Saturday, January 30, 2010

Poor planning results in busy nurses

She was an RN. Her boss sat next to her as she was finishing her charting and asked her if she would work tonight. The RN said she was unable. The boss lectured her that "we are all in this together, and part of being a team means we all need to do our part."

The RN said, "I am doing my part. I work my one day a week and that's all I want to work. If I wanted to work more I would schedule myself for more."

The boss was dumbfounded. She picked her ear with one hand, and with the back of her other hand wiped away the drool swirling around the corner of her lower lip as it dropped almost to her jaw.

I thought for a moment she might cry. I, for a brief moment, felt empathy for this boss. Finally she said, "We need you. We're in a crisis here and we really need you."

"Look, I don't mean to be disrespectful," the RN said, "But poor planning on your part doesn't constitute an emergency on mine."

That ended the discussion. I won't go on about how it ended. I won't explain how I so happened to be there to hear the discussion, for neither of those facts matter.

Tonight I was sitting in the ER. I noticed that the charge nurse was sitting at the unit secretaries desk putting in all the orders. From time to time she'd get up, run to a patients room, do some chore there, and return to finish typing away, and flitting through sheets of paper.

"Why are you doing all this work?" I asked, knowing she didn't have time to talk with me.

She leaned back in her chair and smiled, "The unit secretary went home at 2:00 in the morning. The rest of the night we have to go without her and without any nurses assistants or techs to help us out. Plus Janet is going home at 3:00 and so is Jim. So basically it will be just me and Susan."

"So basically the powers that be want you guys to work at unsafe levels."

"Wow! That words it about right."

That was the end of that discussion.

A few years ago another nurse named Peggy was sitting in the nurses report room about 40 minutes after her shift was supposed to start. I said, "Why are you sitting in here when all the nurses out there appear to be overworked."

She said, "I'm refusing to take report because they want me to take 14 patients, and I think that is unsafe. I'm not going to put my license on the line because of their poor planning on their part." She was referring to the RN boss.

Due to her persistence another nurse arrived a half hour later and Peggy finally took report on seven patients, a load that she said was safe.

With respect to hospital bosses it is not possible to know when business is going to be swarming and when it's going to be slow. But still, poor planning on their part does not constitute an emergency on the part of the nurse.

RT Cave Rule #41: Poor planning on the part of administrators, bosses and supervisors does not constitute an emergency on the part of the staff.

Friday, January 29, 2010

We need to keep end stage patients happy

I think it was in 1993 at hunting camp my Uncle Donald decided to visit us. He was 80. My dad and I marveled at the fact that our 80 year old uncle was out in the middle of the woods, standing by a fire, and buzzed after drinking some homemade wine that sat up above the cupboards in the cabin kitchen for years.

Every person has one sagacious uncle, and Uncle Donald was mine. He had a white beard and mustache and gave the impression of Mark Train. He read a lot, said little, and when he did talk he impressed you with his wisdom.

You don't really think a lot about 80 year old people getting drunk, but after all they are human. And he wanted to enjoy the evening with dad and me. Dad said to me, "Yep, Rick, when you turn 80 you can do whatever you want."

That makes a lot of sense to me. And now, 15 years later, I use the same philosophy when I'm working. I believe if you are over 80, or if you have an end stage disease, that you can do whatever you want.

Likewise, if you are an end stage COPD patient you can have a breathing treatment whenever you want. And when you're done with that first treatment and you want another, by golly you can have that too.

I had an end stage cancer patient the other day demand a nasal cannula at 10lp. I had another patient who was anxious and labored who demanded a treatment every hour "even if I'm asleep get me up."

Wish granted!

Why not. The only reason I can think of for not giving it to her is if the RT were lazy or annoyed or didn't have any common sense. So, I think we'll make this RT Cave rule #40:
RT Cave Rule #40: Whatever it takes to keep a patient over 80 happy, do it. Whatever it takes to keep an end stage COPD, CHF, CF or cancer patient happy, do it. Use your common sense.

Thursday, January 28, 2010

How to decrease chance of brain injury to neonates

Decrease chance of brain injury by...
  1. Handle baby gently
  2. No trendelenberg
  3. Avoid excessive pressure on CPAP
  4. Use SpO2 and ABG to gradually adjust FiO2, as rapid chanages in CO2 result in increased risk of intracraneal bleeding
  5. Do not give rapid infusions of fluid
  6. Avoid hypertonic solutions

Wednesday, January 27, 2010

Fluid imbalance

When we RTs are called to assess a patient due to a low spo2, or increased crackles in the bases, or increased dyspnea as noted by the nurse, one of the #1 things to consider is if the patient is wet.

For the record, normal urine output is 1-2 liters per day, or 25-50 ml/hr. Likewise, a patient's normal fluid balance is a measure of fluid intakes mainly form drinking or through the IV. It is my observation that fluid overload is quite often overlooked by the nurse.

I say this with no disrespect to nurses. We, as RTs, are a part of the patient care team. If the nurse (or the physician) does not pick up on the probable cause of the patient's symptoms, we RTs -- via our assessment and skills -- must pick it up.

Often, by being proactive, the teamwork and observant skills of the nurse and the respiratory therapist, or a combination of the two, can pick up on early signs of fluid overload and prevent a worsening condition from developing.

The best ways to assess for fluid overload is to assess the patient:
  • drop in spo2
  • dyspnea at rest (late sign) or with exertion (early sign)
  • cyanotic
  • diaphoretic
  • audible wheezes (very common sign, and quite often mistaken for bronchospasm)
  • auscultation: crackles or rhales in bases, should have good air movement if lungs are otherwise not compromised, COPD patients may sound diminished and may be hard to determine if there are crackles, may have coarse wheezes on inspiration and expiration that are heard well in throat (may be audible too).
  • check flow sheet or nurses notes for urine inputs and outputs (i&o's). If the ins exceed the outs, or if there is a trend where the ins are exceeding the outs.
  • IVs are set high
  • patient is post operative (pt's are overhydrated during surgery)
  • history if kidney (renal) failure
  • history of CHF, pulmonary edema, heart surgery or other cardiac history
  • COPD history, particularly late stage (they retain fluid due to right heart to left heart failure)
  • old age
  • end stage disease process
  • peripheral edema
  • hypertension

Of course you'll want to give the bronchodilator breathing treatment the nurse will recommend and the doctor will order, but then you provide the nurse and/or physician with your assessment. A good RT will get good at this rather within the first few weeks on the job.

We will continue to teach the following:

  • Not all that wheezes is bronchospasm.
  • Dyspnea is not always caused by bronchospasm
  • Not all that causes dyspnea is bornchospasm
  • Audible wheeze is not bronchospasm, it's secretions (or dehydration or inflammation)
  • We RTs are open minded, and wrong sometimes

A negative fluid balance may also cause an upper airway wheeze that radiates throughout the lungfields and mimics a bronchospasm wheeze. A trained ear can tell the difference.

The following can cause negative output:

  • insufficient hydration
  • asthmatic (exacerbation)
  • excessive urine output from meds (diuretics like lasix, bumex or xanthines like theophylline

Low urine output can result in:

  • Hypotension (low cardiac output)
  • upper airway wheeze
  • severe vomiting (watch for electrolyte imbalance)
  • diarrhea

Tuesday, January 26, 2010

Advair/Symbicort: Is overuse really dangerous???

Warning: The following post is meant to make you think, and perhaps give you something to discuss with your doctor. Please do not change your asthma regime without first consulting your physician.

There has been much hype the past several years regarding the safety of long acting bronchodilators such as serevent (which is also a component in Advair) and formoterol (which is also a component in Symbicort). In fact, there was once a threat that the FDA would take this medicine off the market.

Some reports say these medicines are linked to worsening asthma and even death, such as this warning about Advair from MyAsthmaCentral.com:

"University of Iowa researchers have added their voices to growing warnings about Advair, saying that drugs that use salmeterol in combination with an inhaled corticosteroid can make asthma more severe or even fatal."

Or this warning regarding Symbicort:

"Rarely, serious (sometimes fatal) asthma-related breathing problems may occur in people with asthma who are treated with drugs similar to the formoterol in this product (long-acting inhaled beta agonists). "

Studies have been conducted to determine if it is the medicine itself that is causing asthmatics who use it to die? Or is it the fact that these patients are overusing it?

I think these folks are all wrong. I think they are so pent on looking in one direction that they fail to see the big picture. I say this because I do not believe overuse of Serevent is what causes most people to die

I believe what causes most people to die of asthma when they are on Serevent (or a similar such drug) is the fact that instead of seeking help they clutch to the inhaler seeking relief. Instead of controlling their asthma, instead of talking to their doctor or calling an ambulance, they stay home thinking they are going to get "relief" from the inhaler in their hand.

What they lack, really, is proper education.

