Canadian Journal of Respiratory Therapy

Print ISSN: 1205-9838
Background: The severity of disease and mortality due to coronavirus disease (COVID-19) was found to be high among patients with concurrent medical illnesses. Serum biomarkers can be used to predict the course of COVID-19 pneumonia. Data from India are very scarce about predictors of mortality among COVID-19 patients. Methodology: In the present retrospective study of 65 RT-PCR confirmed COVID-19 patients, we retrieved data regarding clinical symptoms, laboratory parameters, and radiological grading of severity. Further, we also collected data about their hospital course, duration of stay, treatment, and outcome. Data analysis was done to compare the patient characteristics between survivor and non-survivor groups and to assess the predictors of mortality. Results: The mean age of the study population was 56.23 years (SD, 12.91) and most of them were males (63%); 81.5% of patients survived and were discharged, whereas 18.5% of patients succumbed to the disease. Univariate analysis across both groups showed that older age, diabetes mellitus, higher computed tomogram (CT) severity score, and raised levels of laboratory parameters viz, D-dimer, CPK-MB (creatine kinase), and lactate dehydrogenase (LDH) were associated with increased mortality among hospitalized patients. On multivariate analysis, elevated levels of serum D-dimer (odds ratio, 95% CI: 10.98, 1.13-106.62, p = 0.04) and LDH (odds ratio, 95% CI: 19.15, 3.28-111.87, p = 0.001) were independently associated with mortality. Conclusion: Older patients, diabetics, and patients with high CT severity scores at admission are at increased risk of death from COVID-19. Serum biomarkers such as D-dimer and LDH help in predicting mortality in COVID-19 patients.
Kaplan-Meier curves for cumulative survival stratified by patients tracheostomized and non-tracheostomized.
Background: We report the characteristics, timing, and factors related to the decision to perform a tracheostomy in patients with confirmed COVID-19 infection admitted to eight Italian intensive care units (ICUs). Materials and methods: Prospective observational cohort study of patients with COVID-19 disease on mechanical ventilation. Long-term functional impairment (up to 180 days’ post-hospital discharge) was assessed using the Karnofsky scale. Kaplan–Meier analysis assessed differences in survival and freedom from tracheostomy in relation to ICU stay. Cox regression model was used to assess which variables impacted on tracheostomy as a categorical outcome. Results: A total of 248 patients were recruited in the eight participating ICUs. Patients undergoing tracheostomy (n = 128) had longer ICU (25 (18–36) vs. 10 (7–16), P = 0.001) and hospital (37 (26.5–50) vs. 19 (8.5–34.5) P = 0.02) stays. ICU and hospital mortality of patients tracheostomized was 34% and 37%, respectively. Cumulative survival Kaplan–Meier analysis documented improved survival rates in patients undergoing tracheostomy (Log-Rank, Mantel–Cox = 4.8, P = 0.028). Median Karnofsky scale values improved over time but were similar between survivors receiving or not receiving tracheostomy. No healthcare worker involved in the tracheostomy procedure developed COVID-19 infection during the study period. Conclusions: Patients with COVID-19 infection who underwent tracheostomy had a better cumulative survival but similar long-term functional outcomes at 30, 60, and 180 days after hospital discharge.
Background: The treatments of COVID-19 involve some degree of uncertainty. Current evidence also shows mixed findings with regards to bioaerosol dispersion and airborne transmission of COVID-19 during high flow nasal cannula (HFNC) therapy. While coping with this global pandemic created hot debates on the use of HFNC, it is important to bring detached opinions and current evidence to the attention of health care professionals (HCPs) who may need to use HFNC in patients with COVID-19. Aim: The purpose of this paper is to provide a framework on the selection, placement, and use of nebulizers as well as HFNC prongs, gas flow, and delivery technique via HFNC to help clinicians deliver aerosolized medications through HFNC safely and effectively in the era of COVID-19 and beyond. Methods: We searched PubMed, Medline, CINAHL, and Science Direct to identify studies on aerosol drug delivery through HFNC using the following keywords: ("aerosols," OR "nebulizers") AND ("high flow nasal cannula" OR "high flow oxygen therapy" OR "HFNC") AND ("COVID-19," OR "SARS-CoV-2"). Twenty-eight articles including in vitro studies, randomized clinical trials, scintigraphy studies, review articles, prospective and retrospective research were included in this review. Discussion and results: It is not clear if the findings of the previous studies on bacterial contamination could be applied to viral transmission because they do not provide data that could be extrapolated to the risk of SARS-CoV-2 transmission. In the face of the unknown risk with the transmission of COVID-19 during HFNC therapy, the benefits of HFNC must be weighed against the risk of infection to HCPs and other patients. Due to the limited number of ventilators available in hospitals and the confirmed effectiveness of HFNC in treating hypoxemic respiratory failure, HFNC may prevent early intubation, and prolonged intensive care unit stays in patients with COVID-19. Conclusion: Clinicians should review the magnitude of this risk based on current evidence and use the suggested strategies of this paper for safe and effective delivery of aerosolized medications through HFNC in the era of COVID-19 and beyond.
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.
