Respiratory Care Research Articles

Lung Point of Care Ultrasound (POCUS) in Cardiorespiratory Physiotherapy and Respiratory Therapy Practices: Current Status and Future Directions

Lung Point of Care Ultrasound (POCUS) strongly influences physiotherapy and respiratory therapy clinical decision-making in the intensive care unit (ICU). The uptake of Lung POCUS training by physiotherapists and respiratory therapists is low in some countries, often due to many barriers to its implementation. The safe and appropriate integration of Lung POCUS into physiotherapy and respiratory therapy clinical practice may be achieved by various means. This article describes the pathway for physiotherapists to become Lung POCUS-accredited in Australia, focusing on a novel fast-track approach that may apply internationally and in other professions, such as respiratory therapy. While a fast-track approach is resource intensive, such resource allocation may be justified to support the growth of Lung POCUS in physiotherapy and respiratory therapy practice where mentor support may be inconsistent, lacking, or absent.

The Care of Preterm and Term Newborns with Respiratory Conditions: A Systematic Synthesis of Evidence from Low- and Middle-Income Countries.

Neonatal respiratory conditions are leading causes of mortality and morbidity during the neonatal period. This review evaluated 11 management interventions for respiratory distress syndrome (RDS), apnoea of prematurity (AOP), meconium aspiration syndrome (MAS), transient tachypnea of the newborn (TTN), as well as bronchopulmonary dysplasia (BPD) as a potential complication from respiratory care in low- and middle-income countries (LMICs). Two different methodological approaches were completed: (1) updating outdated reviews and pooling all LMIC studies and (2) re-analysis of LMIC studies from up-to-date reviews. Review updates were conducted between October 2022 and February 2023 and followed systematic methodology. A total of 50 studies were included across four review updates and seven review re-analyses. Findings indicate that bubble CPAP (RR 0.74, 95% CI 0.58 to 0.96) and prophylactic CPAP (RR 0.39, 95% CI 0.26 to 0.57) for RDS reduced the risk of treatment failure compared to other ventilation types or supportive care, respectively. Postnatal corticosteroids reduced BPD assessed as oxygen requirement at 36 weeks' postmenstrual age (RR 0.56, 95% CI 0.41 to 0.77). All other outcomes were found to be non-significant across remaining interventions. Our findings indicate that prophylactic and bubble CPAP may provide some benefit by reducing treatment failure compared to other pressure sources. The safety and efficacy of other management interventions for RDS, AOP, BPD, MAS, and TTN remains uncertain given limited evaluations in LMICs. Future research should conduct adequately powered trials in underrepresented LMIC regions, investigate long-term outcomes, and evaluate cost-effectiveness.

"Unidos Hablemos" - description of a virtual conference series to engage the Hispanic and Latino community in asthma and COVID-19 education and research.

Inequity in asthma and COVID-19 outcomes and research among Hispanic or Latino individuals is well established. Patient centered outcomes research (PCOR) may help address these inequalities. This report describes the development, implementation, and evaluation of a virtual conference series program titled "Unidos Hablemos de/United, Let's Talk About" intended to address the health literacy of the Hispanic/Latino community regarding asthma and COVID-19 and to encourage involvement in PCOR. A Project Advisory Group consisting of Hispanic/Latino patient advisors who had been diagnosed with asthma and/or COVID-19, healthcare providers, researchers, a Hispanic faith-based leader, and a program evaluator designed and implemented a six-month series of monthly one-hour virtual sessions. Speakers and topics were selected that fit the Hispanic/Latino community and culture regarding asthma, COVID-19, and PCOR. Recruitment was through a multichannel digital promotion strategy, including social media. The virtual sessions were free on the ZOOM webinar platform and included interactive polling questions, live chat box, and Q&A. All audio and written materials from the sessions were translated into Spanish and English. Evaluations were used to rate the overall satisfaction with the program. An average of 382 participants attended each of the six sessions, and participation generally increased with each session. The proportion of participants who considered themselves a Hispanic/Latino patient with asthma, caregiver, or clergy who served Hispanic/Latino communities increased by 100% from session one to session two. Preference for materials in Spanish ranged from 12 to 20% of participants over the six sessions. Among the sessions, 74-84% of polling question respondents indicated they would be willing to participate in research or a study, and 88% said they would be willing to serve as a patient partner/advocate. Program evaluations consistently indicated high satisfaction with the session content, session format, and feeling of inclusion. Unidos Hablemos provided a voice to the Hispanic/Latino community that will inform future strategies to improve equity in asthma management, COVID-19, and PCOR. Patient speakers generated trust from the participants and "bridged the gap" between physicians, researchers, and the Hispanic/Latino community. Providing evidence-based, current information will empower patients and caregivers to make informed healthcare decisions.

