No more T-Piece

Remember how we used to hook up intubated patients to a t-piece connected to wide bore tubing and an oxygen source to see if a patient was ready to be weaned? Well T-piece no more.


Most microprosessor ventilators allow for you to place the patient in CPAP, and with minimal pressure support to make up for the resistance of the narrow tubing, you can allow the patient to spontaneously breathe, while also having the advantage of alarms to warn you if the patient stops breathing, or is breathing too fast, or otherwise is pooping out.


Our protocol recommends that we use a pressure support of 5 for ETT less than 8, and 0 for ETT greater than 8 during our spontaneous breathing trials (SBT). T-pieces are no longer recommended and rarely used.


Our anesthesiologists still, on occasion, use T-Pieces to make sure a patient is ready to be extubated. That is the only place T-Pieces are still used at Shoreline Medical.


Does your hospital still use T-Pieces to wean?

What's it like to be intubated?

As I was looking at my blog statistics, and checking the recent keyword activity that landed someone on my site, I noticed one person had typed in the query, "What's it like to be intubated."

I remember waking up from a surgery once, and this person pulling something out of my mouth. I had no idea until I went to RT school what had actually transpired at that moment: I was being extubated.

So because I was medicated, I had no memory of being intubated, and had no memory of my time on the vent during the surgery. Thankfully, I must add, I have no memory.

Fortunately, I think that is the case for most people who are intubated. I think that we keep them sedated enough that they do not remember much. However, on occasion, we do have to intubate people under emergency situations where there is no time to medicate the person, and usually that person gags and groans during the process. There is no doubting the this is not a pleasant procedure to have done.

Which is why Succiconine is such a great drug, because it paralyzes a person just long enough to get the job done. And then, while the patient is serving time with a ventilator doing all the breathing or assisting with it, a patient is sedated enough with some good meds to allow the person to rest comfortably. And, while the patient is often awake, the meds are good at causing amnesia.

Lots of times I have to communicate with a person on a vent. Of course they can't talk, but you get pretty accustomed to lip reading after a while. Then, a few days after the patient is over the hump and is extubated, you ask them if they remember being on the vent, and they will tell you they have no memory of it. That's not always the case, but most of the time it is.

Occasionally, a patient remembers everything. Some patients are awake, alert and orientated the entire time they are on a vent. It's these people where you can learn the most from of what it's really like to be intubated.

It doesn't always suck either. I remember this one chronic end-stage COPD patient who was extremely short-of-breath. She told me she felt like she was suffocating. The next time I saw her she was on a vent, and she looked at me with eyes of joy. She smiled. She took in a deep comfortable breath. That vent was her savior.

That patient did not want to get off that vent.

I like to explain to my vent patients, if they are at all comprehensive, that they have not been placed on a ventilator permanently, it's just short term until their lungs get better. It's more or less to allow their bodies time to get over the hump. That's the case most of the time. And, usually, the person is off the vent in a day or two.

While I can honestly say that I have experienced much of the things I do for patients on a daily basis, I have never been on a vent; and I have never been suctioned.

One of my co-workers and good friends and fellow asthmatic was placed on a vent once, and she said she remembers the whole thing. She remembers being awake and alert and looking out the window and seeing a Burger King, which sucked because she was starving. And, she said, that wasn't even the worse part. The worse part was getting suctioned. She said there is absolutely nothing worse than that.

That in mind, a fellow blogger who used to be an RT, and who is unfortunately a victim of severe persistent asthma, was placed on a ventilator recently. I thought his story was very inspiring, and I would like to link you to his blog: The Bay City Walker.

Most Drs are patient, but some just intubate

To be fair to the nurses and the doctors in my last post who were eager to intubate the patient who tried to kill herself with a massive amount of a certain drug I can't remember the name of, I did leave one very important key point out. I was suffering from lack of sleep yesterday, and from massive burnout, so you have to cut me some slack here.

When the patient was first transferred to her new bed in CCU she had no gag reflex when I suctioned her airway to remove a massive amount of secretions that had accumulated there. Then she provided no response to the sternal rub. She was out. That, coupled with the fact she was agonal breathing, the nurse and the patient's physician decided the patient should be intubated to protect the airway.

