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Background: In the first months of the pandemic, prior to the introduction of proven-effective treatments, 15-37% of patients hospitalized with COVID-19 were discharged on home oxygen. After proven-effective treatments for acute COVID-19 were established by evidence-based guidelines, little remains known about home oxygen requirements following hospitalization for COVID-19., Methods: This was a retrospective, multi-center cohort study of subjects hospitalized for COVID-19 between October 2020-September 2021 at 3 academic health centers. Information was abstracted from electronic health records at the index hospitalization and for 60 d after discharge. The World Health Organization COVID-19 Clinical Progression Scale score was used to identify patients with severe COVID-19., Results: Of 517 subjects (mean age 58 y, 47% female, 42% Black, 36% Hispanic, 22% with severe COVID-19), 81% were treated with systemic corticosteroids, 61% with remdesivir, and 2.5% with tocilizumab. About one quarter of subjects were discharged on home oxygen (26% [95% CI 22-29]). Older age (adjusted odds ratio [aOR] 1.02 per 5 y [95% CI 1.02-1.02]), higher body mass index (aOR 1.02 per kg/m 2 [1.00-1.04]), diabetes (yes vs no, aOR 1.73 [1.46-2.02]), severe COVID-19 (vs moderate, aOR 3.19 [2.19-4.64]), and treatment with systemic corticosteroids (yes vs no, aOR 30.63 [4.51-208.17]) were associated with an increased odds of discharge on home oxygen. Comorbid hypertension (yes vs no, aOR 0.71 [0.66-0.77) was associated with a decreased odds of home oxygen. Within 60 d of hospital discharge, 50% had documentation of pulse oximetry; in this group, home oxygen was discontinued in 46%., Conclusions: About one in 4 subjects were prescribed home oxygen after hospitalization for COVID-19, even after guidelines established proven-effective treatments for acute illness. Evidence-based strategies to reduce the requirement for home oxygen in patients hospitalized for COVID-19 are needed., Competing Interests: Dr Adegunsoye discloses relationships with the National Institute of Health, Genentech, Inogen, and Boehringer Ingelheim. Dr Gerald discloses relationships with the National Institute of Health, American Lung Association, UpToDate, American Lung Association of Arizona, and the Arizona Asthma Coalition. Dr Krishnan discloses relationships with the National Institutes of Health, COPD Foundation, Regeneron, Sergey Brin Family Foundation, Patient-Centered Outcomes Research Institute, American Lung Association, GSK, AstraZeneca, CereVu Medical, Propeller Health and ResMed, BData, University of Chicago, American Academy of Asthma, Allergy, and Immunology, Global Initiative for Asthma, American Thoracic Society, Central Society of Clinical and Translational Research, and the Respiratory Health Association. Dr Vines discloses relationships with the Rice Foundation, Teleflex Medical, Elsevier, Dräger, Mayo Clinic Didier Memorial Lecture, and the National Board for Respiratory Care. The remaining authors have disclosed no conflicts of interest., (Copyright © 2024 by Daedalus Enterprises.)

Background: Diaphragm atrophy has been observed in subjects who undergo invasive mechanical ventilation. We propose a new method to assess for respiratory muscle (RM) changes in subjects who undergo invasive mechanical ventilation by assessing for changes in respiratory muscles through computed tomography (CT)., Methods: A retrospective case series study was conducted on subjects who underwent invasive mechanical ventilation and received at least 2 chest CT scans during admission. Exclusion criteria included history of chronic mechanical ventilation dependence and neuromuscular disease. Respiratory muscle cross-sectional area (CSA) was measured at the T6 vertebrae., Results: Fourteen subjects were included: mean (± SD) age, BMI, and admission APACHE II scores were 54.0 y (± 14.9), 32.6 kg/m 2 (± 10.9), and 23.5 (± 6.0), respectively. Ten (71%) subjects were male. Mean length of time between CT chest scans was 7.5 d (± 3.3). Mean duration of invasive mechanical ventilation was 4.5 d (± 3.4). The percentage change in TM CSA among those who underwent invasive mechanical ventilation was 10.5% (± 6.1)., Conclusions: We demonstrated that serial analysis of respiratory muscle CSA through CT chest scans can be a method to assess for respiratory muscle atrophy in subjects undergoing mechanical ventilation. Future prospective studies involving larger populations are needed to better understand how this method can be used to predict outcomes in mechanically ventilated patients., Competing Interests: The authors have disclosed no conflicts of interest., (Copyright © 2023 by Daedalus Enterprises.)

Background: Endotracheal tube (ETT) scraping or sweeping refers to mucus removal from an ETT that can increase airway resistance. The study objective was to evaluate the effect of ETT scraping on the duration of mechanical ventilation, time to first successful spontaneous breathing trial (SBT), duration of hospital stay, and occurrence of ventilator-associated events (VAEs)., Methods: This was a single-center, randomized clinical trial of adult subjects intubated between October 2019-October 2021. Subjects were randomly assigned to either ETT suctioning via a standard in-line suction catheter (control group) or ETT suctioning and scraping via a suction catheter with balloon-sweeping technology (experimental group). Airway suctioning was performed as clinically indicated, and the ETT was scraped every time a respiratory therapist suctioned the subject. The study outcome was duration of mechanical ventilation, time to first successful SBT, hospital length of stay, and VAE rate. Intent-to-treat statistical analysis was performed., Results: Of 272 randomized subjects, the median age was 63 (interquartile range [IQR] 52-73) y; 143 (53%) were males, and 154 (57%) had a primary diagnosis of acute respiratory failure. There were no significant differences between the groups in median duration (h) of mechanical ventilation (72 [37-187] vs 70.6 [37-148], P = .58). There was no significant difference between the study groups in median time (h) to the first successful SBT (46.7 [IQR 30-87] vs 45.7 [IQR 27-95], P = .81), length of hospital stay ( P = .76), the incidences of ventilator-associated conditions ( P = .13), or infection-related ventilator-associated complications ( P = .47)., Conclusions: ETT suctioning plus scraping, compared to ETT suctioning alone, did not significantly improve the duration of mechanical ventilation, time to first successful SBT, length of hospital stay, and VAEs. These study findings do not support the routine use of ETT scraping for mechanically ventilated patients., Competing Interests: Dr Scott discloses relationships with Teleflex, Aerogen, and Medline Industries, LP. Dr. Kaur discloses a relationship with the American Association for Respiratory Care. Dr Vines discloses relationships with Teleflex Medical, Inc, and the Rice Foundation. The other authors have disclosed no conflicts of interest., (Copyright © 2023 by Daedalus Enterprises.)

