Respiratory Therapy
Canadian Society of Respiratory Therapists
Last updated: October 2024
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Patients and their families and carers may not wish for invasive or aggressive life-sustaining measures at end of life. Understanding their preferences can relieve them of undue burden and prevent unwanted or unnecessary interventions.
Sources:
Canadian Critical Care Society Ethics Committee, Bandrauk N, Downar J, Paunovic B. Withholding and withdrawing life-sustaining treatment: The Canadian Critical Care Society position paper. Can J Anaesth. 2018 Jan;65(1):105-122. PMID: 29150778.
Choosing Wisely Canada. Canadian Critical Care Society, Canadian Association of Critical Care Nurses, Canadian Society of Respiratory Therapists: Twelve Tests and Treatments to Question . [Internet]. 2022 Jul, updated August 2024 [cited 2024 Jan 11].
Dybwik, K., Nielsen, E. W., & Brinchmann, B. S. (2012). Ethical challenges in home mechanical ventilation: a secondary analysis. Nursing ethics, 19(2), 233–244. PMID: 22183963.
Welsch K, Gottschling S. Wishes and needs at the end of life–communication strategies, counseling, and administrative aspects. Dtsch Arztebl Int. 2021 Apr 30;118(17):303-312. PMID: 34180804.
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The prolonged use of sedatives is associated with increased delirium, excessive use of medical resources, greaterduration of mechanical ventilation and longer ICU length of stay. Daily spontaneous breathing trials allow earlierrecognition that a patient may be ready to breathe spontaneously without invasive ventilation.
Sources:
Blackwood B, Tume LN, Morris KP, Clarke M, McDowell C, Hemming K, Peters MJ, McIlmurray L, Jordan J, Agus A, Murray M, Parslow R, Walsh TS, Macrae D, Easter C, Feltbower RG, McAuley DF; SANDWICH Collaborators. Effect of a sedation and ventilator liberation protocol vs usual care on duration of invasive mechanical ventilation in pediatric intensive care units: A randomized clinical trial. JAMA. 2021 Aug 3;326(5):401-410. PMID: 34342620.
Choosing Wisely Canada. Canadian Critical Care Society, Canadian Association of Critical Care Nurses, Canadian Society of Respiratory Therapists: Twelve Tests and Treatments to Question. [Internet]. 2022 Jul, updated August 2024 [cited 2024 Jan 11].
Hooper MH, Girard TD. Sedation and weaning from mechanical ventilation: linking spontaneous awakening trials and spontaneous breathing trials to improve patient outcomes. Anesthesiol Clin. 2011 Dec;29(4):651-61. PMID: 22078914.
Vagionas D, Vasileiadis I, Rovina N, Alevrakis E, Koutsoukou A, Koulouris N. Daily sedation interruption and mechanical ventilation weaning: a literature review. Anaesthesiol Intensive Ther. 2019;51(5):380-389. PMID: 31893604.
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Arterial blood gas testing is one of the most ordered tests in the ICU environment and is often done routinely rather thanrestricting it to assess a change in oxygenation, ventilation or acid-base that cannot be assessed through other means. The evidence indicates that 33-66% of ABG tests may not be clinically warranted and that redundant testing can besafely reduced.
Chest radiographs are indicated following procedures requiring verification after insertion (e.g., endotracheal intubation),or to provide information for a specific question related to a change in patient’s clinical condition. Blood tests should only be performed to monitor specific conditions or answer specific clinical questions.
Sources:
Chandran J, D’Silva C, Sriram S, Krishna B. Clinical utility of arterial blood gas test in an intensive care unit: An observational study. Indian J Crit Care Med. 2021 Feb;25(2):172-175. PMID: 33707895.
Choosing Wisely Canada. Canadian Critical Care Society, Canadian Association of Critical Care Nurses, Canadian Society of Respiratory Therapists: Twelve Tests and Treatments to Question . [Internet]. 2022 Jul. Updated August 2024 [cited 2024 Jan 11].
Martínez-Balzano CD, Oliveira P, O’Rourke M, Hills L, Sosa AF; Critical Care Operations Committee of the UMass Memorial Healthcare Center. An educational intervention optimizes the use of arterial blood gas determinations across ICUs from different specialties: A quality-improvement study. Chest. 2017 Mar;151(3):579-585. Epub 2016 Nov 3. PMID: 27818327.
