Gender equity of authorship in pulmonary medicine over the past decade

BACKGROUND

Gender disparity in authorship broadly persists in medical literature, little is known about female authorship within pulmonary medicine.

METHODS

A bibliometric analysis of publications from 2012 to 2021 in 12 journals with the highest impact in pulmonary medicine was conducted. Only original research and review articles were included. Names of the first and last authors were extracted and their genders were identified using the Gender-API web. Female authorship was described by overall distribution and distribution by country/region/continent and journal. We compared the article citations by gender combinations, evaluated the trend in female authorship, and forecasted when parity for first and last authorship would be reached. We also conducted a systematic review of female authorship in clinical medicine.

RESULTS

14,875 articles were included, and the overall percentage of female first authors was higher than last authors (37.0% vs 22.2%, p<0.001). Asia had the lowest percentage of female first (27.6%) and last (15.2%) authors. The percentages of female first and last authors increased slightly over time, except for a rapid increase in the COVID-19 pandemic periods. Parity was predicted in 2046 for the first authors and 2059 for the last authors. Articles with male authors were cited more than articles with female authors. However, male-male collaborations significantly decreased, whereas female-female collaborations significantly increased.

CONCLUSIONS

Despite the slow improvement in female authorship over the past decade, there is still a substantial gender disparity in female first and last authorship in high-impact medical journals in pulmonary medicine.

Enhancing Respiratory Therapists' Well-Being: Battling Burnout in Respiratory Care

Burnout is a major problem in health care and is associated with adverse sequelae for patients, health care workers, and organizations. Burnout among respiratory therapists (RTs) is as high as 79% and is associated with poor or ineffective leadership, inadequate staffing, high work load, non-leadership position, and work environment. An understanding of burnout is necessary for both staff and leadership to ensure RT well-being. This narrative review will discuss the psychology of burnout, prevalence, drivers, mitigation strategies, and future directions for research.

Burnout Among Respiratory Therapists Amid the COVID-19 Pandemic

BACKGROUND

Burnout is a major challenge in health care and is associated with poor overall well-being, increased medical errors, worse patient outcomes, and low job satisfaction. There is scant literature focused on the respiratory therapist's (RT) experience of burnout, and a thorough exploration of RTs' perception of factors associated with burnout has not been reported. The aim of this qualitative study was to understand the factors associated with burnout as experienced by RTs amid the COVID-19 pandemic.

METHODS

We performed a post hoc, qualitative analysis of free-text responses from a survey of burnout prevalence in RTs.

RESULTS

There were 1,114 total and 220 free-text responses. Five overarching themes emerged from the analysis: staffing, workload, physical/emotional consequences, lack of effective leadership, and lack of respect. Respondents discussed feelings of anxiety, depression, and compassion fatigue as well as concerns that lack of adequate staffing, high workload assignments, and inadequate support from leadership contributed to feelings of burnout. Specific instances of higher patient acuity, surge in critically ill patients, rapidly evolving changes in treatment recommendations, and minimal training and preparation for an extended scope of practice were reported as stressors that led to burnout. Some respondents stated that they felt a lack of respect for both the RT profession and the contribution of RTs to patient care.

CONCLUSIONS

Themes associated with burnout in RTs included staffing, workload, physical and emotional exhaustion, lack of effective leadership, and lack of respect. These results provide potential targets for interventions to combat burnout among RTs.

Factors Associated With a Positive View of Respiratory Care Leadership

BACKGROUND

Burnout within health care is prevalent, and its effects are detrimental to patient outcomes, organizations, and individuals. Effects stemming from burnout include anxiety, depression, excessive alcohol and drug use, cardiovascular problems, time off work, and worse patient outcomes. Published data have suggested up to 50% of health care workers experience burnout and 79% of respiratory therapists (RTs) experience burnout. Leadership has been cited as a key driver of burnout among RTs. We aimed to identify factors associated with a positive or negative leadership perception.

METHODS

A post hoc analysis of an institutional review board-approved survey to evaluate RT burnout, administered via REDCap by convenience sample to 26 health care centers (3,124 potential respondents) from January 17-March 15, 2021, was performed to identify factors associated with a positive view of leadership. Survey questions included validated tools to measure leadership, burnout, staffing, COVID-19 exposure, and demographics. Data analysis was descriptive, and logistic regression was performed to evaluate factors associated with leadership perception.

