Respiratory Care Clinics Of North America[JOURNAL]
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200 papers
Incorporating geriatrics into the respiratory care curriculum.
Sorenson HM
Respir Care Clin N Am · 2005 Sep · PMID 16168913 · Publisher ↗
The absolute number of adults over the age of 65 years is increasing nationwide and worldwide. Older adults today are more independent and self-sufficient than persons of that age were a generation ago. An increased inci...
The absolute number of adults over the age of 65 years is increasing nationwide and worldwide. Older adults today are more independent and self-sufficient than persons of that age were a generation ago. An increased incidence of acute and chronic disease results in relative morbidity but less mortality in those aged 65 years and older. The decision to incorporate or infuse education in geriatrics into existing respiratory care classes is not difficult. Implementation may be a little more challenging, but gradually adding geriatric components to courses over time is a perfectly reasonable way to introduce students to their future patient population. Fortunately, a growing number of elderly individuals desire to treat pathology rather than accept it as an inevitable consequence of aging. For these reasons, respiratory therapists have been brought into the realm of geriatric medicine, more by default than by organizational planning. The most passionate converts to the important role of geriatrics are physicians, nurses, and therapists who have recently attempted to shepherd their own aging parents through a health care system. If that experience that leads to these conversions could be measured and communicated, the world at large might be convinced of the value of education in geriatrics.
Clinical education and clinical evaluation of respiratory therapy students.
Cullen DL
Respir Care Clin N Am · 2005 Sep · PMID 16168912 · Publisher ↗
Different blends of knowledge, decision making, problem solving,professional behaviors, values, and technical skills are necessary in the changing health care environments in which respiratory therapists practice. Freque...
Different blends of knowledge, decision making, problem solving,professional behaviors, values, and technical skills are necessary in the changing health care environments in which respiratory therapists practice. Frequently, novice students are expected to perform quickly and efficiently,and it may be forgotten that students are still learning and mastering the foundation pieces of practice. Clinical educators take on the responsibility of student development in addition to overseeing patient care. Normally,these volunteer instructors are role models for respiratory therapy students. The characteristic of initiative when demonstrated by a beginning student is attractive to the clinical instructor, promotes sharing of experiences, and may evolve into a mentor-protege relationship. Some clinical instructors may be underprepared to teach and are uncomfortable with student evaluation. Respiratory therapy facilities in conjunction with academic institutions may consider sponsoring ongoing programs for clinical teachers. Teaching and learning in the clinical environment is more than demonstration of skills and knowledge. Furthermore, it can be debated whether the memorization of facts or of the steps of a skill is more valuable than competency in problem solving, clinical reasoning, or information retrieval. New knowledge is built within a context and is further integrated when grounded by experience. Development of "prediction in practice" or the anticipation of the next necessary actions may be worth integrating into the instructional toolbox. Intuition has been defined as an "understanding without a rationale". This definition separates intuition from rational decision making and presents intuition as a type of innate ability. Reflection when guided by clinical instructors can help deepen critical thinking, as will Socratic questioning on a regular basis. Most clinical staff can agree on the performance of an incompetent student, but discrimination of the levels of competence is more challenging. Observations allow the assessor to obtain the data necessary to evaluate performance, followed by assessment, which denotes a judgment made on the basis of an observation of events. Performance assessment should have stability and consistency, measure what is intended to be measured, and truly determine competence. In contrast, reflective analysis has been shown to be successful for clinical evaluation, thus departing from strict competency and product-based assessment. Students yearn to become clinically knowledgeable, and their enthusiasm should be fostered. An interest in clinical practice is the primary reason individuals enroll in respiratory therapy education programs. Educators,managers, and staff should assure that students experience an appropriate, rich, and diverse clinical curriculum that with practice develops clinical judgment, reasoning, and reflection on practice.
Graduate degree education programs: organization, structure, and curriculum.
LeGrand TS
Respir Care Clin N Am · 2005 Sep · PMID 16168911 · Publisher ↗
A master's degree is quickly becoming the minimum requirement for many professions across the United States. Leaving college with a baccalaureate degree alone is no longer the sure ticket to employment that it once was....
A master's degree is quickly becoming the minimum requirement for many professions across the United States. Leaving college with a baccalaureate degree alone is no longer the sure ticket to employment that it once was. In respiratory care graduate education, it is essential to advance the science and practice of the profession. The MS degree in respiratory care can provide "a link between the sciences, clinical research, and practice; increase knowledge within the discipline; provide for interdisciplinary collaboration and research;and train future faculty for the profession" of respiratory care.
