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Monday, June 12, 2017

Why aren't there more RT blogs?

Your Question: Why aren't there more RT blogs like yours.

My Answer: There are a few, as you can see by the "Links" tab above. However, many of those blogs have not been updated in so long that I might as well delete them from my list. This is unfortunate, but I think fear has a lot to do with it. In fact, I know of one blogger who was told to quit blogging or he would lose his job. He had the best RT blog ever. Okay? And now he's done because he didn't want to lose his job.

I don't know if you have ever noticed this or not, but sometimes I publish posts on this blog and then think better of it and hit the delete button.  I don't do this very often, but sometimes I have to act as editor and protect the real me from the writer me. I have a tendency to be non-politically correct and truthful, and, Lord knows, the truth can get you into trouble sometimes.

Of course, you might be thinking, "What about freedom of speech?" I think that freedom of speech gets overblown sometimes. There really is no such thing as freedom of speech in the respiratory therapy cave. I can't observe a certain situation at work and then write about it, and then publish it. I mean, I could if I tread carefully. I could if I stayed on the safe side of the line. But that line is invisible, so it's often hard to tell where exactly it is. So, it's better to play it safe and simply avoid these types of articles.

Which is unfortunate, I think. I think the world would be better served if people like me could be honest about what they see at their work. So many times I see something interesting. Something that worked good. Something that didn't go so good. Something that was rare. Something that happens a lot, and shouldn't. So many things I see that have to remain in my head, only to be forgotten to time.

HIPPA I think is good in a way. I think people should have some medical privacy if they want it. But I think the whole HIPPA thing also has been overblown and taken out of context to the extent that people have lost their jobs for no good reason because of it. And I also think it has been a disservice to the medical profession as a whole. So many times, for example, we package up a trauma and ship that person out, and then we never hear a peep about that patient again. What did we do right? What did we do wrong? What could have we done better? We will never know, because of that dumb law.

Actually, we shouldn't blame the law, per se. We should blame the sue happy people who ruined the healthcare system. I think the HIPPA law was the result of lawmakers saying, "We have to do something." Yet I always think that -- the way the founding fathers used to think, I believe -- is that government should leave making laws to the states and to the people, and it's best to do nothing than to do something stupid. And I think HIPPA was that something stupid that resulted from people thinking they just had to do something.

So, it is probably because of this law that you don't see more blogs like this. And it's also why you won't see an article written by me that is too overly honest about my job. That is why I almost have to take a humorous take on much of what is wrong with our job -- and there are a few things wrong, I'm sure you will agree. It's a great profession, but it's imperfect, and it's not our fault it's imperfect. But I think that laws prohibiting bloggers -- or at least scaring them away -- from telling on the job stories work to the detriment to the profession as a whole.

Thoughts?

Thursday, June 1, 2017

Nurses Describe Why It's Important To Respect Your RT's

One of my coworkers introduced me to this Youtube video where three critical care nurses describe how important it is to respect your respiratory therapists. This is pretty good.

Sunday, May 28, 2017

Study: Ventolin Shown To Prolong Life

A new version of Ventolin, aptly termed "Keep-me-alive-olin," has been shown to prolong life. This is according to analysis of studies conducted by the Real Doctor's Creed Committee.

Keepmealivolin was listed as the #61 most popular version of Ventolin prescribed by doctors by our own experts here at the RT Cave.

This version of Ventolin was first recognized by Dr. Happy Lackluster in 1985. He t he ordered a respiratory therapist to give a Ventolin breathing treatment by mask to a patient who was terminally ill, who had an ejection fraction of 20%, and who was in otherwise poor health with terminal bone cancer, diabetes, and kidney failure.

Dr. Lackluster sadly passed away in 1998. However, the RT Cave was able to get ahold of Dr. Will Chambers, a longtime coworker of the beloved Dr. Lackluster.

"He was a fine fellow," said Dr. Chambers. "We were all so impressed with his discovery. I remember Happy  telling the story. He about keeled over laughing because, as he said, 'the respiratory therapist was so unhappy to be giving the treatment.'  He said the therapist said, 'He is not even short of breath.' But, in the end (no pun intended), the therapist was proven wrong, as the patient lived an extra day, long enough to say good-bye to loved ones who had to fly all the way into California from Great Britain."

Dr. Chambers added, "But we were taught in medical school back in the 1980's that if all else fails, order a breathing treatment. Little did we know that Happy stumbled on a new version of Ventolin now aptly titled Keepmealiveolin."

