Really there is a proper way to wean a vent.

One of the problems with small town hospitals is that there are usually only one specialist in a certain field. In our field as Respiratory Therapist we use the the pulmonologist specialist for our profession because they are the specialty doctor who deals with the lungs.

Here is a good page on what a pulmonologist does if your interested: Pulmonology

So anyways because I work at a small hospital we only have one pulmonologist on staff which creates the problem of not having the chance to consult another pulmonologist on a case. With only one of these doctors on staff also lets them be the know all do all doctor in this field, saying we do it they way he/she likes it done.

On with my problem of weaning ventilator patients. When I was in school and also when I was at other hospitals vent patients were weaned much more smoother, the rate was slowly decreased as needed, the oxygen level was decreased, they were given time to just breathe on only pressure support ventilation, and then if they survived that we would run weaning parameters and extubate. This to me is a humane way to wean and extubate a patient, much more friendly. Now back to my one pulmonologist and the way he does it. First off we use Assist Control mode like it's going out of style (which is actually is) and SIMV is almost unheard of as if this pulmonologist forgot to renew his subscription to Pulmonology Today. These poor patients are always put on Assist Control with a rate of 12 or greater but now here is the part that drives me nuts we wean directly off of this, for weaning parameters or a Tube Compensation trial we got straight from Assist Control with a Rate of 16 to NOTHING and hope there are good weaning parameters!!! How can you expect a patient to do well if you go from full support to nothing, this is not weaning. Weaning is a gradual process to remove something from something, like a bottle from a baby, you slowly give the child less and less bottles and more sippy cups or whatever. We do a sink or swim type of wean. Full support to nothing, this is not how I was taught nor how I've ever seen it done at a hospital where I have worked.

Amazingly though this doctor is well liked and respected with how he treats patients and their illnesses but when it comes to vents, my department cringes but does our best to deal with it.

Any comments would be much appreciated, I would like to hear if anyone else weans like this.

Keep driving on RT's.

Nebulizers or MDI's inline with a Ventilator?

Here at my hospital we seem to go through streaks of how we give medication to patients on ventilators. For a couple of months we might use MDI's and then we might just switch over to Nebulizers inline for a couple of months, and it is normally the same doctor who will oversee these patients on vents, it would be our pulmonologist who does it.

Tonight I just came back from being off for 2 days and we now have 3 ventilators running and all three of them are getting nebulized medications. One of the vent patients used to be getting MDI treatments but has now been switched over to nebulizer treatments. So I got to thinking which is better? Could this just be because he has Xopenex ordered as one of the medications along with Atrovent? Shouldn't be the reason we carry these by MDI also I have heard, even though I have yet to see a Xopenex MDI here at this hospital.

Doing some reading online and my own personal experience I have found different pro's and con's of using either a nebulizer or MDI with a ventilated patient, this is what I'm going to try and share with everyone, and I am looking forward to any opinions you might have for either side.


Metered Dose Inhalers Inline with a Ventilator

• MDI's have to be perfectly timed with a vent cycle
• MDI's give better deposition
• You need more puffs from the MDI to get a regular dose to a patient due to the moisture in the ETT that will cause the medication to stick to the ETT or inspiratory limb of the vent circuit. I have seen anywhere from 4 to 24 puffs given at any one time.
• MDI's treatments are faster than nebs.
  
• Need to give a pause after the breath otherwise the majority of the medication could possible go out the exhalation limb.
• You have to push the MDI right after the inhalation cycle starts or if your to early a lot of the medication goes out the exhalation side, you can actually watch this.
  

Nebulized medications Inline with a Ventilator

• Becomes a vapor like the humidification
• Do Not have to time with the ventilation cycle
• Same dose as you would use with a non ventilated patient
• Does take longer
• Does increase measured exhaled tidal volume and minute volume
• decreases the trigger sensitivity of the pressure supported breaths due to higher flow making a bigger negative pressure necessary, increasing he work of breathing in the patient
• may cause problems with the internal ventilator components due to the medication sticking to the components
• should possibly use a extra expiratory filter and maybe a inspiratory filter to protect the ventilator

Those are just some quick little notes of interest I have come across in my researching information for this article along with information I have learned as my time of being a RT.

Some more information I have learned about the placement of the nebulizer and MDI's when you give the treatments I have found and some I have known or used in the past.

When giving a MDI through a ventilator you should put the MDI inline as close to the wye as possible and up to 6 inches behind the wye. Always give the puff timed with a inhalation cycle or it will go down the exhalation side and not to the patient.

