Experts in respiratory health care, business, and education offer a glimpse into current and future trends in respiratory therapy technology.
Gazing intently into their crystal balls, experts say the shape of things to come in respiratory care technology is partly the stuff of science fiction but mostly soon-to-be science fact.
The most advanced technology with which therapists can someday look forward to working is the nano-probe—a computer-controlled, molecular-level robot. This, and scores of others like it, would be inserted into the lungs to fight infection and otherwise repair damage, such as that found in leaky capillaries. At least that is what futurists envision, according to Mike Czervinske, RRT-NPS, director of clinical education in the School of Allied Health’s Respiratory Care Education Department at the University of Kansas Medical Center, Kansas City.
“Nano-probes are possibly decades away from becoming a commonplace tool,” he says.
A related type of nano-probe being talked about is the “pulmonary janitor.” Czervinske describes this as a device to remove debris and foreign objects from the lungs. “Theoretically, nano-probes could even be capable of engaging in one-for-one replacement of oxygen and CO2 molecules,” he says.
Gains in Vent Technology
Less spectacular but no less advantageous will be marked enhancements in the technology of mechanical ventilation, experts foresee.
Terry L. Forrette, MHS, RRT, owner of the consulting firm T.L. Forrette and Associates in Mandeville, La, speculates that the ventilators of tomorrow perhaps will come with just two modes, rather than the plethora they offer today.
“The problem with ventilators right now is that they are overburdening us with more ways to get the good air in and the bad air out than we know what to do with,” he says. “So, I think we’re heading toward ventilators that have a mode for full machine-controlled breathing and a mode for patient-spontaneous breathing—with the ventilator having the capability of automatically self-adjusting between each mode to whatever blend best meets the patient’s needs.”
At the very least, ventilators will likely become as enlightening as they are enlightened, contends Jeff Whitnack, RRT/RPFT, a lead therapist at Sequoia Hospital in Redwood City, Calif. He looks ahead several years to an age in which ventilators come equipped with a CD player and headphones to abet patient education.
“Imagine that you have a Vietnamese-speaking patient who has just been placed on a ventilator at your facility—and no one in your department speaks his language,” Whitnack proposes. “The CD would be there to provide to the patient various calming and informative messages in his own language to help make the experience less confusing and unpleasant.”
Awash in Data
Patient monitoring is another aspect of respiratory care in which experts see big future strides in technology.
“We’re discovering more and more aspects of physiology that can be monitored,” says Bill Farnham, RRT, respiratory care services specialist with the University of Tennessee Medical Center in Knoxville. “The difficulty is that a lot of the output of all that monitoring has to be processed manually. Many current ventilators will give certain information, and lots of modern cardiac monitors will provide certain information. As a further example, there are monitors that will continuously read out cardiac output and mixed venous oxygen saturation. Pulse oximeters read out what is essentially arterial oxygen saturation. Nowadays, to compute more sophisticated pieces of information, such as systemic vascular resistance and oxygen delivery and uptake, we have to take information from four or five pieces of equipment and manually enter numbers into a computer inside the cardiac monitor—and then it will calculate lots of things.
“The future I am looking at is one where we won’t have to take a piece of data from one discrete measuring device, a piece of data from another discrete device, and so on, put those discrete pieces into some calculator, and come up with other numbers or solutions. We will see discrete pieces of data integrated by processors within the ventilator system to give us more sophisticated answers—without our having to manually synthesize them.
“I’m talking about the kind of integration that lets all those monitors talk to each other simultaneously, and eliminating our manual reading and entering of data to achieve sophisticated detail in critical care monitoring. I’m reasonably certain we’re going to see a higher level of integration of physiologic measurements into ventilators in the coming years. Data captured by one machine will be seamlessly conveyed to another without need for manual intervention.”
Gary Hospodar, RRT, MOAM, with Southwest Healthcare Consultants in Placitas, NM, says, “I foresee a totally integrated monitoring system that links all the components into a real-time, interactive, relational database that surrounds patient care decisions; performance improvement, ie, benchmarks, outcomes, and physiologic calculations; and automatic ventilator parameter manipulation, to name a few. I also see most industry monitoring devices becoming totally integrated and interfaceable through joint ventures or acquisitions no matter which manufacturer devices are utilized.