Effectiveness and safety of hydrogen inhalation therapy as an additional treatment for hypertension in real-world practice: a retrospective, observational study in China

AimTo evaluate the real-life effectiveness and safety of hydrogen inhalation (HI) therapy as an additional treatment in Chinese adults with hypertension.MethodsThis observational, retrospective clinical study included hypertensive patients receiving routine antihypertensives with or without HI initiation from 2018 to 2023. Participants were assigned to the HI group or non-HI group (control group) after propensity score matching. The changes in mean systolic blood pressure (SBP) level during the 24-week follow-up period in different groups were examined primarily. The secondary outcome was the changes in diastolic blood pressure (DBP) and blood pressure (BP) control rate during the study. Several subgroup and sensitivity analyses were performed to confirm the robustness of our main findings. Adverse event (AE) was also assessed in patients of both groups.ResultsIn total, we selected 2,364 patients into the analysis. Both mean SBP and DBP levels significantly decreased in the HI group compared to control group at each follow-up visit with the between group difference of −4.63 mm Hg (95% CI, −6.51 to −2.74) at week 8, −6.69 mm Hg (95% CI, −8.54 to −4.85) at week 16, −7.81 mm Hg (95% CI, −9.57 to −6.04) at week 24 for SBP, and −1.83 mm Hg (95% CI, −3.21 to −0.45) at week 8, −2.57 mm Hg (95% CI, −3.97 to −1.17) at week 16, −2.89 mm Hg (95% CI, −4.24 to −1.54) at week 24 for DBP. Patients in the HI group were more likely to attain controlled BP at the follow-up period with odds ratio of 1.44 (95% CI, 1.21–1.72) at week 8, 1.90 (95% CI, 1.59–2.27) at week 16, and 2.24 (95% CI, 1.87–2.68) at the end. The trends of subgroup and sensitivity analyses were mostly consistent with the main analysis. The incidences of AEs were similar between the HI group and control group with all p-value >0.05.ConclusionThe HI therapy is related to significant amelioration in BP levels with acceptable safety profile in Chinese hypertensive adults after 24 weeks of treatment, building a clinical ground for further research to evaluate the antihypertensive effect of HI therapy.

Abstract Su403: Iterative Simulation to Optimize Mechanical CPR Device Application

Mechanical chest compression devices (MCDs) are commonly used for in-hospital and emergency department (ED) cardiac arrest resuscitation. Manufacturer guidelines and educational materials demonstrate that in the prehospital setting, MCDs can be deployed with an interruption in CPR of less than 15 seconds. No similar materials exist for the in-hospital environment, where observational studies have noted median CPR interruptions of up to 40 seconds for MCD deployment. With the integration of extracorporeal CPR (eCPR) into OHCA systems of care, the need to transfer patients with ongoing CPR to MCDs in the ED is growing. To develop a hospital-specific procedure for receiving a patient in cardiac arrest and deploying the MCD with minimal no-flow time. We used an iterative participatory design process to develop a procedure for receiving patients in cardiac arrest from Emergency Medical Services (EMS). Tasks included transferring a patient, replacing defibrillator pads, and deploying the hospital MCD with minimal no-flow time. Participants including ED physicians, nurses, and respiratory therapists performed a series of simulations using a high-fidelity manikin, resuscitation equipment, and an MCD. Simulations were followed by focused debriefings, participant-directed modification of the working procedure, and repeat simulation until participants expressed satisfaction with the procedure. Participant roles were shuffled after each round. The primary outcome was the duration of CPR interruption required to deploy the MCD; change in this time over successive iterations was assessed using a Wilcoxon signed-rank test. The final procedure described a sequence of steps and responsibilities that participants deemed efficient and reproducible. Through seven simulation-debriefing cycles, CPR interruption associated with MCD deployment decreased from 19 to 10 seconds (p = 0.033). The most common failure modes that participants corrected during modifications involved needed equipment that was out of reach, obstructed provider positioning, and poorly defined roles. On subsequent days, two additional groups of on-shift ED providers deployed the MCD in less than 15 seconds following the developed procedure. Using an iterative design process, we created an MCD deployment procedure that minimized CPR interruptions and was acceptable to hospital staff. This represents an effective, low-cost methodology to design a process for transfer of care during CPR and MCD deployment.