Walsh OM, Davis K, Gatward J. Reducing inappropriate arterial blood gas testing in a level III intensive care unit: a before-and-after observational study. Crit Care Resusc. 2023 Oct 18;22(4):370-377. PMID: 38046871.
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Palliative oxygen therapy is often ordered to treat dyspnea in patients with life-limiting diseases. It has not been shown to benefit patients who are short of breath and normoxemic when they are not exercising. In the resting patient, supplemental flow of air is as effective as oxygen for non-hypoxemic dyspnea.
A recent meta-analysis noted supplemental oxygen may improve exercise-induced dyspnea in some patients with advanced progressive illnesses (e.g., COPD, CHF, cancer).
Sources:
Abernethy AP, et al. Effect of palliative oxygen versus room air in relief of breathlessness in patients with refractory dyspnoea: a double-blind, randomised controlled Lancet. 2010 Sep 4;376(9743):784-93. PMID: 20816546.
Choosing Wisely Canada. Canadian Society of Palliative Care Physicians: Five things physicians and patients should question [Internet]. 2021 Sep [cited 2024 Jan 8].
Hasegawa T, Ochi T, Goya S, Matsuda Y, Kako J, Watanabe H, Kasahara Y, Kohara H, Mori M, Nakayama T,Yamaguchi Efficacy of supplemental oxygen for dyspnea relief in patients with advanced progressive illness: A systematic review and meta-analysis. Respir Investig. 2023 Jul;61(4):418-437. Epub 2023 Apr 25. PMID: 37105126.
Uronis HE, et Oxygen for relief of dyspnoea in mildly- or non-hypoxaemic patients with cancer: a systematicreview and meta-analysis. Br J Cancer. 2008 Jan 29;98(2):294-9. PMID: 18182991.
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Bronchiolitis is the most common cause for hospital admission in children less than 1 year of age and may be inappropriately treated using aerosolized respiratory therapeutics (pharmacologic and non-pharmacologic). It is usually a self-limiting disease that can be managed supportively.
Just as the use of inhaled or systemic antimicrobials and corticosteroids for the management of bronchiolitis is not supported by evidence, neither is the use of saline aerosols or cool mist therapy. Inhaled bronchodilators (e.g., salbutamol or epinephrine) have not been shown to reduce length of stay for admitted infants and should not be used routinely. For selected patients with significant respiratory distress, inhaled epinephrine should be considered, with the patient assessed before and after treatment. If no objective improvement is noted or if the patient’s status worsens as a result of the treatment, the bronchodilator should be discontinued.
Sources:
Choosing Wisely Canada. Bronchiolitis: Less is Best. [Internet]. January 2024 [cited 2024 February 21].
Choosing Wisely Canada. Canadian Association of Emergency Physicians: Ten tests and treatments to question in emergency medicine [Internet]. 2021 Dec [cited 2024 Jan 8].
Friedman JN, Rieder MJ, Walton JM; Canadian Paediatric Society, Acute Care Committee, Drug Therapy. Bronchiolitis: Recommendations for diagnosis, monitoring and management of children one to 24 months of age. November 2021.
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Although COPD should be suspected in patients with a history of risk factors (tobacco smoking, inhalation of toxicparticles, α1-antitrypsin deficiency) and dyspnea, chronic cough and/or sputum production, confirmation of non-fullyreversible air-flow limitation through spirometry testing (post- bronchodilator FEV1.0/FVC < 70%) can prevent theunnecessary and inappropriate administration of inhaled medication.
Additional research is required to determine the most-appropriate treatment for patients with preserved FEV1.0/FVC ratios who have other indicators of chronic lung disease (e.g., emphysematous lung changes, decreased FEV1.0 or rapid decline in FEV1.0, hyperinflation, gas trapping, diffusion abnormalities).
Sources:
Bourbeau J, Bhutani M, Hernandez P, Aaron SD, Beauchesne MF, Kermelly SB, D’Urzo A, Lal A, Maltais F, Marciniuk JD, Mulpuru S, Penz E, Sin DD, Van Dam A, Wald J, Walker BL, Marciniuk DD. 2023 Canadian Thoracic Society Guideline on Pharmacotherapy in Patients With Stable COPD. Chest. 2023 Nov;164(5):1159-1183. Epub 2023 Sep 9. PMID: 37690008.
Choosing Wisely Canada. Canadian Thoracic Society: Eight tests and treatments to question [Internet]. 2023 Dec [cited 2024 Jan 8].