I can say this because I have had COPD and asthma patients who have overused their Advair or symbicort inhalers. I have accidentally taken extra puffs of mine too, and even while I was a bit nervous about it for a while due to the "scare," nothing happened. My heart never stopped.

I think long-acting bronchodilators do not kill. I think overuse of long-acting bronchodilators does not kill. I think what kills is poor asthma control. What kills is the false belief you are going to get relief from your inhaler when what you should be doing is getting your butt to the ER.

This does not just go for long-acting bronchodilators either. I've seen reports of Ventolin getting a bad rap because some asthmatic dies with the inhaler in his grasp. The report notes: "Asthmatic dies from Ventolin overdose?" Really? You think so?

Back in the 1980s Alupent was deemed such a safe medicine by the FDA that it was made to be legal to sell over the counter. I remember my mom going to get me an inhaler and just grabbing one off the shelf. But shortly after this ruling seven asthmatics died of asthma while clutching their Alupent inhalers. So did poor asthma management get the blame? No! What got the blame was the Alupent. The patient abused the inhaler because it was so easy to get, and soon thereafter Alupent was taken off the shelves.

I'm not proposing that all asthmatics go out and start using their Advair or Symbicort more than they currently do. What I am proposing is that instead of blaming the medicine used to treat asthma, that doctors and scientists and scaremongers spend more time educating asthmatics instead. Let's stop scaring people away from the asthma medicines that work the best, and start educating them how they can manage their asthma and prevent themselves from getting so bad that they'd clutch an inhaler to their deaths in the first place.

For most asthmatics, one puff twice a day of Advair or a similar regime of Symbicort works just fine. For most asthmatics, if you need to use your Ventolin or Xopenex more often than three times in a week your asthma is not controlled, and you need to work with your asthma doctor to get your asthma controlled. You can do it.

Yet there are some asthmatics whose asthma is more severe and who need to use their rescue medicine more frequently. And it's for patients like this who may find a scientifically proven benefit from using medicines like Serevent and Formeterol more frequently. Which is why further open minded studies are relevent.

Yet due to the fear of death and lawsuits American companies fear advancing this research, and the FDA continues to send out warnings that serevent and formoterol are linked to fatal asthma. However, to give the FDA credit, it likes to wait until a medicine beyond a reasonable doubt is safe for patient use.

That said, I have learned that in Britain and Canada Symbicort has been approved to be used not only as a preventative medicine, but as a rescue inhaler. It's called the SMART program. Stay tuned, because next Tuesday I will discuss the SMART program, and discuss whether this, or a similar program, would be good for American asthmatics.

Monday, January 25, 2010

Asthma: is a gift from God?

I watched an interview a while back of Vince Flynn, the best selling author of Pursuit of Honor and Extreme Measures. I'm not positive, but I think the interviewer was Sean Hannity. Regardless, it was what Flynn revealed about his own personal struggle with dyslexia that caught my attention.

When he was a kid he said he was unable to read. He said he was basically an utter failure. His disease held him back in every imaginable way. Then one day he realized that what he often viewed as a problem was actually a gift from God. It was a gift because it gave him a unique perspective on life.

That's the philosophy I was thinking as I started writing about the benefits of having asthma. It's not something that holds me back, it's a gift from God.

(This is a followup to a previous post I wrote: "The 7 Benefits To Having Asthma."

Seven Ways Asthma Has Benefited My Life
by Rick Frea Thursday, November 12, 2009 from MyAsthmaCentral.com

As a follow up to a previous post I wrote, Seven benefits of having asthma, I thought that -- just for fun, I'd personalize this theme a bit by writing about the seven ways asthma has benefited my life.

Sure there have been rough days. When I was a kid there were rough years. Still, I'm one of those people who believe everything happens for a reason.

So, with that in mind, here are seven ways asthma has benefited my life:

1. Disposition: When I was a kid I spent six months at an asthma hospital. Now, you might think this doesn't sound like something good, but it was time spent with therapists there that taught me how to take my asthma, and life, in a stride.

2. I don't smoke: Well, since two of my four brothers and my dad smoke cigarettes, I bet this horrible habit would have been my destiny if I didn't have asthma. So, having asthma kept me away from an unhealthy habit.

3. Education: Since many of my siblings work in factories, this may have been my fate had I not had asthma. I had no choice but to go to college and enter a profession where I could be in an allergy-free, dust-free, pollution-free work environment. So, in this sense, asthma forced me to get an education.

4. Career: Having a long history as a
hardluck asthmatic has made me empathetic towards other people with lung diseases. I guess it's fair to say this kind of led me in the path to becoming a respiratory therapist (RT). This job has turned out to be a pretty good fit for this asthmatic.

5. Soul mate: One day while working as an RT a nurse with a beautiful smile and perfect personality was assigned to follow me for the day. Little did I know at the time this was a set up by her instructor who wanted to set one of her students with "that RT guy." Two years later we were married. So, indirectly, asthma lead me to my soul mate.

6. A hobby: It gets busy where I work, although there is plenty of downtime too. Since I don't like to waste time, and I love to write, one night I decided to start a blog:
Respiratory Therapy Cave. Now I have a place to share my experience as an RT and asthmatic to satiate my desire to write. So, by way of slow nights at work, my asthma led me to the blogosphere.

7. Asthma blog: Lo and behold, one day the editor for MyAsthmaCentral.com sent me an email that said, "I love your blog and everything about it." She asked if I would like to write an asthma blog. And, hence, my asthma led me to what you are reading right now. Now I get to share all the asthma wisdom I've obtained over the years and meet other asthmatics in the process.

Well that's my list. I know most people don't think of asthma in such a positive light as I do, but it's a lot better than the "Why Me?" approach.

It's kinda neat how things work out, hey? It's neat to think so many great things could come out of something not so good.

If your asthma has benefited you in some way, feel free to share in the comments below.

Saturday, January 23, 2010

Dear Doctors: Albuterol is not an expectorant

I dare you to post this on your bulleton board!!!


Note to doctors:

I just want you to know that Albuterol is a bronchodilator and not an expectorant. It will not help a patient who is breathing normal produce a gob of sputum and cough it up.

If you order for me to do a treatment for a sputum induction, and I go into the room and the patient has good lung sounds and is breathing normal, all I'm going to do is give the breathing treatment and hand the patient a sputum cup.

In fact, in the past when your brethren have asked me to give a treatment for a sputum I have been known to say, "I'll give him a cup."

I have no idea where you guys got the idea that Albuterol is an expectorant or a cough inducer (
well actually I do), but you are wrong. It does not produce sputum. Normal healthy lungs are not going to produce sputum even with a bronchodilator.

Nuff said. Thanks for listening. I hope you hear me too.

Sincerely, your humble respiratory therapist

I dare you!

Friday, January 22, 2010

RTs, you gotta watch these

Sometimes you gotta wonder what happens in the ER before RT arrives. Well, wonder no more.



For more videos click here

Thursday, January 21, 2010

Neonatal abnormalities to consider

For those of us who rarely see sick neonates, it's all the more important to keep up on our neonatal wisdom. Therefore, I have compiled this list of diseases or special considerations that you might see in OB. By keeping up on our wisdom perhaps we can spot something, or provide some incite, that might save the life of someone's prescous baby.

Congenital Heart anomalies: click here

The following are special considerations to consider:

