Respiratory Therapy Fun and Games

While nurses are stuck in one unit taking care of only a few patients (how boring), we RTs have free roam of the hospital, which means we can have a little fun on the side. That's right: we RTs like to have fun.

Here are some games we RTs are known to play from time to time:

EKG clock: Take some EKG stickers and toss them at a clock on the wall. Whomever can get the most stickers to stick on the clock wins. You can also play by adding up the points for the hour or minute the sticker is closest to, or by seeing who can get closest to the bulls eye. By this you can have a little fun on the clock (pun intended).

Vent race: Ready set.... you and your co-worker each grab a vent, line-up at the beginning of a long hallway, and the first one to the unit wins. This is a game better off played during night shift when the halls are silent.

Stair spit: Climb to the top of the stairs, and then you lean over so you can see the bottom floor between the steps, and you spit. The challenge here is to get your spit all the way to the bottom. Winner is whomever accomplishes this goal, or comes the closest.

EKG race: Your humble RT is proud to claim pride in the name, "fastest EKG draw in Michigan." That's right. To earn this prize, time starts when you unplug the machine and ends when you plug it back in. The trick here is you have to have good patient technique, and the EKG has to be of good quality.

Ventilator fart: This is my favorite game. You walk into the room of a patient who is on a ventilator and you let out a silent fart. The goal is you can't get caught, and the nurse has to be convinced the patient needs his diaper changed. Then you stand by the nurses station and giggle when the nurse says something like, "It was a false alarm." This is also a fun game to play by yourself, with a good laugh as the reward for victory.

Sleep time: Perhaps this isn't so much a game but a necessity. Whatever RT can get the most amount of sleep without missing out on required work wins the prize. One former co-worker put his head on his pillow at 2 a.m. and forgot to wake up until 30 minutes before shift's end. We all helped him get his work done, because otherwise we'd all be busted. Goal was accomplished as we all sat down in the RT Cave mere seconds before the morning workers shuffled in. As you can see, this also makes for a good team game. Plus if you push the limits as we did, it makes for a good story.

Sharps shootout: Fill your pocket with empty amps of ventolin, and find an empty room. Line two chairs opposite the sharps container, and whip the amps across the room at the opening on the sharps container. The RT with the most amps inside the sharps container is the winner.

Persistent Pessimism: This game involves being aware of the pessimist. You know who they are. Ask them how they are doing and wait to see how long it takes them to start complaining. They might say things like, "Oh, my back aches," or, "I'm soooo tired," or, "Jack is soooo annoying," or, "I'm soooo burned out," or, "I'm so tired of this job." Then you just sit back and smile. I'm telling you, melancholy folks are very consistent.

RT lecture: I've noticed from time to time RT Bosses like to show off their power by lecturing an RT or two about some piddling little task that wasn't done completely right. Now you know no patinet was harmed, and the only reason you are getting lectured is because of process, "We won't get reimbursed if you don't do this." I've noticed that it's easy to try to defend yourself or te get mad at your boss. You know how your blood can boil when your boss starts to rip you apart. The goal of this game is to stand there like a man the next time you are being humiliated by your boss, smile and say, "Thank you!" The objective of this very difficult game is to get the better of your boss.

Rules:

1. If your RT Boss catches you having a little fun, don't act scared. Ask him to participate. That's right. You know darn well he had a little fun when he was in your shoes.
2. Use common sense.
3. Pick an appropriate time to have your fun (Pick a down time)
4. Games are best played during night shift or on weekends when RT bosses are out.

Regardless, RT games are a good way of taking the monotony out of long 12-hour shifts. If you've participated in an RT Game not mentioned here, let me know.

Interesting cases at Shoreline during 2011 season

1. Pt came in claiming he can't move..... diagnosis = potassium 1.4

2. vomiting nausea abd pain x3 days, ceizure, pale.... diagnosis = hemoglobin 2.2


3. man came in with garbage legs wrapped around legs with maggots inside


4. Lady came in , sat on the toilet, and dropped in a baby surprise


5. DNR patient sent upstairs with 6.9 pH and went home next day feeling great


6. Baby born with no butt hole

Charity and Justice verse pride and arrogance

Two keys to a successful life are charity and justice.

What is charity? It's making sure the needs of everyone are taken care of.

What is justice?  It is making sure no one is taken advantage of

Two things that get in the way of justice and charity are arrogance and pride.

What is arrogance?  It's thinking you know all.

What is pride? It's putting yourself above all others.

There are two things that help with charity and justice, and they are humility and avoiding judgements.

What is humility?  It's putting other people before yourself and admitting you don't know all

What is avoiding judgements?  It's accepting people for what they are.

There's an old saying that says: "Pride comes before the fall." (Proverb 16: 18) This means that pride can lead to a person becoming unable to see the selfish, and a selfish thinking often leads one to do selfish things, such as stealing and committing murder.

In order to stand upright and depart from evil, it is important to depart from evil. In this way, it is better to be humble in spirit with the lowly and to realize that you are no better than any other person, than to be haughty and stumble through life with no real vision as to your true purpose.

Those who are exalted become humbled. (Matthew 23:12).  This means that the greatest among us -- the wisest, the leaders, the chief executive officers, the inventors, the Hollywood actors, the professional athletes -- become our servants. They are the ones who we call into action when we need to rise up as a society to better ourselves.  Worded another way: the greatest among us shall be our servants.

Those who become humbled shall be exalted.  (Matthew 23:13)  This means that all people who put others before themselves, all people who admit they don't know everything and continue to search for answers for the benefit of themselves and mankind, are equals to those who are exalted by their fame.

Those who become humbled learn not to judge. Then they bring all people together and come up with the best solution to make charity and justice possible.

Regardless of whether the homeless choose to be that way or not, we should not judge them and we should offer our charity. Charity does not have to be in the form of money or food, it may be something simple as lending an ear.

Some of us are arrogant and feel we have all the answers, that they are always right, and therefore we feel we have no need to hear the opinions of others.  These people may offer charity, but may not provide equal justice.

A good example here is a doctor who refuses to listen to the opinions of his patients. This neither benefits the patient nor the physician. It's arrogance at the expense of justice.

Another example is politicians who creates policies that force their views on other people. This is arrogance and does not provide for justice nor charity.

Another example is judges who make rulings based on their views and opinions rather than by the laws that rule the land. This is not justice, nor is it charity.

A child is born and He lead the way to freedom

It's Christmas time so I'd thought I'd write a little bit about Christmas. Matthew, Mark, Luke and John all start in with the birth of Jesus and quickly segway into the story of John the Baptist and John's baptising Jesus in the River Jordan. They all give a little bit different version of the story, yet they're all pretty much the same (although all interesting in and of themselves).

One of the neat things we realize when reading the Bible is that John the Baptist and Jesus were born at about the same time. In fact, John's mother Elizabeth and Jesus's mother Mary spent a few months together at one point, according to the writings of Luke.

Luke writes the only account of Jesus as a young boy of about 12. Mary and Joseph took him to town shopping, and Jesus disappeared. Mary and Joseph searched three days before they found him at an alter where another man was speaking the word of God. Jesus said, "How is it that you sought me? Did you not know that I must be in my Father's house?"

That's about all we know about his childhood. The bible does mention many times Jesus had siblings, yet only in passing. Yet historians note that at the time of the birth of Jesus about 40% of children did not make it to adulthood, so most people would have as many children as they could. And back then children were assets, as they could be put to work. So chances are he had many siblings.

The modern English version of the Bible states that Jesus was probably a carpenter, yet this may be a mistake in translation. In Nazareth, where Jesus grew up, working with stone was more common than working with wood. So chances are his father worked with stone instead of as a carpenter.

When Jesus was 30 he met John the Baptist. Jesus liked the way he worshiped. Jesus wanted to be Baptised by John the Baptist, although John said that it was Jesus who should be baptizing him, and that he, John the Baptist, was not worthy of walking in Jesus's shoes. Yet he also said that he was paving the way for Jesus (just as the prophet Isaiah had earlier predicted).

Jesus needed to be cleansed not so much of his original sin but of any sins he had committed up to that time. Chances are this was not the first time Jesus was Baptised. It was common for people to be Baptised many times back then. Every time a woman, for instance, had a period she was supposed to be Baptised before going before the Lord's house. The same was true for men who'se seman did not conceive a life.

Yet at 30 Jesus wanted to share the word of the Lord himself, and to travel to sacred places like Jerusalem Jesus had to be purified, and he loved the way John the Baptist worshiped the Lord, and so he chose to be Baptised in the River Jordan by John the Baptist.

While the Bible does not say this, Jesus followed John for a while to learn his way. Soon after the Baptism of Jesus, the King of Judea, King Herod, learned of John the Baptist and was afraid that he would take over his throne.

