Direct observation of respiratory treatments in cystic fibrosis: parent-child interactions relate to medical regimen adherence.

OBJECTIVE: Use a standardized system to code parent-child interactions during respiratory treatments for cystic fibrosis (CF) and analyze relations between behaviors during treatments and medical regimen adherence. METHODS: A total of 15 families (53% girls; M age = 8.9 years; SD = 1.8) had three respiratory treatments recorded in the home environment and coded. Families provided six 24-hr recalls of child medical regimen activities, and electronic airway clearance time was recorded over 3 months to measure medical regimen adherence. RESULTS: Parent positive attention, instructions, and avoidance of negative statements were significantly related to child cooperation during respiratory treatments. Parental presence, positive attention, instructions, and child cooperation during treatments were related to higher respiratory adherence rates. CONCLUSIONS: Direct observation methodology has led to effective nutritional adherence intervention for children with CF. These preliminary data demonstrate that an observational method could also be used to develop interventions to promote respiratory medication adherence.

Nasal insufflation treatment adherence in obstructive sleep apnea.

BACKGROUND: Nasal insufflation (NI) is a novel treatment method that has been introduced for improving respiration during sleep. NI's warmed and humidified nasal airflow provides ventilatory assistance delivered as a rapidly dispersed pressure head, with minimal side wall pressures, that may affect treatment tolerability. The aim of the current study was to investigate objective and subjective adherence rates for NI therapy in mild to moderate obstructive sleep apnea (OSA). METHODS: Ten patients (three men and seven women; age, 51.3 ± 9.6 years; BMI, 32.2 ± 7.7 kg/m2 [mean ± sd]) with recently diagnosed mild to moderate OSA (10.9 ± 5.8 events/h) were investigated. A crossover design was used to compare adherence to NI and continuous positive airway pressure (CPAP) therapy using a range of objective and subjective measurements. Objective (sleep efficiency (%) and arousal indices (arousal/h)) and subjective evaluations of sleep quality were carried out each night in the laboratory. During in-home treatment, adherence for both therapies was assessed objectively (time on therapy) and subjectively (self-reported sleep diary). RESULTS: Objectively derived adherence values were comparable for CPAP and NI, with both treatment devices sharing similar usage per night (3.5 ± 2.5 vs. 3.6 ± 1.6 h/night; respectively) and the number of nights with at least 4 h of treatment (5.5 ± 4.3 vs. 6.8 ± 3.3 nights/trial, respectively). Self-reported adherence was significantly higher than objectively assessed adherence (p < 0.03). CONCLUSIONS: This study showed similar adherence to NI and CPAP over a short period of usage. A randomized clinical trial is now essential for determining the comparative effectiveness of NI therapy in relation to treatment with CPAP.

Implementation of physical activity programs after COPD hospitalizations: Lessons from a randomized study.

Pulmonary rehabilitation (PR), following an acute exacerbation of chronic obstructive pulmonary disease (COPD), has been found effective in some studies in reducing readmission rates as and has recently been recommended by the PR guidelines. However, very recent reports suggested that PR is not feasible after a hospital admission for a COPD exacerbation. The objective of this study is to investigate the knowledge gap on the underlying reasons for nonparticipation in PR in the posthospitalization period. We qualitatively analyzed the responses of 531 patients hospitalized for a COPD exacerbation who were not interested in participating in either PR (home or center based) or physical activity monitoring program after being discharged from the hospital. The responses were coded thematically, and independent reviewers compiled the raw data into themes. The characteristics of the 531 subjects (45% male) who declined the intervention are as follows: age was 70 ± 10 years, mean forced expiratory volume in one second (FEV1%) predicted 40 ± 16, and age, dyspnea, and airflow obstruction index 6.0 ± 1.6 (scale 0-10). The themes for not attending include lack of interest (39%), the perception of "being too ill or frail or disabled" (24%), the perception of being "too busy or having too much to do" (11%), distance or the need of travel (11%), commitment issues (7%), comorbidities (6%), and lack of social support (2%). We identified barriers for PR or just physical activity programs after a hospitalization that may affect implementation of such programs. Implementing posthospitalizations program in COPD may require patient engagement and mindful and compassionate professionals who may individualize program components to focus specific deficits and particularly patients' preferences.

Psychological interventions for individuals with cystic fibrosis and their families.

