What is a tracheostomy?

Your humble question:  What is a tracheotomy and why is it needed?

My humble question:  A tracheostomy is a small hole or stoma in your neck -- your windpipe -- that the person can breathe through.  It's usually temporary, yet in some cases it can be permanent.

Your question:  Who inserts a trach and where and how is it inserted?

My humble answer:  The procedure is usually done in a sterile environment such as in an operating room by a surgeon, however an emergency trach can be inserted just about anywhere.  Any hollow tube can be used in emergency procedures.  An incision is made through the crichoid cartilage between the 2nd and 4th tracheal rings.  

Your humble question:  What are the indications for tracheostomies?

My humble answer:  There are a variety of indications:  

• To create an easy passage for the person to breathe when there is an obstruction of the upper airways caused by disease (epiglotitis, cancer, foreign object, paralysis of vocal cords, and trauma).
• Long term ventilation is required.  This makes it easier to manage the airway and is more convenient to the patient than having an ETT in her throat.  It's also improves infection control.  It also makes it easier to wean some patients off a ventilator.  
• It shortens the airway and makes breathing easier by reducing airway resistance.  This is essential for diseases such as chronic bronchitis, empysema, severe pneumonia or chest injury.
• Respiratory muscle paralysis.  This may be permanent as a result of a disease such as a neuromuscluar disorder such polio or ALS.   It can also be temporary as with head trauma.
• Diseases with thick secretions such as cystic fibrosis or chronic bronchitis associated with pneumonia. This makes it easier to clear secretions.
• Inability to cough and remove secretions, as with a stroke or neuromuscular disorder

Your humble question:  What are the advantages of a tracheostomy?

My humble answer:  There are a variety of advantages:

• More comfortable than an ETT
• Makes it easier to wean a patient off a ventilator
• Reduces need for sedation because it's not as uncomfortable as an ETT
• Reduces risk of trauma to airway as might be causes by an ETT
• Reduces airway resistance to make breathing easier for patients
• Allows patient to breathe when upper airway is swollen or collapses (such as with paralysis caused by neuromuscular disorders or epiglotitis)
• Makes it easier to suction the patient with thick, or copious secretions
• A patient can talk with special trachs

Your question: What does a trach consist of?  What does it come with?

My humble answer:  Most trachs come with three parts:  Outer cannula, Inner cannula, and obturator.  The outer cannula holds the stoma open and it has neck plates that extend on both sides so it can be secured by a velcro trach collar or trach ties.  The inner cannula has a lock to keep it from being coughed out.  It is easily removed so it can be cleaned.  Essentially, the inner cannula makes cleaning easier.  The obturator is used to insert the trach.  It slips into the tube and helps the doctor guide the trach into place.

Your question:  What is a fenestrated trach?  What are the benefits and disadvantages of it?

My humble answer:  It's a trach with holes or fenestrations in the outer cannula that allow air to pass into the upper airway so the patient can cough to remove secretions and talk.  Basically, it allows normal breathing and the ability to speak. It allows a trial of normal breathing and normal talking before a trach is removed, and may also necessary for long term trachs.  To take advantage of the fenestrations the inner cannula must be removed and the cuff (if there is one) deflated.

Your question:  What are the different types of trachs?  

My humble answer:  What trach to use depends on the patient, and trach should be 3/4 the diameter of the patient's trachea.  The following are the types of tracheotomy tubes according to John Hopkins:

• Cuffed with inner cannula:  The inner cannula may be either disposable or reusable.  Cuff should be inflated only for positive pressure breaths.  It must be deflated to use a speaking valve.  
• Cuffless tube with inner cannula:  T'he inner cannula may be either disposable or reusable.  Good trach for people who don't need to be on a ventilator.
• Fenstrated cuffed tracheostomy tube:  This increases the risk for aspiration due to the fenestrations.  The fenestrations also make it difficult to ventilate these patients.  However, good for weaning off trachs and for some patients who want to use a speaking valve. This type of tube is good for long term ventilator patients.
• Fenestrated cuffless tracheostomy tube:  Only used for patients who have difficulty using a speaking valve with the other trach tubes. There are risks associated with using fenestrations, such as aspiration and glanulation formation around the site of the fenestrations
• Metal tracheostomy tubes:  Rarely used.  Cannot use during MRI, and will cause alarm during airport security checks.  

Your question:  What is an inner cannula?

My humble answer: An inner cannula is a cannula inserted into the trach.  It allows for easy maintenance of the trach especially if there are thick secretions.  It also has a universal adaptor on it so the patient can be connected to a Ambubag or ventilator circuit to receive positive pressure ventilation.  

Your question:  How can a person with a trach speak?  

My humble answer:   The patient can speak either if the tube has a speaking valve or if the patient simply covers the opening with a finger.  For this to occur, the outer cuff must be fenestrated.  

Your question:  When should the trach cuff be inflated?  Deflated?

