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

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.

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

Giving Albuterol to decrease potassium.

Lately we at my humble hospital have been getting more and more orders for albuterol nebulizer treatments to decrease a elevated potassium level in a patient. This has made me curious as to why this works and if it really is a viable reason to give albuterol and a elevated potassium situation so I did some digging and here are some facts I found:

- Potassium is both an electrolyt and a mineral. It helps keep the water and electrolyte balance of the body. Potassium is also important in how nerves and muscles work.

- The normal level of potassium is 3.5-5.0 mEq/L

- Albuterol works to create smooth muscle relaxation through the beta-2 receptor site but one of it's other effects, is to reduce extracellular potassium concentrations by pushing the potassium into the cells. This action is quite handy, in a pinch, but do not rely on it because the action is too slow in it's onset to be of emergent help.

- Doses of 15 mg albuterol via nebulizer, hyperkalemic patients on hemodialysis experienced a 0.9 mEq/L decrease in plasma potassium which was sustained for 6 hours. Albuterol may stimulate sodium-potassium ATPase, resulting in an intracellular shift of potassium.

- Albuterol works to lower potassium concentrations by stimulating the release of insulin. This release of insulin shifts the potassium into the cells thus lowering the potassium level.

- Albuterol also stimulates the Na/k+ pump causing potassium to be shifted into the cells.

- A study compared the efficacy of 1) insulin + glucose. 2) albuterol and 3) both regimens combined when used to lower potassium concentrations. The study found that albuterol was just as effective and quick at lowering potassium concentration as insulin + glucose. The study also found that the two treatments administered together worked even better in reducing potassium level. Albuterol reduced the potassium level by up to almost 1mEq (0.62 - 0.98mEq).

Source: http://www.ncbi.nlm.nih.gov/pubmed/2266671

- Using a large amount of albuterol in a patent not in hyperkalemia may cause the patient to become hypokalemic.

- The dose for albuterol when administered in hyperkalemia is 10-20mg.

- It is mentioned in ACLS for Experienced Providers (2003) p.162.

• For moderate elevation of potassium (6 to 7 mEq/L):
  
• Initiate a temporary intracellular shift of potassium using the following agents:
  
• * Sodium bicarbonate: 50 mEq IV or up to 1 mEq/kg over 5 minutes
  
• * Glucose/insulin: Mix 10 U regular insulin and 25 g (50 mL of D50) glucose, and give IV over 10 to 15 minutes
  
• * Nebulized Albuterol: 5 to 20 mg over 15 min.
  

Well after doing some research on the subject to me it does look like a viable treatment to assist in the treatment of Hyperkalemia in patients, but from what I have been noticing is that the Doctors are not ordering this properly to even make a dent. We here at my hospital get orders for just a regular nebulized albuterol treatment of 2.5mg which is nowhere near the recommended 10-20mg to even cause a dent in the potassium levels.

To be curious about why your doing something is a good thing and the internet is a plethera of information to be found in our profession. If you have questions, research it.

Keep driving on RT's.

Allergy Season is on it's way.

It's becoming that time of year for another bout of respiratory problems, the allergy season. This time of year brings on the great problem called Hay Fever and there are more than 35,000,000 Americans who suffer from this type of problem.

Hay Fever is a type of allergen rhinitis triggered by pollens from different plants this time of year because they are all beginning to grow. Some major players in the problem of pollen are the Birch tree which can cause problems for 15-20% of suffers and then the largest player for people who suffer from the type of problem is grass pollen, it is estimated that 90% of hay fever sufferers are affected by grass pollen. Hay Fever is not caused by a virus its caused from a allergen. Hay fever can begin at any age, you're most likely to develop it during childhood to early adulthood. It's common for the severity of reactions to change over the years and for most people the symptoms tend to diminish slowly, often over decades.

Some common trigger of Hay Fever can include:

• Tree pollen, common in the spring
• Grass pollen, common in the late spring and summer
• Weed pollen, common in the fall
• Spores from fungi and molds, which can be worse during warm-weather months
• Dust mites or cockroaches
• Dander (dried skin flakes and saliva) from pets such as cats, dogs or birds
• Cockroaches
• Spores from indoor and outdoor fungi and molds

Some of the signs to look for in a allergen problem are:

• Sneezing more than usual
• Eyes that continually water
• Cold symptoms that last more than 10 days without fever
• Repeated ear and sinus infections
• Prolonged loss of smell or taste
• Frequent throat clearing or hoarseness
• Persistent coughing
• Sinus pressure and facial pain
• Swollen, blue-colored skin under the eyes (allergic shiners)
• Decreased sense of smell or taste

Where this comes in for Respiratory Therapy is the coughing, doctors really like to give nebs for coughing to help it stop so there goes our case load in the E.R. more neb treatments for coughing. Asthma though is one problems which often occur along with Hay Fever, along with Sinusitus, Eczema, and Ear infections.

