Respiratory care最新文献

Background: Diaphragmatic excursion is a crucial predictor of extubation outcomes in subjects on mechanical ventilation. However, its measurement can be influenced by various factors, which leads to inconsistent optimal thresholds and accuracy. Tissue Doppler imaging variables of the diaphragm have been established as reliable indicators for predicting extubation outcomes. This study aimed to assess the predictive ability of combining diaphragmatic excursion with tissue Doppler imaging variables of the diaphragm in subjects on mechanical ventilation. Methods: This prospective observational study was conducted from April 2023 to April 2024, eligible subjects who underwent mechanical ventilation for > 48 h and successfully completed a 30-min spontaneous breathing test in the ICU of our center. Diaphragmatic excursion and tissue Doppler imaging variables (including peak contraction velocity, peak relaxation velocity, maximal contraction rate, and maximal relaxation rate) were assessed immediately after a 30-min spontaneous breathing trial. The subjects were categorized into successful extubation and failed extubation groups based on their extubation outcomes. Differences in diaphragmatic ultrasound variables between these groups were analyzed. Results: The study included 63 subjects in the successful extubation group and 28 subjects in the failed extubation group. The area under the receiver operating characteristic curve for diaphragmatic excursion in predicting successful extubation was determined as 0.79 (95% CI, 0.69 ∼ 0.89), with a sensitivity of 82.5% and a specificity of 75.0%. The combined area under the receiver operating characteristic curve for diaphragmatic excursion and tissue Doppler imaging variables (including peak contraction velocity and maximal relaxation rate) in predicting successful extubation was determined as 0.94 (95% CI, 0.88 ∼ 0.99), with a sensitivity of 92.1% and a specificity of 89.3%. Conclusions: Combining diaphragmatic excursion with tissue Doppler imaging variables of the diaphragm enhanced the prediction of extubation outcomes in the subjects on mechanical ventilation compared with diaphragmatic excursion alone.

Background: The aim of this study was to test the ability of a low-pressure, low-flow, heliox-based rebreathing system to reduce work of breathing and conserve gas while preserving CO₂ concentration, temperature, and humidity at physiological levels in a bench study. Methods: We performed a bench study of a novel low-pressure, low-flow, noninvasive heliox rebreathing system with CO₂ scrubber that was connected to an artificial lung simulator with careful monitoring of flow, pressure, work of breathing, O₂, CO₂, temperature, and humidity levels. Multiple runs of breathing were performed while manipulating levels of resistance (5-30 cm H₂O/L/s), gas mixtures (room air, 79% helium [He] and 21% O₂, and 70% He and 30% O₂), and leak levels (ultralow, low, and high). Results: We found significant reductions in work of breathing (up to 64%) while conserving gas with estimates of up to 10- to 54-fold reduction in medical gas wastage (P < .001). Specifically, at resistances of 5, 10, 20, and 30 cm H₂O/L/s, we demonstrated 64, 57, 36, and 7% reduction in work of breathing (P < .001). Gas wastage was reduced by 10- to 54-fold while the end-tidal CO₂ concentration, humidity, and temperature were maintained by the device at physiological levels. Conclusions: In a bench test, a low-pressure, low-flow, noninvasive heliox rebreathing system with CO₂ scrubber reduced work of breathing and conserved gas while preserving CO₂ concentration, temperature, and humidity at physiological levels. Future studies in human subjects need to be performed to determine whether reduction of work of breathing and gas conservation can be achieved.