Technically speaking, that was not a bad idea. However, I knew for a fact the patient was not like this an hour before, and that's why I thought maybe there was something else we were missing that might prevent her from needing to be intubated. So I did a blood gas while the nurses called the patient's physician.

When I noticed the gases were not exceptionally well, I called the patient's RN from the laboratory and informed her Dr. Krane should be notified with these ABG results since this was her patient in her, and I told the nurse I'd rush down to ER and show her myself. Then, en route, I decided I would just go up to the CCU to be with the patient, and, lo and behold, when I got up there Dr. Krane was standing alongside the patients bed.

"Holy cow," I said, "How in the world did you know we needed you? And how did you get up here so fast?"

"I was just concerned about the patient," Dr. Krane said, "And I wanted to make sure she was okay for you guys."

"Well, I'm very impressed."

Then she stunned me with this: "Give a breathing treatment."

Oh, come on. Here the patient is crashing and you want to give a breathing treatment? Like a good boy, I set up the treatment and fitted the mask on the patient's face. This ought to cure her of all her ailments.

Then Dr. Krane provided us with some information we did not receive in report. "I just talked to the husband, and he informed us that she (the patient) uses her rescue inhaler 5-8 times per day."

Aha, well, that makes more sense. "Well," I said, "In that case she probably uses it 10-16 times per day, because it's usually double what they say."

"True," she said.

Dr. Krane and I watched over the patient, literally, for the next 30 minutes, and I kept watching the clock and the entry way to the CCU for any signs of the doctor who said he would be here any minute. I prayed he was really late.

As she watched over the patient, eyed the numbers on the monitor which showed a heart rate of 126 but otherwise normal vitals, I wondered if she thought she had overlooked something in ER. Was she sleeping the last 6 hours the patient was down there and too lazy to check in on the patient and the nurses didn't pick up on the fact the patient was failing?

"You saw this patient in ER," she said, "Did you notice she was labored?" Perhaps I'm right.

"No," I said, "She wasn't labored at all. What do you think?"

"Well, I think she's going to be fine with the breathing treatments. I think that she hasn't had her bronchodilator in well over 12 hours, and her body responded to the transfer to the floor by having an excacerbation of asthma." She continued to look at the patient, and only occasionally looked up at me. "I think if we just be patient here we won't need to intubate."

"I really like that idea," I reassured her, as though it mattered what I said.

"What do you think of this doctor," she said. I figured she was referring to Dr. Seamon.

"I don't know Dr. Seamon very well," I said, "But I think he'll want to intubate as soon as he gets here regardless, and he'll want a massive tidal volume like 1000 or something stupid like that." Dr. Krane laughed.

Seriously, while I think she does order some stupid treatments, she is really nice. I didn't always think that way though. I've learned to keep an open mind about people I meet while working, and not take anything they say personally. Many people I talk to can't stand her because she is such a control freak.

"I think she will be fine," she said.

"Well, did she have a gag reflex in ER?" I asked.

"Yes, we tried to put in an oral airway, and she definitely responded."

I hesitated a second, as I didn't want to ask a stupid question, then I decided the heck with it. "Why do you think she's has no gag reflex all of a sudden?"

"I think the (drug she took) has peeked. In ER she was just lying there almost obtunded, but she was comfortably breathing. She was in a deep drug induced sleep."

"How long is that drug supposed to last?"

"I know she does cocaine and other stuff too, but poison control said about 24 hours. We can't know for sure how long it will last, but if we monitor her very closely we should be able to avoid intubation. However, that's my opinion, and I won't have jurisdiction over this patient as soon as Dr, what's his name? gets here."

"Dr. Seamon."

"I thought you guys said he would be here any minute." She smiled.

"That's what he said.

Now, fast forward over what I wrote yesterday to the intubation. As soon as we turned the patient on her back she started fighting. When the anesthesiologist started to insert the tube, the patient fought vigorously and even sat up -- twice.

She was obviously no longer under the deep, dark influence of the drug. And she had an obvious gag reflex. That, coupled with the good repeat ABGs, made me wonder if the patient didn't need to be intubated after all. But Dr. Krane was no longer in control, and I had transferred my beeper to my relief.

