Is there a benefit from getting a bachelor's degree in RT?

Your Question:  Do RTs who come from 2yr respiratory therapy programs share the same responsibilities as those from 4yr programs? Do new grads get treated differently from the seasoned veterans?

My humble answer:  Pretty much.  It's the same with nursing.  The main advantage of earning a higher degree is opportunity.  New grads are generally orientated as appropriate.  RT school is so intense that most RTs come out of school fully prepared to function as an RT, and most are not treated differently than a veteran. 

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Smoking rates decline -- slightly

Fewer people are smoking these days, and those who do are smoking less.  This is according to a report released by the Centers for Disease Control and Prevention, the Associated Press notes. 

In 2005 21 percent of adults acknowledged smoking.  In 2011 19.3 percent of adults acknowledged smoking.  This was a decline of 3 million smokers.  While only a slight decline in the general scheme, this is a trend in the right direction. 

This is significant to us RTs because smoking is the number one contributor to lung disease.  Studies have shown that those who quit smoking allow their bodies to heal, and this reduces the risk of smoking related diseases. 

If the current trend continues, 17 percent will be smoking by 2020.  This will be far short of the government set goal of 12 percent.  Likewise, credit for the decline is given to educational efforts to inform people of the dangers of smoking, and the advantages of quitting if you do smoke.

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Everything you need to know about the Neopuff

Introduction to the NeoPuff:

The need to perform positive pressure ventilation (PPV) on neonates is rare.  In fact, statistics show that about 90% of infants make the transition to extra-uterine life with no problem.  The other 10% will need resuscitation, with 1% requiring an extensive work-up.

In the past PPV has been performed with an AMBU-bag, and rate and depth of breaths determined by a steady hand.  New evidence shows that using AMBU-bags on neonates is too risky, and many hospitals, including ours, are making the transition to using a NeoPuff instead of AMBU-bag.

What can a NeoPuff be used for?

• Blowby oxygen
• PPV
• CPAP

How to get NeoPuff ready for use? (Must be completed when birth expected)

1. Check manometer reads zero with no gas flow. (If not, call RT)
2. Make sure patient supply line is connected to outlet port
3. Make sure a T-piece is connected to the patient supply line
4. Turn on air & oxygen tanks (not needed if air & oxygen connected to wall source)
5. Connect test lung to T-piece
6. Turn flowmeter on NeoPuff to 8lpm (or 5-10lpm)
7. Check for desired oxygen (recommended setting is 40% FiO2)
8. Place finger over PEEP valve.  Pressure manometer should read 20cwp. 
9. While still occluding PEEP valve, turn PIP valve clockwise as far as it can go.  It should not go higher than 40.  If it does go to step 10.  If not, go to step 11
10. Continue occluding PEEP valve.  Remove cap from Maximum Pressure control knob.  Turn knob until Maximum Pressure set at 40 (or as desired)*
11. Close cap that so Maximum Pressure knob is covered
12. Turn PIP** knob to set desired PIP (We like to use 20cwp)
13. Adjust PEEP cap to desired PEEP level.  We like to use 5 CWP.  The PEEP cap is located on the T-Piece
14. Turn off gas supply from flowmeter on NeoPuff
15. If used, make sure you turn off the air and oxygen tanks (otherwise you’ll have to replace them when they go empty)
16. Make sure neonatal resuscitation mask is in the basket
17. Remove test lung from patient circuit
18. If used, check oxygen and air tanks and replace as necessary
19. Failure to complete any of the above steps may cause unacceptable delays in resuscitating newborns.

*The factory setting of the Maximum Pressure Relief is 40 cwp. This is to prevent the PIP from being adjusted over 40 cwp.  Likewise, resuscitation above 40 cwp cannot be achieved unless the Maximum Pressure Relief valve is adjusted.  So long as no one does this, step 10 above can be skipped.

**PIP is Peak Inspiratory Pressure.  This is the pressure given for each breath. 

How to get NeoPuff ready when you need it NOW?

• Turn on oxygen and air tanks (not necessary if O2 & air plugged into wall outlet)
• Turn flowmeter on NeoPuff to 8lpm (or 5-10lpm)
• Make sure PIP is set at 20
• Make sure PEEP is set at 5
• Make sure FiO2 is set to 40%
• Fit neonatal resuscitation mask to the T-Piece
• Now it is ready for the impending delivery.  Hopefully you won’t need it.

Blowby oxygen:  If the infant is breathing yet continues to be blue or otherwise requires oxygen, the NeoPuff can be used to blow oxygen past the patient’s face (an AMBU-bag cannot be used to give blowby oxygen) 

• Place mask close to baby’s mouth and/nose
• Occlude PEEP valve with your finger and hold it there
• Oxygen should now be blowing by the patient’s face
• Adjust oxygen as required to maintain desired SpO2 (see below)

How to give PPV with NeoPuff? 

If the infant is not breathing adequately, or the heart rate dips below 100, you should do the following:

• Place mask over the baby’s mouth and/nose (or fit patient T-piece to ETT).
• Resuscitate by placing and removing thumb over the PEEP cap to allow inspiration and expiration. 
• Give 40-60 breaths per minute (recommended by NRP)
• Do this until HR > 100 and patient breathing adequately

How do you know PPV is working?

• Heart rate increases
• Improved Color
• Spontaneous respirations
• Increased muscle tone

If the NeoPuff appears to not be working:

• Check equipment
• Make sure have good seal
• Make sure PIP is adequate
• Check respirations
• Reposition infant

How to give CPAP with NeoPuff?