While we have never revealed the true history of it on this blog before, we called the wife of Dr. Lucky Happluster and she was more than happy to provide for us a study. It was performed in 1964, and involved an entirety of four whole patients. Two were given a placebo and two were given Keepmealivolin, and they all lived a little while longer. This was all the proof needed to convince the medical community of the efficacy of keepmealivolin. Two hundred studies since then seemingly proved this initial study wrong, but those studies never changed anything: keepmealivolin is still used to this day.

So, ever since that initial study was published, whenever doctors don't know what else to do when a patient is terminal and things don't look good, it's time to order Ventolin. And, likewise, during a code, when there is nothing else to do, it's time for Keepmealiveolin. If necessary, it can be given inline with the AMBU-bag.

And it's not like this is unusual. The hypoxic drive theory is based on a study of 4 COPD patients from the late 1960's. So, who's to say 4 patients can't prove that Keepmealivolin won't prolong life. It can at least buy a patient a day or two, perhaps an opportunity to say goodbye to loved ones who live 10 or more hours away who need time to travel.

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Monday, May 8, 2017

How can we make the RT profession better?

The following is a guest post.

By Wanda Bunch
I'd like to voice my frustrations as a Respiratory Therapist today. I'd like some ideas or suggestions on how we can make changes on a state level for Respiratory Therapist. I want my ideas/opinions/ and my voice to be heard.

I LOVE being a therapist (5 years) in Oklahoma. The respect and understanding of what we truly are capable of doing needs to be recognized. Our career (notice I didn't put job) is in jeopardy due to health care changes and we need to grow with the changes; so our career path we choose can continue to exist.

It sadness me to hear therapist of under 10 years talk about being burnt out due to being disappointed (due to department leadership and policies ). I feel the field has become stagnant with old policies/ goals/ and career ladder.


YES we have them available to us. I feel strongly about my career choice and want to continue to Excel at it and make improvements. So all therapist around the US should be asking themselves if we want to better this career and it to continue to exist 


What do we need to do to better the system?


So my questions to all of you.

  1. How do we get changes made on a state level? 
  2. Why are some states so behind in our field (Oklahoma)?
  3. How do we get rid of this stagnant ideas/policies and leadership?
  4. How can we bring up the morale among us and others?
  5. How can we encourage health care professionals that they need us and worth so much more?

Monday, May 1, 2017

BiPAP and CPAP: Answering all your questions

Your question: How high can you set CPAP? What are the disadvantages of CPAP that is too high?

My answer. This is a good question. According to Egans, CPAP is a continuous flow of pressure on inspiration and expiration.If there are alveoli that are collapsed due to atelectasis, CPAP acts to recruit them, and open them up. It thereby acts as a splint to keep them open to improve oxygenation. If CPAP levels are set too high, alveoli will be over-distended, and this may result in air trapping. (1, page 1066)

Another thing to keep in mind here is that CPAP acts to reduce venous return to the heart so the heart doesn't have to work so hard to pump blood through the body. This is the advantage of using CPAP to treat heart failure. If CPAP is set too high, this pressure may ultimately reduce venous return enough as to cause a reduction in cardiac output, which can be measured by a drop in blood pressure.

Over-distended alveoli and air trapping can also result in a drop in oxygen levels, and this can be measured by oxygen saturation monitor.

Your Question. How high can you set IPAP on a BiPAP machine?

My answer. The best answer I can give to this question is a theory, as is much of the medical profession. From what I have read (and you can help me find a source here) is that a pressure support or IPAP higher than 20 in a non-intubated patient may act to obstruct, or block, the esophagus. This can prevent the patient from swallowing. You can exceed a pressure of 20 if you absolutely must to improve oxygenation or ventilation. However, if you must do this, talk to the doctor about ordering a nasal gastric tube (NG)

While it's generally not a good idea to exceed the recommended settings, I have from time to time had doctors insist I do this. I just make sure to remind the physician that there is a down side to too much pressure.

Your question.  Is it true that you need an IPAP greater than 10 to be therapeutic?

My answer. The goal of IPAP is to assist with inhalation to reduce work of breathing and improve ventilation. If an IPAP of 10 results in an ideal tidal volume for that patient, then an IPAP of 10 will be fine. Some patients have small frames, in which case an IPAP of 10 (or less) may provide adequate support. Keep in mind here that some people with COPD do not have enough lung function, especially during flare-ups, to adequately blow off CO2. For these patients, just assisting them get to their normal, ideal tidal volumes will be all that is needed. So, you do not necessarily have to blast patients with the highest pressure support. If you are getting adequate tidal volumes (using your usual formula of 6- ml/kg ideal body weight), then you are probably fine.

