Physiologic Monitoring: Improving Safety or Increasing Risk?

This paper will present a focused and personal history of physiologic monitoring, beginning with the discovery of modern anesthesia and its development from a technical practice to a scientific discipline. Emphasis will be on the essence of monitoring in the anesthesia evolution, and this work will attempt to answer the question of how to evaluate the impact of monitoring on patient outcome. Understanding that monitors are passive and that only caregivers using monitors can impact outcome is at the crux of this approach to analysis. The limited quality data involving monitoring analysis, including that from pulse oximetry, will be discussed and critiqued. The invention and rapid spread of pulse oximetry will be highlighted and used as an example throughout, but the principles developed will apply to other monitors and patient monitoring in general. The problems created by monitoring alarms will also be discussed.

Variability in Mechanical Ventilation: What's All the Noise About?

Controlled mechanical ventilation is characterized by a fixed breathing frequency and tidal volume. Physiological and mathematical models have demonstrated the beneficial effects of varying tidal volume and/or inspiratory pressure during positive-pressure ventilation. The addition of noise (random changes) to a monotonous nonlinear biological system, such as the lung, induces stochastic resonance that contributes to the recruitment of collapsed alveoli and atelectatic lung segments. In this article, we review the mechanism of physiological pulmonary variability, the principles of noise and stochastic resonance, and the emerging understanding that there are beneficial effects of variability during mechanical ventilation.

Elective intubation.

Endotracheal intubation is a commonly performed operating room (OR) procedure that provides safe delivery of anesthetic gases and airway protection during surgery. The most common intubation technique in the perioperative environment is direct laryngoscopy with orotracheal tube insertion. Infrequently, difficulties that require an alternative intubation technique are encountered due to patient anatomy, equipment limitations, or patient pathophysiology. Careful patient evaluation, advanced planning, equipment preparation, system redundancy, use of checklists, familiarity with airway algorithms, and availability of additional help when needed during OR intubations have resulted in exceptional success and safety. Airway difficulties during intubation outside the controlled environment of the OR are more frequent and more serious. Translating the intubation processes practiced in the OR to intubations outside the perioperative setting should improve patient safety. This paper considers each step in the OR intubation process in detail and proposes ways of incorporating perioperative procedures into intubations outside the OR. Management of the physiologic impact of intubation, lack of readily available specialized equipment and experienced help, and planning for transfer of care following intubation are all challenges during these intubations.

Respiratory Care year in review 2013: airway management, noninvasive monitoring, and invasive mechanical ventilation.

Fundamental to respiratory care practice are airway management, noninvasive monitoring, and invasive mechanical ventilation. The purpose of this paper is to review the recent literature related to these topics in a manner that is most likely to have interest to the readers of Respiratory Care.

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.

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.

Tracheostomy: why, when, and how?

Tracheostomy is one of the most frequent procedures performed in intensive care unit (ICU) patients. Of the many purported advantages of tracheostomy, only patient comfort, early movement from the ICU, and shorter ICU and hospital stay have significant supporting data. Even the belief of increased safety with tracheostomy may not be correct. Various techniques for tracheostomy have been developed; however, use of percutaneous dilation techniques with bronchoscopic control continue to expand in popularity throughout the world. Tracheostomy should occur as soon as the need for prolonged intubation (longer than 14 d) is identified. Accurate prediction of this duration by day 3 remains elusive. Mortality is not worse with tracheotomy and may be improved with earlier provision, especially in head-injured and critically ill medical patients. The timing of when to perform a tracheostomy continues to be individualized, should include daily weaning assessment, and can generally be made within 7 days of intubation. Bedside techniques are safe and efficient, allowing timely tracheostomy with low morbidity.

Should a patient be extubated and placed on noninvasive ventilation after failing a spontaneous breathing trial?

Between 15% and 35% of mechanically ventilated patients fail an initial spontaneous breathing trial. For these patients, 40% of total time on mechanical ventilation is consumed by the weaning process (60% for patients with chronic obstructive pulmonary disease). Longer duration of mechanical ventilation is associated with higher risk of complications and probably with higher mortality. Noninvasive ventilation (NIV) has been used successfully in some forms of acute respiratory failure. Randomized controlled trials have indicated that, in selected patients with chronic obstructive pulmonary disease and acute-on-chronic respiratory failure, NIV can facilitate weaning, reduce the duration of invasive mechanical ventilation, decrease complications, and reduce mortality, compared to weaning on continued invasive ventilation. However, extubation failure resulting in re-intubation is associated with higher mortality, and this mortality risk increases with delay of re-intubation and may not be prevented by application of NIV. Patients extubated to NIV must have careful monitoring by skilled clinicians able to provide timely re-intubation if the patient shows signs of intolerance or worsening respiratory failure.

Should tracheostomy be performed as early as 72 hours in patients requiring prolonged mechanical ventilation?

