Exploring knowledge gaps and research needs in respiratory therapy: a qualitative description study.

Background: Respiratory therapists (RTs) are expected to stay updated on technology, treatments, research, and best practices to provide high-quality patient care. They must possess the skills to interpret, evaluate, and contribute to evidence-based practices. However, RTs often rely on research from other professions that may not fully address their specific needs, leading to insufficient guidance for their practice. Additionally, there has been no exploration of knowledge gaps and research needs from RTs' perspectives to enhance their practice and patient outcomes. The research questions guiding this study were: (i) what are the perceived practice-oriented knowledge gaps? and (ii) what are the necessary research priorities across the respiratory therapy profession according to experts in respiratory therapy? Methods: A qualitative description study was conducted using semi-structured focus groups with 40 expert RTs from seven areas of practice across Canada. Data was analyzed using qualitative content analysis. Results: We identified four major themes relating to what these experts perceive as the practice-oriented gaps and necessary research priorities across the respiratory therapy profession: 1) system-level impact of RTs, 2) optimizing respiratory therapy practices, 3) scholarship on the respiratory therapy profession and 4) respiratory therapy education. Discussion: The findings establish a fundamental understanding of the current gaps and the specific needs of RTs that require further investigation. Participants strongly emphasized the significance of research priorities that consider the breadth and depth of the respiratory therapy profession, which underscores the complex nature of respiratory therapy and its application in practice. Conclusion: The unique insights garnered from this study highlight the knowledge gaps and research needs specific to RTs. These findings pave the way for further exploration, discourse, and research aimed at understanding the specific contributions and requirements of RTs.

A cross-sectional survey on the effects of ambient temperature and humidity on health outcomes in individuals with chronic respiratory disease.

Rationale: Extremes of temperature and humidity are associated with adverse respiratory symptoms, reduced lung function, and increased exacerbations among individuals living with chronic obstructive pulmonary disease (COPD). Objectives: To describe the reported effects of temperature and humidity extremes on the health outcomes, health status and physical activity (PA) in individuals living with COPD. Methods: A cross-sectional self-reported survey collected the effects on health status (COPD Assessment Test [CAT]), PA, and health outcomes in 1) moderate/ideal (14 to 21°C, 30 to 50% relative humidity [RH]), 2) hot and humid (≥ 25°C, > 50% RH) and 3) cold and dry (≤ 5°C, < 30% RH) weather conditions. Participants were ≥ 40 years old with COPD or related chronic respiratory diseases (e.g., asthma, sleep apnea, interstitial lung disease, lung cancer) and residing in Canada for ≥ 1 year. Negative responders to weather extremes were a priori defined as having a change of ≥ 2 points in the CAT. Main Results: Thirty-six participants responded; the mean age (SD) was 65 (11) years, and 23 (64%) were females. Compared to ideal conditions, 23 (66%) and 24 (69%) were negatively affected by cold/dry and hot/humid weather, respectively. Health status was significantly lower, and PA amount and difficulty level were reduced in hot/humid and cold/dry conditions compared with ideal conditions. The number of exacerbations in hot/humid was significantly higher compared to ideal conditions. Conclusions: More participants were negatively affected by extremes of weather: health status worsened, PA decreased, and frequency of exacerbations was higher compared to ideal. Future prospective studies should directly and objectively investigate different combinations of extreme temperature and humidity levels on symptoms and PA to understand their long-term health outcomes.

Changes in Quantity Measures of Various Forms of Cannabis Consumption among Emerging Adults in Canada in Relation to Policy and Public Health Developments.

