AARC Clinical Practice Guideline: Spontaneous Breathing Trials for Liberation From Adult Mechanical Ventilation

Despite prior publications of clinical practice guidelines related to ventilator liberation, some questions remain unanswered. Many of these questions relate to the details of bedside implementation. We, therefore, formed a guidelines committee of individuals with experience and knowledge of ventilator liberation as well as a medical librarian. Using Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology, we make the following recommendations: (1) We suggest that calculation of a rapid shallow breathing index is not needed to determine readiness for a spontaneous breathing trial (SBT) (conditional recommendation; moderate certainty); (2) We suggest that SBTs can be conducted with or without pressure support ventilation (conditional recommendation, moderate certainty); (3) We suggest a standardized approach to assessment and, if appropriate, completion of an SBT before noon each day (conditional recommendation, very low certainty); and (4) We suggest that FIO2 should not be increased during an SBT (conditional recommendation, very low certainty). These recommendations are intended to assist bedside clinicians to liberate adult critically ill patients more rapidly from mechanical ventilation.

The Continuum of Research in Entry-Level Education and Post-Graduate Clinical Respiratory Care

The greater and stronger your knowledge about a subject, the more you will be able to address a new problem in that subject. In entry-level respiratory care education, incorporating research into curricula can be challenging due to the limited time to cover all necessary topics. This is also true in clinical post-graduate respiratory care practice. This paper addresses the need and the rationale for research integration into respiratory therapy education and post-graduate respiratory care practice as a continuum. Without learning the importance of being a consumer of research and being immersed in research-oriented teaching and practice, the respiratory care profession cannot provide evidence-based care to patients. Devoting resources to develop research expectations and priorities should be a joint effort of educators and leaders. Mentorship is critically important to guide and nurture those with an inquisitive mindset. However, first, educators must cultivate an interest in research.

E-cigarette use and respiratory symptoms in adults: A systematic review and meta-analysis

INTRODUCTION

Electronic cigarette (e-cigarette) use is gaining popularity among adults. Monitoring e-cigarette-induced respiratory symptoms is crucial for both clinical and regulatory purposes. We systematically reviewed the current literature to understand the prevalence of respiratory symptoms among exclusive e-cigarette users, dual users, and former smokers.

METHODS

Databases searched included PubMed, CINAHL, Cochrane Library, Embase, and Scopus. We included all English-language, empirical quantitative articles that explored the prevalence of e-cigarette-related respiratory symptoms. Random-effects models were utilized in conducting the meta-analyses. The quality of identified studies was evaluated using the NIH Study Quality Assessment Tools. This study is registered with PROSPERO(#CRD42020165973).

RESULTS

The literature search identified 1240 references. After removing duplicates and screening for eligibility, 168 studies were included in the final review. The majority of included studies reported a wide range of adverse respiratory symptoms. The respiratory symptoms were prevalent among the exclusive e-cigarette users, dual users, and those who switched from combustible cigarettes to e-cigarettes. Further, out of the RCT studies, 5 were rated as good quality, while 3 were rated as fair. Among the observational studies, 24 were rated as good quality, and 9 were rated as fair. The two experimental studies were both rated as fair quality.

CONCLUSIONS

Continued monitoring of respiratory symptoms among e-cigarette users is warranted. Due to the heterogeneity and inconsistencies among studies, which limit result interpretation and highlight the need for studies assessing causal inference, further research using robust study designs is essential. This will provide clinicians with comprehensive knowledge about the potential respiratory risks of e-cigarette use.

An Overview of How to Search and Write a Medical Literature Review

Without a literature review, there can be no research project. Literature reviews are necessary to learn what is known (and not known) about a topic of interest. In the respiratory care profession, the body of research is enormous, so a method to search the medical literature efficiently is needed. Selecting the correct databases, use of Boolean logic operators, and consultations with librarians are used to optimize searches. For a narrow and precise search, use PubMed, MEDLINE, Ovid, EBSCO, the Cochrane Library, or Google Scholar. Reference management tools assist with organizing the evidence found from the search. Analyzing the search results and writing the review provides an understanding of why the research question is important and its meaning. Spending time in reviewing published literature reviews can serve as a guide or model for understanding the components and style of a well-written literature review.