BACKGROUND: With increasing survival estimates for individuals with cystic fibrosis, long-term management has become an important focus. Psychological interventions are largely concerned with adherence to treatment, emotional and social adaptation and health-related quality of life. We are unaware of any relevant systematic reviews. OBJECTIVES: To determine whether psychological interventions for people with cystic fibrosis provide significant psychosocial and physical benefits in addition to standard medical care. SEARCH METHODS: Studies were identified from two Cochrane trials registers (Cystic Fibrosis and Genetic Disorders Group; Depression, Anxiety and Neurosis Group), Ovid MEDLINE and PsychINFO; unpublished trials were located through professional networks and Listserves. Most recent search of the Cystic Fibrosis and Genetic Disorders Group's register: 19 December 2013.Most recent search of the Depression, Anxiety and Neurosis Group's register: 12 November 2013. SELECTION CRITERIA: Randomised controlled studies of a broad range of psychological interventions evaluating subjective and objective health outcomes, such as quality of life or pulmonary function, in individuals of all ages with cystic fibrosis and their immediate family. We were interested in psychological interventions, including psychological methods within the scope of psychotherapeutic or psychosomatic mechanism of action (e.g. cognitive behavioural, cognitive, family systems or systemic, psycho-dynamic, or other, e.g. supportive, relaxation, or biofeedback), which were aimed at improving psychological and psychosocial outcomes (e.g. quality of life, levels of stress or distress, psychopathology, etc.), adaptation to disease management and physiological outcomes. DATA COLLECTION AND ANALYSIS: Three authors were involved in selecting the eligible studies and two of these authors assessed their risk of bias. MAIN RESULTS: The review includes 16 studies (eight new studies included in this update) representing data from 556 participants. Studies are diverse in their design and their methods. They cover interventions with generic approaches, as well as interventions developed specifically to target disease-specific symptoms and problems in people with cystic fibrosis. These include cognitive behavioural interventions to improve adherence to nutrition or psychosocial adjustment, cognitive interventions to improve adherence or those associated with decision making in lung transplantation, a community-based support intervention and other interventions, such as self-hypnosis, respiratory muscle biofeedback, music therapy, dance and movement therapy, and a tele-medicine intervention to support patients awaiting transplantation.A substantial proportion of outcomes relate to adherence, changes in physical status or other specific treatment concerns during the chronic phase of the disease.There is some evidence that behavioural interventions targeting nutrition and growth in children (4 to 12 years) with cystic fibrosis are effective in the short term. Evidence was found that providing a structured decision-making tool for patients considering lung transplantation improves patients' knowledge of and expectations about the transplant, and reduces decisional conflict in the short term. One study about training in biofeedback-assisted breathing demonstrated some evidence that it improved some lung function measurements. Currently there is insufficient evidence for interventions aimed at other aspects of the disease process. AUTHORS' CONCLUSIONS: Currently, insufficient evidence exists on psychological interventions or approaches to support people with cystic fibrosis and their caregivers, although some of the studies were promising. Due to the heterogeneity between studies, more of each type of intervention are needed to support preliminary evidence. Multicentre studies, with consequent funding implications, are needed to increase the sample size of these studies and enhance the statistical power and precision to detect important findings. In addition, multicentre studies could improve the generalisation of results by minimizing centre or therapist effects. Psychological interventions should be targeted to illness-specific symptoms or behaviours to demonstrate efficacy.

[Inhalation therapy, patient's perspective]. / Patientenpräferenz von Inhalern.

The cornerstone of drug application in obstructive pulmonary diseases is by inhalation as advocated by all treatment guidelines. Today, there exists an extensive choice of inhalers and new models. Numerous inhaler types are constantly being developed and introduced into the market making the "correct" selection a wearying task for the physician as well as for the patient. Improvement in the management of this aspect, which is often neglected in its importance in daily practice as well as in guidelines, is therefore reliant not only on the medications themselves but also on their effective delivery. Complicated inhaler mechanics and poor inhaler technique which do not meet the patient requirements and desires contribute to poor compliance eventually leading to poor disease control. In this review, the importance of inhaler acceptance and the degree of satisfaction with different inhaler types are discussed. This paper focuses on the behavioral and attitudinal evidence that the acceptance of the inhaler is linked to patient compliance, and its linkage on health and patient-reported outcomes.