Improving Outcomes for Patients With Tracheostomy Through Implementation of AARC Clinical Practice Guidelines.

The COVID-19 global pandemic dramatically increased our institution's tracheostomy census. Comparing our existing protocols with American Association for Respiratory Care (AARC) January 2021 clinical practice guideline (CPG) relevant to caring for adult patients with tracheostomy in the acute care setting revealed numerous opportunities for improving our care of those patients. We assembled an interdisciplinary tracheostomy team to implement AARC CPG recommendations and manage all patients with tracheostomy in our hospital. We examined the effect our interdisciplinary team approach and implementation of AARC CPG recommendations had on the following metrics: average patient length of stay (LOS); ICU LOS; percentage of ventilator days; percentage of tracheostomy mask days; tracheostomy tube changes; decannulations; average time to decannulation; mortality; 30-d readmissions; and consultations for speech-language pathology (SLP), one-way speaking valves, physical therapy, and occupational therapy. A total of 203 subjects with tracheostomy were followed in a quality improvement study from June 2019-June 2023 (94 in the pre-intervention group, 109 in the post group). There were significant increases between before and after intervention groups in percentage of decannulations in acutely patients with tracheostomy/not present on admission, non-COVID subjects who survived hospitalization (11.8% vs 33.3%, P = .043), percentage of SLP consults (53.2% vs 89.0%, P < .001), and percentage of one-way speaking valve consults (17.0% vs 32.1%, P = .02). Establishment of an interdisciplinary tracheostomy team and implementation of AARC CPG recommendations for care of adult patients with tracheostomy in the acute care setting resulted in positive, statistically significant outcomes.

ADHERENCE TO INHALER THERAPY IN PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE AND CONTRIBUTING FACTOR

Chronic Obstructive Pulmonary Disease (COPD) is a leading cause of morbidity and mortality worldwide, with inhaler therapy being a cornerstone of its management. This review aims to evaluate adherence to inhaler therapy among COPD patients and identify factors influencing this adherence. A comprehensive literature search was conducted using databases such as PubMed, Scopus, and Web of Science, focusing on studies published between 2010 and 2023. The findings indicate that adherence rates to inhaler therapy range between 20% and 60%, primarily due to factors such as patient education, inhaler technique, and comorbid conditions. The review highlights the importance of effective patient education and simplified inhalation devices to improve adherence and, consequently, health outcomes in COPD patients.

Advancing extracorporeal carbon dioxide removal technology: bridging basic science and clinical practice.

Recently, advancements in extracorporeal carbon dioxide removal (ECCO2R) technology have markedly enhanced its clinical applicability and efficacy for managing severe respiratory conditions. This review highlights critical innovations in ECCO2R, such as advanced catheter technologies, active mixing methods, and biochemical enhancements, which have substantially improved gas exchange efficiency and broadened the scope of ECCO2R applications. Integrating ECCO2R into acute and chronic respiratory care has led to a shift toward more mobile and less invasive modalities, promising for extending ECCO2R usage from intensive care units to home settings. By examining these technological advancements and their clinical impacts, this paper outlines the potential future directions of ECCO2R technology, emphasizing its role in transforming respiratory care practices and enhancing patient outcomes.

Exploring pharmacists’ understanding and use of antifungals at a tertiary hospital in England - an interview study