An Overview of Survey Research

Surveys provide evidence for the social sciences for knowledge, attitudes, and other behaviors, and, in health care, to quantify qualitative research and to assist in policymaking. A survey-designed research project is about asking questions of individuals, and, from the answers, the researcher can generalize the findings from a sample of respondents to a population. Therefore, this overview can serve as a guide to conducting survey research that can provide answers for practitioners, educators, and leaders, but only if the right questions and methods are used. The main advantage of using surveys is their economical access to participants online. A major disadvantage of survey research is the low response rates in most situations. Online surveys have many limitations that should be expected before conducting a search, and then described after the survey is complete. Any conclusions and recommendations are to be supported by evidence in a clear and objective manner. Presenting evidence in a structured format is crucial but well-developed reporting guidelines are needed for researchers who conduct survey research.

Determinants of Telerehabilitation Acceptance among Patients Attending Pulmonary Rehabilitation Programs in the United States

Background:

Pulmonary rehabilitation (PR) is an interdisciplinary intervention designed to improve the physical status and the psychological condition of people with chronic respiratory diseases. To improve patients' participation in PR programs, telerehabilitation has been introduced.

Objective:

This study aimed to identify factors that could influence the intention to use telerehabilitation among patients attending traditional PR programs.

Methods:

This cross-sectional study recruited subjects attending the PR centers in the hospitals of the Indiana State University, United States of America, between January and May 2017. Data were collected using self-administered Tele-Pulmonary Rehabilitation Acceptance Scale (TPRAS). TPRAS had two subscales: perceived usefulness and perceived ease of use. Behavioral intention (BI) was the dependent variable, and all responses were dichotomized into positive and negative intention to use. Multiple logistic regressions were performed to assess the influence of variables on the intention to use telerehabilitation.

Results:

A total of 134 respondents were included in this study, of which 61.2% indicated positive intention to use telerehabilitation. Perceived usefulness was a significant predictor of the positive intentions to use of telerehabilitation. Duration of respiratory disease was negatively associated with the use of telerehabilitation.

Conclusion:

Perceived usefulness was a significant predictor of using telerehabilitation. The findings of this study may be useful for health-care organizations in improving the adoption of telerehabilitation or in its implementation. Future telerehabilitation acceptance studies could explore the effects of additional factors including computer literacy and culture on the intention to use telerehabilitation.

The Effectiveness of Cardiopulmonary Rehabilitation Programs on Psychosocial Factors in Patients With Pulmonary and Cardiac Disease

PURPOSE

Those with chronic cardiac and pulmonary diseases are predisposed to several psychosocial disorders. Tailored rehabilitation programs have been shown to improve physiological and psychosocial well-being. The purpose of this study was, first, to assess the psychosocial improvements among patients with cardiac and pulmonary diseases who have finished cardiac rehabilitation (CR) and pulmonary rehabilitation (PR) programs; second, to assess the differences in psychosocial factors among those patients based on smoking status at the beginning and end of these programs.

METHODS

The CR and PR programs in hospital settings were retrospectively analyzed from 2013-2018. Before and after, all patients completed the sociodemographic characteristics along with the Psychosocial Risk Factor Survey that measures total distress, depression, anxiety, hostility, and social isolation.

RESULTS

There were 355 patients with cardiac and 244 patients with pulmonary disease who completed 6- to 12-wk CR or PR programs. There were significant improvements in all psychosocial symptoms among cardiac patients. Patients with pulmonary disease exhibited significant improvements in all psychosocial factors except for social isolation. Moreover, current smokers in the CR group reported elevated symptoms of several psychosocial scores.

CONCLUSION

These findings provide critical information about the effects of tailored rehabilitation programs among patients with chronic cardiac and pulmonary diseases on psychosocial levels. By using the Psychosocial Risk Factor Survey, we have found that total distress, depression, anxiety, and hostility were reduced among patients who completed the CR or PR programs. Current smokers exhibited the elevated mean scores on psychosocial symptoms in the cardiac group that may be a target for smoking cessation program. The advantages of tailored rehabilitation programs are significant, which may be of benefit for physical, social, behavioral, and psychological well-being.

Dual Use of Electronic Cigarettes and Traditional Cigarettes Among Adults: Psychosocial Correlates and Associated Respiratory Symptoms

BACKGROUND

Prolonged use of both electronic cigarettes (e-cigarettes) and traditional cigarettes can increase breathing difficulties and other adverse health effects. Research is needed to provide a deeper understanding of predictors of dual use, particularly given rapid changes in the e-cigarette market and related public health communications and policy.

