The Science Journal of the American Association for Respiratory Care

Editorials

March 2002 / Volume 47 / Number 3 / Page 238

The RESPIRATORY CARE Journal Conferences:
20 Years of Excellence and Innovation

Appearing in this and next month’s issues of RESPIRATORY CARE are the proceedings of a state-of-the-art conference on invasive mechanical ventilation in adults, convened last fall on the Journal’s behalf by the American Respiratory Care Foundation (ARCF). Publication of this 29th set of conference-based special issues marks the beginning of a third decade of a unique and most successful undertaking. In this editorial I review the genesis and purpose of the RESPIRATORY CARE Journal conferences, describe the scope of their contents and the diversity of the participants they have brought together, and touch on some of the highlights of the series as they have appeared in these pages.

Evolution of the State-of-the-Art Conference Format

Most of the Journal conferences held between the fall of 1981 and the spring of 2001 were “state-of-the-art” conferences, like the one whose proceedings begin in this issue. The 23 previous conferences generated 42 special issues (Table 1), with 322 individual papers and 22 conference summaries—4,053 pages in all, including introductions and discussions—and comprise a substantial and most ambitious collective document.1-23 With only a few exceptions, these state-of-the-art conferences have all followed the same format in planning, presentation, and publication. A carefully selected multidisciplinary group of 12 to 16 speaker-authors, along with the Journal’s editors and staff, convene at some pleasant location for 2 days of formal presentations on the salient aspects of the topic under consideration. The discussions following each presentation are recorded. There is no audience, and for most conferences only about 20 individuals are involved. On the morning of the third day a designated summarizer presents a distillation and interpretation of the material covered at the conference, and the group is adjourned. Each speaker provides a manuscript on his or her assigned topic, the summarizer elaborates in writing on what was presented on the final morning, and all the discussions are transcribed and edited. Together they are published as 2 consecutive issues of RESPIRATORY CARE.

Table 1. RESPIRATORY CARE Journal’s State-of-the-Art Conferences: Topics and Publication Dates During the First 20 Years
Conference Number Topic Publication Date Reference
1 Complications of Respiratory Therapy April 1982 1
2 The Management of Acute Respiratory Failure May 1983 2
3 Perioperative Respiratory Care May and June 1984 3
4 Monitoring of Critically Ill Patients June and July 1985 4
5 Neonatal Respiratory Care June and July 1986 5
6 Mechanical Ventilation June and July 1987 6
7 Positive End-Expiratory Pressure June and July 1988 7
8 Pulmonary Function Testing June and July 1989 8
9 Noninvasive Monitoring in Respiratory Care June and July 1990 9
10 Respiratory Care of Infants and Children June and July 1991 10
11 Emergency Respiratory Care June and July 1992 11
12 Oxygenation in the Critically Ill Patient June and July 1993 12
13 Controversies in Home Respiratory Care April and May 1994 13
14 Resuscitation in Acute Care Hospitals April and May 1995 14
15 Mechanical Ventilation: Ventilatory Techniques, Pharmacology, —and Patient Management Strategies April and May 1996 15
16 Emerging Health Care Delivery Models and Respiratory Care January 1997 16
17 Sleep-Disordered Breathing April and May 1998 17
18 Inhaled Nitric Oxide February and March 1999 18
19 Artificial Airways June and July 1999 19
20 Long-Term Oxygen Therapy January and February 2000 20
21 Palliative Respiratory Care November and December 2000 21
22 Tracheal Gas Insufflation February 2001 22
23 Evidence-Based Medicine in Respiratory Care November and December 2001 23

This formula has proven both successful and durable. It was derived by the Editorial Board after an initial exploratory symposium with a somewhat different format, tested in its present form at a second conference, and then fine-tuned with some minor changes the following year. Little has changed in the 17 years since that time with respect to how the conferences are conceived, planned, and held, or how the published documents are generated.

