Oxygenation and Ventilation, there is a difference.

I got a call from a nurse the other day at the beginning of my shift telling me about a patient who's oxygenation saturation had dropped to the 80's, she continues to tell me that this patient has a neb treatment coming up and if I can give it a bit early.  I ask her what oxygen device and flow the patient is on and she tells me and I respond with, "Increase the flow and give the patient more oxygen."  The nurse continues with chatter about the neb tx so I tell her, "You know that neb tx's are not to increase oxygenation they are to help with ventilation."  There is a pause and she says, "Nebs don't help the oxygen of a patient?"  She seems just plain stunned, and this is a seasoned nurse.

This is a topic that I've had to explain it multiple times to non RT's.  Neb's relax the smooth muscle tissue so it's easier to take a deeper breath if there is bronchoconstriction.  Neb's do not increase the oxygen in the blood, honestly you only running the neb and giving about 40% oxygen, if the patient is on a higher oxygen percentage their sat will most likely decrease if we go from a non-rebreather to a neb.  The particle size from a neb is 0.5 micron's where the size of alveoli is only 0.1 micron's,  how is Albuterol supposed to fit into the alveoli to help it oxygenate the blood?  Albuterol helps with ventilation not oxygenation, if you want to increase the oxygen level of a patient GIVE MORE OXYGEN, and then figure out why they need more oxygen.

Oxygenation and ventilation do not correlate with each other, increased ventilation does not necessarily increase oxygenation and visa-versa.  I have seen asthmatics struggling to get a breath and still have good sats and I have seen people with sat's in the 70's and still be breathing comfortably.   Treat the problem, if oxygen is low give oxygen, if the patient can not get a breath in and is tight treat the problem causing ventilation issues, just as if CO2 is elevated increase ventilation to remove this CO2.

This is another reason why there are RT's to educate on about one the most important systems in the body, we need to breath.  Oxygenation vs Ventilation, if we teach the difference we may start to get calls for the correct treatments.

Frustrations of Advancing up the chain in Respiratory.

Respiratory Therapy is a great and rewarding career, you get to help people daily, see them improve and unfortunately see their health deteriorate also, but that's the nature of the game in a health care field.  RT's get to move around the hospital getting to know many areas of the hospital and you're not stuck in a cubicle anywhere.  Unfortunately I do see a downside to this career, and that's room for advancement.

I've been a RT for 20 years now and have been looking for opportunities to advance and move up the so called "Chain of Command" and get into the management side of healthcare, and the problem is there is not a lot of room for RT's to move up, really the only spot is the head of the RT department or maybe if you're in a bigger hospital a shift leader position.  Nursing on the other hand can move into management in many different area's of a hospital, for instance my department just went through 2 years of having our Operations Leader who is a RN, not a RT which is was for decades.  Fortunately recently we went back to having a RT as a Operations Leader.

RT's who are looking to move up in management have to look around outside of the hospital unless a opening comes up in your department because it seems people who get into RT management like to stay there because of the lack of opportunities for positions in management in the RT field.  I've known RT's who have moved a few states over just to take a management position over a RT department, or just moving to another hospital when they noticed something opened up.

So if you're looking for move up in the chain, a lot of times it's not easy and you either get lucky and something opens up in your department, otherwise you basically have to look outside of where you work, or get a degree and something else.

Drive On RT's.

The good old days for helping asthmatics.

I present to you:

Dr. R. Shiffman's Asthmador Cigarettes.

     Apparently when doing some research Stramonium and Belladonna both have bronchodialation and anti-inflammatory properties.  Belladonna is also a type of Nightshade plant which was used as a poison in the middle ages.

Women who quit smoking before 30 cut risk of tobacco-related death by 97%

Women who quit smoking before 30 cut risk of tobacco-related death by 97% according the a new study from the Lancet of more than 1 million women.  This is good news for those female teenagers who started in High School and then decide to quit early.

"Women who smoke into middle-age have three times the death rate of non-smokers and risk dying at least 10 years early, according to adefinitive study of the effects of tobacco in more than a million women in the UK.