1. Meconium Aspiration:
  • Meconium is basically the baby's first bowel movement. It's poop.
  • This is mostly prevalent in post term baby's (40 weeks or greater gestation)
  • If the baby is born vigorous (breathing, rapid heart rate greater than 100, and good muscle tone) all you need to do is suction mouth and nose with a bulb syringe
  • If baby not vigorous intubate and suction mouth and trachea
  • Suction should be set at 100 cwp
  • Connect suction tubing to meconium aspirator and connect aspirator to ETT and suction while removing the ETT.
  • If Meconium baby not breathing it is important to intubate and look beyond the vocal cords to make sure there is no meconium in lungs.
  • Meconium in lungs can become an obstruction and cause air trapping you don't want.
  • If you need to put patient on ventilator, make sure you consider air trapping.
2. Choanal Atresia:
  • Back of nasal passage is blocked
  • Usually baby pink and fine when crying
  • but blue and apneic when not crying
  • Ventilates fine with PPV but not with spontaneous breaths
  • Test by inerting NG through both nares
  • If symptomatic insert oral airway or 2.5 ETT but not all the way
3. Pierre Robin Syndrome:
  • Small mandible
  • Retraction of tongue which can block airway
  • Incomplete closure of mouth (cleft palate)
  • Baby's often have trouble breathing initially at birth
  • Put baby on stomach (prone), or...
  • If still symptomatic, insert 2.5 ETT or sx catheter
  • VEry hard to intubate orally
  • Prone usually works great
4. Pneumothorax (collapsed lung):
  • Normal for newborn
  • Decreased ability to expand lungs
  • Lung sounds dim on side of lung effected
  • Lung sounds dim on left side can also mean right mainstem intubation
  • Increased respiratory distress (tachypnea, grunting, nasal flaring, retractions, cyanosis
  • Irritability, restlessness
  • Diagnose with x-ray or transillumination or chest asymmetry
  • May have poor peripheral pulses and hypotension, and mottled appearance
  • Flattened or decreased QRS comles on EKG
  • Don't wait if suspect
  • Insert catheter to withdraw air
  • Chest tube
5. Pleural effusion:
  • Decreased ability to expand lungs
  • Diagnose with x-ray
  • inser catheter to withdraw fluid
  • Chest tube
6. Diaghragmatic hernia:
  • Usually diagnosed before birth
  • Respiratory distress
  • Scaphoid (flat) abdomen
  • PPHN and cyanotic
  • Pulmonary hypoplasia
  • lung cannot expand
  • Do not use PPV
  • Intubate and insert NG
7. Pulnonary Hypoplasia:
  • Incomplete development of lung tissue
  • Usually Cardiac problem too
  • Respiratory distress
  • Usually high PPV pressures required
  • High risk of pneumo and death
  • Usually develops @ 15-24 weeks gestation when amniotic fluid in trachea has less pressure than lungs causing amniotic fluid to leave alveoli and so they collapse and don't grow right
  • Normally pressure in trachea is 2 mmHg higher than lungs to prevent amniotic fluid from leaving alveoli
  • May be caused by kidney (agenisis and displasia) problems
  • May be caused by diaphragmatic hernia
  • Treat the symptoms: Supplemental oxygen, intubation and transfer to neonatal ICU (may need ventilator, high frequency ventilation, ECMO, etc)
8. Transient Tachypnea (TTN):
  • 1% of newborns
  • Wet lung (type II RDS)
  • Results when fluid in lungs clears too slowly
  • Diagnose with x-ray
  • Can happen to premie and full term
  • Hard to inhale air
  • Sometimes CPAP needed, vent in some cases
  • Risk: C-section, Diabetes, asthma mom, small baby for age
9. Persistent Pulmonary Hypertension:
  • Arterioles in lungs remain constricted despite 100% FiO2
  • This causes the ductus arteriosis to stay open
  • Systemic blood pressure remains relatively low
  • Causes continued right to left shunt
  • Pre ductal SpO2 will be greater than post ductal
  • Pre ductal SpO2 (ABG) should be done on right arm
  • Post ductal SpO2 should be done on either leg or umbilica vein
  • If you have greater than a 15% disparity in post and pre ductal SpO2 (PO2) consider this
10. Hyline Membrane Disease (also called respiratory distress syndrome or RDS):
  • is one of the most common problems of premature babies
  • occurs in over half of babies born before 28 weeks gestation, but only in less than one-third of those born between 32 and 36 weeks
  • The more premature the baby, the more severe the HMD,
  • Other risk factors are c-section, twins, perinatal infection, caucasion, male, diabetic mothers, patent ductus arteriosis
  • It can cause babies to need extra oxygen and help breathing.
  • Caused due to lack of surfactant, which helps keep the alveolar sac open
  • Lack of surfactant causes alveoli to collaps with each breath
  • As the alveoli collapse, damaged cells collect in the airways and further affect breathing ability.
  • These cells are called hyaline membranes
  • The baby works harder and harder at breathing, trying to re-inflate the collapsed airways
  • As the baby's lung function decreases, less oxygen is taken in and more carbon dioxide builds up in the blood. This can lead to increased acid in the blood called acidosis
  • Intubation with mechanical ventilator is needed to decrease work of breathing
  • typically worsens over the first 48 to 72 hours, then improves with treatment.
  • respiratory difficulty at birth that gets progressively worse
  • Symptoms at birth include: central cyanosis, flaring of the nostrils, tachypnea (rapid breathing), grunting sounds with breathing, chest retractions.
11. Happy cyanosis:
  • You have cyanotic baby who appears to be otherwise doing well
  • Does not respond to supplemental oxygen
  • Congenital Heart Disease
  • Rare
  • 85% SpO2 acceptable
  • Seldom critically ill at birth
12. Bradycardia:
  • Despite chest compressions and PPV patient bradycardic
  • May be due to brain injury (also limp and blue)
  • HIE: Hypoxic ischemic encepalopathy (brain injury due to hypoxia which may lead to developmental delay. Cause is usually unknown)
  • Acidosis (give Bicarb)
  • Congenital neuromuscular disorder - transfer to neonatal critical care
  • Sedation: drug to mom passed through placenta -- give narcan
13. Acidosis:
  • Causes pulmonary arteriolse to constrict
  • treat accordingly
14. Hypoxic Ischemic Encepalopathy*:
  • Anoxic brain injury that can be caused due to prolonged resuscitation or lack of resuscitation such as what occured prior to the 1970s and before programs such as the Neonatal Resuscitaion Program were started (resulted in many law suits back then)
  • This is the reason NRP was started in the 1970s to prevent litigation (and save lives)
  • Follow necessary steps of NRP as best you can to help prevent this
  • Make call to neonatal ICU to determine if qualify for body cooling (new program)
  • Studies show body cooling may prevent HIE after NRP done
  • Closely monitor temperature every 5 minutes (goal to prevent hyperthermia)
  • Goal skin temperatature is 35-36 celcius
  • Secure IV access (UAC/UVC or peripheral
  • Brain damage rarely occurs before birth, and often appears after resuscitation
  • Not diagnosed until baby convulses hours after birth
  • Mental and behavioral problems may not surface for years
  • NRP -- mainly VENTILATION -- can prevent anoxia and hypoxia
  • Baby's organs thrived in hypoxic environment, and baby therefore immune to hypoxia so long as perfusion is adequate (perfusion new key to NRP, not so much as oxygen).
  • Diagnosed by assessment of color and breathing effort, x-ray, ABG shows hypoxia and acidosis,
  • EKG to rule out heart problems that may result in similar symptoms
  • Treatment: intubation, CPAP, ventilator, oxygen
15. Bronchopulmonary dysplasia (chronic lung disease)**:
  • A complication that may result from Hyline membrane disease
  • Other risk factors: birth prior to 34 weeks gestation, birthweight less than 2 kg, premature birth, pulmonary interstitial emphysema (PIE), male, caucasion, family history of asthma, patent ductus arteriosis, maternal womb infection
  • Causes: premature birth, excessive oxygen damaged cells of lungs, surfactant deficiency, damage due to mechanical ventilation and suctioning
  • general term for long-term respiratory problems in premature babies
  • results from lung injury to newborns who must use a mechanical ventilator and extra oxygen for breathing
  • Usually occurs in premature infants due to fragule lungs that are easily damaged
  • With injury, the tissues inside the lungs become inflamed and can break down causing scarring.
  • This scarring can result in difficulty breathing and increased oxygen needs.
  • Not diagnosed at birth. Usually diagnosed by history and x-ray
  • An ASD is an opening or hole (defect) in the wall (septum) between the heart’s two upper chambers (atria).
  • This is called the ductus arteriosis, and is normal before birth. However, it usually closes on its own within the first few weeks of life.
  • If too large, may not close on own. Etiology unknown
  • Oxygenated blood travels from left ventricle to the right side of the heart
  • Some adults have a patent foramen ovale (PFO)
  • If the ASD is large, the extra blood being pumped into the lung arteries makes the heart and lungs work harder and the lung arteries can become gradually damaged.
  • If the hole is small, it may not cause symptoms or problems
  • large hole may cause murmur
16. Malrotation/ Midgut Volvulus:
  • Normally, Between 6-12 weeks gestation the bowel enters the abdomen, and cecum rotates counter clockwise to the right lower quadrant, and intestine fixed to posterior abdominal wall by a wide fan of mesentery
  • Malrotation is when the mesentery fails to attach to entire posterior abdominal wall
  • Instead abnormally attaches in region of duodenum
  • Midgut Valvulus, thus, is when the gut is twisted clockwise, or clockwise rotation with strangulation -- blood supply to small intestine is cut off
  • Presentation: vomiting green colored (bile stained) emisis
  • significant pain, bloody stools due to ischemia
  • Make patient NPO (no food), have nurse set up an NG tube and set up to low suction
  • Abdominal surgery to correct
17. Pneumopericardium:
  • Air in pericardial sac that surrounds the heart
  • Rarely occurs in absence of mechanical ventilation
  • May be acute and life threatening
  • Require immediate detection and evacuation.
  • Signs: Sudden onset, severe cyanosis, muffled or inaudible heart sounds
  • flattened or decreased QRS complex on EKG tracing
  • Bradycardia, poor or absent peripheral pulses (brachial or femerol)
  • Treatment is pericardiocentesis
18. Tracheosophageal Fistula (TEF) / Esophageal Atresia (EA):
  • Esophageal Atresia means there is a blockage in the esophagus so that food cannot travel to the stomach. The most common type is where the top half of the esophagus does not connect to the bottom half.
  • Signs of this are cyanosis, coughing, gagging, and choking when feeding. Drooling.
  • Poor feeding
  • Risk of aspiration and pneumonia is high
  • Tracheosophhageal Fistula means there is a passage between the trachea and the esophagus. This may cause food to cross to the trachea and end up in the stomach.
  • If TEF suspected, attempt to pass an NG tube and observe that it is coiled in the esophagus when you take a chest x-ray. If NG passes, check stomach for distension, because there could still be a fistula (see below)
  • There are five types of TEF (refer to the picture)
  • Type A: does not have a fistula from the esophagus to the trachea (x-ray will show absence of bowel gas)
  • Type B: there is a fistula connecting the upper esophagus to the trachea, making food enter into the trachea and to the lungs causing aspiration of feedings. (X-ray will show absence of bowel gas)
  • Type C: There is a fistula from the lower esophagus to the trachea. Air will be able to enter the stomach via the tracheal fistula, but there is no way to place an NG tube to the stomach to remove air that collects. Significant abdominal distension may develop
  • Type D: There is a fistula from the upper esophagus to the trachea causing feedings to enter the stomach, and there is a fistula from the lower esophagus to the stomach, causing air from the trachea to enter the stomach. You will be unable to feed baby and unable to pass NG tube, plus severe gastric distension will result.
  • Type E: There is a fistula between the trachea and esophagus, although there is no esophageal fistula. This will cause air to enter the stomach, yet an NG tube can be placed. Likewise, feedings may also enter the trachea causing aspiration.
  • Do not feed, establish IV access, support with oxygen and ventilation, and insert NG into pouch or stomach.
  • Place the infant prone with head of bed elevated to reduce reflux from stomach to trachea
  • If type B or D is present, then the infant should be positioned with the HOB tipped down 20-30 degrees. This is to prevent oral secretions from draining directly to trachea.
*University of Virginia Health System (hyline membrane disease
**University of Virginia Health System (bronchopulmonary dysplasia)
***Kid's Health (coarctation of the aorta)
S.T.A.B.L.E. Program