The best way for these patients to limit problems to these allergens is to keep from being exposed to much to these allergens:

• Close doors and windows during pollen season.
• Don't hang laundry outside — pollen can stick to sheets and towels.
• Use air conditioning in your house and car.
• Use an allergy-grade filter in the ventilation system.
• Avoid outdoor activity in the early morning when pollen counts are highest.
• Stay indoors on dry, windy days.
• Use a dehumidifier to reduce indoor humidity.
• Use a high-efficiency particulate air (HEPA) filter in your bedroom.
• Avoid mowing the lawn or raking leaves, which stirs up pollen and molds.
• Wear a dust mask when doing outdoor activities such as gardening.

These are just some ideas I found reading about this online and if you suffer from hay fever you might want to take some of these precautions.

There are quite a few types of medications which help with Hay Fever:

• Nasal corticosteroids. These nasal sprays help prevent and treat the inflammation caused by hay fever. Examples include fluticasone (Flonase), fluticasone (Veramyst), mometasone (Nasonex) and beclomethasone (Beconase).
  
• Oral corticosteroids. Corticosteroid medications in pill form, such as prednisone, are sometimes used to relieve severe allergy symptoms.
  
• Antihistamines. These oral medications and nasal sprays can help with itching, sneezing and runny nose, but have less effect on congestion. Older over-the-counter antihistamines such as diphenhydramine (Benadryl) and clemastine (Tavist) work as well as newer ones, but can make you drowsy. Newer oral antihistamines are less likely to make you drowsy, but are more costly than the older antihistamines. Over-the-counter examples include loratadine (Claritin, Alavert) and cetirizine (Zyrtec). Fexofenadine (Allegra) is available by prescription. The prescription antihistamine nasal spray azelastine (Astelin) starts to relieve symptoms within minutes of use. It can be used up to eight times a day, but can cause drowsiness. Side effects include a bad taste in the mouth right after use.
• Decongestants. These medications are available in over-the-counter and prescription liquids, tablets and nasal sprays. Over-the-counter oral decongestants include Sudafed, Actifed and Drixoral. Nasal sprays include phenylephrine (Neo-Synephrine) and oxymetazoline (Afrin). Because oral decongestants can raise blood pressure, avoid them if you have high blood pressure (hypertension). Oral decongestants can also worsen the symptoms of prostate enlargement, making urination more difficult. Don't use a decongestant nasal spray for more than two or three days at a time because it can cause rebound congestion when used longer.
• Cromolyn sodium. This medication (NasalCrom) is available as an over-the-counter nasal spray that must be used several times a day. It helps relieve hay fever symptoms by preventing the release of histamine.
  
• Leukotriene modifiers. Montelukast (Singulair) is a prescription tablet taken to block the action of leukotrienes — immune system chemicals that cause allergy symptoms such as excess mucus production. It has proved effective in treating allergic asthma, and it's also effective in treating hay fever. Like antihistamines, this medication is not as effective as inhaled corticosteroids.
  
• Nasal atropine. Available in a prescription nasal spray, ipratropium bromide (Atrovent) helps relieve a severe runny nose by preventing the glands in your nose from producing excess fluid. It's not effective for treating congestion, sneezing or postnasal drip. The drug is not recommended for people with glaucoma or men with an enlarged prostate.

This turned out longer than I expected it to but as a Therapist I figured it something we will deal with in the coming months and one little more tidbit of information about Hay Fever:

Hay fever doesn't mean you're allergic to hay. Despite its name, hay fever is almost never triggered by hay, and it doesn't cause a fever.

Keep driving on RT's.

Need a Prayer for a young boy.

I'm posting this to reach out for a family I know who is having hard times right now with medical problems. The mother of this family is having to deal with her 9 year old son in a pediatric ICU and needs some extra prayers to get this boy to turn around. This 9 year old child has been having small strokes and is in and out of a coma. He was starting to turn around a little bit and was off he ventilator for a couple days then had another stroke which put him back in a coma state and again on the ventilator.