Limited research examines changes in quantities of various forms of smoked/vaped cannabis among regular consumers, including emerging adults (EAs; 18 to 29) in Canada. This information is particularly relevant in the current context of emerging cannabis behaviors among EAs related to political amendments (legalization of cannabis), vaping-related lung illnesses (EVALI), and unprecedented pandemics (COVID-19). This study investigated the impact of legalizing recreational cannabis use in Canada, the EVALI epidemic, and the COVID-19 pandemic on the quantity of smoked/vaped forms of cannabis in relation to gender differences. EAs retrospectively self-reported the quantity of herb, hash, concentrates, joint size, and the number of joints and vaping cartridges in relation to three consecutive developments: pre-legalization, post-legalization; pre-EVALI, post-EVALI, pre-COVID-19, and during COVID-19. The quantity of herb use significantly increased among heavy users, and vaping quantity significantly increased among light users. Overall, an increasing incremental trend was observed in the average quantity of cannabis forms used over time. Males consumed higher quantities of all cannabis forms than females. More males than females reported using concentrates (p < 0.05). These findings reveal unique aspects of the amount of various cannabis forms smoked/vaped in relation to gender and provides preliminary evidence of cannabis consumption behaviors in relation to changing social and cultural contexts.

Long-term mechanical ventilation and transitions in care: A narrative review.

OBJECTIVES: Individuals dependent on long-term mechanical ventilation (LTMV) for their day-to-day living are a heterogenous population who go through several transitions over their lifetime. This paper describes three transitions: 1) institution/hospital to community/home, 2) pediatric to adult care, and 3) active treatment to end-of-life for ventilator-assisted individuals (VAIs). METHODS: A narrative review based on literature and the author's collective practical and research experience. Four online databases were searched for relevant articles. A manual search for additional articles was completed and the results are summarized. RESULTS: Transitions from hospital to home, pediatric to adult care, and to end-of-life for VAIs are complex and challenging processes. Although there are several LTMV clinical practice guidelines highlighting key components for successful transition, there still exists gaps and inconsistencies in care. Most of the literature and experiences reported to date have been in developed countries or geographic areas with funded healthcare systems. CONCLUSIONS: For successful transitions, the VAIs and their support network must be front-and-center. There should be a coordinated, systematic, and holistic plan (including a multi-disciplinary team), life-time follow-up, with bespoke consideration of jurisdiction and individual circumstances.

Representations of clinical practice guidelines and health equity in healthcare literature: An integrative review.

AIM: This paper reports an integrative review of international health literature that discusses health equity in relation to clinical practice guidelines (CPGs). BACKGROUND: Healthcare professionals (HCPs), policy makers, and decision makers rely on sound empirical evidence to make fiscally responsible and appropriate decisions about the allocation of health resources and health service delivery. CPGs provide statements and recommendations that aim to standardize care with an implicit goal of achieving equity of care among diverse populations. Developers of CPGs must be careful not to exacerbate inequity when making recommendations. As such, it is important to determine how equity is discussed within the context of CPGs. DESIGN: This integrative review was conducted according to integrative review methods as outlined by Whittemore and Knafl (2005), and Toronto and Remington (2020). These authors outlined a systematic process for the identification of relevant literature across health disciplines to examine the state of knowledge pertaining to a phenomenon such as health equity. SEARCH METHODS: The computerized databases PubMed, CINAHL, Cochrane, Embase, Medline, and Web of Science were searched using a combination of keywords. Search parameters included international peer-reviewed published, full-text, English language articles, editorials, and reports over the last decade (January 2011 to February 2022). A reference search of included articles was conducted to identify any additional articles. Dissertations and theses were not included. SEARCH OUTCOME: A total of 139 peer-reviewed English language articles were identified. RESULTS: The findings of this review revealed five main ways in which health equity is in context of CPGs including if they target or exacerbate inequity among disadvantaged populations, equity and CPG development, implementation, and evaluation, and checklists and tools to assist developers and users of CPG to consider equity. Although critical appraisal tools exist to assist users of CPGs assess and to evaluate how well CPGs address issues of equity, the definition of equity and how CPG development panels should incorporate and articulate it remains unclear and haphazard. As such, recommendations intended to be implemented by HCPs to optimize health equity remains diverse and unclear. CONCLUSION: The way equity is discussed within the reviewed health literature has implications for their uptake by and utility for HCPs. The ability of HCPs to implement CPGs may be hindered without an appreciation and integration of equity considerations across the various phases of CPG conceptualization, development, implementation, and evaluation, and their relevance and appropriateness to diverse geographic and socioeconomic contexts with variable access to health human resources and services. This situation could be improved if equity were more clearly articulated within all aspects of the CPG process. CLINICAL RELEVANCE: Understanding how equity is discussed in the literature relative to CPGs has implications for their uptake by and utility for HCPs in their goal of providing equitable health care. Successful implementation of CPGs with consideration equity could be improved if equity were more clearly articulated within all aspects of the CPG process including conceptualization, development, implementation, and evaluation.