Wednesday, January 20, 2010

How to ventilate morbidly obese patients

So you have a family practitioner doctor who does not have ventilator privileges standing over the bed of a morbidly obese patient who was just intubated and he says, "Gee, what tidal volume should we use. Let's see. How much does she weigh?"

By now you are already rolling your eyes and biting your cheek to prevent yourself from blurting our or, worse, actually slapping the doctor. Yet you're politically patient.

A nurse says, "I bet she's at least 500 pounds."

"Well then, " the good doctor says, "Let's set the tidal volume at 1,000." He looks at you.

While this is all going on you take your trusty ruler from your pocket and measure the length of the patient. You come up with 5 feet 6.5 inches. Based you your hospital's tidal volume protocol of 6-10cc/kg ideal body weight (not actual body weight), you come up with a tidal volume of between 420 and 700.

The doctor leaves the room, and you set up the vent and place the tidal volume at 500. You go low because the patient has a suspected lung problem. You can always adjust it higher later up or down if needed.

This happens very seldom anymore, but this is a scenario that I experienced in the past year. Thankfully we had a ventilator protocol, and the physician giving me the orders did not have ventilator privileges. Usually when this happens it's a family practice doctor or a surgeon. Surgeons are notorious for wanting those high tidal volumes.

And it's understandable, because back when I went through RT School the tidal volumes taught to us were on the high range. We were taught 10-15 cc/kg ideal body weight. And that tidal volume is fine for a completely healthy person. But you have to consider that most people ventilated in the ER and CCU do not have normal lungs, and you are better off ventilating on the low end, and adjusting later.

That said, obese patients do not have larger lungs. If you have a 100 pound lady who is 5 feet 8 inches tall her lungs are basically the same size as a lady who is 200 pounds at 5 feet 8 inches, and the same size as a lady who is 500 pounds at 5 feet 8 inches.

So if you ventilate either of these ladies based on their weight, you may be under ventilating or over ventilating. However, it's safer to under ventilate than over ventilate. If you over ventilate that 500 pound lady you might end up blowing up her lungs. Thus, it is highly possible you just saved this family practice doctor from a major law suit and he didn't even know about it.

You can read a great article about this here at PulmonaryReviews.com. According to this article there are other things we can do to help these patients better ventilate:

Putting the head of bed up 30 degrees so their abdomen is not pressing up against the diaphragm and impeding breathing. Where I work this is part of the ventilator protocol for all patients to diminish the chance of ventilator acquired pneumonia. Likewise, obese patients may become hypoxic in a supine position.

PEEP may also help with hypoxia. According to the above mentioned article, " In a study of nine obese patients who were anesthetized and supine after abdominal surgery, 10 cm H2O of PEEP was shown to markedly improve lung volumes and pulmonary compliance.[2] Those improvements were minimal in a comparison group of normal-weight patients.

For those with poor vasculature, ultrasonography may be very helpful in helping nurses find a vein, and a doppler may also be helpful. A doppler might also be tried if an ABG draw is needed.

Before these patients are intubated the patient should be trialed on BiPAP. I must admit that BiPAP is a machine that is used much more than it was when I started as an RT 10 years ago, and I have seen remarkable results. In many cases the BiPAP may prevent the patient from needing to be intubated.

According to this article you were just in going with the lower tidal volume, as their recommendation is to ventilate at tidal volumes of 5-7 cc/kg ideal body weight.

When it comes to medication, the article notes that "excessive weight-based dosages may be reasonable for medication-related adverse events in morbidly obese patients." Thus, when administering opoids, it is recommended that this be administered in "frequent small doses... until the desired level of pain control is achieved."

When weaning these patients it's best to have them sitting up in a 90 degree angle, or having them in a "reverse trendelenberg" position with their feet on the ground. With some of our newer beds this is possible. Studies, however, show the 45 degree angle worked best for weaning.

Tuesday, January 19, 2010

Is it safe to use Albuterol with Serevent?

Every day at MyAsthmaCentral.com we get lots of asthma related questions. Below are some questions I thought my readers at the RT Cave would enjoy.

Question: Is it Dangerous to use lots of albuterol when you are using Serevent?

If you are using Advair, is it true that the Serevent in it may make albuterol work less? I recently moved, and my new doctor seems very concerned about it, and doesn't like me to use albuterol every 4 hours, even though my previous doctor never mad an isssue of it. She says my albutrol receptors will get used up, but I thought you could never really overdose on albuterol. Can anyone help?

My humble answer: Ventolin and Serevent are both beta adrenergic medicines in that they seek out and land on beta adrenergic receptor cells in your lungs and the result is bronchodilation, or relaxing of the muscles surrounding air passages (bronchioles) in your lungs. It is a fallacy that these receptor cells become tolerant (used to) these medicines.

It is also a fallacy that Ventolin should not be used when Serevent is taken. Ventolin is not only safe to use in conjunction with serevent, the Serevent does not cause your "ventolin receptors" to become used to the Ventolin.

The asthma guidelines and most asthma experts recommend that even asthmatics who are using Serevent or Advair twice a day for asthma control should also carry a Ventolin inhaler on them at all times to treat acute asthma symptoms.

Just to make you feel better, I have been using Ventolin every 4-6 hours for the past three years even though I'm on Advair with no problems to report.

Question: If I have mild asthma, is it a good idea to quit taking Symbicort or Advair and use just Singulair instead. This is something I've been thinking of doing.

My humble answer: Your idea here might be worth trying, but do not do it without first discussing this with your doctor. It sometimes takes time, and trial and error, to find the right concoction of meds to control your asthma. Ideally you'll want the best asthma control with the least amount of medicine, and if Singulair alone works great. If it doesn't, then your doctor might recommend putting you back on Symbicort or some other medicine.

You and your doctor are a team and you need to work together to keep your asthma under good control. You'll also want to keep up to date on all the new asthma meds and asthma wisdom, as you never know when something new might become available to help you. A great place to do that is right here.

A great article worth reading is: Which asthma med works best?

If you have any further questions email me, or Visit MyAsthmaCentral.com's Q&A section.

Monday, January 18, 2010

How to know if you have a good asthma doctor

Many times we tend to trust our doctors, being confident they are doing what is best. However, when it comes to being a gallant asthmatic, it's important that you not only keep up on your asthma wisdom, but you make sure your doctor does too.

The following is my latest post from MyAsthmaCentral.com where I describe how to know if you have a good asthma doctor.

24 Signs of a Great Asthma Doctor
by Rick Frea Wednesday, November 11, 2009 from MyAsthmaCentral.com

For those of you new to this asthma disease -- and even some of us longtimer asthmatics -- it's good to have an idea of what to expect from your asthma doctor.

