Research Week 1 Part 4.docx

In this table, you can see that we're looking at protein levels, specifically the protein albumin, and this is the amount of protein that actually extravasated through the capillaries into the alveolar air spaces when these mice were subjected to each of their stressors. In the case of the control a...

In this table, you can see that we're looking at protein levels, specifically the protein albumin, and this is the amount of protein that actually extravasated through the capillaries into the alveolar air spaces when these mice were subjected to each of their stressors. In the case of the control animals, as you can see down at the bottom, these were individuals that were not launched. In the case of the experimental group that's right beneath them, these were individuals that were launched. And then in the case of the sham control group at the very bottom, these were individuals that were placed in the rocket. They were actually suited up just like the experimental animals, but they basically just sat in the payload bay for the duration of what it would have taken for the complete launch to occur. So you can see from this that there was a very dramatic increase as far as the protein is concerned in the lung of those animals that were in the experimental group, or the group that was actually launched. And that's why you can see that it says 13.09 milligrams per gram of wet lung. The number behind that is a standard deviation. Now I call your attention to this for two reasons. Number one, because it substantiates what we talked about earlier regarding the pathology. The pathology really resided primarily with the experimental group. I also call your attention to this because today when we have a research paper and we see information like this where we have the average amount for these animals and the average for example for the control would be 1.53, the average for the experimental group is 13.09, and the average for the sham is 5.73. We can actually go to an app, any of the number of apps that are out there, we can actually keep those apps on our phone, and we can do a quick statistical analysis. We're going to look at those apps in just a moment, but I wanted to show you data first that is actually taken from the research paper that was written after this data was collected. These findings were published in a journal called Physiologist. The article is protein concentration elevations in the lungs of mice following sudden rocket acceleration. These are the members of the team. And so we published our findings in a journal, and therefore we shared with our colleagues, what we had found in case they too were working on some kind of basic science projects similar to ours. Now here I'd like to establish a connection between what happened with that basic science research, and what went on to happen with some clinical research, many years later. It's now right after 9/11. And we're at the Tampa VA Hospital, and more specifically at the Spinal Cord Injury Center and casualties are arriving. And not only are they arriving but they're in need of complex neuro respiratory care. We were able to develop a protocol for wounded veterans. And one of them is shown here with one of our respiratory therapists. This is a patient who had a traumatic brain injury, and he is now placed in Trindellum bird. He is receiving chest optimization, a protocol in the Spinal Cord Injury Center, and this is done specifically to expand the basilar regions of his lungs. Because of the fact that we had studied the basilar regions of mouse lungs, and because we were familiar with the basic research, that basic research informed our clinical decision making process, and prompted us to try Trindellum bird positioning in order to improve lung function. And I'm going to show you research later in later units to show just how this happened, and the fact that we were able to improve lung function to a very significant extent, because we had the theoretical understanding from basic research that had been done years and years before. Well now that you've read Egan's Chapter 2, we're at 1.5, why should RT protocols be based on scientific evidence? And in this unit we're going to discuss the role of evidence-based medicine in respiratory therapy. We'll also focus on how scientific findings help us to inform that practice. It helps us to design and develop and modify clinical protocols that of course are then used in order to provide the highest quality care for our patients. We want to know how protocols translate into improved care. Well there are many concepts that are presented in Chapter 2, but probably one of the most important is the fact that scientific evidence is a key ingredient in attaining the clinical outcomes that we're looking for. Along with scientific evidence, we need to also have an eye toward the clinical practice of the practitioners that make up the medical team, as well as the clinical experience of the medical team. Those elements need to be added. And finally, very importantly, we need to also be conscious of the patient's wishes and the family's wishes. What is it that they would like to see happen? When we put all those elements together, we have a much greater probability of having a protocol that is responsive to the patient's needs and will enable us to achieve the therapeutic outcomes that we're looking for. Every respiratory therapy program has a protocol program of some kind, and this is made possible by strong and committed medical direction, the presence of capable registered respiratory therapists, active quality monitoring, which is synonymous with continuous quality improvement, also a collaborative environment that exists between registered respiratory therapists, physicians, nurses, and really all members of the healthcare team. Collaborative environments are very often environments