High-flow oxygen administration by nasal cannula for adult and perinatal patients.

The nasal cannula has been a commonly used patient interface to provide supplemental oxygen since its introduction in the 1940s. Traditionally, it has been categorized as a low-flow device and capable of delivering a 0.4 F(IO(2)) with flows up to 6 L/min to adults with normal minute ventilation. However, there is considerable performance variability among patients and design, which results in an exponential decline in delivered F(IO(2)) as breathing frequencies increase. The nasal cannula has also been successfully adapted for use in perinatal and pediatric respiratory care; flows are reduced, in the range of 0.25-1 L/min, due to smaller minute volumes. A decade or so ago, high-flow nasal cannula (HFNC) oxygen therapy was introduced, accompanied by heated humidification systems to prevent the associated drying of upper airway mucosa and to increase patient comfort. Therapeutic flows for adults were in the 15-40 L/min range; F(IO(2)) could be independently adjusted with air/O(2) blending. The HFNC has also found additional clinical application in perinatal care, as delivery systems with flows > 2 L/min could create a distending pressure similar to nasal CPAP. There is a small but growing body of information from clinical trials that supports use of HFNC as an alternative oxygen interface for adults who present with moderate hypoxemia that persists after receiving oxygen by reservoir-bag masks or similar therapy. Clinical observations report greater patient acceptance and comfort versus oxygen masks. HFNC therapy has also been considered valuable in perinatal care in treating the respiratory distress syndrome or supporting patients after extubation similar to nasal CPAP. At present, research-based evidence for the role of HFNC for its perinatal applications remains unclear. This review will identify proposed mechanisms for therapeutic effectiveness, current delivery equipment, guidelines for rational patient application, and direction for further research.

Technology for enhancing chest auscultation in clinical simulation.

The ability to use an acoustic stethoscope to detect lung and/or heart sounds, and then to then communicate one's interpretation of those sounds is an essential skill for many medical professionals. Interpretation of lung and heart sounds, in the context of history and other examination findings, often aids the differential diagnosis. Bedside assessment of changing auscultation findings may also guide treatment. Learning lung and heart auscultation skills typically involves listening to pre-recorded normal and adventitious sounds, often followed by laboratory instruction to guide stethoscope placement, and finally correlating the sounds with the associated pathophysiology and pathology. Recently, medical simulation has become an important tool for teaching prior to clinical practice, and for evaluating bedside auscultation skills. When simulating cardiovascular or pulmonary problems, high-quality lung and heart sounds should be able to accurately corroborate other findings such as vital signs, arterial blood gas values, or imaging. Digital audio technology, the Internet, and high-fidelity simulators have increased opportunities for educators and learners. We review the application of these technologies and describe options for reproducing lung and heart sounds, as well as their advantages and potential limitations.

Facilitating research projects in schools and clinical respiratory care departments.

As the profession of respiratory care evolves, greater demands are being placed on educators, managers, and practitioners as they encounter a mass of new literature and the latest technology. Respiratory care schools and clinical departments are under increasing pressure to prepare students and staff with the skills needed to efficiently and effectively consider the numerous primary research investigations, systematic reviews, consensus practice guidelines, and institutional continuous-quality-improvement data. A classroom and work environment that encourages openness and discussion and rewards inquiry is of fundamental importance. Cooperative efforts from school and workplace can provide both student and practitioner with courses on scientific methodology, journal clubs, and equipment seminars. A student body and clinical staff that receive foundational and ongoing education in empirical methodology will respond by assisting in the development and implementation of practice protocols, quality assurance programs, and clinical research. A school and workplace that embrace these attitudes and practices will provide an environment that enhances learning, stimulates professional development, and ultimately provides the most current and best care for its patients.