This child was born with hydroencephalitis and had an operation to place a shunt in his brain and the parents were told he would not live to be more than 2 years old. Well he is 9 and was doing everything a normal child would do, did good in school, loved the Iowa Hawkeyes, and played with his friends and brother. These current events started when he went in for a checkup on his shunt and things went bad, this was about 2 weeks ago. The medical staff at the medical center he is at are still trying to track down what is going on and the cause of the strokes but nothing is promising yet at this time, but we are still hopefull.

What makes this so hard for the mother of this child is that just over a year ago her husband, this boys father, lost out on his battle with brain cancer and he was only 39 years old. This woman now has to deal with her youngest son possible not pulling through which would be devastating to her as this would be 2 major losses to her family in under 2 years. Something like this would be hard to fathom by most people, and she has another son to stay strong for with all this going on.

I'm just asking for a little prayer, thought or anything just to help this family get through this time of need and sadness. I do believe there is the possibility of the power of prayer and thought to help people in need. Thank you for any thoughts and prayers, and if you where wondering, this boys name is Jack, and her is a HUGE Iowa Hawkeye's Fan like his father was.

Shortage of Health Carre Workers in 6 years predicted.

I was recently reading through the April 2009 AARC journal magazine and there were predictions on different health care topic which would affect RT's. One I saw that interested me was:

"There will be a national shortage of all health care providers in all sectors, Even those who frequently interact directly with patients."

This struck me as interesting because you would thinks with the unemployment rate as high as it is this would be a job sector which people would maybe flock to because of the job security of there always being sick people to take care of, but I guess this isn't so.

I starting thinking about this and realized there are large portions of society who are hardly even tapped to work as health care workers. These people would be the men of the United States. If you work in the health care sector think about it, who so you see mainly working directly with patients as a majority? Women right. There you can even break it down even more, these would mostly be white women also as a majority. Now I'm not trying to bring in the race card it's just a observation and I tried looking up some facts which I could find on this topic.

As for men in the health care workforce I wasn't able to find a overall men in health care number but I found a number for male nurses. According to the American Nursing Association only 6% of all RN's are male. Here in this article: "Is there a male nurse in the house?" about 7.5% of male nurse graduates leave the profession within 4 years of graduating. These are not good numbers.

Now when we look at the minority sector of the health care work force I found out that 1/4 of our population is made up of African American, Hispanic and American Indians but only 10% of them are in the health care field, this is according this this article: Diversity in Health care. This leaves a lot of possibilities for more health care workers.

Why don't more men work in the health care field? I believe it's the stigma and stereotype of women always being the nurses. When I say nurse I do picture a female and it's because of stereotype. Men also are not normally brought up to be caregivers like mothers. More men should really look into health care because were going to need to fill the gaps if this prediction is correct. Honestly there are a lot of perks, good pay, stability, job security, air conditioning and heat, hot looking nurses, friendly atmosphere, and the list goes one. If we are to fill these gaps in health care jobs were going to need to disperse of the stigma of men being in health care other than being doctors. Like we all know, Respiratory Therapy is a good field, and the women dig us.

Discoid Atelectasis, what might that be?

Tonight I had a patient I was assessing for out therapy driven protocols and was reading this person's xray and I noticed a word I have never came across before in my medical travels and it was describing a type of atelectasis:

Discoid Atelectasis which is also known as Plate Atelectasis.

Now being the good RT that I am, I had to do and look it up so I could do a proper assessment of this patient and what I found was interesting to me and I thought I would share it with anyone who might read this blog of mine.

Discoid or platelike atelectasis is a form of atelectasis which has s disc or platelike appearance on a xray which is linear or horizontal position. They often look like a CD or a dinner plate and thought to occur from shallow breathing or hypoventilation which can occur after a abdominal or thoracic surgery. It can be also seen in other conditions such as painful breathing, general anaesthesia, pulmonary embolism, ascites and diaphragmatic paralysis.

There is really no different type of treatment for this versus any other type of atelectasis because it is just a term to describe what is seen on the xray but overall it's still just atelectasis.

Really there is not to much alarming about this it's just something I came across and have never seen so I thought I would share it with everyone and hopefully if you come across this in a report you will now know that those radiologist are talking about because it seems they like to try and stump us, but because of the Internet things can be looked up quickly now.

If you didn't know, now you know ... 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.

Peds Pneumonia VS. Adult Pneumonia

We are not in a time of year where there seems to be a larger than usual amount of Pneumonia cases coming into my hospital. There are many different types of pneumonia out there but we mainly deal with only a couple of them.