The National Board for Respiratory Care credentials general respiratory therapists and therapists specializing in pulmonary function testing, neonatal/pediatrics, sleep, and adult critical care. A sponsor of the NBRC requested a new specialty certification program. The request came with the intent to serve a candidate population from multidisciplinary backgrounds (eg, nurse, nurse practitioner, physician assistant) in addition to respiratory therapists. This article describes the policy that governed the response along with details about two evaluations: a viability study and a personnel study. The research question for the viability study was as follows: Is a new pulmonary disease educator certification program desirable and feasible? After an affirmative outcome from the viability study indicated interest in a new certification program, the research question for the personnel study was as follows: Were there enough potential candidates from multidisciplinary backgrounds to support a new program that would certify pulmonary disease educators? Access to 10 databases was secured to solicit personnel from multidisciplinary backgrounds, netting up to 240,000 potential survey respondents. After pilot testing, one survey was distributed to those with managerial/supervisory relationships with pulmonary disease educators; 407 such personnel responded. A second survey was simultaneously distributed to those directly working in the pulmonary disease educator role; 3,095 responded. Results from both surveys, including the limitations, were summarized for the NBRC, which decided against continued development of the program. A pulmonary disease educator certification program was subjectively desirable and feasible; however, there did not objectively seem to be enough potential candidates to support the program., (Copyright © 2023 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Background: Extubation failure occurs in 5%-20% of patients and is associated with poor clinical outcomes. The primary aim of this project was to determine the predictive ability of the Respiratory Insufficiency (RI) index, Respiratory Oxygenation (ROX) index and Modified Early Warning Score (MEWS) in identifying extubation failure., Methods: This was a secondary analysis of a prior cross-sectional retrospective study conducted from February 2018 through December 2018 among adult subjects who received mechanical ventilation for more than 24 h. Extubation failure was defined as the need for reintubation or rescue non-invasive ventilation (NIV) within 48 h after planned extubation. Univariate analysis and logistic regression were used to identify the predictors and final model was validated using 10 - fold cross validation. Nomogram was constructed based on the final model., Results: Of 216 enrolled subjects, 46 (21.3%) experienced extubation failure. The median RI index 1-h post extubation was 20 [interquartile range [IQR] 16.33-24.24] for success group and 27.02 [IQR 22.42-33.83] for the failure group (P<0.001). The median ROX index 1-h post extubation was 16.66 [IQR 12.57-19.84] for success group and 11.11 [IQR 8.09-14.67] for failure group (P<0.001). The median MEWS 1-h post extubation was 2 [IQR 1-3] for the success group and 4 [IQR 3-5] for the failure group (P<0.001). In multivariable analysis, age >60 years [OR 3.89 (95% CI 1.56-9.73); P=0.004], MEWS >4 [OR 4.01 (95% CI (1.59-10.14); P=0.003] and, RI index >20 [OR 4.50 (95% CI 1.43-14.21); P=0.010] were independently associated with extubation failure., Conclusion: In the present study, RI index and MEWS were independently associated with predicting extubation failure within 1 h of extubation. A prospective validation study is warranted to establish the role of these indices in predicting extubation outcome., Competing Interests: RK discloses funding from American Association of Respiratory Care. DV discloses research funding from Teleflex Medical, Inc. and Rice Foundation and speaker fees from Theravance Biopharma. AA reports no conflict of interest.

Awake prone positioning (APP) of patients with acute hypoxaemic respiratory failure gained considerable attention during the early phases of the coronavirus disease 2019 (COVID-19) pandemic. Prior to the pandemic, reports of APP were limited to case series in patients with influenza and in immunocompromised patients, with encouraging results in terms of tolerance and oxygenation improvement. Prone positioning of awake patients with acute hypoxaemic respiratory failure appears to result in many of the same physiological changes improving oxygenation seen in invasively ventilated patients with moderate-severe acute respiratory distress syndrome. A number of randomised controlled studies published on patients with varying severity of COVID-19 have reported apparently contrasting outcomes. However, there is consistent evidence that more hypoxaemic patients requiring advanced respiratory support, who are managed in higher care environments and who can be prone for several hours, benefit most from APP use. We review the physiological basis by which prone positioning results in changes in lung mechanics and gas exchange and summarise the latest evidence base for APP primarily in COVID-19. We examine the key factors that influence the success of APP, the optimal target populations for APP and the key unknowns that will shape future research., Competing Interests: Conflicts of interest: M. Ibarra-Estrada, A. Kharat, D. Cosgrave and C. Guerin report no conflicts of interest. B.A. McNicholas reports consulting fees received personally from Teleflex. Y. Perez reports grants to institution and personal support for attending medical congress from Fisher & Paykel. J. Li reports grants to institution from Fisher & Paykel, Aerogen, Rice Foundation and American Association for Respiratory Care; personal honoraria for lectures from Fisher & Paykel, Aerogen, Heyer lts, and American Association for Respiratory Care. I. Pavlov reports grants to institution from Open AI inc and Fisher & Paykel. D.L. Vines reports grants to institution from Teleflex Medical and Rice Foundation; personal honoraria from Theravance Biopharma; unpaid role as President, National board for Respiratory Care. O. Roca reports grants to institution from Hamilton Medical AG and Fisher & Paykel; personal consulting fees from Aerogen, and honoraria received from Hamilton Medical AG, Fisher & Paykel, Aerogen and Ambu Ltd; unpaid role as chair of Acute Respiratory Failure group of Spanish Society of Intensive Care Medicine; non-funded research support from Timpel Ltd. S. Ehrmann reports grants to institution from Aerogen Ltd and Fisher & Paykel; personal consulting fees from Aerogen Ltd; personal honoraria and support for attending meetings from Aerogen Ltd and Fisher & Paykel; participation on Data Safety Monitoring Board for Aerogen Ltd; receipt of equipment/materials from Aerogen Ltd and Fisher & Paykel. J.G. Laffey reports funding to institution from Science Foundation Ireland; personal consulting fees from Baxter Healthcare; unpaid participation in Data Safety Monitoring Board (investigator trials); unpaid role as chair of Translational Biology Section of European Society of Intensive Care Medicine., (Copyright ©The authors 2023.)

