Respiratory Therapy 101: Just Keep Breathing

Before I saw the living dead man, I had been optimistic about the world of respiratory therapy. Academically it sounds great: you’re helping people to breathe, and breathing is a fundamental aspect of living. If one ceases to breathe, or ceases breathing as well as before, very few things have higher priority. We half-joked in school that if you are not breathing, you will not be doing anything else either. And what could be more satisfying than aiding people’s breathing? It is an important and vital job. That attitude colored most of my first clinical education day.

Cheerfully I made the rounds, following a real respiratory therapist around and passing out nebulizers to patients who needed close maintenance to keep their lungs functional. I listened to lung sounds and was happy to hear, for the first time, real wheezing in an asthmatic in the ER. I coached patients on breathing exercises designed to expand the lungs and prevent pneumonia. I felt ecstatic at the opportunity to help people, to really make a difference in their lives. On our first round, we passed out more than a dozen breathing treatments, and I studiously made note of each one in my clinical notebook. For a few high moments, I truly felt that I was living the dream. But there was an exception coming. One thing I have learned is that there is always an exception.

The exception, that pesky and bothersome exception, was the living dead man.

The first time I saw a living dead man was at a hospital in Southern Maine. I was following a respiratory therapist on one of the medical floors where chronic patients gradually erode away under time’s ceaseless waves. He was the final patient on our first round of therapy, sequestered away in a corner room at the end of a long hallway. An ominous smell, a mix of tube feeding and plastic and feces, filled the hallway near his room. A battered metal cart stacked with synthetic isolation gowns, gloves, and eye-shielded masks was parked next to the door. Bright orange signs reading CONTACT ISOLATION: NO ENTRY WITHOUT PROTECTION were tacked to the door. From inside the room came the frantic, gurgling sound of a tracheotomy full of slime. It sounded like a monster from my childhood nightmares, breathing hard and waiting to suck me in and devour me. GGHHRR-ghrrr….GGHHRR-ghrrr…

Following the therapist, I donned the protective outfit of gloves, gown, and mask. We knocked loudly and entered the room. The wall of smell hit my virgin nostrils hard and I blinked back tears and shock. An incongruous advertisement for Clorox played loudly on the television and I caught a glimpse of the unfortunate man before me. Contorted, skeletal limbs, coated with peeling and bruised skin, were folded over a large, puffy torso that was topped with a melon-like head. A pair of panicked and pained eyes peered at out us and I was reminded of the look I‘d seen on slaughtered livestock. The patient was breathing heavily, hacking yellow phlegm out from his tracheotomy, bubbles spewing from between his lips.

The therapist, a pleasant and kind middle-aged woman, took a long suction catheter and advanced it into the trachea. A horrible slurping noise and a grimace from the patient followed, and then the plastic tubing attached to the catheter was suddenly full of yellow snot. The patient coughed one more time, my preceptor sucked the last bits of yellow from his trachea, and suddenly things were eerily quiet.

“What’s wrong with him?” I asked her as we set up for the man‘s therapy. We poured a vial of Albuterol into a nebulizer and hooked it into the man’s oxygen collar.

“He had a stroke…family wanted us to do everything, so here we are. He was in the ICU for months before he got the trache.”

“Will he get better?”

“Sometimes, stroke patients get better. This time probably not. It was a big stroke. He can’t do much.”

“What will happen to him?”

“He’ll probably go to a rehab center or a nursing home, but long-term, this is probably how he’ll be. Probably he’ll end up with a bad infection and then come back here and pass away.”

We finished our treatment, and the man stared off into the middle distance, the same look of horror on his face that he’d had when we came in. This was his life, day in and day out; tube feedings and colostomy bags and the endless fountain of mucous from his tracheotomy tube.