Abstract Introduction Antimicrobial resistance (AMR) is an emerging crisis worldwide. If continued, it is estimated AMR could cause over 10 million deaths annually by 20501. Antifungals are critical in the treatment and prophylaxis of fungal infections, especially invasive fungal infections which can be life-threatening. The national and international antimicrobial stewardship action plan focus primarily on the use of antibacterials. Antifungals have not yet been a focus for stewardship programmes. The appropriate use and understanding surrounding antifungals remain a challenge among healthcare professionals, including pharmacists but there is scarce empirical evidence to demonstrate this problem. Aim To explore pharmacists’ understanding and use of antifungals at a tertiary hospital in England. Methods A qualitative study utilising a constructivist approach involving one-to-one online semi-structured interview based on the Critical Incident Technique2 was conducted. Pharmacists working in the tertiary hospital were purposively sampled and recruited to participate in the study. Following informed consent, participants took part in a semi-structured interview via Microsoft Teams with a researcher. Interviews explored 1) the general purpose of using antifungals and 2) system factors and decisions taken when managing a routine and unusual or challenging case using antifungals. The interviews were audio-recorded and then transcribed verbatim. Transcripts were analysed using reflexive thematic analysis3. The study was registered with the tertiary hospital where participants were recruited from. This study was registered with Oxford University Hospitals NHS Foundation Trust (ref no. 8482) and received ethical approval from the University of Reading School of Chemistry, Food and Nutritional Sciences and Pharmacy internal ethics review committee (study no: 46/2023). Results Nine participants took part in the study. Interviews took an average of 29 minutes (range 15-55 minutes). Participants worked in different specialties including oncology, haematology, paediatrics, and respiratory care. Three themes were generated through the analysis. Theme 1: Diagnosing and managing fungal infections is complex. Limited and/or lack of reliable and timely diagnostic testing makes diagnosing fungal infections difficult. Consequently, patients were sometimes prescribed empiric antifungals to avoid treatment delay. Treatment was then reviewed once test results were available. Patient-related issues such as comorbidities and drug-drug interactions contribute to complex treatment plans. Theme 2: Antifungal stewardship involved a multidisciplinary approach. Pooling together expertise amongst healthcare professionals was imperative in decision-making. Pharmacists were often key antifungal stewards and medication experts despite working with uncertainty. Theme 3: Expressed need to upskill on antifungal stewardship. Participants were aware of gaps in their experience and knowledge when managing complex fungal infections. They want to be more confident in their role. Discussion/conclusions To our knowledge, this is the first study investigating hospital pharmacists’ understanding and use of antifungals in England. Our study showed that pharmacists navigate uncertainties when using antifungals. Pharmacists were viewed as antifungal stewards and medication experts in a multidisciplinary team but pharmacists were themselves aware that they need more exposure to a wider range of scenarios to enhance their confidence. Our findings suggest a need for reliable diagnostic-driven approaches and education and training initiatives for pharmacists to steward antifungals. Our participants worked in one tertiary hospital representing the culture and work practice specific to the hospital. It would be interesting to explore experiences of pharmacists working in other hospitals.

Post-Discharge Growth Among Extremely Preterm Infants With or Without Bronchopulmonary Dysplasia.

This study aimed to evaluate whether bronchopulmonary dysplasia (BPD) and home respiratory care (HRC) after discharge, including home oxygen therapy (HOT) or home mechanical ventilation (HMV), were associated with the growth of extremely preterm infants. This secondary study uses data from a study on the infant and early childhood development survey of low-birth-weight infants in the Health, Labor, and Welfare Science Research. We enrolled 788 singleton extremely preterm infants appropriate for gestational age (GA). BPD was defined as the requirement of supplemental oxygen or respiratory support at 36 weeks corrected GA. We compared trends of anthropometric measurements from age 0 to 5 years among infants with non-BPD, BPD without HRC, and BPD with HRC. We obtained 4113 weight and length measurements. At age 0-5 years, the BPD with the HRC group weighed less and was shorter than the other two groups. Lower GA and BPD status were significantly associated with growth failure of weight at 3 and 5 years after adjustment for potential risk factors. Lower GA was significantly associated with growth failure of length at 3 and 5 years. Conversely, although BPD status was significantly associated with growth failure of length at 3 years, it was not at 5 years. Among extremely preterm infants, BPD with HRC was associated with a significant growth delay at 0-5 years compared with non-BPD and BPD without HRC. However, the effect of different severities of BPD on growth failure of length was attenuated with age.

Reducing the diameter of the atomized particles by coating polymer membrane on the inner wall of micro-tapered holes of the ultrasonic mesh atomizers