Global Initiative for Chronic Obstructive Lung Disease (GOLD). GOLD 2023 Global Strategy for the Prevention, Diagnosis and Management of COPD [Internet]. 2023. [cited 2024 Jan 8].
Qaseem A, et al. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med. 2011 Aug 2;155(3):179-91. PMID: 21810710.
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Respiratory therapists should advocate for objective testing for confirmation of asthma diagnoses when such testing is feasible. More than one-third of asthma diagnoses are incorrect, which may lead to the inappropriate use of medications or delay the diagnosis of other conditions. Where feasible, objective confirmation of reversibleairflow obstruction or bronchial hyperreactivity, or other diagnostic testing for asthma are recommended before initiating treatment, since the hallmarks of asthma (wheezing, dyspnea, cough) are also associated with otherdisorders. In some cases*, diagnosis may be based on clinical signs and symptoms rather than objective pulmonary function testing. In these cases, management should include reassessment and confirmation of clinical benefit, and testing as soon as is possible.
*Suspected false negative test, patients less than 6 years of age, those receiving inhaled steroids, those unable to perform tests of pulmonary function, and in cases of resource scarcity
Sources:
Choosing Wisely Canada. Canadian Society of Allergy and Clinical Immunology: Seven Tests and Treatments to Question. [Internet]. 2021 Aug [cited 2024 Jan 8].
Global Initiative for Asthma. 2023 GINA Report, Global Strategy for Asthma Management and Prevention. [Internet]. 2023 [cited 2024 Jan 8]. [cited 30th July 2018].
Gupta S, Thériault G. Do not diagnose or routinely treat asthma or chronic obstructive pulmonary disease without pulmonary function testing. BMJ. 2023 Mar 20;380:e072834. PMID: 36940980.
Yang C, Hicks E, Mitchell P, Reisman J, Podgers D, Hayward K, Waite M, Ramsey C. (2021): Canadian Thoracic Society 2021 Guideline update: Diagnosis and management of asthma in preschoolers, children and adults, Canadian Journal of Respiratory, Critical Care, and Sleep Medicine.
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Respiratory therapists are often in a position to recommend respiratory treatments to a range of prescribers (e.g., primary care teams). The Canadian healthcare system is a significant contributor to Canada’s total greenhouse gas and other pollutant emissions. Cumulatively, pressurized metered dose inhalers (pMDI) contribute to healthcare greenhouse gases emissions by virtue of their use of hydrofluorocarbon propellants. If an inhaler is required, that which mosteffectively controls the patient’s symptoms, reduces exacerbations and which aligns with patient preference and ability should be recommended. If more than one inhaler option meets these criteria, the option with the lowest carbon footprint should be used.
For some patients, pMDIs may be the best medication delivery option (e.g., those who are acutely short of breath, with physical or cognitive limitations, young children). As part of a collaborative care team, respiratory therapists should participate in shared decision-making processes, considering patient outcomes and environmental impact. In alignment with Canadian and international recommendations, objective confirmation of airflow obstruction and optimized disease control (i.e., through controller agents, education, action plans, trigger avoidance) are important and must not be overlooked as they can enhance patient outcomes and reduce reliance on rescue inhalers.
Sources:
Choosing Wisely Canada. Canadian Thoracic Society: Eight tests and treatments to question [Internet]. 2023 Dec [cited 2024 Jan 8].
Eckelman MJ, Sherman JD, MacNeill AJ (2018). Life cycle environmental emissions and health damages from the Canadian healthcare system: an economic-environmental-epidemiological analysis. PMID: 30063712.
Global Initiative for Asthma. 2023 GINA Report, Global strategy for asthma management and prevention [Internet]. 2023 [cited 2024 Jan 8].
Stoynova V, Culley C. Climate Conscious Inhaler Practices in Inpatient Care [Internet]. CASCADES (Creating a Sustainable Canadian Health System in a Climate Crisis). [Cited 2024 March 4].
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The Canadian Society of Respiratory Therapists (CSRT) has been an active participant in Choosing Wisely Canada since 2015, having been active in reviewing and contributing to the development of recommendations of other societies as well as in shared recommendations. Through those activities, there has emerged a body of recommendations pertinent to respiratory therapists, but recommendations have not been compiled to reflect their scope and practice.
