Dr. Brian J Ring

Background: Individuals with asthma are disproportionately affected by depression relative to those without asthma. However, this relationship in those ≥65 years of age with asthma remains unclear. This study aims to determine the association between asthma and depression in individuals aged ≥65 receiving Medicare support. Methods: A pooled cross-sectional analysis of Medicare Current Beneficiary Survey data examined the association between asthma and depression from 2018 to 2020. Depression was defined as a score of ≥10 from the Patient Health Questionnaire-9. Disease-related variables were recorded if the subject met Medicare claims criteria for the calendar year regardless of sufficient fee-for-service coverage. Adjusted regression models were developed to determine the association between prevalent asthma, comorbidities, gender, area deprivation index, and depression. Results: Among 31,064 individuals available for analysis, the weighted prevalence of depression in subjects with asthma was 38.6%. The adjusted regression model indicated that asthma was not independently associated with depression in this population (odds ratio (OR) = 1.18, 95% confidence interval (CI) [0.96–1.45]). Subjects with asthma and anxiety (OR = 1.11, 95% CI [1.06–1.16]), cardiovascular disease (OR = 1.24, 95% confidence interval (CI) [1.15–1.32]), or diabetes (OR = 1.30, 95% CI [1.24–1.36]) were more likely to report concomitant depression. Women ≥65 years of age with asthma had greater odds of reporting depression compared to men with asthma (OR = 1.09, 95% CI [1.06–1.12]). Conclusions: Based on our findings, in older adults in the United States, asthma is not independently associated with greater odds of depression when compared to those without asthma.

Hypothermia, defined as a core body temperature <= 35 degrees C, significantly increases morbidity and mortality in mechanically ventilated patients across numerous care settings. Physiologically, the upper airway conditions inspired gases to body temperature and humidity, minimizing heat energy loss and preventing mucosal damage. Instrumentation, such as endotracheal intubation, bypasses this natural mechanism, leading to considerable heat and moisture loss, potentially exacerbating hypothermia risks in critically ill patients. Active humidifiers and heat and moisture exchangers represent common strategies to mitigate airway heat loss, yet their effectiveness as a method to assist in whole-body rewarming is controversial. Emerging technologies indicate renewed interest in airway-based warming devices, especially for prehospital and military trauma scenarios, but robust clinical validation remains necessary. This narrative review evaluates the feasibility and effectiveness of airway-based thermoregulation through inhalation of heated, humidified gases.

Mechanical ventilation is essential for supporting critically ill patients but increases the risk of bacterial colonization resulting from instrumental, biological, and practice-related factors. Ventilator-associated pneumonia (VAP), a common complication, is linked to prolonged mechanical ventilation and poor outcomes. Although decades of research have emphasized prevention through care bundles and best practices, VAP remains a significant concern. This review highlights current evidence and emerging strategies for VAP prevention and management in 2024, with practical relevance for respiratory therapists caring for mechanically ventilated adult patients.

Recent studies show e-cigarette (EC) users have increased rates of chronic bronchitic symptoms that may be associated with depressed mucociliary clearance (MCC). Little is known about the acute or chronic effects of EC inhalation on in vivo MCC.

MCC was measured in young adult vapers (n = 5 males, mean age = 21) after controlled inhalation of a radiolabeled (Tc99m sulfur colloid) aerosol. Whole-lung clearance of radiolabeled deposited particles was measured over a 90-minute period for baseline MCC and associated with controlled periodic vaping over the first 60 minutes of MCC measurements. The vaping challenge was administered from a fourth generation box mod EC containing unflavored e-liquid (65% propylene glycol/35% vegetable glycerin, 3 mg/mL freebase nicotine). The challenge was administered at the start of each 10-minute interval of MCC measurements and consisted of 1 puff every 30 seconds for 5 minutes (i.e., 10 puffs for each 10-minute period for a total of 60 puffs during the initial 60 minutes of MCC measurements).

Compared with baseline, peripheral lung average clearance (%) over the 90 minutes of MCC measures was enhanced, associated with EC challenge, 12 (±6) versus 24 (±6), respectively (p  < 0.05 by Wilcoxon signed-rank test).

Acute enhancement of in vivo MCC during EC challenge is contrary to recent studies showing nicotine-associated slowing of ciliary beat and mucus transport at higher nicotine levels than those used here. However, our findings are consistent with an acute increase in fluid volume and mucin secretion to the bronchial airway surface that is likely short lived.

Excerpt - Determining the relationships between risk factors and an outcome suggests the desire for understanding causality regardless of analysis intention. The COVID-19 pandemic inspired a wave of investigations that generated interesting and useful regression models for risk factors associated with various patient outcomes. That said, issues associated with variable transparency, poor model design, and misinterpretation of effect measures have seemingly become prevalent with the rush to generate relevant content during the COVID-19 pandemic. Thus, we enter the conundrum of the infamous Table 2 fallacy.

Excerpt - Respiratory therapy practice brings sophisticated technology to the bedside to monitor and treat patients with acute and chronic respiratory diseases. Consequently, applying this technology results in a dizzying array of disposables. Face masks, ventilator circuits, suction catheters, nebulizers,
humidification chambers, and adapters of all shapes and sizes are single-use items disposed of as medical waste. The move from reusable devices to disposable devices in respiratory therapy is typically justified by concerns related to ethics, infection control, costs of cleaning (personnel and equipment), and simplicity. However, in many cases, the infection risk of reusables is overestimated.

Background: During neonatal and paediatric high-flow nasal cannula therapy, optimising the flow setting is crucial for favourable physiological and clinical outcomes. However, considerable variability exists in clinical practice regarding initial flows and subsequent adjustments for these patients. Our review aimed to summarise the impact of various flows during high-flow nasal cannula treatment in neonates and children.

Methods: Two investigators independently searched PubMed, Embase, Web of Science, Scopus and Cochrane for in vitro and in vivo studies published in English before 30 April 2023. Studies enrolling adults (≥18 years) or those using a single flow setting were excluded. Data extraction and risk of bias assessments were performed independently by two investigators. The study protocol was prospectively registered with PROSPERO (CRD42022345419).

Results: 38 406 studies were identified, with 44 included. In vitro studies explored flow settings’ effects on airway pressures, humidity and carbon dioxide clearance; all were flow-dependent. Observational clinical studies consistently reported that higher flows led to increased pharyngeal pressure and potentially increased intrathoracic airway pressure (especially among neonates), improved oxygenation, and reduced respiratory rate and work of breathing up to a certain threshold. Three randomised controlled trials found no significant differences in treatment failure among different flow settings. Flow impacts exhibited significant heterogeneity among different patients.

Conclusion: Individualising flow settings in neonates and young children requires consideration of the patient's peak inspiratory flow, respiratory rate, heart rate, tolerance, work of breathing and lung aeration for optimal care.