In 1981, concerned by a prevailing atmosphere of unquestioning enthusiasm for the new in respiratory therapy, often without overt concern for adverse effects, the Editorial Board decided to put on a one-day symposium devoted just to complications. Jointly sponsored with the American College of Chest Physicians, this symposium was held in San Francisco in conjunction with the College’s annual fall meeting. Its topics were selected for their practical importance to clinicians, and the 8 speakers were asked to prepare state-of-the art review articles on their topics for publication in RESPIRATORY CARE. I chaired the conference and served as guest editor for the subsequent special issue of the Journal.1 The enthusiastic reception of this issue convinced the Editorial Board that it should try the process again, but we decided to make it less formal and more interactive. Rather than holding another symposium (a series of lectures presented by experts before an audience) the Journal decided to change to the format of a conference: that is, presentations by experts to a small group of other experts, with interactive discussion involving everyone present.24

Publication of the proceedings of the Sugarloaf Conference on respiratory therapy in 197425 had had an enormous impact on the field. That conference, convened by the National Institutes of Health, took a hard look at the respiratory therapy modalities used in treating ambulatory patients. It concluded that there was little evidence to support the then-widespread use of intermittent positive-pressure breathing treatments and several other mainstays of the profession. A second conference examining respiratory therapy in hospitalized patients came to similar conclusions.26 In the light of those generally disappointing reports about the state of the science in its field at that time, the Journal’s Editorial Board decided to hold its ownSugarloaf-type conference, this one focusing on modalities used in the intensive care unit, to round out the profession’s sites of practice and—it hoped—to come to a somewhat more positive verdict. This third conference turned out to have a different format from the 2 “Sugarloaf” conferences, and was somewhat upbeat if not frankly positive.

That second RESPIRATORY CARE Journal conference, chaired by Editorial Board chairman Ronald B George, was held in Cancún, Mexico, in November 1982. Its subject was the management of acute respiratory failure. Two-and-one-half days in length, it was attended only by the 12 speakers, 2 additional invited discussants, and the Journal’s editorial staff. The participants were 8 pulmonary physicians, 3 anesthesiologists, and 3 respiratory therapists. There was a 15-minute discussion after each formal presentation, which was tape-recorded, and at the end of the conference a summarizer invited specifically for the purpose reviewed the main points that had been made. At 147 pages, the proceedings, published in May 1983,2 made up the largest issue the Journal had published to date. This special issue was a great success, a number of its articles having since been cited repeatedly by clinical investigators and the authors of reviews and textbooks.

Buoyed by its success, the Editorial Board quickly moved ahead with plans for a third conference. Held this time in Vail, Colorado, it focused on perioperative respiratory care. Its format was the same as in Cancún. Because of the amount of material generated—131 pages of articles and another 43 of sometimes spirited discussion—the proceedings were published in 2 issues,3 and a group photograph of the 16 speaker-authors was included. The only feature of the present state-of-the-art conference format to be added after that third conference was to have two co-chairs, starting the following year.

Conference Themes and Presentation Topics

The state-of-the-art conferences tackle subjects that are important to clinicians working in the field of respiratory care, about which relevant published information available to them is judged to be lacking, incomplete, or unacceptably biased. Potential conference themes are suggested by members of the Journal’s Editorial Board or by members of the Board of Trustees of the ARCF, and are selected by the editors based on their current topicality and practical importance.

Each speaker is charged with a number of specific tasks.27 The assigned topic should first be carefully defined or the issue clarified. Many topics are chosen for their unsettled or controversial nature, and in such instances the speakers are instructed to make clear what the real bone of contention is and how any opposing contingents view the issue. The speaker is then to summarize the topic’s current state of the art, emphasizing not only its theoretical underpinnings and the claims made by its proponents but also the quality of its clinical evidence base. Once that evidence base has been summarized, the speaker is to interpret it from a clinical perspective, say how it jibes with his or her own personal experience, and predict what is likely to happen as more evidence and experience accumulate. The written version of each speaker’s talk is expected to contain the same material and to be from the same perspective as presented at the conference. More data and discussion can be included, but the approach, attitude, and conclusions are to be the same.