The experience of family caregivers of ventilator-assisted individuals who participated in a pilot web-based peer support program: A qualitative study.

Introduction: Family caregivers play an important role supporting the day-to-day needs of ventilator-assisted individuals (VAIs) living at home. Peer-to-peer communication can help support these caregivers and help them sustain caregiving in the community. Online peer-support has been suggested as a way to help meet caregivers' support needs. Methods: A qualitative descriptive approach was used to elicit the perspectives of support received from caregivers who participated in a pilot web-based peer support program from October to December 2018. Data were collected through the transcripts of weekly online peer-to-peer group chats. Data were analyzed using an integration of thematic and framework analysis. Results: In total, eight caregivers and five peer mentors participated in the pilot. All five mentors and four of the caregivers participated in the weekly chats. We identified three themes, a) The experience of caregivers is characterized by unique challenges related to the complexity of VAI care including technology; b) Mentors and caregiver participants reciprocally share support; c) Despite hardships, there are things that make caregiving easier and joyful. Discussion: Our results add to the growing body of evidence pointing to the importance of online communities for supporting vulnerable caregivers. The reciprocal element of peer support, where trained mentors and untrained participants both benefit from support, can help sustain peer-support interventions. Despite the challenges of providing care to a VAI, there are facilitators that may help ease the caregiving experience and caregivers can benefit from ongoing support that is tailored to their needs along the caregiving trajectory.

Underrepresentation of Respiratory Therapists as Experts in Delphi Studies on Respiratory Practices and Research Priorities.

Delphi survey techniques are a common consensus method used to collect feedback from an expert panel to inform practices, establish guidelines, and identify research priorities. Collecting respiratory therapists' (RT) expertise and experiences as part of consensus-building methodologies is one way to ensure that they align with RT practices and to better influence respiratory care practice. This narrative review aimed to report the RT representation in expert panels of Delphi studies focused on respiratory therapy practices and research priorities. The research question that guided this review is: to what extent are RTs included as expert participants among published Delphi studies relate to respiratory therapy and research topics? We conducted a structured search of the literature and identified 23 papers that reported Delphi studies related to respiratory care practices and 15 that reported on respiratory-related research priorities. Delphi studies that focused on reporting consensus on respiratory care practices included the following: (1) mechanical ventilation, (2) high-flow nasal cannula therapy, (3) COVID-19 respiratory management, (4) home oxygen therapy, (5) cardiopulmonary monitoring, and (6) disease-specific guidelines. Delphi studies that focused on establishing respiratory research priorities included the following: (1) theory and practice-orientated knowledge gaps, and (2) priority research topics for empirical investigation. The results of this review suggest that RTs were rarely included as expert participants and, when involved, were minimally represented (5% to 33%). Given RTs' diverse and relevant experience in respiratory care, incorporating their perspectives to inform future education, respiratory care practices, and research priorities would allow evidence to better align with knowledge gaps deemed important for the respiratory therapy profession.

A Delphi Survey of Canadian Respiratory Therapists' Practice Statements on Pediatric Mechanical Ventilation.

