Clinical Practice of High-Flow Nasal Cannula Therapy in ARDS Patients: A Cross-Sectional Survey of Respiratory Therapists.

Background: High-flow nasal cannula (HFNC) is an essential non-invasive oxygen therapy in acute respiratory distress syndrome (ARDS) patients. Despite its wide use, research assessing the knowledge, practice, and barriers to using HFNC among respiratory therapists (RT) is lacking. Methods: A cross-sectional questionnaire was conducted among RTs in Saudi Arabia between December 19, 2022, and July 15, 2023. Data were analyzed as means and standard deviation or frequency and percentages. A Chi-square test was used to compare the differences between groups. Results: A total of 1001 RTs completed the online survey. Two-thirds of the respondents 659 (65.8%) had received training in using HFNC and 785 (78.4%) had used HFNC in clinical settings. The top conditions for HFNC indication were COVID-19 (78%), post-extubation (65%), and do-not-intubate patients (64%). Participants strongly agreed that helping maintain conversation and eating abilities (32.95%) and improving shortness of breath (34.1%) were advantages of HFNC. Surprisingly, 568 (57%) of RT staff did not follow a protocol for HFNC with ARDS patients. When starting HFNC, 40.2% of the participants started with FiO2 of 61% to 80%. Additionally, high percentages of RT staff started with a flow rate between 30 L/minute and 40 L/minute (40.6%) and a temperature of 37°C (57.7%). When weaning ARDS patients, 482 (48.1%) recommended first reducing gas flow by 5-10 L/minute every two to four hours. Moreover, 549 (54.8%) believed that ARDS patients could be disconnected from HFNC if they achieved a flow rate of <20 L/minute and FiO2 of <35%. Lack of knowledge was the most common challenge concerning HFNC implementation. Conclusion: The findings revealed nuanced applications marked by significant endorsement in certain clinical scenarios and a lack of protocol adherence, underscoring the need for uniform, evidence-based guidelines and enhanced training for RTs. Addressing these challenges is pivotal to optimizing the benefits of HFNC across varied clinical contexts.

A population-based study of 15,000 people on Knowledge and awareness of lung cancer symptoms and risk factors in Saudi Arabia.

Background: Lung cancer is currently the most fatal form of cancer worldwide, ranking as the fourth most prevalent type in Saudi Arabia, particularly among males. This trend is expected to increase with growing population, lifestyle changes, and aging population. Understanding the awareness of the Saudi population regarding the risk factors and symptoms of lung cancer is necessary to attenuate the predicted increase in cases. Method: A cross-sectional, population-based survey was performed using a previously validated questionnaire (Lung CAM). Multiple linear regression analysis was used to assess variables associated with deficiency in knowledge and awareness of risk factors and symptoms of lung cancer. Results: Majority of the 15,099 respondents were male (65%), aged between 18 and 30 years (53%), 50% of which were educated up to a bachelor's degree level. Overall awareness of lung cancer signs and symptoms was 53%, with painful cough and coughing up blood being the best-known symptoms. Conversely, persistent shoulder pain (44%) and clubbing fingers (47%) were the least known lung cancer symptoms. Also, 60% of the respondents showed low confidence in identifying the signs and symptoms of lung cancer. The overall awareness of the risk factors for lung cancer development was 74%, with first-hand (74%) and second-hand (68%) smoking being the most known risk factors. However, only ≤ 62% know the other non-smoking risk factors. Awareness of the risk factors and symptoms of lung cancer depended on age, gender, education, marital and employment status (p < 0.001). Conclusion: Public awareness of the risk factors and symptoms of lung cancer in Saudi Arabia is inadequate and heavily dependent on education and socio-economic status. Awareness can be improved through campaigns to raise awareness about other lesser-known lung cancer risk factors and symptoms.

E-cigarette use and respiratory symptoms in adults: A systematic review and meta-analysis.

