sometimes i breathe : respiratory therapy blog

ADVANCE: Highlights of December 2011

noreply@blogger.com (Steven Ling-Duan) — Thu, 22 Dec 2011 07:27:00 +0000

Stakeholders Address Sleep Apnea In the Transportation Workplace
-The 2010 conference was a landmark event. Before then, no meeting had ever been held that brought together representatives from all the trucking industry stakeholders (company executives, regulators, occupational medicine physicians, and truckers) with the professional sleep community (physicians, dentists, and service providers) for a day-long meeting.
-The goal was to promote a common understanding about sleep apnea and to provide information about the options available for diagnosis and treatment.
-The Sleep Apnea and Multi-modal Transportation Conference, (www.samtc2011.org), held in November expanded beyond trucking to include other modes of transportation: rail, aviation, marine, and transit.

Severe Asthma Remains Poorly Understood
-Up to 15 percent of people with asthma do not respond to standard inhaled corticosteroid therapy.
-Genetic factors may help to predict patients’ response to urgent therapies currently available.
-Halothane, sevoflurane, and isoflurane have been shown to facilitate positive pressure ventilation, while a small study of ketamine showed it increased partial pressure of oxygen and decreased partial pressure of carbon dioxide in arterial blood of patients in status asthmaticus who did not respond to conventional mechanical ventilation.

Treading a Fine Line

-The debate on how to mechanically ventilate patients with traumatic brain injury has largely focused on the dangers posed by CO2, a potent cerebral vasodilator.
-Twenty years ago, the goals of mechanical ventilation in TBI were to maintain good oxygenation and maintain mild hypocapnia to reduce cerebral hyperemia. Now, the thinking is toward strategies that limit ventilator-induced lung injury. These are conflicting paradigms.
-Most patients with brain injury do not have problems with ICP and should receive lung-protective mechanical ventilation.
-Don’t hyperventilate the patient. Mild hypercapnea is well tolerated and not a problem. Too much CO2 is less often a problem but low CO2 is a problem for almost everyone.

On the Cutting Edge

-March 21 to 24, 2012, Fairmont Sonoma Mission Inn and Spa will open its doors to the 35th Annual Meeting and Educational Conference of NAMDRC (National Association for Medical Direction of Respiratory Care).
-“We’ve held the meeting in California’s wine region twice before, and they were our best attended meetings ever,” said Phillip Porte.

How to Choose a Sleep Center
- Check for a center’s accreditation.
-Check websites such as www.achc.org/accredited_organizations.php; www.sleepcenters.org; www.thecomplianceteam.org; and www.jointcommission.org/accreditation/ambulatory_sleep_centers.aspx.
-When calling centers, ask key questions:
Are you accredited and by whom? Is there a doctor consult before and after the sleep evaluation? Is the sleep physician board-certified and accredited? Are registered polysomnographic technologists on staff? Who will score my sleep study? How long will it take to get the results? Who will notify me of results and explain those results and any recommendations? If therapy is recommended, who will supply treatment, support, advice, and help in getting acclimated? May I have a full and complete copy of the sleep study and any prescription?

Top Issues for 2012
-Nearly everyone in the audience has been sending staff home because of low census. To compensate for revenue, hospital administrators are looking for ways to trim labor costs.
-Validating respiratory staffing levels can be difficult because about 85 percent of respiratory services do not have a current procedural terminology code.
-Respiratory therapists attend complicated labor and deliver y cases to give preemies’ their first breaths. They avert dislodged intubation tubes while transporting ventilator patients to radiology for computed tomography scans. Or they avoid full blown codes by participating on rapid response teams. Yet these important tasks can make the department appear less productive because fewer minutes are being spent on direct bill procedures
-Medicare plans to decrease reimbursement for the physician fee schedule by 27.4 percent Jan. 1.
-Looking for potential revenue sources outside of the department can help improve the department’s budget.
-Respiratory departments also should prepare for more careful inspection of the way care is delivered because hospitals are being pressured to determine the exact costs of providing services.

Shining a Light on Circadian Alignment
-About 20 percent of t he population is comprised of shift workers, and many experience shift work sleep disorder (SWSD).
-The disorder is characterized by insomnia, poor cognitive performance at night, and fatigue, as well as a higher risk for accidents, depression, stress, tobacco and alcohol addiction, hypertension, cancer, gastrointestinal problems, heart disease, obesity, sleep apnea, and more.
-Humans are diurnal animals who have evolved over millennia to live by circadian rhythms, which are driven mostly by daylight.
-While the U.S. Food and Drug Administration has approved modafinil, a wake-promoting agent, that can help shift workers stay alert, this pharmacological approach is not the primary treatment for SWSD.
-Light therapy has emerged as the most reliable means of dealing with circadian misalignment, simply because bright light is the most potent motivator of wakefulness

Patients Feel at Home With Spirometry
-Pulmonary function testing with spirometry is a standard component in the face-to-face evaluation and management of CF patients. FEV1 is easy to measure, is reproducible, and has been shown to be an excellent predictor of morbidity and mortality in CF.
-While it’s speculation, it may be that patients gained insight into t heir health through t he use of home spirometry and were able to take steps to maintain t heir health t hrough better medication adherence and better adherence with airway clearance techniques.

