Long-Term Ventilation in Neuromuscular Patients: Review of Concerns, Beliefs, and Ethical Dilemmas.

BACKGROUND: Noninvasive mechanical ventilation (NIV) is an effective treatment in patients with neuromuscular diseases (NMD) to improve symptoms, quality of life, and survival. SUMMARY: NIV should be used early in the course of respiratory muscle involvement in NMD patients and its requirements may increase over time. Therefore, training on technical equipment at home and advice on problem solving are warranted. Remote monitoring of ventilator parameters using built-in ventilator software is recommended. Telemedicine may be helpful in reducing hospital admissions. Anticipatory planning and palliative care should be carried out to lessen the burden of care, to maintain or withdraw from NIV, and to guarantee the most respectful management in the last days of NMD patients' life. Key Message: Long-term NIV is effective but challenging in NMD patients. Efforts should be made by health care providers in arranging a planned transition to home and end-of-life discussions for ventilator-assisted individuals and their families.

An intervention to improve respiratory therapists' comfort with end-of-life care.

BACKGROUND: Respiratory therapists (RTs) are often involved in treating seriously ill and dying patients, but receive little instruction in end-of-life care. Prompted by several difficult cases, we developed an interdisciplinary program to introduce practicing RTs to ethical and end-of-life issues, and evaluated the program with a dedicated survey instrument. METHODS: A convenience sample of RTs from a university hospital and nearby community hospitals participated in a one-day interactive program, in 2005 (n = 49) and in 2008 (n = 36), that included role-play and didactic components. The questionnaire completed before and after the program included scales on comfort with end-of-life care and role in end-of-life care, and knowledge indices. RESULTS: Nearly all the RTs had recently encountered end-of-life situations, yet most had not received dedicated training and felt ill-prepared to deal with these situations; one third reported distress related to withdrawal of treatment. The 78 participants who completed both the before and after surveys had increased comfort with end-of-life care (P < .001) and their perception of their role in end-of-life care (P < .001). Knowledge about end-of-life care also increased (P < .001). CONCLUSIONS: A one-day interactive educational intervention can improve short-term RT comfort and role perception concerning end-of-life care. Evaluation of longer-term clinical outcomes and implementation in other venues is needed.

Micro-gas analysis system for measurement of nitric oxide and nitrogen dioxide: respiratory treatment and environmental mobile monitoring.

In this paper, novel microsystems for gas analysis and gas generation are described. The same microchannel devices covered with a gas permeable membrane were used for both the gas collection and the gas generation. For the first time, a dual liquid flow system was utilized in a micro-gas analysis system. Even though micropumps are utilized in the dual line microsystem, a good baseline was obtained in the NO2 measurement with Griess-Saltzman chemistry. The system was developed for on-site measurements in medical treatment; the treatment is of respiratory disease syndrome by NO inhalation and the monitoring is of the product NO and the harmful byproduct NO2. The system was also applied to mobile atmospheric monitoring. Chemical NO generation using the microchannel device was investigated for safe NO inhalation as an alternative to a NO generator based on pulsed arc discharge.

Assessing moral distress in respiratory care practitioners.

OBJECTIVE: To test the reliability and validity of a modified moral distress tool, originally developed for the nursing profession, on respiratory care practitioners. To describe the relationship between moral distress, career dissatisfaction, and job turnover in respiratory care. DESIGN: A 28-question survey was developed. Three categories of survey questions were predefined: "individual responsibility," "not in the patient's best interest," and "deception." Additional questions measured career dissatisfaction, job turnover, and demographic information. SETTING: University Hospital at the University of Virginia Health System, a 552-bed tertiary care hospital. SUBJECTS: Fifty-seven of 115 (49.6%) of respiratory care practitioners responded to the survey. INTERVENTIONS: Exploratory factor analysis was used to investigate the underlying factor structure. After we extracted theoretically meaningful factors, reliability of each factor was estimated. Multiple regression analysis was conducted to test if the underlying factors predicted career dissatisfaction and job turnover. MEASUREMENTS AND MAIN RESULTS: The factor analysis yielded a five-factor structure. Several questions in the "not in patient's best interest" category scored the highest moral distress including disagreements with surrogate decision makers and providing futile care. Higher scores were also found with questions regarding the perception of unsafe staffing and passively or actively participating in deception. None of the demographic variables predicted career dissatisfaction or job turnover. However, the perception of unsafe staffing was found to be a significant factor in predicting career dissatisfaction and job turnover. CONCLUSIONS: In this one-center pilot study, respiratory care practitioners reported experiencing moral distress in many areas of their practice. Distress related to the perception of unsafe staffing may be related to career dissatisfaction and job turnover. Further exploration of the factors that contribute to respiratory care practitioners' moral distress is needed, as well as implementing ways to ameliorate it.