in which one finds transdisciplinary teams, and we'll have more to say about that in later units. The responsiveness of all these participants together working as a unit to address the patient's concerns and the family's concerns are what drives successful protocol programs. Well, recently, the American Association for Respiratory Care has developed the APEX Award, and this is an award that is given to RT departments that have really reached the pinnacle. They've really done tremendous work in being able to deliver high quality patient care, and to a very significant extent, the reason we see that in these departments is because of the caliber of their registered respiratory therapists. The caliber really depends on the training of these therapists, their education, their experience, and their professionalism. RRTs are a primary source of quality care delivered by these departments. There's no question about that. So, departments who are vying for the APEX Award from the American Association for Respiratory Care know that their chances of achieving that award are significantly higher if they have high caliber registered respiratory therapists. Well, we know that EBM informs protocols. Let's talk a little bit about respiratory therapy protocols. These were first brought to light by Judy Tietzor and George Burton. Sometimes these protocols are referred to as therapist-driven protocols because respiratory therapists very often are in a position to be able to decide which way to go in terms of these protocols. Sometimes they're called evidence-based protocol-guided respiratory care. In many places they're called patient-centered protocols or patient-focused protocols. These evidence-based protocols deliver appropriate and timely respiratory therapy services. RRTs are able to deliver care when it's appropriate to deliver that care and to discontinue the care when it is no longer required. That latter portion, that latter part is key because there was a time when patients would continue to get therapy no matter what, ad infinitum, without any end in sight until they left the hospital. And so we can't really afford to do that anymore and we'll see later that insurance companies no longer pay for that. So we are in a position where we have to know what we're doing and we have to know where to stop. Evidence-based protocols help improve patient care in many, many ways and I've listed some of those here. One is the decrease in mortality. The decrease in morbidity is also important. A decrease in the length of stay at the hospital or the length of stay in a specific ICU. The decrease in ventilator days for those individuals that are mechanically ventilated. A decrease in ventilator-associated pneumonia or tube-associated pneumonia. And finally, an increase in health-related quality of life, which is becoming a metric that we see more and more in being able to measure high-quality patient care. Now we've talked a lot about evidence-based medicine and its ability to inform protocols. Let's start to parcel out exactly what we're talking about. And I'd like to begin our examination of this by highlighting case studies, a case series, and randomized controlled trials. These are not the only types of studies that we might see in the scientific literature, but they are scientific studies that occur quite often in the scientific literature. So we should be familiar with them. First is case studies. Case study is a simple, not really a very rigorous type of study. There is no control group. There is no experimental group as such. And sometimes we refer to these as N of 1 studies. They are pertaining to one solitary case. When we have a number of cases together, then we refer to this as a case series. And here we have a collection of patients with similar clinical features. But again, there's no control group, there's no experimental group either. By far, the gold standard for studies is a randomized controlled trial, sometimes known as the RCT. This is the most rigorous evidence. It's what typically drives protocol production. And the reason that we refer to this as the gold standard is because there is a control group. There is an experimental group. And we compare the experimental group against the control group. So by using evidence-based techniques like the ones enunciated in chapter 2, new treatments, new medications, diagnostics, monitoring tools, all of these can be implemented to improve patient care outcomes and to do so systematically. Here we have one type of protocol. You've probably seen this or used this in a clinical environment. And it's basically a flow diagram. You get to a certain decision point and it branches and then you get to another decision point and it branches again. And what it does is it helps you to standardize your care. Here's another type of protocol. There are many, many types of protocols. This is a step-by-step protocol that guides you through. It is also a data collection sheet. So even though you're receiving guidance, it gives you a place to actually place data that you're collecting from the patient. We're actually going to work with a protocol that looks like this. This happens to be a hard copy, but of course protocols can exist electronically, digital formats. It's not at all usual to see people with iPads and obviously workstations on wheels with their protocols opened up and them following the protocol in order to be able to determine some facet of patient care. Well, now that you've read chapter 8, let's broaden our understanding of the fundamentals of respiratory therapy research methods. Chatburn maintains that there are three main missions in the field of medicine and we're going to refer to each of those in just a moment. We want to discuss the important role that ethics play in clinical research. And we want to also explain three methods that are used by scientists to