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

Does albuterol treat pneumonia?

Many times in the hospital setting physicians order scheduled albuterol breathing treatments for patients admitted with pneumonia.  The question of the day is: does ventolin have any effect on pneumonia?

First of all, what is pneumonia?  Pneumonia is an inflammatory disease of the peripheral airways, particularly the alveolar (air) sacs.  The air sacs may become filled with fluid or pus, causing symptoms such as cough with colorful phlegm, fever, chills, and dyspnea.

So, what is the evidence that albuterol benefits pneumonia?  So far I have not been able to find any studies in this regard.  I am told there was a study done in the late 1980s, and the results were inconclusive.

Lacking studies, let's investigate the available wisdom.

1.  Pneumonia is an inflammatory disease.  To this date there is no evidence that albuterol has anti-inflammatory properties.

2.  Albuterol is attracted to beta 2 (B2) adrenergic receptors lining the smooth muscles that line the air passages in the lungs.  There is no evidence of smooth muscles in the alveoli, and no evidence of B2 receptors in the alveoli.

3.  Nebulizers are ideal for the inhalation of B2 adrenergic medicine because it creates aerosolized particles the size of 0.5 microns, an ideal size for medicine to get to the air passages.  For the medicine to get to the alveoli the nebulizer would have to produce aerosolized particles 0.1 to 02 microns.

4.  Pneumonia may cause a cough with increased secretions.  There is evidence that albuterol may increase mucociliary clearance and enhance cough.  However, in order to produce this effect a dose greater than the standard dose of 2.5 mg (0.5cc) would be necessary.  Studies regarding albuterol and mucociliary clearance were reviewed by Dr. Ruben D. in the September, 2007, issue of Respiratory Care, "Inhaled Adrenergics and Anticholinergics in Obstructive Lung Disease: Do They Enhance Mucociliary Clearance?"

5.  Some patients diagnosed with pneumonia who will claim to breathe easier after a treatment with albuterol.  However, the reason for this is because some patients with pneumonia present with bronchospasm secondary to pneumonia. The albuterol will treat the bronchospasm.  This is most likely to occur in patients with underlying or undiagnosed asthma.  While clinical evidence may suggests albuterol opens up air passages and breaks up secretions to enhance cough, no studies have been done to show this.

6. Cavallazzi R, et al shows that inhaled corticosteroids (mainly Budesonide) are the most widely used agents to treat pneumonia, as they are shown to have anti-inflammatory properties. They are generally recommended, with albuterol, to prevent COPD exacerbations in patients with severe COPD.  However, inhaled steroids may be systemically absorbed and have immonosuppresant effects.  The evidence that inhaled steroids may actually lead to pneumonia is modest.

7.  Systemic steroids are shown to reduce inflammation associated with pneumonia, and are a common treatment option. 

8.  Antibiotics are also frequently prescribed for pneumonia, considering most are caused by bacterial agents.

Conclusion:  There is no evidence that albuterol particles even make it to the alveoli, and even if they did make it there, there is no evidence they would produce any effect on the pneumonia. The best treatment for pneumonia should be inhaled or systemic steroids and antibiotics.

However, an initial treatment of albuterol may prove beneficial in opening up air passages when bronchospasm is present, and help break up secretions to enhance cough and expectoration.  This author recommends a trial and then PRN if the trial proves beneficial.  

What causes pneunonia?

Pneumonia is a disease where the normally sterile lungs become infested with a pathogen. It usually occurs because the normal immune defence mechanisms do not function properly. Inflammation occurs in the lung parynchema, particularly in the alveoli, causing fluid buildup in that region.

Bacterial pneumonia is the most common pneumonia, and it can usually be identified by crackles heard only over one particular lobe, such as only in the left lower lobe, or only in right lower lobe. Bacterial pneumonias are treatable with antibiotics.

Pneumonia can also be caused by a virus or fungus, with viral pneumonias being the most difficult to diagnose and treat. Viral pneumonias usually effect more than one lobe of the lung, and usually result in crackles in both bases or crackles throughout the lung fields mimicking pulmonary edema. Viral pneumonias tend to be more deadly than bacterial.

The following are factors that predispose a patient to bacterial pneumonia:

A. Airway Disease: Increased sputum production

1. Chronic Bronchitis: Unable to bring up sputum due to loss of cilia
2. Asthma: Increased sputum production
3. Bronchiectasis: Sputum too thick to expectorate (Cystic Fibrosis)
4. Obstructed bronchus due to tumor:
5. Smoking history:

B. Poor cough:

1. Neuromuscular disease: Weak respiratory muscles
2. Emphysema: Loss of lung tissue
3. Abdominal pain: Post operative patients don't want to take deep breath due to pain
4. Drug overdose: Relaxed respiratory muscles

C. Reduced gag reflex and aspiration:

1. Drug overdose:
2. Alcohol abuse:
3. Stroke:
4. Neuromuscular disease:

D. Decreased immunity:

1. Leukemia
2. Chemotherapy:
3. AIDS: They are highly susceptible to pneumocystis carinii pneumonia
4. Organ transplant:

E. Chronic diseases

1. Diabetes:
2. Cirrhosis:
3. Renal Failure:
4. Heart Failure:

F. Procedures:

1. Intubation: Bacteria pushed down by insertion
2. Mechanical ventilation: Ventilator acquired pneumonia
3. Use of humidifiers and aerosols: Creates breeding ground
4. Lack of handwashing: #1 most preventable
5. Lack of sterile technique:
6. Contaminated equipment:

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Pneumonia readmissions on the decline

It appears Shoreline Medical is doing something right, at least when it comes to pneumonia readmission rates. As, compared to the national pneumonia readmission rate of 18%, our hospital had only a 2% readmission rate for the given time period of about a year.

Because of this, I was chosen to give a presentation to a group of respiratory therapy supervisors and managers. This was a unique and exciting opportunity for me, especially considering I was the lowest ranking RT at this meeting. Plus my boss chose me among all my peers to give the presentation.

I worked with the Quality Assurance Analyst for our hospital and created this really nice presentation. Then I spent quality time interviewing, going through charts, and researching all the things we do once a patient is diagnosed with pneumonia, and what we do to keep pneumonia rates down.

I actually learned quite a bit in this process about the administration side of things. What follows here is a summary of my presentation:

A goal at Shoreline Medical is that we all have our priorities in order.

Shoreline Medical is in a small town only a few miles off the shore of Lake Michigan. It's in a small town, a close nit community. And being a close nit community results in a close nit hospital. One of the reasons I chose to work here is because I felt Shoreline was kind of had a down home feel to it. Everyone got along, were good friends, had pot lucks, and stuff like that.

We started the process of getting our ducks in a row by focusing on the CMS Core Measures. To make sure all doctors, nurses and respiratory therapists are always thinking about the core measures, we are all in serviced on this every year by the Quality Assurance Department.