This whole scenario bothered me. What kind of cruel joke was this? Were we seriously going to prolong this man’s suffering, delay the inevitable? Was I actively participating in the extension of suffering? Our job as respiratory therapists is to help people, not to torture the dying and prolong the misery. I was confused. I was frightened. My head was spinning. I could not fathom a life in bed, a life without speaking, a life without moving, a life spent staring into the middle distance listening to Clorox commercials as clinicians tried to slow the inevitable decay of my body. Being alive but with no control and no voice seemed like a veritable hell on earth to me. I tried not to think about him much, but he haunted me and as the day wore on I kept seeing his horrified eyes staring out into space. I pondered his fate and asked myself what kind of people could put a man through that kind of suffering instead of letting him die.

Later that day, we encountered his family, a large group of old Maine Catholics. They seemed to be nice people, but I couldn‘t face them. All I could think was that his family either hated him or had advanced to a state of pure denial. It bothered me, and I couldn’t look at them. It was my first encounter with the dark side of modern medicine, and it was the first time that I ever asked myself: is our help just hurting this man?

If only the Iranian police had killed Michael Jackson, maybe the world would pay more attention to the travesties going on in that formerly great nation.

That is all.

“I’d be really happy that we made so much progress on this guy today if it weren’t for the fact that, when he does get better, he’s just going to go out and fuck himself up again.”

Sometimes, it seems like we’re more in the business of prolonging the inevitable than in the business of saving lives. All the albuterol in the universe won’t cure someone who has a 180 pack-year smoking history. The most amazing ventilator in the world won’t cure cancer. And all the respiratory care in the world won’t cure stupid.

What really gets me is the absurdity of what we are often asked to do. Many times physicians have said things to me such as, “This man has lung cancer. I’m going to start him on Q4 albuterol.” I have some terrible news for these optimistic physicians, but albuterol does not have tumor-shrinking properties, and all the bronchodilation on earth won’t shrink the baseball-size mass that’s crushing this poor patient’s airway. To even order such a ridiculous treatment is totally absurd. It does nothing to treat the root cause of the problem, and will do nothing to alleviate the symptoms of lung cancer. Don’t get me wrong, I feel bad for the patients, I really do. But these treatments are useless.

Another absurdly overused therapy, at least where I work, is volume expansion. “Give everybody a therapep and an EZ-PAP!” is the mantra here. Giving a COPD exacerbation an EZ-PAP seems sort of silly to me. Most of them tell me it makes them feel worse, and they can’t take the treatment as well. We’re losing ground. Fools!

Ah, well. It pays the bills. Off to revel in the absurdity for a weekend.

Headline 1: MICHAEL JACKSON DIES OMG

Headline 2: N. Korea says will nuke US if provoked

Good to know where our priorities are.

Got a patient in the ICU from the nursing home the other day. One leg, out of her mind, decrepit, pitiable…as are many of the unfortunate patients we receive from the homes.

But this one was different. She was only 45.

She was also positive for benzos, cocaine, and marijuana.

I don’t know what nursing home she came from, but damn, I hope I can get that kind of hookup if I ever have to go to the home. I imagine the ol’ nursing home routine is a lot more exciting when you’re jacked up on coke or tripped out on acid.

“Some people may call me a bad parent for not having my children vaccinated. Other people may call me an irresponsible asshole. But personally, I don’t see why I can’t be both.”

The Onion on anti-vaccinators.

The waveform: one of the most underutilized tools in the respiratory therapists’ arsenal. Unless you’re working at Bill’s Wilderness Remote Survival Band-Aid Station, you probably are working with a mechanical ventilator that is capable of displaying waveforms. But unless you’re unlike most of my colleagues at Sunny Flats, you will probably be ignoring these waveforms as a mere distraction, a set of pretty lines that are mystifying and slightly disoncerting.

This is a travesty of respiratory care. Proper waveform interpretation is invaluable in the clinical setting. I will give you a concrete example. Just the other day I was working one of our ICUs when I received a patient from the thoracic surgery team. Anesthesia mentioned no problems with the case and denied any medical history for the patient. I took the ambu and hooked the patient up to the ventilator. Something seemed a little awry. I wrote a quick vent check, noted very diminished breath sounds, and obtained an ABG.