With the nebulizer inline I was really curious about the best way to place the nebulizer inline as to get the best treatment and from what I found which was the consensus was to put the nebulizer as far back from the wye on the inspiratory side as possible. Some even will put it behind the humidifier as they found that the aerosol of the nebulizer will mix with the humidified water aerosol, which are basically both the same. The reason it is said to place it farther back is so the inspiratory limb on exhalation will fill up with the nebulized medication aerosol and on inhalation there is a larger concentration of medication given to the patient. There is also the old law that says a gas will go towards the area with the least resistance, so if its closer to the wye the exhalation flow will be the area of least resistance due to the flow and there is a entrainment aspect to that side of the tubing also. Which makes sense to me.

I now after reading am more partial towards the use of nebulizers inline with a vent than MDI's at this time. I also will be moving my nebulizers farther back from the wye, which I will do here in about a hour's time. I lot of my questions were answered by doing some research and I hope I might of given you some more information that you never really knew.

One more thing, DON'T Forget to remove the HME before you give a treatment!!!

Drive on RT's

Miracle, sure it is, but something is missing.

I ran across this new article here from Newsnet 5 talking about a woman who was clinically dead but miraculously came back to life and all was well.

Here is the article, for you RT's out there you might find something out of the ordinary, or which I have given a hint by making the area's bold. This will also all into line a bit with my previous article about respiratory mishaps in movies and TV shows.

Woman Wakes Up After Family Says Goodbye, Tubes Pulled

CLEVELAND, Ohio -- A West Virginia woman was being transferred to the Cleveland Clinic after walking the line between life and death. Doctors are calling Val Thomas a medical miracle. They said they can't explain how she is alive. They said Thomas suffered two heart attacks and had no brain waves for more than 17 hours. At about 1:30 a.m. Saturday, her heart stopped and she had no pulse. A respiratory machine kept her breathing and rigor mortis had set in, doctors said. "Her skin had already started to harden and her fingers curled. Death had set in," said son Jim Thomas. They rushed her to a West Virginia hospital. Doctors put Thomas on a special machine which induces hypothermia. The treatment involves lowering the body temperature for up to 24 hours before warming a patient up.After that procedure, her heart stopped again.

"She had no neurological function," said Dr. Kevin Eggleston. Her family said goodbye and doctors removed all the tubes.

However, Thomas was kept on a ventilator a little while longer as an organ donor issue was discussed.

Ten minutes later the woman woke up and started talking.
"She (nurse) said, 'I'm so sorry Mrs. Thomas.'
And mom said, 'That's OK honey. That's OK," Jim Thomas said.
Val Thomas and her family strongly believe that the Lord granted them their miracle and they want everyone to know."I know God has something in store for me, another purpose. I don't know what it is but I'm sure he'll tell me," she said. She was taken to the Cleveland Clinic for specialist to check her out. Doctors said amazingly she has no blockage and will be fine.

I just find this funny as we all know what you cannot talk while on a ventilator especially with a endotracheal tube in. I'm sure she wasn't trached with a Passey Muir valve on or a capped trach with fenestration since this seemed to only happen in about 24 hours. As bad off as she was I'm thinking a trach was the last thing they were thinking about. I just found that interesting how the media can get things wrong.

So what to do, well I'm going to drop a email off to this news channel just to see if I get a response. I'm thinking this was maybe make to be a little over dramatic as most of the public has not clue with some of this medical stuff. But us RT's will catch the little respiratory inconsistencies that people will make when it comes to our profession right.

If I get a response, it will be posted here for all to see at a later time, but I'm not really expecting anything to much, you never know though.

Drive on RT's.

Moments of Busy.

As you might of noticed from my last post that we are really not all that busy here in my RT Cave, but we do have our moments of busy and last night was one of them.

I get here at my normal time of 1830 figuring on a pretty decent night. I do the normal thing, put my coat and my food in my locker and fridge and then page the RT on shift to see if they need any help, usually it's a "Nope, I'll be right up.". Well not this tonight it was more of a "Could you get started on the treatments and meet me in the ICU, or I'll find you when I'm done." Ok still nothing to really get me thinking busy, I mean our treatment load is 2 QID's and one Q4, sure I can knock that out.

After I get those 3 really tough nebs (sarcasm) done I head off down to the ICU to see if my partner needs any help, well yep she does with a patient who is vented. Now I notice that she is bagging this patient and the vent is next to her and running, so I ask whats going on? She had been bagging this patient for over a hour now because the vent will not ventilate the patient. I go ahead and check out the vent to make sure it's working properly and passes all the self tests ... Yep works just fine, this patient is crap.

I go ahead and take over the bagging and get some report, this patient is septic in falling deeper into ARDS (Adult Respiratory Distress Syndrome) and is so tight that on Assist Control the most tidal volume we can get in is 30-50 ml's, not good. Alright next try is Pressure Control, great we have a Inspiratory Pressure up to 40 with no peep and can only get about 100-150 ml's VT, still not good.

