What is a medical train wreck?

So, we in the medical profession often refer to some patients as train wrecks.  The official term here is "Medical Train Wreck," although we Americans are good at shortening longer words that take too long to say, which is why some of us refer to them as MTWs.

That in mind, We figured we would officially define the term for our Faux Lexicon.

Word:  Train Wreck

Definition.  A person with greater than ten co-morbidities; treatment of one condition may exacerbate another condition

"The patient might be here forever, she is a medical train wreck."

Example #1:  A patient with heart failure, COPD, small bowel obstruction, hypertension,, CVA, myocardial infarction, chest pain, renal failure, sepsis, etc.  Surgery to repair the small bowel obstruction will probably require high doses of fluid; Due to bad lungs the anesthesiologist will refuse to extubate the patient, who will now be moved to intensive care.  The patient will be treated as exacerbation of COPD for three days until the physician realizes heart failure is the actual diagnosis. In the mean time the patient develops sepsis, pulmonary edema, and dyspnea.  Because the pulmonary edema causes an upper airway audible rhonchi, the episode may continue to be confused as bronchospasm, thus requiring a stat bronchodilator. You see, one thing leads to another.  These patients are train wrecks.

Example #2:  COPD, CHF, Diabetic, dementia, kidney failure, rib fracture from falling due to hyponatremia.  This patient has a GI bleed and is given blood, which causes pulmonary edema, which is treated with lasix, which exacerbates the hyponatremia; the patient is given an incentive spirometer, but you can't teach it to the patient due to dementia and the fact the patient is still on a ventilator due to the fact the patient was too sick to be extubated in the Operating Room.  The patient then develops pneumonia, and when the patient is extubated she has a forced expiratory upper airway rhonchi-ish wheeze that is mistaken by the physician for bronchospasm requiring Q4ever breathing treatments. This, in essence, is a medical train wreck.

Urban Dictionary Definition

Trainwreck:  A total f#@#ing disaster ...the kind that makes you want to shake your head.

The people at the party were so wack...it was a train wreck.

Trainwreck:  A person or situation that can't escape an inevitable bad outcome; hence, a trainwreck.

"The woman can't ever get a good man, a good job, or education. Her life sucks. She is a trainwreck!"

"The patient may never be extubated, she is a trainwreck

Trainwreck:  A name used to describe a clumsy, dangerous respiratory therapist or nurse. This person will damage things and hurt people (on accident or on purpose). They also take things too far. Rumors are also spreading about a trainwreck virus that causes these symptoms.  Ventolin is suspected as being the antiviral required to reverse Trainwreck-ism, and it will probably be recommended Q4 while in the hospital, and QID once released to home.  Some doctors catch this disease, although most are immune due to surreptitious knowledge obtained from medical school (perhaps they take ventolin at home).  

Definitions to be added to our lexicons

BDCHF = BiPAP Deferred Congested Heart Failure. BiPAP will prevent fluid from entering the lungs. Indicated for patients with poor kidney function who require large fluid boluses (i.e. for low blood pressure). A bonus is the BiPAP might cause the anxiety needed to raise blood pressure. Note: Ignore silly RT rants about BiPAP decreasing venous return and possibly lowering blood pressure).

DCHF = Deferred Congested Heart Failure. The patient was wet when admitted, but the doctor won't figure it out until the patient has been treated with bronchodilators for three days.

Diagnosis: PACHF = Physician Induced Congested Heart Failure.

Float away:  Pulmicort/ Albuterol dilate airways so foam pneumonia just floats away.

Nosocomial COPD. A fake diagnoses in order to meet criteria for reimbursement.  Requires Q4 breathing treatments regardless that patient is breathing normal and has clear lung sounds. 

Nosocomial CHF.  a.  Fluid overloading patients who don't look quite right but need to be admitted.  b. loading patients with fluid during surgery and sending them up to the floor claiming they are fine.

Schnockered:  Drug induced sleep

The Four Types of Pneumonia

A 1930 edition of the Real Physician's Creed.
It's now so huge it's non-photogenic.

In medical school, most physicians learn from the Real Physician's Creed, which by now is about 300,000 pages and still growing. I only found out about it because one physician is a friend of mine who used to be a respiratory therapist. But he is now retired, so he has given me permission to release some of the contents thereof.

On page 304,403, of edition 4,432, is a note describing the three types of pneumonia.  Listed they are as follows:

1.  Walking Pneumonia:  Don't have it but something must be ordered to make everyone happy.  

2.  Pneumonia.  They really have it and you can see it on the x-ray and everything.  Or, as noted, sometimes you can hear it via crackles before you can see it on x-ray.  Or, the white blood count is elevated, indicating there is an infection somewhere so it might be pneumonia.  It is generally lobal and caused by a bacteria. Treatment is antibioitic to treat the infection and systemic corticosteroids to treat the inflammation.  However, you may also treat it with ventolin because one study showed it enhances sputum production which, uh, somehow is twisted into making some doctors think it... well, it does help, errr, bring up the pneumonia... IT JUST DOES!!!

3.  Faux-pneumonia.  The patient doesn't have it, but you need a better diagnosis than walking pneumonia in order so that the patient may meet criteria.  You can see it on the x-ray only if you have the superior vision abilities only taught in medical school, which can be found on page 3,133 of the Creed.  (I at present do not have a copy of that page, as this part of the book I have has been destroyed by too many coffee stains).

4.  Double Pneumonia.  They have twice as much pneumonia than the average person who actually has a diagnosis of pneumonia, which some call real pneumonia as compared with faux pneumonia.  It is generally caused by a virus and is deadlier than regular pneumonia.  Treatment is to hit it with everything, including systemic corticosteroids to treat inflammation, antibiotic to treat the infection, ventolin to help the patient cough up the pneumonia, and anything else you feel like throwing at it. Usually it involves treating the symptoms.  Treatment is generally supportive.

Further reading:

1. The real physician's creed
2. 999 types of ventolin

Two types of lung sounds

Lung sounds are generally broken down into two types:

1. Quantitative:  How much air movement is there? Normal (can hear air movement), diminisshed (can't hear much), absent (barely moving air)
2. Qualitative:  How is it moving?  Is it moving through secretions (rhonchi), through junk in lungs (such as a tumor or object), or through obstruction (wheeze)

Pulmonary Toilet Lexicon

Bronchial Pulmonary Hygeine: Use of a variety of procedures and medicines to try to help the patient expectorate thick secretions, or to help losen secretions from the bronchioles to the upper airways so the patient can more easily spit it up.  The goal is enhance secretion clearance to help prevent lung infections, enhance ventilation, improve pulmonary function and gas exchange.

Expectorate:  To spit up

Pulmonary Toilet: It's a generic term to describe any effort, medicinal or other, to help loosen or break up thick secretions that are causing respiratory distress, to help bring secretions to the upper airway so they can be either swallowed or expectorated.  The most common therapies here are albuterol and mucomyst nebulizer treatments, followed by either use of flutter valve or postural drainage and chest percussion.

Who needs it?  The patient feels like they have something to cough up, but are unable to generate enough flow to expectorate it.  Rhonchi is a common lung sound heard upon auscultation.

What are Indications for Pulmonary hygiene or toilet?