So Herod had John the Baptist imprisoned and later had his head cut off. Herod knew of the new King of the Jews, and he saw him as a threat. And Lord knows he also saw Jesus as a threat, yet could never catch up to him because Jesus was protected by angels.

Jesus worshiped in much the same way as John the Baptist yet he went a step further. He taught that Heaven begins right here on Earth. He taught that if you were humble in this life, frugal and honest, if you care about others before yourself, you have already started on the journey to Heaven.

He was the first philosopher to preach that one should live a good life to get to Heaven. Many modern philosophers believe that he set the way for Christianity, and Christianity is what set the way for freedom in the West and the revolutions that lead to all the great technologies that allow so many people to enjoy their freedom. The same technologies kids yearn to receive on Christmas.

Christianity lead to the people of Britain speaking out against the powers of the king and yearning for more freedom. It lead to the signing of the Magna Carta. It lead even further to the signing of the Declaration of Independence,the American Revolution and finally to the signing of the U.S. Constitution that limited government and prevented it from making any law abridging any of the freedoms of which we are born with.

Being humble and honest in THIS life was the key, Jesus taught, to getting to Heaven. That you couldn't kill other people, you couldn't deceive others, you couldn't spend a life being dishonest and evil, and still get to Heaven. The journey to Heaven starts right now, Jesus taught.

Everything around you you can thank Jesus for. While Jesus set the way for everything we have, it is not materialism that we should be thankful for on Christmas, for Christmas is a more humbling celebration.

The purpose of Christmas is the Celebration of the start of Jesus's life. It's a celebration of His Life. It's youth. It's Children. It's the family. It's the basic core of life. I wrote more about this here.

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Jesus and Christmas in America

Christmas is a celebration of the family and the virtues that Jesus taught. When I was a child Christmas was a time for family. It was a time to make memories. It was a time to tell stories about the past. It was a time for games. It was a time for creating a bond with your parents so they can teach virtues that make you a better man or woman.

Actually, according to ahistoryofchristmas.com, The Pilgrims who came to the U.S. in 1620 were Puritans who didn't celebrate Christmas. In fact, after the American Revolution Christmas wasn't even considered a Holiday, and Congress was in session on December 25, 1789, which was the first Christmas under the new Constitution.

Attention was brought to Christmas when Washington Irving wrote a book called, "The Sketchbook of Jeffery Crayon, gent," which was a series about the celebration of Christmas. AhistoryofChristmas.com writes that, "In Irving’s mind, Christmas should be a peaceful, warm-hearted holiday bringing groups together across lines of wealth or social status."

Christmas became more popular after the Civil War when the nation was broken and needed to be repaired. The simple message of Christmas was just what the nation needed.

The article notes that, "By the last quarter of the nineteenth century, America eagerly decorated trees, caroled, baked, and shopped for the Christmas season. Since that time, materialism, media, advertising, and mass marketing has made Christmas what it is today. The traditions that we enjoy at Christmas today were invented by blending together customs from many different countries into what is considered by many to be our national holiday."

The truth is, Christmas wasn't declared a national holiday in the U.S. until June 2, 1870. From that time on carolling, Christmas trees, Santa Clause and the Birth of Jesus have been a part of the celebration each year.

Back in the last quarter of the 19th century moms and dads and kids would sit around the living room with a fire burning in the fireplace and they would play games that would last a long time. Dad would play the fiddle and mom would play the piano and all the kids would join in and sing. Stories would be told. There was nothing else to do. People would pray.

Back then kids would be happy to receive a chocolate bar or a book. A book was the best gift of all. A girl would be happy to receive a dress that was hand crafted, and a boy would be happy with a suit and socks and maybe even a new pair of shoes.

Today we plug in our Internets and our video games and become isolated from each other. We don't take the time to pray together. We don't take the time to tell stories.

Today kids expect material things like TVs and Internets. Heck, they might think those things are uncool. I can't even give my kid a green DSI because that is too uncool. I have to go out of my way to get a blue one or a black one. And when I buy clothes for my kids they cringe.

Christmas used to be about creating memories. Memories may still be created, yet most are about how they defeated the game Zelda or a game of NBA 2K11 on the Wii.

Back in the 1800s no kid was upset if he didn't receive a present at all. Back then just being able to slow down, to get off the farm and to have all the family present in the same room was the best gift of all. Just knowing everyone was safe and happy and virtuous was all it took to create a happy moment.

Kids these days don't get the real meaning of Christmas, and the real meaning of Christmas is not shared on TV and by politicians. They don't' get the real meaning of Christmas. In fact, many are afraid to say the word Christmas, let alone Christ, out of fear of offending someone. It's not the meaning of Christmas anymore.

In fact, I heard a mom say the other day to her son, "Son, what do you want for Christmas?"

The son said, "How much do you want to spend?"

To that the mom said, "Two hundred dollars. Why?"

"Then why don't you just give me the money?"

I thought to this, "That kid doesn't get the true meaning of Christmas. That kid was a jerk. That kid was spoiled. He wanted material things before simple things he needs. He definitely didn't get the true meaning of Christmas.

Christmas is about giving. It's about spending time together and to share stories and to create memories. It's about taking time to remember why we are on this planet in the first place. It's a time for remembering what is important in life.

It's not about receiving. It's not about material things. It's not about presents. It's about love. It's about Jesus.

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Looking for up to date lung blogs

Hey folks!

Once again this year I plan on updating my links page for the New Year. This tends to be one of my more popular pages as many people yearn for the wisdom of people with similar interests as them.

I will update the following links:

• Respiratory Therapy blogs
• EMT blogs
• Doctor blogs
• Nurse blogs
• Asthma blogs
• Chronic Lunger Blogs (COPD, CF, etc)
• Lung Wisdom Blogs and Websites
• Etc.

I think it's important to keep these links updated because people want to read only sites that are updated on a regular basis. So the only qualification for placement on my link list is the following:

1. Updated or recent post within the past 3 months
2. A valid reason why no recent postings

Obviously the classic blogs will make the list. Some of you guys I've gotten to know quite well in the 3 plus years I've been doing this. Yet there are some bloggers who start a blog, write for a while, and are never heard from again. These are the ones I will be deleting from my list.

There are also many great blogs out there that I would love to include on my list that I am unfamiliar with. If you write a lung blog or read a blog you feel my readers would be interested in, feel free to email me and I will include it.

If you have a lung blog that's already on my list and you haven't written a post in a while, there's no better time than the present to start clicking on the keyboard.

If you have a valid reason for not updating, that's great, just put a note on your blog or send me an email. I don't want to give up on any blogger because I know I have blogs out there I haven't updated in a while and for good reasons (like this one).

So I'm fair.

Lets see. How about if I make the deadline January 1, 2011 at midnight.

However, anytime during the year you want to include your name on my list just let me know. Yet due to family matters and work I can't guarantee when I'll have to make updates during the year.

Perhaps in the future we can make a contest or something.

Here is the present blog list. I've already had some inactive bloggers inform me they are now active, so this will all be included in my knew links.

Thanks. Rick.

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New procedure may benefit emphysema patients

A new procedure that does not involve surgery was discovered and studied in a European trial that might prove to help Emphysema patients catch their breath, according to thedenverchannel.com, "Emphysema Patients Breathing Easier Without Drugs, Surgery."

The new procedure involves doctors placing an umbrella-like bronchial valve in the airway. Then airflow is redirected from the diseased part of the lung to the healthy parts, according to the article. "In a European trial, experts found the valves were safe to use and improved quality of life. The bronchial valves are in the final phase of testing in the U.S."

The device is called an IBV Valve System. The device is inserted during a bronchoscopy.

"When it's put inside the airways, it [the valve] expands open and sort of seals the airway to prevent more air from going into the bad region of the lung. But when people are breathing out, it closes down a little bit so that air can come out and so that secretions in the lung can also come out," D. Kyle Hogarth, M.D., of the University of Chicago Medical Center.

Experts note the device is better for those who have emphysema of the upper lobes as compared to the lower lobes.

Likewise, it is not a replacement for common sense, as experts recommend the best therapy for treating emphysema is to quit smoking and seek appropriate medical treatment. Quitting smoking is the best way to stop progression of the disease.

Since there needed to be a control group for comparison purposes, those involved in the study who got a "sham" valve will be eligible to receive the real thing after six months.

The latest wisdom on mucolytics

We don't see much mucomyst being ordered anymore here at Shoreline. Of all the days I've worked, I can only remember one patient since January who was ordered to get 1cc of Mucomyst with every other breathing treatment.

This observation of mine makes sence, considering a recent review of Mucomyst, according to this Medscape.com, "Best Evidence Review: Mucolytics -- An Update on Their Use in COPD: Discussion," notes that the rate of Mucolytic (such as Mucomyst) has declined by as much as 50% since a previous review in 1996.

