DIABETIC LUNG DISEASE 1 Continuing Education Course Proposal for Respiratory Therapists: Introduction to Diabetic Lung Disease Kami Clark A proposal submitted in partial fulfillment of the requirements for the degree of MASTER OF EDUCATION with an emphasis in CURRICULUM AND INSTRUCTION WEBER STATE UNIVERSITY Ogden, Utah December 6, 2022 DIABETIC LUNG DISEASE 2 Acknowledgments I want to thank my family and friends for their support, not only as I work on this project but throughout the last two years as I returned to school and worked as a respiratory therapist throughout a pandemic. I would specifically like to thank my amazing mom who has been my biggest cheerleader throughout my life, thank you for always having my back. I also want to thank my best friend Jennifer Kasper, you are the best “Crazy Momma Friend” a girl could ever have. Thank you for the hours you spent helping me with your expertise as a respiratory therapist and for being there with me throughout the pandemic. I also want to thank my three amazing committee members. Janelle Gardiner, you have been there with me from the start. Thank you for not laughing at me when I took on such a little-known disease. Tabatha Dragonberry, thank you for being willing to help a complete stranger. Your recommendation for learning technology was vital to my project. Stephanie Speicher, you are the most amazing committee chair and mentor a person could have. Your support, knowledge, and enthusiasm mean more to me than you could ever fully understand, thank you for being a teacher. I would also like to thank Intermountain Healthcare and Weber State University for the financial aid they provided to return to school. I appreciate the dedication these companies have to improve the education of their employees. Thank you all for your phenomanal support. DIABETIC LUNG DISEASE 3 Table of Contents Nature of the Problem 6 Respiratory Therapist Continuing Education 6 Diabetic Lung Disease 7 Lack of Continuing Education 8 Literature Review 9 Respiratory Therapists Continuing Education 9 Importance of CRCEs 10 Improved Patient Outcomes. 11 Increased Retention Rates. 12 A Need for Continuing Education 13 Basics Facts About DM 14 Effects of DM on the Respiratory System 15 Hyperglycemic Lung Damage 15 Hyperinsulinemic Lung Damage 16 Testing for Diabetic Lung Damage 16 Pulmonary Function Testing 16 CT Scans 17 Why Should RT Learn About DM 17 DM Role in Health Burdens and Disparities. 17 DM and Respiratory Infections. 17 The COVID-19 Pandemic’s Impact on DM. 18 Gaps in Knowledge about DLD 18 No Official Diagnosis 18 No Formal Education about DLD 19 Lack CRCR 19 Purpose 20 Methods 21 Project Approval 21 Technological Learning Tools 22 Canva and AHA Slides 22 Course Evaluation and Certifications 23 Development of the DLD Curriculum 23 Backwards Design 24 Pilot Course and Evaluation 26 Feedback and Future Application 26 DIABETIC LUNG DISEASE 4 Pilot Course Evaluations 26 Evaluation of Course Content. 26 Evaluation of Interactive Activities and Technology. 27 Drawbacks of Course Technology and Interactives Activities 28 Planned Changes to Interactive Activity 28 Valuable and Helpful Course Content 29 High Quality Slides 29 Course Content. 29 Presenter’s Delivery 30 Case Studies 30 Evaluation of the Course Goals 30 Improved Understanding of Subject Matter 32 Future Recommendations 33 Summary 34 References 35 Appendix A-Social Media Ad 43 Appendix B-Event Registration Form 44 Appendix C-Consent to Participate 45 Appendix D- Course Evaluation 46 Appendix E-DLD AHA Slide Presentation 47 Appendix F-Certificate of Completion 92 Appendix G- CRCE Certificate Template 93 Appendix H-UbD Lesson Planner 94 Appendix I-DLD Lesson Plan 100 DIABETIC LUNG DISEASE 5 Abstract Diabetes cases worldwide are increasing. This will lead to an increase in Diabetic Lung Disease, a pathology that most healthcare workers, including respiratory therapists, are unfamiliar with at this time. No current continuing education is available for respiratory therapists at this time regarding Diabetic Lung Disease. Continuing Respiratory Care Education is approved and credentialled through the American Association of Respiratory Care. The goal of this curriculum development project was to create a continuing education course about Diabetic Lung Disease that can be approved for continuing education credits by the AARC. Keywords: Diabetic Lung Disease Curriculum, Continuing Respiratory Care Education DIABETIC LUNG DISEASE 6 Nature of the Problem Respiratory Therapists (RTs) are healthcare professionals that specialize in the care, treatment, and education of diseases of the pulmonary system (American Association for Respiratory Care [AARC], 2022a). RTs’ rapidly changing role and responsibilities require them to receive continuing professional education (AARC, 2022a; AARC, 2022d). RTs although experts in the cardiopulmonary system have limited understanding about Diabetic Lung Disease (DLD) and need continuing education about the newly emerging research about DLD, because the incidence of Diabetes Mellitus (DM) is growing worldwide. Respiratory Therapist Continuing Education An RT's profession is rapidly changing due to the constantly evolving healthcare field and advancing research which results in a need for RTs to receive continuing professional education (AARC, 2022a; AARC, 2022d). The Continuing Respiratory Care Education (CRCE) system provides RTs with an opportunity to learn about the advances and changes in their field and enhances their related knowledge (AARC, 2022d). The American Association for Respiratory Care (AARC) accredits all continuing education for RTs in the United States. As such, the AARC provides RTs with the approved CRCE credits that are required for state licensure and credentialing by the National Board of Respiratory Care (AARC, 2022c). Continuing education is also shown to improve patient outcomes, reduce health disparities, and reduce burnout (Adams et al., 2012; Almutahar et al., 2020; Cotel et al., 2021; Gagné et al., 2018; Institute of Medicine; 2010; Health Management, 2017; 2021; Miller et al., 2021; Minnesota Department of Health: Office of Rural Health and Primary Care, 2022; Poureslami et al., 2016; Rhina, 2018; Rowe et al., 2018; Sandelowsky et al., 2020; Sehlbach et al., 2018). DIABETIC LUNG DISEASE 7 Continuing education for RTs about DM’s effects on the respiratory system is crucial to improve outcomes and reduce health disparities of patients with DLD. Diabetic Lung Disease Research has identified damage to the respiratory system associated with DM and insulin resistance (Hao et al., 2016; Khateeb et al., 2019; Kim et al., 2014; Kolahian et al., 2019; Mamillapalli et al., 2019; Pitocco et al., 2012; Rajasurya et al., 2020; Sen et al., 2021; Widger et al., 2013; Zheng et al., 2017). Systemic complications from DM are well known; however, the damage to the respiratory system has historically been overlooked (Khateeb et al., 2019; Kolahian et al., 2019; Pitocco et al., 2012; Rajasurya et al., 2020; Zheng et al., 2017). Research shows that DM can damage the respiratory system (Khateeb et al., 2019; Kolahian et al., 2019; Pitocco et al., 2012; Rajasurya et al., 2020; Zheng et al., 2017). This damage to the respiratory system from DM has been coined "Diabetic Lung Disease" by researchers (Khateeb et al., 2019; Kolahian et al., 2019; Pitocco et al., 2012; Rajasurya et al., 2020; Zheng et al., 2017). Unfortunately, "Diabetic Lung Disease" (DLD) is often understated and not well understood by most healthcare professionals (Kolahian et al., 2019; Pitocco, 2012). Most healthcare professionals, including RTs, need to become familiar with how DLD and its impacts on their patients (Khateeb et al., 2019; Kolahian et al.; Pitocco, 2012). The need for RTs to receive further education about DLD is vital due to the global increase in DM and prediabetes that will ultimately lead to an increased incidence of DLD (Center for Disease Control [CDC], 2021; CDC, 2022; International Diabetes Federation [IDF], 2021; World Health Organization [WHO], 2021). Furthermore, DM impacts some of RTs' most vulnerable patients and is a comorbidity for many chronic respiratory conditions (Bolin & Ferdinand, 2018; Caruso & Giorgino, 2020; CDC, 2022; Hao et al., 2016; IDF, 2021; Khateeb et DIABETIC LUNG DISEASE 8 al., 2019; Kolahian et al., 2019; Mamillapalli et al., 2019; Sen et al., 2021; Widger et al., 2013). Most recently, the COVID- 19 pandemic has magnified the need for RTs and other healthcare professionals to understand DM's impact on the lungs (Caruso & Giorgino, 2020: Mamillapalli et al., 2019; Reiterer et al., 2021; Sen et al., 2021). Emerging COVID-19 research is implicating the virus in causing new-onset Type 1 and Type 2 DM (Reiterer et al., 2021; Sen et al., 2021). COVID-19 infections are also associated with causing injuries within the respiratory system similar to DM due to the corresponding inflammatory pathways (Caruso & Giorgino, 2020; Reiterer et al., 2021; Sen et al., 2021). Lack of Continuing Education The RTs' responsibilities are continually evolving, including their role as patient educators, creating a need for RTs to have continuing education to increase their knowledge regarding the effects of DLD on the respiratory system (AARC, 2022c; Groninger, 2021; IDF, 2021; Mamillapalli et al., 2019; Rhina, 2018; Sehlbach et al., 2018; Sen et al., 2021). Providing RTs with this continuing education research will promote discussion, foster health literacy, and identify and drive future treatments for DLD. Currently continuing education resources do not exist for RTs about the effects of hyperglycemia and hyperinsulinemia on the respiratory system or DLD. A search revealed that AARC has no continuing education about DLD available at this time (AARC, May & July 2022). There is a need to create and provide RTs with a learning opportunity approved for CRCE, to increase awareness and understanding of the DLD, enhance health literacy about DLD, and reduce the healthcare burden of DM. DIABETIC LUNG DISEASE 9 Literature Review RTs play an essential role in the care and management of respiratory diseases and have an in-depth understanding and knowledge of the anatomy and pathology of the respiratory system (AARC, 2022a; Groninger, 2021; Walker, 2004). According to the AARC (2022c), RTs play an important part in the healthcare team and aid in diagnosing, treating, managing, and educating patients with respiratory diseases. They are expected to stay current on changes and advances in the field. One way health professionals, like RTs, can keep their skills and knowledge current is through continuing professional education (AARC, 2022c). Continuing education can enhance healthcare workers' knowledge and improve their clinical practice (Sehlbach et al., 2018). Continuing education positively correlates with improved patient outcomes and potentially reduces workforce burnout (Health Management, 2022). Continuing education provides RTs, as healthcare professionals, with the ability to act as a bridge between the patient and the new research, and as a