Some Different types are:

• Viral


• Bacterial


• Fungal


• Parasitic


• Comunity Aquired


• Hospital Aquired


• Severe Acute Respiratory Syndrome(SARS)

If you want more information on the different types of pneumonia just go look it up, many sites are out there with this information.

Now if you noticed in my title of this post I'm talking about Peds VS. Adult pneumonia's. The reason I am talking about this is because my hospital will isolate all pediatric patients for Droplet Precautions if they have any lung problems, including pneumonia. Now my question is why do we just isolate the kids with pneumonia and not the adults with pneumonia? This I am confused about, but I do understand the the underlying virus or bacteria which cause pneumonia could be contagious but why more so in kids than adults?

With our kids we need to gown and mask but with adults nothing extra as of precautions is taken which is perplexing to me as I cannot find a decent answer to this question and unfortunately I don't see the Peds doc very ofter as I work nights.

So if anyone can shed some light on this for me I would be much obliged, but until then I will keep searching and wearing my gown and mask for the kids, but I'm sure we would look less scary to them without that garb on.

Thanks for reading

Keep driving on RT's.

We need a law for resusitation age limits!!!

Just a quick note of something that I think needs to be implemented for the humane treatment of older adults who would happen to have their heart stop beating:

"Anyone over the age of 90 years should automatically deemed DNR."

I would even go as low as 85 years old if allowed. It's almost inhumane to code an patient who is over 90 years old and put them through that.

Maybe I will get into this more in depth later.


Just a thought.

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.

It's been awhile.

I've been gone for awhile, I started taking classes again and just got myself busy trying to get back into this school thing and realized I missed having a outlet to post things on my mind when it comes to Respiratory Therapy. So, I'm back and hopefully I can get some good posts out here in the RT blogosphere which can spark some thoughts and conversation.

There that's my 2 cents worth and I will be posting something more substantial later.

Thanks for reading.

Attempt to stop teen teen smoking

We all know that smoking makes you look really cool these days and who doesn't want to look the coolest ... well Teens of course.

Japan have rolled out a cigarette machine that is supposed to verify if you are of age to smoke or not. How this worked is the machine has a face recognition camera that supposedly can detect your age. Interesting enough, and of course it's in Japan where they are quite good a finding ideas for things via technology.

So now these machines have been rolled out onto the street and they did seem to be working until someone figured out a way to hack it. How you ask? Well the kids are able to use a picture of a someone older and hold it up to the machine and look at there you are verified.

Here is the link to the article: Linky

Why did I post this, well it relates to smoking and the fight against it. And of course us RT's are anti-smokers right! Just thought it was interesting and fun. People are trying to cut down smoking.


Enjoy.

What we see, not everyone does.

We are currently very low in our census of respiratory patients but we still have some interesting ones come in and out of my place here. Tonight I had a patient come into my ER who was very tachycardic to the tune of 170's and higher along with a respiratory rate of 40's and sweating very profusely.

What does that sound like? If you said a pulmonary embolism you would be correct. Now this really is nothing very new to most RT's but what really struck me about this one is the mortality of this person that was brought up to me. I had previously done a EKG on this patient when he first came into the ER and was called back to do another one about a half hour later. What I noticed was his rate had increased along with his heart rate and the patient just being very anxious, but he was very alert and awake.

When I finished I went out and talked with the doctor, I asked him if this patient had some sort of bad infection also because of a high fever according the the nurse. The doc said no, he has a bad PE and he was pretty sure this person was going to die.

Right there is was struck me, "pretty sure this person was going to die". Does this patient know that, are we looking at a dead man walking type of issue, somehow he can tell that this person who is alert and awake has a clock that is ready to stop. Well the doc was right, he got to the point that he needed intubated and not more than 2 minutes after the intubation his HR went from 170's to the 30's and a code was started.

After all was said and done this patient didn't make it, but between when I talked to the doctor until the code was stopped, I couldn't help but think that I was this alert person that we knew that his time was up and it was just a matter of time. I was talking to this person knowing that the doctor could be right and I could be the last person he talks to. We watched this person just fade away, did all we could to save him but in some sense we all knew there was not much hope at all.


This all started me thinking about what we see as RT's compared to other people in the world. If you think about it how many people actually get the chance to actually watch someone take their last breath? How many people get to see a person who is injured beyond recognition from a car accident? Really I don't think many people get the chance to experience the things we sometimes do and a daily basis. Yes most people will probably see a dead body after the fact at a funeral but really how many are able to see life just slip away from a person or see us as caregivers struggle to resuscitate a person and get their heart started again?

