The Flyp Nebulizer

Can be used anywhere.

It's called the Flyp Portable Hand-Held Nebulizer. It's the most impressive nebulizer I've ever used.

It's a mesh nebulizer. As you can see by the picture, it's quite compact. It has no tubing. Like an inhaler or iPhone you can hold it in one hand. You can easily store it in a pocket or purse. And using it is as easy as 1-2-3:

1. Open the reservoir cover on the back.
2. Gently lift the stopper and squirt in your medicine.
3. Close the stopper and lift the mouthpiece. 

Then you push a button. A nice mist is produced. Particle sizes of the medicine are right around the 0.5 micron range. This is the same as those produced by jet nebulizers. Treatment times average 7 minutes. That's less than jet nebulizer treatment times of up to 20 minutes. 

I charged the device for about 2 hours. I got 15 treatments out of it. I took one in my car and one at work. I took one while writing this article. It's so easy to use.

It comes with quality packaging.

It's so quiet!

You can't say that about jet nebulizers.

So, say you wake up in the middle of the night. Your wife and kids are sleeping. Jet nebulizers are  so noisy. You literally had to get out of bed to take a treatment. You had to go to the living room. Even then you had to hope it didn't wake up the kids. 

With the Flyp you don't even have to get out of bed. The reason is because it's whisper quiet. It would not wake up a fly. You could lie there in bed. You could do a quick treatment and go back to sleep. Nice!

My coworkers loved it!

I showed it to all my friends at work. They were very impressed. My asthmatic coworker said she was, "jealous." She added "I want one."

I said that it costs $199. I figured that would be a downside to this nebulizer. Traditional jet nebulizers cost under $40. Portable jet nebulizers cost $100. But, my asthmatic friend said she thought that price was quite reasonable.

She said, "Inhalers today are expensive. If you bought one Flyp, and it lasted one year, it would be more than worth it."

So I told her there was a three year warranty. She said, "That's icing on the cake." 

It comes with a nice carrying bag. 

The three year warranty is proof that the manufacturer has confidence in their product.

Is there  downside? 

It costs more than a traditional jet nebulizer. Medicare and insurance companies will not pay for one. Still, my friends thought $199 was very reasonable.

It will require cleaning after each use. This will definitely take some discipline. But, it must be done because you will want to keep the mesh disc clean. Medicine particles can build up on it over time. Cleaning it after each use can prevent this from happening. So, it must be cleaned as recommended. 

It is going to take some maintenance. It must also be charged regularly. The nebulizer disk must be properly maintained. It must not be touched with a finger or cotton swab. You can only clean it with distilled water. So, it definitely takes some care.

Thankfully, cleaning it is pretty easy. It's just a matter of doing it. 

What to make of this? 

The Flyp Nebulizer is a nice nebulizer. I have never seen anything quite like it. It's pocket-size like an inhaler or iPhone. It's pretty and quiet. You can take treatments any place and any time. All you have to do is charge it and you're ready to go.

At the present time it's only available in the U.S.. It's ideal for anyone who uses nebulizers. 

Nebulizers -vs- Inhalers for COPDers

The follow
ing was originally published at healthcentral.com/copd on May 20, 2015

Inhaler -vs- nebulizer: which one is best for COPD

One of the best ways of controlling COPD is by inhaling COPD medicine. To do this, some use an inhaler with a spacer, some use a nebulizer, and some use both. So which one is the best way to deliver COPD medicine to your lungs?

To learn about inhalers, check out my post “What is an inhaler?” To learn about nebulizers, check out my post “What is a nebulizer?”

Both inhalers and nebulizers allow patients to inhale a low dose of a medicine to receive a more rapid response (sometimes immediate), with fewer side effects than taking the medicine systemically. So they both work great for people with lung disease.

That said, let’s delve into this subject a little deeper and compare the two.

Medicine Distribution. Many studies have been done comparing inhalers with nebulizers. Most suggest that, when used properly, inhalers used with a spacer work equally well as nebulizers. So, it would appear at first that there’s no difference between the two, as far as getting the most medicine.