My humble answer:  The cuff, if there is one, should only be inflated during positive pressure ventilation, such as with a ventilator, bagging, or BiPAP.  The only reason a cuffed tracheotomy tube is necessary is when positive pressure breaths is indicated.  A cuff will irritate the trachea, and therefore should not be used unless needed for positive pressure breaths.  It also traps secretions (even when deflated) and can increase rates of infection.  If a patient requires continuous positive pressure ventilation, the cuff should be deflated four times a day to prevent tracheal necrosis and the lowest possible pressure should be used to inflate the cuff.

Your humble question:  What is a stoma?

My humble answer:  Any opening between an internal body part and the external environment.  A colostomy is a form of stoma because it allows feces to bypass the rectum and anis so it can be removed from the body into a clostomy bag.  A tracheotomy is another form of stoma because air can bypass the upper airway.  Stoma is Greek for mouth, in when we refer to a stoma we are generally referring to providing a "mouth" to some internal part.  Generally speaking, when an RT refers to a stoma he's referring to a tracheostomy of any form, either when their is a trach present or when there is simply a hole in the neck.  A tracheostomy is the opening or stoma made by the incision in the neck.

Your question:  So what is a tracheotomy?

My humble answer:    A tracheotomy is the opening or stoma made by the incision in the neck.

Your humble question:  When a tracheotomy is removed, what happens to the hole?

My humble answer:  The hole will seal and seal fast.  It's for this reason if a trach slips out it must be reinserted as rapidly as possible.  A person will continue to have a scar where the incision was.

MCAT question #37

I cannot reveal my source, but I once again am privy to esoteric wisdom. The following is a question I have obtained from the Medical College Admission Exam (MCAT):


Your phone rings at 2 a.m. and you are awakened from a sound sleep.  The annoying nurse tells that Mrs. Ranger -- your infamous CO2 retainer -- is in respiratory distress with an Spo2 of 86 percent.  She says the RT made the decision to place the patient on a 40 percent air entrainment mask and that brought the SpO2 up to 88 percent.  The nurse says the CO2 on admission was 58. A prn ABG was obtained per protocol on the present O2 settings to reveal a CO2 of 65.  The patient is now breathing fine, and she's only calling you because hospital protocol instructs the doctor to be called when a patient requires an increase in FiO2.  Which of the following choices is the best statement to say to this nurse?

• a.  "Why do you call me for such B.S. at 2 a.m."
• b.  "Decrease the oxygen back to 2lpm."
• c.  "Decrease the oxygen back to 2lpm and tell RT to quit messing with oxygen on my CO2 retainers."
• d.  "You guys did a good job.  Try to keep the sat 88-92 with the lowest oxygen possible.  Call me anytime."
• e.  All of the above except d because RTs are a bunch of useless dummies

Do we learn too much in RT school?

Your Question:  Is it common that the things we learn in RT school are not what we deal with once we start working?


My humble answer:  There's always going to be things we cover in RT school that we don't use in the real world.  Yet I think this is a good thing.  It's good because it helps you with critical thinking.  It's better to know the why and the how rather just that it is.  This additional wisdom is what separates the neb jockeys from the professional respiratory therapist.

Facebook
Twitter

What is genetic emphysema?

Other than smoking cigarettes, one of the most common ways a person can develop emphysema is by receiving bad genes from your parents.  If you inherit genes that cause alpha 1 antitrypson deficiency you most likely will develop emphysema.

While studying this condition I was surprised to learn that 200,000 people have been diagnosed with this condition, and this makes antitrypson 1 deficiency one of the most common hereditary disorders among Caucasians in the Western world, which includes Europe and the United States.  Yet it's believed many who have it are not diagnosed (1).

Alpha 1 Antitrypson is a protein that is produced by liver cells and circulates in the blood and generally effects the lungs and liver.  Elastase is a component of white blood cells used to kill invading bacteria and "neutralize invading particles inhaled into the lungs," according to National Jewish Health.

Once the job of elastase is complete, alpha 1 antitrypson inactivates elastase so that it does not destroy lung tissue.  In the absense of alpha 1 antitrypson, elastase destroys lung tissue and this results in genetic emphysema.  

Once a person has genetic emphysema diagnosis and treatment is the same as for any person with chronic obstructive pulmonary disease (COPD), and you can learn more by clicking here.  The only difference is there is a blood test to check for alpha 1 antitrypson and other blood test to check for the gene that causes this genetic disorder.

References:

1. Reuters
2. National Jewish Health

How passionate are you about your job?

A good morale is often the key to creating a good work environment.  The higher the morale of  each respiratory therapist the greater the customer service they provide.  Hence, the happier the RT the happier the customer will be.

One study suggests that worker morale is directly related to worker satisfaction.  Hence, study researchers might ask you which of the following describes your mood about your job.  Are you:

1. Passionate about your work?
2. Satisfied with your work? 
3. Engaged in your work?
4. Apathetic about your work?
5. Numb about your work?

Based on responses, studies showed the following:

1. 10-29% are passionate about their work; they are completely engaged
2. 60-80% are satisfied with their work but not engaged
3. 10-20% are disengaged; they just work to get a pay check

Disengaged workers feel there is no hope no matter what they do, so they just do what they are asked to do and that's it.  Disengaged workers tend to be apathetic, such as is the case with respiratory therapy apathy syndrome. 