Why is this even news?

noreply@blogger.com (Steven Ling-Duan) — Thu, 15 Dec 2011 02:11:00 +0000

Severe Asthma Attacks Could Be Reduced By Improved Medication Use

Did they really have to do a compliance research stating that medication is good?
That's like saying, "Studies have shown that eating less like a hippo will help you lose weight."

Sometimes there is no real respiratory news and that's fine.
We don't always have to update a news site even if nothing is happening.

Don't get me started a CNN.

Dust is bad for your lungs

noreply@blogger.com (Steven Ling-Duan) — Thu, 08 Dec 2011 07:52:00 +0000

The American Journal of Industrial Medicine recently published a study showing that World Trade Center (WTC) responders suffer from asthma at more than twice the rate of the general U.S. population as a result of their exposure to the toxic dust from the collapse of the WTC towers in 2001.

-What exactly is considered toxic dust? I had to look it up. Apparently, it's nearly everything found in a building.

"Analysis showed that the substances in the dust included cement, gypsum, asbestos, glass fibers, calcium carbonate, lead and other metal particles."

-According to this, only half of the 9/11 workers wore masks. It looks like there needs to be more education on personal protective equipment.

A new study published in the journal Respirology reveals that dust storms have an adverse effect on emergency hospital admission for chronic lung disease.

-All of this information seems like common sense but I see doctors who "forget" to wear their masks simply because they are uncomfortable. It's true the N-95 masks inhibit your breathing a little but would you rather settle for some discomfort or possibly end up at the hospital?

Why I hate introducing myself to new nurses

noreply@blogger.com (Steven Ling-Duan) — Mon, 05 Dec 2011 02:13:00 +0000

What is pepper spray?

noreply@blogger.com (Steven Ling-Duan) — Sat, 26 Nov 2011 02:12:00 +0000

I walked by Occupy D.C. during the night and nobody was in their tent. It was a little disappointing. With all these protests going around it would be inevitable that someone would get pepper sprayed in the face.

What is pepper spray? And what's the difference between that and mace?

"Mace is a an irritant, while pepper spray is an inflammatory agent. Mace causes the eyes to tear up and stings the skin. Pepper spray causes temporary blindness and temporary breathing difficulties (virtually always non-life-threatening).Pepper spray will work against somebody who is drunk or under the influence of drugs, Mace might not. "Mace" is a also brand name. Some "Mace" products may be pepper sprays.

When a person is sprayed with pepper spray their eyes clamp shut, if they manage to open them they most likely will not see anything because the capillaries in their eyes will be dilated, causing temporary blindness."

Sounds scary.

Happy Thanksgiving 2011

noreply@blogger.com (Steven Ling-Duan) — Fri, 25 Nov 2011 01:31:00 +0000

I'm stuck at work for tonight. I'm also thankful I have work.
It's not so bad really. My family is in another country and my friends all went home for the holidays.
So if I didn't work, I would sit at home and play Skyrim until I passed out on food.

Hopefully tonight is a slow night so I could get some online shopping done.

Proof that congressmen are idiots

noreply@blogger.com (Steven Ling-Duan) — Sat, 19 Nov 2011 06:35:00 +0000

Pizza is now a vegetable.
Since pizza is now considered a vegetable, can I get pizza as a topping on my pizza?
...and tomatoes are considered fruits.

Prison food was already healthier than school food.

ADVANCE: Highlights of November 2011

noreply@blogger.com (Steven Ling-Duan) — Fri, 18 Nov 2011 00:52:00 +0000

Improve efficiency
-Some sleep centers are using autoscoring software to score overnight studies in real time.
-Physicians can order a home sleep study before the patient leaves the office. The company verifies the patient’s insurance and obtains insurer preauthorization before shipping equipment to the patient’s home.
-Replacing a spreadsheet with workflow software has helped Redwood Sleep Centers identify patients who were slipping through the cracks.
-Automated phone calls check patient compliance and remind them to replace supplies. Patients can opt for mailed or emailed notices or be transferred to a manual call list.
-Basically, four ideas to improve efficiency for sleep centers are; use automated software, outsource sleep studies by sending people home testing kits, use better charting, and create automated compliance checks.

Spirometry from a Real-life Perspective
-Spirometry provides an objective, measurable evaluation of pulmonary function, is easily performed in the office setting, needs only a modest investment in capital equipment, is a billable evaluation, and enables the health care provider to better evaluate and treat COPD and asthma.

Pros and Cons of Lung Recruitment
APRV
Pro: Airway pressure release ventilation uses spontaneous ventilation to mimic our normal respirations.
Pro: Permits the diaphragm to pull down on the lung instead of being forced down by positive pressure.
Pro: Gas pulled into the lung by the diaphragm enters the lung’s dependent regions, allowing for a more natural, sinusoidal respiratory pattern that may decrease sedation requirements.
Con: Due to its infrequent use, the most common issue with APRV is therapist and physician unfamiliarity with the mode.
Con: With a low pressure (P-low) of zero, the expiratory time constants are difficult to measure and monitor.