Speakers and Authors

Respiratory care is both a profession and a subject area within health care.28,29 Its multidisciplinary nature is one of its strengths. The Editorial Board’s mix of respiratory therapists, physicians, and others reflects this diversity, and over the years so has the list of participants in its conferences. Speaker-authors are invited either because they possess recognized expertise on the specific topic or have a reputation for critical thinking and the ability to both speak and write well. Conscious attempts are made to achieve diversity in the participants’ credentials, jobs, genders, and geographical locations. Because the overall atmosphere of the conferences is so important and interactions during the discussion sessions so central to their success, we try to avoid people whose views are extreme, who have chips on their shoulders, or are not good team players. During the first 20 years, 198 (63%) of the state-of-the-art conference presentations were given by physicians, 99 (32%) by respiratory therapists, 7 by PhD physiologists or bioengineers, 5 by nurses, and 1 each by a social worker, a law professor, and a speech-language pathologist. Most of these faculty members have come from the United States, but there have also been speakers from Canada, France, Germany, Poland, Spain, Sweden, and the United Kingdom.

On 4 occasions during the first 20 years, a sudden illness or other emergency has prevented a speaker from attending. In all but one of those instances, the absent speaker’s paper has been read at the conference in its proper sequence and followed by discussion, and in all cases the published proceedings have included the paper as planned. There have been 2 occasions on which a presenter at the conference did not subsequently come through with an acceptable manuscript, but publication of 322 out of 324 intended papers in 42 special issues is really quite an accomplishment.

With only one exception (for a conference on an area of expertise not represented in its membership at that time),5 at least one of the co-chairs has always been a member of the Editorial Board and a previous conference participant. We consider the conference format to be vital and try to assure that there is a critical mass of experienced participants at each one so that the intended structure, flow, and chemistry of the proceedings can be maintained. This has in fact turned out to be the case for every conference to date.

Sponsorship and Support

The ARCF Board of Trustees has consistently and enthusiastically supported the conferences, and has taken on the considerable task of raising the money to put on and publish most of them. Respiratory care is a field heavily involved with devices, apparatus, and pharmaceutical agents, and by its nature has a special and necessary relationship with industry.30 Without the continuing support of its numerous corporate sponsors the ARCF would not be able to continue to underwrite the Journal’s conferences and special issues. A number of manufacturers have been both generous and consistent in their financial support of the Journal conferences. For all but one of the conferences for which contributions to the ARCF have been solicited, several companies have participated jointly. In every case the conference topic has been decided upon and all speakers selected prior to approaching any potential sponsors.

None of the RESPIRATORY CARE Journal conferences, and none of the special issues derived from them, would have been possible without the inspiration, dedication, and steadfast support of Ray Masferrer, AARC Associate Executive Director and Managing Editor of the Journal throughout the lifetime of the series. Both he and Executive Director Sam Giordano have been present at every conference and have gone to considerable lengths to ensure its success. They have enabled the Editorial Board to convene the conferences it felt were important to the Journal’s readers and to the respiratory care profession, regardless of their potential appeal to sponsors, and have seen to it that the participants could concentrate on the subject at hand without distraction by other concerns.

The Discussions: Where the Action Is

The speakers and discussants at the Journal’s conferences sit around a U-shaped table with a projection screen and podium at its open end. Each presentation is limited to 30 minutes duration. Speakers always used slides until the last several years, and now nearly everyone presents directly from a laptop computer. Fifteen minutes after each talk is budgeted for discussion, although when the topic is important, the presentation is provocative, and the chemistry in the room is right, these periods can be twice that long. All comments are recorded, although in the heat of interaction it can become a challenge to capture everything with the microphones and identify all the speakers. It became obvious the very first time we built discussions into a conference agenda that these were of major importance to the project as a whole. It quickly became an expectation that every conference participant be present throughout all the sessions in order to be involved in the discussion sessions.

