Aerosols no longer indicated for airway clearance

We respiratory therapists seem to grumble and gripe a lot about useless breathing treatments, and usually to no avail.  However, it seems the good people working for American Association For Respiratory Care (AARC) have heeded some of the criticism and performed some of their own research into the matter.

RT Magazine reports the following:

A new evidence-based Clinical Practice Guideline (CPG) published in Respiratory Care found that evidence is lacking that proves pharmacologic agents routinely administered for airway clearance are effective in improving oxygenation and respiratory mechanics, reducing ventilator time and ICU stay, or resolving atelectasis.

The CPG is based on the work of an American Association for Respiratory Care (AARC) task force and Vanderbilt University researchers.

The following are the new recommendations regarding use of aerosols for

• The routine use of aerosolized acetylcysteine (Mucomyst) to improve airway clearance is not recommended in hospitalized adult and pediatric patients. 
• Aerosolized agents to change mucus biophysical properties or promote airway clearance are not recommended for adult or pediatric patients with neuromuscular disease, respiratory muscle weakness, or impaired cough.
• Mucolytics are not recommended to treat atelectasis in postoperative adult or pediatric patients, and the routine administration of bronchodilators to postoperative patients is not recommended. 
• There is no high-level evidence related to the use of bronchodilators, mucolytics, mucokinetics, and novel therapy to promote airway clearance in the studied populations. 

This is vindication, of sorts, to all of us RTs who have complained for years that this type of therapy rarely results in the desired benefits.  We'll have to wait and see if the medical profession eventually catches on to this new wisdom.  Using history as our guide, this will probably occur in the year 2035.

Further reading:

• RT Magazine: New CPG Questions Value of Aerosols for Airway Clearance
• RT Cave: Hypoxic Drive Theory: Reality or Hoax

Answers to your web queries

What follows are web queries that lead someone to my blog, and my humble responses.

1. how we know bipap is failing: By observing the patient, checking ABGs, checking SPO2s, ETCO2, etc.

2. respiratory therapy for dummies: I could write this book.

3. do hospitals use oxygen or air to give ventolin? Either or.

4. drink albuterol: Pinheads do this.

5. how much does a respiratory therapist get paid: Not enough.

6. which is more effective mucomist by itself or mixing with albuterol: Never give Mucomyst by itself as it can cause bronchospasm. It should ALWAYS be given with Ventolin.

7. doctor of respiratory therapy: Doctors get so much more respect than RTs, but doctors also have a lot more stress and responsibility.

8. albuterol pneumonia: Why? Albuterol is a bronchodilator and does not go into the alveoli. It does not remove fluid and it does not reduce inflammation.

9. i drank lamp oil by accident what will soothe my throat?: If you drank this you best go to the ER, because you will probably be in respiratory distress. Chances are, if you wrote this, you did not drink it.

10. is beer bad for copd patients: Yes. It dried out your lungs.

11. full code patient: If your loved one is a full code patient, then if his heart stops we will do whatever it takes to try to revive him -- regardless of his age, regardless that he is terminal. I think it's crucial that you consider advanced directives before it's too late.

My response to your websearch queries

Here is my weekly response to Internet search engine questions that lead someone to my blog.

1. side effects of respiratory therapy: I will consider a side effect as something negative that could happen. I think that the #1 side effect is burnout, followed closely behind by frustration at not having more control over who gets respiratory therapies, not having more protocols, etc. In some rare cases there has been seen complete animosity toward this profession, which is probably no different from any other career.

2. can i take only serevent for asthma: It's recommended that if Serevent is indicated, Flovent should be taken with it. Thus, if both are prescribed, the patient should talk to his or her doctor about taking Advair, which is a combination of both drugs and only requires one puff in the morning and one at night. For more information regarding Serevent, click here.

3. mixing mucomyst with albuterol: It is mandatory that if Mucomyst be given that Albuterol be given with it. While Mucomyst is supposed to break up thick mucus, it can also cause bronchospasm.

4. what do people think of respiratory therapists: I think that most people don't even know who RTs are until they see us in the hospital. But, once they get to know us, I think we are highly thought of by most patients. We do our own surveys here at shoreline, and most of the comments are excellent when it comes to "what do you think of your RT services."

5. albuterol steam machine: I think you are thinking of an air compressor and a nebulizer. When the air passes through the nebulizer, it forms a mist not steam. And, breathing in this mist is what causes the medicine to get into the lungs and do what it's supposed to do, which is relax bronchial muscles.