HFOV
High frequency oscillator y ventilation (HFOV) can best be described as continuous positive airway pressure with a “wiggle” because the mode works by oscillating around a constant mean airway pressure.
Pro: Prevents the lung from deflating and eliminates the need to focus on ventilation over a defined time constant.
Con: The cost of its use and ICU practitioners’ unfamiliarity with it may undermine its overall efficacy.
Con: Requires a high level of sedation and/or paralytics.

40/40 maneuver
The theory behind using 40 cm H2O of PEEP for 40 seconds after a course of traditional ventilator mode application is to recruit as much lung as possible prior to the initiation of HFOV.
Con: Lung deflation occurs for a variety of reasons, and simply forcing open the lung does not stop the forces that caused the initial collapse to occur again

Incremental PEEP
It is performed by titrating up PEEP in steps of 2 cm H2O while monitoring oxygen delivery, lung compliance, and VCO2.
Pro: The goal is to appreciate oxygenation improvement as the lung recruits.

Con: Must be closely monitored by a well-trained respiratory therapist because forcing the lungs open with too much pressure can damage the lung and heart.

Con: Crucial to allow time for the patient to equilibrate between each change and to constantly monitor the process to avoid loss of oxygenation from overdistention of the lung.

Pressure volume loop
Pro: Using a conventional mechanical ventilator’s pressure volume waveform can help identify the critical opening and closing pressures during volume ventilation. If PEEP is set to this level, it can prevent the lung from collapsing.
Con: Numbers are more accurate when the flow is slower. Some institutions use sedation and paralytics to obtain lower, more accurate number

Making the Most of OneBreath
OneBreath campaign/project will provide easy-to-understand resources on an interactive website that clinicians can use to supplement patient education and inform their community about lung and chest health.

Noninvasive ventilation
-NIV results in lower cost when compared to invasive ventilation. Patients who use NIV usually spend less time using the ventilator and have shorter hospital stays due to fewer complications. Patients also report greater ease of interaction and communication, and they generally have an improved patient experience.

RTs First to Act
-After 9/11, ventilator manufacturers created portable, battery-operated ventilators that don’t rely on a room air source gas or are totally pneumatically controlled.
-All therapists should be comfortable wit h any ventilator.
-All RTs must be skilled in manual ventilation, and our competencies must be assessed annually.

Is Exhaled Nitric Oxide Useful: Yes or NO
-Asthma affects an estimated 20 million Americans, 300 million people worldwide, and 10 percent of all children.
-Measuring the fraction of nitric oxide in exhaled air (FeNO) is a convenient test for airway inflammation that is helpful in the diagnosis of atopic asthma.
-This is especially true in preschool age children, a population in whom other test modalities, such as spirometry, may be unproductive.

-A low FeNO is considered <5 parts per billion (ppb).
-A normal FeNO value is 5 to 25 ppb and implies the absence of eosinophilic airway inflammation.
-Intermediate FeNO levels are 25 to 35 ppb. This may reflect inadequate treatment or noncompliance with inhaled corticosteroids.
-Elevated FeNO evels of >35 ppb, indicate uncontrolled eosinophilic airway inflammation.Asthma is then a very likely diagnosis.

-FeNO is highly dependent on exhalation flow rate. For example, FeNO levels will drop with a higher flow.
-An expiratory flow of 50 mL/s is recommended.
-Higher concentrations of nitric oxide relative to the lower airways are found in the nose and paranasal sinuses, so it is important to avoid contamination of exhaled air with nasal air when measuring FeNO.
-Environmental nitric oxide can increase during peak traffic hours or in poorly ventilated areas, so contamination with ambient air should also be avoided.
-Food and beverages also can alter FeNO levels, so patients should refrain from eating or drinking at least one hour before testing.

-Gaining reimbursement from commercial insurers is difficult. Many carriers still classify the test as investigational, experimental, or unproven, and not reimbursable.
-Because of eNO reimbursement issues and disparities, cost, and the many other factors that can influence its measurement, evidence for the overall diagnostic utility of FeNO in young children remains mixed at this time.

Under Surveillance
-Patients with acute respiratory distress syndrome are difficult to manage from a ventilation perspective. Patients present wit h reduced lung compliance (CL) and poor oxygenation status.
-During ventilation with ARDS the normal alveoli in the nondependent areas tend to receive the bulk of tidal volume (Vt) delivery and maybecome hyperinflated.
-Both the phenomena of hyperinflation and of tidal opening and closing are functions of ventilation that can lead to ventilator-induced lung injur y (VILI) in patients whose lungs are already compromised.
-The ARDSnet study found using lower Vt during ventilation of patients wit h ARDS (6 ml/kg compared to 12 ml/kg) resulted in reduced mortality rates.
-Some researchers advocate use of low Vt and higher PEEP levels in patients with ARDS, while others also suggest the use of recruitment maneuvers (RM). A RM is the application of higher pressures for a sustained time (40 to 60 seconds) to open as many lung units as possible in an effort to improve compliance and oxygenation and to reduce shunting.