Background: Interstitial lung diseases (ILDs) include a broad range of diffuse parenchymal lung disorders and are characterized by diffuse parenchymal lung abnormalities leading to irreversible fibrosis. ILDs are correlated with the occurrence of pulmonary fibrosis (PF), which generally also results in pulmonary hypertension (PH). Interferons, secreted in larger amounts during viral infections, are an important possible risk factor contributing to this outcome. Aims: In this narrative review, the role of 10 different viral infections on the generation/development of ILDs and their outcomes are described in detail. The aim of this review is to determine the probable risk that COVID-19 and other viral infections pose in the post-infection development of ILDs, PF, and PH. Methods: Searches in PubMed (Medline), Google Scholar, Web of Science (ISI, Researcher ID, Publons), ResearchGate, Scopus, and secondary sources yielded 134 studies. After exclusion criteria, 92 studies containing the terms "Coronavirus" (COVID-19), "Interstitial Lung Diseases," "Pulmonary Fibrosis," "Pulmonary Hypertension" and "viral infections" were selected for inclusion. Selected articles were read with a focus on the roles of the 10 commonly studied viral infections on generation/intensification of ILDs and classified according to their dominant effect on the respiratory system, with a focus on each infection's effects on parenchyma of the lungs and generation and/or intensification of ILDs. Results: This review found that ILDs, PF, and PH can occur after a COVID-19 viral infection. Similar results are also seen in post-infection cases of other viral infections, including Epstein-Barr virus, Cytomegalovirus, Human herpesvirus-8, adenovirus, Hepatitis C, Torque-Teno (Transfusion-Transmitted) Virus, Human Immunodeficiency Virus, Severe Acute Respiratory Syndrome, and Middle East Respiratory Syndrome. Conclusion: Results of current studies show probable possibility for generation and/or intensification of ILDs in COVID-19 infected patients like other studied viruses. Studies on determination of the actual prevalence of ILD, PF and PH in post-COVID-19 infected patients, follow-up studies on the prevention of ILDs in recovered COVID-19 patients, and meta-analyzed studies on pulmonary outcomes of pandemic corona viruses are strongly recommended as topics for future studies.
Sample characteristics of 738 COVID-19 patients
Logistic regression analyses for mortality
Introduction/Background: Patients with Coronavirus Disease 2019 (COVID-19) present with a spectrum of respiratory symptoms. There are no studies describing respiratory system involvement adjusted for other organ systems, oxygen saturation nadir, hospitalization days until respiratory involvement, proportion of days of respiratory system involvement, and persistent respiratory involvement at discharge in COVID-19 patients. We studied these parameters in COVID-19 patients that received respiratory therapy interventions and their association with mortality and length of stay (LOS). Methods: A single-center cross-sectional retrospective study of 738 COVID-19 patients with respiratory involvement at a hospital in the New York metropolitan area. Results: COVID-19 patients with respiratory involvement had increased mortality with oxygen requirement of FiO2 >55% (OR:39.02, 95% CI:1.59–960.51, P < 0.05) and mechanical ventilation (OR:236.64, 95% CI:8.24–6798.93, P < 0.01). Respiratory system involvement adjusted for other organ system involvement was associated with increased mortality (OR:1.60, 95% CI:1.20, 2.14, P < 0.01) and LOS (B = 0.02, SE = 0.01, P < 0.01). Oxygen saturation nadir of 70%–89% was significantly associated with increased LOS (B = 0.07, SE = 0.03, P < 0.05), whereas oxygen saturation nadir of
Therapeutic protocol: Early phase of COVID-19
The global pandemic COVID-19 is a contagious disease and its mortality rates ranging from 1% to 5% are likely due to acute respiratory distress syndrome (ARDS), and cytokine storm. A significant proportion of patients who require intubation succumb to the disease, despite the availability of ventilators and the best treatment practices. Researchers worldwide are in search of anti-inflammatory medicines in the hope of finding a cure for COVID-19. Low-level laser therapy (LLLT) has strong, anti-inflammatory effects confirmed by meta-analyses, and it may be therapeutic to ARDS. LLLT has been used for pain management, wound healing, and other health conditions by physicians, physiotherapists, and nurses worldwide for decades. In addition, it has been used in veterinary medicine for respiratory tract disease such as pneumonia. Laser light with low-power intensity is applied to the surface of the skin to produce local and systemic effects. Based on the clinical experience, peer-reviewed studies, and solid laboratory data in experimental animal models, LLLT attenuates cytokine storm at multiple levels and reduces the major inflammatory metabolites. LLLT is a safe, effective, low-cost modality without any side-effects that may be combined with conventional treatment of ARDS. We summarize the effects of LLLT on pulmonary inflammation and we provide a protocol for augmenting medical treatment in COVID-19 patients. LLLT combined with conventional medical therapy has the potential to prevent the progression of COVID-19, minimize the length of time needed on a ventilator, enhance the healing process, and shorten recovery time. Key Words: COVID-19; ARDS; cytokine storm; low level laser therapy; anti-inflammatory; ventilator; photobiomodulation
Clinical characteristics of COVID-19 diagnosis patients
Introduction: Lower respiratory tract infections remain the deadliest communicable disease worldwide. The relationship between cardiovascular diseases and viral infections is well known; for example, during the AH1N1 influenza pandemic, many patients developed acute cardiovascular disease. In the SARS-CoV2 pandemic, cardiovascular health has again become a challenge, with early reports showing cardiac damage in these patients. Objective: The study aims to describe the clinical characteristics of COVID-19 patients with an emphasis on cardiovascular compromises, compared with past outbreaks of influenza AH1N1, to identify prognostic factors of severity. Methods: A cross-sectional study of 72 subjects with a confirmed diagnosis of COVID-19 was conducted. Subjects were evaluated in two groups: 38 hospitalized patients and 34 patients in the Intensive Care Unit (ICU). Data from different outbreaks of influenza AH1N1 were then compared with this group. Results: The 34 subjects in the ICU had higher levels of high sensible troponin, D dimer, creatinine, and leukocytes compared with the 38 hospitalized subjects. The lymphocytes count was diminished in 85.29% of ICU subjects. When compared with AH1N1 patients, it was found that SARS-CoV2 patients were 10 years older on average. The proportion of overweight and obese SARS-CoV2 patients was double that in the influenza outbreaks. In addition, it was observed that a high number of SARS-CoV2 subjects presented with diabetes mellitus. Conclusion: There were various clinical and severity differences between each of these outbreaks. However, viral respiratory infection diseases such as SARS-CoV2 are a significant risk factor for acute ischemic, functional, and structural cardiovascular complications. The only way to combat this risk is a prevention approach, specifically through vaccines, but also through measures that force drastic changes in health policies to reduce perhaps the worst of pandemics, obesity, and its metabolic consequences.