6. what are post-op crackles in the lungs caused by?: Can be caused by a lot of things actually, but the general idea is that they are caused because abdominal or thoracic pain from the surgery is preventing the patient from taking in deep enough breaths and stretching the alveoli in the bases of the lungs, and thus making them more prone to pneumonia. Likewise, some pain medicines and sedatives can also make a person take shallow breaths, and this too can cause crackles. It is for this reason we encourage post op patients to use an incentive spirometer and to do cough and deep breathing exercises, of which I wrote about right here.

7. what to do when you dread going to work: We all have those days. What I do is go to work and hope for the best. It's also a good idea to get a good nights (or in my case days) sleep.

8. respiratory school formulas printout: I actually have a list of the relevent formulas I can post if you want me to.

9. how often should a patient use combivent: Recommended QID or no more than Q4. If you need it more often see your doctor. However, there are exceptions to this guideline.

10. how does ventolin work in the respiratory system: The Ventolin particles are nebulized into a particle size of 0.5 microns and work their way into the bronchioles, where they bind with beta adrenergic receptor cells and cause bronchodilation.

11. does nasal cannula make pneumothorax worse in children : Why would it?

12. advantage of using a mist tent over nasal cannula : A mist tent is good for use with a child with croup in that it provides a cool mist to help reduce swelling in the throat. However, at Shoreline we've decided the mist tent more or less just gets in the way of caring for the child, and we've pretty much scrapped them. If a child need oxygen, we use nasal cannulas. However, the mist tent is still always an option.

13. which is stronger ventolin mdi or ventolin aerosol mask: According to scientific data obtained, an MDI used with a spacer and used correctly should be just as effective as a Ventolin nebulizer treatment. And, a nebulizer taken with a mouth piece is more effective than via a mask, and a mask is more effective than a blowby treatment.

14. does singulair make it easier to cough up flem from lungs? : Not that I know. Singulair blocks the release of leukotreins which cause bronchospasm.

15. which should be given first if both are ordered serevent or flovent: Good question. Check out my answer to #2, and then I'd have to say Serevent because it's a bronchodilator. Considering neither has an immediate effect, I would guess that it doesn't matter. Any one else care to chime in here?

16. best respiratory therapist: Who decides? Is the person who loves button pushing really better than the RT sage? I wouldn't think so.

17. using bipap in place on ippb : I have debated this with some of the older RTs who will defend the IPPB machine to the death, but I think that all the IPPB does is over distend the good alveoli. I can produce some reliable studies that have come to the same conclusion.

18. continuous albuterol with bipap vision: Connect the neb as close to the mask as you can get it and have at it.

19. what does a respiratory therapist wear: Well, I wear scrubs and a white lab coat. Boring hey?

If you have a question I have not addressed here, or if you want an answer right now, feel free to contact us anytime and we'll get you an answer ASAP. You can contact me at Freadom1776@yahoo.com.

Monday's class: My response to your queries

This post is my weekly attempt to answer Internet search engine queries that lead someone to clicking onto my medblog.

I know that most people click on my site and leave two minutes later frustrated that my site is not what they were looking for. When, in actuality, if they would have hung around a bit, had a cup of coffee with me, they may have found the answer they were looking for.

Here we go:

1. giving mucomyst iv : I had never heard of it. However, upon doing a quick Google search, I found that it can be given IV. Here's what RXmed.com had to say: "Administered orally or i.v., as an antidote to prevent or lessen hepatic injury which may occur following the ingestion of a potentially hepatotoxic quantity of acetaminophen."
   
2. asthma attack albuterol nebulizer : The medicine has the ability to generate instant relief when a person is having trouble breathing. This and COPD are the two main indications for this medicine.


3. how are asthmatic attack in adults graded : Adults can use a peek flow meter just like children, and they and their doctor can adjust their therapy according to how well they do on their peek flow, likewise pulmonary function testing can be used for this too. Likewise, all asthmatics should maintain an asthma diary to keep track of your symptoms so the next time you see your doctor she knows if current medicines are working, and so she can change the plan accordingly. For more information, click here.
   
4. copd and ventolin treatment : Check out my answer for #2.


5. vaponephrine : This medicine is the watered down version of Epinephrine that can be used as as a bronchodilator like Albuterol, but it has a greater effect on the heart, and if this medicine is given, it is recommended the doctor keep the patient for 1-2 hours after therapy to watch for rebound. Vaponepherine (Racemic Epinepherine), is mostly used for croup, which causes swelling of the upper airway above the vocal chords. At our hospital, it is used only as a last resort, and whether or not it really has the desired effect here is still open to debate. Personally, I don't think it does anything. Vaponepherine is also used on occasion in adults with swollen upper airways, which is usually due to post intubation. Again, it is used here as a last resort. Some doctors do not like using it, and some do. There is one other illness that studies show this medicine to have some efficacy, and that is for young children with RSV. New RSV guidelines recommend trying this medicine to see if it has a benefit, and if not, to discontinue it. Studies have also shown that severe asthma patients do respond to Vaponepherine, especially among patients who have been puffing on their inhaler all day and have saturated their beta receptor cells with Albuterol.


