Richard Wettstein

Medication adherence issues in patients treated for COPD

Although medical treatment of COPD has advanced, nonadherence to medication regimens poses a significant barrier to optimal management. Underuse, overuse, and improper use continue to be the most common causes of poor adherence to therapy. An average of 40%–60% of patients with COPD adheres to the prescribed regimen and only 1 out of 10 patients with a metered dose inhaler performs all essential steps correctly. Adherence to therapy is multifactorial and involves both the patient and the primary care provider. The effect of patient instruction on inhaler adherence and rescue medication utilization in patients with COPD does not seem to parallel the good results reported in patients with asthma. While use of a combined inhaler may facilitate adherence to medications and improve efficacy, pharmacoeconomic factors may influence patient’s selection of both the device and the regimen. Patient’s health beliefs, experiences, and behaviors play a significant role in adherence to pharmacological therapy. This manuscript reviews important aspects associated with medication adherence in patients with COPD and identifies some predictors of poor adherence.

AARC Clinical Practice Guideline: Transcutaneous Monitoring of Carbon Dioxide and Oxygen: 2012

An electronic literature search for articles published between January 1990 and September 2011 was conducted by using the PubMed, CINAHL, SCOPUS, and Cochrane Library databases. The update of this clinical practice guideline is the result of reviewing a total of 124 articles: 3 randomized controlled trials, 103 prospective trials, 1 retrospective study, 3 case studies, 11 review articles, 2 surveys and 1 consensus paper on transcutaneous monitoring (TCM) for PtcO2 and PtcCO2. The following recommendations are made following the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria: (1) Although PtcCO2 has a good correlation with PaCO2 and is a reliable method to evaluate plasma CO2 levels, it is recommended that arterial blood gas values be compared to transcutaneous readings taken at the time of arterial sampling, in order to verify the transcutaneous values, and periodically as dictated by the patients clinical condition. (2) It is suggested that PtcCO2 may be used in clinical settings where monitoring the adequacy of ventilation is indicated. (3) It is suggested that PtcO2 and PtcCO2 may be used in determining the adequacy of tissue perfusion and monitoring of reperfusion. (4) It is suggested that TCM should be avoided in the presence of increased thickness or edema of the skin and/or subcutaneous tissue where the sensor is applied. (5) It is recommended that sites used for a TCM be changed as often as necessary and that they be alternated and observed to avoid thermal injury. Manufacturer recommendations should be followed.

Incentive Spirometry: 2011

We searched the MEDLINE, CINAHL, and Cochrane Library databases for articles published between January 1995 and April 2011. The update of this clinical practice guideline is the result of reviewing a total of 54 clinical trials and systematic reviews on incentive spirometry. The following recommendations are made following the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) scoring system. 1: Incentive spirometry alone is not recommended for routine use in the preoperative and postoperative setting to prevent postoperative pulmonary complications. 2: It is recommended that incentive spirometry be used with deep breathing techniques, directed coughing, early mobilization, and optimal analgesia to prevent postoperative pulmonary complications. 3: It is suggested that deep breathing exercises provide the same benefit as incentive spirometry in the preoperative and postoperative setting to prevent postoperative pulmonary complications. 4: Routine use of incentive spirometry to prevent atelectasis in patients after upper-abdominal surgery is not recommended. 5: Routine use of incentive spirometry to prevent atelectasis after coronary artery bypass graft surgery is not recommended. 6: It is suggested that a volume-oriented device be selected as an incentive spirometry device.

A Fresh Look at the Physiologic Effects of High-Flow Nasal Cannulae and the Role They Play in Patient Care

Treatment strategies to address oxygenation problems in critically ill patients with hypoxemic respiratory failure commonly fall into 3 categories: use of simple oxygen equipment, use of noninvasive ventilation, or use of invasive ventilation. These categories typically represent a stepwise approach

Critical-Thinking Ability in Respiratory Care Students and Its Correlation With Age, Educational Background, and Performance on National Board Examinations

BACKGROUND: Critical thinking is an important characteristic to develop in respiratory care students. METHODS: We used the short-form Watson-Glaser Critical Thinking Appraisal instrument to measure critical-thinking ability in 55 senior respiratory care students in a baccalaureate respiratory care program. We calculated the Pearson correlation coefficient to assess the relationships between critical-thinking score, age, and student performance on the clinical-simulation component of the national respiratory care boards examination. We used chi-square analysis to assess the association between critical-thinking score and educational background. RESULTS: There was no significant relationship between critical-thinking score and age, or between critical-thinking score and student performance on the clinical-simulation component. There was a significant (P = .04) positive association between a strong science-course background and critical-thinking score, which might be useful in predicting a students ability to perform in areas where critical thinking is of paramount importance, such as clinical competencies, and to guide candidate-selection for respiratory care programs.

Nasal Cycling Revisited.

As Marshall et al[1][1] point out in their article published in this issue of Respiratory Care, nasal cycling appeared in the literature over 100 years ago, and it continues to be regularly reported in medical and scientific journals.[2][2]–[7][3] Respiratory texts and journals have seldom