Cost. Your first nebulizer will cost anywhere from $50 on up. It includes the nebulizer and the air compressor used to power it. You’ll need to purchase supplies a few times a year, plus the medicine each month. Albuterol inhalers cost about $50, although other inhalers (such as Advair), may cost upwards to $200 plus each month. However, any cost for COPD medicines can usually be picked up by co-pays and Medicare.

Medicinal Waste. Most people who use inhalers don’t realize this, but most of the medicine is wasted. Furthermore, it does not matter whether you are using an inhaler or a nebulizer. Studies suggest that when an inhaler with a spacer is used, only 15 percent of the medicine gets to the airways. When a nebulizer is used, only 12 percent of the medicine gets to the airways. However, this fact is accommodated for by the dosing.

Convenience. Nebulizers require an air compressor and a power source and about 10-20 minutes of your time. Inhalers with spacers are small, compact devices, are convenient for travel, can be used anywhere, and require no power source.

Coordination. Studies show most people don’t use inhalers correctly. This has been confirmed by many studies. Age, and disease severity, may also impact your ability to use inhalers correctly. Poor technique means less medicine gets to your lungs, resulting in less benefit from the medicine. Inhalers often require training and practice to get it right. Nebulizers require less training. They simply require breathing normal through a mouthpiece. This assures an ideal dose and ideal benefit.

Airflow Limitation. Some people cannot generate enough flow to operate inhalers. This may occur during asthma attacks, COPD flare-ups, and during the end stages of COPD. Nebulizer treatments allow you to inhale the medicine over a period of time regardless of flare-ups or disease severity. Nebulizers, therefore, appear to work better during flare-ups, and for severe COPD.

Decision. There really is no winner or loser here. The convenience of inhalers makes them ideal for most people. However, if you have severe COPD, or frequent flare-ups, nebulizers may work better. Still, the best way of learning which one is better for you is by talking to your physician.

Further reading:

• What is an inhaler?
• What is a spacer?
• What is a nebulizer?
• National Jewish Health: Inhaler Instruction Videos
• Most People Don’t Use Inhalers Correctly
• Most aerosolized medicine is wasted
• RT Magazine: Nebulizers VS Inhalers: And The Winner Is?

Most Aerosolized medicine is wasted

According to the American Association of Respiratory Care's "Guide to Aerosolized Medications," not much of the medicine inhaled by inhalers and nebulizers makes it into airways.

By device, here's how much medicine reaches the lungs?

• Metered Dose Inhalers:  9%
• Metered Dose Inhalers with spacer:  15%
• Small Volume Nebulizer:  12%
• Dry Powdered Inhaler:  13%

So that means that most of the inhaled medicine, or a whopping 85-91% depending on the device used, "is lost in the oropharynx, the device, the exhaled breath, and the environment," according to the guidelines.

When a patient is intubated the percentage of medicine getting to airways is 2.9%, according to one study. 

It appears that the best distribution into the airway is obtained by inhaler and spacer.  Of course, this would only be possible if good technique is used.  Considering studies show that up to 93% of asthmatics do not correctly use their inhalers (93% to be exact), this kind of knocks inhalers and inhalers with spacers down to a level playing ground with nebulizers.  

While some might panic at these percentages, one should not worry. Pharmaceutical companies are well aware these when the formulate their dosing criteria.  So chances are that, regardless of the route used, most patients get plenty of medicine for maximum effect. 

Plus, it must be considered that 2.5 mg of albuterol solution mixed with 3cc of normal saline contains about twice as much ventolin as in the 200 mcg of albuterol inhaled via an inhaler.  So, again, patients are getting plenty of albuterol, and probably more than enough when an SVN is used. 

So who wins the battle of inhalers vs. nebulizers?  Well, as far as distributing medicine to airways, they all work equally well.

This post was originally published on March 11, 2010.  It has been edited for accuracy by Rick Frea.  