METHODS

The sample consists of subjects in the National Longitudinal Study of Adolescent to Adult Health Wave 5 (cross-sectional) subsample (N = 3,800) from 2016 to 2018. Participants were 31-42 y old. Multinomial logistic regression analyses were used to determine predictors of mutually exclusive categories: e-cigarette use only, cigarette use only, and concurrent e-cigarette and traditional cigarette use (compared to no use). Predictors included sex, age, poverty status, race/ethnicity, self-reported diagnosed depression, self-reported diagnosed anxiety, and previous experience of child maltreatment.

RESULTS

Among the total sample (N = 3,800), 2% reported e-cigarette use only, 20% reported traditional cigarette use only, and 3% reported dual use of both e-cigarettes and traditional cigarettes. Among subjects who reported any e-cigarette or traditional cigarette use (n = 957), 12% reported dual use. In the final adjusted multivariable multinomial model, dual use was associated with living at or below the poverty line (odds ratio 2.49 [95% CI 1.19-5.70]), self-reported diagnosed depression (odds ratio 1.99 [95% CI 1.10-3.61]), and a history of child maltreatment (odds ratio 1.80 [95% CI 1.10-2.95]). Additionally, Hispanic-American individuals were more likely to report dual use compared to cigarette-only use.

CONCLUSIONS

Prolonged dual use of both e-cigarettes and traditional cigarettes is a considerable public health problem. While our study identified a low percentage of dual usage among U.S. adults, dual use was disproportionately prevalent among those with depression, history of child maltreatment, living at or below the poverty line, and among Hispanic-American individuals. Culturally appropriate interventions and increasing access to cessation programs may help mitigate health disparities pertaining to dual use.

Physician Support for Non-Physician Advanced Practice Providers for Persons With Cardiopulmonary Disease

BACKGROUND

The use of non-physician advanced practice providers (NPAPP) has increased in the United States to offset shortages in the physician workforce. Yet there are still gaps in some locations where there is little to no access to quality health care. This study sought to identify whether physicians perceived a workforce gap and their level of interest in hiring an NPAPP with cardiopulmonary expertise to fill the perceived gap.

METHODS

An American Association for Respiratory Care (AARC)-led workgroup surveyed 1,401 physicians in 6 different specialties. The survey instrument contained 32 closed-ended questions and 4 open-ended questions.

RESULTS

74% of the 1,401 physician respondents agreed or strongly agreed that there will be a future need for an NPAPP with cardiopulmonary expertise. Respondents from sleep, pediatrics, pulmonary, and critical care were most likely to indicate that there is a current need for an NPAPP. A majority of respondents perceived that the specialized NPAPP would improve efficiency and productivity (74%), patient experience (73%), and patient outcomes (72%). Interest in adding this NPAPP did not increase when participants were told to presume authority for hiring, budget, and reimbursement.

CONCLUSIONS

These results indicate that there is both a need for and an interest in hiring an NPAPP with cardiopulmonary expertise. Having an NPAPP would boost physician efficiency and productivity, improve the patient care experience, and provide benefits that other clinicians are not trained to provide to persons with cardiopulmonary disease. Results suggest there should be continued efforts to develop the NPAPP role to add value for physicians and patients alike.

Health Care Practitioners' Determinants of Telerehabilitation Acceptance

Background:

Pulmonary rehabilitation is a multidisciplinary patient-tailored intervention that aims to improve the physical and psychological condition of people with chronic respiratory diseases. Providing pulmonary rehabilitation (PR) services to the growing population of patients is challenging due to shortages in health care practitioners and pulmonary rehabilitation programs. Telerehabilitation has the potential to address this shortage in practitioners and PR programs as well as improve patients' participation and adherence. This study's purpose was to identify and evaluate the influences of intention of health care practitioners to use telerehabilitation.

Methods:

Data were collected through a self-administered Internet-based survey.

Results:

Surveys were completed by 222 health care practitioners working in pulmonary rehabilitation with 79% having a positive intention to use telerehabilitation. Specifically, perceived usefulness was a significant individual predictor of positive intentions to use telerehabilitation.