BACKGROUND: Pediatric mechanical ventilation practice guidelines are not well established; therefore, the European Society for Paediatric and Neonatal Intensive Care (ESPNIC) developed consensus recommendations on pediatric mechanical ventilation management in 2017. However, the guideline's applicability in different health care settings is unknown. This study aimed to determine the consensus on pediatric mechanical ventilation practices from Canadian respiratory therapists' (RTs) perspectives and consensually validate aspects of the ESPNIC guideline. METHODS: A 3-round modified electronic Delphi survey was conducted; contents were guided by ESPNIC. Participants were RTs with at least 5 years of experience working in standalone pediatric ICUs or units with dedicated pediatric intensive care beds across Canada. Round 1 collected open-text feedback, and subsequent rounds gathered feedback using a 6-point Likert scale. Consensus was defined as ≥ 75% agreement; if consensus was unmet, statements were revised for re-ranking in the subsequent round. RESULTS: Fifty-two RTs from 14 different pediatric facilities participated in at least one of the 3 rounds. Rounds 1, 2, and 3 had a response rate of 80%, 93%, and 96%, respectively. A total of 59 practice statements achieved consensus by the end of round 3, categorized into 10 sections: (1) noninvasive ventilation and high-flow oxygen therapy, (2) tidal volume and inspiratory pressures, (3) breathing frequency and inspiratory times, (4) PEEP and FIO2 , (5) advanced modes of ventilation, (6) weaning, (7) physiological targets, (8) monitoring, (9) general, and (10) equipment adjuncts. Cumulative text feedback guided the formation of the clinical remarks to supplement these practice statements. CONCLUSIONS: This was the first study to survey RTs for their perspectives on the general practice of pediatric mechanical ventilation management in Canada, generally aligning with the ESPNIC guideline. These practice statements considered information from health organizations and institutes, supplemented with clinical remarks. Future studies are necessary to verify and understand these practices' effectiveness.

Risk Factors of Extubation Failure in Intubated Preterm Infants at a Tertiary Care Hospital in Oman.

Objectives: This study aimed to determine extubation failure (EF) rate among intubated preterm infants (<37 weeks gestational age [GA]) admitted to a tertiary care neonatal intensive care unit (NICU) in Oman and identify the risk factors associated with EF. Methods: This retrospective study included all intubated preterm infants (<37 weeks GA) admitted to the NICU at Sultan Qaboos University Hospital (SQUH) from January 2013 to December 2017. EF was defined as reintubation within seven days of planned extubation. Demographics, ventilation parameters, blood gas values and other possible risk factors of EF were collected. Statistical analysis included comparisons between EF and extubation success (ES) groups and a binary logistic regression analysis. Results: A total of 190 preterm infants were intubated during the study period with 140 eligible for analysis. A total of 106 infants (75.7%) were successfully extubated while 34 (24.3%) failed extubation. GA <28 weeks (P = 0.029), lower 1-minute Apgar score (P = 0.023) and patent ductus arteriosus diagnosis (P = 0.018) were significantly associated with EF. After the multivariate analysis, only GA <28 weeks predicted EF with an adjusted odds ratio of 2.621 (95% confidence interval: 1.118 - 6.146). Conclusion: EF rate in preterm infants admitted at the NICU of SQUH was within international rates. GA <28 weeks was the only predictor of the identified extubation failure. Neonatal practitioners need to seriously consider extreme prematurity in the extubation process and consider implementing strategies to decrease extubation failure in this group of fragile infants.

Outcomes and follow-up for children intubated in an adult-based community hospital system: A retrospective chart review.

Objectives: Emergency intubation is a high-risk procedure in children. Studies describing intubation practices in locations other than pediatric centres are scarce and varied. This study described pediatric intubations in adult-based community emergency departments (EDs) and determined what factors were associated with intubated-related adverse events (AEs) and described outcomes of children transferred to a quaternary care pediatric institution. Methods: This is a retrospective review of data collected between January 2006 and March 2017 at Lakeridge Health and Hospital for Sick Children (SickKids). Patients were <18 years and intubated in Lakeridge Health EDs; those intubated prior to ED arrival were excluded. Primary outcomes were intubation first-pass success (FPS) and AEs secondary to intubation. Results: Patients (n = 121) were analyzed, and median (interquartile range (IQR)) age was 3.7 (0.4-14.3) years. There were 76 (62.8%) FPS, with no difference between pediatricians (n = 25, 23%) or anaesthetists (n = 12, 11%), versus all other providers (paramedic n = 13 (12%), ED physician n = 37 (34%), respiratory therapist n = 20 (18%), transfer team n = 2 (2%)). The proportion of AEs was 24 (19.8%, n = 21 minor, n = 3 major), with no significant difference between pediatricians or anaesthetists versus all other providers. Data from 68 children transferred to SickKids were available, with the majority extubated within a short median (IQR) time of admission, 1.2 (0.29-3.8) days. Conclusions: Pediatric intubations were rare in a Canadian adult-based community hospital system. Most intubations demonstrated FPS with relatively few AEs and no significant differences between health provider type. Future investigations should utilize multi-centred data to inform strategies suited for organizations' unique practice cultures, including training programs.