The CSRT reviewed existing Choosing Wisely Canada recommendations and compiled a list of those of relevance to respiratory therapists. New literature searches were performed to ensure up-to-date information supported each recommendation, and each recommendation was reformulated to reflect respiratory therapists’ scope and recent evidence. Recommendations were reviewed by the Board of Directors through an evaluation process that determined that each item was important and relevant to the Respiratory Therapy Profession.
These recommendations create a body of Respiratory Therapy recommendations. The CSRT is actively engagedin the development of novel guidelines to further contribute to the wider body of Choosing Wisely Canada recommendations.
Sources:
Canadian Critical Care Society Ethics Committee, Bandrauk N, Downar J, Paunovic B. Withholding and withdrawing life-sustaining treatment: The Canadian Critical Care Society position paper. Can J Anaesth. 2018 Jan;65(1):105-122. PMID: 29150778.
Choosing Wisely Canada. Canadian Critical Care Society, Canadian Association of Critical Care Nurses, Canadian Society of Respiratory Therapists: Twelve Tests and Treatments to Question . [Internet]. 2022 Jul, updated August 2024 [cited 2024 Jan 11].
Dybwik, K., Nielsen, E. W., & Brinchmann, B. S. (2012). Ethical challenges in home mechanical ventilation: a secondary analysis. Nursing ethics, 19(2), 233–244. PMID: 22183963.
Welsch K, Gottschling S. Wishes and needs at the end of life–communication strategies, counseling, and administrative aspects. Dtsch Arztebl Int. 2021 Apr 30;118(17):303-312. PMID: 34180804.
Blackwood B, Tume LN, Morris KP, Clarke M, McDowell C, Hemming K, Peters MJ, McIlmurray L, Jordan J, Agus A, Murray M, Parslow R, Walsh TS, Macrae D, Easter C, Feltbower RG, McAuley DF; SANDWICH Collaborators. Effect of a sedation and ventilator liberation protocol vs usual care on duration of invasive mechanical ventilation in pediatric intensive care units: A randomized clinical trial. JAMA. 2021 Aug 3;326(5):401-410. PMID: 34342620.
Choosing Wisely Canada. Canadian Critical Care Society, Canadian Association of Critical Care Nurses, Canadian Society of Respiratory Therapists: Twelve Tests and Treatments to Question. [Internet]. 2022 Jul, updated August 2024 [cited 2024 Jan 11].
Hooper MH, Girard TD. Sedation and weaning from mechanical ventilation: linking spontaneous awakening trials and spontaneous breathing trials to improve patient outcomes. Anesthesiol Clin. 2011 Dec;29(4):651-61. PMID: 22078914.
Vagionas D, Vasileiadis I, Rovina N, Alevrakis E, Koutsoukou A, Koulouris N. Daily sedation interruption and mechanical ventilation weaning: a literature review. Anaesthesiol Intensive Ther. 2019;51(5):380-389. PMID: 31893604.
Chandran J, D’Silva C, Sriram S, Krishna B. Clinical utility of arterial blood gas test in an intensive care unit: An observational study. Indian J Crit Care Med. 2021 Feb;25(2):172-175. PMID: 33707895.
Choosing Wisely Canada. Canadian Critical Care Society, Canadian Association of Critical Care Nurses, Canadian Society of Respiratory Therapists: Twelve Tests and Treatments to Question . [Internet]. 2022 Jul. Updated August 2024 [cited 2024 Jan 11].
Martínez-Balzano CD, Oliveira P, O’Rourke M, Hills L, Sosa AF; Critical Care Operations Committee of the UMass Memorial Healthcare Center. An educational intervention optimizes the use of arterial blood gas determinations across ICUs from different specialties: A quality-improvement study. Chest. 2017 Mar;151(3):579-585. Epub 2016 Nov 3. PMID: 27818327.
Walsh OM, Davis K, Gatward J. Reducing inappropriate arterial blood gas testing in a level III intensive care unit: a before-and-after observational study. Crit Care Resusc. 2023 Oct 18;22(4):370-377. PMID: 38046871.
Abernethy AP, et al. Effect of palliative oxygen versus room air in relief of breathlessness in patients with refractory dyspnoea: a double-blind, randomised controlled Lancet. 2010 Sep 4;376(9743):784-93. PMID: 20816546.
Choosing Wisely Canada. Canadian Society of Palliative Care Physicians: Five things physicians and patients should question [Internet]. 2021 Sep [cited 2024 Jan 8].