If infant heart rate is above 100 and breathing remains labored, CPAP may be trialed:

• Place mask over the baby’s mouth and/nose (or fit patient T-piece to ETT)
• Resuscitate by placing and removing thumb over the PEEP cap to allow inspiration and expiration.
• Place finger over PEEP valve and hold
• This will allow patient to breath spontaneously while providing CPAP (PEEP)

Why use the NeoPuff to give PPV rather than an AMBU-bagBag?

• Evidence shows the NeoPuff is the best way to ventilate neonates
• Less pressure (prevents pneumo)
• Consistent Pressure (prevents Hyaline Membrane Disease*)
• Bags should be available for backup only
• I-Time and Rate controlled by finger instead of whole hand
• Less stress on caregiver (don’t have to worry about giving too much or too little pressure)

*Evidence shows that inconsistent pressures from AMBU-bags actually cause bruising in the neonate airway and can result in further complications for newborns making them extremely difficult to treat.  The Neopuff gives constant, equal breaths that are much easier for the infant.

Fallacies about using Neo-Puff to give PPV: 

Many medical care practitioners are afraid to use the Neo-Puff because they are used to “feeling” each breath go into the baby with their hands by squeezing the bag. When using the Neo-Puff you will not “feel” the breath go in. 

However, every study so far completed comparing the Neo-Puff to PPV overwhelmingly supports using the Neo-Puff to the Ambu-Bag.  The Neonatal Resuscitation program (NRP) highly recommends we get over our fear of the Neo-Puff and use them. 

Oxygenating Neonates:

When using our AMBU-bags you have to give 100% oxygen.  The NeoPuff allows you to adjust the FiO2 from 21% to 100%.

A growing number of literatures have proven you shouldn’t use 100% oxygen for newborn infants.  New studies show that high levels of oxygen -- even for term babies -- can be detrimental to the short term and possibly even long term health of newborns.

Several studies have linked 100% oxygen (even for as little as ONE minute) to:

• Leukemia
• Cancer
• Cellular death
• Infection
• Delayed development of oxygen sensing tissues
• Oxygen radical disease of neonate

It is for this reason that 40% is the recommended starting point for FiO2.  If needed, this can be titrated as appropriate for the patient, or as recommended by physician.

Pay attention to oxygen sats, don’t just leave baby at 100% SpO2.  With Baby less than 30 weeks, Spo2 should be kept <90, the concern is early eye development.  Plus scientists are not sure if primie organs should be rapidly exposed to too much oxygen too fast; when in utero they were developing in a SpO2 of 60% or less. 

Butterworth is currently doing a study of using 21% on all newborns.  It is now believed that it’s not oxygen that stimulates a baby to take its first breath, but heat, stimulation, and PPV.  So some hospitals have gone to 21% FiO2 already.

Benefits of lowering oxygen Sats:

• Increased neurological function
• Decreased Retinopathy of Prematurity
• Decreased Chronic lung disease
• Increased weight gain
• Decreased Infection 
• Decreased Ventilator days
• Decreased Oxygen days
• Decreased Length of stay
• Decreased neonate mortality rate by 30-40%

However, if a baby is not responding to 40% FiO2 after 90 seconds, you should increase to 100%

The recommended goals of oxygenation:

Weeks Gestation	SpO2	Alarms High  Low
<30	85%	93	80
30-34	88%	93	83
35-39	91%	96	86
40 or >	94%	99	89

1. Achieve Sat gradually (increasing PO2 too fast has potential to cause harm)
2. Decrease FiO2 as Sats rise > 95%
3. If HR not rising, check for correct ventilation
4. Increase to 100% FiO2 if no improvement after 90 seconds
5. Do not chase saturations, fluctuations in sats is normal (better to bounce low than to bounce high
6. SPO2 should not exceed 95% unless suspect Persistent Pulmonary Hypertension

Benefits of CPAP for neonates: (PEEP and CPAP is the same thing)

• Always keeps little air in lungs to make next breath easier.
• If HR >100 and breathing remains labored, then you can try CPAP. 

1. Keeps small amount of air in lungs
2. Keeps alveoli open, and prevents alveoli from collapsing
3. Improves oxygenation
4. Makes next breath easier

Conclusion:  So you can see the NeoPuff is proven to be a safe and effective method of providing blowby oxygen, PPV and CPAP for neonates.  It’s also easy to set up, requires only one finger to use, and takes away the stress of squeezing the bag too hard.  In this regard, a well educated caregiver will realize it’s actually easier to use than an AMBU-bag.

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Study: Doctors admit to ordering useless procedures

Breitbart.com reports today on an interesting study that reveals 42 percent of doctors say they over treat patients just to cover their butts in case of a lawsuit.  As a person who works in a hospital this is not surprising news to me, and I bet many doctors are being dishonest -- that the percentage is much higher.

The study, published in the Journal of the American Medical Association, also showed that 52 percent of doctors said their patients received the right amount of care, and 45 percent reported that 1 of 10 patients didn't even need to be in the doctor's office.

Seventy six percent said they believed the main reason for useless medical procedures was the result of fear of a malpractice suit.  For this reason they order a variety of tests and procedures that they don't think are needed, but order just so they look good in a court of law.

Breitbart notes that the United States has the highest per capita spending on healthcare of developed nations of about $5,475, and the second highest nation is Switzerland at $3,581. 

