Thomas L Petty's lessons for the respiratory care clinician of today.

Because of the importance of his original contributions and their practical relevance today, Thomas L Petty (1932-2009) was arguably the most important physician in the history of respiratory care. As much as any single individual, he was responsible for the concept of intensive and multidisciplinary respiratory care. In the 1960s and 1970s, he made key observations and introduced pioneering therapies in the ICU and in the home.

Oxygen in respiratory care: a personal perspective from 40 years in the field.

Oxygen is necessary for all aerobic life, and nothing is more important in respiratory care than its proper understanding, assessment, and administration. By the early 1970s P(aO(2)) had become the gold standard for clinically assessing oxygenation in the body. Since the 1980s the measurement of arterial oxygen saturation by pulse oximetry has also been increasingly used as an adjunct to (but not a replacement for) P(aO(2)).

Obesity and COPD: associated symptoms, health-related quality of life, and medication use.

Background: There is little data about the combined effects of COPD and obesity. We compared dyspnea, health-related quality of life (HRQoL), exacerbations, and inhaled medication use among patients who are overweight and obese to those of normal weight with COPD.

Methods: We performed secondary data analysis on 364 Veterans with COPD.

Patient-ventilator interaction.

Patient-ventilator interaction has been the focus of increasing attention from both manufacturers and researchers during the last 25 years. There is now compelling evidence that passive (controlled) mechanical ventilation leads to respiratory muscle dysfunction and atrophy, prolonging the need for ventilatory support and predisposing to a number of adverse patient outcomes. Although there is consensus that the respiratory muscles should retain some activity during acute respiratory failure, patient-ventilator asynchrony is now recognized as a cause of ineffective ventilation, impaired gas exchange, lung overdistention, increased work of breathing, and patient discomfort.

Impact of offering continuing respiratory care education credit hours on staff participation in a respiratory care journal club.

Background: Journal clubs are employed by education and healthcare institutions to facilitate learning about study design, to teach critical reading of the literature, and to help trainees and practitioners keep abreast in their fields. Our respiratory care department initiated a journal club that was open to all respiratory therapists in the community. The articles were selected by the journal club coordinator and posted on the club's web site.

A porcine model for initial surge mechanical ventilator assessment and evaluation of two limited-function ventilators.

Objectives: To adapt an animal model of acute lung injury for use as a standard protocol for a screening initial evaluation of limited function, or "surge," ventilators for use in mass casualty scenarios.

Design: Prospective, experimental animal study.

Setting: University research laboratory.

Translating evidence into practice.

Appropriately designed and conducted research is necessary for improving patient care and optimizing health outcomes, but access to best evidence is not enough to make these things happen. In respiratory care, as in other fields, patients do not benefit as much as they should from research findings and evidence-based practice guidelines. Current standards for the diagnosis, staging, and management of chronic obstructive pulmonary disease are based in large part on the results of spirometry, yet most patients carrying this diagnosis have not had this test performed.

How to read a case report (or teaching case of the month).

Case reports are of minor importance in evidence-based medicine but can nonetheless make meaningful contributions to both knowledge and education. Although many traditional medical journals publish fewer case reports in this era of space constraints and preoccupation with Impact Factors, new Internet-based journals are appearing that focus exclusively on reports of individual cases. Given the variability of documentation, objectivity, and interpretation among the case reports now accessible by clinicians and trainees, it is important to be able to read them critically and to use the information they contain appropriately.

The physiology of dinosaurs: circulatory and respiratory function in the largest animals ever to walk the earth.

The cardiopulmonary physiology of dinosaurs-and especially of the long-necked sauropods, which grew much larger than any land animals before or since-should be inherently fascinating to anyone involved in respiratory care. What would the blood pressure be in an animal 12 m (40 ft) tall? How could airway resistance and dead space be overcome while breathing through a trachea 9 m (30 ft) long? The last decade has seen a dramatic increase in evidence bearing on these questions. Insight has come not only from new fossil discoveries but also from comparative studies of living species, clarification of evolutionary relationships, new evaluation techniques, computer modeling, and discoveries about the earth's ancient atmosphere.

History and epidemiology of noninvasive ventilation in the acute-care setting.

Although noninvasive ventilation (NIV) was first used to treat patients with acute respiratory failure in the 1940s, the history of this mainstay of today's respiratory care armamentarium has mainly been written in the last 20 years. There is now a robust evidence base documenting the efficacy of NIV in exacerbations of chronic obstructive pulmonary disease, cardiogenic pulmonary edema, and acute respiratory failure in immunocompromised patients, and evidence in support of NIV in other settings, such as hypoxemic acute respiratory failure and the management of patients who decline endotracheal intubation, is accumulating rapidly. Efficacy as demonstrated in clinical trials does not necessarily translate to clinical effectiveness in practice, however, and important barriers need to be overcome if NIV is to realize for the average patient the potential it has shown in research studies.

Tracheal rupture resulting in life-threatening subcutaneous emphysema.

We present a case of a patient with severe chronic obstructive pulmonary disease who developed dramatic mediastinal and subcutaneous emphysema, without pneumothorax, following a difficult intubation. Misdiagnosis of tracheal rupture as barotrauma from alveolar overdistention initially delayed intervention and caused persistence of subcutaneous emphysema. Despite efforts to minimize tidal volume and airway pressure, the large airway disruption and positive-pressure ventilation resulted in tension subcutaneous emphysema with near-fatal hemodynamic compromise, oliguria, and respiratory acidosis.