To keep workers engaged, it's best to involve each member of the department in tasks.  Yes, that means that  you might be asked to do a certain task, such as teaching oxygen therapy to nurses, or becoming a Basic Life Support educator, or making a presentation at your local respiratory therapy conference. 

You also may be asked to write a protocol or hospital policy, or anything that keeps you engaged.  The catch here is that the RT Bosses must show that they are equally enthused about what you are working on, and work hard to both support and implement your ideas.  Without support, such efforts will simply result in continued apathy.

Another technique is to have you write a blog such as the RT Cave.  Surely you may have no control over your work, yet you will have control over your own projects. Knowing your work will provide you with ideas for your writing will give you an incentive to get up and go to work, and to smile while you're doing it.

The catch here, however, is you'll have to be careful what you write as to not compromise your contract with the institution you work for, and your promise to maintain patient confidentiality.  So you'll have to get creative, which is a good treatment for apathy.

The more you do, the more involved you are, the more you accomplish and feel respected, the greater your morale will be.  This has a direct impact on your satisfaction, and the happier you are the happier your customers (patients) will be. 

Another way to improve your satisfaction is for your boss to ensure you have the best benefit package possible, make sure you get an annual raise for inflation plus bonuses if possible, and to involve you in departmental decision making, and to heed your opinion.

It also helps to get praise.  It also helps to be listened to.  It also helps when you are respected when you make a recommendation.  It also helps when you have automony to use your experience and education to do what's best for the patient.

Yet doing all these things isn't always possible.  RT bosses get busy, and they get a lot of pressure from their bosses to mak your RT Cave look good on paper.  The end result is you may not get the results you want, and you become apathetic and disengaged.

So, how passionate are you about your job?

(see natural progression of satisfaction)
Facebook
Twitter

MCAT question #39

I cannot reveal my source, but I once again am privy to esoteric wisdom. The following is a question I have obtained from the Medical College Admission Exam (MCAT):


In 1960, based on a study of four COPD retainers, the hypoxic drive was formed.  Since then 300 studies have disproved this theory.  At what point are you to admit the medical profession is wrong to continue teaching this theory?

• a.  Never
• b.  Never in a blue moon
• c.  Never in a million years.
• d.  Never in a million years unless that hot CCU nurse decides to go on a date with you

What is a slug patient?

Have you seen this patient?

Slug:  These are patients who are originally bedridden because they are lazy and unwilling to care for themselves.  Yet ultimately they become dependent on the bed due to muscle fatigue.

Many are depressed, and most are obese and have a variety of maladies due to poor self care during their active years. They can be very demanding initially, yet as their body fades they will become completely dependent on you for all their needs, including butt wiping, rolling over in bed, scratching their faces, eating, drinking, and scratching their cheeks when they itch.

In the later stages you can do anything you want to them and they won't care, including putting the patient on a BiPAP mask or even ventilator.  Most will even become deconditioned to the pain of needles, and you can put IVs in them without as much as a wince.  You can draw labs and ABGs without much trouble from the patient, even though you'll often have trouble obtaining blood on the first poke due to poor circulation.

These patients are quite often full codes so you have to do everything possible to save them.  Yet even if they have DNR orders the doctor will insist that you get an ABG even if it's physiologically impossible to feel a pulse and you've already missed 22 times.

They most frequently come from nursing homes.  They can be very friendly early on, yet as their disease progresses they will only open their eyes and look at you and smile.  It's sad in a way as ultimately you watch as a nice patient fades away due to her own laziness.  However, most will not call her on it, not even her own doctor.

Most will also be ordered on aerosolized breathing treatments even though there is no evidence of bronchospasm and the patient never complains of dyspnea.  The reason for the treatment is of one of the following reasons:

• Doctors don't know what else to do and have to do something, so they order treatments
• Audible annoying wheeze due to dehydration 
• Audible annoying wheeze due to over hydration 
• Audible annoying wheeze due to secretions in throat
• Diminished lungsounds must be due to bronchospasm
• In order for the patient to meet criteria for admission and reimbursement
• To cover their bases (order sets)
• The patient was diagnosed with pneumonia even though the patient doesn't have pneumonia because pneumonia is a reimbursable diagnosis.  If patient has a lung diagnosis a bronchodilator must be ordered at all times at a minimum of every six hours.  
• The doctor wants the RT to assess the patient so he doesn't have to

As their body's slowly wade off they cease even watching TV, and simply spend their time either staring off into space or sleeping.  However, they do cheer up and become quite loquacious whenever one of their friends or family members enters the room.

Synonym:  A sluggish patient

Antonym:  The Spirited patient

Note:  This post is a generalization and not a description of any one particular patient.  If you work in a hospital or nursing home you will meet many patients who fit this vague description.  

What is bronchiectasis?

Bronchiectasis is a disease that causes the air passages (bronchioles) in the lungs to become abnormally widened or dilated and inflamed or swollen.  This makes it so the patient is unable to clear secretions from their lungs, these secretions become abnormally thick, and this creates a breeding ground for bacteria.

This is a condition commonly associated with cystic fibrosis patients as that disease progresses.  Usually these patients have to take prophylactic antibiotics to prevent pneumonia, and during exacerbations of their condition IV antibiotics are often required to fight off lung infections.

