Texas RT Delicensing

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RT Focus

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Here's a thought...

Sure, there are plenty of things to complain about in the Respiratory field. One of the most viewed comments on AARC's connect blog is titled, "Respect of Respiratory Therapist, where has it gone?" Other websites and bloggers write about how small their department is, the lack of physician knowledge, the awful relationship with their staff, etc.

Here's a thought: Rather than eliciting more complaints, let's invite some positive feedback. What do you like most about the Respiratory Field?

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If I could, I would...

You've worked with patients and various therapy devices. Has a great idea for an invention ever cross your mind? If you could invent something, what would it be? Bluetooth stethoscope? Wireless EKG? Built-in artery finder for the ABG syringe? If you are a respiratory therapist, your mind is probably always spinning. I'm curious to hear where your mind goes as you look for ways to improve respiratory therapy. Go ahead and share...

What is the HR 2619 Bill?

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There is a bi-partisan bill in congress known as the HR 2619 bill. For those not familiar with ‘bi-partisan,’ it means that a bill has been sent to congress and it has both (bi) Democrat and Republican support. So what’s so significant about this bill? This bill will help ensure that patient’s receive competent care by competent therapists. How?

The bill is seeking to add coverage of pulmonary management education and training when done by a qualified respiratory therapist under the supervision of a practicing physician. In other words, Medicare patients will be covered when they seek education and training by qualified respiratory therapists. In other words, qualified respiratory therapists will finally be reimbursed for these services. In other words, respiratory therapists will be more marketable. Need some examples of what may be covered? Observing and teaching MDI techniques, educating the importance of proper medication use, recommending flu and pneumonia vaccines, developing action plans, education on oxygen systems, education on pulse ox monitoring, etc. These probably are things you already do, but are not reimbursed for. This is a big incentive because the bill will take the guesswork out of whether the physician will get paid for the RT services.

To qualify, the RT must hold a “registered” credential and have at a minimum a bachelor’s degree or other advanced degree in a health science field appropriate to the services RTs provide. RTs can be part-time or full-time employees of the physician practice or be contracted to provide the services. They will not, however, be able to start their own independent practice.[1]

What if you don’t have a “registered” credential or a bachelor’s degree? You are still qualified to support this bill! The bill positively impacts the entire profession. Please help in making this happen!

How can you support the bill? The AARC has made the process very easy. If you are a respiratory therapist, click on this link http://capwiz.com/aarc/issues/alert/?alertid=62340161. This will compose a message to your U.S. Senators and U.S. House Representative. The wording of the email has already been written. All you have to do is type your name, email, home address, and hit send. That’s it!

If you are a student respiratory therapist, you can click on this link http://capwiz.com/aarc/issues/alert/?alertid=62340241. This will compose a message to your U.S. Senators and U.S. House Representative. The wording of the email has already been written. All you have to do is type your name, email, home address, and hit send. That’s it!

What are you waiting for? Do it!

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[1] http://www.aarc.org/advocacy/activities/FAQs_HR2619_FINAL_rev3-6-14.pdf

CRT vs RRT

CRT vs RRT

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Question: I’ve been a CRT for over 15 years. Do I really need an RRT?

This is a loaded question. Before there’s an answer to this question, I believe there has to be an answer to the motive behind the question. Is the person really seeking advice? Hopefully the answer is 'yes.' Or is the person seeking to engage in a debate to argue whether a CRT can outsmart or outperform a RRT? If the person is merely seeking to engage in a debate whether a CRT can outsmart or outperform a RRT, do not bother engaging. You will inevitably get drawn into a fruitless conversation that goes nowhere, really fast. However, if the person is genuinely seeking advice, here are a few thoughts to consider.

First off, all RRTs were once CRTs. I have heard many CRTs justify their reluctance to obtaining the RRT credential because they profess that CRTs 'outperform' RRTs. What they sometimes fail to remember is that a therapist with a RRT credential was first a therapist with a CRT credential. In fact, all RRTs were once CRTs. The issue in "outperforming" is childish and has little to nothing to do with credentials. Rather, it has more to do with experience. Remember, not all RRTs are new grads. Some RRTs have more mileage and years of experience than seasoned CRTs. So let us not keep reverting to the fruitless point of, "there are many CRTs that can outperform an RRT." Believe me, the reverse is also true.