Exploring the factors that influence equitable access to and social participation in dementia care programs by foreign-born population living in Toronto and Durham region.

This paper reports the findings of a qualitative study conducted in Ontario, Canada with the purpose of identifying the barriers and facilitating factors of access to dementia care by foreign-born individuals, including immigrants and refugees. Interview data revealed seven overarching themes related to access and participation in dementia care programs by migrants, including structural, process, and outcome barriers. Our study findings suggest that incorporating culturally inclusive activity components in recreational dementia care programs will promote program participation by individuals from ethno-cultural backgrounds. It is essential to train health care providers to assist with building competence in working with people from different cultural and linguistic backgrounds. To prevent normalization of symptoms of dementia and promote timely access to dementia care, it is important to focus on generating awareness and acknowledgement of dementia as an illness rather than as a normal part of aging or a condition associated with stigmatization.

Design and delivery of home-based telehealth pulmonary rehabilitation programs in COPD: A systematic review and meta-analysis.

RATIONALE: Home-based telehealth pulmonary rehabilitation (HTPR) for chronic obstructive pulmonary disease (COPD) is increasingly common partly due to the COVID-19 pandemic. However, optimal HTPR programming has not been described. This review provides a comprehensive overview of the design, delivery, and effects of HTPR for people with COPD. METHODS: Relevant databases were searched to July 2021 for studies on adults with COPD utilizing information or communication technology to monitor or deliver HTPR. A meta-analysis was performed on a subset of randomized controlled trials. RESULTS: Of 3124 records retrieved, 38 studies evaluating 1993 individuals with stable COPD (age 54-75 and FEV1 31-92% predicted) were included. Program components included exercise and education (n = 17) or exercise alone (n = 15) with in-clinic baseline assessments commonly conducted (n = 26). Few trials (n = 7) featured synchronous virtual exercise supervision. Aerobic exercise commonly involved walking (n = 14) and cycling (n = 11) and most programs included resistance training (n = 25). Exercise progressions and emergency action plans were inconsistently reported. Meta-analysis demonstrated HTPR was comparable to outpatient PR and had a greater effect than usual care for the modified Medical Research Council dyspnea scale (mean difference [95 %CI]: -0.49 [-0.77, -0.22], p < 0.01) and COPD Assessment Test score (-4.90 [-7.13, -2.67], p < 0.01). Neither HTPR nor outpatient PR impacted sedentary time or step count. Only 6% of studies reported race and no studies reported participant ethnicity. CONCLUSION: This review revealed the heterogeneity of HTPR program designs in COPD. HTPR programs had similar effects to outpatient PR programs and greater effects than usual care for people with COPD.

Assessing the inter-rater and intra-rater reliability of the Physical Therapy Competence Assessment for Airway Suctioning (PT-CAAS).