Exacerbations generally include the following symptoms:

• Cough
• Increased sputum production
• Sputum may be thick and chunky
• Sputum may contain blood
• Sputum may be colorful and putrid
• Short of breath (dyspnea)
• Wheezing
• Sinus infections (often resulting in sinusitis)

This condition is caused as the result of an infection, often early in life, that causes the lungs to become inflammed and this inflammation becomes permanant.  This causes permanant widening of the air passages and future exacerbations occur.  

Since cystic fibrosis patients are prone to have this secretions this makes them susceptible to lung infections, and this is believed to cause bronchiectasis. Each progressive lung infection can make the condition worse, and this is why early diagnosis and treatment is essential.  

While most cystic fibrosis patients have bronchiectasis, you don't have to have cystic fibrosis to have bronchiectasis.

It's usually the bronchiectasis component of cystic fibrosis that causes these patients to die at a young age.  Yet thanks to modern wisdom, better antibiotics and prophylactic care, these patients are now living into their 30s.

Some people do develop this condition later in life, and these patients are also able to live longer with the condition thanks to modern wisdom and better medicines available to treat this condition.

Usually you'll see these patients come to the hospital at least once a year for their yearly recharge.  Treatment usually consists mainly of:  

• Antibiotics to treat infection
• Bronchodilators to treat bronchospasm
• Mucus thinners to chop up thick secretions
• Chest physiotherapy to help bring up secretions
• Mucus clearance devices such as chest wall oscillators, Acapella and flutter valves
• Underlying condition should also be treated.

Besides cystic fibrosis, there are other conditions that can cause bronchiectasis, including:

• Viral infections
• Bacterial infections
• Tuberculosis
• Fungal infections
• Immune deficiencies (make person more susceptible to lung infections)
• Aspiration (GERD, oralpharyngeal dysphagia)
• Rheumatoid arthritis
• Lupus
• Primary ciliary dyyskinesia
• Alpha 1 antitrypson deficiency
• Lung tumors
• COPD

Diagnosis may involve a patient assessment, medical history, cat scan of the lungs, and pulmonary function testing, and consideration of any underlying medical conditions such as listed above.  

References:

National Jewish Health

Facebook
Twitter

How can I manage asthma around smoke?

The following Q and A sequence is from healthcentral.com/asthma:

Your question:  How can I manage asthma around smoke?  I am currently having trouble managing my asthma because of the brush fires that are around my neighborhood. Do you have any advice for management when there is a trigger you cant control?

My humble answer:  That's one of the things that's kind of crappy about having asthma:  there are certain things beyond your control.  It's not like you can walk up to all your neighbors and tell them all to stop burning wood.  The same can be said of backyard campfires and bar b ques. 

The same can also be said of allergens.  You can close all your windows and sit in a hot and stuffy house if you want, but tree, grass and ragweed pollen still have a way of getting indoors.  And no matter what you do, you'll have to go outdoors at some point. 

At least for allergies there's a few medicinal options that aren't avaiable to prevent smoke induced asthma

Of course another option may be to move to a neighborhood that bans brush fires, camp fires and the like.  However, from my own personal experience, such asthma triggers will find you no matter where you live. 

The best advice I can give is to try to stay indoors as best you can on days the air is filled with smoke.  The only other really good option is to continue to do what you've already been doing, and that's work with your doctor to obtain good asthma control.  

Facebook

Twitter

Does McDonalds trigger asthma?

The following post was originally published at healthcentral.com/asthma on May 16, 2011:

"Can eating high fat foods trigger asthma?"

American's love Big Macs, Whoppers, French fries, onion rings and deep fried chicken.  These are convenient foods that are simply delicious.  Yet the old saying goes, "If it tastes good, it's probably not good for you."

Now we already knew such high-fat foods are bad for your heart.  Yet new evidence suggests they may also be bad for your lungs.

A study completed by Australian researchers in 2010 tested asthmatics before and after eating a meal, and determined that lung function was worse after eating a high-fat meal.

If that wasn't bad enough, the study also concluded that high-fat foods also made it so asthma rescue medicine (like Albuterol) worked less well.

Scientists aren't sure why this is, yet there are theories.  One theory suggests that your asthmatic immune system might recognize saturated fat as an enemy and promptly acts to rid it from your system.

This response results in an increase in markers of inflammation such as leukotrienes and hystamine, and these increase inflammation in your respiratory tract.  This causes muscles lining your air passages to constrict, and thus an asthma attack is the result.

Perhaps due to the increased inflammation, asthmatics who used their rescue medicine after eating a high-fat meal did not get as much relief as those who ate low-fat meals.   Likewise, lung function improved less in subjects who used their rescue medicine after eating high-fat meals.

Obviously asthma rates have increased incrementally in the U.S. and other western nations over the past 20 years.  This new theory suggests one of the factors might be the high-fat foods we put into our bodies.

I've also read other studies that suggest that if you're exposed to something that triggers inflammation in your lungs, and exposed to it often enough, the inflammation may become permanent.  Thus, asthma is developed.