Second, I have heard some selfish reasons why not to pursue the RRT credential: “It doesn’t make me a better therapist,” “it has not held me back yet,” “it will not affect my current employment.” I find it curious that people write-off the credential because of what it doesn’t do for them as opposed to what it does for the profession at large. It is curious to me because we have entered a profession where we are charged to look out for the good of others, our patients, and not just for our own good. Our profession needs more people with selfless attitudes. No, I'm not suggesting that CRTs are selfish. What I am suggesting is that obtaining the RRT credential advances the profession and also sets a good example for those coming behind us to continue to advance their credentials. Some things are never just about you.

Thirdly, there is always something to learn in our field. At the very least, in studying for the exam, even the most experienced CRT will learn a few new things, whether it be theoretical or practical. I have yet to come across that one therapist who has seen absolutely every device and every scenario imaginable. This means that we are never done learning. In fact, if you are done learning, you are… done. It is probably time to hang up your stethoscope and turn in your license, yes, even if you have a bachelor’s or master’s. You have lost interest in the actual field of respiratory. This is not necessarily bad. Ambitions change and other career paths open up. This may be a good time to exit stage left, and allow someone with higher ambitions in the field of respiratory to carry the torch.

If you are a CRT and have not taken the RRT yet, you are not a lesser therapist. However, you do carry a lesser credential. You can take that first step in advancing your credential by obtaining the RRT license, and in so doing, you will help set the tone for future therapists to pursue a higher credential and advance our profession.

E-Cig ban?

Let the debate continue. It looks like Los Angeles, California has decided on the issue for Southern Californians. The LA city council approved a new measure that would treat e-cigarettes like cigarettes. 

Read more about the outlawing of "vaping" in certain areas here: http://www.latimes.com/local/lanow/la-me-ln-los-angeles-ecigarettes-ban-20140304,0,4359853.story

So let's hear it. What are your thoughts?

HFOV

The high frequency oscillatory ventilator (HFOV) has been around for quite some time now. It has been used on adults to treat ARDS, but its main implementation is on the neonate RDS (respiratory distress syndrome) population. 

HFOV has 5 main knobs. 

1. Amplitude 

2. I-Time %

3. Frequency (Hz)

4. Flow

5. Mean pressure

Amplitude - This knob can also be referred to as "delta P" or "driving pressure." This is the main knob adjusted for CO2 correction. Increasing the amplitude will increase the amount of volume delivered through each oscillation. As in conventional ventilation, increased volumes will decrease CO2 levels in the blood. So always remember that this is the first line of defense to reduce the PaCO2 on a blood gas. 

To ensure the patient has adequate volume, obtain a blood gas and adjust for CO2 accordingly. 

In addition, adjust the amplitude for chest wiggle. Chest wiggle ensures that there is an adequate volume being delivered. For a neonate, the chest should wiggle. For a pediatric, the chest down to the navel should wiggle. For the adult, the shoulders down to the mid-thigh should wiggle. 

I-Time % - A typical I:E ratio is 1:2. On the HFOV, a patient doesn't have a true I:E ratio as in conventional ventilation. The oscillations happen so fast that one can not physically count and determine the I:E ratio. But the oscillator will deliver an oscillation at the 1:2 ratio. 

So how do you set an I:E of 1:2? First, take the sum of the I:E (1+2). Then, divide 1 by the sum of the I:E (1/3). This comes out to 33%. Therefore, for an I:E of 1:2, set the I-Time % to 33%. 

Typically, this knob is rarely adjusted. I suppose if you wanted to dedicate more time to "exhalation" during the oscillation, you can change the I:E to 1:3. This translates to an I-Time % of 25% (1/4). 

Frequency - The frequency determines how many cycles ('breaths') the patient will receive. 1 hertz (Hz) delivers 60 cycles per minute. Depending on the size of a premature neonate, the Hz can be set as high as 15. This comes out to 900 cycles per minute!

Some wrongly think that increasing the Hz will have the same effect as in conventional ventilation when the RR is increased. However, this isn't the case. In HFOV, increasing the Hz will actually reduced the amplitude (volume) of each oscillation. If volume is reduced, PaCO2 increases. 