Introduction/background: Coronavirus disease 2019 (COVID-19) has high transmissibility and mortality rates. High-flow nasal cannula therapy (HFNC) might reduce the need for orotracheal intubation, easing the burden on the health system caused by COVID-19. The objective of the present study was to examine the effectiveness of HFNC in adult patients hospitalized with COVID-19. Specifically, the present study explores the effects of HFNC on rates of mortality, intubation and intensive care units (ICU) length of stay. The present study also seeks to define predictors of success and failure of HFNC. Methods: A systematic literature search was conducted in the PubMed, EMBASE and SCOPUS databases, and the study was prepared according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Study quality was assessed using the National Heart, Lung, and Blood Institute's Study Quality Assessment Tools. Results: The search identified 1,476 unique titles; 95 articles received full-text reviews and 40 studies were included in this review. HFNC was associated with a reduction in the rate of orotracheal intubation, notably when compared to conventional oxygen therapy. Studies reported inconsistency in whether HFNC reduced ICU length of stay or mortality rates. Among the predictors of HFNC failure/success, a ratio of oxygen saturation index of approximately 5 or more was associated with HFNC success. Conclusion: In adult patients hospitalized with COVID-19, HFNC may prove effective in reducing the rate of orotracheal intubation. The ratio of the oxygen saturation index was the parameter most examined as a predictor of HFNC success. Low-level research designs, inherent study weaknesses and inconsistent findings made it impossible to conclude whether HFNC reduces ICU length of stay or mortality. Future studies should employ higher level research designs.
Introduction: Registered respiratory therapists (RRTs) are heavily involved in the care of individuals infected with COVID-19. The experiences and challenges specific to the RRT profession during the pandemic have not been qualified and the aim of this study is to bridge that gap. Methods: With institutional ethics approval, a cross-sectional survey was created through the survey software Redcap and made available online from 29 May to 6 July 2020. Any RRT working in Canada during the COVID-19 pandemic was eligible to participate. Responses to yes/no questions were calculated as frequencies and percentages, and free-text responses were summarized. Results: In total, 345 RRTs working in 11/13 of the provinces and territories, with varying years of experience completed the survey. The results reflected impacts of the pandemic that affected RRTs in a variety of ways at work, from being reassigned (30.7%) to caring for COVID-19 positive patients (57.4%) and intubated COVID-19 positive patients (50.7%). RRTs experienced communication issues around guidelines (66.7%) and some departments had run out of personal protective equipment (PPE; 19%). RRTs were personally impacted, including feeling overwhelmed by new and frequently changing guidelines (89.6%) and feeling concerned for themselves or their family members becoming infected because of their proximity to COVID-19 positive patients (89%). Discussion: RRTs reported being required to work more during the pandemic. The unpredictability and constantly changing schedules were sources of stress and anxiety. RRTs were faced with issues of overwhelming amounts of new information and had difficulty in disseminating it in a timely manner. Lack of guidance and lack of confidence in the current protocols added to the confusion, anxiety, and stress. RRTs were at the center of many high-risk moments for contracting the virus (intubation, extubation), and PPE shortages were a major challenge reported. RRTs working during the pandemic have been concerned for their own health and the health of their family members. Conclusion: The COVID-19 pandemic adds another layer of stress for RRT professionals who are working in high-risk situations and feel anxious, overwhelmed, and concerned about their personal safety.
Summary of studies that investigated post-traumatic stress disorder prevalence in patients post-COVID-19 hospitalizations
Introduction: The coronavirus Severe Acute Respiratory Syndrome Coronavirus Type 1 induces a severe respiratory disease, coronavirus disease 2019 (COVID-19). After Severe Acute Respiratory Syndrome Coronavirus Type 1 and Middle East Respiratory Syndrome infection, increased post-traumatic stress disorder (PTSD) rates were described. Methods: This single-centred, prospective study aimed to evaluate the rates of PTSD in patients who were hospitalized for COVID-19. Inclusion criteria were COVID-19 patients hospitalized in the intensive care unit (ICU) or in a standard unit with at least 2 L/min oxygen. Six months post-hospitalization, subjects were assessed for PTSD using a validated screening tool, the Post-Traumatic Stress Checklist-5 (PCL-5). Results: A total of 40 patients were included. No demographic differences between the ICU and non-ICU groups were found. The mean PCL-5 score for the population was 8.85±10. The mean PCL-5 score was 6.7±8 in the ICU group and 10.5±11 in the non-ICU group (P=0.27). We screened one patient with a positive PCL-5 score and one with a possible PCL-5 cluster score. Nine patients had a PCL-5 score of up to 15. Seven patients reported no symptoms. Seven patients accepted a psychological follow-up: one for PTSD, three for possible PTSD and three for other psychological problems. Discussion: The PCL-5 tool can be used by lung physicians during consultations to identify patients for whom follow-up mental health assessment and treatment for PTSD are warranted. Conclusion: Lung physicians should be aware of the risk of PTSD in patients hospitalized for COVID-19 and ensure appropriate screening and follow-up care.
ROX index. Daily ROX index of patients included in the case studies. The red line represents a ROX index value of 5. ROX index=((SaO 2 /FiO 2 )/ RR). SaO 2 /FiO 2 = ratio of arterial oxygen saturation to fraction of inspired oxygen; RR = respiratory rate.
Introduction: The use of high-flow nasal oxygen (HFNO) is a simple method that can reduce intubation in patients with hypoxemic acute respiratory failure (ARF). Early and prolonged prone position has demonstrated benefits on mortality in mechanically ventilated patients and on intubation in awake patients with ARF. However, strategies to achieve adherence to awake prone positioning (APP) have not been previously described. Case and outcomes: We present six patients with ARF due to COVID-19 treated with HFNO and APP. The median (p25–75) of PaFiO2 upon admission was 121 (112–175). The average duration of APP on the first day was 16 h (SD 5 h). Duration (median p25–75) in APP for the following 20 days was 13 (10–18) h/day. Several strategies such as the presence of a health care team, recreational activities, adaptation of the circadian rhythm, oral nutritional support, and analgesics were used to improve prone tolerance. None of the patients suffered from delirium, all were ambulating on discharge from the ICU and none require intubation. Conclusion: The case series presented show the feasibility of prolonged use of HFNO and APP in patients with COVID-19 and severe persistent hypoxemia and described strategies to enhance adherence.
