Types of Crackles

I've noticed none of my patients are short of breath today, but because they have crackles they for some reason need Albuterol QID.  So I've decided there must be something about Albuterol that requires a nebulizer, something we RTs are not privy to.  And I found it.  I found, somewhere between the pages of 1001 and 1002, in an old dusty version of the Real Doctor's Creed, a listing of the ten different types of crackles.  Here they are as best I can read them (some of the letters are worn with age).

1.  Positional Crackles:  They follow the path of least resistance, like water. When the patient lies on left side, crackles are on left side, and when patient sits up crackles on in bases. 

2.  Fever Crackles:  (synonym: atelectasis). These are your fine bibasilar crackles usually associated with a mild fever.  They are very common in post operative patients, sometimes referred to as a post operative respiratory complication.  Since they may be the precursor to pneumonia, a nebulizer must be indicated.

3.  Lobar crackles:  Crackles usually only present in a particular lobe.  These are usually used to diagnose lobar pneumonia. 

4.  Bibasilar crackles:  Crackles heard only in bases no matter what position patient is in.  Usually associated with COPD.  Can either be fine inspiratory type (COPD), or coarse type (heart failure, kidney failure, viral pneumonia)

5.  Coarse crackles: See wet crackles, see rhales.

6.  Fine inspiratory crackles:  Sound of alveoli popping open on inspiration.  Usually heard with lobar crackles or bibasilar crackles (COPD type)

7.  Wet crackles:  loud, and heard on inspiration and expiration.  Usually this is fluid. Synonym: Rhales.  Often associated with heart failure, kidney failure, pulmonary edema.  Can often be heard 1/2 way up the chest, maybe to the nipples.  May also be caused by viral pneumonia, and this is usually an "Oh Shit! lung sound if that's the case. 

8.  Rhales:  See coarse crackles, wet crackles

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The cure for RT apathy is the ABSOLUTE TRUTH

One of the things we have gotten away from in this country is telling people about absolute truths because we are afraid of offending people.  We've gotten away from this in church, courts, school, politics and, you guessed it, the medical field.  The result has lead to many of the problems we face today.

There are two things we are told never to discuss with strangers, and these are religion and politics.  The reason is because we don't want to offend them.  Yet in church, in court, in school, and in politics we should be exploring the truth and teaching about absolute truths.

Yet out of fear of offending someone, we don't do this anymore.  Today we are more interested in keeping the peace than telling the truth.  The reason for this is because the truth can hurt.  And, by golly, in today's world of political correctness, we are more interested in keeping the peace than teaching truths.

To make matters worse, since we have quit talking about absolute truths, we have become lazy intellectually.  Instead of continuously looking for answers, we settle for what we already know.  And I think there are no better examples of this than right here in the medical field.

For years evidence has been coming out -- and reported right here at the RT Cave -- that the hypoxic drive is real but the hypoxic drive theory is not real.  Evidence supports the idea of giving patients the oxygen they need, and yet doctors continue to underoxygenate COPD patients out of fear they will cause the patent's carbon dioxide to rise and their drive to breathe to become diminished.

Yet in all my years as an RT, I have only seen this happen once.  I've seen CO2 rise slightly, yet that's it.  I have only seen a COPD patient have a syncopal episode following oxygen therapy once.  And he was put on a ventilator and his breathing supported, and he lived on another two years. 

Yet because we RTs are enablers, in that we are more concerned to keep the peace than to risk offending a doctor and stating the truth, this theory continues to be worshiped by many physicians.  Because we are afraid to tell the absolute truth, patients are needlessly suffering.  Because we are afraid to tell the truth, the science world has become lazy in is research because doctors are not pushing for the absolute truth.

Instead, doctors in this country continue to teach and practice based on theories that are older than dirt.  Patients suffer, respiratory therapists and nurses are overworked and burned out (resulting in apathy), and the entire medical field suffers as a result.  And we RTs and RNs know about the problem and solutions, yet we don't tell the truth because we are afraid of offending physicians.

We need to step up and rise above the fear to educate doctors that bronchodilators treat only a select number of disease processes that result in bronchospasm and not the list of nearly 30 disease process that they order them for. I'm sorry if this makes you mad, but Ventolin does not benefit all that wheezes and all that causes shortness of breath. 

Ventolin does not treat inflammation (pneumonia), it does not get into the alveoli (pneumonia and CHF), it does not reduce fluid in your lungs (CHF), it does not treat processes outside the bronchioles (lung cancer, pleural effusion, pulmonary embolus) and it does not treat processes of the upper airway (croup, dry throat), it is not a cure for aging, and it won't prevent death (death rattle). 

Yet speaking these truths may hurt the person you're telling it to.  You Will insult their intelligence.  You may even risk losing respect, and even your job.  You will be called lazy and trying to get out of work.  Yet this is what's needed in the medical field. 

I don't know if you guys know about this, but when Moses escaped Israel, only 20 percent of the Israelites left with him out of fear of the absolute truths that lay out there.  They weren't sure they wanted to make the sacrifice, take the risk of going where no one has gone before.  They were afraid to face the absolute truth. So for this reason only 20 percent of Israelites stood by Mt. Sinai when Moses introduced them to the Ten Commandments.

Yet that's all it took was a small 20 percent to stand up and tell the truth.  All it takes is for a small group to peaceably assemble and say that the medical field is broke and we need to fix it, that we need to find the absolute truths and teach.  We need to put a kingdom of light over the darkness caused by the power of deception.

Related posts:

• Respiratory Therapy Apathy Syndrome (RATS)
• RATS NEST Formed
• Ativan Nebs:  A Treatment Whose Time Has Come
• Respiratory Therapy Depression
• Idealism versus Realism
• RT Idealists versus Ideal Realists
• The Hypoxic Drive Hoax
• 28 Non-Indications For Bronchodilators
• Pneumonia Not Indication for Albuterol
• Cardiac Asthma Should Not Be Treated As Asthma
• Fake 'olins

Another example how we are RT enablers

So, I said to the nurse, "Is he short of breath?"

She said, "No, uh, I just thought he could use a treatment. I think you should at least put him on top of your list of priorities."

"Um," I said, "Should I put him before the ambulance that's coming in with a patient who's not breathing."

"Well, can you asses him real quick?

I did. The patient was not short of breath. Why would I need to go back there and do a bronchodilator treatment? This is a perfect example of how I'm an enabler. I ended up giving the treatment and bit my tongue in the process.

I did it and then I went down to meet the ambulance.

The forgotten Patient

I find I have no choice but to talk about the economy on this RT blog. I find I must do this considering we have been running on an extremely low census the past several months here at Shoreline. I'm talking half the hospital is closed kind of slow. I'm talking, like, 10 total patients kind of slow.

I'm talking many RTs and RNs who were living pay check to pay check before the recession hit are now finding themselves in a serious rough spot. Some are wondering if we will be able to pay our bills. Some are not paying them. Some of us have already become statistics.

Other hospitals in this area of Michigan are also experiencing a low census, although some of the larger hospitals have yet to get to the point where they have had to lay off RTs, some have been sent home early, and few hours are available for the pool RTs.

If you would have asked me two years ago how the recession would effect the medical profession, I would have predicted fewer elective surgical procedures, but I never would have predicted what is going on right now.

I think that not only are there fewer elective surgeries, I think there are a few people who require surgery who are staying home and suffering. In fact, I think there might be many people like this. I think there are many chest pain sufferers who are being modest and biting the bullet instead. I think there are COPD patients who are staying home until they can't stand the agony anymore.

Hence, I expect that some day soon we are going to be hit hard. The patients we get are going to be patients in critical condition; chronic lungers and asthmatics who have not taken their controller meds because they can't afford them, and chest pain folks who are coming in with the big one or a stroke because they ran out of their blood pressure medicine.