The reason for this, as the article notes, "Two significant factors may have contributed to the apparent decrease in efficacy of mucolytics over the years. First, the quality of the studies has improved, with larger trials completed recently. Second, the routine use of inhaled corticosteroids may have blunted the effect of mucolytics in improving COPD outcomes."

Still, studies have consistently shown that the use of mucolytics may reduce the risk of COPD exacerbations by as much as 56%, and "significantly effective in reducing patient symptoms," according to the review.

The article concludes that, "Nonetheless, mucolytics can be a safe, effective, and inexpensive option to improve chronic bronchitis and COPD. The collective research suggests that mucolytics do not need to be used year-round. They might be most effective among more symptomatic patients and used in anticipation of more exacerbations during the winter. Mucolytics might also be particularly helpful for patients who are intolerant of inhaled corticosteroids or have difficulty with handheld inhalers. Overall, mucolytics deserve consideration to improve the lives of patients with COPD and chronic bronchitis."

I know we RTs tend to complain when the pulmonary toilet is ordered, yet there continues to be supportive evidence that at least Mucomyst shows some merit as an effective therapy for treating COPD patients.

Charity

Charity should be a principle good deed in life. If you have money and time that is. It's more important to your spirit to give than to build up your personal empire. It's good to give of yourself and your time. The greatest gift anyone can ever give is charity.

By chaity I'm not referring just to money. I'm referring to anything that you give: time, money, an ear, encouraging words, etc. Any act of humility in a sense is a charitable contribution. It's anything that makes someone else better.

You can make a difference in another person's life. Don't let bad events change you either. don't stop giving just because bad things happen, because bad things happen to everyone. Don't close off your heart.

It's important that you care about the entire human condition, not jut about this and not just about that and not just about yourself and not just about your family. You have to give of yourself in a way that you make the entire human condition better.

And it doesn't have to be something big either. For instance, I'm writing this blog and I have kids and I'm a respiratory therapist and I help people. In that way I have made the world better in just a small way. You have your own way of contributing.

Are you an RT or a nurse or an EMT or a doctor? Then you are contributing. You are giving a charity to each person you touch in a positive way. Every time you smile to your boss instead of getting angry at him you are, in a sense, giving charity.

You are one person in a material world. No matter how much you have, no matter what gifts God has given you (or the peanut butter ferry if you don't believe in God), share it. Because you can make a huge difference. Give to charity. Give of yourself in some way.

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Christmas list for asthmatics

Merry Christmas. The following is my Christmas list I published at MyAsthmaCentral.com.

A Pragmatic Asthmatic’s Christmas Wish List
by Rick Frea Friday, December 18, 2009 @ MyAsthmacentral.com

Asthma-like symptoms have been recorded in the annals of history for well over 5,000 years. So it’s about time we asthmatics caught a break, and maybe even a cure. With that in mind, I created the following Christmas wish list for the benefit of all of our kids -- and us.

Dear Santa: The following are some pragmatic things we humble asthmatics wish to find under our Christmas trees.

1. Hygiene vaccine: A relatively new hypothesis (the hygiene hypothesis) proposes that asthma is acquired because those of us with the asthma gene are not exposed to enough germs for our immune systems to develop normally, and, thus, asthma is the result. This vaccine would expose our kids to the germs they require to develop normal immune systems and, therefore, prevent asthma. This would not cure our asthma, but it would prevent most of our kids from developing it.

2. One-Puff: I don’t know about other asthmatics, but I get tired of taking medicine all the time. I think it would be neat if you, Santa, could have your elves create a medicine called One-Puff. One puff of One-Puff and that’s it for the day. I bet this would make us more compliant too.

3. Allbetterol: In the early 1980s you gave us a medicine called Albuterol. Well, this type of medicine is great in that it helps us catch our breath right away. Still, when it doesn’t work, we have to pester doctors and make hospital visits. I think it would be great to have a medicine that would instantly make the asthma attack just go away for good. Then we can go on with our normal routine and not have to worry about dealing with doctors and hospitals all the time.

4. Trigger-B-Gone: Asthma triggers often force us asthmatics to make difficult changes in our lives. For instance, I love going to my dad’s cabin with the guys, but since dust-mites and molds in that place trigger my asthma, I have no choice but to avoid it. Well, if your elves could make a product called Trigger-B-Gone, we asthmatics wouldn’t be forced to make annoying changes in the way we live.

5. Do-Allolin: While most asthma medicines work to treat the symptoms of asthma, such as airway narrowing and swelling, Do-Allolin would literally block the asthma gene. So if your awesome elves could produce this medicine, two puffs-a-day of Do-Allolin and the asthma would be cured for a day. It may also cure allergies and eczema too, thus the name: Do-Allolin.

6. Remodolin: Some hard luck asthmatics have suffered from asthma so often they’ve actually developed airway remodeling. This makes treating and controlling their asthma more difficult. One puff of Remodolin before breakfast each day for 30 days and lungs will gradually – magically -- be re-modeled back to normal.

7. Allergy-B-Gone: Look, Santa, 75 percent of us asthmatics have allergies too, and in many cases the allergies (sniff-sniff) are almost worse than the asthma itself (achoo!). So, if Trigger-B-Gone or Do-Allolin aren’t in the cards, perhaps your elves can whip up a dose of Allergy-B-Gone to at least relieve us asthmatics of this miserable beast. Oh, and perhaps some of us might like a dose of Eczema-B-Gone too.

If you and your wonderful elves have the magic in you to make the above list of wishes come true, or any one wish, we asthmatics would greatly appreciate it.

Regardless, thank you and Merry Christmas! Rick Frea.

If you have an asthma wish for Santa, please share it in the comments below.

Humility

I often say on this blog how I am the humble RT. Yet the question of the day is, is your humble RT really humble? Are you humble?

Let's investigate this "humble" word.

According to Wikepedia, humble is defined as such:

"Humility (adjectival form: humble) is the quality of being modest, reverential, even politely submissive, and never being arrogant, contemptuous, rude or even self-abasing. Humility, in various interpretations, is widely seen as a virtue in many religious and philosophical traditions, being connected with notions of transcendent
unity with the universe or the divine, and of egolessness.

Humility means being aware of the feelings and needs of the people around you and finding a place for them in your heart. Sometimes needs are short term, sometimes long term.

Needs? What are needs?

Needs can be something physical like food and water and shelter, or something internal, like an ear to listen to you, a hug, or a friend.

Most people who are nurses and RTs say they went into medical field because they love people. Yet do they truly have "empathy?" Do they truly have humility?

I don't see humility when I approach the nurses station and the staff is complaining about how they didn't get a raise for the year, and how the bosses are "ignorant" for not giving "me" a raise.
I don't see humility in that, because a person with humility would see that the boss didn't give anyone raises so all staff could keep their jobs. A humble person would jump into his bosses shoes and see what it's like from that perspective.

I have humility, I would imagine, when I get called stat to do an EKG that is not needed in my opinion. The whole time I'm walking down there I'm thinking what I'm going to tell the irritating nurses who keep calling me stat for non life threatening instances.

Yet, once I see the nurse, I see them as the people they are, just working to make a living. So, instead of complaining to them, instead of lecturing them, I keep my mouth shut and just do the job.

I do it with a smile. I enjoy it.

Say it's slow at work and your boss says, "One of you RTs needs to go home." Your coworker is burned out and really wants to go home. Yet she says, "Why don't you go home, you have little kids and a wife who is sick."

That was a humble act in my opinion.

Some doctors in the emergency room will not consider the opinions of any other person in the room. They order what they want and complain when it's not done. They walk with their heads high as though they are better than everyone else. Humble they are not.

On the other hand, the humble doctor says, "Does any one else in the room have any ideas that might help this patient?"

Humility is sacrificing your pride to make someone else happy. Humility is sacrificing your time to make someone else happy. Humility is sacrificing yourself to make someone else happy.

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Common sense

Some people are task orientated.

Some people are people orientated.

Some people are common sense orientated.

What more needs to be said.

Common sense is best.

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RTs might be the smartest of s-m-r-t

I said, as I read the order for Q5 hour Xopenex on an RSV patient with clear lungs who didn't need to be admitted but was, "That kid don't need no frickin treatments."

"You say that about all treatments," the RN supervisor said.

"That's because there's no scientific evidence treatments treat anything but bronchospasm."

Sometimes I wonder if it's just RTs that questions stupid doctor orders. Is it just RTs who wonder why things are ordered without scientific evidence they do any good?

Is it possible the smartest of the medical profession are your humble RTs?

In lieu of the evidence, I'm obligate to assume this is so until further evidence reveals otherwise.

