Respiratory Therapy 101: Just Keep Breathing

One thing I’ve mostly avoided in the years of my career has been contact with disgusting body fluids. I’ve narrowly escaped rivers of liquid stool, lakes of spilled urine, pools of tacky blood and fountains of vomit. I’ve narrowly dodged the gale-force flatus of a 400-pound man who was facedown on the floor. Whether through pure luck, a sixth sense, or simple good timing, I’ve been able to avoid being hit with anything disgusting for several years straight.

Today, my streak came to an end. I was assisting one of the ICU nurses with a turn, something I am more than happy to do simply because working in intensive care is a team effort. We were turning a patient who has recently been bestowed with a tracheotomy. The turn went from mellow to slightly more frantic when the patient suddenly became distressed. The heart rate went up, the respirations increased to a frantic pace, the blood pressure skyrocketed. Without even exchanging a word the nurse and I quickened our pace, stuffed the old blankets beneath the patients back and flipped them over the hump.

At that moment several things happened. As the patient rolled over the hump the ventilator tubing disconnected from the trache. The disconnect caused the trache to pull. The pulling of the trache caused the patient to cough madly. Time slowed down to a crawl. I watched from a distance as a giant wad of tan phlegm came flying out of the patients throat. I turned my head and braced for impact.

And then it hit me. It was rather like a very unpleasant rain shower. The patient had scored a direct hit. I winced in disgust. I could feel the clammy muck spattered about my face. I left the room to the sound of the nurse laughing (in a sympathetic way) and found my way to the closest sink, in which I dunked my head.

And so it goes in the wonderful world of respiratory care.

30 years old with terminal cancer of a non-removable deeply essential organ. No family. No friends. No wife. No children. Just a man alone with his tumors, wasting quietly away in the ICU where we can do absolutely nothing beyond meaninglessly prolonging his suffering.

That, my friends, just plain sucks.

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.

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.

We have had a rash of people lately in the ICU who have been expressing frustration at the perceived slowness of their loves ones’ recoveries. I have been glared at when patients fail Spontaneous Breathing Trials and accosted by angry family members who are upset because their loved ones have been on the trache for a month. I have begun to believe that these people are angry because they believe that their loved ones should be recovering much more quickly than they are.

I blame TV for this. On TV, medicine is fast. People don’t get sick for long, and if they do they tend to wake up and be exactly the same as they were before. On TV, patients will awaken from a coma and speak in full coherent sentences. People will be on the verge of death and then suddenly better. TV has a nasty habit of presenting a terrifying illness and then a remarkable cure, but they don’t present the wait in between.

People have got to understand: there is no silver bullet. People don’t just “get better” and walk out of the hospital. They get sick, they get sicker, they linger, they take two steps forward and one back. Very very rarely someone will get sick and then get better quickly. In the ICU especially, people are likely to have long and complex illnesses, not to just miraculously snap out of it.

We have got to do a better job of preparing people for this. People have an insane belief that cures are instant and that if we can’t just give their loved ones a pill to cure them of all their ills, we’re incompetent or apathetic or something. I’m sick of being hassled because people have unrealistic expectations, and I’m at the point where the temptation to whack the thick skull of ignorance with the two-by-four of reality is becoming overbearing.

That is all for now. I’m sure more will come later.

A success:

The patient presented approximately one month ago after a severe motor vehicle collision in which he was mostly paralyzed. He went into ARDS and had a prolonged and difficult ventilator wean. The patients care was complicated by his paralysis, but through intensive prophylactic respiratory care including EZ-PAP therapy and inspiratory muscle training, he pulled through and was discharged to rehab. He will never walk again, but he isn’t dead, either.

A failure:

The patient presented with acute abdominal pain. To avoid complications I will avoid the specific diagnosis but abdominal surgery was performed and the patient was placed on the med-surg floor. Due to substandard monitoring and a healthy dose of apathy, nobody noticed as her heart rate and temperature climbed while her BP fell. Eventually somebody cared and called the Critical Assessment Team, who transferred her to the ICU. We were unable to get a blood pressure and her heart rate was 160. Ultimately it was determined that the patient had developed necrotizing fasciitis at the surgical site; by the time it was discovered she was too sick to save. Ultimately the patient died.

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A  success and a failure. Such is life.

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.

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

I feel good about today. Usually work leaves me tired, numb, or indifferent; on a really bad day I come home and regret the things I did. Today…was not one of those days. Today was a special day.

I actually made a difference today.

Today, the average age of my patients was a heartbreakingly low 23. One of those patients was involved in a traumatic chest-wall injury. He sustained broken ribs, pulmonary contusions, and a hemo/pneumothorax. He was a perfect candidate for Acute Respiratory Distress Syndrome (ARDS.) Over several days, I have watched this patient slip into ARDS, his peak pressures slowly trending up and his chest x-rays slowly worsening as his lungs began to fail. To me, it is like watching a train approach a school bus parked on the tracks; you want to stop the train but short of a miracle you can’t do it. When I came in this morning, the patient’s P/F ratio* (a measure of lung injury, the lower the number the worse the injury) was a suboptimal 130. By noon it was down to 90. Anything less than 300 is acute lung injury; less than 200 is ARDS.

It was go time. The whole team began to move, working together in a fast and hard rhythm. We’d make a change, monitor it, tweak it, change something else and then keep moving, like spinning plates in a minefield. I tweaked the ventilator and spent time with the family explaining our process for ventilating ARDS patients. The doc and the nurse played with drips and worked to balance everything out. We worked together and communicated. We had a common goal and a well-defined purpose: don’t let this patient die. He is young, he is viable, and he is not even in here because of his own stupidity, and we will be damned before we will let him die on our time. It felt like we were practicing real medicine. We were working towards a real and clearly defined goal. Our patient was viable.