• Thick secretions (may be heard in large airways by auscultation (rhonchi)
• Retention of secretions
• Difficulty clearing the airway (trouble getting phlegm up)
• Artificial airways (intubation or tracheotomy)
• Atelectasis caused by mucus plug or obstruction
• Conditions that increase amount and thickness of secretions (COPD, Cystic fibrosis, asthma)

Rhonchi.  This is the sound of air moving through large airways.  It is commonly described as coarse. Sometimes it is mistaken for a wheeze, especially as it resonates throughout the lung fields. Sometimes it may present as a forced, expiratory wheeze, and may even be audible.

What does the pulmonary toilet involve? 

Bronchodilator.  Inhaling this medicine will help to open up air passages, releasing trapped secretions so they may be expectorated.  The most common medicine is albuterol, although  xopenex may also be prescribed.

Mucolytic: Inhaling these medicines will help to break up secretions so they may be expectorated.  It makes phlegm more liquid and easier to spit up. This medicine may cause bronchospasm, so it should always be given with a bronchodilator. The most common medicine used in the hospital setting is Mucomyst (acetylcysteine). Pulmoyme (dornase alfa) is commonly prescribed for cystic fibrosis patients.  Other mucolytics may include ambroxel, carbocisteine, and erdosteine.

Chest physiotherapy (CPT): This describes the various techniques a therapist might use in order to help knock thick secretions loose so they may be more easily expectorated.  Procedures may include chest percussion, mechanical percussors, postural drainage, PEP valves, and flutter valves.  Ideally, CPD should be performed prior to meals, or 60-90 minutes after meals.  If the patient is on pain management, it should be performed 30-60 minutes after pain medicines are given.

Chest Percussion: A therapist uses cupped hands and applies rythmic clapping on a patient's chest in order to break up secretions so they can be more easily expectorated.  It may be performed over the entire chest, although is more commonly performed only over the infected area.

Vibration: This is where you put one hand over the other over the infected area and generate vibrations during expiration to help loosen secretions. This is generally done after percussion, and particularly for patients with thick and copious secretions.

Mechanical Percussor

Mechanical Percussor:  Due to the trauma that may be caused by CPT, mechanical percussors are thought to accomplish the same goal as CPT. Constant vibrations from the device are thought to break up thick secretions so they may be more easily expectorated.

Postural Drainage.  This is using gravity to aid in draining secretions from various areas of the lungs.

• Postural drainage and CPT or mechanical percussors are often used in tandem to enhance secretion removal
• Ideally, the infected side should be up to allow gravity to enhance movement of secretions to trachea to enhance removal.  
• After postural drainage is complete, the infected side should be down so that secretions do not drain into good areas of the lungs to make breathing more difficult.  If a patient's SpO2 suddenly drops, this is something that might be considered.  
• To learn more check out the AARC Clinical Practice Guidelines. 

Positive Expiratory Pressure (PEP) valves:  These are small, hand-held devices that a patient exhales into.  A positive pressure is thought to enhance secretion production and prevent and treat atelectasis.

Flutter Valves:  The most common one is referred to as an Accapella Flutter Valve.  It combines PEP therapy with gentle vibrations.  The small, hand-held device consists of a mouthpiece connected to a cylinder in which a stainless steel ball rests in a cone shaped valve. The patient exhales through the cylinder and causes the ball to move up and down during the exhalation. The effect is threefold

1. Vibrate the airways to facilitate movement of mucus
2. Increase endobronchial pressure to avoid air trapping
3. Accelerate expiratory airflow to facilitate the upward movement of mucus.

Many hospitals are now using these instead of the more invasive chest percussion and postural drainage. Although, sometimes a combination of the two are used.  Just about any alert patient can do this regardless of lung capacity. It takes about half the time of CPT and postural drainage.

Suction: This involves using negative pressure to suck secretions from the airway.  

• Upper Airway:  A common device for suctioning the upper airway is a Yankaur. It helps facilitate secretion removal of upper airway, and is similar to devices used in dentist offices.  
• Lower Airway.  Various suction catheters may be inserted through the mouth, or one of the nostrils, into the large airway (usually to just above the corina).  Negative pressure helps suck secretions blocking the airways.  This is generally referred to as deep tracheal suctioning. It should rarely be performed on an awake and alert patient.  It is most commonly performed on a patient who is intubated.  
• Suction pressure: This is usually determined as follows:
• Adults = -100 to -120 Hg
• Children = -80 to -100 Hg
• Infants = -60 to -80 Hg
• Catheter Size: A common formula for choosing the ideal suction catheter for a patient who is intubated:
• Double the internal diameter (ID) of the endotracheal tube (ETT) and multiply by 2, then use the next smallest catheter size. For example, if the patient has a size 8 ID ETT, 8*2=16 or a size 14 suction catheter.

Yankaur: As noted above, this is a device that fits into the patient's mouth, and can be used to suction secretions in the mouth to the back of their throat. This is generally considered to be non-invasive.

Deep tracheal suction: As noted above, this involves inserting a catheter beyond the trachea to just above the corina.  Ideally, a catheter should never touch the corina in order to prevent trauma.  Also, this procedure should never be performed on a non-intubated patient who is awake and alert, as it is considered extremely traumatic.  It should be performed as needed on intubated and trached patients in order to clear the airways of secretions.  It's ideal for generating a sterile sputum sample for analysis.

Closes suction system: The most common one used is called a Ballard. This is used on intubated patients so you don't have to break the circuit to suction the airway. This prevents loss of PEEP and reduces risk of Ventilator Acquired Pneumonia.

Incentive Spirometer:   During normal breathing, people sigh 3-5 times per hour.  This is a natural mechanism to clear secretions from airway to prevent pneumonia and alveolar recruitment to prevent atelectasis.  This natural mechanism is blunted due to pain from abdominal or chest operations.  It is also blunted due to pain medicine.  Ten inhalations per hour using an incentive spirometer is meant to encourage secretion removal and alveolar recruitment.  Volume spirometers provide some resistance to inhalation, and allow therapists to monitor a patient's progress. It is usually followed by cough and deep breathing exercises.

Cough and deep breathing exercises: A patient should be encouraged to take in a deep breath to fill the lungs with air, and then to cough.  This is yet another means of enhancing secretion clearance and alveolar recruitment.

Abdominal Thrust: This is performed only on quadraplegic patients. This is where you push in and up on the abdomin to force up the diaphragn to facilitate a cough. You'll need to do this in sync with the patient.  I find that the best teachers of this procedure are the patients themselves.

Mechanical Insufflation-Exsufflation: It's a machine that alternates positive and negative pressure to the airway to help increase expiratory flows and remove secretions. It's a non-invasive procedure that can be performed with a mouthpiece or mask for spontaneously breathing patients, or with an adapter to an artificial airway. It's usually used with patients with neuromuscular disorders.

When should pulmonary hygiene be discontinued?

• Improvement in chest x-ray
• Improved vital signs
• Improved oxygenation (monitored by pulse oximetry or ABG)
• Less demand for oxygen (less supplemental oxygen required, lower FiO2s)
• Sputum production (patient coughing up sputum without assistance)
• Auscultation (improved lung sounds)
• The patient can generate an effective spontaneous cough

Originally published on 5/20/09 on respiratorytherapycave.blogspot.com; Edited and updated for accuracy by Rick Frea

Respiratory Tolerance

Respiratory Tolerance: It's when you know a doctor, nurse, respiratory therapist, administrator, or politician is wrong and you let that person go on being wrong out of fear of alienating important people, or out of fear of losing your job.  It's respecting what is perceived as ignorance in order to keep the peace.

It's when you know all the facts are on your side, yet it's not worth the risks to educate at this time.  It's when you don't believe the risks of educating, debating and arguing are worth the benefits of doing so.

