Survey of directors of respiratory therapy departments regarding the future education and credentialing of respiratory care students and staff.

OBJECTIVE: Information and opinions were sought on the need for graduating and practicing respiratory therapists to obtain 66 competencies necessary for practice in 2015 and beyond, the required length of respiratory care programs, the educational needs of practicing therapists, current and future workforce positions, and the appropriate credential needed by graduating therapists. METHODS: Survey responses from respiratory therapy department directors or managers are the basis of this report. After pilot testing and refining the questions, a self-administered, Internet based, American Association for Respiratory Care (AARC) endorsed survey was used to gather information from 2,368 individuals designated as respiratory therapy department directors or managers in the AARC membership list as of May 2010. RESULTS: A total of 663 valid survey responses (28.0%) were received. On average, the vacancy rate of surveyed hospitals was only 0.81 full-time equivalents (FTEs). Responses by directors on 66 competencies described in the second 2015 conference as needed by graduate and practicing respiratory therapists indicated 90% agreement on 37, between 50% and 90% agreement on 25, and < 50% agreement on 4 competencies. There was no consensus among directors on the academic preparation of new graduates, with 245 (36.8%) indicating a preference for a baccalaureate or master's degree, 243 (36.7%) indicating a preference for an associate degree, and 176 (26.5%) indicating no preference. There were 270 (41.8%) respondents who indicated that a baccalaureate or master's degree in respiratory therapy should be required to qualify for a license to deliver respiratory care. The survey indicated that 523 (81.2%) of directors are in favor of the RRT credential being required to practice in 2015 and beyond. CONCLUSIONS: There was good agreement that graduate and practicing therapists should obtain the vast majority of the 66 competencies surveyed and that the entry level credential should be the RRT. Similar numbers of managers favored an entry level baccalaureate degree as favored an associate degree.

Survey of respiratory therapy education program directors in the United States.

OBJECTIVE: As background for the American Association for Respiratory Care (AARC) third 2015 and Beyond conference, we sought information and opinions on the ability of the current respiratory therapy education infrastructure to make changes that would assure competent respiratory therapists in the envisioned healthcare future. METHODS: After pilot testing and refining the questions, we invited the directors of 435 respiratory therapy programs (based in 411 colleges) that were fully accredited or in the process of being accredited by the Commission on Accreditation for Respiratory Care as of May, 2010, to participate in the survey. RESULTS: Three-hundred forty-eight program directors (80%) provided valid survey responses. Three of the 5 competencies related to evidence-based medicine and respiratory care protocols were taught less often in the associate-degree programs than in the baccalaureate-degree programs. Eighty percent of the baccalaureate-degree programs, compared to 42% of the associate-degree programs, instruct students how to critique published research (P < .001). Only 34% of the associate-degree programs teach students the general meaning of statistical tests, compared to 78% of the baccalaureate-degree programs (P < .001). Ninety-four percent of the baccalaureate-degree programs, versus 81% of the associate-degree programs, teach the students to apply evidence-based medicine to clinical practice (P = .01). Teaching students how to describe healthcare and financial reimbursement systems and the need to reduce the cost of delivering respiratory care (a leadership competency identified by the second 2015 and Beyond conference) was significantly more common in the baccalaureate-degree programs (72%) than in the associate-degree programs (56%) (P = .03). Other competencies showed trends toward differences, and the baccalaureate-degree programs reported higher percentages of success than the associate-degree programs. CONCLUSIONS: There are important differences between the baccalaureate-degree and associate-degree programs.

Spirometry use: detection of chronic obstructive pulmonary disease in the primary care setting.

OBJECTIVE: To describe a practical method for family practitioners to stage chronic obstructive pulmonary disease (COPD) by the use of office spirometry. METHODS: This is a review of the lessons learned from evaluations of the use of office spirometry in the primary care setting to identify best practices using the most recent published evaluations of office spirometry and the analysis of preliminary data from a recent spirometry mass screening project. A mass screening study by the American Association for Respiratory Care and the COPD Foundation was used to identify the most effective way for general practitioners to implement office spirometry in order to stage COPD. RESULTS: A simple three-step method is described to identify people with a high pre-test probability in an attempt to detect moderate to severe COPD: COPD questionnaire, measurement of peak expiratory flow, and office spirometry. Clinical practice guidelines exist for office spirometry basics for safety, use of electronic peak flow devices, and portable spirometers. CONCLUSION: Spirometry can be undertaken in primary care offices with acceptable levels of technical expertise. Using office spirometry, primary care physicians can diagnose the presence and severity of COPD. Spirometry can guide therapies for COPD and predict outcomes when used in general practice.

Transitioning the respiratory therapy workforce for 2015 and beyond.

