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.

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

Oxygen Dependant COPD man to run marathon.

I ran across this article and thought is was interesting:

COLORADO MAN TO BE THE FIRST COPD OXYGEN PATIENT ALLOWED TO RUN IN BOSTON MARATHON!

Its about a man who is oxygen dependent, diagnosed with COPD and is the first person with COPD allowed to run the Boston Marathon. This person is on some serious O2, when asked what is prescription is he responded:

"I have been on supplement oxygen for 4 years. My current prescription is 4-6 liters at rest and 7-18 liters when I’m active or exercise."

Now that's some serious O2 he is on for exercise, just think how many tanks he might go through in a 26 mile race.

This guy has already completed 2 full marathons, 14 half marathons, 1 ten mile, a 5 mile, 4 times did the 10k the Bolder Boulder, a bunch of 5k's and climbed 2 14,000 plus foot mountains. Quite amazing. He says that he went through 5 tanks a marathon and was lucky to have friends to help with the changing of tanks when needed.

This is pretty amazing for a COPD oxygen dependent person to do and it just shows their is life after a COPD diagnosis, you just have to take care of yourself and work to acheive some added health to help cope with the problem.

To add to his accomplishments on March 10 of this year he finished the Climb Chicago event for the American Lung Association. 4 buildings; 180 floors; 360 flights; and 2340 stairs, for a time of 1:06:13. Really amazing, that would hurt me.

Well hope that article was inspiring and hopefully this guy can inspire other COPD patients in the future.

Drive 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.

We have a Drought!!!

This is just a FYI and a call for anymore information.

So my little department here is down to just 2 Nasal Cannula Humidifiers (AKA Bubblers) here in my hospital. Where have they all gone?

OK word around here has it that the FDA has decided to put stronger rules or whatever on the Sterile water for Inhalation and how it's made and packaged, so they have not stopped the companies from making anymore at this time. What more do they want? Extra sterilization, better packaging, fruity flavors? Hell I don' t know.

What I do know is that is what we are told here at my Cave and that there is a nationwide shortage now of Bubble humidifiers for nasal cannulas. Has anyone else head of anything about this, or can anyone find any articles on this topic that is current ... I have found some from 2003 but am looking for something more current.

Oh well just thought this was interesting and would like to know if anyone else out there in Respiratory land has been told anything.



Drive on and keep em breathing.

Vaseline and Oxygen: Flame On

I have been told before that you cannot mix oxygen and vaseline together because they can cause a flame and cause problems. How many others of you have heard this information, maybe this should be put on a new Myth Buster's show.

So I started looking around a bit and have came across some posting on nursing sites about whether this is a myth or not. I have found numerous references to this article, "Dispelling the petroleum jelly myth," in the November 1998 American Journal of Nursing but I have no way to access this article and cannot find a good free source for this. If anyone out there has access to this I would be interested to hear or see the information in this article.

Information I have found out about this being a combustible subject is that when a patient used a thin layer of petroleum jelly on their lips due to dryness from the oxygen that the oxygen from a oxygen device to provide the patient with oxygen can cause the petroleum jelly can cause a gas that when combined with oxygen can become very combustible, and then is a static spark can cause a flame. Supposedly there are many reports if this in a surgical rooms versus not many report from patient floor rooms. Could this be from a lack of people reporting this problem, I don't know but I think it's a interesting subject because I see vaseline and Carmex used a lot to moisten the lips of patients on oxygen. I do understand that oxygen does make your mouth and lips dry.

I am interested to see if anyone else out there has any good information on this topic.

Keep Driving on RT's