It's when you do what you are told to the best of your ability, even when you know what you are doing is frivolous and pointless.  It's when humility reigns over you and you realize it's best simply to do as instructed.

The key to respiratory tolerance is the subject in reference must involve something considered to be harmless to the patient.  For example, many times we have heard the following expression regarding respiratory therapies: "It can't hurt."

It-Can't-hurt:  These three words are a definition in and of themselves.  When people say things like "It can't hurt" as the justification for doing something with no justification, they are closing their eyes to the big picture and only seeing what is right before their eyes.

They see the respiratory therapist giving the treatment.  What they don't see is that the respiratory therapist is getting burned out as a result of these "it can't hurt" therapies.  What they don't see are the unintended consequences, such as the exhorbitant cost to the hospital, insurance company, and government.

Respiratory tolerance is letting all this pass.  I would say letting it pass so long as no one is getting hurt.  Yet, the undeniable truth is, even when it appears no one is getting hurt, someone IS getting hurt, either spiritually or financially.  

However, tolerance in no way means acceptance.  Just because we do as told and keep our mouths shut, does not mean that we will not judge; does not mean we will not question authority.  Of course such inactive action is in itself frivolous and pointless.

What is palliative care?

The natural progression of chronic obstructive pulmonary disease (COPD) may ultimately lead to dyspnea, anxiety, depression, discomfort, and pain. When it becomes apparent any of these symptoms is chronic, it's time to make the shift to palliative care.

Shawna Strickland, in the April issue of AARC Times, "Palliative Care for the Patient with Chronic Pulmonary Disease," defines palliative care as follows:

Palliative care: the application of care strategies to alleviate the patient's suffering.  Many times, palliative care is confused with hospice care.  

Hospice care: is the shift in care goals from curative to comfort only.  Patients qualify for hospice care when their life expectancies fall to six months.

Curative care:  Efforts are made to cure symptoms and treat the disease.  This is generally done until  

Palliative care is often given in conjunction with curative care, and is generally started when the disease progresses to the point where symptoms such as pain, discomfort, anxiety, depression and dyspnea (air hunger) become chronic

It includes medicines like Ativan to reduce anxiety,  morphine to reduce the feeling of air hunger, or dyspnea, and morphine and other medicines to reduce pain and suffering.  Morphine or other opoids and cough suppressants may be needed to help reduce or prevent excessive coughing.  Oxygen may also be indicated to reduce the feeling of dyspnea.

In her article, Strickland said:  "Researchers have shown that respiratory therapists may have a poor understanding of palliative care principles and may not be prepared for these chronic disease and end-of-life issues.

Well, now you know.  What we do is a part of the palliative treatment.  Oxygen, and bronchodilator therapy may not always have a scientific benefit to the patient, although evidence suggests the placebo effect of albuterol may be all that is needed to sooth the mind of a patient.

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Emotional State Lexicon

The following are the emotional states.

• Anxiety/ nervousness: An emotional state; indicative of a patient watching every movement; asthma, respiratory failure, hypoxia
• Depressed: An emotional state indicative of quiet, denial, in hospital too long
• Anger/ combative/ irritable: An emotional state which often presents with electrolyte imbalance
• Euphoria: An emotional state which usually presents with drugs or overdose.
• Panic: An emotional state which resents often with hypoxia, tension pneumothorax, status asthmaticus

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Level of consciousness lexicon

The following are the levels of consciousness.

• Lethargic: somnolence: sleepy
• Stuporious: confused: responds inappropriately, OD, intoxication
• Semi-comatose: responds only to painful stimuli
• Comatose: does not respond to painful stimuli
• Obtunded: drowsy, maybe decreased cough/gag reflex

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Types of breathing lexicon

The following are terms associated with types of breathing.

• Unconscious breathing: Most of the time you don't think about breathing, yet you continue to do it. This is an important safety net for life, because if we had to think about breathing 24-7 we'd accomplish little and most life would cease to exist. Air goes into your lungs because a negative pressure is created that sucks air in, kind of like a vacuum. Normal exhalation is passive. Normal unconscious breathing is generally called quiet breathing.
• Diaphragm: The main muscle of respiration is this large muscle that contracts during inspiration. When it contracts it moves downward making more room in the lungs and creates a negative pressure, causing air to be drawn in.
• External Intercostal Muscles: These are positioned between the ribs and contract during normal breathing, pulling the ribcage outward. These assists the diaphragm in lifting the rib cage and creating negative pressure in the lungs. They also assist with expiration.
• Scalene: This might assist the diaphram.
• Exhalation: Normally passive. It occurs when the muscles of respiration relax. When this occurs the rib cage is drawn in, and the lungs are compressed. This increases the pressure in the lungs, and air is pushed out. This is also referred to as normal elastic recoil of the lungs.
• Conscious breathing: When you take in a breath by thinking about it. When you do so you will be using your accessory muscles of respiration. 
• Normal Muscles of Respiration: These are the muscles you use during most breaths. Generally, these include the diaphragm, external intercostals and scalene muscles.
• Negative recoil of lungs: Natural relaxation of muscles of respiration causing air to be released from the lungs.
• Forced exhalation: If the lungs lose their elasticity (if they become stiff and unable to recoil), your body will have to use all the above mentioned muscles to force air out of your lungs. This is generally called active forced breathing or forced exhalation. It is generally active or conscious, and is often referred to as labored breathing. Other examples of this are emphysema and pulmonary fibrosis .Muscles that assist with forced exhalation include: Abdominal Muscles, Internal Intercostals, and Innermost Intercostals
• Diaphragmatic breathing: When you are breathing normally you are using your diaphragm. This allows you to get the most out of each breath. When this occurs, your stomach moves out, and your chest does not move.
• Accessory Muscles of Respiration: Muscles you normally don't use to inhale, and when you do use them they will be sore the next day. Examples include: 

The main accessory muscles are:

• Sternocleidomastoid (neck)
• Scalene (neck)

The minor accessory muscles are:

1. Serratus Anterior (minor role, side of chest)
2. Pectoralis Major (minor role, chest)
3. Pectoralis Minor (minor role, chest)
4. Upper Trapezius (back, shoulder and neck)
5. Latissimus Dorsi (side of chest and abdomen)
6. Erector Spinae (deep back)
7. Iliocostalis Lumborum (deep back)
8. Serratus Posterior (mid back)
9. Serratus Inferior (mid back)
10. Serratus Superior (mid back)
11. Levatores Costarum (chest)
12. Tranversus Thoracis (chest)
13. Subclavius (chest)

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Lung Anatomy Lexicon

The following is basic lung anatomy terms.

