Factors associated with having uncontrolled asthma in rural Appalachia.

BACKGROUND: Chronic respiratory disease disproportionately affects residents of Appalachia, particularly those residing in Central Appalachia. Asthma is particularly burdensome to Central Appalachian residents regarding cost and disability. Improving our understanding of how to mitigate these burdens requires understanding the factors influencing asthma control among individuals with asthma living in Central Appalachia, specifically rural Kentucky. METHODS: This community-based, cross-sectional epidemiologic study used survey data to identify characteristics associated with uncontrolled and controlled asthma. The designation of "uncontrolled asthma" was based on a self-report of ≥ 2 asthma exacerbations in the past year. Individuals with ≤ 1 or no exacerbations were considered to have controlled asthma. Chi-square or Fisher exact tests assessed the association between categorical variables and asthma control categories. Logistic regression was conducted to determine the impact of factors on the likelihood of uncontrolled asthma. RESULTS: In a sample of 211 individuals with self-reported asthma, 29% (n = 61, 46 females) had uncontrolled asthma. Predictors of uncontrolled asthma included depression (odds ratio 2.61, 95% CI 1.22-5.61, p = .014) and living in multi-unit housing (odds ratio 4.99, 95% CI 1.47-16.96, p = .010) when controlling for age, sex, financial status, and occupation. Being overweight or obese was not a predictor of uncontrolled asthma. Physical activity and BMI did not predict the likelihood of uncontrolled asthma. CONCLUSION: This study highlights significant challenges rural communities in Appalachian Kentucky face in managing asthma. Factors like depression, housing conditions, and a lack of self-management strategies play pivotal roles in asthma control in this population.

Enhancing Respiratory Therapists' Well-Being: Battling Burnout in Respiratory Care.

Burnout is a major problem in health care and is associated with adverse sequelae for patients, health care workers, and organizations. Burnout among respiratory therapists (RTs) is as high as 79% and is associated with poor or ineffective leadership, inadequate staffing, high work load, non-leadership position, and work environment. An understanding of burnout is necessary for both staff and leadership to ensure RT well-being. This narrative review will discuss the psychology of burnout, prevalence, drivers, mitigation strategies, and future directions for research.

AARC Clinical Practice Guidelines: Capillary Blood Gas Sampling for Neonatal and Pediatric Patients.

In the absence of an indwelling arterial catheter, capillary blood gas sampling may be used to evaluate the acid/base and ventilation status of neonatal and pediatric patients with cardiorespiratory conditions. These guidelines were developed from a comprehensive review of the literature to provide guidance for the collection, handling, and interpretation of blood obtained from an arterialized capillary sample. Capillary and venous blood gas measurements are a useful alternative to arterial blood gas measurements for neonatal and pediatric patients who do not require close monitoring of [Formula: see text] In the presence of alterations in body temperature, blood pressure, or peripheral perfusion, agreement between a capillary blood gas with an arterial sample is recommended to determine whether changes in these physiologic conditions reduce reliability. Perfusion to the sample site should be assessed and preference given to blood sampling from a well perfused site, and blood should be analyzed within 15 min of sampling to minimize the propensity for pre-analytical errors. Clinicians should consider re-collecting a blood sample, obtained from an artery, vein, or capillary, when the blood gas or analyte result interpretation does not align with the patient's clinical presentation. A pneumatic tube system can be reliably used to transport blood gas samples collected in a syringe and capillary tube to a clinical laboratory for analysis. To reduce the cumulative pain effect and risk of complications, the capillary puncture procedure should be minimized when possible. Non-pharmacologic interventions should be used to reduce pain associated with capillary blood gas sampling. Automatic lancets are preferred to puncture the skin for capillary blood gas collection.

AARC Clinical Practice Guideline: Management of Adult Patients With Oxygen in the Acute Care Setting.

Providing supplemental oxygen to hospitalized adults is a frequent practice and can be administered via a variety of devices. Oxygen therapy has evolved over the years, and clinicians should follow evidence-based practices to provide maximum benefit and avoid harm. This systematic review and subsequent clinical practice guidelines were developed to answer questions about oxygenation targets, monitoring, early initiation of high-flow oxygen (HFO), benefits of HFO compared to conventional oxygen therapy, and humidification of supplemental oxygen. Using a modification of the RAND/UCLA Appropriateness Method, 7 recommendations were developed to guide the delivery of supplemental oxygen to hospitalized adults: (1) aim for [Formula: see text] range of 94-98% for most hospitalized patients (88-92% for those with COPD), (2) the same [Formula: see text] range of 94-98% for critically ill patients, (3) promote early initiation of HFO, (4) consider HFO to avoid escalation to noninvasive ventilation, (5) consider HFO immediately postextubation to avoid re-intubation, (6) either HFO or conventional oxygen therapy may be used with patients who are immunocompromised, and (7) consider humidification for supplemental oxygen when flows > 4 L/min are used.

AARC Clinical Practice Guidelines: Artificial Airway Suctioning.