Further reading:

• When do you end a breathing treatment?
• Aerosolized delivery in intubated, mechanically ventilated patients, Critical Care Medicine, Feb., 1985, MacIntyre, et al
• AARC: Guide to Aerosolized Medications
• Respiratory Care Principles and Practice, 2nd edition, 2012, page 316, edited by Hess, et al
• Aerosols in Critical Care, by James Fink, April, 2009, slideshow
• Most people don't correctly use their inhalers
• RT Magazine: Nebulizers VS Inhalers: And The Winner Is?

The best way to add value to aerosol therapy

So I'm reading this article in RT Magazine called "Adding Value to Aerosol Therapy" by Mark Grzeskowiak.  The article is about adding value to aerosol therapy without cutting on quality of care.

He writes:

When a respiratory care practitioner enters a hospital room, they bring with them their experiences, assessment skills, and the necessary equipment to the bedside in order to make a patient’s breathing a little easier. But in today’s healthcare environment, there is an increasing emphasis on becoming more productive. RCPs must be able to do more in less time and with fewer resources. This scenario can sometimes leave the RCP wondering which goal is more important: providing quality care, or completing more billable procedures.

In the case of aerosol therapy, value can be added to the treatment by increasing quality while decreasing costs. However, inexpensive products do not always provide a reasonable quality of care, and it is up to respiratory care departments to resist cost-cutting strategies that look good on paper but may compromise patient care. This article will focus on strategies that can allow RCPs to provide high-quality care and still keep budget offices happy.

He offers some viable solutions:

1. Adding value with equipment:  Here he explains that by preventing half the medicine from being wasted, the patient will get more of it. This can be done by adding a reservoir to the end of the nebulizer.  Another solution is breath actuated nebulizers.  The problem with these options is that the equipment costs more, with the breath actuated costly slightly less than the reservoir nebulizer.  Personally, I think it would be too hard for some patients with true bronchospasm to initiate the breath actuated nebulizer, and I think it would be less expensive just to give another breathing treatment when it is indicated. I emphasize "when indicated" because most patients would probably not need the second treatment anyway.  
2. Adding value by subtracting:  This would involve eliminating aerosol therapy for patients where there is no perceivable benefit.  The problem is that too many doctors and nurses thing aerosol therapy is the solution for all annoying lung sounds and all causes of dyspnea.  Personally, if a hospital would incorporate a system of RT driven aerosol therapy protocols, I think this is the way to go.  I think this would save the hospital money, save the insurance companies money, save the government money.  It would  even reduce RT burnout and apathy, and stop RTs from waking up patients in the middle of the night for no good reason.  It's a win-win for everyone. 
3. Adding value through change in practice:  Give a mouthpiece instead of a mask, because studies show 50% more medicine is lost when a mask is used. Placing the aerosol close to the patient in a ventilator or BiPAP circuit. The problem:  Most of the time masks are used by patient preference, or because the patient can't hold a mouthpiece.  Personally, if the patient needs more medicine to feel better, then we might as well be giving two breathing treatments.  If we went with option #2 above, giving an extra treatment once in a while when needed would not be a burden either financially or physically.   

I think another option that's missing here is to use metered dose inhaers (MDI) instead of aerosols.  Most studies show that aerosols are equally as effective at delivering medicine to the lungs as MDIs used properly with a spacer.  So, once a patient is breathing normal, MDIs should be used.

Albuterol MDIs cost about $40 a piece, and the instruction cost is about $140, which is way less than the cost of aerosol therapy, which is estimated at between $100 and $200 each treatment.

I think you can work to try to find better ways of delivering aerosolized medication to patients, but the best method of cutting costs, if that's the goal, is simply to make sure such therapy is only given to those who would truly benefit from them, and the only way to accomplish this is with RT driven protocols.

If, on the other hand, physicians are intent on giving aerosol therapy, then RTs should be allowed, per protocol, to give MDIs to those who can generate enough flow and otherwise coordinate the therapy.

Alcohol nebs

Well, tell me you've never thought of giving yourself a vodka nebulizer before?  Or how about putting some Jack Daniels in the neb? Or how about some White Zin?  The buzz would be phenomenal.

