Thursday, October 30, 2014

Fifth period of respiratory therapy: How will it end?

So at the present time our profession finds itself amid the fifth period of respiratory therapy, whereby many wonder if cost cutting measures will result in our profession being cut.  While we used to be a pay for service department, we are now mainly just a service department.  And while our services are essential to ideal patient care, There are those who believe our services have out lived their usefulness.

In many regards they are right.  For many years now our profession has sort of milked the system, as many of us find ourselves doing procedures that we know are pointless, but we don't say anything because we are being paid.

Hospital administrators don't say anything either, because they know, even though most of what we do is a waste of time, that many of the things we do are absolutely essential to good patient care. I mean, who gets called first when a patient is in respiratory distress.  It's the respiratory therapist.  In many cases, the therapist is called even before the doctor.  And even if the therapist isn't called first, the physician insists on the therapist being present.

The truth of the matter is, no one knows respiratory like the respiratory therapist.  I even had a hospitalist come up to me recently and admit this.  He said, "You respiratory therapists are our pulmonologists.  When we have a respiratory patient we call you and we heed your advice."

The fifth period of respiratory therapy exists in a time where the government is getting more and more involved in healthcare.  What this means is that many decisions regarding patient care have been removed from the physician, removed from hospital administrators, and given to government officials who sit in comfy leather chairs hundreds, if not thousands, of miles away from the patients they intend to help.

These government officials consider themselves the experts.  They know what's best for every patient in the United States.  This is where your protocols and order sets come from.  They say they are an attempt to improve patient care. But we know the true reason for them is an attempt to cut reimbursement costs to hospitals.

They say they are not being forced on hospitals.  But the truth is, if hospitals don't adapt them reimbursements will be cut.  So, in this way, hospitals are forced to adapt them whether they want to or not.  In the end, while the government saves money, hospitals have to eat the cost of implementing and enforcing these protocols and order sets that no one wants and that don't work.

In the midst of all this, sits the respiratory therapist in the RT Cave.  He grumbles and gripes under his breath when asked to do yet another breathing treatment on a patient who is not short of breath and probably doesn't need it.  Yet he keep his mouth shut for fear of alienating the very folks he relies upon.

Yet the time appears to have arisen whereby the word has gotten out, and certain members of Congress have established bills that would deregulate respiratory therapists in order to save costs. In other words, the process has begun whereby the powers that be will be looking at everything we do, and deciding if we are really needed.  There has even been talk of educating certain nurses to do what we do.  "After all," one nurse said to me, "All you guys do is turn knobs anyway, as most vents just work themselves."

You think that's true?  Most therapists know that we are more than just button pushers and neb jockeys: we are an essential part of the patient care team.  While most physicians, nurses, and hospital administrators understand this too, their hands might be forced to pull the rug out from under us for no other reason than to cut costs.

Will our profession survive?  Surely we will.  Yet the scope of our practice might result in us picking up duties we don't want to do, such as wiping butts and cleaning up puke.  Yet, if we play our cards right, it might evolve the other way too, where the scope of our practice allows us to remain an integral part of the patient care team.

Wednesday, October 29, 2014

NIV proven useful for COPD, CHF, yet failure rates still high

Noninvasive ventilation (NIV), either in the form of Noninvasive Positive Pressure Ventilation (NPPV) or Continuous Positive Airway Pressure (CPAP), has been used in the critical care setting since the end of the 1980s, and is now commonly used in both Europe and the United States for the treatment of COPD exacerbatons and heart failure.

Studies also show that NIV may significantly decrease work of breathing, either by improving minute ventilation (COPD) or by decreasing venous return to the heart (CHF), and thereby reducing the need for intubation to 15% (although it is as high as 38% in patients with chronic respiratory disease).

However, despite it being so commonly used, and despite all the advancements in technology and equipment that have improved patient comfort, studies continue to show that anywhere from 20-30% of patients fail.  Of the patients who fail, 30-40% require intubation and mechanical ventilation.

A good indication of failure, or a good predictor of who will fail, is hypercapnia after initiation of NIV.

Contou et al, however, concluded that experienced respiratory therapists may make adjustments at the patient interface (mask) or changes in settings that make the experience more comfortable and more effective, thus resulting in a reduction in NIV failure rates to under 15%, thereby reducing mortality rates to 5%.

Contou et al also showed that, by using an NIV protocol and having the patient closely monitored in by experienced personnel, including a nurse and respiratory therapist, 48% of patients who were semi-comatose responded well to NIV therapy without the need for intubation.

The study shows that trialing patients on NIV in an experienced unit where the patient was closely monitored, even those who would otherwise have been intubated, has proven to be effective, thus further reducing the need for intubation.

