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Wednesday, February 24, 2010

Your RT querries

Every so often I check my statcounter to see who's typing things into Google or Yahoo and being linked to my RT Cave blog. Assuming the queries were not answered, I provide in this spot each week my humble responses.And, hey, if the query is comical, it deserves a comical response. If it's serious, I treat it as serious. That in mind, here are this weeks queries:

1. is chf an indication for albuterol: The only indicatin for albuterol is bronchospasm. CHF is fluid in the lungs, and it causes an upper airway wheeze that is audible, and often presents as bronchospasm. The wheeze is caused because the increased pressure and fluid in the lungs are squeezing the bronchioles. Albuterol will not help CHF patients. Plus, if you read the insert for Albuterol you will see that it says for use for COPD and asthma patients only. However, according to a lot of doctors and nurses, chf is an indication for albuterol. Go figure.

2. how to set up a ventilator: If you can tie your shoe you can set up a ventilator. The only reason we put all those buttons and all those graphics up there is to scare nurses and doctors away.

3. can copd affect a patient post-op: Yes iti can. If you have compromised lungs, you have an increased risk of respiratory complications following surgery. Likewise, many COPD patients have cor pulmonale which means the heart is working extra hard already. It may sometimes take these patients longer to recover from anesthetics, and they often will need to be on a ventilator 24-48 hours.

4. carbon dioxide retainers do not give 100% oxygen: If you have someone who needs oxygen you must provide them oxygen. You will want to maintain an SpO2 over 88% on every patient regardless of disease. If the patient stops breathing due to the increased oxygen, then you should intubate and ventilate those patients. If you allow a patient to go without oxygen, that patient is at grave risk for cardiac complications and death. Do not withold oxygen due to the hypoxic drive fallacy. However, you should also discus this with the physician and do what he says.

5. beer asthma: Beer causes you rlungs to dry out. Plus there are posible asthma triggers in beer. It is recommended if you drink you do so in moderation.

6. tremors and copd: Many COPD patients have tremors. It's not necessarily due to the disease but a result of the treatments used to treat COPD. Both corticosteroids and bronchodilators have tremors as a side effect.

7. ventolin for smokers: If you are to the point you smoke and need ventolin, then please stop smoking. While you cannot undo the damage already caused from smoking, you can slow down the progression of your lung disease.

8. how to fake pneumonia: You cannot fake pneumonia. However, to justify a stay in the hospital, I have seen doctors write pneumonia as the diagnosis for the stay. That way the insurance will pay. I've never had a doctor admit this, but I have seen pneumonia as the diagnosis many times with normal x-ray, normal labs, etc.

9. indications of albuterol with pneumonia: Albuterol is only indicated for bronchospasm. If the pneumonia is causing bronchospasm (as in COPD and asthma) then it is indicated, otherwise it is of no use for pneumonia. I will write a post about this soon, so stay tuned.

10. how would you like to die drowning: Quite frankly I wouldn't. Yet, I do know I can't breathe under water.

If you disagree or agree with my opinion feel free to leave a comment below, as we are all entitled to an opinion. If you have further comments or questions, feel free to write it below or email me.


EloquentRT said...

Bear with me, I'm a second semester RT student from Canada.

Tell number 2 to the rest of my intro mech vent class. The class average is a gentleman's 55%. At first people had a lot of trouble understanding the difference between pressure control and volume control -- "pressure and volume are directly related, what's the point in having both volume and pressure control," they'd ask. Then when that became more clear, people got hung up on I:E. And so on.

And that's not even mentioning the different terminology between ventilators and textbooks. Or normal values. A classmate didn't set up her high pressure cycler properly, set Ppeak at something ridiculous, and gave one of our dummies a pneumo.

I would rephrase your answer to: If you can figure out a new computer operating system with some assistance, you set up a ventilator.

This is turning into a long comment, but I have a question about the CO2 retainers. In your answer, you're talking about intubating when a patient's sat stays at 88% or drops below it, and still doesn't have drive, right? If you've cranked a CO2 retainer's sat up to 96 and he stops breathing, would you not attempt to bring the sat back down and see if he regains his drive (while bagging)? Isn't best protocol to do everything you can before intubating?

TOTWTYTR said...

I look forward to your post about pneumonia and bronchodilators. I've had this discussion with several doctors and nurses. In fact, one nurse wrote me up when I told him that there was no indication to use Albuterol in pneumonia.