When unnecessary procedures are ordered this increases the price of the product, according to economics 101.  As the demand for a product or service increases (more patients getting x-rays for example) and the supply stays the same (same # of x-ray machines and x-ray technicians) the price has no where to go but up.

Other things that have been proven to drive up the cost of healthcare is free healthcare that results from medicare and Medicaid services.  When something is available for free to the patient they don't hesitate to seek help even when they could have stayed home.

This study sheds more light on the need for healthcare reform that provides doctors with an incentive to order what is needed rather than what they think lawyers would like to have ordered or what needs to be ordered to meet reimbursement criteria.

What do you think?

9 breathing exercises for asthmatics

If you have asthma there are plenty of exercises you can do do strengthen your lungs and make your breathing easier in the short and long term.

This post was my asthma column from MyAsthmaCentral.com on March 14, 2011:  "Breathing Exercises to Control Asthma."

I remember the first time a respiratory therapist talked to me about the importance of breathing exercises to control my breathing. I was 11, and the year was 1981. Several years later, 2006 to be exact, a study was completed to confirm that breathing exercises really do help us asthmatics.

In fact, the study was completed in Australia and first reported inThorax, and showed that asthmatics who used their rescue inhalers regularly for mild asthma, and who performed breathing exercises on a regular basis, reduced their need for rescue inhaler use by 86 percent. Also, inhaled corticosteroid use dropped by 50 percent.

Likewise, the study confirmed that it does not matter what breathing exercises you do, all that matters is you do one or the other. Other evidence already confirmed, as the RT back in 1981 already knew, that breathing exercises during asthma episodes can help make breathing better.

How does the way we breath affect our asthma?

Experts now believe that asthmatics tend to breath faster than people with normal lungs, and many also have a tendency to be mouth breathers. This exposes the lung to cooler and drier air which is an asthma trigger. This results in increased need for rescue medicine.

So it only makes sence that breathing exercises that encourage shallow breathing at a controlled rate may actually reduce asthma symptoms and the need for rescue and preventative medicine.

What are good breathing exercises for asthmatics?

1. Diaphragmatic breathing (belly breathing): (Click here for video) This is what I was taught back in 1981, and what I was encouraged to teach in RT school. It's a basic and simple breathing technique that maximizes air distribution in your lungs.

• You can lie down or sit.
• Concentrate on your breathing
• Preferably you should breathe in slowly through your nose
• When you inhale your abdomen should go out (not your chest)
• Exhale slowly with your abdomen going inward
• Ideally exhalation should be twice as long as inhalation

2. Reduced breathing exercises: (Click here for video)

• Sit upright, relax, focus on posture feet on floor with legs uncrossed
• Relax chest and belly muscles while breathing
• Focus, close your eyes and look up
• Breath through your nose gently (keep mouth closed)
• Breath slowly and shallow
• After exhaling slowly until you feel their is no air left in your lungs
• Hold your breath as long as you can and then return to gentle breathing (do not hold breath so long that you feel urge to inhale through mouth)

3. Physical movement exercises: (Click here for video)

• Focus on good posture (sitting in firm chair with feet on floor, legs uncrossed with your back straight)
• Relax (Tense all muscles, and then relax, paying particular attention to muscles in shoulders and belly. This should release all tension) This makes breathing easier. This is rest position
• Concentrate on breathing (close eyes)
• Focus on breathing while relaxed in rest position
• Focus on breathing with shoulder rotation
• Focus on breathing with Forward curl
• Focus on breathing with arm raises
• Rest position with focus breathing can be done anywhere

4. Yoga: One study showed that regular yoga participation reduced asthma symptoms and rescue inhaler use by 43 percent. In doing yoga you hold poses and concentrate on your breathing. Click here to learn more and to see if Yoga classes are held in your area.

5. Buteyko: According to the Mayo clinic this is a a breathing technique that teaches asthmatics to "habitually breathe less." Click here for the Buteyko website.

6. Papworth method: Similar to diaphragmatic breathing and Buteyko method. You can read more about it here.

These breathing exercises are believed to be beneficial to patients with mild asthma that is caused by rapid breathing and mouth breathing, and may not necessarily benefit those with more severe asthma, or those asthma episodes caused by other asthma triggers, such as colds and allergies.

There are other methods of controlling your asthma:

7. Pursed lip breathing: This can be used when you are having an asthma attack. Since asthma causes air to become trapped in your lungs, this may help you get more air out and may make breathing easier. This is where you inhale slowly through your nose and then exhale through pursed lips, or exhale slowly as though you were going to whistle. You should exhale twice as long as you inhale. This should be done while using diaphragmatic breathing as described above.

8. Progressive Relaxation Technique: This is a technique I was taught while I was a patient at National Jewish in 1985, and it works great. In fact, I think this works so great that I might dedicate an entire post to it some day.

• Lie down and close your eyes
• Concentrate on breathing through your nose
• Use Diaphragmatic breathing
• Tighten muscles of right foot and hold for 20-30 seconds, relax, feel tension release
• Do same for right upper leg, left foot, left upper leg, right hand and forearm, right shoulder, left hand and forearm, left shoulder, jaw area, mouth chin, and forehead.
• Continue to concentrate on your breathing this entire time.
• When done your body should feel "heavy and warm... weightless."
• Stay in relaxed state for as long as you want or need

9.  Other:  Work with your doctor and use whatever method that works for you. 

The recommendation of the researchers is that asthmatics incorporate breathing exercises to go along with asthma preventative medicine. The recommendation is first thing in morning, and last thing at night (the same as most asthma controller meds are taken).