Introduction/background: COVID-19 vaccination uptake rates and responses by Canadian respiratory therapists (RTs) were investigated along with factors that may be shown to play a role in vaccination hesitancy. Methods: An anonymous survey using SurveyMonkey® on vaccination uptake rates, responses and attitudes was made available to student RTs, graduate RTs and registered RTs in Canada from July to October of 2021. Pearson’s chi-square tests were performed to evaluate association between vaccination status and the other categorical parameters evaluated. Results: A total of 1013 surveys (8.0% of target population) were completed fully and included in the data analysis. Of the surveyed RT population, 90.42% received their vaccination as soon as it was made available compared to Canada’s Ministry of Health’s published rate at the time of 86.27% for all Canadian healthcare workers. There was a significant (p = 0.013) association between early vaccination and age and a significant (p = 0.036) association between vaccination status and a participant’s response on whether or not they have a family member or know someone who has had COVID-19. There was also a significant (p < 0.001) association between vaccination status and attitudes towards trusting science to develop safe, effective, new vaccines and trusting the Ministry of Health to ensure that vaccines are safe. There was no significant association between vaccination status and gender, province/territory of residency/work, level of education and level of involvement with COVID-19 patients. Conclusion: The results suggest that RT groups across Canada had higher early vaccination uptake rates than general healthcare worker groups and that age, relationship to people with COVID-19 and trust in science played a significant role in their vaccination uptake rates.
Because of the wide and rapid spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the number of hospitalized patients with coronavirus disease 2019 (COVID-19) has rapidly increased medically complex and resource-intensive treatment requirements in health care settings. Although tracheostomy is frequently needed for critically ill patients requiring extended mechanical ventilation, it has been described as an aerosol-generating procedure that puts health care professionals at an increased risk of viral transmission. In addition, the delivery of aerosolized medications to this patient population has become controversial because of concerns on the transmission of SARS-CoV-2 via droplets. Although aerosol therapy in spontaneously breathing patients with COVID-19 was described in recent publications, innovations in aerosol drug delivery to COVID-19 patients with tracheostomy have not been presented. Therefore, empirically based guidance on how to deliver aerosols safely and effectively to tracheotomized patients with COVID-19 is still lacking. This paper provides recommendations and rationales for device selection, interface selection, delivery techniques, and infection control based on the evolving body of literature.
Illustration of how the helmet noninvasive positive pressure ventilation (NIPPV) fits over a patient.
Introduction: Noninvasive positive pressure ventilation (NIPPV) plays an important role in the management of respiratory failure. However, since the emergence of the COVID-19 pandemic, utilization of traditional face mask NIPPV has been curtailed in part due to risk of aerosolization of respiratory particles and subsequent health care worker exposure. A randomized clinical trial in 2016 reported that an alternative interface, helmet NIPPV, may be more effective than traditional NIPPV at preventing intubation and improving mortality. The helmet NIPPV interface provides positive airway pressure, while also theoretically minimizing aerosolization, making it a feasible modality in management of respiratory failure in COVID-19 patients. Case and outcomes: This report describes a single-center experience of a series of three COVID-19 patients with hypoxemic respiratory failure managed with helmet NIPPV. One patient was able to avoid intubation while a second patient was successfully extubated to NIPPV. Ultimately, the third patient was unable to avoid intubation with helmet NIPPV, although the application of the device was late in the progression of the disease. Discussion: NIPPV is an important modality in the management of respiratory failure and has been shown to reduce the need for immediate endotracheal intubation in select populations. For patients unable to tolerate facemask NIPPV, the helmet provides an alternate interface. In COVID-19 patients, the helmet interface may reduce the risk of virus exposure to health care workers from aerosolization. Based on this experience, we recommend that helmet NIPPV can be considered as a feasible option for the management of patients with COVID-19, whether the goal is to prevent immediate intubation or avoid post-extubation respiratory failure. Randomized studies are needed to definitively validate the use of helmet NIPPV in this population. Conclusion: Helmet NIPPV is a feasible therapy to manage COVID-19 patients.
Prevalence of compassion satisfaction, burnout, and sec- ondary traumatic stress
Background: Respiratory therapists (RTs) faced many unpredicted challenges and higher stress levels while managing critically ill patients with the coronavirus disease (COVID-19). This study’s primary objective was to evaluate the compassion satisfaction and compassion fatigue among RTs in the United States during the COVID-19 pandemic. Methods: This cross-sectional, descriptive, survey-based study conducted from July 2020 to August 2020 was administered to all active members of the American Association of Respiratory Care via AARConnect. RTs’ characteristics including personal, job-specific, and organizational factors were collected. Professional Quality of Life Scale (ProQOL, version 5) was used to measure compassion satisfaction and fatigue. Results: A total of 218 participants fully completed the survey, 143 (65.6%) were female, 107 (49.1%) were between 35 and 54 years of age and 72 (33%) were above 55 years of age. Compassion satisfaction was moderate in 123 (56.4%) and high in 93 (42.7%) RTs. Higher compassion satisfaction was found in RTs who have a higher salary (P = 0.003), work overtime (P = 0.01), hold leadership positions (P < 0.001), work in research/education (P < 0.001) and work for departments that provide help in managing burnout and stress (P = 0.007) and that promote a positive work environment (P < 0.001). Burnout score was low in 90 (41.3%) and moderate in 127 (58.3%) RTs. Higher burnout was found among younger RTs (P = 0.019), those with fewer years of experience (P = 0.013) and those with less than a year at their current job (P = 0.045). Secondary traumatic stress (STS) was low in 106 (48.6%) and moderate in 112 (51.4%) RTs. Higher STS levels were noted among younger RTs (P = 0.02) and RTs with lower education levels (P = 0.016). Conclusion: This survey study identified various personal, job and organizational-related factors associated with increased compassion satisfaction as well as compassion fatigue among RTs.