Sure, I bet, in this way, the recession may be responsible for many deaths this way. It will be slow, insidious, and agonizing. And yet it will not be seen, and therefore it will not be noticed, nor recorded in the annuls of history.

Yes, the recession is effecting the medical field. Since hospitals have little money, they are making do with what they have, and they are not expanding, not adding on, not making repairs, and not giving raises.

Actually, one hospital in my region is spending millions on room repairs, yet the money is from outside groups and donations. So, since no money is being spent this way, local contractors are not getting contracted out. They are -- the contractors -- having a lull time too.

And so they are losing jobs, and, with their jobs, they are losing their health insurances. And with no health insurance, they stay home when they get sick. Sometimes this is fine, yet sometimes this can increase morbidity and mortality.

So the lull has lasted a while now. Instead of having 2 RTs working during the day shift, we have been doing 8 hour shifts three days a week. Sure we have vacation hours we can use, yet those will die out some day. This cannot continue too much longer. Bills need to be paid.

Actually, I wrote before how those of us who live frugally as though we are always in a recession don't have to fret so much. Yet look around at all the people who have 2 cars that are rented, a camper that is rented, a house that is too extravagant for their income. These folks have been living above their means, check to check, assuming the recession would never come.

Those folks are the ones being the hardest hit. Those folks did not prepare. Those folks are the ones who bought houses they couldn't afford and are thus going to have no choice but to file for bankruptcy.

Temporary jobs can keep an economy going for a while, yet will it pull us out of the recession altogether? What happens when those bridges are done? What happens when those dams are built? What happens when roads are repaired? What happens when that shrimp farm research in Florida is finished? (These are all things in the Obama Stimulus Plan).

And what happens when the Bush Tax cuts expire? Some economists write that some business people will continue to spend until those tax cuts expire, because they expect the economy will hit the skids at that time. And then the economy will slip into a prolonged recession or even a depression as they make cuts and further stop spending.

Yet some predict the Obama stimulus will eventually pull us out. What we do know is the business cycle history proves that the economic lull will end at some point. What we don't know is how long it will last. The Great Depression was the longest economic lull in history. Some say FDR got us out of it. Yet some say he prolonged it. Yet FDR was popular, and Obama is copying his economic strategy.

One of the neatest things about an economy is that most people only look at what they see. The job of the economist is to look at what is not seen as well as what is seen. For example, say you have three men. Man A is the owner of a shoe business. Man B just filed for unemployment. Man C sells suit coats for $100.

Man A is planning to buy a new suit coat. He has the $100. The public has empathy for Man B, so they encourage their Senators to sign a bill raising man As taxes by $100 so they can help out Man B. Since man A has to pay $100 in taxes, he can no longer afford to buy a new suit coat. While the unemployed man is being helped with that $100 and we are all happy about that, Man C is actually the forgotten man here. He will lose business, because during a recession people find better ways to spend money than buying things like suit coats and entertainment and other such things.

I imagine many medical care workers are forgotten men and women. Yes it's true many are still working, yet we are not getting raises to keep up with inflation, and we are not getting all our hours. So we cannot spend money on things like, say, suit coats. So man C suffers even more. He cannot pay for his hernia repair.

And, another forgotten man is the RT Student who has a family and bills to pay and just spent $100,000 to get through RT school and now he can't find a job. What is he to do? He in essence becomes man D. So, if man D has asthma, and he has an asthma attack, he might stay home because he can't afford the $50 nebulizer treatment, or the $100 mandatory ER Room fee, or the $500 for a chest x-ray.

He thus becomes the forgotten patient. We do not see him, yet he exists He is in agony. He is suffering. Yet he does not become a statistic because we do not see him. Some day, though, he will enter the doors of some ER room. The question is: in what condition will he enter this door when we finally do see man D.

It is the job of economists to see man A through D. It is the job of those in Washington to heed the advice of the true economists, and not make rash decisions based on sympathy for the men who are suffering that we do see.

Lest the recession will continue, and we RTs will continue to work during lull times, and one day all those forgotten man Ds will come strolling through those ER doors and it won't be pretty.

Types of airflow obstruction

This venn diagram is used in many respiratory books and articles to show the relationship between chronic bronchitis, emphysema and asthma. As you can see there is some overlapping.

The patients that fall within the rectangle have some degree of airflow limitation or obstruction. I actually would put all of asthma inside this rectangle.

(1) The asthmatics that fall outside the shaded blue area consist of a majority of asthmatics who have completely reversible asthma, or pure asthma. They have episodes of asthma while exposed to their asthma triggers, but live most of their lives symptoms free. If they have an attack, asthma treatment will at least eventually reverse the process.

Those asthmatics who fall inside the shaded blue area have more than just your typical asthma. In many cases you may classify these asthmatics as your severe asthmatics. They, to some extent, have some permanent damage to their airways causing some degree of constant airflow obstruction. In some cases this may involve airway changes or scarring caused by uncontrolled asthma, or perhaps loss of tissue caused by smoking (emphysema). When an asthmatic smokes, he may end up chronic bronchitis at a young age.

Asthmatics who fall into the shaded blue area have asthma with either a (2) chronic cough or (3) emphysema. Likewise, some asthmatics may have (4) COPD/asthma, or both chronic bronchitis and emphysema. Chances are that the majority of patients we RTs see in the hospital fall into this category 7 as I describe below.

Some believe that COPD may result in hyperactivity in some patients. I believe that it is more
likely the patient had asthma all along, and never had trouble breathing until the diagnosis of COPD was made (probably after years of smoking). These patients, perhaps, have the most
grim outlook, and may have a shortened lifespan.

Those patients with (5) pure chronic bronchitis (they do not fall into the asthma or emphysema circles but are in the rectangle) have a chronic productive cough and chronic airflow obstruction. They do not have emphysema and do not have asthma, and they may always have some degree of mild shortness of breath. The dyspnea may be so mild they may not even notice it.

Those patients with (6) pure emphysema (they do not fall into the asthma or chronic bronchitis circles but are in the rectangle) have loss of lung tissue and chronic airflow obstruction as a result. Of all the diseases listed here, emphysema is the easiest to diagnose as the x-ray will always show an increased airway diameter.

(7) Severe COPD would consist of those patients who fall inside the shaded blue area, inside the rectangle, and have both emphysema and COPD, but not asthma. Along with your COPD/asthmatics. Patients who fall within this area, along with your COPD/asthmatics, are the patients we see most often in hospitals.

(8) Simple chronic bronchitis are those patients that have chronic bronchitis but fall outside the shaded blue area. They do not have airflow obstruction. Their FEV1 will show up as normal on their pulmonary function test, yet their x-ray may show signs of chronic bronchitis.

(9) Simple emphysema are those patients that have emphysema but fall outside the shaded blue area. They do not have airflow obstruction. Their FEV1 will show up as normal on their pulmonary function test, yet their x-ray will show signs of emphysema.

Of all the above listed emphysema is the easiest to diagnose. Asthma can be tricky to diagnose, although not altogether impossible, although when a patient has both asthma and one or both bronchitis and emphysema diagnosis can be tricky, although a good history can be helpful.

While asthma, chronic bronchitis and emphysema are all typically diseases of airway obstruction, pure asthma is usually not defined as COPD. Thus, 2 through 8 as defined above ARE all classified as COPD.

It is not possible to know what percentages fall within each of the above. I would imagine that 90% of asthmatics have pure asthma. I have seen many COPD patients who have also been diagnosed with asthma, and these are usually your more difficult patients to care for and treat. These are the one's who continue to return to the hospital, and become our regulars.