-However, use of higher PEEP in managing ARDS has not been clinically substantiated.
-High PEEP levels (15 to 20 cm H2O) may only minimally recruit consolidated areas, but also might significantly hyperinflate nondependent normal areas of the lung.
-It is difficult to determine how much PEEP is appropriate.

-An alternative tool for evaluating appropriate PEEP and volume settings in patients with ARDs has recently been identified. This tool, called the stress index (SI), is a number that describes the slope of the pressure-time (P-t)curve during constant flow volume ventilation.

-Previously, the ability y to calculate the slope of the P-t curve to obtain the SI was a difficult process. The calculation and display of the stress index is now available on t he SERVO-i® ventilator. Both the visual ability to identify the change in the P-t curve and the quantitative information provided by the SI can be used in the intensive care setting. According to the literature, the monitored SI could be used to adjust such settings as Vt and PEEP in an effort to prevent progressive over-distension of the lungs on one hand and the cyclic opening and closing of alveoli on the other

Saving myself Broke
-Cute story about a RT who bought a scooter to save money. Then he kept buying expensive accessories with it and actually did not save him money. So he sold his scooter and went back to his car.

AARC News: COPD Month Offers Time to Reflect on Successes

noreply@blogger.com (Steven Ling-Duan) — Tue, 15 Nov 2011 14:24:00 +0000

This month is COPD Awareness Month and World COPD Day on Nov. 16.

COPD has risen to the third leading cause of death in the U.S.
-Not surprised. Sometime back in the day (before 2008), COPD was classified differently. Pneumonia and other acute lower respiratory infections were coded as COPD/unspecified. Now everything is coded under chronic lower respiratory disease (CLRD) which also includes emphysema, chronic bronchitis, and bronchiectasis.

Up to 30% of the U.S. population doesn’t know what COPD is.

-I'm surprised that it is this low. Get a average person and look at the leading causes of death list. The one that would most likely be a little blurry would be chronic lower respiratory disease. Maybe I should have a little more faith in humanity.

“COPD kills more than 120,000 adults each year. That’s one death every four minutes—more than breast cancer and diabetes combined. Yet people go undiagnosed and untreated because they don’t recognize the symptoms,” said James P. Kiley, Ph.D., director of the NHLBI's Division of Lung Diseases.

-Pop quiz! What color is the COPD ribbon? Now name the one for breast cancer and heart disease.

CPOD is gold. Yea. I had to look it up too. Apparently COPD and childhood cancer share the same ribbon.

Residents who give in

noreply@blogger.com (Steven Ling-Duan) — Mon, 14 Nov 2011 14:18:00 +0000

ECMO classes days 6 and testing

noreply@blogger.com (Steven Ling-Duan) — Wed, 09 Nov 2011 02:32:00 +0000

ECMO Day 6
We got a lecture from a cardiac fellow about taking care of cardiac patients on ECMO. She was very nice and informative. Unfortunately, she also used a lot of big words and cardiac surgeon terms that fried my brain. Fortunately, I took notes. Then more emergency drills.

Testing
There was a written test that was surprisingly not that difficult. In the afternoon, we ran emergency drills that were timed. Not my intention to brag or anything but I did pretty well. I surprised myself honestly because somewhere between days 3 and 4, I had a nightmare about killing a patient on ECMO.

sometimes i breathe : ECMO specialist!

ECMO classes days 4 and 5

noreply@blogger.com (Steven Ling-Duan) — Tue, 08 Nov 2011 00:16:00 +0000

ECMO Day 4
We spent most of the day on the Cardio-Pulmonary Support rapid response system. This is what we uses when someone is "crashing."

The ECMO circuit takes a long time to get ready(prime) and CPS only takes 20 minutes, patients that are arresting will go on CPS and then they transfer into ECMO.

Then we spent the afternoon covering drills.

ECMO Day 5
We had a four hour course over the Ventricular assist device and ran drills in the afternoon.

I sliced my finger with scissors while exchanging a bladder.

We have a written test tomorrow on everything we have covered. Then we have drill stations where everything we do is timed.

ECMO classes days 2 and 3

noreply@blogger.com (Steven Ling-Duan) — Wed, 02 Nov 2011 22:07:00 +0000

ECMO Day 2
We took a short quiz then had a lecture on being friendly to the blood bank and the overall ECMO equipment. Then we played around with the equipment.

ECMO Day 3
Getting air out of the circuits and changing ECMO components. While changing out a component out of the ECMO circuit, the patient needs to be disconnected. While replacing equipment: everything is timed, the physicians are in the room, and everybody is watching. A lot of things can go wrong. It can be a little stressful.