It's studies like this that remind us that the way we eat may determine the lives we live.  If you want to prevent asthma, or prevent an asthma flare, it may be a good idea to eat a healthy diet.

Does that mean we asthmatics should never eat great tasting, convenient and high-fat foods?  Absolutely not.  Yet it's good to know the facts, and it's good to know what foods might not be good for us.

The natural progression of satisfaction

I remember way back before I was hired as an RT, back when I had a new job every summer.  I remember observing how the people who worked for five or more years tended to be apathetic and disengaged from their work.  These people spent a lot of time complaining. 

I saw the same thing when I was hired as an RT.  My coworkers acted like they hated their work.  They often complained and were slow to get up when their pagers went off.  I didn't understand this because I was absolutely passionate about my work.  I even remember thinking once I loved my job so much I could work every day.

What I observed was what is referred to as the natural progression of satisfaction.  Most of the people who complained, I observed, were those who had worked for over five years of the same job, doing the same tasks, caring for the same customers. 

Those who were the happiest were those who were new on the job -- like myself.  Little did I know my own satisfaction would remain high for a while, yet it too would slowly dissipate.  Yes, I too became infatuated with apathy and I too became disengaged in my work.

This disengagement results in a reduction in the quality of your work.  It's something bosses want to reduce, and therefore it's been studied by experts. 

When we first get a job there is a new excitement.  We are learning new tasks and we are excited as we get better and faster at it.  We feel as though what we do matters, and the better we are at it the more satisfied we become.  The quality of our work is high.  Our customers are satisfied with our work.

Yet then time happens.  What was once challenging now becomes a redundant procedure.  You become educated and learn some of what you do isn't needed.  You learn shortcuts that make the job easier, and you start to simplify your speech so each customer hears the same things from you.  Instead of treating each customer unique, you treat them all the same.  You, in essence, become an automaton.

What happens is your job becomes routine.  Routines result in shortcuts.  Short cuts cause quality to be diminished.  Instead of feeling the need to run to a code you walk.  You are relaxed when you should feel an adrenaline rush.  When a sense of urgency is replaced by routine this is akin to working in a factory spending the entire day wrapping paper around cigarettes.

Think back to when you first got your job as an RT.  When your pager went off you were eager to see what your message was.  You rushed to complete the job, and you were eager to provide your services.  When you were done you were eager to discuss what you did with your coworkers.  You cared about your work.  You were proud.

Then over time, after learning that many of the patients you care for don't even need to be in the hospital, after realizing most doctors have no clue what a bronchodilator does, and after realizing most nurses want breathing treatments for all dyspnea, the thrill of your job wears out.  You start working just so you can get a day off.  When you do work you can't wait till the end of the day.

We still care about our patients, yet much of our concentration has shifted from what we can do to benefit our patients to just doing your job as fast as you can so you can get back to your game on the Internet.  You are good at what you do, and too good.  The task has become routine.  You take shortcuts, and the quality of your work diminishes.

Many RT bosses have no clue about the natural progression of satisfaction.  Many know about it because they were RTs once too, yet because they are now above it they don't care.  Others learn about it and work hard to try to prevent it.  They want to prevent it because they want quality to remain high. 

Quality comes from pride. So the goal here is to keep RTs proud of their jobs.  This reminds me of a recent encounter I had with my boss.  I was called to assess a patient who had aspirated and was now short of breath, and I advised the nurse that a breathing treatment wouldn't be of any use.

Regardless of my recommendation, 20 minutes later my pager went off with the message:  "Breathing treatment needed on that patient STAT!"  My boss happened to be standing next to me when my pager went off, and I said, "Sometimes instead of thinking nurses just order breathing treatments."

"You should be proud of your job," my boss said.  "You should want to do things you're asked to do."

I said, "I would be proud if my recommendations were respected.  When I recommend one thing and the nurse completely ignores what I recommend, that makes me not proud.  It makes me feel disconnected.  It makes me feel that I don't matter."

So what can my boss do to keep RTs proud of their work?  I think the simplest thing to do is to listen to what we say, and respect what we recommend.  We all spent two years in RT school to become experts on the lungs and how to treat respiratory diseases.  We spend every working day with respiratory patients developing skills. 

I think all that is needed to make an RT proud is to respect us.  All we want is to be treated like the professionals we are.

Facebook
Twitter

MCAT question #40

I cannot reveal my source, but I once again am privy to esoteric wisdom. The following is a question I have obtained from the Medical College Admission Exam (MCAT):


Which is the following cases presents the best example of the hypoxic drive theory:

• a. COPD retainer on 100% FiO2 for six hours in the ER to maintain an SpO2 of 90%. The patient is AAOX3 and denies shortness of breath.
• b.  COPD retainer on 2lpm to maintain an SpO2 of 86%.  The patient is cyanotic and complains of dyspnea.
• c.  The patient is on 35% air entrainment mask to maintain an SpO2 of 86.  The CO2 rose from 56-62 after the mask was placed on the patient.  The doctor instructs the RT to decrease the FiO2 on the mask to 30%
• d.  All of the above
• e.  Both b and c

What do RTs really do?