Likewise, the researchers reported, "it has been shown that NIV failure was not associated with an increased mortality rate in hypercapnic patients; thus, delayed intubation in some patients likely did not worsen their outcome."

The bottom line here is that NIV protocols that allow the nurse and respiratory therapist to closely monitor and adjust the settings on the NIV "might reduce the intubation rate.

References:

  1. Contou, Damien, Chiara Fragnoli, Ana cordoba-Izquierdo, Florence Boissier, Christan Brun-Buisson, and Arnaud W. Thille, "Noninvasive Ventilation for Acute Hypercapnic Respiratory Failure:  Intubation Rate in an Experienced Unit," Respiratory Care, December, 2013, volume 58, number 12, pages 2045-2052

Monday, October 27, 2014

The fifth period of respiratory therapy: will our profession survive?

The profession of respiratory therapy has traveled through four periods where there was a fear that our profession would disappear, and we survived them all.  We are at the current time amidst a fifth period where there is, once again, a raging fear that our profession will some day soon cease to exist. Will we survive this time around?

First of all, it must be noted here that respiratory therapists are an integral part of the patient care team.  Respiratory therapists exit college with a knowledge base unique to any other medical professional.  Even in the 4th edition of his book "Fundamentals of Respiratory Care, Dr. Donald F. Egan said:
"The techniques that have evolved for the treatment of (respiratory) patients required the supervision of highly educated and skilled professionals whose degree of specialization is beyond the scope of the average attending physician or nurse."
Based on my own experience I believe this to be true to this day.  Over the years I have read many peer reviewed articles, and have seen similar quotes by various well respected physicians, respiratory therapists and even nurses.  It didn't take long after the first orderlies started taking care of oxygen equipment and Iron Lungs during the 1940s for them to realize that they knew more about this equipment than the ordering physicians.  This is a truth that continues to this day, and it should not be -- although often is -- denied.

During the 1960s the first professional organizations were created in order to improve the relationship between physicians and the respiratory therapy profession.  While much progress has been made in this regard since then, there continues to be a disconnect between the two professions. Thus, while individual respiratory therapists may earn the respect of individual physicians,
the respiratory therapy "profession" continues to be seen as an ancillary service where doctors write the orders and we just do as we are told (of course we often know this results in respiratory therapy apathy syndrome).

Why would this be?  You'd think that they would be more than happy to delegate responsibility to trained respiratory therapists.  You'd think they'd be happy to allow trained therapists do what they were trained to do, as this would be to the benefit of the patient and the entire patient care team. And while some physicians do allow such, the majority continue to have a poor understanding of what we are capable of doing.  I honestly think it's not because they don't like us, I think it's because that's how they were trained.

Yet there remain those who say the reason is because we only have an associate's degree, while they have doctorates along with many years of training. So while our professional organizations have done wonders as far as preparing us for the world of respiratory therapy, they have failed to improve the image of our profession to the medical profession.  It is for this reason why much of what we do is a waste of time, such as giving breathing treatments to patients with pneumonia, or patients with heart failure, or just because they smoked in the past.  It's for this reason patients often stay on a ventilator three days, when they could have been extubated on the first day.

The reason could be that some physicians are too proud to bequeath some of their responsibility to people with associate's degrees, although, more than likely, it's that they are unaware of the qualifications and skill set that the average respiratory therapist has. This is in no way the fault of individual therapists, and, to be honest, no way the fault of individual physicians either.  The more likely cause is that we are still a relatively young profession in search of respect that has yet to be discovered on the grand scale.

Making light of the lack of respect for the profession (and not the individual therapist) are bills presently alive in the State of Michigan and in the State of Texas that would would deregulate the profession.  They will try to spin this off as an effort to improve healthcare, although we all know the effort is to cut healthcare costs.  As the government slowly takes over the healthcare industry, it will do whatever is in its power -- even at the expense of good patient care -- to cut costs.

Will the medical profession succeed in getting rid of the much needed respiratory therapy profession? Will we survive the fifth period of respiratory therapy?  Well, most people don't know this, but Congress once tried to end science and thankfully failed.  So, chances are, our profession will likely survive the fifth period of respiratory therapy too.

Saturday, October 25, 2014

New website: asthmahistory.blogspot.com

Over the past few years I've been off on an adventure through time to learn about the history of asthma.  A few months ago I started publishing what I learned on this blog.    

This project has grown so large that I have decided to separate it from the RT Cave, and have created a new website called asthmahistory.blogspot.com. This is a history of asthma, and it's also a history of all diseases that cause difficult breathing, plus the history of inhalation and respiratory therapy.

So, if you are in any way interested in learning what it was like to deal with difficult breathing in such and such a time in our history, of if you want to know what it was like caring for these folks, you might want to check out this new site.