Bachelor of science degree education programs: organization, structure, and curriculum.
Douce FH
Respir Care Clin N Am · 2005 Sep · PMID 16168910 · Publisher ↗
Therapists with bachelor's degrees in respiratory therapy have become the new advanced clinicians of the twenty-first century. Although the opportunity has increased in recent years, earning a baccalaureate degree in res...
Therapists with bachelor's degrees in respiratory therapy have become the new advanced clinicians of the twenty-first century. Although the opportunity has increased in recent years, earning a baccalaureate degree in respiratory therapy remains a limited option. The "2-year preprofessional plus 2-year respiratory therapy" is the most popular curriculum design, but several other notable designs also fulfill the definition of a bachelor's degree in respiratory therapy. Two landmark documents issued in 2003 make strong arguments for expanding opportunities for baccalaureate education in respiratory therapy. Recognizing the "need to increase the number of respiratory therapists with advanced levels of training and education to meet the demands of providing services requiring complex cognitive abilities and patient management skills," the American Association for Respiratory Therapy has strongly encouraged the continuing development of baccalaureate education. Strategies for expanding baccalaureate opportunities include increasing the number and capacities of traditional programs, creating more articulation and bridge agreements between community and junior colleges with 4-year colleges and universities, and offering baccalaureate respiratory therapy through distance education. For the profession of respiratory therapy to require a baccalaureate at entry level, expansion of baccalaureate education will be necessary, and educators, managers, practitioners, and professional leaders will need to pursue all viable strategies. As an interim phase in the evolution of the profession, Becker suggests a strategy of"reprofessionalism" aimed at assisting therapists currently in the workforce to complete their degrees. Through a combination of strategies, a bachelor's degree in respiratory therapy will inevitably become the standard for clinicians in the decades to come.
Associate in science degree education programs: organization, structure, and curriculum.
Galvin WF
Respir Care Clin N Am · 2005 Sep · PMID 16168909 · Publisher ↗
After years of discussion, debate, and study, the respiratory care curriculum has evolved to a minimum of an associate degree for entry into practice. Although programs are at liberty to offer the entry-level or advanced...
After years of discussion, debate, and study, the respiratory care curriculum has evolved to a minimum of an associate degree for entry into practice. Although programs are at liberty to offer the entry-level or advanced level associate degree, most are at the advanced level. The most popular site for sponsorship of the associate degree in respiratory care is the community college. The basis for community college sponsorship seems to be its comprehensive curriculum, which focuses on a strong academic foundation in writing, communication, and the basic sciences as well as supporting a career-directed focus in respiratory care. Issues facing the community college are tied to literacy, outcomes, assessment, placement,cooperation with the community, partnerships with industry, and articulation arrangements with granting institutions granting baccalaureate degrees. Community colleges must produce a literate graduate capable of thriving in an information-saturated society. Assessment and placement will intensify as the laissez-faire attitudes toward attendance and allowing students to select courses without any accountability and evaluation of outcome become less acceptable. Students will be required to demonstrate steady progress toward established outcomes. Maintaining relations and cooperation with the local community and the health care industry will continue to be a prominent role for the community college. The challenge facing associate degree education in respiratory care at the community college level is the ability to continue to meet the needs of an expanding professional scope of practice and to provide a strong liberal arts or general education core curriculum. The needs for a more demanding and expanding respiratory care curriculum and for a rich general education core curriculum have led to increased interest in baccalaureate and graduate degree education. The value of associate degree education at the community college level is well established. It is affordable, accessible, and responsive to the local health care industry it serves. It is likely to enjoy acceptance and popularity until its curricular limitations and time constraints no longer allow it to meet the needs of the respiratory care profession.
Characteristics of a successful respiratory therapy education program.
Ari A, Goodfellow LT, Rau JL
Respir Care Clin N Am · 2005 Sep · PMID 16168908 · Publisher ↗
Because of the increasing demand for program effectiveness, program outcomes have become important for quality assessment in respiratory care education. Respiratory care programs and their institutions must ensure that p...
Because of the increasing demand for program effectiveness, program outcomes have become important for quality assessment in respiratory care education. Respiratory care programs and their institutions must ensure that programs in which they invest their time, energy, and money have there sources necessary to provide quality preparation of program graduates. To determine how well an educational program achieves its goal in producing competent respiratory therapists, respiratory therapy programs must be assessed through key personnel, teaching, clinical education, and enrollment management. The processes such as developing faculty,improving instruction and enhancing students' learning, and strengthening the structure of the respiratory therapy program with competent personnel and effective enrollment management practices determine the direction and rate of success of the respiratory care program at GSU.