Background: Respiratory therapists (RTs) faced many unpredicted challenges and higher stress levels while managing critically ill patients with the coronavirus disease (COVID-19). This study's primary objective was to evaluate the compassion satisfaction and compassion fatigue among RTs in the United States during the COVID-19 pandemic., Methods: This cross-sectional, descriptive, survey-based study conducted from July 2020 to August 2020 was administered to all active members of the American Association of Respiratory Care via AARConnect. RTs' characteristics including personal, job-specific, and organizational factors were collected. Professional Quality of Life Scale (ProQOL, version 5) was used to measure compassion satisfaction and fatigue., Results: A total of 218 participants fully completed the survey, 143 (65.6%) were female, 107 (49.1%) were between 35 and 54 years of age and 72 (33%) were above 55 years of age. Compassion satisfaction was moderate in 123 (56.4%) and high in 93 (42.7%) RTs. Higher compassion satisfaction was found in RTs who have a higher salary ( P = 0.003), work overtime ( P = 0.01), hold leadership positions ( P < 0.001), work in research/education ( P < 0.001) and work for departments that provide help in managing burnout and stress ( P = 0.007) and that promote a positive work environment ( P < 0.001). Burnout score was low in 90 (41.3%) and moderate in 127 (58.3%) RTs. Higher burnout was found among younger RTs ( P = 0.019), those with fewer years of experience ( P = 0.013) and those with less than a year at their current job ( P = 0.045). Secondary traumatic stress (STS) was low in 106 (48.6%) and moderate in 112 (51.4%) RTs. Higher STS levels were noted among younger RTs ( P = 0.02) and RTs with lower education levels ( P = 0.016)., Conclusion: This survey study identified various personal, job and organizational related factors associated with increased compassion satisfaction as well as compassion fatigue among RTs., Competing Interests: All authors have completed the ICMJE uniform disclosure form and declare no conflict of interest.

Background: Postextubation monitoring helps identify patients at risk of developing respiratory failure. This study aimed to evaluate the effect of our standard respiratory therapist (RT) assessment tool versus an automated continuous monitoring alert to initiate postextubation RT-driven care on the re-intubation rate., Methods: This was a single-center randomized clinical trial from March 2020 to September 2021 of adult subjects who received mechanical ventilation for > 24 h and underwent planned extubation in the ICU. The subjects were assigned to the standard RT assessment tool or an automated monitoring alert to identify the need for postextubation RT-driven care. The primary outcome was the need for re-intubation due to respiratory failure within 72 h. Secondary outcomes included re-intubation within 7 d, ICU and hospital lengths of stay, hospital mortality, ICU cost, and RT time associated with patient assessment and therapy provision., Results: Of 234 randomized subjects, 32 were excluded from the primary analysis due to disruption in RT-driven care during the surge of patients with COVID-19, and 1 subject was excluded due to delay in the automated monitoring initiation. Analysis of the primary outcome included 85 subjects assigned to the standard RT assessment group and 116 assigned to the automated monitoring alert group to initiate RT-driven care. There was no significant difference between the study groups in re-intubation rate, median length of stay, mortality, or ICU costs. The RT time associated with patient assessment ( P < .001) and therapy provided ( P = .031) were significantly lower in the automated continuous monitoring alert group., Conclusions: In subjects who received mechanical ventilation for > 24 h, there were no significant outcome or cost differences between our standard RT assessment tool or an automated monitoring alert to initiate postextubation RT-driven care. Using an automated continuous monitoring alert to initiate RT-driven care saved RT time. (ClinicalTrials.gov registration NCT04231890)., Competing Interests: Dr Kaur discloses a relationship with the American Association of Respiratory Care. Dr Vines discloses relationships with Teleflex Medical, the Rice Foundation, and Theravance Biopharma. The other authors have disclosed no conflicts of interest., (Copyright © 2022 by Daedalus Enterprises.)

Background: Compassionate extubation (CE) refers to withdrawing mechanical ventilation and allowing a patient to die peacefully at the end of life. The primary objective of this pilot study was to quantify the emotional impact of CE on Respiratory Therapists (RT) and Registered Nurses (RNs)., Methods: This pilot survey was conducted between March and April 2021 at an academic medical center among RTs and RNs. It included questions on participants' demographics, work characteristics, and Impact of Events (IES) scale to assess the subjective stress caused by CE. Data were analyzed using descriptive and χ 2 statistics., Results: Among 20 participants, 18 (90%) were females, 12 (60%) were in the 20-40-year age group, 12 (60%) were RTs, and 8 (40%) RNs. Around 15 (75%) participants worked day shifts with a weekly average of 3-4 shifts, and 14 (70%) performed/observed CE within 1 month before taking this survey. CE performed/observed in a month was ≤2 among 15 (75%) and 3-5 among 4 (20%) participants. Mean total IES score was 16.7 (12.3) among all participants representing 7 (35%) having low, 6 (30%) moderate, and 7 (35%) high emotional impact when performing CE. Risk of developing post-traumatic stress disorder (PTSD) was present in 6 (30%) participants. A significantly higher number of participants in the low impact group were satisfied with the institutional CE process ( p = 0.043) than those in the medium/high impact group., Conclusion: This pilot study findings reveal that RTs and RNs experience moderate to high levels of subjective stress when performing CE. One-third of the survey participants were at risk of developing PTSD., Competing Interests: RK discloses research funding from American Association of Respiratory Care. DV discloses research funding from Teleflex Medical, Inc. and Rice Foundation, and speaker fees from Theravance Biopharma. JBS discloses research funding from Teleflex and speaker fees from Aerogen and Medline Industries, LC. EC, AF and VJL reports no potential conflict of interest.