The ABG was quite acidotic. High CO2 with normal bicarb. The acidosis was therefore my problem. I returned to the ventilator and pondered what I could do to troubleshoot. The first thing I examined was the flow waveform. I saw something sort of like this:

For the uninitiated, this is a rough drawing of a flow waveform. Beginning from the left, the slope angles up sharply. This is inspiration: the ventilator is slamming a positive-pressure breath into the patient. The sharp drop in flow is the end of inhalation and the beginning of exhalation. As the graphic curves back up towards baseline, you can see that the flow gradually tapers off, but before the graphic returns to “baseline” the ventilator slams another positive-pressure breath into the patient. Exhalation is incomplete.

What do we have with incomplete exhalation? Why, we have air trapping, which means we have leftover volume in the lungs! Why would we have that? One of two reasons. First, our I:E ratio could be too low, leaving scarce time to exhale before the next breath is initiated. That is a function of inspiratory time and respiratory rate. Second, we could have airway obstruction caused by reactive airways or a penny lodged in the airways. One other piece of information to gather: let’s look at the flow-volume loop.

A normal flow-volume loop should look something like this:

It’s hand-drawn so don’t ding me for accuracy. MS Paint is not what Michelangelo would have used but it’s all I have. Moving on, instead of seeing the nice shape above, I saw this shape:

That distinctive inverse-bowl shape at the bottom of the flow-volume loop is a BAD THING. It indicates airway obstruction. All of the expiratory flow comes out rather quickly, and you’re left with a prolonged expiratory phase to try and squeeze out all the remaining volume.

So, my conclusion was that the patient was obstructed. I checked the auto-PEEP and got a whopping 18 of auto-PEEP. Per our ventilator management protocol I shortened the inspiratory time and increased the respiratory rate, with a “net” lengthening of expiratory time. I also increased my PEEP to 10 and initiated a long albuterol neb with 5 mg of the Magic Stuff.

Within an hour, the waveforms had regained normalcy. The breath sounds were clearer. A repeat ABG was still somewhat acidotic, but our CO2 was moving in the right direction. Another followup ABG one hour and one more treatment later noted a return to normalcy and much louder breath sounds. The patient was successfully weaned and extubated, and continued to deny any history of lung disease of any kind.

So there you have it, folks. A brief example of how useful I find ventilator waveforms. If you’re not paying attention to these, you’re missing out on a vital and useful assessment tool.

Good luck out there. Keep them breathing.

Me: “Hi. I’m Keepbreathing from the respiratory department. I need to draw some blood from your artery to check your breathing.”

Patient: “What’s a artery?”

Me: *silence*

That’s the first time I’ve ever been asked that. Ever. Even my least educated patients seem to have an understanding of the fact that there are both arteries and veins in the body. But this dude was 100% clueless, even when I tried to explain it to him.

I guess there is no cure for stupid.

…the delivering EMT has to physically restrain herself from vomiting on the patient, who has himself vomited astonishing quantities of gastric contents. I feel sorry for my colleague who was in the Splash Zone…I feel even sorrier for the poor Environmental Services guy who had to clean it all up.

Gross.

This job can be mighty depressing.

A few weeks ago, we had a pediatric cardiac arrest in the ER. Having to do CPR on a baby is an awful, awful feeling and one that I never want to experience again, ever.

Last week, one of our chronic CF kids was back again. At age 19, she just wants to be normal, out with her friends having fun or off to college to party down learn about things. But instead she’s an inpatient every three weeks or so, sucking down hypertonic saline and pulmozyme and coughing up phlegm and experiencing the horror of serious illness at too young an age.

This week, we had a 16 year old Sickle-Cell anemia patient come in in crisis. She progressed from room air to the nonrebreather to the BiPAP to the vent to APRV to the oscillator to dead.

Then, before I went home yesterday, I had to terminally extubate a young (middle-aged) woman. On her birthday. She took one breath, then stopped.

This job can be mighty depressing sometimes.