communicate their findings to the rest of their scientific community. All right. So in this chapter, Chatburn maintains that all RRTs have a responsibility and their responsibility, among other things, is to evaluate their clinical practice in light of emerging scientific evidence. This is just another way of saying what we have been saying for the last couple of units, and that is that scientific evidence informs clinical practice. Only those practices that are based on the best available scientific evidence should be practiced. Now that's a theoretical statement. We would like for it to be that way. It is in fact not that way. And I think you realize that already. Much of what you read in your textbook is not based on the best available scientific evidence. And that's not because we don't want it to be. It's simply because not everything has been researched as thoroughly as we would like for it to be. And it's not just in respiratory therapy. It's in really all of the healthcare professions. And you can even broaden that out more and say that's the case in all of science. There are areas that we know very, very well as a result of our research. And there are lots and lots of other areas that have numerous questions yet to be answered. Even after doing research, we probably won't have all the answers. As a matter of fact, I'm pretty sure we won't have all the answers. But hopefully we will have a little bit more confidence in the things that we know. And remember, science is always evolving. So the things that we think we know today are subject to modification tomorrow. Paths toward becoming a respiratory therapy researcher. Well, there are of course many, many paths that can be taken toward becoming a researcher. But the primary thing is to really identify your professional motivation. What is it that drives you? What is it that you're really interested in? What's your passion? Are you curious about specific things that happen in respiratory therapy? I hope that you are. And the more experience you have clinically, I think the more curious you will become about a lot of different things. Not just interventions, but different types of concepts that may be circulating in your department. Maybe new ideas that are being generated by your reading. The science articles that are in respiratory care and other professional journals. You should think about working with a mentor or with mentors. These can be people that work in the ICU or the cath lab, in the emergency room, out on the general practice floor care areas. These are areas that have individuals that are experienced in many cases in doing research. And if you can establish a professional relationship with those individuals, this can help you tremendously because they can show you the way, so to speak. Reading RT scientific articles and other scientific articles, not just respiratory therapy articles, is an important dimension because it gives you the background necessary to really carefully define some of the questions that you may be developing. Develop ideas. Think about ideas for clinical study. How would you possibly write a study protocol? It certainly doesn't mean that you have to undertake that clinical study. All you are really doing is just thinking about how you would do that. This is really step one. Just conceptualizing how to do a clinical study, how to perform a study, is really, really crucial. Before you can actually do that, you have to conceive it. Sometimes this takes a little bit of time and it can take some months, it can take a year. So you have to kind of be patient with yourself. What about developing a database? Maybe you have something that interests you at work and you can keep some records that are de-identified records and see if you can't see some kind of pattern that emerges that maybe nobody has seen before. Possibly use statistical models to evaluate the data to see if there is anything that you can infer from that information. And very importantly, if you find something that you think is of note, something that is of importance, you may want to think about submitting an abstract to the AARC Congress, for example, or even constructing a scientific poster that you could present at the AARC conference. A scientific paper would of course be very desirable, but this is something that you might not want to think about right away, but perhaps do later on after you have perhaps a little bit more experience. So since we're talking about these things, let's talk about some of the major parts of a scientific abstract or a poster or a paper. It's pretty much the same for each of these. There's an introduction, there's a methods section. Sometimes they refer to this as a methods and materials section. There's a results section, a discussion section, and a conclusions section. Now some papers don't necessarily have a discussion section, but as a general rule you're going to find at least four out of five of these present, regardless as to whether you're talking about an abstract, a poster, or a paper. In an introduction you're providing a background explaining why this study was conducted. Why is this important for you to read? It also includes a research problem or a hypothesis. Your hypothesis is a possible explanation as to why you came up with the scientific evidence that you did. A methods section explains exactly what was done in the study. As a matter of fact, this should be so detailed that another team of researchers should be able to come to your paper, and they should be able to follow your paper, and they should be able to reproduce your study in its entirety. Theoretically, that is what is desired. That is what we would like to see. Does it happen all the time each time? No, not necessarily, but again, science is a work in progress. We're working on making that better, and it will be better in the future. But unless we talk