It was amazing how different this was from what I often wind up doing in the ICU. A lot of the time ICU work feels like rearranging the deck chairs on the Titanic; you can do it as much as you like but the ship is sinking regardless of the arrangement of the furnishings. Today was more like steering the ship hard-a-port in order to avoid that gigantic and fast-approaching iceberg: the ship swayed, the crew worked hard, and we may have even scraped a little bit of the paint off onto the ice–but we didn’t hit the berg. And after hours of labor and work and sweat, we finally got the patient settled into something that we could live with that wouldn’t tax any one system too much at the expense of any other.

For tonight, we avoided the iceberg. It was exhausting mentally and physically. It took a lot of time and a lot of resources and I am totally drained. We’re not out of the icy straits yet, but just for today we managed to keep the ship afloat. And it feels good, really good, to know that today my work actually made a difference. If it weren’t for the work our ICU team did today this patient would have died. I feel like I accomplished something today and it feels really, really good.

I only hope that tomorrow is like today.

*PaO2/FIO2. Take your PaO2 and divide by the decimal expression of FIO2. Numbers corrected thanks to IronLung.

“Mr. D came in last night, somethin’ wrong with his bowels or somethin’. He was a DNR but the ER doc talked the family into trying to resuscitate him and now he’s intubated. He’s septic or somethin’ cuz he’s breathing fast.” I nodded and looked at Mr. D, who was breathing a phenomenal fifty times a minute. His thick and distended abdomen heaved as he worked against the ventilator. His mouth opened in the classic “guppy breathing” posture as he worked.

“Do you know anything else about him?” I asked the night therapist. She eyeballed me quickly and shook her head.

“Nope. I’m off. See you tonight.” I nodded back at her and went to work.

Over the course of the morning, I spent a couple of hours with Mr. D. I put him on our ARDS protocol, ran mixed venous blood samples. I put in an arterial line, which was something of a personal triumph for me because even the Intensivist couldn’t insert one on this gentleman. The nurse and I played with PEEP and pressors and tried to balance oxygenation with perfusion. It was an uphill battle. Finally, at noon, the family asked us to cease our efforts. Mr. D died within three minutes after I extubated him. I was standing outside his room when his wife pulled the curtain back. Her eyes were blooshot. She grabbed me by the arm and began sobbing.

“Is he supposed to turn blue? What should I do?” She burst into tears and began sobbing hysterically all over my sleeve. I looked over her shoulder. Mr. D was bright purple, and as I watched he heaved his last breath and gave up the ghost. He was a family man, worked diligently in his church, served his country in the army for twenty years. Within twenty hours of coming to the ER for serious sudden abdominal pain he was dead. His family was devastated.

Down the hall, I had another patient, a middle-aged ex-IV drug user, unemployed woman who had come to the hospital more than two months ago because she didn’t feel right. She progressed into respiratory failure and got intubated in mid-December. Her family refuses to give her a tracheostomy because “she wouldn’t want that,” yet they refuse to let us withdraw support because she “wants everything done…” except for a trach, evidently. We’ve explained to them how her tube is surely eroding her throat, but they won’t listen. This woman has been on and off the oscillating ventilator, she has been in and out of surgery a number of times, and she is not neurologically intact in any meaningful sense–yet she is not brain-dead. She emits a smell that could stun a musk ox at a hundred yards. She absolutely refuses to die, and her family absolutely refuses to let us withdraw support. She never worked, she spent her life abusing drugs and grunting out babies, and she sits in our ICU and wastes your tax dollars to the tune of 5,000 dollars a day so that her high-quality life of staring into the middle distance and having tubes and lines inserted into her can continue indefinitely. We are no longer treating her for any curable condition; we are now keeping her alive for no reason. If she was aware of what was going on, I’d call it torture, but luckily for her she’s in a persistent vegetative state.Her family visits for about five minutes a day and then pronounces that “The Good Lord will make her better!” and leaves. I suspect that they are attending the church of the idiot pastor, but I can’t prove that.

Sometimes the contrast between my patients astounds me.

A nurse and I were talking about a patient today. The patient is a young woman who was recently paralyzed. She has only just begun to understand that it’s not “paralyzed for now,” it’s “paralyzed for the rest of your life.” The horror and the enormity of being permanently paralyzed from the neck down has sunk in. She is quite understandably devastated.

“In fact,” I said to the nurse with whom I was conversing, “just the other day we were talking and she asked me to pull the plug and let her die. It was really sad. I really think she wishes she had died in the accident. She kept mouthing ‘pull the plug, pull the plug’ until I left.”

“Awww…that’s terrible. But doesn’t she have that right? I mean, if she’s competent and she can voice her wishes, don’t we have to honor them?”

“I think she does, absolutely. If she’s competent and she can tell us to stop*, I don’t know why we should keep going. I don’t know if I would want to live like that.”

There was a slight pause as the nurse and I pondered. What would it be like to have such a fate, conscious and aware but completely immobile forever? How do you deal with that, with the horror of never being able to do anything for yourself?

I was brought back to the moment as the nurse took a deep breath and spoke.

“I guess she’d probably have a hard time signing the consent to withdraw form, wouldn’t she?”

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I thought it was funny. But then I may be crazy.

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*Of course, it can be argued that anybody who is expressing suicidal ideation is incompetent by definition. This is a tricky argument and one I won’t get into for now.