes data from 396 COPD cases, examining the DOSE index, BODE index, ADO index, CCI, medical expenses, hospitalizations, and emergency room treatments. Baseline characteristics are expressed as the mean and standard deviation (mean ± SD), median (interquartile range, IQR), or n (%). The distributions of DOSE and CCI were evaluated by descriptive statistical analysis. DOSE quartiles and two CCI groups by Chi-square. Fisher’s exact test, and one-way analysis of variance (one-way ANOVA) were applied to compare the differences in variables by quartiles, and then posteriori comparisons were made using Scheffes test.

Significant associations were discovered between the DOSE index and the CCI in patients with COPD (P < .001). Of the 396 COPD patients meeting inclusion criteria, 382 (96.5%) were male, with an average age of 71.3 ± 8.4 y. Various healthcare parameters showed significant associations with the DOSE index. Notably, DOSE quartiles exhibited meaningful correlations with outpatient visits (P = .01) and outpatient medical expenses (P = .01). Additionally, substantial correlations were observed with hospitalization frequency, duration, and associated expenses (P < .001).When categorizing CCI into high (CCI ≥ 3) and low (CCI < 3) levels, a statistically significant difference was found when comparing DOSE quartiles between these groups with total medical expenses (P < .001).

The findings underscore the DOSE index and CCI potential in predicting medical expenses, extending its application beyond traditional risk assessment in COPD management. This study contributes valuable insights to the development of tools for forecasting healthcare expenses in COPD patients.

Total medical expenses by DOSE quartiles for the high CCI and low CCI groups. Patients with high CCI level had higher total medical expenses than those with low CCI level after adjusting for DOSE quartiles (p < 0.001).

The U.S. Bureau of Labor and Statistics reported that by 2032 the respiratory therapy profession will see an increase of 13% in positions available as over 92,000 therapists leave the field for a variety of reasons (U.S. Bureau of Labor Statistics, 2023). While accredited programs are interested in accommodating the needs of their hospital partners, the main focus is placed on providing students with an education that produces exceptional therapists. However, respiratory programs are also faced with increasing decline in programmatic enrollment. Across the country, respiratory programs are seeing a 27% decrease in enrollment since 2010 (American Association for Respiratory Care, 2021-2022). This study was conducted to determine if this is an appropriate time for schools to address specialty credentialing in respiratory therapy.

An anonymous, electronic survey was created and sent to 175 respiratory program directors from accredited AAS and AS programs across the United States. Two questions were presented to the program directors. The first asked what specialty credentialing courses were offered at their colleges, and the second asked whether there were notable benefits in their students and alumni receiving these credentials.

A total of 74 respondents completed the survey with three schools indicating that they offered review courses for certification of the following specialty credentials: NPS, PFT, ACCS, VA-BC and AE-C. Fifty-two percent of those schools acknowledged that there is benefit for the students to obtain these additional credentials with regard to increase in monetary compensation from employers, quantifiable knowledge, and producing more marketable candidates for employment.

The need for qualified respiratory therapists continues to grow nationwide. Obtaining specialty credentials helps to assure employers that the therapist is committed to best patient outcomes through high competency measures. Maintaining these credentials also help to ensure employers that the therapist is dedicated to the profession and a lasting relationship with learning.

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

Protocols were identified in published literature, and voluntarily submitted after an email was sent via a list-serve and posted on AARConnect. Settings were categorized based on the VDR-4 manual, recommendations from Forrest Bird,⁸ and feedback from subject matter experts (SME). Categories were developed with SME interviews to establish low, moderate, high, and variable/match conventional settings. The category table was reviewed by SMEs for feedback based on clinical experiences. Demand and oscillatory PEEP categories were off, low (1-3 cm H₂O), moderate (4-6 cm H₂O), high (≥ 7 cm H₂O), and match conventional. Pulsatile flow categories were low (20-30 cm H₂O), moderate (31-40 cm H₂O), high (≥ 40 cm H₂O), and match conventional/variable.

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

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

There is limited data regarding mechanical ventilation practices in overweight patients with PARDS. Our study aims to understand the differences in ventilator management and its effect on clinical outcomes in overweight and non-overweight PARDS patients. We hypothesize that the use of PEEP had a differential effect on overweight vs non-overweight PARDS patients.

This study analyzed patients recruited based on the PALICC 2015 definition of PARDS. Correlation between ventilator settings and BMI Z-score were studied using Spearman correlation. Overweight status was defined as BMI Z-score ≥ +1. Ventilator settings were analyzed in overweight vs. non-overweight groups and the association between PEEP with PICU mortality and 28-day ventilator free days was studied using multivariable regression, adjusting for age and oxygenation index and stratified by overweight status

132 patients with PARDS were included in this study. There were no clinical or statistical differences in ventilator settings comparing overweight vs non-overweight patients, though there was a trend towards the use of higher PEEP with patients of higher BMI Z-scores (r = 0.19, P = .056). Among patients who were not overweight, there was a significant difference in mortality comparing patients who were adherent vs. not adherent to the PEEP/FIO₂ grid [0 (0%), vs 9 (17.5%); P = .053], however, this effect was missing in the overweight group. Similarly, VFD was also improved comparing patients who were adherent vs. not adherent [21 (18.5, 23) vs. 15 (0, 21); P = .007] only in the non-overweight group. In the multivariable analysis, adherence to the PEEP/FIO₂ grid was only associated with improved VFD [adjusted beta 6.05 (95% confidence interval 0.43, 11.66); P = .035] in non-overweight patients.

The beneficial effects of the PEEP/FIO₂ grid were only observed in non-overweight patients. A larger cohort is required to confirm these findings and to determine the mechanism of this effect.

Respiratory care departments are experiencing an increased need to demonstrate value in the care they deliver. Value-efficiency is a concept that incorporates the value of individual treatments into the normal operations of a department. The purpose of this study is to describe and evaluate respiratory care leaders’ attitudes about value-efficiency.

An electronic survey was distributed via social media, professional networks, and a manager work group. The survey was targeted to directors, managers, and supervisors of respiratory care departments. We asked questions related to value efficiency. Data analysis was descriptive.

We received 116 responses, 86% were from managers or directors. The five most valuable services delivered were conventional mechanical ventilation (82%), noninvasive ventilation or CPAP (71%), protocol-driven care (47%), code team (44%), and rapid response team (41%). The five least valuable services delivered by respiratory care departments were electrocardiograms (63%), stress testing (44%), lung expansion therapies (41%), sleep studies staffed by the respiratory care department (36%), and smoking cessation (36%). The primary barrier to value efficiency were physician prescribing practices (68%). There was general agreement (> 50% of respondents agreed) that physicians are supportive of RT protocols (71%), value should be considered when evaluating the effectiveness of respiratory care services (95%), and would you direct your resources to more valuable services if possible (73%). Respondents did not agree that hospital administrators understand RT workflow and FTE needs (35%) and hospital administrators would be supportive if we reduced services (18%).

There was limited consensus on what respiratory care services are the most and least valuable. Physician prescribing practice was the primary barrier to value efficiency. Nearly all respondents felt value should be considered when evaluating respiratory care services.

COPD is a progressive and life limiting lung condition characterized by restriction of airflow into the lungs. This condition is now the third leading cause of death worldwide, so new research in this area is needed urgently. Protease-activated receptor 2 (PAR2) is a G-protein coupled receptor (GPCR) which has been recognized as an inflammatory receptor, with crosstalk reported with the innate toll-like receptor (TLR) 4. This concept has not been extensively explored in lung epithelial cells, nor has the potential interaction with other TLRs involved in infection-driven exacerbation (TLR2 and TLR3). The aim of this study was to investigate inflammatory responses in lung epithelial cells driven by PAR2 and TLRs known to be involved in exacerbation (TLR3 and 4).

The bronchial epithelial cell line, BEAS-2B, was used for all experiments. Immunofluorescence (IF) was initially used to establish the presence of PAR2, 3, 4. BEAS-2B cells were stimulated with PAR2 activating peptide FLIGRL or TLR agonists; lipopolysaccharide (LPS) and Poly I:C, in the presence or absence of the PAR2 antagonist AZ8838. After 48 h, IL-6 and IL-8 levels were measured in cell culture supernatants by ELISA.

BEAS-2B cells expressed PAR2, TLR3 and TLR4. PAR2, TLR3 and TLR4 agonists were able to induce significant levels of IL-6 and IL-8 production (inflammatory cytokines) from BEAS-2B cells over a range of concentrations (*P < .05) after a 24-h stimulation period.

Future plans include looking at CRISPR in order to edit out PAR2 and observe inflammatory effects in its absence. PAR2 antagonists will also be used in an attempt to downregulate the impact of PAR2-related inflammation. Human bronchial epithelial cells will be explored as well as COPD HBECs. These cell lines will give a more realistic model and allow for the comparison of healthy and COPD cells.

Bronchoscopy aids in viewing airway anatomy to determine treatment plans. Current infection prevention guidelines for bronchoscope reprocessing are rigid, time consuming, and create risk. Respiratory therapists (RTs) assist in bronchoscopy procedures from set up to equipment reprocessing. Cost often inhibits departments from purchasing unlimited reusable scopes which are fragile and limits availability. We aim to reduce risk in reprocessing, repair, purchase costs, and evaluate the convenience impact of disposable bronchoscopes (DB) in a 766-bed hospital facility (Level 1 Trauma Center, Academic Adult Care Facility).

An IRB exempt retrospective review (7/1/2022 to 09/30/2023) assessed frequency and cost of bronchoscopy services for ICU patients (119 beds). Affected RTs and providers were educated on the use of DB. The new equipment and process was implemented in February of 2023 with appropriate education, EMR, and policy updates. The following data metrics were reviewed for the 7 months pre and post go live to determine impact: number of bronchoscopies completed, number of ventilator days, time per procedure, number of trained RTs, and cost per procedure.

After implementation of DB, RT time per procedure was reduced by 43 min. RT labor cost per procedure was reduced by $35.11, however supply cost per procedure was increased by $163.34 (excludes original capital purchase for reusable supplies). Additional capital costs for reusable bronchoscopes were estimated at $113.38 per procedure (based on 3,192 bronchoscopies over 7-year life span for 9 scopes and 3 carts). Ease of use of DB allowed for additional staff to be trained, increasing available trained RTs from 20% to 67.5% (Table 1). There was no difference in number of bronchoscopy procedures performed per 1,000 ventilator days pre- and post-implementation (27.01 to 28.18). The total additional cost for disposable equipment was $14.85 per procedure.

Our facility prioritizes value efficiency, and while DB incurs added costs, reduced RT procedure time offsets labor expenses. The increase of trained RT caregivers for this procedure, increases availability, access, and provides opportunities for RT career growth. The absence of notable procedure increases suggests that enhancing access and availability may not significantly impact utilization. Further research must be done relative to infection prevention impact and within outpatient and pediatric care environments.

Preterm infants are at risk for respiratory distress syndrome due to immature lung development. The administration of surfactant reduces the risk of severe respiratory disease, and studies show that early surfactant administration, rather than delayed rescue administration, leads to a decrease in mortality and chronic lung disease, and a shorter duration on mechanical ventilation. From July 2023 thru September 2023 at a Level-III NICU, 56% of preterm infants born between 29 weeks gestational age and 37+6 weeks gestational age, not intubated in the delivery room, received surfactant administration more than 2 h after birth, which may lead to increased length of stay, more days on respiratory support, and may negatively impact long-term outcomes.

A quality improvement project was conducted in conjunction with Mass General Brigham Clinical Process Improvement Program (CPIP). Process mapping identified main contributors to delayed surfactant; contributors were explored through a driver diagram. Diagnostic data was collected using retrospective chart review (n = 15). The most common causes for delayed surfactant administration were protocol not followed, waiting on chest x-ray/line placement, and borderline patient status. Baseline data (n = 27) showed the average time to surfactant administration was 3 h and 23 min. The driver diagram was expanded to include tertiary drivers and change ideas (Image 1). Two PDSA cycles were implemented: CXR text reminder, and noninvasive surfactant administration (SALSA).

The introduction of PDSA Cycle #1, a chest x-ray text reminder sent from the delivery room RT to the admitting team, included 5 eligible patients. PDSA Cycle #2, noninvasive surfactant administration, or SALSA, has included 9 patients to date. Following the first 2 SALSA patients, eligibility criteria was changed so that surfactant must be delivered within the first 8 h of life in order to be given via LMA. There appears to be a positive trend, at the time of abstract submission, due to the implementation of SALSA. The resulting data is displayed in an XmR chart (Image 2).

Due to a decrease in eligible patient admissions/low census during the implementation of both PDSA cycles, there is insufficient data as of yet to determine if the interventions reduced time to surfactant administration. Data collection will continue as SALSA becomes a standard practice in this NICU. This project will inform future QI endeavors in this NICU.

Patients with a mild or asymptomatic acute phase of COVID-19 have reported persisting or emerging symptoms weeks or months after the initial infection. The purpose of this study was to review pulmonary function testing of patients with either a diagnosis or symptoms of long COVID following a mild acute phase. The aim was to identify what, if any, relationships existed among symptoms of pulmonary sequelae and measurements of pulmonary function.

A retrospective review of patients at a single center who received PFT and 6MWT for long COVID symptoms following a mild acute phase of COVID-19 was completed. Adult subjects were identified through electronic medical records if they received services between March 1, 2020, and September 2, 2023. The records of 19 patients were included in this review. Pearson’s correlation coefficient was used to analyze the relationship between dyspnea symptoms and overall pulmonary function, and D_LCO and fatigue scores. Finally, the relationship between dyspnea and 6MWD was analyzed using the Phi correlation coefficient.

Weak correlations were identified between the reported dyspnea and pulmonary function (r(17) = -0.09, P = .72, D_LCO (r(17) = -0.14, P = .58), and 6MWD (r(1) = 0.05, P = .37). There was a strong positive correlation between dyspnea and fatigue (r(17) = 0.75, P < .001). The sample size limits the analysis, but the data substantiates the need for additional research.

The degree of pulmonary impairment did not appear to correlate with the degree of symptoms reported by patients. Additionally, pulmonary function impairment did not appear to be the primary cause of dyspnea and fatigue in patients following a mild acute phase of COVID-19.

As part of a rapid response team (RRT), respiratory therapists (RTs) respond to deteriorating patients, bringing tools for diagnostics and intervention to the bedside. Introducing standards to improve care by RRTs is associated with improved outcomes. Additionally, it is recommended that RRTs have tools available for relevant interventions, such as medications, oxygen delivery devices, pulse oximetry, and capnography. However, excessive equipment may impact timely care delivery. We aimed to standardize RRT RT equipment packs, evaluate cost differences, quality concerns and overall staff satisfaction.

RRTs shared that RRT rapid packs (RP) were heavy and that supplies were difficult to find, leading to care delays. An interprofessional group (providers, RNs, RTs, security) reviewed RP contents as part of the medical emergency response team (MERT) debrief, developed a color-coded inventory system, selected an equipment bag (not included in total costs), and aligned contents with group recommendations. Post-implementation, the MERT members and RTs were surveyed utilizing a Likert scale (Fig. 1). In an IRB exempt review, usability, cost, and weight pre- and post- changes were evaluated.

Prior to the April 1, 2024 inventory adjustments to the RRT rapid packs (RP), 66 items were included in the RP and 43 items were in the RRT RP after modifications. The cost of the items pre ($1,559.71) and post ($1,491.26) was reduced by $68.45 per pack. The weight of the bag was 9 lbs pre and 7.9 lbs post (12.2% reduction in RP weight). Survey results showed 39% response rate (13/33 RTs responded) with an 84.6% of respondents preferring the new RP over the old version. Additionally, 92.3% of respondents felt the necessary equipment was available in the new RP. No supply availability-related increase in incident reports, safety events, or RRT to code escalations occurred during the study period.

Using an interdisciplinary approach to standardizing RRT supplies, we were able to decrease supply weight and cost while increasing accessibility for RTs. Involving the end-users in the process improvement efforts led to a positive response to the new RPs and ensured the right supplies were available. Further investigation is needed to determine impact on patient outcomes.

Figure 1 Details the new rapid pack staff survey results

In Taiwan, the Respiratory Care Center (RCC) acts as a transitional unit for patients who are difficult to wean from mechanical ventilation in the ICU and thus require prolonged mechanical ventilation (PMV). This phase is critical for determining whether patients can be weaned from invasive mechanical ventilation. The main purpose of this study is to develop and validate an easy-to-use nomogram for predicting the risk of weaning failure and to compare its accuracy with commonly used weaning indicators, RSBI and MIP, to assist physicians in clinical decision-making.

This retrospective study spanned from January 2010 to December 2021. We selected 1,060 patients who were difficult to wean due to respiratory failure from January 1, 2010, to December 31, 2015, and who were transferred from the ICU to the RCC. To test the accuracy of the model, another 612 patients with the same criteria were transferred to the RCC from January 1, 2016, to December 31, 2021, for internal validation. Clinical data collected on the day of transfer to RCC included basic demographics, etiology of mechanical ventilation, airway interfaces, blood test data, presence of cancer, GCS, APACHE II, Provent score, etc. Statistical analysis was conducted using SAS 9.4 and R software. (IRB number: 202201806B0).

Four variables were identified through multivariate analysis: etiology of mechanical ventilation, NLR, APACHE II, and cancer, and a nomogram was developed to predict the probability of weaning failure. The predictive capability of the model was assessed by the area under the ROC curve (AUC); the nomogram’s accuracy in the development group was AUC = 0.688 and in the validation group AUC = 0.626. Additionally, to assess the clinical applicability of the results from the development group, a comparison of accuracy with common weaning predictors was conducted; development group vs. RSBI (AUC = 0.688 vs. 0.601, P = .004), development group vs. MIP (AUC = 0.688 vs. 0.563, P < .001), showing statistically significant improvements over RSBI and MIP.

The nomogram is more accurate than RSBI and MIP, providing the medical team with a tool to evaluate and intervene timely with appropriate treatment, thereby increasing the rate of weaning from ventilators and enhancing the quality of clinical care.

Algal blooms of Karena brevis produce brevetoxins that lead to the natural phenomenon of red tide. Beyond monitoring red tide concentration and forecasting future outbreaks, uncertainty exists in the field when examining these toxins in relation to physiological aspect of humans. Contaminated air quality resulting from outbreaks of Karena brevis leads to inhalation of aerosolized brevetoxins, directly impacting the human respiratory system.

This systematic review focused on the respiratory effects of red tide and was conducted using a comparative method between two researchers. Relevant abstracts were collected, and full texted articles were reviewed with the use of PubMed, Science Direct, Cinahl Complete, and BioMed Central.

Thirty manuscripts were included in the final analysis and categorized by study design, location, number and age of participants, and respiratory effects. The research indicates respiratory health issues with exposure to red tide, specifically upper respiratory symptoms. Both symptomatic issues and pulmonary function tests were of concern when individuals were subjected to brevetoxin exposure.

Red tide is common in many areas of the world. The toxins released can cause respiratory compromise in humans. This manuscript provides for a comprehensive summary of scholarly research focused on the respiratory systema and red tide.