In the chart, before the doctor's orders section, is a bright orange laminated sheet that has all the core measures on it. This way, every time anyone looks at the orders he or she has to flip this page aside. And even if you don't read it, you know what's on it: the core measures. This is one simple reminder to everyone to focus on the core measures when writing and fulfilling orders.

The Core Measures for pneumonia are as follows:

1. Initial Antibiotic Timing (given within 6 hours)
2. Pneumococcal Vaccination if eligible
3. Influenza Vaccination if eligible (October to March)
4. Blood Culture drawn before initial antibiotics
5. Appropriate antibiotic selection
6. Smoking cessation advice and counseling given if indicated (if patient has smoked within the last 12 months)

The most important of the above are the pneumococcal Vaccination, Influenza vaccination and smoking cessation, as studies have linked all three with a reduction in secondary pneumonia. So our major emphasis was on these three.

These core measures are what works according to the most recent best practice evidence to improve patient outcomes and decrease costs for pneumonia patients. The question we had to ask ourselves is: how do we use these core values to get our ducks in a row

Data from our core values back in 2007 showed that Shoreline Medical was about 80% in all of these core measures except for antibiotic timing within 6 hours. In this, we had no data whatsoever, which means we probably didn't even do it.

Yet if you look at data from the first and second quarters of 2010 you can see that we are at or near 100% on nearly every core measure. When it comes to smoking cessation we were at 92%, yet that was basically due to a miscommunication between a doctor and a nurse. So even while we've improved, we still use this data to improve even further, as there is always room for improvement.

So basically back in 2007 we did not have all our priorities in order, and in 2010 we did. So how do we get our priorities in order?

Actually, if you look at pneumonia readmission data other than the above mentioned three month period our hospital at at 16.5%, which is no different than the U.S. National Rate. .

Yet from January to March 2010. During that span we had 52 pneumonia patients, and only one readmission rate.

These improved statistics based on the core measures show we are doing something right. They prove that we have our ducks in a row. The question you are asking is: how did we get our ducks in a row?

The first thing we did was back in 2007 we joined the Keystone Collaborative. We have a champion Internist, a physician from ER, and one from surgery and general practice as our champions. Then we have one nurse from critical care, the general floors, and one from the emergency room.

We also have a representative from lab, x-ray, pharmacy, quality assurance, computer analysis, respiratory therapy (that's me) etc., and we meet every month to analyze data from core measures to create and improve clinical pathways and order sets to improve patient outcomes and reduce costs for our hospital.

The key here is that we review modern wisdom and come up with better practices for our hospital. Anyone can do research, or come up with new ideas, and can share them with any member of the keystone

committee, and then this new wisdom is brought to and reviewed by the committee and changes are made as appropriate.

Basically the point of the Keystone Committee is to do what works and skip doing what's not working.

The following is our pneumonia order set:

Our order set includes the following as options for the doctor to check:

• Code status
• Vitals routine or ___________
• Record input and output, daily weight, pulse oximetry every shift
• EKG on admission
• Chest x-ray on admission and on day 3
• Lab work (if not already done): CBC, CMP, UA, Sputum for gram stain, culture and sensitivity, blood culture prior to administration of antibiotic (this has to be done within three hours of admission)
• AM labs_______________
• Oxygen at _______ lpm or per protocol or _________
• Respiratory treatments: Albuterol 2.5mg with 3cc normal saline Q6 hours, up to ____ hours prn
• Respiratory treatment: Atrovent 0.5 mg in 2.5 ml normal saline QID
• Antibiotic therapy (1st dose to be given in ER) or immediately after blood culture drawn)
• Community Acquired Pneumonia (non CCU): Levaquinn 500 mg IVPB Q24 hours times 3 days, then Levaquin 500 mg PO daily
• Community Acquired Pneumonia (CCU or stepdown patients): Rocephin 1 gm IVPB Q24 hours and Zithromax 500 mg IVPB Q24 hours and Levaquin 750 mg IVPB Q24 hours and Azactam 2 GM IVPB Q12 hours
• Nosocomial Pneumonis (check all that are indicated from list of meds and doses)
• IV Fluid ____________
• Tylenol 650 MG PO Q4 hours prn for pain
• Xanax 0.25 mg PO Q6 prn for anxiety
• Restoril 15 MG PO QHS prn for insomnia
• MOM 30 ML PO BID prn for constipation
• Robitussin 10 ml PO Q4 hours prn for cough

(I left a few things off, but that's basically the gist of it).

This is our pneumonia hymn book. It's all the things that the best practice evidence shows works to help pneumonia patients get well. It's one sheet of paper, which makes it very simple.

As you'll note, some of the things on here are automatically ordered -- the doctor has no choice. For instance, x-ray on admission and in the am times three days, and certain labs on admission and in the am.

The ER nurses are involved right away, because if that patient is in the ER at the five hour mark, they have to make sure a sputum is obtained, and that the patient has been given that initial antibiotic within 6 hours. They have a system to assure this is done, and checks and balances.

As soon as the patient is admitted, the orders are entered into the computer system, and reminders are automatically sent to all the respective departments as to what they have to do and when. In RT department sheets are printed off so we know what our role is for that patient.

For lab and x-ray, what they have to do is printed up on their respective printers, and plus the procedures they have to do are put on the tracker when they are due so they are reminded in that way too.

It's simple. This order sheet is our hymn book: it makes sure we are all singing from the same hymn book.

Then we have our extubation protocol (to see our extubation protocol click here). This order set is part of the ventilator bundle. It works similar to the pneumonia bundle, in that when it comes to intubated patients, it makes sure we are all singing from the same hymn book.

The neat things about our extubation protocol is that when we were in school in 1995 we learned that the cuff pressure should never exceed 20 cwp. Now we are taught to always exceed 20 cwp. The reason is to prevent aspiration , and to prevent ventilator acquired pneumonia.

Another thing to prevent pneumonia is that the circuit not be broken. To do this we use MDIs instead of nebulizers. Also, we do not disconnect the circuit to suction, and use in line suction catheters instead.

Another key is the daily sedation protocol. Every night around 2 a.m. we automatically take all our patients off sedation so that by 6 a.m. we can analyze the patient for readiness to wean.

Here comes another laminated sheet. As part of our ventilator protocol we have a sheet that acts as an algorithm to speed time from intubation to extubation. Actually, the key to a good extubation protocol is that as soon as the patient is intubated we start thinking about extubation.

If the patient can be extubated in 2 hours, now that's possible. Years ago if the attending went on vacation the other doctors didn't extubate because they didn't want to offend the attending. Sometimes we RTs would wonder why the patient was still intubated. Now, that never happens, or rarely happens.