Your question. Is it true you can't set a rate on BiPAP?

My answer. Part of the advantage of BiPAP, is if the machines senses that a patient hasn't taken a breath, it can force the patient to take a breath. This is ideal for preventing sleep apnea. So, ideally, you should set the BiPAP rate at around 6-8. Usually patients will breathe over this set rate. However, if they don't, then the machine will assure at least a minimum respiratory rate.

Your question. How are CPAP and BiPAP set? What are the ideal settings to use?

My answer. The ideal settings should be determined by doing a sleep study. A sleep study technician will titrate settings until the best settings are determined. You will want the lowest setting necessary to keep airways open and maintain adequate oxygenation. Of course, you don't want too high to prevent drops in blood pressure and oxygenation as noted above. There are also newer machines that are auto-titrating.

Your question. When you are setting up a patient on BiPAP in the clinical setting, what are good start settings?

My answer. This is open to debate. It is also open to varying opinions. The general consensus where I work is ideal start-up settings are IPAP 10 and EPAP 4. Settings can be adjusted until an ideal tital volume and oxygenation status is determined.

Your question. How big of a gap between IPAP and EPAP do you need.

My answer. The answer here is another one that is open to personal opinion. The general consensus where I work is that you would like to keep the gap at a minimum of 5. For example, you will want to set the IPAP at least 5 over EPAP. Keep in mind, however, the ventilator that you are using.

Your question. How is Pressure Support (PS) measured on BiPAP. It depends on the machine you are using. On the V60, it is measured over PEEP. So, if you are using a V60 ventilator, and you have the IPAP set at 10 and the EPAP set at 5, you are essentially using a Pressure Support of 10 and a CPAP of 5. On the other hand, if you are using a machine that does not measure PS over PEEP, and you use settings of 10/4, then the measured PS is 5. So, this is why it's important to know your machine.

Your question. Is it true that if a patient requires BiPAP post extubation that the patient never should have been extubated and should be re-intubated?

My answer. Actually, this subject has been extensively studied, and the results are relatively inconclusive. However, some studies show that BiPAP post extubation may prove useful in some patients, especially those with end stage COPD where airway protection and pulmonary toilet is not a concern. This may occur when patients are incorrectly assessed for readiness to wean, or when patients self extubate. It may also occur in some patients, such as those with end stage COPD who are anticipated to still need some support although you don't want to risk further complications of intubation, and a trial of post-extubation BiPAP is done on purpose. Some studies do show this may prove beneficial. However, it should also be noted that the patients described here have a 40% mortality rate.  (5)


Your Question. Does BiPAP really help with heart failure? Doctors say it pushes fluid out of the lungs.

My answer. Both CPAP and BiPAP, by providing increased intrathoracic pressure, have been shown to reduce both cardiac preload and afterload, which reduces the amount of work the heart has to do. Some physicians think it works by pushing fluid out of interstitial spaces, and this is why it works. However, while this does occur to a small extent, it's not enough to have a therapeutic benefit. (5)


Your Question. Does BiPAP truly benefit people with COPD.

My answer. Yes. Studies seem to show that IPAP reduces airway resistance due to bronchospasm and secretions to make it easier to take in a breath and reduce dyspnea The machines can also sense when a patient has not taken a breath to force them to take a breath, thereby preventing apnea. EPAP also acts to splint the upper and lower airways to keep them open at end expiration. This prevents soft tissues in the upper airway from collapsing and causing apnea, and it also recruits collapsed alveoli and keeps them open to improve oxygenation. Various studies have shown that BiPAP used to treat episodes of severe COPD, whether caused by COPD or heart failure, in the hospital setting greatly improves outcomes and hospital length of stays, and reduced hospital costs. Part of this is because BiPAP often prevents the need for invasive intubation and mechanical ventilation. Nocturnal BiPAP used every day at home for a minimum of four hours per day significantly reduces COPD flare-ups and makes them less-severe when they do occur. This has made it so that people living with COPD can live long lives with quality. (1, 4, 6)