The good news, according to the study by a team of Oxford University researchers led by Sir Richard Peto, is that giving up cigarettes before the age of 40 reduces a woman's risk of smoking-related death by 90%. Quitting by 30 reduces it by 97%."  - from the Guardian Article.

Common Sense in Respiratory

Why is that when someone is coughing outside of the hospital they will go get cough medicine or a decongestant?  But when there is a patient coughing in the hospital the first treatment of choice is the great a powerful nebulizer.  This always amazes me because I see quite a few patients where just a nice cough medicine would probably do the trick to get rid to the dry throat or the tickle in their upper airway.  Now I do know that some cough's are caused by a bronchospasm, but ER's are notorious for calling for a nebulizer treatment on any patient with a cough even though they have not actual respiratory history.  I'm pretty sure that cough medicine is much cheaper than calling us RT's for a nebulizer tx.

In another aspect of common sense I see quite a bit in my 16 years as a therapist is the classic, "The patient got up to use the bathroom and now is back in bed and winded."  Yes a COPD patient or a morbidly obese patient will get winded by walking to the bathroom and back when they are sick.  Lets compare this walk with a 5 mile run in a healthy person.  When I go for a run and I stop yes I am winded but I do not have bronchospasms going on.  Now lets think what works for relieving my windedness (not sure if thats a word), well I just rest and can re-cooperate back to my normal breathing.  Back to the sick COPD or morbidly obese patient, or even a pneumonia patient, moving that short distance in their present condition can cause them to be winded or short of breathe, not really due to a bronchospasm but because their body is out of shape due to their current condition, so it is my thought that if your allow these people to sit and re-cooperate they will recover.  Again as I said previously there are situations where one of these patients could definitely be having a legitimate bronchospasm, but I've seen it multiple times where I'm called for a breathing treatment on these patients when I'm with another patient and by the time I get to this patient they have recovered.  The recovery can also be sped up by increasing their oxygen flow if they are on for a little while.

These are all just observations I have noticed, but they seem to fall under the use of common sense and just thinking things through, even though most of the time the nurse and patient really don't want to hear this they just want immediate solutions and in their mind medicine is the best treatment.

Grave risk of silica.

Study Exposes Grave Health Risks of Silica

A study conducted in China has recently unearthed some new findings that could be very important to the prevention of future respiratory problems. The study, which was conducted by Chinese scientists over many years, followed and examined a large group of Chinese mine workers that were exposed to a compound called silica. Silica is a substance that is present in both sand and rock, and can be extremely harmful if inhaled. It is perfectly harmless if contained within the rock or the sand, but when rocks and sand are drilled or broken, fine silica dust particles then escape. These are easily inhaled and then lodge themselves deep within the lungs. This leads to all kinds of problems, such as scarring and respiratory issues and even death.

The problems experienced by the Chinese workers - who were working in places such as mines, pottery factories and gem stone factories - had a sinister outlook. The study found that the workers were not only experiencing problems with breathing, but as a result were also at a greater risk of contracting very serious heart problems, infectious diseases and even cancer.

Significant findings

The study is of particular significance due to its sheer size. The scientists monitored the health of 74,040 mine and pottery workers in China, and over a period of 33 years. They then compared the health of these workers to that of people who were not exposed to silica.

One of the leading researchers on the study, Professor Weihong Chen at the School of Public Health, Huazhong University of Science and Technology in Wuhan, Hubei province, acknowledged the new significance of the findings: "In addition to a higher risk of respiratory disease, we see a heightened risk of cardiovascular disease in exposed workers," she said. "This is a new discovery."

The findings of the study are likely to change the focus of health concerns for those conducting jobs with a high exposure to silica and other harmful dust particles; not only for those in mining jobs but also those conducting regular activities such as joinery, glass engraving or sanding. "Before we were mostly concerned about respiratory diseases," Professor Weihong Chen explained. "As to whether it raises the risk of cancer, we can give a definite answer: We see a heightened risk of lung cancer in workers exposed to silica."