RESULTS

Of 1,080 respondents, 710 (66%) had a positive view of leadership. Univariate analysis revealed those with a positive view of leadership were more likely to be working with adequate staffing, were rarely unable to complete all work, were less likely to be burned out, disagreed that people in this work environment were burned out, were less likely to miss work for any reason, more likely to be in a leadership position, worked fewer hours in intensive care, worked in a center affiliated with a medical school, worked day shift, were less likely to care for adult patients, and were more likely to be male. Logistic regression revealed providing care to patients with COVID-19 (odds ratio [OR] 5.8-10.5, P < .001-.006) was the only factor associated with a positive view of leadership, whereas working without adequate staffing (OR 0.27-0.28, P = .002-.006), staff RTs (OR 0.33, P < .001), work environment (OR 0.42, P = .003), missing work for any reason (OR 0.69, P = .003), and burnout score (OR 0.98, P < .001) were associated with a negative view of leadership.

CONCLUSIONS

Most RTs had a positive view of their leadership. A negative leadership score was associated with higher burnout and missing work. This relationship requires further investigation to evaluate if changes in leadership practices can improve employee well-being and reduce burnout.

AARC Clinical Practice Guidelines: Artificial Airway Suctioning

Artificial airway suctioning is a key component of airway management and a core skill for clinicians charged with assuring airway patency. Suctioning of the artificial airway is a common procedure performed worldwide on a daily basis. As such, it is imperative that clinicians are familiar with the most-effective and efficient methods to perform the procedure. We conducted a systematic review to assist in the development of evidence-based recommendations that pertain to the care of patients with artificial airways. From our systematic review, we developed guidelines and recommendations that addressed questions related to the indications, complications, timing, duration, and methods of artificial airway suctioning. By using a modified version of the RAND/UCLA Appropriateness Method, the following recommendations for suctioning were developed for neonatal, pediatric, and adult patients with an artificial airway: (1) breath sounds, visual secretions in the artificial airway, and a sawtooth pattern on the ventilator waveform are indicators for suctioning pediatric and adult patients, and an acute increase in airway resistance may be an indicator for suctioning in neonates; (2) as-needed only, rather than scheduled, suctioning is sufficient for neonatal and pediatric patients; (3) both closed and open suction systems may be used to safely and effectively remove secretions from the artificial airway of adult patients; (4) preoxygenation should be performed before suctioning in pediatric and adult patients; (5) the use of normal saline solution should generally be avoided during suctioning; (6) during open suctioning, sterile technique should be used; (7) suction catheters should occlude < 70% of the endotracheal tube lumen in neonates and < 50% in pediatric and adult patients, and suction pressure should be kept below -120 mm Hg in neonatal and pediatric patients and -200 mm Hg in adult patients; (8) suction should be applied for a maximum of 15 s per suctioning procedure; (9) deep suctioning should only be used when shallow suctioning is ineffective; (10) routine bronchoscopy for secretion removal is not recommended; and (11) devices used to clear endotracheal tubes may be used when airway resistance is increased due to secretion accumulation.

Management of Adult Patients With Oxygen in the Acute Care Setting

Providing supplemental oxygen to hospitalized adults is a frequent practice and can be administered via a variety of devices. Oxygen therapy has evolved over the years, and clinicians should follow evidence-based practices to provide maximum benefit and avoid harm. This systematic review and subsequent clinical practice guidelines were developed to answer questions about oxygenation targets, monitoring, early initiation of high-flow oxygen (HFO), benefits of HFO compared to conventional oxygen therapy, and humidification of supplemental oxygen. Using a modification of the RAND/UCLA Appropriateness Method, 7 recommendations were developed to guide the delivery of supplemental oxygen to hospitalized adults: (1) aim for S_pO2 range of 94-98% for most hospitalized patients (88-92% for those with COPD), (2) the same S_pO2 range of 94-98% for critically ill patients, (3) promote early initiation of HFO, (4) consider HFO to avoid escalation to noninvasive ventilation, (5) consider HFO immediately postextubation to avoid re-intubation, (6) either HFO or conventional oxygen therapy may be used with patients who are immunocompromised, and (7) consider humidification for supplemental oxygen when flows > 4 L/min are used.