Okay, so it's only a thought we had today in the RT Cave.  We figured we could have a whisky inhaling party, or a wine inhaling party.  You could try the different drinks to see which one you like best, or which one give the best buzz the fastest.

You gotta figure the buzz would be rapid, considering you're bypassing the system and going straight to the lungs, where it will be absorbed into the bloodstream.

Can you imagine the buzz when we RTs used to give Vodka nebs for foaming pulmonary edema?  Surely you know it works.  Give an alcohol neb and you surely wouldn't have to worry about pulmonary edema.

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Why give treatments to intubated patients?

Studies show that about 75 percent of the medicine given by aerosolized nebulization is wasted to the atmosphere.  When it comes to an intubated pateint, the studies show about 97.1 percent of the medicine is wasted.

According to MacIntyre, "Aerosolized delivery in intubated, mechanically ventilated patients," Critical Care Medicine, 1985 (13, 81), the amount of inhaled medicine that gets to the air passages of an intubated patient is even less, about 2.9 percent. This information is according to James Fink.

So according to this evidence, there really is no reason to give an aerosolized breathing treatment to an intubated patient.  If a physician wanted to give the equivelent dose to an intubated patient as compared to a nonintubated patient, he would have to give about eight treatments.

According to Gay, et al, "Metered Dose Inhalers for Bronchodilator Delivery in intubated, mechanically ventilated patients," Chest (1991, 99, pages 66-71), a metered dose inhaler treatment is equally effective as compared to a nebulzed breathing treatment.

A 1993 study reported in the American Review of Respiratory Disorders, "Metered Dose Inhaler Versus Nebulized Albuterol in Mechanically Ventilated Patients," concluded that for non-intubated patients a properly used MDI treatment is equally as effective to a nebulized treatment.  Yet when a patient is intubated, a nebulzier works better.  They conclude as I did above, that to get more of teh medicine, more breathing treatments should be given.

In the study, 7.5 mg of albuterol was given in a breathing treatment led to a reduction in resistance in 8 of 10 patients, and 100 puffs of albuterol MDI had no effect on resistance

A problem with studies like this is the method of delivering the MDI to the patient.  Later studies showed that by using appropriate spacers in the ventilator circuit, the MDI is of equal efficacy to an aerosolized breathing treatment.

Plus, as an added incentive not to use an inline nebulizer treatment, some of the aerosolized particles were impacting inside the ventilator, and this was causing problems with the machines.  This was the main reason Shoreline Medical does not allow physicians to give nebulizers treatments to intubated patients, and we use MDIs instead.

According to Claude Guerin, et all, "Inhaled Bronchodilator Administration During
Mechanical Ventilation: How to Optimize It, and For Which Clinical Benefit?, Journal of Aerosol Medicine and Pulmonary Drug Delivery, (Volume 21, Number 1, 2008), The amount of bronchodilator that deposits at its site of action depends on:

1. Amount of drug
2. Inhaled mass
3. Deposited mass

The challenges of Mechanical Ventilation on aerosolized deposition to the lungs are:

1. Ventilatory circuit
2. Endotracheal tube
3. Ventilator settings

Guerin, et al, concluded that the ETT is not as significant a barrier as once thought.  As I noted above, the key variables that effect deposition to the airway in intubated patients are:

1. Attachments of the inhalation device in the inspiratory line 10 to 30 cm to the endotracheal tube
2. Use of chamber with metered-dose inhaler
3. Dry air
4. High tidal volume
5. Low respiratory frequency
6. Low inspiratory flow (which can increase the drug deposition)

The evidence shows, according to Guerin, et al, that there is no difference between reduction in resistance from an MDI and Nebulizer in an intubated patient, and therefore either one can be used for this reason.  

However, many hospitals have chosen to use the MDI instead due to the following reasons:

1. Cost effect:  Each nebulized treatment exceeds $100, plus the cost of the medicine for each dose.  The inhaler is one charge for the medicine, which is probably around $20 (or probably less when you include the hospital discount)
2. Time Savings:  An inhaler treatment can be given in less time
3. MDI = less medicine deposition into the ventilator

Reality versus science: The Nebulizer debate

I think too much emphasis is put into how long a breathing treatment lasts.  I think too much emphasis is put into how much of the medicine is wasted. I think scientists stress over these things, but patients couldn't care less.