result, will have the skills to implement policies and practices utilizing their knowledge and wisdom (Institute of Medicine, 2010). Advancing science about DLD and its effects on patients with chronic respiratory diseases are examples of recently emerging research about which healthcare workers need to receive some education. While RTs know the most common complications caused by DM, they have received little to no education about how DM can damage the respiratory system. RTs need to understand the impact of DM on their patient population due to its damage to the respiratory system. At this time, RTs are presented with a learning obstacle as no current education is available to them about DLD. Respiratory Therapists Continuing Education The AARC is a professional organization that provides ongoing respiratory research and education to respiratory therapists in the United States. In addition, it is responsible for the DIABETIC LUNG DISEASE 10 accreditation of all required respiratory therapy continuing education, known as Continuing Respiratory Care Education (CRCE). The AARC (2022d) stated that "continuing education is defined as a variety of learning experiences meant to enhance the knowledge of respiratory therapists, enabling them to provide safe, effective care to patients (pg 3, para 3)." According to the AARC (2022d), RTs credentialled after 2002 must take at least 30 CRCEs every five years to maintain their respiratory credentials. A CRCE is defined as 60 minutes of a provider-directed or learner-directed learning activity. Provider-directed learning activities do not include an examination, unlike learner-directed activities. The time for the examination may be included as part of the total time of the learning activity. The continuing education topics must be approved for CRCEs through the AARC and include topics such as education, healthcare costs, preventive health services, and health promotion (AARC, 2022d). In addition to credentialing requirements, many states have additional continuing education requirements for RTs to meet state licensure requirements (AARC, 2022c). These are designated by each state's licensing board requirements and vary from state to state, including specific subject requirements and a required number of CRCEs per a designated time period (AARC, 2022c). Importance of CRCEs The goal of AARC (2022d) is to provide learning experiences that strengthen and expand a respiratory therapist's knowledge and skills. RTs are a vital part of the healthcare team, who must know the anatomy and physiology of the disorders they treat. They need extensive training and continuing education to safely and effectively deliver the best possible care and education to patients and their families (Walker, 2004). DIABETIC LUNG DISEASE 11 Continuing education improves healthcare professionals' health literacy and, thereby, patients' ability to access, comprehend, evaluate, communicate and act on health information to improve their health and well-being (Poureslami et al., 2017). Continuing education improves patient outcomes, reduces health disparities, and increases the retention of healthcare workers. Improved Patient Outcomes. Continuing education is considered critical to quality practice and patient care. Training is critical to healthcare practices to promote wellness, disease prevention, and improved quality of life because it updates and reinforces knowledge, resulting in improved patient care. The European Respiratory Society (ERS) understands that continuing professional education is essential to maintaining currency of knowledge and practice and safeguarding patient care, especially for those with chronic conditions (Riha, 2018). Enhancing and collaborating on continuing education opportunities has become a focus of the ERS due to the constantly changing medical field due to technology, the healthcare environment, changing societal needs, and the discovery of new information (Sehlbach et al., 2018). Research on continuing education of RTs and patient outcomes is minimal and warrants further studies. However, continuing education has been shown to improve patient outcomes of respiratory diseases, including asthma (Cheng et al., 2021) and Chronic Obstructive Pulmonary Disease (COPD) (Adams et al., 2012; Gagné et al., 2018; Sandelowsky et al., 2020). Continuing education also improves the outcomes of patients suffering from DM (Almutahar et al., 2020). The Institute of Medicines (2010) has identified that continuing professional development is crucial for a well-educated healthcare workforce. Continuing healthcare provider education is a potential strategy for improving health disparities faced by low-income and middle-income countries. Rowe et al. (2018) found that inadequate health-provider performance is an obstacle to DIABETIC LUNG DISEASE 12 receiving high-quality healthcare in low-income and middle-income countries and can be strategically overcome by further healthcare provider training and continuing education. It is evident that continuing education improves patient outcomes, improves healthcare provider skills, and may reduce healthcare disparities. Health Management (2017) states "The advantages of investing into continuous education are obvious: highly skilled staff, high staff retention, magnificent reputation, optimized financial performance, better patient outcomes, and fewer medical malpractice lawsuits" (para. 2). These results can lead us to believe that continuing education of RTs would benefit patients with DLD as well. Increased Retention Rates. In addition to improved patient outcomes, continuing education may also decrease burnout and improve healthcare staff retention. The burnout rate among RTs is high. Miller et al. (2020) report that prior to the COVID-19 Pandemic, burnout was considered a significant problem in healthcare workforce retention, with rates of approximately 33% and 50% in nurses and physicians, respectively. In this same report, Miller et al. found that RTs, prior to the COVID-19 Pandemic, experience burnout at much higher rates, with 72% of study participants reporting burnout. The recent COVID-19 Pandemic increased burnout rates of RTs, and many have left or plan on leaving the profession altogether as a result, which will only increase the shortage of RTs nationwide (Groninger, 2021; Minnesota Department of Health: Office of Rural Health and Primary Care, 2022). Miller et al.(2021) found that education and training can lead to more fulfilling careers for RTs and may reduce burnout. A study of 523 Romanian healthcare workers during the COVID-19 Pandemic identified that a lack of access to job resources such as continuing education, training, and professional development increased exhaustion and burnout (Cotel et al., 2021). DIABETIC LUNG DISEASE 13 A Need for Continuing Education Continuing education provides many benefits and is invaluable for helping healthcare professionals keep up to date with emerging research relevant to the healthcare industry (AARC, 2022c; AARC, 2022d; Health Management, 2022; Miller et al., 2021; Minnesota Department of Health: Office of Rural Health and Primary Care, 2022; Poureslami et al., 2017; Riha, 2018; Sehlbach et al., 2018; Walker, 2004; Rowe et al., 2018; Sandelowsky et al., 2020; Sehlbach et al., 2018). Continuing education is also crucial to improving patient outcomes and reducing healthcare burdens (Adams et al., 2012; Almutahar et al., 2020; Cheng et al., 2021; Cotel et al., 2021;Gagné et al., 2018; Health Management, 2022; Institute of Medicine, 2010; Miller et al., 2021; Poureslami et al., 2017; Sandelowsky et al., 2020; Walker, 2004). DM is a chronic disease and there is novel research regarding its role in causing DLD (Hao et al., 2016; Khateeb et al., 2019; Kim et al., 2014; Kolahian et al., 2019; Mamillapalli et al., 2019; Pitocco et al., 2012; Rajasurya et al., 2020; Sen et al., 2021; Widger et al., 2013; Zheng et al., 2017). This research needs to be summarized and disseminated worldwide to promote health literacy about these recent findings. The evidence shows how providing continuing education to RTs is essential to improving patient outcomes and reducing the healthcare burden of DM including DLD. RTs should have a basic understanding of DM and its effects on the Respiratory System. Basics Facts About DM The World Health Organization (WHO) (2021) defined DM as a chronic disease marked by high blood sugar, known as hyperglycemia. DM is frequently a result of insufficient insulin production by the pancreas or an inability of the body to use insulin efficiently. Insulin is the hormone that regulates the amount of sugar, known as glucose, in the blood. Diabetes Mellitus Type I (DMT1) is most commonly diagnosed in children and is when the pancreas no longer DIABETIC LUNG DISEASE 14 produces enough insulin. Diabetes Type II (DMT2) is primarily a result of insufficient use of insulin (insulin resistance), which over time, can lead to a deficiency in the production of insulin (CDC, 2022; WHO, 2021). DMT2 is associated with obesity and physical inactivity and makes up more than 95% of diabetes cases (WHO, 2021). DMT2 often precedes prediabetes or insulin resistance (American Diabetes Association, 2010; CDC, 2021). While the cause of DMT1 is primarily unknown, it has been linked to an autoimmune reaction associated with specific genes and environmental factors, including viral infections (National Institute of Diabetes and Digestive and Kidney Diseases, 2017; WHO, 2021). Insulin resistance, also known as prediabetes, is when the insulin receptors on the cell malfunction and do not respond adequately to the insulin. Insulin resistance can result in hyperglycemia because too much glucose remains in the blood (CDC, 2021). The pancreas will continue to increase insulin levels (hyperinsulinemia) to maintain normal glycemia. Over time, however, it wears out and will lead to prediabetes and DMT2 (CDC, 2021). Reiterer et al. (2021) recently implicated the COVID-19 virus in the malfunction of adipose cells resulting in insulin resistance and DMT2. Effects of DM on the Respiratory System Over time, DM contributes to many well-known complications due to advanced glycation end-products (AGEs), oxidative stress, and chronic inflammation. Well-known complications from DM include damage to the heart, blood vessels, kidneys, nerves, and eyes, but the damage to the lungs often remains understated (Khateeb et al., 2019; Kolahian et al., 2019; Pitocco, 2012). DM's microvasculation and macrovasculation of blood vessels are often altogether overlooked, although the lungs are highly vascular (Hao et al., 2016; Khateeb et al., 2019; Kim et al., 2014; Kolahian et al., 2019; Mamillapalli et al., 2019; Pitocco et al., 2012; Rajasurya et al., DIABETIC LUNG DISEASE 15 2020; Sen et al., 2021; Widger et al., 2013; Zheng et al., 2017). The nerves responsible for regulating the respiratory system are also frequently overlooked. An example is the vagus nerve, commonly known to cause gastroparesis in patients with DM. The vagus nerve also plays an essential role in regulating the