Quality indicators in respiratory therapy

Quality indicators in healthcare refer to measurable and quantifiable parameters used to assess and monitor the performance,effectiveness,and safety of healthcare services.These indicators provide a systematic way to evaluate the quality of care offered,and thereby to identify areas for improvement and to ensure that patient care meets established standards and best practices.Respiratory therapists play a vital role in areas of clinical administration such as infection control practices and quality improvement initiatives.Quality indicators serve as essential metrics for respiratory therapy departments to assess and enhance the overall quality of care.By systematically tracking and analyzing indicators related to infection control,treatment effectiveness,and adherence to protocols,respiratory care practitioners can identify areas to improve and implement evidence-based changes.This article reviewed how to identify,implement,and monitor quality indicators specific to the respiratory therapy departments to set benchmarks and enhance patient outcomes.

Exhaled nitric oxide in neonates with or without hypoxemic respiratory failure

BACKGROUND： Exhaled nitric oxide （eNO） is one of the airway condensate derived markers, reflecting mainly airway inflammation in asthma and other lung diseases. The changes of eNO levels as pathophysiology of neonatal hypoxemic respiratory failure （HRF） in early postnatal life have not been thoroughly studied. The present study was to establish a method for measuring eNO concentrations in neonates with or without HRF. METHODS： Twenty-two newborn infants with HRF and 26 non-NRF controls were included within the first 24 hours of postnatal life. Their eNO levels were detected with a rapid-response chemiluminescence analyzer daily during the first week of their postnatal life, and lung mechanics and gas exchange efficiency were monitored at the same time, such as pulse oxygen saturation （SpO2）, inspired fraction of oxygen （FiO2） and other parameters. RESULTS：During the first two days of postnatal life, eNO values of HRF neonates were significantly higher than those of the control neonates （day 1,7.9±3.2 vs. 5.8±1.8 parts per billion [ppb], P〈0.05; day 2, 8.8±3.2 vs. 6.0±2.4 ppb, P〈0.05）, but there were no significant differences in the following days. With SpOJFiO2 increasing, difference of eNO values between the HRF and non-HRF neonates became narrowed, but there was still a two-fold difference of eNO/[SpO2/（FiO2×100）] on days 5-7. CONCLUSION： We established a method for measuring eNO and found difference in neonates with or without HRF, which diminished with prolonged postnatal days, reflecting pathophysiological characteristics of HRF.

Effect of intensive vs conventional insulin therapy on perioperative nutritional substrates metabolism in patients undergoing gastrectomy

AIM: To investigate the effect of intensive vs conventional insulin therapy on perioperative nutritional substrates metabolism in patients undergoing radical distal gastrectomy. METHODS: Within 24 h of intensive care unit management, patients with gastric cancer were enrolled after written informed consent and randomized to the intensive insulin therapy (IIT) group to keep glucose levels from 4.4 to 6.1 mmol/L or the conventional insulin therapy (CIT) group to keep levels less than 10 mmol/L. Resting energy expenditure (REE), respiratory quotient (RQ), resting energy expenditure per kilogram (REE/kg), and the lipid oxidation rate were monitored by the indirect calorimeter of calcium citrate malate nutrition metabolism investigation system. The changes in body composition were analyzed by multi-frequency bioimpedance analysis. Blood fasting glucose and insulin concentration were measured for assessment of Homeostasis model assessment of insulin resistance. RESULTS: Sixty patients were enrolled. Compared with preoperative baseline, postoperative REE increased by over 22.15% and 11.07%; REE/kg rose up to 27.22 ± 1.33 kcal/kg and 24.72 ± 1.43 kcal/kg; RQ decreased to 0.759 ± 0.034 and 0.791 ± 0.037; the lipid oxidation ratio was up to 78.25% ± 17.74% and 67.13% ± 12.76% supported by parenteral nutrition solutions from 37.56% ± 11.64% at the baseline; the level of Ln-HOMA-IR went up dramatically (P < 0.05, respectively) on postoperative days 1 and 3 in the IIT group. Meanwhile the concentration of total protein, albumin and triglyceride declined significantly on postoperative days 1 and 3 compared with pre-operative levels (P < 0.05, respectively). Compared with the CIT group, IIT reduced the REE/kg level (27.22 ± 1.33 kcal/kg vs 29.97 ± 1.47 kcal/kg, P = 0.008; 24.72 ± 1.43 kcal/kg vs 25.66 ± 1.63 kcal/kg, P = 0.013); and decreased the Ln-HOMA-IR score (P = 0.019, 0.028) on postoperative days 1 and 3; IIT decreased the level of CRP on postoperative days 1 and 3 (P = 0.017, 0.006); the total protein and albumin concentrations in the IIT group were greater than those in the CIT group (P = 0.023, 0.009). Postoperative values of internal cell fluid (ICF), fat mass, protein mass (PM), muscle mass, free fat mass and body weight decreased obviously on postoperative 7th day compared with the preoperative baseline in the CIT group (P < 0.05, respectively). IIT reduced markedly consumption of fat mass, PM and ICF compared with CIT (P = 0.009 to 0.026). CONCLUSION: There were some benefits of IIT in decreasing the perioperative insulin resistance state, reducing energy expenditure and consumption of proteins and lipids tissue in patients undergoing gastrectomy.