Our Algorithm goes something like this:

Weaning Screen:

1. FiO2 less than or equal to 40%
2. PEEP less than or equal to 5
3. HR greater than 50 or less than 120
4. Temp. less than 100.5
5. SpO2 greater than 90 unless otherwise directed by physician
6. Systolic BP greater than 90
7. Minimal or no sedation
8. No Vasopressors
9. No signs of respiratory distress
10. Able to follow commands
11. Adequate cough
12. Secretion thin and minimal
13. Plateau pressure less than 30 cwp

If the answer is no, then you stop and reanalyze the next day. If the answer is yes, then you move on to the next step, which is to do a 5 minute spontaneous breathing trial (SBT). (ETT 8.0 or greater use a CPAP of 5 and PSV of 0, ETT 7.5 or smaller use CPAP of 5 and PSV of 5)

Now you do a second weaning screen based on the same criteria as above.

If the patient fails the screen, the SBT is stopped and patient returned to previous settings.
If the patient passes, the following is completed and analyzed:

1. NIF greater than 20
2. VC greater than 10 ml/kg
3. VT greater than 5
4. RR less than 30
5. VE greater than 5 and less than 15
6. RSBI (f/vt) less than 100

If the patient passes this criteria, continue SBT for 30-120 minutes. Then do another weening screen as mentioned above. If patient passes do an ABG and call physician for order to extubate.

So basically we no longer simply do weaning parameters every day, we are actually completely assessing the patient using the common sense, best practice evidence approach. Patients are getting extubated quicker, and VAP is now pretty much nonexistent at our hospital.

Another key is education. As soon as the pnuem order set is initiated the emergency nurse educates the patient about pneumonia. Then the nurse on the floor educates the patient, and then the RT is in the room every six hours, and he or she educates the patient some more.

We make sure not only do our patients learn about pneumonia, they also know about their disease. For example, if they have COPD we make sure they know the early warning signs of an exacerbation so they can nip it in the bud next time and don't have to be readmitted.

We make sure they know if they start to get more short of breath than usual, or have increased cough or sputum production, or change in color of sputum, that they call their doctor or come into the emergency room.

Plus, as soon as pneumonia order set is entered in the computer, an order for RT to do smoking cessation is printed off in the RT department. Several studies show that if when a patient is vulnerable, when he's sick in the hospital, that if someone nudges them to quit they are more likely to quit.

And then when the patient is discharged another paper is printed off that is a pneuminia fact sheet for the patient to take home with them. It is basically a reinforcement of everything they've learned about pneumonia, and is reviewed by the discharge planner.

It's also a reminder to the RN to make sure the patient has had his vaccines while admitted, and to reinforce to the patient that they get their annual pneumonia and flu vaccines.

So basically the pneumonia order set is our hymn book: it gets everyone on the same page from the RT to lab to nurse and x-ray and lab and doctor. We all know exactly what our role is for that patient

Another thing we have an emphasis no is good hand washing. We have signs over every sink that remind of the importance of hand washing. Another sign over every sink describes proper hand washing technique.

We also have hand sanitizer in every room and in various locations, and we encourage or professionals to use this between every patient, and after touching anything in the room, and before touching anything even on their own possession. We also encourage use of hand sanitizers before leaving the room, even if they ultimately wash their hands.

We have some of our nurses are anonymous spies who make note of who they see not washing their hands, or not doing so correctly. We have other pamphlets around the hospital that remind nurses, RTs, and even patients to keep your eyes open, and "It's okay to ask."

So good hand washing is key to preventing the spread of infection.

Another bonus at Shoreline is we are a close nit hospital. This results in really good communication. For example, if I'm in the room and I see something wrong with the patient, I talk to the nurse or sometimes I go right to the doctor.

Instead of the nurses calling the doctor and assuming they know what's wrong with the patient, they often call RT instead so we can use our experience and education to work with the nurse in deciding what needs to be done.

Likewise, many times the doctor calls me up and asks me what I'm thinking is wrong with the patient and what we should do. This is great for morale.


We also have a Rapid Response Team. And another thing is we have good support and encouragement. For example, if an RN calls me to assess a patient, and the patient is fine when I get their, is on the crapper or something, I don't say, "You stupid dummy. Why did you waste my time?"

Instead I say, "Hey, that's fine. You were being proactive. That's good. It's better to be safe than sorry. You did great."

Besides, it's better to be proactive than reactive. If you're proactive you are nipping it in the bud. If you're proactive you may stop the problem from occuring, and then you get no credit. But it's better to be proactive and get no credit becasue the problem never occured, than to be reactive. If you're reactive, that means the problem already occured.

It means the patient is already septic, or in failure, or whatever. If you're being reactive, it means the patient is already in need of critical care services, and may need to be in the hospital longer, and cost the hospital more. If your'e proactive, that means improved outcomes and reduced costs.

So it's better to be proactive than reactive.

So starting with the core measures, the keystone collaborative and weekly keystone meetings, to the pneumonia bundle, and then with the small town close nit touch, we have been able to get all of our priorities in order here at Shoreline Medical. That's how we did it.

Thank you. Any questions.

For more information, check out the following resources:

• AHRQ (Agency for Healthcare Research and Quality) http://www.ahrq.gov/
• MHA Keystone Center http://www.mhakeystonecenter.org/
• MPRO http://www.mpro.gov/
• Quality Net http://www.qualitynet.org/
• Blue Cross/Blue Shield www.bcbs.com/innovations

This RT is impressed tonight

I was in the process of doing an EKG while Tracy, the new nurses practitioner, questioned the patient. The NP said, "Does your chest pain hurt more when you take a deep breath?"

"No," the pt. said. "But my doctor did put me on breathing treatments when I saw him last week."

"Why were you put on treatments?"

"Because the doctor said the treatment would help loosen up phlegm from the part of the lung the pneumonia was and help me feel better. But I don't notice a bit of difference and I've taken them now for two weeks."

"Well," the NP said, "That's not what treatments are for."

My face lit up. Tracy looked up at me and smiled. She worked with me years ago on nights. She learned well.
---------------------
So, then I ended up back in the ER 30 minutes later with Tracy and the ER Doc standing next to us, "So, I just don't think when that guys doctor says Ventolin will thin secretions that that's the purpose of the medicine, don't you think?"

"Absolutely," I said. "The medicine doesn't even go to that part of the lung the pneumonia is. But, believe it or not, our protocol upstairs has us doing Ventolin every 6 hours on all pneumonia patients."

The old ER doc said, "I guess they just want to assume Ventolin cures everything and not just bronchospasm."

This RT was impressed. Wow! Not only is the new NP educated properly about Ventolin, so is the old ER Doc.

This is a step forward in the battle for bronchodilator reform.

Answers to your web search querries

Here are my responses to Internet search engine questions that lead someone to my blog.

1. do respiratory therapists still do floor bronchodilator therapy: It really depends on where you work. In most hospitals I'd say yes. But I have a co-worker who used to work in Detroit, and he said the RTs didn't have time to do floor therapy. After the initial set-up, floor therapy was basically done by the RNs. At most hospitals, though, RTs do floor therapy.


2. serevent and pneumonia: I don't see what good Serevent would do for pneumonia. Serevent is a bronchodilator, and bronchodilators dilate bronchioles. Bronchodilators are not made to go into the alveoli where the pneumonia is. So, unless there is some kind of underlying bronchocontriction going on, I see no benefit from using Serevent. That's my humble opinion based on scientific research. Some doctors, however, will disagree with me, and they have a right to.


