Respiratory Therapy 101: Just Keep Breathing

As part of the ongoing reader response to my interesting airway scenario, one reader asked whether BiPAP had been considered as a post-extubation plan. The answer in short is no, but that does bring us to the interesting idea of extubating from the ventilator directly to BiPAP.

Recently, Respiratory Care Journal did a meta-analysis of the current research on BiPAP as an extubation strategy. The results were interesting: in patients who were extubated and then developed respiratory failure as a result of the extubation, BiPAP was shown to be ineffective; the best course of action for patients who fail after extubation would be immediate reintubation.

However, if you extubate a patient who is at risk for respiratory failure…as opposed to a patient who is extubated and subsequently is in respiratory failure…BiPAP could just be the strategy for you. To clarify that once more here is a chart:

Patient in respiratory failure —> BiPAP = NO! —> Reintubation = YES!

Patient at high risk of respiratory failure —> BiPAP = YES!

I think that my little illustration is pretty clear. If you have a patient who is borderline, extubation directly to BiPAP could be your answer–especially if you have a ventilator that can be configured to do noninvasive ventilation, such as the beloved Drager. And as far as reintubation goes, remember that contrary to your instincts you actually want to have a reintubation rate somewhere around 15%. If you’re not reintubating anybody, you’re not trying hard enough to get everybody extubated and that’s the hallmark of a failed weaning program.  That’s the subject of a whole other post though…

Getting back to the subject of my patient and his interesting airway, I’m not sure if BiPAP would have worked or not. He definitely meets the criteria: he was at high risk of reintubation but not actually in failure for some time after the tube came out. Next time I’m faced with a situation like this, I’ll think back to the professional journals and be glad of their thickly-worded, glossy-paged glory. Knowing more is always better.

As with all science and medicine on this blog, remember that this is my opinion. I’m not a physician and this shouldn’t be substituted for professional medical advice and you should really just go read the disclaimer.

Thank you, dear readers, for your responses to the previous post. Most of you guessed that the patient would end up being reintubated. One of you mentioned having seen this unusual technique used before as a temporary measure, which makes sense to me, but using this technique over several hours is a recipe for certain failure.

I know this because as you guessed, the patient was reintubated several hours after extubation. His airway was apparently very anterior and very small, making it difficult for our one-of-a-kind intensivist/anesthesiologist to place the tube. The patient was ultimately tubed with a 7.5 tube and returned to mechanical ventilation.

Prior to this, the patient had been on mechanical ventilation for a number of days. Tracheostomy had been debated but everyone involved seemed to be hesitant. The physicians didn’t really want to trache the patient, the patient’s family had some sort of mental block to it, and nursing seemed indifferent. Anyway, the patient will likely undergo bedside tracheostomy at some time in the near future, which should just about wrap up the difficult airway situation.

Today at work there was an interesting airway situation. We had a patient who had had a lengthy and complex course on the ventilator. The time had come to attempt an extubation.

However, because of the patient’s borderline respiratory status the attending physician was concerned that reintubation would occur. Reintubation would not normally be a terrible thing, but this patient had an extremely difficult airway; he had been intubated using fiber-optics by anesthesia in the OR, and even then the anesthesiologist had reportedly used the words “a f***ing doozy” when describing the airway.

To summarize: physician wants to extubate but is concerned about reintubation because of a fiendish airway.

The solution that the physician came up with was to insert a rubber ET tube changer into the ET tube, and then extubate the patient while leaving the tube changer in the airway. The theory was that if the patient crashed, we could simply slide a new ET tube over the changer and the problem would be solved. However, this poses some problems.

** First, the presence of an artificial catheter in the airway makes it impossible for the patient to swallow secretions. Even with application of continuous oral suctioning, secretion management is a concern.

** Second, leaving a catheter in the airway is going to increase airway resistance and make it more difficult for the patient to breathe, thus increasing the likelihood of reintubation.

** Third, leaving a catheter in the airway is likely to stimulate the cough and gag reflexes. If the patient vomits with a catheter in the airway, they are going to aspirate.

** Fourth, leaving a catheter in the airway for a prolonged period of time seems likely to lead to soft tissue damage or vocal cord irritation. Either of those problems could easily lead to total chaos.