ACUPUNCTURE TREATMENT OF 42 CASES OF ACUTE UPPER RESPIRATORY TRACT INFECTION

We made clinical observations on the therapeutic effect of acupuncture on acute upper respiratory tract infection and compared with the effect of paracetamol and Antondine, The result showed that acupuncture therapy could allay fever more rapidly than drugs, so long as the differentiation of syndromes is correct and the acupoint is selected properly.

Assessment of the Effects of Manual Chest Compression Technique on Atelectasis in Infants: A Randomized Clinical Trial

Objectives: To evaluate the effect of manual chest compression (MCC) in the variables of oxygenation, hemodynamic and respiratory effeteness in infants suffering from respiratory diseases with atelectasis. Methods: Controlled clinical trial, in which 38 infants were evaluated,19 ineach study group (group A: atelectasis and group B: control). Data were measured before, immediately after and 10 minutes after the end of the technique’s application. Results: The average age was of 5.05 months. There was an increase of RR in group A immediately after the application of the technique and signs of respiratory distress with a decrease in the oxygen saturation. Conclusion: There was a reduction in SpO2, an increase of RR and a worsening of clinical signs of respiratory distress. Given this, one may consider that there is a controversy about the benefits, mechanism of action, physiological and therapeutic effects of MCC when applied to infants.

Treatment of Recurrent Respiratory Infection with Chinese Drug Therapy of Tonifying-Shen(肾) and Solidifying Superficiality—A Clinical Case Report

Children recurrent respiratory infection （CRRI） indicates that children suffer from frequent infections along the upper or lower respiratory tract for a certain number of times. It is not an independent disease but a clinical syndrome mostly brought about by some basic diseases such as nonspecific immunity, specific immune suppression or deficiency disease, congenital bronchopulmonary dysplasia, vitamin or microelement deficiency, or is induced by some factors such as smoking, cross infection, and nursing errors.（2） Clinically, CRRI is commonly treated by anti-infective agents, symptomatic and supportive treatment, and immune-regulatory therapy. However, the therapeutic effectiveness is always imperfect, which could even lead to a premium on asthma, or nephritis, etc.

Effects of inhaled nitric oxide in neonatal hypoxemic respiratory failure from a multicenter controlled trial

Background Hypoxemic respiratory failure （HRF） is one of the most common causes for neonatal infants requiring aggressive respiratory support. Inhaled nitric oxide （iNO） has been established routinely as an adjunct to conventional respiratory support in developed countries. The aim of this study was to investigate effects of iNO in neonates with HRF in resource limited condition with no or limited use of surfactant, high frequency oscillatory ventilation （HFOV） and extracorporeal membrane oxygenation.Methods A non-randomized, open, controlled study of efficacy of iNO was conducted over 18 months. Eligible term and near-term neonates from 28 hospitals with HRF （oxygenation index ＞15） were enrolled prospectively into two groups as either iNO or control. Oxygenation improvement and mortality as primary endpoint were determined in relation with dosing and timing of iNO, severity of underlying diseases, complications and burden. Intention-to-treat principle was adopted for outcome assessment. Response to iNO at 10 or 20 parts per million （ppm） was determined by oxygenation in reference to the control （between-group） and the baseline （within-group）.Results Compared to 93 controls, initial dose of iNO at 10 ppm in 107 treated infants significantly improved oxygenation from first hour （P=0.046）, with more partial- and non-responders improved oxygenation with subsequent 20ppm NO （P=0.018）. This effect persisted on days 1 and 3, and resulted in relatively lower mortalities （11.2% vs. 15%）whereas fewer were treated with surfactant （10% vs. 27%）,HFOV （＜5%） or postnatal corticosteroids （＜10%） in both groups. The overall outcomes at 28 days of postnatal life in the iNO-treated was not related to perinatal asphyxia,underlying diseases, severity of hypoxemia, or complications,but to the early use of iNO. The cost of hospital stay was not significantly different in both groups.Conclusions With relatively limited use of surfactant and/or HFOV in neonatal HRF, significantly more responders were found in the iNO-treated patients as reflected by improved oxygenation in the first three days over the baseline level. It warrants a randomized, controlled trial for assessment of appropriate timing and long-term outcome of iNO.