The next generation of respiratory therapists: student recruitment and selection.
Gardner DD, Vines DL
Respir Care Clin N Am · 2005 Sep · PMID 16168907 · Publisher ↗
Successful outcomes are vital for respiratory care education programs. These outcomes rely heavily on student recruitment and selection. Future graduates practicing respiratory care must have a basic understanding of res...
Successful outcomes are vital for respiratory care education programs. These outcomes rely heavily on student recruitment and selection. Future graduates practicing respiratory care must have a basic understanding of respiratory care and possess the advanced skills that enable them to problem solve, communicate effectively, and become active leaders in the health care team. It is the responsibility of respiratory care educators to produce the respiratory therapists of the future. It is crucial for the faculty of respiratory care education programs to recruit and select candidates who will complete the educational program and develop the technical and critical-thinking skills needed to pass the advanced level credentialing examinations and succeed in the respiratory care profession.
New and future developments to improve patient-ventilator interaction.
Kondili E, Georgopoulos D
Respir Care Clin N Am · 2005 Jun · PMID 15936697 · Publisher ↗
The new and future developments to improve the patient-ventilator interaction are mainly based on the concept of the tight coupling between neural output and ventilator function. This tight coupling should be present thr...
The new and future developments to improve the patient-ventilator interaction are mainly based on the concept of the tight coupling between neural output and ventilator function. This tight coupling should be present throughout a patient's respiratory cycle, a task that is demanding from a technical point of view. By achieving a tight neuromechanical coupling, the ventilator operates as an external respiratory muscle of high capabilities controlled mainly by the patient. This task, however, necessitates knowledge of respiratory system physiology and pathophysiology and the interaction between patient and ventilator. Although currently sophisticated computer algorithms have been developed, the caregiver is the one who controls the patient-ventilator system. Without indepth knowledge of this system, the algorithms may induce harm rather than benefit.
Potential advantages of patient-ventilator synchrony.
Ramar K, Sassoon CS
Respir Care Clin N Am · 2005 Jun · PMID 15936696 · Publisher ↗
During conventional mechanical ventilation, fixed set pressure, flow, and tidal volume result in a mismatch between patient and ventilator inspiratory time and in a patient's inability to adapt to changing ventilatory de...
During conventional mechanical ventilation, fixed set pressure, flow, and tidal volume result in a mismatch between patient and ventilator inspiratory time and in a patient's inability to adapt to changing ventilatory demand. Synchrony between the patient and ventilator improves neuromuscular coupling and the ability to adapt to increased ventilatory demand or loading. The sensation of dyspnea prevents ineffective inspiratory efforts and attenuates periodic breathing during sleep.
Effects of sleep on patient-ventilator interaction.
Parthasarathy S
Respir Care Clin N Am · 2005 Jun · PMID 15936695 · Publisher ↗
Sleep influences patient-ventilator interaction. Adjustment of ventilator settings in critically ill patients may require understanding and monitoring of the influence of the sleep-wakefulness state on patient-ventilator...
Sleep influences patient-ventilator interaction. Adjustment of ventilator settings in critically ill patients may require understanding and monitoring of the influence of the sleep-wakefulness state on patient-ventilator interaction. Research studies of patient-ventilator interactions should be controlled for the confounding influence of changes in the sleep-wakefulness state.
Patient-ventilator interaction during noninvasive positive pressure ventilation.
Nava S, Ceriana P
Respir Care Clin N Am · 2005 Jun · PMID 15936694 · Publisher ↗
The interaction between the patient and the ventilator is complex,especially in a "semi-open" system as for noninvasive ventilation(NIV). Air leaks around the mask are likely to occur, and they affect patient-ventilator...
The interaction between the patient and the ventilator is complex,especially in a "semi-open" system as for noninvasive ventilation(NIV). Air leaks around the mask are likely to occur, and they affect patient-ventilator synchrony. Several variables may be responsible for the mismatch between the start of the neural output and that of ventilatory aid during NIV. The most common mode of ventilation is pressure support ventilation (PSV), which may result in a number of inspiratory efforts not being followed by ventilator aid. New modes of ventilation, such as proportional assist ventilation, maybe useful in improving patient tolerance to ventilation without affecting clinical outcome. The ventilatory settings are important during PSV to determine the synchrony. The inspiratory trigger function may be influenced by the amount of leaks, whereas a better synchrony may be achieved if the termination of the inspiratory phase is time cycled instead of flow cycled. A high pressurization rate results in poor compliance. Care should be paid in the choice of the interfaces because leaks in the system are associated with a substantial breath-to-breath inspiratory variation independent from the patient effort. Last, NIV should be delivered with turbine- or piston-based ventilators that are able to compensate for air leaks. With respect to the problem of sedation, we point out the importance of optimizing the environmental conditions, avoiding excessive light and noise, assuring patient comfort, and providing reassurance. When sedation is needed, we suggest the use of low doses of analgesics and neuroleptic agents in selected cases.