Hasegawa T, Ochi T, Goya S, Matsuda Y, Kako J, Watanabe H, Kasahara Y, Kohara H, Mori M, Nakayama T,Yamaguchi Efficacy of supplemental oxygen for dyspnea relief in patients with advanced progressive illness: A systematic review and meta-analysis. Respir Investig. 2023 Jul;61(4):418-437. Epub 2023 Apr 25. PMID: 37105126.
Uronis HE, et Oxygen for relief of dyspnoea in mildly- or non-hypoxaemic patients with cancer: a systematicreview and meta-analysis. Br J Cancer. 2008 Jan 29;98(2):294-9. PMID: 18182991.
Choosing Wisely Canada. Bronchiolitis: Less is Best. [Internet]. January 2024 [cited 2024 February 21].
Choosing Wisely Canada. Canadian Association of Emergency Physicians: Ten tests and treatments to question in emergency medicine [Internet]. 2021 Dec [cited 2024 Jan 8].
Friedman JN, Rieder MJ, Walton JM; Canadian Paediatric Society, Acute Care Committee, Drug Therapy. Bronchiolitis: Recommendations for diagnosis, monitoring and management of children one to 24 months of age. November 2021.
Bourbeau J, Bhutani M, Hernandez P, Aaron SD, Beauchesne MF, Kermelly SB, D’Urzo A, Lal A, Maltais F, Marciniuk JD, Mulpuru S, Penz E, Sin DD, Van Dam A, Wald J, Walker BL, Marciniuk DD. 2023 Canadian Thoracic Society Guideline on Pharmacotherapy in Patients With Stable COPD. Chest. 2023 Nov;164(5):1159-1183. Epub 2023 Sep 9. PMID: 37690008.
Choosing Wisely Canada. Canadian Thoracic Society: Eight tests and treatments to question [Internet]. 2023 Dec [cited 2024 Jan 8].
Global Initiative for Chronic Obstructive Lung Disease (GOLD). GOLD 2023 Global Strategy for the Prevention, Diagnosis and Management of COPD [Internet]. 2023. [cited 2024 Jan 8].
Qaseem A, et al. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med. 2011 Aug 2;155(3):179-91. PMID: 21810710.
Choosing Wisely Canada. Canadian Society of Allergy and Clinical Immunology: Seven Tests and Treatments to Question. [Internet]. 2021 Aug [cited 2024 Jan 8].
Global Initiative for Asthma. 2023 GINA Report, Global Strategy for Asthma Management and Prevention. [Internet]. 2023 [cited 2024 Jan 8]. [cited 30th July 2018].
Gupta S, Thériault G. Do not diagnose or routinely treat asthma or chronic obstructive pulmonary disease without pulmonary function testing. BMJ. 2023 Mar 20;380:e072834. PMID: 36940980.
Yang C, Hicks E, Mitchell P, Reisman J, Podgers D, Hayward K, Waite M, Ramsey C. (2021): Canadian Thoracic Society 2021 Guideline update: Diagnosis and management of asthma in preschoolers, children and adults, Canadian Journal of Respiratory, Critical Care, and Sleep Medicine.
Choosing Wisely Canada. Canadian Thoracic Society: Eight tests and treatments to question [Internet]. 2023 Dec [cited 2024 Jan 8].
Eckelman MJ, Sherman JD, MacNeill AJ (2018). Life cycle environmental emissions and health damages from the Canadian healthcare system: an economic-environmental-epidemiological analysis. PMID: 30063712.
Global Initiative for Asthma. 2023 GINA Report, Global strategy for asthma management and prevention [Internet]. 2023 [cited 2024 Jan 8].
Stoynova V, Culley C. Climate Conscious Inhaler Practices in Inpatient Care [Internet]. CASCADES (Creating a Sustainable Canadian Health System in a Climate Crisis). [Cited 2024 March 4].
About Choosing Wisely Canada
Choosing Wisely Canada is the national voice for reducing unnecessary tests and treatments in health care. One of its important functions is to help clinicians and patients engage in conversations that lead to smart and effective care choices.
Web: choosingwiselycanada.org
Email: info@choosingwiselycanada.org
Twitter: @ChooseWiselyCA
Facebook: /ChoosingWiselyCanada
Bronchiolitis: Less is Best
A toolkit for the management and assessment of bronchiolitis.