So, congrats fellow RTs, you're apathetic because you're of the smartest lot. In fact, I think it was Ben Franklin who said, "I'd rather be the dumbest lot on earth than the smartest person with no one to have an intelligent discussion with."

I wonder if he had RTs in mind when he said that. I doubt it, but it makes you think doesn't it.

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Everything you need to know about Bronchiectasis

It seems that about twice a year we have a patient admitted to the hospital with bronchiectasis. They tend to have a presentation similar to other patients with chronic respiratory diseases, yet the cause of their illness is unique.

According to nationaljewishhealth.com, the disease in characteristic of air passages that are chronically inflamed, dilated, and prone to infections that effect the entire airway from the nasal passages all the way down to the alveoli. Where exactly in the air passage the infection occurs is dependent on the infecting agent.

Thus, these patients are prone to getting both pneumonia, ear infections and sinus infections. Of course sinus infections, over time, can lead to other nasal complications such as nasal polyps and deviated nasal septums.

I found this article called, "Bronchiectasis Is" which notes a little of the history of bronchiectasis. Rene Laennec, the man who invented the stethescope, "used his creation to first discover bronchiectasis in 1819. The disease was researched in greater detail by Dr. William Osler in the late 1800s..."

Like asthma, it is kind of a mysterious disease, a conundrum of sorts, as why a person develops it is unknown, although the gene has been isolated and research is ongoing. While asthma wisdom has been ongoing since 1903 when epinepherine was invented, bronchiectasis research and wisdom was generally started in the 1930s when cystic fibrosis was recognized as a disease and research was started to learn more about it.

Inexplicably, some people get bronchiectasis by itself, and it is the main pulmonary complication of those with cystic fibrosis.

The disease is indicative of thick secretions which make the patient susceptible to getting pneumonia, and these infections (including those of the upper airway) tend to make the disease worse over time. NJH also notes that these infections are more likely in patients with impaired drainage, which would include those with increased number of goblet cells that secrete thick, tenacious secretions (as in CF) that are hard to cough up and therefore create a climate in the lungs ideal for certain bacteria.

So, what causes bronchiectasis? Ironically, while this is a disease indicative of chronic respiratory infections, it's believed to be caused due to damage caused by respiratory infections. Otherwise, it's one of the components of the disease cystic fibrosis (which you can read about here) and occasionally even COPD who are also susceptible to reapeated respiratory infections.

Specific ailments that might cause this disease include:

1. Viral infections (measles, adenovirus, influenza),


2. Bacterial infections (Pseudomonas aeruginosa, Staphylococcus aureus, Klebsiella),


3. Mycobacterial infections (tuberculosis, Mycobacterium avium complex) and


4. Fungal infections (histoplasmosis).


5. Antibody deficiencies (e.g., common variable immunodeficiency) (immune disorder)


6. White blood cell dysfunctions (e.g., chronic granulomatous disease). (immune disorder)


7. Diseases that effect the cilia (Impaired drainage and high risk of infection by diseases such as primary ciliary dyskinesia, Kartagener's syndrome and Young's syndrome)


8. Post inflammatory pneumonitis


9. Gastrointestinal Reflux (GERD) due to long term lung exposure to stomach acids damaging the linings of the lungs


10. Autoimmune and Connective tissue diseases (Rheumatoid arthritis, Sjogren's syndrome and Wegener's granulomatosis)


11. Cystic Fibrosis (Due to impaired drainage and high infection rate)


12. Tumor that obstructs the airway and causes impaired drainage


13. COPD due to thick secretions that create a good environment for bacteria


14. Alpha-1 Antitrypsin Deficiency (genetic COPD)


15. Other

Another interesting thing that might cause bronchiectasis is post inflammatory pneumonitis which is generally caused by aspiration (food to enter the lungs) due to an impaired ability to swallow (dysphagia). Another cause of this is GERD, which is when gastric return up the esophagus and enter the lungs due to an impaired or relaxed esophageal sphincter.

Gastric material may damage the airways in such a way that it results in chronic inflammation that leads to asthma or bronchiectasis.

Symptoms include:

1. Chronic cough


2. Productive cough (thick secretions)


3. Hemoptysis (bloody sputum)


4. Smelly sputum (due to infection)
5. Colored sputum (due to infection)
6. Dyspnea (shortness of breath)


7. Wheezing


8. Weight loss


9. Fatigue

Early warning signs of bronchiectasis exacerbation:

1. Increased shortness of breath


2. New onset or worsening cough


3. Increased secretions


4. worsening quality of life (inability to perform normal things, such as walking, brushing teeth, etc.)


5. Heart Failure (pedal edema, high blood pressure, etc.)

Diagnosis is made by:

1. Medical history


2. CT


3. Pulmonary Function Testing


4. Testing for underlying disease such as cystic fibrosis or other based on patient or family history

Early treatment is essential to prevent worsening of the condition. According to "What Are The Treatment Options For Bronchiectasis (Bronchiectasia)?" , from medicalnewstoday.com (April 17, 2010), treatment included:

1. Controlling infections: This includes use of antibiotics as soon as the patient notices the symptoms. Sometimes antibiotics are given long term, and sometimes the patient (especially the CF patient) will even take IV antibiotics at home.

2. Bronchodilators: As the pulmonary complications often result in bronchospasm (asthma-like symptoms), medicines such as Ventolin and Xopenex are generaly a regular part of therapy.

3. Hydration: Drinking lots of water is a good way to prevent the mucus from getting too thick. This makes it easier to expectorate secretions.

4. Corticosteroids: Medicines like Flovent, Pulmicort, Azmanex, and even Advair and Symbicort, are often prescribed. This helps to treat chronic inflammation that is usually present in the lungs.

5. Mucolytics: Medicine such as Mucomyst and Pulmizyne are often used to help thin secretions.

6. Hypertonic aerosols: Inhaling solutions that have more salt that that of which is in cells lining your airways can help thin secretions.

7. Postural drainage and chest percussion : Also referred to as Chest Physiotherapy (CPT). The vibrations caused by cupping your hands and pounding on their chests is believed to help "pound" secretions from their lungs so they can cough it up. Likewise, by performing chest percussion while having the patient lie in certain positions allows gravity to move secretions up.

8. Bronchoscopy: Thick secretions can often cause mucus plugs which block air from getting to the alveoli and the arterioles. When this occurs, a scope of the lungs can help to remove the obstruction.

9. Surgery: This will remove part of the lungs where the mucus plug occurs. This may also be done to remove lungs damaged by constant infections, especially if the lung damage causes the patient to cough up lots of bloody secretions. This is very rare.

10. Embolization: A catheter is inserted into the airway to inject a substance that stops the lungs from bleeding.

11. Oxygen therapy: As the disease progresses it may cause less oxygen from getting from the lungs to the blood (hypoxemia) and tissues (hypoxia). When this occurs supplemental oxygen may be necessary.

12. Lung transplantation: Usually only done with those with advanced bronchiectasis who also have cystic fibrosis. This also presents with a lot of complications of its own.

13. Treat co-existing conditions: Any condition that leads to bronchiectasis must be treated as well, such as CF, GERD, COPD, etc.

Prognosis for patients with bronchiectasis depends on the progression and treatment of the co-existing condition, yet it also depends on early diagnosis and swift treatment.

Medicalnewstoday.com likewise notes that "Patients with co-existing conditions generally have worse outcomes. Examples of co-existing conditions include chronic bronchitis, emphysema. Individuals with complications, such as pulmonary hypertension or cor pulmonale tend to have worse outcomes."

Prognosis (outlook) may also be based on compliance of the patient. Those who take their meds as prescribed, knows the early signs and symptoms and seek speedy help, have the greatest chance of slowing progression of the disease.

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Simple sputum may assure reimbursement

One of the things that has been incorporated into our pneumonia protocol is that a sputum must be obtained before an antibiotic is initiated. Another is that on all ventilator patients a sputum must be obtained as soon as possible.

The purpose of both of these is to prove the patient did not have community acquired pneumonia upon admission. If these tests come up negative, and the patient is later diagnosed during the admission with pneumonia, it is then termed nosocomial pneumonia.

This is important, because in 2005 the Deficit Reduction Act passed by Congress requires the Centers for Medicare and Medicaid Services (CMS) to identify conditions that could have been prevented by implementing practices based on best practice evidence, and nosocomial pneumonia is one such instance.

Hospitals are now encouraged to screen patients on admission (hence the sputum sample being obtained) and procedures and therapies are ordered based on best practice evidence (this is accomplished via the pneumonia and ventilator extubation protocols*) are completed for that particular patient.

If proper procedures are not followed, and that patient develops an infection CMS believes could have been prevented, and no additional reimbursements will be given to the hospital to offset the cost of that admission.

This is why it is essential for hospitals to implement a program similar to Shoreline, which has a monthly Keystone meeting to review and analyze best practice evidence to improve order sets and clinical pathways based on the CMS core values. (You can read about core values here).