Patient safety attitudes among respiratory therapists in Taiwan.

BACKGROUND: Safety attitude surveys have been widely conducted in various disciplines, but not among respiratory therapists (RTs), to assess clinician's awareness of patient safety. We conducted a nationwide survey in Taiwan to assess RTs' safety attitudes in several hospital settings. METHODS: We adapted the Safety Attitude Questionnaire for RTs, and, via the RTs' union, invited all Taiwan RTs to take the survey. The questionnaire assessed safety attitudes in 6 domains: teamwork climate, safety climate, job satisfaction, stress recognition, perception of hospital management, and perception of working conditions. We analyzed the associations between positive attitudes and each domain. RESULTS: The response rate was 60%. Overall, the RTs had low positive attitudes about the teamwork climate (37%), safety climate (21%), job satisfaction (29%), stress recognition (32%), perception of hospital management (24%), and perception of working conditions (21%). The positive attitudes to all safety domains were lower among senior RTs than among junior RTs. The RTs working in the medical centers had higher positive-attitude scores for stress recognition but lower scores for the other 5 safety domains than the RTs working in the (smaller) regional and district hospitals. CONCLUSIONS: Taiwanese RTs had low positive attitudes about the surveyed 6 safety domains in their hospitals. High work load, management of RTs under other professions, and lack of protocol use probably contribute to their low opinions about the patient safety situation and low job satisfaction.

Respiratory support withdrawal in intensive care units: families, physicians and nurses views on two hypothetical clinical scenarios.

INTRODUCTION: Evidence suggests that dying patients' physical and emotional suffering is inadequately treated in intensive care units. Although there are recommendations regarding decisions to forgo life-sustaining therapy, deciding on withdrawal of life support is difficult, and it is also difficult to decide who should participate in this decision. METHODS: We distributed a self-administered questionnaire in 13 adult intensive care units (ICUs) assessing the attitudes of physicians and nurses regarding end-of-life decisions. Family members from a medical-surgical ICU in a tertiary cancer hospital were also invited to participate. Questions were related to two hypothetical clinical scenarios, one with a competent patient and the other with an incompetent patient, asking whether the ventilator treatment should be withdrawn and about who should make this decision. RESULTS: Physicians (155) and nurses (204) of 12 ICUs agreed to take part in this study, along with 300 family members. The vast majority of families (78.6%), physicians (74.8%) and nurses (75%) want to discuss end-of-life decisions with competent patients. Most of the physicians and nurses desire family involvement in end-of-life decisions. Physicians are more likely to propose withdrawal of the ventilator with competent patients than with incompetent patients (74.8% × 60.7%, P = 0.028). When the patient was incompetent, physicians (34.8%) were significantly less prone than nurses (23.0%) and families (14.7%) to propose decisions regarding withdrawal of the ventilator support (P < 0.001). CONCLUSIONS: Physicians, nurses and families recommended limiting life-support therapy with terminally ill patients and favored family participation. In decisions concerning an incompetent patient, physicians were more likely to maintain the therapy.

Trajectories of adherence to airway clearance therapy for patients with cystic fibrosis.

OBJECTIVE: Although cross-sectional studies have demonstrated poor adherence to airway clearance therapy (ACT) for patients with cystic fibrosis (CF), no studies have identified longitudinal patterns of adherence. The objective was to characterize and identify predictors of ACT adherence trajectories for individuals with CF. METHODS: Secondary data analyses were conducted for a randomized clinical trial examining differences in three ACTs. Participants (n = 153; M = 14.3 years, 55% male, 86% Caucasian, baseline FEV(1)% predicted: M = 86.7)/primary caregivers completed Daily Phone Diaries, an empirically supported adherence measure, every 4 months. RESULTS: Group-based trajectory modeling revealed the best-fitting solution was a three-group model: low-adherence (14%), medium-adherence (49%), and high-adherence (37%) groups. ACT type was the only significant predictor of adherence trajectories. DISCUSSION: Three trajectories of adherence to ACT for patients with CF were found. With the identification of trajectories, adherence interventions can be targeted for the subgroup at highest risk in order to prevent poor health outcomes.

Efficacy of pulmonary rehabilitation in improving the quality of life for patients with chronic obstructive pulmonary disease: Evidence based on nineteen randomized controlled trials.