Expiratory asynchrony.
Du HL, Yamada Y
Respir Care Clin N Am · 2005 Jun · PMID 15936693 · Publisher ↗
Expiratory asynchrony is a universal phenomenon, and expiratory synchrony occurs only by chance. Expiratory asynchrony exists in all breath modes and has a significant impact on the patient's work of breathing and the we...
Expiratory asynchrony is a universal phenomenon, and expiratory synchrony occurs only by chance. Expiratory asynchrony exists in all breath modes and has a significant impact on the patient's work of breathing and the weaning process. Advancements in ventilator designs and basic physiologic science could lead to the improvement of the expiratory asynchrony.
Modes of pressure delivery and patient-ventilator interaction.
Bonetto C, Caló MN, Delgado MO … +1 more , Mancebo J
Respir Care Clin N Am · 2005 Jun · PMID 15936692 · Publisher ↗
Differences between assist-control pressure and volume ventilation are minimal provided that peak inspiratory flow delivered at early inspiration matches patient demand Ventilation at constant flow and controlled tidal v...
Differences between assist-control pressure and volume ventilation are minimal provided that peak inspiratory flow delivered at early inspiration matches patient demand Ventilation at constant flow and controlled tidal volume allow instantaneous analysis of the patient-ventilator interactions and the mechanical properties of the respiratory system. The cycle-per-cycle variability of peak inspiratory flow, which is permitted in pressure-limited modes, may allow better patient comfort. We do not know if one mode (pressure controlled or volume controlled) is superior to the other in terms of outcomes.
Patient-ventilator interaction during the triggering phase.
Racca F, Squadrone V, Ranieri VM
Respir Care Clin N Am · 2005 Jun · PMID 15936691 · Publisher ↗
Partial patient-controlled mechanical support mode ventilators provide positive pressure assistance whenever a patient's inspiratory effort decreases pressure or flow in the ventilator circuit below the sensitivity set b...
Partial patient-controlled mechanical support mode ventilators provide positive pressure assistance whenever a patient's inspiratory effort decreases pressure or flow in the ventilator circuit below the sensitivity set by clinicians; these modes minimize disuse atrophy of the respiratory muscles, can facilitate the weaning process, and usually require lower ventilator pressures. The capability of restoring gas exchange, unloading respiratory muscles, and relieving the patient's dyspnea with partial patient-controlled mechanical support modes depends on matching between the ventilator setting and the patient's ventilatory demand (ie, patient-ventilator interactions).
Patient-ventilator interaction: an overview.
Prinianakis G, Kondili E, Georgopoulos D
Respir Care Clin N Am · 2005 Jun · PMID 15936690 · Publisher ↗
During assisted mechanical ventilation, the total pressure applied to respiratory system is the sum of ventilator and muscle pressure. As a result, the respiratory system is under the influence of two pumps, the ventilat...
During assisted mechanical ventilation, the total pressure applied to respiratory system is the sum of ventilator and muscle pressure. As a result, the respiratory system is under the influence of two pumps, the ventilator pump (ie, Paw), which is controlled by the physician's brain and the capabilities of the ventilator, and the patient's own respiratory muscle pump (Pmus), which is controlled by the patient's brain. The patient-ventilator interaction is mainly an expression of the function of these two brains, which should be in harmony to promote patient-ventilator synchrony. The achievement of this harmony depends exclusively on the physician, who should be aware that during assisted mechanical ventilation the respiratory system is not a passive structure but reacts to pressure delivered by the ventilator via various feedback systems and, depending on several factors both to the ventilator and patient, may modify the function of the ventilator. Finally, the physician should know that the ventilator imposes significant constraints to the respiratory system, the magnitude of which depends heavily on the triggering variable, the variable that controls the gas delivery and the cycling off criterion.
Assessment of respiratory output in mechanically ventilated patients.
Laghi F
Respir Care Clin N Am · 2005 Jun · PMID 15936689 · Publisher ↗
Mechanically ventilated patients are subject to few pathophysiologic disturbances that have such intuitive importance as abnormal function of the respiratory output. Abnormal function of the respiratory output plays a fu...