In his foreword to the proceedings of the Journal’s third conference, then editor Philip Kittredge wrote the following about the role and unique value of these discussions:24

Although much of the “scientific” literature is constrained by fairly rigid rules about elaboration of data, replication of results, and statistical analysis, it remains true that the young science of medicine largely lacks unifying theories and scientific agreement. Too many parts of the puzzle have not yet been found. Therefore, particularly in the context of the applied science to which this journal is devoted for the most part, so-called anecdotal information remains important. What Dr X’s group has noticed, even though it remains unexplained, may be useful for Dr Y’s group to know about. At the very least the anecdotal observation may point the way to a promising direction in which a guess can lead to scientific observation. When we have to play hunches, the more informed those hunches are, the better. What the conferees at Cancún and at Vail said to each other, and now tell our readers, includes a fair amount of personal experience and speculation, untried by rigid scientific experiment. It is interesting, and some of it may turn out to be most useful.24

The Journal publishes these discussions verbatim, except for some occasional grammatical cleanup and insertion of references to cited studies, immediately following each paper and clearly designated for what they are: questions, comments, and opinions, but not necessarily science. The constraints of objectivity and the scientific method limit what authors can say in their papers, but these constraints seem to apply less during the discussion periods. Consequently, the conferees are sometimes quite uninhibited in expressing their views or disagreeing with each other. Sometimes the interchanges are fairly spicy, and they can be entertaining. More importantly, they frequently reveal to the reader how the expert clinicians sitting around the table personally view the material being presented, and how they actually manage their own patients. Someone will pin a speaker down about the data supporting something just presented, or call for a show of hands indicating how many of the participants actually use the technique or approach they are discussing.

Here is an example from the conference on perioperative respiratory care:3

[Dr X]: Dr Y, you made the statement, “if you treat the atelectasis the effusion goes away.” I wonder if you would like to tell us what evidence you have? Does clearing of atelectasis facilitate drainage of effusion, or does draining of effusion facilitate expansion of atelectasis?

[Dr Y]: I do not have any direct evidence for that.

[Dr X]: You also indicated that one mechanism for the pleural effusion is that the diaphragm is contused. I wonder if you’d tell us what evidence you have for that?

[Dr Y]: I also do not have any direct evidence for that. When we discovered all the pleural effusions postoperatively, we had to come up with some explanation for them.

[Dr X]: I don’t think you needed to.

[Dr Y]: What is your explanation for the pleural effusion that occurs in the immediate postoperative period?

[Dr X]: I don’t have an explanation, but that’s often a good place to leave an unexplained phenomenon. There are some intriguing and important phenomena in the diaphragm-pleural interactions that we don’t understand, and if we now label them, we may discourage others from exploring questions.3,p.547

These comments by 2 participants during a discussion of postoperative acute respiratory distress syndrome, also at the 1983 conference, illustrate the spirit of skepticism that tends to prevail during these discussions, and also have a familiar ring to us 18 years later:

I liked your comments about the rotating bed. We’ve seen these beds clone themselves all through our hospital, too, and we haven’t been able to find any data supporting their use. I’m wondering if anybody else assembled here has even the clinical impression that they do any good, specifically for the kinds of patients that have diffuse lung disease. Maybe what we need is to change the gears, so that they go all the way over to the prone position instead of stopping at 60 degrees. 3,p.483

Although we seldom get them, for technical reasons, lateral chest x-rays can be very revealing in ARDS. What we generally assume to be diffuse, homogeneous lung disease can often be shown on the lateral to be concentrated mainly posteriorly, that is, at the lung bases, since patients are usually managed supine or in a slightly head-up position. It would make a lot of sense that reversing their position to prone would improve gas exchange by sending the blood flow to relatively less-involved areas—at least until the edema fluid managed to percolate down again and restore the previous situation.3,p.482

Except for the 2 single-day conferences,1,22 every state-of-the-art conference has included such discussions, whose published versions have run from 23 to 53 pages per conference with an average of 35. Over the years, Editorial Board members have been told repeatedly by colleagues that they always turn to the discussions first when a new conference issue arrives, to get right to the action.