Vaping or the use of an electronic nicotine delivery system (ENDS) has continued to remain a public health threat in the U.S., primarily among youth and young adults. This scoping review focused on assessing the literature focused on the prevention or deterrence of e-cigarettes in the youth and young adult population.

This scoping review aimed to identify and describe effective interventions for college students to prevent vaping or aid in cessation. The search included the following databases: PubMed, CINALH, Embase, MEDLINE, PsychINFO, and Web of Science as well as Google Scholar and the reference lists of relevant articles. Eligible articles had to fit the following inclusion criteria: focused on youth aged 18-25, published from 2000-present, published in the English language, and focused on e-cigarette interventions/programs/prevention strategies.

After screening the titles and abstracts of the remaining 613 articles as well as full texts of any items needing further review, 63 total articles were deemed eligible. Of the 63 total articles, the majority used randomized controlled (no. = 18) and cross-sectional (no. = 12) study designs. Remaining study designs included qualitative, exploratory, experimental, multiple baseline design, longitudinal analysis, content analysis, scoping reviews, meta-analyses, and mixed methods.

This review summarizes the current evidence around prevention and cessation interventions for electronic vape products (EVPs) targeted at college students. Using the Socio-Ecological Model, the results can be analyzed on four different levels: individual, interpersonal, organizational/community, and society/policy.

Patients undergoing thoraco-abdominal surgery often experience limited spontaneous deep breathing due to pain, resulting in inadequate lung expansion. Thus, interventions for peri-operative respiratory care are crucial for lung expansion and airway secretion clearance. Peri-operative respiratory care includes the active cycle of breathing technique and incentive inspiratory exercise for incentive spirometry (IS). However, extended treatment durations can adversely affect patient satisfaction and resource management. This study endeavors to optimize peri-operative respiratory care by employing a quality control circle approach to achieve a 50% reduction in treatment time.

Data regarding treatment duration were gathered both prior to (May 2021) and subsequent to (September 2021 to May 2022) the initiation of quality control circle initiatives. The data, analyzed from 30 treatment sessions, were used to inform the process. Employing the PDCA (Plan-Do-Check-Act) method iteratively, the study aimed to refine and improve the efficiency of the interventions. The analysis of the care process identified two primary issues: 1) Patients expend considerable time self-preparing IS. 2) The utilization of abstract teaching methodologies prolongs patient learning durations. To optimize this process, the following solutions are proposed: 1) After medical order approval, nurses at the nursing station will provide IS to patients. 2) Record instructional videos for peri-operative respiratory care and place the video links along with IS at the nursing station. This allows patients to watch the instructional videos while receiving IS. Subsequently, a respiratory therapist will proceed with therapy.

Post-intervention, there was a significant reduction in treatment time. The average total duration decreased from 266.65 to 28.75 min. Preparing IS decreased from 240 to 8.71 min, and treatment execution decreased from 17.5 to 10.55 min. The achievement rate was 178%, with an improvement rate of 89.2%.

The quality control circle approach has effectively optimized peri-operative respiratory care, notably reducing treatment time. This method shows promise in enhancing patient outcomes and streamlining healthcare delivery. Additionally, amid the COVID-19 pandemic, it minimizes unnecessary contact, lowering infection risks. Further research is needed to fully assess its long-term impact and refine its application.

Figure1. Pre-intervention date collection and analysis

Figure 2. Comparison of treatment durations before and after intervention

The risk of transferring patients on a ventilator is a significant global issue in critical care medicine. To mitigate adverse events during transfer, pre-transfer ventilator tests are imperative before MRI examinations. This study statistically demonstrates clinical delays resulting from unknown or altered examination schedules. When multiple patients require MRI scans on the same day, if the examination times are unclear or too closely scheduled, respiratory therapists (RTs) must shuttle between units, conducting tests and cleaning ventilators for transfer, a process taking about 40 min per test. Ensuring sufficient testing time for each patient often leads to delays for subsequent examinations. When the examination schedule becomes congested, patients are delayed, on average, by 30 min. Proper scheduling of MRI examinations and ventilator tests can curtail unnecessary time wastage, enhancing workplace efficiency.

Data collected in ICU from November 2022 to January 2023, 133 samples for MRI examinations of ventilator-dependent patients, analyze the current status of failure rate of ventilator preparation for MRI examinations. Based on a cause-and-effect diagram and root cause verification, pinpointed the failure as ‘unknown examination times’ and ‘examination time change on the same day.’ Matrix analysis was then employed to select intervention measures: instructing colleagues to inquire about the examination room integration system and query the system for urgent examination schedules on the same day, making adjustments accordingly. After implementation, reassessment confirmed effectiveness.

After implementation, data collected in ICU from July to September 2023 demonstrated a decline in ventilator preparation failure rate for MRI examinations from 36.75% to 17.5%. Stratified analysis showed a decrease in unknown examination times from 21% to 9.4%, while examination time change on the same day increased from 4.5% to 5.4%. Overall, failure rate reduction exceeded 50% in both comprehensive and detailed analyses.

Apply quality control circle activities to reduce ventilator preparation failure for MRI examinations offers various benefits: decreased patient waiting times, improved allocation of RTs’ time for critical patient care, and reduced need for additional ventilator purchases, enhancing economic cost-effectiveness. This management tool warrants clinical promotion and application, contributing to continuous improvement in healthcare quality.

Figure 1. Pareto Chart before implementation

Figure 2. Failure rate

Standardized endotracheal tube (ETT) securement processes have been linked to a decreased rate of unplanned extubation (UE), an adverse event common in NICUs. Our level IV NICU follows a standardized ETT securement bundle with use of the NeoBar as an integral component of ETT securement. Kamishibai cards (K-Cards) are a quality improvement auditing tool originally developed in the manufacturing industry, and when applied in healthcare, they can be used to list individual bundle elements needed to mitigate event risks. Our UE prevention team developed a K-Card specific for the standardized ETT securement bundle to measure adherence and drive-actionable interventions to prevent UEs. This was a main intervention we implemented to help reduce our unplanned extubation rate from 1.6 UE events/100 ventilator days to a rate ≤ 1.

Data collected for the study, deemed a quality improvement initiative and thus IRB exempt, included K-Card audit responses which were reviewed for individual element adherence. Project data was recorded over the period between January and October 2023. Based on review of data collected from Jan-May, coupled with failure mode analysis revealing ETT slippage through the tape or tape tears at the NeoBar tip as root cause for several UEs, the UE prevention team implemented a revised bundle ETT taping procedure in June 2023. Data was reviewed following this intervention (June-October 2023) and compared with earlier data to identify changes in bundle adherence.

From January-May, the K-card audit completion rate was 70% (420/600 completed audits). Of 420 completed K-Cards, 42 were non-adherent with missed bundle elements for a non-adherence rate of 10%. Of 344 completed audits from June-October 28 had missing bundle elements (8.1%) for an overall increase in bundle adherence of 18.6% post-securement bundle revision.

K-Cards are an efficient way to measure bundle adherence for ETT securement. Analyzing information from K-Card tracking data can lead to actionable interventions for hospital quality initiatives.

Many respiratory care students find that classroom learning often leaves gaps in essential bedside skills. Preceptors are crucial in bridging these gaps, as they help students connect theoretical knowledge with practical application. However, despite being skilled practitioners, preceptors may lack the teaching skills necessary to effectively mentor students which may impact the learning outcomes. Additionally, preceptors face various barriers that hinder the clinical experience. This study aims to survey California respiratory therapists about existing barriers associated with clinical preceptorship and assess training needs.

An online survey was sent to California Society of Respiratory Care (CSRC) members via email (UCSF IRB #24-40771). The survey included questions on sociodemographics, barriers, and training content needs using a 5-point Likert scale for responses. Continuous measures were reported as mean ± standard deviation for normally distributed data, and non-normally distributed data were reported as median and interquartile range. Categorical data were reported in percentages and frequencies.

59 responses were collected between April and May 2024. 50% of participants were female, the mean age was 43 ± 10 y old, and the mean experience was 15 ± 10 years. 30 (51 %) participants were staff therapists who precept students, and 25 (42%) had a bachelor’s degree. The top barriers identified in the survey were heavy workloads (26), no monetary incentive (18), lack of appropriate preceptor training(s) (10), and preceptor fatigue (10). The top 3 recommended training contents were understanding the role and responsibility of a preceptor (41), balancing workload and teaching responsibilities (38), and effective communication skills (38).

Survey results from various sociodemographic backgrounds, including specialties and education levels, indicated that there are barriers existing in clinical education and a need for preceptor training for California RT preceptors.

Figure 1: Barriers/Difficulties in Effective Clinical Preceptorship

Figure 2: Training content needs

In recent decades, ventilator-associated pneumonia (VAP) has been one of the major issues in global critical care medicine. Previous studies have shown that irregular and frequent circuit tubing replacements may increase the incidence of VAP. Therefore, the purpose of this study is to reduce the rate of unconventional replacement of ventilator circuit tubes and to explore the necessity and timing of replacing heat and moisture exchangers (HMEs) with heated humidifiers (HHs).

This study aims to establish a quality control circle to reduce the incidence of unconventional replacement of ventilator circuit tube in the surgical intensive care unit (SICU). Pre-intervention data were collected from April 2018 to March 2019 and analyzed to identify the primary and second causes of unconventional replacement of ventilator circuit tube: 1) clinical judgment by nursing staff regarding excessively viscous sputum, and 2) prolonged duration of general anesthesia surgery (Figure 1). Using the PDCA (Plan-Do-Check-Act) method from August 2019 to October 2019, we implemented targeted interventions. These included an education program for nurse to accurately assess sputum viscosity and the development of a standard operating procedure (SOP) for respiratory therapists’ tube-changing procedures. The effectiveness of these interventions was regularly reviewed and necessary adjustments were made to ensure continuous improvement. The results indicate that these measures effectively reduce the rate of unconventional replacement of ventilator circuit tube, enhancing patient care quality and safety in the SICU.

The results of this study show that the overall rate of unconventional replacement of ventilator circuit tubes decreased from 38.1% before the intervention to 16.0% after the intervention. The analysis of causes revealed that the rate of unconventional replacement of ventilator circuit tube due to clinical judgment by nurse decreased from 23.52% before the intervention to 10.10% after the intervention. Additionally, the rate of unplanned extubations due to prolonged duration of general anesthesia decreased from 20.3% before the intervention to 0% after the intervention (Figure 2).

Health education for nurses and the development of standard operating procedures can significantly reduce the unconventional replacement rate of ventilator circuits. Reducing this rate not only improves the work efficiency of respiratory therapists but also decreases the incidence of VAP.

Since FY 2013 the respiratory care department has been tracking unplanned tracheostomy tube dislodgements (TD). By FY 2019, TD rate in the medical unit tripled from 0.15 to 0.5 with a continued steady rise in events. Apparent causes were reviewed showing trach care as a leading contributor to unplanned TDs. In 2020-2021, a PDSA was conducted to address trach care as an apparent cause, however iterative PDSA cycles or changes were unable to be implemented. Between Q3 of FY 2021 and Q3 of FY 2022, an increasing number of eFeedback reports described loose trach ties as the primary cause of dislodgement. Additional staff feedback noted concerns for loose ties just prior to dislodgement. Further investigation of this growing trend in TD cause revealed inconsistent securement practices and a clear trend where parents/staff preferred looser ties. We determined the current standard for ‘one-finger tightness’ needed further visual clarification and reinforcement due to varying understanding of what that standard looked like on a patient.

A multi-disciplinary team came together to create a video presentation that demonstrated the standard definition of what one-finger tightness tracheostomy tie securement looked like on a real patient. Non-standard securement was also demonstrated for providers to ensure prevention of unplanned tracheostomy dislodgments from ties that are too loose and pressure injuries from ties that were too tight. The video was adopted into the medical unit training FY 23 with additional peer-to-peer demonstration. Appropriate standard was reiterated during staff meetings and huddles in the respiratory care department.

We continued to track unplanned TD primary causes and staff feedback in the medical unit following implementation of standardized messaging and video release. When reviewing trach TD rates, we saw a 63% decrease in total TD events from Q3 FY 22 to end of FY 23. Apparent causes contributing to unplanned trach dislodgements for FY 23 showed 0 cases involving loose ties. For FY 23 cases in the medical unit – feedback collected from staff did not allude to any concerns for loose ties as a secondary contributor to dislodgement events.

Through communication and demonstration of a standard definition for one-finger tightness when evaluating trach tie tightness, the group was able to reduce incidence of TD associated with loose ties.

Institutional cultures promote nurses as the primary skilled providers for recognizing and preventing injuries. However, ETT management is primarily the responsibility of the respiratory therapist (RT) at many institutions. The purpose of this study is to determine the disparity in injury awareness between nurses and RTs.

A process assessment was created to determine the value of trained RTs in the early detection, prevention, and management pertaining to medical device-related injuries (MDRI) in the Department of Respiratory Care Services at Emory Midtown Hospital. During a 27-month period, RT and nursing documentation of 191 ETT device-related injuries, cheeks, lips, gums, nose, nares, and skin irritation of mechanically ventilated patients (n = 145) were reviewed. Quantitative indicators represented the number of monthly ETT-associated MDRI. Data from chart audits were performed regarding incidences, injury locations, and provider documentation adherence for RT device-related injury.

The results reveal a large disparity in the awareness of ETT device-related injuries among the providers which was reflected in their documentation. RTs were 98% more likely aware of injuries discovered than their nursing counterparts 57%. The likelihood of RTs and nurses both being aware of injuries was 43%, suggesting provider collaboration for patient safety. The lack of documentation alignment between providers can be associated with the underreporting of injuries, if nursing reports and documentation are the only provider sources utilized.

This assessment exposes the value of knowledgeable and trained RTs as partners to assist in early detection, prevention, management, and quality improvements of MDRI in respiratory care.

This study explores the perspectives of supervisors and physicians in the respiratory therapy department in Taiwan on the timing of acquiring evidence-based medicine competencies as outlined by the AARC in 2016: 1. Retrieve credible sources of evidence, 2. Critique published research, 3. Explain general statistical tests, and 4. Apply evidence-based medicine to clinical practice.

Researchers translated the AARC competencies into Mandarin Chinese and administered the questionnaire to respiratory therapist (RT) supervisors and medical directors in Taiwan starting in April 2022. The chi-square test compared differences between RTs’ and physicians’ opinions on when these competencies should be gained, using SAS 9.4 as the primary analysis tool. The study underwent IRB review (CMUH111-REC3-013(FR)) and received grant support from China Medical University Hospital (CMUH-EDU10901).

41 experts participated, including 29 RTs and 12 medical consultants or physicians. 43.9% of RT directors supported having the competence to retrieve credible sources of evidence (Q1) before entering professional practice. However, they believed the ability to critically evaluate published research (Q2), explain statistical tests (Q3), and apply evidence-based medicine to clinical practice (Q4) were acquired after entering practice. Medical directors supported having all 4 competencies before entering practice. There were significant differences between RT directors and medical directors regarding explaining statistical tests (Q3) (P = .043) and applying evidence-based medicine to clinical practice (Q4) (P = .045) (see Table 1).

RT directors supported having the competence to retrieve credible sources of evidence (Q1) before entering professional practice but believed the other competencies are acquired afterward. Medical directors supported having all 4 competencies before entering professional practice.

In response to the shortage of respiratory therapists, hospitals are seeking different strategies to attract and retain respiratory therapists. The opportunity to practice at the top of one’s professional scope is often cited as being attractive when considering a place of employment. A comprehensive survey explored whether respiratory-driven protocols (mechanical ventilation pathway, asthma, secretion clearance pathway, spinal cord injury) increase job satisfaction and assist with retention or if therapists feel protocols are a workflow burden and decrease job satisfaction.

The survey was conducted at a 700-bed medical center to better understand the impact of protocolized care. The University of Maryland Medical Center’s respiratory therapists were invited to complete a web-based survey via social media and department announcements. IRB approval was obtained.

Fifty-three (38%) respiratory therapists responded to the survey from the 139 within the respiratory department. The high agreement rates (94% and 86%) indicate that respiratory protocols significantly increase autonomy and job satisfaction among respiratory therapists. This is a positive outcome as it suggests that the implementation of these protocols has a direct and beneficial impact on the staff. The protocols also increased participation in critical care rounds, with 89% (66% strongly agreed, 23% agreed) stating that it increased the feeling of being part of the critical care team. This finding is particularly important as it demonstrates the role of protocols in fostering a sense of teamwork and collaboration among the staff.

Based on this survey feedback, implementing respiratory protocols can increase practice autonomy and job satisfaction within respiratory care departments. Supporting respiratory protocols could also enhance recruitment and retention by increasing respiratory therapists’ pride in being recognized and appreciated for their professional contributions. Ultimately, the facility benefits by filling vacant positions, respiratory therapists see longevity within an organization, and our patients receive the benefits of respiratory care best practices.

Inhaled nitric oxide (iNO) is frequently delivered with noninvasive methods at our institution for children with congenital heart disease. This includes a high-flow nasal cannula (HFNC) system and noninvasive ventilation (NIV). Previous evaluation of iNO delivery via HFNC in an infant model found that delivery efficiency ranged from 63-78% (Berlinski A, Moore M, Willis D. Inhaled nitric oxide delivery in a 7-month-old spontaneously breathing infant model. J Cystic Fibrosis 2023;22(Suppl):S6). The aim of this study was to evaluate iNO delivery with NIV and to compare it to previously obtained data using HFNC system.

An anatomically correct 3D airway model of a 7 month-old child was connected in series to a scavenger filter and breathing simulator (frequency 30 breaths/min, V_T 50 mL, I:E 1:2). A nasal cannula (Medium Optiflow Jr 2, Fisher & Paykel) was used with flows 2, 6, and 10 L/min for the HFNC system. NIV was used with a nasal cannula (RAM, Neotech) and ventilator (Servo-i, Getinge) with breathing frequency 30 breaths/min, pressure control 10 cm H₂O, and PEEP 8 cm H₂O. The iNO system (INOMax, Mallinckrodt) was set to deliver 5, 20, and 40 ppm. NO analyzers were placed before the nasal cannula and at the tracheal level. Delivered and tracheal iNO measurements were recorded after 3 min and experiments were performed in quadruplicate. Ambient NO and NO₂ were monitored. Tracheal iNO/dialed iNO(%) values were calculated. ANOVA for repeated measures followed by Tukey for multiple comparisons was used to compare NIV data (different iNO concentrations). Unpaired t-test was used to compare NIV and HFNC data at each iNO concentration. A P < .05 was considered statistically significant.

NIV system delivery efficiency ranged from 86-98% and increased with increasing iNO concentration. Tracheal percentage was higher for 5, 20, and 40 ppm with NIV than HFNC at 2 L/min (P < .04), 6 L/min (P < .001), and 10 L/min (P < .001). Ambient NO and NO₂ were 0 for all experiments.

