Changing practices in Respiratory Care!

Changes in evaluation and treatment of Retinopathy of Prematurity
Important changes include recommendations for treatment of high-risk prethreshold ROP as well as for threshold ROP and more frequent evaluation of infants with suspected aggressive posterior ROP and infants with immature vascularization without ROP.¹

Respiratory Distress Syndrome and CPAP
A follow-up report of the SUPPORT trial provided further evidence that the initial use of continuous positive airway pressure (CPAP) is a good alternative to early intubation and surfactant administration for extremely premature infants (gestational age between 24 and 27 weeks), who are at-risk for respiratory distress syndrome.²

At 18 to 22 months corrected age, there was no difference in death or neurodevelopmental outcome between the initial CPAP and intubation with surfactant administration groups (27.9 versus 29.9 percent). Impaired neurodevelopmental outcome was defined as a predefined poor score on cognitive testing, moderate or severe cerebral palsy, hearing impairment, or bilateral visual impairment.

Narcolepsy following adjuvanted 2009 pandemic H1N1 influenza vaccination
Individuals in several countries in Europe have developed narcolepsy after receiving Pandemrix, an AS03 (oil-in-water emulsion)-adjuvanted 2009 pandemic H1N1 influenza vaccine. Pandemrix was used in certain countries during the 2009-2010 H1N1 influenza pandemic, but it was not used in the United States. This association was first reported among children and adolescents in Finland and Sweden in 2010.³ These findings have been confirmed in a subsequent large retrospective database review that included six countries in Europe over a 10-year period; increased narcolepsy rates were observed in Sweden, Finland, and Denmark after the initiation of Pandemrix vaccination campaigns, primarily in children and adolescents.³ An increased risk of narcolepsy was also observed in children and adolescents who received Pandemrix in the United Kingdom.⁴

2012-2013 seasonal influenza vaccine effectiveness

In a case-control study conducted early in the 2012-2013 influenza season, the United States Centers for Disease Control and Prevention estimated that the effectiveness of 2012-2013 seasonal influenza vaccine in preventing laboratory-confirmed influenza is approximately 60 percent overall (55 percent for influenza A viruses and 70 percent for influenza B viruses).⁵ Given the moderate effectiveness of the vaccine, influenza infection will occur among some individuals who received the influenza vaccine. This highlights the importance of early antiviral therapy (regardless of vaccination status), particularly for those at risk for severe or complicated influenza infection.

High-frequency oscillatory ventilation in adults with ARDS

High-frequency oscillatory ventilation (HFOV), with respiratory rates up to 900 breaths per minute, improves oxygenation in patients with severe hypoxemia due to adult respiratory distress syndrome (ARDS), although two new studies have shown it does not improve survival for most patients. In one large multicenter trial (OSCILLATE), adult patients with new-onset, moderate-to-severe ARDS were randomly assigned to HFOV or to an ARDSNet (low tidal volume) ventilation strategy.⁶

The study was terminated for harm after enrollment of 548 of a planned 1200 patients, due to an in-hospital mortality of 47 percent in the HFOV arm compared with 35 percent in the ARDSNet arm. The OSCAR trial, which enrolled nearly 800 patients in the United Kingdom, also failed to demonstrate a mortality benefit with HFOV at 30 days, although the detrimental effect of HFOV on mortality observed in the OSCILLATE trial was not seen.⁷ Thus, HFOV is not recommended as an initial treatment strategy for adult patients with ARDS.

Long-term azithromycin for bronchiectasis

The role of long-term azithromycin in preventing exacerbations of bronchiectasis has been examined in patients with non-cystic fibrosis bronchiectasis. In the Effectiveness of Macrolides in patients with Bronchiectasis using Azithromycin to Control Exacerbations (EMBRACE) trial, 141 patients with at least one exacerbation of bronchiectasis in the prior year were randomly assigned to take azithromycin 500 mg or placebo, three times a week for six months.⁸

Azithromycin was associated with a significant decrease in exacerbations compared with placebo. Although no significant difference was noted in lung function or quality of life, long-term azithromycin may be useful in some patients with bronchiectasis.