Plus if you decide you like Asthma History, feel free to share it with your friends who also might be interested.  

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Friday, October 24, 2014

Myth Buster: FiO2 less than 60% is safe

One of the myths of respiratory therapy is if we get the FiO2 down to 60% we are safe.  In fact, most of us were taught in school that an FiO2 greater than 60% produced more side effects than an FiO2 less than 60%.

This apparently is a myth, and the following is the evidence:
  1. Register et al conducted a study with subjects under going open heart surgery, all of whom were breathing room air preoperatively  It was found that in subjects administered FiO2s of 0.50 postoperatively had a greater degree of hypoxemia on room air on postoperative day 2 than those given sufficient oygen to maintain SpO2 (greater than) 90%.  After repeating the study using only room air intra- and post-operatively, and finding that most subjects did not have a decrease in blood oxygen levels, as compared to preoperative values, it was postulated that the hypoxemia experienced in the first study was due to the use of oxygen during and after surgery.
  1. Garner et al exposed rats with peritonitis to FiO2 of 0.80, 0.4, or 0.21. Mortality was lowest in the FiO2 O.21 group, and highest in the Fio2 0.80 group.  Upon postmortem examination it was found that lung pathology did not differ between the groups but there was substantial liver damage with FiO2 (greater than) 0.21.  It was postulated that free radical formation caused the liver damage. 
This is yet another example that oxygen should not be administered unless necessary, and that every effort should be made to reduce oxygen as soon as possible.  Thankfully, most hospital oxygen protocols call for maintaining an SpO2 of somewhere in the range of 88-94%.  

References:
  1. Blakeman, Thomas C., "Evidence for Oxygen in the Hospitalized Patient: Is more Really the Enemy of Good," Respiratory Care, October, 2013, volume 58, number 10, pages 1679-1693
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Wednesday, October 22, 2014

Here's how NIV benefits CO2-retaining COPD patients

I often tell my patients that nothing I do cures any ailment.  To the contrary, I tell them that the procedures I perform treat acute symptoms, while the doctor and nurse do other things that will provide the cure.

A perfect example of this is with noninvasive ventilation (NIV) for treatment of acute respiratory distress due to chronic obstructive pulmonary disease (COPD). Savi et al, 2014, notes the following:
Noninvasive ventilation benefits patients with COPD, and it seems reasonable to expect that NIV would increase tidal volume and improve CO2 elimination, and thus reduce respiratory drive.
The note the studies have proven that NIV results in the following when used on COPD patient's presenting to the emergency room with flare-ups:
  • Reduction of treatment failure
  • Lower mortality
  • Fewer complications
  • Lower Intubation rates
However, the studies also conclude that:  "In these patients CO2 elimination is increased but overall ventilation-perfusion mismatch is not changed during NIV. 

What does improve ventilation, the authors note, are the following:
  • Treating precipitating factors (eg, infection with antibiotics)
  • Increase expiratory flow (eg, with beta agonists)
  • Reduce pulmonary inflammation (eg, with corticosteroids)
  • Manage gas exchange (eg, improve oxygenation)
Without NIV, studies have shown, patient's who have COPD with CO2 retainers should receive an FiO2 just enough to maintain an SpO2 of 88-92%, as higher FiO2s (either due to the loss of hypoxic drive, or V/Q mismatching) have been shown to cause a rise in PaCO2.  

However, this effect is negated with NIV.  Savi et al concludes:
During NIV with an FiO2 sufficient to maintain a normal PaO2, a further increase in FiO2 does not result in an increase in PaCO2 in CO2-rataining COPD patients, since no changes occur in (minute ventilation).
Crossley et al had similar results, concluding, that "CO2-retaining COPD patients following a period of mechanical ventilation with PaO2 in the normal range can safely receive supplemental oxygen without retaining CO2 or a depression of respiratory drive.  A new ventilation-perfusion relationship is established during ventilation to normoxia, and it is not altered by further increasing FiO2," Savi et all reports.

Since NIV helps COPD patients take deeper breaths, thus improving their ventilation (allowing them to blow off CO2), high levels of oxygen do not cause rising PaCO2 levels while a patient is receiving NIV therapy.  However, we often find that, while using NIV, many patients require less oxygen compared to prior to the NIV start.

Bottom line:  NIV is beneficial to CO2-retaining COPD patients because it increases their tidal volume, increases CO2 elimination, and reduces their drive to breathe.  By treating these symptoms, caregivers are provided an opportunity to do whatever is necessary to treat the cause of the exacerbation (even if that means utilizing higher oxygen levels).