INTRODUCTION: Electronic cigarette (e-cigarette) use is gaining popularity among adults. Monitoring e-cigarette-induced respiratory symptoms is crucial for both clinical and regulatory purposes. We systematically reviewed the current literature to understand the prevalence of respiratory symptoms among exclusive e-cigarette users, dual users, and former smokers. METHODS: Databases searched included PubMed, CINAHL, Cochrane Library, Embase, and Scopus. We included all English-language, empirical quantitative articles that explored the prevalence of e-cigarette-related respiratory symptoms. Random-effects models were utilized in conducting the meta-analyses. The quality of identified studies was evaluated using the NIH Study Quality Assessment Tools. This study is registered with PROSPERO(#CRD42020165973). RESULTS: The literature search identified 1240 references. After removing duplicates and screening for eligibility, 168 studies were included in the final review. The majority of included studies reported a wide range of adverse respiratory symptoms. The respiratory symptoms were prevalent among the exclusive e-cigarette users, dual users, and those who switched from combustible cigarettes to e-cigarettes. Further, out of the RCT studies, 5 were rated as good quality, while 3 were rated as fair. Among the observational studies, 24 were rated as good quality, and 9 were rated as fair. The two experimental studies were both rated as fair quality. CONCLUSIONS: Continued monitoring of respiratory symptoms among e-cigarette users is warranted. Due to the heterogeneity and inconsistencies among studies, which limit result interpretation and highlight the need for studies assessing causal inference, further research using robust study designs is essential. This will provide clinicians with comprehensive knowledge about the potential respiratory risks of e-cigarette use.

Knowledge and practice of using airway pressure release ventilation mode in ARDS patients: A survey of physicians.

Background: Limited data is available on awareness and clinical management of the airway pressure release ventilation (APRV) mode of ventilation for acute respiratory distress syndrome (ARDS) patients among physicians who work at in adult critical areas. This study aimed to assess the knowledge and current practice of using APRV mode with ARDS patients and identify barriers to not using this mode of ventilation among physicians who work in adult critical areas in Saudi Arabia. Methods: Between November 2022 and April 2023, a cross-sectional online survey was disseminated to physicians who work in adult critical areas in Saudi Arabia. The characteristics of the respondents were analyzed using descriptive statistics. Percentages and frequencies were used to report categorical variables. Results: Overall, 498 physicians responded to the online survey. All responders (498, 100 %) reported that APRV is indicated in patients with ARDS, but 260 (52.2 %) did not know if there was an institutionally approved APRV protocol. Prone positioning was the highest recommended intervention by 164 (33.0 %) when a conventional MV failed to improve oxygenation in patients with ARDS. 136 (27.3 %) responders stated that the P-high should be set equal to the plateau pressure on a conventional ventilator while 198 (39.8 %) said that P-low should be 0 cmH2O. Almost half of (229, 46.0 %) responders stated that the T-high should be set between 4 and 6 s, while 286 (57.4 %) said that the T-low should be set at 0.4-0.8 s. The maximum allowed tidal volume during the release phase should be 4-6 ml/kg. Moreover, just over half (257, 51.6 %) believed that the maximum allowed P-high setting should be 35 cmH2O. One third of the responders (171, 34.3 %) stated that when weaning patients with ARDS while in APRV mode, the P-high should be reduced gradually to reach a target of 10 cmH2O. However, 284 (36.9 %) thought that the T-high should be gradually increased to reach a target of 10 s. Most responders (331, 66.5 %) felt that the criteria to switch the patient to CPAP would be to have an FiO2 ≤ 0.4, P-high ≤10 cm H2O, and T-high ≥10 s. Lack of training has been the most common barrier to not using APRV by 388 (77.9 %). Conclusion: There is a lack of consensus on the use of APRV mode, probably due to several barriers. While there were some agreements on the management of ventilation and oxygenation, there were variations in the selection of the initial setting of APRV. Education, training, and the presence of standardized protocols may help to provide better management.

Small airways dysfunction: The importance of utilising Z-scores to define MMEF abnormalities in clinical practice.