Delivery of iNO with a NIV system was very efficient. Practitioners should be aware that when transitioning to ventilatory support with HFNC a decrease in iNO delivery efficiency may occur.

Experimental Set-up

Continuous nebulization is commonly used to treat asthma exacerbations and can be administered with different delivery devices such as a large volume nebulizer (LVN) or vibrating mesh nebulizer (VMN). The VMN can be used to deliver continuous albuterol in conjunction with high-flow nasal cannula (HFNC) and noninvasive ventilation, whereas the LVN requires a mask or mouthpiece. In 2021, our specialized, pediatric interfacility transport team changed from LVN to VMN to deliver continuous albuterol during medical transport. The aim of this study was to compare outcomes for children treated with continuous albuterol via LVN or VMN during air and ground interfacility transport.

A retrospective review was completed for children with asthma who were admitted to the hospital and treated with continuous albuterol during transport from 6/1/2018 to 6/30/2023. The primary outcomes were hospital length of stay and total duration of continuous albuterol (transport + admission). Descriptive statistics were used to summarize results. Mann-Whitney test was used to compare continuous outcomes and Chi-square statistics were used to compare nominal variables. P < .05 was considered statistically significant.

98 children met inclusion criteria with 52 and 46 in the LVN and VMN groups, respectively. Median (IQR) age was 6 (3-9) y, and the majority were male (56, 57%). The LVN group had more non-Hispanics (P = .02). No differences were found between groups with regard to sex, race, asthma classification, transport type, admission unit (PICU vs. intermediate care unit), initial albuterol dose during transport or admission, transport time, or PRISM 3 score. The VMN used more HFNC during transport (P < .001). Total duration of continuous albuterol and hospital length of stay were similar for each group.

Total duration of continuous albuterol and hospital length of stay were not affected by the choice of nebulizer system used during pediatric interfacility transport.

While studies have investigated perceptions of various disciplines on incorporating artificial intelligence (AI) into clinical practice, there has been no exploration within respiratory care. As the role of AI expands, understanding clinicians’ perceptions and knowledge will be crucial for effective implementation. This study aims to assess the familiarity and comfort of undergraduate respiratory care students with AI and explore their perspectives on using AI as an adjunct assessment tool in the clinical setting.

A 13-item mixed methods survey was administered via Qualtrics to a convenience sample of undergraduate respiratory care students at Boise State University via Canvas. This study received exempt approval from the Boise State University Institutional Review Board (#IRB24-285). The survey included 5 quantitative Likert-scale questions on familiarity, comfort, and receptivity to AI, 3 demographic questions, and 4 open-ended qualitative questions. Primary outcomes were students’ familiarity and comfort with AI in respiratory care. Secondary outcomes were their perspectives on AI as an adjunct assessment tool. The research team performed an inductive thematic analysis on the open-ended responses following Braun and Clarke’s framework. Theory triangulation was used to ensure data validity.

Of the 44 students contacted, 16 completed the survey, a 36% response rate. Incomplete responses were excluded from analysis. The study found that only two respondents were uninterested in incorporating AI into their future practice. Three themes were extracted from the qualitative data: potential, error, and clinical knowledge.

The survey supports a general qualitative distrust of AI among students, particularly regarding bias, limitations, and safety. Despite this, the survey also supports a quantitative lack of knowledge but openness to further education and future integration. These findings suggest that while concerns about AI persist, there is a willingness among emerging respiratory therapists to learn more and potentially incorporate AI into their practice. Additionally, the students’ limited understanding of bias and ethics in AI highlights a significant opportunity for respiratory care education programs to address these critical issues. By incorporating comprehensive AI ethics and bias training into their curricula, these programs can better prepare students to navigate and implement AI technologies responsibly in the clinical setting.

The AARC Clinical Practice Guideline (AARC CPG) for care of the ventilator circuit does not recommend routine circuit change for infection control purposes. Based on this, our practice for routine change of heated circuits was every 30 days unless visibly soiled. Joint Commission standards require that evidence-based guidelines cannot be less strict than manufacturer instructions for use (MIFU). MIFU frequency of replacement vary depending on the circuit type, ranging from 7-14 d for most circuits and 30 d for an oscillator circuit. The aim of this study was to evaluate the impact of replacing circuits per MIFU.

A retrospective chart review (1/1/23 to 12/31/23) was completed to quantify the number of heated circuits utilized based on the number of documented days per modality of respiratory support for invasive mechanical ventilation (IMV), noninvasive ventilation (NIV), high-flow nasal cannula (HFNC), and heated tracheostomy collar (HTC). Number of days per modality was used to calculate the number of circuits based on AARC CPG and MIFU frequency of replacement. MIFU for the NIV, HFNC, and infant invasive MV circuits we utilize recommend changing every 7 d. Replacement for HTC and adult MV circuits is recommended every 14 d. Change within modality was analyzed with 2-tailed Wilcoxon matched pair signed rank test. Variation between modalities was analyzed with Kruskal-Wallis followed by Dunn’s multiple comparisons test.

There were 1,501 admissions (401 used > 1 respiratory support modality). 59% (891) of the admissions were ≤ 7 d. HFNC was the most used modality during all admissions (1,052, 70%) followed by IMV (569, 38%), NIV (322, 21%), and HTC (69, 5%). A shift from AARC CPG to MIFU frequency of replacement would result in a 62% increase in the total number of circuits (2,688 vs. 4,362). IMV, NIV, HFNC, and HTC will increase 111%, 60%, 23%, and 48% respectively (P < .001 for each modality) (Figure 1). HFNC modality had the lowest impact when compared to other modalities (P < .01) with no statistically significant difference among the others. The most ordered circuit would change from HFNC to IMV when switching from AARC CPG to MIFU guidelines.

Change in practice to replace circuits per MIFU will increase the number of circuits utilized for all modalities with a heated circuit, with the greatest impact on IMV. The implications extend beyond cost including procurement, tracking, documentation, and staffing.

National guidelines regarding type of transportation recommended for initial discharge of tracheostomized children requiring home mechanical ventilation are lacking. The standard practice at our institution is to use non-emergency ambulance services. However, these children have been deemed medically stable to discharge home and many families have their own transportation. The aim of this study was to identify discharge transportation practices used by children’s hospitals caring for these children.

Clinicians involved in the care of tracheostomized ventilator-dependent children were invited to complete a survey regarding discharge transportation. The invitation was sent to the Neonatal Pediatrics section of AARC Connect and the Children’s Hospital Association discharge planning listserve in April 2024 and was available for 2 weeks. Responses were collected electronically. Institutions were grouped by regional location and only counted once when more than one response was received from the same institution.

There were 26 respondents representing 21 children’s hospitals. The majority of respondents were RTs (17, 65%) and most hospitals were located in the Southeastern US (10, 47%). The general service area was > 150 miles for 47% of hospitals. All institutions required a minimum of 2 trained caregivers and successful room-in prior to discharge. However, the duration of the room-in varied from 1 to ≥ 3 days. More than one mode of discharge transportation was used by 62% of all institutions. The most common methods were non-emergency ambulance or personal vehicle. Distance from the hospital and patient stability were the main criteria identified when ambulance and personal vehicle are used.

The method of discharge transportation for ventilator-dependent children varies amongst children’s hospitals. Caregiver’s training requirements varied among institutions. Non-emergency ambulance and personal vehicle were the most reported methods of transportation for the initial discharge home for tracheostomized ventilator-dependent children.

A heated tracheostomy collar (HTC) is frequently used for humidification at our institution for spontaneously breathing tracheostomized children. Nebulized medications are commonly administered using different methods. The purpose of this study was to evaluate aerosol delivery using a vibrating mesh nebulizer (VMN) and jet nebulizer (JN) in-line with an HTC.

A model of a spontaneously breathing tracheostomized child was used. The model consisted of a breathing simulator connected in series to a collecting filter (lung dose), a tracheal model with 4.5 mm uncuffed tracheostomy tube and an expiratory filter. The HTC was used with a heated humidifier set to 37°C with 15 L/min airflow (FIO₂ 0.21). A heated-wired circuit was used with a tracheostomy direct connection adapter. Different breathing patterns were used for an infant (30 breaths, 80 mL, I:E 1:3), child (25 breaths, 155 mL, I:E 1:2), and older child (20 breaths, 310 mL, I:E 1:2). A VMN or JN was used in 3 different positions: on the dry side of the humidifier (distal) with and without the adapter and between the circuit and the tracheostomy (proximal). Albuterol 2.5 mg/3 mLs and 5 mg/6 mLs were used for VMN and JN respectively. The JN was operated at 6 L/min and additional 9 L/min was provided at the humidifier inlet. Each condition was repeated in triplicate. Albuterol mass was measured via spectrophotometer (276 nm) and reported as absolute mass. Mann-Whitney was used to compare outcome measures at each scenario. Friedman test/Dunn’s test were used to compare different breathing pattern for each scenario as well as different configurations.

No differences in absolute lung dose were found between nebulizers (P value ranged from .10 to .70) (Figure 1, median + 95% CI). Lung dose was higher for the older child when compared to infant both for VMN and JN (P = .043). Adding the connector to the circuit resulted in a 37 and 17% decrease in lung dose for VMN and JN respectively (P = .49). Moving the nebulizer from a distal to a proximal position resulted in in a resulted in a 16 and 66% increase in lung dose for VMN and JN respectively P = .16).

Doubling loading albuterol in a JN resulted in similar absolute lung dose to VMN when delivering aerosols through an HTC system. Tracheostomy connector reduced lung dose while moving the nebulizer from distal to proximal increased it.

CMS Hospital Readmissions Reduction Program aims to reduce 30-d readmissions by encouraging hospitals to improve care coordination and communication between patients and care givers. Evidence has shown that COPD care bundles may be beneficial in reducing length of stay (LOS) and/or readmissions for a COPD exacerbation¹. An interdisciplinary workgroup was created to research best practices and develop a new care bundle. A COPD order set had already been in place at this organization for several years. However, utilization was low at 31.68% (FY21) and in need of some improvements. Additionally, after a review of the literature it was identified key items were missing from our original order set that might be of benefit.

A review was conducted of 6 studies that met certain criteria (quality, value, and ethical principles)². An interdisciplinary workgroup had identified some gaps for patients that were being discharged with traditional inhalers. Issues included delays in receiving medication, drug cost, and failure to use proper technique. Studies have shown a high rate of inhaler misuse among hospitalized patients. Patients had their technique tested using AIM (Aerosol Inhaler Monitor) 58%, 52%, and 38% failed to use proper technique at the first, second, and third test, respectively³. So, in addition to standard order set items like O₂, meds, ABG, etc, a novel concept was added to our orders to provide bedside education and a take-home kit. The free kit includes: albuterol, portable pocket neb, a COPD action plan and handbook. After several iterations of trial and error, a consistent process was implemented in April, 2023 by utilizing the outpatient pulmonary rehab therapist.

With increased focus on order set utilization, a 10% increase occurred by (FY24-March). Use of the order set helped ensure that COPD education was provided to 50% of the COPD order set group, with 39% receiving a take home kit. COPD payment reductions were issued by CMS for FFY22-24 for higher-than-expected readmission rates (16.23%-17.58%). Our CMS FFY25 and FFY26 (3 years of data) are projecting no payment reductions as rates have dropped to as low as 12.50%.

Order set utilization is an important foundation to reducing LOS and readmissions for patients with COPD. Education, proper medication delivery technique, and a take home kit which includes a 30-d supply of medication are important items to consider adding to a COPD order set and may help to reduce COPD readmissions.

In normal subjects, during tidal breathing, aerosols deposit by settling in small airways. With obstructive lung disease (OLD), collapse of airways during expiration causes turbulence and increased deposition in central airways. High-flow nasal cannula (HFNC) therapy, washing out dead space, may affect mechanisms of particle deposition. This study compared aerosol deposition and responsiveness in OLD after traditional and HFNC therapy.

Twelve subjects with moderate to severe OLD were enrolled for a two-day study. Spirometry was measured pre- and post-aerosol inhalation. On Day 1 (D1) subjects tidally inhaled radiolabeled albuterol (^99mTc DTPA) via AeroTech II, (Biodex, Shirley, NY). Day 2 (D2) inhalation was via HFNC using i-AIRE (InspiRx, Somerset, NJ). The HFNC system (60 L/min) was infused by syringe pump at 50 mL/h. D2 lung deposition was monitored in real time by gamma camera to match D1. Pre and post pulse, O₂ sat, and nasopharyngeal deposition (NP) were measured. Mechanistic contributions were modeled using multiple linear regression (MLR) of deposition rate (DR µg/min) as a function of breathing frequency, airway geometry (FEV₁) and parenchymal integrity (D_LCO).

Figure 1 illustrates the change in deposition from D1 to D2 in a single patient. Albuterol lung depositions were matched (P = .13) with D1 central/peripheral (sC/P) ratios 1.99 ± 0.98 (Figure 2 left). Following HFNC, peripheral deposition increased (31% ± 33%, sC/P = 1.51 ± 0.43, P = .01). D2/D1 % change FVC increased by 16.1 ± 16.7% (P = .003)(Figure 2 right). NP deposition averaged 332.6% of lung. Pulse and O₂ sat were unaffected (P = .31, P = .63 respectively). DR analysis was markedly different between D1 (R² = 0.829) and D2 (R² = 0.071).

HFNC nebulization at 60 L/min was well tolerated and practical. HFNC increased peripheral drug delivery in subjects with OLD with improvements in spirometry. Systemic effects were undetected indicating limited nasal absorption. MVA indicated different mechanisms of deposition govern traditional vs HFNC aerosol delivery. Breath-enhanced nebulization with HFNC may provide controllable and effective aerosol therapy in OLD.

The aim of this study was to develop a self-scheduling system to optimize skill mix on a day-to-day basis, thereby enhancing clinical competency and employee satisfaction. The study sought to determine if creating a skill-based schedule could address competency concerns and reduce employee absenteeism.

The scheduling system was designed by first allocating shifts to highly skilled team members to ensure the minimum staffing requirements for each unit/day were met. Subsequently, additional shifts were assigned to less experienced team members who could benefit from mentorship. This approach facilitated self-scheduling and self-balancing, promoting work-life balance for employees, and reducing managerial burden. The creation of a skill-mixed schedule aimed to strengthen team dynamics, provide robust support, enhance employee satisfaction, and lower absenteeism rates. The study posited that employees who felt supported in their learning and work-life balance would be more likely to take ownership of their assigned patient care unit.

Initially, the scheduling system required 46 adjustments (pulls) for the first schedule. After iterative refinements and considering vacancies, paid time off requests, holidays, and other off requests, the system evolved. This optimization process reduced the number of pulls to 46, then to 26, 21, 11, 8, and eventually only 3. The results showed a significant decrease in absenteeism and punitive action, along with improved retention rates (< 5%) and employee satisfaction (above benchmark).

Implementing a skill-based scheduling system ensures that the right skills are available in the right units at the right times. This system supports mentorship and skill development, leading to better clinical outcomes, such as reduced safety events, length of stay, and readmissions. While also improving patient satisfaction. The study demonstrates that a well-designed self-scheduling system can enhance team performance, reduce absenteeism, and improve overall employee satisfaction.

Staffing challenges within the respiratory care profession limit the availability of respiratory therapists (RTs). Within the homecare environment, availability of RTs is further limited. In the state of Michigan, home positive airway pressure (PAP) setups do not require an RT, however the importance of PAP adherence cannot be understated. Our home care company (large regional DME, all ages) transitioned the majority of PAP setups from RTs to trained unlicensed clinical assistants (CAs) to allow RTs to focus time on higher acuity needs. We aim to evaluate the relationship between trainer type during setup and patient adherence to PAP therapy.

Change in practice from primarily RT PAP setups to CA at the headquarter location (Grand Rapids, MI) occurred in January of 2023. In an IRB exempt retrospective quality analysis, PAP adherence data from 2023 was reviewed to determine impact in patient adherence based on trainer type. De-identified patient data was collected from U-Sleep and Airview. Data metrics reviewed included quantity of PAP starts, setup trainer (RT versus CA), CMS adherence data met (4 h/night for 21/30 days), and the estimated cost of labor for PAP setup (average pay and average time). Data were exported to Excel and reviewed to determine impact based on practice change from RT to CA setups.

Overall adherence with PAP therapy, regardless of trainer type, was 65.5% (n = 3,239). There were 10 CAs and 9 RTs who completed PAP setups in the study period. Patients trained by RTs had a 65.6% adherence rate (n = 1,086) and trained by a CA had an adherence rate of 65.4% (n = 2,153). When reviewing only trainers with 100 or more setups in the year, adherence rate was 71.3% for RTs (680 PAP trainings done by 3 RTs) and 67.6% for CAs (2,083 PAP trainings done by 5 CAs). Based on an average training time of 45 min and an hourly rate of $30.92 per RT and $19.10 per CA, a PAP setup costs $23.19 by an RT and $14.33 by a CA. There were cost savings with this practice change, and it did not significantly affect overall patient adherence with PAP therapy.

Clinicians are an important component of PAP setup for patients in the home environment. The use of a trained CA was not impactful for PAP therapy patient adherence when sampled, and significant cost savings were noted. Further studies must be done relative to trainer type, PAP adherence, and training/re-training time to determine impact more globally.

Figure 1 details the difference in PAP compliance based on trainer type.

COVID-19 changed the way that respiratory care students were trained and how they gained clinical experience. With the pandemic sometimes interfering with clinical rotations, respiratory care students often did not have the opportunity to develop the knowledge and experience required to be safely enter practice. It became imperative for healthcare systems to improve clinical onboarding to support these new respiratory therapists (RTs). To address this need, a multi-campus health system implemented a Respiratory Care Residency Program (RCRP) with the goal of enhance onboarding, education, and improving the standard of care given by a newly graduated RTs.

The program duration was 6 months and included a streamlined clinical based orientation with a dedicated preceptor, didactic learning, evidence-based practice plan, and incorporated simulation. This project received approval by the organization’s IRB. The RCRP covered information on all patient populations, ages, and types. A curriculum was created with campus leaders and educators to ensure different clinical and professional gaps were addressed. The didactic learning and simulation focused on different respiratory skills such as patient assessment, critical thinking, advanced life support for adults and neonates, inhaled nitric oxide (iNO) administration, noninvasive and invasive ventilator set up, specialty modes, and more. The residents were given anonymous questionnaires throughout the program to assess satisfaction, comfort, and confidence levels.

There was an increase in the overall factor score measures for role confidence, clinical skills and knowledge-based topics. Communication and leadership saw an increase at 12.59%, followed by overall role confidence at 4.5%. Participants reported an increase in most clinical skills, with the largest increases in iNO administration (32.34%), laryngectomy (20.22%), and assist with bronchoscopy (15.83%).

The collected responses showed increase in a wide range of clinical skills and other human skills. The retrospective data obtained in this project suggests these programs are effective in supporting transition to practice and improving patient care by adding value to the training, overall well-being, and retention of the newly graduated RT. Respiratory care residency programs could be modelled after the wide array of data available for nursing residency programs to allow for benchmarking and information sharing.