The Conference Summary

Each state-of-the-art Journal conference ends with a summary presentation by a faculty member invited specifically for that purpose. These individuals are well-known authorities on the general subject of the conference, or sometimes respected investigators or teachers in a related field who have the ability to think broadly about the subject and interpret it in the context of both the conference and their own experience. The summarizer has the least work to do in preparation for the conference but the most during the meeting itself, taking copious notes and asking clarifying questions throughout the 2 days of prepared presentations. Then, while the rest of the speakers spend the evening of the second day unwinding and enjoying the locale, the summarizer usually stays up late sorting notes and putting together a coherent and presumably insightful presentation for the group the following morning.

While the rest of the conference presentations are carefully structured in order to address the desired points and stay on track, the summarizer is given free reign in preparing that presentation and subsequent manuscript. Most have put their summaries together as compressed versions of the conferences themselves, stating the main messages of each presentation in turn along with a variable amount of editorializing. Some have reorganized what was presented at the conference into a free-standing commentary on the topic’s state of the art and where it is likely to go in the future. A few have done both, and at least one has offered a highly personal interpretation of the conference topic that was only vaguely tied to any of the actual presentations.21 Summaries have been anywhere from 2–15 pages long, and I am pleased to say that all of them have succeeded. Nearly all have emphasized the incomplete nature of the available data, urged caution in everyday application, and called for further research. Some have been extraordinarily creative. One even featured two original poems composed on site during the conference, one of which ends with a stanza that nicely summarizes the purpose of all the conferences:

So stay in the critic’s mode,
Fight data overload,
Reject excess numbers that turn your brain numb,
Look for true meaning,
And perhaps we’ll be gleaning
A glimpse of more meaningful data to come. 31

Being asked to summarize a Journal conference is an honor and a challenge. Having done it (twice), I can testify to the adrenalin rush that comes with attempting to synthesize more than 12 hours of high-powered lectures and comments into a coherent presentation of 30 or 45 minutes that both captures the essence of the conference and is also original and instructive. Laptop computers and PowerPoint have certainly made this phase of the conference process easier, but the summarizer’s task is still a daunting one.

The Venue: Why Cancún?

In planning the first full-fledged state-of-the-art conference, the Journal’s Editorial Board made it top priority to get the very best, most well-known experts in managing acute respiratory failure as participants. The planners realized that most of the speakers would be senior academic physicians, people with already busy travel schedules and many invitations to speak around the country. We also realized that the AARC (then the AART) and RESPIRATORY CARE Journal were not the National Institutes of Health or the American Review of Respiratory Disease, and a main goal was to increase our visibility among the leaders in pulmonary medicine and intensive care. We decided that having the conference in an exotic location would help to entice the people on the “first choice” list to participate. Cancún was not yet the familiar holiday destination that it is today, and the strategy worked: everyone we asked agreed to come.

Despite the fact that a tropical storm of barely sub-hurricane force swept the area while the conference was being held, forcing the group to move twice because of flooded meeting rooms, the invited speakers liked the venue and the conference was a definite success. The original strategy of taking a hand-picked group of invitees to an exciting place for an equally exciting scholarly activity has been used ever since. Two-thirds of the full state-of-the-art conferences to date have been held in Mexico, and most of the others have taken place in resort-type locations.

Publication of the Conference Proceedings

From initial concept to publication of proceedings takes about 2 years. Presenters are asked to bring copies of their completed manuscripts to the conference, although not all do. The final products, as published, vary in length from just a few pages to nearly 30, and range in comprehensiveness from cursory summaries to in-depth reviews of every aspect of the topic, some citing more than 300 references. The discussion recordings are transcribed and sent to all participants for editing. In most cases the special issues containing the papers, discussions, and conference summary are delivered to the Journal’s readers 4 or 6 months after the conference itself.