Conclusion:

Perceived usefulness may be an important factor associated with health care providers' intent to use telerehabilitation for pulmonary rehabilitation.

Development and Validation of the Tele-Pulmonary Rehabilitation Acceptance Scale

BACKGROUND

Using telehealth in pulmonary rehabilitation (telerehabilitation) is a new field of health-care practice. To successfully implement a telerehabilitation program, measures of acceptance of this new type of program need to be assessed among potential users. The purpose of this study was to develop a scale to measure acceptance of using telerehabilitation by health-care practitioners and patients.

METHODS

Three objectives were met (a) constructing a modified scale of the technology acceptance model, (b) judging the items for content validity, and (c) judging the scale for face validity. Nine experts agreed to participate and evaluate item relevance to theoretical definitions of domains. To establish face validity, 7 health-care practitioners and 5 patients were interviewed to provide feedback about the scale's clarity and ease of reading.

RESULTS

The final items were divided into 2 scales that reflected the health-care practitioner and patient responses. Each scale included 3 subscales: perceived usefulness, perceived ease of use, and behavioral intention.

CONCLUSIONS

The 2 scales, each with 3 subscales, exhibited evidence of content validity and face validity. The 17-item telerehabilitation acceptance scale for health-care practitioners and the 13-item telerehabilitation acceptance scale among patients warrant further psychometric testing as valuable measures for pulmonary rehabilitation programs.

Acute Reduction in Spirometry Values After Prolonged Exercise Among Recreational Runners

BACKGROUND

Prolonged endurance running may acutely reduce spirometric lung values. This study examined changes in spirometry before and immediately after prolonged endurance exercise (running and/or walking). Specifically, we examined potential factors that predict the presence of at least a 10% postexercise reduction in FEV₁.

METHODS

After institutional review board approval, recruitment occurred at a pre-race exposition, where informed consent was obtained. Pre-and post-race spirometry measurements were taken from 79 study subjects who competed in a half-marathon (n = 66) or a marathon (n = 13). Spirometry was performed 1-2 days before the marathon or half-marathon and 25 min after finish the race.

RESULTS

We identified a subgroup of 23 subjects with a postexercise decrease in FEV₁ of ≥10%. In this subgroup, the mean post-race values for FEV₁, FVC, and peak expiratory flow were 19-24% lower than the pre-race values. In the 56 subjects with a change in FEV₁ of <10%, the mean post-race changes in spirometry values were not >6%. There was no difference between the 2 groups in sex distribution or between subjects who completed the half-marathon or the full marathon. For every 1-y increase in age, the likelihood of developing a postexercise reduction in FEV₁ of at least 10% decreased by nearly 10% (R² = 0.15, P = .003).

CONCLUSIONS

Exercise-induced bronchoconstriction (EIB) is the most probable explanation for the reduction in post-race FEV₁. Prolonged endurance exercise reduced spirometric lung function by ∼20% in those with EIB. Age was the only predictor for EIB, and EIB did not affect the finish times among recreational runners and/or walkers.

Protocol-Driven Ventilator Management in Children: Comparison to Nonprotocol Care

The purpose of this study was to compare ventilator weaning time, time to spontaneous breathing, and overall ventilator hours duration with use of a ventilator management protocol (VMP) versus standard nonprotocol-based care in a pediatric intensive care unit. A multidisciplinary task force developed a comprehensive protocol for ventilator management with four specific phases: initial ventilator set up and adjustment, weaning, minimal settings, and spontaneous mode prior to extubation. Medical records of ventilated patients both before and after protocol implementation were reviewed. A total of 187 patients were studied (89 nonprotocol and 98 VMP patients). No differences were seen between groups in PRISM scores, Murray scores, or oxygenation indices, but VMP patients were significantly younger (P= .03). Ventilator weaning times (P= .005) and time to spontaneous breathing modes (P= .006) were significantly decreased in VMP patients compared to nonprotocol patients, but overall ventilator duration was not significantly different. No significant differences were seen in extubation failure, use of corticosteroids, or use of racemic epinephrine between groups. Use of an institution-specific VMP developed by a multidisciplinary team was associated with significantly reduced ventilator weaning time and time to spontaneous breathing. Further studies are needed.