The AirLife Open Mask made by Vyaire (Mettawa, IL) specifies that it delivers an FIO₂ range of 0.24-0.9 between 1-15 L/min. The OxyMask made by Southmedic (Ontario, CA) specifies that it delivers an FIO₂ of 0.24-0.9 between 1-15+ L/min. The Adult 3-in-1 Mask with Standard Connector made by Medline (Northfield, IL) specifies that, as a medium concentration mask, it delivers an FIO₂ of 0.35-0.5 between 5-10 L/min. This study aims to test the average FIO₂ delivered by each mask at 3 different flows. We hypothesized that there is no difference in the FIO₂ delivery between each mask type.

Each mask listed above was attached to an intubation trainer mannequin (Laerdal Medical, NY) and ASL 5000 (Ingmar Medical, Pittsburgh, PA) breathing simulator. The mannequin’s trachea was connected to the simulator using a T adapter, and an Ohio Medical Mini-Ox (Ohio Medical, Gurnee, Il) O₂ analyzer was used to obtain an FIO₂ reading in the trachea. The ASL simulator was set up using the normal adult patient model with a V_T of 500 mL, frequency 12 breaths/min, and T_I of 1 s. The oxygen flow set to each mask was 1 L/min, 7 L/min, and 15 L/min respectively. The simulator was allowed to run until the V_T was stable and the FIO₂ for each scenario was recorded once the measurement reached equilibrium. Each set flow and mask combination were performed 5 times each. The O₂ analyzer was calibrated between each run.

At 1 L/min, the AirLife Open Mask, OxyMask, and Adult 3-in-1 Mask resulted in mean FIO₂ values of 28.58%, 28.8%, and 28.96%, respectively. There was no statistically significant difference (F(2,12) = 2.060, P = .17). At 7 L/min, the mean FIO₂ values were 49.04%, 51.82%, and 44.48%, respectively, with a statistically significant difference (F(2,12) = 70.950, P < .001). At 15 L/min, the mean FIO₂ values were 54.1%, 61.6%, and 53.6%, respectively, with a statistically significant difference (F(2,12) = 212.896, P < .001).

This study demonstrated that there was no statistically significant difference in FIO₂ delivered among the three masks at 1 L/min with a normal breathing pattern. However, there was a statistically significant difference in FIO₂ delivery among the three masks at 7 and 15 L/min with the same breathing pattern. Based on the above, our hypothesis is rejected.

The delivery of tidal volume (V_T) through mechanical ventilation is impacted by variations in atmospheric pressure. According to Boyle’s law (P₁V₁ = P₂V₂), the pressure and volume of gas exhibit an inverse correlation when temperature is kept consistent. The performance of mechanical ventilators is also compromised by these physical changes. Commercially available mechanical ventilators are designed to function during use at or near sea-level atmospheric pressure and will typically exhibit some variation when exposed to pressure changes in a hyperbaric chamber. This study aimed to evaluate the Zoll 731 Series Z-Vent and determine a method to correct for the tidal volume changes seen during alterations of atmospheric pressure.

A commercially available mechanical ventilation system (Z Vent- 731 Series, Zoll Medical, Chelmsford, MA) was evaluated for use in a clinical hyperbaric therapy setting. Validation of flow characteristics (delivered V_T, and breathing frequency) was measured using a pneumotachometer (PNT-4813, Hans Rudolph, Shawnee, KS), connected to an analog-to-digital converter, which was calibrated with a 1-L syringe at each hyperbaric depth. V_T settings (300, 400, and 500 mL) and frequency (12, 18, and 24 breaths/min) were measured at 1.0, 2.0, 2.4 (Figure 1), 2.8, and 3.0 ATA (atmospheres absolute). A PEEP of 5 cm H₂O and an inspiratory time of 1 s were maintained at all V_T settings. A modification formula was then derived from simple linear regression to correct for the desired V_T output at all barometric pressures (Figure 2) and retested to evaluate the desired V_T delivery after correction.

Across all ATA conditions, the ventilator showed a strong linear relationship between output and measured V_T (all, R > 0.9, P < 0.01). The frequency was unaffected by changes in barometric pressure. Variations in output V_T ranged from 1.0 mL (2.0 ATA) to 4.8 mL (3.0 ATA). At ATA >1.0 the ventilator output volume underestimated the measured volume (Figure 1). After applying a correction factor unique to each ATA condition, the mean difference between the desired and measured V_T was ± 2.1 mL.

In hyperbaric conditions between 2.0 – 3.0 ATA the 731 Series Z Vent V_T delivery output was underestimated compared to the expected value as indicated by the V_T setting on the machine. This difference can be effectively minimized through a correction factor derived from simple linear regression, tested at various levels of hyperbaria.

Heliox is a low density gas that enhances aerosol drug delivery, increases laminar flow, and improves carbon dioxide diffusion. High frequency jet ventilation (HFJV) is a time-cycled pressure limited ventilator that delivers less than dead space tidal volumes with transitional gas flows at high celerity. The purpose of this study was to evaluate whether heliox at any admixture affected MAP and Servo pressure on the HFJV.

The QuickLung Breather (IngMar Medical, Pittsburgh, PA) test lung model was used to simulate spontaneous respirations while connected to a LifePulse HFJV (Salt Lake City, UT) and a Servo-U conventional ventilator (CV) (Getinge, Wayne, NJ). The test lung was attached to a 2.5 mm ETT set to a resistance of 50 cm H₂0 /L/S, frequency 42 breaths/min, 25% inspiratory time (0.36 s), with measured exhaled tidal volumes of 9-10 mL while using CPAP +8 on CV. A LifePort ETT connected the HFJV and CV circuit to the ETT and lung model. A jet rate of 300 breaths/min and I-time 0.02 s, and CPAP +8 (CV) were constant throughout the study. HFJV was powered by wall sourced, 50 PSI oxygen and then added a heliox blender (Precision Medical (Northampton, PA.) for the test separately. Peak inspiratory pressure (PIP) on HFJV was increased to 20, 30, and 40 cm H₂O on room air, and 80/20, heliox gas admixture upon achieving a 5-min steady state for changes in PIP and heliox concentration exhaled tidal volumes (CV) and Servo pressure, MAP (HFJV) was recorded. Mean and standard deviations of combined HFJV + CV on room air vs 80/20 heliox powered to the CV and the HFJV were calculated and compared using a t-test with a statistical significance level set at P < .05.

There was a statistically significant difference in MAP (P = .035) with changes in heliox compared to room air. In the presence of heliox, neither Servo pressure nor MAP were different.

Tidal volume increases as a heliox gas admixture is added to HFJV. Future applications and testing with different Heliox concentrations needs to be studied further.

Exceptional communication among medical teams is imperative for ensuring optimal patient care. Note documentation is a critical part of this communication. Our department encounters patients with a wide array of respiratory needs and therefore is responsible for generating a diverse set of notes. Our progress note documentation had largely been in a free form fashion. We discovered several inconsistencies in the quality. Some notes depicted patient care in a great detail while others lacked essential information, potentially influencing other medical teams’ decision-making. Our department sought to make a change that would lead to more comprehensive and user-friendly notes.

Standardized note templates were created along with smart phrase accessibility in order to improve note quality and consistency. The note templates were attainable individually as well as from a drop-down menu. Each note consisted of three sections that were specific to different types of respiratory care. A survey was provided to the department to investigate whether the therapists preferred the new templates or if they favored writing notes in a free form. They were also encouraged to provide feedback.

Out of the 69 RRTs approached with our survey, 55% responded. Out of the 55%, 97% were in favor of utilizing note templates. Supportive comments included improved note consistency and efficient documentation. They also expressed that the templates served as a checklist and helped ensure that their documentation was detailed and complete. Only one concern was mentioned and it revealed some aspects of the automatically populated content, such as history of present illness, occasionally contained inaccuracies. Comments provided also led to a request and subsequent introduction of a new template for patients with laryngectomies.

The institution of smart phrase note templates achieved our goal of providing a platform to improve note integrity and consistency. The survey results revealed an overwhelming support for the templates in comparison to our previous free form notes. The smart phrases and note templates were accepted by therapists for their ease of use and time-saving potential. Theoretically, they are also able to enhance the communication among medical teams. We anticipate them being very helpful to a newly hired staff since they distinctly depict patient care expectations set by our respiratory care department.

Implementation of early mobility in the ICU as part of routine clinical may involve many challenges and difficulties. This study aims to determine the barriers and facilitators of ICU early mobilization from respiratory therapist’s point of view.

This is a qualitative research study which utilized structured interviews with respiratory therapists (RTs) and supervisors from 4 hospitals in KSA, Riyadh City. Grounded theory was used to analyze the results and produce themes for the interviews. The interview consists of questions about barriers and facilitators of early mobility. Inclusion criteria: All RTs and respiratory therapy supervisors. Exclusion criteria: RTs with less than 2 years of experience.

A total of 20 RTs were interviewed (Table 1). The common themes of barriers mainly involve unstable patient condition, staff shortage, lack of equipment, and lack of perception about importance of early mobilization. The interviewed RTs identified increasing the awareness of early mobilization, education and training, establishing a multidisciplinary mobilization team, and availability of portable equipment as facilitators of ICU mobilization (Figure 1).

The participating RTs were aware of early mobility benefits; the majority of them had a high positive attitude towards its implementation in the ICU. Various barriers to early mobilization have been identified, and different solution and facilitators were proposed by RTs that can implemented to overcome difficulties of ICU mobility. The most important of these was staffing, and creating a specialized team for ICU mobilization.

Aerosol therapy is crucial for treating respiratory conditions by delivering medication directly to the lungs. However, secondhand aerosol exposure among healthcare workers (HCWs) during nebulization poses significant health risks. This study aimed to quantify the inhalation exposure of clinicians during nebulization treatments.

Experiments were conducted at 22°C in an ICU room at Rush University Medical Center, using a simulated adult spontaneous breathing model with breathing parameters of tidal volume 470 mL, frequency 21 breaths/min, and inspiratory time 1.1 s. Nebulization was administered via mouth-breathing with an aerosol mask and tracheostomized breathing with a T-piece or trach collar (tracheostomy tube size 8.0 mm). Two simulated HCW models were positioned at 1 ft and 3 ft from the patient model (Figure 1). The T-piece setup also involved positioning the 1 ft HCW directly facing the T-piece reservoir and at the opposite side of the T-piece reservoir. Albuterol sulfate (15 mg/3 mL) was nebulized via a jet nebulizer in two consecutive sessions, totaling 30 mg in 30 min. The inhaled drug captured on the collecting filters placed between the trachea and the model lung was assayed using ultraviolet spectrophotometry at 276 nm. Particle concentrations at 1 μm were continuously measured at 1 ft and 3 ft from the patient model using two particle concentration counters, with intervals of 20-30 min between experiments to allow particle concentration to return to baseline.

During nebulization, HCWs’ inhaled doses were similar across all settings, interfaces, and distances (all P >.05), with a peak inhaled dose observed with tracheostomy via trach collar (0.29 ± 0.05 at 1 ft and 0.22 ± 0.05% at 3 ft) (Figure 2A). Particle concentrations were similar at 1 ft and 3 ft, except for the trach collar, where concentrations were higher at 1 ft compared to 3 ft ([1.82 ± 0.33] vs [0.17 ± 0.05 ] x 10⁸ particles/m³), (P = .0286) (Figure 2B).

Exposure to fugitive aerosol particles during nebulization treatment was consistent across all tested interfaces and patient-HCW distances, with inhaled doses ranging from 0.1% to 0.3%. Further studies are required to assess the potential risk this level of exposure to secondhand fugitive aerosols represents to HCWs.

Figure 1: Experimental setup for quantifying healthcare worker (HCW) inhalation exposure to fugitive aerosols during nebulization treatment. The setup includes a patient manikin connected to a lung simulator via a ventilator, and two clinician manikins positioned at distances of 1 ft and 3 ft from the patient. Collecting filters are placed to capture aerosol particles, while protection filters are used to protect the lung simulators and prevent water buildup. This configuration simulates different scenarios involving mouth-breathing with an aerosol mask and tracheostomized breathing through a T-piece or trach collar.

(A) Inhaled dose (%) of albuterol for healthcare workers (HCWs) positioned at distances of 1 ft and 3 ft from the patient model. The inhaled doses were measured for different scenarios: at the reservoir side, opposite to the reservoir, using a trach collar, and using an aerosol mask.(B) Particle concentration (particles/m³) measured at distances of 1 ft and 3 ft from the patient model. Particle concentrations were recorded for different scenarios: at the reservoir side, opposite to the reservoir, using a trach collar, and using an aerosol mask.

Skeletal muscle weakness impairs health-related quality of life (HRQOL) in patients with exacerbation of chronic pulmonary diseases; however, few studies have examined the prevalence of skeletal muscle weakness in patients with acute exacerbation of interstitial lung disease (AE-ILD). This study aimed to determine the prevalence of skeletal muscle weakness in patients with AE-ILD and the relationship between muscle weakness and HRQOL.

This multicenter prospective study enrolled patients admitted for AE-ILD who underwent pulmonary rehabilitation during hospitalization from August 2023 to March 2024. We assessed skeletal muscle strength, 6-min walk distance (6MWD), activities of daily living (ADL) score, and HRQOL using the COPD Assessment Test (CAT). Skeletal muscle strength was measured using handgrip strength (HGS) at admission and discharge. Skeletal muscle weakness was defined as a difference in HGS (ΔHGS) < -2.7 kg or cut-off HGS values of < 11 kg in men and < 7 kg in women at discharge. The results of the two groups were compared using the Mann-Whitney U-test and the chi-square test. This study was approved by the Human Ethics Review Committee of our university (2023-37).

Forty patients with AE-ILD were enrolled (mean age 79 y, 30 men). All the patients were diagnosed with ILD, including idiopathic interstitial pneumonia (n = 24), connective tissue disease-related ILD (n = 8), or other (n = 8). The rate of skeletal muscle weakness during hospitalization was 22.5% (n = 9). HGS and 6MWD at discharge were significantly lower in the weakness group than in the non-weakness group (HGS, 10.8 kg vs 21.9 kg, P = .001; 6MWD, 90.0 m vs 287.5 m, P = .007). The proportion of patients with AE-ILD impaired ADL was higher in the weakness group than in the non-weakness group (77.8% vs. 33.0%, P = .03). CAT score was significantly higher in the weakness group than in the non-weakness group (24.0 points vs 13.0 points, P = .041). There were no significant differences in laboratory data (KL-6, SP-D, LDH, and P/F ratio), HGS, or ADL scores at admission.

The prevalence of skeletal muscle weakness in patients with AE-ILD during hospitalization was 22.5%. Patients with skeletal muscle weakness experienced ADL impairment, lower exercise tolerance, and poor HRQOL during their hospital stay. Preventing muscle weakness in patients with AE-ILD could improve their quality of life after discharge.

ICU delirium is common in critically ill patients resulting in adverse outcomes, such as extended length of stays, and cognitive impairment post-discharge. This research aims to explore the impact of COVID-19 era on ICU delirium rate, aiding the awareness of treatment and monitoring mechanisms.

This research utilized a retrospective study design. Data were collected and analyzed using a medical record database. The study population comprised of patients with ICU delirium both before and during the COVID-19 pandemic. We assessed the delirium rate before the COVID-19 pandemic by 2 years (January 2018 – March 2020) and after the pandemic by 2 years (March 2020 – Dec 2022).

A total of 396 patients with delirium were collected. Females were 166 (42%) and females were 230 (58%). Mean age was 67 y (± 18). Patients with delirium before the pandemic was 143 (36%) while delirium patients after the pandemic was (64%) (P = .006). No significant differences were observed in age, length of stay, morbidity, or mortality rates between the two groups. However, delirium was significantly higher in patients who tested COVID positive (1%) before the pandemic and 7% after the pandemic (P = .006)

The rate of delirium is higher in post COVID-19 pandemic era. This research highlights the importance and significance of delirium treatment and follow up of patients admitted during the pandemic. Also, our research raises the question of effective preventive measures and practices taken to avoid delirium and its consequences during global pandemics.

High concentration nonrebreathing reservoir masks (reservoir masks) used for patients with hypoxemia vary in shape by product. A good mask fitting and the ability to inhale gas from the reservoir bag during inspiration are the keys to administering a reliable high concentration of oxygen. It has been reported that FIO₂ delivery by conventional products is affected by mask fit. The EcoLite reservoir mask reports a more consistent FIO₂ delivery based on mask fit. An investigational bench study was performed to evaluate the differences, if any, in FIO₂ delivery between a conventional reservoir mask and the EcoLite reservoir mask at varied inspiratory flows and O₂ flow delivery.

A bench study between a conventional reservoir mask (Inspiron oxygen masks three in one type) and the EcoLite reservoir mask was performed using an artificial lung (HR1101) and a mannequin (Laerdal airway management trainer) to simulate spontaneous breathing. Each mask was applied to the mannequin per product instructions. An oxygen analyzer (Multigas/Flow unit DF-220R) was placed in the left bronchi (the right bronchi was completely closed) and oxygen was delivered through each mask at 6, 8, 10, 12 and 14 L/min. Inspiratory flow for the artificial lung was set at 20, 30, 40, 50, 60, 70, 80 90, and 100 L/min for each O₂ flow delivered. The bronchi FIO₂ was recorded for each procedure and measurement was measured three times at each run.

The EcoLite mask exhibited higher inspired oxygen concentrations at each oxygen flow and inspiratory flow. The cumulative mean FIO₂ across set parameters was 64% (42%-96%) for the EcoLite mask and 50% (32%-77%) for the Inspiron oxygen mask three in one type. With a mean difference of 13.9 (2-31). Inspiratory flow impact on FIO₂ revealed a mean difference of 25.8 at Vinsp 20 L/min and 10 at Vinsp 100 L/min favoring the EcoLite. At an inspiratory flow of 60 L/min, the inspiratory oxygen concentration increased with each mask as the oxygen flow was increased.

Reliable delivery of oxygen concentration delivery is necessary diagnostically and therapeutically. The EcoLite mask provided an FIO₂ consistently higher than the conventional product observed. This may be attributed to mask fit, valve assembly, and reservoir bag function. These results may impact clinical decisions in product use and applications. Further studies are needed to assess the clinical impact of this product.

Accidental decannulation (AD) of a tracheostomy tube is an unfortunate complication with the potential for dire consequences. With the goal of developing a quality improvement initiative to reduce the cases of AD at our facility, we set out to investigate whether specific variables were more prevalent in past incidents.

A retrospective analysis was performed spanning the course of 16 months at Brigham and Women’s Hospital in Boston. Patient, system, and airway related data was collected by means of chart review and internal incident reports and was exclusive to the adult population. This study was approved by the BWH Human Research Affairs Committee.

