Teresa A Volsko

Determining the Basis for a Taxonomy of Mechanical Ventilation

BACKGROUND: Mechanical ventilation technology has evolved rapidly over the last 30 years. One consequence is the creation of an unmanageable number of names to describe modes of ventilation. The proliferation of names makes education of end users difficult, potentially compromising the quality of patient care. OBJECTIVE: To determine if stakeholders are familiar enough with published constructs related to modes of mechanical ventilation to form a basis for a consensus, by surveying the medical, education, and business communities. The hypotheses tested were: there is concordance (> 50%) on 10 basic constructs related to modes; concordance with the basic constructs varies among stakeholders according to professional training and professional activity; and concordance varies among the set of constructs. METHODS: The survey was distributed through an Internet-based tool to 2,994 physicians, respiratory therapists, nurses, engineers, and others involved with mechanical ventilation. Hypotheses were tested with chi-square, with P < .05 considered significant. RESULTS: The response rate was 15%. Respondents were 55% respiratory therapists, 35% physicians, 3% nurses, 1% engineers, and 5% other professionals. There was an 82% concordance with the 10 constructs (P < .001). Respiratory therapists showed the highest degree of concordance (84%) and “other profession” showed the lowest (79%) (P = .006). No significant difference (P = .07) in concordance was observed when data were grouped by professional activity. Concordance differed significantly among the survey questions (P < .001). CONCLUSIONS: Survey results indicate that respondents were either familiar with or amenable to the previously published literature that the survey constructs represented. The degree of familiarity and concordance with these constructs represents a sufficient basis for attempting to formalize a taxonomy. Further analysis of the pattern of concordance among the constructs will inform future educational and consensus building efforts.

The Effect of Targeting Scheme on Tidal Volume Delivery During Volume Control Mechanical Ventilation

BACKGROUND: Technological advances have increased ventilator mode complexity and risk of operator error. OBJECTIVE: To compare differences in volume control (VC) ventilation with set-point and dual targeting. Two hypotheses were tested: tidal volume (VT) delivery is different with VC using set-point versus dual targeting during active versus passive breathing; VC with dual targeting delivers VT similar to pressure support ventilation (PS) with active breathing. METHODS: The Ingmar Medical ASL 5000 lung model simulated pulmonary mechanics of an adult patient with ARDS during active and passive ventilation. Resistance was standardized at 10 cm H2O/L/s and compliance at 32 mL/cm H2O. Active breathing was simulated by setting the frequency (f) = 26 breaths/min, and adjusting the muscle pressure (Pmus) to produce a VT of 384 mL. VC was initiated with the Puritan Bennett 840 (set-point targeting) and the Servo-i (dual targeting) at VT = 430 mL, mandatory f = 15 breaths/min, and PEEP = 10 cm H2O. During PS, cycle threshold was set to 30% and peak inspiratory pressure adjusted to produce a VT similar to that delivered during VC. Expiratory VT was collected on 10 consecutive breaths during active and passive breathing with VC and PS. Mean VT differences (active vs passive model) were compared using analysis of variance. Statistical significance was established at P < .05. RESULTS: The mean ± SD VT difference varied with targeting schemes: VC set-point = 37.3 ± 3.5 mL, VC-dual = 77.1 ± 3.3 mL, and PS = 406.1 ± 1.5 mL (P < .001). Auto-triggering occurred during VC set-point with the active model. CONCLUSIONS: Dual targeting during VC allows increased VT, compared to set-point, but not as much as PS.

Neonatal Respiratory Therapist-Led Rounds Can Improve Staff Satisfaction and Timeliness of Respiratory Interventions

BACKGROUND: Interdisciplinary rounding is used to establish and communicate patient care goals and monitor progress toward goal attainment. This study describes staff satisfaction and process outcomes associated with respiratory therapist (RT)-led interdisciplinary rounds in the neonatal ICU. We hypothesized improved staff satisfaction, execution of orders within 30 min of order entry into the electronic medical record, and communication of accurate and complete data during rounds to the interdisciplinary team. METHODS: Nurses, RTs, nurse practitioners, residents, and attending physicians completed the 13-question survey eliciting demographic information and evaluating staff engagement and professional satisfaction. The survey was anonymous and confidential, and informed consent was implied. Process data were collected for a 10-d period at 2 intervals through direct observation of the rounding process and electronic medical record review. Descriptive statistics reported patient demographics, responses to job satisfaction and engagement survey questions, the number of patients who were visited in daily rounds, the number and type of orders given during rounds, and the number of respiratory orders that were addressed in multidisciplinary teaching rounds rather than during respiratory rounds. The chi-square test was used to determine differences in the proportion of inaccurate and incomplete data communicated during rounds between the 2 data collection periods. The Mann-Whitney U test was used to determine differences in the timeliness of electronic medical record order entry and time to order completion. RESULTS: A 94.8% survey response rate (n = 55) was obtained. Seventy-six percent of participants reported improved communication. Sixty-nine percent of participants reported improved teamwork. Eighty-six percent of orders were implemented immediately after electronic medical record entry. Correct information was provided on 95% and 99.3% of patients (P < .066) and complete information on 93% and 96% of patients (P = .41). CONCLUSIONS: Implementation of respiratory rounds improved staff satisfaction and the timeliness of completing respiratory orders. Spot monitoring at intermittent intervals verified process sustainability.

Body Mass Index Moderates the Effects of Portable Oxygen Transport Modality on 6-Minute Walk Distance in Patients With COPD.

PURPOSE: While portable, supplemental oxygen is often necessary for patients with chronic obstructive pulmonary disease (COPD) to retain independence, it may provide functional limitations because of the increased workload imposed. This issue may result in nonuse, creating a need to identify carrying modalities that optimize transport. This study assessed the effects of 3 methods of portable oxygen transport on 6-minute walk distance (6MWD), rate of perceived exertion (RPE), heart rate (HR), and oxyhemoglobin saturation (SpO2). As weight status is known to impact functional ability in COPD, effects of body mass index (BMI) were also assessed. METHODS: Data were analyzed using the mixed-model procedure to test for effects of transport modality (reference, rolling cart, backpack, shoulderstrap), time (minutes 1-6), BMI, non-overweight, overweight, and interactions of these variables on outcome parameters. RESULTS: A main effect of condition was found for 6MWD, and an interaction of condition × BMI was found for HR and RPE, and of time × BMI for 6MWD and SpO2. Participants walked the least distance in rolling cart condition, which was also characterized by the greatest RPE. For the overweight group, HR was least in the reference compared with other conditions; but for the non-overweight group, the opposite pattern was observed. At latter time points, 6MWD was greater in the non-overweight group, while SpO2 was reduced. CONCLUSION: Results demonstrate that transport modality of portable oxygen exerts differential effects on functional performance in COPD patients and that BMI may moderate underlying physiologic factors that contribute to performance outcomes.

Mentoring and Respiratory Care

Approximately 6 years ago, the American Association for Respiratory Care (AARC) established a task force to identify the evolving role of the respiratory therapist (RT). The members of this task force acknowledged the complexities of providing medical interventions along the continuum of care, and