The chest CT scan without intravenous contrast revealed large ground-glass opacitiesin both lungs: (A) S 10 right and left; (B) S4, S5, S7, S8 right/blue arrows and S10 right and left/orange arrows; (C) S3 right/orange arrow, S2, S4, S5, S6 right/blue arrow, S4, S5, S6 left/blue arrow; (D) S2 right/green arrow, S1 dan S2 left/orange arrow.
Background: Late diagnosis of COVID-19 in young patients in a hypercoagulable state can cause a high mortality rate. Clinical manifestations of COVID-19 include respiratory and extrapulmonary symptoms such as a hypercoagulable state, increased transaminase enzymes, and multiple-organ failure. Case and outcomes: A 34-year-old male presented to the emergency room after 3 days of high fever, weakness, and flatulence. The patient had thrombocytopenia and elevated liver transaminase enzymes and was initially diagnosed with dengue hemorrhagic fever. He was given hydration intravenous fluids, oxygen, antipyretic, and hepatoprotector. On day 4, the patient was diagnosed with COVID-19 and received therapy to decrease the Alanine transaminase and Aspartate transaminase levels. While waiting for outsourced D dimer and prothrombin time results, the patient was given low molecular weight heparin (LMWH) on day 5. On day 13, his condition deteriorated with cephalgia and shortness of breath, but the patient's family refused intubation. The chest CT scan revealed large ground-glass opacities in both lungs. The patient was given additional medications, such as Meropenem, Dexamethasone, and Remdesivir. On day 15, the patient passed away. Discussion: Intermediate LMWH dosage seems to be associated with a lower mortality incidence than standard Deep Vein Thrombosis (DVT) prophylaxis in hospitalized COVID-19 patients. However, due to the late COVID-19 diagnosis, the patient was not given LMWH at the beginning of treatment. Conclusion: A hypercoagulable state is partly responsible for the high mortality rate of COVID-19 patients. Early detection and management of the hypercoagulable state, including the use of LMWH, can decrease the severity of COVID-19 symptoms.
brief summary of reviewed articles with details regarding incentive spirometry (ISy) 
-CONTINueD brief summary of reviewed articles with details regarding incentive spirometry (ISy) 
Background: Evidence regarding the effectiveness of incentive spirometry (ISy) on postoperative pulmonary outcomes after thoracic, cardiac and abdominal surgery remains inconclusive. This is attributed to various methodological issues inherent in ISy trials. Patient compliance has also been highlighted as a possible confounding factor; however, the status of evidence regarding patient compliance in these trials is unknown. Objective: To explore the status of evidence on patient compliance with ISy interventions in randomized controlled trials (RCTs) in the above contexts. Method: A systematic search using MEDLINE, EMBASE and CINAHL databases was conducted to obtain relevant RCTs from 1972 to 2015 using the inclusion criteria. These were examined for specific ISy parameters, methods used for determining compliance and reporting on compliance. Main outcome measures were comparison of ISy parameters prescribed and assessed, and reporting on compliance. Results: Thirty-six relevant RCTs were obtained. Six ISy parameters were identified in ISy prescriptions from these trials. Almost all (97.2%) of the trials had ISy prescriptions with specific parameters. Wilcoxon signed-rank test revealed that the ISy parameters assessed were significantly lower (Z=-5.433; P<0.001) than those prescribed; 66.7% of the trials indicated use of various methods to assess these parameters. Only six (16.7%) trials included reports on compliance; however, these were also incomprehensive. Conclusions: There is a scarcity and inconsistency of evidence regarding ISy compliance. Compliance data should be obtained using reliable and standardized methods to facilitate comparisons between and among trials. These should be reported comprehensively to facilitate valid inferences regarding ISy intervention effectiveness.
Background: The Sustainable Development Goals and the National Health Policy of India aim to reduce premature mortality from noncommunicable diseases (NCD) by one-third in the next decade and by 25% by 2025, respectively. Among NCDs globally, chronic obstructive pulmonary disease (COPD) is a major contributor to death and disability. This underscores the need to understand the burden of COPD at the national level by synthesizing evidence and collating the state-wise COPD data to estimate the prevalence of COPD and to highlight the associated risk factors to inform policymakers. Method: The systematic literature search will be carried out in PubMed, Cochrane, Scopus, Web of Science, CINAHL, and ProQuest databases with restrictions for studies published between 2000 and 2020 and available in English. Cross-sectional or cohort studies conducted in and among the Indian population aged 30 years and above will be included. Case reports, randomized trials, meta-analysis, commentaries, and qualitative studies will be excluded from the review. Quality assessment of the included studies will be performed using New Castle Ottawa scale and adherence to reporting standards will be checked using STROBE checklist for Observational Cohort and Cross-Sectional Studies. Discussion: Prevalence of COPD in the population aged 30 years and above, diagnosed through spirometry and nonspirometry, will be compared and reported and a meta-analysis will be performed to obtain pooled prevalence rates of COPD and the risk factors associated with COPD.
The following investigation describes the case of a young male admitted to the emergency room with diabetic ketoacidosis (DKA). The challenges faced by respiratory therapists in the treatment of this metabolic disorder require an in-depth comprehension of metabolic acidosis, the body's normal respiratory compensation, and ventilatory management. For correction of a metabolic acidosis concurrent with DKA, the goal of the respiratory therapist is to support carbon dioxide (CO 2) removal (in this case with mechanical ventilation) while additional therapies such as an insulin infusion, fluid replacement, and electrolyte corrections are taking place. The main issue with DKA is determining how sustainable the respiratory compensation is, and at what point mechanical ventilation is indicated. Ultimately, this case study concludes that conscientious and appropriate mechanical ventilation that mimics the patient's normal ventilatory response to metabolic acidosis is essential to avoid cardiac, cerebral, and other organ complications. Multiple choice questions and answers related to this case study are provided to enhance understanding of the ventilatory management of the patient who presents with DKA.
