Respiratory Therapy 101: Just Keep Breathing

Just the other night, I was asked to put CPAP* on an elderly patient. So far, so good: I’ve seen hundreds of old folks get the ‘pap on and then recover from whatever respiratory ailment was plaguing them at the moment. I do CPAP every day, sometimes twice a day. Sometimes I put it on myself just for fun. You know, to stay in practice with it.

But this patient was special. This patient was an elderly man who I knew from his long stay in our ICU, where he had been mechanically ventilated for ages before finally getting a tracheostomy and working his way out the door to stepdown. Now he was sitting bolt upright on the edge of his bed, as far from the wall as his trach collar would allow him to be, breathing like it was going out of style. I gave him a few treatments to no avail before the nurse and I decided to call up our friend, Dr. Grumples.

Grumples (not his real name) is a favorite pulmonologist at our hospital. His habit of having affairs with young nurses, being a total ass, and never showing up when you call him has made him our favorite around Our Lady of Immaculate Grace. The merest mention of his name will cause strong, even visceral reactions among the staff. He was alluded to in my earlier post about scientists…

Grumples listened to me as I explained the predicament: our patient, the one with an uncuffed fenestrated tracheotomy tube in place, dyspnea and the tachycardia, low sats and also abominable blood gases, needed to be placed back on a ventilator, maybe just for some CPAP or even a little A/C** overnight until we could figure out why he was having this difficulty.  Grumples listened, and then screamed at us:

“Why are you calling me at two AM for this? Just put a goddamn CPAP on him and he’ll be fine!”

I screamed back. “We can’t put CPAP on him, he’s got an uncuffed fenestrated trach! All of the air pressure and oxygen will go out the trach. We can’t plug his trach because the air pressure will either pop off the trache plug or blow out his trach, maybe even leak into the interstitium and give him a lovely little interstitial emphysema. What we need is for you to come in and change his trach, because we’re not allowed to.”

Grumples was pissed. “I’ll do it in the morning. Put the CPAP on his trach until then.”

I explained to Grumples the physics of uncuffed traches, and how if you pump pressurized air into a fenestrated uncuffed tube it will follow the path of least resistance and blow out the patients upper airways instead. What he was asking us to do, I explained, was to turn our patient into an enormous leaf-blower. It would be about as effective as hooking the CPAP up to his ass, and it could actually cause him some significant distress. Grumples got really angry now: “Fine! I’ll come in.  But mark my words! Respiratory Director will be hearing about this!” With that he slammed down the phone.

I tended to the patient while awaiting the arrival of Grumples. I turned up his oxygen a bit and talked with him, kept him some company and made sure he didn’t stop breathing. I heard a distant stomping, and suddenly the shadow of Grumples loomed in the doorway. He stalked in, glaring at me with a look that could freeze the ice off a glacier.

“Well, Anonymous Therapist, I’m just going to try something because apparently you’re too chicken. Get me a CPAP.”

“I’m not going to put CPAP on this mans tracheostomy. It’s not a good idea. Just change the trach and go home.”

“No! I’m not changing the goddamn trach. I’m going to put CPAP on him. And when it works, I’m going to go home, and in the morning I’ll call up Respiratory Director and we’ll have a little chat. CPAP. Now.”

I decided to stop fighting with Grumples. It would be like trying to claw my way through a cement wall.  I wandered away and got one of our BiPAP-on-a-sticks and wheeled it in. “Set it to ten of CPAP,” Grumples muttered at me.

I set up the machine and handed the end of it to Grumples. The air blowing out of the tube seemed to give him pause, but he pressed onward. I objected one last time:

“I really don’t think–”

“I don’t care what you think, this is gonna work.” With those words Grumples gathered himself together and then plugged the CPAP onto the end of the patient’s trach tube. Immediately, a number of things happened:  the patients eyes widened in terror as an astonishing whooshing noise came from the patients nose and mouth. Mucous and spittle flew out of his cavities as he flailed his arms around and tried to remove the CPAP. The oral and nasal debris spackled Grumples’ nice shirt with dots of phlegm, and just as he was about to step backwards and trip over the CPAP cord, probably taking either the trach or the patient down with him, I stepped forward and popped the CPAP off of the patients trach tube. His heart rate was astonishing: the ten seconds or so he had been unable to breathe normally had thrown him into a panic. Dr. Grumples got caught up in the CPAP tubing and wound up knocking our 15,000 dollar BiPAP machine down onto the floor, where it busted open. I applied oxygen to the patient and pulled the call light out of the wall to get some nursing assistance for our now considerably more distressed patient and also for the tangled physician, why lay helpless on the floor.

A short time later, Grumples had changed the trach and apologized to the patient, who was resting comfortably with his new trach, on assist-control and some PEEP.  Grumples never did apologize to me, but I wrote up the whole incident and forwarded it to medical affairs, the Respiratory Director, and risk management, where the scary lawyers live. I hear that Grumples himself may have to pay for the smashed-up CPAP, and fortunately the patient didn’t seem to suffer any long-term problems except for a transient tachycardia whenever Grumples walks past the room.

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So I don’t know what to make of this. On the one hand, while I probably could have changed the trach myself and avoided the call, it’s against hospital policy and it exposes me to liability and the patient to possible harm. On the other hand, calling in Grumples is mainly an exercise in transfer of liability: the patient apparently is still at risk, if last night and a bunch of similar nights are any indication. Maybe next time I’ll ask the ER doctor to do it first, and failing at that, I can always try to circumvent the call system.

We shall see.

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*CPAP is Continuous Positive Airway Pressure. It is used to reduce the work of breathing in patients who don’t breathe well; it assists them in ventilating, or blowing off CO2. BiPAP is Bilevel Positive Airway Pressure, and it gives the patiens two levels of pressure intermittently. It helps to oxygenate and ventilate the patient. Both are applied either through an endotracheal tube that goes into the lungs (hopefully it does, anyway) or through a face mask of some sort.

CPAP is also used for people who have sleep apnea, because it splints open their airways.

Fenestrated tracheostomy tubes have little “windows” or openings in the top of them so that patients can move air up past their vocal cords by plugging the end of the trache with a finger or a commercial plug. Uncuffed tubes have no cuff inside of them, so air goes around the tube as well as through it. They are used to wean patients off of a tracheotomy.

**A/C is not air conditioning, not in this context anyway. A/C stands for “Assist/Control,” and it is a ventilator mode that lets you have total control over your patients respirations in volumetric or barometric terms.