While watching all this, and assisting in holding the patient down so she didn't whack some nurse or my fellow RT in the head, I watched as the anesthesiologist drew up a white medication via syringe. These doctor's are very intense on intubating this patient. Are they forgetting to look at the big picture?

I audaciously tossed out an idea, "Um, you guys might want to disagree with me here, but I just wanted to toss this idea out. Since she appears to be responding to your efforts here, do you think we still need to intubate?"

"Oh definitely," Dr. Seamon said without hesitation, "We need to protect the airway."

My coworker, while holding cricoid pressure with one hand and bagging with the other, looked at me with a funny grin and rolled his eyes. We RTs, you know, have no control. And it's not that we don't want to take care of another vent patient, it's more that we wonder if sometimes, just sometimes, hospital staff get over aggressive with some patients.

After a lot of tinkering, finally the patient was intubated, and the airway secure. Dr. Seamon said, "Let's see, I think a tidal volume of 750 should be good, a respiratory rate of 14 and, oh, how about 50% oxygen."

My coworker looked at me, cocked his head and rolled his eyes. I knew exactly what he was thinking. "I calculate a tidal volume of 600 for this patient, and definitely no more."

"Well," Dr. Seamon said, "I learned to go by weight, and this patient weighs 230 pounds."

"No!," my coworker chimed, "We go by size..size definitely. How tall is this lady."

"I was told she's 5 feet 3 inches," I said, "and I calculate 350 to 600 is the tidal volume range based upon our ventilator protocol of 6 to 10 millimeters per kilogram of ideal body weight." There, that should help you out Dave.

"Okay, well, start out at 700 tidal volume then," Dr. Seamon ordered.

Dave rolled his eyes again, and made no effort to hide it from Dr. Seamon.

I laughed audibly. I'm sorry, but I was very tired, as I had been at work 13 hours at this time. Nobody but Dave noticed I was laughing, though. I looked at each person in the room, and they were all intense with their respective tasks.

I couldn't hold it in any longer. I wished Dr. Krane was still here, because she had a clue.

Later, as I was finally giving Dale report, he said, "What the hell tidal volume do you figure for this patient."

"Max 600, but with her asthma I'd go lower."

"Good, because the vent was set at 500, and that's what I used."

"I thought it was cool you showed frustration to Dr. Seamon," I said, "but I had that discussion earlier with him and I didn't care what he said, because he doesn't have vent privileges here, and we have our protocol. I was just doing to set it at what I wanted, and hope the Internist agrees with me when he gets here.

"Right on," he said, and smiled. "I just give up."

We have to keep in mind here, however, that the medical field is an art that is based on science. And there is often more than one right answer. Thus, while I disagreed with this intubation, I could still be wrong.

Fewer Vent paitents is ailing small town RT Caves

It used to be really busy here at Shoreline. In fact, even back two years ago I remember being so busy I didn't even have the time to read a chapter of whatever book I stuffed into my tote bag.

In the past year, however, I feel like I could literally sit here in the RT Cave and write an entire novel -- each night.

About a week ago we had a patient on the ventilator when I arrived. Don't laugh, but I had to actually search for the silence button. And then, that same night, I had to set up a vent. My brain was a little rusty, and I couldn't remember the formula for determining ideal body weight.

Other than that I was in RT Heaven that night; it felt great to be doing real RT work.

But that was one night. The next night we were back to our usual 10 patients, 9-10 of whom giving the treatment was equivalent to having them drink a glass of water for pneumonia.

I saw a recent trends report for Shoreline, and it went something like this: 99 vents set up in2000, 98 set up in 2001, 88 in 2002, 80 in 2003, 84 in 2004, 74 in 2005, 48 in 2006, 24 in 2007.

None the downward trend.

What's the reason for this? Total patient admissions have been consistent, so it's not because people are choosing a different hospital. BiPAP set-ups have been consistent, so it's not because the BiPAP is saving people from going on vents.

Another trend is length of stay on the ventilators, which has dramatically dropped from an average of 100 hours per patient all the way down to 21 hours per patient. This, I believe, can be attributed to a variety of factors, including quality staff, great doctors who are more receptive to protocols, and new microprosessor ventilators.

