This month's Editor's Choice is a study of the impact of extracorporeal membrane oxygenation (ECMO) on spontaneous breathing patterns in subjects with early severe ARDS. Spinelli and colleagues evaluated breathing pattern in subjects receiving pressure support ventilation and maximal extracorporeal carbon dioxide (CO2) removal. They were able to eliminate >90% of subjects' total CO2 production and arterial blood gases remained normal. They concluded that in severe ARDS, rapidshallow breathing was associated with less efficient CO2 andoxygen exchange by the native lung, a higher degree of organ failure, and greater lung edema. Davies and others contribute an accompanying editorial discussing the multiple factors which impact breathing pattern aside from CO2 including lung mechanics and neural control.
Predicted ventilator shortages as a consequence of COVID-19 have led to a number of potential solutions. A controversial ‘solution’ has been ventilating more than one patient with a single ventilator. In separate papers Chatburn et al and Herrmann et al describe the dangers of shared ventilation in unmatched pairs. Both papers describe circuit modifications to help overcome the limitations of the naïve approach. Hess and others provide an accompanying editorial detailing the physiologic consequences, ethical concerns, and practical implications of this technique. They conclude that this technique is a short-term bridge todefinitive care in the most dire of circumstances.
Matlock and others evaluated the use of noninvasive ventilation (NIV) with and without neurally-adjusted ventilatory assist (NAVA) in neonates in a cross-over study. They estimated work of breathing (WOB) using respiratory inductance plethysmography and determined asynchrony. They found that while asynchrony was reduced during NAVA, there were a number of instances where apnea resulted in subjects receiving mandatory breaths and did not find a reduction in WOB.
Miller and others surveyed respiratory therapists (RTs) in North Carolina regarding their intubation practices. Reporting a 68% response rate they found that RTs performing intubations were more likely to work in community hospitals and were more likely to care for adults. They reported that during training, the number of supervised intubations to be deemed competent was five. In North Carolina, RTs frequently performed intubations and were confident in the success of their programs.
Rice and Mathieson compared practice patterns between certified and non-certified asthma educators using a Likert scale survey based on the asthma educator certification exam. All survey respondents provided direct patient education. They reported that for the majority of education tasks, there were no differences between groups on the reported frequency of education task performance.
Armaghan et al conducted a survey of RTs in Pennsylvania to determine practice within hospitals. They achieved a response rate of 63.5% with half of respondents coming from academic medical centers. They found the use of protocols in threequarters of hospitals and the performance of non-traditional procedures in 4 of 5. The practice of respiratory therapy varied widely, with only a small number of hospitals allowing practice to the full extent of their license.
Ringer and others evaluated the impact of nasal aspiration and nasopharyngeal suctioning on physiologic parameters in infants with bronchiolitis. They measured transcutaneous CO2, oxygen saturation, and electrical impedance tomography (EIT) changes during each procedure. EIT determined inspiratory and end-expiratory lung volume loss and recovery. They reported that subjects tolerated both procedures equally as measured by short-term physiologic changes.
Vempilly and others evaluated the relationship between increased albuterol usage and air-trapping in subjects with asthma. They applied linear modeling to evaluate the association between lung volumes, spirometry, asthma symptoms, and rescue inhaler use. The group concluded that frequent albuterol use and wheezing might be a sign of unrelieved air-trapping. They suggest the use oflung volume measurements during routine spirometry in patients with asthma.
Ke et al compared aerosol delivery efficiency between a soft mist inhaler (SMI) and pressurized metered dose inhaler (pMDI) during mechanical ventilation. They found that the SMI generated the smaller median mass aerodynamic diameter (MMAD) and higher fine particle fraction (<5 μm) than the pMDI. They concluded that during mechanical ventilation, the optimal placement of the SMI and pMDI was 15 cm from Y-piece with actuation at the end of expiration and the onset of inspiration.
Herer studied the impact of respiratory intensive care units (RICUs) on the outcomes of subjects requiring prolonged mechanical ventilation (PMV). RICUs in France are care facilities bridging intensive care and long-term care. Using a historical control prior to RICU introduction, Herer reported improved outcomes of tracheostomized subjects undergoing PMV, a reduced length of stay, decreased in-hospital mortality, and increased weaning success. However, the 1-year survival remained unchanged.
Burr and colleagues evaluated secondary traumatic stress (STS) and post-traumatic stress disorder in RTs using a survey. They found that STS occurred in a third of respondents, with no difference between neonatal/pediatric and adult care environments or years of work experience. They conclude that STS is common in hospital-based RTs.
AbuNurah et al evaluated the impact of international respiratory therapy education of RT students from Saudi Arabia on their life experiences and professional development. Data were collected using a validated survey. Respondents were predominantly male, with half having a graduate degree and half an undergraduate degree. They reported that international education had a positive impact on students' life experience and development. The study supports the value of promoting international education in respiratory therapy programs.
Vieira et al evaluated the 4-min step test (4MST) as a possible surrogate for the 6-min walk test (6MWT) using a modified BODE step index, to predict mortality in COPD. BODE is the body mass index, airflow obstruction, dyspnea, and exercise score. They hypothesized that step tests may create physiological responses similar to the 6MWT, but' would be simpler to perform. In a sample of almost 200 subjects they demonstrated that the BODE step index was a prognostic marker, independent of cardiovascular comorbidities and oxygen desaturation. They concluded that the 4MST used as a surrogate of exercise capacity in the BODE step index was an independent predictor of mortality in COPD.
Davis and Smallwood contribute a Year in Review on asthma covering the most important papers in 2019. Haynes and colleagues provide a narrative review on the history of pulmonary function reference equations. Their paper helps to define the strengths and weaknesses of using reference equations to interpret pulmonary function data in the context of research and clinical practice. Jin et al contribute a systematic review on the impact of pre-hospital anti-platelet therapy on ARDS. A significant number of adults are receiving anti-platelet therapy for prevention of thromboembolic events. The incidental use of anti-platelet therapy appears to reduce the rate of ARDS, but without an impact on outcomes.
Marini, Gattinoni, and Rocco contribute a Special Article on the damage caused by high stress ventilation. This group of renowned experts describe the impact of power on ventilator induced lung injury and help to explain the role of driving pressure.
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