autonomic nervous system, which is vital in regulating the bronchomotor tone and mucociliary function (Kolahain et al., 2019). The phrenic nerve is also vulnerable to damage from DM, which can result in weak diaphragm muscles (Almeida et al., 2016; Kolahian et al., 2019). In addition to the damage to the respiratory vasculature and nerves from DM, researchers have identified other pathological damage to the respiratory system due to hyperglycemia and hyperinsulinemia. These conditions contribute to DLD. Hyperglycemic Lung Damage. Hyperglycemia causes permanent lung tissue remodeling due to the accumulation of AGES and the overproduction of collagen and elastin in the extracellular matrix, which causes matrix stiffening and interstitial fibrosis (Kheetab et al., 2019; Kolahian et al., 2019; Pitocco et al., 2012,). Other manifestations of DLD include the narrowing of alveolar space, flattening of the alveolar epithelium, and thickening of the alveolar basal lamina (Kolahian et al., 2019). Hyperglycemia is also associated with bronchial tree fibrosis and airway dysfunction (Almeida et al., 2016). Hyperinsulinemic Lung Damage. The normal functions of insulin can be magnified in people with DMT2 and prediabetes because of heightened insulin levels (Kolahian et al., 2019). Research on inhaled insulin shows that it can lead to a proliferation of the smooth muscles in the respiratory system (Kolahain et al., 2019). Hyperinsulinemia effects include inhibition of surfactant protein, hypertrophy of lung tissue, and an exaggeration of inflammation manifested by increased Type 2 T-helper cells, mast cell degranulation, and macrophage activation (Kolahian et al., 2019). DIABETIC LUNG DISEASE 16 Testing for Diabetic Lung Damage. DM is shown in research to cause alterations in pulmonary function tests that could aid in diagnosing DLD. Pitocco et al. (2011) noted that pulmonary function is altered in patients with DLD, and restrictive lung dysfunction is associated with prediabetic patients without any previous history of lung impairment (Kim et al., 2015; Zhang et al.). A standard blood test for diabetes, Hemoglobin A1c (HbA1c) test, also shows a correlation between a high HbA1c and reduced pulmonary function in patients with DM (Rajasurya et al., 2020). Pulmonary Function Testing. Pulmonary function testing carried out in people with diabetes has been shown to reduce: vital capacity, medium expiratory flow, residual expiratory volume, total lung capacity (TLC), forced vital capacity (FVC), and forced expiratory volume in one second (FEV1) (Zhang et al., 2017). In addition to restrictive and obstructive lung disease, patients with diabetic lung damage show a reduced lung diffusion capacity for carbon monoxide (DLCO) when measuring the exchange of gas across the alveolar tissue membrane into the capillary (Kim et al., 2014; Zhang et al., 2017)). In DMT2 patients, the tests show a low membrane diffusing capacity and reduced capillary blood volume (Kim et al., 2014; Zhang et al., 2017). These results lead us to the conclusion that DLD causes restrictive lung disease. CT Scans. Besides pulmonary function tests, Widger et al. (2013) showed that CT scans could aid in diagnosing DLD as they have shown increased structural changes in children with cystic fibrosis and diabetes versus just children with cystic fibrosis. Tuberculosis patients with diabetes also show increased structural lung changes on CT scans compared to their nondiabetic peers (Hao et al., 2016). DIABETIC LUNG DISEASE 17 Why Should RT Learn About DM DM Role in Health Burdens and Disparities. Chronic diseases like DM create global health burdens (Hajat & Stein, 2018). DM affects approximately 537 million people worldwide (IDF, 2021; WHO, 2021). The International Diabetes Federation (2021) estimated that by 2030 this number would increase to 643 million. Currently, an estimated 37.3 million people in the United States have DM, with medical care costs of at least $237 billion yearly (CDC, 2022). The CDC (2022) reported that the increase in DM and prediabetes disproportionately affects some of our most vulnerable populations. Diabetes affects ethnic populations at much higher rates, including ethnic youth (CDC, 2022). Worldwide, 3 out of 4 adults with DM come from low- middle-income countries (IDF, 2022). In the United States, our rural populations have a 17% higher prevalence of DM than those living in urban areas, and (Sen et al., 2021) rural populations already face healthcare disparities, including access to many specialists (Bolin & Ferdinand, 2018). DM and Respiratory Infections. DM results in increased respiratory infections that can result in additional damage to the lungs. Increased respiratory infection risks are also associated with hyperglycemia due to the increased sugar levels within the airway surface liquid, which, along with structural changes to bronchomotor tone.(Kheetab et al., 2019; Kolahian et al., 2019; Pitocco et al., 2012). DLD is also associated with a higher incidence of infections due to opportunistic bacteria, fungi, and viruses and increased morbidity in patients with chronic respiratory diseases, including COPD, asthma, idiopathic pulmonary fibrosis, pulmonary hypertension, lung cancer, and cystic fibrosis (Kheteeb et al., 2019; Kolahian et al., 2019). DIABETIC LUNG DISEASE 18 The COVID-19 Pandemic’s Impact on DM. The recent COVID-19 Pandemic has exacerbated the growing burden of DM. Patients with DM have higher mortality from COVID-19 as a result of similar inflammatory pathways causing acute respiratory syndrome (Sen et al., 2021). Research is beginning to showing that COVID-19 infections can cause DMT1 (Sen et al., 2021) and DMT2 (Reiterer et al., 2021), and COVID-19 causes changes in the tissue of adipose tissue that can lead to insulin resistance (Cotel et al., 2021; Reiterer et al., 2021). The impact of the COVID-19 Pandemic means that the predicted global increase in diabetes may be much higher than projected. Gaps in Knowledge about DLD No Official Diagnosis. The research on DLD is advancing; however, the effects of DM on the pulmonary systems are complicated and are not yet fully understood at this time (Khateeb et al., 2019; Kolahian et al., 2019). Even though researchers have begun to recognize and define it, there currently needs to be an official diagnosis for DLD. The research showing reduced lung function in pulmonary function tests, as well as structural damage in CT scans in patients with prediabetes and DM offer some promise as diagnostic criteria in the future, but further research is still warranted (Hao et al., 2016; Widger et al., 2013; Zheng et al., 2017). No Formal Education about DLD. While healthcare providers, like RTs, are well-informed about the complications associated with diabetes. They are likely ignorant of DLD and unfamiliar with lung damage due to chronic hyperglycemia, hyperinsulinemia, and DLD (Mamillapalli et al., 2019). Because DLD research is just emerging, respiratory therapists may need to learn about it. Currently, DLD is not commonly taught as part of the RT curriculum of university programs. In a personal interview in the fall of 2020 with Paul Eberle and Janelle Gardiner, Professors at DIABETIC LUNG DISEASE 19 Weber State University's Respiratory Therapy program, it was noted that neither DLD nor any of its resulting pathologies was taught in any of Weber State's Respiratory courses. In another interview with Lisa Trujillo (2021), the respiratory therapy program director at the University of Kansas Medical Center, she also commented that she was unfamiliar with DLD. However, these respiratory therapy programs do provide a strong foundation of knowledge on the respiratory system, which adult learners will find essential to understanding DLD in the future. Lack of CRCE. Additionally, a search of the commonly accessed professional journals on the AARC website did not reveal any articles about DLD or the effects of hyperglycemia or hyperinsulinemia on the lungs. Neither was any continuing professional education for RTs, including through the AARC. DIABETIC LUNG DISEASE 20 Purpose Diabetes Mellitus (DM) is a systemic disease that can cause many complications. The damage to the respiratory system from DM is known as Diabetic Lung Disease (DLD). Unfortunately, knowledge about DLD needs improvement among healthcare professionals, including RTs. Further education is needed for RTs to understand how DM causes DLD and its impact on the profession; however, there appears to be no education available at this time about DLD. As such, the purpose of this project was to consolidate the research on DLD, create clear learning objectives, and develop a curriculum about DLD which can be submitted to the AARC or the Utah Society for Respiratory Care as a proposed presentation and CRCE credit. The learning goals of this continuing education project are: ● Learn to utilize technology and the backward design method (Wiggins & McTighe, 2005) to create an interactive curriculum with a presentation and lesson plan. ● Create a continuing education course for RTs that allows them to explain how diabetes (DM) causes damage to the respiratory system, known as Diabetic Lung Disease (DLD), and discuss its impact on the profession. ● Learn how to begin to conduct research to evaluate a course curriculum and content and apply the feedback to improve participants' understanding of the subject matter (Wiggins & McTighe, 2005) . DIABETIC LUNG DISEASE 21 Methods This curriculum project aimed to create a professional continuing education course for RTs that enhances their understanding of DLD. To achieve this goal, the curriculum development was guided by the AARC's Continuing Education Manual (AARC, 2022) to meet the criteria for submission for CRCE credit. The typical duration of an RT conference presentation is one hour and counts as one CRCE. A one-hour course with a lesson plan was built using backward design (Wiggins & McTighe, 2005) to create an interactive presentation. The course was designed to introduce RTs to DLD and encourage them to begin thinking about DLD. The curriculum, including the presentation, interactive activities, and course evaluation were built to accommodate a hybrid audience. A hybrid course enabled the course to be trialed and reviewed online before submission as a live conference presentation. A pilot course was conducted online through Zoom, after which feedback was collected using an online course evaluation. A recording of the pilot course and course evaluation provided feedback that enabled improvements and changes to be made to the curriculum prior to its submission as a presenter proposal for the 2023 Utah Society for Respiratory Care’s Annual Conference and Exhibition.. Project Approval IRB approval for the curriculum project and course evaluation was obtained. To complete the IRB application, the following were created: 1. A social media ad (See Appendix A) using Canva to recruit participants for the pilot course. 2. An event registration (See Appendix B) using Google Forms to register participants. 