Honestly do people in our lives, friends and family really understand what we see and deal with at our job? Do you think they have a good idea of what our job involves? Unless you are around our job you can never really know what we see or do. In my 12 years as a RT I couldn't even guess how many people I have seen die, and really I feel I have been desensitized to the reality of death and dying. I often wonder that if, God forbide, one of my parents would pass away that I wouldn't be able to show much emotion but I do know I would be sad. It is possible that I am so used to seeing people die that I might not even be able to cry for my loved ones.

All in all as a RT I really think that we see more death that a lot of RN's in the hospital. Think about it, as the RT we are required to respond to all codes, not all RN's are. There is the possibility of a code happening in the floor that the RN works at, but we as RT's are responsible to respond to ALL codes in the hospital. So are we around it more, I think so. This fact I can see in the eyes of some RN's who I see in codes, it's in their eyes they just seem a little out of sorts. We on the other hand usually have been though many of codes and are a rock in the sea of turmoil called a code. Don't get me wrong there are a lot of RN's in the position to see a lot of this also, namely ER nurses, they probably see a bit more than us. They are also a special breed.

There are many jobs out there that see things that most people would not want to but that's what separates the people who are able to do these types of jobs. It's not for everyone, you have to have a certain toughness and mindset to do this type of work. We have that mindset, and it is needed to not only do you job but to be a calm face in a stressful situation.

Friends and family might know what a RT is, but will never understand really what we see and deal with as a RT. Sometimes it can get to you when you think about it.


Drive on RT's.

Small Town Patient Privileges

Patients in a small town hospital like the one I work happen to be a totally different animal than the ones in the bigger cities. This idea I'm pretty sure Freadom over a Respiratory Therapy Cave and agree with me about because it seems that he is in this same small town hospital category.

Some of the differences I have noticed are the types of reasons that people come in for are pretty simple compared to larger hospitals but there are exceptions also to this. There are the injuries that can be more local to the type of hospital you work in. For example where I work is a large farming community, we have had rolled over tractors, getting kicked by horses, falling off of barns, and my favorite the guy who him and a couple of buddies were drinking out in the cow barn and had a little to much and passed out and coded right in the middle of cows, down in the hay and manure. The EMT's said they were worried that the cows would kick them while they were working on the patient. This guy smelled awful and had cow manure and hay all over him, unfortunately he didn't make it and the ER room smelled and had hay all over the place. Then there was the Ethenol Toxicity patient who decided to drink some straight ethenol from the ethenol plant, yep not smart it's 200 proof!!!! He was quite red.

Tonight I had another one of my small town patient who received a privilege that I have not come across so far in my 12 years as a RT.

I was on my way to do a breathing treatment with a older patient at around 8 pm and when I got to her room there was no one there. Fine I thought she must be walking around the unit, we do encourage our patients to get up and walk. I see her nurse and ask if she is out walking and I'm told no she isn't, she is - get ready for this -

Ok here is the dialog:

Me: Hey Nurse Betty do you know where Mrs. Bing is at, she is due for her treatment?
Nurse Betty: No she isn't here right now, she's out.
Me: Out, not here, is she at a test?
Nurse Betty: Uhhh nope, she is at a Wedding.
Me: She is what??? (confused look on my face)
Nurse Betty: Yep you heard me right she is actually at a wedding, she left about 1 pm.
Me: Really, is she coming back?
Nurse Betty: Yea the doctor said she had to be back by 9:30 pm.
Me: So she is gone to a wedding and has a curfew. She is really sick isn't she. (dumbfounded)
Nurse Betty: (sarcasm) Oh yea she is so totally sick.
Me: Did she wear a dress? Get all dolled up?
Nurse Betty: No Idea I just go here at 7 pm.

Ok this I found interesting as she must not be very sick at all, send her home and have her follow up with a doc at the clinic. Your wasting our time.

So about Midnight I have to go assess her for respiratory status and she is there finally and I can give her the treatment also now.

Me: So I hear you went to a wedding today?
Mrs. Bing: Oh yes I sure did.
Me: Was it a good wedding?
Mrs. Bing: Yes very pretty and the reception was a lot of fun to.
Me: So what time did you get back?
Mrs. Bing: A little before 10pm, the doctor gave me a curfew. Can you believe it, I'm 86 years old and I was given a curfew. I really don't remember ever getting a curfew.
Me: Yea that is pretty funny, well glad you had fun and made it back before the doctor grounded you. Alright here's your neb.