Artificial airway suctioning is a key component of airway management and a core skill for clinicians charged with assuring airway patency. Suctioning of the artificial airway is a common procedure performed worldwide on a daily basis. As such, it is imperative that clinicians are familiar with the most-effective and efficient methods to perform the procedure. We conducted a systematic review to assist in the development of evidence-based recommendations that pertain to the care of patients with artificial airways. From our systematic review, we developed guidelines and recommendations that addressed questions related to the indications, complications, timing, duration, and methods of artificial airway suctioning. By using a modified version of the RAND/UCLA Appropriateness Method, the following recommendations for suctioning were developed for neonatal, pediatric, and adult patients with an artificial airway: (1) breath sounds, visual secretions in the artificial airway, and a sawtooth pattern on the ventilator waveform are indicators for suctioning pediatric and adult patients, and an acute increase in airway resistance may be an indicator for suctioning in neonates; (2) as-needed only, rather than scheduled, suctioning is sufficient for neonatal and pediatric patients; (3) both closed and open suction systems may be used to safely and effectively remove secretions from the artificial airway of adult patients; (4) preoxygenation should be performed before suctioning in pediatric and adult patients; (5) the use of normal saline solution should generally be avoided during suctioning; (6) during open suctioning, sterile technique should be used; (7) suction catheters should occlude < 70% of the endotracheal tube lumen in neonates and < 50% in pediatric and adult patients, and suction pressure should be kept below -120 mm Hg in neonatal and pediatric patients and -200 mm Hg in adult patients; (8) suction should be applied for a maximum of 15 s per suctioning procedure; (9) deep suctioning should only be used when shallow suctioning is ineffective; (10) routine bronchoscopy for secretion removal is not recommended; and (11) devices used to clear endotracheal tubes may be used when airway resistance is increased due to secretion accumulation.

Factors Associated With a Positive View of Respiratory Care Leadership.

BACKGROUND: Burnout within health care is prevalent, and its effects are detrimental to patient outcomes, organizations, and individuals. Effects stemming from burnout include anxiety, depression, excessive alcohol and drug use, cardiovascular problems, time off work, and worse patient outcomes. Published data have suggested up to 50% of health care workers experience burnout and 79% of respiratory therapists (RTs) experience burnout. Leadership has been cited as a key driver of burnout among RTs. We aimed to identify factors associated with a positive or negative leadership perception. METHODS: A post hoc analysis of an institutional review board-approved survey to evaluate RT burnout, administered via REDCap by convenience sample to 26 health care centers (3,124 potential respondents) from January 17-March 15, 2021, was performed to identify factors associated with a positive view of leadership. Survey questions included validated tools to measure leadership, burnout, staffing, COVID-19 exposure, and demographics. Data analysis was descriptive, and logistic regression was performed to evaluate factors associated with leadership perception. RESULTS: Of 1,080 respondents, 710 (66%) had a positive view of leadership. Univariate analysis revealed those with a positive view of leadership were more likely to be working with adequate staffing, were rarely unable to complete all work, were less likely to be burned out, disagreed that people in this work environment were burned out, were less likely to miss work for any reason, more likely to be in a leadership position, worked fewer hours in intensive care, worked in a center affiliated with a medical school, worked day shift, were less likely to care for adult patients, and were more likely to be male. Logistic regression revealed providing care to patients with COVID-19 (odds ratio [OR] 5.8-10.5, P < .001-.006) was the only factor associated with a positive view of leadership, whereas working without adequate staffing (OR 0.27-0.28, P = .002-.006), staff RTs (OR 0.33, P < .001), work environment (OR 0.42, P = .003), missing work for any reason (OR 0.69, P = .003), and burnout score (OR 0.98, P < .001) were associated with a negative view of leadership. CONCLUSIONS: Most RTs had a positive view of their leadership. A negative leadership score was associated with higher burnout and missing work. This relationship requires further investigation to evaluate if changes in leadership practices can improve employee well-being and reduce burnout.

Burnout Among Respiratory Therapists Amid the COVID-19 Pandemic.

BACKGROUND: Burnout is a major challenge in health care and is associated with poor overall well-being, increased medical errors, worse patient outcomes, and low job satisfaction. There is scant literature focused on the respiratory therapist's (RT) experience of burnout, and a thorough exploration of RTs' perception of factors associated with burnout has not been reported. The aim of this qualitative study was to understand the factors associated with burnout as experienced by RTs amid the COVID-19 pandemic. METHODS: We performed a post hoc, qualitative analysis of free-text responses from a survey of burnout prevalence in RTs. RESULTS: There were 1,114 total and 220 free-text responses. Five overarching themes emerged from the analysis: staffing, workload, physical/emotional consequences, lack of effective leadership, and lack of respect. Respondents discussed feelings of anxiety, depression, and compassion fatigue as well as concerns that lack of adequate staffing, high workload assignments, and inadequate support from leadership contributed to feelings of burnout. Specific instances of higher patient acuity, surge in critically ill patients, rapidly evolving changes in treatment recommendations, and minimal training and preparation for an extended scope of practice were reported as stressors that led to burnout. Some respondents stated that they felt a lack of respect for both the RT profession and the contribution of RTs to patient care. CONCLUSIONS: Themes associated with burnout in RTs included staffing, workload, physical and emotional exhaustion, lack of effective leadership, and lack of respect. These results provide potential targets for interventions to combat burnout among RTs.

