Respiratory Care K.I.S.S.

Catagory: Physical Assessment - FLOWCHART

2012-01-15T12:42:00.004-06:00

Basic Classification & Severity of Wheeze

(Refer first to post of SATURDAY, JANUARY 10, 2009)

Catagory: Physical Assessment - FLOWCHART

2012-01-15T12:30:00.005-06:00

Basic Classification & Severity of Crackles

(REFER FIRST TO POST OF SATURDAY, JANUARY 10, 2009)

Category: Pulmonary Function - ACRONYM

2011-12-18T21:29:00.006-06:00

Catagory: Physical Assessment - BUNCHING

2011-06-17T22:33:00.001-05:00

Catagory: Physical Assessment - BUNCHING

2011-06-16T22:10:00.007-05:00

Catagory: Inhaled Medication - BUNCHING

2011-01-22T09:53:00.002-06:00

Catagory: Smart phone and PDA

2011-01-16T11:38:00.005-06:00

The Medical PDA is Not Dead - Expanding your ectopic brain without changing your phone.

Smartphones are terrific but not the only option.

With the Palm Garnet and Windows Mobile operating systems retiring (and their associated PDAs), access to free or cheap quality software is still within reach without a smartphone and its associated monthly costs. The Wi-Fi capable Apple iPod Touch gives you access to numerous quality iOS medical applications without having to switch your phone or carrier.

3 Exceptional Examples of General iOS Programs Useful for the Respiratory Therapist:

Calculator

MedCalc gives you easy access to an astounding array of medical formulas. It includes detailed information and bibliographic references for each formula. Free http://itunes.apple.com/app/medcalc-medical-calculator/id299470331?mt=8

Drug Reference

Epocrates is one of the most most widely used medical apps. It provides clinical information on thousands of prescriptions and OTC drug products. It features a pill identifier, formulary information, a drug interaction checker and calculations. It is the exceptional free 1^st part of a paid for comprehensive suite. http://itunes.apple.com/us/app/epocrates/id281935788?mt=8

General Resource

Diagnosauras DDX is a reference tool that assists healthcare professionals with differential diagnosis at the point of care. You can quickly search over 1,000 diagnoses by organ system, symptom, disease or view all entries. $0.99 http://itunes.apple.com/app/diagnosaurus-ddx/id306402834?mt=8

Catagory: Smart phone and PDA

2011-01-05T22:13:00.002-06:00

Most respiratory therapist think of Blackberry as an excellent messaging device without appreciating what an excellent smartphone and clinical information tool this platform can be. This is particularly true since the Blackberry operating system (OS) makes a capable replacement to the retiring Palm Garnet and Windows Mobile OS.

Epocrates Rx free remains my primary go-to drug guide in this OS with the included MedMath calculator being a positive free addition to this suite. The application includes monographs for more than 3,500 drugs and is updated “over the air” weekly.

Blackberry’s do not have the depth and breadth of the iPhone clinical software but if this device is already part of your routine why not use it to expand your portable clinical brain power.

Beauty in Simplicity

2011-01-03T20:28:00.002-06:00

There is a natural beauty in simplicity.
Whether in the arts, the sciences or in making complex tasks and concepts more comprehensible.

Catagory: Quiting Smoking - ACRONYM

2011-01-01T22:44:00.001-06:00

Catagory: Quiting Smoking - ACRONYM

2011-01-01T22:31:00.003-06:00

Catagory: Quiting Smoking - ACRONYM

2009-09-30T21:06:00.001-05:00

Catagory: PATTERNS IN PULMONARY PATHOPHYSIOLOGY

2009-09-28T19:40:00.003-05:00

Formulating a clinical impression from physical assessment of the lungs and thorax is a complex task. It does not lend itself to “simplification”.
This chart is not intended to be a comprehensive table of pathophysiology of the lungs and thorax but as a tool to illustrate patterns of pulmonary abnormalities.
You may use the nonsense word/acronym I.P.A.P.i.c. to recall the categories of assessment.
Pulmonary abnormalities are often considered:
Obstructive, Restrictive or Mixed Obstructive & Restrictive
They can also be considered:
Parenchymal, Extraparenchymal or Mixed

Click on the table below to enlarge.