During the 16 months reviewed, there were 28 events of AD. 61% were male, 39% were female. 82% of the patients that experienced AD were classified as either overweight or obese. The most common age demographic revealed 71% were age 60 or older. 14% had a tracheostomy tube placed in ≤ 7 d, 86% had a tracheostomy tube placed in > 7 d. 93% of tracheostomy tubes were secured with ties only, 7% were secured with ties and sutures. A timeline of events revealed that 57% of all ADs occurred during the middle of the shift for both day and night shift, represented by the hours of 11:00-15:00 and 23:00-03:00. Only one event occurred during shift change. The two most common causes of AD involved patient repositioning/turns (32%) and patient self-removal (39%). Of the patients who self-decannulated, 100% exhibited altered mental status (AMS) with variable degrees of delirium, were classified as overweight or obese, had a tracheostomy tube placed >7 d, and had tracheostomy tubes secured with ties only. 82% of events occurred in a non-ICU setting, 82% of patients were not on mechanical ventilators, and 82% were male. ADs that occurred during turns/repositioning revealed 78% occurred in the ICU, 67% of patients were classified as overweight or obese, 78% of tracheostomy tubes were secured with ties only, and 67% were receiving mechanical ventilation.

The analysis of past AD events provided valuable information towards narrowing our areas of focus in creating our initiative. We were able to identify the need to address best practices for patient repositioning to avoid AD. The need for improvement to prevent AD in patients exhibiting AMS was made apparent. Focus was also directed towards investigating the prevalence of events occurring during the middle of standard shifts.

Table 1: Patient demographic, airway, and system data

Table 2: AD resulting from turns/repositioning and self-removal

The use of evidence-based practice (EBP) has been shown to improve patient outcomes, increase resource utilization, and be cost-effective. However, there is often a lack of knowledge and expertise in the use of EBP, and there are concerns about the lack of implementation and reinforcement of these practices. The study aims to investigate the current levels of awareness, understanding, beliefs, attitudes, skills, and utilization of EBP among respiratory therapists (RTs) in select countries, namely the Middle-East countries, India, and the Philippines.

The study protocol was approved by the institutional review board, and investigated EBP awareness, understanding, attitudes, skills, and utilization among RTs. An online survey was conducted from October 2022 to March 2023, with 560 valid responses analyzed. We assessed the 8 sources of professional information utilized by RTs using a 5-point Likert scale.

A significant majority (67.9%) of RTs acknowledged the role of EBP in enhancing patient care. However, 56.6% expressed neutrality regarding the impact of research findings on daily practice. Key barriers to EBP implementation included difficulty in formulating clinical questions (61.5%), time constraints (60.8%), and limited access to evidence (55.4%). RTs primarily used online databases (64.5%) and web portals (58.4%) for professional information. ProQuest (22.9%) and the Cochrane Library (22.3%) were the most frequently accessed databases. Younger RTs and those with higher academic qualifications exhibited greater engagement with EBP. Significant associations were found between EBP knowledge and demographic variables such as age (P = .03), qualification (P = .006), and experience (P = .02).

While RTs recognize the importance of EBP, many remain uncertain about its practical impact, highlighting a need for clearer demonstration of research applicability. Younger and more educated RTs are more engaged with EBP, emphasizing the role of education in promoting EBP skills. Addressing barriers such as time constraints and evidence access through targeted interventions is essential for fostering a culture of evidence-based care in respiratory therapy.

Perceived barriers to the implementation of evidence-based practice.

Attitude towards Implementation of EBP (A), and motivation for accessing (B) EBP retrieval database among RTs

Trigger asynchrony is a common problem during mechanical ventilation and occurs primarily in patients with dynamic hyperinflation and COPD. We were curious if the brand of ventilator platform also played a role in trigger asynchrony. In other words, do some ventilators inherently allow for easier triggering than others. Our null hypothesis is that no variation of missed triggers will occur across 5 different ventilator platforms.

An Ingmar Medical ASL 5000 breathing simulator was used to evaluate 5 adult ventilators: Servo-U, Servo-i, Hamilton G5, Hamilton C6, and Dräger V500. Three different patient models were also evaluated: normal, ARDS, and COPD. The ASL was set for 20 breaths/min across all model types, but compliance, resistance, and waveform patterns were left pre-set for the given patient model. Four different inspiratory muscle pressures (IMP) of 20, 10, 5, and 2.5 cm H₂O were used to simulate strong to weak muscle movement. The simulator was then set for one of the three patient models, 5 cm H₂O PEEP, and IMP of 20 cm H₂O. Each ventilator was placed in pressure support mode, flow trigger of 2 L/min, and allowed to run for 1 min while the total number of triggered breaths were counted. The process was repeated for IMPs of 15, 5, and 2.5 cm H₂O. Three runs were performed at each IMP level. The PEEP was then increased to 10 cm H₂O and this process was repeated. After collecting data for one of the model types, the entire process was repeated for the other two model types.

When using normal and ARDS models all ventilator platforms triggered 100% of ASL set breaths at all muscle pressures and both PEEP levels. When using the COPD model, the Servo-i and Servo-U triggered 100% of set breaths at all IMPs except 2.5 cm H₂O in which 90% of breaths were triggered. The Hamilton C6 triggered 90% of set breaths at all IMPs except 2.5 cm H₂O in which 67% were triggered. When PEEP was increased to 10 cm H₂O on the Hamilton C6, triggering improved from 67% to 90%. The Hamilton G5 and Dräger V500 triggered 100% of set breaths at all IMPs except 2.5 cm H₂O in which 40% were triggered. When PEEP was increased to 10 cm H₂O on the Hamilton G5, triggering improved from 40% to 52%. Increasing the PEEP on the Dräger V500 did not improve triggering.

We rejected our null hypothesis and concluded that the Servo-i and Servo-U distal flow sensor was the most responsive in detecting flow in the weak COPD patient model when compared to the Hamilton C6, Hamilton G5, and Drager V500.

Nebulizers utilize various aerosol-generating mechanisms. Recently, breath-actuated nebulizers have emerged to optimize delivery efficiency and reduce medication waste. However, their consistent and reliable inhalation triggering regarding uncertainties in aerosol drug absorption remains controversial for clinical use. We have developed a nasal sound-detected breathing-triggered mesh nebulizer that demonstrated enhanced drug delivery efficacy in in-vitro and ex-vivo studies. The current study aimed to compare this breathing-triggered mesh nebulizer with a continuous mesh nebulizer through a pharmacokinetic study involving healthy volunteers and assess environmental aerosol counts.

This was a crossover prospective clinical study (NCT06157515). Single salbutamol doses (2,500 μg) were administered using breath-triggered and continuous nebulizers, with a 1-week washout period. Delivery efficacy was assessed by measuring urine salbutamol concentration 30 min before/after inhalation and 24 h post-nebulization using high-performance liquid chromatography. Drug side effects, such as changes in heart rate, blood pressure, and other symptoms, were monitored. Fugitive aerosol concentrations in the environment were measured by aerodynamic particle sizers (APS) at 1-meter distances. Statistical analysis was conducted using paired t-tests, with significance set at P < .05.

Twenty-four healthy volunteers with a mean age of 35 (± 10) y completed the study. No significant differences were observed in demographics and lung function tests. The baseline salbutamol urine concentrations were similar between the two nebulizers (P = .89). However, after 30 min, the nasal sound-detected trigger nebulizer showed a significantly higher salbutamol concentration (P < 0.05), a 1.8-fold increase over the continuous nebulizer. Despite higher drug absorption, vital signs remained stable with both nebulizers. No significant difference in 24-h metabolized salbutamol in urine (P = .82). Environmental aerosol concentration during inhalation indicated the continuous nebulizer released a significantly greater fugitive aerosol, approximately 5.2-fold higher than breath-triggered nebulization.

The nasal sound-detected breathing-triggered nebulizer demonstrated increased pulmonary drug delivery and reduced environmental drug waste compared to continuous nebulization, suggesting a more reliable and efficient option for clinical use.

Literature suggests there is variability in the clinical practice of spontaneous breathing trials (SBTs). Evidence-based literature and clinical practice guidelines (CPGs) have been published over time to address various aspects of SBT implementation. It can take many years for evidence-based literature to be adopted into clinical practice. The American Association of Respiratory Care (AARC) recently published CPGs addressing 4 aspects of SBT implementation. This study evaluated how the clinical practice of SBTs compares to the recommendations of the CPGs.

An online survey was developed to assess how hospitals with SBT protocols perform different components of SBTs. This study received IRB exemption. The published survey was posted on AARC Connect and the National Alliance of Respiratory Care Professionals LinkedIn page. A hospital with a formal protocol for an SBT in adult mechanically ventilated patients was the inclusion criteria for survey participation. Descriptive statistics were used in the data analysis.

A total of 26 representatives from different healthcare institutions in the United States met the criteria for data analysis. 61.5% of reported protocols use RSBI, which is not in alignment with the current recommendation. 77% reported the use of pressure support (PS), 11.5% specified the use of a T-piece, and 11% specified the option of either PS or T-piece during the SBT. The responses are 100% in alignment with the current recommendation of performing a SBT with or without support. 73.1% align with having a standardized approach to performing SBTs by specifying when the SBT will be initiated. 65.4% perform an SBT during the day, though it is not specified if it occurs before noon each day. 53.8% allow for an increase in FIO₂ during an SBT, which is not in alignment with the current recommendations.

The reported hospitals’ protocols demonstrated moderate alignment with the 4 CPGs’ recommendations. Identifying current discrepancies between clinical practice and CPGs will allow the adoption of CPG recommendations into clinical practice to be assessed over time. Further assessment could be performed to determine if there is an impact on patient outcomes.

Ventilator-associated pneumonia (VAP) is the most common ICU-acquired pneumonia among patients who are invasively intubated for mechanical ventilation. Our aim was to comprehensively analyze the effectiveness of various VAP prevention strategies, which is crucial for improving patient outcomes.

A comprehensive literature search was conducted across multiple databases, including PubMed, Scopus, and CINAHL, with a 20-year (2004-2024) date restriction, focusing on articles published in the Middle East and North Africa (MENA) region. Duplicates were removed using EndNote, and preliminary screening was performed on the Rayyan platform. Data extraction was performed using a standardized form, and both internal and external validity was assessed using the risk of bias tool developed by Hoy et al.

We identified 1,756 records, of which 88 were selected for full-text review. Following methodological examination and quality assessment, 37 studies were included in the data synthesis highlighting various VAP prevention strategies implemented in the MENA region. Oral care protocols using chlorhexidine mouthwash significantly reduced VAP rates, with one study reporting a decrease from 5.8% to 0% over 2 years. Comparisons between chlorhexidine and miswak, a traditional Middle Eastern oral care tool, were also evaluated. Elevating the head of the bed to 30-45 degrees proved effective, with a clinical trial showing lower VAP incidence at 45 degrees compared to 30 degrees. Ventilator care bundles, including oral care, hand hygiene, and regular suctioning, were associated with substantial VAP reductions; one study reported a decrease from 33.8% to 8.8% with comprehensive training and adherence. A daily sedation interruption protocol also showed effectiveness, with lower VAP rates in the intervention group. Additional strategies, such as subglottic secretion drainage and continual oral hygiene, further supported VAP prevention efforts.

The findings indicate that comprehensive, multifaceted VAP prevention strategies significantly reduce VAP occurrence in the MENA region. Effective strategies include oral care protocols, head-of-bed elevation, ventilator care bundles, and daily sedation interruption. This review underscores the need for standardized protocols and continuous education for healthcare providers to enhance VAP prevention and improve patient outcomes.

PRISMA Flowchart

Blended medical gas is required for premature infants in the NICU, a high resource-utilization area during a disaster. Portable ventilators are powered by battery or plugged into generator- supported emergency electrical outlets. Oxygen is bled in, or attached to a 50 PSI gas source, while air is provided by compressed gas cylinder, a turbine driven source, or compressor. Portable ventilators are often needed when a disaster resulting in a power outage or gas failure occurs. The purpose of this bench study is to compare the duration of gas consumption on two frequently used portable ventilators for neonates.

A pNeuton mini pneumatic portable ventilator (Airon, Melbourne, FL) was attached to a pNeuton Mini Patient Circuit (Airon). A Hamilton T1 ventilator (Hamilton Medical, Reno, NV) was connected to a RT 265 neonatal ventilator circuit (Fisher & Paykel, Irvine, CA). The circuit was attached to an Infant Ingmar Neo Lung (Ingmar, Pittsburgh, PA) for the individual gas duration tests at differing oxygenation percentages on both ventilators. We compared the duration of oxygen gas at a FIO₂ of 21%, 40%, 60% and 100% when attached to 2200 PSI e-cylinder oxygen. The settings used for both ventilators tested were pressure control PIP 25, PEEP +5, rate 30, and inspiratory time 0.5 s. The pNeuton was set to a constant flow of 6 L/min. The Hamilton T1 flow was calculated by the ventilator for the given settings. Duration of gas was determined as compressed oxygen gas from an E cylinder transitioned from full to empty cylinder at each of the specified oxygen percentages.

The results of oxygen gas duration in minutes were displayed in the accompanying table. The Hamilton T1 ventilator consumed oxygen three times less than the pNeuton Mini ventilator.

At neonatal settings, an electrically powered and turbine-driven powered portable ventilators are good options for mechanical ventilation when a blended gas is needed in the presence of a gas failure. The Hamilton T1’s turbine driven mechanism is gas conserving and preferred over pneumatic driven ventilators as long as a power source is available. However, understanding your gas and ventilator resources and choosing the correct ventilator to support these emergencies is critical.

Ventilator-associated pneumonia is a common infection in medical care settings. High-frequency chest wall oscillation (HFCWO) is frequently used as an airway clearance therapy for patients undergoing invasive mechanical ventilation. Previous studies have demonstrated that HFCWO enhances mucous mobilization and airway clearance. We hypothesize that the therapeutic efficacy of HFCWO exceeds that of chest physiotherapy (CPT) for airway clearance, potentially leading to greater improvements in local lung ventilation in patients. This study aims to compare the effects of HFCWO and CPT on lung aeration, measured using electrical impedance tomography (EIT).

This study was a single-center randomized crossover trial approved by the Internal Review Board of Chang Gung Memorial Hospital. We enrolled patients aged 18 years and older who were intubated due to respiratory failure, subsequently admitted to a medical ICU, and displayed infiltrations on chest x-ray within 48 h. HFCWO and CPT were administered twice daily for two consecutive days in random order, with the treatment modality switched on the following day. HFCWO was administered for 15 min, while CPT was combined with postural drainage and percussion for 10 min on each side of the lung. On both days, EIT monitoring was conducted in the afternoon session before HFCWO/CPT treatment to establish a baseline (T0). Measurements included tidal impedance variation, change in end-expiratory lung impedance, global inhomogeneity index, center of ventilation, and non-ventilated areas. EIT data were recorded for 10 min each session at the end of the treatment (T1) and subsequently at 1 (T2) and 2 h (T3) post-treatment. Statistical analyses were performed using the Mann-Whitney test to compare between groups and the Friedman test to compare different time points within each group.

Thirty patients were recruited for the study, with twenty-three completing the protocol for final analysis. The figure displays comparisons of each measurement at different time points. Interestingly, while no significant differences were observed in all EIT data between the two treatments, differences in tidal impedance variance were noted within the HFCWO, indicating a reduced volume after 2 h of treatment. The non-ventilated region was lower at baseline but increased after HFCWO.

The study found that airway clearance therapy with HFCWO or CPT resulted in similar therapeutic effects in terms of lung volume changes.

Comparisons of EIT paramters between two treatments

High-flow nasal cannula (HFNC) is an essential treatment for acute respiratory failure (ARF), a key symptom of COVID-19. The ROX index, defined as the ratio of SpO₂/FIO₂ to frequency, is used to predict HFNC success in COVID-19 patients. A ROX score ≥ 4.88 at 12 h indicates a decreased likelihood of needing mechanical ventilation.

This retrospective observational study analyzed prospectively collected data from 136 COVID-19 patients in the ICUs at King Abdulaziz Medical City (KAMC) from February 1, 2020, to December 30, 2021. Inclusion criteria were adults (≥18 y) with a positive COVID-19 test requiring HFNC. ROX index was calculated every 12 h and correlated with intubation outcomes. Descriptive and inferential statistics were utilized to assess the predictive value of the ROX index.

Out of 136 patients, 46.3% were intubated, and 53.7% were weaned off HFNC. The ROX index varied significantly over the study period, with the highest mean value of 8.22 and the lowest of 4.88. T-test results showed statistically significant mean differences between intubated and weaned-off patients on multiple days, indicating that higher ROX values were associated with successful HFNC therapy. Specifically, a ROX index cut-off point of 5.35 at day 10-2 predicted HFNC success.

The study concludes that the ROX index is a reliable predictor of HFNC success in COVID-19 patients in the ICU. Higher ROX values are linked to a greater chance of successful HFNC therapy and a lower risk of mortality, providing a valuable tool for clinicians in managing ARF in COVID-19 patients.

Sleep disorders (SD) are known to affect daily function and impact various aspects of life. Almost 70% of college students worldwide report having insomnia and almost 10% have sleep-disordered breathing. These SD have been associated with poor mental health and impaired academic performance. Mental health disorders, such as anxiety, can further deteriorate sleep quality. This study was designed to evaluate the presence of sleep disorders in a group of college students in the U.S.

For this cross-sectional study, a 25-question survey including the Epworth Sleepiness Scale (ESS) and the Generalized Anxiety Disorder 7-items scale (GAD-7) was created and distributed via email and social media from February to April 2024 to university students around the U.S. IRB approval was obtained. Data collected included answers to general sleep quality questions and demographics. Microsoft Excel was used to analyze data using descriptive statistics.

A total of 121 students with a median age of 25 years old (range 20-46) responded to the survey. Of these, 53% were Hispanic and 23% Caucasian. Majority were female (80%), graduate students (67.7%), rarely drink (61.9%), and have never smoked (91%). When asked about sleep, 74% reported having problems to sleep. Similarly, 59% of graduate students and 45% of undergraduate students answered having more than 4 days of poor sleep per week and 82% reported feeling generally stressed. Almost 60% felt that stress was affecting their school performance while 80% indicated that poor sleep affected different areas of their life, especially the lack of energy, and school performance. Students also indicated having difficulty falling asleep (59%), and 97% take 10 min to 1 h to fall asleep, using sleeping aids medication like melatonin to help falling asleep (42%). While only 5.3% reported a previous diagnosis of with a SD, a moderate correlation was observed between mild to severe ESS and GAD-7 score (r = 0.39 P = .05).

According to the results of this study, a significant number of college students report sleep disorders. These SD are associated with high levels of stress and appear to significantly impact their school performance, energy levels, mood, and personal relationships. Academic institutions should use this information to implement initiatives and intervention strategies to assess and offer support to students with sleep disorders and minimize complications such as sleep-disordered breathing.

Ventilator-associated pneumonia (VAP) has become archetypal among hospital-acquired infections. A higher prevalence rate for VAP increases LOS, significant hospital costs and mortality. The Trauma Quality Improvement Program reports the VAP national benchmark prevalence rate at 0.8% in level I and II trauma centers. In 2020 the VAP prevalence was reported by TQIP at 0.9%, over the national benchmark. By implementing a strict VAP adherence bundle and post-intubation N-BAL procedure for all qualifying trauma patients, the VAP prevalence significantly decreased in the trauma population.