Regardless, the attending physician wrote the order to extubate and leave the tube changer in the airway. The respiratory therapist (a colleague of mine; I was merely an interested observer) complied with the order. The patient was extubated to an aerosol mask, tube changer sticking unceremoniously out one of the holes in the front of the mask.

What do you think of this situation, dear readers? Drop me a note and tell me what your opinion is on this extubation strategy, and later on I’ll post the sequel to this, in which I reveal what happened to the patient.

When you’re looking down a laryngoscope, and you pop the epiglottis out of the way and you see the vocal cords, you feel good. “Look, here I am!” says the trachea. “I’m right here! Put a big plastic tube in me!”  That is a happy feeling, and when the big plastic tube goes through the cords you feel good. No matter what else may be happening, the airway is secure, and that’s important.

But it is not always so nice. For example, you might insert the tip of the laryngoscope right into the vallecula and lift the epiglottis gingerly out of the way, only to see a giant puddle of green liquid rushing up the laryngoscope at you. If you’re extra special lucky, you’ll see the puddle of green liquid go swirling down between the vocal cords as you desperately suck pure bile out of your patients throat with a yankauer.

But despite it all you might see the tube go in. The tip will go through the vocal cords, and then the cuff, and then the markings as you advance the tube to the appropriate depth. This will make you very happy. But then you may see a thing which makes you sad, which is vomit shooting from the ET tube; this will be followed by an intensivist pulling the tube out because “there’s no way there’s that much vomit in the lungs.”

You win some, you lose some.

Good: Patient meets parameters for extubation. Termination of mechanical ventilation and removal of the ET tube commences.

Bad: Patient immediately develops audible stridor. Accessory muscle use noted.

Worse: Administration of two back-to-back racemic epinephrine nebs does not improve the stridor. Patient begins paradoxical respiration at a rate of almost forty. Stridor worsens. Physician is called but is stuck in elevator. Emergency Backup Physician is called.

Even Worse: During the physicians first attempt at intubation, the patient coughs violently and sends yellow-blood-tinged sputum flying across the room, spreading infectious disease and generally being nasty.

Even More Worse: During physicians second attempt at intubation, the patient wretches and a funnel of gore gurgles up from within his innards and percolates in his mouth before being sucked down by the patients rapid inspiration. Suction recovers some but certainly not all of the gore.

Worser than all that: Once the airway is in place and confirmed with lung sounds and CO2, the ventilator is connected. The ventilator tubing fills with vomit and needs to be changed immediately. The gore was evidently much worse than anticipated. It is chunky. RT tries heroically to avoid adding their own vomit to this already impressive collection of emesis.

The worsest: Before all this, the respiratory therapist told the family that “99 times out of 100, this goes smoothly.” Evidently nature abhors the implied promise of smoothness in medicine.

:::

You’d think I’d have learned that by now, but apparently I’m a lordly work of irony.

The old lady lay gasping for air on the bed. I clicked the laryngoscope blade, a #3 mac, into the handle and checked the light as The Brazilian Intensivist (B.I.) worked his way to the head of the bed.

“Help…me!…not enough…air!” The old lady continued her gasping and panting, the effort of her respirations shaking her ample pannus and chest as she rolled her eyes in their sockets and cried for help.

“We’re going to fix it, Mrs. Redacted. Just hang on.” Her nurse, a compassionate young lady, gathered sedatives as the B.I. eyeballed the patient.

“This is going to be a hard one. Probably take me a long time. Maybe you should get some extra things ready just in case.” I nodded at the B.I. and handed him the laryngoscope. I placed an 8.0 tube next to the patient’s head and affixed a CO2 detector to the bag-valve mask. The B.I. continued to look at the patient. As the nurse administered her sedation, he began to bag the patient in synch with her own respirations.

“Yes. She has a thick neck, lots of edema, sort of dry. She will be difficult to intubate.”

I nodded and concurred with the B.I. He seemed content bagging the patient, so I turned my back on him for a moment and rooted around in the airway box for a tube-tie to secure the ETT should he place it. I estimate that I was in the box for a total of about five seconds. I turned back around, and much to my surprise the B.I. was removing the laryngoscope from the patient’s mouth and holding the tube in one hand.  This was confusing: he had apparently been able to intubate the difficult patient in a matter of seconds with no adverse attempts, suctioning, repositioning of the head or cricoid pressure. I gave him a look of bewilderment and awe. He straightened his back and gave me a slow smile.