AARC Clinical Practice Guideline: Management of Pediatric Patients With Oxygen in the Acute Care Setting

Oxygen therapy is one of the most important therapeutics offered in the clinical management of pediatric patients with cardiopulmonary disease. As the medical community seeks to ensure evidence-based management of clinical interventions, we conducted a systematic review with the goal of providing evidence-based clinical practice guidelines to answer questions surrounding the use of simple oxygen therapy to improve oxygenation, including a comparison of delivery devices, the efficacy of humidification, comparison of flows, and goals for use in children. Using a modification of the RAND/UCLA Appropriateness Method, we developed 4 recommendations to assist clinicians in the utilization of oxygen therapy in hospitalized children: (1) the use of an oxygen hood or tent in lieu of a low-flow oxygen device for consistent oxygen delivery is not recommended; (2) the use of high-flow nasal cannula therapy is safe and more effective than low-flow oxygen to treat infants with moderate to severe bronchiolitis; (3) the application of humidification with low-flow oxygen delivery is not recommended; (4) targeting [Formula: see text] 90-97% for infants and children with bronchiolitis is recommended; however, no specific target can be recommended for pediatric patients with respiratory diseases outside of bronchiolitis, and establishing a patient/disease oxygen therapy target upon admission is considered best practice.

Resilience and Burnout Resources in Respiratory Care Departments

BACKGROUND

Burnout is a major problem in health care, with rates of approximately 33% and 50% in nurses and physicians, respectively, prior to the COVID-19 pandemic. Respiratory therapist (RT) burnout rates and drivers have not been specifically examined. The purpose of this project was to determine resilience and burnout resources available within respiratory care departments and to provide an estimate of pre- and post-COVID-19 RT burnout rates.

METHODS

A survey was developed to evaluate resilience and burnout resources in respiratory care departments. The survey was posted online to the AARConnect management, education, adult acute care, neonatal/pediatrics, COVID-19, and help line communities. Data analysis was descriptive. Key drivers of burnout among RTs were identified from qualitative answers.

RESULTS

There were 221 responses, and 72% reported experiencing burnout. Ten percent of the departments that responded measured burnout; 36% utilized resilience tools, and 83% offered free employee assistance for those struggling with burnout. In January 2020, 30% of departments reported an estimated burnout rate > 40%, which increased to 44% of departments (P = .007) in the COVID-19 pandemic period. The most common drivers reported were poor leadership (32%), high work load (31%), and staffing (29%); 93% of respondents agreed that burnout is a major problem in health care, 33% agreed that burnout is primarily driven by external factors, 92% agreed that RTs have a similar risk of burnout as other health care professionals, 73% agreed that they were comfortable discussing challenging situations with colleagues, 32% agreed that their leadership provided adequate support for those suffering from burnout, and 79% agreed that they would be open to utilizing resilience tools from the AARC or other professional organizations.

CONCLUSIONS

Most respondents experienced burnout and few respiratory care departments measured burnout. Resilience resources were not commonly used but employee assistance and wellness programs were common. Key drivers of burnout identified were poor leadership, staffing, and high workloads.

Evaluation of an Interprofessional Tobacco Cessation Train-the-Trainer Program for Respiratory Therapy Faculty

BACKGROUND

Although tobacco use is the leading cause of numerous preventable diseases, including respiratory illnesses, respiratory therapy students historically have received inadequate education for treating tobacco use and dependence. To address this gap, a respiratory-specific tobacco cessation training program was created and disseminated via a train-the-trainer approach for faculty in respiratory therapy and respiratory care programs across the United States. The purpose of this study was to estimate the impact of the live, web-based, train-the-trainer programs on participating faculty, and to assess changes in the extent of adoption of tobacco cessation content in respiratory therapy curricula across institutions in the United States.

METHODS

Five live, 2.5-h web-based train-the-trainer programs for respiratory therapy faculty were conducted. To characterize impact of this national initiative, surveys were administered at baseline, immediately after training, and then at the end of the subsequent academic year.

RESULTS

A total of 270 respiratory therapy faculty members participated in a live webinar training, representing 248 of the 402 (61.7%) respiratory therapy schools in the United States. At the end of the subsequent academic year, faculty reported significant improvement in their overall ability to teach tobacco cessation (P < .001). Nearly all (97.4%) agreed that the webinar train-the-trainer format was conducive to learning, and high self-ratings were reported for skills to teach the tobacco cessation content. During the 2016-2017 academic year, 1,248 respiratory therapy students received training. Faculty anticipated teaching a median of 3 h of tobacco cessation in the subsequent academic year.

CONCLUSIONS

Training respiratory therapy faculty using a train-the-trainer approach had a positive impact on faculty's perceived confidence and ability to teach tobacco cessation at their institutions.