Evidence-based VAP prevention guidelines were executed as a monitored standard of care. Adherence to outlined VAP prevention model was guaranteed with collaboration between the respiratory and ICU nursing staff. Subjects were identified by the necessity for mechanical ventilation immediately following a trauma-related incident. Implementation of adherence management was completed in 2 stages over 6 months. The VAP bundle included: oral care Q4h, suction supplies/cannisters changed Q24h and head of bed (HOB) greater than 30 degrees, assessed Q4h. The N-BAL procedure was completed within 24 h post intubation specifically to capture presence of infection on admission.

A decrease in VAP prevalence rate was rapidly achieved. TQIP reported VAP prevalence at 0.9% in 2020. TQIP reported VAP prevalence rate decreased below the TQIP benchmark of 0.8% to 0.6% in 2021. Post-implementation performance revealed a 9.7% increase in patient volume and 33% decrease in VAP prevalence.

Initiation of adherence to the VAP guideline bundle and early administration of N-BAL procedures significantly decreased VAP prevalence resulting in hospital percentages falling below the national average.

Twenty-four years ago, the ARDSNet trial promoted setting initial tidal volumes (V_T) of 6-8 mL/kg of ideal body weight (IBW) to reduce the risk of ventilator-induced lung injury (VILI) and decrease mortality. Despite the evidence, this lung protective approach continues to be inconsistently implemented. This study was designed to evaluate adherence to this low-V_T (LTV) strategy in a group of patients receiving mechanical ventilation (MV) at large university-affiliated institution in Texas.

This retrospective descriptive non-experimental study was conducted in the ICU at University Hospital in San Antonio, Texas, between March 2022 and April 2022. Patients admitted to the ICU aged 18 to 80 years old who received mechanical ventilation more than 24 h were included in this study. Selected V_T was recorded for every subject and compared to recommended LTV strategy. General information and ventilator parameters collected included IBW, V_T, PEEP, PIP, IBW, MAP and FIO₂. Descriptive statistical analyses were conducted on the collected data. The Institutional Review Board approved this study.

Of the 61 subjects included in the study the median age was 53 y old (± 17.6). Most were male (65.6%) and Hispanic (45.9%). Mean V_T was 436 mL (± 57.1; range: 270-450 mL). Based on IBW, the V_T selected was 6.68 mL/kg/PBW (SD 1.03; range: IQR 25-75 5.94-8.36). The most selected V_T was 420 mL (n = 11, 18%), followed by 420 mL (n = 10, 16%). Almost 1 out of 4 subjects (24.6%) were placed on a V_T ≤ 6 mL/kg PBW, and 14% received a set V_T of > 8 mL/kg PBW. While most subjects (98.3%) were on volume-limited ventilation, Pplat was measured and documented in only 64% of the subjects.

Most patients ventilated in this medical ICU were placed on V_Ts appropriate for the IBW. However, selection of a tidal volume below and above the published guidelines on almost 50% of the subjects in this study indicates a need for better adherence to recommendations to reduce the risk of atelectrauma or overdistension.

Continuous albuterol manufacturing changes have created supply chain shortages and differences in manufacturing processes for available products. Drug diluents have a significant impact on inhaled respiratory medications that can be interfaced with mechanical ventilators. Two major manufacturers, Nephron and STAQ Pharma, dilute albuterol with sterile water and normal saline solution, respectively. We observed, via the Children’s Hospital Association (CHA) discussion forum, that various children’s hospitals faced issues with increased crystallization in their ventilators during continuous albuterol nebulization. We aim to determine if the albuterol diluent type influences filter weight and build-up that could impact ventilator functionality.

In an IRB-exempt bench study, two models were used: model 1, simulating a 40 kg patient, and model 2, a 10 kg patient. In all models, a Getinge Servo-U ventilator, F&P MR850 heater (set 37°C), Intersurgical LTD filta-guard bacterial filters, and Alaris syringe pump were utilized. A F&P RT280 circuit was used for model 1 and a F&P RT265 for model 2. Model 1 ventilator settings included SIMV/PRVC, V_T 240 mL, frequency 20, PEEP 5, i-Time 0.8 s, and PS 10 cm H₂O. Model 2 ventilator settings included SIMV/PRVC, V_T 60 mL, frequency 30, PEEP 5 cm H₂O, i-Time 0.5 s, and PS 10 cm H₂O. The Alaris syringe pumps were set with an albuterol dosage of 20mg/h utilizing a syringe filled with 1.67mg/mL albuterol concentration. Per our institution’s policy, two bacterial filters were placed on the expiratory end of the circuit for each trial. The bacterial filters were measured before nebulization initiation and again at 3- and 5-h intervals. The filters were measured again 24 h later. Bench models were completed twice, once with albuterol with sterile water diluent and once with albuterol with normal saline diluent. The filter weights were compared.

In both models, at all time intervals, the total weight of the bacterial filters from normal saline diluent was heavier than that of the sterile water diluent filters (Table 1).

In our bench model, diluent type utilized with continuous albuterol influences ventilator circuit moisture and filter build-up. In our practice, double filters, changed frequently, prevent negative patient impact with both diluent types. Further studies must be done to assess the effects in a patient care setting on ventilator functionality with varying drug delivery rates.

Administration of nebulized medications is a very common practice in the ICU. Although several aerosol generating devices can be selected, most ICUs use the small volume jet nebulizers. Although some recommendations on where to place aerosol generators when administering aerosol treatments to patients undergoing invasive and noninvasive mechanical ventilation or high-flow nasal cannula (HFNC) have been published, there are still many inconsistencies in the clinical setting. Placement of these aerosol generators can be adversely affected by humidification devices and lead to significant changes in pulmonary mechanics. The goal of this study was to determine where respiratory therapists (RTs) place nebulizer when administering a treatment in the ICU.

For this prospective, observational study, pediatric and adult subjects who were placed on invasive mechanical ventilation (IMV), and noninvasive mechanical ventilation (NIV) or high flow nasal cannula (HFNC) with an order to receive a nebulized treatment were included. The study was conducted at a large university-affiliated hospital in Texas and was approved by the IRB. The research team communicated with RTs when it was time to administer an aerosol treatment to subjects in the ICU. Once the subject was identified, the electronic medical record was accessed to collect demographic information and placement of the nebulizer was documented in the data collection form as the treatment was administered.

A total of 32 subjects were selected for analysis; 18 from the pediatric ICU and 14 from the adult ICU. The majority of the sample was on IMV (50%), followed by HFNC (28.1%), and NIV (21.9%). The nebulizer was placed on the dry side of the heated humidifier (HH) in every patient on IMV. For all patients on NIV, nebulizers were placed on the inspiratory limb of the circuit between the interface and the exhalation valve. When placed on HFNC, the nebulizer was connected to the dry side of the HH in 3 subjects while 6 subjects had their nebulizers placed on the inspiratory limb of the breathing circuit.

The results of this study suggest that while there is variation in regard to where RTs place the aerosol generator when using HFNC, they are consistent in their practice of placing the nebulizer when using IMV or NIV as recommended in published guidelines. Further evaluation of practices while delivering aerosol treatments to patients on HFNC may be required.

Interstitial lung diseases (ILD) are a unique group of lung disease that carries significant morbidity and mortality with increased incidence and prevalence with age. The heterogeneity and evolution of diagnosis has made defining true incidence and characteristics of disease difficult. This study aims to describe the etiology and characteristic in a young healthy military population with various deployment exposures.

A retrospective chart review was conducted using the electronic medical record for active duty service members with a diagnosis of ILD. Basic demographic data, diagnosis, pulmonary function testing, chest imaging, and pathologic results were reviewed. The groups were then subdivided for further analysis based on exposure and deployment history. Further subgroup analysis was performed on the major idiopathic interstitial pneumonias (IIP) and connective tissue disease-related ILD (CTD-ILD) within this cohort.

Initial review of medical records identified 323 individuals with a diagnosis of ILD of which only 158 were analyzed. The cohort was 70.9% male with a mean age of 38.9 y. Chest imaging was performed in 158 (100%) patients while PFTs were done in 147 (93%) patients. Average FVC 3.52 L (77% predicted), FEV₁ 2.75 L (75% predicted), FEV₁/FVC 79%, TLC 6.32 L (78% predicted), and D_LCO 18.8 mL/Hg/min (63% predicted). Tissue diagnosis was made in 39.2 % of patients. BAL was performed in 20.9% of patients. Notably, 82 (51.9%) individuals were under the age of 40 while the remaining 76 (48.1%) over 40 years old. 32.3% had a diagnosis characterized as a major IIP, 29.7% with CTD-ILD, and 38% alternative diagnosis. There was a notably higher proportion of females in CTD-ILD subgroup when compared to major IIPs (44.7% vs 21.6%).

In this study we describe the etiology and characteristics of active duty military members diagnosed with ILD during military service. Despite a young population a variety of causes were found for underlying ILD. A higher proportion of females were noted to have CTD-ILD when compared to other subgroups. PFT data reviewed showed more subtle changes suggestive of early ILD. ILD is typically diagnosed later in life and early detection may help decrease long-term morbidity and mortality. Further investigation should be performed to evaluate any relationship of ILD to deployment or other exposures during military service.

UPMC Presbyterian Pulmonary Rehab implemented a more intensive pulmonary rehab (IPR) protocol for post-lung transplant recipients with the aim of accelerating improvement of patients’ functional capacity, strength, and endurance to facilitate home discharge. A traditional pulmonary rehab (TPR) consists of 2-3 days per week for up to 12-18 weeks, whereas IPR consists of training 4-5 days per week for 3-5 weeks. We assessed the effectiveness of the IPR compared to TPR.

After receiving IRB approval, we performed a comparison of retrospective data collected on all post-transplant recipients enrolled in the TPR program prior to the implementation of the IPR program with those measures in the IPR population. Criteria for the IPR group for discharge to their home maintenance program is observation of a plateau in the patients’ weekly physical assessments of grip strength, balance, frailty, and functional capacity. We compared proportion of patients in the two groups achieving: minimally important improvement in 6-minute walk functional capacity (98 feet), any improvement in Timed Up and Go (TUG), and any increase in maximal Metabolic Equivalency Threshold (MET) achieved during incremental testing on a recumbent cycle. We considered non-inferiority in outcome to be less than a 10% drop (or increase) in proportion of patients achieving the stated goal.

46 patients were included in the IPR group and 88 patients in the TPR group. 98% of patients enrolled in IPR and 92% of patients enrolled in TPR met minimum clinically important differences for 6-minute walk functional capacity. TUG measurements improved in 93% of IPR and 92% of TPR patients. METS during incremental recumbent cycling improved in 89% of IPR population and 94% of TPR population. IPR patients were discharged after 14.5 ± 5.5 sessions over 4.1 ± 1.1 weeks in contrast to TPR goals of 36 sessions over 12-18 weeks.

The post-lung transplant population is benefited by being enrolled in an intensive pulmonary rehab program as evidenced by non-inferior outcomes assessing functional status and frailty measures achievable in significantly fewer sessions over a shorter time period. Continuation or implementation of an IPR program for post-lung transplant recipients is justified by our findings.

Children with ≥2 ED visits or ≥1 hospitalization for asthma are considered high risk. There is a strong link to asthma morbidity, social determinants, and neighborhood conditions. The Child Opportunity Index (COI) is a publicly available resource for measuring neighborhood conditions where higher scores reflect higher opportunity. Children living in neighborhoods with a very low or low score are at higher risk for asthma morbidity and may benefit from care coordination and health navigation to address barriers affecting health outcomes.

Starting July 1, 2023, children (<6 years) who are seen in our children’s hospital primary care and pulmonary clinics for asthma were identified for the asthma intensive reinforcement (AIR) QI pilot via EMR if they had ≥ 2 ED visits and/or ≥1 hospitalizations in the preceding 12 months and lived in identified zip code with a low or very low COI score. Children > 6 years of age and/or who were already enrolled in a home visit program, currently being managed within our multidisciplinary asthma clinic, or their primary pulmonary provider requested that they not be included in the AIR pilot were excluded. The multidisciplinary AIR team reviewed the EMR monthly for each child to determine if there were any clinical (communication, refill, access) or social barriers potentially preventing the child from following their asthma action plan. Over a 6-month period an identified team member would call the child’s caregiver to review the AAP, identify and/or address any barriers to care. Identified clinical and/or social barriers and health care utilization was tracked prior and after the start of the AIR pilot.

A total of 17 children were initially identified, 8 were excluded. The demographics were median age 4 y, male (78%), English (56%), Black (44%) and Hispanic (56%). There was difficulty contacting 33% of the caregivers. Findings included 33% had social barriers (food, transportation, financial insecurity), 66% had at least one clinical barrier, and 22% had a subsequent hospitalization or ED visit within 6 months.

Clinical and social barriers can negatively impact children with asthma being able to follow their asthma action plan. Addressing these barriers after a hospitalization or clinic visit through ongoing care coordination and health navigation can decrease health care utilization. Factors affecting ongoing healthcare utilization may include lack of insurance, beliefs, and ongoing exposure to environmental triggers.

:Local Child Opportunity Index 2.0 Neighborhood Mapping

The Respiratory Acute Care Unit (RACU) is a 12-bed intensive care unit specializing in weaning patients from prolonged mechanical ventilator support. Education for RNs about the care for patients with tracheostomy tubes and invasive and noninvasive mechanical ventilation has been delivered mainly by nurses during hospital orientation or the new graduate RN residency program. Due to the specialized care needs of these patients, we developed a 4-h course to increase the confidence of new RNs orienting to the RACU.

Eleven RNs participating in the RACU new hire orientation program were asked to complete a 25-question survey (SurveyMonkey) to assess their confidence in caring for tracheostomized and mechanically ventilated patients. A Likert-Scale 1 (not at all confident) to 5 (very confident) was used. The RNs then attended a 4-h course focusing on tracheostomy tubes and mechanical ventilation. RNs were asked to complete the same survey to assess their learning. The post-survey also asked 3 open-ended questions to collect feedback from the participants. Statistical analysis was performed using Stata/SE 17.0 for Windows (StataCorp, College Station, TX). Descriptive statistics were used to describe the demographic data. The Shapiro-Wilk test was employed to assess the normality of the data distribution. A paired samples t-test was used to determine if there was a significant difference in the mean values between the pre- and post-survey results. The open-ended questions on the post-survey were analyzed for themes by the primary investigator.

Six RNs completed the pre-and post-survey. The mean difference between the pre (2.59 ± 1.3SD) and post (3.71 ± 0.9) survey scores was 1.12 ± 1.0SD. There was a significant increase in confidence (P < .001) between the pre- and post-survey scores. For the open-ended questions, there were several themes identified. Subjects appreciated the hands-on and practical components of the training, suggested scheduling these sessions earlier, and desired more detailed emergency response training.

Implementing a focused 4-h course for new RNs in the Respiratory Acute Care Unit (RACU) significantly enhanced their confidence in managing patients with tracheostomy tubes and mechanical ventilation. Overall, the specialized training course successfully addressed the unique educational needs of the RACU staff, leading to better-prepared nurses capable of providing high-quality care to this complex patient population.

Expiratory cassettes (EC) often play a vital role in mechanical ventilation (MV).ECs serve as the brain of the MV, measuring pressures and flows, among other functions after gas is exhaled from the patient. To protect the EC, filters are placed before it to prevent internal damage. Cases of filters creating PEEPtot (intrinsic PEEP) have resulted from the presence of sodium or aerosol medication deposition in the filters. The amount of time it takes for filter blockages or EC malfunction, however, has not been studied.

Two ventilators were used side by side this bench study. Both used heated wire circuits and a filter attached to the EC according to the manufacturer’s recommendations. No filters were added to the inspiratory side. Sterilized ECs were used for the trial. MV settings were consistent for both ventilators: VC/AC, V_T of 120 mL, frequency of 15, PEEP of 5 cm H₂O and 1 s i-time were used in this bench study. Both MV circuits were attached to a 1 L max V_T test lung. A continuous solution of 0.9% normal saline (NSS) was ran through a syringe pump at 10 mL/h using a vibrating mesh nebulizer. This was chosen to simulate continuous albuterol nebulization used for critical pediatric asthma exacerbations, as albuterol is mixed with NSS. The first ventilator (V1) received expiratory filter changes every 4 h, while the second ventilator (V2) had no filter changes throughout the study to determine its impact on the filters, EC readings, and the ability to ventilate. The following parameters were assessed every 4 h: Vti, Vte, PIP, PEEP actual, intrinsic PEEP (PEEPtot), expiratory airway resistance (Re), EC percentage of life expectancy. The trial ran for 6 days.

V1 had no significant change in Vti, Vte, PIP, PEEPtot, compliance (Ces), or Re over a 6-day period. V2 began to see changes in PEEPtot within 24 h. It was also subjectively reported that within 24 h the expiratory flow took significantly longer to get back to baseline. At 24, 48, and 72 h, values for PEEPtot in cm H₂O (5.5, 12, 16), Re (11, 76, 452), PIP cm H₂O (13, 18, 23).

While running continuous albuterol mixed with NSS, ventilators that require EC filters, must be changed more frequently than at 24 h intervals, to prevent external factors of expiratory resistance. This may lead to caregivers mistaking airtrapping within the circuit of the ventilator for increased airway resistance in a patient who is at risk for severe airway resistance, ultimately leading to care mismanagement and potential patient harm.

Previous studies have shown that alternative medicine products (AMP) were used during the pandemic; however, they are not considered standard of care. In 2022, we reported the results of an international survey showing that nearly 100% of participants used AMP during the COVID-19 pandemic. Although the number of COVID cases has dramatically decreased, AMPs are often considered for the prevention and management of health challenges, including infections. This follow-up study was designed to determine if, 2 years after the last survey, use and perception of benefit of AMP has changed.

For this cross-sectional study, a 25-question survey was created using Google Forms. It was distributed via social media from February to April 2024 to subjects at least 18 years of age across the U.S. The instrument explored participants demographics, general health condition, which alternative medicine products (AMP) were used and why, and COVID-19 infection and immunization history. Excel (Microsoft) was used to tabulate data and report descriptive statistics. IRB approval was obtained.

A total of 76 responses were obtained. Mean age was 34.7 y old (± 13.3) and 82.3% were female. Most participants were Hispanic (56.6%, n = 43). Most participants held a university degree (55%, n = 42; BS 34.2% and 18.4% MS). Of participants who had health insurance (93.4%), 38% (n = 27) reported always or often using AMP to boost their immune system. Of the healthcare providers (47%), 33% are not using AMP. More than 80% (n = 62) received at least 2 or more dose of the vaccine. Twenty-seven participants use AMP (35.5%) either always or often, and during the pandemic 77.6% (n = 59) to either prevent COVID-19 or lessen symptoms. The most common AMP used were Vitamin D (46.1%), Vitamin C (27.6%), Zinc (26.3%), and antioxidants (10.5%). Over 90% reported that AMP let them achieve their desired results. Majority of the participants (88.2%) believed that AMP should be considered in addition to prescribed medications to improve outcomes of patients with COVID-19.