I have taken care of many COPD patients with simple bronchitis or emphysema. So, it is difficult to truly put a percentage inside any of these COPD types.

It's important to note here that any of the above conditions can be controlled with proper medication and management.

Likewise, any one of the above conditions that fall outside the rectangle (pure asthma, pure COPD, and pure emphysema) can progress to the more severe types inside the rectangle without proper management.

This is why it is important to get proper diagnosis and treatment as soon as possible, and for you and your doctor to take your disease seriously regardless of severity.

(Source: Robert L. Wilkins, James R. Dexter, "Respiratory Disease: Principles of Respiratory Care," 1993, page 30.)

RT Procrastinate, RT hope and RT frustration

I remember when I was 11-years-old in 1981 I was admitted to the hospital for exacerbation of asthma. The RT in the ER put a nasal cannula in my nose, and I plucked it out. He put it back in later, and I took it back out.

I imagine my lips were blue, but that thing in my nose made me feel uncomfortable. I didn't want it. So, on day #2, my doctor ordered for me to be put in an oxygen tent. I know the order was written in the morning, and the RT came in and explained the procedure to me. Yet I had a feeling he didn't want to do it.

It wasn't until about 4:00 he mosied in and set up that tent, and by dinner time I was out of the tent intent I was never going back in. So, in retrospect, I'm thinking that RT was involved in a grand case of RT procrastination. By definition, this is where an RT delays setting up something ordered via a stupid doctor order.

Another example was tonight when I had a patient come in because she fell and broke her femur. Due to a blood gas that showed her CO2 was 64 she was ordered on BiPAP. She was in no respiratory distress and had no other indication for the BiPAP. So, I participated in RT procrastination.

I suppose another definition her is RT hope. You delay, and then you set it up hoping the patient will realize he doesn't want it, it's inconvenient, and refuse the therapy. However, more often than not, RT hope merely comes down to RT frustration, which is irritation that a patient says something like, "Well, the doctor ordered it, so I must need it."

Look, patients, I was 11-years-old and I knew a stupid doctor order when I saw it. If you don't want to do it, if it makes you uncomfortable, and you don't need it, refuse it. That's simple common sense.

Bronchodilator defenders

Some RTs Will defend useless treatments tooth and nail. They don't want to believe their livelihood is based on doing something that has no value, no purpose, and no scientific benefit to the patient -- and that spreads germs.

For now on we'll call these RTs bronchodilator defenders. They, like many doctors, believe a bronchodilator is of benefit to any lungsounds they find that are annoying. They also feel as though they are doing something to help the patient, when they might as well be nebulizing water for most of them.

The FDA has now made a recommendation that all doctors stop ordering nebulized medicines and, with the exception of exacerbations of COPD and Asthma, an MDI be used instead. The purpose here is that the patient will inhale the mist, and exhale the mist with H1H1 virus attached. Basically, we nebulize h1n1 all over the hospital.

Yet, even though the admins here made the recommendation, I have not seen any fewer nebulized medications in this hospital. I'm telling you, the reason is because even if the nebulized medicine isn't doing anything it makes the doctor feel like he is doing something.

Another reason is that doctors falsely believe that nebulized form of Albuterol is somehow better than that inhaled by inhaler. All studies I've ever seen show MDI with spacer is just as effective. These doctors don't care about studies.

I bet some doctors actually think nebulized Ventolin prevents patients from getting h1n1 in the first place.

These doctors are bronchodilator defenders. They use their hoax, nonscientific theories to prove to themselves they are doing what is right.

Yet, in the end, they're wasting money and spreading germs. How's that for real science?

The Sputum Lexicon

Sputum is what we RTs are all about. We become RTs because we aren't afraid to suck it up. If you are an RT you've probably seen all of these at some point. If your an RT student, you'll become familiar with these soon enough.

Hey, if you're a lunger (COPD, asthma, bronchiectasis, cystic fibrosis), you also should be familiar with the various types of sputum. If you notice changes you should call your physician.

Sputum sample: A good sputum sample is of mucus from deep inside the lungs. You do not want it to be contaminated by mucus of the upper airway++.

Normal secretions*: Clear, thin, none, and with no odor

White*: May be first sign of a problem. May be normal with asthma.

Thick white*: May be sign of problem. May be normal with asthma. May also be sign of dehydration.

Light Yellow: May be sign of viral infection (especially if they have small grade or no fever). May be normal with COPD.

Yellow*: This can be a sign of an upper airway infection. May be normal variant with COPD. May be thick. May have an odor. (Bacterial infections may come with high grade fever)

Dark yellow or green*: Sign of worsening lung infection (bacterial).

Brown: Sign of bacterial pneumonia. May also be a sign of aspiration pneumonia.

Bloody: Sign of pneumonia or tuberculosis (hemoptysis).

Pink Frothy: A sign of pulmonary edema and cardiac failure.

Cream colored*: This may also be thick and will probably have an odor. This is puss coming from the lungs, and may be a sign of an infectious disease.

Chunky and dark brown*: May be aspiration pneumonia, gangrenous lung, really bad lung infection.

Bad odor**: May be sign of anaerobic infection or bronchiectasis

Mucoid secretions***: Clear or white in color. Generally they are produced in response to inflammation, and are seen commonly during acute asthmatic attacks and in uncomplicated chronic bronchitis*.

Purulent secretions***: Dark yellow or green and are seen mainly in bacterial infections. They tend to be very viscous. If caused by anaerobic bacteria it can have a disagreeable (fetid) odor and terrible taste. Examples of where this might be seen: aspiration pneumonia, lung abscess, and bronchiectasis *. Likewise, when normally clear mucus comes into contact with pus it becomes purulent. Thus, the word purulent comes from the word "pus." The presence of eosinophils ,which may be increased during an asthma exacerbation or during the common cold, may make mucus appear purulent.

Mucopurulent secretions***: A mix of mucoid and purulent secretions. They tend to be light to medium yellow and less viscous than purulent. They probably represent either the early or late (resolution) stage of an infection process.*

Antibiotics: These are only indicated if the sputum or nasal discharge color change is caused by an infection. Usually, an infection is indicated by purulent secretions. However, recent studies show purulent secretions only indicate a bacterial infection 31% of the time+++.

++Note: It must be noted here that green or yellow nasal secretions may indicate an infection in the nasal passages and not necessarily a lung infection. This is why the best sputum sample is one that bypasses the upper airway.

+++Anahad O'Connor, a NYTimes.com blogger, recently wrote a great post about this I will link to here.

*Nursinghomesabuseblog.com
**familypracticenotebook.com
***"Egan's Fundamentals of Respiratory Care, 6th Edition, 1995)

The PFT Lexicon

These are some of the most common terms regarding spirometry and pulmonary function testing.

Pulmonary Function Test (PFT): Synonym: Spirometry. This is a test where you breath into a mouthpiece to a device called a spirometer. The Spirometer measures your lung function, determines if you have lung disease and if you do how severe your lung disease is.

• It's a test that uses a spirometer that measures airflow, usually before and 15 minutes after using rescue medicine. The test is not used to diagnose but to determine the type of airway disease a patient has (obstructive or restrictive), the degree or severity of airflow obstruction, and whether it is reversible over the short term.
• It measures the maximal volume of air forcibly exhaled from the point of maximal inhalation (FVC) and the volume of air exhaled during the first second of this meneuver (FEV1). It is valuable for children greater than 5 years old (some children cannot do it until they are 7).
• it can help a doctor determine if shortness-of-breath is due to restrictive diseases like obesity, pregnancy, pneumonia, cancer, pleural effusion, etc., or an obstructive
  disorder like COPD and asthma. Also, it can also be used to differentiate COPD from asthma. Thus, if you are considering Asthma or COPD, this is a great test to rule out other disease processes.
• A test used most often for assessing the risk of future adverse events in asthma and COPD patients. It is the best test for determining severity of obstruction.
• Patient's perception of airflow obstruction is highly variable, and spirometry sometimes reveals obstruction much more severe than would have been estimated from the history and physical examination.
• For diagnostic purposes, spirometry is generally recommended over measurement with a peak flow meter, because values for each brand of peak flow meter can be specific to that particular brand. (peak flow meters should be used for patient monitoring only, not diagnosing).
• Followup spirometrymeasures are indicated as asthma control improves.