“Sometimes, this can be a tough job.”

A tough job indeed, sir. A tough job indeed.

Sorry for the lack of content here lately. I’ve had a few days off and some family is in town for a visit, and last time I worked all of my patients were boring or crazy. I had one crazy woman who was out of it and believed me to be trying to kill her. For some reason a lot of delusional people think I am trying to kill them.

I had a delusional patient a few days ago who was involved in an MVA in November. He was busy smoking drugs when he crashed his car into some sort of obstacle and ejected himself onto the roadway, spattering his brains against the inside of his skull. But the brain-spattering wasn’t enough to kill him outright, just enough to make him a little loopy. When I saw him at the end of last week, he demanded that I stop trying to shoot him and then tried to strangle me, an attempt which was hindered by his wrist restraints. When he realized that strangling me was not an option, he settled for kicking violently at me and screaming. Now, his history with me was long and complex. He had been on the vent for a couple of weeks and given me endless amounts of trouble by being “difficult to wean.” He was a COPDer on top of his many problems and his respiratory status was suboptimal. A further complication was his psychosis; trying to treat a combative and insane patient is not easy for anyone, especially for mask-and-needle wielding RTs.

I left his room to a symphony of shouted profanity and threats. I covered my ears and closed my eyes, trying to make my patient-generated headache leave. As I uncovered my ears I overheard the trauma doc discussing when to bring the psychotic man to the OR to give him a PEG tube. My head continued to pound as the patient continued screaming his delusions. An idea formed in my head.  I sidled up to the doc and insinuated myself into his discussion with the nurse.

“What’s going on? You’re going to take him and PEG him?”

“Yeah. He needs the feeding tube and I figure he’s too marginal to do him bedside, so I’m going to bring him to the OR and do it there.”

“You know, this guy was a pain to wean. It took us almost two weeks to get him off the vent and he’s just now recovering enough to be feisty. If you take him to the OR and reintubate him, he’s going to wind up right back where we started and we’ll be behind another two weeks. Why don’t you trache him while you’re in there anyway? It would save us all a lot of time and effort.”

“You think that’s a good idea?”

“Absolutely! I think we need to do more early traches here actually*. Why not begin with this guy?”

The trauma doc nodded and I excused myself. My work here was done. A day later the psychotic man was trached. Why, you ask, would I ask trauma to trache the psychotic man?

First and foremost, his respiratory status was marginal. If he had been intubated he would have stayed intubated and run up an enormous bill over the next several weeks which we would see very little of. He would have been more likely to get ventilator-associated pneumonia, sepsis, a worsening of his psychosis or some other ICU complication. With a trache he could be weaned from the vent sooner and then sent out to a chronic-care floor.

Second but equally as important: when you’re trached, nobody can hear you scream. And after days and days of being abused by this man, I didn’t care if he never spoke again. In this case a trache was a perfect panacea: it would sidestep a medical complication, it would facilitate the patient’s eventual transfer to another facility (placement comes first,) it would probably reduce his ICU length of stay and it would greatly reduce the amount of time I had to spend listening to the worthless garbage coming from his mouth. Respiratory Therapy: it’s all about problem solving.

* I really do advocate for early tracheotomy. Many studies I’ve read have indicated that after seven days of intubation, tracheotomy is indicated and can greatly reduce lengths of stay and medical complications. It facilitates ventilator weaning, facilitates airway management, and ultimately can lead to better outcomes. All kidding aside I really think we should be traching more people.

As you may recall I had some rage issues with a nurse in the PACU a little while ago. Today, much to my delight, I met that same nurse in the PACU when I had to wheel over a “wake-up vent.”

When I saw her, I made eye contact and then simply turned and ignored her. This made her decide to agitate me. She nudged the anesthesiologist, a mellow bearded man sitting next to her documenting, and spoke to him.

“Hey, last time this guy was here he freaked out when I extubated somebody.” She was all smirks and giggles, the unspoken message being: look at this clown! Thinks he’s all that and he can’t even take an extubation. The anesthesiologist looked up at her.

“Oh really?” He gave me a quizzical glance. I remained silent,dialing some settings into the vent.

“Yeah, he got all angry at me when I did it.” At this point I spoke up.