It's true that a treatment should last until the sputtering starts, as opposed to ten minutes.  It's true that 75 percent of the medicine is wasted, because the treatment is run continuously through the inspiratory and expiratory phases of respiration, which is a one to three ratio.

These truths seem to stress some people out.  My argument about this is: who cares? What difference does it make?

My argument is this.  When I'm having an asthma attack, I don't care about what science says.  The fact is, a breathing treatment is better than an inhaler during an asthma attack.  The reason is you don't generate good flow to inhale the medicine by inhaler.

You do not need to sit there and tap the nebulizer cup to make the treatment last ten minutes, when  most of the time all it takes is 1-2 minutes inhaling Albuterol to get your breath back.  I find this to be the case 90 percent of the time I use my nebulizer, and when I ask my asthma and COPD patients, most of them tend to agree.

The exception here is when the treatment doesn't give a person his breath back.  It's these people, those with COPD more than likely, where the cause of dyspnea is due to permanent damage to the air passages or cardiac failure, or a severe attack.  In the case of heart failure, the treatment will have nothing to do with the patient getting his breath back.  In this case it's simply rest; allowing the heart to catch up.

In the case where the treatment doesn't open the lungs all the way, having a nebulizer that has the ability to eliminate wasted medicine will not make the medicine work better.  If a patient needs more medicine, all he has to do is take another breathing treatment.  It's that simple.

There are some who want to make the treatment last longer by way of one way valves.  But I hate one way valves because all they do is make it hard to suck in the medicine.  I don't know about you, but when I'm short of breath I don't want to suck in harder.  So I pray they don't put one way valves on all nebulizers.

However, and this is where it gets tricky.  I do believe that in the hospital setting we are spreading germs through the mists we create.  Here we have patients come into the ER coughing and we place masks over these patient's airways to prevent them from spreading their germs, and then we take the mask off and give them a breathing treatment to spread those germs.

Here I think a one way valve would be nice, if it was proven to stop the spread of germs.  And considering 90 percent of the treatments we give are useless, I'm all for this.  The problem is, my boss doesn't understand why we can't just give all breathing treatments this way.  I try to explain to him that asthmatics and COPDers feel more dyspneic inhaling through the resistance created by the one way valve.

So the battle continues.

Check out what your COPD, Asthma meds cost

Ever wonder what aerosolized medicine cost. The following facts were obtained from the recent AARC "Guidelines to Aerosolized Medications."