Mechanically ventilated patients are subject to few pathophysiologic disturbances that have such intuitive importance as abnormal function of the respiratory output. Abnormal function of the respiratory output plays a fundamental role in all aspects of mechanical ventilation: in determining which patients require mechanical ventilation, in determining the interaction between a patient and the ventilator, and in determining when a patient can tolerate discontinuation of mechanical ventilation. Monitoring indexes such as the rate of rise in electrical activity of the diaphragm, Po.1, (dP/dt)max, and Pmus, has provided insight into the performance of the respiratory centers in critically ill patients, but these methods require considerable refinement. A large body of research on measurements of energy expenditure of the respiratory muscles, such as pressure-time product, and measurements of inspiratory effort, such as the tension-time index, is currently accumulating. Several challenges, however, lay ahead regarding these indices. First, there is the need to identify the correct level of pressure generation and respiratory muscle effort that should be attained in the day-to-day management of mechanically ventilated patients. The correct titration of ventilator setting should not cause iatrogenic muscle damage because the support is excessive or insufficient. One of the challenges in reaching this goal is that for the same patient, different underlying pathologic conditions (eg, sepsis or ventilator-associated muscle injury) may require different levels of support. Second, many of the measurements of pressure generation and effort have been confined to the research laboratory. Modifications of the technology to achieve accurate measurements in the intensive care unit-outside of the research laboratory--are needed. To facilitate individual titration of ventilator settings, the new technologies must provide easier access to quantification of drive, pressure output, and effort. Finally, more research is needed to define the effect of monitoring respiratory output on patient outcome and containment of costs.
Basic principles of control of breathing.
Corne S, Bshouty Z
Respir Care Clin N Am · 2005 Jun · PMID 15936688 · Publisher ↗
The metabolic demands of the body, including consumption of oxygen and removal of carbon dioxide, vary widely in health and disease. Ventilation must adjust to meet these demands and accommodate volitional and behavioral...
The metabolic demands of the body, including consumption of oxygen and removal of carbon dioxide, vary widely in health and disease. Ventilation must adjust to meet these demands and accommodate volitional and behavioral activities. Control of breathing depends on a complex and intricate feedback control system that integrates these automatic and volitional aspects of ventilation. Sensors, including chemoreceptors and lung volume receptors, relay information to a central controller located primarily in the medulla. The central controller integrates this information and determines the level of activation of the effectors (the respiratory motoneurons and muscles), which affects ventilation and gas exchange. Inputs from suprapontine structures, including the cerebral cortex, are also important in integrating volitional aspects of breathing into the control system.
Functional principles of positive pressure ventilators: implications for patient-ventilator interaction.
Branson RD
Respir Care Clin N Am · 2005 Jun · PMID 15936687 · Publisher ↗
Ventilator performance can be tied to the individual systems that control delivery of pressure, volume, and flow. Clinician's need not be engineers but should understand how individual device mechanics and algorithms can...
Ventilator performance can be tied to the individual systems that control delivery of pressure, volume, and flow. Clinician's need not be engineers but should understand how individual device mechanics and algorithms can affect patient ventilator synchrony.
The effect of malnutrition on risk and outcome of community-acquired pneumonia.
Loeb M, High K
Respir Care Clin N Am · 2005 Mar · PMID 15763225 · Publisher ↗
There are many potential mechanisms by which nutritional deficiencies can predispose to an increased risk and worse outcome for CAP. The elderly population is particularly vulnerable. There is a relative lack of data on...
There are many potential mechanisms by which nutritional deficiencies can predispose to an increased risk and worse outcome for CAP. The elderly population is particularly vulnerable. There is a relative lack of data on the effect of nutrition on risk and outcome of CAP. More research is needed to better delineate the impact of nutrition on risk and outcome of CAP.
What have we learned about how to measure quality of care for patients with community-acquired pneumonia?
Metersky ML, Abend SL, Meehan TP
Respir Care Clin N Am · 2005 Mar · PMID 15763224 · Publisher ↗
The most commonly used measures of quality of care for hospitalized pneumonia patients are process measures as opposed to outcome measures.For a process measure to be useful in assessing quality of care, it must be linke...
The most commonly used measures of quality of care for hospitalized pneumonia patients are process measures as opposed to outcome measures.For a process measure to be useful in assessing quality of care, it must be linked to a desired outcome. For patients hospitalized with pneumonia, the obtaining of blood cultures, the timely use of appropriate antibiotics, and the delivery of the influenza and pneumococcal vaccines are the process measures most widely used for assessing quality of care in relation to clinical outcomes. The admission decision and the length of time that intravenous antibiotics are used are process measurements that directly affect financial outcomes.
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