6. obtunded with ards : I do not deal with ARDS patients much at my hospital, so I will have to defer answering this question. The most important thing I would recommend regarding obtunded patients is that they not be given tidal volumes according to their actual weight, but ml/kg ideal body weight. At Shoreline we use 6-10 ml/kg ideal body weight.


7. acute renal failure; respiratory therapist : We do deal with these patients on occasion, and the most pressing respiratory issue here would be pulmonary edema and the patients inability to excrete urine. How these patients are treated is up to the physician, and is usually based on the patient's signs and symptoms. If the patient is in respiratory failure, RT may be required to draw an ABG or, if need be, intubate the patient and set him or her up on a ventilator. At shoreline, if the patient needs dialysis, we ship.


8. pneumothorax : I had a COPD patient with severe respiratory distress once who was initially ordered to receive continuous Albuterol treatments. I started the treatment, listened to the patient, and thought I heard a rub on the right side. Since that can be a sign of a pneumo, I reported my findings to the doctor, who put in a chest tube. Soon thereafter the patient was transferred to the floor and was breathing easy.


9. respiratory therapy teaching materials for kids : You mean for asthma? There is plenty of it. When I was a kid I got a big box of fun stuff to play with that taught me about asthma. I even had this cool game that nobody wanted to play with me. I think I even still have it somewhere in my basement in a box. Perhaps I should try selling it on EBAY. For a good website, click here.


10. respiratory floor charting form : We actually had a good one when I started working at Shoreline, but we've been doing computer charting the past eight years or so. I don't know about other hospitals, but our computer charting is very cool.


11. 90 cartoons large dragon in a cave : Technically speaking, there are no dragons here.


12. are blow-by treatments effective for pediatric patients : Yes. You do lose a lot of medicine to the atmosphere, but I think they are still very effective. That's my personal opinion. I know there is a lot of research that says otherwise, but my personal opinion says yes. We use blowby treatments with almost all of our young kids.


13. protocols of hypokalemia : There is nothing in the RT bag of tricks for this.


14. protocol for bi pap : We do not have a written protocol, however doctors usually write the order for Bipap, and we determine the settings on our own. I wish we were provided this same responsibility with vents.


15. how much does an hour of respiratory therapy cost? : The hospital charges for the procedures we do, not for our time. I wish that I was paid for each procedure I did. If that were the case, I would never complain about a useless breathing treatment, and we RTs would be rich.


16. as a respiratory therapist should i cross over in nursing : If you think you can handle it, I would highly recommend it. The pay is better and there are far more opportunities.


17. does albuterol have alcohol in it : I wish.


18. how many days should it take to know if singulair is working : It usually takes 7-10 days to get into your system. This is one medicine you need to keep in your system, unlike other allergy medicine.
    
19. how long does advair stay in your system : Advair should never leave your system. It is one of the preventative medicines you take on a regular basis and never stop unless your doctor says otherwise.
    
20. give ventolin before atrovent : A good question. Ventolin opens up the bronchioles immediately, so it only makes sense to give Ventolin first. However, one of my teachers argued that Atrovent opens the large airways, in which case, if he is right, then Atrovent should be given first. You decide. What do my fellow RTs think about this?
    
21. vents bipap nursing : I think it's important for RNs to understand some of the basics of both these machines. I don't think RT needs to be called every time a BiPAP patient wants to take off his mask, so the RN should know how to do this. The same with the vent. Especially being the lone RT at night, I teach my RN friends how to do certain things on the vent, like preoxygenate, turn it on standby during suctioning, etc.

If you have a question I have not addressed here, or if you want an answer right now, feel free to contact us anytime and we'll get you an answer ASAP. You can contact us at Freadom1776@yahoo.com, or RTcave@yahoo.com.

That concludes today's class.

Monday's class: My response to your queries

This post is my weekly attempt to answer Internet search engine queries that lead someone to clicking onto my medblog.

I know that most people click on my site and leave two minutes later frustrated that my site is not what they were looking for. When, in actuality, if they would have hung around a bit, had a cup of coffee with me, they may have found the answer they were looking for.

This is what I'm going to make an effort to do every Monday.

