Alarm Strategies and Surveillance for Mechanical Ventilation.

Clinical alarms, including those for mechanical ventilation, have been one of the leading causes of health technology hazards. It has been reported that < 15% of alarms studied rose to the level of being clinically relevant or actionable. Most alarms in health care, whether by default or intention, are set to a hypothetical average patient, which is essentially a one size fits most approach. A method of tuning to individual patient characteristics is possible, similar to the treatment philosophy of precision medicine. The excessive amount of alarms in a clinical environment is thought to be the largest contributing factor to alarm-related adverse events. All these factors come to bear on human perception and response to mechanical ventilation and clinical alarms. Observations of human response to stimuli suggest that response to alarms is closely matched to the perceived reliability and value of the alarm system. This paper provides a review examining vulnerabilities in the current management of mechanical ventilation alarms and summarizes best practices identified to help prevent patient injury. This review examines the factors that affect alarm utility and provides recommendations for applying research findings to improve safety for patients, clinician efficiency, and clinician well-being.

Benefits and harms of capnography during procedures involving moderate sedation: A rapid review and meta-analysis.

BACKGROUND: Patient safety is a priority in dentistry. Evaluating the benefits and harms associated with the addition of capnography to standard monitoring during moderate sedation for adult patients in the dental practice setting is needed. TYPES OF STUDIES REVIEWED: The authors used rapid review methodology to identify relevant systematic reviews, which they updated through a systematic search by using the same search strategy as the identified reviews. The authors searched PubMed and Google Scholar and through the references of the identified systematic reviews, which yielded 2,892 studies. Inclusion criteria were that the article was available in English, was original research in adult humans who had undergone moderate procedural sedation, and involved comparing standard monitoring with the addition of capnography. RESULTS: Sixteen studies were eligible, involving 3,866 adults undergoing procedural sedation. The authors used the Grading of Recommendations Assessment, Development and Evaluation approach to evaluate the evidence and rate it as being of moderate to low quality because of high risk of bias and heterogeneous effects for the outcomes of hypoxemia and adverse respiratory events. Capnography had higher sensitivity to detect adverse respiratory events than did standard monitoring alone (0.92; 95% confidence interval, 0.65 to 0.99) and may reduce the risk of developing hypoxemia by 31% (risk ratio, 0.69; 95% confidence interval, 0.57 to 0.82). Capnography did not affect the risk of developing serious adverse events, procedure time, sedation quality, or patient satisfaction. CONCLUSIONS AND PRACTICAL IMPLICATIONS: Adding capnography to standard monitoring of adults during moderate sedation may reduce the risk of developing hypoxemia, increase detection of adverse respiratory events, and is not associated with additional harms. These findings suggest routine use of capnography during moderate sedation has the potential to reduce adverse anesthetic outcomes in dental practice.

Teaching Medical Students to Help Patients Quit Smoking: Outcomes of a 10-School Randomized Controlled Trial.

BACKGROUND: Early in medical education, physicians must develop competencies needed for tobacco dependence treatment. OBJECTIVE: To assess the effect of a multi-modal tobacco dependence treatment curriculum on medical students' counseling skills. DESIGN: A group-randomized controlled trial (2010-2014) included ten U.S. medical schools that were randomized to receive either multi-modal tobacco treatment education (MME) or traditional tobacco treatment education (TE). SETTING/PARTICIPANTS: Students from the classes of 2012 and 2014 at ten medical schools participated. Students from the class of 2012 (N = 1345) completed objective structured clinical examinations (OSCEs), and 50 % (N = 660) were randomly selected for pre-intervention evaluation. A total of 72.9 % of eligible students (N = 1096) from the class of 2014 completed an OSCE and 69.7 % (N = 1047) completed pre and post surveys. INTERVENTIONS: The MME included a Web-based course, a role-play classroom demonstration, and a clerkship booster session. Clerkship preceptors in MME schools participated in an academic detailing module and were encouraged to be role models for third-year students. MEASUREMENTS: The primary outcome was student tobacco treatment skills using the 5As measured by an objective structured clinical examination (OSCE) scored on a 33-item behavior checklist. Secondary outcomes were student self-reported skills for performing 5As and pharmacotherapy counseling. RESULTS: Although the difference was not statistically significant, MME students completed more tobacco counseling behaviors on the OSCE checklist (mean 8.7 [SE 0.6] vs. mean 8.0 [SE 0.6], p = 0.52) than TE students. Several of the individual Assist and Arrange items were significantly more likely to have been completed by MME students, including suggesting behavioral strategies (11.8 % vs. 4.5 %, p < 0.001) and providing information regarding quitline (21.0 % vs. 3.8 %, p < 0.001). MME students reported higher self-efficacy for Assist, Arrange, and Pharmacotherapy counseling items (ps ≤0.05). LIMITATIONS: Inclusion of only ten schools limits generalizability. CONCLUSIONS: Subsequent interventions should incorporate lessons learned from this first randomized controlled trial of a multi-modal longitudinal tobacco treatment curriculum in multiple U.S. medical schools. NIH Trial Registry Number: NCT01905618.