The American Association for Respiratory Care (AARC) lists the following tasks that respiratory therapists do:.

• Diagnosing lung and breathing disorders and recommending treatment methods.

• Interviewing patients and doing chest physical exams to determine what kind of therapy is best for their condition. 

• Consulting with physicians to recommend a change in therapy, based on your evaluation of the patient.   

• Analyzing breath, tissue, and blood specimens to determine levels of oxygen and other gases.

• Managing ventilators and artificial airway devices for patients who can’t breathe normally on their own.

• Responding to Code Blue or other urgent calls for care.

This list is an ideal list of the tasks RTs do.  For all you RTs out there in the real world, how accurate do you think this list is?  Does this paint an accurate picture to prospective RT students? 

Based on your responses I will update this list so that it is accurate if necessary.  So what do you think?

Facebook
Twitter

Placebo Effect: Misinterpreted Study Proves It

Once again, folks, we have a medical study misenterpreted by the so called experts.  They are now said to have proven "inhaling Albuterol helps asthmatic lungs work better, yet patients who get it don't feel much better than those treated with a placebo inhaler."  That's the results of a study, and they have totally blown it.

Thankfully you have me to give you guys an accurate analysis of these study results, because they show something the researchers have completely missed.

Let me put it this way.  Since I started this blog I've been telling you that doctors think that all pulmonary diseases should be treated as asthma.  They think all dyspnea, regardless of the cause, should be treated as asthma.  They think all dyspnea, regardless of the cause, can be treated with albuterol.  

So you have a patient come into the emergency room with dyspnea and wheezing, and the doctor automatically orders up an Albuterol breathing treatment.  Upon your pre and post treatment assessment the patient neither looks better nor worse, yet then you pose the question:  "Do you feel better?"  The answer is almost always a resounding, "Yes!  I do feel better."  Yet you often wonder:  Is the patient accurate?"

My theory has always been that many patients say they feel better when they actually don't.  In fact, many times a patient will say something like, "Yeah, my breathing is better.  My nose isn't as stuffed as it was before the treatment."  Of course then you know the treatment only had a perceived effect.  

A study was done recently and reported in the New England Journal of Medicine that studied the perceived benefits of Albuterol on subjects, half that were given actual Albuterol and half that were given a placebo.  A good review of this study was written by Reuters "Treatment, not medicine, helps asthma patients feel better: study."  

The test was only done on a small sample of 39 mild to moderate asthmatics.  Of those who received Albuterol, 50 percent reported improvement.  Of those who received a placebo, 50 percent reported improvement.

Thus, the researchers conclusion, as the headline to the Reuters post suggests, is that of the placebo effect, whereby just the mere presence of a medical care worker is all that's needed to help asthmatics feel better. They conclude that the presence of a doctor -- or in this case the RT -- is just as beneficial as acupuncture. In this case, the medicine is Palbuterol. 

Yet I think the researchers have totally blown these results.  I think these results tell a completely different story than the researchers are telling us, and this is not surprising.  I think the conclusion we should be drawing from this study is that patients have no clue whether or not they feel better.  I think these asthmatics only had a perceived benefit from Albuterol.  I think what these results tell us is the patient is unreliable.

This goes back to common asthma wisdom that says that the only true way to determine if an Albuterol nebulizer has improved lung function is to either do a pre and post pulmonary function test or to have the patient use a peak flow meter.  To go by what the patient says isn't enough.

Obviously if you have an asthmatic who is short of breath and the Albuterol provides instant relief in breathing then the patient is going to be accurate when he says, "I feel better."  Yet if the patient's dyspnea and wheezing is caused by a cold, or heart failure, or pneumonia, or kidney failure, or lung cancer, or rickets, the Albuterol will have no effect, and yet the patient will feel the placebo effect. 

As to be expected, the researchers got it all wrong. Yet your humble RT here is once again proven right. I've written before that Albuterol should be renamed Palbuterol because the medicine may not have any effect, but the presence of an RT will.

This is interesting to say the least.  We know that albuterol really does make breathing easier in patients who are having actual bronchospasm.  However, evidence also suggests that giving albuterol to anyone who is short of breath may produce the placebo response.  So now you know why doctors treat all pulmonary diseases as asthma.

Once again the results of a study are misinterpreted.  Thankfully your humble RT is on the job because these study results prove that Albuterol doesn't cure all dyspnea and wheezing.

Advair Diskus versus Advair HFA

Your Question:  The Dr. told me that there is now an arosol puffer for advair now. Can you tell me about it, please?

My humble answer:   We have covered this topic to some extent, and you can read more here.  Of the studies done so far regarding the new HFA propellant, it appears it takes the medicine deeper into the lungs than the old CFC propellent and the dry powdered version of inhalers.  While studies are ongoing, and so the debate is ongoing, some asthma experts recommend switching to the HFA version of a medicine if you continue to have trouble with your asthma. Personally, I'd recommend trying the DPI first if you have uncontrolled mild-moderate asthma, and then if that doesn't work try the HFA version.