3. A consent to participate (see Appendix C) from a Weber State University template. 4. A course evaluation (Appendix D) using Google Forms to evaluate the pilot course. DIABETIC LUNG DISEASE 22 A link to the event registration was placed in the ad allowing participants to register for the course online. The consent to participate was embedded into the event registration and had to be acknowledged as part of the participant’s registration for the course. After registration, the participants were automatically emailed the Zoom link for the pilot course. The course evaluation was created to obtain both qualitative and quantitative feedback about the course content. These documents were all submitted for approval with the IRB application. Technological Learning Tools Canva and AhaSlides Canva and AhaSlides were chosen as the software to create the DLD slide presentation (see appendix E). The DLD slide presentation guides and enhances the lecture using visual aids and interactive activities. Canva provided stock images and premade slides that could be used to create a presentation that was downloaded into AhaSlides. AhaSlides is a software that enables live interactive presentations with additional interactive tools that can be used to engage students and improve their motivation to participate. AhaSlides interactive tools allow participants to use their cell phones to participate in a word cloud activity, various formative assessments, and a Q&A session using a course link. AhaSlides tools were used to create the course activities, and formative assessment, and record participants' answers in the DLD slide presentations. Course Evaluation and Certifications A QR code that linked the course evaluation was added to the end of the DLD slide presentation. This course evaluation provided a way to improve future lectures and obtain a passive assessment of the course curriculum and student learning. A Certificate of Participation (see Appendix F) for the pilot course was embedded into the course evaluation for the students to print. This certificate provided any RT students with evidence of participation for attendance if DIABETIC LUNG DISEASE 23 their instructors needed it. However, for the official course, the AARC has a premade template (see Appendix F) for a CRCE certificate that can be used to create and replace the Certificate of Participation in future course evaluations. The CRCE certificate must first be authorized by the AARC and will provide future course participants with a way to track and record the course once it is approved for a CRCE. Development of the DLD Curriculum The learning content and objectives for the course were created; this was done by utilizing the current literature reviews about DLD. Current literature reviews about "Diabetic Lung Disease" were identified by conducting a search on Google Scholar. The information in these literature reviews was utilized to develop the course content and identify key concepts about DLD. RTs and physicians from the local hospital were then consulted about potential learning content and asked, "What would they like to know about DLD?" to help match learning content with future participants' learning needs and interests (personal communications, September 2022). Backward Design As developing a basic understanding and encouraging participants to begin thinking about DLD was the goal of the course, two books about how to build understanding and "thinking" into the curriculum and instruction design process were chosen to guide the creation process. The first was a book written by Grant Wiggins and Jay McTighe called Understanding by Design (UbD) (2005), which was used to create the course objectives and then create a lesson plan using the UbD backward design method. This process was recorded using a UbD Lesson Planner (See Appendix H), a Google template found free online. The second book Making Thinking Visible (Ritchart et al., 2011), was used to design an instructional method that would DIABETIC LUNG DISEASE 24 help promote thinking and understanding about how DM affects the respiratory system and the implications of DLD upon the RT profession. After the Ubd process was complete Canva was used to create an easy-to-read DLD lesson plan (See Appendix H) which could be used by RT faculty to teach their students about DLD. In addition, the capabilities and limitations of the chosen technology, Canva and AhaSlides, were identified during the UbD process to identify assessment methods for the course to be chosen during the lesson plan development. Five interactive activity tools from AhaSlides were chosen for the presentation, a Poll, a Word Cloud, an Open-Ended Question, Brainstorming, and a Q&A were included in the presentation. Pilot Course and Evaluation After receiving IRB approval, a date for the pilot course to be held via Zoom was confirmed. Participants were a random group of interested RT Students, RT faculty members, and current clinical RTs who registered for the pilot course after being recruited from the social media platform LinkedIn. A few instructors from different RT programs who heard about the pilot course also passed the registration information along to their students via email or text. A reminder about the pilot course was sent out the day before to the 25 registered participants; however, only 11 participated in the pilot course. The majority of the participants in the course were RT Students.See Figure 1. Figure 1 Participants Learning Level DIABETIC LUNG DISEASE 25 The course ran from 4:30 pm to 5:30 pm on November 3rd, 2022. Many participants did not turn on their cameras even after being directed that it would improve the course environment if they did so. Not having students on camera may have influenced participation in the discussions and made it difficult for the presenter to use visual cues to identify students' learning states. After self-introduction by the presenter, participants were introduced to AhaSlides and asked to scan the course barcode and take the initial poll for practice. The initial poll asked about their current knowledge of DLD. Participants were informed to use the Q&A button at the bottom of the screen to submit questions. No visual example of what participants would see on their cell phone screens was provided, which could have assisted participants in understanding the technology. All the participants, however, were able to participate in the first poll successfully. They then participated in the remainder of the presentation and interactive activities. At the end of the presentation, the participants were asked if they had any additional questions. It was also requested that participants complete the course evaluation, accessible using the QR code. They were reminded that their suggestions for improving the course were valuable. Instructions were provided for accessing and printing the Certificate of Completion once the evaluation was submitted. The instructor recorded the entire one-hour pilot course on Zoom for a personal review. DIABETIC LUNG DISEASE 26 Feedback and Future Application Pilot Course Evaluations All 11 participants filled out the course evaluation form. This evaluation provided valuable feedback on the course that can be used to make changes before its submission as a proposal for the 2023 Utah Society for Respiratory Care’s Annual Conference and Exhibition. Overall, the course appears to have well-defined and organized learning objectives, visual aids, and graphics that promoted learning and was interactive for learners. The survey on the overall content of the course identified two participants who scored the overall course content poorly. Upon closer examination, one of these participants’ Likert scale answers did not match their quantitative answers for improvements for the course, as they commented, "The course was great." Unfortunately, further investigation into the other participant's scores did not reveal any suggestions for improvements that could be made to the course. It would be beneficial in the future for willing participants to voluntarily give their contact information to allow the instructor to enquire about individual participants' responses. Evaluation of Course Content. The course evaluation used a Likert scale to evaluate how well the course met specific goals about the course content seen in Figure 2.This evaluation enabled the presenter to identify specific areas where the content of the course could be improved. The results identified that the areas with the most room for improvement in the course were the interactive elements and technology. DIABETIC LUNG DISEASE 27 Figure 2 Evaluation of Course Content Note. Participants’ evaluation of how well the course content met defined goals. (Graph from Google Course Evaluation Results, 2022) Evaluation of Interactive Activities and Technology. Overall, the interactive material ran well. The participation and results of the interactivities did identify that participants may need additional clarification about how to complete the interactive activity and how the question was stated. This issue may be resolved by improving the wording of the questions and adding instructions to each activity. The comments about the interactive activities ranged from "All of it was pretty interesting. I loved the interaction part. Maybe more of that" to "The interactive slides were confusing at times." Some of this variance may be due to individual participants' digital literacy skills and their comfort using technology. Some participants expressed that they would prefer an embedded quiz over a cell phone app to improve the course. While this cannot be done using AhaSlides, students could be directed that they are also able to use the link to complete the learning activities on their computers. DIABETIC LUNG DISEASE 28 Drawbacks of Course Technology and Interactives Activities. A drawback to AhaSlides is that the slides and notes are only accessible to the presenter online through the “backstage” platform and cannot be printed or downloaded. This means that the slides and notes cannot be printed or downloaded, providing the presenter with a paper copy that can be used during presentations. The presenter version was complicated and did not readily support a novice presenter being able to see the slide notes while presenting to the participants. The spacing of the interactive activities also interrupted the flow of the presentation. Upon reviewing the Zoom recording, the presenter confirmed that the availability of the presenter notes and the spacing of the interactive activities lead to interruption in her train of thought. It may improve the presenter’s flow of speech and decrease interruptions if some of the interactive activities are clumped together. The presenter also identified that some activities need to be changed to better prime the students for learning and assess the participants' understanding of course material. Planned Changes to Interactive Activity. To prime the participants in the pilot course, an interactive word cloud activity was used to help students identify their personal bias towards