Background: Awake prone positioning (APP) reduces the intubation rate in COVID-19 patients treated by high-flow nasal cannula (HFNC). However, the lung aeration response to APP has not been addressed. We aimed to explore the lung aeration response to APP by lung ultrasound (LUS)., Methods: This two-center, prospective, observational study enrolled patients with COVID-19-induced acute hypoxemic respiratory failure treated by HFNC and APP. LUS score was recorded 5-10 min before, 1 h after APP, and 5-10 min after supine in the first APP session within the first three days. The primary outcome was LUS score changes in the first three days. Secondary outcomes included changes in SpO 2 /FiO 2 ratio, respiratory rate and ROX index (SpO 2 /FiO 2 /respiratory rate) related to APP, and the rate of treatment success (patients who avoided intubation)., Results: Seventy-one patients were enrolled. LUS score decreased from 20 (interquartile range [IQR] 19-24) to 19 (18-21) (p < 0.001) after the first APP session, and to 19 (18-21) (p < 0.001) after three days. Compared to patients with treatment failure (n = 20, 28%), LUS score reduction after the first three days in patients with treatment success (n = 51) was greater (- 2.6 [95% confidence intervals - 3.1 to - 2.0] vs 0 [- 1.2 to 1.2], p = 0.001). A decrease in dorsal LUS score > 1 after the first APP session was associated with decreased risk for intubation (Relative risk 0.25 [0.09-0.69]). APP daily duration was correlated with LUS score reduction in patients with treatment success, especially in dorsal lung zones (r =  - 0.76; p < 0.001)., Conclusions: In patients with acute hypoxemic respiratory failure due to COVID-19 and treated by HFNC, APP reduced LUS score. The reduction in dorsal LUS scores after APP was associated with treatment success. The longer duration on APP was correlated with greater lung aeration. Trial registration This study was prospectively registered on clinicaltrials.gov on April 22, 2021. Identification number NCT04855162 ., (© 2022. The Author(s).)

Background: Awake prone positioning has been broadly utilised for non-intubated patients with COVID-19-related acute hypoxaemic respiratory failure, but the results from published randomised controlled trials (RCTs) in the past year are contradictory. We aimed to systematically synthesise the outcomes associated with awake prone positioning, and evaluate these outcomes in relevant subpopulations., Methods: In this systematic review and meta-analysis, two independent groups of researchers searched MEDLINE, Embase, PubMed, Web of Science, Scopus, MedRxiv, BioRxiv, and ClinicalTrials.gov for RCTs and observational studies (with a control group) of awake prone positioning in patients with COVID-19-related acute hypoxaemic respiratory failure published in English from Jan 1, 2020, to Nov 8, 2021. We excluded trials that included patients intubated before or at enrolment, paediatric patients (ie, younger than 18 years), or trials that did not include the supine position in the control group. The same two independent groups screened studies, extracted the summary data from published reports, and assessed the risk of bias. We used a random-effects meta-analysis to pool individual studies. We used the Grading of Recommendations Assessment, Development, and Evaluation approach to assess the certainty and quality of the evidence. The primary outcome was the reported cumulative intubation risk across RCTs, and effect estimates were calculated as risk ratios (RR;95% CI). The analysis was primarily conducted on RCTs, and observational studies were used for sensitivity analyses. No serious adverse events associated with awake prone positioning were reported. The study protocol was prospectively registered with PROSPERO, CRD42021271285., Findings: A total of 1243 studies were identified, we assessed 138 full-text articles and received the aggregated results of three unpublished RCTs; therefore, after exclusions, 29 studies were included in the study. Ten were RCTs (1985 patients) and 19 were observational studies (2669 patients). In ten RCTs, awake prone positioning compared with the supine position significantly reduced the need for intubation in the overall population (RR 0·84 [95% CI 0·72-0·97]). A reduced need for intubation was shown among patients who received advanced respiratory support (ie, high-flow nasal cannula or non-invasive ventilation) at enrolment (RR 0·83 [0·71-0·97]) and in intensive care unit (ICU) settings (RR 0·83 [0·71-0·97]) but not in patients receiving conventional oxygen therapy (RR 0·87 [0·45-1·69]) or in non-ICU settings (RR 0·88 [0·44-1·76]). No obvious risk of bias and publication bias was found among the included RCTs for the primary outcome., Interpretation: In patients with COVID-19-related acute hypoxaemic respiratory failure, awake prone positioning reduced the need for intubation, particularly among those requiring advanced respiratory support and those in ICU settings. Awake prone positioning should be used in patients who have acute hypoxaemic respiratory failure due to COVID-19 and require advanced respiratory support or are treated in the ICU., Funding: OpenAI, Rice Foundation, National Institute for Health Research, and Oxford Biomedical Research Centre., Competing Interests: Declaration of interests SE discloses consultancy fees from Aerogen, research support from Aerogen and Fisher & Paykel Healthcare, and travel reimbursements from Aerogen and Fisher & Paykel Healthcare. JL discloses research funding from Fisher & Paykel Healthcare, Aerogen, and Rice Foundation, and speaker fees from American Association for Respiratory Care, Aerogen, Heyer, and Fisher & Paykel Healthcare. IP discloses a research grant and speaker fees from Fisher & Paykel Healthcare. YP discloses research support from Fisher & Paykel Healthcare. OR discloses a research grant from Hamilton Medical and speaker fees from Hamilton Medical, Ambu, Fisher & Paykel and Aerogen, and non-financial research support from Timpel and Masimo. DV discloses research funding from Teleflex Medical and Rice Foundation, and speaker fees from Theravance Biopharma. MT discloses consulting fees from Fisher & Paykel Healthcare. JRM discloses research support from Fisher & Paykel Healthcare, and speaker fees from Fisher & Paykel Healthcare, Gilead, Dextro and Linet. JGL discloses consulting fees from Baxter Healthcare and GlaxoSmithKline. KM is the primary investigator for the industry funded trial NCT03808922. MF is a consultant for a start-up company (ProofDx) developing a CRISPR based diagnostic test for COVID-19. All other authors declare no competing interests., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: Hospital-acquired pneumonia (HAP) and the need for positive-pressure ventilation (PPV) are significant postoperative pulmonary complications (PPCs) that increase patients' lengths of stay, mortality, and costs. Current tools used to predict PPCs use nonmodifiable preoperative factors; thus, they cannot assess provided respiratory therapy effectiveness. The Respiratory Assessment and Allocation of Therapy (RAAT) tool was created to identify HAP and the need for PPV and assist in assigning respiratory therapies. This study aimed to assess the RAAT tool's reliability and validity and determine if allocated respiratory procedures based on scores prevented HAP and the need for PPV., Methods: Electronic medical record data for nonintubated surgical ICU subjects scored with the RAAT tool were pulled from July 1, 2015-January 31, 2016, using a consecutive sampling technique. Sensitivity, specificity, and jackknife analysis were generated based on total RAAT scores. A unit-weighted analysis and mean differences of consecutive RAAT scores were analyzed with RAAT total scores ≥ 10 and the need for PPV., Results: The first or second RAAT score of ≤ 5 (unlikely to receive PPV) and ≥ 10 (likely to receive PPV) provided a sensitivity of 0.833 and 0.783 and specificity of 0.761 and 0.804, respectively. Jackknifed sensitivity and specificity for identified cutoffs above were 0.800-0.917 and 0.775-0.739 for the first RAAT score and 0.667-0.889 and 0.815-0.79 for the second RAAT score. The initial RAAT scores of ≥ 10 predicted the need for PPV ( P < .001) and was associated with higher in-hospital mortality ( P < .001). Mean differences between consecutive RAAT scores revealed decreasing scores did not need PPV., Conclusions: The RAAT scoring tool demonstrated an association with the need for PPV using modifiable factors and appears to provide a quantitative method of determining if allocated respiratory therapy is effective., Competing Interests: Dr Vines discloses relationships with Theravance Biopharma, Teleflex Medical, and the Rice Foundation. Dr Scott discloses a relationship with Teleflex Medical. The remaining authors have disclosed no conflicts of interest., (Copyright © 2022 by Daedalus Enterprises.)