Background: The small airways comprise the largest cross-sectional area of the lungs, however, assessing and reporting abnormalities for this region of the bronchial tree has been practically and scientifically uncertain. Methods: Using routinely collected spirometry data for patients with either asthma or COPD, the accuracy of % predicted values for defining small airways dysfunction was assessed. A z-score of ≤ -1.645 of the maximal-mid expiratory flow (MMEF) was used as the gold standard for defining abnormality in the small airways. Results: Records of 3396 patients were included in the analysis. The false positive (FP) rates were 24.6 %, 16.1 %, 11.5 %, or 7.9 % when the % predicted value of 80 %, 70 %, 65 %, or 60 % were used, respectively. Sex, age, and BMI were associated with FP rates. Males were more likely to be categorised as FP with odds ratio (OR) between 1.10 and 1.49 across % predicted groups. Age was associated with FP rates with an OR between 1.01 and 1.08. The BMI was also associated with FP rates with an OR of 1.03 across all % predicted groups. Assessing the association of age groups with FP rate showed that those above 60 years old were more likely to be categorised as FP with an OR between 1.23 and 73.2 compared to those less than 30 years old. Conclusion: When assessing the small airways in clinical practice or for scientific purposes, the % predicted values overestimate the actual impairment leading to FP interpretation. Utilising z-score values are recommended to assess the small airways using the spirometric index, MMEF.

Relationship Between Heart Disease and Obesity Indicators Among Adults: A Secondary Data Analysis.

Background Body mass index (BMI), waist circumference (WC), and hip circumference (HC) determine obesity. Several studies have examined the association between obesity and many diseases, including heart disease, and found it to be a substantial risk factor. However, the relationship between heart disease and obesity has not been investigated. This study investigated the relationship between heart disease and obesity indicators among adults encompassing sociodemographic and lifestyle factors. Methodology This cross-sectional study included data from 3,574 individuals who participated in the 2011-2014 National Survey of Midlife Development in the United States refresher. The presence or absence of heart conditions such as irregular heartbeat, heart murmur, heart attack, and heart failure was determined using self-reported questionnaires. The association between heart disease and obesity indicators such as BMI, WC, HC, and waist-to-hip ratio (WHR) was investigated using linear regression. Results After controlling for all factors, the findings demonstrated a significant relationship between heart disease and BMI, WC, and HC high scores of 1.12 kg/m2, 0.63 inches, and 0.81 inches, respectively. A higher score in all obesity indicators was linked to being 65 years or older; male gender (for HC); having a school/college level of education; being unmarried, divorced, or widowed; having a history of smoking; and avoiding alcohol use. Conclusions Heart disease and sociodemographic and lifestyle factors are substantially associated with a high score in all obesity indicators. The findings of this study are important because they can assist healthcare providers in implementing different therapies to prevent high BMI, WC, HC, and WHR.

The prevalence of bronchodilator responsiveness of the small airway (using mid-maximal expiratory flow) in COPD - a retrospective study.

BACKGROUND: Bronchodilator responsiveness (BDR) using FEV1 is often utilised to separate COPD patients from asthmatics, although it can be present in some COPD patients. With the advent of treatments with distal airway deposition, BDR in the small airways (SA) may be of value in the management of COPD. We aimed to identify the prevalence of BDR in the SA, utilizing maximal mid-expiratory flow (MMEF) as a measure of SA. We further evaluated the prevalence of BDR in MMEF with and without BDR in FEV1 and its association with baseline demographics, including conventional airflow obstruction severity and smoking history. METHODS: Lung function data of ever-smoking COPD patients were retrospectively analysed. BDR was evaluated 20 min after administering 2.5 mg of salbutamol via jet nebulizer. Increase in percent change of ≥ 12% and absolute change of ≥ 200 ml was used to define a BDR in FEV1, whereas an increase percent change of MMEF ≥ 30% was used to define a BDR in MMEF. Patients were classified as one of three groups according to BDR levels: group 1 (BDR in MMEF and FEV1), group 2 (BDR in MMEF alone) and group 3 (no BDR in either measure). RESULT: BDR in MMEF was present in 59.2% of the patients. Of note, BDR in MMEF was present in all patients with BDR in FEV1 (group 1) but also in 37.9% of the patients without BDR in FEV1 (group 2). Patients in group 1 were younger than in groups 2 and 3. BMI was higher in group 1 than in group 3. Baseline FEV1% predicted and FVC % predicted were also higher in groups 1 and 2 than in group 3. CONCLUSION: BDR in the SA (evaluated by MMEF) is common in COPD, and it is also feature seen in all patients with BDR in FEV1. Even in the absence of BDR in FEV1, BDR in MMEF is detected in some patients with COPD, potentially identifying a subgroup of patients who may benefit from different treatment strategies.