Catagory: PATTERNS IN PULMONARY PATHOPHYSIOLOGY

2009-09-28T19:28:00.004-05:00

Catagory: COUGH - ACRONYM

2009-08-16T23:19:00.005-05:00

Some Causes of Cough

G.A.S.P.

G.E.R.D.

Asthma or ACE Inhibitor

Smoking, Chronic Bronchitis or Sinusitis, Post Nasel Drip

Post Infection

Catagory: Timing Studies

2009-08-16T22:34:00.004-05:00

Catagory: COPD - BUNCHING

2009-07-05T22:44:00.006-05:00

Signs for High Index of Suspicion of Chronic Obstructive Pulmonary Disease (COPD)

1) Shortness of breath on exertion.
2) More than a 10 pack/year history of cigarette smoking.
3) More than 40 years old.

Catagory: COPD - ACRONYM

2009-07-05T22:35:00.002-05:00

Catagory: Pulmonary Function - FLOWCHART

2009-06-22T17:54:00.003-05:00

FVC, a Tool You Can Use.

Formulating a clinical impression of a Forced Vital Capacity (FVC) maneuver is a high level task. It does not lend itself to “simplification”.
The intention of the algorithm below is to provide an organized method to review and use the FVC and to assist the practitioner in determining appropriate care. (Not formulate a comprehensive interpretation)

Click on the algorithm image to enlarge.

Catagory: Pulmonary Function - FLOWCHART

2009-06-06T15:44:00.004-05:00

Catagory: Physical Assessment - ACRONYM

2009-06-02T21:09:00.009-05:00

The 5 W's, Causes of Post-Op Fever

Wind: the lungs (the most common in the 1st 48 hrs)
Wound: infection at the surgical site
Water: phlebitis at intravenous access
Walk: deep venous thrombosis
Whiz: urinary tract infection

The 5 most frequent to Worry about.

Catagory: Inhaled Medication - RHYMES & SONGS

2009-06-02T16:46:00.001-05:00

Catagory: Smart phone and PDA - TECHNOLOGY

2009-05-13T21:16:00.002-05:00

The two healthcare resources I find myself using most consistently on my ectopic brain (a.k.a. my PDA /Smart phone) are ePocrates and MedCalc. My earlier recommendations of these excellent portable memory expanders on the Palm and Windows Mobile operating systems still stands, with this addition.
If you are an iPhone or iTouch user the excellent characteristics of these programs shine on Apples portable systems.

http://med-ia.ch/medcalc/iphone_description.html
http://www.epocrates.com/index.html

Catagory: Inhaled Medication - BUNCHING

2009-03-26T20:28:00.001-05:00

Catagory: Blood Gas - ACRONYM

2009-03-15T10:59:00.003-05:00

The directions pH and HCO3 move with Alkalosis vs. Acidosis:

ROME:

Respiratory move Opposite: pH is up, PCO2 is down (Alkalosis). pH is down, PCO2 is up (Acidosis).
Metabolic move Equal: pH is up, HCO3 is up (Alkalosis). pH is down, HCO3 is down(Acidosis).

2009-03-02T21:53:00.002-06:00

Healthcare Education is stressful.

Memory tools don’t necessarily make learning fun but can add some lightheartedness to study time.

Catagory: Inhaled Medication - RHYMES & SONGS

2009-03-02T21:26:00.002-06:00

End in ide or end in sone
Always an inhaled steroid.

budesonide
ciclesonide
flunisolide
beclomethasone
fluticasone
triamcinolone

Catagory: Inhaled Medication - RHYMES & SONGS

2009-02-15T09:53:00.001-06:00

Catagory: Physical Assessment - BUNCHING

2009-02-08T09:23:00.008-06:00

Recalling the “Mid-range Normal” of the primary Hematology Tests
Using multiples of 3

Red Blood Cell Count (RBC) “Mid-range Normal” is approximately 5
Hemoglobin (Hgb) “Mid-range Normal” is approximately 5 x 3 = 15
Hematocrit (Hct) “Mid-range Normal” is approximately 15 x 3 = 45

Consult a lab resource for the actual normal range of pediatric, female and male values.