obese diabetic patients who comes in with shortness of breath. After reviewing the pilot course, it is evident that this activity did not sufficiently engage the students in thinking about DM and did not activate their prior knowledge about diabetes. This activity will be removed entirely and replaced with a new word cloud activity that primes participants to recall what they think they know about DM. This new activity will also be placed at the beginning of the presentation with the first poll to improve the lecture flow. The resulting word cloud will help participants recall their knowledge about DM and give the presenter a preassessment of the participants' current knowledge. The presenter can then begin stacking new information about DM onto students' DIABETIC LUNG DISEASE 29 current knowledge as they introduce participants to the course's "big" question, "Does Diabetes Cause Damage to the Lungs (Respiratory System)?" Valuable and Helpful Course Content High-Quality Slides. Participants were asked “What aspect of this course was most valuable or helpful?” on the course evaluation (See Appendix E). Two of the participants reported they found the slides "very good and helpful." These comments support that the purpose of the slides, to serve as visual guides to help students remember key concepts and build connections, was achieved. Reflection upon the pilot course revealed to the presenter that two slides need to be simplified due to their amount of information. For future presentations, the information on these slides will be simplified to allow students to properly chunk the information about insulin's role in the body and the function of endothelial cells. Course Content. Participants also identified that information in the course about DLD was very informative and valuable. The AhaSlide Brainstorming Activity also confirmed that participants found the course valuable, as can be seen in Slide 39 of Appendix E. While the responses are limited, the participant feedback about the value of understanding DLD is essential because adult learners need to understand how and why something will be of value to them when engaging in the learning process. It also provides the instructor with a visual idea of what the participants took away from the course. Participants' Suggestions for Improvements. Participants also provided qualitative feedback about how to improve the course (See Appendix E). Most of the participants did not offer any suggestions to improve the course. More constructive feedback would have been helpful in understanding what improvements could be made to the course. The limited feedback did point to differing views about the technology and how the presenter could enhance her DIABETIC LUNG DISEASE 30 delivery of the content. No formal questions about the delivery of the presentation were included as the purpose of the course evaluation was to improve the course content. However, some of the participants did provide some feedback about the presenter’s delivery of the course evaluation. Presenter’s Delivery. Participants confirmed the presenter's observation of their delivery of the course material. It was observed during the presentation that through the Zoom recording that more practice in public speaking and memorizing the course material would improve articulation and improve transitions. One participant suggested that the presenter should " take a deep breath when you want to say hum," which was said very frequently. Additional opportunities in front of small groups, such as at a staff meeting, would also offer further opportunities for the presenter to become more familiar and confident with the delivery of the course material and in general public speaking. In addition, these opportunities would also provide more valuable feedback about the course and the suggested changes. Case Studies. Another participant commented, "I would like more case studies type information to correlate with the elements presented.". Unfortunately, this suggestion cannot be added to the course as there is still minimal research available. In fact, at this time, no case studies can be found. However, more specific research examples can be added to the course content, and the presenter can collect case studies as they become available for future use. Evaluation of the Course Goals At the beginning of the course, an AhaSlides poll (Figure 3) was conducted to identify students' current depth of knowledge about how DM affects the respiratory system. It is interesting to note that there is some contradiction between the AhaSlide poll answers and a similar question from the course evaluation (Figure 3), using a Likert scale to collect information about participants' perceived knowledge of the subject prior to the course. DIABETIC LUNG DISEASE 31 This contradiction seen between the AhaSlide poll and course evaluation may be due to how participants understood the question on the course evaluation compared to the poll question asking directly about participants' knowledge about DM's effect on the respiratory system prior to this course. These questions should be revised to improve clarity before future presentations so that the course evaluation directly asks about participants' knowledge of DLD. Figure 3 Comparison Between AhaSlides Poll and Course Evaluation Note. The learner’s perceived knowledge about the subject of DLD. (DLD Pilot Course AHA Slide, 2022; Course Evaluation Results, 2022) DIABETIC LUNG DISEASE 32 Improved Understanding of Subject Matter Overall, the course participants reported improved subject knowledge after the pilot course in the evaluations. All participants reported improved subject knowledge upon course completion. The following comments on what aspects of this course they found valuable or useful show an understanding of DLD. ● "Thinking of how other diseases affect the lungs." ● "How diabetes directly affects the respiratory system." ● "Basic knowledge of lung and diabetes" ● "Understanding how diabetes contributes to respiratory exacerbations and chronic lung damage." ● "My dad has type II diabetes, so this was very interesting to learn about and how the lungs are affected with someone who has diabetes." Participants maintained that the information on DLD was very interesting and informative. Most participants were unfamiliar with DLD and were able to take away some new understanding of how DM affects the respiratory system. Future Recommendations Creating the course objectives was time consuming due to the novelty of DLD. In hindsight, it may have been beneficial to conduct a survey to fully understand the general learning needs of RTs, their current knowledge of DLD. This understanding would have given some valuable insight into the creation of course objectives and content for this course. Conducting the pilot course was invaluable. It revealed where changes could be made to improve the course and learners' perceptions of the interactive activities. The participants of the pilot course reported a positive learning experience and increased understanding of DLD after DIABETIC LUNG DISEASE 33 the course material. The evaluation results from the pilot course also revealed that in the future, it might benefit understanding learners' digital fluency. RTs' digital fluency can be evaluated as part of the course evaluation by adding a question about participants' perceived comfort with technology or by researching RTs' comfort and preferences for the different types of learning technology. Additional experience giving this presentation would provide the instructor with beneficial experience presenting not only this material but any future instructional activities in which they participate. It is also beneficial for them to identify resources to help them overcome public speaking challenges. These resources could be added to the lesson plan to assist any others who would like to present on DLD. To promote an overall increased understanding of DLD in the healthcare industry, creating a shorter presentation that would be appropriate for general healthcare professionals' staff meetings may also be beneficial due to the budget restraints of education in the healthcare industry. Finally, before submitting this course for an AARC conference or the 2023 Utah Society for Respiratory Care’s Annual Conference and Exhibition the following changes will need to be made: ● The new word cloud activity needs to be made and the slides reorganized to accommodate a change in priming learners. ● Two slides previously discussed need to be edited by simplifying and chunking their critical ideas to promote learning. ● Questions for both the interactive activities and course evaluation need to be reviewed to ensure they promote thinking and are fully understood as intended. DIABETIC LUNG DISEASE 34 ● The AARC CRCE certification template must be completed and approved for any future courses and attached to the updated course evaluation form. Summary. This curriculum project has provided RTs with a continuing education course that is shown to effectively introduce them to DLD. Creating this course required an understanding of how to use learning technology, a Backward Design (Wiggins & McTighe, 2005) curriculum process, and evaluation methods to create a lesson with well-defined objectives and a learning assessment. In the future, to become more successful in developing curriculums time can be spent learning how to create better assessments and continuing to learn about how adult students learn. In addition, it will be beneficial to improve presentation skills for better course delivery. DIABETIC LUNG DISEASE 35 References Adams, S., Pitts, J., Wynne, J., Yawn, B., Diamond, E. J., Lee, S., Dellert, E., & Hanania, N. (2012, September). 