So you can see why it's so important to follow your hospitals order sets, protocols, and procedures to a tee. This is why many hospitals have anonymous people (like this) on duty who watch out to make sure everyone is washing their hands, or at least using hand sanitizer.

I know there have been instances here at Shoreline where CMS did not reimburse for a patient because a sputum sample was not obtained. Since the government is paying the bills, it has a right to tell you what to do in this way. I guess you can say this is a perfect example of every new law taking away another freedom.

Yet the ultimate goal here is to make sure nosocomial infections are minimized, and so the hospital gets full reimbursement for that patient. Not even close to the ideal system, yet that's the way it is when Uncle Sam has it's grip around an industry.

*Where I work order sets are called protocols. The reality is order sets and protocols are the opposite of one another.

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Ventolin with GPS: Good idea?

I think a wise doctor will always know what medicines his patient is using and when he is using them. This wisdom should be obtained by monitoring pharmacy records and by a good question and answer seminar at each doctor's apointment. To me that's the job of a gallant doctor.

However, I don't think most doctors do that. I think most doctors write a prescription and let you do with it what you want. They assume you are using the medicine as prescribed. Yet they have no proof. They may ask at the appointment, but some patients lie. I dont', you may not, yet many do.

Well, I have lied in the past. When I was a kid I would never let the ER doctor know I had just used up 200 puffs from my Ventolin inhaler over the past 4 hours. I didn't, but I also thought there was some kind of test to determine how much I used. I certainly didn't want him to find out.

Yet while the ER doctor may not have known, Lord knows my regular doctor should have. Yet what choice did he have. I needed Ventolin, and he continued to renew my prescription. I asked him about it once, and he said, "If you need it you need it. It's better than not breathing and dying."

He was right. But that was way back in 1984 when my asthma was really bad and asthma wisdom was not what it is today.

So should doctors have a better way of monitoring when you use your Ventolin inhaler and how much you use? This was a topic brought up recently in the question section over at MyAsthmaCentral.com.

Here is the question:

My FIRST Lego League team has been researching asthma. We are working to create an innovative solution for asthma treatment that will provide an improvement in patient care. We need experts to confirm that our idea is valid. Our idea is to add a couple of features to the rescue inhaler. We want to provide physicans with specific puff counts as well as GPS locations. We'd like the inhaler to have GSM networking capabilities for sending the information to a physican database. The doctor could then have access to more accurate information for each patient. We feel that this information could be used to better identify triggers and improve overall patient care. We believe that these features could be very compact and not change the 'portabilty' of the inhaler.

I'd appreciate any input.

After much thought about this, I wrote the following:

Sounds like a good idea yet is also sounds kind of scary. In a way the idea reminds me of the book 1984 where the government knows everything everyone does and punishes people for not living ideal lives.

Of course I had no intention of being smart or facetious, I was simply being honest. While I think it's a good idea for doctors to know where and when Ventolin is being used, this kind of power plays right into the hands of people who like to abuse power.

I think if a doctor wants to know how much we are using our Ventolin they can just ask. If a patient is too ignorant to tell the doctor the truth, then that's his problem. It's called individual responsibility.

Or am I out of whack here? Perhaps a Ventolin with a GPS system in it might be a good idea after all. Let me know what you think?

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Many patients do not use inhalers properly

Studies show most asthmatics do not use their inhalers correctly. In fact, this may be a greater problem than you suspect. I recently wrote about his at MyAsthmaCenteral.com

Proper inhaler use is essential

(August 10, 2010)

Chances are most asthmatics have a metered dose inhaler (MDI) tucked away somewhere in their possession. Yet studies (like these) show too many of us do not use our MDIs correctly.

Of course improper use of your medicines will inevitably mean you're not getting as much of the medicine as you should, and may result in difficulty controlling your asthma.

Take your MDI and squirt it into your mouth. When you do this you'll note most of the medicine impacts hard on the back of your throat. You can taste it strongly. Of course then it has to make a hard turn to get into your lungs.

Studies show even with proper use only 9 percent of the medicine reaches the air passages of your lungs. Thus, with improper use, you won't be getting much medicine at all.

It's evident: proper inhaler use is essential.

So, to get the most out of your MDI, you'll have to be aware of the following facts:

1. Prime the pump: According to, "Asthma for Dummies," by Dr. William E. Berger, "Loss of prime occurs when the inhaler's propellant evaporates or escapes from the metering chamber after days or weeks of non-use. If you haven't used an inhaler recently, waste a puff of medication (often less than a full dose) to be sure you're getting a full dose.

The MDI Albuterol should be primed after three days of nonuse. To see recommendations for priming other inhalers click here.

2. Tail off: Berger notes that many asthmatics try to squeeze every last drop out of an MDI. Studies show that after so many puffs all that's left in an MDI is propellant. Most MDIs have a counter so you know how many puffs are in a canister. Do not try to get more out of it.

3. Correct use: There's more than one way to properly use an MDI, yet the most effective way is to use a spacer (see below). Since many guys don't carry a spacer, experts recommend you shake the inhaler well, and place the inhaler one to two inches from your mouth before inhaling. These one to two inches help reduce upper airway impaction of medicine. For a more detailed instruction on correct MDI use, click here.

4. Spacers and holding chambers: To see a spacer, click here. However inconvenient and bulky, spacers have two major advantages: they improve coordination and reduce your risk for systemic side effects.

Large inhalent particles are trapped inside the spacer instead of sticking to your upper airway.

When you inhale, the spacer allows you to generate a smooth, laminar flow, which improves the amount of medicine that gets to the air passages of your lungs by up to 70 percent.

In fact, studies like this one prove proper use of an inhaler with a spacer is equally as effective as a nebulizer breathing treatment.

Likewise, due to less impaction in your mouth, your risk of side effects is greatly reduced. Follow this with a good rinse, and you'll reduce the risk of side effects even more.

Asthma experts note the exception here is adults who are having an acute exacerbation of asthma. In this case airflow may be so obstructed generating enough force to properly use the inhaler may pose a problem.

For children, on the other hand, an inhaler with spacer and mask is the most effective means of inhaling the medicine even during an acute attack. This is because other methods have been proven pretty ineffective with most children. I wrote about this more extensively here.

The latest craze in asthma treatment is dry powdered inhalers (DPI) like Advair. The neat thing about DPIs is they eliminate the need for spacers. The reason is because the medicine is inhaled by the force you create, and this eliminates any coordination problems

The problem with DPIs is they cost too much, and adequate distribution of the medicine is determined by the flow you create, so it's still important to be taught proper technique. (For a neat article on DPIs, click here)

Another problem with DPIs is each device is different, so for each one you may need to learn a different technique. To refresh yourself on the proper use of your DPI, check out this link.

Actually, while many newer meds are now available as DPIs, most research shows that MDIs used properly with a spacer work better than DPIs. (For a great post comparing the MDI with the DPI click here.)

So, for this reason, and because of the chemical composition of bronchodilators like Albuterol and xopenex, the MDI will not be available as a DPI anytime soon.

To learn how to properly use an inhaler with a spacer click here.

When I was a kid spacers were hard to come by, and my doctor recommended I use a used toilet paper roll as a spacer. I couldn't find a toilet paper roll recommended here online, but I did find this and, better yet, this. In nations where spacers are unavailable or expensive, these old ideas still work.

Still, while spacers work best, one study showed that fewer than 20 percent of asthmatics use them. Recently, my asthma blogging friends and I came up with some theories why this might be:

1. Grew up in the no spacer era (old habits die hard)
2. Carrying a spacer is inconvenient
3. Laziness
4. Never showed proper inhaler technique (do you have a good doctor?)
5. Don't know what a spacer is (I get this a lot where I work)
6. Don't know advantages of spacers
7. Spacers make being discreet with inhaler use impossible
8. Personal preference
9. Don't need 70 percent more medicine
10. It works just fine without a spacer
11. Can't afford one

I'll be honest. When I was a bronchodilatoraholic kid, I spent many nights running the inhaler under warm water trying to get the last drop out. I also cringed at the idea of wasting my holy Ventolin by priming it.

I think most asthmatics are like me, and use their spacer sometimes. We may use it at home, yet when we travel we use it as is. Not many people, I think, like to carry that bulky spacer around -- yet we all should.

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Unprofitable Servant

I talk a lot about humility on this blog. I mention often how I am your humble RT. In that sense I do not place myself above anyone else. I am no better than any of my peers. I may be more famous due to my blog, but I am no better than anyone else.

Humility is important. It's important because, I think, as humans, we must be humble to our position here on earth. We must be aware that we are all just little blimps on a large planet, and what we do, no matter how great, no matter how powerful, or no matter how small, is just fulfilling our role.

