bmxRRT

I understand where you are coming from. There was a reason why I said case-by-case basis.... not every patient needs bipap and not everyone can tolerate it either. Frankly it is difficult to tolerate. FWIW, heated HFNC can be billed as a different charge as NC, I use HFNC often and whenever possible as it's far more comfortable and pt compliance is very good.

There is no "maximum limit" per say. Every patient is different, it is not a device you set and forget. The IPAP needs to be titrated to ensure the measured tidal volumes are in normal ranges for the child's IBW, generally we look for Vt's at least 5ml/kg IBW while on NPPV. EPAP should start at at least 5cm, if it's an acute setting. A CXR will better dictate what you set the EPAP, you may want more if there's atelectasis, or a really bad P/F ratio. You'll know immediately if the settings are appropriate, based on 1. pt's physical response (reduction in neck and intercostal retractions, belly breathing, nasal flaring, etc), 2. reduction of resp rate and heart rate, 3. ABG's. Based on the ABG you'll know exactly how you need to revise the settings, if the pt is still acidotic you should increase the delta P between EPAP and IPAP to improve the ventilatory aspect, this is also known as pressure support. If the oxygenation is still bad, an increase of EPAP may be of use, but remember, increasing the EPAP without increasing the IPAP will yield less pressure support, so the pt may lose some ventilation in that scenario and could become tachypneic once again. NPPV is only as effective as the clinician managing it, need to look at "the big picture". Bipap is an acceptable means of therapy in someone with acute resp. compromise(and chronic, if bad enough), especially if it means preventing an intubation. Of course, as long as there's no contraindications for it, and keen monitoring is vital! I've had a couple respiratory arrests in front of my eyes with acute asthma pt's on bipap. They can tire out very quickly on you. As far as HFNC goes, it really depends on the patient, commonly patient's that have primary oxygenation issues will benefit from HFNC. Ventilation issues are better met with NPPV. In kids, HFNC can create a peep effect on them, which can help their work of breathing, oxygenation and sometimes ventilation...but if their gas is crappy (

Careful, not all COPD'ers are chronically hypercapneic! Many of them have normal range PCo2, it has a lot to do with the severity of their disease and the amount of time they've been at that level of severity. If a patient has a chronically high PCo2 the kidneys will compensate by excreting more HCO3- to make the pH more alkalotic to bring it back into 7.35-7.45 range, so yes you are correct on that. It doesn't happen overnight, it takes a good amount of time for the kidneys to react in this manner. The kidney's reabsorb more bicarbonate if it senses a low pH (acidic), instead of excreting it into the urine. It's all apart of homeostasis.

It's all about the ratio of air to oxygen. If you set the nasal cannula to 2Lpm, it stays at 2Lpm, it's constant. If the patient increases the amount of air they inhale, that means more of the 21% fio2 room air will be mixed in with the constant 2Lpm that is going into the patient, thus diluting and reducing the total fio2 the patient receives. Think of it as watering down the fio2. The oxygen coming out of the nasal cannula is 100% oxygen, the room air is 21%. At 2Lpm the fio2 is calculated to be around 28% assuming normal resting minute ventilation. If the patient huffs and puffs, they are pulling in more of the 21% room air thus "watering down" the end mixture with the 2Lpm coming in, equating to a lower total fio2 than 28%. This is why high flow devices exist, to be able to set a particular fio2 and ensure the patient receives that at all times regardless of minute ventilation. -BSRRT

Unfortunately with pulmonary fibrosis there is a limited amount of adjunct therapies, seeing as their alveolar tissue is essentially scar tissue now with maybe a hint of underlying inflammation. Even in the ICU, oxygenation is the primary problem with restrictive lung disease patients. Vent settings can only go so far with this, what is commonly solved with a PEEP adjustment on other patients is not necessarily beneficial with PF due to the lack of lung tissue elasticity. (PF turns the lung into a theoretical leather bag with minimal stretch) They are commonly fast tracked on the lung transplant list, especially if they can't oxygenate even on 100% fio2. These patients commonly will live at low sp02's. True PF patients will not benefit from inhalers unless their PFT shows reversibility. If the patient has CHF and is on diuretics, making sure that is managed well will help reduce potential pulm edema which would directly effect oxygenation. There are several research studies under way to help find a treatment or a cure for PF, but as of right now there are only a few anti-inflammatory meds that can help slow it down, most patients immediately get put on a transplant list.

Hello, I'm sorry you can't get an RT there to troubleshoot, it sounds like the home care company is slacking or simply short staffed. This question is open-ended, there can be many reasons why a patient may desat while back on the vent, including incorrect mode, or not enough oxygen bled in while on the vent. I presume the patient goes on the vent at night to sleep. Some pulmonary patients require supplemental oxygen only at night while asleep. Commonly, vent settings need to be adjusted over time, because what may have worked when they were discharged simply doesn't cut it now, especially if the patient's confounding pulmonary disease gets worse over time. There are various settings on the vent that can improve oxygenation alone, aside from adding in oxygen- which frankly should be the last step as it is a drug. A review of current vent settings by the provider should be in order, coupled with a chest xray to see if the patient is underinflated or has atelectasis. If the patient has secretion issues, the patient may benefit from more PEEP, or a higher tidal volume, which should help with oxygenation. It could even mean that while asleep on the vent the patient may need to be suctioned, or given bronchodilators. There's no sure fire answer here as there could be several answers. In short, really have an RT get out there, even if it means filing a complaint- because it is the patient that is suffering.