Needs Assessment for the Establishment of Master's Degree Programs in Respiratory Care in the Kingdom of Saudi Arabia.

Background: Despite recent advancements in the respiratory care (RC) profession, no single institution in the Kingdom of Saudi Arabia (KSA) offers a master's degree program in RC. Methods: A nationwide and validated survey was used to explore the current needs and interests in establishing RC master's degree programs in the KSA. The process included representatives from the healthcare industry, universities, and professional societies. Results: A total of 1250 stakeholders across the KSA completed the survey. The sample includes 722 (58%) males, 504 (40%) respiratory therapists, 547 (44%) students, 138 (11%) leaders, and 61 (5%) were academic respondents. Most respondents were from Central 491 (39%) and Eastern 307 (25%) regions, with 1003 (80%) of the total sample worked or studied in governmental sectors. A total of 574 (82%) of the leaders and RTs had Bachelor degree and 430 (61%) of them had 1-5 years working experience. According to 80% of the employers and employees, only 0-5% of the RTs in their organization had a master's degree. The calculated mean % of the agreement (agree/strongly agree) on the needs was 83% in all needs' assessment items, which shows a great support for establishing a master's in RC to meet the personal, professional and society needs. The mean % of the agreement for the level of interests among all participants was 86%, indicating a great level of interests in establishing a master degree in RC. The agreement % on the needs assessment and level of interests in establishing a master degree in RC in KSA were ≥80% in each stakeholder group. Conclusion: There are obvious needs and interests in establishing master's degree programs in RC in the KSA. A master's degree in RC should be established to address the growing needs for advanced RC services throughout the nation and enhance RC research.

The Status of Respiratory Care Education in Saudi Arabia: A National Survey of Program Directors.

Background: Respiratory Care Practitioner (RCP) is a vital healthcare professional in Saudi Arabia (SA). Many factors regarding the education of RCPs in SA are unknown, including the number of active institutions, levels of education and barriers to promoting the profession. Methods: A cross sectional-based survey was conducted between June 1st, 2020 and September 20th, 2020 in SA to explore the status of RCPs education. Institutions that offered RCP programs were identified through the Ministry of Education and Ministry of Defense academic programs websites. The RCP program directors were invited to participate in an electronic survey. Results: Among the 74 institutions searched, 23 indicated that they offered RC programs. Only 13 (56.52%) responded to the survey. Among all programs, four (17.39%) were inactive, 17 (73.91%) were governmental institutions, and only one (4.35%) obtained a national accreditation. From the 13 respondents, there were 1297 students enrolled and 123 full-time faculty members. None of the institutions reported offering postgraduate RC degrees. The respondents reported many barriers; however, shortage of staff (76.92%), lack of postgraduate programs (69.23%), lack of research activity (69.23%), and ineffective communications between institutions (61.54%) were the most reported barriers. Conclusion: The RC education in SA is developing but not well distributed throughout the country. The shortage of staff and the limited number of postgraduate degree holders potentially contributed to the delay in establishing postgraduate RC degrees, obtaining accreditation, and implementing subspecialties to advance the profession in terms of research and quality of care.

Incidence and risk factors of acute kidney injury in COVID-19 patients with and without acute respiratory distress syndrome (ARDS) during the first wave of COVID-19: a systematic review and Meta-Analysis.