Likewise breathing exercises should be incorporated into your asthma action plan. If you're feeling mild asthma symptoms slow down and concentrate on your breathing. Do this and you may find you won't need your rescue medicine.

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Learning from our mistakes

I believe it's best that we learn for ourselves. I think that it's important for parents to teach as much as we can while our children are younger, yet there comes a time we must let them go and hope we taught well.

Even during the course of teaching, I believe it's important to let kids figure things out for themselves as opposed to correcting them every time they do something we think might not be right.

Some people tend to be more choleric and they tell kids how to do everything. They show kids how to fix everything. Every time their children attempt something that parent shows the right way.

There are forms of government that do this to. They have experts decide what is best force everyone and then force us to do it right. Yet my problem with this is: what if the experts are wrong? What if the parent or the politician is wrong?

If you're deciding what is right all the time, then you must darn well hope you are right. If you are wrong, chaos will ensue. The child (or you) will have a much tougher road than if you had been encouraged to tough it out on your own.

That's one reason why I think it's a good idea not to start kids out with an inheritance, or with a ton of money. We should provide them with a wealth of information and very little money. That way they are forced to live and learn.

I'll tell you from my own personal experience that I wouldn't be who I am today, I would not be here right now doing this, if my parents or my government had provided a blanket for me, or a bridge that I could re-cross for comfort.

And Lord knows I've failed along the way. I was fired more than once. I endured over 18 jobs before I became an RT, and I endured much suffering before I finally got married when I was 32. Yet thanks to that rocky road, I am what I am and I'm happy what I am.

Yet I believe that we don't know any more which way is the right way unless we have the directions sitting right in front of us.

Sure we might have the correct and best way to piece a model together, yet we do not have such blueprints for piecing our lives together. So I believe it's best for our children to be shown the best way, yet there comes a time we must allow them to attempt things on their own.

While they are younger we may need to stop them when they are set on a course for disaster, we might need to help them cross a bridge, yet once they are across the bridge it is best to take the bridge away and let the child learn how to survive. If the bridge is still there, they may be tempted to go back to it to be suckled by the parent.

If the bridge is still there, then that child may not take the risk that might make a difference to the world. Perhaps if Einstein or Thomas Edison had had such a bridge, they never would have taken the risks that make our world what it is. We might also place the founding fathers in this same boat, and any other discoverer or inventor or creator.

I believe it's important to guide my kids, yet then it's time to allow them to discover. It will start with something simple, like making scrambled eggs for breakfast. The choleric parent will never allow this, yet the parent like myself will allow that child to make breakfast even at the risk of getting eggs on the floor, and even at the risk of getting a child's hair in your poached egg.

If you do everything for your child, if you provide cover from all pain, or if you provide money for everything they want to do, then they will become lazy and dependent. If you let them go, you may have to watch them suffer, yet even if they fail they will learn a life's lesson. There's no lesson learned if you do it for them.

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What to do if your patient has a low sat

Dear RNs:

So your patient suddenly has low sats.  Do the following before calling the doctor:

1. Check the connections
2. Check the flowmeter (is it on?)
3. Assess the patient
4. Call respiratory therapy. 

Follow these three simple steps and your RT will love you.

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What are the most violated ethical standards in RT?

Your question:  What are the most violated ethical standards in RT? The AARC statement has some dramatic case examples, but I would love to get a better picture of the day-to-day.

My humble answer:   The two big ones that I'm concerned about most is delaying time and wasting time.  I think much of what we do keeps people alive when we should let nature take it's course.  Example:  someone comes in full arrest, is blue and has taken a major anoxic hit, yet we spend hours -- maybe even days -- trying to save that patient.  If he lives he's a ward of the state at the cost of millions of dollars.  If he dies he still costs thousands in our efforts to save him.  However, it's not my decision to make.  If someone hasn't already declared what they want at the end of their lives, or if they don't have a responsible person making those decisions, it can get pretty tricky.

The other thing that concerns me as unethical are all therapies we do just to make sure the patient meets criteria for reimbursement, or just because the doctor wants the patient or patent's family to think we're doing something.  I think this is a waste of my time and all of our money.  For example:  CMS won't reimburse for pneumonia patients unless the patient was sick enough to need oxygen, breathing treatments and something else I can't remember.  So to cover our bases doctors simply order all of these procedures on every patient admitted with a certain DRG (diagnosis).  I feel it's unethical to give breathing treatments to people who don't need them, yet I do so all the time because they are ordered.

I also find myself lying to patients and telling them what I'm doing will help them get better.  I find this is unethical.  Yet I find I have no choice in the matter.  If a doctor tells a patient one thing, I feel it's my obligation to back up the doctor. 

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COPD now affects more women than men

Since smoking became a popular trend during WWI and WWII more men smoked, more men developed COPD, and more men died of the disease than women.  Yet that trend seems to have changed, as a new report by the Center for Disease Control (CDC) confirms.

U.S.News.com writes that the study followed COPD patients from 1998 through 2009, and found that COPD prevalence has relatively stayed the same, and the only trend that changed was that more women than men died of the disease.  In fact, in 2007, as WebMD notes, "COPD killed nearly 60,000 men and nearly 65,000 women."

U.S.News notes the report concluded that "Just over 6 percent of women now have COPD, the study found, compared to just over 4 percent of men."