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Aging and Disease, 8(1), 7-16. https://doi.org/10.14336/AD.2016.0627 DIABETIC LUNG DISEASE 43 Appendix A-Social Media Ad DIABETIC LUNG DISEASE 44 Appendix B-Event Registration Form DIABETIC LUNG DISEASE 45 DIABETIC LUNG DISEASE 46 Appendix C-Consent to Participate IRB STUDY #XXXXXXXXXX WEBER STATE UNIVERSITY INFORMED CONSENT Diabetic Lung Disease Curriculum Study You are invited to participate in a research study evaluating a curriculum being developed about Diabetic Lung Disease. You were selected as a possible subject because you are a respiratory therapy student/faculty member who is registering for this course online. We ask that you read this form and ask any questions you may have before agreeing to be in the study. The study is being conducted as part of a graduate project by Kami Clark, a Student in Master of Education Program. It has no funding. STUDY PURPOSE The purpose of this study is to evaluate the quality of the Introduction to Diabetic Lung Disease course curriculum thru an online survey to provide feedback on how it can be improved before it is submitted to the American Association of Respiratory Care (AARC) as a presenter proposal. This study is to collect information as part of Kami Clark’s curriculum graduate project. This study does NOT involve any use of drugs or devices. NUMBER OF PEOPLE TAKING PART IN THE STUDY: If you agree to participate, you will be one of approximately 20-50 subjects who will be participating in this research. PROCEDURES FOR THE STUDY: If you agree to be in the study, you will do the following things: Complete the online registration form. You will then be registered to participate in a live online course about Diabetic Lung Disease. A Zoom link will be sent to all registered participants that will allow you to attend the course on the selected date. You will then participate in the 1-2 hour course on Zoom. The session will possibly be recorded for the researcher graduate project and for potential submission of the presenter proposal only. Immediately after the course you will take a 5-10 minute survey that will ask you about the course design. The survey will be immediately distributed through a Google Form that can be retrieved by a QRS code or link and can be taken on your phone, tablet, or computer. The course content will not be surveyed, only the design of the course. Once the survey is completed the feedback will be used to improve the curriculum before it is submitted as a presenter proposal to the AARC. RISKS OF TAKING PART IN THE STUDY Possible risks/side effects of participating in this study include: The risks of completing the survey are being uncomfortable answering questions. DIABETIC LUNG DISEASE 47 The risk of possible loss of confidentiality. BENEFITS OF TAKING PART IN THE STUDY You will not receive payment for taking part in this study. You will possibly gain some knowledge about Diabetic Lung Disease. ALTERNATIVES TO TAKING PART IN THE STUDY: Instead of being in the study, you have these options: The only alternative to this study at this time is not participating. COSTS/ COMPENSATION FOR INJURY In the event of physical injury resulting from your participation in this research, necessary medical treatment will be provided to you and billed as part of your medical expenses. Costs not covered by your health care insurer will be your responsibility. Also, it is your responsibility to determine the extent of your health care coverage. There is no program in place for other monetary compensation for such injuries. However, you are not giving up any legal rights or benefits to which you are otherwise entitled. If you are participating in research which is not conducted at a medical facility, you will be responsible for seeking medical care and for the expenses associated with any care received. CONFIDENTIALITY Efforts will be made to keep your personal information confidential. We cannot guarantee absolute confidentiality. Your personal information may be disclosed if required by law. Your identity will be held in confidence in reports and databases in which results may be stored. If tape recordings or videotapes of the session are recorded, they will only be used by Kami Clark for her graduate project review and defense. Kami Clark and her graduate committee will have access to these videos for educational purposes only. They will be destroyed 3 years after the research study is completed. Organizations that may inspect and/or copy your research records for quality assurance and data analysis include groups such as the study investigator and his/her research associates, the Weber State University Institutional Review Board or its designees, the study sponsor, and (as allowed by law) state or federal agencies, specifically the Office for Human Research Protections (OHRP) and the Food and Drug Administration (FDA) [for FDA-regulated research and research involving positron-emission scanning], the National Cancer Institute (NCI) [for research funded or supported by NCI], the National Institutes of Health (NIH) [for research funded or supported by NIH], etc., who may need to access your medical and/or research records. CONTACTS FOR QUESTIONS OR PROBLEMS For questions about the study, contact the researcher Kami Clark at (801)821-0526 or the researcher’s mentor Stephanie Speicher at (801)626-6214 For questions about your rights as a research participant or to discuss problems, complaints or concerns about a research study, or to obtain information, or offer input, contact the Chair of the IRB Committee IRB@weber.edu. DIABETIC LUNG DISEASE 48 VOLUNTARY NATURE OF STUDY Taking part in this study is voluntary. You may choose not to take part or may leave the study at any time. Leaving the study will not result in any penalty or loss of benefits to which you are entitled. Your decision whether or not to participate in this study will not affect your current or future relations with Weber State University. If you choose to withdraw from this study prior to completion there is no risk to the participant. We ask that if you choose not to complete the study that you notify the researcher by phone or email (kamiclark@weber.edu) prior to the scheduled course date and time. SUBJECT’S CONSENT In consideration of all of the above, I give my consent to participate in this research study. I will be given a copy of this informed consent document to keep for my records. I agree to take part in this study. Subject’s Printed Name: Subject’s Signature: Date: (must be dated by the subject) Printed Name of Person Obtaining Consent: Kami Clark - DIABETIC LUNG DISEASE 49 Appendix D- Course Evaluation DIABETIC LUNG DISEASE 50 Appendix E-DLD AhaSlide Presentation Slide 1 Notes- DIABETIC LUNG DISEASE 51 Slide 2 Notes- DIABETIC LUNG DISEASE 52 Slide 3 Notes-Today we are going to use AHA Slides. First I need you to scan the barcode with your phone or you can put the link at the top of the screen in your browser so you can participate. We are going to practice with this first poll. Also, you can see on the bottom of the screen a button that says Q&A. You can click on that if you have questions you would like answered later or you can raise your hand. There are also emojis at the bottom you can use to let me know whether you understand or not. DIABETIC LUNG DISEASE 53 Slide 4 Notes-Here are the results of the first poll. As you can see by the result most of us did not know about DM caused damage to the respiratory system. Why is this important? DIABETIC LUNG DISEASE 54 Slide 5 Notes- Diabetes impacts us all. 1 in 10 people has diabetes. In fact, Globally Diabetes impacts 537 million adults and is only predicted to increase. These odds are higher if you are related to me because in my Mom’s family 8 out of 9 kids had diabetes or prediabetes. Yes,my grandparents had 9 kids and No the 9th is not out of the woods yet. Yep, I have definitely hit the genetic jackpot and the chance of not getting diabetes or prediabetes is against all my odds. As a result, I have spent years trying to figure out how to overcome these odds, and yes, lose that extra weight that I was packing which insisted on following me everywhere regardless of any amount of exercise. Today, I am here to share what I have learned about Diabetic Lung Disease and help you think about and answer this question. DIABETIC LUNG DISEASE 55 Slide 6 Notes-I am here to share what I have learned about Diabetic Lung Disease and help you think about and answer this question. DIABETIC LUNG DISEASE 56 Slide 7 Notes- Globally and Nationally Diabetes cases are increasing. Sadly most of these cases are in low or middle-income countries. This means that health disparities are continuing to increase. DIABETIC LUNG DISEASE 57 Slide 8 Notes- In the US Minorities are Affected at Much Higher Rates. Especially those living in rural areas that have trouble with access to healthcare. Most of us know that obesity and cases of Type-2 diabetes in children in the US have been steadily climbing. While this trend continues, The US no longer has the Highest Rate of Diabetes Worldwide. In the US Minorities are Affected at much Higher Rates. Especially those living in rural areas that have trouble with access to healthcare. DIABETIC LUNG DISEASE 58 Slide 9 Notes- Why should we as RTs care about this growing burden? It increases infections. COVID has recently been identified as an example of a disease that impacts diabetics at a higher rate. Unfortunately, COVID-19 has been shown to infect and kill diabetics at a higher rate and has also been implicated in causing new-onset diabetes. Even scarier researchers have found that COVID-19 is causing insulin resistance due to changes in fat cells and metabolism, which can lead to prediabetes and diabetes.) Imagine what it means if COVID is not only increasing diabetes but Obesity numbers. DIABETIC LUNG DISEASE 59 Slide 10 Notes- If it was not for my family's experiences with obesity as well as a few wonderful patients I would have never questioned what I understood about obesity and diabetes. Before we dive into more details I would first like us to understand how common misconceptions about diabetes might limit RTs in our thinking. We have all had this patient with diabetes. The obese one, who comes in with SOB, and the Dr. orders Albuterol x 3 but we know that it never helps them. I would like you all to think about what you see in this picture. DIABETIC LUNG DISEASE 60 Slide 11 Notes-Okay, Pull out your phones. Time for a question. I would like you all to think about what you see in this picture. Why is this patient SOB? What word do you commonly think when you see this patient? Direct Students to be Honest!!! DIABETIC LUNG DISEASE 61 Slide 12 Notes-As we go through this learning, today. I want you to get curious. I want you to be thinking: Is there something else going on? Maybe something that is internal and more invisible? Specifically, what is going on in the respiratory system in our patients with diabetes? DIABETIC LUNG DISEASE 62 Slide 13 Notes-One thing we often forget about diabetes is that it is a systemic disease. Which means it affects everything. Most of us know that it affects the heart, kidneys, nerves, eyes, and blood vessels. Most of us know that it affects the heart, kidneys, nerves, eyes, and blood vessels. But have you ever wondered if diabetes might be causing the SOB in your obese diabetic? Maybe it is not just about a lack of a healthy diet, exercise, and that fat pressing on the diaphragm. Raise your hand, How many of you know that Diabetes affects a newborn's lung development? Have you ever considered that maybe it could also affect a diabetic's lungs? DIABETIC LUNG DISEASE 63 Slide 14 Notes-Does diabetes affect the respiratory system? I have spent the last two years exploring this idea, but the first thing I did was what most of you would do, it is the most obvious thing an RT can do... DIABETIC LUNG DISEASE 64 Slide 15 Notes- GOOGLE IT. This graphic is an example of what I found all over the internet. I would like you to take a moment and think about what you see. Do you find it PUZZLING that most diagrams of diabetes show that it affects every part of the body, but has little or no effect on the lungs and respiratory system? Do you THINK it is correct to assume diabetes would not affect the lungs (respiratory system)? Take a minute and share your thoughts with the person next to you. ZOOM IN and then use