BACKGROUND: Acute kidney injury (AKI) is common among patients with COVID-19. However, AKI incidence may increase when COVID-19 patients develop acute respiratory distress syndrome (ARDS). Thus, this systematic review and meta-analysis aimed to assess the incidence and risk factors of AKI, need for kidney replacement therapy (KRT), and mortality rate among COVID-19 patients with and without ARDS from the first wave of COVID-19. METHODS: The databases MEDLINE and EMBASE were searched using relevant keywords. Only articles available in English published between December 1, 2019, and November 1, 2020, were included. Studies that included AKI in COVID-19 patients with or without ARDS were included. Meta-analyses were conducted using random-effects models. RESULTS: Out of 618 studies identified and screened, 31 studies met the inclusion criteria. A total of 27,500 patients with confirmed COVID-19 were included. The overall incidence of AKI in patients with COVID-19 was 26% (95% CI 19% to 33%). The incidence of AKI was significantly higher among COVID-19 patients with ARDS than COVID-19 patients without ARDS (59% vs. 6%, p < 0.001). Comparing ARDS with non-ARDS COVID-19 cohorts, the need for KRT was also higher in ARDS cohorts (20% vs. 1%). The mortality among COVID-19 patients with AKI was significantly higher (Risk ratio = 4.46; 95% CI 3.31-6; p < 0.00001) than patients without AKI. CONCLUSION: This study shows that ARDS development in COVID-19-patients leads to a higher incidence of AKI and increased mortality rate. Therefore, healthcare providers should be aware of kidney dysfunction, especially among elderly patients with multiple comorbidities. Early kidney function assessment and treatments are vital in COVID-19 patients with ARDS.

Small Airways Response to Bronchodilators in Adults with Asthma or COPD: A Systematic Review.

BACKGROUND: Bronchodilator responsiveness (BDR) is commonly used in the diagnosis of lung disease. Although small airways dysfunction is a feature of asthma and COPD, physiological tests of small airways are not included in guidelines for BDR testing. This systematic review assessed the current evidence of BDR using small airways function in asthma and COPD. METHODS: The systematic review used standard methodology with the protocol prospectively registered on PROSPERO (CRD42020164140). Electronic medical databases (EMBASE and Medline) were searched using related keywords. Abstracts and full texts were screened independently by two reviewers. Studies that reported the change of physiological small airways function and FEV1 were included in the review. The revised Cochrane risk of bias tool for RCT and NIH quality assessment tool for cohort and cross-sectional studies were used to evaluate the studies. RESULTS: A total of 934 articles were identified, with 12 meeting the inclusion criteria. Ten studies included asthma patients, 1 study included COPD patients and 1 study included both asthma and COPD. A total of 1104 participants were included, of whom 941 were asthmatic, 64 had COPD and 109 were healthy controls. Studies were heterogeneous in design including the device, dose and time intervals for BDR assessment. A small airway BDR was seen for most tests in asthma and COPD, including oscillometry (R5-20, reactance (X5), area of reactance (AX) and resonant frequency (Fres)) and Maximal Mid Expiratory Flow. CONCLUSION: There is a measurable BDR in the small airways. However, with no consensus on how to assess BDR, studies were heterogeneous. Further research is needed to inform how BDR should be assessed, its clinical impact and place in routine clinical practice.

The diagnosis of asthma. Can physiological tests of small airways function help?

Asthma is a common, chronic, and heterogeneous disease with a global impact and substantial economic costs. It is also associated with significant mortality and morbidity and the burden of undiagnosed asthma is significant. Asthma can be difficult to diagnose as there is no gold standard test and, while spirometry is central in diagnosing asthma, it may not be sufficient to confirm or exclude the diagnosis. The most commonly reported spirometric measures (forced expiratory volume in one second (FEV1) and forced vital capacity assess function in the larger airways. However, small airway dysfunction is highly prevalent in asthma and some studies suggest small airway involvement is one of the earliest disease manifestations. Moreover, there are new inhaled therapies with ultrafine particles that are specifically designed to target the small airways. Potentially, tests of small airways may more accurately diagnose early or mild asthma and assess the response to treatment than spirometry. Furthermore, some assessment techniques do not rely on forced ventilatory manoeuvres and may, therefore, be easier for certain groups to perform. This review discusses the current evidence of small airways tests in asthma and future research that may be needed to further assess their utility.

