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Given the important role of patient-ventilator assessments in ensuring the safety and efficacy of mechanical ventilation, a team of respiratory therapists and a librarian used Grading of Recommendations, Assessment, Development, and Evaluation methodology to make the following recommendations: (1) We recommend assessment of plateau pressure to ensure lung-protective ventilator settings (strong recommendation, high certainty); (2) We recommend an assessment of tidal volume (VT) to ensure lung-protective ventilation (4-8 mL/kg/predicted body weight) (strong recommendation, high certainty); (3) We recommend documenting VT as mL/kg predicted body weight (strong recommendation, high certainty); (4) We recommend an assessment of PEEP and auto-PEEP (strong recommendation, high certainty); (5) We suggest assessing driving pressure to prevent ventilator-induced injury (conditional recommendation, low certainty); (6) We suggest assessing FIO2 to ensure normoxemia (conditional recommendation, very low certainty); (7) We suggest telemonitoring to supplement direct bedside assessment in settings with limited resources (conditional recommendation, low certainty); (8) We suggest direct bedside assessment rather than telemonitoring when resources are adequate (conditional recommendation, low certainty); (9) We suggest assessing adequate humidification for patients receiving noninvasive ventilation (NIV) and invasive mechanical ventilation (conditional recommendation, very low certainty); (10) We suggest assessing the appropriateness of the humidification device during NIV and invasive mechanical ventilation (conditional recommendation, low certainty); (11) We recommend that the skin surrounding artificial airways and NIV interfaces be assessed (strong recommendation, high certainty); (12) We suggest assessing the dressing used for tracheostomy tubes and NIV interfaces (conditional recommendation, low certainty); (13) We recommend assessing the pressure inside the cuff of artificial airways using a manometer (strong recommendation, high certainty); (14) We recommend that continuous cuff pressure assessment should not be implemented to decrease the risk of ventilator-associated pneumonia (strong recommendation, high certainty); and (15) We suggest assessing the proper placement and securement of artificial airways (conditional recommendation, very low certainty). [ABSTRACT FROM AUTHOR]

Pulse oximetry is arguably the most impactful monitor ever introduced into respiratory care practice. Recently there has been increased attention to the problem of occult hypoxemia in which patients are hypoxemic despite an acceptable SpO2. Although occult hypoxemia might be greater in Black patients than white patients, it is not insignificant in whites. In a given population of patients, the bias between SpO2 and arterial oxygen saturation (SaO2) might be close to zero. However, the limits of agreement can be wide, meaning that SpO2 might overestimate SaO2 in many individual patients, which can result in occult hypoxemia in some. Manufactures report accuracy of SpO2 derived from normal individuals, which might differ from that in the clinical setting. That SpO2 overestimates SaO2 in an important number of individuals has caused some to recommend higher SpO2 targets to avoid occult hypoxemia. There is also evidence that suggests that SpO2 might not accurately trend SaO2. Additional research is needed to investigate strategies to mitigate the bias between SpO2 and SaO2. Clinicians must be cognizant of the limitations of pulse oximetry when clinically using SpO2. The aim of this paper is to provide an update on pulse oximetry. [ABSTRACT FROM AUTHOR]

Despite prior publications of clinical practice guidelines related to ventilator liberation, some questions remain unanswered. Many of these questions relate to the details of bedside implementation. We, therefore, formed a guidelines committee of individuals with experience and knowledge of ventilator liberation as well as a medical librarian. Using Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology, we make the following recommendations: (1) We suggest that calculation of a rapid shallow breathing index is not needed to determine readiness for a spontaneous breathing trial (SBT) (conditional recommendation; moderate certainty); (2) We suggest that SBTs can be conducted with or without pressure support ventilation (conditional recommendation, moderate certainty); (3) We suggest a standardized approach to assessment and, if appropriate, completion of an SBT before noon each day (conditional recommendation, very low certainty); and (4) We suggest that FIO2 should not be increased during an SBT (conditional recommendation, very low certainty). These recommendations are intended to assist bedside clinicians to liberate adult critically ill patients more rapidly from mechanical ventilation. [ABSTRACT FROM AUTHOR]

Statistical analysis is an important part of the research process. Researchers are advised to include a statistician from the moment that the study is being planned. The statistical plan informs the research process, including sample size requirements and the most robust data collection. Once the data are collected, descriptive and inferential statistical analyses are performed. The results of this analysis determine whether the findings are significant, which leads to an interpretation of the findings. The importance of the statistical plan and analysis for the researcher is self-evident. However, it is also important for the reader of published papers to have some knowledge of statistical analysis. This allows critical review of all aspects of the published manuscript. The intent of this paper is to review some basic statistical concepts and thus allow the reader to become a better consumer of the literature. [ABSTRACT FROM AUTHOR]