I just really found this interesting that a inpatient is released to go to a wedding or really anything while they are sick. Granted we cannot hold someone against their will but why not just discharge this person, they seem to be okay. Oh well I thought it was funny.

Then tonight there is this younger 20 something in the ER who I had to do a EKG on. The police were here for this one because he was a bit unruly. Seem like he had a couple to many drinks or drugs of some sort. So anyways I'm in there and he threatens to spit on people so the conversation proceeds:

Big Dork: Get away or I will spit on you and give you the SARS I have!!!!
Me: I don't really think you have SARS.
Big Dork: Yes I do get away.
Me: How did you get SARS?
Big Dork: I don't know, how can you get SARS?
Me: It's not in the United States, have you traveled overseas recently?
Big Dork: Yes I've traveled overseas recently.
Me: Where to, because there are not to many places that have SARS?
Big Dork: What places have SARS?
Me: Japan, China, over in that area.
Big Dork: Well yeah exactly, that's were I went to Japan.
Me: Yea Okay, if you spit on me SARS or not I will let that cop beat on you.
Big Dork: I'm not really going to spit on you.
Me: Ok hold still so I can run this EKG, thanks all done and good luck with your SARS.
Big Dork: Thanks, can I have a glass of water.
Me: Let me ask you nurse, cya.

That was just plain funny, I like funny drunk/high people you can mess with then and they will never even really notice you messing with them.

Well hope this was as entertaining to you as it was to me tonight as it did make the night more interesting because I actually had no patient that were due anything overnight. Easy night

Drive on RT's

What do Cord Gas values mean?

In the different hospitals I have worked at over the years where the respiratory therapists either draw or run the umbilical cord gases I have often wondered about what the normal values of a cord gas was. Just from running a lot of cord gases I have came to my own conclusion of what a cord gas value should probably be but have never really looked into what the real normal values are and what a value out of the norm would mean.

I have done some research online to see what I could find out. Here are some fact about umbilical cord gases and the normal values:

• The umbilical cord blood is studied for the status of the fetal acid base. Cord gases are obtained to detect the presence or absence of acidosis and to decide whether the cause of the acidosis is respiratory or metabolic. Establishing the source and type of acidosis make it easier to a.) plan resuscitation b.) treat complications.
• Umbilical cord blood pH and acid-base balance is most useful in association with the delivery of an infant with a low APGAR score.
  
• Only newborns who have a persistent APGAR score of 0-3 for 5 minutes or longer and an umbilical artery blood pH of less than 7.00 are at risk of manifesting anoxic brain injuries.
• Premature infants are at higher risk for intracranial hemorrhage and subsequent neurological dysfunction, such as cerebral palsy. Without umbilical cord blood gas analysis, these neurological complications could be incorrectly attributed to intrapartum or birth asphyxia, especially if the latter is solely based on APGAR scores. Normal umbilical cord blood values in the premature infant virtually eliminate the diagnosis of significant intrapartum hypoxia or birth asphyxia.

The information I used above was found from different sources who are all basically saying the same thing. Now how about those normal values and the values the show a respiratory or metabolic acidosis.

As a reminder the umbilical cord is backwards as the Venous side carries the oxygenated blood and the Arterial side the unoxygenated blood. Doctors prefer to use the Venous cord blood but can assess PH with he arterial side also. Also these values are not set in stone, they are just a reference point, I have came across values the differ but very slightly.

After Birth­Normal Fetal cord blood pH and gas values:

	VEIN	ARTERY
pH	7.25 - ­7.35	7.28
p02	28­ - 32 mmHg.	16­ - 20 mmHg.
pC02	40­ - 50 mmHg.	40 - ­50 mmHg.
Base Excess	+/- 0 - ­5 mEq/Liter	+/- 0­ - 10 mEq/Liter

Abnormal Venous cord blood pH and gas values

	Respiratory Acidosis	Metabolic Acidosis
pH	<>	< 7.25
P02	Variable	< 20 mmHg
pC02	> 50 mmHg	45­ - 55 mmHg.
Base Deficit	< 10mEq/liter	> 10mEq/liter
	Respiratory Acidosis	Metabolic Acidosis
	Low pH	Low pH
	High pC02	Normal to high pC02
	Normal Base Excess	High base excess

As always I hope you have learned or been refreshed on this topic, I know just researching for this information I have learned a bit of information.

Thanks for reading.

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.