I had two accidents:

Scenario 1: The bladder was leaking and needed to be changed.
While I was fiddling with the equipment while changing the bladder, one of the ports was loose. The cap came off and "blood" squirted all over my face. I chucked and shook it off because it was just normal saline. In real life, I probably would've cried a little.

Scenario 2: Helping a coworker change the bladder.
My co-worker did not clamp the tubing completely off so "blood" squirted all over my legs. I did the only thing I could think of; plug the hole off with my thumb.

We also got a excellent lecture on nursing care and dialysis on ECMO.
The classes are going well and I am learning a lot but I'm so very tired.

-

-In the latest interesting news, lung regeneration may be possible in humans soon. When they mean soon, they probably mean "just a few decades." The research has not gone beyond mice yet.

Day 1 of ECMO class

noreply@blogger.com (Steven Ling-Duan) — Mon, 31 Oct 2011 23:40:00 +0000

Pictured here is the father of ECMO and the first patient on EMCO. She is still alive and keeping it real.

I pretty much sat through 10 hours of lecture today. It went at a steady pace but there was a lot of information. Unfortunately, not all of it soaked in even though I had a good nights sleep last night. There is a quiz tomorrow over what we have covered today so I have to get to studying.

Topics we covered today:
Introduction to ECMO
Cannulation / Decannulation
Initiation / Maintenance
Weaning / Discontinuation
Physiology
Coagulation, ACT and Heparin Management
Chemistry, Hematology, Lab Values

My brain wants to explode but ...dinner first.

AARC News: Be Aware of the Pitfalls of Drowsy Driving

noreply@blogger.com (Steven Ling-Duan) — Sun, 30 Oct 2011 13:20:00 +0000

November 6–12 as Drowsy Driving Prevention Week.
The National Highway Traffic Safety Administration estimates that drowsy driving results in 1,550 deaths, 71,000 injuries and more than 100,000 accidents each year.

-Here is a excellent pdf about how to prevent drowsy driving.
-It seems like the only real solution to drowsy driving is to take a power nap.
-I sometimes take 5 second power naps at stop lights (joking).

-Since I work night shift, I'm no stranger to drowsy driving. There have been incidents where I would get home after a 12-hour night shift and think to my self, "I don't remember making that right turn into my neighborhood. How the hell did I get here?"

-I noticed a interesting correlation among my coworkers; There seems to be a direct correlation between how far someone lives from the hospital and how many accidents that have occurred.
-I once lived 15 minutes away and now I live 20 minutes. Yes I feel the difference.

Dumb question from a patient

noreply@blogger.com (Steven Ling-Duan) — Fri, 28 Oct 2011 16:39:00 +0000

CHEST 2011 Highlights

noreply@blogger.com (Steven Ling-Duan) — Thu, 27 Oct 2011 03:09:00 +0000

Bath Salts Emerging as New Recreational Drugs

Bath salt poisoning incidents have skyrocketed, with 1,782 since January 2011 compared with 302 in all of 2010. It produces a produce a "high" along with increased blood pressure, increased heart rate, agitation, hallucinations, extreme paranoia, and delusions. Treatment is sedation until side effects wear off. Although currently federally unregulated, 26 states have made these substances illegal.

-Really kids? WTF is wrong with you?

-I got a solution: Don't put that warning label: "Not for human consumption" on anything anymore. That's how it starts right? A kid looks at the label and gets curious. Then he shares his experience with his friends.

-I bet if you put that label on a shoe kids these days will try to find a way to get high off it.

Caffeinated Alcoholic Beverages May Harm Patients With Chronic Medical Conditions
The alcohol content in some of these beverages can range from 11% to 12%, with 60 grams of sugar. Since being evaluated by the US Food and Drug Administration, 4 Loko maker Phusion Products has removed caffeine, taurine, and guarana from their drinks.

-Caffeinated allcoholic beverage may harm anybody even without chronic medical conditions.
-The caffeine made 4 Loko taste decent. Now it tastes horrible. The purple one tastes like Dimetapp.

Silicone Injections May Prove Deadly According to Several Research Studies
Reports of adverse events, including death, from silicone injections for cosmetic purposes have been increasing in both medical and consumer literature.

-No comment

Cryotherapy Proves Invaluable Tool in Aspirating Foreign Bodies from Airways
Foreign bodies (FB) often enter the body through oral cavities, and retrieval can sometimes be difficult. Woman swallows push pin. The researchers used a cryoprobe, positioning it so the tip contacted the FB, and then lifted it out of position and extracted it with forceps without damaging any tissues.

In cryotherapy, a coolant is delivered under pressure to the tip of a probe that passes through the working channel of a flexible bronchoscope. When placed in contact with the FB, the cryoprobe can be iced and made to adhere to the FB. Additional advantages include vasoconstriction (narrowing the blood vessel cavity), analgesia (pain relief), and slowed blood flow. Cryotherapy also causes shrinkage in organic objects. The patient survived.

-Sounds awesome but will it work with slippery foodstuff? Retrieving a grape may not be as easy as a rigid metal object.