References:
  1. Savi, Augusto, Jucara Gasparetto Maccari, Tulio Frederico Tonietto, Ana Carolina Pecanha Antonio, Roselaine Pinheiro de Oliveira, Marcelo de Mello Rieder, Evelyn Cristina Zignani, Emerson Boschi da Silva, and Cassiano Teixeira, "Influence of FiO2 on PaCO2 During Noninvasive Ventilation in Patients With COPD," Respiratory Care, March, 2014, volume 59, number 3, pages 383-387

Tuesday, October 21, 2014

Respiratory Therapy Formulas and Normal Values

The following are the most common respiratory therapy formulas and normal values used by respiratory therapists.


1. Ideal Body Weight (IBW):
  • a. Female: 100 lb for 1st 5ft + 5lbs ea additional inch
  • b. Male: 106 lb for 1st 5 ft + 6lbs ea additional inch
2. Static Compliance: (VT/Static pressure – PEEP)
  • a. Normal = 60-100
  • b. less than 60 = lungs becoming less compliant
  • c. greater than 25 is acceptable
  • d. less than 25 is unacceptable
3. Desired FiO2 = Desired PaO2 + Known FiO2 divided by known PaO2
(Normal PaO2 on 21% or room air = 105)
4. Desired Ve= Known Ve*Known PaCO2 divided by desired PaCO2
5. Desired Vt = (Known PaCO2 x Known Vt)/Desired PaCO2
6. Desired f = (Known PaCO2 x Known f)/Desired PaCO2
7. RAW: PIP–Plateau/ Flow, or PIP–plateau
8. French size sx catheter = ETT size * 3/2
9. PAO2: (713 *Fio2 – PaCO2)/0.8or 0.1 if 100% O2
10. A-a gradient (ratio or A-ADO2): PAO2 – PaO2
  • a. Normal on RA = 10-40 or on 100% = 25 – 70
  • b. Increased 66-300 = acute lung injury
  • c. greater than 300 = severe shunting, ARDS (unacceptable)
11. To determine cause of hypoxia, refer to the A-a gradient:
  • a. If normal, hypoxia caused by hypoventilation,consider drug overdose, neuromuscular disorder.
  • b. If abnormal & SpO2 improves with increased FiO2. Consider PE, pneumothorax, asthma,emphysema, pneumonia, bronchitis, heartfailure, congenital heart disease, aging.
  • c. If abnormal & refractory hypoxemia occurs, hypoxia caused by shunting problem considerpneumonia, atelectasis, pulmonary edema or ARDS.
12. Shunt % = A-a gradient/20
  • normal=20%
  • if greater than 20 an increase in PEEP is indicated
13. a-A ratio: PaO2/PAO2
  • a. Normal = 80% (74% elderly)
  • b. 60% = V/Q imbalance
  • c. 15% = shunting
14. P/F Ratio: PaO2/FiO2
  • a. Normal = 300 – 500
  • b. Acute lung injury = 200 – 300
  • c. less than 200 = ARDS (shunt)
15. Expected PaO2 = FiO2 x5

Even though normal PaO2 is 105 on room air, a PaO2 of 200 on 100% FiO2 is not necessarily good. It should be 500. Therefore you know patient still not oxygenating effectively.
16. e-cylinder time remaining=0.30(PSI) / LPM
17. Oral intubation = 21-25cm @ lip.
18. Nasal intubation = 26-29cm
19. PEEP therapy = greater than 6-8 CWP
20. Humidity should be set at 37 degrees Celcius.
21.  Suction:Adult=100-120,Child=80-100,Infant=60-80
22.  Patient WOB (available on newer microprocessor ventilators)
  • a. Less than 0.8 = normal
  • b. Measures effectiveness of rise time and sensitivity.
  • c. Measured in spontaneous mode.
23.  Actual PaO2/ Expected PaO2 = % of patient expected PaO2:
  • a. Should be recorded daily
  • b. Shows if patient is oxygenating better
  • c. Better indicator than simply looking at actual PaO2 and FiO2
  • d. Normal = zero (patient requiring no supplememtal oxygen)
Examples of % expected PaO2: (Despite lower PaO2, patient still oxygenating better)
  • e. January 1 PaO2 40 on 100% FiO2 = 80%
  • f. January 5 PaO2 60 on 40% FiO2 = 30%
  • g. January 6 PaO2 55 on 50% FiO2 = 20%
Another example of % expected PaO2 (PaO2 looks good, but is patient really oxygenating?)
  • h. January 1 PaO2 200 on 100% FiO2 = 40%
  • i. January 5 PaO2 100 on 100% = 20%
  • j. January 6 PaO2 100 on 90% = 22%
24.  Temperature Conversion:
  • Celcus = Fahrenheit minus 32/ 9      
  • Fahrenheit = (Celcus*9)/32

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