Respiratory care最新文献

Background: ICU patients are weaned from sedation and mechanical ventilation through spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs). Weaning can be distressing for patients and their families. Family-led coaching could reassure patients and reduce stress for families by engaging them in patient care. This study developed and piloted a family-led coaching tool to support patients undergoing SATs/SBTs. Methods: Patient and family member dyads were recruited from 2 medical-surgical ICUs in Calgary, Canada (February 3-August 1, 2023). Surveys were administered to collect family (1) demographics, (2) anxiety and satisfaction with ICU care, (3) feedback on the tool, and (4) attitudes about family presence during SATs/SBTs (also collected from clinicians). Tool feasibility was determined by calculating the proportions of (1) eligible patients who were recommended for participation in the study by clinicians and (2) families approached who consented to participate in the study. Results: One thousand one hundred fifty patients were admitted to the study ICUs during the study period of which 819 received mechanical ventilation, and 42 were recommended by bedside clinicians for participation in the study. Twenty-five dyads were approached, 21 dyads consented to participate, and one withdrew consent before data collection. Of the enrolled families, 12 (60%) reported the coaching tool to be useful, and 5 (25%) recommended minor suggestions such as "shortening" the tool. Fourteen (70%) families reported positive experiences (through open-ended feedback) with being present for the SAT/SBT. State-Trait Anxiety Inventory (Y1) scores (scale range 20-80 points) significantly decreased in families from the first (pre coaching) to the second (post coaching) measures (mean decrease 8.2 points, SD 10.3, P = .001). All clinicians indicated they were comfortable with family presence and/or coaching during SATs/SBTs. Conclusion: Family-led coaching of patients during SATs/SBTs appears to be feasible, favorably perceived by families and clinicians, and potentially associated with lower family anxiety.

Quality assurance and quality improvement initiatives are being performed widely across the respiratory care profession. Common goals of quality assurance and quality improvement include the detection and prevention of errors, establishment of standards to improve respiratory care practice, and overall delivery of quality care to the patient. For these reasons, respiratory care departments participate in quality assurance and quality improvement initiatives at multiple levels: (1) interdepartmental (hospital/systemwide/multi-center), (2) intradepartmental (local/respiratory care department), or (3) grassroots approach (bottom-up approach). Utilization of a systematic approach to quality assurance and quality improvement is essential in ensuring the work is germane, and using appropriate research methodology can assure the results can benefit a generalized audience. A description of quality assurance and quality improvement research is presented with considerations and examples from Respiratory Care.

Background: Tracheostomy bypasses physical barriers that decrease microbial access to the lower airway, which can lead to changes to the lung microbiota. Patients often become chronically colonized with potential pathogens. This study described the incidence and prevalence of specific organisms in a 5-y cohort of children with tracheostomy. Methods: This retrospective cohort of children aged 0-18 y with tracheostomy identified associations between microbial species and subject characteristics including reason for tracheostomy, gastrostomy tube (G-tube), fundoplication, and ventilator use using chi-square test or Fisher exact test. Results: Of 113 eligible patients, 79 (57% male) met study inclusion criteria. Reasons for tracheostomy included airway obstruction secondary to craniofacial anomalies in 16 children (20%), upper-airway obstruction in 14 subjects (17.3%), neuromuscular disorder in 19 subjects (24%), bronchopulmonary dysplasia with or without pulmonary hypertension in 17 subjects (21%), and congenital heart disease in 13 subjects (16%). Most (69%) used a ventilator for at least 6 h/d; 63% had a G-tube; 41% also had a Nissen fundoplication. Of the 20% with upper-airway obstruction, one third were ventilator dependent, unlike other diagnoses where 57% used a ventilator. Staphylococcus aureus (52/113), Pseudomonas aeruginosa (43/113), and Stenotrophomonas species (39/113) were the most frequently identified bacterial species. Most microbes identified were not associated with subjects underlying diagnoses, ventilator use, or feeding type. However, there was a significant association between upper-airway obstruction and group B Streptococcus species and G-tube with P. aeruginosa. Conclusions: This retrospective single-site descriptive cohort analysis of pediatric subjects with long-term tracheostomy identified trends in microbial prevalence. The presence of specific bacterial strains was more likely to follow individual subject trajectories than sequential appearance of species. P. aeruginosa was associated with G-tube and Streptococcus species with upper-airway obstruction. Ventilator dependence was not associated with specific microbial profiles.