Yes, it is true that most asthma doctors are
gallant asthma doctors. Still, it is your job as a Gallant Asthmatic to make sure you have a top notch asthma doctor who's going to do the best job of managing your asthma.

So, with that in mind, and based on my personal and professional experience with asthma doctors, I've come up with a test for you to determine if your doctor is a gallant one.

Essentially, there are 24 signs your doctor is asthma wise:

  • She does more than just sit in her chair and ask you questions. She actually assesses you.
  • He takes out his stethescope and listens to your lungs.
  • She orders a pulmonary function test (PFT) at some point. This is the only definitive way to diagnose asthma.
  • During your initial visit, he orders lab tests and possibly even a chest x-ray. He also orders tests to rule out other diseases, such as if you're a kid, a sweat test to rule our cystic fibrosis. Or if you're an adult an EKG to rule out cardiac asthma.
  • During your initial visit, She asks you questions like, "Does asthma run in your family?" This questioning is important for diagnosing asthma because asthma is believed to be genetic.
  • She discusses with you the importance of having a quick-relief inhaler like Albuterol with you at all times and encourages the use of a spacer with your rescue inhaler. (The medicine is proven to work 175% better with a spacer, while exibiting fewer side effects).
  • She teaches you proper use of all your asthma inhalers and has you demonstrate the techniques to make sure you got them right. She will answer any questions you might have.
  • He explains that you should only use your rescue inhaler for relief of acute asthma symptoms, or as premedication before exercise.
  • She explains that the ultimate goal for you is not to have asthma symptoms more often than twice in a two week period. If you have to use your quick-relief inhaler more often than she prescribes, then you need to call her because your asthma is likely not controlled.
  • She works with you on creating an Asthma Action Plan.
  • He gives you a peak flow meter and shows you how to use it in accordance with your Asthma Action Plan.
  • She answers your questions about asthma: what is it? what causes it? what are YOUR asthma triggers? What are YOUR early and late signs of asthma? Or at least shows you how to learn more about asthma, like telling you about sites like ours.
  • He makes sure you know that asthma has two components: chronic inflammation that is controlled with controller meds, and episodic airway narrowing that is reversible with rescue medicines.
  • She makes sure you know the difference between quick-relief meds like Albuterol and controller meds like Singulair, Advair and Symbicort. If she determines your asthma is not well controlled, she prescribes for you an asthma controller medicine (or two).
  • He makes sure you understand the importance of taking your asthma controller meds exactly as he prescribes.
  • She makes sure you understand you must continue taking your controller meds no matter how good you feel, and not to stop taking them without calling her first.
  • If he prescribes corticosteroids (the most common asthma controller medicine), he makes sure you understand the importance of rinsing after each time you use it to prevent systemic side effects, and to prevent oral thrush.
  • For any new medicine she orders she explains why she's ordering it and goes over possible side effects.
  • He makes sure you know to call him if you experience any side effects to your medicines.
  • She tells you that you can live a normal active life with asthma if you follow the Asthma Action Plan she worked out with you, and come to see her twice a year, as per the new asthma recommendations. You should at the very least see her once a year.
  • If you have allergies (which 70% of asthmatics do), and once your asthma is controlled, he refers you to an allergy specialist who can perform appropriate allergy tests so you can learn what to avoid. He may also recommend some medicines (like Singulair, Accolate, Claritin or Zyrtec) or allergy shots.
  • If your asthma is still not controlledl, she refers you to a pulmonologist or other appropriate physician who can help you.
  • He is open minded about answering your questions and considering any suggestions about new asthma meds and wisdom you might have as you learn more about your asthma and asthma in general.

Overall, within a relatively short period of time she should have your asthma well controlled, and have you on your way to becoming a gallant asthmatic (if you're not one already).
Of course no doctor is perfect, which is why it's especially important to stay up to date on your asthma wisdom (which you're doing by hanging out here) so you can challenge your doctor from time to time. After all, it's your life and your asthma.

So, how does your doctor fare? Mine got a perfect grade.

Sunday, January 17, 2010

The horror that was 2-May (part 6)

This is a continuation of my hardluck asthma story. In a way, things weren't much different at the asthma hospital than they were back home. The bullies -- different yet the same -- just came out of the woodwork, and followed me to Denver.

So Eric was gone, yet there were still other monsters on 2-May I could not get rid of -- or away from. While Eric was a thorn in my side only when he was briefly my room mate on 7-Goodman and later on 2-May, Grant was a long-term 2-May resident who was a thorn in my side every time I was beyond the safety of the nurses on 7-Goodman, and constantly on 2-May. Now that I was a resident on the same patient floor as he was, 16-year-old Grant Hill, Metallica shirt and all, would continue to be a thorn in my side. He, and his buddies, were an incentive for me to either hide in the unused lobby at the far side of the west hall, or in the confines of my own private room.

A week earlier, while I was reading Frankenstein in the west lobby, Grant chanced a visit, and discovered my hideout. "So, what do we have here?"

I said nothing. Saying nothing, I hoped, was the way to get him to leave, however, deep inside, I suspected better.

"What book are you reading?" He bent forward, pretending to read the cover. "Frankenstein? I love Frankenstein. I like to think of myself as Frankenstein. I'm the tall, lean, mean version of Frankenstein. I am the monster. You probably think of me as the bully, but I'm really a reincarnation of Frankenstein."

"Reincarnation," I said. "That's a big word for you. Are you sure you know what that means." I said. Dumb. This was the masochistic attitude my psychologist referred to when describing me in his interpretation of my visits with him, and what he learned from talking to Ric, my counselor on 7-Goodman. However, while Ric worked hard in closed door sessions with me, acting out scenario after scenario of how to deal with bullies, I rejected this help. Yep, I sought out help, then rejected it. I didn't see it that way at the time, but the experts did. "Doing that isn't going to help me with the bullies," I said to Ric three weeks earlier. "All that will do is nothing. The other kids are going to pick on me regardless."

"How can you be so sure," Ric said back then. "How can you be so sure what we are working on won't work for you. You have to try it and be patient. You can't expect things to change over night. You have to try it for it to work. You can't reject. You have to listen and try."

Well, I knew it wouldn't work. Although, years later, after I forgot my lessons with Ric, after I conveniently forgot all the lessons learned on 7-Goodman because what happened on 2-May were more recent, more intense. And, also, because I later was afraid to mention to anyone later in life about my experience at the asthma hospital because I was embarrassed to have spent three months on 2-May, the so called psychological unit where we were admitted to work on asthma related psychological and family problems. Yet, I suppose, I was naive in this thinking too. However, ironically, it would take me 24 years to figure this out. Kind of like the kids in Stephen King's "IT" forgot their childhood experience, so I would forget my 2-May experience only to remember it when something else happens later in adulthood that forces them (me) to remember.

However, in a strange way, what I learned there benefited me greatly in my life. I have become now, what I am, because of my asthma hospital experience as much as my asthma experience itself.

"You need to be careful what you say to a bully like me," Grant warned. "I could really," he motioned a wide open hand to within in inches from my face, "Mess... you... up." He pumped his hand toward my face, away from it, and to my face again with each word he spoke.

For some reason, however, I knew Grant wouldn't really hurt me. However, based on my basketball experience with him earlier when he pounded on my back because I called his mother a name and got us both sent to level one, I knew he would hit me. I knew he was psychotic enough to hit me. I knew he was mentally screwed up enough to want to cross the line. However, I still had a feeling he wouldn't REALLY hurt me.

Yet Zane, on the other hand. Zane showed up in the lobby. He was looking for Grant. And he found Grant. And when he saw me sitting in the chair, quenched in a cowardly way, his eyes lit up. His eyes were pure evil. His eyelids were squeezed in an inward direction, the little horns could have risen out above his eyes, his face was red as the devil himself. His eyes were dark, deep set, and full of intensity. Lucifer, I mean Zane, unlike Grant, would kill me if given the chance.

Grant was giggling like a hyena -- literally. Now he was flailing his hands up and down, wriggling his body in awkward gestures, while Zane continued to look at me. Then, not wanting to find out what they were going to do with me, I hopped out of my chair and ran. I ran out of the little lounge, past the girl's bathrooms, past all the boy's rooms, past the nurses station and past my room.

Oh, I thought about stopping in my room, but, as I took a quit glance to my left, there were no nurses at the station. So I figured these two clowns would just follow me in there and have me trapped. My only hope was the elevator at the end of the hall. I did not know where the stairs were, so it was the elevator or nothing

Yes, as I passed the nurses station I slowed down a tad, hoping, praying one of the nurses would spot me running, or Zane or Grant who were lumbering behind me. But, to my bad fortune, the nurses and the aides were all seated at a table in the confines of the nurses lounge at this exact moment. Thus, I was once more forced to fend for myself.