So why this shifting trend.  U.S. News quotes Dr. Lara J. Akinbami, a medical officer in the Office of Analysis and Epidemiology at the CDC's National Center for Health Statistics with the explaination. 

She said, " "The relative increase of COPD among women is largely due to more women taking up smoking in the 1970s and 1980s, Akinbami believes. These women are only now entering a time when the symptoms of COPD start to appear."

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Pleurisy and Pleural effusions

When fluid or air make it into the pleural cavity this can cause a restriction that makes it impossible for the lungs to completely expand.  Pleurisy, pleural effusions, pneumothorax and hemothorax are three disease processes that involve the pleural cavity..

Pleural cavity:  Surrounding the lungs is a small cavity filled with air.  The outer layer is called the parietal pleura, and this is attached to the chest wall. This outer layer is attached to neurons and is highly sensitive to pain.  The inner layer is called the visceral layer and it covers the lungs.  The space within the visceral and parietal layers is called the pleural space.

The pleural space contains mostly air, although there is a small amount of pleural fluid. The fluid is used as a lubricant to allow the two layers of membranes to easily rub against each other to aid in inspiration.  When the muscles of respiration contract, this pulls the pleural cavity outward creating a negative pressure that expands to the lungs.  This allows for air to be drawn in. I discussed how we breathe in this post.

There are not connections between the pleural cavity of the right and left lung, and it is for this reason if you have air in the right lung (collapsed lung or pneumothorax) it will not effect the other lung.

Pleurisy:  This is usually a complication of some other disease, and generally causes pain with inspiration. Likewise, it can precede a pleural effusion.  According to Egan's Fundamentals of Respiratory Care, it's characterized by "fibrinous exudate on the pleural surface."  It can also produce a rub on inspiration.

Rub:  This is a grating sound on inspiration. 

Pleural effusion:  This is when fluid accumulates in the pleural cavity that surrounds the lungs.  The only way fluid can increase in the pleural cavity is if more is produced than is reabsorbed by the body.  The only way for this to happen is if there is an underlying disease process.

There are two types of pleural effusions.  Yet first we must define oncotic pressure and hydrostatic pressure.

Oncotic pressure:  This is pressure exerted by proteins in the pleural space (or blood) that pulls water into this area.  This pressure must be balanced with hydrostatic pressure in order for the fluid in the pleural space to stay at a normal, healthy level.

Hydrostatic pressure:  Also called fluid statics.  It's a pressure that drives fluid out of the cavity.

Transudative causes:  This is when either the oncotic or hydrostatic pressure increases and causes water to accumulate in the plueral spaces.  This can be caused by:

• Congested heart failure
• Liver cirrhosis
• Pneumothorax
• Atelectasis
• Pulmonary embolism

Exudative causes:  This is when fluid builds up in the pleural space without the hydrostatic pressure or osmotic pressure changing.  They differentiate from transudates in that there will be a higher protein buildup. This is usually due to inflammation, infiltrative diseases, or tumors:  Other causes include:

• Lung cancer
• Mesothelioma
• Lymphoma
• Tuberculosis
• Fungal or Viral infections
• Systemic Lupas
• Rheumatoid arthritis
• Pulmonary embolism
• Pancreatitis

Small effusions may go without notice, yet large effusions may effect a patient's ability to breath.  Common signs and symptoms are:

• Atelectisis due to lack of ability of lungs to expand
• Dyspnea (feeling of air hunger)
• Fever
• Sweats
• Increased sputum production
• Lack of chest movement
• Diminished or absent breath sounds over effusion
• Vocal fremitis is absent
• Percussion of chest wall is flat
• Egophany may on effected side
• Medistinal shift away from the fluid
• Tracheal shift away from the fluid

Pneumothorax and hemothorax will be discussed next Wednesday.

References:  Egans Fundamentals of Respiratory Care

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School kids need quick access to rescue medicine

Think about this.  There are many asthmatic adults who are embarrassed or too modest to seek medical attention.  Many are even so modest that they prefer to use their rescue medicine in private.  So why would this be any different with children.

The truth is -- and this only makes sense -- that children are even more likely to not want to seek out help when they're having trouble breathing, let alone want to use their inhaler in front of someone.  And it's for this reason alone that school policies that ban kids from carrying their own inhalers are ridiculous.

The main concern of schools is that kids will abuse the medicine.  Yet the facts show that when an asthmatic kid needs his rescue medicine, he needs it prompt.  If he hesitates to seek out help, and it then takes a while to gain access to the rescue inhaler, this can result in worsening asthma and even death.

The fact is that kids need rapid access to their inhalers.  They shouldn't have to stress about how they are going to gain access to it, it should be right in their own little pockets.  If they want to grab it and hide around a corner to use it, then they should be allowed to do that.

I know for a fact when I was a kid I hated the other kids to see me using my inhaler.  I also hated them to see I was having trouble breathing.  So when I needed it I hid around a corner and took my puffs.  I was a shy kid, so seeking out adult help wasn't an option and probably never would have happened.

Many schools with "no medicine in kid pockets" policies are learning the hard way that these policies may not always be such a good thing.  It's sometimes better to risk kids abusing their rescue medicine than it is for those kids to suffer or die.

Likewise, it should be noted here that using your rescue inhaler when you are short of breath is not abusing it.  I think that some people assume -- especially those who don't have asthma -- that if a child uses his inhaler more than the doctor recommends that this constitutes abuse.  Yet that's not true at all.