Use of siRNA molecular beacons to detect and attenuate mycobacterial infection in macrophages.

Tuberculosis is one of the leading infectious diseases plaguing mankind and is mediated by the facultative pathogen, Mycobacterium tuberculosis (MTB). Once the pathogen enters the body, it subverts the host immune defenses and thrives for extended periods of time within the host macrophages in the lung granulomas, a condition called latent tuberculosis (LTB). Persons with LTB are prone to reactivation of the disease when the body's immunity is compromised. Currently there are no reliable and effective diagnosis and treatment options for LTB, which necessitates new research in this area. The mycobacterial proteins and genes mediating the adaptive responses inside the macrophage is largely yet to be determined. Recently, it has been shown that the mce operon genes are critical for host cell invasion by the mycobacterium and for establishing a persistent infection in both in vitro and in mouse models of tuberculosis. The YrbE and Mce proteins which are encoded by the MTB mce operons display high degrees of homology to the permeases and the surface binding protein of the ABC transports, respectively. Similarities in structure and cell surface location impute a role in cell invasion at cholesterol rich regions and immunomodulation. The mce4 operon is also thought to encode a cholesterol transport system that enables the mycobacterium to derive both energy and carbon from the host membrane lipids and possibly generating virulence mediating metabolites, thus enabling the bacteria in its long term survival within the granuloma. Various deletion mutation studies involving individual or whole mce operon genes have shown to be conferring varying degrees of attenuation of infectivity or at times hypervirulence to the host MTB, with the deletion of mce4A operon gene conferring the greatest degree of attenuation of virulence. Antisense technology using synthetic siRNAs has been used in knocking down genes in bacteria and over the years this has evolved into a powerful tool for elucidating the roles of various genes mediating infectivity and survival in mycobacteria. Molecular beacons are a newer class of antisense RNA tagged with a fluorophore/quencher pair and their use for in vivo detection and knockdown of mRNA is rapidly gaining popularity.

Improving the validity and reliability of a health promotion survey for physical therapists.

PURPOSE: Physical therapists (PTs) have a unique opportunity to intervene in the area of health promotion. However, no instrument has been validated to measure PTs' views on health promotion in physical therapy practice. The purpose of this study was to evaluate the content validity and test-retest reliability of a health promotion survey designed for PTs. METHODS: An expert panel of PTs assessed the content validity of "The Role of Health Promotion in Physical Therapy Survey" and provided suggestions for revision. Item content validity was assessed using the content validity ratio (CVR) as well as the modified kappa statistic. Therapists then participated in the test-retest reliability assessment of the revised health promotion survey, which was assessed using a weighted kappa statistic. RESULTS: Based on feedback from the expert panelists, significant revisions were made to the original survey. The expert panel reached at least a majority consensus agreement for all items in the revised survey and the survey-CVR improved from 0.44 to 0.66. Only one item on the revised survey had substantial test-retest agreement, with 55% of the items having moderate agreement and 43% poor agreement. CONCLUSIONS: All items on the revised health promotion survey demonstrated at least fair validity, but few items had reasonable test-retest reliability. Further modifications should be made to strengthen the validity and improve the reliability of this survey.

Effect of heliox on end-tidal CO2 measurement in healthy adults.

BACKGROUND: Therapeutic gases and other modalities delivered by inhalation may affect the accuracy of capnographic measurements in 2 ways. First is the specificity of the measurement of CO2 within the device, and second is the dilution effect of supplemental gases in the ambient air during CO2 sampling by the device. Our goal was to determine if variables such as inhaled gas composition, gas flows delivered via non-rebreather mask, and mouth open or closed affect measurements of end-tidal CO2 pressure (PETCO2) measured with the Capnostream 20 capnograph. METHODS: We measured PETCO2 and breathing frequency by capnography in 20 adult normal subjects, with coaching to maintain respiratory frequency between 10 and 20 breaths/min. SpO2 was monitored to detect hypoxemia. A 6 min wash-out period occurred between each 6 min level of testing. RESULTS: A mixed models analysis revealed that the mean ± SD PETCO2 for all subjects and flows while breathing heliox (37 ± 5 mm Hg) was not different (P = .50) from the value while breathing room air (36 ± 5 mm Hg). Repeated measurements with given subjects over 6 min periods of breathing spontaneously 0 L/min, with 10 L/min, and with 15 L/min of either air or heliox showed no difference in PETCO2 related to flow: P = .97 for 0 L/min vs 10 L/min, P = .87 for 0 L/min vs. 15 L/min. CONCLUSIONS: In normal subjects, PETCO2 measurements with the Capnostream 20 were not affected by heliox or gas flow at 10 or 15 L/min through a non-rebreathing mask.

