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The term respiratory care has more than one meaning, referring both to a subject area within clinical medicine and to a distinct health care profession. In the light of several fundamental transformations of health care during the 20th century, this article reviews the history of respiratory care in both of these contexts and offers 10 predictions for the future: (1) Less focus on raising P(aO2) as a primary goal in managing patients with acute hypoxemic respiratory failure. (2) More attention to the adequacy of tissue oxygenation in such patients, irrespective of P(aO2), and the emergence of "permissive hypoxemia," analogous to permissive hypercapnia, in managing them. (3) Smarter monitors that display information less but process it more, while interacting directly with ventilators and other devices to modify therapeutic interventions. (4) Increased use of and expertise with noninvasive ventilation, with a corresponding decrease in intubations and complications, in treating patients with acute exacerbations of COPD. (5) Increased use of triage in the intensive care unit, including earlier determination of the appropriateness of maximal supportive intervention. (6) Greater use of protocols in patient assessment and management, in all clinical settings. (7) Increased awareness of, expertise in, and resources for palliative care, with a more active and acknowledged role for respiratory therapists. (8) Accelerating progress in smoking cessation and prevention, and also in early detection and intervention in COPD, led by the respiratory care profession. (9) An increasing presence and impact of respiratory therapists as coordinators and care givers in home care. (10) A continued and enlarging role for the journal Respiratory Care in disseminating research findings, clinical practice guidelines, protocols, and practical educational materials in all areas of the field.

Hypoxia exists when there is a reduced amount of oxygen in the tissues of the body. Hypoxemia refers to a reduction in PO2 below the normal range, regardless of whether gas exchange is impaired in the lung, CaO2 is adequate, or tissue hypoxia exists. There are several potential physiologic mechanisms for hypoxemia, but in patients with COPD the predominant one is V/Q mismatching, with or without alveolar hypoventilation, as indicated by PaCO2. Hypoxemia caused by V/Q mismatching as seen in COPD is relatively easy to correct, so that only comparatively small amounts of supplemental oxygen (less than 3 L/min for the majority of patients) are required for LTOT. Although hypoxemia normally stimulates ventilation and produces dyspnea, these phenomena and the other symptoms and signs of hypoxia are sufficiently variable in patients with COPD as to be of limited value in patient assessment. Chronic alveolar hypoxia is the main factor leading to development of cor pulmonale--right ventricular hypertrophy with or without overt right ventricular failure--in patients with COPD. Pulmonary hypertension adversely affects survival in COPD, to an extent that parallels the degree to which resting mean pulmonary artery pressure is elevated. Although the severity of airflow obstruction as measured by FEV1 is the best correlate with overall prognosis in patients with COPD, chronic hypoxemia increases mortality and morbidity for any severity of disease. Large-scale studies of LTOT in patients with COPD have demonstrated a dose-response relationship between daily hours of oxygen use and survival. There is reason to believe that continuous, 24-hours-per-day oxygen use in appropriately selected patients would produce a survival benefit even greater than that shown in the NOTT and MRC studies.

Unlabelled: Hospital inpatients frequently leave their rooms for diagnostic procedures and for other reasons. For some, interruption of oxygen therapy during transport could lead to serious complications. In our institution, non-ICU patient transport is done mainly by nonclinical personnel from an independent transport service., Materials & Methods: We reviewed respiratory care department and transport service records for 5 arbitrarily selected days to determine the number of non-ICU patients receiving O2 therapy, the number of times these patients were transported, and the number of occasions on which O2 was used during the transport. We then interviewed the primary nurse for each patient transported without O2 and reviewed the charts of those patients to determine whether this practice was consistent with the therapy as it had been ordered. After our initial investigation showed a high rate of transport without prescribed O2, we sent memoranda to all nursing units describing proper procedures for transport of patients for whom O2 had been ordered. We then repeated the audit. Because the second audit showed the need, we conducted education sessions with all nursing personnel on the affected units and posted guidelines for O2 use during transport. A third audit was then conducted. In addition, we performed a telephone survey of respiratory care department managers to learn the patient-transport practices in all hospitals in our state with more than 200 beds, using a structured questionnaire., Results: During the initial 125 patient-days of O2 therapy, O2 accompanied patients on only 30 of 55 transports (55%). After distribution of memoranda, O2 use increased to 28 of 35 transports (80%) during 82 patient-days. The second educational effort resulted in O2 use with all 35 transports (100%) performed during 99 patient-days. Survey results from 24 hospitals with 225-680 beds showed that 11 (46%) had separate transport services and that decisions on O2 use during patient transport were generally made by nursing staff. Although respiratory care departments supplied the O2 equipment, their personnel were involved in non-ICU transports in only 5/24 hospitals., Conclusions: Patients receiving O2 therapy on acute-care wards are often transported to other areas of the hospital without O2. This potentially dangerous practice can be corrected by respiratory care practitioners through educational efforts targeted toward those responsible for administering O2 therapy in non-ICU hospital areas.

