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.

Some are more sensitive than others.

Over the years of being a Respiratory Therapist I have learned a few different schools of though on the use of oxygen and how effective it is at different levels.

It has varied from:

• 100% Nonrebreather to in reality a 70-80% nonrebreather. A lot of nurses actually believe it is really 100% oxygen the NRB is giving.
• OWL protocol, or Oxygen With Love. This actually really seemed to work and what it was used for was to decrease the occurrences of retinal detachment in babies in the NICU. The protol was to keep the SPO2 level between 88-92%. We all know that high levels of oxygen can cause retinal detachment in infants, well this protocol actually worked, it decreased the amount of infant that needed eye surgery due retinal detachment from around 60% down to below 20% at the hospital I worked at. So did it work, I think so.
• You need a bubbler with oxygen. No you don't, not always. I do give them our for levels over 4 lpm on the nasal cannula IF they are at that level for awhile, or they are getting bloody or burning nares.
• All Post-Op patient need 2lpm of O2 for 12hrs after surgery. I think not.
• Anything under 2 lpm with a Nasal Cannula is a worthless on a adult.

That last one is a area that I'm dealing with right now. All of the other hospitals that I have worked for we were in the school of thought that under 2 lpm, you might as well just take them off because it doesn't do anything for that patient.

For some reason that has been true so far for me and my patients, until I started here at my current hospital. I recently had 3 different patient who I just couldn't wean off of oxygen. They were a 15 month old, a 60 year old and a 83 year old and they were all on the under 2 lpm levels of oxygen, which seemed to be the kicker.

Now that 15 month old I do understand that pediatric patients do respond to lower levels of oxygen flow, which is why they make a low flow oxygen flowmeter which goes from 0.1 to 1 lpm. This patient had a possible pneumonia but great sounding lung sounds after a day, but we could not get this child off of the 0.1-0.2 lpm of oxygen. She would drop to the mid to low 80's without it and as soon as I put it back on, poof back up to the high 90's.

Then the 60 year old I had. This person was a long term smoker, probably had COPD also so I would assume that this person lived in the low 90s to the high 80s. But what was interesting is that on RA this patient would drop down to 80% so we would put 0.5 lpm O2 on and the sats would jump back up to 97% right away. Seriously 1/2 lpm and the spo2 would jump that high. I was amazed. I had always learned that under 2 lpm was a waste of oxygen and equipment.

Now the last patient, my 83 year old was the same way. I was doing my oxygen rounds and I checked her spo2 on 1 lpm and she was 99% on the 1 liter. Great I though, I can take her off the oxygen, which I did. I then came back in a hour just to make sure that the sats were fine and wow was I shocked. 78% on RA!!!! I'm thinking, "Really no kidding, that 1 liter made that much difference with her!!!". Well it did, I put her back on the 1 liter of O2 and BoooYahhh, it shot right up to 97%. Amazing.

This was in the same night, all three of them had their oxygen issues. This night right here disapproved the idea to me that anything under 2 liters per minute of oxygen is worthless in adults, I was a skeptic but now I think I might be a believer. Even most of the books say a nasal cannula is set between 2-6 lpm and 24-36%. Now 1/2 lpm is 23% according to the formula:

21% + (oxygen liters per minute *3) = fio2.

That there is under the book definition of the nasal cannula, but it seems to do some good. Oh well as long as they are not dying on me and it's that 1 lpm that is keeping them from doing so, I will keep using the lower levels now as needed.

if anyone has any information or web sites about the lower levels of oxygen on adults I would be very interesting in that information, because like I said I have always heard it worthless under 2 lpm, but apparently some patients are more sensitive than others.

Drive on RT's and thanks for reading.

Diagnosing my Grandfather

My Grandfather was in the hospital again this last week for a couple of days because of shortness of breath and he has a doctor that seems to just beat around the bush by not giving my grandparents a definite diagnosis. He was told that he did have a blood clot behind that knee that is taking Lovenox for at home, yep my Grandmother is giving his shots in the stomach. I saw her do it today, she does a good job.

The problem my grandparents are having is that this doctor has never given a good distinct diagnosis of what is causing his breathing issues that he has been into the hospital for two times this year and has also been in before, so as a good RT I am going to lay out the facts and give my diagnosis. Maybe a good case study here.

• He is 86 years old
• Has had 2 heart attacks both with CABG surgery
• He smoked for over 50 years, quit about 15-20 years ago
• He does a lot of woodwork with lots of sawdust
• He gets very SOB when it is hot and humid
• Has a productive cough
• When SOB he sleeps better sitting up
• Breathing treatments do help him
• He gets bronchitis fairly often
• He is diabetic
• He is very active, does woodworking, walks to mow lawn, plays with grand kids
  

Ok from what I have here I really think that he has a good case for COPD. I understand that there could be some heart issues here, but I would rule out COPD and would like for him to have a PFT test done. There is a good possibility that a corticosteroid would do some good for him and a rescue inhaler.

This particular doctor will not say what this could be. He has said there could be a touch of emphysema, and that the cough is "chronic in nature", but he will not send him for the proper tests to check to see if the lungs have problems. This is driving me nuts. How hard is it to order a PFT testing to be done? Why not send him home with some MDI's. He did send him home with a antibiotic called Avelox that after reading is supposed to be good for upper respiratory infections. This med only takes 4 pills to kick bacterias butt, pretty cool and powerful.

This is added as a late entry, but this doctor also stated to my grandparents that the Sawdust from his hobby has no effect on his lungs as the particle size is to large to get into his lung. Huhh. Yep he said it's gets stuck in the upper airway and that's why there is sawdust in his sputum when he coughs because it is filtered out by the nose and upper airway. Yea ok quack.

Well that's the deal, I really hate this cannot make up my mind mentality of this particular doctor and I'm glad he is not from my hospital.

Let me know what you think.

Pixie Dust...What can it do for us?

There is a article at CNN.com about some stuff coined "Pixie Dust" which is being experimented with on soldiers who have a amputated body part like fingers, arms, legs or toes but not heads. This is being trialed at Brooke Army Medical Center (BAMC) in San Antonio Texas where I took my Respiratory Training.

You can read the article here: Pixie Dust

This pixie dust is supposed to give the body a salamander effect and trick the body into regenerating the missing body part. The powder forms a microscopic "scaffold" that attracts stem cells and convinces them to grow into the tissue that used to be there.

"If it is next to the skin, it will start making skin. If it's next to a tendon, it will start making a tendon, and so that's the hope, at least in this particular project, that we can grow a finger," Wolf said.

This is pretty interesting, how could this help our profession? Could this "pixie dust" help regenerate lungs destroyed by smoking, improving quality of life for COPD patients? Could it help people exposed to substances cause them to get fibrosis?

Interesting to say the least and I will keep a look out in for how it turns our for humans and for the soldier in the article. Hope it works.