Large scale

The results of the Chinese study are not only significant in terms of focus and direction of health care issues for these workers, but also in terms of the scale of the risk being posed. The study found that workers exposed to silica were a massive seven times more likely to develop harmful infectious diseases, five times more likely to develop serious respiratory tuberculosis, and around twice as likely to develop some form of cardiovascular illness than those people that worked in clean environments with little exposure to silica. Also among the findings of the study was that those working in environments such as pottery factories or mining wells were almost twice as likely to develop nose or throat cancers.

This study should set off warning bells for industries such as mining, pottery and stone farming, not just in China, but throughout the rest of the world. China is one of the many countries that has a strong industrial dependency, with around 23 million workers exposed to silica through their jobs. Although the United States has nowhere near this number (we currently have around 1.7 million people in these trades), we still have a huge number of people to think about.

Silicosis

One form of harmful respiratory disease is a condition called silicosis that, as its name suggests, is caused by silica. In China, around 24,000 workers die from this disease every year as a result of silica getting into their lungs and staying there. The silica causes so much inflammation, scarring and pain that people with the disease die young - commonly in their forties. This is a huge proportion and a grave cause for concern.

It is hoped that the publication of this study and its findings will lead to increased awareness of the dangers of exposure to silica and will prompt companies to do all they can to decrease the risk of harm to their workers. Professor Chen has made the following recommendations for organisations.

"We recommend that worksites control levels of such pollutants; it's a public health problem. Through changes in the work environment, we can reduce the risk of disease and (early) death. Factories can use stronger ventilators, and more effective masks for workers will reduce silica exposure."

Members of the general public should also take this study as a warning of the dangers of dust compounds such as silica. It is always dangerous to expose your lungs to overly dusty environments. Wearing masks in these circumstances will go some way to protecting your lungs against harmful long term damage.

The ground-breaking study was published this week in the Public Library of Science journal PLoS Medicine.

Obese children with asthma need more Steroids

Obese children need more corticosteroids then these children do according to this study.
Obese children with asthma require more steroids.

This goes well with I do you said to people lost more weight would spend less time because our country is at an all time high score obesity.

Ondine's Curse - Rare form of sleep apenea

So I happened upon this Wikipedia article about Ondine's Curse, also called congenital central hypoventilation syndrome (CCHS) which is a respiratory disorder that is fatal if untreated due to the person with he curse having a respiratory arrest while sleeping.  This is a central sleep apnea which is congenital by nature but can occur from a head injury, this can occur in 1 in 200,000 people born so it is quite rare, according the information in 2006 there were only 200 known cases at the time in the USA.  What I overall understand about OnDine's Curse is that basically you body loses the involuntary ability to breathe so you only can breathe when conscious and most people to survive get a tracheotomy and use a ventilator at night to breathe.

Here is a article about a girl who has this issue, it's interesting.

As respiratory therapist I figured this would be something interesting to find out about and just have a background knowledge of to make us better in our jobs even though the odds are against us at dealing with a patient with Odine's Curse, but it's always better to learn something new.

Caffeine to help asthmatics.

Here is a interesting on the effect of caffeine and people with asthma.  It's actually a positive effect as caffeine is found in this study to have a bronchodialation affect on people with bronchoconstriction.  My conclusion, if you have respiratory issues drink tea or coffee on a consistent basis for maintenance it could work.  Wonder though if your having an attack if you could down a Mountain Dew quick to get some relief?

Here is the link to the study: Caffeine helps Asthmatics.

PTSD and Respiratory Illnesses

New article showing a correlation of Post Traumatic Stress Disorder (PTSD) and respiratory illnesses.  The information found in this article was mainly a result of studying people who were around the World Trade Center when 9/11 happened.

WTC Responders' PTSD Linked To Respiratory Illness

Interesting how is shows Psychological issued can cause physical issues.

Oxygen Protocols

Where I currently work we are looking to implement a better Oxygen protocol where the RT's are more involved/informed about major changes to a patients oxygen use, for example a patient is on 2L nasal cannula and is increased to a non re-breather mask we want to be informed.