What the State-of-the-Art Conferences Have Accomplished

The field of respiratory care and the respiratory care profession are different today because of the Journal conferences. Many of the articles so generated have become core material for courses at respiratory therapy schools and incorporated into syllabi for hospital departments and medical schools. Several have been reprinted or adapted as chapters in major textbooks. In 1986, the AARC and its publishing subsidiary, Daedalus Enterprises Inc, reissued 36 of the articles from the first 4 conferences, together with 3 other reviews the Journal had published, in a monograph,32 in order to make the material more widely available in the days before RESPIRATORY CARE was in Index Medicus. Despite the Journal’s not being indexed until the year 2000, the conference papers have been cited hundreds of times by papers in indexed publications, as a citation search in the Science Citation Index will confirm.

Conference-generated articles have documented important aspects of the history of respiratory care,33-38 and some of them have become classics on their subjects. Just 2 examples of the latter are Stauffer and Silvestri’s exhaustive review of the complications of intubation and artificial airways from 1982,39 which was updated in 1999,40 and Stoller’s compendium of helpful information on travel for patients dependent on supplemental oxygen and other respiratory care technology, published in 199441 and revisited for long-term oxygen therapy in 2000.42 From many possible examples, I have selected 10 articles from state-of-the-art special issues that nicely illustrate the high quality of the conference papers, and also their practical focus, creativity, and uniqueness (Table 2).43-52

Table 2. Ten RESPIRATORY CARE Journal Conference Reports That Have Been Unique in Content or Focus, or Were the First Discussions of Their Topics That Were Readily Accessible to Clinicians
Tyler ML. Complications of positioning and chest physiotherapy. Respir Care 1982;27(4):458–466. This article was the first to review the adverse physiological effects and clinical complications, both potential and reported, of chest percussion and postural drainage, the use of which was greatly increasing in the wake of the negative image of intermittent positive-pressure breathing treatments that followed the Sugarloaf Conference.*
Tobin MJ, Suffredini AF, Grenvik A. Short-term effects of smoking cessation. Respir Care 1984;29(6):641–649. Although the beneficial long-term effects of smoking cessation on the progression of chronic obstructive pulmonary disease and the incidence of lung cancer had become well known, almost nothing had been published on the effects of smoking cessation in the initial days and weeks. This article reviewed both theoretical and practical aspects of smoking cessation as applied to the prevention of postoperative respiratory complications.
Hudson LD. Design of the intensive care unit from a monitoring point of view. Respir Care 1985;30(7):549–556. Both theoretically and in practical terms, this article addressed such seldom-discussed issues as which hospitals should have intensive care units (ICUs), which patients are best served by being in an ICU, and how an ICU should be set up from the standpoints of location, space requirements, and the needs of patients and caregivers, giving special attention to patient monitoring.
Hudson LD. Positive end-expiratory pressure: reduction and withdrawal. Respir Care 1988;33(7):613–617. How positive end-expiratory pressure should be adjusted and its effects assessed in the initial management of acute respiratory failure had been the subject of numerous studies and reviews, but before this article was published there was essentially nothing dealing with how positive end-expiratory pressure should be weaned once improvement had occurred.
Branson RD. Intrahospital transport of critically ill, mechanically ventilated patients. Respir Care 1992;37(7):775–793. Transporting critically ill patients receiving ventilatory support to other parts of the hospital from the ICU is now known to be fraught with risks and complications, but when this article was published the nature of these hazards and how to avoid them had received almost no attention in the literature.
Gilmartin M. Transition from the intensive care unit to home: patient selection and discharge planning. Respir Care 1994;39(5):456–477. Prior to the introduction of financial incentives for accepting patients on ventilators, it was exceedingly difficult to place such patients outside the ICU of an acute care hospital. This article discussed the prerequisites and procedures for successfully moving selected patients from ICU to home care.
Jaeger JM, Durbin CG Jr. Special purpose endotracheal tubes. Respir Care 1999;44(6):661–683. Clinicians working outside the operating room tend to have little knowledge of double-lumen endotracheal tubes and other specialized airways, and this topic has received little coverage in the respiratory care literature despite the occasional use of such devices in the ICU.
Benditt JO. Adverse effects of low-flow oxygen therapy. Respir Care 2000;45(1):54–61. This article comprehensively reviewed the various potential complications of oxygen therapy as used in the home, a topic seldom addressed elsewhere in print, including possible oxygen toxicity, effects on respiratory drive, the risk of fire, and other physical dangers.
Rubenfeld GD. Withdrawing life-sustaining treatment in the intensive care unit. Respir Care 2000;45(11):1399–1407. Despite many publications on advance directives and ethical aspects of withdrawing life support in critically ill patients, prior to this article there were virtually nothing providing the clinician with practical guidance on how to prepare for and actually carry out such withdrawal in the most humane and least stressful manner.
Hess DR. The evidence for secretion clearance techniques. Respir Care 2001;46(11):1276-93. Although there had been previous literature reviews on chest physical therapy and the various techniques and devices available for facilitating secretion clearance, none had rigorously examined available studies with respect to design and results using currently accepted standards for judging evidence. Such an examination revealed almost no scientific support for the use of any of the studied techniques.
*Pierce AK, Saltzman HA, eds. Conference on the scientific basis of respiratory therapy. Am Rev Respir Dis 1974;110(suppl):1–204.