Respiratory considerations in the patient with renal failure.

Lung and kidney function are intimately related in both health and disease. Respiratory changes help to mitigate the systemic effects of renal acid-base disturbances, and the reverse is also true, although renal compensation occurs more slowly than its respiratory counterpart. A large number of diseases affect both the lungs and the kidneys, presenting most often with alveolar hemorrhage and glomerulonephritis.

Clinical practice guidelines for chronic obstructive pulmonary disease: a review and comparison of current resources.

The first clinical practice guidelines (CPGs) for the assessment and management of patients with chronic obstructive pulmonary disease (COPD) were published 30 years ago. These and subsequent CPGs issued by professional societies and other groups prior to 2000 were consensus recommendations based on expert opinion and available studies, and they have been criticized for being inconsistent and not explicitly evidence-based. The Global Initiative for Chronic Obstructive Lung Disease (GOLD), a joint project of the National Heart, Lung, and Blood Institute and the World Health Organization, released the first of a new generation of rigorous, evidence-based COPD guidelines in 2001.

Tracheostomy and weaning.

No hypothesis relating to respiratory care in the intensive care unit has proved more difficult to study in an objective fashion than the commonly held belief that tracheostomy hastens weaning from ventilatory support. Tracheostomy might facilitate weaning by reducing dead space and decreasing airway resistance, by improving secretion clearance, by reducing the need for sedation, and by decreasing the risk of aspiration. Available evidence indicates that dead space and airway resistance are in fact reduced, although whether the magnitude of these reductions explains the clinical observation of more rapid weaning after tracheotomy is less certain.

Changing pattern of ventilator settings in patients without acute lung injury: changes over 11 years in a single institution.

Study Objectives: To determine whether the widely accepted concept of using lower tidal volume (Vt) values in patients with ARDS or obstructive lung disease has affected the pattern of ventilator settings in mechanically ventilated patients who do not have one of these conditions.

Design And Patients: We performed a retrospective chart review of all patients who had experienced out-of-hospital cardiac arrest and had received ventilatory support for > or = 1 day at a university-affiliated county hospital during the years 1990, 1991, 1992, 1995, 1998, 1999, and 2000.

Results: In 139 such patients, the mean final Vt values used on the first day of mechanical ventilation were 11.

The top 10 reasons why manuscripts are not accepted for publication.

This article discusses why many research projects that have been presented in abstract form are never published as full articles, and lists 10 reasons why manuscripts are not accepted for publication in Respiratory Care. Some of these reasons are easily avoidable or readily overcome. Included in this category is submission of manuscripts that do not correspond to the kinds of articles the Journal publishes, either in subject matter or in format.

How to write an abstract that will be accepted for presentation at a national meeting.

Preparation, submission, and presentation of an abstract are important facets of the research process, which benefit the investigator/author in several ways. Writing an abstract consists primarily of answering the questions, "Why did you start?" "What did you do?" "What did you find?" and "What does it mean?" A few practical steps in preparing to write the abstract can facilitate the process. This article discusses those steps and offers suggestions for writing each of an abstract's components (title, author list, introduction, methods, results, and conclusions); considers the advantages and disadvantages of incorporating a table or figure into the abstract; offers several general writing tips; and provides annotated examples of well-prepared abstracts: one from an original study, one from a method/device evaluation, and one from a case report.

Case reports in respiratory care.

The information in a case report should be viewed cautiously in terms of generalization beyond the reported example. Appropriately written and interpreted, however, a case report can be a valuable contribution to medical knowledge and educational for both author and reader. This article discusses the essential components of a case report, important issues of patient confidentiality, and how authorship should be determined.

Acute inhalation injury with evidence of diffuse bronchiolitis following chlorine gas exposure at a swimming pool.

A previously healthy 23-year-old man with nonproductive cough and sore throat presented to the hospital a few hours after chlorine gas exposure at a fitness center swimming pool. Initial physical examination and chest radiograph were normal. Thirty-six hours later he developed worsening dyspnea and cough, with development of blood-tinged sputum.

Translating new understanding into better care for the patient with chronic obstructive pulmonary disease.

Despite an enormous amount of research and many official statements, the definition, diagnosis, and staging of chronic obstructive pulmonary disease (COPD) remain inconsistent, and we have yet to agree on who should be tested with spirometry or on where and how to do it. We know that inflammation, not just airflow limitation, is important in determining the course of COPD, especially with respect to exacerbations. We can detect and treat alpha-1 antitrypsin deficiency, an under-recognized condition, but whether alpha-1 antitrypsin augmentation therapy affects the disease's clinical course remains unclear.

Practice variation in respiratory therapy documentation during mechanical ventilation.

Study Objectives: Implementation of new ventilatory strategies such as lung-protective ventilation for ARDS will require a multidisciplinary approach with considerable physician and respiratory therapy (RT) interaction. One of the key factors in this communication is complete and accurate RT documentation of ventilator settings. Few studies have explored the quality and variability of this documentation.