Think-Pair-Share to have students answer these questions about this slide. DIABETIC LUNG DISEASE 65 Slide 16 Notes-Because Dr. GOOGLE does not have the answer for us, We are going to have to EXPLORE what we do know about diabetes and how it causes damage. And thinking about what we know about diabetes we are going to have to CONNECT it to what we know as the Respiratory System. DIABETIC LUNG DISEASE 66 Slide 17 Notes-Most of you are familiar with Diabetes, however, I would like to review a few things that will help us understand DLD. Type- 1 is most frequently diagnosed in children. It is still not fully understood but it is thought to be caused by an autoimmune response to a virus. Type- 2 is most commonly associated with obesity and insulin resistance. While it is known that obesity can cause insulin resistance. It can also be a result of genetics, environmental exposures, steroid use, or as mentioned earlier COVID. Insulin Resistance can eventually lead to the beta cells in the pancreas burning out and decreased production of insulin. DIABETIC LUNG DISEASE 67 Slide 18 Notes-The chronically high blood sugar associated with both types of diabetes can lead to systemic damage. Hyperglycemia causes damage primarily as a result of Glycation and resulting AGEs, Oxidative stress, and Chronic Inflammation. Hyperglycemia causes damage to the respiratory system thru these same pathways as well. DIABETIC LUNG DISEASE 68 Slide 19 Notes-AGES, Oxidation, and Inflammation lead to endothelial cell dysfunction and tissue remodeling within the respiratory system. This cellular damage and dysfunction can lead to dysfunctional tissue within the respiratory system, such as microvasculation of the blood vessels and capillaries, fibrosis, and neuropathy. Endothelial damage is important for RTs to understand the due to its implications on the respiratory system. DIABETIC LUNG DISEASE 69 Slide 20 Notes-Let us EXTEND what we know about endothelial cells. Remember that they provide a defensive and protective lining between our tissues and organs in particular are slaughtered and maimed. These cells provide our tissues, organs, and bodies with a protective layer that regulates what can get through and sends out chemicals calling in additional troops if damaged. It is IMPORTANT to know endothelial cells' other roles as little factories that produce numerous chemicals to help the body function. A few which are important to RTs include those that regulate vasodilation and vasoconstriction (Nitric Oxide), others that regulate inflammation and blood clotting, and those that produce the building blocks of the matrix and influence cell proliferation (growth). The damage from AGES, oxidation, and inflammation to these cells contributes to much of the damage to the respiratory system as a result of diabetes. DIABETIC LUNG DISEASE 70 Slide 21 Notes-Damage from diabetes to the respiratory system has also been linked to insulin roles within the body as well. Insulin's role in moving sugar into the cells is well understood by most RTs. However, I know that I had little understanding of its role as an anabolic or growth-promoting hormone. Both deficiencies and an overabundance of insulin can result in pathological changes that can also impact the respiratory system. DIABETIC LUNG DISEASE 71 Slide 22 Notes-Insulin modulates the production/release of cytokines, cell migration, deposition of collagen, and mucus secretion this is important when it comes to understanding its impact on lung remodeling. Insulin is necessary for skeletal muscle function and growth. Defects of muscle metabolism include the diaphragm. Insulin also important role in smooth muscle contraction. Without it, the parasympathetic nervous system cannot tell the muscles surrounding the blood vessels and airways to contract. This also means that without insulin mucus cells do not produce secretions. How do you think this might be impacted if there is too much insulin? DIABETIC LUNG DISEASE 72 Slide 23 Notes-Hyperinsulinemia affects the lung in multiple ways (Kolahian, 2019): 1. Studies of inhaled insulin revealed that high insulin levels in the lungs results in contractions and thickening of the smooth muscles of the airways. 2. It has also been shown to inhibit surfactant production in the alveoli. 3. Insulin shifts the immune response in the lungs. Increasing Type-2 T Helper cells (Increased IL) and decreasing the Type-1 cells (delay hypersensitivity). It also increases mast cell degranulation and histamine release in the lungs, and activation of Macrophages. 4. Promotes the thickening of the extracellular matrix, endothelial cell migration, and fibrosis. DIABETIC LUNG DISEASE 73 Slide 24 Notes-The chronically high blood sugar associated with both types of diabetes can lead to systemic damage. Hyperglycemia causes damage primarily as a result of Glycation and resulting AGEs, Oxidative stress, and Chronic Inflammation, which cause damage to the respiratory system as well. Low and High levels of insulin also lead to further pathological changes in the respiratory system and These changes within the respiratory system have been dubbed DLD by Researchers. DIABETIC LUNG DISEASE 74 Slide 25 Notes-Because DLD research is advancing but it is not well-known or understood by most healthcare professionals. The name DLD was created by researchers to allow them to begin discussing the idea that diabetes leads to a group of pathological problems within the respiratory system. Giving a name to this advancing research also allows healthcare professionals to begin to discuss the little-understood and not, well-known complications of diabetes. For RTS to understand DLD we must first recognize what it is not. DLD research is advancing but it is not well-known or understood by most healthcare professionals. What DLD is not: DLD is not recognized as an official at this time. DLD has no official diagnostic criteria. DLD has no approved treatment. DIABETIC LUNG DISEASE 75 Slide 26 Notes-DLD is the name used by researchers to describe the newly recognized idea that diabetes causes damage to the respiratory system. DLD research is advancing but it is not well-known or understood by most healthcare professionals. DLD (Hyperglycemia and Hyperinsulinemia have been shown to affect the pathophysiology of the respiratory system. DIABETIC LUNG DISEASE 76 Slide 27 Notes-How Do you think DM effects the respiratory system? DIABETIC LUNG DISEASE 77 Slide 28 Notes-DLD is shown to affect the muscles of the respiratory system. Hyperglycemia causes muscle dysfunction and weakness. The intercostal muscles are likely also affected. In addition, the Nerves to the diaphragm are also affected. The result is hypoventilation and a feeling of SOB. DIABETIC LUNG DISEASE 78 Slide 29 Notes-As I said the nerves to the diaphragm are affected, however, the nervous system has many different functions in the respiratory system. Damage to the vagus nerve is frequently associated with diabetic gastroparesis, but the vagus nerve plays an important part in the autonomic nervous system. Specifically, airway bronchodilation and mucus production. You may better know this as the cholinergic pathway. Chronic inflammation associated also affects the sympathetic pathways by causing the smooth muscles surrounding the airways to become hyperresponsive. DIABETIC LUNG DISEASE 79 Slide 30 Notes-So to review we now know that the airways can become hyperresponsive from chronic inflammation. The damage to the autonomic process in the lungs from hyperglycemia can result in reduced airway tone (floppy airways), thickened airway walls, and decreased mucociliary motility. Remember that insulin also can impact the airways. Insufficient insulin can cause decreased mucus production and floppy airways, while hyperinsulinemia can cause increased mucus production and constricted airways. All of this can lead to a cycle of increased infections causing further airway remodeling. DIABETIC LUNG DISEASE 80 Slide 31 Notes-Hyperglycemia also leads to the remodeling of the matrix of the lungs. The lung matrix has been shown to be especially prone to glycation. This causes scarring, thickening, and stiffening of the lung tissue leading to fibrosis. Additionally, chronic inflammation also affects the matrix resulting in an increased number of inflammatory cells, such as neutrophils, macrophages, mast cells, and Th2 cells. This results in changes to the alveoli. DIABETIC LUNG DISEASE 81 Slide 32 Notes-The matrix remodeling can result in narrow airway spaces. This is a result of a thickened basal lamina and flattened epithelium. Damage to the epithelium can result in a leaky fluid membrane which can worsen the already impaired gas perfusion. DIABETIC LUNG DISEASE 82 Slide 33 Notes-Diabetes damages the blood vessels of the lungs. The lungs have a very extensive capillary network, and numerous small vessels surround the airways. Diabetes causes damage to these airways, impedes gas exchange, blood flow, clotting, and NO production. As a consequence of the damage to the epithelium lining the vessel walls diabetes increases your risk of developing pulmonary hypertension. DIABETIC LUNG DISEASE 83 Slide 34 Notes-In addition to pulmonary hypertension and pulmonary fibrosis, diabetes increases the risk of lung cancer. Diabetes also complicates and increases mortality rates of some of our (RTs) most common patient populations, such as those with COPD, TB, CF, OSA, and Pulmonary Fibrosis. It is interesting to note that the relationship between DM and asthma is more complex and is showing mixed results. While more research is needed, one study showed an increased risk of T1DM if you are asthmatic and another a reduced chance of asthma if you had T1DM. HbA1c does correlate with an increased risk of asthma. T2DM & obesity may increase the risk of asthma (specifically adult onset) DIABETIC LUNG DISEASE 84 Slide 35 Notes-Research is also offering us potential diagnostic testing. Studies utilizing PFTs show that DLD is a restrictive disease, with a low membrane diffusing capacity and reduced capillary blood volume. More recent research is confirming that DLD indeed causes structural changes to the lungs that can be seen on CT Scans. Routine Blood Diabetic blood tests like HbA1c have also been looked at and show a correlation between glucose control and lung restriction. DIABETIC LUNG DISEASE 85 Slide 36 Notes-Our profession has to overcome some future challenges that need to be addressed before we can begin to help our patients with DLD. However first more health professionals need to know about DLD. DIABETIC LUNG DISEASE 86 Slide 37 Notes-I would like you to think about these two questions before you answer my final question. DIABETIC LUNG DISEASE 87 Slide 38 Notes- DIABETIC LUNG DISEASE 88 Slide 39 Notes-Think about the last two questions as you answer this last question. Now let's take a look and discuss your answers. DIABETIC LUNG DISEASE 89 Slide 40 Notes- DIABETIC LUNG DISEASE 90 Slide 40 Notes- DIABETIC LUNG DISEASE 91 Slide 41 Notes- DIABETIC LUNG DISEASE 92 Appendix F-Certificate of Completion DIABETIC LUNG DISEASE 93 