Objectives: to evaluate Expiratory Flow Increase Technique (EFIT) effects on respiratory rate (RR), heart rate (HR) and peripheral oxygen saturation (SpO2) in children and teenagers with acute stage community-acquired pneumonia (CAP). Design: a non-controlled and non-randomised study of intervention was carried out, in which each patient was his or her own control. Setting: Medical Emergency Unit at the University of Campinas Medical School Population: One hundred and twenty-three patients (68 males / 55 females) aged from 0.8 to 143.2 months (mean ± standard deviation: 24,3 ± 24,6) with CAP diagnosis were analyzed. Intervention: respiratory physiotherapy using EFIT, performed once daily. Outcome measures: HR, RR and SpO2 values were recorded during three different periods of time: before EFIT was performed, immediately after the intervention, and after a 20 minute-rest. Results: SpO2 values improved significantly after the technique was performed (92.5 ± 4.2 vs 93.2 ± 4.1, p = 0.019) and were maintained elevated for all patients. HR and RR values increased significandy after the procedure (137.3 ± 21.7 vs 145.2 ± 22.3, p = 0.010; 46 ± 11.4 vs 48.5 ± 11.7, p = 0.000) and returned to basal values after resting. Conclusion: Although EFIT increases HR and RR values transitorily, the technique is favorable for treating children and teenagers with CAP, as this technique increases SpO2 values, regardless of their ages or disease association with pneumonic episodes.
Lung zones to be scanned. AAXL anterior axillary line; ACW anterior chest wall; COSTO costophrenic angle; L1-L4 left; PLAPS posterolateral alveolar pleural syndrome; R1-R4 right. (Left image courtesy of Ylivdesign and Dreamstime [17]; Right image courtesy of 123RF Limited [18])
Proportion of lung ultrasound scans (%) in which respiratory therapists self-reported high, moderate, low, no confidence or when they did not report their confidence level in the final three scans. Upper lung zones: anterior chest wall and anterior axillary line. Lower lung zones: costophrenic angle and posterolateral alveolar pleural syndrome
Purpose: Lung point-of-care ultrasound (POCUS) is a versatile bedside tool. The utility of POCUS has grown during the coronavirus disease 2019 pandemic, as it allows clinicians to obtain real-time images without requiring transport of the patient outside the intensive care unit. As respiratory therapists (RTs) are involved in caring for those with respiratory failure, there is a good rationale for their adoption of lung ultrasound. However, no training standards have been defined. Our objective was to develop and implement a training programme for RTs to achieve and sustain competence in lung ultrasound. Methods: This was a single-centre, prospective, single-cohort observational study. A total of 10 RTs completed our curriculum and were tasked with independently completing and interpreting 10 initial lung ultrasound exams and 3 subsequent exams after a 6-week interim period. All exams were blindly overread by a local expert in lung ultrasound. Results: After completing the curriculum, RTs were able to acquire and accurately interpret their images over 85% of the time. They were more successful in the upper lung zone image acquisition and interpretation compared with the lower lung zones. After 6 weeks, the RTs' lung POCUS skills remained stable, and their lower lung zone image interpretation improved. The RTs reported that their confidence improved throughout the study. Conclusion: The RTs in our study have demonstrated competence in acquisition and interpretation of upper lung zone images. They have also reported confidence in acquiring and interpreting upper lung zone images. More experience appears to be required to gain competence and confidence in lower lung zone ultrasound. Next steps would be to repeat the present study with a higher number of RTs completing at least 20 lung POCUS studies.
The following is a response to a recent editorial published in the Canadian Journal of Respiratory Therapy on the need for clarification of the definition of respiratory compromise (RC) [1]. We thank the author for his frank and insightful comments regarding the need for a useful definition of RC in the current literature. We see this as a timely discussion that helps to articulate what many of us are thinking—how best to take action on RC into both research and clinical practice. © 2019 Canadian Society of Respiratory Therapists. All rights reserved.
Low tidal volume mechanical ventilation has become the standard of care for the treatment of acute lung injury and acute respiratory distress syndrome. In this paper we briefly review the physiologic rationale for applying low tidal volume ventilation and the evidence supporting its use in patients with and without acute lung injury and acute respiratory distress syndrome. Moreover, some of the barriers and pitfalls in effectively utilizing low tidal volumes in clinical practice are discussed. Whether a strategy of protective ventilation should be applied to patients without lung injury remains controversial, however there is increasing data that suggests these patients could benefit from the prophylactic use of lung protective ventilation.
A 63 y/o male presents with sudden onset shortness of breath, and is coughing up pink, frothy sputum. A chest radiograph reveals pulmonary edema and an enlarged heart, which is interpreted as congestive heart failure. The patient is first treated with non-invasive positive pressure ventilation (NIPPV) and then invasive positive pressure ventilation (PPV) with 100% oxygen as his condition worsens. Despite these interventions, his PaO 2 remains low. A transesophageal echocardiogram reveals severe mitral valve regurgitation, which is then successfully surgically repaired. Despite these interventions, the patient develops multi-organ failure post-op and passed away. This case report examines the pathophysiology and management of congestive heart failure.
The use of alveolar recruitment manoeuvres for the treatment of acute respiratory distress syndrome is a topic of uncertainty in current critical care practice. Acute respiratory distress syndrome leads to inflammatory atelectasis, which challenges the gas exchange properties of the lung. Recruitment of atelectatic lung tissue requires elevation of transpulmonary pressure. Transpulmonary pressure can be suppressed at a given airway pressure when pleural pressures are elevated. The present review discusses recruitment of lung tissue in detail, highlighting the key research in the field. Differing techniques for recruiting lung tissue, as well as various outcome measures to determine efficacy, are analyzed and critiqued. The commonly used sustained inflation manoeuvre is perhaps regarded as the only strategy to recruit the lung, explaining its prevalence. Staircase recruitment with positive end-expiratory pressure titration is shown to be an equally - if not more - effective therapy that devotes attention to the maintenance of lung recruitment.