Citations

1. Fierson WM. Screening examination of premature infants for retinopathy of prematurity. Pediatrics. 2013;131(1):189-95.
2. Vaucher YE, Peralta-carcelen M, Finer NN, et al. Neurodevelopmental outcomes in the early CPAP and pulse oximetry trial. N Engl J Med. 2012;367(26):2495-504.
3. Wijnans L, Lecomte C, De vries C, et al. The incidence of narcolepsy in Europe: before, during, and after the influenza A(H1N1)pdm09 pandemic and vaccination campaigns. Vaccine. 2013;31(8):1246-54.
4. Miller E, Andrews N, Stellitano L, et al. Risk of narcolepsy in children and young people receiving AS03 adjuvanted pandemic A/H1N1 2009 influenza vaccine: retrospective analysis. BMJ. 2013;346:f794.
5. Early estimates of seasonal influenza vaccine effectiveness—United States, January 2013; MMWR Morb Mortal Wkly Rep. 2013;62 (Early release):1.
6. Ferguson ND, Cook DJ, Guyatt GH, et al. High-frequency oscillation in early acute respiratory distress syndrome. N Engl J Med. 2013;368(9):795-805.
7. Young D, Lamb SE, Shah S, et al. High-frequency oscillation for acute respiratory distress syndrome. N Engl J Med. 2013;368(9):806-13.
8. Wong C, Jayaram L, Karalus N, et al. Azithromycin for prevention of exacerbations in non-cystic fibrosis bronchiectasis (EMBRACE): a randomised, double-blind, placebo-controlled trial. Lancet. 2012;380(9842):660-7.

RT in the news, Alena Talbot

San Diego Respiratory Therapist Heads To The Young Hollywood Awards… Courtesy Of Her Crest 3D White Smile As a respiratory therapist at Rady Children’s Hospital in San Diego, Alena Talbot’s smile brightens the lives of some very special children and their parents daily. “A Crest 3D White smile helps me achieve my goals and dreams each and every day. When my smile is white and bright, I feel like I can express my feelings and affection for these brave souls in the ward. A smile can make them feel a little more at ease and hopefully comfort them through tough times,” said Alena. link to the article

Case: Neonatal Diagnosis and Age

I am going to try to list some tiny case studies but I am not sure of how I'd like to list the information so bare with me as I list these things.


NEURO

CARDIAC

PULMONARY

GI/GU

SKIN

ACCESSES

LABS

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Background and narrative.

That is a dumb thing to say

Student Respiratory Therapist: I got into this because I wanted to be a nurse but I didn't want to deal with poop.
Registered Respiratory Therapist: Oh, well, you're in for a rude awakening.  Also, I hate you.

I don't really have a lot to say.  I have applied to Graduate schools for Nurse Practitioner (non-nurse to NP pathways) and Medical Schools.  We will see what happens and honestly, I am comfortable doing either path and I am really leaning toward the holistic NP coursework.  It is very much in the vein of the DO approach, but there are no DO programs anywhere close to me at all.

Chest Radiograph Explained Very Well

I did not make this but I found it and thought it was amazing so I would share it.  It's unedited so hopefully the signature in the lower right is the proper credit.

Education Tool

Feel free to take my drawing and use it to help teach others.  Obviously not anatomically correct, but its an excellent way to explain to a beginner how blood paths in a neonate.

Students, Every group is worse than the group before.

Quick Tips for Students.

1. Take Report, if you don't have a census sheet, suck it up, start scribbling on a blank sheet of paper.
2. Write down words you don't know and look them up later.
3. If the RT you're with doesn't know the answer, that doesn't mean you don't have to know the answer, look it up later.
4. Be proactive, many RT departments don't have the preception structure nurses do so you're with someone who probably hasn't been officially trained to know how to use you.  They're nervous about being wrong or a bad teacher or teaching you all the things you already know.  Be up front, tell them you don't know anything even if you think you do and follow them like a duckling.  Even the ones who act bitchy about you doing that will talk about how good you were when you are gone.  The "cool" students (the ones who relax and laugh the whole day with the RTs instead of learning) are always the ones most complained about.
5. Even if you don't want to work at that hospital, act like you do.  When you graduate your teachers send out recommendations to hospitals and they'll sometimes be too real about your skills and personality.  RT departments also all tend to know eachother.  Its a small society and being a douchebag will get you blackballed from a hospital you've never even been to.
6. Get at LEAST 1 year, more preferably 3 years of ICU experience right out of school.  Doing anything else destroys your resume.  3 years of ICU experience, then open your oxygen supply company.  Your life-goals will thank you.
7. Get your Bachelor of Science in Respiratory Care.  Get it asap.  Boise State has an online completion program and KU has one.  I prefer KU.  Its going to be mandatory soon and while you'll be allowed to practice with an associates it will be hard to get a job.  Physicians Assistants used to be Associate Degrees and the PAs who didn't get a higher degree find it very difficult to get a job, even with experience.