Spirometry frequency: Spirometry is recommended at the following frequencies: (1) at the time of initial assessment, (2) after treatment is initiated and symptoms and PEF have stabilized, (3) during periods of progressive or prolonged loss of asthma control, and (4) at least every 1-2 years.
Abnormalities of lung function: Are considered as restrictive or obstructive defects.

Restrictive Diseases:

• Is indicated by proportianately reduced FVC (or FEV6 in adults) with a normal or increased FEV1/FVC (or FEV1/FEV6) ratio.
• are caused by anything that decreases the lungs ability to expand and properly ventilate the patient by getting rid of CO2 from the blood and adding O2 to the blood stream. The following are restrictive diseases:Sarcoidosis, pulmonary, fibrosis, pneumonia, cancer, granulomatous disorder, obesity, pregnancy, pneumothorax, pleural effusion, kyphoscoliosis, emphysema (loss of lung tissue), Neuromuscular and neurologic (Guillain-Barre Syndrome, polio myelitis or myasthenia gravis), Pickwickian syndrome, and Pleurisy.

Obstructive Diseases:  a) Is indicated by a reduced ratio of FEV!/FVC or FEV1/FEV6, b) Airway obstruction is anything that causes narrowing or blocking of the Air passages that results in a decreased exhaled airflow. The causes of airway obstruction are as follows:

• Upper Airway obstruction: Rhinitis/ pharyngitis, Diptheria, Croup,
  Epiglottitis, Obstructive Sleep Apnea, Laryngeal paralysis, Tracheal
  stenosis, Tracheal malacia, Foreign body, Tetanus
• Lower Airway obstruction: Emhysema, Chronic bronchitis, Asthma, Cystic
  fibrosis, bronchiectasis, Bronchiolitis, Bronchial cmpression (tumor, lymph
  nodes), Endobronchial tumors, Foreign body, and Mucus plugging.

Significant reversibility: Is indicated by an increase in FEV1 of greater than 200 ml and greater than 12% from the baseline measure of inhalation of rescue medicine (Albuterol breathing treatment or 2 puffs Albuterol MDI).
Severity of abnormality of spirometric values: is evaluated by comparison of the patient's results with reference values based on age, height, sex and race.

Impairment: An assessment of the frequency of intensity of symptoms and functional limitations that a patient is experienciencing or has recently experienced.

Risk: is an estimate of the likelihood of either asthma or COPD exacerbations or of progressive loss of pulmonary function over time. Some degree of the risk of exacerbations can be obtained from the medical history and patient assessment. Patients who have had exacerbations requiring ER visits, hospitalization, or ICU admissions, especially in the past year, have a great risk of exacerbations in the future.

Dyspnea tolerance: The inibility of a patient to notice when he or she is dyspneic (feeling like he or she cannot get air in). Patients who perceive the degree of airflow poorly. Usually they are hardluck asthmatics who are short of breath so often they lose the objective means of perceiving degree of dyspnea. Or, patients who have unconsciously accomodated to their symptoms. Spirometry or peak flow monitoring are useful tools in monitoring asthma for these patients.

Percent predicted: This is a formula for determing the predicted normal for a person based on age, height and weight and body mass index. You can find a calculator for finding your percent predicted by clicking here.

FVC: The maximum volume (in liters) of air that you can exhale after taking in as deep a breath as you can. FEV1 and FEV6 are both calculated from the FVC. In severe cases where airway obstruction is present (asthma, COPD) the FVC may be reduced due to air trapping of air in the lungs.

FEV1:

1. A measurement made during a spirometry test which measures the amount of exhaled air during the first second of FVC. One is considered to have "airflow obstruction" when this value is low in comparison to patient predicted. This measurement is considered the best way of diagnosing obstructive disorders because it cannot be faked.
2. The post bronchodilator FEV1 can be used to determine lung growth paterns over time.
3. A low FEV1 indicates current obstruction and risk for future exacerbation.
4. A baseline FEV1 (before using bronchodilator) that is lower than normal but that increases by at least 12-15% 15 minutes after inhaling rescue medicine (Albuterol) is indicitive of airflow obstruction that is reversible. This appears to be a useful measure indicating risk of exacerbations.
5. Normal FEV1 is 80% of the predicted value. The predicted value is based on a formula using age, weight and height.

FEV1/FEV6: A measurement made during a spirometry test which measures the amount of exhaled air during the first six second of the meneuver. This test is used as a substitute for FEV1 in adults who have significant air trapping and who get "light headed" while trying to forcibly do spirometry.

FEV1/FVC: FEV1 expressed as a percent of the predicted value or as a proportion of the forced vital capacity. This appears to be a more sensitive measure of severity in the impairment domain, especially in children. It may be more reliable in assessing asthma severity in children as opposed to FEV1 because it is more sensitive.

FEV0.5: Used instead of FEV1 in children because some asthmatic children have a hard time exhaling for a full second.

FEV 0.75: Used instead of FEV1 in children because some asthmatic children have a hard time exhaling for a full second.

Percent change: This is used to determine how much a patient's lungs improve following a bronchodilator. % change =(post-test FEV1 - Pretest FEV1/ Pretest FEV1 X 100. An increase in expiratory flow greater than 15% indicates beneficial effects of the medication.

Peak flow meter: This is a device used to determine "how well your lungs are functioning," according to National Jewish Health. This is recommended as part of the asthma action plan for children and anyone who has difficulty perceiving asthma symptoms. It should be noted that peak flows are a great tool for monitoring asthma status, but should not be used to diagnose.

Diffusion capacity: The surface area of the lung where oxygen can 'get in' to the body is very limited in people with COPD. For example, in patients with emphysema, both the small air sacs (alveoli) and the small blood vessels (capillaries) that run past them are destroyed, leaving a smaller area for oxygen to come in contact with the oxygen-carrying proteins in the blood (hemoglobin).

"Diffusing capacity" refers to the capacity of the lung to release carbon dioxide and take in fresh oxygen. This lung function test measures the amount of area of the lung where oxygen can move into the blood vessels. It is performed much like the spirometry test, except that during this test, you breathe in a small amount of carbon monoxide gas. Carbon monoxide is used because it binds very quickly and well with hemoglobin and the amount is easily measured.

The test is usually performed during a single breath. To measure the diffusing capacity, you have to have certain minimal lung volumes and be able to hold your breath for a brief period of time. Also since diffusing capacity varies with the concentration of hemoglobin in the blood, the values obtained need to be revised if your hemoglobin level is not normal. (Definition by nbcnewyork.com)

Severity of obstruction: How severe is your asthma? How severe is your COPD? This can be determined by your pre-bronchodilator percent of predicted FEV1. Degree of severity:

• Normal: FEV1 80% of predicted value or greater
• Mild: FEV1 65-79% of predicted value
• Moderate: FEV1 50-64% of predicted value
• Severe: 35-49% of predicted value
• Very severe: FEV1 below 35% of predicted value

Degree of Reversibility: (as determined by pre and post bronchodilator FEV1):

• Slight: 15-25% change
• Moderate: 25-50% change
• Marked: Greater than 50% change

References:

• NHLBI Asthma Guidelines
• Egans: Fundamentals of Respiratory Care

The two types of protocols

I have determined that there are two different kinds of hospital protocols.