Physiological tests of small airways function in diagnosing asthma: a systematic review.

BACKGROUND: Asthma is a common, heterogeneous disease that is characterised by chronic airway inflammation and variable expiratory airflow limitation. Current guidelines use spirometric measures for asthma assessment. This systematic review aimed to assess whether the most commonly reported tests of small airways function could contribute to the diagnosis of asthma. METHODS: Standard systematic review methodology was used, and a range of electronic databases was searched (Embase, MEDLINE, CINAHL, CENTRAL, Web of Science, DARE). Studies that included physiological tests of small airways function to diagnose asthma in adults were included, with no restrictions on language or date. The risk of bias and quality assessment tools used were Agency for Healthcare Research and Quality tool for cross-sectional studies and Quality Assessment of Diagnostic Accuracy Studies 2 for diagnostic test accuracy (DTA) studies. RESULTS: 7072 studies were identified and 10 studies met review criteria. 7 included oscillation techniques and 5 included maximal mid-expiratory flow (MMEF). Studies were small and of variable quality. In oscillometry, total resistance (R5) and reactance at 5 Hz (X5) was altered in asthma compared with healthy controls. The percentage predicted of MMEF was lower in patients with asthma compared with controls in all studies and lower than the % predicted forced expiratory volume in 1 s. In DTA of oscillometry, R5 showed a sensitivity between 69% and 72% and specificity between 61% and 86%. CONCLUSION: There were differences in the results of physiological tests of small airway function in patients with asthma compared with controls. However, studies are small and heterogeneous. Further studies are needed to assess the effectiveness of these tests on a larger scale, including studies to determine which test methodology is the most useful in asthma.

Global Current Practices of Ventilatory Support Management in COVID-19 Patients: An International Survey.

BACKGROUND: As the global outbreak of COVID-19 continues to ravage the world, it is important to understand how frontline clinicians manage ventilatory support and the various limiting factors. METHODS: An online survey composed of 32 questions was developed and validated by an international expert panel. RESULTS: Overall, 502 respondents from 40 countries across six continents completed the survey. The mean number (±SD) of ICU beds was 64 ± 84. The most popular initial diagnostic tools used for treatment initiation were arterial blood gas (48%) and clinical presentation (37.5%), while the national COVID-19 guidelines were the most used (61.2%). High flow nasal cannula (HFNC) (53.8%), non-invasive ventilation (NIV) (47%), and invasive mechanical ventilation (IMV) (92%) were mostly used for mild, moderate, and severe COVID-19 cases, respectively. However, only 38.8%, 56.6% and 82.9% of the respondents had standard protocols for HFNC, NIV, and IMV, respectively. The most frequently used modes of IMV and NIV were volume control (VC) (36.1%) and continuous positive airway pressure/pressure support (CPAP/PS) (40.6%). About 54% of the respondents did not adhere to the recommended, regular ventilator check interval. The majority of the respondents (85.7%) used proning with IMV, with 48.4% using it for 12-16 hours, and 46.2% had tried awake proning in combination with HFNC or NIV. Increased staff workload (45.02%), lack of trained staff (44.22%) and shortage of personal protective equipment (PPE) (42.63%) were the main barriers to COVID-19 management. CONCLUSION: Our results show that general clinical practices involving ventilatory support were highly heterogeneous, with limited use of standard protocols and most frontline clinicians depending on isolated and varied management guidelines. We found increased staff workload, lack of trained staff and shortage of PPE to be the main limiting factors affecting global COVID-19 ventilatory support management.