Pulmonologists Experience Pain While Performing Bronchoscopy
Of the 132 respondents, 50 (39.1%) pulmonologists experienced pain while operating a bronchoscope. 22% experienced recurring pain, mainly in the shoulder, back, wrist, neck, and thumb. The pain appeared to be associated with overuse injury and height less than 5'7".

-I might have a solution for that; lower the bed.

Combination Therapy Shows Promise for PAH Treatment
Current treatments for pulmonary arterial hypertension(PAH) often entail observing patient deterioration when using a single medication and seeing its effects before starting a second medication.

Researchers from conducted clinical trials on high-risk patients with a mean age of 60 years who had idiopathic and connective tissue disease-associated PAH. The researchers administered a first-line oral combination therapy of bosentan and sildenafil, which yielded improvements in 6-min walk test, symptoms, and blood flow and cardiac function parameters. This strategy appears to be relatively safe and well tolerated by the patients. The magnitude and durability of clinical improvements along with the risks of early drug-induced liver damage remain unclear and warrant further study.

-We like to do things one step at a time. This way when something goes wrong, we know exactly which drug caused the problem.

Catheter-Related Bloodstream Infections Significantly Decreased After Guideline Implementation
Evidence-based guidelines have been shown to improve health-care outcomes. In 2006, a guideline called the Institute of Health Improvement Bundle was created to help hospitals reduce the rate of catheter-related bloodstream infection (CRBSI), the most frequently occurring nosocomial infection.

Researchers retrospectively reviewed the charts of 895 patients admitted to the SCI who required the placement of a central venous catheter (CVC) between 2007 and 2010. CRBSI rate demonstrated a significant decrease and confirmed that the implementation of evidence-based practice guidelines in the care of CVCs may reduce CRBSI rates.

-Guidelines are always a good idea.

Hospitalizations for Stomach Bacterial Infection Growing at Epidemic Rates
A recent study emphasizes the increasing frequency and severity of Clostridium difficile infection (CDI), a stomach infection caused by bacteria. In the United States, age-adjusted CDI hospital fatalities nearly doubled between 2000 and 2005. The growth of CDI hospitalizations continues to rise in this country, and their growth far outpaces the rate of general hospitalizations. Increased focus needs to be spent on prevention.

-Wash your freaking hands people.

Beware of Toxins in Household Products
Approximately 60 deaths per year occur due to ethylene glycol (EG) exposure, a water soluble solvent used in a variety of products including printing inks, leather finishers, antifreeze, plumbing fluids, and cleaning solutions. In 1999, 6,281 cases of EG exposure were reported, with 23 deaths from toxic exposure. As little as 100 mL of EG can be poisonous to a human being. If unrecognized and untreated, renal failure may develop between 24 and 48 hours after ingestion; however, subacute poisoning can result from skin exposure. This can include multiorgan injury, central nervous system injury, psychiatric symptoms, and personality changes. A single massive exposure to the skin can be toxic.

-That's why you wear gloves when cleaning your bathroom.

source

Learning ECMO

noreply@blogger.com (Steven Ling-Duan) — Tue, 25 Oct 2011 04:18:00 +0000

I'm all set to take the extracorporeal membrane oxygenation class next week. The ECMO pump is a machine that provides cardiac and respiratory support oxygen to patients whose heart and lungs are severely diseased or damaged. I honestly don't know much about it. My RT school talked about it for one day from a ECMO specialist.

From what I remember:
1. ECMO can't cure anything: It's used for rest while the body naturally recovers. No cancer patients or brain dead patients on ECMO.
2. There are two types: veno-arterial (VA) and veno-venous (VV). VA provides cardiac support while VV does not.

I'm a little nervous but also excited. I never see RTs stressed out as much as when someone is about to go on EMCO. Since I am not ECMO specialist yet, when a patient goes on ECMO I end up supporting the rest of the ICU patients. The ones that are ECMO certified end up with help setting up the pump. The non-ECMO people check on the other patients in the ICU and make sure they are still ticking.

For the education program, I was given large packets of reading material. There is a pre-test before the class. It looks like it's time for "back to school studying mode" for me.

ADVANCE: Highlights of October 2011

noreply@blogger.com (Steven Ling-Duan) — Mon, 24 Oct 2011 01:03:00 +0000

Pediatric OSA screening
-While polysomnography is the gold standard of sleep testing, it is still flawed.
-History and physical exam are poor at predicting OSA.
-Carbon dioxide measurement should be included in all pediatric OSA testing.
-In 2009, Dr. Gozal and fellow researchers found that proteins in a child’s urine can “reliably distinguish” between a child with OSA and one snoring.
-Imagine that. A home pregnancy test-like kit for determining OSA.