Surely overuse of an inhaler can be a sign of worsening asthma and prompt medical attention is necessary.  Yet it can also be a sign of hardluck asthma, or asthma that is not well controlled with common asthma preventative medicines.

Perhaps with this wisdom in mind as many school policies -- like this one -- are being changed to the way it was when I was a kid where asthmatic kids can carry their inhalers and have quick access to them when they need them.

Sure kids should be educated.  Parents should be educated.  And even more important, teachers and any person who will be responsible for that child at school -- including janitors, cooks, and aides --- must be educated about asthma.  They must know who has it, what signs to look for, what to do if the signs are observed, what that kid's asthma triggers are, etc., etc., etc.

To be honest, when I was a kid, if a school had such a policy, I would have ignored it.  Not that I would be trying to be a rebel, but one size fits all school policies that don't consider the different personalities and needs of asthma students are bogus.  Asthmatic kids need to carry their own inhalers.  Period.

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Nasal congestion linked to severe asthma

Of course we've known for quite some time that nasal congestion can be an asthma trigger, yet a new study shows that nasal congestion may also be the main culprit when it comes to severe asthma.

The journal of Respiratory Research, and reported here at RTmagazine.com, was the first to publish the findings of a study done in Sweden. The results are significant because it's the first to estimate the "prevalence" of asthma in a given population. In Sweden, the number of Severe Asthmatics is estimated to be about 2 percent.

Nasal symptoms may be sinusitis, rhinitis (hay fever), runny nose and colds are all linked to causing nasal congestion. This is significant to asthma because sinus drainage makes its way to the lungs and triggers asthma.

The study author noted these results are significant because, "effective treatment for troublesome nasal and sinus complaints could, in theory, reduce the risk of severe asthma, though this is something that needs further research... and this may lead to new forms of treatment in the long run."

I think scientists have already been working on medicines to help with nasal congestion. Perhaps this might be an incentive to speed up research in this area.

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Learning from our past

Sometimes I wonder whether to orate my thoughts and opinions to my children, or if it's better to lead by example. While I do believe most of the time it's best to teach by example, I've learned that sometimes it's good to find the right moment to let your children know what you believe.

“You shall teach them diligently to your sons and shall talk of them when you sit in your house and when you walk by the way and when you lie down and when you rise up. You shall bind them as a sign on your hand and they shall be as emblems on your forehead. You shall write them on the doorposts of your house and on your gates” (Deuteronomy 6:7-9).

I remember my mom would find a right moment to talk to us kids. Once there was an episode of Facts of Life (yeah, we did watch that silly show as kids) where one of the girls had a boyfriend who wanted to do it. And then mom took the opportunity to give us a pithy talk about the importance of respecting your body, and only giving yourself to someone you truly love.

The commercial was over and that was the end of it. And I might have thought nothing of what she was saying right then, yet later when the moment came up, I could hear mom's words in the back of my head. While it's hard to really know for sure, moments like that are what prevented me from taking a wrong path, and lead me to where I am today.

That is what Asaph talks about in Psalm 78 (1-8). He discusses that it is important for parents to take the time to educate their kids about virtues. It is not good enough to just assume your children are learning virtues the way you learned them. There comes a time when you should stop and say what you believe.

Yet too often, Asaph writes, we think we teach our kids by assumption. If virtues are going to be passed on from one generation to the next, it is up to parents to relay these virtues. It is up to parents to teach about the past, so that the future generations do not repeat the mistakes of the past.

I think this was done from about 1976 to 1960 in the U.S., but then the hustle and bustle of life has made it so parents no longer have the time, and don't take the time to relay these messages. I think this is the reason that virtuous people are on the decline. There are few among us today who would say that Americans are more virtuous today than we were when our parents were kids.

And, as I've written before, this might be one of the main reasons for all the troubles we now face in America and the rest of the world. We did not teach the lessons, such as the lesson of the Tower of Babel, or the parables such as the Parable of the Seeds.

In a way, it may be their fault. Thankfully my parents took the time to sit with my brothers and me. Yet there are many among us who work two jobs, or who grow up in single parent families. While the intent might be good, these parents don't (or didn't) have the time to sit down with their kids to relay the message about the importance of virtues.

And it is for this reason that values have declined.

References:

• psalm 78

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Signs that assume we are all stupid and lazy

Signs.  Notes.  You see them everywhere, especially at your work or office.  Most of them are written by choleric people who love rules and must have everything done their way.  And, yes, there is usually at least one choleric in every office.

They put signs up like the following:

• We do not have a maid service, clean up after yourself.
• Please shut off coffee pot when not in use
• This is a garbage, not a recycling bin
• This is for cans only, this is not a garbage!
• This room for employees and patients only! 
• This room is in use/ not in use
• Meeting this month is mandatory
• Label and date all food containers in refrigerator
• All unlabeled food will be tossed every Monday
• No drinking by computers
• No food in office

You get the drift.  These are signs written by people who have to have control.  Yet they don't realize that we are all people, and we all have different personalities, and we get busy.  These are signs written by people who think most people are stupid and lazy.

Some of us are lazy for sure, but the majority of us have more important things to think about than whether or not we leave a cup of water lying next to the computer, or have a container that's been in the fridge for two weeks.  Some people are clean and organized (the cholerics and melancholy) and some people aren't (sanguine and phlegmatic). 

