This month’s Editor’s Choice is a paper by Truumees and colleagues evaluating the impact of a home respiratory therapist (RT) on COPD readmission rates. They conducted a pre/post interventional trial comparing readmission of COPD subjects with the intervention being an at-home RT operating as a disease manager. Prior to the disease management program, readmission rates were 22% within 30 days compared with only 12% following implementation. In addition, 60- and 90-d readmission rates were also statistically lower reducing readmission rates by 20% and 30%. They concluded that disease management conducted by a home RT effectively reduced readmission rates. Baker contributes an accompanying editorial suggesting that healthcare costs can be reduced through education and prevention in COPD. An instance of the proverbial ‘an ounce of prevention being worth a pound of cure.’
Abi Abdallah and others describe the incidence of postextubation stridor in subjects following mechanical ventilation for COVID-19. In this retrospective review they evaluated all subjects ventilated for > 48 h and defined postextubation stridor as audible stridor within 2 h of extubation. Compared to postextubation stridor occurring in 3% of a control group of 211 subjects, those following COVID-19 had a rate of 23%. They also noted that subjects with greater viral burden in tracheal secretions were more likely to have postextubation stridor. The incidence of postextubation stridor was associated with female sex, prone positioning, and re-intubation. Pangilinan and colleagues provide commentary. They note that subjects in the COVID-19 group had a duration of ventilation three times greater than controls and that half received prone position compared to 3% for controls. They suggest that severity of illness, duration of ventilation, and use of prone position are likely far more important to the incidence of postextubation stridor than the viral load.
Moy et al describe the ventilation practices aboard air medical transports in a multicenter retrospective review of 130 bases. The cohort includes over 68,000 subjects, but importantly height was only documented in 6% of subjects. Larger tidal volumes and higher plateau pressures were seen in 75% of women and 25% of men. Gender was an independent predictor of non-lung protective ventilation. Perhaps as importantly, over 90% of subjects had tidal volume set empirically. Blakeman provides an accompanying editorial describing a multitude of methods for determining height in this scenario and the opportunity for process improvement. He suggests that lung protection starts at time zero.
Vitacca and others describe pulmonary rehabilitation in COVID-19 survivors. Based on admission condition they allocated subjects to increasing levels of activity from passive exercises, to free walking, balance exercises, strength exercises, and tailored cycle-ergometer endurance training. They found that in-patient pulmonary rehabilitation was able to be progressivly increased in survivors and that cycle training was feasible in half of subjects. The impact of these findings on outcomes requires further study.
Harrison et al retrospectively evaluated prognosis and outcomes in subjects receiving home oxygen therapy for COPD and interstitial lung disease (ILD) over a 7-year period. In a cohort of 384 subjects, 59% had COPD and 49% were prescribed continuous oxygen therapy while 187 were initially prescribed oxygen during ambulation. The 5-year survival was 10% in ILD subjects and 52% in COPD subjects. They also found that despite dismal survival in ILD few subjects were referred to palliative care. They suggest early referrals to palliative care and improved care coordination as key areas for improvement in clinical practice.
Davis and co-workers performed a survey of 412 CoARC entry-to-practice programs to determine the use of simulation in teaching. The response rate was 30%, and 75% of these programs used simulation. They also found that the majority of programs had mandatory simulation programs and believed the amount of simulation should be increased. Importantly, faculty training in simulation was deemed inadequate.
Baker and colleagues evaluated an in-patient pulmonary consult program for patients with asthma and >1 y old who were admitted to the ICU or identified as having poor medication adherence. In 126 subjects, the odds of returning to the emergency department/urgent care or hospital within the following 12 months did not differ between asthma consult and control group. However, after adjusting for covariates of age, race, ethnicity, previous health care utilization and existing specialist there was a significant difference in the odds of readmission and revisits for the asthma consult group compared to the control group. They concluded that the program could improve medication adherence and decrease healthcare utilization.
Rosner et al retrospectively reviewed the use of bronchoscopy in pediatric subjects undergoing veno-venous extracorporeal membrane oxygenation. Bronchoscopy was performed in 63% of subjects resulting in larger tidal volumes and improved dynamic compliance post procedure. They reported few complications in subjects who underwent early bronchoscopy.
Hunninghake and others performed a retrospective review of pulmonary function tests in military personnel over a 12-year period in an effort to retrospectively correlate baseline spirometry values with methacholine challenge testing (MCT) responsiveness. In over 1,900 methacholine challenge studies, one-quarter were judged as positive. They concluded that in subjects with exertional dyspnea and normal baseline spirometry, the use of the FEF25-75 may be a useful surrogate measurement to predict reactivity during MCT.
Becker et al retrospectively evaluated variations in spirometry biological quality controls in a cohort of individuals to determine the standard for the coefficient of variation (CV%). Data were collected over 3 years from 114 laboratories. They found that the CV% for the 5-day separated method was <5% for 94.1% of FVC and 93.5% of FEV1 values in the first year. By year three, 90% of FVC and FEV1 CV% values were <4%. They suggest that acceptable CV% values are achievable.
Culbreth and colleagues contribute a Year in Review that discusses the issues related to e-cigarettes, hookah use, and vaping-related lung injury during the COVID-19 pandemic. They point out that hookah smoking in particular continues to be a concerning public health issue, with increases in hookah bars and venues coupled with lack of regulations for hookah smoking. Varekojis provides a Year in Review on the role of interprofessional education in health professions education. She suggests that there are opportunities for respiratory therapy educators, researchers, managers, and clinicians to discover ways to develop interprofessional collaborative practice to ultimately impact patient outcomes.
Piraino provides an invited review on the principles of operation of electrical impedance tomography (EIT) and the potential role of EIT in monitoring mechanically ventilated patients. EIT is a unique form of monitoring that RTs will need to master.
Kallet provides a paper based on the first annual Kacmarek Lecture, entitled Mechanical Ventilation in ARDS; Quo Vadis?, literally, ‘whither thou goest’. This is an extensive review of where we have been with ventilatory support in ARDS and what the future holds. Mannino describes the changing definition and perception of COPD based on his Petty Lecture. This work focuses on future treatment of COPD and the importance of genetics. Volsko contributes a paper on airway safety in pediatrics and neonates based on her Kittredge Lecture. The papers based on the honor lectures at the annual AARC meeting represent state-of the-art reviews by recognized authorities.
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