The results of this the survey indicate that AMP are often used by fully vaccinated individuals, those with health insurance and healthcare providers. Despite the lack of scientific data supporting the use of AMP, there was strong belief that they are important in preventing and/or lessening symptoms associated with disease, and they should be considered in addition to prescribed medications.

Ventilation modes with set tidal volume have been proven beneficial and widely used as a lung protective strategy in adult patients for decades. More recently, volume-targeted ventilation (VTV) was demonstrated to be protective against BPD in premature infants. As a consequence, mechanical ventilator manufacturers have developed VTV modes for neonatal patients. We detail our experience of incorporating VTV in our NICU.

Utilization of VTV in our NICU began with literature review and bench evaluation of pressure-regulated volume control (PRVC) mode of 4 mechanical ventilators available at our institution. Education was provided to all clinical role groups. Use of VTV mode was added to our existing Small Baby Initiative, where infants whose BW was < 1,500 g and/or GA < 32 weeks were preferentially ventilated in this manner. Retrospective chart review of all inborn infants was conducted 7 months before and after the initiative began. This research has been reviewed by local IRB.

Through the 7 months after initiation, 22 intubated infants were ventilated with VTV as the preferred mode. Average GA was 24 4/7 weeks (22 3/7 to 29 weeks) with a birth weight average of 841 g (495 to 1,538 g). Feedback from RT staff included lack of objective assessment of work of breathing as pressure control levels were down titrated. Therefore, a routine assessment of P_0.1 was implemented and monitored. The mean P_0.1 was 0.78 (0.4-2.8). Of the 22 patients, 17 (77%) had no oxygen requirement upon discharge and no infants were diagnosed with severe BPD (requiring invasive ventilatory support after 36 weeks PMA or discharge). In comparison to the 7 months prior to practice change, 21 intubated premature infants received mechanical ventilation in our NICU. Average GA of these patients was 27 1/7 weeks (23 1/7 to 29 6/7) with a birth weight average of 939 g (603 to 1,985 g). Number of patients with no oxygen requirement were similar (n = 16, 76%), but there were 2 patients with severe BPD who required tracheostomy and high-level mechanical ventilatory support and were transferred to a long-term care facility.

Technology of volume-targeted ventilation has recently improved for support of premature neonates. Significant change in practice can be accomplished easily through a multidisciplinary approach. Understanding the latest technology and implementing new approaches can have a large impact on the life of a newborn infant and their family, and our healthcare system.

Exogenous pulmonary surfactant replacement therapy is indicated to treat infants with surfactant deficiency, either congenital or acquired. Common examples include preterm infants with respiratory distress syndrome (RDS) and term infants with meconium aspiratory syndrome (MAS). The main method of surfactant is direct instillation into the lungs through an endotracheal tube. Recently, surfactant administration through a laryngeal or supraglottic airway (SALSA) has become available. We aimed to implement SALSA in our NICU with the goal of decreasing intubations and sedation use for surfactant administration.

The protocol for surfactant administration through a supraglottic airway included those neonates with birth weight ≥ 1,500 g and less than 48 h of life. The airway can be placed by the provider (MD/NNP) or the RRT. Surfactant is instilled through the airway in one position and two aliquots, which is identical to our endotracheal tube procedure. When delivering surfactant through a supraglottic airway, the RT maintains a noninvasive CPAP interface and device on the patient, and CPAP is resumed immediately after airway removal, preventing significant loss of FRC. The nasogastric tube is aspirated and amount of surfactant in the stomach, if any, quantified. Data is recorded in REDCap by the provider supervising the procedure. Exemption granted by local IRB for initial quality improvement initiative.

In the two years since implementation, we have utilized the SALSA procedure 73 times. Average gestational age is 34 and 5/7 weeks (31 1/7 to 39 4/7) with average birth weight of 2,541 g (1,508 to 4,410 g). Intubation after SALSA was performed in 23 of the 76 subjects (30%). Of those 23 patients, 17 received a second dose of surfactant. Complication rate was low and included desaturation (16.5%) and bradycardia (30.1%). The SALSA procedure was aborted due to complications in 9 cases (12.3%). Patients requiring FIO₂ ≥ 0.4 after the procedure decreased by 44% (25 to 14). In addition, for patients receiving SALSA, use of intravenous sedative medications was completely avoided.

Through multidisciplinary collaboration, we were able to successfully implement a change in approach to giving exogenous surfactant to newborns. In administering surfactant via a supraglottic airway, we avoid known complications of endotracheal intubation, such as airway bleeding, airway trauma, oversedation, and need for mechanical ventilation.

There are only few Master of Science in Respiratory Care (MSRC) programs in the U.S. They are designed to prepare competent advanced level RTs. While evaluating perspectives of existing MSRC programs and their infrastructures, most programs rely on survey-based research from current or recently graduated students to determine their quality. Exit surveys are distributed to new grads to identify variables that can be addressed to improve program quality. However, a distinct gap exists in research specifically targeting the quality of respiratory care education, making this study a unique and valuable contribution to the field. The purpose of this study was to determine specific variables that graduates consider important to qualify their educational program.

Exit surveys were distributed to all students who graduated between 2018 and 2022 from the MSRC program at UT Health San Antonio. The survey consisted of 55 items to assess achievement of program competencies, curriculum, faculty, quality of instruction, learning resources, tuition, financial aid, clinical rotations, and career planning. A Likert scale was used to rate each item. Descriptive statistics and Pearson product-moment correlations were performed (Statistica 14.0.1, StatSoft, TIBCO Data Science). IRB approval was obtained.

Exit survey data was collected from 186 students who graduated from UT Health MSRC between the years 2018 to 2022. Mean age for participants was 27.6 (± 5.0) y. Most respondents were female (69.4%), attending full-time (99.8%), and Hispanic or Latino (38.8%). Overall satisfaction with the quality of the MSRC educational program was 4.12 (± 0.8) on a 5-point scale. The 5 variables that participants scored the highest on program included provided knowledge (4.56 ± 0.63), provided technical skills (4.49 ± 0.60), prepared me to conduct myself ethically (4.49 ± 0.63), prepared me to think critically (4.47 ± 0.60), and campus safety (4.46 ± 0.59). Topics related to blend and variety (R = 0.91), quality instruction (R = 0.98), faculty (R = 0.95), and mentoring (R = 0.91) demonstrated the highest correlation with the quality of the UTHSCSA MSRC program.

The results of this study suggest that the quality of instruction is a critical component to determine how well students will score their MSRC educational program. There are important aspects of education like ethics and critical thinking that probably need more emphasis as students are ready to be part of the task force.

RT workflow has the potential to be more efficient by integrating ventilator data into the electronic medical record (EMR). Data integration should lessen EMR associated fatigue, increase more face-to-face patient care, and decrease transcription errors. Changing the design of the EMR flowsheet has the possibility to decrease errors and improve safe handoff by improving accuracy of data entered.

The RT division partnered with the IT department to develop a process improvement plan. The Servo U, Trilogy 202, EVO EV300 and INOmax DSIR Nitric Oxide are the devices that needed to be integrated into the EMR. Servo U, Trilogy 202, INOmax DSIR had existing parm IDs to integrate the ventilator data into the EMR. The RT/IT department worked with the engineers at Phillips and Baxter to develop parm IDs for the EV300 and EVO. The ventilator flowsheets were restructured to improve visualization of patient data and settings. Prior to ventilator integration all ventilator data was on one flowsheet. This was cumbersome to not only document but put the RTs at risk to pass along incorrect information or increase transcription error. Ventilator data updates every minute into EPIC. Data needs to be validated into EPIC for the data to become part of the medical record. All unvalidated data remains in the chart for 72 h. Improved efficiency will be measured by keystrokes, clicks and time in seconds.

Pre and post data was measured for keystrokes, clicks and time (s). Prior to integration the average time to enter a ventilator check was 111 s, 39 clicks and 46 keystrokes. After integration the average time to a ventilator check was 64 s, 14 clicks and 8 keystrokes. The total time to enter a nitric oxide check was 360 s. The total time post integration was 90 s.

On average there was a 42% reduction in time spent entering a ventilator or nitric oxide check. There was a 64% reduction in clicks and an 83% reduction in keystrokes. The reduction in keystrokes significantly reduces the chance for transcription errors. Integrating ventilator data into EPIC improved end user support and flowsheet design. Reducing time spent entering data allows for more time to be spent with the patient. Overcall care and accuracy has the potential to increase staff satisfaction. Safe handoff improved due to the accuracy of the information displayed. We will continue to work with the IT department to integrate more devices as technology allows.

Bronchiolitis management of pediatric, critically ill patients can be challenging and resource intensive. Implementing AAP based guidelines and developing collaborative education is essential for best practice care. High-flow nasal cannula (HFNC) protocols are necessary to identify and treat patients efficiently and may prevent unwarranted ICU transfers. This was a quality improvement project implementing HFNC management on pediatric wards as a strategy to decrease ICU transfers.

Previous pediatric floor HFNC L/min limits did not allow continuation of care within pediatric ward, requiring patients needing HFNC an ICU transfer. In 2023, bronchiolitis protocol was developed and presented to collaborative practice team. New guidelines increased L/min flow in correlation to specific weight and age in reflection of maintaining frequent care. Primary outcome was to monitor ICU days prevented when maintaining patients on wards, avoiding ICU transfer after new protocol implementation. Secondary outcomes were to decrease length of stay (LOS) while improving practice. Institutional Review Board committee approved for monitoring purposes.

Pre-protocol, 79 HFNC patients transferred from pediatric floor to ICU in 2021 and subsequently 68 in 2022. Post-protocol, 128 patients in 2023 were above old HFNC policy that met new criteria. Of patients, 36 (28%) HFNC patients were transferred to ICU, with 69.4% of transfers due to increased respiratory distress, 11.1% surgery consults, and 19.4% required extensive bronchodilator intervention. New HFNC policy resulted in 53% reduction of internal transfers. Total of 92 patients were discharged from pediatric floor that would have met previous ICU criteria with 215 ICU days prevented. Pre-protocol, HFNC metric observed LOS for 2021 was 4.43 d and 3.36 d in 2022. Post-protocol in 2023, LOS decreased to 2.75 d. Cost difference between average PICU patient day and pediatric floor day is $663, with annual cost saving calculated as $142,600.

Implementing an evidence-based practice and promoting efficient HFNC management decreased hospital LOS and ICU transfers. Change in management allowed the ICU to keep open beds for patients of higher acuity and maintain community access. Designing safe processes and conducting education made a direct impact to valued respiratory care. Reducing LOS improved operational, financial, and clinical outcomes by decreasing cost of patient care with more efficient bed management flow.

COPD affects about 14.2 million (6.5%) of U.S. adults and incurred about $49B in 2020 US healthcare costs. Despite wide availability of diverse pharmacological treatment, including nebulized and handheld, adherence to COPD treatment is low, and patient preferences can influence treatment use. There is a need to better understand patient preferences in COPD and integrate patient perspectives into COPD management strategies.

This was a qualitative study using online focus groups for patients with moderate-to-severe COPD on maintenance therapy. Semi-structured interview guides were used for two patient groups (n = 6, n = 7) and one caregiver group (n = 5) to elucidate personal experience and factors influencing perceptions of medication delivery devices. This study received approval from Advarra IRB (study Pro00079092).

Among patients, 6 (46%) were male and average age was 72.1. Eight were diagnosed >10 years earlier. Six patients used inhaler only and another 6 used both inhaler and nebulizer as part of their maintenance regimen. Overall, effectiveness was most frequently cited (n = 4) as an important attribute of treatment. Three patients cited that their treatment cost was a challenge (inhaler = 2, oxygen = 1). Six (46%) patients said that reducing dose frequency was important. While all expressed involvement of healthcare providers in treatment choices, 6 (46%) said the choice was ultimately theirs. For inhalers, portability was cited as an advantage (n = 2), while requiring device adjustment (spacer) (n = 5) and triggering cough due to powder (n = 4) were the most frequently reported difficulties. Current nebulizer users found their treatment to be ‘effective’ (n = 2) and ‘fast-acting’ (n = 1), while portability (n = 3) and time consumption (n = 4) were cited as disadvantages. Among caregivers, 3 (60%) were female and average age was 55. All caregivers reported playing a supportive role in gathering information [GL1] [SH2], and overall expressed similar advantages/disadvantages about treatments as the patients. These results are the precursor for 1:1 concept elicitation interviews and a planned discrete choice experiment (DCE) to quantify patient trade-offs.

Several factors, such as effectiveness, dose frequency, cost, and portability can play a key role in COPD treatment decisions and regular use of maintenance therapy. Further research is planned to examine how these preferences impact COPD management.

Arab Gulf Countries face a growing threat from air pollution and its impact on respiratory health, particularly regarding COPD, asthma, pneumoconiosis, and idiopathic pulmonary fibrosis. While existing research points to a link between poor air quality and worsened respiratory outcomes, with green spaces, studies specifically exploring this relationship in this region are insufficient. Eventually, the gaps in the previous studies include a limited number of studies that explore the relationship between the air quality and respiratory diseases, which this research includes (COPD, asthma, pneumoconiosis, and idiopathic pulmonary fibrosis) among AGC.

The type of this study is retrospective, secondary data, descriptive and analytical study. The study data were extracted from two publicly available data [1] Environmental performance index and [2] Global health data exchange. According to references of the GHDx, an open number of sample size was extracted from published resource since all parameters were used and the data was collected from all populations to measure the prevalence, incidence, and mortality of the respiratory diseases that this research covered in the AGC from 2013 to 2019.

COPD deaths dominated (60.74%) from 2013-2019, while pneumoconiosis deaths were least common (0.15%). Significantly, a strong association (P ≤ .05) existed between air quality and reported respiratory disease deaths. Prevalence: The study found that asthma was the most common prevalence respiratory disease at (72.53%), while pneumoconiosis was the least common at (0.0089%). There was a statistically significant relationship between air quality and the prevalence of respiratory diseases in the region (P ≤ .05). Incidence: The study found that asthma was the most common respiratory disease at (53.14%), while pneumoconiosis was the least common at (0.0230%). There was a statistically significant correlation between air quality and the incidence of respiratory diseases (P ≤ .05).

There is a significant relationship between air quality and respiratory diseases, including COPD, asthma, pneumoconiosis, idiopathic pulmonary fibrosis among AGC in terms of mortality, prevalence, and incidence. Furthermore, additional research on the relationship between air quality and respiratory diseases is essential to determine if there is a significant improvement or worsening in respiratory conditions when air quality improves.

The relationship between air quality and (Mortality, Prevalence, Incidence)of COPD, asthma, pneumoconiosis, and IPF in Arab Gulf Countries

The relationship between air quality and (Mortality, Prevalence, Incidence)of COPD, asthma, pneumoconiosis, and IPF in Arab Gulf Countries graph

The COVID-19 pandemic had significant and lasting financial and resource impacts on hospitals and their respiratory care staff, including voluntary and involuntary staffing reduction. Despite rising patient acuity post-pandemic, requiring more complex care, hospitals remain challenged to rebuild permanent staff, continuing to work understaffed, which can lead to missed respiratory care. Missed care, or ‘care left undone’, is a well-researched concept in nursing, but evidence in respiratory therapy is limited.

A cross-sectional survey was administered at two time points to staff RTs in an academic medical center and its associated community hospital campus. The survey aimed to identify staff perceptions about the types of/reasons for missed respiratory care, workload, and assignments. Descriptive statistics, (eg, frequency, mean, and median) were used to describe survey respondents; an independent samples t-test was used to compare differences between the survey time points. Timed studies were also completed during this project (daily vent rounds, rapid response, patient transport) to validate AARC standards for productivity management. IRB status deemed exempt.

Missed care was reported by 80% of RTs surveyed. Most frequent activities missed: timeliness in giving scheduled medications, pre and post treatment vital signs, focused reassessment and required documentation. The top 3 reasons for missed care: labor, inequitable assignments, and unavailable medications. Understaffing is associated with adverse patient and staff outcomes, and hospital revenue loss. Many staff reported end of shift exhaustion, a harbinger of burnout.

The Missed Care Nursing Model is appropriate for use in respiratory care. The probability of missed respiratory care can be reduced by mitigating structural problems in the team, unit, and organization. Further study of the respiratory care work environment is needed to understand differences between teams, shifts, and service areas to address and prevent burnout, increase job satisfaction, create assignment equity, and improve patient, staff, and hospital finance outcomes. Supporting strong, healthy, and well-staffed respiratory care teams will improve care quality and all-around outcomes. Integration of evidence-based RVU-based productivity tools for all clinical activities should be considered in hospital financial management systems to justify/predict labor needs based on actual work, patient census, and care complexity trends.

The Missed Nursing Care Model Reproduced from Kalisch, B. J. (2015)

Most Frequent Types and Reasons for Missed Care

The novel coronavirus infection (COVID-19) has spread worldwide and wearing a mask has become essential in daily life in Japan. Compared to other countries around the world, the rate of mask-wearing among Japanese people is extremely high, with most people wearing masks even when exercising, both indoors and outdoors. The WHO recommended wearing a mask, but not during strenuous exercise. Therefore, in this study, we investigated the effects of wearing a mask or not during exercise on cardiopulmonary function, as well as the effects of wearing a mask, and investigated whether there are differences depending on the type of mask.

This study was conducted with the approval of the Kyorin University Ethics Review Committee (approval number: 2021-81). The subjects were 21 healthy adult males with no history of orthopedic or cardiopulmonary diseases and no history of smoking. The subjects underwent exercise stress testing on a treadmill, with the speed and angle set to 60% of their maximum oxygen intake at an exercise level equivalent to the anaerobic threshold. The subjects performed treadmill exercise for 10 min at these settings. The measurements were carried out under three conditions: surgical mask, urethane mask, and no mask. Statistical methods were performed using SPSS 21.0J, and all statistical significance levels were set at less than 5%. One-way analysis of variance was used to compare the ventilation index during exercise obtained from the exhaled gas analyzer between the three conditions, and multiple comparisons using the Bonferroni method were used to compare the three conditions.

1) The inspiratory time (T_I) was significantly higher when wearing a surgical mask or a urethane mask than when not wearing a mask. The T_I of the surgical mask significantly increased than the urethane mask. 2) The frequency was significantly lower when wearing a surgical mask and a urethane mask than when not wearing a mask. 3) End-tidal carbon dioxide partial pressure (ETCO₂) showed significantly higher with surgical mask than no mask.

It was thought that wearing a mask increases airway resistance during breathing and lengthens T_I, which reduces frequency. ETCO₂ is an index of ventilation efficiency, and wearing a surgical mask was considered to have poor ventilation efficiency. Our findings suggest that exercising at anaerobic threshold level while wearing a mask in healthy adults affects respiratory function, including ventilatory efficiency.