Yet the main reason for making an HFA inhaler, I think,  is to provide another option for asthmatics who have trouble generating enough flow to suck in the medicine using a Dry Powder Inhaler.  With the HFA inhaler you squirt the device and the flow is automatically generated, and all you have to do is inhaler.  
Regardless, studies seem to show the medicine is at least equally as effective as the Advair Diskuss and is another option for us asthmatics to try.  For more information regarding the Advair HFA check out this link.  

What happens when asthma goes untreated?

The following post was originally published at Healthcentral/ asthma on May 3, 2011:

What Other Medical Problems Can Occur When Asthma is Untreated?

It's said a gallant asthmatics can live a normal, active life.  Yet what happens to the goofus asthmatic who doesn't treat his asthma?  

The truth is, many goofus asthmatics are lucky and are able to escape without asthma trouble, yet far too often they end up making frequent visits to their doctor, or to the local emergency room for asthma flares.  Sometimes they simply stay home and tough it out like our Martyr Asthmatic.

While it's rare, untreated asthma can lead to serious medical problems that can make asthma even harder to control.  Consider the following worse case scenario.

Joe Goofus refuses to see his doctor, and he is too dog-gone lazy to take his Advair discus, or maybe he simply forgets to take his medicine.  He also refuses to avoid his asthma triggers. He's simply a bad asthmatic patient.

So after sifting through dusty boxes in his basement, he makes yet another rushed trip to the emergency room.  His asthma is so bad this time that he needs to be admitted to the hospital.  He's put on systemic corticosteroids.

Finally after a couple weeks in prison he's released on good behavior, and he once again quits taking his asthma medicine.  He's short of breath for two weeks before he finally decides to seek help. 

He's readmitted to the hospital and put back on inhaled corticosteroids.  The cycle continues.

The following are the risks of untreated asthma:

1.  Severe Asthma:  Asthma that is not diagnosed and treated agressively with asthma controller medicines can increase the risk for lung scarring.  This is permanent damage to your lungs that can make you always feel short of breath.  It also makes it so your asthma might not be reversible when you use your rescue medicine (Ventolin or Xopenex).  This type of asthma is called severe, persistent asthma, Chronic Obstructive Pulmonary Disease (COPD) or what I like to call hard luck asthma. 

2.  Steroid side effects:  If Joe needs systemic corticosteroids long term to control his asthma, serious side effects can occur that can make it even harder to manage his asthma, such as:

• Fluid retention:  Swelling in your legs
• Increased blood pressure
• Mood swings:  Can effect how you manage your asthma
• Weight gain:  Chemicals released from fat can trigger asthma, plus obesity makes it even harder for you to get the exercise you need to manage your asthma, and keep your heart and lungs strong
• High blood sugar:  You'll now have diabetes that needs to be controlled
• Infections:  Can you imagine if you also developed pneumonia?
• Thin skin:  It easily bruises and is slow to heal. 

3.  Anxiety/ stress/ depression:  These can make it even more difficult for Joe to manage his disease, although treatable. 

4.  Muscle wasting:  His lungs become so bad he's unable to get the exercise he needs. This can greatly complicate caring for Joe.  It can lead to obesity, which complicates things even 

5.  Respiratory Failure:  If Joe doesn't seek help, his asthma attack might get so bad he simply poops out.  This is a serious complication that must be treated immediately.  It can lead to death.

While what I describe here is the worse case scenario, I've seen it.  It's basically self-induced hardluck asthma.  It's not pretty.  It can also be avoided. 

It's much better to be a gallant asthmatic.  It's much better to be properly diagnosed and stay on a treatment plan. 

Asthma experts have long said asthma is easiest to control when it's diagnosed right away and treated aggressively.  Now you know why.

Facebook

Twitter

The consequences of thought

Quite often -- too often -- the process of thought gets us into more trouble than it's worth.  Thought often results in judging.  If you don't judge, then you'll be forced to accept the status quo.  Yet if you judge you'll be judged in return as mean.  So what do you do?

We RTs often "think" treatments are of no use.  We are ordered to do one on a patient with an audible wheeze yet no shortness of breath, and we "think" to explain to the nurse why the treatment isn't needed.  The process is like trying to drum a nail into a brick.  By the time you're done you could have already been done with the treatment and back in the RT Cave.

Progress, thought, is never made without some form of thought, and then the reacting to that thought.  Without thought we'd have no cars, no assembly line, no electric light bulb, no Ventolin.

Yet if everyone reacted to every thought ("boy, does she have ugly hair today!") peace and tranquility would be hard to keep.  So some thoughts are best kept secret.  If you don't believe me, just ask the person who can read minds.  He went insane.

Thought can be good, and for proof just read about Ben Franklin, Thomas Edison, Henry Ford, Einstein, and Stephen King.

Yet thought can also get you into trouble.  For example, I thought it was a good idea to talk to my boss about all the "useless" holter monitors that were being ordered in the ER.  I thought it was a good idea to tell him holters are not an emergency procedure and shouldn't be ordered in the ER.

Yet, lo and behold, my thought got me into trouble.  Instead of telling doctors that holter monitors were no longer to be ordered in the ER, our boss ordered 4500 new holter monitors to make sure we have enough to cover all the new holter monitor orders.  Never again will we be able to get out of work by telling ER we don't have any holter monitors. 