Advances in treating the critically ill have resulted in more patients requiring prolonged airway intubation and respiratory support. If intubation is projected to be longer than several weeks, tracheostomy is often recommended. Tracheostomy offers the potential benefits of improved patient comfort, the ability to communicate, opportunity for oral feeding, and easier, safer nursing care. In addition, less need for sedation and lower airway resistance (than through an endotracheal tube) may facilitate the weaning process and shorten intensive care unit and hospital stay. By preventing microaspiration of secretions, tracheostomy might reduce ventilator-associated pneumonia. There is controversy, however, over the optimal timing of the procedure. While there have been many randomized controlled trials on tracheostomy timing, most were insufficiently powered to detect important differences, and systematic reviews and meta-analyses are limited by the heterogeneity of the primary studies. Based on the available data, we think it is reasonable to perform early tracheostomy in all patients projected to require prolonged mechanical ventilation. Unfortunately, identifying those patients can be difficult, and for many patient populations we lack the necessary tools to predict prolonged ventilation. We propose an early-tracheostomy decision algorithm.

How to read a scientific research paper.

Reading is the most common way that adults learn. With the exponential growth in information, no one has time to read all they need. Reading original research, although difficult, is rewarding and important for growth. Building on past knowledge, the reader should select papers about which he already holds an opinion. Rather than starting at the beginning, this author suggests approaching a paper by reading the conclusions in the abstract first. The methods should be next reviewed, then the results--first in the abstract, and then the full paper. For efficiency, at each step, reasons should be sought not to read any further in the paper. By using this approach, new knowledge will be obtained and many papers will be evaluated, read, and considered.

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.

2006 Philip Kittredge Memorial Lecture. What to do when protocols fail.

Though advances in medical science have created improved therapies, often these are not widely provided throughout the health-care system. Also, there is growing recognition of the lack of safety in health-care delivery. The development of evidence-based, best practice, national guidelines has been encouraged to reduce unnecessary variation in care and for improving quality. Adoption of guidelines through local protocols has been disappointingly slow. This paper explores the parallel developments in safety and quality-of-care assessment, evidence-based medicine, guideline creation, and how development of national and international quality-improvement campaigns are promoting rapid change in care delivery processes. I discuss how this new opportunity can improve the quality of respiratory care and enhance the adoption of respiratory care protocols.

Tracheostomy in the critically ill: indications, timing and techniques.

PURPOSE OF REVIEW: Tracheostomy is one of the most common procedures performed in the intensive care unit. Indications, risks, benefits, timing and technique of the procedure, however, remain controversial. The decision of when and how to perform a tracheostomy is often subjective, but must be individualized to the patient. The following review gives an update on recent literature related to tracheostomy in the critically ill. RECENT FINDINGS: Surprisingly, few data are available on the current practice of tracheostomy in the intensive care unit setting. Very few trials address this issue in a prospective, randomized fashion (randomized controlled trial). Most reports include small numbers representing a heterogeneous population, describing contrary results and precluding any definite conclusions. Evidence seems to suggest that early tracheostomy, however, might be preferable in selected patients. SUMMARY: Due to increased experience and advanced techniques, percutaneous tracheostomy has become a popular, relatively safe procedure in the intensive care unit. The question of appropriate timing, however, has not been definitely answered with a randomized controlled trial. Instead, a number of retrospective studies and a single prospective study have shed some light on this issue. Most reports favor the performance of tracheostomy within 10 days of respiratory failure.

Team model: advocating for the optimal method of care delivery in the intensive care unit.

OBJECTIVE: To review published data on the team model of intensive care unit (ICU) care delivery. DESIGN: Nonexhaustive, selective literature search. SETTING: Review of literature published in the English language. PATIENTS/SUBJECTS: Humans cared for in ICUs. INTERVENTIONS: None. RESULTS: The team model for delivery of ICU care reduces mortality, ICU length of stay, hospital length of stay, and cost of care. Convincing data suggest that merely having daily rounds led by an intensivist enhances patient care significantly. Further improvements can be obtained by maintaining a nurse-to-patient ratio of no greater than 1:2, adding critical care pharmacists, and providing dedicated respiratory therapists to the ICU team. CONCLUSION: Current and looming shortages of all ICU healthcare providers is a barrier to universal implementation of the team model. Advocating for the ICU team model for critical care delivery requires local, regional, national, and international activities for success.

Indications for and timing of tracheostomy.

Tracheostomy is one of the most common intensive care unit procedures performed. The advantages include patient comfort, safety, ability to communicate, and better oral and airway care. Patients may have shorter intensive care unit stays, days of mechanical ventilation, and hospital stays. There are risks, long-term and acute, and the timing of when to do a tracheostomy must be individualized. As soon as the need for prolonged airway access is identified, the tracheostomy should be considered. Generally, this decision can be made within 7-10 days. Bedside techniques allow rapid tracheostomy with low morbidity.