BACKGROUND AND PURPOSE: The Physical Therapy Competence Assessment for Airway Suctioning (PT-CAAS) is a recently developed measure to assess the clinical competence of physiotherapists who perform airway suctioning with adults. The purpose of this study was to assess the inter-rater and intra-rater reliability of the PT-CAAS. METHODS: Scoring rules were developed through expert consultation. Reliability was then assessed using nine videos of suctioning performed in a simulated learning environment. A repeated measures design was used, with two replicate sets of measurements made by each participant for all videos. Data were analyzed using a repeated measures model for the concurrent assessment of inter-rater and intra-rater reliability. Participants were physiotherapists with suctioning experience. RESULTS: Twenty physiotherapists completed initial scoring and re-scoring for all nine videos; their data were included in the analysis. Intraclass correlation coefficients (ICCs) for inter-rater reliability ranged from 0.569 [lower one-sided 95% confidence interval (CI): 0.395; standard error of measurement (SEM): 0.963] for infection control to 0.759 (lower one-sided 95% CI: 0.612; SEM: 0.722) for post-suctioning assessment and care. The inter-rater ICC for overall performance was 0.752 (lower one-sided 95% CI: 0.602; SEM: 0.660). ICCs for intra-rater reliability ranged from 0.759 (lower one-sided 95% CI: 0.197; SEM 0.721) for infection control to 0.860 (lower one-sided 95% CI: 0.544; SEM: 0.550) for post-suctioning assessment and care. The intra-rater ICC for overall performance was 0.867 (lower one-sided 95% CI: 0.559; SEM: 0.483). DISCUSSION: Evidence of moderate to good inter-rater and good intra-rater reliability was found; however, the results should be interpreted with caution given the wide CIs and relatively large SEMs. Improved assessor training and assessments of reliability using a larger sample size are recommended.

Changes in Cannabis Consumption Among Emerging Adults in Relation to Policy and Public Health Developments.

Background: Rates of cannabis use appear to be highest among emerging adults (EA). Evidence suggests that cannabis smoking, as well as alternate methods of cannabis use (e.g., vaping, edibles) have become a prevalent mode of consumption among this population. Substance use or misuse peaks during emerging adulthood and may be influenced by extreme economic, social and community developments, such as policy changes, public health concerns, and significant global events such as pandemics. For instance, it is highly likely that cannabis consumption trends among at-risk populations were influenced by the legalization of recreational cannabis in Canada, the declaration of the "e-cigarette or vaping product use associated lung injury" or "EVALI" outbreak, and the "COVID-19" pandemic. ObjectivesWe aimed to examine self-reported changes in frequency of cannabis use among EA in Canada (N = 312): pre-legalization, post-legalization; pre-EVALI, post-EVALI; pre-COVID-19, since-COVID-19. ResultsThere was a gradual increase in average frequency of smoking and vaping cannabis across the six different time intervals from the pre-legalization period (2018) to the COVID-19 pandemic period (2020). Males reported higher frequencies of cannabis smoking and vaping compared to females. ConclusionsDespite health concerns and expectations that EVALI and COVID-19 events would lead to decreased consumption, our results suggest an average increase in smoking and vaping cannabis, although the most notable increase was after legalization. There are important sex differences in behavioral factors of cannabis use in EA, though it appears that the "gender-gap" in cannabis consumption is closing. These findings may facilitate the development of intervention programs for policy measures to address cannabis-attributable outcomes in the face of contextual factors that promote use, such as public emergencies or changes in policy landscapes.

Health Care Use, Costs, and Survival Trajectory of Home Mechanical Insufflation-Exsufflation.

BACKGROUND: Despite expert recommendations for use, limited evidence identifies effectiveness of mechanical insufflation-exsufflation (MI-E) in addressing respiratory morbidity and resultant health care utilization and costs for individuals with neuromuscular disorders. We examined the impact of provision of publicly funded MI-E devices on health care utilization, health care costs, and survival trajectory. METHODS: This is a retrospective pre/post cohort study linking data on prospectively recruited participants using MI-E to health administrative databases to quantify outcomes. RESULTS: We linked data from 106 participants (8 age < 15 y) and determined annualized health care use pre/post device. We found no difference in emergency department (ED) visit or hospital admission rates. Following MI-E approval, participants required fewer hospital days (median [interquartile range] [IQR]) 0 [0-9] vs 0 [0-4], P = .03). Rates of physician specialist visits also decreased (median IQR 7 [4-11] vs 4 [2-7], P < .001). Conversely, rates of home care nursing and homemaking/personal support visits increased. Following MI-E, total costs were lower for 59.4%, not different for 13.2%, and higher for 27.4%. Physician billing costs decreased whereas home care costs increased. Regression modeling identified pre-MI-E costs were the most important predictor of costs after approval. At 12 months, 23 (21.7%) participants had died. Risk of death was higher for those using more medical devices (hazard ratio 1.12, [95% CI 1.02-1.22]) in the home. CONCLUSIONS: Provision of publicly funded MI-E devices did not influence rates of ED visits or hospital admission but did shift health care utilization and costs from the acute care to community sector. Although increased community costs negated cost savings from physician billings, evidence suggests costs savings from reduced hospital days and fewer specialist visits. Risk of death was highest in individuals requiring multiple medical technologies.