That's right. We all have a role on this planet. We all have a duty. We all have a task we are to accomplish. And there is not one role that is greater than any other. In that sense, we are all equals.

President Obama, for example, and George W. Bush may be more famous, yet they are no more valuable to human kind than you or I. We are all equals in that sense. We are, as the Bible explains (Luke 17:7-10) in "The Parable of Jesus," we are all unprofitable servants.

Defined, unprofitable servant means that we do what is expected of us and nothing more. We all have a task that we are to accomplish, and we accomplish it, and then we are done. In that sense, we are unprofitable. This is a means for us to keep things in proper perspective: to be humble.

We pray. We are given gifts in life (for example I was given the gift of writing), and we need to use our gift to help our fellow humans (as I'm here blogging to you).

The neat thing is God does not answer all prayers, nor does he heal all the sick. He answers some prayers, and he heals some of the sick, but never all. Yet he does heal everyone spiritually.

He heals spiritually by allowing us to be in Heaven if we are good in this life. No matter how much we suffer, we are given that great reward. That's the best gift of all. That's the best healing power. In that regard, there is nothing we can accomplish on earth more profitable than that. We are, therefore, unprofitable.

Yet there are other gifts, or healings, that are less valuable, such as property and material things like money and other riches and communication skills, math skill, wisdom about asthma and writing skills, the Internet. These are gifts we are given so we can make the world better -- but never better than how Jesus left it when he ascended into Heaven.

Not all who are prophets are rich, or healthy all the time, or are healed when they pray for healing. Some of the best and greatest prophets of the Lord, some of the greatest and most useful people on this planet, have nothing at all but spiritual gifts. They live in poverty.

Most humans are unprofitable servants. That means we do what is expected of us and nothing more. The Lord gives us each an assignment, and it is up to us to accomplish the goals He sets out for us. Which basically means we do what is expected of us.

All the good we do as RTs and RNs and DRs or simple human beings, no matter how good, will never be as good as what Jesus did for us. Therefore, we are not profitable. We are servants. We are not masters.

In this sense, we are humbled. And we use our gifts to make this world a better place, each in our own humble way.

Bronchodilator Osmosis

Here's the deal. A patient who is not quite right upstairs because he took too many drugs when he was younger, and who was off his psyche meds, was threatening to leave the hospital. And, therefore, his psychologist ordered for him to be given a shot.


And, he was refusing the shot, "I just want to go home," he said.


So the nurse who was watching the patient all night -- he was a one on one -- called in the reinforcements. Then, as soon as I walked into the room, the patient said, "Oh, okay, just give me the shot." he cooperated, and moments later all the reinforcements were no longer needed.


As I was leaving the room, one of the nurses said, "Rick, I think that patient calmed down just due to your presence."


"Actually," I said, "It was the fact I have Ventolin in my pocket. Just the fact there was ventolin in the room calmed the patient. Ventolin has magic calming abilities by Osmosis."

The ideal patient

One of the greatest joys of being an RT for me are the rare moments when I provide RT services to a patient who actually needs it. If you're an RT, I'm sure you understand what I'm referring to.

Today I had an asthma patient. He was a boy, aged 8. He didn't look like the typical asthmatic of old, frogged up on the edge of the bed, shoulders high, fingernails dug deep into the paper covered mattress on the bed.

He didn't look that bad because he was on all the right controller medications. He was on Advair, singular and as needed Albuterol. And, most important, his mom was a good asthma mom. She was wise to the signs and symptoms of asthma, and knew exactly what the best time was to come to the emergency room.

Her son was treated with one breathing treatment, given a small dose of oral prednisone, and sent on his way. If all patients were this intelligent, we RTs would be looking for a new job. Or at least the scope of our practice would be different.

RTs may see fewer CF patients in future

Here's an interesting study done at John Hopkins that shows cystic fibrosis patients recover equally as well from their CF exacerbations whether they are admitted to the hospital for therapy or whether they care for themselves at home.

One of the main reasons CF patients are admitted is to obtain IV therapy, yet many CF patients (or their family members) learn to do this on their own so they don't have to be admitted for their annual "recharge."

The study notes that "Outpatient intravenous antibiotic therapy is becoming increasingly popular because of its advantages over hospitalisation including; fewer absences from school or work, less disruption of family life, decreased costs per treatment course and high patient satisfaction."

Likewise, the study concluded that "The researchers found that periods of worsening symptoms were followed by long-term declines in lung function, regardless of whether antibiotics were administered in the hospital or at home, and the optimal duration of antibiotic therapy was 7–10 days, compared with the current practice of 10–21 days."

Acute Respiratory Distress Syndrome (ARDS)

One of the most interesting conditions we RTs have to deal with in the hospital setting is adult respiratory distress syndrome (ARDS). The key here is this is a syndrome more so than a disease process, and is usually secondary to another condition.

Gordon R. Bernard, in "Acute Respiratory Distress Syndrome: A Historical Perspective," July 14, 2005, in Respiratory and Critical Care Medicine, wrote that ARDS was actually described in ancient writings, although it didn't gain national attention until the ventilator was invented in the 1930s.

Since then there has been much wisdom learned about the syndrome, and much progress made in the care of patients diagnosed with it.

Other names for ARDS include noncardiogenic pulmonary edema, shock lung, white lung syndrome (due to whited out x-ray), hemorrhagic atelectasis, capillary leak syndrome, post-traumatic pulmonary insufficiency (often results after trauma), and wet lung syndrome.

According to emedicine.medscapes.com, "Adult respiratory Distress Syndrome," ARDS was actually used in a 1967 report describing the patients with sepsis, blood transfusions, and diffuse lung infiltrates who suffered from respiratory failure hours after the initial insult.

However, it wasn't until 1994 that the American-European Consensus Conference developed a clear definition of ARDS so that its pathogenesis and treatment could be further studied, and "adult" was removed from the term and "Acute" was added because it was learned the "syndrome" occurs in both adults and children.

The definition of ARDS is "an acute condition characterized by bilateral pulmonary infiltrates and severe hypoxemia in the absence of evidence for cardiogenic pulmonary edema." Or, more simply put, ARDS is pulmonary edema not caused by a failing heart. (To learn more of how to differentiate between ARDS and heart failure, click here)

Generally speaking, ARDS is the reaction of the lungs to some form of injury, and generally occurs to patients who are already hospitalized. Those who are at greatest risk, therefore, would be any one of the following conditions:

• Aspiration of stomach contents (damages alveolar/capillary membrane)
• Pneumonia
• Sepsis or shock (any cause)
• Blood transfusion
• Disseminated Intravascular Coagulation (DIC)
• Lung contusion (as in a trauma or personal injury accident to thoracic or non thoracic)
• Drug toxicity (overdose or toxic effects)
• Inhalation injury (oxygen toxicity, smoke inhalation, caustic chemicals)
• Near drowning
• Chemical inhalation
• Metabolic disorders (pancreatitis or uremia)
• Neurologic disorders (head trauma, brain tumor)
• High tidal volumes (this is why we now recommend lower volumes6-10cc/kg ideal body weight as opposed to 10-15cc kg ideal body weight that was taught in 1995)

Again, please note that ARDS, like Sepsis and DIC, do not occur spontaneously. There has to be one of the above occurring for some time for these syndromes to develop.

High volumes are believed to cause lung injury, according to "Ventilatory management of the Adult ARDS Patient," by Douglas S. Laher in AARC Times (June 2007), because healthy lung tissue is "inter-dispersed with that of damaged lung. Under these conditions, the healthy lung tissue receives a disproportionate amount of regional volume in the setting of high inflation pressures, thus causing lung injury to occur."

If you have a patient with any of these conditions you must observe them closely for signs of pneumonia, sepsis, DIC and ARDS. They are all at risk. So preventative measures must be in place, you must be proactive, and you must anticipate the worst and be prepared to treat the patient accordingly. This is where order sets and ventilator and sepsis and pneuonia protocols come in handy. Extubate early and treat pneumonia and sepsis early and aggressively.

In 1967 when ARDS was first described mortality was near 95%, and a majority of those patients died due to respiratory failure. When I was in RT school in 1995 the mortality rate was 70% mainly due to measures to prevent the syndrome and improvements in treatment and improved ARDS wisdom. Now the mortality rate is less than 60% and the cause is usually due to organ failure.

So ARDS is often accompanied by multiple organ failure mainly due to lack of oxygen getting to these organs. Thus, ARDS has a high occurance of organ failure.

According to "Respiratory Disease," edited by Robert L. Wilkins and James R. Dexter, the greatest incidence of organ failure is kidney failure, which presents in 40-55% of cases, followed by heart failure in 10-23% of cases, and liver failure in 12-95% of cases, followed by gastrointestinal (7-30%) and central nervous system (7-30%)

According to the National Heart Lung and Blood Institute (nih.gov), "In ARDS, infections, injuries, or other conditions cause the lung's capillaries to leak more fluid than normal into the air sacs and interstitial spaces. This prevents the lungs from filling with air and moving enough oxygen into the bloodstream."