BACKGROUND: Increasing studies have shown that application of pulmonary rehabilitation may improve the quality of life of chronic obstructive pulmonary disease (COPD) patients. However, the results of some studies still remained controversial and sample size of them limited to small number of participants. A systematic review and meta-analysis was designed to evaluate the efficacy of pulmonary rehabilitation for improving the quality of life in patients with COPD. METHODS: We searched the Cochrane Library, PubMed, EMBASE and Web of Science up to March 29, 2019 to identify relevant randomized controlled trials (RCTs) analyzing and evaluating the efficacy of pulmonary rehabilitation (PR) in patients with COPD. Participants were randomly assigned to receive PR (intervention group) or usual care (controller group). We used St. George's Respiratory Questionnaire (SGRQ) scores as evaluating indicators of quality of life. Mean differences (MDs) with 95% confidence intervals (CIs) were estimated to compare the outcomes of the groups. We also performed subgroup analysis for the pooled results of pulmonary rehabilitation effects in COPD patients. Besides, sensitivity analysis was performed to examine the stability of the combined results. Two reviewers assessed trial quality and extracted data independently. All statistical analyses were performed using standard statistical procedures provided in Review Manager 5.2 and Stata 12.0. RESULTS: Nineteen randomized controlled trials (N = 1146 participants) were identified for the present analysis. Comparing pulmonary rehabilitation groups with usual care groups (control groups), statistically significant improvements were noted in total score of SGRQ, with MD of -6.53. In addition, life quality improvement of SGRQ scores was better than 5 units in symptoms score, impacts score and activity score, with MDs of -5.01, -7.23 and -6.08, respectively. CONCLUSIONS: Rehabilitation may constitute one of important components of the management of COPD and may be beneficial in improving the quality of life. Future research should focus on identifying which components of pulmonary rehabilitation are essential, its ideal length and location, the degree of supervision and intensity of training required and how long treatment effects persist.

Death and Dying: Tools to Help Respiratory Therapists Handle Frequent Exposure to End of Life Care.

Education and recognition of death anxiety are important for respiratory therapists. A vital component of respiratory therapy is managing mechanical ventilation and dealing with death and dying. For most institutions, respiratory therapy is a vital component of the rapid response team, code team, and trauma team. Removal of mechanical ventilation is a duty primarily bestowed upon the respiratory therapist. Exposure to death, on a frequent basis, can take an emotional toll and lead to burnout, stress, and increased turnover. Managers and leaders in the hospital must make efforts to provide counseling and education to support respiratory therapists and their ongoing exposure to death and dying. This paper examines coping mechanisms for physicians and paramedics, resulting in tools that can be used to provide support to the respiratory therapist.

Predicting Respiratory Therapists' Intentions to Use the Modified Early Warning Score by Using an Enhanced Technology Acceptance Model.

BACKGROUND: The modified early warning score (MEWS) is used to detect early clinical deterioration and to escalate care as needed. Respiratory therapists (RTs) usually do not use the MEWS even when it is implemented as a default in the electronic health record system. This study explored whether the technology acceptance model could predict the intentions of RTs to use the MEWS. METHODS: A validated survey that uses a pretest/posttest design was used to determine the effect of an educational intervention (lecture and interactive small group session) on RTs' MEWS knowledge. We also measured key determinants of the intention by RTs to use the MEWS based on the constructs of the technology acceptance model. The survey was distributed to 75 RTs employed at a Midwestern academic medical center. RESULTS: There was a 61% survey response rate. Statistical analysis of the survey data demonstrated that the educational intervention increased the MEWS knowledge score from 2.0 before education to 4.0 after education (P < .001). Moreover, there was a statistically significant increase in the behavioral intention score, from 3.0 before education to 4.0 after education (P < .001). Partial least squares structural equation modeling revealed that MEWS knowledge influenced perceived ease of use, which influenced attitude, which influenced behavioral intention. CONCLUSIONS: Numerous studies have demonstrated that a change in behavioral intention is a good predictor of change in behavior. The increase in the RTs' knowledge, attitude, and behavioral intention scores after MEWS education indicated that these RTs may be more inclined to use the MEWS if they were educated about its clinical relevance and if their attitude toward using it were favorable. Analysis of the study results also indicated that the technology acceptance model could serve as a framework to guide respiratory care managers in the development of strategies to successfully implement new systems or processes that are intended to be used by RTs.