So what I'm looking for is if anyone reading this could send me a basic idea of what your O2 protocols are your respective hospital or any ideas you could send my way.  I have used protocols at prior workplaces and some I like but just want to see what else is out there for use to improve our care and possibly decrease the length of time a patient might be on oxygen.

Anti Snoring stuffed bear.

Stuffed bear lightly smacks you in the face if your snoring to get you to turn your head along with a smaller bear to monitor your Spo2 levels.  Not sure if this will take away CPAP machines but a novel idea.  This does look much more comfortable for people with very mild sleep apnea.

Anti Snoring Bear with video

Handheld computers for RT's?

Just a quick post here, my department is looking for some type of handheld computer we can use for charting and scanning of medications, if anyone has any recommendations I would love to hear them and possible a website where I could get the company information about them also.

We use the Meditech system for charting and eMAR.

Thanks for any information

Radio waves can significantly help asthmatics

This is a promising article about a new treatment for asthmatics to reduce attacks as much as 75% as claimed in trials. Check it out, it's good to see that there are still people working on new asthma treatments.

Help asthmatics with radio waves.

Check out the article

Symptoms of asthma can be treated with a roller coaster ride?

Not the most practical way to decrease the effects of asthma but...

A pair of Dutch researchers discovered that the symptoms of asthma can be treated with a roller coaster ride where among the recipients of this years lg Nobel awards, the annual tribute to scientific research that seems wacky but actually could have some real world applications.

This study here has more to do with how asthmatics perceive dyspnea during times of either positive or negative stress. It seems in this study that dyspnea seemed less after the ride on a roller coaster was over. To me it just seems like it can't breathe good because I'm scared versus the scary stuff is over and I feel better, but I thought is was a bit of interesting asthma research whether practical or not.

Take a look at this article on the lg Nobel Awards.

Something fun, drive on RT's

The Air up there!!!

Well I haven't wrote anything in awhile here but I have a reason for this lapse in time. I was on vacation in the Rocky Mountains and surprise I can relate this to something respiratory.

Now this is not my first time up in the mountains of Colorado because I was stationed in Colorado Springs in the early 90's but this is my first time in the mountains up there as a Respiratory Therapist. With my profession being in the respiratory department I did notice how much harder it was to breathe between 8,000 and over 10,000 feet above sea level and I couldn't help but try and remember the full explanation of why this is so I thought I would look it up and blog about it.

One experience that I really noticed besides my hikes to up over 10k was when my wife and I went to Leadville which is the highest incorporated city in the USA, topping out at 10,600 feet above sea level. My wife and I were walking around the downtown area and we were talking away and I noticed that I actually had to stop and take a couple deep breathes as I was getting quite winded just walking and talking this really kind of stunned me as I'm not in bad shape, even my wife who runs 6 miles at least 5 times a week was noticing this with herself it's really kind of amazing the difference here with your breathing. I do recall however that the Army gave new soldiers to Ft. Carson Colorado a month to acclimate before they really started making you run hard and on this trip I didn't have nearly that long so I never fully acclimated to this air.

Why is this? Well I found a good analogy to this effect, if you take a jar of air at sea level and compare it to a jar of air at 10,000 feet above sea level there will be less molecules of air in that jar at the higher sea level, this is due to basically less partial pressure of the oxygen and less barometric pressure which helps make the molecules more dense at lower levels so in actuality I was getting less molecules of oxygen in my lungs with a breathe at higher altitudes than I would get with the same size breathe at the lower sea level.

Makes sense to me.

Here is a nice article on asthma in higher altitudes on Livestrong.com. Yes it's worse up there, when I was stationed in Colorado I seem to remember more people coming down with "Asthma" it seemed like, not I wasn't a RT but I was a Medic so I did have some medical knowledge there.

Some diseases make going to a high altitude very dangerous. People who have sickle cell anemia shouldn't go to a high altitude. A high altitude is also dangerous for people who have severe lung disease, such as chronic obstructive pulmonary disease (COPD) or severe emphysema, and for people who have severe heart disease.