3. overdoing albuterol: How do you define overdoing? Is overdoing Albuterol what you refer to bronchodilator abuse? If that's the case, how do you define abuse? Is abuse using it more than the guidelines recommend? If that's the case, guidelines don't take into consideration individual uniqueness.


4. cardiac asthma: To make it simple, this is where the left side of the heart fails, causing fluid to back up into the lungs. This causes an increased pulmonary blood pressure, which in turn squeezes the bronchioles and causing them to wheeze. This is not the same as bronchospasm, and therefore bronchodilators will not work to fix this problem. To solve this problem, cardiac medications and, perhaps, some diuretics are the therapy indicated here. However, since the lung sounds are annoying to most doctors and RNs, a bronchodilator is often ordered, even though it has no effect on cardiac asthma or the cardiac wheeze it creates.


5. i don't want to be a respiratory therapist anymore: You have to remember that this IS a job, and the purpose of any job is to make a paycheck. And, one must also take into consideration that the grass is not always greener on the other side. Likewise, a job is what you make it to be. If you do not like your job the way it is, you can make it what you want it to be. Or, there is always the unpopular option of complaining.


6. body therapy: If you are bored, you can always blow some Albuterol over your skin. It has the effect of smoothing it out and, at the same time, it's relaxing.


7. respiratory therapists frustrated with doctors: It happens. Some doctors write stupid orders.


8. fake acls cards: What would be the purpose of this?


9. lizer liposuction: I don't think Ventolin will help you lose weight. Oops, hold on! It can. Check this link out. So Ventolin might be an option. What should we call this? Liposucion-olin? I don't know much about liposuction (not my game), but I've heard it benefits some people. I have no idea why this question lead someone to my sight.


10. what stops the hypoxic drive: Oxygen. The hypoxic drive is real, it's the hypoxic drive theory that is a fallacy.

If you have any further questions, check out the q&a link to the right, or feel free to contact me anytime: Freadom1776@yahoo.com.

Preventing Ventilator-Associated Pneumonia

How to prevent Ventilator-Associated Pneumonia has been extensively studied. Here are the most common recommendations. Chances are your hospital has already incorporated most of these.

1. Ventilator Bundles are protocols based on best practice medicine. These should be incorporated in all critical care units to assure all of the following guidelines are met. 
2. Good handwashing
3. Sterile technique (as much as possible)
4. Implementing a ventilator extubation protocol to speed up time from intubation to extubation. 
5. Making sure the cuff pressure is always 30 CWP or greater. The idea here is that this will prevent secretions from leaking around the cuff. Higher pressures are acceptable so long as intubation is short term, which is the goal of any intubation.
6. Tracheotomy should be considered for anyone requiring greater than seven days of mechanical ventilation. 
7. Heated wires should be used to limit opening of the circuit (this seems to be no longer an issue)
8. Inline suctioning (such as a Ballard) should be used instead of tracheal lavage and suctioning. Lavage and suctioning can still be used, although this should be left to the discretion of the respiratory therapist. 
9. The head of bed should be raised 45 degrees at all times to prevent aspiration of stomach contents. This should be started as soon as possible, and may even be started in the emergency room prior to the patient being transferred or admitted to critical care.
10. A feeding tube should be inserted to assure adequate nutrition. 
11. The mouth should be washed with a Chlorhexidine Oral Rinse and suctioned out every two hours (as appropriate). Studies have shown a good mouth cleansing can greatly reduce the chance of VAP.
12. Do not use heat and moisture exchangers unless absolutely necessary, such as when you need to transfer the patient. Studies have shown HMEs tend to increase likelihood of VAP.
13. Sedatives should be limited. There have been a lot of studies and discussions on the use of sedatives on intubated patients. Some suggest limiting sedation in the morning to make sure the patient is awake, cooperative, and understands the plan. Ideally, sedatives should be stopped at least four hours prior to beginning any weaning screen.
14. Studies show that it is most effective if the circuit is changed weekly, as opposed to daily as the best way of preventing VAP.
15. Daily chest-x-ray to monitor for signs of pneumonia
16. Sterile technique and proper technique when inserting lines. We are all instructed to monitor physicians to make sure they use this proper technique.
17. Stress-ulcer prophylaxis (this would be part of the ventilator bundle, and would be a nursing protocol. Ours includes a daily proton pump inhibitor like Prilosec (omeprazole)
18. Prophylactic antibiotic therapy (of course there is controversy here too). This is to prevent infections such as pneumonia and sepsis. 

These are some ideas that have been researched over and over the past several years. Newer studies are changing some of the older ideas we had regarding intubation. For instance, back in 1997 when I attended RT school, we were taught never to exceed a cuff pressure of 24 cwp to prevent the occlusion of blood flow. So, as you can see, this has changed considerably, although it's supposedly all for the better. 

Intubation and mechanical ventilation is not a science: it is an art based on a science. So, as you will learn (or have learned) in this profession, we do the best we can with what we know today, and as we learn more we do better. This is the case with advancements in intubation and extubation, as it is in other areas of healthcare. 

Pneumonia: Here's how you can prevent it

As I wrote in yesterdays post, over 3 million people are diagnosed with pneumonia each year, 500,000 require admission to the hospital.

A question I get often from my patients is: "What can I do to prevent myself from getting pneumonia?"

To get a good overall idea of what pneumonia is, and who exactly is at risk, you should check out the post I wrote yesterday, which I will link to here.

Every person, particularly the elderly (over age 65) and/or chronically ill, should keep pneumonia in the back of their mind, because chances are they are at a high risk of getting it. There are a few simple things you guys can do to reduce the risk of getting pneumonia.

Keep in mind, however, that there are no guarantees.

The simplest thing you can do is wash your hands. There is no more effective thing you can do to prevent the transfer of viruses and bacterias than by simply washing your hands often.

Another simple thing you can do is get the pneumonia vaccine offered to you by your doctor. Currently, there are vaccines available for pneumonias caused by pneumococcal pneumonia, Haemophilus influenzae, and influenza virus.

Respiratory-lung-healthcare.net reports that the vaccines are about 80% effective in young adults, but not so effective in those who are at high risk. Likewise, not all pneumonias have a vaccine. Needless to say, that's no revelation there. Many patients who have been diagnosed with pneumonia also say they received the vaccine.

Thus, we obviously cannot rely just on the vaccine to prevent pneumonia.

So, besides vaccines, the best therapies to prevent pneumonia is cough and deep breathing exercises (with a good 3-6 second breath hold), and exercise, even a simple walk around the room can be effective enough to prevent pneumonia.

At our hospital, doctors order all patients at high risk for pneumonia to be provided and instructed on the use of an Incentive Spirometer (IS). It is their belief that any patient can do an IS, and that it's equally effective in preventing pneumonia in all patients. However, that is not always the case in the ideal world.