Capnography enhances surveillance of respiratory events during procedural sedation: a meta-analysis.

STUDY OBJECTIVE: To determine if capnography, in addition to standard monitoring, identified more respiratory complications than standard monitoring alone. DESIGN: Meta-analysis. SETTING: University medical center. MEASUREMENTS: The electronic databases PubMed, CINAHL, and Cochrane Library (Cochrane Reviews, CENTRAL) were searched for studies published between 1995-2009 reporting adverse respiratory events during procedural sedation and analgesia (PSA) with clearly defined end-tidal carbon dioxide threshold, adult population, clear study design, P-value calculation, similar outcome and predictor variable definitions, and binary independent and dependent variable raw data. Five such studies were evaluated independently. A meta-analysis of these studies was performed. MAIN RESULTS: During PSA, cases of respiratory depression were 17.6 times more likely to be detected if monitored by capnography than cases not monitored by capnography (95% CI, 2.5-122.1; P < 0.004). CONCLUSION: End-tidal carbon dioxide monitoring is an important addition in detecting respiratory depression during PSA.

Incidence, relevance and response for Ralsfonia respiratory infections.

BACKGROUND: Cases of Ralstonia colonization/infection occasionally reported by hospitals has generated increased interest in an organism previously little known to most clinicians. Our goal was to determine the incidence of respiratory colonizations and infections involving Ralstonia and the association of mechanical ventilation (limited to reports on respiratory-related occurrences in the U.S.A.) and propose a decision chart to assist response. METHODS: We performed a secondary analysis of published clinical reports of Ralstonia to determine the potential risks for respiratory colonization and infection in the USA and if being on mechanical ventilation (MV) had an influence on colonization and conversion to infection (symptomatic). RESULTS: The odds of developing colonization with Ralstonia were eight times higher and the likelihood of developing infection with Ralstonia was twelve times higher in those mechanically ventilated compared to those not mechanically ventilated. CONCLUSIONS: Our results suggest that individuals who are currently on mechanical ventilation and are Ralstonia culture-positive have an increased risk for colonization and may have increased propensity to the development of infection (two decision trees for approaching diagnosis and therapy included).

Tobacco treatment and prevention: what works and why.

Tobacco abuse is one of the main reasons that chronic obstructive pulmonary disease is the fourth leading cause of death in the United States. Many people kick the habit easily, while others struggle through a difficult cycle of addiction. Respiratory therapists often have contact with patients with chronic lung disease who want to quit smoking but do not know where to begin. Smoking bans and clean air laws are in place across the United States, but this is not enough for a complete tobacco treatment and prevention program. For any successful disease-management program, tobacco-control education and support must be included. Studies show that when pharmacologic interventions are used along with the appropriate counseling and other resources, the success of tobacco cessation increases. This must be understood, because if the regulatory efforts of our governing bodies are not enough and if patients do not receive the care that is essential for disease management and rehabilitation, then how will our role as respiratory therapist matter in any health-care system of the future? The respiratory therapist plays a key role in asking patients, especially newly diagnosed patients with chronic lung disease, if they are smokers and if they are interested in tobacco use interventions. This is a role that should not be taken lightly.

An evaluation of 2 new devices for nasal high-flow gas therapy.

BACKGROUND: The traditional nasal cannula with bubble humidifier is limited to a maximum flow of 6 L/min to minimize the risk of complications. We conducted a bench study of 2 new Food and Drug Administration-approved nasal cannula/humidifier products designed to deliver at flows> 6 L/min. METHODS: Using a digital psychrometer we measured the relative humidity and temperature of delivered gas from each device, at 5 L/min increments over the specified functional high-flow range. RESULTS: The Salter Labs unit achieved 72.5-78.7% relative humidity (5-15 L/min range) at ambient temperature (21-23 degrees C). The Vapotherm device achieved 99.9% relative humidity at a temperature setting of 37 degrees C (5-40 L/min). CONCLUSIONS: Both devices meet minimum humidification standards and offer practical new treatment options. The patient-selection criteria are primarily the severity of the patient's condition and cost.