about it, you might not necessarily know that this is an area that needs attention. The results, well, this is where of course the data are gathered from the experiment. This is where they are presented. The discussion is really an explanation of what you and your team believe the results mean. Now, could this change if another team had access to those results? Could they come up with a different explanation? They might, and in some cases they do, and that's okay. That too is part of science. Conclusions. Well, conclusions are the take home message. What do the findings mean for everyday patient care? You might want to include some reasons for rejecting alternative or alternate interpretations. So, whether you're talking about an abstract, a poster or a paper, there should be an introduction, a method section, result section, discussion, and conclusion, and they should follow this order. Here's a different type of poster. This is not a hard copy. This is actually an electronic scientific poster, and what you see here looks like a TV screen, and that's because it's a TV screen. And this poster is on this screen. This is a poster that was worked on several years ago by one of our respiratory therapy students, a very capable young man, class of 2016. He's now a clinical instructor at that hospital in Tampa. At that time, he and his team presented that at the first annual HCC Research Symposium. And in case you didn't know this, the HCC Research Symposium is an annual event, and it's open to any student who's done any type of research that is worthy of being published. So this is an important opportunity for those of you who are interested in research to follow through and produce a product that can be presented at this research. That is something that you can report in your curriculum data or in your resume, and it's very impressive to an employer. Here's one example of a scientific poster. This is a poster that was presented by the Department of Respiratory Therapy a few years ago, and we'll have occasion to look at this again later on. But this is an example of what we call a hard copy. This is basically a large sheet of paper. This is about six feet in length, so this is a fairly large production. And we'll also see how this is actually produced in another unit. Well, since we're talking about a lot of different things regarding the fundamentals of RT research, let's talk for just a moment about funding. There are opportunities for funding from various sources. The two that a registered respiratory therapist might want to look at first are the American Respiratory Care Foundation. The ARCF has traditionally provided research awards and grants for registered respiratory therapists, and they also offer fellowships for individuals who want to go on to advanced degrees in undergraduate training programs as well as graduate training programs. So something to keep in mind going forward as you develop your careers. And here are some researchers that are actually from the Tampa Bay area. And what these folks have in common is that they began their clinical careers in Florida, just like you're doing. The first of these is Dr. Granger, Dr. Wesley Granger, who is an RT professor at the University of Alabama. He actually started at Advent Hospital, Maine in Tampa back when it was University Community Hospital years ago. Also, Dave Chelladey, Dr. Chelladey is the dean of the College of Health at the University of Texas. And before that, many, many years before that, he actually was the founder of St. Petersburg College's RT program back when it was St. Petersburg Junior College. Next is a gentleman that I've worked with off and on throughout the years, James Fink. Dr. Fink is now the chief science officer for Aerogen Pharma, but he was once a student at St. Petersburg Junior College. And Dr. Fink has gone on to publish many, many important articles in the area of aerosolization and bronchodilation. And finally, but certainly not last, because there are many, many other individuals, is just a very, very small listing of what is a rather substantial group of people that precede you, is Mary Martinesek. Dr. Martinesek is currently a professor at the University of Tampa at the College of Health and Performance, but before that, she was our Gina Ricard years ago. She was the DCE before Gina arrived here in the HCC RT program. And she has gone on, Dr. Martinesek has gone on to be an expert on a lot of different things, most notably the mechanisms and the epidemiology of vaping. So she's actually going to be presenting an overview on her area of expertise at the AARC conference. All right, class, well, you have completed module one, and here we are at the end of module one. And what we'd like to do now is to give you an opportunity to use a lot of the information that you have learned in these modules. And again, I know that we just basically scratched the surface, but we want to give you an opportunity to use that knowledge and to apply that knowledge. And I think by now you realize that what we want to really try to do during this next period of training and research is to be able to get you to the point where you're comfortable reading a scientific paper, something that you find in a journal with the intention of improving your respiratory care practice. It may be that there's a clinical problem that has come up, and so you're trying to research this problem to see what is known about the problem. You want to find out what the best available evidence may be regarding that problem so that you can help your patient. So what we'd like to do now is to apply research in order to improve patient care. And to do that, we're going to use an article that talks about the influence of placing a nebulizer, a specific type of nebulizer, at a specific position in the patient's circuit, and trying to determine whether that has an impact