AARC Clinical Practice Guideline: Management of Adult Patients with Tracheostomy in the Acute Care Setting.

Management of patients with a tracheostomy tube includes many components of care provided by clinicians from various health care disciplines. In recent years, clinicians worldwide have demonstrated a renewed interest in the management of patients with tracheostomy due to the recognition that more effective and efficient management of this patient population is necessary to decrease morbidity and mortality and to optimize the value of the procedure. Commensurate with the goal of enhancing the care of patients with tracheostomy, we conducted a systematic review to facilitate the development of recommendations relevant to the care of adult patients with tracheostomy in the acute care setting. From our systematic review, clinical practice guidelines were developed to address questions regarding the impact of tracheostomy bundles, tracheostomy teams, and protocol-directed care on time to decannulation, length of stay, tracheostomy-related cost, tracheostomy-related adverse events, and other tracheostomy-related outcomes in tracheostomized adult patients in the acute care setting. Using a modification of the RAND/UCLA Appropriateness Method, 3 recommendations were developed to assist clinicians with tracheostomy management of adult patients in the acute care setting: (1) evidence supports the use of tracheostomy bundles that have been evaluated and approved by a team of individuals experienced in tracheostomy management to decrease time to decannulation, tracheostomy-related adverse events, and other tracheostomy-related outcomes, namely, improved tolerance of oral diet; (2) evidence supports the addition of a multidisciplinary tracheostomy team to improve time to decannulation, length of stay, tracheostomy-related adverse events, and other tracheostomy-related outcomes, namely, increased speaking valve use; (3) evidence supports the use of a weaning/decannulation protocol to guide weaning and removal of the tracheostomy tube to improve time to decannulation.

AARC Clinical Practice Guideline: Management of Pediatric Patients With Oxygen in the Acute Care Setting.

Oxygen therapy is one of the most important therapeutics offered in the clinical management of pediatric patients with cardiopulmonary disease. As the medical community seeks to ensure evidence-based management of clinical interventions, we conducted a systematic review with the goal of providing evidence-based clinical practice guidelines to answer questions surrounding the use of simple oxygen therapy to improve oxygenation, including a comparison of delivery devices, the efficacy of humidification, comparison of flows, and goals for use in children. Using a modification of the RAND/UCLA Appropriateness Method, we developed 4 recommendations to assist clinicians in the utilization of oxygen therapy in hospitalized children: (1) the use of an oxygen hood or tent in lieu of a low-flow oxygen device for consistent oxygen delivery is not recommended; (2) the use of high-flow nasal cannula therapy is safe and more effective than low-flow oxygen to treat infants with moderate to severe bronchiolitis; (3) the application of humidification with low-flow oxygen delivery is not recommended; (4) targeting [Formula: see text] 90-97% for infants and children with bronchiolitis is recommended; however, no specific target can be recommended for pediatric patients with respiratory diseases outside of bronchiolitis, and establishing a patient/disease oxygen therapy target upon admission is considered best practice.

Evaluation of an Interprofessional Tobacco Cessation Train-the-Trainer Program for Respiratory Therapy Faculty.

BACKGROUND: Although tobacco use is the leading cause of numerous preventable diseases, including respiratory illnesses, respiratory therapy students historically have received inadequate education for treating tobacco use and dependence. To address this gap, a respiratory-specific tobacco cessation training program was created and disseminated via a train-the-trainer approach for faculty in respiratory therapy and respiratory care programs across the United States. The purpose of this study was to estimate the impact of the live, web-based, train-the-trainer programs on participating faculty, and to assess changes in the extent of adoption of tobacco cessation content in respiratory therapy curricula across institutions in the United States. METHODS: Five live, 2.5-h web-based train-the-trainer programs for respiratory therapy faculty were conducted. To characterize impact of this national initiative, surveys were administered at baseline, immediately after training, and then at the end of the subsequent academic year. RESULTS: A total of 270 respiratory therapy faculty members participated in a live webinar training, representing 248 of the 402 (61.7%) respiratory therapy schools in the United States. At the end of the subsequent academic year, faculty reported significant improvement in their overall ability to teach tobacco cessation (P < .001). Nearly all (97.4%) agreed that the webinar train-the-trainer format was conducive to learning, and high self-ratings were reported for skills to teach the tobacco cessation content. During the 2016-2017 academic year, 1,248 respiratory therapy students received training. Faculty anticipated teaching a median of 3 h of tobacco cessation in the subsequent academic year. CONCLUSIONS: Training respiratory therapy faculty using a train-the-trainer approach had a positive impact on faculty's perceived confidence and ability to teach tobacco cessation at their institutions.