According to Wikipedia symptoms usually occur within 24 to 48 hours after initial injury or acute illness, so if you have any patients with the above conditions they merit close watch.

Symptoms to watch for include but are not limited to:

• Shortness of breath
• Labored
• Cyanosis
• Tachypnea
• Symptoms of underlying cause, such as shock, pneumonia, etc.
• Decreased blood pressure (shock)
• Organ failure (due to lack of oxygen)
• Rales/ crackles (due to fluid in lungs, pulmonary edema)
• ABG = respiratory acidosis
• Chest x-ray shows bilateral infiltrates
• High oxygen levels over a period of greater than three hours

One criteria for the diagnosis of ARDS is if the patient requires greater than 50% oxygen and the PaO2 continues to be under 100, otherwise known as refractory hypoxemia. Usually these patients need to be intubated and placed on a ventilator.

Ventilating ARDS patients can often be a conundrum, and some techniques are still experimental.

"Respiratory Disease" describes the typical course of the disease to follow the same pattern:

• Initial injury
• Apparent respiratory stability (it occurs patient has no pulmonary abnormalities and lasts from 1 to 24 hours
• Respiratory deterioration (dyspnea, tachypnea, tachycardia, cough are present and x-ray may appear normal and ABG reveal uncompensated respiratory acidosis with moderate hypoxemia with an increased P(A-a)O2
• Terminal stage (Increased fluid in interstitial spaces makes breathing severely difficult. Symptoms at this stage include tachypnea, labored breathing and cyanosis, inspiratory crackles, severe hypoxia and respiratory acidosis. Severe hypoxemia can lead to anaerobic metabolism and ultimately organ failure and death if not treated)

The early stage of ARDS is generally exudative, which, according to dictionary.com, is a discharge of fluid from the blood to the tissues. This stage lasts for up to a week.

According to emedicine.medscapes.com, some injury occurs (a precipitating event) that causes diffuse alveolar damage (DAD) and lung capillary endothelial damage.

DAD is characterized by:

• Damage to the lining of the alveolis (as in aspiration) or the capilary lining (as in sepsis)
• This causes the alveolar or capillary lining to swell (inflammation)
• The gap between the capillary and alveoli to widen
• Widespread damage to type I cells (pneumocytes),
• Fluid to leak from the capillary to the alveoli
• Causing alveolar and interstitial pulmonary edema (fluid in the lungs).
• Hyaline membranes are formed

The next stage is the proliferative stage which is, according to "Respiratory Disease," characterized by regeneration of alveolar epithelial cells. The third stage is the fibrotic stage, "which occurs 3-4 weeks after the onset of the syndrome and is characterized by widespread formation of collagenous tissue by fibroblasts causing thickened alveolar septa."

Emedicine notes that there are two types of cells in the lining of the lungs (epithelium), which are your type I and type II cells or pneumocytes. Ninety percent are of the type I variety, and these are the most easily damaged resulting in leakage in the first stage of ARDS.

Type II are more resistant to injury, yet when they are injured this can lead to the decreased production of surfactant, which is the soap like substance in the lungs that makes it easy for the alveoli to open up. Thus, with less surfactant, the alveoli don't open easily, and this leads to increased atelectasis (collapsed alveoli) and decreased pulmonary compliance.

The later stages of ARDS is also referred to as the fibroproliferative phase, which is a complicated way of saying pulmonary fibrosis. Anything that interferes with the repair process here may lead to fibrosis of the lungs, and even further decrease in compliance.

Many patients survive the initial stages of ARDS only to succumb to the later stages. Yet the later stages also often result in permanent remodeling of the pulmonary vasculature which further complicate things.

Collapsed alveoli (atelectasis), and stiffened alveolar and capillary membranes, and fluid in the lungs, all result in areas in the lung that are ventilating but not perfusing from the alveoli to the capillary, and this is known as a shunt. This results in low oxygen in the blood (hypoxemia) that is not responsive to increased oxygen, which explains why one way to diagnose ARDS is hypoxemic hypoxia.

Hypoxemia then results in hypoxia (lack of oxygen to the tissues), which can lead to sepsis and eventually organ failure as mentioned above.

It's actually a lot more complicated than I describe here, yet I'm trying to dumb it down for simplicity sakes. After the initial injury, pro inflammatory cells (such as cytokines, leukotrines, etc) are released and anti-inflammatory cells are inhibited. This leads to inflammation that results in leaky alveolar/capillary membranes.

Due to stiff membranes, too much tidal volume can easily result in barotrauma, air in pleural spaces, and worsening ARDS, and therefore studies have shown that ARDS is most responsive to lower tidal volumes. You'll generaly want to use volumes at the lowest end of your scale (like 6cc/ kg ideal body weight as opposed to 10cc/kg ideal body weight).

(This is significant, because when I was in RT school the recommended tidal volumes were 10-15cc/kg ideal body weight for patients on a ventilator)

Likewise, the overexpansion of alveoli, plus the force to reopen them, may result in what is called volutrauma, according to emedicine.medscapes.com. This triggers the release of even more pro-inflammatory cytokines and increases the inflammation and edema of the lungs even more.

Treatment includes mechanical ventilation and PEEP therapy. PEEP (positive end expiratory pressure) prevents the alveoli from collapsing all the way and lower tidal volumes. Laher notes that a low tidal volume strategy is "thought to reduce parenchymal lung injury by limiting 'stretching' of the lungs that takes place during mechanical ventilation, in which peak inspiratory pressures are routinely found to be between 30 and 35 cm H2o and static pressures in excess of 30 cm H2o."

However, he notes it is not the low tidal volumes that protects the lung, "but rather the decrease in ventilating pressures as a result of the lower tidal volumes." So the goal of mechanical ventilation is to maintain a plateau pressure less than or equal to 30, and a mean airway pressure between 20-25 cm H2o.

(It should be noted here that varying pressures from an Ambu-bag have been proven to bruise the lungs and therefore cuase Hyline Membrane Disease in neonates, and this is why the NeoPuff is recommended. One would have to wonder if varying pressures in adults might cause ARDS. Just a thought here).

Laher adds that using the lower tidal volume strategy has actually reduced mortality by 25% and ventilator lengh of stay by 2 days for the ARDS patients.

Usually higher amounts of oxygen are needed to maintain an adequate oxygen level to maintain life. The disadvantage to using high levels of oxygen is that after three hours (see this post for more) on a greater than 60% FiO2 (fraction of inspired oxygen) may lead to DAD. So, it's kind of a damned if you do damned if you don't kind of thing.

Too much oxygen causes the release of oxygen free radicals and oxidative stresses which may result in DAD, and is called oxygen toxicity. It was historically believed that high levels of oxygen for a period of days causes oxygen toxicity, yet new research shows this effect may actually start in a short of a period of time as just three hours.

Another problem with ARDS is vasoconstriction. This further increases shunting (areas where oxygen doesn't reach the blood) and ventilation/ perfusion mismatching (areas not ventilated). It also causes pulmonary hypertension, which means the right ventricle of the heart has to work overtime to pump blood through the lungs, and this can often lead to heart failure.

If diagnosed promptly, and treated aggressively, and if the patient does not progress to the secondary phase where fibrosis develops, the ARDS may resolve completely. Yet if fibrosis occurs, mortality and morbidity is increased.

Diagnosis:

• ABG to determine oxygenation status and respiratory acidosis
• Complete Blood Count and chemistry profile are usually abnormal due to stress on body
• Lactic acid to monitor for sepsis
• EKG to monitor cardiac function
• X-ray: After 24 hours of injury patchy bilateral infiltrates in both lungs that may ultimately appear as a whiteout, and no cardiomyopathy.
• PaO2/FiO2 less than 200 (does not improve with increased oxygen)
• PAO2 - PaO2 of greater than 300
• Static compliance (VT/Static pressure – PEEP) less than 25
• Hypoxic Hypoxemia (PaO2 less than 100 on greater than 60% FiO2)
• Pulmonary Capilary Wedge Pressure less than 18 (will rule out cardiogenic pulmonary edema or heart failure as the cause of pulmonary edema)

Treatment

Initial treatment should focus on treating the underlying condition and to work to prevent infection and ARDS. If a patient needs respiratory support, noninvasive procedures should be trialed before intubation. If intubation is required, studies show that 73% of patient intubated nasally end up with VAP (Ventilator acquired pneumonia) as opposed to only 34% orally intubated. So oral intubations are preferred. (study noted at medscapes)

The first order of business is to treat the initial or underlying condition, such as by treating pneumonia or sepsis with an appropriate antibiotic, or by treating hypotension (shock) with vasopressors to improve cardiac function.