It was ordered 7 days ago and no one remembers why.

When I argue about the necessity of a treatment I am not trying to be lazy.  Stop looking at me with that sassy face.

It has taken me 4 times as long now to argue with you about it than to have just given it and I can't charge the patient for arguing with you.  

Quick Case

1200g 25wk, week 3 of life, week 3 on jet ventilator (HFV-P)

Capillary Blood Gas at 6am

7.60 / 42 / -- / +16

Vent: HFV-P  29/10 f240 (Backup Rate of 8)

ServoP: ~4.0

ETT: 3.0mm @ 7cm (2.5mm Jet Adapter)

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Capillary Blood Gas at 9pm the night before

7.39 / 70 / -- / +10

Vent: HFV-P  29/10 f240 (Backup Rate of 8)

ServoP: ~2.5

ETT: 3.0mm @ 7cm (3.5mm Jet Adapter)

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Polydactyly

When a neonate I pick up from a referring facility has 6 or 7 fingers normal people make faces and comments about how weird it is.  As a Neonatal Respiratory Therapist I only care that this neonate has more fingers to grip their ETT with.

Plus its kind of cute that when its reaching for its pacifier it looks like its waving at everyone with its many fingers.

HeRO®

HeRO® is an FDA cleared medical device for the identification of transient decelerations and reduced baseline variability in heart rate.

•	HeRO generates an hourly numeric score that quantifies the prevalence of abnormal patterns in each patient's heart rate.
•	HeRO continuously acquires, records, measures and analyzes heart rate characteristics.
•	HeRO provides real time display of the HeRO Score at multiple viewing stations located throughout the NICU.
•	HeRO is non-invasive and requires no applied parts or new patient leads.
•	HeRO interfaces with any make off existing ECG monitoring systems.
•	HeRO provides secure remote monitoring capabilities.
•	HeRO allows covered entities to remain HIPAA compliant.

Advocacy

Patient advocacy is exhausting.  I might "just" be a Respiratory Therapist but since its within my scope of practice to interpret chest radiographs, I am going to.

I won't move an ETT without personally reviewing the film, I will notify you when I see free-air or "bowel shaped aeration above the diaphragm" and I expect you to accept that.  I don't "joust" or anything and I try my damndest to communicate with you one-on-one to save your ego but its not always possible.

Next time though, when a Respiratory Therapist tells you they're concerned about a patient's cardio-pulmonary status, listen to them like you would listen to an expert on the topic.

Not just because we're colleagues or friends, but because we are actually experts on the topic.

How to set-up the Life Pulse High-Frequency Ventilator (HFV-P) for Nitric Oxide using INOmax DS

Dr. Travis Stork's Top 10 Health Tips for the New Year

• Find an activity you enjoy, and exercise with a friend. Finding an activity you really enjoy is the key, Stork says. And it's OK if that activity changes every few years. "Your likes and dislikes change throughout your life," he says. When he was in his early 20s, rock climbing was his thing, but as he grew older, riding his bike became a priority. "I don't even have a car out here," the California-based ER doctor says. "I bike to and from work every day."
  
•  Sign up for a race. "Don't sign up for a marathon if you don't like running," he warns; the point is to set some sort of goal. "It's motivation," he explains. "It doesn't need to be hardcore; it could be a 5K walk to raise money for breast cancer, as long as it's something that you mark on the calendar and have as a goal."
  
• Wear a pedometer. Stork admits that he doesn't do this anymore, but that could change. "I don't wear a pedometer, since it doesn't work on a bike," he confesses with a laugh. But he's considering strapping one on, joking that the exercise will count twice.
  
  
• Eat an apple before a meal. Eating a healthy snack—like an apple—before a meal can help you cut calories. Apples offer fiber and volume, Stork said, both of which make you feel full and can help you stop eating more than your body needs. Don't have an apple on hand? A glass of water can also do the trick. "You're filling up your stomach beforehand," he explains. "You're going to get that signal to you brain a little bit quicker that you're full."
  