Background: Awake prone positioning (APP) has been advocated to improve oxygenation and prevent intubation of patients with acute hypoxemic respiratory failure due to coronavirus disease 2019 (COVID-19). This paper aims to synthesize the available evidence on the efficacy of APP., Methods: We performed a systematic review of proportional outcomes from observational studies to compare intubation rate in patients treated with APP or with standard care., Results: A total of 46 published and 4 unpublished observational studies that included 2,994 subjects were included, of which 921 were managed with APP and 870 were managed with usual care. APP was associated with significant improvement of oxygenation parameters in 381 cases of 19 studies that reported this outcome. Among the 41 studies assessing intubation rates (870 subjects treated with APP and 852 subjects treated with usual care), the intubation rate was 27% (95% CI 19-37%) as compared to 30% (95% CI 20-42%) ( P = .71), even when duration of application, use of adjunctive respiratory assist device (high-flow nasal cannula or noninvasive ventilation), and severity of oxygenation deficit were taken into account. There appeared to be a trend toward improved mortality when APP was compared with usual care (11% vs 22%), which was not statistically significant., Conclusions: APP was associated with improvement of oxygenation but did not reduce the intubation rate in subjects with acute respiratory failure due to COVID-19. This finding is limited by the high heterogeneity and the observational nature of included studies. Randomized controlled clinical studies are needed to definitively assess whether APP could improve key outcome such as intubation rate and mortality in these patients., (Copyright © 2022 by Daedalus Enterprises.)

Competing Interests: Dr. Vines’ institution received funding from the Rice Foundation and Teleflex Medical, INC; he received funding from Ohio Medical and Theravance Biopharma. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Background: Early detection and prevention of extubation failure offers the potential to improve patient outcome. The primary aim of this study was to compare the predictive ability of the Integrated Pulmonary Index and presence of high-risk factors in determining extubation failure., Methods: A retrospective cross-sectional study of intubated adult subjects receiving mechanical ventilation for > 24 h was conducted at an academic medical center. The primary outcome was extubation failure, defined as the need for re-intubation or rescue noninvasive ventilation within 48 h after planned extubation., Results: Among 216 subjects, 170 (78.7%) were successfully extubated, and 46 (21.3%) failed extubation. Extubation failure group had higher body mass index (26.21 vs 28.5 kg/m 2 , P = .033), rapid shallow breathing index during spontaneous breathing trial (43 vs 53.5, P = .02), and APACHE II score (11.86 vs 15.73, P < .001). Presence of ≥3 high-risk factors (odds ratio 3.11 [95% CI 1.32-7.31], P = .009), APACHE II > 12 on extubation day (odds ratio 2.98 [95% CI 1.22-7.27], P = .02), and Integrated Pulmonary Index decrease within 1 h after extubation (odds ratio 7.74 [95% CI 3.45-17.38], P < .001) were independently associated with extubation failure. The failed extubation group had higher ICU mortality (8.8% vs 19.6%; absolute difference 10.7% [95% CI -1.9% to 23.4%], P = .040) and hospital mortality (10% vs 22%; absolute difference 16.1% [95% CI 2.2-30%], P = .005) compared to the successful group., Conclusions: Among subjects receiving mechanical ventilation for > 24 h, decreasing Integrated Pulmonary Index within the first hour postextubation was a predictor of extubation failure and was superior to other weaning variables collected in this retrospective study. The presence of ≥ 3 high-risk factors was also independently associated with extubation failure. Future clinical studies are required to prospectively test the ability of postextubation Integrated Pulmonary Index monitoring to guide additional interventions designed to reduce re-intubation rates and improve patient outcome., Competing Interests: Dr Vines has disclosed relationships with Teleflex Medical, Rice Foundation, and Ohio Medical. The other authors have disclosed no conflicts of interest., (Copyright © 2021 by Daedalus Enterprises.)

Background: Awake prone positioning (APP) is widely used in the management of patients with coronavirus disease (COVID-19). The primary objective of this study was to compare the outcome of COVID-19 patients who received early versus late APP., Methods: Post hoc analysis of data collected for a randomized controlled trial (ClinicalTrials.gov NCT04325906). Adult patients with acute hypoxemic respiratory failure secondary to COVID-19 who received APP for at least one hour were included. Early prone positioning was defined as APP initiated within 24 h of high-flow nasal cannula (HFNC) start. Primary outcomes were 28-day mortality and intubation rate., Results: We included 125 patients (79 male) with a mean age of 62 years. Of them, 92 (73.6%) received early APP and 33 (26.4%) received late APP. Median time from HFNC initiation to APP was 2.25 (0.8-12.82) vs 36.35 (30.2-75.23) hours in the early and late APP group (p < 0.0001), respectively. Average APP duration was 5.07 (2.0-9.05) and 3.0 (1.09-5.64) hours per day in early and late APP group (p < 0.0001), respectively. The early APP group had lower mortality compared to the late APP group (26% vs 45%, p = 0.039), but no difference was found in intubation rate. Advanced age (OR 1.12 [95% CI 1.0-1.95], p = 0.001), intubation (OR 10.65 [95% CI 2.77-40.91], p = 0.001), longer time to initiate APP (OR 1.02 [95% CI 1.0-1.04], p = 0.047) and hydrocortisone use (OR 6.2 [95% CI 1.23-31.1], p = 0.027) were associated with increased mortality., Conclusions: Early initiation (< 24 h of HFNC use) of APP in acute hypoxemic respiratory failure secondary to COVID-19 improves 28-day survival. Trial registration ClinicalTrials.gov NCT04325906., (© 2021. The Author(s).)