• Nares (nostrils): You waft through the nasal openings, barely inching between hairs meant to keep particles out. This begins the upper airway.
• Nose: It's not just an organ of smell, it also aids in phonation and easily lets air in. It's also the first line of defense against inhaled particles. 
• Epithelial cells: You'll see these cells lining the air passages from the oropharynx to the respiratory bronchioles. Their main function is protection of underlying tissue and secretion. Note the wavelike movement of hair-like structures on the surfaces.
• Goblet cells: These are specialized epithelial cells that are randomly scattered along the way. Their job is to secrete mucin, which dissolves in water to form mucus.
• Mucus: This is formed by goblet cells and traps particles in inspired air to prevent them from getting to the lungs. It then rides up on those fine hair-like structures to the mouth. Once in the mouth it's called sputum.
• Cilia: These are those fine hair-like structures referred to above. They wave in rhythmic fashion and act as an escalator to move mucus to the mouth. Each ciliated cell has 200 cilia, and there are 1 to 2 billion cilia per square centimeter.
• Nasal septum: This is what divides the two nasal passages from the nare to the nasopharynx. 
• Vestibule: This is the main cavity of the nose. Air is warmed to 98.6° Fahrenheit and humidified.
• Turbinates: These are three bone-like shelves that project into the nasal cavity from the lateral wall. They help with the sense of smell and warm and humidify inspired air. 
• Pharynx: This is a funnel shaped passage where are travels from the nasal cavity to the larynx. It too aids in phonation. Both food and air travel this way.
• Nasal pharynx: This is the upper portion of the pharynx.
• Oropharynx: This is the middle portion of the pharynx, and from here you travel to the larynx. Look down! That dark opening is called the glottis, and those white objects on either side are the vocal cords.
• Vocal cords: These are only open when you inhale. This is another means to keep particles out of the lungs. As air brushes past them when you breathe out they vibrate, creating sound.
• Epiglottis: This is the object projecting upward and guarding the opening to the glottis. When you swallow it lies down to keep food out of the lungs. 
• Glottis: Only air is allowed to pass (yet a few particles sneak by). This is the opening to the Larynx.
• Larynx: This is a very short passage that protects the lungs during swallowing, helps produce a voice, and is often referred to as the voice box.
• Laryngeal skeleton: The larynx is kept open by nine cartilages, the largest of which is the thyroid cartilage, better known as the pomas adamus, or Adams Apple. Just inferior to the Thyroid cartilage you'll see the cricoid cartilage in the neck.
• Trachea: This is the main tube-like passage to the lungs, and is often referred to as the windpipe. It's kept open by 16-20 c-shaped cartilages.
• Carina: This is a fork in the road. Go right to the right lung, and left to the left lung. The respiratory tract from this point is called the lower airway.
• Lungs: The lungs are normally kept sterile by many of the mechanisms we described on our journey. Occasionally particles make it this far and cause havoc. Yet healthy lungs move particles out within 24 hours. Most particles are filtered by the upper airway. A porous and spongy organ, the lungs provide a space whereby large amounts of air and blood can come in contact for rapid exchange of gases to occur.
• Right lung: It's actually larger than the left and has three lobes.
• Left lung: This side has only two lobes. Can you guess why? I'll give you a clue. Listen! Lub dub... lub dub... lub dub... lub dub... lub dub...
• Bronchus (large airways): This is the passage air takes as it begins its travel through the lungs. Air passes through the lobar region, segmental, then subsegmental. These airways divide into smaller and smaller but more numerous airways.
• Bronchioles (small airways): These airways continue to get smaller and divide exponentially. Air travels through the terminal then respiratory airways. There's no cartilage to keep the airways open here, which isn't good during an asthma attack (see picture). 
• Bronchial tree: The bronchus, bronchioles and alveoli make up the bronchial tree.
• Bronchial Smooth Muscle: Crisscrossing and spiralling the outside the bronchial airways are smooth muscle fibers. During asthma these spasm and contract, narrowingthese hallways, making it hard to breathe.
• Beta 2 Adrenergic Receptors: On the bronchial walls are tiny receptors. When you inhale beta-adrenergic medicine like Ventolin or Xopenex, the medicine binds to these receptors, and the reaction causes bronchial muscles to relax, opening the airway, and making breathing easier.
• Alveolar Duct: The respiratory bronchioles leads air to these fine ducts that terminate in clusters of 10-16 fine balloon-like structures called alveoli.
• Alveoli: Most adults have over 300 million of these in their lungs, and this is where most gas exchange occurs. Oxygen molecules inhaled wait here for an available hemoglobin molecule.
• Red Blood Cells (RBC): These look like little red boats or donuts. In the middle is a protein called hemoglobin. RBCs ride single file down the capillary beds in the lungs where they come into contact with the alveoli.
• Capillary: These tiny vessels transports RBCs that have carbon dioxide (a cellular waste product) attached to the hemoglobin instead of oxygen. These RBCs are purplish-blue in color.

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Basic respiratory therapy lexicon

Here are some basic terms used by respiratory therapists.