“That’s because we do it the right way, and you do it the wrong way. And you know that’s fine. I’m not here to pick a fight, and if you guys want do it the wrong way then that’s fine. But over in the ICU we like to do it right.” The nurse scoffed at me and the anesthesiologist looked over at her.

“How did you do it?”

“Just like you guys do. I just popped the balloon off and pulled the tube out.” The anesthesiologist cocked an eyebrow.

“Um, that’s the wrong way. You can’t do that.”

“What? Why not?”  She gave the doctor a wide-eyed stare, incredulous at being corrected by the person she was hoping would back her up. Sensing an opportunity I chipped in at this point.

“Because if you don’t take the air out of the balloon first, then you could theoretically cause vocal cord paralysis or damage the cords. There could be swelling and even airway compromise. You could really screw somebody up that way. Ripping the pilot balloon off is no guarantee that the air will leave the cuff, which is why we prefer to deflate it first. It’s a small risk but to prevent it only takes a few seconds.” The anesthesiologist nodded and went back to his paperwork with a final word of advice to my nemesis “Yeah. You should really be deflating the balloons.” I resisted the urge to jump across the table and scream“In yo’ FACE!” at the nurse, and instead settled for giving her a shit-eating grin and sauntering out of the unit, vindicated.

Round two:

RT 1

PACU RN 0

Forgive me for the relatively poor quality of this post. It has been a long and tiring few days; I was working in the ER Friday and did 32 blood gases, 35 treatments, a couple of BiPAPs and transports and general nonsense so I was beat. And today I had a lengthy and insane day in which everything happened at once right at the end of the day. On the bright side, I did intubate two people within ten minutes, bringing my total to five. Not many but it’s still exciting to me. Anyway, enjoy this post about The Screamers.

We have had a lot of screamers lately in the hospital. In addition to a lady who sounded exactly like a train, I’ve had a number of encounters with screamers lately–more so than usual. I’m not sure what is bringing them all in but it has made life interesting.

The first in this chain of screamers came when I was relegated to the floors. Floor care is not normally something I mind, but the way that floor care is stacked here in Sunny Flats one therapist typically winds up with something like thirty patients to see and they’re all spread out across our million-square-foot physical plant. “Floor care” here means “get out your walking shoes and bring a Sherpa along.”

Anyway, I had hiked all the way from our main RT office across the hospital campus to East Three. I ran several treatments, and oddly enough most of my patients had been fairly normal. This was odd; East Three has a Reputation. Soon enough I discovered why. I strode into a room and saw my patient, a 90-year old lady lying supine and staring at the ceiling. I checked my treatment list and saw the legend “HoH” next to her name. Knowing now that she was mostly deaf I took a deep breath and shouted.
“Hello, Mrs. Redacted! I’m here to give you some breathing medicine!” I reached out and softly tapped the patient’s shoulder. She began a Slow Roll, turning her steady unblinking gaze from the air in front of her face to my general direction. She opened her mouth and took in a slow, raspy breath–

“HEEELP MEEEE! H-E-L-L-E-L-P! HEEEEELP MEEEE!”

I winced. The volume of her voice was unexpected compared to the size of her body and the age of her lungs. She took another deep breath and screamed again.

“HEEELP MEEEE! H-E-L-L-E-L-P!” She continued screaming for the duration of her treatment and for some hours after. What intrigued me was her spelling; most patients don’t spell, but the manner of her misspelling seems odd to me.

:::

Today, in the CCU, I was assigned to an elderly patient who had self-extubated just before my arrival in the morning. She had self-extubated mainly to facilitate her desire to scream, which she did liberally.

“STANLEY! STANLEY! GET THIS NOSE OFF OF MY NOSE!” was her first chant, but soon enough she replaced it with “I CAN SEE MY BLADDER!”  and then “STANLEY! I WANT POTTY!”

Nobody knows who Stanley is.

I am not an easily angered person. Today, I almost blew my top at an absolutely infuriating PACU nurse. She treated me like crap, and when I suggested that her patient should stay on the ventilator, she looked me in the eye and ripped the ET tube out. I yelled at her to stop and deflate the cuff, and she ripped the pilot balloon off and spat “we don’t do it that way here” at me. I told my supervisor, and she told me to fill out an incident report and then abandon all hope. Her exact words were “The PACU here is ridiculous. They’re so backwards and they refuse to change.” I guess the PACU is the “hell unit” of the house…next time I see that nurse we will be having words.