1. Professional Protocols: Protocols that allow the professional (RN or RT) the opportunity to assess and treat as appropriate based on the guidelines of the protocol (i.e. an RT assesses patient and determines indication and appropriate drug, dose and frequency.)

2. Order Sheet Protocols: Protocols that are basically a list of procedures that are automatically ordered for a particular diagnosis. (i.e. some patients don't meet criteria unless a breathing treatment is ordered. Such is the case with pneumonia and RSV)

Professional protocols are more like the RT Driven protocols whereby the RT is allowed to use his experience and education to make the best decision for the patient, and are the protocols I refer to frequently on this blog.

These protocols work to the benefit of the RT in that they allow these professionals to fully utilize their skills, the hospital in that it eliminates wasteful spending, and the patient in that appropriate therapies are given as indicated.

Order Sheet Protocols are made with the sole intention of making money for the hospital. Some person sitting in an office in Washington D.C. decided it will only reimburse for this particular disease if the patient was sick enough to need certain procedures, such as a breathing treatment.

In order to be reimbursed for said diagnosis (pneumonia, RSV), an order sheet the hospital calls a protocol is made up so that certain procedures are automatically ordered.

This type of protocol amounts to inappropriate usage of a professional's time, inappropriate use of hospital recourse's, and inappropriate procedures being ordered on patients. It is for this reason we end up with bronchodilator breathing treatments on all RSV and pneumonia patients.

Thus, under Order Sheet Protocols the hospital does not make money on each individual procedure as Medicaid, Medicare and Major Insurance Companies pay one flat fee regardless of how many procedures are completed.

Also, Order Sheet Protocols often result in RT burnout and frustration, apathy. Professional Protocols work to the benefit of all parties involved.

Do you have RT Deja Vu?

As I was performing an EKG on a patient the doctor asked the patient who her family practitioner was, and the patient said, "Dr. Pepperhead."

A minute later I was typing in my information on the EKG machine and I asked, "Who's your family doctor."

"It's Pepperhead," the patient politely said.

The RN said to me, "And she already said it."

"What?" I asked.

"The patient already said who her doctor was.

"Now that I think of it, I did hear you ask. I guess I have selective hearing

Along with selective hearing, I also have:

1. Selective hearing.
2. Lack of attention.
3. Habit of asking questions automatically at that point in the procedure.
4. Burnout
5. Brain infarct
6. Exhaustion
7. Combination of the above
8. Selective hearing

Chances are the reason I ask repeat questions is #7, or simple exhaustion from working nights

It's funny, but many times I find myself asking the patient the same questions, especially late into my shifts.

It's funny, but many times I find myself asking the patient the same question, especially late into my shifts.

"Is there anything I can get for you?" I say.

"No." Says the patient.

I proceed to wrap up the nebulizer and put it away, then say, "Is there anything I can get for you."

"No," says the patient. "I'm fine."

I do the same with EKGs. We need to put reason for visit on the EKG when they are done in ER. I ask, "So, are you having chest pain?" The patient says, "Yes." A moment later, as I'm typing in the information , I ask habitually, "So, are you having chest pain."

"Yes," the patient says.

I ask the question the second time, and then I feel a sense of deja vu.

It's funny patients, nurses, or even doctors don't make fun of me regarding this as often as I make fun of myself. Am I alone in doing this?

Perhaps we can call this situation RT deja vu, and add it to our RT Lexicon.

RT Deja vu: When an RT asks a patient the same question over and over again. When an RT askes a patient the same question over and over again."

The debate: Are RTs professionals or Ancillary

My boss referred to us RTs as ancillary staff in a recent meeting. I personally have argued against this term for RTs, claiming that we are professionals. Yet the debate continues.

How about if we define these terms before we go on:

Ancillary staff: These are workers who are told what to do, and do them as instructed without asking questions.

Professional staff: These are professionals who are involved in the care of the patient and are a part of the team that "thinks" of solutions to acute and/or chronic problems the patient is confronted with.

By these definitions, the following are ancillary services:

1. doing abgs
2. doing breathing treatments
3. being a treatment jockey
4. performing ekgs
5. doing cpt
6. assisting with a boost

By these definitions, the following are professional services:

1. interpreting abgs
2. understanding what decisions to make based on your interpretation of it
3. educating a patient
4. questioning a physician order
5. knowing what to do as a patient is failing
6. delving into the patient's history to solve an acute problem
7. recommending new therapies to the attending physician
8. researching and coming up with new ideas to help the patient
9. researching and coming up with new ideas to help the RT department or hospital

So, I think the RTs of old may have been ancillary, and I can think of a few who exists in the RT Cave today who would qualify as ancillary RTs. Yet I am convinced most of us work alongside the patient with RNs and doctors for the benefit of the patient, and are thus professionals.

What do you think?

Ventilator Delerium should not be overlooked

I don't think this matters so much on day shift, but I think on the night shift we RTs and RNs and doctors when writing orders ought to have more consideration for the amount of sleep our patients get, especially patients in the critical care on a ventilator.

There's this thing called Ventilator Narcosis (Delirium) that I think is way underdiagnosed. In fact, I bet it hardly ever gets diagnosed.

According to the August, 2007, issue of Chest, Ventilator Delirium effects 85% of patients receiving mechanical ventilation, resulting in , "and has been linked to prolonged length of stay, reintubation, higher mortality, and higher costs of care."

Delirium, or cognitive decline, often effects elderly patients who are on narcotics or benzodiazepines and left in a state of coma (or "suspended animation") for lengthy periods of time, thus resulting in a poor quality of sleep.

Or, poor lighting coupled with the above and continued patient agitation resulting in lack of adequate sleep often causes a patient (particularly the elderly) to enter into a state of cognitive decline. This happens even in elderly patients who are in otherwise good physical condition.

Likewise, "recommendations by professional societies have established the importance of delirium monitoring and recommended it as standard practice in ICUs all over the world."

Roger Striker at RTMagazine.com provides a more cons ice definition:

"Delirium, as defined by the DSM-IV, requires an acute disturbance of consciousness with reduced clarity or awareness of the environment (eg, an inability to focus or to sustain or shift attention) and either (1) a new cognitive change (eg, deficits in memory or orientation, or a language disturbance) or (2) a new perceptual disturbance (eg, hallucinations or misinterpretations).2 Delirium frequently develops over hours or days, and fluctuates over time.

One of the major contributing factors is believed to be poorly dosed, or too much, narcotics for the age of the patient. Many experts who study ventilator delirium note that most doctors dose narcotics the same for most patients, when the dose should be adjusted for age and size -- particularly in the elderly.

Along with too much, or poorly dosed narcotics, we hospital staffers add to this problem by constantly irritating the patient.

Think about it though. You would go nuts too if the lights were on in your bedroom all night long, and every two hours someone came in to brush your teeth, and every hour between that someone came in to roll you over, or wipe your bottom, or break the circuit of the vent to give you a breathing treatment or squirt in an MDI, or dump water out of the circuit, or insert a new IV.

There have been studies done on this, and the result to every one I've read the experts conclude that the lights need to be out for at least 8 consecutive hours a night, and interfering with the patient needs to be kept to a complete minimum in order for that patient to get a good nights sleep to prevent Ventilator Narcosis.

However, at Shoreline Medical, we have a protocol that calls for 2 puffs of Ventolin every 6 hours, and a good mouth cleaning every 2 hours, and shifting the patient from side to side every hour. The result here is that the patient never gets more than one hour of consecutive sleep.

Since the average sleep cycle lasts 1.5 hours, one can assume that ventilated patient rarely if ever gets through a cycle. And, the result of lack of enough REM sleep is psychosis.