I ran past the girl's rooms on West 2-May, and, in doing so, prayed the elevator was open. I prayed the door to the staircases was open. Yet, I also knew leaving 2-May while on level 2 would end me up on level 1 again, and I would lose privileges, or at least lose the few privileges I had. Worse, I would have a harder time in a meeting convincing the counselors I was ready for level 3. Yet I never had to face these fears, because as the end of the hall approached, I fell flat on my face and rolled away from Grant and Zane who, in my confused state, grabbed one leg each and were dragging me to my demise.

"Hurry up! Get him to the elevator. We can kill him in there and leave his body," Zane roared. I did not know Zane when I was on 7-Goodman. It was almost as though he were admitted right to 2-May, which I thought was not possible. Yet Lucifer can do whatever he wants, can't he?

I knew Grant was on 7-Goodman long before I was admitted to 7-Goodman, because I only knew him because the 7-Goodman kids joined with the 2-May kids in school, during aerobics, and on off campus outings. We were all pretty much the same ages, between 15 and 18.

"We can rough him up, but not kill him," Grant said. "We can mess him up. Have a little fun." He laughed his usual dopey laugh. "Then we'll leave him scarred for life." My body quickly moving backwards, I dug into the carpet with my fingernails, my palms, my wrist. I dug my wrist into the carpet pent on saving my life. My wrist burned, and my legs were suddenly free. I looked at the back of my wrist -- it was blood red.

"You got a little owie," Grant whined in a showy tantrum.

"Grab him!" Zane shouted. Grant stood there looking down at me, still smiling, still feigning his goofy laugh.

My heart was racing. For the first time in my life, I felt I was doomed. I had faced bullies many times in my life, but none as hellish as Zane. I hated Grant, but, in a way, I think it was he who distracted Zane just enough to give me time to run. Which I did. Fast. But not to my room. I sat, heart still racing, breath fast and shallow and tight, on the treatment chair next to my room, in the hall, across from the protection of the nurses station. Grant and Zane mossied on by, providing me with an evil look as they did so, and disappeared down the hall.

"Having trouble breathing?" Asiala, the short, stout, Spanish-American, nurse said. She was leaning over the desk, only her head showing from where I sat.

"Yes," I panted. "Can I have a treatment?"

She set me up with one. By the time I turned on the compressor, the audible whir-r-r-r-r-r vibrating the neb in my trembling hands, I was genuinely short-of-breath --yet again.

Saturday, January 16, 2010

Some doctors don't like RTs to think

I was paged to the ER for a "diff breather." I assessed the patient and determined a breathing treatment was indicated. I grabbed a neb off the shelf, a vial of Ventolin from my pocket, and fixed up the treatment. Yet, before I hooked it up to the wall I hesitated. I looked at the nurse and said:

"Is the doc that's on today one of the kind who doesn't like us to think?"

"I don't know," she said. I'm certain she knew exactly what I was referring to. Two of the docs that regularly work in our ER have lectured many of us RTs and RNs that we are not to give anything without an order, protocol or no protocol.

It's pretty bad when you know exactly what to do, are trained to do it, yet you have to wait to treat the patient. It's even worse when the patient knows what he needs and still I can't do anything.

Most of the doctors we've had in the past just let us RTs and RNs do what we think is necessary, especially if the patient is critical. Yet these new docs seem to be less willing to give away some of their autonomy. They seem to be control freaks. I'm not sure if something happened to make them this way, or if it's their personality.

Yet I can't help but think this is not good for the patient. It's not good to wait to start a therapy you know is needed.

Now I'm not talking about invasive procedures, I'm talking about doing simple tests to keep the pace moving. I'm talking about ordering or doing EKGs, breathing treatments. An RT is trained in knowing when a treatment is indicated even more so than doctors in many cases. And it's not like we want to create unnecessary work for ourselves either. We certainly aren't going to do a procedure we think is not needed.

It's not like I'm going to give the patient 20 breathing treatments without talking to the doctor. It's not like I'm going to set up the patient on BiPAP without an order. It's not like I'm going to do a racemic epi treatment without an order.

Yet, still, here I was holding the nebulizer in front of a patient having obvious bronchospasm and I was hesitating. This was bad. Yet I was scared to get lectured again. If we had a protocol (or a decent doctor working) we wouldn't have this problem, but I've been told by these two docs that RTs aren't doctors, and aren't to do things without first an order.

I suppose you can say I'm tired of it all. I like to think. I like to question doctor orders. Yet also I like to do what I think needs to be done, within reason. So now it's come to me thinking but not doing anything. It's pretty bad when it comes to this.

The problem is I don't know how to stop thinking. I don't know how to be one of these RTs who just does what he is told without questioning. I don't know how to become one of those RTs who never make recommendations.

Yet some doctors look at you when you make recommendations. They give you THAT look. They turn a blind eye. They give you 1 reason why they are doing it the way they are doing it, if they give you the time of day. So it's come to the point when some doctors are working it's easier to just do what he orders and shut up.

It's frustrating that it's come to this. Then again, sometimes I think it's better to do what you think is best and apologize later. It's never wrong to question doctors and make recommendations even when they grumble and gripe or give you that look you hate to see.

Thinking is good. Doctors who don't like it when RTs and RNs think, who prefer us to be ancillary services, are not good doctors at all. And that's the thought of the day.

Friday, January 15, 2010

Here's why we give unindicated nebulizers

In the past week I have seen the following written in two different books on asthma: "All that wheezes is not asthma."

Likewise, all studies I've ever seen show that an MDI with spacer works equally well as a nebulizer, and the asthma guidelines recommend using an MDI except for cases of severe breathing exacerbations.

I mentioned this to my coworker, and asked her this question: "Don't doctors read this stuff. Don't doctors get these books?"

She said, "Yes they do. But people expect when they come to the ER, or get admitted to the hospital, that we are going to do something. Giving them the breathing treatment as opposed to just an IV and a bunch of pills makes the patient feel like we are doing something."

That about explains it in a nutshell. That's 50% of the reason why we do bronchodilator breathing treatments on every person who comes in with a wheeze or any respiratory ailment. There are other reasons though. What follows are the real indications for bronchodilator breathing treatments:
  1. To make the patient feel like we're doing something. (20% of treatments)
  2. To make the doctor feel like he's doing something to help the patient (20% of treatments)
  3. To create a procedure so the respiratory therapist doesn't lose his job. (20% of treatments)
  4. To meet admission criteria (20% of treatments)
  5. Bronchospasm (20% of treatments)

There you have it. Now if you add up the percentages that I just made up, you have 20% of the breathing treatments we do are indicated, and 80% are not indicated.

In other words, most therapies we do are because of the government, big companies and doctors who don't care about wasting money.

Thursday, January 14, 2010

Congenital Heart Abnormalities Lexicon

One out of 100 newborn babies are born with congenital heart defects. If you're an RT who works in a neonatal intensive care unit you'll learn these like the back of your hands. Yet even we small town hospital RTs should understand the basics of these defects. You never know what you might run into in your hospital's OB.

Note: The following information was obtained from the American Heart Association:

1. Coarctation of the Aorta:
  • The aorta is narrowed at some point.
  • Narrowing is called coarctation
  • Occurs in 8% of patients with heart anomalies
  • Left heart has to work twice as hard to pump freshly oxygenated blood through aorta and to rest of body
  • Etiology unknown
  • more common in boys, and in many cases not diagnosed until teen or adult (no symptoms until then)
  • Often associated with other anomalies of left side of heart, particularly the bicuspid valve (the valve between left ventricle and aorta) having only 2 leaflets instead of three
  • Usually diagnosed due to high blood pressure, lower pulses in groin, or heart murmur
  • Symptoms: cold feet, shortness of breath with exertion, chest pain
  • Severe coarctation will be repaired right away by surgery
  • May also be treated in older patients (over 40) due to high blood pressure and the possibility of causing large heart, dissection or rupture that may cause death.
  • Common surgery is to remove the coarctation part of aorta and reconnect the two ends
  • Another procedure is balloon angioplasty, where a balloon is inserted through the a vessel in the leg to the aorta and expanded to dilate the coartation and improve blood flow.
2. Tetralogy of Fallot : :Heart anomaly that consists of four features
  • A ventricular septal defect (a hole between the ventricles)
  • obstruction of blood flow from the right ventricle to the lungs (due to pulmonary stenosis or obstruction of pulmonary valve) are the most important. Sometimes the pulmonary valve isn’t just narrowed but is completely obstructed (pulmonary atresia).
  • the aorta (major artery from the heart to the body) lies directly over the ventricular septal defect (VSD)
  • the right ventricle develops hypertrophy (thickened muscle).
  • Because of the pulmonary stenosis, blood can’t get to the lungs easily, so the blood doesn’t get as much oxygen as it should
  • Because the aorta overrides the ventricular septal defect, blood from both ventricles (oxygen-rich and oxygen-poor) is pumped into the body
  • blood can travel across the hole (VSD) from the right pumping chamber (right ventricle) to the left pumping chamber (left ventricle) and out into the body artery (aorta).
  • People with unrepaired tetralogy of Fallot are often blue (cyanotic) because of the oxygen-poor blood that’s pumped to the body.
  • Causes: Genetic, down syndrome, unknown
  • Most patients are diagnosed with tetralogy of Fallot as infants or young children
  • Most adults with tetralogy of Fallot have had it repaired in childhood
  • Treatment: 1) Shunt to increase blood flow to lungs. The shunt is usually a small tube of synthetic material sewn between a body artery (or the aorta) and the pulmonary artery. Removed when complete repair done. 2) Complete repair: Closure of ventricular septal defect with a patch, removal or repair of obstructed pulmonary valve and maybe enlarging the pulmonary artery branches
  • Sometimes a tube (conduit) with a valve in it is placed between the right ventricle and the pulmonary artery.
  • The above surgeries may cause leaky pulmonary valve that may need to be repaired in adolescence.
  • Constant contact with cardiologist will be needed to monitor for complications
  • Depending on severity, some will have to limit activity
3. Atrial Septal Defect: (ASD)
  • An ASD is an opening or hole (defect) in the wall (septum) between the heart’s two upper chambers (atria).
  • This is called the ductus arteriosis, and is normal before birth. However, it usually closes on its own within the first few weeks of life.
  • If too large, may not close on own. Etiology unknown
  • Oxygenated blood travels from left ventricle to the right side of the heart
  • Some adults have a patent foramen ovale (PFO)
  • If the ASD is large, the extra blood being pumped into the lung arteries makes the heart and lungs work harder and the lung arteries can become gradually damaged.
  • If the hole is small, it may not cause symptoms or problems
    large hole may cause murmur
  • A hole in the heart
  • Most common congenital heart defect
  • Etiology unknown or may be part of another congenital heart defect
  • A ventricular septal defect (VSD) is a defect in the septum between the right and left ventricle
  • This allows freshly oxygenated blood to return right ventricle & back to the lungs
  • This causes heart to pump more blood
  • The heart, particularly left ventricle, becomes enlarged due to added workload
  • Causes increased blood pressure in pulmonary vasculature due to extra blood that may damage blood vessel walls
  • If hole is small enough little blood will cross and there will be little complications
  • Many holes will close on their own over time
  • Most children have shortness of breath which is indication for surgery to repair hole.
  • Patients with closed hole and normal pulmonary artery pressure have normal lifespan
5. Mitral Valve Prolapse:
  • a very common heart condition
  • occurs when one of the heart's valves doesn't work properly
  • can be frightening because it involves the heart and can cause sharp chest pains, but it isn't a critical heart problem or a sign of other serious medical conditions.
6. Tricuspid Atresia:
  • there’s no tricuspid valve so blood can’t flow normally from the right atrium to the right ventricle
  • As a result, the right ventricle is small and not fully developed
  • As a result, the low-oxygen (bluish) blood that returns from the body veins to the right atrium flows through the atrial septal defect and into the left atrium
  • There it mixes with oxygen-rich (red) blood from the lungs
  • Most of this partially oxygenated blood goes from the left ventricle into the aorta and on to the body
  • A smaller-than-normal amount flows through the ventricular septal defect into the small right ventricle, through the pulmonary artery, and back to the lungs
  • Because of this abnormal circulation, the patient with this condition looks blue (cyanotic) until surgery can be performed
7. Hypoplastic Left Heart Syndrome (HLHS):
  • the heart’s left side — including the aorta, aortic valve, left ventricle and mitral valve — is underdeveloped.
  • Blood returning from the lungs must flow through an opening in the wall between the atria (atrial septal defect).
  • The right ventricle pumps the blood into the pulmonary artery,
  • and blood reaches the aorta through a patent ductus arteriosus.
  • The series of operations are similar to those done in other patients with single ventricles; however the first operation (Stage I Norwood) is more complicated than for other patients with single ventricles
  • Etiology: unknown
  • Without early intervention many patients die in infancy.
  • Almost all adults with single ventricles have had at least one, and in many cases, two or three operations in childhood.
    A procedure called a shunt is done to increase blood flow to the lungs in the first week of life
  • This improves the cyanosis
  • There are a series of surgeries to repair HLHS you can read about here.
  • Many patients with surgery have lived several decades with good life function
8. Pulmonary Atresia/Intact Ventricular Septum:
  • no pulmonary valve exists
  • Blood can’t flow from the right ventricle into the pulmonary artery and on to the lungs.
  • The right ventricle and tricuspid valve are often poorly developed.
  • An opening in the atrial septum (Patent Ductus Arteriosis or PDA) lets blood exit the right atrium, so low-oxygen (bluish) blood mixes with the oxygen-rich (red) blood in the left atrium. The only source of lung blood flow
    The left ventricle pumps this mixture of oxygen-poor blood into the aorta and out to the body.
  • The infant appears blue (cyanotic) because there’s less oxygen in the blood
  • Some patients with pulmonary atresia/intact septum can have a repair that allows the right ventricle to grow and function in a more normal way
  • If the pulmonary artery and right ventricle are very small, the patient may require the same type of operation as other single ventricle patients (see HLHS above)
9. Transposition of Great Arteries:
  • the aorta and pulmonary artery are reversed.
  • The aorta receives the oxygen-poor blood from the right ventricle, but it’s carried back to the body without receiving more oxygen.
  • Likewise, the pulmonary artery receives the oxygen-rich blood from the left ventricle but carries it back to the lungs.
  • Patients with transposition of the great arteries require surgery early in life to survive
  • Many infants undergo a procedure to enlarge ductus arteriosis to let blood mix so some oxygen rich blood can get to aorta and to vital organs. This is done to buy time for more invasive procedure when infant is ready.
  • Two procedures are available to correct this problem:
  • 1) Mustard procedure: creates a tunnel (a baffle) between the atria so unoxygenated blood gets to left ventricle and to the lungs, and oxygenated blood gets to right ventricle and aorta to body.
  • 2) Atrial switch operation: The aorta and pulmonary artery are switched back to their normal positions. Coronory arteries also need to be reattached to the new aorta
  • Constant contact with cardiologist will always be needed as future complications are possible.
  • The mustard procedure may result in decline in right heart function and valve failure
  • The Atrial switch procedure may result in better heart function but may have leakage or coronory artery problems
  • Arrythmias are common with either procedure
  • If heart too slow pacemaker may be indicated
  • Physical activity should be limited
10. Pulmonary Atresia:
  • No pulmonary valve exist, so no blood can get to lungs
  • The right ventricle and tricuspid valve are often poorly developed.
  • Etiology unknown (Tetrology of Felot)
  • PDA allows blood to exit right atria to left atria so unoxygenated blood mixes with oxygenated blood
  • Infant is blue
  • If PDA closes blood to lungs greatly diminished
  • Early treatment is drugs to keep PDA open
  • A surgeon can create a shunt between the aorta and the pulmonary artery that may help increase blood flow to the lungs.
  • If the pulmonary artery is large enough, surgery can be done to correct the problem
  • If the right ventricle stays too small to be a good pumping chamber, the surgeon can connect the body veins directly to the pulmonary arteries.
  • The atrial defect also can be closed to relieve the cyanosis.
  • These surgeries are called the Glenn and Fontan procedures.
  • Children with pulmonary atresia may be advised to limit their physical activities to their own endurance
11. Total Anomalous Pulmonary Venous Connection (TAPVC):
  • the pulmonary veins that bring oxygen-rich (red) blood from the lungs back to the heart aren’t connected to the left atrium
  • Instead, the pulmonary veins drain through abnormal connections to the right atrium.
  • Etiology: unknown
  • In the right atrium, oxygen-rich (red) blood from the pulmonary veins mixes with low-oxygen (bluish) blood from the body
  • Part of this mixture passes through the atrial septum (atrial septal defect) into the left atrium.
  • From there it goes into the left ventricle, then into the aorta and out to the body.
  • The rest of the blood flows through the right ventricle, into the pulmonary artery and on to the lungs
  • The blood passing through the aorta to the body doesn’t have a normal amount of oxygen, which causes the child to look blue.
  • Symptoms may develop at birth, sometimes they are delayed depending on severity
  • Severe obstruction of the pulmonary veins tends to make infants breathe harder and look bluer (have lower oxygen levels) than infants with little obstruction.
  • This defect must be surgically repaired in early infancy
  • At the time of open-heart surgery, the pulmonary veins are reconnected to the left atrium and the atrial septal defect is closed.
  • Children with repaired TAPVC may be advised to limit their physical activities to their own endurance
  • Long term outlook is good with surgery
12. Ebstein's Anomaly:
  • tricuspid valve is abnormally formed (valve between right atria and right ventricle)
  • one or two of the three leaflets are stuck to the wall of the heart and don't move normally.
  • Usually there is a patent ductus arteriosis
  • If the tricuspid tvalve leaks, some of the blood pumped by the right ventricle goes backwards through the valve with each heartbeat.
  • In some children, the right ventricle downstream from the tricuspid valve is smaller than normal and doesn’t work properly.
  • Ebstein's anomaly is mild in many children that they don’t need surgery
  • Surgery required if leaks too much. This can result in heart failure and cyanosis
  • It's complicated, but valve can often be repaired (PDA is closed at same time)
  • Most can participate in most sports. However, if severe enough, a cardiologist may recommend not participating in some activities.
13. Truncus Arteriosis:
  • two large arteries carrying blood away from the heart don’t form properly and one large artery is present instead
  • This artery (the truncus) sits over a large opening or hole in the wall between the two pumping chambers (ventricular septal defect).
  • This single great vessel carries blood both to the body and to the lungs.
  • Surgery is necessary to close the ventricular septal defect and separate blood flow to the body from blood flow to the lungs
  • This is usually done early in infancy to prevent high blood pressure from damaging the lung arteries
  • A patch is used to close the ventricular defect.
  • The pulmonary arteries are then disconnected from the single great vessel (the truncus) and a tube (a conduit or tunnel) is placed from the right ventricle to the pulmonary arteries
  • This is sometimes called a Rastelli repair.
  • Conduit may have to be replaced over time
  • Child can play in some sports if symptoms are minimal
14. Aortic Valve Stenosis (AS) and Aortic Insufficiency (AI):
  • The aortic valve opens to let blood flow from the main left pumping chamber (left ventricle) to the main body artery (aorta).
  • Narrowing of aorta makes left heart pump harder (AS)
  • Blood is regurgitated back through the Mitral valve into right aria between heartbeats (AI)
  • Some children have one or the other, some have both
  • Caused due to tricuspid valve with one or two leaflets instead of three
  • Etiology: unknown (may be in conjunction with other heart anomalies)
  • AS = heart works harder = large left heart (hypertrophy)
  • Mild = no symptoms. Severe = chest pain, unusual tiring, dizziness or fainting may occur.
  • If necessary, The valve can be treated to improve the obstruction and leak, but the valve can’t be made normal
  • Treatment for AS: treat left ventricular high blood pressure
  • AS can be treated be relieved during cardiac catheterization by balloon valvotomy. The balloon is inflated for a short time to stretch open the valve (called a valvotomy).
  • If AI is severe, or if leakage occurs, valve can be replaced (click here)
  • If no leak, there will be no physical restrictions
15. Pulmonary Stenosis (PS):
  • The pulmonary valve opens to let blood flow from the right ventricle to the lungs
  • Narrowing of the pulmonary valve (valvar pulmonary stenosis) causes the right ventricle to pump harder to get blood past the blockage
  • Etiology: unknown
  • High pressure in right ventricle may cause damage over time due to overworked right heart
  • Severe = cyanosis. Mild = no symptoms
  • The pulmonary valve can be treated to improve the obstruction and leak, but the valve can’t be made normal.
  • Medicine can relieve pressure in right ventricle
  • Cardiac cath can insert a balloon to dilate the pulmonary artery
  • Mild, or resolved with cath, no limits on activity
16. Atrioventricular Canal Defect:
  • A large hole between the atria and ventricles.
  • The Bicuspid and Tricuspid valves do not form properly, and one valve covers the hold
  • Blood travels from left ventricle to right ventricle.
  • This forces extra blood to lungs, and forces right heart to work extra hard to pump blood to lungs.
  • This can cause damage to lung blood vessels over time
  • A child with AV canal defect may breathe faster and harder than normal.
  • Infants may have trouble feeding and growing at a normal rate.
  • Symptoms may not occur until several weeks after birth
  • Regurgitation may occure too causing heart to work harder too.
  • Surgery is needed to fix valve
  • If severe enough, a band may be needed to narrow pulmonary artery to decrease blood flow to lungs
  • In adolescence, the band is removed and surgery done to repair valves
  • Some children may need to limit activity.