• Ventilation: Moving air in and out of the lungs. Measured by respiratory rate, tidal volume, chest movement, breath sounds, Measurement of Carbon Dioxide (PaCO2), etc. This is your first priority in an emergency (establish and open the airway)
• Oxygenation: Getting oxygen from the air, to the lungs, and then to the bloodstream. Measured by Heart rate, color, sensorium, Oxygen (PaO2 and SpO2), color (cyanosis, gray or normal), sensorium, etc. This is your second priority in an emergency (increase FiO2). This is also the most common problem.
• Circulation: Moving the blood through the body. Measured by pulse and heart rate and strength, cardiac output (blood pressure). This is your third priority in an emergency (chest compressions, defibrillate, heart drugs, etc.)
• Perfusion: Getting blood and oxygen to the tissues. Measured by blood pressure (cardiac output), sensorium, temperature, urine output, hemodynamics. This is your fourth priority in an emergency, raise the blood pressure.
• Signs: Objective information, those things that you can see or measure. Examples include color, pulse, edema, blood pressure, pulse ox, etc.
• Symptoms: Subjective information, those things that the patient must tell you. Examples include dy spnea, pain, nausea, muscle weakness, etc.
• Objective:  Judgement not based on personal feeling; opinions based on fact; what you find upon assessment; examples include blood pressure, pulse oximetry, lung sounds, temperature, level of consciousness, etc. 
• Subjective:  Judgement or opinion based on personal feelings.  Examples include pain level, level of dyspnea, anxiety, etc. 
• Smoking history: How many years and how many packs per day. Measured by # of packs per day times years smoked.
• Advanced directives: Set of instructions documenting what treatment a patient would want if he was unable to make medical decisions on his own. Does the patient want to be a full code, or does he want all measures to be taken to restart his heart if it stops beating. Does he want to be placed on a ventilator. These are questions that should be answered.
• Do not Resuscitate (DNR): This is an order from a patient requesting that no efforts be made to restart the heart if it should so happen to stop, and no efforts should be made to intubate the patient (No Mechanical Ventilation) should he stop breathing. Otherwise, the patient should be treated, but no invasive procedures should take place.
• Arterial Blood Gas: A sampling of arterial blood drawn from the radial, brachial or femerol arteries to determine PAO2, PCO2, HCO3 and accurate SaO2, and pH. Used to monitor respiratory status and metabolic status.
• Venous Blood Gas: In a patient who is not showing signs of respiratory distress, recent research shows this should be just as useful as an ABG (unless your goal is to monitor oxygenation status). Venous pH and HCO3 are basically similar, and PO2 is expected to be a normal of 75, so if it is low, you can be assured PO2 is low. Actually, VBG is just as useful as ABG so long as you can momitor oxygen status with a pulse oximeter (SpO2).
• Capilary Blood Gas: Used to determine pH, HCO3 and pH values in a newborn, especially when no cord blood access is available, or if it's difficult to get an ABG. With the exception of oxygen status, the values are similar as an ABG and just as useful. CBGs are now coming back into play, as for a while they were not being ordered much.
• Pulmonary Function Test: A test that measures lung function. It measure how much air you exhale, and how fast this air flows.  It's a very useful tool to help physicians diagnose various lung diseases.
• Urine output: This is the measure of the normal output of a person per day. Normal is 40 ml/hour or 1 liter per day. When input is greater than output, this results in weight gain, electrolyte imbalance, increased hemodynamic pressures, decreased lung compliance, etc. (see central venous pressure below)
• Sensible water loss: Water lost by urine, vomiting.
• Insensible water loss: Water lost by lungs and skin
• Hypervolemia: Too much fluid in the body.
• Hypovolemia: Too little fluid in the body, dehydration, also indicated by a high hematocrit.
• Level of Consciousness: Normal is awake, alert and orientated (AAOx). Abnormal is lethargic, somnolent, stuporiouis, confused, obtunded, coma.
• Lethargic: Very sleepy, somnolent. May be too many sedatives or possible CO2 toxicity (although rare).
• Confused: Stuporious; change in mental status; responds inappropriately from patients normal; also consider drug overdose, too many sedatives (valium, morphine, psychotropic drugs, etc.)
• Obtunded: This is a drowsy state where the patient is so tired he can barely plop his eyes open. At this point you should consider high CO2, decreased gag reflux and decreased cough. May consider drug toxicity, respiratory failure, sepsis, etc. You'll have to problem shoot.
• Coma: Patient does not respond even to painful stimuli. This may be an end stage disease condition, or it may be drug induced, or it may be a sign of drug toxicity, etc. You'll have to problem shoot. May also be normal in a ventilated patient to allow their lungs and system to relax while the body heals.
• Orthopnea: Shortness of breath when lying down, have to be sitting up to breath. Common with congested heart failure
• Malaise: Geneeral feeling of nausea or pain; flu-like symptoms, headache, tired, weakness, fatigue.
• Dyspnea: A feeling that you can't catch your breath. It's a subjective measure.   It's the medical description of shortness of breath (see #73). Shortness of breath, or breathing discomfort, or uneasy breathing feelings. You may feel dyspnea after a long sprint, and this is normal and it resolves itself. More severe is dyspnea at rest. Dyspnea while slowly walking is less severe than dyspnea while walking fast. Chronic end stage lung patients may feel dyspnea doing normal tasks like shaving, preparing food, etc.
• Clubbing of fingers: This is caused by any disease that caused chronic hypoxia, such as lung cancer of cystic fibrosis. The anlge of the nails is increased, almost smooth looking.
• Venous distention: A popping out of the veins, especially in the neck. Common in patients with end stage lung disease due to high pressure needed to pump blood through lungs and body
• Edema: This is excess fluid somewhere in the body, causing swelling, such as in the ankles. It's common with heart failure, or kidney failure.
• Ascites: Accumulation of fluid in the abdomen; liver failure
• Diaphoresis: Sweating. May be sign of heart failure (CHF), fever, infection, anxiety, nervousness, etc.
• Jaundice: Yellow skin; liver failure; increased biliruben (new born infants). If newborn, patient may be placed under radiant light and the problem will resolve itself.
• Barrel Chest: Increased a/p diameter of chest, and a result of air trapping. This may be a short term condition (asthma) or chronic (end stage emphysema, COPD)
• Nasal flaring: A flaring out of the nostrils during inspiration. This is usually a signs of respiratory distress in newborn babies and infants
• Retractions: This is a sucking in of the chest during inspiration, and is a sign of respiratory distress in neonates. The higher up in the chest the retractions are the more severe the respiratory distress.
• Grunting: A grunting on expiration, and is usually a common sign of respiratory distress in neonates. It's the patients natural attempt to keep the alveoli open and get more oxygen.
• Tracheal deviation: This is when the trachea is moved either to the left or right. The trachea is usually pushed away from pathologies such as pleural effusions, tension pneumothorax, neck or thyroid tumors, large mediastinal masses. ( or things that take up space in the lungs). It moves toward pulmonary atelectasis, pulmonary fibrosis, pneumonectomy and diagphragmatic paralysis (or things that make more room in the lungs).
• Crepitis: A crunchy feeling felt by the hand over the chest wall, neck, and around a chest tube. It's usually air that creeps and bubbles under the skin. Subcutaneous emphysema.
• Vesicular: Normal lung sounds
• Bronchial: Normal lung sounds heard over the upper airway (trachea and bronchi).
• Adventitious: Abnormal lung sounds (wheezing, rhonchi, rhales, crackles, etc.)
• Coarse lung sounds: Rhonchi (see rhonchi below)
• Wheezes: High pitched sound heard on inspiration and or expiration, and is usually indicitive of bronchospasm. Don't get upper airway wheezes confused for bronchospasm, because all that wheezes is not necessarily bronchospasm. Usually, if it's audible, it's not a wheeze technically speaking.
• Crackles:  The sound of fluid in the lungs or the alveoli popping open with inspiration.  There are two types:  1) Coarse crackles (a.k.a. rhales) are heard on inspiration and expiration and represent fluid in the lungs, 2) Fine crackles are heard on inspiration only and represent alveoli popping open with inspiration; often a sign of atelectasis; may be sign of early pneumonia.
• Fluid challenge: If you have a patient who has a low blood pressure, shock, hypovolemia, etc. you'll challenge him with a rapid bolus of fluid to try to get blood pressure up.
• Blood pressure: Normal is 120/80. Greater than 140/90 should be treated as hypertension, and less than 90/60 should be treated as hypotension. Consider normal values for patinet however.
• Pulmonary Hypertension: High blood pressure in the lungs, which is usually indicative of end stage pulmonary disease, such as COPD, lung cancer, pulmonary fibrosis, cystic fibrosis, etc. It means the heart is working extra hard to push blood through the lungs, and often results in a large right heart (Cor pulmonale) that eventually results in a large left heart and heart failure.
• Cor pulmonale: An enlarged right heart secondary to long term high pulmonary blood pressure (pulmonary vascular resistance) secondary to end stage chronic lung disease.
• Auscultation: Listening to lung sounds
• Bronchial Hygene therapy: positioning a patinet to drain secretions (done in cystic fibrosis patients)
• Chest percussion: Clapping with cupped hands over chest wall to create vibrations in an attempt to move thick and stubborn secretions so they may be expectorated.
• Expectoration: Spitting up phlegm
• Chest physiotherapy (CPT): Using bronchial hygene and chest percussion to stimulate expectoration of secretions; pulmonary toilet.
• Pulmonary toilet: Doing whatever is necessary to help a patient expectorate thick and stubborn secretions; COPD; breathing treatment with bronchodilator and sometimes with Mucomyst; chest physiotherapy; PEP therapy, Flutter valves, etc.
• Suctioning: Removing secretions from the patients airway by artificial means. It is invasive and should never be done on any patient who is awake and alert. It can traumatize the patient and the airway. It is a necessary procedure in an intubated patient.
• Intubation: The process of inserting an endotracheal tube into a patients airway to the lungs to facilitate breathing for that patient. It is necessary for patients who cannot breath on their own. A patient is usually hooked up to mechanical ventilation.
• Mechanical Ventilation: The process of breathing for a patient with a machine called a ventilator.
• Prone position: Lying on belly
• Supine position: Lying on back
• Fowlers position: Sitting up straight
• Semi fowlers position: Sitting up withe the head of bed at a 30-40 degree angle.
• Death Rattle: Increased saliva and secretions in throat due to loss of ability to swallow and clear oral secretions. It's harmless to the patient, but can often be stressful for the family member not familiar with it, or not ecucated about it.
• Cardiac Wheezes: These are usually coarse wheezes, sometimes audible, and often of the upper airway that are caused because of increased pressure around the bronchial tree of the lungs due to heart failure and increased pulmonary edema. The increased pressure and fluid actually squeeze the bronchial tubes, thus causing them to wheeze. This presents similar to asthma, and is often confused as asthma, thus the name.
• Cardiac Asthma: See Cardiac Wheeze. This is asthma-like symptoms caused by heart failure. It presents as dyspnea at rest or on exertion and wheezes. It is often confused for asthma
• Ventilator Delirium: (synonym is psychosis) According to RT Magazine: "Delirium, as defined by the DSM-IV, requires an acute disturbance of consciousness with reduced clarity or awareness of the environment (eg, an inability to focus or to sustain or shift attention) and either (1) a new cognitive change (eg, deficits in memory or orientation, or a language disturbance) or (2) a new perceptual disturbance (eg, hallucinations or misinterpretations).2 Delirium frequently develops over hours or days, and fluctuates over time.
• Ventilator Acquired Pneumonia: This is pneumonia acquired once a patient is on a Vent. For the most part, a vent cannot cause pneumonia, however the term sticks.
• Circadian Rhythm Sleep Disorder: This is what happens to people who work nights. It's the totally whacking out of your circadian rhythm, thus making it difficult to sleep. The only cure is to stop working nights.
• Concurrent therapy:  See treatment stacking
• Treatment stacking:  When you do more than one breathing treatment at a time. 
• Nauseated: You feel sick
• Nauseous:  You make others feel sick
• Shortness of breath (SOB): It's a subjective measure. It's how your breathing feels to you. Do you feel winded? Do you feel you can't get air in? Do you feel dypneic. (see above)