That in mind, here is the long version of what I tell my patients:

"Many years ago pneumonia was very prevalent in hospitals. Many post-op patients were getting pneumonia, and many of them were dying. Familiar with these statistics, some wise person decided that they were developing pneumonia because they weren't taking in deep breaths.

"Normal healthy people take in three or four sighs every hour. This is the bodies natural mechanism for exercising the parts of the lungs that are not used during normal respiration's.

"However, when you become debilitated in one way or another, you are elderly, weak, sore from breaking your ribs, sore because you had surgery on your chest or abdomen and don't want to take in a deep breath, you have Lou Gehrig's disease, are paralyzed, or something else that diminishes your ability to move or take deep breaths, then you are susceptible to getting pneumonia.

"What you need to do is to concentrate on your breathing, something most people take for granted. While you are home, after eating breakfast, you should concentrate on taking deep breaths. In fact, you should do this once every hour or two. And then you should force yourself to cough.

"You take in a slow deep breath through your nose, hold your breath for three to five seconds, and then you exhale slowly. You should do this five to ten times, and then cough. This whole process helps you to recruit and fill with air any collapsed alveoli that are susceptible to pneumonia, expectorate secretions, and exercise your lungs.

"In the hospital, we encourage those at high risk for pneumonia to not only do this, but we use what we call an incentive spirometer. But, in essence, an incentive spirometer is no more effective for preventing pneumonia than a good cough and deep breathing session with breath hold."

Of course, here is where I show them how to use the IS. Most patients do well with the IS, however, some patients just can't seem to get the hang of it. For these patients, I revert them back to the simple cough and deep breathing exercises.

I have never found a patient not be able to do effective cough and deep breathing exercises, even most dementia and Alzheimer's patients do well with this.

Some RTs and RN, in my humble opinion, get so wrapped up in the idea that the IS must be used to prevent pneumonia, that they focus all their energy on having the patient use it, even though the patient is not using it correctly, or, more than likely, is simply unable to comprehend how to use it.

On these patients, I say, "Forget the IS."

This is just something to keep in mind.

Now, our RT bosses might be mad at me for telling you how to prevent pneumonia, because they want you to get sick so they can make money off you, but not me; I want you guys to be educated on the best means of avoiding the need for our services.

The other thing to keep in mind is that your body is not used to being immobile. If you're not moving around, you open the door for a variety of complications, pneumonia being one of them.

This is why, even after you have a major abdominal or chest surgery, your nurse will have you walking the halls, regardless of your level of pain. You might get some good drugs to help with the pain, such as Morphine, but doing this may still be a challenge.

We here at the RT Cave, when teaching the IS or cough and deep breathing exercisers, encourage our patients to push themselves to that pain threshold. It may be agonizing now, but it will allow you to get out of the hospital quicker, which will not be the case if you get pneumonia.

Immobile hospital patients will be taken care of by qualified RTs and RNs who know the best techniques of preventing pneumonia. For people living at home who are at high risk, it's your job to educate yourself, and that's the purpose of this post.

If you want an incentive spirometer, you'll have to refer to your doctor. If you want to know how to use an incentive spirometer, click here. For a boring but effective video on how to use an IS, click here.

Still, nothing is more effective than simple cough and deep breathing and breath hold exercises to eliminate your odds of getting pneumonia. You healthy people don't have to think about your breathing, but anyone at high risk must and should.

That concludes today's class.

Everything RTs need to know about pneumonia

Normally, a person's lungs are sterile (or so we thought before I wrote this post), or completely free of bacteria, viruses, fungi, or any other little particles that might cause harm to them. However, on occasion, something might make it's way into the lungs and cause what is commonly known as pneumonia.

Simply put, pneumonia is inflammation of the lung parenchyma. The most common cause of pneumonia is bacteria, although it can also be caused by viruses or fungi.

Pneumonia Statistics: According to Medicine.net, "over 3 million people develop pneumonia each year in the United States. Over a half a million of these people are admitted to a hospital for treatment. Although most of these people recover, approximately 5% will die from pneumonia."

It's the sixth leading cause of death in the United States." according to mayoclinic.com, that 5% comes to about 60,000 Americans who die of pneumonia in any given year, most of these patients were compromised in one way or another, be it that they were elderly or had some disease such as cancer, COPD or other chronic illness. It's also the leading cause of death in children.
It can be deadly, but it can also be treated.
Signs and symptoms of pneumonia: Two common types of pneumonia are either viral or bacterial. Here are the signs of symptoms: 1. Shortness of breath 2. Rapid, shallow breathing 3. Auscultation

• Crackles isolated to one lobe is usually bacterial
• Crackles/ rhonchi in bases or throughout is usually viral

4. SpO2 levels decreasing below patient normal value
5. Cough: either dry or productive (green, brown, yellow and/or bloody secretions if bacterial, and clear to white if viral)
6. Chest pain that worsens with deep breath or when coughing
7. Fever, shaking, chills
8. Lab values: Increased WBC and/or increased neutrophils (if bacterial)

9. X-Ray shows dense white patch in infected lobe (bacterial). Viral pneumonias produces faint, widely scattered white streaks or patches
10. Sputum sample: lab may isolate bacteria if caused by bacteria (According to Merck.com, the organism is not isolated in 50% of patients.)
11. Patient may be pale, dusky, blue

12. Patient may be Diaphoretic, loss of appetite, fatigue, and (in elderly) confusion
13. With bacterial pneumonia, elderly patients may even have a decreased temp
Diagnosis of pneumonia:
Aside from a good sputum sample, a good history from the patient or patent's family can help you determine which type of pneumonia the patient has. If the symptoms occurred all of a sudden, then it may be bacterial or mycoplasma. On the other hand, if symptoms occurred following a bout of flu like symptoms, than a virus is probably the culprit.
Was the patient drinking? He may have aspiration pneumonia. Is he immunocompromised? Perhaps he has Pneumocystis carinii. Is it community acquired? It's probably gram-positive bacterium Streptococcus pneumoniae. Was it hospital acquired? Then it's probably Staphylococcus aureus or a gram-negative bacterium such as Klebsiella pneumoniae or Pseudomonas aeruginosa.
A third type of pneumonia is called walking pneumonia, so called because most patients develop mild flu like symptoms and are usually not sick enough to seek medical help. This type of pneumonia is caused my Mycoplasma, and is rarely seen in hospitals.
However, this disease is very common among people who work or hang around where there are lots of other people, and it spreads easily. Walking pneumonia is treated the same way that bacterial pneumonia is treated, with the right anti bacterial.
Another type of pneumonia, which is rare, is fungal pneumonia, which is usually less severe, but can cause a prolonged dry cough that might last for months. Patients with severely compromised immune systems may develop Pneumocystis carinii. This is usually reserved to patients who have AIDS, are receiving chemotherapy, and chronic lungers.
Aspiration pneumonia is where a patient inhales a foreign object, such as vomit (sounds yummy, hey?) This is a major concern for our drug overdose patients or other patients who have lost their gag reflex. Likewise, a drunk, inebriated person who has passed out may also be at high risk of aspiration and, thus, aspiration pneumonia.
Okay, let's back up a second.
What is pneumonia?
Say a bacteria gets past the normal immune responses that keep the lungs sterile, and makes it's way into the lungs. It is inhaled, goes down the trachea, takes a right or left turn at the Corina, goes through the bronchioles, and to the tiny microscopic air sacs at the end of the air passages.
Infections of this area cause inflammation of the tissue, which increases white blood cells to that area to fight the infection.
This results in edema, or fluid buildup in that area of the lung parynchema. This increases ventilation/ perfusion mismatching, thus making it difficult or impossible for oxygen to cross into the blood stream.
Lung compliance is reduced in affected regionThus you can see why pneumonia may cause someone to become short of breath, and have a lower oxygen level. In essence, oxygen is shunted away from the infested area. And, if the pneumonia is untreated, or becomes large enough, can cause serious problems, and even death.
Anyone can get pneumonia, but normally it is reserved to patients who are compromised in one way or another. And, while it is normally treated on an outpatient basis, occasionally a person has to be admitted, and these are the people we see.
Who is at risk for pneumonia?
The following is a list of who is at risk:

1. Chronic diseases such as COPD, AIDS, diabetes of whom are immunocompromised
2. Person's who've had spleen removed
3. Corticosteroids can impair the immune system
4. People who smoke or COPD. These people destroy their cilia, which is one of the bodies prime mechanisms for keeping the lungs sterile. Without cilia, a smoker has a weakened ability to remove secretions, and if they are not removed they can cause pneumonia.
5. People who drink too much
6. People exposed to chemicals or pollutants.
7. Post op patients who refuse to or are unable to take in a deep breath and cough up secretions (this is where scare tactics, cough and deep breathing exercises, incentive spirometers, CPT, and forcing the patient to go for a walk come in handy.)
8. Hospital acquired. This may or may not go hand in hand with #6. Intubated patients are at high risk of ventilator acquired pneumonia.


9. Patients who's immune system is worn down by other illness, and this may also lead to nosocomial infections
10. Heart failure
11. broken ribs
12. Very old and very young
13. people who are debilitated, paralyzed, bedridden, unconscious

How to treat pneumonia:
What medicines or therapies to give the patient is up to the doctor. Usually all of these patients get an antibiotic, however an antibiotic will not benefit patients with viral pneumonia. They will also get something to control fever such as Tylenol and nausea. Fluids are beneficial to help the patient hydrate and spit up phlegm
Bronchodilator breathing treatments are controversial for pneumonia, yet many doctors like to prescribe them due to some studies that show beta adrenergics, along with dilating bronchioles, may also help the patient produce and bring up phlegm.
Likewise, many hospitals have pneumonia order sets that include Albuterol to assure the patient meets Intensity of Service, or to make the Centers for Medicaid and Medicare Services (CMS) will reimburse the hospital. If a bronchodilator is ordered, this often assures Intensity of Service is met.
In my experience that first breathing treatment sometimes opens the patient up a bit because that fluid breaking up may cause bronchospam and a wheeze, especially in COPD and asthma patients.
Since nosocomial pneumonia is the most common infection acquired in hospitals, RTs and RNs have been given the responsibility of working together with patients to prevent pneumonia.
Further reading about pneumonia:
Click here to learn how to prevent pneumonia
Click here to learn about Ventilator Acquired pneumonia (VAP)

Your Respiratory Therapy Search Engine Queries: Here are the responses from the RT Cave

I don't really spend a lot of time checking my stat counter, but about once a week I check it out for fun just to see who's been clicking on my blog. One of my favorite things to do while I'm there is click on "Recent Keyword Activity."

This is where my stat counter records what was typed into a search engine, such as Google or Yahoo, that led someone to clicking on my website. A few of the searches have nothing to do with respiratory, such as "Scratchy Neck," but the majority are respiratory related.

As I glance through the list, I wonder if that person had his question or concern answered. And, I think, they should just email me and I'd give them a legitimate reply, or at least I could tell them I don't know.

The reason I think this way is that some of these questions could only possibly be answered by an RT. So, with that in mind, I have listed some of the "recent keyword activity," and my humble responses.

1. "blowing into computer for respiratory": Um, I have no clue.


2. "Itchy neck pain": Um, how did that cause Google to link you to me.


3. "Duoneb pediatrics": Some studies show it works well in ER. Other than that I'd recommend just Albuteral. Personally, though, I don't see what it would hurt.


4. "Doctor doesn't believe in Peek flow meters: The doctor is a fool to disregard the benefits of a peek flow meter. It's a great tool to use in asthmatics to measure the effect of a breathing treatment, and to be an adequate tool to determine when to use a rescue inhaler, go to the doctor, or come here to the ER.


5. "Persistent croup": You can try the shower. You can taking the child outside in the cool air because many times it goes away on the way to the hospital. But don't be afraid to come in and get checked out. That's why we are here.


6. "Will Ventolin harm you if taken unprescribed": NO. However, I would not recommend it. If you have a need for Ventolin, you should go see your doctor.


7. "Does Albuterol Help Crackles?": No. The medicine particle size is too large to even get down in to the colapsed alveoli, and even if it did it wouldn't be able to re inflate it. But this is a great question, because often doctors prescribe Albuterol for this.


8. "Needle shot stings": Yes.


9. "How to write BiPap orders": With a pen in the doctors order section. It works best if you write the doctor's name followed by your signature. Plus I'd write "RT to set up BiPap to patient tolerance." Seriously, every patient is different, and every patient tolerates BiPap differently. That's how we write the order where I work.


10. "House filled with smoke from fireplace fever coughing": I would recommend not having the fire in the fireplace if it causes you to have trouble breathing due to it. It may cause you to cough, but it will not cause the fever. However, if you do have a respiratory illness, it may exacerbate your problem. Also note that it is not uncommon for smoke to bother people with respiratory illnesses.


11. "Respiratory therapy one treatment at a time": I would recommend it, but sometimes you will have no choice. If your patient takes nebs at home, or if the nebs are not indicated, then you should be okay doing more than one treatment at a time, just make sure you are only one or two rooms away. This is where it really comes in handy to know your patient. However, if you are new at this, or not sure, then you should definitely do one at a time.


12. "I hate respiratory therapists": What's your point.


13. "Breathing treaments for pneumonia": Same as for the question on atelectasis above: Albuterol does not get down to the alveoli. Besides, Albuterol relaxes bronchiolar muscles, and there are no bronchiolar muscles in the alveoli anyway. However, if the pneumonia causes bronchospasm, the treatment might work. Usually the first treatment in ER does the trick. If I were a doctor, I'd order Albuterol Q4 prn for these patients so we can give a treatment if indicated.