So, technology can be attributed to some of our decline, but what about the lack of ventilators overall trending down? I have theories here too.

Many of the most critical patients are being shipped to specialty hospitals, i.e. cardiac, neuro, trauma. While we used to take care of more cardiac patients, it doesn't make much sense to keep them here when they can be minutes away from a cardiac doctor.

Not that we still couldn't take care of these patients here. We could.

Likewise, more and more patients are prevented from moving to the critical care floor due to early intervention and treatment. This goes along with improved education, quality of care and increased vigilance regarding patient's showing early signs of problems and nipping them in the bud.

So, now I sit here with seven or eight expensive state of the art ventilators collecting dust in the back closet. I'm prepared to take on an epidemic, and yet here I sit while my skills atrophy.

I've written before on these pages how we have been trying to get protocols, and how the RT leaders are against them more so because they are afraid they will result in less work for us. Well, what better time than the present for them to make their case.

I know from reading other blogs, and talking with other therapists, that we are not alone in this.

This is part of a developing trend for small town hospitals. In fact, it might be the wave of the future. We might never get back to the level of having 100 vents in a year again, even though we are more than equipped to handle it.

The reason I saw these statistics is because the admins are concerned about recruiting RTs here in the future. Are we going to be able to recruit RTs to a hospital when they know they'd just sit around waiting for an emergency to happen, as my main character does in "The RT Cave in the Year 2020."

If you're a young RT fresh out of RT school who wants to keep his skills up, a small town RT cave may not be for you anymore. But trust me when I say that wasn't true two years ago, and it definitely wasn't true when I started here.

Rumor has it the admins are aware of how a high quality area is being underutilized, and are seeking to bring something in to generate some business for us. That in itself is a scary idea, especially if this downward trend is an aberration.

Negative pressure ventilation come full circle?

The respiratory therapy profession basically began with the iron lung, or negative pressure ventilator. Wouldn't it be ironic if this type of therapy made a comeback, and negative pressure ventilators were the wave of the RT future.

The latest negative pressure ventilator is called the Biphasic Cuirass Ventilation, and one such ventilator is the Medivent Hayek RTX Biphasic Cuirass Ventilator made by Medivent International, and involves a simple shell placed over the patient's chest, instead of over the entire body as was the case with the inconvenient iron lung of the 1950s.

I can certainly see some advantages of the cuirass ventilator. For one thing, you would avoid the barotrauma associated with positive pressure ventilators and the risk of pulmonary infection because you wouldn't have a tube in the patient's airway nor a tracheotomy.

According to this company, since negative pressure ventilation is "more normal," it would be more comfortable for the patient, and allow RTs greater control over tidal volume and respiratory rate, and, ultimately, make weaning easier.

Likewise, the company claims that the vent "helps to maintain and redevelop the respiratory muscles which often wither and waste with respiratory failure and mechanical ventilation (and also) improves cardiac output."

Here are some more uses, as listed on Medivent International's website:

• It can be used as an aid in weaning a patient from conventional positive pressure vents, particularly those difficult to wean patients.
• Assists patient with removal of secretions, and is used as a glorified chest physiotherapy machine. It has been used in this way for Cystic Fibrosis patients and COPD patients.
• Can be used similar to BiPAP to provide treatment for patients before their condition deteriorates, and thus requiring intubation.
• Can be used as an at home vent and in hospitals for neuromuscular diseases and head and spinal injuries.
• It has been used on post-operative patients
• Can be used on Asthma and COPD patients

This type of therapy would be better for the patient in that they wouldn't have to have a tube in their throat, which can be very uncomfortable and annoying, and requires, most of the time, that sedative be used to make the patient more comfortable, or to forget the event all together. Sometimes this can make weaning difficult.

However, despite these claims, I'm not convinced this machine would be anything more than a glorified and expensive BiPAP machine, of course without the annoying and often difficult to get used to nasal or face mask.

I can also think of some cases where this type of ventilator would not be beneficial, especially if you had excessive secretions or pulmonary edema. Of course, even in these cases, nasal tracheal suctioning would always be an option.