What has me most concerned is brushing the teeth every 2 hours. I understand that a good mouth cleaning is a great way to prevent ventilator acquired pneumonia, but I think there comes a time you use an amount of common sense and just let the patient miss a few of these mouth cleanings so he can get some sleep.

Some RNs I've talked to agree with me, and they ignore the protocol at night. Some, however (those who do everything by the book), never miss a mouth cleaning. To these individuals, the reasoning "I have to do it because it's protocol," or "I have to do it because the doctor ordered it," supersedes common sense.

I understand that rotating the patient often is a great way to prevent blood clots from forming, although I don't see why a little night time common sense can't prevail to allow the patient to sleep.

I understand why the overhead light needs to be on most of the day to so we can see the patient from the nurses station, but putting on the nightlight for six hours during the night shift is a great way to allow the patient to fall asleep and get some REM.

Thankfully most patients don't remember being on a ventilator anyway, even if they appear to be awake and appropriate at the moment. I have asked many patients a day or two after extubation if they remember anything, and a majority of them say, "No. I remember nothing."

Riker notes, "Most trauma patients have no recall of their ICU stay, but slightly more than one third do remember these events; 88 percent of the time, they have fantasies or hallucinations about being in prison and trying to escape."

So, the next time you are taking care of a patient on mechanical ventilation, ventilator psychosis or delirium or cognitive decline should be something for you to consider discussing with the attending physician.

Asthma or COPD: Which one do you have?

Many times in the course of my job as an RT, and now a few times on these pages, I am asked what the difference is between COPD and Asthma.

They do have many things in common, as they both are diseases of the direst suffering. They both cause stress, distress and anxiety for those suffering from it. Yet, they also both cause anxiety for family members of those suffering from these diseases.

Yet, as my fellow asthma experts and I explain in this this Q&A, while these diseases may be similar in that they both cause episodes of air trapping, the mechanisms involved with both diseases are unique. Likewise, the effects of these diseases on the patient is unique as well.

So, that in mind, I thought would provide some basic definitions here to help my readers understand the difference between Asthma and COPD.

Asthma: This is a disease of chronic inflammation of the air passages (bronchioles) of the lungs, and is associated with acute episodes bronchospasm leading to shortness-of breath that is reversible with time and/or medicine.

While their lungs are chronically inflamed, an asthmatic can go days, weeks, months, even years without symptoms.

Because of the chronically inf lammed airways, when an asthmatic is exposed to his asthma triggers, his lungs swell up even more, produce excess sputum, and become narrowed (bronchoconstriction). In other words, the airways are sensitive or "twitchy" to asthma triggers resulting in spasms of the air passages in the lungs (bronchospasm). This results in air becoming trapped inside his lungs, making him feel like a fish out of water during these episodes.

These acute episodes of bronchospasm can be treated with either time or medicines such as beta-adrenergic medicines like Ventolin and Xopenex. They can also be treated by controlling the inflammation with anti-inflammatory medicines like corticosteroids.

With new anti-inflammatory medicines like Advair and Singulair, this chronic inflammation can be controlled so that episodes of asthma are "prevented" and/ or easier to treat.

Asthmatics generally do not need to use oxygen, and it is rare that oxygen levels decrease except for in severe episodes. Therefore, oxygen is not needed outside of hospitals.

While we know what triggers asthma, and we do suspect it is a genetic disorder, what causes a person to develop asthma is unknown (although there are theories).

Chronic Obstructive Pulmonary Disease. According to HealthCentral.com, 80% of current COPD cases are caused by smoking, however they can be caused by inhaling other hazardous chemicals. There are three types of COPD: Emphysema , chronic bronchitis and in some cases Hardluck Asthma. COPD is not reversible, although if a person is removed from the exposure of hazardous chemicals (i.e. stops smoking), the disease may stop progressing.

Oh, and by the way, yes you can get COPD from second hand exposure to smoke. I have a few patients who have never smoked in their lives yet still have this disease.

And, yes, you can get COPD from second hand exposure to smoke.

Most COPD patients have some degree of dyspnea on a daily basis, which may be partially reversible with beta-adrenergic and corticosteroid therapy.

As the disease progresses, many will require oxygen usage at home.

Emphysema: Basically, this is where a person is exposed to hazardous chemicals (Alpha 1-antitrypsin deficiency) and therefore tissue in the lungs literally erodes away. According to HealthCentral.com:

• The walls of the alveoli become inflamed and damaged; over time they lose elasticity (the ability to stretch and shrink), and pockets of dead air (called bullae) form in the injured areas.
• These pockets are formed by damaged alveoli that merged, and have become irregular in shape.
• The pockets interfere with the normal working of the lungs, making breathing out more difficult.
• Inhalation (breathing in) is not impaired. Until the late stages of the disease, oxygen and carbon dioxide levels are normal.

The result here is, as the disease progresses, the person has less and less lung volume to work with. In many cases, these patients are thin smokers, are pink, and due to the loss of lung elasticity, their shoulders are always high and hunched. We RTs refer to them as pink puffers.

Chronic Bronchitis: This is a disease where a person is exposed to hazardous chemicals (mostly cigarette smoke, but not always) and this results in a loss of cilia that is normally in the airways and is used to bring up sputum. As the disease progresses, sputum becomes trapped in the patients lungs, making it difficult for these people to expectorate. They quite often develop a chronic cough (smokers cough). As a result, they become highly prone to lung infections such as pneumonia.

According to HealthCentral.com:

• Irritation of the bronchial tubes (from smoking, air pollution, etc.) causes mucus production. The mucus is cleared through coughing.
• Constant coughing causes damage to the bronchial tubes. The tubes swell and thicken, leaving less room for air flow.
• The reduced airflow into the lungs usually leads to lung damage that results in emphysema.

If I had a choice between these three diseases I'd much rather have Asthma because not only is reversible. While asthma attacks can be preventable with new asthma controller medicines, COPD is also preventable in most cases by simply staying away from hazardous chemicals, or by not smoking or not being in the presence of those who do smoke.

Usually asthma is caused in your youth, so most people who get it have adjusted to that lifestyle before they become an adult. However, adult onset asthma may be equally frustrating as COPD, because it requires a person to change his lifestyle, which may be extremely difficult.

Like asthma, COPD can be controlled if the person quits smoking, avoids living in places that irritates his breathing, is compliant with his medicine, and eats right.

Most mild and moderate asthmatics can live a normal life if their asthma is treated appropriately. If a patient who is diagnosed with COPD quits smoking in the initial stages of the disease, life expectancy can be normal. While it is not possible for the lungs to regenerate tissue, further damage can be spared.

However, if COPD is diagnosed in the later stages, or if a person refused to quit smoking, the disease may progress and result in a shortened lifespan.

So, there you have it. Now you know the difference between COPD an d Asthma. If you'd like to learn more check out MyAsthmaCentral.com or Stopsmoking/COPDConnection.com

I am no longer an RT, I am an Internal Therapist

I am no longer an RT, I am now an IT. I am in and of myself, and with a few other top notch RTs, a new type of respiratory therapist (to see the other six types of RTs click here).

We are an extension among the Learner (optomist) RTs, and we are always making an effort to go above and beyond the call of duty.

In short, I am IT. I am the one person nurses call in times of crisis, and they trust and rely on my expertise and clinical judgement to determine their course of action to the benefit of the patient.