My Partners pager goes off ... now what. Of course it's nothing good, we have another patient that I had done a neb on just about 20 mins ago now crashing so off she goes and there I am bagging a patient who cannot ventilate and is stiff as a board.

So it's now a Hour and a Half later, my hands are cramping and I'm still bagging and trying to figure out what to do, well dialysis is called in to get some fluid, almost 5 kilo's are wanted to be taken off, and hey here comes my partner with the other patient behind her while she is pushing a bipap machine, great what the hell is going on there. Turns out he has a reaction to a antibiotic that was just given to him that looked just like orange juice, now I'd think that would be rough going in on the veins. With further questioning I find out that the med he was give required you to premedicate the patient with Tylenol and Benedryl before it's administered, wow hardcore stuff there.

Finally 2 hours later my partner is able to give me some relief in the bagging area and the dialysis is started finally and a half hour later we are able to ventilate with PC on the ventilator, phew finally we can step back and relax a bit.

Now This patient pretty much stayed the same during the night. I ran three ABG's on the patient and from number 1 to number 3 the biggest change was a PO2 from 45-49 to good in the oxygenation department and spo2 was showing in the low 80's, but Doc said he was good with that and really didn't know what else to do because nothing was working.

Now getting a chance to think of everything that happened you start to notice the limitations of a smaller hospital. Heli-Ox would of been nice but we have none of that. PRVC mode might of worked but we don't have that on the PB 840 vent, there is VC+ which is supposed to be like PRVC but didn't really work to well as I tried it. Would of been perfect patient to transfer out but the weather was crap. So what do you do? Improvise and do the best with what you have, what else can you do, in a way it does make you use you knowledge a bit more versus using technology so much.

I must say I do like interesting patients and this one is interesting. Tonight I get the honor to having this patient again and so far nothing is improving, just a little increase in the saturation of oxygen area, but that could be due to the peep going from 12-16 cmh2o today. So tonight my last day before Christmas working I am still slow, with a Ventilator and a Q4 neb but as we all know anything can change at anytime.

Happy Holidays.

Respiratory Therapy in TV and Movies.

Have you ever caught yourself watching a movie or TV show, where there are hospital scenes, looking for respiratory related things in the show? Finding something done correctly is hard to do. What got me on to this idea? Well I was watching the movie with Billy Bob Thorton called "Astronaut Farmer" and there is a part where he ends up pretty injured and in the hospital supposedly on life support. Looking a little closer in the scene I notice that he is connected via endotracheal tube to a Vision Bipap and with a closer shot he is on a t-piece connected to that Bipap. Finally the scene pans out and I notice there is a Puritan Bennet 840 Ventilator on the other side of the bed with NOTHING connected to it, now granted the average person will not notice these things but Us as RT's should notice these things. So yes this is what has me thinking where have I scene RT issues in movies and TV shows and what better way to get this going but to start a list.

My List to Respiratory Therapy things in Movies and TV shows

1. Astronaut Farmer - Billy Bob Thorton connected to Vision Bipap with a T-Piece and a PB 840 Ventilator next to the other side of the bed.
2. ER - Many shows the yell "Page Respiratory", but you never see them. The Doc's bag the patient then they either die or move off to O.R.
3. Sopranos - Tony's nephew Chris is in the hospital and a Incentive Spirometer is on the bedside, and there is a Episode where Uncle Junior gets fitted for a CPAP machine for his sleep apnea, and a scene he falls asleep and his girlfriend puts in on him. I'm actually impressed here, to items you wouldn't think directors would think of for a show.
4. Sherlock Holmes Returns (TV) - on there is a film credit for Peter Kelamis as the Respiratory Therapist. This I came across in a google search, click on the link to see, never actually saw the show but now I'm curious.
5. Million Dollar Baby - Hillary Swank's character Maggy Fitzgerald is shown talking, while she is being ventilated via a tracheostomy tube in her throat. Although people can talk using "fenestrated" tracheostomy tubes, they can't be ventilated at the same time. But then again how many people actually know this.

Anyways I'm sure there are many others out there, I know I have seen a show/movie where the MA-1 ventilator in the corner breathing away and the patient is sitting there talking with a cannula on. I think there is a shock factor of the bellows moving and the sound of, shuuuu hahhh shuuuu hahhhh. I will continue to explore this RT related issue on the silver screen and would appreciate any noticeable scenes anyone else might have seen. Maybe somehow I could become a consultant for Respiratory Therapy on upcoming movies and TV shows, I would love to show the proper way to do mouth to mouth to Halle Berry or Jessica Alba and check some lung sounds, hell I'll even do a EKG on them. Could happen right?

Talk care and keep breathing.