The Journal’s Consensus Conferences

This editorial has focused on the state-of-the-art conferences, but would be remiss if it did not include some mention of the Journal’s “other” conference series, its 5 consensus conferences (Table 3).53-57 Although there have been fewer of them, these conferences have been at least as influential as their state-of-the-art counterparts. The issue generated from the first one,53 long since out of print, is the most requested single issue the Journal has ever published.

Table 3. RESPIRATORY CARE Journal’s Consensus Conferences: Topics and Publication Dates During the First 20 Years
Conference Number Topic Publication Date Reference
1 Aerosol Delivery September 1991 53
2 The Essentials of Mechanical Ventilators September 1992 54
3 Assessing Innovations in Mechanical Ventilatory Support September 1995 55
4 Noninvasive Positive Pressure Ventilation April 1997 56
5 Aerosols and Delivery Devices June 2000 57

The consensus conferences have been convened by the ARCF to clarify and provide authoritative synthesis on specific areas of respiratory care practice that are controversial or otherwise problematic for the practitioner. Each of them has been planned by a specially designated committee chaired by Neil MacIntyre, and has been chaired or co-chaired by him. The topics have been different aspects of aerosol therapy and mechanical ventilation. Twenty-nine first-time Journal conference participants and a number of previous speakers have composed the faculties. The papers and consensus statements in the issues comprising the proceedings of these conferences amount to some 600 pages of the Journal.

The format for the consensus conferences is different from that of the state-of-the-art conferences. The intent is not to survey the topic, appraise the quality of the evidence supporting it, and provide practical guidance to the clinician. Instead, these conferences seek as much consensus as can comfortably be achieved among the assembled experts and generate a specific document representing that consensus. A writing committee prepares an outline of the main issues and sometimes a draft of a possible consensus position beforehand, and after presentations on different aspects of the topic the conferees create a draft of the final consensus statement while still at the conference. That document is subsequently revised and circulated among all participants, sometimes several times, until approved for publication. Discussions following the individual papers are not recorded and there are no conference summaries.

Why These Conferences Are Important

A central issue that has run through all 28 of the Journal conferences in the first 20 years of the series was brought up in the introduction to the very first one:

In a field marked by a burgeoning assortment of new apparatus and techniques, too much attention has been devoted to technical description and initial clinical experience and not enough to the sober assessment of complications. New procedures are often put into wide use before their hazards have been documented or even studied.58

One of the main purposes of these conferences has been to reconcile the entrepreneurism and urge to try new things that are inherent in respiratory care with the requirements and safeguards of the scientific method, and also with the need for safeguarding patients from harm or less-than-optimal outcomes. The Journal has tried to keep to the high road when parochial and commercial interests have intersected with the goals of patient care, its articles seeking objectivity in documenting the state of the art, even as its discussions revealed the uncertainty and contentiousness of many of the topics encountered along the way.