Unlabelled: Multiple-use (M-U) closed-system endotracheal suction catheters are effective in preventing arterial oxygen desaturation in patients on positive end-expiratory pressure (PEEP) and may lessen the frequency of bradycardia and hypotension in unstable patients who are prone to these complications of suctioning. However, because M-U catheters remain attached to the ventilator circuit and are reintroduced repeatedly into the patient's airway over 24 hours or longer, they could become heavily contaminated with pathogens. We hypothesized a risk of autocontamination to the patient by re-inoculation of the respiratory tract with organisms that flourished on the M-U catheter while it was isolated from the patient's immune defenses or antibiotic therapy., Methods: We tested this hypothesis in 30 mechanically ventilated adult patients with positive sputum cultures. We measured and compared the amount of bacteria present on an M-U catheter at the end of a 24-hour use period, the amount of bacteria present in the patient's sputum at that time, and the amount of bacteria present on a single-use (S-U) catheter at that time, after it had made one pass into the patient's airway. Organisms recovered and colony counts were also compared to results of a sputum culture obtained before the study began., Results: Fourteen different pathogens or potential pathogens were recovered, in numbers of 2 x 10(1) to 2 x 10(7)colony-forming units. The greatest number of colonies was most often recovered from the sputum specimen, and statistical analysis showed no differences in rate or magnitude of contamination between M-U and S-U catheters.(ABSTRACT TRUNCATED AT 250 WORDS)

Unlabelled: In patients with permanent tracheostomies, the clinician can encounter difficulty in creating a satisfactory seal between the patient and pulmonary function testing (PFT) equipment. We have developed a simple apparatus and procedure for effecting a tight seal during testing., Materials and Methods: The seal around the tracheostomy is made with a newborn-size resuscitation mask, the hole of which is larger than the tracheal stoma. A sealing lubricant is applied to the soft rim of the mask and around the tracheostomy site, and adapters enable connection of the resuscitation mask and the large-bore PFT-equipment tubing. After affixing the adapters to the mask, we check that the seal is tight; if airleak is evident, more lubricant or a mask of different size or style may be necessary. Once a tight seal is achieved without airway compromise, the mask is attached to the PFT equipment and testing can begin. During testing, the patient should wear nose clips to prevent volume loss through the upper airway., Comments: This equipment is simple, inexpensive, and readily available. Further, it permits pulmonary function testing whether or not a tracheostomy tube is in place, an advantage if variable extrathoracic upper airway obstruction is a consideration. If the patient has a cuffed tracheostomy tube in place, the PFT equipment can be connected directly to the tube. We have found that this apparatus and technique are well tolerated and that test results are reproducible.

Analgesic use of nitrous oxide (N2O) in nontraditional settings requires safe and effective scavenging systems to rid the work area of hazardous waste gas. Significant health risks to health care workers are associated with repetitive exposure to excessive levels of N2O. Regulations limit the exposure level to 25 parts per million and also require the use of effective scavenging systems. We tested the existing room ventilation and a suction-powered scavenging system in our burn unit's hydrotherapy room and found them to be inadequate in maintaining safe room air levels. We therefore developed a fan-powered scavenging system using a ceiling-mounted hood, under which N2O is administered, and found it to maintain safe levels while requiring little patient cooperation and allowing complete access to the patient.