• Carry nuts with you. Nut are packed with heart-healthy fats and protein. "They're about the best fast food I know of," he says. "It's an easy go-to when you're traveling." If you're allergic to nuts (or in a nut-free zone, like a school or a plane), any high-protein, portable alternative—like Greek yogurt or hard boiled eggs—will do. "Be your own fast food outlet," Stork advises. "Nothing's faster than pulling some mixed nuts out of your bag, and it's cheaper and healthier" than other convenient choices.
  
• Add strength training. Aerobic workouts are well and good, but strength training can help you burn calories better, reduce your body fat, and increase your lean muscle mass. It can also help you increase bone density, reduce your risk of injury, sharpen your focus, and keep your stamina up, according to the experts at the Mayo Clinic.
  
• Use cinnamon and nutmeg instead of sugar. You can cut calories easily by boosting flavor, and so called "sweet" spices like cinnamon and nutmeg make things taste more indulgent without adding calories.
  
• Wait 20 minutes to beat a craving. This may be the most difficult tip for people to follow, Stork said. "We live in a quick-fix society, and we tend to give in to gratings, not because we want to, but because we're almost forced to," he told Yahoo! Shine. With vending machines in almost every office and a fast-food joint on almost every corner, "It's hard to walk anywhere or go anywhere without access to a quick fix to our cravings," he says. It takes about 20 minutes for your brain to register that you're satisfied, so waiting that long before indulging may eliminate the desire to indulge at all. In other words, "have a cookie," Stork says, "but wait 20 minutes before you eat 10 more."
  
• Take deep breaths to reduce stress. When you're stressed, your body releases hormones including adrenaline and cortisol, which amp up your heart rate and triggers your body's fight or flight repines. Deep breathing can slow your heart rate and reduce the rate at which the hormones are flowing into your system and giving you a chance to ward off anxiety.
  
• Be a part-time vegetarian. In his book, "Food Matters," New York Times food columnist Mark Bittman suggests avoiding animal products and processed food during the day, and eating "what you want" at night. Stork agrees that upping your vegetable intake is a healthy choice to make in the new year. Vegetables are loaded with fiber and water, which helps you feel full, and it's easy to incorporate them into meals without feeling like you're going completely vegan.

Chest Radiograph (Pediatric) Foreign Body Aspiration

I get a called stat to ED upon arrival I see a 2 month with upper airway distress 
nurse says is croup, MD agrees but I keep assessing and I hear the upper airway noise is not stridor, epi is given an decadron IM, 

I look at the DR an tell him I don't think is croup and I asked him for an X-Ray 
I think is a foreign body. 

X-ray is done an this is what we get, oh yeah RT is always right.

existentialism

I am deciding between a non-nurse to DNP program or an MD(or DO) program.

I feel like I need to do something else.  They've been cutting our jobs and cutting our hours and it makes me nervous for the future.

9 things I wish I could say to a candidate.

1. I want you to be likable.

2. I'm taken aback when you say you want the job right away.

3. I want you to stand out....

4. ...But not for being negative.

5. I want you to ask lots of questions about what really matters to you...

6. ...But only if the majority of those questions relate to work.

7. I love when you bring a "project."

8. I want you to ask for the job... and I want to know why. (I wouldn’t literally say “Can I have the job, but tell me WHY you want it.”

9. I want you to follow up... especially if it's genuine.  

To read the full article by Jeff Haden click the link below.

 http://www.inc.com/jeff-haden/9-things-you-wish-you-could-say-to-job-candidates.html

tragedy

my heart is broken for the families involved in this terrible tragedy.

Levels in Health Care

Job Description: Respiratory Therapist

Respiratory Therapists serve as a specialist in Respiratory Care and provide examination, diagnostic and treatment services for patients who have medical problems characteristic of this specialty, and including the more complex cases where symptoms are difficult to identify, treatment regimens involve use of prolonged or complicated procedures or new techniques, or where patient's condition is critical.

Serves as consultant in the field for physicians, nurses and other providers in this and other specialties.

Examine patients and provide care as prescribed or by established protocol.

Provide appropriate documentation.