March's Editor's Choice paper is a multicenter retrospective studyfrom 10 pediatric sites. Friedman et al attempted to define the optimumstrategy for ventilatory support during extracorporeal membraneoxygenation (ECMO). Pediatric subjects on veno-venous ECMOover a 5-y period were included. They report that 75% of subjectsremained on conventional ventilation and that pressure settings werenot related to survival. FIO2, even after adjustment for disease severityand the number of ventilator days prior to ECMO, was associatedwith worse outcome. Rettig provides an accompanying editorialhighlighting the finding that subjects with both high SpO2 and highFIO2 had diminished survival compared to subjects with high SpO2and low FIO2. She suggests that the therapeutic window for oxygen inpediatric ECMO may be narrower than previously appreciated.
Yuan and colleagues studied the impact of conventional oxygentherapy and high-flow nasal cannula (HFNC) and body position on thedistribution of lung volumes as measured with electrical impedancetomography (EIT). In a group of subjects following abdominalsurgery, HFNC improved end expiratory lung impedance (EELI) inthe ventral and dorsal lung regions compared to baseline. Head ofbed elevation improved EELI in dorsal but not ventral lung regions.HFNC was also associated with improved subject comfort. Nishimuraopines that these findings are not surprising or unexpected. HFNC,and more importantly, elevation of the head results in improved lungfunction. He notes that EIT provides a new tool to evaluate lungfunction with the distinct advantage of visualizing regional changes.
In a bench study, d'Aranda et al demonstrate the impact of thesite of oxygen delivery to a portable ventilator on the deliveredtidal volume (VT). This work reinforces the impact of oxygensupplementation on the VT measured, displayed and reported by theventilator. Telemedicine holds promise in a number of care scenarios,from the eICU to home care. Data provided for interpretation mustbe accurate and this study includes knowledge that can only beobtained by direct observation. Rodriquez provides commentary onmodifications to medical devices, the importance of skilled caregiversin the home, and assuring that what you see is, in fact, what you get.
Peixoto and others describe the use of ultrasound to evaluate lungdysfunction in subjects with cystic fibrosis. They compared lungultrasound to pulmonary function testing and the modified Bhallascore. Lung ultrasound correlated well with the high-resolutioncomputed tomography evaluated by the modified Bhalla score. Lungultrasound had significant correlation with pulmonary function andnutritional status.
Miura et al describe the use of ultrasound to evaluate pharyngealresidue in the upper airway, the presence of which is associatedwith aspiration risk. They studied 35 subjects with dysphagia anddemonstrated that ultrasound images compared well with fiberopticendoscopic evaluation of swallowing, providing a noninvasivemethod of evaluating aspiration risk.
Ultrasound has a number of uses in pulmonary disease. Cho et altested ultrasound assessment of diaphragmatic motion during PEEPtitration in subjects with ARDS. They compared dorsal and ventraldiaphragmatic excursion during PEEP titration based on creationof both a positive and negative transpulmonary pressure (Ptp). Theyfound that the dorsal region of the right hemidiaphragm was affectedby PEEP-induced changes and that ultrasound assessment usinganatomic M-mode was useful in the specific measurement of dorsaldiaphragmatic excursion. This pattern of motion in the dependentregions of the diaphragm during PEEP titration in ARDS subjectsachieving a positive Ptp may reflect a potential target for assessment of lung recruitment.
Saeed and colleagues evaluated the dose and aerodynamiccharacteristics of salbutamol from pressurized meter dose inhalers using different spacers and holding chambers. They found thatantistatic accessory devices (including a disposable device) optimizedthe mass median aerodynamic diameter. The same authors have asecond paper evaluating a smartphone application for counselingasthma subjects. They compared groups who received advancedcounseling or verbal counseling. Inhalation technique and lungfunction improved in both groups, but more advantages were seenwith advanced counseling including the smartphone application.
Hartmann and others evaluated provider opinion of a decisionsupport tool for weaning in a pediatric ICU. The decision supportsystem was based on the ARDSnet protocol for hypoxemicrespiratory failure. They compared physician and respiratorytherapists' assessment of the tool's recommendations and whetherthe clinical staff would implement these suggestions. Only a thirdof recommendations would have been implemented by the ICU staffwho preferred to make no changes and felt the recommendationswere too aggressive.
Schlosser and colleagues performed a 3-y long retrospectivechart review of noninvasive ventilation (NIV) use in a pediatric ICU.They found a diurnal pattern of NIV use, with an average of 6 h ofcontinuous use before the first interruption. Approximately half ofsubjects began NIV use after 7:00 pm and a similar number interruptedsupport between 5:00 am and 10:00 am. They conclude that NIVwas frequently interrupted, and initiation and discontinuation of NIVfollowed a diurnal pattern.
Burgess and others conducted an e-Delphi study to identifypriorities for education in advanced care planning (ACP) for COPDsubjects. After 2 survey rounds they developed 40 statementsregarding ACP assessed by a 5 point Likert score. Consensus wasconsidered to be achieved with a score of ≥80%. They identified aclear need for training that addresses the legal issues surroundingACP and discussions with patients with COPD.
Tamulevicius et al used a 33-item survey to evaluate students'knowledge of electronic nicotine delivery systems. They found ageneral lack of knowledge regarding secondhand vapor effects andthat use in young adults was primarily due to peer influence and stressrelief. They conclude that education from respiratory therapists andwith students would be valuable.
Dodia and colleagues performed a 16-question survey regardingneuromuscular blockade (NMB) use in ARDS including indications,frequency of use, and dosing strategy. Over 90% of respondentspracticed in academic medical centers. They reported using NMB inmore than half of ARDS patients. The most frequent indications wereto achieve lung protective strategies and improve patient-ventilatorsynchrony.
Kang and others contribute a systematic review on the use of HFNC in immunocompromised subjects. Relying on 8 studies compromising over 2,000 subjects, they conclude that HFNC maybe a feasible alternative to NIV to reduce intubation compared toconventional oxygen therapy without increasing the risk of ICU-acquired infections. However, HFNC did not reduce mortalitycompared to traditional oxygen therapy.
Lu et al contribute a systematic review on home-based breathingexercises in COPD. Using 13 trials including nearly 1,000 subjectsthey found that home-based breathing exercises had a positiveimpact on pulmonary function, respiratory muscle strength, exercisecapacity, dyspnea, and health-related quality of life in subjects withCOPD.
In a special article, Rich Kallet provides guidance on developing aresearch program within a hospital-based respiratory care department.Rich's experience and success provide a template for mentoring andpractical steps in developing a research program.
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