Anonymous said...

Is there an indication to give IV steroids in pneumonia?

Rick Frea said...

I've had the same discussion with doctors and nurses. There's really nothing you can do when so many people chose to deny the facts.

Always know that the #1 sign of arrogance, elitism, ignorance and denial is to belittle the messengers of the truth. I can think of many examples, but you can find your own just by studying Hitler, Stalin and Castro. Anyone who disagrees with those folks was killed or imprisoned.

That's why some doctors and nurses talk about RTs who state the facts as "lazy" and "trying to get out of work." Most doctors aren't this way, but the fact that some are scares us all into submission. It's kind of a do-you-want-to-take-the-chance kind of a situation.

I believe, however, that the fear of write-ups, of rocking the boat, and the desire to be politically correct and to "keep the peace" is exactly why we are in this mess in the first place. Too many times we RTs do the treatment not because it's needed, but because that's easier than confronting the ignorant. I know that sounds harsh, but it's the truth.

And I'm the same way. You'll rarely hear me saying to a doctor, "That's not a wheeze, it's stridor," or, "What good is a treatment going to do for inflammation of the alveoli, which is what pneumonia is."

It's easier to just do the treatment and go back to the RT Cave. It's easier to just do the job they want you to do, go home and collect that pay check. It's easier, but is it really the right thing? Well, in a hire at will fire at will society, it is I guess.

Yet, so long as you are polite and professional in your approach to educating doctors, you shouldn't need to worry about a write-up. Sometimes they can be good. Sometimes that's how the powers that be become aware of problems, and the seeds to solving the problem are planted.

So continue to be yourself, be careful as to know who you are confronting, and know when it's a good idea to back off and shut your mouth. It's also a good idea to know if you can trust your boss to back you up. That's the nice thing about my boss, so long as I'm not "complaining," she will always back me up, and my fellow RTs too.

Rick Frea said...

Are corticosteroids beneficial for pneumonia? I would say the answer is a resounding yes. Corticosteroids treat inflammation everywhere in the body, and they will treat inflammation of the alveoli as well. However, I believe the corticosteroids given need be by the systemic route, as very few of the particles from a hand held nebulizer get down to the alveoli. IV Steroids should work for pneumonia.

Despite what some nurses and doctors and perhaps even some RTs believe, pneumonia does not cause inflammation of the bronchioles. Likewise, pneumonia does not cause bronchospasm "unless" there is an underlying case of asthma or COPD involved. In this case, corticosteroids will help with bronchial inflammation to make breathing easier, and a bronchodilator like Ventolin will dilate the smooth muscles lining the air passages of the lungs making it easier to breath.

If you do not know if a patient has COPD or asthma, it is okay to try a breathing treatment. You can use peak flows, a good assessment, and common sense to determine if further bronchodilator therapy is indicated. Most of the time, however, it is not.

So, to answer your question, I believe corticosteroids do work for pneumonia.

Rick Frea said...

EloquentRT: Personally, I wouldn't worry about an SpO2 of 88%. Too many times I see doctors and nurses all stressed out about this, and it's not the end of the world. You also have to consider that a pulse oximiter measures at +/- 2%, so 88% could actually be 90%.

Another thing to consider is that 90% of COPD patients do not stop breathing because of high oxygen levels. For this to happen the patient has to already be near failing when the oxygen was placed on the patient. It is very rare for this to happen, although the fallacy is that all CO2 retainers are subject to becoming lethargic with increased oxygen.

Thirdly, you are correct. If you overoxygenate a patient, and this causes the patient to stop breathing, you'd definitely cut back on oxygen first. You might as well try it at this point. However, once a patient loses consciousness, chances are he's not going to regain it without some assistance.

However, as you say, it may be worth a try.

Yet it's difficult to decrease FiO2 while bagging. You may be able to get it down to 40% by taking off the tail of the bag, but that's not possible on some bags, like the ones we have at our hospital.

You are wise to be thinking this way. It's a sign of a good RT and a good medical worker. It's always good to be thinking outside the box like this.

Also note that I believe, as perhaps you are figuring out, that most of the time when a patient is intubated it's out of a panic rather than out of wisdom. I believe that most intubations can be avoided by allowing meds to work, being patient, giving the patient time to heal, and thinking outside the box.

Rick Frea said...

Here's a good post about how Albuterol does not work for pneumonia.