References:
  1. Kacmarek, Robert M., James K. Stoller, Albert J. Heuer, “Egan’s Fundamentals of Respiratory Care,” 10th edition, 2013, Elsevier Mosby, pages 1066, 1134-5
  2. “Non-Invasive Ventilation in COPD Exacerbations,” Nursing Times, September 3, 2013, https://www.nursingtimes.net/clinical-archive/respiratory/non-invasive-ventilation-in-copd-exacerbations/5062992.article
  3. Criner, Gerard J., Rodger E. Barnette, Gilbert E. D’Alonzo, editors, “Critical Care Study Guide: Text and Review,” 2nd edition, 2010, Springer
  4. Respiratory Therapy Magazine: Noninvasive BiPAP Systems May Help COPD Patients, January 28, 2015, http://www.rtmagazine.com/2015/01/noninvasive-bipap-systems-may-help-copd-patients/, accessed 3/31/17
  5. Maclntyre, Neil R., “Mechanical Ventilation: Noninvasive Strategies in the Acute Care Setting,” Medscape, http://www.medscape.org/viewarticle/450209, accessed 3/31/17
  6. Ankjærgaard, Kasper Linde , et al., "Home Non Invasive Ventilation (NIV) treatment for COPD patients with a history of NIV-treated exacerbation a randomized, controlled, multi-center study," BMC Pulmonary Medicine, 2016, http://bmcpulmmed.biomedcentral.com/articles/10.1186/s12890-016-0184-6, accessed 4/1/17
  7. Respiratory Therapy Magazine: Nocturnal BiLevel Ventilation for the COPD patient," February 7, 2007 http://www.rtmagazine.com/2007/02/nocturnal-bilevel-ventilation-for-the-copd-patient/, accessed 4/1/17
  8. Lainscak, Mitja, Stefan D. Anker, "Heart failure, chronic obstructive pulmonary disease, and asthma: numbers, facts, and challenges," ESC Heart Failure, volume 2, issue 3, 2015, pages 103-107, http://onlinelibrary.wiley.com/doi/10.1002/ehf2.12055/pdf, accessed 4/2/17

Tuesday, April 11, 2017

What is PEEP? How to do a PEEP study?

PEEP is an abbreviation for Positive End Expiratory Pressure. It's a small amount of pressure above what is in room air that remains at the end of expiration.

The benefits of PEEP are.
  1. Increased Residual Capacity. This essentially means that it increases the amount of air that stays in the lungs. This works to...
  2. Recruit collapsed (atelectic) alveoli. This makes it so they participate in gas exchange. It also works to...
  3. Keep alveoli from collapsing. It keeps alveoli open so the effects of fluid or atelectasis do not cause shunting. This also helps to reduce V/Q mismatching. This also makes it so you have an...
  4. Increased PaO2 for a given FiO2. It's a good way of improving oxygenation. 
  5. Decreases Cardiac preload and afterload. It reduces the amount of blood returning to the heart, and thereby reduces the amount of blood leaving the heart. In this way, it can help patients who are in heart failure (pulmonary edema) by reducing the amount of work their heart has to do to pump blood through your body. This also means that too much PEEP can be observed by drops in cardiac output, which can be measured by bloodpressure and oxygen saturation (SpO2). 
  6. Reduction in tissue injury and inflammation. It prevents the alveoli from constantly opening and closing and thereby inuring them and causing inflammation, which may be associated with the development of ARDS. Studies have shown that it is protective against "ventilator induced lung injury." This is often called volutrauma. Volutrauma was more prevalent back in the days when it was thought that people on ventilators should be on higher tidal volumes, hence the old formula of setting tidal volumes based on 10-15cc/kg ideal body weight. This has now been lowered to 6-8cc/kg ideal body weight in order to prevent volutrauma. 
There are disadvantages of this.
  1. Over-distention of alveoli. It causes too much air to stay in the lungs resulting in decreased cardiac output, as would be shown by blood pressure and SpPO2. There are certain instances where you would benefit from higher PEEP, although too much PEEP can lead to over-distention and volutrauma, which may mimic respiratory disease states. So, in such instances, you would want the highest PEEP that doesn't cause over-distention. (Described below is how to accomplish this with a PEEP study). Over-distention results in increased dead space, increased work of breathing, and medical disorders such as ARDS. 
  2. Diminished Cardiac Function. As noted, PEEP that is set too high can decrease venous return and cardiac output. This can be measured by complex formulas, although the simplest way is by taking a blood pressure and monitoring pulse oximetry. 
  3. Diminished Renal Function. May decrease renal blood flow resulting in diminished urinary output. So, this is another reason to keep PEEP as low as clinically possible, especially when you have a patient in heart or kidney failure. 
  4. Increased Intracraneal Pressure. When venous return decreases, intracraneal pressure may increase. This is usually not clinically significant. However, if you have a patient who already has an elevated intracraneal pressure (ICP), such as due to a head trauma, this is something you'll need to watch out for. This is another reason to raise the head of the bed, as this may offset any increase in ICP (the other reason for raising the head is to prevent GERD, which can increase the risk for ventilator associated pneumonia). 
Now that you know about PEEP, along with its benefits and disadvantages, we can now get into how to perform a PEEP study. The purpose here is to determine the perfect PEEP for an individual patient at any given moment in time. Keep in mind here that the ideal PEEP may increase or decrease over time, especially as a patient's medical condition worsens or improves.