AARC Clinical Practice Guideline: Management of Pediatric Patients With Tracheostomy in the Acute Care Setting

Children requiring a tracheostomy to maintain airway patency or to facilitate long-term mechanical ventilatory support require comprehensive care and committed, trained, direct caregivers to manage their complex needs safely. These guidelines were developed from a comprehensive review of the literature to provide guidance for the selection of the type of tracheostomy tube (cuffed vs uncuffed), use of communication devices, implementation of daily care bundles, timing of first tracheostomy change, type of humidification used (active vs passive), timing of oral feedings, care coordination, and routine cleaning. Cuffed tracheostomy tubes should only be used for positive-pressure ventilation or to prevent aspiration. Manufacturer guidelines should be followed for cuff management and tracheostomy tube hygiene. Daily care bundles, skin care, and the use of moisture-wicking materials reduce device-associated complications. Tracheostomy tubes may be safely changed at postoperative day 3, and they should be changed with some regularity (at a minimum of every 1-2 weeks) as well as on an as-needed basis, such as when an obstruction within the lumen occurs. Care coordination can reduce length of hospital and ICU stay. Published evidence is insufficient to support recommendations for a specific device to humidify the inspired gas, the use of a communication device, or timing for the initiation of feedings.

AARC Clinical Practice Guideline: Management of Adult Patients with Tracheostomy in the Acute Care Setting

Management of patients with a tracheostomy tube includes many components of care provided by clinicians from various health care disciplines. In recent years, clinicians worldwide have demonstrated a renewed interest in the management of patients with tracheostomy due to the recognition that more effective and efficient management of this patient population is necessary to decrease morbidity and mortality and to optimize the value of the procedure. Commensurate with the goal of enhancing the care of patients with tracheostomy, we conducted a systematic review to facilitate the development of recommendations relevant to the care of adult patients with tracheostomy in the acute care setting. From our systematic review, clinical practice guidelines were developed to address questions regarding the impact of tracheostomy bundles, tracheostomy teams, and protocol-directed care on time to decannulation, length of stay, tracheostomy-related cost, tracheostomy-related adverse events, and other tracheostomy-related outcomes in tracheostomized adult patients in the acute care setting. Using a modification of the RAND/UCLA Appropriateness Method, 3 recommendations were developed to assist clinicians with tracheostomy management of adult patients in the acute care setting: (1) evidence supports the use of tracheostomy bundles that have been evaluated and approved by a team of individuals experienced in tracheostomy management to decrease time to decannulation, tracheostomy-related adverse events, and other tracheostomy-related outcomes, namely, improved tolerance of oral diet; (2) evidence supports the addition of a multidisciplinary tracheostomy team to improve time to decannulation, length of stay, tracheostomy-related adverse events, and other tracheostomy-related outcomes, namely, increased speaking valve use; (3) evidence supports the use of a weaning/decannulation protocol to guide weaning and removal of the tracheostomy tube to improve time to decannulation.

Physician Support for Non-Physician Advanced Practice Providers for Persons With Cardiopulmonary Disease

BACKGROUND

The use of non-physician advanced practice providers (NPAPP) has increased in the United States to offset shortages in the physician workforce. Yet there are still gaps in some locations where there is little to no access to quality health care. This study sought to identify whether physicians perceived a workforce gap and their level of interest in hiring an NPAPP with cardiopulmonary expertise to fill the perceived gap.

METHODS

An American Association for Respiratory Care (AARC)-led workgroup surveyed 1,401 physicians in 6 different specialties. The survey instrument contained 32 closed-ended questions and 4 open-ended questions.

RESULTS

74% of the 1,401 physician respondents agreed or strongly agreed that there will be a future need for an NPAPP with cardiopulmonary expertise. Respondents from sleep, pediatrics, pulmonary, and critical care were most likely to indicate that there is a current need for an NPAPP. A majority of respondents perceived that the specialized NPAPP would improve efficiency and productivity (74%), patient experience (73%), and patient outcomes (72%). Interest in adding this NPAPP did not increase when participants were told to presume authority for hiring, budget, and reimbursement.

CONCLUSIONS

These results indicate that there is both a need for and an interest in hiring an NPAPP with cardiopulmonary expertise. Having an NPAPP would boost physician efficiency and productivity, improve the patient care experience, and provide benefits that other clinicians are not trained to provide to persons with cardiopulmonary disease. Results suggest there should be continued efforts to develop the NPAPP role to add value for physicians and patients alike.

The Patient Experience During Noninvasive Respiratory Support

Noninvasive respiratory support has been a proven intervention for patients with acute respiratory failure. CPAP, noninvasive ventilation, and high-flow nasal cannula have been effectively used to support the respiratory needs of this patient population. Even with the application of these devices over many years, however, some patients are not successfully managed on noninvasive support modalities. Many factors can lead to failure of these interventions, several of which impact patient-ventilator synchrony. This paper reviews these factors, along with other issues that may impact tolerance of these devices. By addressing these factors and tailoring the intervention to the needs of the individual patient, the clinician can improve the likelihood of successful management of the respiratory condition in the patient with acute respiratory failure who receives noninvasive respiratory support.