Background: Unplanned extubation (UE) is the premature or unintended removal of an artificial airway and can cause worse patient outcomes. Study objectives were to describe implementation strategies used to reduce UE in the Hospital for Sick Children neonatal ICU (NICU) and their influence on UE rates, and contributing factors and patient characteristics of infants who had an UE, and compare them between the biological sexes. We hypothesized that the boys would experience more UEs and worse outcomes compared to the girls. Methods: The single-center retrospective cohort study included all infants who experienced UE (2007-2019). Outcomes consisted of implementation reduction strategies developed by using the plan-do-study-act quality-improvement methodology and UE characteristics, including patient (eg, sex, length of stay) and unplanned extubation situation characteristics (eg, events and/or procedures, repeats). Five plan-do-study-act cycles were implemented. Analyses included text summaries of all strategies, and quantitative descriptive and comparative statistics. Results: UE per 100 ventilator days decreased from 3.46 to 0.14. Key success factors included setting achievable goals; ensuring that strategies were evaluated and amended; maintaining consistency over the long-term; incorporating strategies in the NICU; having institutional support and validation; and having good communication. There were 302 UE in 257 infants, 141 boys (55%), average ± SD gestational age of 31 ± 6 weeks, and 31 (12%) had 45 repeated UEs. The only significant difference between the biological sexes was that more boys (129 [92%]) versus girls (94 [83%]) received the Hospital for Sick Children NICU endotracheal tube taping protocol (P = .030). The incidence of UE occurred in a 2-peaked pattern, highest for those < 32 weeks and ≥ 32 weeks of gestational age. Infants < 32 weeks of gestational age and with repeated UE had longer durations of invasive mechanical ventilation and length of stay. For infants <32 versus => 32 weeks gestational age, the median (interquartile range) duration of mechanical ventilation was 38 (16-77) d versus 6 (3-13) d and hospital length of stay 61 (30-100) d versus 16 (10-41) d. For infants with repeated versus no repeated unplanned extubations, duration of mechanical ventilation was 69 (26-125) d versus 13 (4-52) d and hospital length of stay 90 (39-137) d versus 32 (12-75) d. Conclusions: Detailed well-planned UE reduction strategies significantly reduced the rate of UEs with key factors of success identified. UE characteristics and infant morbidity did not differ between the biological sexes. Infants < 32 weeks of gestational age and with repeated UE had a longer duration of mechanical ventilation and length of stay.

Background: The new Global definition of ARDS recently introduced a subgroup known as non-intubated ARDS. This study aimed to assess the risk of progression from noninvasive oxygen support to intubation and ARDS severity based on the S_pO2/F_IO2 among non-intubated subjects with ARDS. Methods: This retrospective study included subjects with COVID-19 admitted to 7 hospitals (5 in the United States and 2 in Argentina) from January 2020-January 2023. Subjects meeting the new non-intubated ARDS definition (high-flow nasal cannula [HFNC] with an S_pO2/F_IO2 ≤315 [with S_pO2 ≤97%] or a P_aO2/F_IO2 ≤300 mm Hg while receiving ≥30 L/min O₂ via HFNC) were included. The study evaluated the proportion of subjects who progressed to intubation, severity levels using the S_pO2/F_IO2 cutoff proposed in the new ARDS definition, and mortality. Results: Nine hundred sixty-five non-intubated subjects with ARDS were included, of whom 27% (n = 262) progressed to meet the Berlin criteria within a median of 3 d (interquartile range 2-6). The overall mortality was 23% (95% CI 20-26) (n = 225), and among subjects who progressed to the Berlin criteria, it was 37% (95% CI 31-43) (n = 98). Additionally, the worst S_pO2/F_IO2 within 1 d of ARDS diagnosis was correlated with mortality, with mortality rates of 26% (95% CI 23-30) (n = 177) for subjects with S_pO2/F_IO2 ≤148, 17% (95% CI 12-23) (n = 38) for those with S_pO2/F_IO2 between 149-234, and 16% (95% CI 8-28) (n = 10) for subjects maintaining an S_pO2/F_IO2 higher than 235 (P < .001). Conclusions: The non-intubated ARDS criteria encompassed a broader spectrum of subjects with lower in-hospital mortality compared to the Berlin criteria. The S_pO2/F_IO2 and ARDS severity cutoff proposed in the new Global ARDS definition were valuable predictors of in-hospital mortality in these subjects.