Supporting the need for community exercise programs: a case study.

Introduction: Participation in exercise activities post spinal cord injury (SCI) can positively impact physical functioning and quality of life. Physically active individuals have improved functional performance compared with sedentary individuals with SCI. Consistent exercise interventions following SCI not only prompt neural recovery and offer myriad health benefits but they may also have persisting effects on functional abilities. Case presentation: A 29-year-old male subject had a 15-year history of a C5-C6 AIS B SCI. The subject demonstrated improvements in the outcome measures and he reported enhanced ability to cough and to clear secretions, as well as an enhanced overall quality of life, after undergoing a 14-week course of Spinal Mobility training in combination with inspiratory muscle training (IMT). In addition to the Spinal Mobility training and IMT, he continued to partake in his normal exercise routine, which consisted of aerobic and strength training 3 days per week. Discussion: This case reaffirms the benefits of consistent exercise training, in combination with IMT, for individuals with SCI. Community programs specifically targeted to individuals with SCI are needed. The subject's functional improvements demonstrate that incorporating Spinal Mobility training into a regular exercise routine may assist with functional gains in the chronic stage of SCI.

Psychological interventions for people with cystic fibrosis and their families.

BACKGROUND: With increasing survival estimates for cystic fibrosis (CF) long-term management has become an important focus. Psychological interventions are largely concerned with adherence to treatment, emotional and social adjustments and quality of life. We are unaware of any relevant systematic reviews. OBJECTIVES: Assess whether psychological interventions for CF provide significant psychosocial and physical benefits in addition to standard care. SEARCH STRATEGY: Trials were identified from two Cochrane trial registers (CF and Genetic Disorders Group; Depression, Anxiety and Neurosis Group), Ovid MEDLINE and PsychINFO; unpublished trials were located through professional networks and Listserves. Most recent search: September 2007. SELECTION CRITERIA: Randomised controlled trials of a broad range of psychological interventions in children and adults with CF and their immediate family. DATA COLLECTION AND ANALYSIS: Two authors independently selected relevant trials and assessed their methodological quality. MAIN RESULTS: The review includes 13 studies (five new at this update) representing data from 529 participants. Studies mainly assessed behavioural and educational interventions:1. gene pre-test education counselling for relatives of those with CF;2. biofeedback, massage and music therapy to assist physiotherapy;3. behavioural and educational interventions to improve dietary intake and airway clearance;4. self-administration of medication and education to promote independence, knowledge and quality of life; and5. systemic interventions promoting psychosocial functioning.A substantial proportion of outcomes were educational or behavioural relating to issues of adherence, change in physical status or other specific treatment concerns during the chronic phase of the disease. Some evidence was found for relative's acceptance of a genetic test for carrier status when using home-based rather than clinic-based information leaflets and testing. There is some evidence that behavioural interventions improve emotional outcomes in people with CF and their carers, and that psychoeducational interventions improve knowledge in the short term. There was no consistent effect on lung function, although one small study showed that biofeedback-assisted breathing re-training helped improve some lung function measurements. Some studies point to educational and behavioural interventions aiding nutrition and growth in people with CF. Currently there is insufficient evidence for interventions aimed at other aspects of the disease process. AUTHORS' CONCLUSIONS: Currently no clear evidence exists on the best psychological interventions to help people with CF and their carers manage the disease. Trials of interventions to improve adherence to treatment are needed. Multicentre approaches, with consequent funding implications, will increase the sample size of trials and enhance the power and precision of their findings.

An exploratory examination of medical gas booms versus traditional headwalls in intensive care unit design.

Should power, medical gases, and monitoring and communications systems be located in a headwall or a ceiling-mounted boom in intensive care unit (ICU) rooms? Often, only the financial costs could be determined for the options, whereas data regarding its potential influence on teamwork, safety, and efficiency are lacking. Hence, purchase decisions are more arbitrary than evidence based. This study simulated care delivery in settings with a traditional headwall and a ceiling boom. Observed were the way the following elements were managed and the extent either system affected flexibility, ergonomics, and teamwork: tubing for intravenous fluids, medical gases, and suction drainage; monitoring leads and equipment power cords; and the medical equipment itself. Simulation runs involving 6 scenarios were conducted with the voluntary participation of 2 physicians, 2 nurse practitioners, 2 respiratory therapists, and 4 registered nurses at a children's tertiary care center in December 2007. Analysis suggests that booms have an advantage over headwalls in case of high-acuity ICU patients and when procedures are performed inside patient rooms. However, in case of lower-acuity ICU patients, as well as when procedures are not typically conducted in the patient room, booms may not provide a proportionate level of advantage when compared with the additional cost involved in its procurement.