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Types of Asthmatics Lexicon

Types of Asthmatics:

Bronchodilatoraholic: A person who takes more than two puffs twice a week of a rescue inhaler. Some are bronchodilator abusers, and some are simply Hardluck Asthmatics. You can read my experience here and and take the test to see if you are one by clicking here.

Bronchodilator Abuser: A person who abuses his rescue inhaler when what he should be doing is checking in with his asthma physician. Overuse of an inhaler is the #1 sign of uncontrolled asthma.

Hardluck Asthma: Despite all the best asthma medicines and wisdom, these asthmatics continue to have trouble with their asthma. I wrote about one such asthmatic here and here, and I wrote about my experience here. Plus you can click on "my story" under the banner to read more of my story growing up with Hardluck Asthma.

Gallant Asthmatic: She is the asthmatic who does everything right, and has great control of his asthma. He avoids his asthma triggers, has worked with his doctor on an Asthma Action Plan, and follows it to a tee. He is also very compliant with his asthma medicines and sees his asthma physician at least twice a year, but ideally twice a year. I write about Gallant Asthmatics often, such as this post and this post.

Goofus Asthmatic: He's the asthmatic who does everything wrong. He fails to go out of his way to avoid his asthma triggers, only goes to see his doctor when he has to, and does not have an asthma action plan. If he does have one he doesn't follow it. He is not compliant with his medicines, as he takes them only when he is feeling symptoms. He is the asthma type who is most likely to be seen in the ER. On a similar note, since his asthma is so out of control and since he is not on his controller meds, he is most likely to be admitted to the hospital. I write about Goofus Asthmatics on occasion, such as this post.

Phlegmatic Asthmatic: She's the calm, cool and collected asthmatic who takes everything in stride. He could be having an asthma attack right in front of you and you'd never know it (unless you had a keen eye for asthma.) How do you know you're dealing with a phlegmatic asthmatic? You won't unless they tell you they have asthma. These are the zen asthmatics who appear to be accepting of their condition, don't lose their cool and quietly deal with breathing trouble. I am a phlegmatic asthmatic

Actor Asthmatic: He is the asthmatic who always seems to have trouble breathing when you need him most. If it's time to haul in wood for the fire, his asthma flares. If he's dreading going to work he might run laps around the living room to ignite his asthma. When it's time to haul in the groceries he'll be seen puffing on his inhaler. He'll do anything to get out of work and avoid stress. Synynom: Exaggeration of Asthma. The actors are fun to write about.

Martyr Asthmatic:They could by dying and they still don't go to the ER. They are usually tough, macho adult men who only go to the ER at the insistence of their spouses. Their biggest fear, although they won't admit it, is that they will be told their asthma is all in their head, and then they'll feel stupid. So, they think it's easier just to pretend they are fine.

Recovered Asthmatic: Child asthmatics who grow up and no longer have asthma symptoms so they do some unwise things -- like smoke. When their asthma comes back, they are in a world of hurt.

Doubting Thomas: These are mostly adult-onset asthmatics who, all of a sudden, develop mild asthma symptoms, but don't want to admit they have asthma. They would rather suffer at home than seek treatment. But when the RT gives them a treatment they will say, "Wow, I didn't even realize I was short-of-breath." Famous Olympic swimmer Dara Torres may have been this kind of asthmatic. But now, I'm sure, she is a Gallant asthmatic.

Sometimer Asthmatic: Synonym: Asthmatics in Denial: They live normal lives, feel good 95% of the time, and so are in denial about their asthma and don't take their preventative medicines. These are your adult asthmatics who sometimes have mild symptoms, and when they do they take a puff or two or three or four of their inhaler until they feel better.

Poor Patient Asthmatic: These asthmatics would be okay is they had different doctors. We RTs hate to bad mouth doctors, but we know that since this patient has been in the ER 10 times in the last year, he should be on some type of preventative, anti-inflammatory medicine and not just a bronchodilator. Poor patients may also be children whose parents don't have a clue how to manage the asthma.

Bronchodilatoraholic: These are people who use a bronchodilator frequently. Some may be abusing their medicine, but many are gallants who simply have hard luck asthma.Abusers don't work with their doctor on an asthma action plan and they may not bother with controller, anti-inflammatory medications. For them, puffing away is like a bad habit - like biting your fingernails. In contrast, some hard-luck asthmatics may just need their bronchodilator frequently - many times a day, every day.We'll learn more about bronchodilatoraholics on another post.

Unfortunate Asthmatic: These asthmatics don't have access to a healthcare provider, and cannot affort to get their prescriptions refilled. They give the appearance of Goofus Asthmatics, although they are not. Many live in downtrodden city homes filled with allergens they cannot escape. Their homes are often exposed to the elements due to things like a leaky roof, flooded and musty basement, broken windows covered with plastic and duct tape, broken plaster and peeling paint. They have poor ability to remove asthma triggers from clothing due to lack of washer and drier, or inibility to afford to pay the water bill. They are often exposed to second hand smoke due to inibility to choose their surrounding environment. Good asthma control may be hard to come by no matter hard they try.

Best asthma you can be: This is the more realistic asthma type. They strive to be the best they can be, although they are not perfect because, if you think about it, perfection is not achievable. Normal asthmatics will miss an occasional dose of medicine, and will take an occasional extra puff on their inhaler, and may even use their rescue inhaler without a spacer.

Vulnerability: (1)A feeling you get when you realize you're not going to live forever. It most often occurs when you require prolonged or frequent stays in a hospital. (2) The realization if you want to live a long, healthy life you have to take care of your self, which may include making some changes (like quitting smoking, avoiding allergens, etc.
Vulnerability: (1)A feeling you get when you realize you're not going to live forever. It most often occurs when you require prolonged or frequent stays in a hospital. (2) The realization if you want to live a long, healthy life you have to take care of your self, which may include making some changes (like quitting smoking, avoiding allergens, etc.