Tuesday, January 12, 2010

Asthmatics can live pretty much anywhere

Every day at MyAsthmaCentral.com we get lots of asthma related questions. Below are some questions I thought my readers at the RT Cave would enjoy.

Question: Where should I live if I do have asthma?

My humble answer: According to the latest asthma research there is not added benefit to the location where you live. Most asthma experts believe that asthma can be controlled by working with your doctor on finding a good asthma regime, creating an asthma action plan, and avoiding your asthma triggers.

If you have any further questions email me, or Visit MyAsthmaCentral.com's Q&A section.

Monday, January 11, 2010

How to choose best delivery device for asthma meds

I have a lot of asthma patients who inquire whether they should be using an inhaler at home or if they should get a nebulizer so they can take breathing treatments at home. This is what inspired the following post:

Nebulizer or inhaler: Which one works best for your child?
by Rick Frea Tuesday, October 27, 2009 @MyAsthmaCentral.com.

So you have an asthmatic child at home. Chances are you also have quick-relief medicine, sometimes called "rescue inhalers" to give to him if he has an asthma attack. If so, you should also be aware of the latest recommendations for administering this medicine.

Bronchodilator is the medication in quick-relief inhalers. The most common bronchodilators that provide instant relief to a child having trouble breathing are Albuterol and Xopenex (levalbuterol). I think both these medicines work equally well, but some doctors and patients prefer one over the other.

There are two basic ways to deliver this kind of medicine: a metered dose inhaler (MDI) or a Nebulizer.

1. Metered Dose Inhaler (MDI): This is the preferred method for most asthmatics because it's easily portable and can be used anywhere. This is also the best method to deliver medicine to children who cannot tolerate a mask or mouthpiece nebulizer.

According to NationalJewishHealth.org, using an MDI with a spacer (or spacer/mask) is just as effective as a nebulizer if proper technique is used (the only exception is with severe exacerbations).

2.
Nebulizer: This is a device that turns a liquid form of Albuterol into a mist to inhale. A treatment usually takes several minutes to complete, but this is the easiest way of getting the medicine to anyone who has trouble with inhalers, such as young children. It's also the preferred delivery method for some asthmatics when they are having severe trouble breathing (for example, we use this method most often in the hospital).

There are three ways to give a nebulizer:

Mouthpiece: I think this is the best delivery method for nebulized medicine because the medicine is delivered right to the lungs. But the problem with the mouthpiece is some kids can't use it properly.

Mask: The second best method is to connect a mask to the nebulizer and strap the mask to the child's face. The mask acts like a reservoir and stores some of the medicine as the child breathes, resulting in good medicine distribution to the lungs. The problem with the mask is that some kids don't like them.

Blowby: This is where the parent or respiratory therapist simply prepares the nebulizer so the medicine blows by the child's mouth and nose. This method is the easiest for both child and caregiver, but studies show hardly any of the medicine actually makes it down to the lungs. And, according to Bill Pruit's article RT Magazine, "
Kids and Asthma: Making (and Teaching) the Right Choices," blowby's are "considered to be inappropriate and should not be used."

That in mind, the following are the latest recommendations by the American Association of Respiratory Care (AARC) according to Arzu Ari (PhD, PT, RRT, CPFT) in the August, 2009 issue of AARC Times, "Optimal Delivery of Aerosol Drugs in the Pediatric/Neonatal Patient Population":

  • Nebulizer with mask is recommended for children under three years of age
  • Nebulizer with mouthpiece for children greater than three years of age
  • MDI with holding chamber/spacer and mask for children less than four years of age
  • MDI with holding chamber/ spacer for children greater than 4 years of age
  • Breath actuated MDI for children greater than five years of age
  • Dry Powdered Inhalers (DPI) for children greater than 4 years of age and older
  • Breath actuated nebulizers for children five and older

Here are some additional notes to keep in mind:

  • Using a mask with a nebulizer is acceptable, however Arzu notes that it's important to have a good seal, whereas "a leak as small as 0.5cm around the face mask decreases the amount of drug inhaled by children and infants by more than 50%."
  • Pruitt notes the best way to get good distribution of the medicine to the lungs is with a nice smooth, laminar flow, or simple quiet breathing.
  • Do not have your child take rapid deep breaths.
  • Encourage your child not to breath fast during the treatment as this may result in lightheadness.
  • Pruitt also notes it is a common fallacy that deep breaths with crying result in better distribution of the medicine. Calm, quiet breathing is considered best.
  • Sleeping children usually breathe calmly, and this is a great time to give a breathing treatment. However, since we can no longer use a blowby, you will have to use a mask and hope your child doesn't wake up.
  • Breath actuated nebulizers are new and are supposed to make it so your child gets more of the medicine. My experience with these is it's too hard to inhale using these, especially when an asthmatic is having trouble breathing. However this is another option for you to try.

It's up to you, your child, and your child's pediatrician whether you'll want to use an MDI or a nebulizer. For the most part you'll want to use whichever method works best for your child.