Respiratory Therapy

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.

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.

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).

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.

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).

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

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.