Background: Complications can arise after removal of tracheostomies, including delayed or failed spontaneous closure. Little is known about the healing time after decannulation, especially for decannulation that occurs outside of the acute-care setting. This study aimed to establish the average time required for stoma closure after decannulation in an in-patient rehabilitation setting and explores patient factors that may impact healing time. Methods: In this prospective observational study, clinicians measured and photographed the stoma on decannulation, every 8 h until initial stoma closure, and every 24 h until complete healing of the skin over the stoma site. Additional data, including personal characteristics, medical diagnoses, and medications taken, were collected through medical record review and participant self-report. Results: A total of: 104 sets of data were included in the analysis. The median (interquartile range [IQR]) cannulation time in this sample was 54 (35-70) d. The median (IQR) days to stoma closure were 5 (2-9) d. The median (IQR) days to complete healing of the stoma site were 16 (10-18) d. The days to closure and days to complete healing were positively correlated. Factors positively correlated with increased days to closure included stoma size, increasing age, diabetes, and steroid use. Conclusions: These findings provide evidence that clinicians may consider when advising patients on what to expect after decannulation.

Background: The profession of respiratory care has not seen an increase in minimum education requirements in over 40 years; however, the roles and responsibilities of providers have dramatically increased. Although degree advancement (DA) opportunities have increased exponentially to support respiratory therapists (RTs) pursue higher levels of education, the number of RTs who pursue a baccalaureate-level degree remain a small percentage of practitioners, indicating that barriers to advancement exist. The purpose of this study was to identify the perceptions and barriers to DA among active RTs. Method: This cross-sectional study utilized a web-based survey to glean descriptive and qualitative information related to the study questions. The survey was conducted using Qualtrics software and released via a social media platform with a specific audience of over 60,000 practicing RTs. Results: Responses from 785 RTs were included in the final analysis. Relevant findings identified variables such as age, time in the field, likelihood and rate of tuition reimbursement, and compensation post completion of DA all represented perceived barriers to DA. Qualitative analysis of open-ended questions revealed four predominant themes in the perception of DA in respiratory care. These themes included the perception of irrelevance, insurmountable alterations to lifestyle, cost of DA, and age in the context of benefits to DA. Conclusions: Findings support the need for institutions to encourage RTs who are concerned about the cost to return for DA. Other factors such as age and years of experience also play large roles in an individual's choice to return for DA. However, individuals who found financial barriers were more likely to signify a positive indication to return for DA; therefore, it is vital to provide a level of tuition reimbursement to minimize this barrier.

Background: Previous reports have emphasized disparities in the utilization of invasive respiratory support for bacterial pneumonia among various racial and ethnic minority groups with bacterial pneumonia. However, there is a shortage of detailed epidemiological data on this, particularly after the onset of the COVID-19 pandemic. Methods: We used the National In-patient Sample to conduct a retrospective cohort analysis from 2017 to 2021. We included patients hospitalized across the United States with a primary diagnosis of bacterial pneumonia. Statistical methods used included Pearson chi-square and multivariable regression analyses. Examining racial and ethnic differences in hospitalized subjects' usage of invasive mechanical ventilation for bacterial pneumonia was the primary outcome of the study. Secondary outcomes included mortality, use of noninvasive ventilation, and hospital stay. Results: The study found significant differences among racial and ethnic groups in pneumonia-related outcomes and the need for advanced respiratory ventilator assistance. Black and Asian American and Pacific Islander (AAPI) subjects had the highest rates of invasive mechanical ventilation compared with other racial groups, with adjusted odds ratios (ORs) indicating a higher likelihood of requiring this intervention for Black (OR 1.15) and AAPI (OR 1.31) subjects. For secondary outcomes, Black and AAPI subjects experienced longer hospital stays than other racial and ethnic groups. Noninvasive ventilation rates were comparable across groups. Mortality rates were the highest among Black subjects, but were elevated for all racial and ethnic minority subjects compared with white subjects. The pandemic exacerbated these disparities, leading to increased rates of both invasive and noninvasive ventilation and higher mortality, with particularly pronounced effects seen in AAPI patients, thereby worsening existing health inequities. Conclusions: The study suggests potential racial-ethnic disparities in invasive mechanical ventilation use among Black and AAPI subjects, but further investigation is needed to confirm these findings and explore underlying causes.