Background: Spinal cord injury (SCI) detrimentally impacts individuals' exercise capacity and respiratory parameters depending on sensory, motor, and autonomic dysfunctions. Regular physical activity (PA) positively impacts cardiovascular health and pulmonary function in these individuals. This study determined the relationship between PA and exercise capacity and respiratory parameters in individuals with SCI. Methods: This cross-sectional study included 40 individuals with paraplegia. Assessments included the Physical Activity Scale for Individuals With Physical Disabilities (PASIPD), 6-min manual wheelchair propulsion test (MWPT_6min), MWPT slalom test (MWPT_slalom), 20-m MWPT propulsion test (MWPT_20m), pulmonary function test (FVC, FEV₁, FEV₁/FVC, and peak expiratory flow [PEF]), maximum inspiratory pressure (P_Imax), and maximum expiratory pressure (P_Emax). Results: Subjects' mean age and body mass index were 46 ± 13 y and 26.8 ± 5.2 kg/m², respectively. PASIPD total score was significantly associated with MWPT_6min (r = 0.657, P < .001), MWPT_slalom (r = 0.403, P = .17) and MWPT_20m (r = 0.477, P = .056), FEV₁ (r = 0.552, P < .001), FEV₁/FVC (r = 0.532, P = .02), PEF (r = 0.683, P = .004), P_Imax (r = 0.484, P = .01), and P_Emax (r = 0.481, P = .16). However, PASIPD total score was not significantly associated with FVC (r = 0.168, P = .41). Conclusions: PA level influenced exercise capacity and pulmonary function in individuals with SCI and may play an important role in delimiting physical fitness.

Background: The airway-occlusion pressure is used to estimate the muscle pressure (${\text{P}}_{\text{mus}}$) and the occlusion pressure at 100 ms (${\text{P}}_{\text{0}\text{.1}}$) to assess respiratory drive in patients on mechanical ventilation. However, the validity of these maneuvers during noninvasive ventilation (NIV) has not been evaluated. This study was designed to validate the airway-occlusion pressure and the ${\text{P}}_{\text{0}\text{.1}}$ described for mechanical ventilation during NIV in a bench model. Methods: This was a bench observational prospective study carried out during January and February 2024 in the ICU laboratory of the Hospital Británico of Buenos Aires. Results: In the non-leakage NIV scenarios with oronasal and total face mask, the NIV-airway-occlusion pressure increased with greater ${\text{P}}_{\text{mus}}$ (P < .00). For a programmed ${\text{P}}_{\text{mus}}$ of 5 cm H₂O, values around 4.5 cm H₂O were recorded for both oronasal and total face masks. At 10 cm H₂O, the values were ∼8 cm H₂O, and at 15 cm H₂O, they were ∼11 cm H₂O. With leaks, this difference worsened as leakage increased and the effort decreased. In the Bland-Altman analysis between mechanical ventilation-airway-occlusion pressure and NIV-airway-occlusion pressure without leakage for oronasal and total face masks, we found a good agreement for the 3 levels of ${\text{P}}_{\text{mus}}$ with both types of masks. With regard to the values of NIV-airway-occlusion pressure with the helmet, Bland-Altman analysis showed a high bias and random error. Multivariate analysis found that NIV-airway-occlusion pressure depends on the type of mask, increased with ${\text{P}}_{\text{mus}}$, and decreased as leakage increased. The agreement of NIV-${\text{P}}_{\text{0}\text{.1}}$ was not good across all noninvasive measurements. Conclusions: This study constitutes a relevant contribution in the validation of indices to assess ${\text{P}}_{\text{mus}}$ during NIV. In a laboratory setting, the measurement of airway-occlusion pressure in NIV may be used to assess effort estimation in the absence of leakage; however, it will likely be underestimated. ${\text{P}}_{\text{0}\text{.1}}$ proved to be an unreliable method. These findings suggest the feasibility of assessing muscle effort during NIV.

Pediatric asthma is a common cause of emergency department visits and hospital admissions. Whereas most patients respond well to standard pharmacologic treatments, those with more severe disease frequently require noninvasive respiratory support (NRS) and adjunct therapies or admission to an ICU-a condition termed critical asthma. NRS modalities include high-flow nasal cannula, CPAP, and noninvasive ventilation to deliver standard air-oxygen mixtures or helium-oxygen (heliox). Each NRS modality offers distinct physiological benefits, primarily aimed at reducing work of breathing, enhancing gas exchange, and optimizing aerosol delivery. Despite the growing use of NRS, robust evidence supporting its efficacy in pediatric critical asthma is limited, with few published clinical trials and a heavy reliance on observational studies to inform clinical practice. This narrative review explores the current evidence, physiological rationale, practical considerations, and future research directions for the use of NRS in pediatric critical asthma. The goal is to provide clinicians with a comprehensive overview of the benefits and limitations of NRS modalities to better inform therapeutic decisions and improve patient outcomes.