I think a few signs or a few rules are good, but when you start to get a collection of them they become too hard to follow and too hard to enforce.  It's better just to have one really important sign, like this:

• Work hard
• Do your best
• We respect your hard work
• We know who the hard workers are, and we appreciate you

Yet communication in this positive way is rare and far in between, and usually comes just prior to communication that relays something you did that was wrong, such as a charting error that has nothing to do with the patient/ customer.

Signs are dumb.  I'd like to rip them down, and sometimes I do. Likewise, few of these prodigal signs say please and thanks.  I'd like to put my own sign up (just one) to put an end to such frivolity:

• Quit putting up stupid signs!  And Thanks

None of these signs are necessary.  If you're anal retentive and want to clean the fridge, clean it.  You'll be more respected that way anyway. 

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Non-RT jobs RTs do

We RTs often do more than what we are trained to do.  We are part of the patient care team and do our part to help out.  Okay, often we are quilted into helping out.  Either way, here's a list of things we RTs often do that aren't RT jobs:

1. Reset IVs
2. Help reposition patients
3. Help change patients
4. Empty urinals
5. Help patient use urinals (we usually try to get out of this one)
6. Help patients on bedpans (again, we usually try to get out of this one)
7. Help make ER beds
8. Help patients with food tray/ eating
9. Relay messages to RN (communicate for patient)
10. Find TV station they want to watch
11. Massage patient's feet/ back (we usually try to get out of this too)
12. Tie up gowns
13. Fetch cups of water/ pop/ coffee/ cocoa/ tea

Yes there are more.  If you can think of any comment below....

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COPD rates remain steady; job security for many RRTs

There's been a lot of concern among RRTs that once people quit smoking many of us may be out of a job.  That may be true some time in the distant future, yet for the time being it appears the COPD rate remains steady.

Surely we're all aware that smoking contributes to 90 percent of Chronic Obstructive Pulmonary Disease cases, and many of these patients are later admitted to hospitals with exacerbations, heart failure, strokes, and other complications of the disease and smoking.

A study performed by the Center for Disease Control and reported to us over at WebMD  tracked COPD patients from 1998 to 2009 and concluded the COPD prevalence rate remained unchanged.  What did change was the death rate, yet only for men. 

WebMD notes the report concluded that:

"Older adults are the most likely to have the disease, and most people are generally diagnosed with it later in life. The disease was most common among women aged 65 to 74, and most common among men between ages 75 and 84. In nearly every age group, women with the disease were in the majority, according the CDC report."

So our job security seems safe for the time being.  I imagine unless some other disease pops onto the scene requireing our services that RT jobs might start to decline as smoking rates decline. 

Yet I imagine it'll be at least 50-100 years before this effects our profession even if all the current smokers quit today.  I say this because we'll continue to need to treat those who currently have the disease, or those current and former smokers who will be diagnosed in the future.

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Conditions that might cause decreased mucociliary clearance

The following conditions might decrease the ability of a patient to expectorate secretions due to impaired mucociliary clearance.  The cause is generally secretions that are either too tenacious to bring up, or destruction of the cilia used to move the secretions out.

Diseases that impair mucociliary clearance are:

• Cystic Fibrosis
• Primary ciliary dyskinesia
• Bacterial infections
• Mycoplasmal infections
• Viral infections
• Bronchiectasis
• Chronic Obstructive Pulmonary Disease
• Smoking (either passive or active)
• Lung transplantation

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Is Albuterol safe for infants?

Your Question:Is albuterol safe for infants?

My humble answer Albuterol is safe for infants. It's a very effective medicine for helping asthmatics breathe better, and it's very safe for all ages.  Doctors have used it with very good results for many years now. I answered a similar questionhere in case you'd like further information.   Facebook
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A tiny virus may be the cause of your asthma

Viral infections are the most common cause of asthma attacks. The culprit when it comes to childhood asthma is RSV. Learn mor in my most recent post from MyAsthmaCentral.com

Common Virus May Cause Asthma

Able to leap tall buildings bound to their victims. Able to travel up to 100 miles per hour in your sneeze. Too small to be seen by the light microscope. And capable of causing grief for you and me.

What I'm referring to here is the common virus. While 5,000 viruses have been described, there are millions. They're ubiquitous. One common one is the influenza virus, yet many are known to cause the common cold.

Any infection caused by a virus can cause major complications for an asthmatic. In fact, many asthma experts, including those at the Mayo Clinic, believe viruses "are the most common cause of asthma flare-ups, especially in children.

Another common virus is the Respiratory Syncytial Virus (RSV). This little pest is known to cause a common head cold in adults, yet in children it can cause bronchiolitis, and RSV pneumonia, which can lead to asthma trouble and even respiratory failure.

Do Viruses Cause Asthma?

As noted by the Food and Drug Administratino (FDA) in this post, new research shows that not only do viruses trigger asthma, they may also cause some children to develop asthma. Since RSV is a common virus, and most infants are exposed to it early in life, it's believed to be the most common virus to cause asthma.

Likewise, studies show that children who develop RSV pneumonia are at an even greater risk for developing asthma.

To understand how viruses cause asthma, we must first revisit the Hygiene hypothesis, which is basically an "educated guess" that postulates that one develops asthma during the first three months of life when the immune system is maturing.

The basis of this hypothesis is that in our modern society children are not being exposed to enough bacteria, and therefore aren't being exposed to enough bacterial lipopolysaccharide (LPS). In other words, we are too clean.