Complications of Prone Positioning During Extracorporeal Membrane Oxygenation for Respiratory Failure: A Systematic Review

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is often used in patients with severe respiratory failure to improve oxygenation and survival. ECMO gives the lungs an opportunity to rest and recover. The addition of prone positioning therapy used concurrently with ECMO can further aid in optimizing alveolar recruitment and reducing ventilator-induced lung injury, ultimately resulting in fewer ICU admission days and improved overall survival. The objective of this review is to perform a systematic analysis of the complications reported with prone positioning and ECMO in the adult population and to briefly report on the patient outcomes in the studies.

METHODS

PubMed, MEDLINE, Cochrane Library, and CINAHL were searched from January 1, 1960 to September 14, 2014. Studies were included if they examined both extracorporeal membrane oxygenation and prone positioning simultaneously for the treatment of respiratory failure in the adult population.

RESULTS

Seven studies fit the study inclusion criteria (1 prospective cohort study, 3 retrospective cohort studies, and 3 case series). All of the studies in this review reported no occurrence of ECMO cannula dislodgment, and 2 studies reported cannula site bleeding. Chest tube dislodgment and airway dislodgment did not occur in any of the studies included. Bleeding from the chest tube site was reported in 13.5% of prone positioning maneuvers in 1 study, and the rest of the studies reported no evidence of chest tube site bleeding. Of the 2 studies that reported hemodynamic instability during the prone positioning maneuvers, very few adverse hemodynamic episodes were reported. The authors who reported adverse effects stated that the episodes were quickly and successfully reversible.

CONCLUSIONS

This review highlights the limited complications documented during prone positioning and ECMO. More studies are needed to assess the clinical efficacy of the addition of prone positioning therapy to ECMO for patients in severe respiratory failure.

Association between exposure to secondhand smoke during pregnancy and low birthweight: a narrative review

Exposure to secondhand smoke (SHS) during pregnancy may have adverse effects on the mother and infant. This study investigates the association of maternal exposure to SHS with low birthweight (LBW) in infants. Smoking during pregnancy has been linked to multiple complications for both mother and infant. To examine association of LBW and environmental tobacco smoke exposure during pregnancy, we reviewed 20 articles. Articles were accessed using the following electronic databases: CINAHL Plus with full text (EBSCO), PubMed, Embase, and MEDLINE. The findings of this review revealed that maternal exposure to environmental smoke is correlated with LBW in infants as well as numerous other adverse effects. The majority of the studies found negative consequences of SHS on the birthweight of infants born to nonsmoking women. Thus, this review helps to confirm the association between maternal exposure to SHS and LBW in infants.

Tobacco treatment and prevention: what works and why

Tobacco abuse is one of the main reasons that chronic obstructive pulmonary disease is the fourth leading cause of death in the United States. Many people kick the habit easily, while others struggle through a difficult cycle of addiction. Respiratory therapists often have contact with patients with chronic lung disease who want to quit smoking but do not know where to begin. Smoking bans and clean air laws are in place across the United States, but this is not enough for a complete tobacco treatment and prevention program. For any successful disease-management program, tobacco-control education and support must be included. Studies show that when pharmacologic interventions are used along with the appropriate counseling and other resources, the success of tobacco cessation increases. This must be understood, because if the regulatory efforts of our governing bodies are not enough and if patients do not receive the care that is essential for disease management and rehabilitation, then how will our role as respiratory therapist matter in any health-care system of the future? The respiratory therapist plays a key role in asking patients, especially newly diagnosed patients with chronic lung disease, if they are smokers and if they are interested in tobacco use interventions. This is a role that should not be taken lightly.

Respiratory therapists and critical-thinking behaviors: a self-assessment

The purpose of this study was to assess critical-thinking behaviors of respiratory therapists through self-report. Using a quantitative survey research method, respiratory therapists rated themselves on seven critical thinking skills. The effects of personal variables on the self-assessments were also investigated. The respiratory therapists self-assessed their critical-thinking behaviors highest in the categories of prioritizing, troubleshooting, and communicating. Anticipating was self-assessed as the lowest-ranked critical-thinking behavior. Age and educational level were found to have no effect on the self-assessed behaviors, while years of experience in respiratory care and gender were found to affect self-assessed troubleshooting, decision making, and anticipating. The results of this study suggest that educators and clinicians should consider learning strategies that incorporate the use of experience when targeting novice practitioners.