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1. Albuterol MDI HFA:
   $30.18 (generic)
   $37.63 - $39.61 (brand name)
2. Albuterol SVN:
   $15.00 for 20 mL bottle of 0.5%; $0.38 per 0.5 mL (usual dose)
   $18.99 for 25 3-mL vials of 0.083%; $0.76/vial
3. Pirbuterol:
   $94.76 MDI (400 actuations); $0.24/puff
4. Levalbuterol MDI HFA:
   $48.99 (200 actuations); $0.24/puff
5. Levalbuterol SVN:
   $79.50 for 24 vials (0.31mg/3mL); $3.31/vial
   $70.84 for 24 vials (0.63mg/3mL); $2.95/vial
   $71.25 for 24 vials (1.25mg/3mL); $2.97/vial
6. Ipratropium MDI HFA:
   $81.75 (200 actuations); $0.41/puff
7. Ipatropium SVN:
   $77.32 for 25 vials (0.02% in 2.5mL); $3.09/vial
8. Ipratropium & albuterol CFC MDI:
   $91.99 (200 actuations); $0.46/puff
9. Ipatropium SVN:
   $123.73 for 60 3-mL vials; $2.06/vial
10. Salmeterol DPI discus:
    $111.94 for 60 doses; $1.87/dose
11. Formoterol DPI aerosolizer:
    $108.17 for 60 capsules; $1.80/capsule
12. Tiotropium DPI handhaler:
    $129.55 for 30 capsules; $4.32/capsule
13. Beclomethasone MDI HFA:
    $60.84 40 mcg/puff (100 actuations); $0.61/puff
    $73.57 80 mcg/puff (100 actuations); $0.74/puff
14. Triamcinolone MDI CFC:
    $105.99 100 mcg/puff (240 actuations); $0.44/puff
15. Flunisolide MDI CFC:
    $77.55 250 mcg/puff (100 actuations); $0.78/puff
    HFA-MDI (Available in 2007)
16. Fluticasone HFA-MDI:
    $78.24 44 mcg/puff (120 actuations); $0.65/puff
    $104.74 110 mcg/puff (120 actuations); $0.87/puff
    $170.82 220 mcg/puff (120 actuations); $1.42/puff
17. Budesonide SVN:
    $149.35 for 30 vials of 0.25 mg/2 mL; $4.98/vial
    $165.80 for 30 vials of 0.5 mg/2 mL; $5.53/vial
18. DPI (Turbuhaler):
    $152.56 (200 inhalations); $0.76/dose
19. Mometasone DPI (Twisthaler):
    $143.62 (120 doses); $1.20/dose
20. fluticasone/salmeterol DPI (Diskus):
    $146.47 for 100/50 mcg/dose (60 inhalations); $2.44/inhalation
    $166.99 for 250/50 mcg/dose (60 inhalations); $2.82/inhalation
    $229.87 for 500/50 mcg/dose (60 inhalations); $3.83/inhalation
21. Budesonide/formoterol DPI (Turbuhaler):
    (Available in 2007)
22. Cromolyn CFC-MDI:
    $107.89 (200 actuations); $0.54/puff
    $71.28 (112 actuations); $0.64/puff
23. Cromolyn SVN:
    $46.61 for 60 vials (20 mg/2mL); $0.78/vial
24. Nedocromil CFC-MDI:
    $81.43 (104 actuations); $0.78/puff
25. Acetylcysteine SVN:
    $7.99 for 10 ml vial of 10% Solution
    $14.99 for 10 ml vial of 20% Solution
    $7.99 for 10 ml vial of 20% Solution
26. Dornase alfa SVN:
    $1,589.32 for 30 2.5-mL vials; $52.98/vial
27. Tobramycin SVN:
    $3,391.92 for 56 5-mL vials; $60.57/vial

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The six different types of respiratory therapists

There is much resistance to change inside the RT Cave. After much thought on the matter, I have figured out why. It has everything to do with the six different types of Respiratory Therapists (RTs).

Many RT Caves do not have protocols. I've heard every complaint

Very, very slowly I think doctors are becoming more and more receptive to the benefits of adding respiratory therapy patient driven protocols. In real time seems tortuously slow, but I think in ten or twenty years we might be talking about some major changes in the rolls of RTs.

While this is true, there are still many RTs themselves who don't seem to be receptive to change. This became ever more so apparent to me after reading an excellent column over at Snotjockeys Revisited, "Clinician Resistance to Adopting New Practices".

I agree with her, and have my own experience to add to the mix.

A fellow RT, Dale, is very fun to work with. He's intelligent, a great RT; but he is a constant complainer. He complains in a fun way, but nevertheless he is still a complainer.

"I circled all the indicated treatments on the board," he said the other day in report.

"Um," I said, looking over the list of patients, "there are none circled."

"That's my point," he said, and chuckled.

One day he handed me a list. I looked at it thinking it was serious at first, then I started to laugh. On it was a list of 'olins that he made up. (You can view parts that list at the bottom of this blog)

He said, "I bet that 60% of what we do here is absolutely not indicated."

I'm a firm believer that if you're not having fun with your job what's the point. So we make fun of our job. We make fun of doctors, we make fun of nurses, we joke around during a code. I think that's medical humor, and we do it to maintain our sanity.

I check doctor blogs and nurses blogs, and I see their humor all the time.

But humor is one thing, complaining is another. And complaining with Dale is fun, but most complaining in the RT Cave is simply annoying. I avoid it every chance I get. If I have no choice but to give report to a complainer, I give a quick report and scram.