Here's what I mean: If you had a PaCO2 of 60mmHg, in conventional, you could increase the RR to reduce the CO2. In HFOV, if you increase the Hz, you'll increase the CO2. If anything, the Hz should be decreased because this will increase the volume, which will help correct a high CO2. 

The general rule of thumb is: The faster it oscillates, the smaller the volume. 

Therefore, the primary control to correct a high CO2 is to increase the amplitude. The secondary control would be to decrease Hz. 

Flow - Flow is set to allow the circuit to be pressurized. This ensures that there is no lapse from when the oscillator sends a volume to when the patient receives the volume. If the patient exhibits retractions, increase the flow. They're trying to 'pull' a breath. Increasing the flow ensures it reaches the patient quickly. 

What's a good initial setting? The smaller the patient, the lower the flow. The bigger the patient, the higher the flow. For a small premature neonate, a flow of 10-15L/m is acceptable. For an adult, 40L/min is acceptable. 

Mean Pressure - Mean Pressure inflates the lung to the set pressure and keeps it there. The lung does not deflate. This helps distend the alveoli, whereby recruitment is enhanced. This is the primary control to improve lung compliance and oxygenation. You can initially set it between 15-20cmH2O, and adjust it upwards to 30cmH2O for non-compliant, atelectatic lungs. 

Others suggest to set the mean pressure to the same, or slightly above, the plateau pressure the patient had on conventional ventilation. This is a good idea if the patient was previously on a conventional ventilator and the therapist had the ability to perform and record an accurate plateau pressure. This is achieved by performing an inspiratory hold for about a second. In other words, on a conventional ventilator, you can press the 'inspiratory hold' feature, and when the patient inhales, the ventilator will hold that breath and measure the pressure in the lung. That pressure is the plateau. 

When all is said and done, the HFOV looks intimidating but as you play with it, you'll discover it is pretty simple. It's been around for quite some time for a reason. As long as you maintain a safe mean pressure, HFOV is a safe method in treating patients with ARDS. 

FACT: Thin people have sleep apnea, too!

Sleep apnea is a common disorder in which you have one or more pauses in breathing while you sleep.[1] Oftentimes, the pauses can last from a few seconds to minutes. This can happen 30 times or more an hour. As it happens, and breathing restarts, a loud snort or choking sound can be heard. It is during this period that you actually move from a deep, comfortable sleep to a light, poor sleep.

Imagine being woken up 30 times or more an hour. You may not be completely woken up, but shaken to the point to where your body is no longer in that deep sleep. This is similar to what takes place with those affected with sleep apnea. It’s no wonder why sleep apnea is a leading cause of excessive daytime sleepiness.

It was commonly held that if you were not overweight, there was no real risk factor for sleep apnea. Although it is more frequent among men than among women,[2] sleep apnea can affect anyone. Whether you’re thin or thick, if you have the symptoms of sleep apnea (excessive snoring, daytime tiredness), you should consult with a physician for a possible work-up (sleep study) and solution.

Untreated sleep apnea can increase the risk of:

• High blood pressure
• Heart attack
• Stroke
• Obesity
• Diabetes
• Driving accidents
• Memory loss

CPAP devices are the most effective in treating sleep apnea. But its size and volume can often be viewed as too invasive. There is another solution aside from CPAP or surgery: Oral Appliance.

The American Academy of Sleep Medicine has endorsed the use of an Oral Appliance for selected patients with sleep apnea. They typically look like the mouth guards worn by athletes. It works by positioning the lower jaw slightly forward to its usual rest position. This allows for air to freely pass from the upper airway to the lower airway without resistance. These appliances cannot be purchased over the counter. Fortunately, most insurance plans cover the cost.

If you are a respiratory therapist, you should brush up on the various risk factors and treatment options with regard to sleep apnea. There are many risk factors and CPAP is not the only option. If you think you or anyone you know may have sleep apnea, follow up with a physician and ask about the oral appliance option.

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[1] http://www.nhlbi.nih.gov/health/health-topics/topics/sleepapnea/

[2] http://www.sleepapnea.org/learn/sleep-apnea.html