I am a patient internal specialist. Sure I know respiratory therapy inside out, I also know the rest of the body and how it relates to breathing. The following are some recommendations I might suggest:

1. Anxiety: Xanax or Ativan
2. Wet lungs & poor urinary ins & outs: Lasix or Bumex
3. Dyspnea not controlled with Ventolin: Morphine
4. Perceived Bronchospasm: Ventolin or Xopenex
5. Stridor or Croupy cough: Racemic epinephrine and/ or systemic corticosteroid

Often times -- more often then not -- the nurse will heed the suggestion of the IT and call the physician with the recommendation. Often times -- more often than not -- the physician will heed the recommendation of the RN and the IT, who are working together as a team.

The RN and the IT together are a member of the Patient Internist Team (PIT). They work together as part of the PIT to the benefit of the patient. Regardless of their feelings for the patient, they do what is in the best interest of the patient, and that is using their skills and wisdom to the best of their ability, and heeding the wisdom of other members of the team, including IT.

So, by definition, what is an Internal Therapist:

Internal Therapist: A type of respiratory therapist who participates in critical thinking in an attempt to assist the nurse and physician in resolving the patient's crisis. They consider the concept of holism, the body as one unit working together, and therefore understand that the whole body effects the function of the lungs, instead of only thinking in terms of the lungs. The internal therapist does not diagnose, he or she deduces the best possible cause of the symptoms and the best possible solution.

You don't become IT overnight. It takes two years of RT education, an RRT degree and many years of RT experience. Plus, it takes a special individual. He has to have the ability to prioritize, to think outside the box, to do extensive critical thinking, and to use common sense.

Along with that, he has to have the special ingredient: he has to have the ability and the desire to never stop learning. He has to learn from reading respiratory and nursing books and magazines, he has to learn on the job.

Yet, at the same time, he remains humble. Because above it all, he knows that medicine is based on science, but at the same time it is an art. And while science is all based on perfection, every patient is far from perfect, and each should be treated as an individual -- as art.

So, I am still a licensed and registered respiratory therapist (RT), I am now a fully qualified IT. I am IT. I've been this way for a while, though. It didn't just happen over night. At what point does the transition occur? I have no idea. That, too, is an individual moment.

Are you an Internal Therapist too? Are you a member of the PIT?

ABGs made easy: The Lexicon

Here are the basic terms you will need to understand in order to get a more detailed grasp of arterial blood gases. The explanation here is the pithy version, and this is to keep it easy for you.

Hyperventilation:  Rapid breathing (will blow off PaCO2)

Hypoventilation:  Slow breathing (will cause PaCO2 to rise)

Metabolic: The breakdown of foods within the cells of the body and its transformation to energy.

Respiratory: The exchange of oxygen (PaO2) and carbon dioxide (PaCO2) by means of the lungs. Humans breathe in oxygen and exhale carbon dioxide.

Homeostasis: The human body has the ability to maintain stability within the body. The human body is constantly trying to maintain homeostasis. When it comes to ABGs, the body alters PaCO2 and HCO3 to constantly work to keep pH within its normal range.

pH: A measure of the acidity or alkalinity of a fluid. In the human body this measure is normal between 7.35 and 7.45. The body is constantly trying to maintain pH homeostasis. A level of 7.30 to 7.50 is generally considered acceptable.

HCO3: (Bicarbonate) This acts as a buffer to maintain a normal pH in blood and other body fluids. The acidity is affected by foods or medications that we ingest and the function of the kidneys and lungs. A normal HCO3 is between 22 and 26. Bicarb has a symbiotic relationship with pH. When HCO3 increases, pH increases and becomes more alkalotic. When HCO3 decreases, pH decreases and becomes more acidotic.

PaCO2: (carbon dioxide): It's a byproduct of cellular metabolism released into the arterial bloodstream, carried on hemoglobin to the lungs where it is excreted from the body during respiration. PaCO2 has an inverse relationship with pH. When PaCO2 increases, arterial pH will decrease (become more acidic). When PaCO2 decreases, arterial pH will increase (become more alkalotic).

Oxygen: A colorless, odorless gas that makes up about 21% of the air we breathe. It is needed by the body for metabolism to occur. It is inhaled by the lungs and then carried through the bloodstream on hemoglobin to the cells, where metabolism occurs.

Acidosis: This occurs when there is too much acid in the body or not enough buffers (HCO3) in the blood to balance out the pH. This occurs when pH is abnormally low (less than 7.35). This can be caused by the lungs (not blowing off enough much PaCO2) or by the body's metabolic system (severe kidney disease, diabetic ketoacidosis,).

Alkalosis: This occurs when there is not enough acid in the body, or too many buffers (HCO3). This can be caused by hyperventilation (blowing off PaCO2), or excessive vomiting or diarrhea.

Respiratory Acidosis:  This is acidosis caused by the inability of the lungs to excrete PaCO2, and therefore PaCO2 levels in the blood rise, resulting in a decrease in pH.  The PaCO2 will be higher than 45 and the pH less than 7.35 (CO2 rises = pH to drop).  It is caused by hypoventilation. Treatment involves things that will ventilation (increase rate and depth of breathing), such as beta adrenergic medicine and positive pressure breaths.  Lacking intervention, the patient's body will try to compensate by the metabolic system increasing buffers to absorb the acid.  If the body is unable to compensate, intervention will be necessary. Possible resolution may include beta adrenergics, diuretics, or positive pressure breaths.

Respiratory Alkalosis:  This is alkalosis caused by the lungs blowing of too much PaCO2, and therefore PaCO2 levels in the blood drop, resulting in a rise in pH.  The pH will be less than 35 and the pH will be higher than 7.45 (CO2 drops = Ph rises).  It is caused by hyperventilation.  Treatment involves slowing the respiratory rate down, or decreasing the depth.   The body may try to compensate by slowing the rate of breathing to increase CO2.

Metabolic Acidosis: This is acidosis caused by the metabolic system. This can occur if a person excretes too many buffers (HCO3), and the kidneys are unable to generate enough HCO3, and therefore there aren't enough buffers in the body to balance out the acid.  HCO3 will be less than 22 and pH will be less than 7.35 (HCO3 drops = pH drops).  It can result from kidney failure, vomiting, diahrrea, or the administration of diuretics. The consequences of this can be severe, and may even result in coma or death if not treated. The respiratory system will try to compensate by increasing rate and depth of breathing.  This often results in kussmaul's breathing pattern (rapid and deep).

Ketoacidosis:  This is a special form of metabolic acidosis caused when a diabetic patient is unable to generate enough insulin.  Insulin is used to draw glucose into cells, and glucose is used for energy.  Lacking insulin, the body breaks down fat tissue for energy, and the result is the release of ketones, which is an acid.  The buildup of ketones in the blood causes acidosis that can be treated with the administration of insulin.  This often results in kussmaul's breathing pattern (rapid and deep).

Metabolic Alkalosis:  This is alkalosis caused by the metabolic system storing up too many buffers (HCO3).  The kidneys are producing too many buffers, or not excreting enough.  It is measured by HCO3 greater than 26 and pH greater than 7.45 (HCO3 rises = pH rises). This can result from poor kidney function (kidney failure).  It can also be caused by hypovolemia (loss of blood, shock), chloride depletion, hypokalemia, etc. It can be resolved by fixing the underlying problem (transfusion, administer chloride or calcium, or administering of magnesium).

Compensation: The body is constantly trying to maintain homeostasis. Compensation occurs when the pH is within the normal range of 7.35 to 7.45.

• If respiratory acidosis occurs, the kidneys will work to excrete HCO3 into the bloodstream until the pH is within normal range.
• If metabolic acidosis occurs, the lungs will try to increase the respiratory rate to blow off CO2 to balance the pH. Usually here you will see your rapid respiratory rate, almost like they are panting for air.
• If respiratory alkalosis occurs (Co2 too low and pH too high), the kidneys will work to excrete HCO3 from the body through the urinary tract.
• If metabolic alkalosis occurs, the lungs will try to compensate by slowing down the respiratory drive to increase CO2

Hypoxemia: A low level of oxygen in your blood. This means that less oxygen will be delivered to your tissues, thereby causing...