Well all in all my wife had a great time together in the mountains with no kids thanks to my mother in law, one other side note about higher altitudes, if you like have some alcoholic drinks they WILL affect you quicker ... I'm just saying!!!

Keep driving on RT's.

Metabolism induced asthma?

A new study is showing that a poor diet and being inactive can increase the chances of kids to develop asthma, which is coined "Metabolism induced asthma".

The article can be read here: Poor Diet, Inactivity May Lead to Metabolism-Induced Asthma

This I've always had a sneaking suspicion of when we see people in the hospital who are obese and are taking inhalers and told they have asthma but with no actually family history of asthma. I do understand that obese people have shortness of breath due to increase body mass causing them to have a harder time taking a breath or just getting short of breath with exertion. Now I'm not sure I believe it's acutally "asthma" in those already obese people but as we all know if you lead a unheatlhy lifestyle you chances of having medical problems do increase a lot, so why should it not be possible for kids to develop asthma if they grow up with poor dietary habits and a inactive lifestyle? It's up to us parents to create a healthy lifestyle for our kids and be examples. Now don't get me wrong I have not problem with partaking in the good foods like pizza, cheeseburgers but moderation works well along with getting kids involved in active things like sports or just getting outside.

I was watching "The Biggest Loser" last night and there was some scary facts about our county and cities in general. I wish I had the direct quotes but I don't and cannot find a transcript online anywhere but here is just basics of what Jillian, Bob and Ali were saying that stuck out

-Our country is at the highest obesity rate in our history
-The 5 cities they went obesity was costing the city over $1 billion per year due to
hospital costs and other issues.
-Our countries hospital admissions have increased over the years due to a increase
obesity.

All this in turn comes back around to us as hospital workers, we deal with the issues of people who are obese and in my opinion if doctors help patients lose weight versus just treating the symptom which present themselves these patients will have less hospital admissions, less medications to take and just be healthier in general. This in turn will save hospitals money in the long run along with helping keep insurance premiums down.

Now this is all just my personal opinion and I'm not some health nut who only weights 170lbs. I am 5'10" 230, but I hit the gym 4 days a week, lift heavy weights and try to eat decent except for some splurges and I like beer, but I can still run a couple miles at a time and I have to keep in shape to keep up with my wife she runs all the time and workouts out at the gym a lot to. This is stuff I like to do, it's instilled in me from my years of Football, Swim team, baseball, and 10 years in the military, I'm just putting this out there so people don't call me a hypocrite.

Anyways whats you opinion?

Drive on RT's

Healthcare Aquired Infection Website HAI

I was contacted by this website HAI Watch to try and pass on the information on this site about Healthcare aquired infections(HAI) and their "Not on my watch" campaign to further educate healthcare workers about new things involving this HAI. This site has a backing of Kimberly-Clark Health Care.

This site seems to be worth checking out for some good information about helping out combating HAI's. I'm not a all affiliated with this HAIwatch site or getting any kickbacks from it, I just thought it sounded interesting and it seems like a worthy site for some upcoming information. Tjere are also about 5 youtube video's on here talking about HAI's.

Let me know what you think.

Seriously, that wheeze is not Asthma!!!

As any good RT knows, not all wheezing is associated with asthma but this knowlege that we have about wheezing has not been disseminated to all the masses that walk the halls of a hospital. I know for myself that I do attempt to educatate nurses about the different types of things that can cause wheezing, for example congestive heart failure wheezes versus asthma. CHF wheezes are more wet sounding and normally are in the upper airway, just have them put their stephescope on the patients larynx and listen, then the sound "echo's" down into the lower airways. In the classic asthma wheezing it's a more cleaner wheeze and it is usually without the coarseness of the fluid buildup of the CHF wheeze, plus it tends to start in the lower airways instead of the upper, CHF of course you can hear some nice crackles also.