Mechanical Ventilation Alarms and Alarm Fatigue

Mechanical ventilation alarms and alerts, both audible and visual, provide the clinician with vital information about the patient's physiologic condition and the status of the machine's function. Not all alarms generated by the mechanical ventilator provide actionable information. Over time, clinicians can become desensitized to audible alarms due to alarm fatigue and may potentially ignore an actionable situation that results in patient harm. Alarm fatigue has been recognized by multiple agencies as a major patient-safety issue. To date, mechanical ventilator alarm settings do not have standardized nomenclature. The aim of this review was to examine and report on the literature that pertains to mechanical ventilation alarms and alarm fatigue and to propose recommendations for future research that may lead to safer mechanical ventilation alarm practices.

Perspectives From COPD Subjects on Portable Long-Term Oxygen Therapy Devices

BACKGROUND

Oxygen therapy for patients with COPD and severe hypoxemia requires the use of oxygen delivery devices that allow mobility as needed. However, the characteristics of some devices may limit the freedom of individuals to be as physically active as they desire. Limited mobility may negatively affect the perceived quality of life of individuals with COPD. The aim of this study was to understand perceived limitations that patients with COPD experience in using long-term oxygen therapy (LTOT) devices.

METHODS

We performed a qualitative analysis of 311 responses to an open-ended question from a previously deployed electronic survey designed to investigate how LTOT devices affect oxygen-dependent patients with COPD. Our thematic analysis was facilitated by NVivo, a qualitative data analysis software package. This involved identifying patterns and themes within the robust, text-rich data from the open-ended survey question regarding the survey subjects' experiences with their LTOT devices. Cluster analysis was also performed to highlight relationships between various concepts.

RESULTS

Themes generated revealed that subjects experienced decreased mobility, which resulted in feelings of decreased autonomy and isolation. We also found that subjects perceived a decrease in quality of life due to their described experience of portable oxygen cylinders being heavy and cumbersome. Subjects described feelings of fear and anxiety due to insufficient support for breathing provided by pulse-dose portable oxygen concentrators, as well as portable oxygen cylinders that run out before they are able to complete errands and other activities of daily living. Some subjects also reported that they willingly pay for liquid oxygen systems out-of-pocket because of the mobility it affords, which in their perception improves their quality of life.

CONCULSIONS

Oxygen-dependent individuals with COPD may be at risk of adverse outcomes associated with decreased mobility encouraged by unsatisfactory physical and technical characteristics of portable oxygen cylinders and concentrators.

Year in review 2014: airway clearance

The respiratory therapist has had integrated adjuncts to improve mucus clearance for decades. However, there is a lack of literature describing the impact of these interventions on specific patient populations, resulting in an inability to make recommendations about the use of devices and techniques. The purpose of this article is to review recent literature regarding airway clearance therapies in a manner that is most likely to have interest to the readers of Respiratory Care.

A randomized multi-arm repeated-measures prospective study of several modalities of portable oxygen delivery during assessment of functional exercise capacity

BACKGROUND

Ambulatory oxygen is an important component of long-term oxygen therapy. Pulse-dose technology conserves oxygen and thus increases the operation time of a portable oxygen system.

METHODS

We tested 4 ambulatory oxygen systems (Helios, HomeFill, FreeStyle, and the compressed-oxygen cylinder system we regularly provide for long-term oxygen therapy at our Veterans Affairs hospital) with 39 subjects with stage-IV chronic obstructive pulmonary disease. Each subject performed one 6-min walk test with each oxygen system, and we measured blood oxygen saturation (via pulse oximetry [S(pO(2))]), heart rate, and modified Borg dyspnea score, and surveyed the subjects' preferences about the oxygen systems. We also studied whether the 2 systems that provide gas with a lower oxygen concentration (from a home concentrator or portable concentrator) showed any evidence of not providing adequate oxygenation.

RESULTS

With all 4 systems the mean pre-walk S(pO(2)) at the prescribed pulse-dose setting was 95-96%. The mean post-walk S(pO(2)) was 88-90% after each of the 4 walk tests. Between the 4 systems there were no statistically significant differences between the pre-walk-versus-post-walk S(pO(2)) ( = .42). With each system, the pre-walk-versus-post-walk S(pO(2)) difference was between -8% and -6%.

CONCLUSIONS

Between these 4 ambulatory oxygen systems there were no significant differences in S(pO(2)), walk time, or walk distance, and there was no evidence of inadequate oxygenation with the 2 systems that provide a lower oxygen concentration.