Mortality and morbidity of acute hypoxemic respiratory failure and acute respiratory distress syndrome in infants and young children

Background Acute hypoxemic respiratory failure （AHRF） often develops acute respiratory distress syndrome （ARDS）, and its incidence and mortalities in critically ill pediatric patients in China were 2% and 40% respectively. This study aimed at prospectively investigating incidence, causes, mortality and its risk factors, and any relationship to initial tidal volume （VT） levels of mechanical ventilation, in children 〈5 years of age with AHRF and ARDS. Methods In 12 consecutive months in 23 pediatric intensive care units （PICU）, AHRF and ARDS were identified in those requiring 〉12 hour intratracheal mechanical ventilation and followed up for 90 days or until death or discharge. ARDS was diagnosed according to the American-European Consensus definitions. The mortality and ventilation free days （VFD） were measured as the primary outcome, and major complications, initial disease severity, and burden were measured as the secondary outcome. Results In 13 491 PICU admissions, there were 439 AHRF, of which 345 （78.6%） developed ARDS, resulting in incidences of 3.3% and 2.6%, and corresponding mortalities of 30.3% and 32.8% respectively along with 8.2 and 6.7 times of relative risk of death in those with pneumonia （62.9%） and sepsis （33.7%） as major underlying diseases respectively. No association was found in VT levels during the first 7 days with mortality, nor for V-r at levels 〈6, 6-8, 8-10, and 〉10 ml/kg in the first 3 days with mortality or length of VFD. By binary Logistic regression analyses, higher pediatric risk of mortality score III, higher initial oxygenation index, and age 〈1 year were associated with higher mortality or shorter VFD in AHRF. Conclusions The incidence and mortalities of AHRF and ARDS in children 〈5 years were similar to or lower than the previously reported rates （in age up to 15 years）, associated with initial disease severity and other confounders, but causal relationship for the initial VT levels as the independent factor to the major outcome was not found.

Current status of neonatal acute respiratory disorders： a one-year prospective survey from a Chinese neonatal network

Background We conducted a prospective, multicenter investigation of incidence, management and outcome of neonatal acute respiratory disorders （NARD）, and evaluated related perinatal risk factors and efficacy of respiratory therapies in neonatal intensive care units （NICUs） in a Chinese neonatal network.Methods Data were prospectively collected in 2004-2005 from infants with NARD defined as presence of respiratory distress and oxygen requirement during the first 3 days of life.Results A total of 2677 NARD was classified （20.5% of NICU admissions）. There were 711 （5.44%） with respiratory distress syndrome （RDS）, 589 （4.51%） pulmonary infection, 409 （3.13%） meconium aspiration syndrome, 658 （5.03%）aspiration of amniotic fluid and 239 （1.83%） transient tachypnoea. Meconium aspiration syndrome had the highest rate with fetal distress, transient tachypnoea from cesarean section, and RDS with maternal disorders. Assisted mechanical ventilation was applied in 53.4% of NARD, and in above five disorders with 84.7%, 52.3%, 39.8%, 24.5%, and 53.6%,respectively. Corresponding mortality in these disorders was 31.4%, 13.6%, 17.8%, 4.1% and 5.0%, respectively.Surfactant was provided to 33.9% of RDS. In all RDS infants, the survival rate was 78.8% if receiving surfactant, and 63.4% if not （P 〈0.001）.Conclusions This study provided NICU admission-based incidence and mortality of NARD, reflecting efficiency of advanced respiratory therapies, which should be a reference for current development of respiratory support in NICU at provincial and sub-provincial levels, justifying efforts in upgrading standard of care in emerging regions through a collaborative manner.