Comparison of acute care to community settings
Introduction: While challenges facing community and acute care practitioners have been studied elsewhere, this is not the case for respiratory therapists (RTs). This study aimed to examine attitudinal differences amongst RTs in British Columbia regarding challenges faced by acute and community settings. Methods: A 40-item anonymous online survey was sent to members of the British Columbia Society or Respiratory Therapists. Of the 40 questions, 11 were relevant to the study’s aim. Results: Of 1024 invitations, 197 (19.2%) responded. One-hundred and seventeen (59.4%) self-identified as working in acute care settings, 53 (26.9%) in community settings, and 27 (13.7%) as “other”. Stress- and interpersonal-related challenges showed statistically significant differences (P ≤ 0.05) based on work setting. Acute care had the highest percentage of responses for challenges related to technology, stress, inter-professional collaboration, and training. Community settings had the highest percentage in challenges related to independence and education. Both being equal received the highest percentage in challenges related to problem-solving, interpersonal, communication, and resource management. Discussion: While attitudinal differences exist, they are not extreme. It did not appear that respondents’ primary motivation was to vote along “party lines”. Conclusions: The setting an RT works in can influence attitudes related to stress and interpersonal challenges. Despite this, one setting is not universally more challenging. Acute care settings can have greater technological, inter-professional, and training-related challenges. Community settings can have greater independence and education-related challenges. Both settings can provide similar challenges with problem-solving, communication, and resource management.
Depiction of demographic and other study variables
Background: Lung ultrasound score (LUS) as well as radiographic assessment of lung edema (RALE) score as calculated from chest radiography (CXR) have been applied to assess Acute Respiratory Distress Syndrome (ARDS) severity. CXRs, which are frequently performed in ARDS patients, pose a greater risk of radiation exposure to patients and health care staff. Aims and objectives: The aim of the study was to evaluate if LUS had a better correlation to oxygenation (PaO2/FiO2) compared with the RALE score in ARDS patients. We also aimed to analyse if there was a correlation between RALE score and LUS. We wanted to determine the LUS and RALE score cut-off, which could predict a prolonged length of intensive care unit (ICU) stay (≥10 days) and survival. Methods: Thirty-seven patients aged above 18 years with ARDS as per Berlin definition and admitted to the ICU were included in the study. It was a retrospective study done over a period of 11 months. On the day of admission to ICU, the global and basal LUS, global and basal RALE score, and PaO2 /FiO2 were recorded. Outcome and days of ICU stay were noted. Results: Global LUS score and PaO2/FiO2 showed the best negative correlation (r = -0.491), which was significant (p = 0.002), followed by global RALE score and PaO2/FiO2 (r = -0.422, p = 0.009). Basal LUS and PaO2/FiO2 also had moderate negative correlation (r = -0.334, p = 0.043) followed by basal RALE score and PaO2/FiO2 (r = -0.34, p = 0.039). Global RALE score and global LUS did not show a significant correlation. Similarly, there was no significant correlation between basal RALE score and basal LUS. Global and basal LUS as well as global and basal RALE score were not beneficial in predicting either a prolonged length of ICU stay or survival as the area under curve was low. Conclusion: In ARDS patients, global LUS had the best correlation to oxygenation (PaO2/FiO2), followed by global RALE score. Basal LUS and basal RALE score also had moderate correlation to oxygenation. However, there was no significant correlation between global LUS and global RALE score as well as between basal LUS and basal RALE score. Global and basal LUS as well as global and basal RALE scores were not able to predict a prolonged ICU stay or survival in ARDS patients.
Acute Respiratory Distress Syndrome remains a major source of morbidity and mortality in the modern intensive care unit (ICU). Major advances in the understanding and management of this condition were made in the last two decades. The use of low tidal ventilation is a well-established therapy. Conservative fluid management is now another cornerstone of management. However, much remains to be understood in this arena. Assessing volume status in these patients may be challenging and the tools available to do so are far from perfect. Several dynamic measures including pulse pressures variation are used. Ultrasound of the lungs and the vascular system may also have a role. In addition, the type of fluid to administer when needed is still open to debate. Finally, supportive measures in these patients, early during their ICU stay and later after discharge continue to be crucial for survival and adequate recovery. © 2019 Canadian Society of Respiratory Therapists. All rights reserved.
Characteristics of the patients in the study (n = 57)
Background: The incidence of acute empyema has increased in various countries; some elderly patients with acute empyema have contraindications for surgery under general anesthesia. Therefore, suitable management based on a patient's clinical condition is required. Methods: We evaluated the different surgical and nonsurgical therapeutic approaches available for patients with acute empyema. This was a retrospective study of 57 patients with acute empyema who received treatment in our department between May 2015 and February 2019. For patients who did not initially improve with drainage or drainage combined with fibrinolytic therapy, surgery, or additional percutaneous drainage was performed based on their general condition. We compared several clinical factors pertaining to the patients who underwent surgical versus nonsurgical treatment. Results: Our study showed that the patients with a performance status of 0-2 and an American Society of Anesthesiologists physical status classification of class II or lower underwent surgery safely without major operative complications. The combination of repeated drainage of the pleural cavity and fibrinolytic therapy appeared to be a reasonable nonsurgical management option for patients in poor overall condition. Conclusion: For an aging population, we think that the combination of repeated pleural cavity drainage procedures and fibrinolytic therapy is a reasonable nonsurgical strategy for the management of patients with acute empyema.