Bronchodilator anxiety: The feeling of anxiety because you don't have your rescue inhaler on your posession. This may bring about an asthma attack just because you don't have it.

Asthma forgetfulness: The tendency of some asthmatics to forget they have asthma because they are feeling well, and do things that they shouldn't. Examples: quit taking meds, rake leaves, clean musty basement, etc.

Hospital Abbreviation Lexicon

The following are abbreviations commonly found by respiratory therapists in the hospital setting.

1. DNR:  Do not resuscitate
2. HMO:  Health maintenance organization
3. HME: Heat and Moisture Exchanger; artificial nose
4. NIV: Noninvasive Ventilation
5. NPPV:  Noninvasive Positive Pressure Ventilation
6. BiPAP: BiLevel Positive Airway Pressure
7. CPAP: Continuous Positive Airway Pressure
8. PEEP: Positive End Expiratory Pressure
9. IPAP: Inspiratory Positive Airway Pressure
10. PS: Pressure Support
11. PSV:  Pressure Support Ventilation
12. PPV: Positive Pressure Ventilation
13. IPPB: Intermittent Positive Pressure Breathing
14. VS: Volume Support
15. AC: Assist Control
16. VCV:  Volume Control Ventilation
17. PRVC:  Pressure Regulated Volume Control
18. VC:  Volume Control
19. SIMV:  Synchronized Intermittent Minute Ventilation
20. IMV:  Intermittent Minute Ventilation
21. PCIRV:  Pressure Controlled Inverse Ratio Ventilation
22. APRV:  Airway Pressure Release Ventilation
23. MV:  Minute Ventilation
24. PEFR:  Peak flow Rate 
25. IC:  Inspiratory Capacity
26. FRC:  Forced Residual Capacity
27. TLC:  Total Lung Capacity
28. RV:  Residual Volume
29. IRV:  Inspiratory Residual Volume
30. ERV:  Expiratory Residual Volume
31. VC:  Vital Capacity
32. COPD:  Chronic Obstructive Pulmonary Disease
33. CF:  Cystic Fibrosis
34. V:  VentilatiO2on
35. Q:  Perfussion
36. FiO2:  Fraction of inspired oxygen
37. PaO2:  Partial Pressure of arterial oxygen (blood gas)
38. PaCO2:  Partial Pressure of arterial carbon dioxide (blood gas)
39. O2:  Oxygen
40. CO2:  Carbon dioxide
41. SpO2:  Oxygen saturation (pulse oximeter)
42. EtCO2:  End tidal CO2 (calculated)
43. OSA: Obstructive Sleep Apnea
44. CHF:  Congested Heart Failure
45. CHD:  Coronary Heart Disease
46. MI:  Myocardial Infarction (heart attack)
47. VT:  Tidal Volume
48. VE:  Minute Volume
49. ICU:  Intensive Care Unit
50. CCU:  Critical Care Unit
51. CXR:  Chest x-ray
52. RX:  Prescriptjion
53. ET:  Endotracheal
54. ETT:  Endotracheal Tube
55. EKG:  Electrocardiogram
56. EEG:  Electroencephalography
57. ABG: Arterial Blood Gas
58. CBC:  Complete Blood Count
59. LDL:  Bad cholesterol
60. HDL:  Good cholesterol
61. WBC: White Blood Cell
62. RBC:  Red Blood Cell
63. HCT:  Hematocrit
64. BMP:  Basic Metabolic Panel
65. BUN:  Blood Urea Nitrogen
66. CK:  Creatine Kinase
67. 
    

Physic's Lexicon

1.  Laminar flow:  Also called streamline flow.  Fluid flows in streamline patterns.  The flow is straight, orderly and smooth.  There is no swirling of the fluid.  Molecular movement is smooth and straight.  fluid runs in straight lines parallel to the pipe walls.  Pressure through the tube is therefore based on Poiseulle's Law.  Normal breathing is often considered laminar flow.  While taking in a breathing treatment, a smooth laminar flow is essential for equal distribution of medicine through the air passages

2.  Poiseulle's Law:  States that the pressure needed for fluid to flow through a tube is directly proportional to the viscosity of the fluid, the length of the tube, and the rate of flow.  If the fluid is thick, if the tube is long, or if the tube is long, or if the tube radius is decreased higher pressures will be needed*.  Bronchospasm, increased secretions, increased viscosity of secretions, and tumors all might change the bronchiole tubes in such a way as to require greater pressures during ventilation.

3.  Turbulant flow:  The flow is not laminar.  The fluid through a tube eddies and swirls.  Molecular movement is chaotic.  Poiseulle's Law is no longer under effect during this type of flow.  It also includes chaotic changes in pressure and velocity.  Inhaling rapidly can cause turbulent flow, and so can crying, laughing, sneezing, etc.  In this way, turbulent flow results in poor distribution of medicine along the air passages.  It causes much of the medicine to impact in the larger airways instead of getting to the deeper air passages where it's needed.

4.  Transitional flow:  Also called tracheobronchial flow.  This is a mixture of both laminar and turbulent flow.  Pressure is based on laminar and turbulent gradients.  An example of this type of flow is where the air passages fork, such as at the corina.  When smooth laminar flow suddenly hits the corina it becomes turbulent.

5.  Toricelli's Law:  It was created by 17th century physician Evalgelista Toricelli.  He postulated that the speed of fluid through an opening is directly relative to the height of fluid above the opening.  For example, he believed if a tiny hole was made in the bottom of a cup, and the cup was filled to the top with water, that water would pour from the hole at the same speed as it would if it were poured at the height of the top of the cup. This was an early variety of the Bernoulii principle

6.  Bernoulli principle:  It was created by 18th century mathematician and physicist Daniel Bernoulli.  When fluid flow horizontally, as the velocity of the fluid increases the static pressure will decrease.  A couple examples will help you visualize this effect.  1)  The shape of an airplane wing is such that air traveling over the wing must flow faster than air under the wing.  The drop in pressure over the wing causes lift.  2)  Nebulizers allow air to flow through a narrowing in a tube.  This narrow passage causes that air to increase in velocity, and this causes a drop in pressure that causes fluid from the cup to be drawn into the flow.  This causes the mist that the patient inhales.

7.  Venturi principle:  Similar to the Bernoulli effect, or another variation of it.  It was developed in the 18th century by Giovanni Venturi.  If you insert an opening just distal to a narrowing in the tube, the drop in pressure caused by the increased velocity of the fluid through the narrowing will cause fluid to be entrained into the flow.  The design of the venuri (the opening) will allow for the amount of fluid entrained to remain constant.  This principle is applied in Venturi mask to assure a patient gets an accurate and desired FiO2.

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RT: Respiratory Intensivists and Germ Spreaders

The following is a post from our friend, the retired RT Will Lessons:

Hello folks.  Even the best of us have bad days.  One of the things I like about this job is even when I'm feeling grumpy my patients still love me.  The reason is because my "grumpiness" ends at the door.

Seriously, folks.  I just didn't feel I was at the top of my game.  I was irritated at all the stupid doctor orders.  The nurses that day seemed to be treating me as a slave rather than a part of the patient care team.

So that's where I stood.  It was right at the middle of my shift. I'm standing by the nurses station, taking in a deep breath, wiping the sweat off my brow, checking the time, and the mom to a ten-year-old asthmatic comes up to me and says:  "My daughter loves you.  She keeps asking when you're coming back."