Documentation is the name of the game, even if it's standing order.

I'm an RRT at BWH in Boston and residents will occasionally perform mechanics and/or compl/Raw/Ppl on the vents without us being there. Infact its illegal for them to even touch a setting on the vent. Last week I walked in on a Frozen waveform with a Fellow standing infront of my vent. I said, "So we wanted mechanics?, I see that it's already been done!" He says, "Oh, are we not suppose to do that?" "AH, NO." I say. (He also did the mechanics with all the wrong settings for a true number, to boot) Sometimes they act unknowing to this when as a fellow, I hope he knows what he can and can't touch. Just another "I'm a doctor and your not" thing.

Newer masks have a safety valve now, thank god. Also, that is why many hospitals require anyone using bipap(whether for severe OSA or for ventilation) to be on an alarmed ventilator.

To the original poster: assess the patient for distress, correlate sp02 rate with palpable heart rate to ensure good quality sp02 signal. Check oxygen delivery device and flow, is it enough for this patient? If not on oxygen, put them on a cannula to start, 2lpm lets say. Wheezing/Diminished/Coorifice? Bronchodilator time! Etc...it takes good patient assessment skills and putting all the pieces together to provide a patient with a low sat with the correct treatment. Don't always jump to give the patient medication/drugs just yet! If the patient is QUICKLY deteriorating, thats another story, ensure proper resuscitation equipment is at hand. Drop HOB to supine, open airway, etc...follow ACLS or BCLS protocol.

Well it sounds like it's orthopnea. Usually chronic respiratory patients like to sleep sitting up(with pillows behind their back) because the leaning forward position provides their AP chest to expand easier than being supine, and they generally feel more comfortable. This is due to the air trapping they have and the emphysemetous alveoli(floppy and baggy). You can sort of relate this posture to tri-poding. Also since their diaphragms are blunted, they don't feel like they can expand their lungs whilst supine. I've experienced patients like this at a MINIMUM of a 30 degree angle of back of bed, all the way to 45 degrees with pillows behind their head. These chronic lungers basically feel more comfortable because they can feel they can breathe a lot easier sitting semi to full fowlers position. This pertains to vent patients as well.

Sorry, I was using the vent patient scenario. Either way, it takes proper patient assessment by both the nurse and the RT. Classic signs of resp distress, assessment findings and initiating proper treatments (IE suctioning, bronchodilators, BIPAP etc..). Unfortunately the quality of health care professions can vary and as we all know, there are some out there that are either 1. incompetent, and/or 2. willing to get out of doing work.

Well, there's the classical patient assessment failure by the RT. I'm an RRT and have been faced with the same EXACT situation you mention. Plugging off vs. anxiety and agitation, can be tricky. My advice is to suggest to the RT to remove the pt from the vent and bag him/her on 100%(of course). You can quickly examine the difficulty in bagging the patient, listen for secretions via exhalation through the ambu valve, ensure proper tube placement, ALL BY BAGGING. Instilling and deep bagging a few breaths and suctioning can do wonders! ......As we all know, some health care professionals are just lazy.

I graduated with an AS in RC in May and took my CRT and RRT within 2 weeks of graduation, I'm now working at Brigham and Women's Hospital in Boston. I love my career choice, I thought for a couple seconds if I wanted to be an RN and realized that I'd rather specialize in a field of importance rather than be a "generalist", I'm not saying nursing isn't important, however airway specialists and ventilatory specialist IMO are just as important . I've found that being the sole RT in a CCU, you are called upon frequently, and urgently. The nurses are essentially in total "care" of the patient, but when you walk in when the patients' crashing, a huge weight is lifted off their shoulders. This means they don't need to worry about the A and B of the ABC's. Think about it, YOU, as an RT, are trained and credentialed in the first 2 golden letters of the medical field. There are so many career possibilities, depending on where you live. If you live near a major city, your chances of making good money are high. You can choose either a small community hospital where you as an RT do everything related to respiratory including incentive spirometry teachings to post-ops, neb tx's (times 3, heh) in the ER, and chest pt. You can also go into marketing, there are MANY companies that sell respiratory equipment that are in need of RT's to travel to different departments and advertise their latest and greatest toys. Also new vent modes and ET tubes etc... Overall, and so far, I enjoy my job. I also work at a 225 bed community hospital per diem, but the critical care aspect of the career is so great that more and more techniques and modalities are introduced to your job every month. Just when you think you know how to ventilate a full-blown ARDS patient, there's always something more you can do. The alrger hospitals provide you with new equipment and endless CE. I never thought as a student that this job would be so stressful though! My pager goes off 5 times an hour and I'm beside myself when I have an ABG to draw on a vent patient, 4 IS's to teach, and 2 ER "stat" nebs to give. IT'S ALL ABOUT TIME MANAGEMENT. You can be busy or bored at any given moment. Nursing definitely a much more popular field, but in my opinion, it seems like everyone is flocking to be an RN. There's a shortage of RT's just about everywhere. Different hospitals have different job descriptions for you as an RT, some are strictly critical care and some are floor therapy, so you can try both and see which you prefer better, as well as home care, marketing, and research. The one thing I suggest potential RT's to do: review the program you are applying to, get the graduating pass rate for the RRT from former graduates. I've been hearing of shotty RT programs in which students will complete the program with flying colors but continually fail the entry-level CRT credential, and never get to the RRT.