Effects of different high-flow nasal cannula flow rates on swallowing function.

BACKGROUND: High-flow nasal cannula therapy is used as a noninvasive treatment for people with acute respiratory disease. The aim of this study was to assess the impact of high-flow nasal cannula different flow rates on different characteristics of swallowing in healthy volunteers. METHODS: A prospective cohort study where healthy adult volunteers were subject to high-flow nasal cannula at different flow rates (0, 10, 20, 30, 40, and 50 L/min, in random order). The 30-mL water swallow test, repetitive saliva swallowing test, and 0-100 mm visual analog scale assessed aspiration, swallow frequency and effort, respectively. FINDINGS: Thirty subjects (mean age 30 years) were enrolled. Nine subjects (30.0%) choked at 10, 40 and 50 L/min during the 30-mL water swallow test (p < 0.05). Swallowing effort was increased during flow rates ≥20 compared to 10 L/min (p < 0.05). Flow rates ≥20 L/min resulted in lower number of swallows during the repetitive saliva swallowing test compared to 0 and 10 L/min (p < 0.05). INTERPRETATION: High-flow nasal cannula flow rates above 40 L/min associated with choking (increased risk of aspiration), and was associated with decreased swallowing function in healthy volunteers. It may be important to assess swallowing function in patients with various clinical conditions and treated with high-flow nasal cannula, especially those at risk of aspiration pneumonia.

Virtual mask fitting in pediatric patients during COVID-19: A case series.

INTRODUCTION: The COVID-19 pandemic has been an unprecedented threat to our health care system. Clinicians had to pivot and develop creative and timely "virtual" solutions to provide clinical care. Our aim was to develop a standardized approach to virtual "mask fitting" for children who are either being initiated or are already on existing long-term ventilation (LTV) at a pediatric hospital. CASE AND OUTCOMES: We present three cases involving the care of children who required mask fitting for noninvasive ventilation (NIV). LTV team consultations were delivered via videoconference or phone. With the guidance of the respiratory therapist (RT), the family caregiver (FC) took measurements on their child using a standardized clinical approach (developed by the LTV RTs). Based on the measurements, an appropriate mask was selected. Successful mask fit was based on patient/FC reports, as well as objective leak data obtained from the NIV download data. DISCUSSION: Virtual clinics used for managing patients in our LTV program were feasible and efficient resulting in improved workflow for the RTs and convenience for patients and FCs. Patients and FCs had significantly less pressure to attend in-person clinics and expressed high satisfaction in terms of their experience and importantly, meeting respiratory care needs. Within the context of COVID-19, remote patient education and intervention can be delivered effectively, while reducing the risk of exposure from in-person visits to hospital. CONCLUSION: A virtual/telemedicine program to manage pediatric patients requiring mask fitting for LTV was a feasible option during COVID-19.

The Withdrawal Assessment Tool to identify iatrogenic withdrawal symptoms in critically ill paediatric patients: A COSMIN systematic review of measurement properties.