I smile, and say, "I'll come say hi to her in a few minutes."

I loved that little girl.  I knew she was one of the few patients who actually needed me.  In fact, I had wanted to check on her an hour ago, but because I kept getting paged for frivolous things, I never had a chance.

I finally check on that little asthmatic girl.  She is all smiles when I walk into the room.  She makes my day.

So this is when my mind starts to twist and turn and an idea occurs to me: we are basically germ spreaders in the emergency room, and respiratory intensivists on the patient floors.  There's no respiratory therapy going on here.

Think about it.

1.  Germ spreaders.  Every person admitted to the ER with sniffles, sneezes, body aches and pains, is ordered to get a beta adrenergic aerosol so we can spread their germs by means of aerosol.

2.  Respiratory intensivists:  An RT who exists just to do breathing treatments required so the insurance company is happy enough to flip the bill.

That right there consists of 90 percent of the therapies we do at Shoreline Medical.  We get burned out to the point we aren't able to spend time with the patients who really need us.  That's life, I guess.

Thanks.  Will Lessons RRT

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False Heroism

"False Heroism:  Saving a life when you know that person will be dead within a month no matter what."  Keep Breathing RT"

When a patient is blue as Brainy Smurf's nose when he's wheeled into the emergency room, there's a small chance we will save him.  But for what? So he can lie in a hospital bed for a week with a tube in every orifice while the family stresses over what to do?

I participated in such an act of false heroism recently, and as I was walking home I watched as the ambulance passed by with lights ablazing.  I wasn't sure whether to pray for the person, or to ask God to make the transition easy.  It was a very humbling moment.

The solution to this problem entails a prolonged discussion in the arena of ideas, and a public educational campaign regarding end of life decisions.

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Stupid doctor orders

I have mentioned stupid doctor orders on this blog, yet I have nary defined them.  So, for the sake of discussion, what, then, are stupid doctor orders as compared to good doctor orders.

1. Stupid doctor orders: 1)Orders from a physician that lack common sense and have no purpose, and therefore have no benefit to the patient.  2) Orders that benefit the hospital by assuring the patient meets reimbursement criteria, although with no otherwise scientifically proven benefit to the patient. 3)  Orders written based on habit and with no scientifically proven value 4) Orders that are based on antediluvian theories.

2.  Normal doctor orders:  1) Doctor Orders written based on scientific evidence, or at least best practice medicine; 2) Orders that benefit the patient

3. Antediluvian theories: Theories that are old and outdated yet are still worshipped by doctors.  A good example is the hypoxic drive theory.

4.  Regular theories:  Based on a rational guess

5.  Scientific fact:  Proven by science, as opposed to proven by "oh, it sounds like a good idea."

Here are some examples of stupid doctor orders:

• Q4 Albuterol (how do you know the patient will be short of breath every four hours?)
• Q6 Albuterol (how do you know the patient will be short of breath every six hours?)
• QID Albuterol (how do you know the patient will be short of breath four times a day?)
• IPPB: (still some physicians who wish to continue the quest to overinflate god alveoli)
• Wean patient at a PS of 10 (like, that's the same as a ventilator breath that decreases WOB)
• Set Fio2 order (40%, 50%, 60%, etc.)(why not just write order to maintain normal spo2?)
• EKG because (let's have a real reason for ordering these, as opposed to just because...)
• Serial ABGs (so what's the point of having patient on EtCO2 and SpO2 monitors if you're going to continue torturing the patient every day anyway?)
• Ventilator tidal volume 1000 on a 500 pound man (Like, let's blow up the patient)
• Ventilator tidal volume 100 on a 100 pound lady (like, let's ventilate the patient)
• Breathing treatment on not breathing post operative patient (like, let's try bagging,  reintubation, or let's have the patient bring in his home CPAP because he's got sleep apneao, not bronchospasm)
• Albuterol stat post operative for stridor (that's not stridor you idiot, the patient is snoring)
• Albutetol stat for dyspnea (the patient has an f'd up heart, you idiot.  Ventolin is a bronchodilator, and will not help with dyapnea with exertion)

These are just some real life examples. 

Ventolin rids body of evil spirits and demons

Ventolin: What does it do?

• Build muscle
• Burn fat
• Kills zombies

Yes, ventolin now proven to kill the evil demons, angry gods and upset spirits that have posessed your body and are causing your lung ailments.  Give 0.5cc of ventolin and it will exorcise these from lungs and the result is better health. 

Some physicians are referring to this type of b2 agonist therapy as Mthologyuterol, and others refer to it as Demonuterol, Spirituterol, and Godexerol. 

There is also another medicine called Placatolin, which placates the gods so they stop causing diseases.  The result of the medicine is similar to the ancient civilizations performing sacrifices to feed the gods and keep them happy. 

Spirituterol:  Provides sacrificial offering to placate the spirits that invaded your lungs causing disease.

Demonuterol:  Provides sacrificial offerings to placate demons that cause disease.

Godexerol:  Placates gods so they quit irritating your lungs.  It also placates godesses.

Any questions, please inquire within. 

Lab Nazis

I hate lab.  I hate every thing about the lab.  I even hate the people.  I hate every thing about lab.  I dread going to lab with my ABG results.  I dread it more than anything else in this field.

Okay, so I don't hate all the people.  I love the lab techs. I love the good folks who draw blood.  They generally have good people skills; they have to.  Yet there are people in the lab, who all they do is look at machines all day.  Those people tend to be choleric and dry in personality.

Okay, so not all, but many.  Enough to make the milieu of the lab seem hot and tense.  And it's not just the lab where I work my full time job, it's every lab I've ever walked into.  The people are focused on numbers, machines and tasks and don't give a rats butt about the whole picture. To them the number tells the whole story.  If a machine shows a CO2 of 60, that value is critical.  It doesn't matter that the patient is a COPD retainer with a normal CO2 of 55.

They also develop their raw, dry, pining personalities because they are forced, by all the companies and government agencies forcing tons of new regulations every day, to worry about being shut down.  Yes, there is a reason they are the way they are, as I wrote about in this post.

There's a reason there are 300,000 not needed steps in entering blood gas results and resulting them into the computer system.  It's because people who have no clue about reality are making rules and regulations.  The lab folks, the lab Nazis as I call then, are that way for a reason.  They don't intent to become Nazis, it's just what they become.  It's like if you hang out with rats all day, you become one by default.

Okay, enough lab bashing.  Seriously, folks, I find no place more stressful and tense than hospital laboratories.  It has to be the most stressful job in the world, worrying about numbers being correct; worrying about machines working properly; worrying that you meet the 289,000 stupid, moronic, regulations.  (Yes, 19,000 of those regulations might actually be necessary).

I know I'm being unfair by saying I hate the people who work in lab, because it's probably not true.  What I hate is what they become, and how they are so obsessed with numbers that they lose track of reality.  But, in their defense, it's not always their fault.  It's the fault of the morons in Washington who can't keep their noses out of our healthcare system.

I think drawing ABGs was better in the old days when ABG machines were inside RT Caves.  Surely we grunted and groaned while maintaining and fixing them, but that stress was nothing compared to what we have to deal with in the lab. Sometimes I wonder if we should have kept our mouths shut and kept it the way it was, and continued to live in happy RT lalal land.

Okay, go ahead and rip my editorial to shreds if you choose.  This is my opinion only.  I am simply terrified of the lab, like my three-year-old daughter is scared of the Ferris Wheel.  I get the ABGbies every time I go there (yes, that was a funny).

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