Bronchopulmonary dysplasia
-Up to 25 percent of infants born weighing less than 1,250 grams to develop chronic lung disease of prematurity, also known as bronchopulmonary dysplasia.
-BPD resolves for many patients during the first two years of life.
-More than 25 percent of extremely premature infants with BPD go on to develop asthma.
-Infants are diagnosed with BPD when they require supplemental oxygen or respiratory support for ≥28 days or have continued use of supplemental oxygen at 36 weeks post-menstrual age.
-Frequently they require complex medicine regimens including diuretics, inhaled corticosteroids, and inhaled
beta-agonists during the first year of life.
-Respiratory illnesses cause the hospitalization of 40 percent of premature infants during the first two years of life. Wash your hands!
-Inhaled beta-agonist therapy and systemic corticosteroids should be considered as therapies because many premature infants wheeze with illness; however, infants and children with a history of BPD often have components of both reactive and fixed airflow limitation, so they may not respond as well to bronchodilators therapy as children with asthma.
-Metered-dose-inhalers with an appropriate spacer-mask combination can be as effective as nebulized treatments even in small infants.

Remote Pulse Oximetry
-Recent developments in pulse oximeter technology allow clinicians to use a Bluetooth® wireless sensor device to remotely monitor patients’ oxyhemoglobin saturation. Data is transmitted to a computer and by the internet. Smartphone or multichannel (capnography) devices are on the horizon.
-A patient who is properly trained to use a pulse oximeter at home can learn to identify early signs that his conditioning is worsening.
-A study has shown benefits of supplemental oxygen in COPD with moderate-to-severe airflow obstruction and mild hypoxemia at rest. Similar findings are seen in patients with pulmonary hypertension who desaturate during exercise.
-Though helpful in many ways for patients’ evaluation, pulse oximetry has certain limitations, and clinicians need to be aware of t hem. They include the following:
• False readings due to hypoperfusion (shock), extremity movements, or rough skin
• Falsely high reading in carbon monoxide poisoning and falsely low reading in methemoglobinemia
• Lack of information about total blood oxygen content (i.e. in case of anemia, blood will be carrying less oxygen, despite the hemoglobin being 100 percent saturated)
• Only provides a measurement of oxygenation, not ventilation
• Cannot determine the metabolism of oxygen, or the amount of oxygen being used by the patient.

Flying With a Ventilator
-In May 2009, the Air Carrier Access Act went into effect, requiring U.S. aircraft (and foreign aircraft operating in the U.S.) with 19 or more seats to allow passengers to bring aboard and operate ventilators, respirators, positive airway pressure machines, and portable oxygen concentrators (POCs).
-Find out if your equipment is on their list of approved ventilators before you purchase your plane ticket.

Baby’s Breath
-Optimal level of oxygenation that should be targeted in infants continues to be debated.
-Too much oxygen, and the excessive pressure could cause lung scarring, ventilator-induced inflammation, brain injury, blindness, retinopathy, or bronchopulmonary dysplasia. Too little oxygen can cause permanent
mental and physical disabilities.
-Recent evidence indicates that targeting of oxygen saturation in the low 90s (91 to 95 percent) results in better outcomes including survival and pulmonary outcomes compared to higher or lower ranges.

AARC News: Respiratory Therapists Weigh In on Clinical Alarms

noreply@blogger.com (Steven Ling-Duan) — Sat, 22 Oct 2011 01:33:00 +0000

Alarms are important to RTs. The 2011 National Clinical Alarms Survey had 4278 responses and nearly half of all respondents were RTs. You could find the results here.

Here are the conclusions:

1. A high priority must be placed on the reduction of nuisance alarms.
-Agreed. Too many nurses freak out over low pulse ox saturation when the pulse ox is not on the patient correctly.

2. The very high level agreement with Quesion 6 — “Alarm sounds and/or visual displays should be distinct based on the parameter or source.” points to consideration by standards organizations to discuss this requirement for future systems.
-This should be standard and obvious. Every alarm we have uses a distinct ringtone and pitch to help differentiate alarms. Certain alarms have certain priorities.

3. Smart alarms are viewed as being advantageous in reducing false alarms and improving
response to alarms.
-What exactly are smart alarms?

4. Central alarm management is viewed as advantageous and many institution utilize monitor watchers.
-I'm sure a lot of hospitals use their budge to hire a specific person to watch alarms all day. That person will have to be disciplined enough to not fall asleep or get on Facebook.

5. Clinical alarm improvement efforts need to be stepped up in healthcare institution.
-Duh. Isn't that the whole point of the survey?

6. Adverse events related to clinical alarm issues were reported by 1 in 5 responders.
-Not surprised.

7. A large proportion of the responders were unsure if adverse events had occurred in the last 2 years and unsure if there had been new solutions to improve alarm safety at their facility. Improved and open communication is needed in healthcare related to these critical issues.
-Communication is always a issue at most hospitals. This happens all the time. We get new equipment. Patient goes on new equipment. We then get a in-service about the new equipment two weeks later.

8. A systems approach is needed to address the complexities of clinical alarm issues in healthcare. The effort needs to involve all stakeholders in developing solutions.
-You must mean systematic?

I'm not really surprised of any of the results from this survey. Alarms are important. More needs to be done with making alarms more efficient.