Atomized inhalation therapy with its rapid efficacy, low side effects and high medicine utilization, has become a crucial method for treating respiratory diseases. The depth of atomized particles deposition in the respiratory tract mainly depends on the particle diameter, making the reducing of the atomized particle size crucial for medicine deposit in lung. In the existing literatures, for the widely used dynamic mesh atomizer, the majority of the researches focused on the mechanical structure and the vibration characteristics of the atomizers. However, there is little researches on the micro-tapered holes of the metal sheet of the atomizer, despite the fact that the diameter of these tapered holes determines the size of the atomized particles. Due to the processing technology, the diameter of the micro-tapered holes cannot be further reduced, which greatly limits the development of the dynamic mesh atomizer in inhalation therapy. In this study, we consider the use of polymer coating on the inner wall of the micro-tapered holes to eliminate burrs, reduce the diameter of the holes, and ultimately reduce the size of the atomized particles. A theoretical model of the initial thickness of the coating polymer membrane and the rupture depth under the uniform air pressure applied to a single tapered hole was established. The metal sheets with different initial coating thicknesses were processed to verify the theoretical model by observing the quality of the inner surface and measuring the diameter of the holes. The particle size measurement experiment results show that when the initial coating thickness was 3 μm and 4.5 μm, the average particle sizes were reduced by 12.5 % and 23.2 %, respectively. Therefore, the proposed method can effectively reduce the atomized particles size, which helps to efficiently deposit atomized drugs in the lungs.

Spray Dried Polymyxin B Liposome for Inhalation Against Gram-Negative Bacteria

This study aimed to provide an alternative and effective delivery system to combat polymyxin B (PMB) toxicity and bacterial resistance through inhalation therapy. PMB was formulated as liposomal dry powder for inhalation using thin-film hydration and spray-dried methods. PMB formulations were characterized physically. The aerodynamic properties were determined using next-generation impactor (NGI). In vitro drug release was done in a phosphate buffer pH 7.4 for 2 h. Cytotoxicity was evaluated by the MTT cell viability assay. Antimicrobiological activities were done using bioassay and flow cytometry. Particle sizes of the spay-dried formulations were between 259.83 ± 9.91 and 518.73 ± 27.08 nm while the zeta potentials ranged between 3.07 ± 0.27 mV and 4.323 ± 0.36 mV. The FT-IR shows no interaction between PMB and other excipients. DSC thermograms revealed amorphousness of the formulated powders and SEM revealed spherical PMB formulations. Similarly, MMAD results were 1.72–2.75 nm, and FPF was 25–26%. The cumulative release of the PMB formulations was 90.3 ± 0.6% within 2 h. The killing kinetics revealed total cell death at 12 and 24 h for Pseudomonas aeruginosa and Escherichia coli respectively. The PMB inhalation liposome showed better activity and was safe for lung-associated cell lines.

Interprofessional Education in Neurology Intensive Care Unit: Learning Activity for Students Completing Clerkships and Field Experiences.

Teaching learners the benefits and challenges of interprofessional collaborative practice (IPCP) in acute care is best done in the context of authentic patient care rather than classroom settings. Yet differing clinical schedules of students and faculty as well as structured, controlled environments of intensive care units are not conducive to bringing multiple interprofessional learners to the bedside. We developed a 2.5-hour interprofessional education (IPE) activity based around neurology intensive care unit patients that was implemented using team-based learning (TBL) methodologies, including individual/team readiness assessments (iRAT/tRAT) and application activities comprising interprofessional student-led care conferences in which authentic patients and their unique, deidentified clinical parameters were discussed. Students represented medicine, nursing, chaplain, physician assistant, social work, respiratory therapy, pharmacy, physical therapy, and law programs. Two hundred ninety-three students participated online during the first year. Mean tRAT scores were 14.9 points higher than iRAT scores (39.5 vs. 24.6 of 44 possible). There was strong agreement from students that the session met educational objectives (all >4.0 on a 5-point Likert scale). Individualized feedback was provided to learners using a rubric; 276 students shared personal reflections of knowledge learned through interactions with other health professional students/faculty. IPE activities that use authentic patient chart data as the basis for student application exercises are useful learning tools since students must teach and learn from each other, interpret data, and propose care plans based upon their collaborations. This enables students to experience acute care IPCP in a low-stakes environment.

Interprofessional Team Staffing in U.S. Intensive Care Units.