Here is the basics of any PEEP study.
  1. Increase PEEP by 2-3 cwp every 20 minutes and continue to monitor the patient. You should write down the patients blood pressure and SpO2. If desired, you can also jot down the patients P/F Ratio and static compliance.
  2. If static compliance, P/F Ratio &/or SpO2 increase, you know it's working. 
  3. Stop when the patient's blood pressure and SpO2 start to drop. Also stop when the P/F Ration is equal or greater than 200. Also stop when the static compliance decreases. 
  4. The required PEEP should be set at the PEEP setting used just prior to where the hazards of PEEP were observed. 
  5. Do not increase PEEP if systolic BP is less than 90
  6. Also, keep mean airway pressure (MAP) less than 15. This is one of the newer markers of too much PEEP. When it starts to drop, this is an early indicator that cardiac output is about to decrease. 
  7. Ideally, static complliance should be between 60-100.
I also have a shortcut. Maybe I shouldn't teach you this, but here goes: essentially, based on the wisdom we learned above, all you really need to do is monitor pulse oximetry and blood pressure. If either starts to drop, then you know it's time to lower your PEEP by 2 cwp, which would be your ideal PEEP. This makes it simple. 

The optimal goal of any PEEP study is to find the optimal PEEP to maintain a desired SpO2 and PO2.

If any of my fellow respiratory therapists has anything further to add (any tips), please feel free to share.

(Post originally published on 8/9/08. It has been edited and updated by RT Cave Staff). 


References:
  1. Vincent, Jean Louis, editor, "Intensive Care Medicine: Annual Update 2002," 2002, Springer, pages 302-303
  2. Criner, Gerard J., Rodger E. Barnette, Gilbert E. D’Alonzo, editors, “Critical Care Study Guide: Text and Review,” 2nd edition, 2010, Springer
  3. Kacmarek, Robert M., James K. Stoller, Albert J. Heuer, “Egan’s Fundamentals of Respiratory Care,” 10th edition, 2013, Elsevier Mosby
  4. Saura, Pilar, Lluis Blanch, "Conference Proceedings: How to set Positive End Expiratory Pressure," Respiratory Care, http://www.rcjournal.com/contents/03.02/03.02.0279.cfm, accessed 4/11/17
  5. Respiratory Update: "Benefits, Contraindications, Adverse Effects for PEEP/CPAP," http://www.respiratoryupdate.com/members/Contraindications_for_PEEPCPAP.cfm, accessed 4/17/17
  6. Valenza, et al., "Positive end-expiratory pressure delays the progression of lung injury during ventilator strategies involving high airway pressure and lung overdistention," Critical Care Medicine, 2003, July, 31 (7), pages 1993-08, https://www.ncbi.nlm.nih.gov/pubmed/12847394, accessed 4/11/17
  7. Respiratory Therapy Cave: Respiratory Failure Lexicon
  8. Respiratory Therapy Cave: ABG Lexicon

Monday, April 10, 2017

When it's busy, this kind of stuff happens

So, I enter the patient's room and leave my cow by her bed. I left because her inhaler was in another cow. I walked to the other cow. I opened the other cow. I took the inhaler out of it, and returned to my patient's room. The curtain was pulled around the bed. A nurse was behind the curtain.

I said to the nurse, "Is my cow back behind there with you?"

She said, "No!"

I said, "I just left it there. Where could it have gone?" I said this in a facetious manner, knowing she must have moved it.

She said, poking her head out from behind the curtain, smiling. "I don't know where it is?"

I walked out of the room. I looked at the room number. I realized I was in room 9. The room I left my cow in was room 11. I said, "Well, it seems I'm in the wrong room."

She laughed. She said, "It seems you need to drink some more coffee."

"Agreed!" I said.