The American Association for Respiratory Care established a task force in late 2007 to identify likely new roles and responsibilities of respiratory therapists (RTs) in the year 2015 and beyond. A series of 3 conferences was held between 2008 and 2010. The first task force conference affirmed that the healthcare system is in the process of dramatic change, driven by the need to improve health while decreasing costs and improving quality. This will be facilitated by application of evidence-based care, prevention and management of disease, and closely integrated interdisciplinary care teams. The second task force conference identified specific competencies needed to assure safe and effective execution of RT roles and responsibilities in the future. The third task force conference was charged with creating plans to change the professional education process so that RTs are able to achieve the needed skills, attitudes, and competencies identified in the previous conferences. Transition plans were developed by participants after review and discussion of the outcomes of the first two conferences and 1,011 survey responses from RT department managers and RT education program directors. This is a report of the recommendations of the third task force conference held July 12-14, 2010, on Marco Island, Florida. The participants, who represented groups concerned with RT education, licensure, and practice, proposed, discussed, and accepted that to be successful in the future a baccalaureate degree must be the minimum entry level for respiratory care practice. Also accepted was the recommendation that the Certified Respiratory Therapist examination be retired, and instead, passing of the Registered Respiratory Therapist examination will be required for beginning clinical practice. A date of 2020 for achieving these changes was proposed, debated, and accepted. Recommendations were approved requesting resources be provided to help RT education programs, existing RT workforce, and state societies work through the issues raised by these changes.

Competencies needed by graduate respiratory therapists in 2015 and beyond.

The American Association for Respiratory Care has established a task force to identify potential new roles and responsibilities of respiratory therapists (RTs) in 2015 and beyond. The first task force conference confirmed that the healthcare system in the United States is on the verge of dramatic change, driven by the need to decrease costs and improve quality. Use of evidence-based protocols that follow a nationally accepted standard of practice, and application of biomedical innovation continue to be important competency areas for RTs. The goal of the second task force conference was to identify specific competencies needed to assure safe and effective execution of RT roles and responsibilities in the future. The education needed by the workforce to assume the new responsibilities emerging as the healthcare system changes starts with a close look at the competencies that will be needed by graduate RTs upon entry into practice. Future specialty practice areas for experienced RTs are identified without defining specific competencies. We present the findings of the task force on the competencies needed by graduate RTs upon entry into practice in 2015.

Creating a vision for respiratory care in 2015 and beyond.

The respiratory care profession is over 60 years old. Throughout its short history, change and innovation have been the terms that best describe the development of the profession. The respiratory therapist (RT) of today barely resembles the clinicians of 60 years ago, and the future role of the RT is clearly open to debate. Medicine is continually changing, with new approaches to disease management emerging almost daily. Third-party payers are challenging payment for iatrogenic injury, manpower issues are affecting all disciplines in medicine, and the nonphysician and physician work force is aging. These factors make us question what the respiratory care profession will look like in the year 2015. To address this issue the American Association for Respiratory Care established a task force to envision the RT of the future. The goal is to identify potential new roles and responsibilities of RTs in 2015 and beyond, and to suggest the elements of education, training, and competency-documentation needed to assure safe and effective execution of those roles and responsibilities. We present the initial findings of that task force.

Comparison of a 10-breaths-per-minute versus a 2-breaths-per-minute strategy during cardiopulmonary resuscitation in a porcine model of cardiac arrest.

BACKGROUND: Hyperventilation during cardiopulmonary resuscitation (CPR) is harmful. METHODS: We tested the hypotheses that, during CPR, 2 breaths/min would result in higher cerebral perfusion pressure and brain-tissue oxygen tension than 10 breaths/min, and an impedance threshold device (known to increase circulation) would further enhance cerebral perfusion and brain-tissue oxygen tension, especially with 2 breaths/min. RESULTS: Female pigs (30.4 +/- 1.3 kg) anesthetized with propofol were subjected to 6 min of untreated ventricular fibrillation, followed by 5 min of CPR (100 compressions/min, compression depth of 25% of the anterior-posterior chest diameter), and ventilated with either 10 breaths/min or 2 breaths/min, while receiving 100% oxygen and a tidal volume of 12 mL/kg. Brain-tissue oxygen tension was measured with a probe in the parietal lobe. The impedance threshold device was then used during an 5 additional min of CPR. During CPR the mean +/- SD calculated coronary and cerebral perfusion pressures with 10 breaths/min versus 2 breaths/min, respectively, were 17.6 +/- 9.3 mm Hg versus 14.3 +/- 6.5 mm Hg (p = 0.20) and 16.0 +/- 9.5 mm Hg versus 9.3 +/- 12.5 mm Hg (p = 0.25). Carotid artery blood flow, which was prospectively designated as the primary end point, was 65.0 +/- 49.6 mL/min in the 10-breaths/min group, versus 34.0 +/- 17.1 mL/min in the 2-breaths/min group (p = 0.037). Brain-tissue oxygen tension was 3.0 +/- 3.3 mm Hg in the 10-breaths/min group, versus 0.5 +/- 0.5 mm Hg in the 2-breaths/min group (p = 0.036). After 5 min of CPR there were no significant differences in arterial pH, PO2, or PCO2 between the groups. During CPR with the impedance threshold device, the mean carotid blood flow and brain-tissue oxygen tension in the 10-breaths/min group and the 2-breaths/min group, respectively, were 102.5 +/- 67.9 mm Hg versus 38.8 +/- 23.7 mm Hg (p = 0.006) and 4.5 +/- 6.0 mm Hg versus 0.7 +/- 0.7 mm Hg (p = 0.032). CONCLUSIONS: Contrary to our initial hypothesis, during the first 5 min of CPR, 2 breaths/min resulted in significantly lower carotid blood flow and brain-tissue oxygen tension than did 10 breaths/min. Subsequent addition of an impedance threshold device significantly enhanced carotid flow and brain-tissue oxygen tension, especially in the 10-breaths/min group.