Appendix G- CRCE Certificate Template This template is provided by the AARC for CRCEs. It can be found at the following link CRCE Document Samples - AARC DIABETIC LUNG DISEASE 94 Appendix H-UbD Lesson Planner Understanding By Design – Backwards Design Process (Developed by Grant Wiggins and Jay McTighe, 2002) Stage 1 – Desired Results Established Goal(s)/Content Standard(s): •What relevant goals will this design address? [Comes from professional standards in your field] ● Respiratory Therapists (RTs) will be able to explain how diabetes (DM) causes damage to the respiratory system, known as Diabetic Lung Disease (DLD), and discuss its impact on the profession. Understanding (s) Students will understand that: ● What are the big ideas? [This is a goal, not an objective. List the big ideas or concepts that you want them to come away with, not facts that they must know Diabetes is a systemic disease, which includes the respiratory system, resulting in significant respiratory health outcomes to the patient. ● What specific understandings about them are desired? The increasing global burden of diabetes impacts respiratory therapists because diabetes can cause damage to the respiratory system. Damage to the respiratory system is a result of cellular injuries and malfunctions from high glucose, insulin, and resulting inflammation. Researchers have coined the term Diabetic Lung Disease to be able to discuss the idea of this damage. DLD creates changes to the cells, tissues, and organs that reduce the functioning of the respiratory system. DLD results from Epithelial Cell damage and malfunction, Micro/macrovasculature, Fibrosis, and Nerve damage. Essential Question(s): ● What provocative questions will foster inquiry, understanding, and transfer the learning? [What leading questions can you ask of students to get them to understand the Big Ideas? Address the heart of the discipline, are framed to provoke and sustain students' interest; unit questions usually have no one obvious “right” answer] Does diabetes affect the respiratory system? How does diabetes affect the respiratory system? What is the value in understanding Diabetes's effect on the respiratory system? DIABETIC LUNG DISEASE 95 PFTs and CT scans are possible diagnostic tools. DLD is shown to negatively impact an RTs most common patients as well as contribute to increased lung infections. (COPD, TB, CF, Fibrosis, Sleep Apnea) More research is needed about DLD to better help RTs understand how it impacts the profession. . ● What misunderstandings are predictable? Type 2 Diabetes is only a problem if you are obese and do not exercise and eat right. Diabetes does not impact the lungs or other parts of the respiratory system. DLD is a diagnosable disease with treatments. Student objectives (outcomes): Students will be able to: ● What key knowledge and skills will students acquire as a result of this unit? [These are observable, measurable outcomes that students should be able to demonstrate and that you can assess. Your assessment evidence in Stage 2 must show how you will assess these.] Summarize how hyperglycemia and hyperinsulinemia affect the different structures of the respiratory system. Apply their combined understanding of DLD and respiratory pathogenesis, to compare and contrast DLD with other respiratory diseases. Interpret their understanding of DLD and apply it to their current roles and specialties to create discussions about their view of DLD and its implications to the profession. ● What should they eventually be able to do as a result of such knowledge and skill? [Your learning activities in Stage 3 must be designed and directly linked to having students be able to achieve the understanding, answer the essential questions, and demonstrate the desired outcomes] Evaluate what they used to think about diabetes's effect on the respiratory system vs. what they now think about diabetes’s effect on the respiratory system. DIABETIC LUNG DISEASE 96 Stage 2 – Assessment Evidence Performance Task(s): ● Through what authentic performance task(s) will students demonstrate the desired understandings? [Authentic, performance-based tasks that have students apply what they have learned and demonstrate their understanding. Designed at least at the application level or higher on Bloom’s Taxonomy. ] Performance Task(s): ● Through what authentic performance task(s) will students demonstrate the desired understandings? [Authentic, performance-based tasks that have students apply what they have learned and demonstrate their understanding. Designed at least at the application level or higher on Bloom’s Taxonomy. ] Utilizing the book Making Thinking Visible by Ritchart, Church, and Morrison See-Think-Wonder Zooming IN Show a diagram of diabetes effects on the body. Think-Pair-Share Think-Puzzle-Explore Connect-Extend-Chall enge ● By what criteria will “performances of understanding” be judged? [Rubrics can be used to guide students in self-assessment of their performance] Other Evidence: ● Through what other evidence will students demonstrate achievement of the desired results? [Includes pre-assessment, formative assessment, and summative assessment evidence. Can be individual or group based. Can include informal methods such as thumbs up, thumbs down, and formal assessments, such as quizzes, answers to questions on a worksheet, written reflections, essay] Word Cloud Pre-assessment- Aha slide poll Using a scale and Poll How much do you think you know about diabetes or the effect of diabetes on the lungs? What do you think the value in understanding diabetes's effect on the respiratory system is? Formative assessment- Think-Puzzle-Explore Connect-Extend-Challenge Question and Answer using Aha Summative assessments- I used to think…, Now I DIABETIC LUNG DISEASE 97 think… What is the value in understanding diabetes's effect on the respiratory system? Student self assessment post eval. On this scale, how much do you know about DLD? Stage 1 Stage 2 If the desired result is for learners to… Then you need evidence of the student’s ability to… SO the assessments need to require something like… Understand that: The increasing global burden of diabetes impacts respiratory therapists because diabetes can cause damage to the respiratory system. Similar to the way diabetes damages the other systems of the body, it also damages the respiratory system Damage is a result of high glucose and high insulin. Hyperglycemia and hyperinsulinemia result in inflammation and proliferation of the tissues. Researchers have coined the term Diabetic Lung Disease to be able to discuss the idea of this damage. DLD creates changes to Explain ● Diabetic Lung Disease ● Causes (pathology) of damage to the respiratory system. Interpret ● The impact of increasing diabetes cases worldwide. ● DLD’s impact on the processes of the respiratory system. ● The implications of DLD on the profession Apply, by ● Comparing and contrasting DLD with other chronic respiratory diseases. ● Extending knowledge of DLD to potential prevention, treatments, and education. See from the point of view of (Perspective) ● Thru limits of current research. ● Challenge our assumptions of who is impacted by diabetes. ● Create a discussion using See-Think- Wonder on the current view of obesity and diabetes. ● Use Zoom In to identify and explain commonly known pathologies of diabetes and create a connection to the lesser-known DLD. ● Use Think-Puzzle-Explore to encourage and guide learners in connecting known etiology and pathologies of diabetes, high glucose, and high insulin to understanding about the pathology of DLD and its impact on the respiratory system. ● Create a discussion and Q&A guided by Connect-Extend-Challen ge to explore: 1) Current research DIABETIC LUNG DISEASE 98 the cells, tissues, and organs, that reduce the functioning of the process of the respiratory system. DLD results from Epithelial Cell damage and malfunction, Micro/macrovasculature, Fibrosis, and Nerve damage. PFTs and CT scans are possible diagnostic tools. DLD is shown to negatively impact an RTs most common patients as well as contribute to increased lung infections. (COPD, TB, CF, Fibrosis, Sleep Apnea) More research is needed about DLD to better help RTs understand how it impacts the profession. Consider the questions: Does diabetes affect the respiratory system? How does diabetes affect the respiratory system? What is the value in understanding diabetes's effect on the respiratory system? ● Patients ● Healthcare field Empathize with ● Patients with pre-diabetes and diabetes ● New idea of DLD Reflect on ● Personal understanding of diabetes ● DLD ● Impact to RT profession ● Future research, diagnostics, and therapies about DLD and other chronic respiratory diseases. 2) Implications to patients and profession. 3) Possible prevention, treatment, and education. ● I used to think…, Now I think… ● Survey of learners using a reflective prompt I used to think…, Now I think… About diabetes and DLD. Stage 3 – Learning Plan Learning Activities: [This is the core of your lesson plan and includes a listing describing briefly (easy to follow)] ● W= Where the unit is going? DIABETIC LUNG DISEASE 99 Learners will use what they currently understand about diabetes to create connections with how diabetes causes damage to the respiratory system. Once learners have identified how diabetes causes DLD, learners will reflect on their patient population to make connections between DLD and other chronic lung diseases, allowing them to reflect on the impact of DLD on patients and the profession. Depending on the required length of the conference presentations, learners could also be asked to reflect on future treatments, diagnostic tools, research, and education. ● H= Hook and hold interest Learners will be asked thought-provoking questions about an obese patient and graphic of complications of diabetes that will engage them in wondering about their current views of diabetes. Learners will then be challenged to use their current knowledge to build a new view of diabetes' effects on the respiratory system and theorize its impact on the profession. ● E= Equip all students Guide learning using PROMPTS (scaffolding and graphic organizer) to guide Thinking activities. Collaborative activities. ● R= Rethink and Revise their understanding Guided Q&A using Thinking activities including I used to think… Now I think…. ● E= Evaluate their work Thru discussion, compare and contrast, AHA word cloud, AHA poll, and AHA brainstorm ● T= Tailored learning (personalization to needs) Lessons designed for adult RTs Activity designed for collaboration. Activities designed to allow personal reflection of diabetes and DLD. Activities for personal reflection on how DLD impacts profession and how thinking has changed. ● O= Organized to maximize engagement AHA slides for interactive responses. Collaborative discussion among peers Questions: How does this impact my profession and patients and I used to think…now I think… Brainstorming solutions for treatment, diagnostics, education, and research. DIABETIC LUNG DISEASE 100 Appendix I-DLD Lesson Plan