However, this type of breathing apparatus would not protect the patient's lungs from aspiration, may not allow for adequate removal of CO2, and may not be effective for obese patients. In these cases, RTs and doctors would have no choice but to opt for the more conventional positive pressure ventilator.

Wikepedia has a nice write up about the curiass ventilator, but it would appear someone from Medivent International transcribed the copy here from their own website, as it's basically the same information not even reworded.

Anyway, that's my review of this ventilator based on some quick research I did. I wonder if this has been used anywhere in the U.S. If so, I wonder what the general opinion of this innovative therapy is, as so far most of what I've learned regarding this vent has been from the company.

From asthma cigarettes to a normal life

Millions of people are alive today becuase of modern medicine, as would probably be true of a majority of the patients we as RTs take care of on a daily basis.

When I was a kid, as I puffed on my Ventolin inhaler for the umpteenth time, or visited the hospital and was given instant relief after a shot of Susprin (Epi), I often wondered if I had lived a hundred years earlier if I would have lived to be a year old. Chances are I would not have.

I remember my grandma telling me the story of her peering through a slightly ajar door into a small room at the old Mercy Hospital as doctors picked up her little brother and frantically held him upside down, patting him on the back, trying to clear the junk from his lungs.

Her little brother didn't live to his second birthday.

He had bad genes, as I have bad genes, as probably do most of our respiratory patients. And, perhaps, had he survived that illness, he would have grown up to have asthma, and probably would have lived miserably as the treatment for that disease was primitive.

When I worked for the museum in Port City they had a shelf with a bunch of 100 year old medicine from an old pharmacy, and one of the medicines was an old box of "Asthma Cigarettes." During an exacerbation of asthma patients were encouraged to smoke.

The medicine had a drug called Stramonium, which, according to this article by the American Journal of Respiratory and Critical Care Medicine is a "dried leaf and the flowering or fruiting tops of the plant, Datura stramonium. This is also referred to as the thorn-apple plant. The active ingredients in this were alkaloids of belladonna, which we now know had the effect of inhibiting cholinergic neurotransmission and thereby reflex bronchoconstriction."

Preventative medicine, also according to this article, was used in the treatment of asthma back then just as it is today. And still, however far we have revolutionized the treatment of asthma, "It is still somewhat controversial as to whether allergen elimination leads to an improvement in asthmatic status. There have been recent controlled clinical trials in which selective covering of mattresses with house–dust-mite–proof covers failed to show a benefit in asthma severity or lung function."

The Belladonna plant was used in the ancient world as far back as Ancient Greece, but more as a sleep aid or as a opiate for poisons rather than as a bronchodilator.

A derivative of the Belladona plant called Atropine was used in the treatment of asthma until the early 1990s when a more toned down version called Atrovent was developed, which basically has fewer side effects.

I remember taking Atropine as a child, and when I accidentally splashed it into my eyes I'd be blurry for a while until the medicine wore off. It was kind of annoying actually. And the only way to take it was via the nebulizer.

But these drugs are used more so as prophylactic or secondary therapy as opposed to as a rescue medicine, since now we have the miracle drug Albuterol (Ventolin) and Levalbuterol (Xoponex).

The iron lung was invented in the mid 1950s as a means of keeping kids alive who had become paralyzed by the polio-epidemic. And the evolution of this ventilator pretty much engraved the career of Inhalation Therapy, now known as respiratory therapy.

This was a negative pressure machine that required for the patient to be inside a box as it sucked the chest out and forcing the patient to breath that way. These machines were complex, and made taking care of the patient difficult.

Later positive pressure ventilators were invented, but these entailed respiratory therapists to get out their watches and calculators and use formulas to determine adequate tidal volumes, pressures, etc. These were a far cry from the microprocessor ventilators we use today that make our job easy as eating pie.

And, they make life for the patients better too, as they have, as I like to tell my patients, mini brains inside them that allows the patient to control the ventilator instead of the other way around. Now, instead of having a patient linger on the ventilator for weeks or months, he or she can be weaned in days.

When I was in respiratory school in the late 1990s, we were informed that nearly all infants born with diseases or prematurely died. By 1998, nearly 80% of infants born survived, and infants as small as 750 grams had a 40% chance of surviving. I'm certain those numbers have risen since then.

