Physiologic Monitoring: Improving Safety or Increasing Risk?

This paper will present a focused and personal history of physiologic monitoring, beginning with the discovery of modern anesthesia and its development from a technical practice to a scientific discipline. Emphasis will be on the essence of monitoring in the anesthesia evolution, and this work will attempt to answer the question of how to evaluate the impact of monitoring on patient outcome. Understanding that monitors are passive and that only caregivers using monitors can impact outcome is at the crux of this approach to analysis.

Variability in Mechanical Ventilation: What's All the Noise About?

Controlled mechanical ventilation is characterized by a fixed breathing frequency and tidal volume. Physiological and mathematical models have demonstrated the beneficial effects of varying tidal volume and/or inspiratory pressure during positive-pressure ventilation. The addition of noise (random changes) to a monotonous nonlinear biological system, such as the lung, induces stochastic resonance that contributes to the recruitment of collapsed alveoli and atelectatic lung segments.

Elective intubation.

Endotracheal intubation is a commonly performed operating room (OR) procedure that provides safe delivery of anesthetic gases and airway protection during surgery. The most common intubation technique in the perioperative environment is direct laryngoscopy with orotracheal tube insertion. Infrequently, difficulties that require an alternative intubation technique are encountered due to patient anatomy, equipment limitations, or patient pathophysiology.

Respiratory Care year in review 2013: airway management, noninvasive monitoring, and invasive mechanical ventilation.

Fundamental to respiratory care practice are airway management, noninvasive monitoring, and invasive mechanical ventilation. The purpose of this paper is to review the recent literature related to these topics in a manner that is most likely to have interest to the readers of Respiratory Care.

Survey of directors of respiratory therapy departments regarding the future education and credentialing of respiratory care students and staff.

Objective: Information and opinions were sought on the need for graduating and practicing respiratory therapists to obtain 66 competencies necessary for practice in 2015 and beyond, the required length of respiratory care programs, the educational needs of practicing therapists, current and future workforce positions, and the appropriate credential needed by graduating therapists.

Methods: Survey responses from respiratory therapy department directors or managers are the basis of this report. After pilot testing and refining the questions, a self-administered, Internet based, American Association for Respiratory Care (AARC) endorsed survey was used to gather information from 2,368 individuals designated as respiratory therapy department directors or managers in the AARC membership list as of May 2010.

Survey of respiratory therapy education program directors in the United States.

Objective: As background for the American Association for Respiratory Care (AARC) third 2015 and Beyond conference, we sought information and opinions on the ability of the current respiratory therapy education infrastructure to make changes that would assure competent respiratory therapists in the envisioned healthcare future.

Methods: After pilot testing and refining the questions, we invited the directors of 435 respiratory therapy programs (based in 411 colleges) that were fully accredited or in the process of being accredited by the Commission on Accreditation for Respiratory Care as of May, 2010, to participate in the survey.

Results: Three-hundred forty-eight program directors (80%) provided valid survey responses.

Transitioning the respiratory therapy workforce for 2015 and beyond.

The American Association for Respiratory Care established a task force in late 2007 to identify likely new roles and responsibilities of respiratory therapists (RTs) in the year 2015 and beyond. A series of 3 conferences was held between 2008 and 2010. The first task force conference affirmed that the healthcare system is in the process of dramatic change, driven by the need to improve health while decreasing costs and improving quality.

Tracheostomy: why, when, and how?

Tracheostomy is one of the most frequent procedures performed in intensive care unit (ICU) patients. Of the many purported advantages of tracheostomy, only patient comfort, early movement from the ICU, and shorter ICU and hospital stay have significant supporting data. Even the belief of increased safety with tracheostomy may not be correct.

Should a patient be extubated and placed on noninvasive ventilation after failing a spontaneous breathing trial?