COVID-19 infection predominantly affects the respiratory system. Long COVID refers to individuals experiencing long-term effects following COVID-19 infection, often leading to various clinical manifestations and lasting morbidity. Pulmonary rehabilitation (PR) is well-established, but under-utilized intervention known to improve lung function, exercise capacity, and quality of life in other pulmonary disease populations. Social determinants of health, including socioeconomic status (SES), neighborhood environment, housing conditions, environmental exposures, and access to healthcare, have been shown to affect outcomes in various pulmonary disease populations across different racial and ethnic groups. This study aimed to investigate the impact of SES on PR participation and morbidity among individuals with Long COVID. We hypothesized that individuals with Long COVID who have SES disparities, such as financial, food, transportation or housing insecurities are less likely to participate in PR and more likely to experience higher odds of morbidity compared to those without such disparities.

This study utilized data from the TriNetX Global Collaborative Network and included adults aged 18 years and older, with an ICD-10 diagnosis of Long COVID (n = 67,019). Outcome variables included PR participation and morbidity, based on hospital visits, emergency room visits, and inpatient hospital stays. The primary independent variables were Long COVID diagnosis and SES disparities. Covariates were socio-demographics, comorbid conditions, and medication usage. Cohorts were defined based on the presence or absence of any SES disparity among Long COVID subjects. Propensity score matching was applied to all covariates to create balanced cohorts. Measures of association, Kaplan-Meier survival analysis, and frequency analyses were used to assess PR participation and morbidity outcomes.

After propensity score matching, each cohort consisted of 4,388 subjects. Long COVID patients with SES disparities had 2.3%, 29.4%, and 38.7% higher risks of hospital visits, emergency room visits, and inpatient hospital stays compared to those without disparities, respectively.

PR is underutilized among Long COVID patients regardless of socioeconomic status. Additionally, socioeconomic disparities are associated with increased morbidity in Long COVID patients, highlighting the need for targeted interventions to address these disparities.

Oscillating positive expiratory pressure (OPEP) device promotes airway clearance in many respiratory diseases. However, the effects differ depending on the device, so we bench tested 7 devices to compare the migration distance of mucus simulants (MS) with different lung mechanics and viscoelasticity.

We measured the movement distance of the MS in PCV A/C mode, Inspiratory pressure 15 cm H₂O, i-time 1 sec, PEEP 0 cm H₂O, frequency 5 breaths/min, under the four types of lung mechanics (normal, obstructive, restrictive, and mixed lung disorder by using Michigan TTL). The movement distance was measured using two types of MS. A 1% lysis of MS is potage-like, corresponding to the secretion of chronic bronchitis, and a 4% lysis MS is jelly-like, close to the viscoelasticity of a mucus plug during an asthma attack. The 7 OPEP devices used were Aerobika, Vibra PEP, Acapella DM, Acapella DH, Acapella Duet, Flutter, and Vibralung. The analysis of the ventilatory dynamics was measured 10 times under each condition using flow analyzer PF300, and the average value was compared. Data analysis used software SPSS version 22 and P values < .05 were considered statistically significant. This research is conducted after obtaining approval from Kochi Professional University of Rehabilitation Ethics Review Board.

1) Vibralung, which uses sound waves, can be used even when spontaneous breathing is weak. It differed from other OPEP devices in that the moving distance of MS was significantly greater (P < .001). 2) In OPEP devices other than Vibralung, the moving distance of MS was significantly greater in the order of Aerobika, Vibra PEP (P < .001). 3) In changes lung mechanics, the movement distance of MS increased in the order of normal lung, restrictive lung, obstructive lung and mixed lung(P < .001). Movement distance of MS was greater in restrictive lung than in obstructive lung (P < .001). 4) There was no difference between Acapella and Flutter in moving distance. 5) Compared to 1% artificial sputum, 4% viscoelastic sputum moved less (P < .001).

1) Among the OPEP devices, Vibralung, which mechanically generates sound waves, seemed to be different from other OPEP devices. 2) Among the OPEP devices, Aerobika, which had the highest Oscillation Index (oscillation frequency multiplied by vibration amplitude) and a long MS movement distance, was thought to be the most effective.

Effective management of blunt thoracic trauma includes optimization of pulmonary hygiene, including lung expansion therapy. Intermittent noninvasive positive pressure therapy (CPAP 10 cm H₂O) for patients with rib fractures has been used at our institution with the goal of preventing or alleviating atelectasis and preventing respiratory-related complications. The decision to initiate therapy was based on the provider’s clinical judgment. In January 2023, we implemented a respiratory therapist (RT)-driven lung expansion therapy assessment pathway for rib fracture patients. Pulmonary function tests (PFTs) were used to select patients for hyperinflation therapy. Serial measurements (Q 6 h x 24 h) of vital capacity (VC) and negative inspiratory force (NIF) were then used to determine the duration of the therapy, as well as for monitoring patients who were not initially initiated on lung expansion therapy.

The data were extracted from the medical records of patients admitted to trauma surgery service at Mayo Clinic Hospital, Rochester between January 2022 and January 2024 with a diagnosis of rib fractures. Patients were divided into 2 groups: pre-protocol group (patients admitted before January 11, 2023), and a post-protocol implementation group including patients admitted on January 11, 2023, or later.

There were 477 patients in the pre-protocol and 440 patients in the post-implementation group. There was a slight decrease in the proportion of patients initiated on lung expansion therapy post-implementation (43% vs 39%, P = .16); average days on CPAP per patient decreased post-implementation from 2.7 ± 11 to 1.7 ± 4 (P = .09). There was no difference in the proportion of patients requiring ventilatory support (12% vs 14%, P = .33) or patients diagnosed with pneumonia during hospital stay (7% vs. 7.5%, P = .93) (Table 1). Combined pre and post-protocol initiation data points indicate little variability in repeated VC assessments during the first 24 h of hospital admission (Figure 1).

There appears to be a decrease in lung expansion therapy use following the implementation of an RT-driven PFT-based protocol without an increase in adverse outcomes. A prospective trial may be required to determine if subsequent VC measurements are beneficial in the assessment for the requirement for lung expansion therapy after the initial patient assessment.

Anemia is common in critically ill patients, with 90% of patients becoming anemic by ICU Day three. Noninvasive hemoglobin (SpHb) monitoring provides continuous, hemoglobin (Hb) measurement. Currently available devices have limitations: low sensitivity for detecting serial changes in Hb, inaccuracy at the lower range (< 9 g/dL) and overestimation of Hb in the presence of poor peripheral perfusion. Recently, a number of studies have demonstrated greater inaccuracy of oxygen saturation (SpO₂) in dark skinned patients. We hypothesized that skin pigment might also impact the accuracy of SpHb.

We compared measured Hb from an arterial blood sample to SpHb measured by an oximeter (Masimo, Irving, CA). The study was approved by the IRB and informed consent was obtained from subjects or their LAR. Data collected included pulse rate, SpO₂, SpHb, perfusion index and complete blood count (CBC). Demographics including age, sex, and primary diagnosis were recorded. Patients self-identified as Black or white, we used Bland-Altman analysis to assess the bias, precision, and limits of agreement (LOA) of SpHb monitoring in the group as a whole and in the two groups based on skin pigment.

We enrolled 123 subjects, 47 (38%) were Black and 76 (62%) were white. 83% of Black subjects and 68% of white subjects were male. The mean age for Black subjects was 59 ± 15 y and 60 ± 12 y for white subjects. Groups did not differ significantly by age, gender, or Hb measured by CBC 10 ± 2.0 g/dL for Black subjects, and 9.9 ± 2.7 g/dL for white subjects. The SpHb bias for Black subjects was 0.27 g/dL with precision 1.39 and LOA was 3.0 g/dL, – 2.5 g/dL. The SpHb bias for white subjects was 0.32 g/dL with a precision of 1.3 and LOA of 3.1 g/dL, – 2.0 g/dL. The SpHb bias for all subjects was 0.43, precision was 1.33 and LOA was 3.0, -2.17. See figure. Proportional bias was present for both racial groups, with the difference between SpHb and CBC tending to decrease as the Hb increased. Spearman’s rho was -0.30 (P = .04) for Black patients, and -0.44 (P < .001) for white patients.

SpHb monitoring can display continuous Hb without repeated blood draws. However, SpHb monitoring has significant limitations. Our study demonstrates that SpHb tends to overestimate the true Hb in patients with low Hb (<9 g/dL), which could lead to patients not receiving necessary blood transfusions. Skin pigment did not impact SpHb accuracy.

Inhaled nitric oxide (iNO) is a selective, but potent pulmonary vasodilator. At present, the only FDA approved indication for iNO is treatment of persistent pulmonary hypertension of the newborn. Use in other patient populations, namely adults, is common, however. Given high cost of this medication, coupled with lack of reimbursement, we hoped to refine the usage of iNO. In addition, safety reports citing technical problems with aerosolized epoprostenol, another pulmonary vasodilator, were rising, causing us to question this method of administration.

Leaders of respiratory care department and physician chiefs of adult ICUs met to develop a standardized guideline for iNO initiation and usage. The guideline is based upon diagnosis, (hypoxemia, right ventricular failure, or pulmonary hypertension) with monitoring of clinical vital signs for positive response to therapy and trigger for weaning iNO. Education was delivered at respiratory care staff meetings, unit faculty meetings, as well as institution critical care operations meeting. A tool was also developed to be posted at the patients’ bedside and a smartphrase created for progress note documentation, both to increase situational awareness for all the heathcare team. Local IRB approval obtained.

The guideline has been active for 3 months (Mar-May 2024). Compared to the 3 months prior, the total number of patients receiving iNO was 134 vs 82 and the total h were 7,655 vs 4,801. This results in a reduction in average hours per patient of 1.42 (57.13 vs 58.55) Prior to implementation, weaning occurred when the clinical team felt the patient was stable. The guideline prompts weaning when specific clinical parameters are met. This has prompted a decrease in time to documented first wean 29.33 prior vs 22.67 after (22.7%). Despite an increase in iNO hours, inhaled epoprostenol decreased during this time period (79 to 53 syringes/week, 30% decrease) with zero safety concerns reported around delivery performance and patient risk.

We were able to successfully implement an iNO guideline based on clinical need and objective vital sign monitoring. Financial consideration for using more iNO exists but is offset by decrease in aerosolized epoprostenol use and decrease in the unquantifiable safety risk to patients. Despite an increase in iNO hours, we were able to treat more patients with increased appropriateness and safety.

How does the prevalence of secondary traumatic stress (STS) among respiratory care students impact their mental well-being and readiness for professional practice? STS is a condition experienced by individuals who encounter trauma indirectly, typically through their professional engagements. In healthcare education, particularly among respiratory care students, the risk of STS is amplified due to the demanding clinical work and stress inherent in their studies. As these students transition into the healthcare field, there is a rising concern regarding the potential impact of STS on their mental well-being and readiness for professional practice.

The study received approval from the Institutional Review Board (IRB) at Utah Valley University. Participating respiratory care students underwent a series of clinically approved mental health surveys. The Patient Health Questionnaire – 9 (PHQ-9), Generalized Anxiety Disorder – 7 (GAD-7), and Stressful Life Events Screening Questionnaire (SLESQ-R) serve as baseline assessments for students’ mental health status. Additionally, the Professional Quality of Life Scale (ProQOL) survey is administered each semester, coinciding with clinical rotations, to assess STS. These surveys are conducted throughout the entirety of the student’s educational programs and during their initial year of employment.

With a current sample size of 52, ongoing data collection is planned across subsequent semesters. Initial analysis, employing ANOVA and T-tests, shows that 65% of the cohort demonstrates a low level of STS, whereas 35% exhibit moderate burnout and STS post their first clinical rotation. Baseline data suggest that more than 50% of students experience mild anxiety and depression before beginning clinical rotations.

Data indicate the presence of both STS and burnout among respiratory care students as early as their initial clinical rotation. Further data collection spanning across multiple years and cohorts is necessary to identify peak occurrences of mental health issues. these findings are consistent with other published data. Identifying the onset of trauma and burnout can inform the development of treatment strategies and resilience training. Current findings underscore the importance of assessing these factors in students and extending the study to encompass a broader range of clinical education programs.

Asthma exacerbations (AE) present a significant burden on emergency departments (EDs). Vibrating mesh nebulizers (VMNs) have been shown to increase aerosol deposition leading to decreased admission rates and ED length of stay (LOS), but research specific to VMNs effects on AE patients in the ED is limited. We aimed to improve patient disposition and decrease ED LOS and admission rates by improving VMN accessibility in our 59 bed ED (766-bed Adult Level-1 Trauma, Academic Medical Center).

An IRB exempt, retrospective review assessed VMN utilization and patient disposition for ED-diagnosed AE cases between October 2022 and April 2024. VMNs were introduced in the ED in March 2022 with limited utilization due to controller accessibility. Subsequently, VMN controllers were installed in all ED patient rooms in September of 2023. Data metrics for the same 7-month period in subsequent years included total ED encounters, ED LOS and boarding hours per patient for all populations, as well as specific metrics for patients diagnosed with AEs.

Following VMN controller installation, VMN utilization among asthma patients surged from 11.3% to 53.5%, driven by enhanced accessibility (P < .001). Patient outcomes improved, with a 10.3% increase in ED discharges (P = .04). ICU admissions decreased substantially from 3.1% to 0.8% (P = .03). Although ED LOS increased (271 min vs. 297 min; +9.6%), this trend paralleled that of all patient populations (306 min vs. 333 min; +8.8%), with a 4.6% year-over-year increase in total ED encounters. An increase in boarding hours per patient (2.49 to 3.58; +44%) significantly affected ED throughput, further influencing ED LOS for AE patients.

The implementation of VMNs in our ED, facilitated by VMN controller installation in patient rooms, has yielded promising outcomes for AE patients. Our study demonstrates a substantial increase in VMN utilization, correlating with higher ED discharges and reduced ICU admissions. While a modest increase in ED LOS was observed post-implementation, consistent trends across all patient populations suggest broader systemic factors influencing ED throughput. The observed rise in boarding hours per patient underscores the ongoing need to optimize ED workflow and resource allocation. Overall, our findings underscore the potential of VMN integration to enhance asthma care in the ED, emphasizing the need for continued evaluation and refinement to improve patient outcomes and ED efficiency.

Figure 1 details the utilization rate of VMN for AE patients pre- and post-controller installation.

Table 1 details the patient disposition and number of encounters for patients diagnosed with AE in the ED.

Burnout and staffing challenges are prevalent within the field of respiratory care (RC). Paid time off (PTO) is an employee benefit that respiratory therapists (RTs) must utilize to combat burnout. Most RC departments experience challenges in staffing safely while granting PTO, even with professional guidelines in place, such as the AARCs Safe and Effective Staffing Guide. Our RC department (91.06 FTEs, 260-bed pediatric hospital, Level 1 Trauma, Level IV NICU) experienced these challenges and was often unable to approve consecutive day PTO requests for RT associates with our current model (full-time RTs with block schedules all request PTO through the scheduling system at least 6 weeks before the scheduling posting). We aim to assess the impact of a PTO week program on approved PTO time for RTs in our department.

In an IRB-approved retrospective review, PTO data from Kronos Scheduler, vacation request submissions, and solicited staff feedback were reviewed from 1/1/2023 to 4/30/2024. In July 2023, a PTO week program was implemented, allowing RTs to request up to 36 consecutive hours from Sunday to Saturday, with limitations during blackout weeks. Requests were submitted using a vacation request form with a requested week and an alternate. Submissions were accepted from 10/1/23-10/31/23 for the 2024 year. A seniority schedule was developed using our current rotating holiday schedule groups, and requests within the group are reviewed based on seniority.

43% of (34 of 79) eligible RTs submitted PTO week requests. All requests were approved, and 94% (n = 32) received their first-week selection. Without changes in total FTE and vacancy, PTO hours increased from 2023 to 2024 (January to April) from 4,011 h to 5,198 h (29.6%), and requests for consecutive days off reduced from 107 to 42 requests in the same period (Figure 1). Staff reported ease of use for the program, less stress, and satisfaction, knowing that their PTO time is approved well in advance. Many who did not utilize the program are excited to utilize it in 2025.

While participation was lower secondary to a new process, implementing the PTO week program in our RC department supported increased PTO time in multiple ways. The proactive approach to vacation planning reduces complicated consecutive shift requests while allowing more time to manage and plan for staffing coverage. Further studies must be done on the relationship of PTO for RTs and staff well-being, burnout, and satisfaction.

Figure 1: Details the PTO Hours taken by RTs from January through April 2023 and 2024 before and after the PTO week request process implementation.

The prevalence of e-cigarettes is significantly increasing among adults as an alternative method to tobacco smoking. However, the chemical products of e-cigarettes have an influence on human general health. Therefore, this study aims to investigate the association between e-cigarette use and psychological distress as well as participation in daily activities among adults in Riyadh, Saudi Arabia. It also evaluates the demographic profile and usage patterns of e-cigarette users.

This cross-sectional study involved 396 e-cigarette smokers in Riyadh city. An online survey was administered, including questions about smoking patterns and the perceived effects of e-cigarettes on activities of daily living. Additionally, mental health were assessed using the Kessler 6 scale.

Most of the participants were educated young males (61.4%). About 29.5% of the participants reported using e-cigarettes primarily to quit tobacco cigarettes. In addition, e-cigarette usage was significantly associated with lower participation in activities of daily living and higher psychological distress.

This study found that many e-cigarette users are well-educated young individuals who use e-cigarettes as a substitute for traditional cigarettes. However, the study also revealed that using e-cigarettes is associated with negative effects on smokers’ daily activities and mental health.

The percentage of participants’ responses regarding the perceived effects on the activities of daily living (A) and psychological distress items during the past 30 days (B).

A scatter plot showing the correlation between ADL and K6 scores.

Unplanned extubation (UE) poses a substantial risk, potentially resulting in clinical instability, cardiac arrest, and need for immediate re-intubation. As a part of a UE reduction effort, our objective was to develop a UE risk assessment score (UERAS) tool to identify risk factors, provide clinicians timely alerts, facilitate bedside mitigation strategies, and decrease UE. We hypothesize that our UERAS tool demonstrates high reliability and UERAS implementation is associated with UE reduction.

In a 75-bed non-cardiac pediatric ICU, we developed the UERAS by modifying Vats’ (PCCM 2017) UE risk assessment tool adding additional factors identified through local UE reviews. Initial UERAS had 14 elements, which was reduced to 12 items in January 2024 by removing two items (significant movement and agitation) due to subjectivity (Table 1). The range of total score remains 0-18 after the change by adding more weight in two existing items (rescue medication administration >3 over 6 h, sedation score > the goal). A pilot of the UERAS was conducted in a 24-bed section of the Pediatric ICU to assess inter-rater reliability (IRR). Pediatric ICU RTs underwent standardized training. For IRR assessment, two RTs independently evaluated ICU patients. IRR was assessed using Pearson’s correlation coefficient. Upon demonstrating high IRR, UERAS was expanded across the entire 75-bed PICU. Mitigation actions were developed for high-risk UE patients including immediate bedside clinicians alert via EHR chat and interdisciplinary bedside huddles (tier 0).