Caring for critically ill patients with advanced COPD at the end of life: a qualitative study.

Providing expert critical care for the high acuity patient with a diagnosis of COPD at the end of life is both complex and challenging. The purpose of this descriptive study was to examine intensive care unit (ICU) clinicians' perspectives on the obstacles to providing quality care for individuals with COPD who die within the critical care environment. Transcripts of three focus groups of ICU clinicians were analyzed using thematic analysis. The three themes of "managing difficult symptoms", "questioning the appropriateness of life-sustaining care" and "conflicting care priorities" were noted to be significant challenges in providing high quality end of life care to this population. Difficulties in palliating dyspnea and anxiety were associated with caregiver feelings of helplessness, empathy and fears about "killing the patient". A sense of futility, concerns about "torturing the patient" and questions about the patient/family's understanding of treatment pervaded much of the discourse about caring for people with advanced COPD in the ICU. The need to prioritize care to the most unstable ICU patients meant that patients with COPD did not always receive the attention clinicians felt they should ideally have. Organizational support must be made available for critical care clinicians to effectively deal with these issues.

Ventilator Boot Camp Improves the Knowledge and Skills Associated With Mechanical Ventilator Use During Interfacility Transport of Intubated Pediatric Patients.

BACKGROUND: The American Academy of Pediatrics Section on Transport recommends the use of portable ventilators during the transport of patients with advanced airways. We sought to identify knowledge gaps and evaluate the effectiveness of a transport ventilator competency boot camp. METHODS: Electronic health records of children requiring ventilatory support during air and ground interfacility transport from January 1 through December 31, 2015, were reviewed to determine when manual ventilation was used in lieu of a portable ventilator, and simulations were constructed from commonly occurring scenarios. All registered respiratory therapists trained in air and ground critical-care transports participated. Demographic data were collected. We assessed performance on 3 facilitated simulated scenarios using a ventilator connected to a low-fidelity pediatric mannequin attached to breathing simulator. Scores were based on the participants' ability to correctly perform pre-use checks, select and optimize ventilator settings, set alarms, and complete safety checks. A 60-min interactive education intervention was conducted between the pre- and post-assessments. The pre-assessment, intervention, and post-assessment were conducted 6 weeks apart. De-identified assessments were scored, and results were shared after study completion. Descriptive statistics reported participant demographics. Paired t tests compared before and after assessments. Statistical significance was established at P < .05. RESULTS: A total of 172 electronic health records were reviewed. Manual ventilation was used more frequently in toddlers requiring pressure control ventilation; noninvasive ventilation was rarely used. A total of 17 registered respiratory therapists participated; 18% were male, 41% had 6-9 years of tenure and 5 years of experience with our transport team. Completing ventilator pre-use check and engaging alarms provided the most opportunity for improvement. Improvements were greater with the use of noninvasive ventilation (P = .006) than pressure control ventilation (P = .10) and volume control ventilation use (P = .07). CONCLUSIONS: Quality data were useful in identifying areas requiring knowledge and competency assessment. Re-assessment results validated the need to conduct education and competency assessment at defined intervals.

Results of a Pulmonologist Survey Regarding Knowledge and Practices With Inhalation Devices for COPD.

BACKGROUND: COPD guidelines advise on inhaled medication use, yet no advice is offered on when to use and which type of patient could benefit from a specific delivery device. We investigated pulmonologists' perception of their knowledge and practices with delivery devices for COPD management. METHODS: An online survey was designed by a steering committee of American Thoracic Society clinicians and scientists and conducted by a national market research firm between January 7 and 29, 2016. RESULTS: Two hundred and five respondents completed the survey. Nearly 80% of the respondents believed that they were very knowledgeable in COPD management and the use of medications; 68% believed that they were knowledgeable about preventing exacerbations. Ninety-eight percent of the respondents stated that they were at least somewhat knowledgeable about devices. Many respondents (70%) stated that small-volume nebulizers were more effective than dry powder inhalers and pressurized metered-dose inhalers in the management of COPD exacerbations, and 63% believed that these were more effective in severe COPD (modified Medical Research Council dyspnea scale grade 4). Only 54% of the respondents discussed device options with their patients. Physician screening for physical or cognitive impairments that could impact device choices was 53% and 16%, respectively. Seventy percent of the respondents discussed device use, whereas 9% discussed cleaning and storage during a patient's first visit. Few respondents were very knowledgeable in teaching patients how to use devices (43%) and, specifically, how to use (32%) or clean and/or maintain (20%) small-volume nebulizers. CONCLUSIONS: Most respondents were confident in their knowledge about treating COPD. Fewer respondents were confident about the use and maintenance of inhalation devices, and most respondents desired to learn more about inhalation devices.