“I also foresee an endotracheal tube in the future that would have the ability to provide 75% to 90% of the patient care data necessary to successfully monitor the patient. This would be performed through wafer-thin chips implanted in the wall of the endotracheal tube that would provide physiologic measurements and data such as tracheal-wall blood gas values, single-breath cardiac output, inspired-expired oxygen and carbon dioxide levels, nitric oxide and nitric dioxide levels, heliox levels, and PVR and SVR measurements, for example.”
As an intermediate step, manufacturers currently are beginning to endow systems with improved calculating ability that allows a therapist to take monitor output data and manually relay them direct to the ventilator, which does the math itself to come up with the numbers for the correct settings. The therapist then presses a key to accept the settings, and the ventilator automatically takes it from there, Farnham notes.
Forrette, meanwhile, predicts success at cost-effectively gathering monitored parameters of greater usefulness. One example is esophageal monometry, in which a catheter is inserted into the esophagus to obtain vastly more precise work-of-breathing measurements on patients being weaned from the ventilator.
“For now, esophageal monometry isn’t the most economical way to obtain those measurements,” says Forrette. “I think that will change before too long. The technology employed in this process will improve, making it a more efficient and affordable option that will add tremendously to our ability to save patient days in high-cost areas of the hospital.”
Other types of monitoring will emerge as new gold standards as well. For Whitnack’s money, these are likely to include electrical impedance monitoring used at bedside to assess the functional residual capacity of ARDS patients. He also anticipates perfusion measurements superseding mere PaCO2 substitution in end-tidal CO2 monitoring. And he is reasonably confident that measurements of exhaled gases—such as 13C-octanoic acid—someday will be routinely monitored for use in assessing the adequacy of gastric emptying.
Farnham, on the other hand, envisions monitoring going more and more wireless. “I believe the time is coming when it will be rare for monitors not to communicate remotely with therapists,” he says. “So, if any of a patient’s parameters rise or fall into a danger zone, the monitor will relay the alarms and accompanying physiologic data via wireless connection to the therapist’s hand-carried computer, no matter where on the floor or in the building that therapist happens to be.”
Wireless technology is nothing new. But the experts promise it will become a lot better than it already is—and soon.
“There is a move away from today’s infrared variety of wireless in favor of more advanced forms of radio-frequency wireless that has minimal vulnerability to interference from electromagnetic fields generated by radiology equipment and other big-energy-using diagnostic or treatment devices,” says Farnham. “While infrared wireless is not at all affected by interference from electromagnetic fields, its drawback is that you have to be within relatively close physical proximity of a receiver to transmit—otherwise, the receiver will not be able to ‘see’ the data transmission signal. With radio-frequency, by contrast, the signal penetrates walls, meaning you can be anywhere on the floor or in the building and still the receiver will pick up the signal. You do not have to walk from here to there to transmit. Radio-frequency lets you be far more mobile, so greatly reducing the interference problem will be a major advance.”
As with ventilators and monitors, the information systems respiratory therapists use in the future also will be far more evolved than they are today, suggests Rajiv Kohli, a health care computer expert now an assistant professor with the University of Notre Dame’s Mendoza College of Business, Department of Management, in Indiana.
“Hospital information systems at present are quite far behind where we need them to be,” he says. “As a result, those providing care are prevented from seeing the big picture and developing care and management strategies that could provide the best, fastest, most cost-effective outcomes.”
Information systems of the future will be not only more powerful but much more fluent in exchanging and managing data collected enterprise-wide. This will make it easier for therapists to access and utilize patient clinical information.
“There needs to be—and there will be—an integration of the systems into which each department’s information is stored in a database,” says Kohli. “Having full, easy access to all of the information—the big picture, in other words—will result in lower infection rates, lower lengths of stay, lower financial impacts, with the patient feeling much better and functioning normally not only at the time of discharge but weeks and months later.”