14. "Coughing spasms albuterol": If it's caused by bronchospasm then Albuterol is a good idea, othersise what's the point. Albuterol will not cause someone to stop coughing if it is not caused by bronchospasm. Personally, I'd try one and see what happens. It's a safe medicine.


15. "COPD on BiPAP": It works. And if it keeps them off the vent, you'll be happy and so will the patient. I've kept many patients off the vent by using a BiPaP. The big problem here is patient compliance. You will have to do a good job of explaining and be very patient with the patient.
    
16. "How long are patients intubated for": Depends on how long it takes them to recover. Depends on how sick they are. Many times, with the new microprocessor ventilators, it takes only one or two days. But every patient is different. If you are the family of someone currently on a vent, you should talk to the RT for an explanation.


17. "Do you give breathing treatment for cough congestion?": Yes, many doctors do. But Albuterol is technically speaking indicated for bronchospasm only.


18. "Where should one live with asthma": While there was once an advantage to living in dry areas like Arizona, research shows that this is no longer a benefit due to air polution.


19. "Why do people need to be intubated": I like to tell people that they, or family member, need to be intubated to get over the hump when they are really having trouble breathing. It allows their lungs to rest. Unlike in the movies, it is also indicated when someone goes into cardiac arrest. It is also done during certain surgeries, if someone is comatose to prevent aspiration, bronchoscopy, or you can check Wikipedia for more information.


20. "Tips for being a great respiratory therapist: Be patient. Don't be afraid to let other people take credit for your ideas. Do your homework. Most important, have fun with your patients and enjoy your job.

Well, I could go on, but I figure I had best stop at 20. There were many that I chose not to list here just because I saw via the stat counter that the person was linked to one of my articles where I know they would have found the answer if they read it.

Perhaps I'll make this a regular feature on this blog.

Albuterol is a bronchodilator and nothing more

Some of the posts on this site, including my list of 'olins on the bottom of the page, are my humble attempts to make a humorous account of why doctors order Albuterol on patients having absolutely no signs of bronchospasm.

RT Cave Rule #5: There is only one purpose for bronchodilators, and that is to treat shortness-of-breath due to bronchospasm

In no way do I think I am smarter than a doctor, for they have knowledge in far more areas than I will ever imagine to have. It is their job, after all, to fix patients. And, when they order therapies I disagree with, I will still do them without complaining.

I have to say, however, that this is difficult not to complain when I know a treatment is not indicated, especially considering I have been using Albuterol since it was invented in the 1980s, and before that I used Alupent, and never once used either one for anything other than SOB due to asthma. In this way, I have over 30 years of bronchodilator experience.

Likewise, I have given many breathing treatments to patient in the hospital the past 12 years as a registered respiratory therapist, and have seen first hand for whom they have a beneficial effect and for whom they have no effect.

Plus I believe my opinion is in concordance with nearly every other RT on the planet.

If you are an RT or suffer from diseases like Asthma or COPD, you know how wonderful a drug Albuterol is. I can tell you from personal experience it's a life saver. In fact, without the drug I'd probably would have died many years ago.

And that brings up my next point. Bronchodilators of the past, such as Alupent and Bronchosol, did have some bad side effects. Alupent was proven to be a great bronchodilator, but had the side effect of making the heart thump. I remember abusing it when I was a kid and fearing that I might now wake up in the morning.

Alupent was a good drug in it's time, and was used for many years, but in 1987 a new refined bronchodilator was invented that was proven to have very little effect on the cardiac muscle, and thus rarely causes the heart to thump or increase. I'm not saying it never does, but very rarely, and usually only when it's given in huge quantities all at one time.

I can tell you from my personal experience as a "Rescue Inhaler Abuser" that I have gone through an entire inhaler in a day and still not had my heart thump like it used to when I used Alupent. Now, I wouldn't recommend using that much Albuterol outside the hospital setting, but my point is that Albuterol is that safe.

When patients come into the hospital, and you are having bronchospasm, we quite often give you an aerosol of Albuterol. If that aerosol doesn't do the job, we have been known to give as many as 10 in a row back to back to back. Again, I wouldn't recommend doing this at home, but I bet many of you chronic asthma and COPD patients have at one point or another. Hey, back me up here.

Now, understanding how quickly and magically Albuterol can get an asthmatic or COPD patient breathing easy, and considering how safe it is, many doctors choose to try it for other respiratory illnesses, even illnesses that are not bronchospasm in nature

I find that some doctors order Albuterol because a patient is short-of-breath because of pneumonia (fluid in alveoli), atelectasis (collapsed alveoli), pleural effusion (fluid in lung) and pneumothorax (collapsed lung) . All of these diseases are in the alveolar sacks, and the aerosol particle of Albuterol are too large to deposit in the alveoli, and thus have no effect there.

If, however, a patient has a bronchospasm component to their disease with any of the diseases listed in the last paragraph, then I'd recommend Albuterol. But if there is not bronchospasm, then it has no benefit to the patient.

Other diseases that Albuterol does not benefit that it is often prescribed for are: Croup, upper airway congestion or excess secretions, CHF, pulmonary edema, post-operative, obesity, cancer and many more.

Let's tackle croup. The harsh inspiratory noise kids make with this illness is because their throats become swollen. The key word here is throat. There are other medications that might help here, but not a bronchodilator. Hence, Albuterol is a bronchodilator, not a throat dilator.

Chronic Heart Failure (CHF) causes fluid to build up in the lungs called pulmonary edema. This does not occur in the bronchioles, but outside them. When this fluid overload causes the pressure inside the lungs to build up, this can cause the fluid to in effect squeeze the bronchioles and causing a wheeze. This is called a cardiac wheeze. Yes, it does cause the bronchioles to tighten, but, since the cause is outside the bronchioles and not inside, Albuterol will not work to solve this problem. This patient will need diuretics like Lasix.

Nonetheless, a cardiac wheeze is very often confused as a bronchospastic wheeze, and treated like bronchospasm.

Many times in the hospital setting I give a breathing treatment the same time a nurse is giving Lasix. The patient is severely SOB. My treatment has no effect on the patient's WOB. But, an hour later when the Lasix has worked, the patient is no longer SOB. Since the patient actually participated in taking the treatment, he or she often thinks the treatment is what eventually solved the SOB.

So, what happens the next time we get a CHF patient? The doctor orders Albuterol back to back to back to back until the Lasix works. Can you see how I can easily make comedy out of this.

Cancer will not be absorbed and broken up by a bronchodilator, nor will it absorb a pleural effusion, nor re inflate a collapsed lung (that's what a chest tube is for). Even if it did get down into the alveoli, it will not remove fluid in the alveolar sacks caused by pneumonia.

Now hopefully by you reading this you understand RT humor. Since doctors use Albuterol for all these diseases, we RTs (me in particular) have a choice between grumbling and griping about it, or making humor of it. We at Shoreline Hospital choose to make humor, and thus our list of 'olins came to be.

One of the reasons I made this post was because I've received more than one emails or comments from patients who wondered if I was being serious or funny when I wrote "Xoponex now a humidifier." I will confess: I was being facetious.