My thought got us into a heap of more work.  In this way, it's often better to shut up and put up with than to think.  It's better to think yet muzzle your mouth.  It's better to do and shut up.  It's better to just do the dog gone treatment than bitch and wine and educate.  Yes, it's better to shut up thought than to teach facts -- sometimes. 

I think through the course of life this is a lesson we all learn at some point or another. Yet the ones who ignore this lesson are the ones who are your inventors, your protocol creators.

You know what thought did.  Thought believed he was on the pot when he peed in his bed.  That's what thought did.  Thought got him in trouble.

Thought could get you fired.  Thought can get you a raise, thought can get you rich, yet thought can also get you fired.

So you thought it was a good idea to write a blog being honest about the profession of RT, yet if your boss ever finds out you could be fired.  To heck with the first amendment.  To heck with all the people who yearn to learn the truth.  To heck with them all.  Who cares about what's needed.  Bah humbug on need. 

Facebook
Twitter

ISO bans use to RT cheat sheets to improve quality

Would you believe I was told by my boss I can no longer carry with me a cheat sheet in my pocket.  I was stunned, and I decided I was still going to carry it with me and just not tell my boss.  It's this type of lying that's been deemed necessary by the International Commission of Idiocy.

According to my boss I can carry cheat sheets with me, but only ones that are officially approved by the powers that be.  You can carry a book like "Dana Oach's Practitioners Pocket Guide to Respiratory Care," but who wants to carry an entire book around with them?  Not me.

(Here's my cheat sheets)

So a few years ago I created a cheat sheet of my own, shrunk it down to size, and carry it with me in my pocket.  I even created a key to help me decide what tidal volume is best for which patients.  Doctors love it so much they even request to see it often, and my coworkers all have one of their own.

The issue that I have is one day recently I updated my cheat sheet and set it out because one of my coworkers and I were trying to decide what color paper would work best.  My boss came out and said, "What you guys up to?'

It's not like we could lie, or felt we needed to.  I said, "We're deciding what color my cheat sheets should be."

"Oh," he said, and picked one up.  "This is some useful information.  I would have loved to have one of these when I was an RT."

"Then take one," I said.  "Or when we get these laminated you can have one."

He paused a moment, as though mulling it over, then said, "Well, you can't use these, you know."

He was joking of course, right?  I thought.  Then I said, "You're joking, right?"

"No.  ISO has a policy that only sheets approved by the forms committee can be used or in possession of any person who is working?"

"Why would they come up with such a stupid policy?" my coworker said.

"Because," my boss answered, "they wanted to improve quality.  This is a quality improvement polity.  If the hospital is sued because you used information on your cheat sheet, and what's on your cheat sheet is not approved by the hospital, you could be in trouble."

"Yes," I said, "but if the patient died because I relied on my memory to set a too high tidal volume on, say, a neonate, then we will all be sued and a baby will be dead.  So my cheat sheet is made to prevent such a thing from happening. My cheat sheet is made to prevent idiocy.  So by ISO telling me I can't carry my cheat sheet to improve quality may have a reverse effect:  It may create idiocy."

"In other words," my coworker said, "It's poppycock."

As it turned out, my boss could not get my cheat sheets approved by the forms committee because many of the formulas and calculators that I created and used are ones that I made up myself or found useful from other therapists.  Many aren't in Dana Oach's book.

So this is a perfect example of what would never happen if I were running the hospital, and it goes against rule #2:  Try something new. Often. Keep whatever works.  You can view my keys a successful RT Cave here.  You can view the old version of my cheat sheets here.  I hope to have the new one up soon (yet don't show your boss).  

MCAT question #41

I cannot reveal my source, but I once again am privy to esoteric wisdom. The following is a question I have obtained from the Medical College Admission Exam (MCAT):

A nurse calls and says the patient in room 234 doesn't look good.  You say, "Why are you calling me at 2 a.m.  Two hours later the nurse calls and says, "The patient died because you didn't do anything."  What do you do next?

• a.  Run to the corner market and grab a bottle of scotch
• b.  Drive to the liquor store and purchase a bottle of whisky and a 2 liter of coke.
• c.  Drink the 30 pack of Natural Ice in your refrigerator
• d.  Take a hit of the joint stuffed in your glove compartment
• e.  Be a man and admit you made a mistake.
• f.  a, b, c, d but not e because we doctors never admit mistakes.

The Tobacco Atlas: Smoking causes preventable deaths

RTmagazine.com, "Globally, Tobacco-related Deaths Have Nearly Tripled Since 2002,"  reports on the latest tobacco statistics mentioned in the latest, and 4th, edition of The Tobacco Atlas.  The following is the latest wisdom:

1.  Tobacco is responsible for 15% of male deaths worldwide

2.  Tobacco is responsible for 7 of female deaths worldwide

3.  Tobacco is a risk factor for the four leading causes of death

• Cancer 
• Heart Disease
• Diabetes
• COPD

It's interesting anyway.  According to the article, the Tobacco Atlas is a book that documents the facts about smoking, and how the smoking industry is marketing a product that causes preventable deaths.  

To read more check out the links above.