Results of a Patient Survey Regarding COPD Knowledge, Treatment Experiences, and Practices With Inhalation Devices.

BACKGROUND: Successful inhalation therapy depends on the ability of patients with COPD to properly use devices. We explored subjects' COPD knowledge, including education they receive from health care providers, treatment experiences, and practices with inhalation devices. METHODS: A multiple-choice online survey, developed by a steering committee of American Thoracic Society clinicians and scientists, was administered to subjects with COPD who were sourced from the Harris Poll Online panel. RESULTS: Of the 254 respondents (mean age 61.8 y; 49% males), most subjects (82%) claimed to understand their disease and available treatments, yet COPD symptoms and causes were well known to only 45% and 44% of subjects, respectively. Forty-three percent of subjects had ever used a pressurized metered-dose inhaler or dry-powder inhaler. Of the 54% of subjects who had ever used a small-volume nebulizer (SVN), 63% considered this device to be easy to use, 55% considered it to be fast-acting, 53% considered it to be convenient, and 38% considered it to be essential for treatment. Among subjects who had ever used them, SVNs were preferred by 54% over other devices. One third of subjects desired more extensive education during office visits; 25% felt the time was insufficient to cover questions, and 15% felt their concerns about COPD treatment(s) were ignored. Subjects believed physicians (32%), nurses (26%), and no single provider (28%) were primarily responsible for training and assessing proper inhalation technique. CONCLUSION: The survey showed differences between patients' beliefs and knowledge of COPD; the need for continuous education from health care providers, particularly on inhalation devices; and extensive use of pressurized metered-dose inhalers and dry-powder inhalers despite positive perceptions of SVNs.

Experiences with unregulated respite care among family caregivers of children dependent on respiratory technologies.

Increasingly, children with respiratory conditions who are dependent on medical technology (e.g. ventilators and tracheostomies) are cared for at home by family caregivers who are at risk for significant health, financial and social burdens. In many jurisdictions, access to quality respite is varied and often the availability of regulated (nursing) providers is insufficient. Rather than go without, some families have secured alternative and unregulated providers to supplement formal home care systems. The purpose of this study was to explore the experiences of family caregivers of children dependent on respiratory technologies who have used unregulated providers for in-home respite care. Through an interpretative description approach, data was gathered from 20 semi-structured parent interviews and analysed using constant comparative analysis. Four themes emerged from the data, which were conceptualized as both opportunities and tensions that parents experienced with both unregulated and regulated home care providers: finding the right fit for the child and family; trusting the provider is everything; using unregulated providers offers unique advantages; and accepting that regulated and unregulated care present challenges. Findings signal that unregulated providers play a pivotal role in supporting parents of children who are dependent on respiratory technologies. Implications for practice, policy and future research initiatives are discussed.

[Physiological and behavioral responses of newborns at risk to nurse's care]. / Respostas fisiologicas e comportamentais do recém-nascido de risco durante o cuidado da enfermeira.

Daily tasks carried out by nurses working at the Neonatal Unit (NU) require expanding practice and observation skills, from the perspective of professional activities. The aim of this study was to investigate physiological and behavioral responses of newborns (NB) at risk being cared by NU nurses. This exploratory-descriptive study was carried out with 33 NB at risk admitted to the NU of a public maternity ward, in Fortaleza, Ceara, Brazil, from December/2004 to March/2005. Direct observation of care provided by, nurses to the NB, and medical records on birth conditions were used. The most frequent physiological response was change in the heart rate, followed by changes in oxygen saturation and skin color. It was also observed that, by means of face expression, body movement, and crying, that infants tried to communicate their feelings.