I used to work with Dale a lot. In fact, I'm glad I had that opportunity to work with him because I learned much and he helped me develop my RT humor. However, I was never going to get anywhere via complaining. Complainers rarely get anything accomplished. But they are abounding in the department.

What's that old saying? "Complainers say more about themselves than the person they're complaining about."

I realized this, and I switched weekends. Now all the complainers work with Dale on the other weekend. The RTs who work on my shift are Jane Sage, a very optimistic, intelligent and fun to work with person. And we have Dee, who happens to be a complacent RT (see list below).

Jane had an epiphany one day, and decided the laid back RTs on our weekend are awesome, and she started referring to us at the "A" team. We called the RTs on the other weekend the "B" team. Once the "B" team got wind of this they decided that they were the New "A" team.

"That's fine," Jane said, "We won't tell them that "A" now stands for Anal and "B" now stands for Better than Anal."

Despite the complainers, we have enough "balance" of different personalities to make things work in our department. You need the complainers so we know of our faults, we need the anal people to make sure we get all our work done, we need the content people to boss around, the laid-back people to ease tensions, and the clowns to make us laugh.

I'd even go as far to say we have a great department. I suppose that means we have good balance. I'm sure the members of this RT Cave are no different than any other.

With this in mind, I created the following list. Based on my experience working with many RTs in the past 10 years, these are the six different types of RTs:

1. The stepping stones: These are the RTs who use the career of RT as a stepping stone to a more illustrious medical profession. In my humble opinion, this is the way to go. What better way to learn about medicine than through the eyes of an RT. I'm serious here.


2. The quitters: These are the RTs who don't like to work. Some "Quitters" take a job of RT because they think it will be an easy job and they won't have to do anything. As soon as they learn what RTs really do, they either quit or are forced out the door.


3. The contents: They are the happy-go-lucky RTs who never complain. They are the RTs you love to give report to because they are always happy. They rarely make any effort at learning new information other than what is required. They usually prefer not to work with critical patients, and when they do they never question doctors and they prefer to be button pushers. Usually, you will see these RTs happily knocking off treatments on the floors.


4. The complainers: This composes probably about 60% of all RTs. These are usually very intelligent people who love the career of respiratory therapy in theory, but hate the reality of it. They are usually well up on all the new technologies, and are very quick to question doctors or offer suggestions. However, while they are not happy, they do nothing to better their career field. After working for a while, they become frustrated and content and they give up. One of the reasons they are so frustrated is that they have decided that they are too old to get another job, or have families which makes changing jobs difficult. Yet, while they complain, they do not support change.


5. The optimists (or learners): These are the RTs who write blogs. They may or may not be more intelligent than complainers, but they love to learn. These are the RTs that consistently do research on the Internet and read magazines. These are the RTs that attend every seminar possible. These are the RTs who write the protocols and make recommendations for new equipment, and then write the policy and procedures for this new equipment. These are the RTs who learn about things like Graphics and educate the rest on how to use them. These are the RTs who make the best of their career even though they know there are a lot of forces working against them. Most important, these are the RTs every one in the department loves to talk to because they are good listeners (they listen because they love to learn). More often than not, they work with the leaders to solve these problems as they occur. They often let other RTs take credit for the work they do. They do this to keep morale in the department high. In essence, the optimists are the strings that keep the department together. A department without optimists does not run very well.


6. The leaders: These RTs, while far and few, take charge and lead. They make changes to the RT Cave and they are resented for it. They make sure everything is stocked. They make sure all the i's are dotted and the t's crossed. They are usually opposed to protocols because they don't want to "rock the boat", but they won't say so openly. They listen to the rants of other RTs, but they usually side with the administration on issues. They question RTs who question the status quo. You might hear them at an RT meeting saying something like, "Don't you think protocols might actually create more work for you guys." When they say things like this, they are catering to the complainers, who will work with them to stymie any change. The leaders do no like change because it goes against their philosophy of "do not rock the boat." It is also important to note that while most leaders are good people with normal home lives, they are often hated and revered at work. Complainers often do not get along with them, and optimists are often seen working with them "for the better of the department."