Background: The majority of prescriptions for supplemental oxygen are written when patients are discharged to home from the hospital and the evaluation of these patients is inconsistent. Respiratory Therapists receive training in the evaluation and management of patients needing oxygen. The primary goal of the study was to estimate the frequency with which respiratory therapists (RTs) evaluate the need for home oxygen in patients hospitalized for COPD exacerbations before discharge., Methods: An online questionnaire was distributed to RTs in the United States by the American Association for Respiratory Care. RTs were asked to indicate how frequently they evaluate the need for home oxygen on an ordinal scale: Never, Rarely/occasionally, Sometimes, Most of the time, Almost every time, or Every time. Consistent evaluation for home oxygen was defined as performing an evaluation for home oxygen therapy Almost every time or Every time (ie, > 75% of the time). Bivariate and multivariable analyses were assessed using the Fisher exact test and logistic regression models., Results: Of 611 respondents, 490 were eligible for analysis. Fifty-eight percent of RTs reported consistently evaluating patients for home oxygen at rest, whereas 43% reported doing so during activity and 14% during sleep. Consistent evaluation for home oxygen requirements at rest was significantly associated with more years of practice ( P = .03; highest among RTs with ≥ 30 y of practice at 40%), region of practice ( P = .001; highest in the Midwest at 44%), and greater familiarity with criteria for home oxygen ( P < .001; highest among RTs who selected Very familiar with guidelines from the Centers for Medicare and Medicaid Services at 58%). Practice in the Midwest and greater familiarity with criteria for home oxygen was associated with consistent evaluation for home oxygen during activity. Practice in the Midwest (vs Northeast; adjusted odds ratio 2.56, P < .001) and being very familiar with home oxygen criteria (vs not at all familiar; adjusted odds ratio 5.66, P < .001) were independently associated with a higher odds of evaluating for home oxygen at rest and with activity. Only 25% of RTs were involved in making decisions about home oxygen equipment., Conclusions: RTs do not consistently evaluate patients hospitalized for COPD exacerbations for home oxygen prior to discharge, and only a minority of RTs are involved in selecting home oxygen equipment., Competing Interests: Dr Tan has disclosed a relationship with the National Institutes of Health (NIH). Dr Krishnan has disclosed relationships with the NIH, the Patient-Centered Outcomes Research Institute, ResMed, and Regeneron. Dr Vines has disclosed a relationship with Ohio Medical. Dr Prieto-Centurion has disclosed relationships with the NIH and ResMed. Mr Kallstrom is Executive Director of the American Association for Respiratory Care and Publisher of Respiratory Care., (Copyright © 2021 by Daedalus Enterprises.)

Introduction: Weaning predictors can help liberate patients in a timely manner from mechanical ventilation. Ventilatory equivalent for oxygen (VEqO 2 ), a surrogate for work of breathing and a measure of the efficiency of breathing, may be an important noninvasive alternative to other weaning predictors. Our study's purpose was to observe any differences in VEqO 2 between extubation outcome groups., Methods: Employing a metabolic cart, oxygen consumption ( V ˙ O 2 ), minute volume (VE), tidal volume (VT), and breathing frequency were recorded during a spontaneous breathing trial (SBT) to calculate VEqO 2 and the rapid shallow breathing index (RSBI) in 34 adult participants in the intensive care unit. Five-breath means of VEqO 2 and the RSBI collected throughout the SBT were examined between SBT pass and fail groups and extubation pass and fail groups using the Mann-Whitney U test with p < 0.05., Results: Data from 31 participants were analyzed between SBT outcome groups. Data from 20 participants were examined for extubation outcome after a successful SBT. Median (interquartile range) VEqO 2 was not different between extubation groups. Participants who passed the SBT had a higher median VEqO 2 than those who did not at the midpoint (25.3 L/L V ˙ O 2 [22-33 L/L V ˙ O 2 ] vs. 23.7 L/L V ˙ O 2 [18-24 L/L V ˙ O 2 ], p = 0.035) and at the end (25.5 L/L  V ˙ O 2 [23-34 L/L V ˙ O 2 ] vs. 21.3 L/L V ˙ O 2 [20-24 L/L V ˙ O 2 ], p = 0.017) of the SBT., Discussion: VEqO 2 may show differences in SBT outcomes, but not differences between extubation outcomes. VEqO 2 may be able to detect differences in work during an SBT, but may not be able to predict change in workload in the respiratory system after extubation. The small sample size may also have prevented any differences in extubation outcomes to be shown., Conclusion: VEqO 2 was higher in patients that passed their SBT. VEqO 2 was not useful in identifying extubation success or failure in adult mechanically ventilated patients.

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., (Copyright © 2018 by Daedalus Enterprises.)