So, not only does modern medicine keep people alive longer, it allows them time on this planet that they otherwise wouldn't have had. I know I'm stating the obvious, but it's interesting to think about.

I'll put it this way: 100 years ago most of those infants would have died. It's simply amazing how far modern technology has come in helping people stay alive. It's to the point where we almost take it for granted.

It's thinking of this that makes me wonder if it is modern medicine that has caused the rapidly growing cases of diseases such as asthma as opposed to simply living in the modern, clean environment as proposed by the hygiene hypothesis.

Sure, technology up to about the mid 20th century provided some relief with knowledge that asthmatics must avoid allergens, and with the ironic asthma cigarettes, but in 2008 no asthmatic should have to live anything other than a normal life.

Basically, due to modern technology, any person with a disease that affects breathing, from asthma to COPD to cystic fibrosis has a chance to live a normal life.

And, perhaps, some day in the future this same technology will lead to an outright cure.

Modern technology basically keeps people alive long enough so that we can have statistics. That's a good thing in my book. Not only has modern technology kept me alive, it's provided me with a really cool career.

The six different types of respiratory therapists

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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


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


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


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


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

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

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

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

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

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

I couldn't have been more wrong.

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

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

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

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

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

I'm smart enough to manage BiPap

I don't know about you guys, but when it comes to my BiPap machine I get to do whatever I want. I don't understand why doctors at my hospital give me that power, but they do. It's amazing.

When it comes to running a vent, I'm pretty much a button pusher here at Shoreline Hospital. Sure, doctors will listen to my advice (on occasion), but he or she gets the last word.

When it comes to BiPap, I am the decision maker. I asked Dr. Piddle once what he recommended, and he told me to "do whatever you need to do to get that sat (Spo2) up."

Cool. I increased PEEP to 18. Heck, I did my own PEEP study. This is great. It's that way with every BiPap and CPAP patient. I even get to decide whether to use PEEP or CPAP. It's awesome.

In fact, almost all of our doctors simply order, "BiPAP to patient tolerance." This means essentially that I get to do whatever I want. I even get to adjust per EtCO2, SpO2 and ABGs.

Funny thing is, I don't see BiPAP as any different than running a vent. It's invasive ventilation, only the patient is wearing a mask instead of having a tube thrust into this or her throat. IPAP is the same as PS, EPAP is the same as PEEP, and FiO2 is the same as FiO2.

My point is: if the doctors at my hospital let us run BiPAP at our own free will, why can't we manage the vent? I bet we could. I bet we'd do a heck of a good job at it.

Considerations for readiness to wean

Here are some things to consider when determining if an intubated patient is ready for a weaning trial.

1. Awake and alert

2. Able to follow commands

3. Spontaneously breathing

4. Adequate cough

5. Pain controlled

6. No obvious signs of respiratory distress

7. Little to no anxiety

8. FiO2 equal or less than 40

9. PEEP 5 or less

10. Temperature equal to or less than 100.4

11. Hemodynamically stable

• No Dopamine infusion greater than 5 mc/kg
• Systolic BP
• Pulse >50

12. ABGs normal for patient

13. A-a gradient less than 300

14. a-A ratio greater than 50%

15. PaO2/FiO2 greater than 150-200

16. Underlying condition resolved

17. Chest X-Ray improving

18. Adequately nourished (Albumin >2.5)

19. Electrolytes stable (CA, Mg, K)

20. Secretions thin and minimal

21. Adequate Hemoglobin (>8-10)

22. Adequate Hematocrit (>25% or baseline)

23. Absence of bowel problems (diarrhea, constipation, ileus)?

24. Weaning parameters within normal limits:

• NIF greater than 20
• VC >10ml/kg IBW (2*VT)
• VE less than 10- 5ml/kg IBW
• VC double VT
• RR less than thirty 30
• RSBI (VT/RR) less than 100

25. PS must be at patients weaning level:

• PS = Static minus PEEP
• Normal PS usually at least<=10

26. P0.1 = or less than 4.2.

27.   P0.1 > 4.2 is "associated with failure to become liberated from the ventilator... If under 4.2, weaning was successful 78% of the time."  (reference is Vent world)