While Dr. Krane is a brilliant doctor, and while I enjoy working with her, and while I have no problem trying one Albuterol treatment with patients with croup just to see if it works, it is not a humidifier. In fact: Albuterol given via nebulizer treatment is a mist.

Just so you know, any post on this site where I'm using RT humor will be labeled on the bottom as "RT humor" or "funny."

Again, I am in no way proposing that RTs know more about the human body than doctors, but we are the experts in the hospital on the respiratory system -- that's all we do. We study respiratory, we learn respiratory, we learn the other systems as they pertain to respiratory, we keep people alive with our respiratory machines, we sleep respiratory, we breath respiratory. We give breathing treatments all day long, and we see how they work first hand. Doctors can only order them. And, when they do, we have to give them. We have no choice.

Now, if you are a medical staff at a hospital other than an RT, or if you are a patient viewing RT sites like RT Cave, it is important that you know that there really is only one true purpose for Albuterol, and that is to treat shortness-of-breath due to bronchospasm.

To determine if someone is having bronhospasm, it requires an assessment of lungsounds and/or a quick review of the patients history, which usually can be provided by the patient. Most of the time, true bronchospasm is very obvious.

In the insert inside the Albuterol inhaler or aerosol solution you will find an insert. Go ahead and pull it out if you have access to one. On that packet it says: Indication: "(Albuterol) is indicated for the treatment and prevention of bronchospasm in adults and children under 12 years of age and older with reversible obstructive airway disease." (emphasis added)

It is a a fact, proven by much research, that Albuterol is a medications that becomes a particle size of 5 microns and fits perfectly into the size 0.5 micron bronchioles of the lungs to relieve bronchospasm. Five microns is too big to go into the alveoli level (which is 0.1 to 0.2 microns wide) and too large to deposit in the throat (although some of them will deposit there).

It is not a cure for any disease. It will only resolve the symptom of bronchospasm. This is my humble personal and professional opinion. And as long as doctors continue to abuse this most wonderful drug, we will continue our effort at bronchodilator reform. And while we may never get it, we will continue our feeble effort at RT humor here at the RT Cave.

I encourage you to challenge me.

Here is a great column that might explain it better than me.

This article describes what bronchospasm is.

Here's a basic definition of bronchospasm.What are bronchodilators?

Here's how to check if a bronchodilator is indicated.

The indications for Albuterol are listed right here. If you're really bored you can read the whole thing.

Boring study on the particle size of bronchodilator. I just don't want you to think I'm making this stuff up.

Ventolin is the medicine used by Angels

"You're my little Angel." She was a middle-aged, dark-haired lady sort of stocky but not really fat. "You're my little Angel. You saved my life." Who in the world are you, I thought as she proceeded to give me a big hug. "I thought I would never see you again, my little Angel."

"Well, uh, hi," I said, "Nice to see you again.

She stepped back and proceeded to peer at me with a big gaping smile. "You probably don't remember me, but I had surgery. I thought I was going to die. When I woke up yours was the first face I saw."

She was right, I had no clue who she was. "Yeah, I remember."

Church was about to begin, so we both took our seats.
--------------------

Work has picked up tremendously in the past three days. We now have 13 patients on the board, and 2 of them are indicated. That aside, I was sitting in my office in the middle of the night, my feet up on the desk, peering out at the parking lot with its dull orange halo of light set against a pitch black background. The window was open and a cool, refreshing breeze was wafting through the room. It was awesome.

We probably have one of the best respiratory therapy caves in the world, with ours having a huge window with an excellent view. In fact, probably 95 percent of the office and patient rooms in this hospital have views of hospital additions. Otherwise called walls.

That was the best part of the night. It lasted about five minutes. My pager went off. "Need a treatment in 206." He was watching TV. He was "a little" short of breath and I could hear audible stridor.

"He's wet," I said to the nurse.

"How do you know without listening to him, " she asked.

"He just looks wet to me." I had the patient sit up and listened to his backside. No wheezes, but the patient did sound coarse throughout. Then I listened to the neck: It was coarse up there. "And 80% of wet patients have that upper airway congestion you hear."

"Really?"

"The noise you hear in his chest is not a wheeze, it's upper airway congestion you hear radiating throughout the lung fields. Here, listen to his neck."

She did. "Oh."

"What are his I&Os?" I started a treatment just just in case, and we preceded to the nurses station to check out the chart. The patient was 2000cc over in the past 24 hours.

As I was finishing up the treatment she gave Lasix.
-------------------------

Overhead page: "Respiratory Stat to 244."

Upon entering the room the lady was standing aside the bed leaning on the bedside table, naked but for a gown flowing freely in front of her. "I can't take it much longer," she said.

I could hear audible, bubbly crackles, "She's wet."

"You think so."

"I know so." I listened to verify. "I'm positive. Have you called the doctor."

"I already did." I was impressed. "I have Lasix to give her. I don't know why, but Dr. Brave ordered a treatment too."

"That's okay, I have no problem with trying a treatment." Not like it's hard putting a pipe in someones mouth, or in this case a mask over it. Then again, nothing like putting an extra 8cc of fluid into an already wet lung.
--------------------

I was trying my best to get my 2:00 breathing treatment done when I was called to ER to do a breathing treatment.

"Why does this patient need a treatment," I asked RN Sarah.

"Because she has pneumonia."

By this time I'm exhausted from running around ragged all night, and have had enough of doing senseless therapy when I have two critical patients upstairs. "Pneumonia isn't an indication for a breathing treatment," I grumbled.

"Yes it is!"

"No it isn't."

"Breathing treatments are for short of breath."

"Breathing treatments are for bronchospasm. Ventolin doesn't even get down to the alveoli where the pneumonia is. It's particle size fits in the bronchioles to open up the bronchioles and resolve bronchospasm."

"Ventolin is for shortness of breath."

"Do you ever give Lasix for bronchospasm."

"Just give the treatment, Rick," she said smiling. She obviously knew I was swamped. That's one of the nice things about working in a close nit hospital like this is we usually don't hold grudges when one of us has a bad moment.

I gave the treatment.

"Do you feel any better after this treatment?" I asked the patient.

"No."
-------------------------

Finally I got out of ER back up to the floors to check on my patients. The man I described earlier had already peed out 500cc. The lady was back in bed and "much more comfortable." By morning they were both fine.

"You are my hero," the lady said when I entered her room in the morning. Her nurse was at the bedside checking her sugar. "You gave me that treatment and now I feel so good. That stuff you give is a gift from God."

"Thank you." I said. "It's so nice getting a compliment. I really appreciate it."

"Well, you can give me a treatment anytime you want."

"You'll be getting them every four hours." Whether you're short of breath or not for now on.

I checked, and the patient had peed out over 2 liters during the night, and started to return to the room when the nurse met me in the hallway.

I said, "Did you see I got credit for her breathing better."

She said, "Yeah, you prick, my Lasix had nothing to do with it."

We laughed.