LPS is a molecule on bacteria that, according to the FDA, "stimulates and educates the immune system by triggering signals through a molecular 'switch' called TLR4, which is found on certain immune system cells."

Thus, when the level of LPS is low in the environment around the child (not enough bacteria), the immune system does not develop properly.

The immune system therefore becomes bored and creates a defense against things that normally don't pose a threat to their bodies, such as dust mites, cockroach urine, pollen, grass, molds, fungus and other allergens.

How does it all work?

So what do viruses have to do with all this. Well, as the FDA explains, RSV is believed to carry "a molecule on its surface called the F protein, which flips the same immune system 'switch' (TLR4) as do bacterial endotoxins."

One would think the F protein would turn the immune system on, or cause it to mature, as bacteria LPS protein would, although this does not seem to be the case.

So, since the immune system is still immature, scientists believe RSV "might inadvertently trigger asthma instead of protecting the infant and clearing the infection. How this happens is a mystery that we are trying to solve," according to the FDA.

In this way, RSV prevents the maturation process of the immune system, and thus leads to those kids exposed to it at an increased risk for developing childhood asthma.

What to do

Sure that might sound a little complicated, yet the bottom line is that viruses can both trigger and cause asthma.

We need to make sure we keep our newborn infants away from people who are sick. This is especially true if there is a history of asthma in your home.

This is one of the reasons most pediatricians recommend not taking your newborn into public areas during the first three months, which would include Walmart and church.

Yet we Americans usually don't let simple fears get in the way we live our lives. And chances are you'll be like me, taking your newborn to church so you can show her off -- virus or no virus.

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Treat others as you'd have them treat you

Contrary to what we might think is normal, when one does something we hate, we should not hate that person back. We must, instead, lead by example. We must do on to others as we would have them do on to us -- or so the saying goes.

In ancient days it was taught an eye for an eye, and a tooth for a tooth. If your friend hit you, you were to hit him back. If he ripped off your ear, you ripped off his ear and beat him to a pulp until he reasoned. And then this would continue to no end.

To the dismay of the masses, Jesus taught that we should do the opposite, and this would make us seen as better prophets by those around us, and, in the end, by the final judge. Instead, Jesus taught (Matthew 5: 38-48), "But now I tell you: do not take revenge on someone who wrongs you. If anyone slaps you on the left cheek, let him slap you on the right."

We do have it in us to respect other people, even those who do not treat us with equal respect. Instead of hating the person back who hates you, instead of complaining and cursing, we should respect that person back. Why? Because you are better than that person.

In Baptism, we all become God's temples; we all becomes temples of Christ. When someone destroy's a temple, God will destroy that person. Since we are all temples of Christ, we are all responsible for being kind and merciful to everyone, including those temples you do not particularly like. (Corinthians 3: 16-23)

As temples, it is our job to spread the word of God. God is symbolic of virtues. In this sense, God made us all in His image. We all have it in us to be perfect (or to strive for it) like Him. We can be good. We can all be virtuous.

The opposite of virtuous is destruction, just as can be seen by the Tower of Babel. By worshiping yourself, or your stuff, or your false gods, you are thus worshiping a path that will only lead to disarray. If you have disarray in your life, you should look in the mirror, and not at those you hate.

The problem is that most fools do not know they are fools.

Thus, since God is merciful and forgiving, so can we be merciful and forgiving. Likewise, those who are virtuous, those who do good on to others, those who do not complain and curse, are more respected by society.

Matthew (5: 38-48) writes that the sun doesn't just shine on the good, and the rain does not shine only on those who worship him. By rain here Matthew is referring to the hand of nature that allows crops to grow and flourish. The sun shines on the good and the evil. The rain falls on those you like and those you do not like. God, in this way (or nature if you do not believe in God), treats all temples the same.

Likewise, we are all judged at the end of our lives, not in the middle. We all have our ups and our downs. And therefore, it is the person that we are in the end that is judged. So if God judges the end result, we should not think ourselves better than God and judge a person by their actions today. We, like God, should reserve judgement.

In other words, we should not judge a person by one event, or one moment, in that person's life.  Yet, as we all know -- such as by the expression "first impressions mean a lot" -- we are all tempted to judge, judge early, and judge often.

In this sense, we are not worthy to judge. The wise person who thinks he is worthy enough to judge is a fool, and will be judged himself as a fool in the end.

Likewise, as recorded in Leviticus (19: 1-2, 17-19), "Do not bear a grudge against anyone, but settle your differences with him, so that you will not commit a sin because of him. Do not take revenge on anyone or continue to hate him, but love your neighbor as you love yourself."

I wrote about this in more detail in this post: The Key to success: stop complaining. Would you want some one cursing and complaining about you if they thought you were imperfect? I think the majority of us would answer that question with a flat out NO.

Your boss may be a fool, and that's no reason to be a fool in return. Your boss may be the wise one all along, and perhaps you are the fool. Since you are not perfect yourself, who are you to judge others, and who are you to hold a grudge against another.

So, in this sense, we must treat others as we'd have them treat us. If someone slaps us on the left cheek, we must offer the right. If someone asks us to walk a mile, we must walk two.

Note:  I have a post coming up "How to deal with criticism and faults" where I'll discuss where it is appropriate to judge.  For example, it's essential to question and judge stupidity.  People hate to be judged, yet at time's it's essential.

References:

Levaticus 19: 1-2, 17-19
Corinthians 3: 16-23
Matthew 5 38-48


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