I can give examples galore, but I'll give just one more.

Even though she had several protocols shot down years earlier, Jane wrote a new and updated ventilator set-up and weaning protocol. The complainers in our department all said it would never be approved by the doctors.

Jane trudged on nonetheless. She had the support of me, another optimist, and Dee, the easy going content on our weekend. Finally, with a bit of luck, the protocol was approved.

With our confidence on high after, Jane and I wrote a breathing treatment protocol we thought might work. We were very proud of our efforts. We thought we'd show it to our co-workers and get their support.

I showed it to Dale first. Surely he'd approve of it since he was the most outspoken RT about useless and not-indicated breathing treatments.

I couldn't have been more wrong.

"So what do you think?" I said after he stared at it for several long minutes, grunting and sighing often.

"Well," he paused while staring off, then spoke slowly, "The biggest offenders will still abuse the system. If it does anything it will just create more work."

"Okay," I said. I made no effort to change his mind. I walked away. No point in beating a dead horse.

Jane brought up the protocol at a department meeting. Gary, the department head and quintessential RT leader, said: "It is possible you might just be creating more work for yourselves by doing this."

He may be right; he may be wrong. Either way, Jane and I keep moving forward. And that's easier to do now that we know about the six different types of RTs.

The latest research on Atrovent

As I wrote last night, we have a doctor here at Shoreline who loves to order Atrovent. Even if a patient needs a continuous treatment, it will be Duoneb, Duoneb, Duoneb, Duoneb and Duoneb. And then an hour later it will be Duoneb again.

I graduated from respiratory school in 1997, and was taught that Atrovent should ideally be given QID but never more frequently than Q4. I don't see what it would hurt to give the drug more often than that, but I also wasn't taught that it had any added benefit either.

But now we have Dr. Krane ordering it galore. She even orders Duoneb on pediatrics and Neonates. Umm, I was under the understanding that it was a drug for COPD patients mostly, or at least just adults. National Jewish Medical and Research Center verifies this.

However, I suppose I could be behind the times in my research. And, as I also wrote yesterday, so too are the other doctors behind on their research, because they still follow the old Atrovent routine.

There is one exception, though, and that would be Dr. Kipper on the floor. He's a new Internist who likes to order Q4 Atrovent treatments. My thinking about this is: why not just go with the inhaler.

So, do these doctors know something I don't? If you guys have any research on this, I'd really appreciate it. I've asked RT students that mosey through here and none of them have heard of anything. I figured if anyone would be up on the latest research it would be the RT teachers.

I did manage to find one article on the Internet "Evidence-Based Medicine for Student Health Services" by Dr. Robert J. Flaherty, MD, of Montana State University, which reports:

The addition of a single inhalation of anticholinergics (such as Ipratropium bromide) to a beta2-agonist regimen may improve lung function in children and adults with acute exacerbations of asthma treated in the emergency department. Multiple-dose anticholinergics improve lung function and may avoid hospitalisation in severe exacerbations.

Dr. Flaherty also lists some studies.

I found a second website which states the same: "(Anticholonergic) can be useful adjunct to beta-agonist in exacerbations for both adults and children-- NHLBI guidelines recommend considering in severe exacerbations." He lists several studies.

Another study from the University of Michigan that states Atrovent works on acute asthma exacerbations in children.

So, based on these reports, the excessive use of Atrovent may benefit Asthma patients, but this still doesn't get to the bottom of every treatment including Atrovent as Dr. Krane does.

Now I have absolutely no problem with giving Duoneb more often than Q4. But, if Atrovent is something that will benefit every person in need of a neb, then I want the other docs to know about this too.

Either way, if these studies are credible, then Atrovent should be given to Asthmatics, and multiple Duoneb treatments do work. If this is true, Dr. Krane appears to be up to date on her research.

If you guys know something I don't, let me know. Sometimes we can be behind the times here at Shoreline, and it's my job to catch us up.