New site direction

noreply@blogger.com (Steven Ling-Duan) — Fri, 21 Oct 2011 12:24:00 +0000

Yes. I am still alive. I spent the past few months "finding myself."

Now that I've been a full time RT for the past two years, I will start converting this site into a more as a resource for other RTs rather than my random thoughts and complaints. Complaining never gets anywhere.

I've realized I truly do have a lot of time on my hands and I really do love my career. It's time to give something back to the community. Stay tuned. This site is getting revamped.

My first real vacation

noreply@blogger.com (Steven Ling-Duan) — Tue, 03 May 2011 05:02:00 +0000

I spent the last two years saving up my PTO to make a trip to China. I'll be gone for a good month.
I've actually had quite a few trips in the past two years: one to Las Vegas and at least five times back to Georgia to visit family and friends. I've gotten away with this by having a awesome 3-4 day work schedule.

I'm looking forward to the trip.
See you in about a month.

Voicera vs pagers

noreply@blogger.com (Steven Ling-Duan) — Wed, 20 Apr 2011 19:31:00 +0000

Voiceras allow you to instantly communicate to other people carrying Voiceras in real time. Voicera is similar to carrying walkie-talkies. Pagers have about a two minute delay but is non intrusive.
Every respiratory therapist has to carry both now.

Speed: Voicera
All you have to do is push a button and say, "Call RT3." I would get a call on my Voicera asking, "Would you like to talk to X?" "Yes or no." A pager requires manual text input and then there is about a two minute delay.

Accuracy: pagers
Voiceras require pretty strong voice and pronunciation. It's especially difficult to transmit a clear voice also when the voicer is covered by a gown or there are people talking next to you.

Reliability: tie

I say "Call Jane Doe." Voicera will ask, "Are you looking for Frank Qyijibo?" "...No." This may continue multiple times with hilarious results until you find the right person.

The pager system will sometimes be down and you won't even know if you received a page or not.

This is also not a big deal but pagers also have a much longer battery life.

Distance: pagers
Our emergency room is in the basement and the ICU is on the 9th floor. The Voicera looses range and becomes useless in the emergency room.

Style: Voicera
Carrying a Voicera makes me feel like I'm in StarTrek. It could use some work but when it works it's pretty high tech.

Intrusiveness: pagers
When you get a call from Voicera, you talk directly to the nurse, doctor, or whoever. It brings awkward situations sometimes when the parent or patient is staring at you.

Usefulness: tie
The Voicera is just so much faster but pagers allow mass texting for rapid responses and other emergencies. We also get order changes from pagers.

Voicera: 4
pagers: 5

So Voiceras are pretty neat but they could use some improvements. If the tiny screen on the back could also double as a rapid response and order change pager, then maybe we could move towards replacing pagers. For now, pagers are king.

First time precepting

noreply@blogger.com (Steven Ling-Duan) — Mon, 18 Apr 2011 19:30:00 +0000

I was a preceptor recently. It was my first time so I didn't know what to expect. I was looking forward to having a little responsibility in shaping a super respiratory therapist.

My goal was to teach as much as I could but I didn't get enough sleep that day. That night also happened to be very busy. It was difficult to keep up with my own assignment, already being tired, and having to teach all night.

Teaching is something I have mixed feelings about. I enjoy spreading the knowledge but I hate repetition. As a teacher, you may build new class lectures your first year but then you spend the next few years toning the same lecture: teaching the same lesson over and over again to a new group of people every semester. As a professor you also have to deal with many other issues like grants and funding that does not appeal to me.

I wasn't going to just throw my student a few patients and tell him to meet me up later. (This is a horrible way to be a preceptor.) I wanted to following him and evaluate and critique every patient interaction. He was a smart student but also slow. I realize that he was just a student but this was his externship so he's had plenty of ICU experience.

It made me realize our hospital is very short staffed.

New policies

noreply@blogger.com (Steven Ling-Duan) — Sat, 09 Apr 2011 23:38:00 +0000

Our new policy prevents people from using their home BiPaps. Before patients would bring their home BiPaps, RTs would call clinical engineering and they would put a little sticker on their BiPaps before the patient can use them. I'm not quite sure what clinical engineering actually does but all machines have passed their checks.

Most patients prefer their own machine and mask.
Now every patient will go on our hospital issued BiPap ST bricks. This could be a good thing and a bad thing:

Good:
Reliable and predictable.

Bad:

Feels different: You can set a inspiratory pressure, expiratory pressure, and breaths per minute like any other BiPap but that's about it. Most home BiPaps are customized to the patients comfort level.

No alarms. These STs do not have alarms and are very basic machines.

BiPap shortages: We already run short on BiPaps sometimes and have to borrow them from the adult side sometimes. Our department plans to order a lot more.

I know a lot of patients and parents are going to complain.

We are also moving towards not allowing patients use their own vests.

So we have enough money in the budge to afford more equipment but not enough for the employees?
Night shift had a $1.25 a hour pay cut due to "budgeting issues."

I know it's a liability issue but this is just getting ridiculous.