Between 15% and 35% of mechanically ventilated patients fail an initial spontaneous breathing trial. For these patients, 40% of total time on mechanical ventilation is consumed by the weaning process (60% for patients with chronic obstructive pulmonary disease). Longer duration of mechanical ventilation is associated with higher risk of complications and probably with higher mortality.

Should tracheostomy be performed as early as 72 hours in patients requiring prolonged mechanical ventilation?

Advances in treating the critically ill have resulted in more patients requiring prolonged airway intubation and respiratory support. If intubation is projected to be longer than several weeks, tracheostomy is often recommended. Tracheostomy offers the potential benefits of improved patient comfort, the ability to communicate, opportunity for oral feeding, and easier, safer nursing care.

How to read a scientific research paper.

Reading is the most common way that adults learn. With the exponential growth in information, no one has time to read all they need. Reading original research, although difficult, is rewarding and important for growth.

Creating a vision for respiratory care in 2015 and beyond.

The respiratory care profession is over 60 years old. Throughout its short history, change and innovation have been the terms that best describe the development of the profession. The respiratory therapist (RT) of today barely resembles the clinicians of 60 years ago, and the future role of the RT is clearly open to debate.

2006 Philip Kittredge Memorial Lecture. What to do when protocols fail.

Though advances in medical science have created improved therapies, often these are not widely provided throughout the health-care system. Also, there is growing recognition of the lack of safety in health-care delivery. The development of evidence-based, best practice, national guidelines has been encouraged to reduce unnecessary variation in care and for improving quality.

Tracheostomy in the critically ill: indications, timing and techniques.

Purpose Of Review: Tracheostomy is one of the most common procedures performed in the intensive care unit. Indications, risks, benefits, timing and technique of the procedure, however, remain controversial. The decision of when and how to perform a tracheostomy is often subjective, but must be individualized to the patient.

Team model: advocating for the optimal method of care delivery in the intensive care unit.

Objective: To review published data on the team model of intensive care unit (ICU) care delivery.

Design: Nonexhaustive, selective literature search.

Setting: Review of literature published in the English language.

Early complications of tracheostomy.

Complications from surgical procedures are common and must be taken into account when assessing the risks and benefits of a particular treatment approach. Common acute risks of tracheostomy include bleeding, airway loss, damage to adjacent structures, and failure of the chosen technique to achieve successful airway placement. The frequency and severity of these occurrences depends on several factors.

Techniques for performing tracheostomy.

One of the most commonly performed procedures in the critically ill, tracheostomy has been described and used for lifesaving treatment of upper-airway obstruction for at least 3,500 years. The procedure can be performed surgically in the operating room or at the bedside in the intensive care unit. Recently, percutaneous techniques performed by a variety of specialists have become popular alternatives to open surgical tracheostomy.

Indications for and timing of tracheostomy.

Tracheostomy is one of the most common intensive care unit procedures performed. The advantages include patient comfort, safety, ability to communicate, and better oral and airway care. Patients may have shorter intensive care unit stays, days of mechanical ventilation, and hospital stays.

Applied respiratory physiology: use of ventilator waveforms and mechanics in the management of critically ill patients.

Graphical waveforms have become ubiquitous in clinical care. Using and understanding pictures and symbols is a daily activity. Humans are neurologically equipped to understand symbolic information and have done so for millennia.

Using ventilator and cardiovascular graphics in the patient who is hemodynamically unstable.

The interaction of a mechanical ventilator and the human cardiovascular system is complex. One of the most important effects of positive-pressure ventilation (PPV) is that it can decrease venous return. PPV also alters right- and left-ventricular ejection.

Effective use of tables and figures in abstracts, presentations, and papers.

In some situations, tables, graphs, and figures can present certain types of information (including complicated relationships and sequences of events) more clearly and in less space than the same information would require in sentence form. However, do not use tables, graphs, and figures for small amounts of data that could be conveyed clearly and succinctly in a sentence. Also, do not reiterate in sentences the data that are shown in a table, graph, or figure: the point of creating a table or graph or figure is to eliminate that type of sentence from your manuscript.