Comparison of an oxygen-powered flow-limited resuscitator to manual ventilation with an adult 1,000-mL self-inflating bag.

BACKGROUND: Positive-pressure ventilation of patients with unprotected airways during cardiopulmonary resuscitation can cause gastric dilation. OBJECTIVE: Determine if there is a significant difference in volume delivered to lungs and stomach while using an adult 1,000-mL disposable bag-valve-mask (BVM) device and the oxygen-powered, flow-limited Oxylator EMX resuscitator. METHODS: We used a bench model to simulate a patient with an unprotected airway, consisting of an intubation manikin, lung analog, and simulated lower esophageal sphincter set at an opening pressure of 20 cm H2O. The BVM and the Oxylator were used to provide mask ventilation at a verbally prompted rate of 12 breaths/min. RESULTS: The volumes delivered with the BVM and the Oxylator to the lungs and stomach were not significantly different: 262 + 112 mL versus 297 + 99 mL and 227 + 199 mL versus 159 + 73 mL, respectively. CONCLUSION: Our study found no significant difference between the Oxylator and BVM when comparing tidal volume delivered to lungs and stomach during ventilation of a simulated unconscious nonintubated patient. More research on BVM use and the Oxylator should be done to validate the American Heart Association's guideline recommendations for ventilating unconscious patients with unprotected airways. Research on gastric dilation during cardiopulmonary resuscitation needs to be done with bench models using manikins that simulate chest excursion, bidirectional airway flow, lung impedance, and gastric compliance.

Evaluation of a prototypic inspiratory impedance threshold valve designed to enhance the efficiency of cardiopulmonary resuscitation.

OBJECTIVE: Assess a prototype inspiratory impedance threshold valve (ITV) designed to enhance vital organ circulation during standard and active compression/decompression cardiopulmonary resuscitation (CPR). BACKGROUND: The ITV attaches to commonly used airway assist devices and decreases intrathoracic pressure during the decompression (chest recoil) phase of CPR by creating a vacuum within the thorax, which increases venous blood flow to the heart and thus increases coronary perfusion pressure and blood flow to the brain. METHODS: The evaluation included laboratory bench testing, according to American Society for Testing and Materials (ASTM) and International Standards Organization (ISO) guidelines, and performance testing with pigs in cardiac arrest. A vacuum pull test was developed to determine the inspiratory impedance under various inspiratory flow conditions. RESULTS: The valve passed all minimum ASTM and ISO performance tests. During cardiac arrest in pigs the ITV decreased intrathoracic pressures by 6-8 mm Hg during the decompression phase. The vacuum pull test demonstrated that the prototype ITV functioned as intended. CONCLUSIONS: The prototype ITV passed all performance testing recommended by international guidelines and functioned effectively as intended for use. The animal study results, when combined with recent clinical data, suggest that an ITV inspiratory cracking pressure of 12 cm H(2)O should be sufficient to decrease intrathoracic pressure during the decompression phase of standard CPR. Clinical studies are now underway.

Airway and ventilation management.

Airway management is fundamental to ACLS. Success with any airway device relies as much on the operator's experience and skill as on the device itself. The purpose of using an airway device is to provide a patent route for ventilating the lungs and to protect against pulmonary aspiration. Training should emphasize the importance of confirming that the airway device is positioned correctly and that the lungs can be ventilated effectively. If airway intervention is to have a positive effect on outcome, the choice of airway device is less important than thorough training, ongoing experience and review, and close attention to complications. Regardless of whether a provider chooses to use the LMA, the combitube, or the tracheal tube, providers must be familiar with more than one method of airway management because of the possibility of failure to insert or ventilate with their primary airway device of choice.