Here are some common reasons for that sound we call wheezing:



By Age:



Infants and Children

• Congenital anomalies
  Bronchopulmonary dysplasia
  Bronchomalacia
  Vascular rings
  Cystic fibrosis
  Foreign body aspiration

Adults

• Asthma
  Chronic obstructive pulmonary disease (COPD)
  Congestive heart failure (CHF)
  Primary endobronchial tumors
  Endobronchial metastasis (from colon, breast, melanoma, kidney, pancreas)

By Onset

Acute

• Asthma
  CHF
  Pneumonia
  Pulmonary embolism
  Anaphylaxis
  Aspiration syndromes
  Foreign body aspiration

Chronic/Insidious

• Bronchogenic carcinoma
  Tracheal tumor
  Endobronchial metastasis
  CHF

Course:

Intermitant

• Aspiration syndromes
  COPD
  Asthma
  CHF
  Carcinoid syndrome
  Vocal cord dysfunction

Persistent

• Endobronchial tumor
  Tracheal stenosis
  Bilateral vocal cord paralysis
  Asthma
  Churg-Strauss syndrome

Progressive

• COPD
  Tumors
  Pulmonary infiltrates/eosinophilia syndromes

Well there you have it, i'm just throwing out things I found which might cause some wheezing in our patients and with what you can see, not everything is from Asthma or COPD there are other things which can cause this lung sound. There are different ways things can wheeze, it can be expiratory, inspiratory, both, or even considered musical but not all of those are asthma related. In reality there can even be asthma issues without even having a audible wheeze associated with it which is something that occurs quite a bit in kids. There are many people in the medical profession who hear wheezing and think, ohhh they need albuterol to stop the all and powerfull wheeze because it MUST BE ASTHMA!!!

Ok well if you would like some really good information on asthma look over at

The Respiratory Cave, Rick is well informed and educated in many things related to asthma.

Thanks for reading,

Drive on RT's

RT's should manage the O2

I have worked in a few different hospitals in my 15 years as a Respiratory Therapist, and over the years I have noticed there have been different ideas in as to how to utilize the role of the Respiratory Therapist in their facility. The role I want to talk about is the role of the RT to manage oxygen therapy which patients are using.

I have worked in places where RT's monitor and manage patients on O2 and I have worked in places where the nurses and techs have free range to do what they want to with patients on O2. The second part is the one I don't agree with and I have worked in a place like this where the RN's just place a patient on any O2 the see fit and it seems that 3 lpm by nasal cannula was the norm here. I would come by and decrease the O2 on a patient on the 3 lpm patient who's spo2 was 99% and I would come back later to find them back up to 3 again with the spo2 at 100% even though they were 92-93% on 1 lpm which I dropped them to. Now this patient was on neb treatments also which were the only patients we knew were on O2 just because we were not informed of anyone placed on just O2. This I totally disagree with.

The reason's why I don't agree with this are the fact that I feel we can be of more use to these patients who need oxygen and notice if there is more oxygen consumption being used and more treatment modalities are needed, also on the other hand we can do a better job at weaning patients off of oxygen for people who don't need this much oxygen or are just plain getting better this in turn can save the patients and the hospital money is we are able to reduce the amount of time a patient is on oxygen. Then there is the whole getting paged to a room because a patient is being increased in their amount of oxygen they are using because they cannot keep their sat up to acceptable levels, and we have not been involved or notified of this patient being on O2 prior to this and now the RN's want help and answers. We are coming into this patients room blind with no prior knowledge of this patient and really no baseline as to what this patient is like but if we were following this patient due to being on O2 better decisions on our part can be made.

I guess all in all I am more a proponent for RT's being involved in patient care not just because they are on a vent or on neb treatments but also if they are using some type of respiratory modalities like oxygen, which IS A DRUG, and we have a real good working knowledge of. I believe we are RT's can really improve patients recovery or stave off possible problems because we might notice something with the patients oxygen which RN's and Techs might not see. If the RT's are keep out of the know of patients who are on O2 we can't be expected to really know much of what might be going on with a patient. Really how many times have you come upon a COPD retainer patient where the RN says they seem really lethargic and they are sitting there on a 6 lpm nasal cannula because their spo2 was only 90% on a 2 lpm nasal cannula. This is something we know, COPDers are good between 88-92%, that's where they usually live.

Drive on RT's