Hypoxia. A low level of oxygen in your tissues. The main symptoms here are increased heart rate, increased respiratory rate, shortness of breath, reduced capacity for exercise, fatigue, and confusion.

Hypoxemic Hypoxia. This is a condition where you have both hypoxemia and hypoxia.

Refractory Hypoxemia: This is when a patient has a low O2 that does not improve with increasing the oxygen. Generally, it is described as a PO2 of 60 torr or less with an FiO2 of 60% or greater.

SpO2: The percentage of oxygen in the inspired air that reaches the blood.

FiO2: Fraction of inspired oxygen. Room air is 21%. With supplemental oxygen, you can increase it up to 100%.

Further reading:

• ABG interpretation part I
• ABG interpretation part II

The 11 types of asthma patients

Look! You can have a doctor who doesn't have asthma or a scientist working in a lab define the types of asthma, or you can have an asthmatic who lives with it define the types of asthma.

So, that in mind, I am the asthmatic who has created a list of the 11 types of asthmatics. By reading my latest blog entry over at MyAsthmaCentral.com you may see yourself or someone you know.

Keep in mind here that you will probably see yourself as more than one type, as no person is perfect. However, as we are all humans who strive to be the best at everything we do, most of us will want to believe we are the quintessential Gallant Asthmatic.

Okay, fine. I would say if you're even close to being a gallant even though you are not perfect, then you probably can classify yourself as one. Still, to be true to yourself, you should consider you are a gallant/?.

Or, if you are really honest, a goofus/?.

For example, I would consider myself a gallant/recovering bronchodilatoraholic

However, at times in my life I have been pretty much all of these at one point or another. When I was a kid I was a goofus/phlegmatic/martyr/hard-luck/bronchodilatoraholic/poor patient, and even an abuser at times.

I'm just being honest here.

This was fun for me to write and I think it will be an equally enjoyable and educational read. Don't take my word for it.

Click here and I will morph you into MyAthmaCentral asthma blog.

11 Types of Asthmatics -- Which One Are You?
by Rick Frea Monday, September 22, 2008

As your humble RT and fellow asthmatic, I have created a list of all the different types of asthmatics. Trust me, I have met hundreds of asthmatics, even lived with a bunch of asthmatics once.

See if you can spot yourself or someone you know in one or more of the following asthma types.

Asthma guidelines were written for the typical asthmatic, which generally fall into one (or even in two) of the following 11 types. For the most part, typical asthmatics have asthma under control and they have no symptoms. However, occasionally they do, and usually no more than 2-3 times per week. However, occasionally, they have their bad episodes and end up at a doctor's office or ER. How often the episodes come about depends on the type of typical asthmatic one falls under.

Types of Typical Asthmatics:

1. Gallant: These asthmatics are a doctor's best patients because they do everything exactly as they are directed. They have an asthma action plan. They have their bronchodilator with them at all times, but only use it when necessary. They religiously take their controller, anti-inflammatory medicines. These are the patients we see in the ER once, educate them, and never see them again.

2. Goofus: These asthmatics don't like anything to interfere with their fun. They have an asthma attack, go to the ER, half-listen to the nurses, doctors and respiratory therapists, and then take their preventative medicine until they start to feel better. Then they go back to having fun, until the next asthma attack.

3. Phlegmatic: These folks are not easily excited into action. They are very composed and calm even under the worse situations. You may not even be able to tell they are having breathing trouble.

4. Actors: They have legitimate asthma, but they take advantage of it to get out of doing things they don't want to do, like attending gym class, going to work, or going to their mother-in-law's 5th wedding.

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

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

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

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

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

10. Hard-luck Asthmatics: These are the asthmatics who, regardless of how compliant they are with their preventative medicines, still have bad asthma episodes. We don't know what bum luck would cause some asthmatics to get so bad, but some simply develop asthma that becomes difficult to control. This can happen to any asthmatic from infant to adult. They see doctors on a regular basis. They are on all the state-of-the-art medicines (possibly even oral steroids), and yet still have asthma episodes regularly. They end up in hospitals more often than they'd like.

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

So, are you happy with the type of asthmatic you are? If not, there is no time like the present to become a better one.

I will go into more detail on all of the above types in my upcoming posts.

An epidemic of Fake Pneumonia

It's spreading hospital to hospital, patient to patient, faster than any disease on the market. Would you believe the disease I'm referring to doesn't even exist. In fact, it's not even contagious.

I'm sure all nurses and RTs have seen it: it's fake pneumonia.

Fake pneumonia: Patients that are diagnosed with pneumonia, but there is nothing on the chart to indicate pneumonia. The x-ray and labs look normal. Auscultation reveals clear lung sounds. When the patient is asked, he or she indicates no trouble breathing. The patient says something like, "I've never been short of breath in my life."

(Click here to check the signs and tests that indicate real pneumonia)

So why the diagnosis of pneumonia. I can only make guesses here.

1. The doctor had no clue what was wrong, so he chose the most common diagnosis


2. Pneumonia is the most reimbursable diagnosis.


3. The pt looked bad, but otherwise didn't meet criteria for admission.


4. The doctor actually thought the patient had pneumonia.
5. The patient is a lot of work for a family member, and they need a break
6. There really is no reason.

And, in order to meet criteria for admission, all pneumonia patients must have Q4 breathing treatments ordered. If they are not sick enough to have breathing treatments, they are not sick enough to be admitted.

Fake pneumonia is very contagious. You cannot get it by person to person contact. You can only get it from your doctor. So be wary.

That is, unless you want to be admitted. If that's the case, see a participating* doctor near you.

*Note: Not all doctors in your area will paritcipate in this program.

Treatment Jockeys and Button Pushers

These are two more types of RTs to add to our list of "The different types of RTs." We'll add this to our RT lexicon.

Treatment Jockey: An RT who goes about his job of passing out breathing treatments without questioning whether they are needed or not; an RT who just does what he or she is told, no questions asked. Quite often, these types of RTs are well liked by RT Bosses and Administration Officers, and doctors seem to like them too because they usually don't provide the lip. However, treatment jockeys tend to not do so well under stressful circumstances.

These types of RTs are related to button pushers who work in the critical care unit.

Button pushers: An RT who works with ventilators in the critical care unit and all he or she does is push buttons without questioning orders. Initial ventilator settings and all succinct ventilator changes are made by the RT pushing a button, but what to change is decided by the doctor. This type of RT is more prevalent in smaller hospitals that don't have ventilator protocols. However, even with a protocol, this type of RT finds it easier just to call the doctor than risk making a mistake.

These types of RTs are related to the treatment jockeys who work throughout the hospital.

Button Pushers and Treatment Jockeys are more prevalent of the contents and the quitters, and only about 20% of the complainers. The learners and the leaders tend lead the charge away from the button pusher/treatment jockey era.

As the latest statistics show, the number of Pushers and Jockeys has actually diminished over the years. In 1965, when most RTs were OJTs (on the job training), 71.2% of all RTs were were among these types, and by 2005 their numbers had dwindled down to about 30%.

The reason the numbers have not dropped further, experts figure, is that some RTs in certain hospitals develop poor attitudes because a few doctors don't want to give up autonomy to RTs.

However, this attitude is quickly changing with the advent of protocols and improved RT morale.

One of the reasons for the steady decline is the improved educational requirements imposed by the NBRC, coupled with all the great RT programs across the country. It is a simple fact that RTs are slowly generating improved respect within the medical community.

The number of Jockeys and Pushers is inversely related with respect within any respective RT department. You will see that as the percent of the previous declines, the later increases.