There is a paucity of data, and no consensus, about the composition of interdisciplinary teams of healthcare worker (HCW) that provide care in intensive care units (ICU). Delineate the nature and variation of HCW staff composition in US adult ICUs before the COVID-19 pandemic. A national survey of 574 adult ICUs inquired about ICU staffing. Two sets of survey items asked about: (a) "availability to provide care" in ICU for 11 HCW types, collapsed into six groupings, and (b) presence in formal ICU clinical rounds of nine HCW types, collapsed into six groupings; bedside nurses were assumed to be involved in both categories. Analysis was descriptive, seeking to examine the predominant and full range of staffing patterns. Of surveyed ICUs: 94% were in metropolitan areas, 63% in teaching hospitals, 74% had >250 beds, 66% cared for mixed adult patient types (e.g. medical-surgical), median ICU bed count was 20 (interquartile range 12-25), 27% used some form of telemedicine. In addition to bedside nurses, the core staffing group comprised intensivists, respiratory therapists and pharmacists; in 88% of ICUs all were available to provide care. However, there were 28 different combinations of the six groupings (intensivists, respiratory therapists, pharmacists, attending physician support, advanced bedside nurse support, nurse aides), with the most common one, present in 38% of ICUs, including all six. 96% of ICUs had interprofessional rounds at least five days a week; 78% had them on weekends. Among the ICUs with rounds, 61% of weekday rounding teams included all of intensivists, respiratory therapists and pharmacists. Nutrition, rehabilitation and social support practitioners each participated in rounds in 35-80% of ICUs, and altogether in 28% of ICUs. Except for intensivists, all HCW types participated much less commonly in weekend than in weekday rounds. ICU care almost always included a core team of bedside nurses, intensivists, respiratory therapists, and pharmacists. Beyond that core, great variability was seen in the presence of many other HCW types. Almost all ICUs had interprofessional rounds, with three-quarters also having them on weekends.

Therapeutic applications of eucalyptus essential oils.

Eucalyptus essential oils (EEOs) have gained significant attention recently anticipated to their broad range of prospective benefits in various biological applications. They have been proven to have strong antibacterial properties against a variety of bacteria, fungi, and viruses. This makes them valuable in combating infections and supporting overall hygiene. The active compounds present in these oils can help alleviate inflammation, making them valuable in addressing inflammatory conditions such as arthritis, respiratory ailments, and skin disorders. Respiratory health benefits are another prominent aspect of EEOs. Inhalation of these oils can help promote clear airways, relieve congestion, and ease symptoms of respiratory conditions like coughs, colds, and sinusitis. They are often utilized in inhalation therapies and chest rubs. They can be used topically or in massage oils to alleviate muscle and joint pain. Furthermore, these oils have shown potential in supporting wound healing. Their antimicrobial activity helps prevent infection, while their anti-inflammatory and analgesic properties contribute to reducing inflammation and pain associated with wounds. In aromatherapy, EEOs are renowned for their invigorating and uplifting qualities, promoting mental clarity, relaxation, and stress relief. Overall, EEOs hold great promise in biological applications, offering a natural and versatile approach to promote health and well-being. Continued research and exploration of their therapeutic potential will further unveil their benefits and broaden their applications in various fields.

Exploring the impact of a clinical extern program on readiness to practice.

The COVID-19 pandemic created an increased demand for healthcare professionals across all healthcare sectors globally. Attrition, retirement, delayed graduations, and sick leaves resulted in an inadequate supply of knowledgeable, skilled, and experienced nurses to care for hospitalized patients and help address hospital capacity pressures. In response to this health human resource crisis in Canada, the Ontario Ministry of Health offered hospitals funding to support the employment of Clinical Externs (CEs), that is, students in nursing, respiratory therapy, physiotherapy, occupational therapy medicine, and paramedicine, hired to work as unregulated staff, alongside an inter-professional team. This mixed-methods study evaluated the CE program that was implemented in one large academic hospital. The primary aim was to identify the outcomes of the clinical extern program from the perspectives of CEs, CE coordinators, and clinical leaders. Findings indicate the clinical extern program reinforces student confidence and supports their transition to formal nursing and respiratory therapy roles.

Association of moderate-to-vigorous physical activity with reduction of acute exacerbation in COPD patients using a dual ultra-long-acting bronchodilators

Inhaler therapy and physical activity (PA) are important methods of chronic obstructive pulmonary disease (COPD) management. This study aimed to investigate the additional benefit of moderate-to-vigorous PA (MVPA) in patients with COPD using a long-acting beta-agonists (LABA)/long-acting muscarinic antagonist (LAMA) combination. We emulated a target trial to estimate the benefit of MVPA in patients with COPD using a dual ultra-long-acting bronchodilators. We enrolled patients aged ≥ 40 who were diagnosed with COPD between 2014 and 2018, initiated a LABA/LAMA combination, and had not undergone regular MVPA. The main exposure was the initiation of MVPA, defined as vigorous aerobic exercise > 20 min per day on ≥ 3 days/week or moderate aerobic exercise > 30 min per day on ≥ 5 days/week. The main outcomes were the future usage of inhaled corticosteroids (ICS) and severe exacerbation. We identified 1,526 patients who initiated MVPA and 4,516 who did not. The median follow-up period was 3.0 years. The hazard ratio (HR) for future ICS usage in the MVPA initiation group was 0.83 (95% confidence intervals (CI): 0.72, 0.97) compared to the control group. The HR for severe exacerbation in the MVPA initiation group was 0.81 (95% CI: 0.68, 0.96) compared to the control group. Subgroup analyses by age, sex, body mass index, residence area, smoking and drinking status showed consistent benefits in these outcomes. Initiation of MVPA may offer an additional benefit for even COPD patients who use a dual ultra-long-acting bronchodilators.