Purpose: Acute exacerbation of chronic obstructive pulmonary disease (COPD) is a major cause of mortality and morbidity. Noninvasive ventilation (NIV) is proven to be effective in the majority of patients with acute exacerbation COPD (AECOPD) complicated with respiratory failure. NIV could be lifesaving but also can delay mechanical ventilation if its efficacy is not assessed in a timely manner. In this study, we analyzed potential predictors of NIV failure in AECOPD in a tertiary medical intensive care unit (MICU). In particular, we wondered whether duration of NIV among those who eventually failed was associated with poor outcomes. Methods: A retrospective review of consecutive patients with a primary diagnosis of AECOPD requiring NIV admitted to the MICU was conducted for the period between 2012 and 2017. Baseline data included demographics, APACHE III score, albumin level, blood lactate, and blood gas elements. Additional chart review was performed to collect NIV setting parameters on presentation to the MICU. Clinical outcome variables collected included outcome and duration of NIV, duration of invasive mechanical ventilation, MICU length of stay, hospital length of stay, and in-hospital mortality. Multivariate regression analysis was performed to determine independent variables associated with clinical outcomes. Results: There were 370 patients who met the inclusion criteria; 53.2% were male. Mean age was 64.7 ± 11.2 years old. Mean baseline FEV1 was 34 ±17% of predicted. Patients had mean pH of 7.20 ± 0.54 and PaCO2 of 70.3 ± 28.7 on presentation; 323 patients (87.3%) were successfully weaned off NIV; 47 patients (12.7%) failed NIV and required invasive mechanical ventilation. APACHE III score was higher among patients who failed NIV (68.3±18.9 versus 48.8± 15.2, P < 0.001). In the subset of 47 patients who failed NIV requiring intubation, duration of NIV was 25.0 ± 58.8 h. Multivariate regression analysis yielded a model consisting of APACHE III score and body mass index as predictive variables for NIV failure (C-statistic = 0.809). Duration of NIV was not associated with worse clinical outcomes among patients who failed NIV. Conclusions: NIV is successful in preventing invasive mechanical ventilation in majority of patients with acute respiratory failure due to COPD. Patients with worse clinical status at presentation are more likely to fail NIV and require mechanical ventilation. In the subgroup of patients who failed NIV, duration of NIV prior to intubation was not associated with poor clinical outcomes.
Purpose of review: The aims of this review are: 1) to discuss the physiological rationale for non invasive respiratory support (NRS) in adults and children with acute respiratory failure; 2) to review clinical available data with preventive and curative NRS and 3) to give some practical recommendations to safely apply NRS in adults and children. Recent findings: NRS refers to techniques allowing respiratory support without the need of an invasive airway. Two types of NRS are commonly used: 1) non invasive continuous positive airway pressure (nCPAP) and 2) non invasive positive pressure ventilation (nPPV). NRS may be an important tool to prevent (prophylactic treatment) or to treat (curative treatment) Acute Respiratory Failure (ARF) avoiding intubation in adult patients with cardiogenic pulmonary oedema, COPD, postoperative respiratory insufficiency, and hematology-oncology patients with ALI/ARDS. In general, the evidence to support the use of NRS in children with acute respiratory failure is scarce. However, two randomized studies have been recently published suggesting that nPPV ameliorates clinical signs and gas exchange while reducing the need for endotracheal intubation. Moreover, nCPAP and heliox may improve clinical scores and CO2 washout in infants with severe bronchiolitis, without major complications. Data from non controlled studies show that NRS unloads the respiratory muscles, and that a helmet can be a valid alternative to facial and/or nasal mask when nCPAP is administered to children in the early stage of ARF. The aims of NRS are: 1) to partially compensate for the affected respiratory function by reducing the work of breathing; 2) to improve alveolar recruitment with better gas exchange (oxygenation and ventilation); 3) to reduce left ventricular afterload increasing cardiac output and improving hemodynamics. Summary: The application of NRS by a trained and experienced ICU team, with careful patient selection, can optimize patient outcome.
Rationale: Mechanically ventilated patients must be disconnected from the ventilator during intra-facility transfers. Intentional and accidental circuit disconnections represent a potential hazard to patients (sudden collapse and re-expansion of the alveoli) as well as to clinical staff (exposure to patient's unfiltered exhalation). Therefore, avoiding abrupt circuit disconnections could better protect the patient's health and reduce or eliminate contamination risks around clinical staff. Objective: The purpose of this in-vitro work was to investigate and evaluate the potential for environmental exposure of Nitric Oxide (NO, as an indicator of any contamination exposure) before and after implementing the novel Flusso™ Bypass adapter during the disconnect procedure of a mechanical ventilator system. Methods: A mechanical ventilator delivering NO was connected to a breathing simulator with and without the Flusso™ Bypass adapter. The ambient NO concentration was measured when the circuit was briefly disconnected (3 s) during inhalation and exhalation. Both volume and pressure ventilation modes were used. Measurements and main results: Disconnecting the standard ventilator circuit (pressure-controlled mode) without the Flusso™ Bypass adapter produced higher NO escape to the surroundings (compared with the volume-controlled mode), leading to a longer NO dissipation time. No ambient NO traces were detected when the Flusso™ adapter was used. Conclusion: The usage of the Flusso™ adapter drastically decreases the unwanted exposure among clinical staff dealing with potentially hazardous airborne biological aerosols emanating from the circuit. Avoiding abrupt disconnection in the ventilator circuit could reduce lung injuries and alveolar over distension and collapse.
Background: There exists a political imperative to have access to data that meets the needs of health care administrators, governments, and funding bodies to support evidence-informed decision making. It is incumbent upon respiratory therapists to examine how they can deliver the highest-quality patient care, but also that they add value to health systems that ensure the benefits of health innovations are shared equitably among all members of our communities. Purpose: To explore the perceived value contributed by the respiratory therapy profession to health care and the health care system in the Province of Alberta at patient, team, and system levels. Research methods: An interpretive descriptive approach was adopted, including the formation of a description and exploration of possible associations, relationships, and patterns within a field of practice. Conclusions: The qualitative data analysis uncovered a framework that could inform research efforts of the respiratory therapy community in a way that contributes to the proposed mechanisms by which the profession generates value for the organization and patients. The RT-PBOI Conceptual Model identified five key concepts relating to the value contributed by respiratory therapists to health care: technical skills, practice across settings, strategic expertise, tools that leverage capacity, and growing value into the future.
Top-cited authors
Peter Papadakos
  • University of Rochester
Marcin Karcz
  • Columbia University
Andrew J. West
  • The University of Calgary
Vanessa Roberts
  • Acadia University
Mariana A. Vetrici
  • University of Lethbridge