1. vomiting bipap: This is a good question and something that was covered extensively in RT school. There are two types of masks patients can wear who are using BiPAP. There is a nasal mask, and a full face mask. If the patient is wearing a nasal mask, then there's no problem. However, in the hospital setting we use full face masks probably 90% of the time. And, if someone is throwing up with a mask on their face, their risk of aspiration (inhaling the vomit into the lungs and risking pneumonia) increases big time. Take the mask off if a patient is vomiting. If the patient is in the hospital and is on BiPAP to prevent him from needing a vent, intubation might need to be considered to protect the airway.
2. giving mucomyst without a bronchodilator: Mucomyst has the ability to break up thick secretions and making them easier to spit up (theoretically). It can cause bronchospasm, and should always be given with a bronchodilator, such as Albuterol.
3. vaponephrine dose for kids: At Shoreline we use 0.5cc Vaponephrine on all kids. It's safe. I have rarely ever notices an increase in heart rate as a result of this medicine, and usually if the heart rate does increase, it's because of the kid crying because he's annoyed by the RT.
4. efficacy of albuterol with chf: I've repeated this many times on this blog, but Albuterol will do nothing for CHF unless -- UNLESS -- the patient also has an underlying bronchospasm component. If you want to try one treatment to see if it does anything, go for it.
5. is a nurse above a respiratory therapist: Absolutely not. We are a team. Now, RNs are know to have a little more respect in society, but that is slowly changing. The reason is that nurses have been around since the Civil War, and RTs are only just getting started. RNs also get paid more than RTs, but that's only because of the nursing shortage and, partially, because of the respect thing. But, all in all, we are a team.
6. azthmacort: I took asthma cort for about 15 years, and never had much success with it. The main reason for this was compliance, as I was prescribed to use it four times a day. I think it's better to use a steroid inhaler that allows you to use it twice a day to increase compliance. I have better success with Flovent or Advair, but there are other options.
7. barriers to being a good respiratory therapist: Lack of respect I think is the main barrier. And lack of protocols that allow us to really excell at providing the best care to our patients at the least cost to the hospitals. However, due to lack of respect by doctors, many hospitals still do not have respiratory therapy or patient driven protocols. That's a shame, I think, and is the biggest barrier in my mind.
8. albuterol blow-by neonates: I find that most babies do not tolerate masks, however the results of using a mask may vary from patient to patient. If the child is sick enough, he or she might not care. Also, a blowby may result in the loss of 80% or more of the medicine to the atmoshphere. That said, giving a blowby is often better than doing nothing for a child who is having true bronchospasm.
9. should i give my daughter albuterol for croup: Only if there is underlying bronchospasm. Albuterol does absolutely nothing for croup.
10. cpap therapy for copd how it works: CPAP works to improve oxygenation. It helps a patient oxygenate better, and thus allows more oxygen to get into the bloodstream.
11. congestive heart failure croupiness: We hear this a lot in CHF patients. And, more often than not, RNs and RTs mistake this for a wheeze and recommend or order breathing treatments. Actually, this is caused due to increased secretions or fluid in the upper airway, and will not go away with a treatment. I would say that abaout 80% of CHF patients, patients with pulmonary edema, will have this harsh, upper airway, stridorous, croupy sound. This is something they should teach in school, but I'm not sure they do.
12. what is my internet time: Huh?
13. extra shift incentive pay respiratory: What do you mean by extra shift? Do you mean overtime. We get paid overtime for anything over 40 hours just like everybody else.
14. bad experiences with advair: Some people have bad experiences with Advair mostly becaue it has Serevent in it, which can make a person shakey and irritable. I would recommend weaning yourself onto the Advair slowly, instead of starting right out taking it twice a day. I'm patenting that idea. I recently wrote a post about this, check it out by clicking here.
15. stridor and aerosol therapy: See my answer to question #9.
16. duoneb and hyperkalemia: It would be the equivelent of taking an asprin for a heart attack. Need I say more.
17. why respiratory therapists are disrespected: I tried to explain this in my answer to #7 above. Maybe one of my fellow bloggers can word it better than me with a comment.
18. my doctor gave me potassium after an asthma attack why and what does potassium do f: Hopefully he gave potassium because lab results showed hyperkalemia, not because of some frivolous idea that one treatment of Albuterol will decrease Potassium. However, for a further answer, see #16 above.
19. definite sign of impending alcoholism: Okay, sorry sir or maam, but you had to read all of the above to learn that I do not have an answer to this question. Now, I could gather a pretty good educated guess, but I'm pretty sure you'd rather hear from a professional in that area rather than a lowly RT.
20. respiratory therapist 12 hours: I do not know of any hospitals where the RT does not work less than 12 hour shifts.
21. does albuterol breathing treatments make baby sleepy: Actually, it can be soporiphic. I know for it fact it puts some babies and even some adults asleep. Ah, maybe this gives me another idea for an 'olin.

If you have a question I have not addressed here, or if you want an answer right now, feel free to contact us anytime and we'll get you an answer ASAP. You can contact us at Freadom1776@yahoo.com, or RTcave@yahoo.com.

That concludes today's class.