Oxidative stress, respiratory muscle dysfunction, and potential therapeutics in chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease （COPD） is a highly relevant disorder that induces respiratory muscle dysfunction. One prevalent symptom of COPD is resistive breathing which causes respiratory muscle to significantly increase the magnitude of contractions, resulting in reactive oxygen species （ROS） formation and oxidative stress. Through cellular signaling cascades, ROS activate molecules such as mitogen-activated protein kinases and nuclear factor-kB. These signaling molecules stimulate the release of cytokines which in turn cause damage to the diaphragm, involving sarcomeric disruptions. In response to COPD induced fatigue, the diaphragm undergoes a beneficial fibertype shift to type I muscle fibers, which are more resistant to hypoxia than type II fibers. The lung hyperinflation that occurs in COPD also causes intercostal muscle dysfunction, thereby exacerbating COPD symptoms. In addition, COPD is known to have a connection with heart failure, diabetes, and aging, further decreasing respiratory function. Currently, there is no cure for this disorder. Nevertheless, various potential therapeutic strategies focusing on respiratory muscle have been identified including respiratory muscle training, β2-agonist therapy, and lung volume reduction surgery. In this review, we will outline the role of COPD, oxidative stress, and related complications in respiratory muscle dysfunction.

Potent and specific inhibition of SARS-CoV antigen expression by RNA interference

Background Severe acute respiratory syndrome (SARS) is an infectious disease caused by SARS-CoV. There are no effective antiviral drugs for SARS although the epidemic of SARS was controlled. The aim of this study was to develop an RNAi (RNA interference) approach that specifically targeted the N gene sequence of severe acute respiratory syndrome associated coronavirus (SARS-CoV) by synthesizing short hairpin RNA (shRNA) in vivo , and to assess the inhibitory effect of this shRNA on SARS-CoV N antigen expression. Methods The eukaryotic expression plasmid pEGFP-C1-N, containing SARS-CoV N gene, was co-transfected into 293 cells with either the RNAi plasmid pshRNA-N or unrelated control plasmid pshRNA-HBV-C4. At 24, 48 and 72 hours post transfection, the green fluorescence was observed through a fluorescence microscope. The RNA levels of SARS-CoV N were determined by reverse transcription polymerase chain reaction (RT-PCR). The expression of Green Fluorescent Protein (GFP) and protein N were detected using Western blot.Results The vector, pshRNA-N expressing shRNA which targeted the N gene of SARS-CoV, was successfully constructed. The introduction of RNAi plasmid efficiently and specifically inhibited the synthesis of protein N. RT-PCR showed that RNAs of N gene were clearly reduced when the pEGFP-C1-N was cotransfected with pshRNA-N, whereas the control vector did not exhibit inhibitory effect on N gene transcription.Conclusions Our results demonstrate that RNAi mediated silencing of SARS-CoV gene could effectively inhibit expression of SARS-CoV antigen, hence RNAi based strategy should be further explored as a more efficacious antiviral therapy of SARS-CoV infection.

Role of Combining Spreading Moxibustion and Point Injection in Reducing ECP and LPO Levels and Improving Lung Function

Objective: To observe the effect of combining spreading moxibustion and point injection on serum eosinophil cationic protein(ECP), lipid peroxidase(LPO) and cellular immunity in patients with cough-variant asthma. Methods: A total of 150 cases who met the inclusion criteria were randomized into three groups, 50 in each group. Spreading moxibustion and point injection were employed in the observation group, spreading moxibustion alone in the spreading moxibustion group and point injection alone in the point injection group. Then the therapeutic efficacies were evaluated after one course of treatment. Results: The recovery rate and total effective rate were 50.0% and 98.0% respectively in the observation group, versus 18.0% and 86.0% in the spreading moxibustion group and 14.0% and 82.0% in the point injection group, showing a statistically significant difference(P < 0.01). Before treatment, there were no inter-group statistically significant differences in levels of ECP, LPO, CD3+,CD4+, CD4+/CD8+ and CD8+, forced vital capacity(FCV), forced expiratory volume 1(FEV1), and peak expiratory flow(PEF)(P>0.05). After treatment, the ECP and LPO levels in the observation group were more significantly reduced than those in the other two groups, showing statistically significant difference(P<0.01); the levels of CD3+, CD4+ and CD4+/CD8+ in the observation group were significantly elevated but CD8+ was significantly reduced, showing statistically significant differences compared with those in the other two groups(P<0.01); and the lung function indexes(FVC, FEV1 and PEF) in the observation group were more significantly elevated than those in the other two groups(P<0.05). Conclusion: Combining spreading moxibustion and point injection could remarkably reduce the contents of ECP and LPO in patients with cough-variant asthma, improve cellular immunity, increase the contents of CD3+, CD4+ and CD4+/CD8+, reduce the content of CD8+ and improve the lung function.