An information system Kohli had a hand in developing not long ago for one health care enterprise dealt with physician profiling and peer-performance benchmarking. He believes that benchmarking is destined to be a widespread practice in the future.
“Benchmarking helps practitioners get a bird’s-eye view of all their patients and how much it costs to treat each one, then compare those costs to those racked up by their peers generally within the enterprise or regionally or nationally in treating patients with similar sets of conditions,” Kohli says. “This can be very helpful in encouraging practitioners who lag behind their peers to change the way they practice in order to catch up. And, in so doing, they help raise the bar for what is considered an acceptable performance.”
Benchmarking has been geared mainly toward doctors. Eventually, though, Kohli hints, respiratory therapists can expect to be benchmarked too. However, where therapists are concerned, benchmarking will be focused on measuring efficiency of work flow rather than costs of care delivery.
“The idea will be to identify strengths and weaknesses in the work flow so that departmental administrators can redesign it and make it easier for tasks to be accomplished successfully,” he says.
Better information systems even will provide a technologic response to the perpetually irksome issue of reimbursement.
“For future information systems to be effective with regard to reimbursement, it first will be necessary for the enterprise to know the costs involved,” says Kohli. “Once these are known, it’s possible to determine to what extent the amount being paid for each service is economically viable. Enterprise-wide, integrated information systems will allow accurate cost-data to be developed by permitting the automatic capture of labor and materials data at the point of care or delivery.”
A complaint voiced in some quarters is that advances in technology even now are unfolding so rapidly and are proving so far-reaching that therapists are finding it increasingly difficult to stay abreast. Yet, understanding innovation and being fluent in its use will be of critical importance, warns Ken Bandy, RRT, head of the Respiratory Care Department and of all home care services at the University of Michigan, Ann Arbor.
“Given the higher levels of technology that tomorrow’s therapists will encounter, we’ve got to seriously look at whether our traditional programs are providing enough time to adequately train new people and bring them up to a functional level of competence,” he urges. “Here at the University of Michigan, for example, we’ve had to evolve over the years from a 6-week orientation of new graduates into our department areas to a 12-week orientation, followed by a period of mentoring.”
Fellow academic Czervinske holds a similar view. “To retain our position as the experts in respiratory, we’ve got to understand the technology and its real capabilities and limitations better than we currently do,” he says.
Consequently, Czervinske expects the Internet will play a major role in the continuing education of therapists. Online, information concerning new technologies can be made available instantly and disseminated everywhere. Texts and other printed literature, by contrast, can be outdated by the time they are published and distributed.
If fast-paced progress is overwhelming therapists, should manufacturers be encouraged to slow down research-and-development efforts to give practitioners a chance to catch up and get fully acquainted with what is available before more innovation comes along to render passe everything learned to this point?
No, says Bandy. “If there is a need, then by all means technology to meet that need should be developed,” he says. “But as new technology is introduced, we in the profession then have a responsibility to determine in an evidence-based manner whether the therapy made possible by that technology is appropriate, safe, and cost-effective. We need to have sound measurements giving evidence that it is going to impact favorably on short- and long-term outcomes. This evidence is important because adding improved technology drives up equipment costs. That is why I expect that there will be more evidence-based guidelines in the coming years to tell us how procedures, patient populations, and equipment should be matched for best results.”
Owing to technology’s march of progress, respiratory therapists may well find that their practice involves not nearly so much the performance of procedures as it does making assessments and then applying those assessments to overall management strategies, says Czervinske.
“That means there will be a lot more roles that we could potentially fill than there will be therapists to fill them,” he predicts. “Traditionally, the roles outside the acute critical care environment have included home care, sales, and pulmonary function rehab. But in the years ahead, look for therapists to move into things like information systems management and the oversight of drug-company research programs and clinical trials, as well as lending their expertise to the engineering of next-generation aerosol delivery systems for use with nonrespiratory medications—such as insulin—or even gene-therapy products.”
In short, for respiratory therapy, the future never looked brighter.
Rich Smith is a contributing writer for RT.