Explaining the meaning of the results to the reader is the purpose of the discussion section of a research paper. There are elements of the discussion section that should be included and pitfalls that should be avoided. Always write the discussion section for the reader. Remember that the focus is to help the reader understand the study and that the focus should be on the study data. [ABSTRACT FROM AUTHOR]

Studies can be observational or experimental. With an observational study, the investigator does not determine the assignment of subjects, and there might not be a control group. If there is a control group, assignment of the independent variable (exposure or intervention) is not under the control of the investigator. Observational studies can be rigorously conducted, but the lack of random assignment of the exposure/intervention introduces confounding and bias. Thus, the quality of evidence resulting from observational studies is lower than that of experimental randomized controlled trials (RCTs). An observational study might be performed if an RCT is unethical, impractical, or outside the control of the investigator. There are many types of prospective and retrospective observational study designs. However, an observational study design should be avoided if an experimental study is possible. Sophisticated statistical approaches can be used, but this does not elevate an observational study to the level of an RCT. Regardless of quality, an observational study cannot establish causality. [ABSTRACT FROM AUTHOR]

Interprofessional teamwork plays a key role in the uptake of evidence-based interventions, such as noninvasive ventilation (NIV) for patients with exacerbated Chronic Obstructive Pulmonary Disease (COPD). We aimed to identify the shared cognitive tasks in interprofessional teams using NIV for patients with COPD exacerbation. We used a cognitive task analysis approach (CTA) to engage nurses, rapid response team members, respiratory therapists, and physicians involved in the use of NIV to treat patients with COPD exacerbation. Clinicians participated in a semi-structured interview (n = 21) that elicited cognitions needed to treat COPD exacerbation. Three shared cognitive tasks were identified: Complete a thorough assessment, Formulate a care plan, and Continuously monitor patient status. Findings attest to the importance of having access to up-to-date information and expertise necessary to make accurate clinical inferences for patient assessment. Shared understanding of the formulated care plan among all members of the care team was important to its execution. Continuous monitoring was crucial; however, this cognitive task relied on patient assessment skills and ongoing collaboration within the clinical care team. Application of NIV for patients with COPD exacerbation may require enhancing collaboration through nontechnical skills and interprofessional training. [ABSTRACT FROM AUTHOR]

A COPD exacerbation is characterized by an increase in symptoms such as dyspnea, cough, and sputum production that worsens over a period of 2 weeks. Exacerbations are common. Respiratory therapists and physicians in an acute care setting often treat these patients. Targeted O2 therapy improves outcomes and should be titrated to an SpO2) of 88-92%. Arterial blood gases remain the standard approach to assessing gas exchange in patients with COPD exacerbation. The limitations of arterial blood gas surrogates (pulse oximetry, capnography, transcutaneous monitoring, peripheral venous blood gases) should be appreciated so that they can be used wisely. Inhaled short-acting bronchodilators can be provided by nebulizer (jet or mesh), pressurized metered-dose inhaler (pMDI), pMDI with spacer or valved holding chamber, soft mist inhaler, or dry powder inhaler. The available evidence for the use of heliox for COPD exacerbation is weak. Noninvasive ventilation (NIV) is standard therapy for patients who present with COPD exacerbation and is supported by clinical practice guidelines. Robust high-level evidence with patient important outcomes is lacking for the use of high-flow nasal cannula in patients with COPD exacerbation. Management of auto-PEEP is the priority in mechanically ventilated patients with COPD. This is achieved by reducing airway resistance and decreasing minute ventilation. Trigger asynchrony and cycle asynchrony are addressed to improve patient-ventilator interaction. Patients with COPD should be extubated to NIV. Additional high-level evidence is needed before widespread use of extracorporeal CO2 removal. Care coordination can improve the effectiveness of care for patients with COPD exacerbation. Evidence-based practices improve outcomes in patients with COPD exacerbation. [ABSTRACT FROM AUTHOR]

The author comments on a study published within the issue which assessed the accuracy of several pulse oximeter brands in the real-world setting of critical care. Topics covered include the study's success in identifying pulse oximeter inaccuracies that may have important clinical impact on the detection of hypoxemia and management of oxygen administration, the strengths and limitations of the study, and clinical implications of the study results.

The evidence that informs respiratory care practice arises from research that generates facts based on the scientific method. A simple definition of research is that it is a method for finding answers to questions. The Common Rule establishes guidelines related to human subjects research, but there are many types of research not subject to the Common Rule. Although conducting research can elevate the stature of investigators, more importantly, it is an essential attribute of a profession to generate research to support clinical practice. [ABSTRACT FROM AUTHOR]