Background: The integrated pulmonary index (IPI) utilizes an algorithm based on the measurement of end-tidal carbon dioxide, breathing frequency, heart rate, and oxygen saturation to provide an assessment of the patient's ventilatory status. This clinical trial was designed to determine whether lower IPI values were associated with extubation failure., Methods: This prospective observational trial was conducted in an academic medical center. After institutional review board approval, 100 mechanically ventilated subjects were enrolled. A stand-alone respiratory monitor that measures IPI was placed on subjects before starting a spontaneous breathing trial and continued for up to 48 h postextubation. Clinicians were blinded, and data were recorded continuously. Extubation failure was defined as the need for positive-pressure ventilation within 48 h after extubation. Mixed-effects regression models were employed to examine differences in IPI patterns between subjects with extubation success or failure. Significant IPI changes from baseline were then evaluated to predict extubation outcome., Results: IPI was successfully recorded on 62 subjects (48 successful and 14 failed extubations). Although mean IPI 5 min before and after extubation were not significantly different, mean IPI 1 h after extubation in the failure group was significantly lower by 1.19 ( P = .044) compared with the successful group. Negative change in IPI 1 h after extubation increased odds of failure (odds ratio = 1.57, 95% CI 1.001-2.454). The last mean IPI recorded after extubation was also significantly lower in the failure group compared with the successful group by 3.03 ( P < .001). Negative change in the last measured IPI increased odds of failure (odds ratio = 1.72, 95% CI 1.26-2.34)., Conclusions: Declining IPI measurements postextubation are predictive of extubation failure. Further clinical trials are needed to assess the role of IPI in guiding interventions in extubated patients., (Copyright © 2017 by Daedalus Enterprises.)

Background: Aerosolized epoprostenol is an alternative for inhaled nitric oxide in the management of pulmonary arterial hypertension and possibly acute hypoxemia. Our objective was to determine differences in drug deposition based on different nebulizer positions in the ventilator circuit, using a vibrating mesh nebulizer., Methods: An 8.0-mm inner diameter endotracheal tube (ETT) was connected to a training test lung, compliance of 30 mL/cm H 2 O, with a collecting filter placed at the ETT-test lung junction. A mechanical ventilator, heated wire circuit, and pass-over humidifier were utilized. A syringe pump continuously instilled a 15,000-ng/mL epoprostenol solution at 30, 50, and 70 ng/kg/min into the vibrating mesh nebulizer at all 4 positions. Tidal volumes (V T ) were set at 4, 6, and 8 mL/kg for a 70-kg patient with breathing frequencies of 25, 16, and 12 breaths/min, respectively. Epoprostenol was eluted from the filters (no. = 180) and analyzed with ultraviolet-visible spectrophotometry at 205 nm to estimate drug deposition., Results: Epoprostenol deposition increased significantly ( P = .02) as the dosage increased from 30 ng/kg/min (median 4,520.0 ng, interquartile range [IQR] 2,285.0-6,712.2 ng) to 50 ng/kg/min (median 6,065.0 ng, IQR 3,220.0-13,002.5 ng) and 70 ng/kg/min (median 9,890.0 ng, IQR 6,270.0-16,140.0 ng). No significant difference was found between variations in ventilator settings. No difference in deposition was found between the humidifier inlet and outlet, but these positions resulted in greater deposition compared with the inspiratory limb and between the ETT and Y-piece., Conclusions: The greatest amount of mean epoprostenol deposition resulted with the nebulizer placed at the humidifier inlet or outlet in a ventilator with bias flow., (Copyright © 2017 by Daedalus Enterprises.)

Background: Spontaneous breathing trials (SBTs) are used to assess the readiness for discontinuation of mechanical ventilation. When airway resistance (R aw ) is elevated, the imposed work of breathing can lead to prolongation of mechanical ventilation. Biofilm and mucus build-up within the endotracheal tube (ETT) can increase R aw . Scraping the ETT can remove the biofilm build-up and decrease mechanical R aw . The primary aim of this study was to evaluate the impact of ETT scraping on R aw . The secondary aim was to determine whether decreasing R aw would impact subsequent SBT success., Methods: Intubated, mechanically ventilated subjects were enrolled if they failed an SBT and had an R aw of > 10 cm H 2 O/L/s. SBT failure was based on institutional guidelines, and R aw was calculated by subtracting the difference between the measured peak and plateau pressures using a square flow waveform with an inspiratory flow set at 60 L/min. The endOclear device was inserted into the ETT and withdrawn per manufacturer's guidelines. Scraping was repeated until the ETT was cleared. Change in R aw was compared pre- and post-ETT scraping using a paired t test. A Mann-Whitney U test evaluated the difference in percentage change in R aw between SBT groups., Results: Twenty-nine subjects completed the study. The mean pre- and post-ETT scraping R aw values were 15.17 ± 3.83 and 12.05 ± 3.19 cm H 2 O/L/s, respectively ( P < .001). Subsequent SBT success was 48%; however, there was no difference in percentage change in R aw between subsequent passed SBT (18.61% [interquartile range 8.90-33.93%]) and failed SBT (23.88% [interquartile range 0.00-34.80%]), U = 78.5, z = -0.284, P = .78. No adverse events were noted with ETT scraping., Conclusions: This study demonstrated that ETT scraping can reduce R aw . The decrease in R aw post-ETT scraping did not affect subsequent SBT success., (Copyright © 2017 by Daedalus Enterprises.)

Background: The impact of various aerosol delivery devices on patient outcomes during mechanical ventilation is unknown. If one method of delivery results in a higher ventilator-associated pneumonia (VAP) rate than another, multiple patient outcomes may be affected. This study aimed to determine whether there was a difference in VAP occurrence and patient outcomes (days receiving ventilation and in-hospital mortality) between the vibrating mesh nebulizer (AeroNeb Solo) and the metered-dose inhaler (MDI)., Methods: This retrospective study reviewed medical records for all mechanically ventilated, adult patients with an order for aerosol treatment from August 2011 to August 2013. The hospital converted from MDI to vibrating mesh nebulizers in August 2012, and data were gathered 1 y before/after conversion. Excluded were patients with a tracheostomy, patients who were mechanically ventilated for <24 h, patients who received a combination of nebulizer and MDI treatments, or patients who were re-intubated., Results: Two hundred twenty-eight subjects were included. Forty-eight (21%) received treatment with an MDI, and 180 (79%) were treated with the vibrating mesh nebulizer. Descriptive data did not significantly differ for age or APACHE II (Acute Physiology and Chronic Health Evaluation II) scores between the groups but did for sex ( P = .03). Difference in median days receiving ventilation for the MDI (5 d, interquartile range 3.0-8.5 d) and the vibrating mesh nebulizer (6 d, interquartile range 4.0-10.0 d) was not statistically significant. No correlation was found between the use of either device and the primary outcomes of VAP and in-hospital mortality. In multivariable logistic regression analysis, the number of days receiving ventilation increased the odds of VAP (odds ratio [OR] 1.3, 95% CI 1.14-1.49, P < .001) and mortality (OR 1.12, 95% CI 1.04-1.21, P = .002). Higher APACHE II scores increased the odds of mortality (OR 1.05, 95% CI 1.001-1.092, P = .044)., Conclusion: We found no association between an MDI or vibrating mesh nebulizer and our primary outcomes, days receiving ventilation, in-hospital mortality, or VAP, in mechanically ventilated subjects., (Copyright © 2017 by Daedalus Enterprises.)