on aerosol drug delivery. I'm sure you've had instances in the past where you have been in ICU and you have a patient who's on a mechanical ventilator, and the orders call for giving that individual a bronchodilator via the mechanical circuit. And so there are a lot of different ways to do that, as you know. And the more recent literature is starting to show some very specific trends. So we want to look at one of those articles that deal with one of those trends over the next three weeks. So here are the objectives for the next three weeks, and this one paper that we're going to take a deep dive into. We want to be able to discuss the role that research articles play in improving patient care. We want to explain how understanding the rationale of a published study actually impacts its use in patient care. It's not just about the findings. We want to know why the authors decided to publish that paper. What was it that they felt was so important that it prompted all the work required to do the research and then to publish that study? I want to also explain how understanding the experimental design of a published study impacts its use in patient care. Again, you'll be using knowledge that you have gleaned from Module 1 and doing all of this. And finally, we'll discuss how understanding the data analysis and the statistics of a published study impacts its use in patient care. So the objectives that we have here are the objectives not just for today, but in fact are the objectives for the next three weeks. At the end of every module, Module 1, Module 2, and Module 3, you will be asked some specific questions about this one article. So a little bit more about our three-week long project. This article is an article by Arie et al., meaning Arie and her research team. The title of this article is "Influence of Nebulizer Type, Position, and Bias Flow on Aerosol Drug Delivery in Simulated Pediatric and Adult Long Models During Mechanical Ventilation." What we want to also do is to tell you that you have a copy of this article. It's the item immediately preceding this particular unit. So if you'd like to make a hard copy of that, please feel free to do that. Or you can study it via an electronic format if you'd like. What we'd like you to do now is to imagine yourself being a registered respiratory therapist. You've already graduated, and the year is 2025. You work in an MICU as the respiratory therapy team leader on day shift. When giving bronchodilator treatments to your mechanically ventilated patients in that ICU, some of your colleagues, some of your RT colleagues tend to place the small volume nebulizer near the patient's Y connector. Others actually place a vibrating mesh nebulizer on the outflow side of the heater's reservoir. One day a pulmonologist who does rounds in the MICU just about every day with you and the rest of the team, comes up to you and says, "You know, I've noticed that the type of nebulizer that you guys use with my patients and the position where you put it in the circuit seems to depend on who's on duty that day. What respiratory therapist? It seems like it's their call. Don't you guys have a protocol or something that you go with that perhaps dictates what it is that you should do and when you should do it?" That's a question that the pulmonologist is asking you. So it turns out that for some time you've actually been wondering if the type of nebulizer and the site, the specific site on that mechanical circuit where it is placed, if that makes any difference in the therapeutic outcomes. You've actually been thinking about that yourself even before the pulmonologist said anything. Fortunately, you are a registered respiratory therapist and here in 2025 you are a member of the ARC and you always look over Respiratory Care, the journal, every month that it comes out and you at least scan through the journal for interesting articles to look at. One day you're looking through the journal and you find, you're looking through the archives of the journal and you find this article by Ari and her research team from 2010. And you think that this article might be very helpful in helping you to address the question or answer the question that the pulmonologist has posed to you. Now, we'd like for you to read this article, familiarize yourself with this article. You can, as I said, make a hard copy if you want to, write notes around it, put questions around it if you would like or answers. You can write a research question if you want on here. But what we'd like you to do during this first week of the three weeks that you'll be analyzing this article is we would like for you to address three questions. First of all, we'd like you to explain whether the authors of this article did clinical research or did they do basic research. Number two, what does peer reviewed mean? And you may have to do a little research on that. What does peer reviewed mean and why would publishing in a peer reviewed journal be of interest to a clinical researcher like you or practicing respiratory therapists like you? Does peer reviewed mean anything that is of importance? That's the question. Question number three is to explain whether these researchers, Arie and her team, whether they have compared an experimental group to a control group. And how many participants are there in each of those two groups, an experimental group and a control group? Please go to the discussion section in Canvas for this course. Beginning with number one, write your answers using, of course, a coherent, orderly style with proper grammar. Please remember to return later after you've written your answers or posted your answers. And please make helpful observations vis-a-vis another classmate. We want you to make observations or suggestions that can help those classmates that you have in your class learn more about how to apply research to patient care.