Other than treating the underlying condition, treatment generally involves:

1. Mechanical ventilation: Usually the increased work of breathing associated with ARDS is not compatible with life, and for this reason mechanical ventilation is usually required. This will not treat the ARDS but will allow the patient's lungs to rest, buying time for medical clinicians to fix the patient's lungs and underlying condition. Since the lungs are more compliant with ARDS (static compliance low), higher pressures will be needed to ventilate. Yet since higher pressures and tidal volumes are associated with worsening outcomes (see study results at nih.gov), it is important to ventilate with lower pressures (6-10cc/kg ideal body weight and preferably the lower side) and to try to maintain a static pressure of less than 30. The ultimate goal is to adequately oxygenate and ventilate the patient until the ARDS and underlying condition is improved, at which time the patient is to be weaned off the ventilator.

2. PEEP: This reopens alveoli that have collapsed and helps to maintain a pressure in them so they stay open, and this converts areas of shunts to areas where gases can now be exchanged, and this results in improved oxygenation (improved SpO2 and SaO2). Recruitment of alveoli also increases Functional Residual Capacity (FRC) and pulmonary compliance. The goal of PEEP is to maintain a PaO2 of 60 or greater with less than 60% FiO2. The best PEEP is the highest PEEP available that does not result in a drop in SpO2 and blood pressure (which monitors cardiac output). PEEP should then be weaned until FiO2 is 40%, at which time PEEP should be weaned to normal physiological PEEP of 3-5cwp. (see guidelines for adjusting ventilator settings here).

3. Oxygen therapy: This will be required to prevent hypoxemia and to make sure tissues continue to get an adequate supply of oxygen to prevent sepsis and organ failure. Without mechanical ventilation, usually an FiO2 of 75-100% is required. A nonrebreather will provide the patient with 75% (or only 60% according to new studies)and BiPap and mechanical ventilator up to 100% FiO2. Generally high FiO2s are required. FiO2 should be weaned before PEEP as higher FiO2s over long periods of time are associated with causing lung damage. FiO2 should be lowered to 40% before PEEP is lowered. One of the first goals once a patient is on a ventilator is to start weaning FiO2, and all ventilator, weaning or extubation protocols should account for this. The goal of oxygen therapy therefore is to maintain an SpO2 of 88% and a PaO2 of 90.

4. BiPAP: Noninvasive ventilation is becoming more and more popular for patient comfort and to decrease risk of high pressures, high tidal volumes and nosocomial pneumonia. This can usually be trialed in the early stages to improve patient compliance, FRC and oxygenation, although in many cases the patient will eventually require intubation and mechanical intubation. This is much less invasive, although if the patient truly has ARDS a full face mask will be required, and the patient will not be able to take the mask off without causing a sudden drop in tissue oxygenation which will be evident by a drop in SpO2.

5. Volume Ventilation: What mode works best for ARDS patients is generally up to the discretion of the person or facility caring for the patient. Some trials have been done at (which you can see here) that show some form of volume control is still the best mode because it assures the patient will not receive too much volume. Where I work we have Servo 300A ventilators which have PRVC mode that allows us to control volume while making sure the lowest pressure is used. This ventilator also has volume support mode which can automatically be used when the patient starts breathing spontaneously. Many hospitals, however, are using the new APRV mode which is similar.

6. Pressure Ventilation: Some doctors like to trial ARDS patients on pressure control modes to guarantee a certain the plateau pressure does not exceed a certain (usually 30 cwp) pressure. However, the RT will not have control over tidal volumes. This is basically a low tidal volume high PEEP strategy. This allows for higher PEEP to be used. Most hospitals now use an APRV type modes, although there really are no studies showing one mode is better than another.

7. Inverse I:E ratios: Occasionally you'll see a physician trial the patient in a reverse inspiratory to expiratory (I:E) ratio, although when this occurs the patient will be uncomfortable, and sedatives and perhaps even paralytics may be necessary. This is generally only done when volume control or pressure control modes with PEEP and oxygenation fail to improve patient outcomes. This is where the the breath is triggered as soon as PEEP is reached and before full inspiration to prevent higher volumes.

8. High Frequency Jet Ventilation: According to Medscapes today, "Reducing Morbidity of Acute Respiratory Distress Syndrome," HFJV "provides adequate gas exchange while avoiding traumatic lung injury and end-expiration alveolar collapse seen with traditional ventilation modalities."

9. ECMO: Medscapes notes that "ECMO involves blood oxygenation outside the body through a veno-arterial or veno-venous access and is reserved for severe ARDS cases. Current survival rates associated with ECMO therapy have been as high as 80%."

10. Prone position: Atelectasis usually occurs in the bases, and by placing the patient on his stomach this allows recruitment of apical alveoli. This is believed to recruit alveoli and improve oxygenation in this way. However, studies have not proven this to be of benefit.

11. Antibiotics: Thse are used to treat any underlying bacterial infection. Studies have shown that patients with ARDS have a 60% chance of developing Ventilator Acquired Pneumonia (VAP), although with ventilator bundles many hospitals have seen this incidence decreased to as low as zero. In a sense, prevention is a good policy, and as soon as you suspect infection an appropriate antibiotic should be started. This is why many hospitals have initiated sepsis and extubation protocols to reduce the risk of sepsis, VAP, and ARDS by preventing them and/ or diagnosing and treating fast and aggressively based on best practice evidence.

12. Diuretics and steroids: These are sometimes useful to help remove pulmonary secretions and lower pulmonary blood pressure. Studies show that systemic corticosteroids help reduce inflammation in ARDS patients and improve outcomes.

13. Sedatives and paralytics: Used to decrease anxiety and reduce oxygen consumption. Propofol and midazolam are commonly used. Neuromuscular blockers such as atracurium or cisatracurium relax the patient to maximize clinical efforts to control their ventilation. If a patient is receiving a neuromuscular blocker they must be given a sedative, because they may feel pain and not be able to communicate. Plus they must receive artificial ventilation because you'll be knocking out their drive to breathe.

11. Surfactant replacement therapy: This has been proven to be beneficial to neonates in with IRDS, (infant RDS) however is not beneficial (according to studies) with adult ARDS.

12. Nutritional feedings: Oral gastric tubes have been proven to be beneficial to nasal gastric tubes because they reduce the rate of infection. Long term feedings should be by gastrostomy or jejunostomy tube placement. Appropriate nutrition is essential to assure patient has proper nutrients to speed time of recovery and extubation.

12. Other therapies are always being studies, including recent studies using nitric oxide, to help increase perfusion of better ventilated areas. Partial liquid ventilation is also a new treatment.

13. Permissive Hypercapnia: Low tidal volumes may cause the patient to have a low pH (less than 7.20) and a high CO2. Instead of increasing the tidal volume to help blow off Co2, physicians either increase respiratory rate, or simply allow the CO2 to stay high while the patient recovers, and until normal tidal volumes can be given. This is allowed when the benefits supercede the disadvantages of a high CO2.

14. Recruitment Meneuver: Increase PEP above the set tidal volume with the goal of achieving maximal physiologicac stretch in as many lung units as possible. Laher notes this is believed to "sustaine inflation at maximal stretching pressures of the lung (30-45 cm H2O) for up to one minute. Unlike PEEP however, RMs are designed to initially open (or recruit) the alveoli, where PEEP is the method of maintaining patency. These methods have been proven very effective in improving oxygenation, but just like PEEP, clinical data does not support using RMs as a means of improving outcomes or mortality." However, the risks must be measured against the risks.

The ARDS Clinical Network recomments the low tidal volume strategy with the following FiO2/PEEP combinations to optimize patient care:

• FiO2 30% set PEEP at 5
• FiO2 40% set PEEP at 5-8
• FiO2 50% set PEEP at 8-19
• FiO2 60% set PEEP at 10
• FiO2 70% set PEEP at 10
• FiO2 80% set PEEP at 14
• FiO2 90% set PEEP at 14-18
• Fio2 100% set PEEP at 20-24

It should be mentioned here that no medicine has proven to reduce length of stay on a ventilator for ARDS patients, so the best strategy is to focus on low pressures and high peep strategy as mentioned above.

To prevent malnutrition, a feeding tube may need to be put in place. The patient will need to be monitored for renal failure, cardiac arrhythmias, and other complications of ARDS and ventilator therapy.

So I'm sure as new wisdom is learned treatment for ARDS will be altered. Studies are always ongoing in this regard, especially considering ARDS is listed as the most critical of all the respiratory ailments.

To learn more, check out the ARDS Network at the National Heart Lung Blood Institute by clickind here. If you have more ARDS wisdom to add, please educate us in the comments below.