Background: Improper inhaler use results in decreased drug deposition in the lungs. The impact of health literacy and poor vision on the patient's ability to learn inhaler technique by reading instructions has not been confirmed. This study evaluated the effectiveness of learning inhaler technique from written instructions and the impact of health literacy for patients diagnosed with COPD who used a dry powder inhaler (DPI)., Methods: This pilot study recruited subjects diagnosed with COPD. A trained assessor scored subjects' inhaler technique before and after reading the appropriate American College of Chest Physicians handouts. Peak inspiratory flows (PIFs) were measured using an InCheck Dial. Health literacy was measured by the S-TOFHLA (Short Test of Functional Health Literacy in Adults), and visual acuity was measured by a Snellen chart. Associations between health literacy and visual acuity and changes in subjects' inhaler technique scores were assessed by Spearman's rho. Inhaler technique change scores were assessed by the Wilcoxon signed-rank test at P = .05., Results: Of the 24 participants enrolled, 63% were female, mean age was 65.6 y, and 83% were Global Initiative for Chronic Obstructive Lung Disease air-flow limitation 2 or 3. Wilcoxon scores were significant for improved total scores for both the Diskus and HandiHaler, with medians improving from 6.5 to 7.0 (interquartile range 6.0-7.8) (P = .047) and from 6.0 to 7.5 (interquartile range 7.0-9.0) (P = .002), respectively. The minimum required PIF was achieved by 93.8% of the Diskus and 94.4% of the HandiHaler groups. There were no associations detected between the handout intervention (Diskus and HandiHaler) and health literacy level and vision., Conclusions: The educational handouts for DPIs helped participants already using a DPI to improve their inhaler technique. Stable participants diagnosed with COPD are able to generate appropriate PIFs to properly use DPIs. Neither vision nor health literacy was associated with the inability to learn inhaler technique from patient education inhaler device handouts., (Copyright © 2017 by Daedalus Enterprises.)

Background: Therapeutic gases and other modalities delivered by inhalation may affect the accuracy of capnographic measurements in 2 ways. First is the specificity of the measurement of CO2 within the device, and second is the dilution effect of supplemental gases in the ambient air during CO2 sampling by the device. Our goal was to determine if variables such as inhaled gas composition, gas flows delivered via non-rebreather mask, and mouth open or closed affect measurements of end-tidal CO2 pressure (PETCO2) measured with the Capnostream 20 capnograph., Methods: We measured PETCO2 and breathing frequency by capnography in 20 adult normal subjects, with coaching to maintain respiratory frequency between 10 and 20 breaths/min. SpO2 was monitored to detect hypoxemia. A 6 min wash-out period occurred between each 6 min level of testing., Results: A mixed models analysis revealed that the mean ± SD PETCO2 for all subjects and flows while breathing heliox (37 ± 5 mm Hg) was not different (P = .50) from the value while breathing room air (36 ± 5 mm Hg). Repeated measurements with given subjects over 6 min periods of breathing spontaneously 0 L/min, with 10 L/min, and with 15 L/min of either air or heliox showed no difference in PETCO2 related to flow: P = .97 for 0 L/min vs 10 L/min, P = .87 for 0 L/min vs. 15 L/min., Conclusions: In normal subjects, PETCO2 measurements with the Capnostream 20 were not affected by heliox or gas flow at 10 or 15 L/min through a non-rebreathing mask.

Although medical treatment of COPD has advanced, nonadherence to medication regimens poses a significant barrier to optimal management. Underuse, overuse, and improper use continue to be the most common causes of poor adherence to therapy. An average of 40%-60% of patients with COPD adheres to the prescribed regimen and only 1 out of 10 patients with a metered dose inhaler performs all essential steps correctly. Adherence to therapy is multifactorial and involves both the patient and the primary care provider. The effect of patient instruction on inhaler adherence and rescue medication utilization in patients with COPD does not seem to parallel the good results reported in patients with asthma. While use of a combined inhaler may facilitate adherence to medications and improve efficacy, pharmacoeconomic factors may influence patient's selection of both the device and the regimen. Patient's health beliefs, experiences, and behaviors play a significant role in adherence to pharmacological therapy. This manuscript reviews important aspects associated with medication adherence in patients with COPD and identifies some predictors of poor adherence.

Successful outcomes are vital for respiratory care education programs. These outcomes rely heavily on student recruitment and selection. Future graduates practicing respiratory care must have a basic understanding of respiratory care and possess the advanced skills that enable them to problem solve, communicate effectively, and become active leaders in the health care team. It is the responsibility of respiratory care educators to produce the respiratory therapists of the future. It is crucial for the faculty of respiratory care education programs to recruit and select candidates who will complete the educational program and develop the technical and critical-thinking skills needed to pass the advanced level credentialing examinations and succeed in the respiratory care profession.

Ventilator circuits should not be changed routinely for infection control purposes. The maximum duration of time that circuits can be used safely is unknown. Evidence is lacking related to ventilator-associated pneumonia (VAP) and issues of heated versus unheated circuits, type of heated humidifier, method for filling the humidifier, and technique for clearing condensate from the ventilator circuit. Although the available evidence suggests a lower VAP rate with passive humidification than with active humidification, other issues related to the use of passive humidifiers (resistance, dead space volume, airway occlusion risk) preclude a recommendation for the general use of passive humidifiers. Passive humidifiers do not need to be changed daily for reasons on infection control or technical performance. They can be safely used for at least 48 hours, and with some patient populations some devices may be able to be used for periods of up to 1 week. The use of closed suction catheters should be considered part of VAP prevention strategy, and they do not need to be changed daily for infection control purposes. The maximum duration of time that closed suction catheters can be used safely is unknown. Clinicians caring for mechanically ventilated patients should be aware of risk factors for VAP (eg, nebulizer therapy, manual ventilation, and patient transport).