These conference proceedings have documented the evolution and increasing maturity of an important area of medicine, and at the same time tracked the steady evolution of a profession during these last 2 decades. Although it was not intentional, it nonetheless seems particularly appropriate that the 20-year point in this evolution was marked by a conference on evidence-based medicine.23 The bar has been raised, and will likely be raised again, repeatedly, in the years to come. RESPIRATORY CARE will be there to document the process for its readers, through its state-of-the-art and consensus conferences and the special issues they generate.

David J Pierson MD FAARC
Editor-in Chief, RESPIRATORY CARE
Division of Pulmonary and Critical Care Medicine
Department of Medicine
Harborview Medical Center
University of Washington
Seattle, Washington

References

  1. Special issue: Complications of respiratory therapy. Respir Care 1982;27(4):399-470.
  2. Conference on the management of acute respiratory failure. Respir Care 1983;28(5):530-678.
  3. Conference on perioperative respiratory care. Respir Care 1984;29(5):457-549 and 29(6):603-683.
  4. Conference on monitoring of critically ill patients. Respir Care 1985;30(6):405-499 and 30(7):549-636.
  5. Conference on neonatal respiratory care. Respir Care 1986;31(6):467-532 and 31(7):581-638.
  6. Conference on mechanical ventilation. Respir Care 1987;32(6):403-478 and 32(7):517-614.
  7. Conference on positive end-expiratory pressure. Respir Care 1988;33(6):419-501 and 33(7):539-637.
  8. Conference on pulmonary function testing. Respir Care 1989;34(6):427-523 and 34(7):571-669.
  9. Conference on noninvasive monitoring in respiratory care. Respir Care 1990;35(6):482-601 and 35(7):640-746.
  10. Conference on respiratory care of infants and children. Respir Care 1991;36(6):489-621 and 36(7):673-760.
  11. Conference on emergency respiratory care. Respir Care 1992;37(6):523-629 and 37(7):673-812.
  12. Conference on oxygenation in the critically ill patient. Respir Care 1993;38(6):587-704 and 38(7):739-846.
  13. Conference on controversies in home respiratory care. Respir Care 1994;39(4):294-400 and 39(5):440-583.
  14. Conference on resuscitation in acute care hospitals. Respir Care 1995;40(4):335-436 and 40(5):479-587.
  15. Conference on mechanical ventilation: Ventilatory techniques, pharmacology, and patient management strategies. Respir Care 1996;41(4):273-340 and 41(5):385-472.
  16. Conference on emerging health care delivery models. Respir Care 1997;42(1):14-168.
  17. Conference on sleep-disordered breathing. Respir Care 1998;43(4):264-325 and 43(5):370-427.
  18. Conference on inhaled nitric oxide. Respir Care 1999;44(2):155-221 and 44(3):281-365.
  19. Conference on artificial airways. Respir Care 1999;44(6):593-701 and 44(7):750-865.
  20. Conference on long-term oxygen therapy. Respir Care 2000;45(1):28-126 and 45(2):172-245.
  21. Conference on palliative respiratory care. Respir Care 2000;45(11):1318-1410 and 45(12):1460-1540.
  22. Conference on tracheal gas insufflation: current status and future prospects. Respir Care 2001;46(2):118-199.
  23. Conference on evidence-based medicine in respiratory care. Respir Care 2001;46(11):1200-1303 and 46(12):1368-1449.
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Correspondence: David J Pierson MD FAARC, RESPIRATORY CARE Editorial Office, 600 Ninth Avenue, Suite 702, Seattle WA 98104. E-mail: pierson@aarc.org.

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