RATIONALE, AIMS AND OBJECTIVES: The Withdrawal Assessment Tool (WAT-1) is one of the most widely used clinician-reported outcome measures to evaluate iatrogenic withdrawal symptoms (IWS) in critically ill children. However, the WAT-1's measurement properties have not been aggregated. Aggregating psychometric research on the WAT-1 will enhance appropriate use, and outline gaps for future empirical research. The aim of this systematic review is to critically appraise, compare, and summarize the measurement properties and evidence quality, and describe the interpretability and feasibility of the WAT-1 for identifying IWS symptoms in critically ill children. METHODS: A systematic search of Medline, Embase and CINAHL was conducted from inception to 15 April 2020. Study inclusion/exclusion, data extraction, and measurement property evidence and the modified GRADE quality scoring were applied according to the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) guidelines. RESULTS: Six studies were included in the review. There was sufficient, high-quality evidence for reliability, structural validity, criterion validity, measurement error, construct validity, and feasibility. More information is required to support the WAT-1's content validity, responsiveness, internal consistency, cross-cultural validity, and interpretability according to COSMIN guidelines. CONCLUSION: The results of this review indicate that the WAT-1 is a precise, easy to use measure of IWS in critically ill children despite some measurement property inconsistencies and gaps in the publication record. More information is required to support its content validity, responsiveness, internal consistency, cross-cultural validity, and interpretability.

Preliminary Design and Development of a Mechanical Ventilator Using Industrial Automation Components for Rapid Deployment During the COVID-19 Pandemic.

The novel coronavirus disease 2019 (COVID-19) created a shortage of mechanical ventilators in the healthcare sector, resulting in rationed distribution, ethical dilemmas, and high mortalities. This technical report outlines the design and product outcome of a mechanical ventilator based on readily available off-the-shelf components, minimizing the dependence on manufacturing facilities. The ventilator was designed to operate in both hospitals and remote locations, having the ability to operate off various gas pressures and low voltage supplies. Due to the COVID-19 restrictions, the challenges of developing a device in an online setting with minimal manufacturing assistance were explored. Within a 10-day period, the team designed, prototyped, and conducted preliminary feasibility testing on the mechanical ventilator. The proposed design was not intended to replace, or be used as a medically approved ventilator, but demonstrates the ability to exploit off-the-shelf components to enable fast development and assembly.

Education Experiences of Adult Subjects and Caregivers for Mechanical Insufflation-Exsufflation at Home.

BACKGROUND: In 2014, the Ministry of Health of Ontario, Canada, approved a program of public funding for specialist-prescribed mechanical insufflation-exsufflation (MI-E) devices for home use by individuals with neuromuscular respiratory insufficiency. Since 2014, 1,926 MI-E devices have been provided, exceeding device-use projections. Few studies describe the initial and ongoing education and support needs of home MI-E users and their family caregivers. This study aimed to explore the requirements of initial and ongoing education and support for MI-E device use, user confidence, and barriers and facilitators to home MI-E. METHODS: We conducted semi-structured interviews with new (< 6 months) and established (6-48 months) MI-E users and family caregivers. Device users rated their confidence on a numeric rating scale of 1 (not confident) to 10 (very confident). RESULTS: We recruited 14 new and 14 established MI-E users and caregivers (including 9 dyads), and we conducted 28 interviews. Both new and established users were highly confident in use of MI-E (mean ± SD scores were 8.8 ± 1.2 and 8.3 ± 2.1, respectively). Overall, the subjects were satisfied with their initial education, which consisted of a 1-2 h one-on-one session at home or in the clinic with a device demonstration and hands-on practice. Subjects viewed hands-on practice and teaching of caregivers as more beneficial than written materials. Ongoing support for device use was variable. Most subjects indicated a lack of specific follow-up, which resulted in uncertainty about whether they were using the MI-E device correctly or whether MI-E was effective. Facilitators to device utilization were ease of use, initial training, support from formal or informal caregivers, and symptom relief. Barriers were inadequate education on MI-E purpose, technique, and benefit; lack of follow-up; and inadequate knowledge of MI-E by nonspecialist health providers. CONCLUSIONS: The current model of home MI-E education at initiation meets user and caregiver needs. Better ongoing education and follow-up are needed to sustain the benefits through assessment of MI-E technique and its effectiveness.