Picturing Empathy in the Intensive Care Unit: Patient Photographs at an Urban Community Teaching Hospital.

Intensive care unit (ICU) clinicians are at risk for burnout, which can be driven by depersonalization. Photographs of patients in their baseline state of health before ICU admission may enhance the connection between clinicians and patients. The use of patient photographs has not been evaluated in an urban community teaching hospital. To evaluate whether an interprofessional group of clinicians perceive that patient photographs in the ICU help them connect with patients and enhance empathy. A prospective observational quality improvement study was performed in the medical ICU of an urban community teaching hospital. Patients' families could display patients' photographs in the unit. Registered nurses, physicians, respiratory therapists, and patient care associates completed anonymous surveys. Families of 21 patients provided photographs; 82 clinicians (47 physicians, 25 nurses, 5 respiratory therapists, and 5 patient care associates) completed surveys. Most clinicians (83%) agreed that the patient's personality and character were emphasized by photographs, 77% agreed that photographs facilitated communication with the patient and/or family, 89% agreed that patient photographs helped them relate to the patient as an individual, and 76% were not upset by comparing the photograph with the patient. Responses did not significantly differ by clinician type. Survey comments highlighted themes of humanization, fulfillment, and hope. Patient photographs may enhance connections between clinicians and patients in the ICU, potentially reducing depersonalization and burnout.

The Role of Respiratory Therapy in Rib Fracture Management

Respiratory therapy (RT) is a key component of modern rib fracture management. This practice encompasses a broad set of nonoperative measures including respiratory monitoring, oxygenation and ventilatory support, device and non-device based maneuvers, and pharmacologic treatments. Despite limited evidence, a number of these measures have demonstrated benefit in patients with traumatic rib fractures, leading to societal recommendations for inclusion in multimodal protocols for rib fracture management.

Analysis of Nirmatrelvir Entry into Pulmonary Lining Fluid in Patients with COVID-19: A Unique Perspective to Explore and Understand the Target Plasma Concentration of 292 ng/mL in Antiviral Activity.

Currently, the applicant has chosen a target plasma trough concentration for nirmatrelvir, which is adjusted to 292 ng/mL based on the drug's molecular weight (499.54 Daltons), its binding to human plasma proteins (69%), and the in vitro antiviral EC90 value (181 nM). However, the current exposure-effect relationships (ER) analysis of viral load in patients enrolled in the EPIC-HR study has not revealed clinically significant trends in the ER. Given that the lungs are the primary site of COVID-19 infection, we aim to further understand this exposure relationship by exploring and analyzing the penetration characteristics of nirmatrelvir in the lungs. To explore and understand the target plasma concentration of 292 ng/mL in antiviral activity. We identified all critically ill patients with coronavirus disease 2019 who received nirmatrelvir/ritonavir treatment in the respiratory intensive care unit of Changhai hospital between January 2023 and October 2023. Samples of plasma and bronchoalveolar lavage fluid were obtained at pre-dose trough concentrations after administration of nirmatrelvir (NMV). The relationship between NMV levels in plasma and the epithelial lining fluid (ELF) was assessed by determining concentrations of NMV. There was a significant relationship between NMV levels in plasma and ELF (ELF = 0.4976*PLASMA- 204; R = 0.96), with a correlation whose slope (0.4976) suggested that the blood-to-ELF ratio of drug penetration was 2:1. A negative value from the equation indicates that NMV requires to reach baseline concentration to penetrate the ELF. The relationship between NMV levels in plasma and ELF with low permeability and a negative baseline value suggests that the target plasma concentration of 292 ng/mL is insufficient for antiviral activity. This study provides a unique perspective to explore and understand no clinically meaningful trend of exposure-response relationships in patients enrolled in EPIC-HR.