Background: The Berlin definition of ARDS has recently been expanded to include the Kigali criteria, which allows for the inclusion of more non-intubated patients. However, there is concern that the expanded criteria may be overly inclusive, potentially representing different pathologies. This study evaluates the characteristics of patients with sepsis who meet the Kigali criteria compared with those who meet the original Berlin criteria. Methods: This retrospective cohort study was conducted at a single institution and included subjects aged 18 and older who were admitted for sepsis. Berlin-ARDS was defined by a P_aO2/F_IO2 ratio of ≤300 mm Hg within the first 7 days of admission, the use of intubation or noninvasive ventilation with PEEP of at least 5 cm H₂O, bilateral opacities on chest imaging, and respiratory failure not attributed to heart failure. Kigali-ARDS was defined for subjects who did not meet the Berlin criteria owing to unavailable arterial blood gas values, a P_aO2/F_IO2 ratio >300 mm Hg, or who had a P_aO2/F_IO2 ratio ≤300 mm Hg but were not ventilated with a PEEP of 5 cm H₂O. Results: Of 427 subjects, 73 developed ARDS according to the Berlin criteria, and 94 met the ARDS criteria only by the Kigali definition, whereas 260 did not meet either definition. Smoking was significantly associated with meeting the Kigali criteria (P = .045) but not the Berlin criteria (P = .49). Higher lactate and white blood cell levels were linked to the Berlin criteria (P = .02 and P = .01, respectively) but not to the Kigali criteria. Conclusions: Smoking was a risk factor for meeting the Kigali criteria but not the Berlin criteria, suggesting that the Kigali criteria might include patients with chronic lung conditions rather than true acute lung injury. Additionally, higher lactate and white blood cell levels were associated with Berlin-ARDS, indicating more severe sepsis in these subjects compared with those meeting the Kigali criteria.

Asthma is a chronic respiratory condition affecting 6.5% of the pediatric population in the United States. Inhaled medications are the mainstay of treatment of asthma. Delivering inhaled medications to children with asthma has several challenges. Personalized device selection and education are paramount for successful asthma treatment. The complexity of drug delivery in pediatric asthma is potentiated by the anatomical, physiological, and behavioral differences present in children. In addition, aerosols are given for preventive and for rescue reasons. The latter might also occur in children receiving respiratory support. This article reviews patient- and device-related factors affecting inhaled drug delivery and deposition. It also provides a framework to understand variations of drug delivery that occur during transition between different respiratory support devices. This review also discusses clinical trial data comparing different devices. Finally, guidance on how to choose the right delivery device for each patient is provided.

Background: Aerosol therapy is commonly used during treatment with high-flow nasal cannula (HFNC) in the ICU. Heated humidification inside the HFNC tubing circuit leads to unwanted condensation, which may greatly limit the efficiency of drug delivery. In this study, we aimed to investigate whether a novel humidification system, which decouples temperature and humidity control, can improve the delivered dose. Methods: In a bench study setup, fluorescein sodium solution was nebulized using a vibrating mesh nebulizer in an infant HFNC circuit to measure the delivered dose, with a conventional versus a decoupled humidifier. The deposition of fluorescein inside each breathing circuit component and a final collection filter at the end of the nasal cannula was collected and quantified with a UV-vis spectrometer. Droplet sizes at different sections of the breathing circuit were measured by laser diffraction. Three air flows, 5, 10, and 15 L/min; and 2 nebulizer positions, (1) at the humidifier and (2) after the inspiratory tube, were tested. Results: The delivered dose decreased with increasing flow for the conventional setup and was higher when the nebulizer was placed after the inspiratory tube. Turning off the conventional humidifier 10 min before and during nebulization did not improve the delivered dose. The decoupled humidifier achieved a significantly higher (P = .002) delivered dose than the conventional setup. The highest delivered dose obtained by the decoupled humidifier was 62.4% when the nebulizer was placed after the humidifier, while the highest dose obtained for the conventional humidifier was 36.3% by placing the nebulizer after the inspiratory tube. Conclusions: In this bench study, we found that the delivered dose for an infant HFNC nebulization setup could be improved significantly by decoupling temperature and humidity control inside the HFNC circuit, as it reduced drug deposition inside the breathing circuit.