Catagory: Asthma - TABLE

2009-01-24T10:56:00.003-06:00

Establishing Asthma Severity 3-2-1

Catagory: Smart phone and PDA - TECHNOLOGY

2009-01-18T12:34:00.004-06:00

Medcalc is still my "go-to" freeware medical calculator, and for my needs is still is the best.
A complimentary alternative free calculator is Archimedes from Skyscape.
http://www.skyscape.com/estore/ProductDetail.aspx?ProductId=227
Skyscape is a leader in mobile medical information. Their huge catalogue of "for sale" and some free specialty content is impressive.

Catagory: Airway - ACRONYM

2009-01-18T10:56:00.007-06:00

Describing Clinical Characteristics of a Tracheotomy Tube

Airway lumens
a) Single lumen
b) Dual lumen
c) Is connecting adaptor (15mmOD) removed with inner cannula out?

Brand & Composition
a) Company of manufacture
b) Metal – stainless steel, silver
c) Plastic – PVC, silicone

Cuff
a) Cuffed or not cuffed
b) Inflated or deflated
c) Characteristics of the cuff (high vol low press, low vol high press, foam)

Diameter and Dimensions of tube
a) Inner diameter (I.D.)
b) Outer diameter (O.D.)
c) Length of tube (standard, short or long length)

FEnestration
a) Fenestration open
b) Fenestration closed
c) Position and construction of fenestration

Catagory: Inhaled Medication - BUNCHING

2009-01-11T10:16:00.001-06:00

Catagory: Physical Assessment - FLOWCHART

2009-01-10T10:18:00.003-06:00

Classifying Adventitious Lung Sounds

Catagory: Quiting Smoking - BUNCHING

2009-01-07T21:54:00.003-06:00

When You Quit Smoking — Health Benefits, pointing out the positive.

Around 20 minutes after quitting: Your heart rate and blood pressure begins to drop.
Around 20 hours after quitting: The carbon monoxide level in your blood drops to near normal.
Around 20 days after quitting: Your circulation improves. Coughing and shortness of breath decrease. Cilia (tiny hair-like structures that move mucus out of the lungs) begin to regain function, increasing their ability to clean the lungs.
Around 20 weeks after quitting: Your risk of heart disease begins to drop.
Around 200 weeks after quitting: Your stroke risk as well as cancer risk begins to drop.

Catagory: Medication - BUNCHING

2009-01-01T23:26:00.007-06:00

Helping Patients With the Change to H.F.A. Metered Dose Inhalers (MDI)

Teaching Points for administration of the new HFA MDI:

HFA inhalers require multiple priming sprays, periodic cleaning of the actuator boot, and longer agitation prior to first use and when unused for a number of days. Refer to the package insert with each individual MDI for specific recommendations.

HFA inhalers have substantially less taste. Patients associated the bitter taste of CFC powered MDIs with effectiveness and the relief of symptoms.

HFA inhalers create a lower plume velocity, which results in less oral and pharyngeal deposition. Patients associated the more vigorous spray of CFC powered MDIs with relief of symptoms and effectiveness.

Terminology:

Metered Dose Inhaler (MDI): A small pressurized metal canister in a plastic actuator that releases a mist of medicine to inhale when pressed.

Chlorofluorocarbon (CFC): A fluorocarbon with chlorine; formerly used as a refrigerant and as a propellant.

Hydroflouroalkane (HFA): The new alternative propellant created to replace CFCs, and the standard for MDIs starting in 2009.

Catagory: Physical Assessment - BUNCHING

2008-12-24T10:54:00.002-06:00

Pediatric Stridor - Potential site of origin

Inspiration Only - More likely above the vocal folds
Inspiraton & Expiration - More likely involving the vocal folds
Expiration Only - More likely below the vocal folds

Catagory: Smart phone and PDA - TECHNOLOGY

2008-12-15T21:43:00.005-06:00

In addition to ePocrates being an excellent clinical PDA program their free online resources are an excellent tool for keeping important facts at your fingertips when you have web access.

Just enter a disease or drug name and click go.

Catagory: Asthma - BUNCHING

2008-12-13T09:44:00.002-06:00

Catagory: Asthma - BUNCHING

2008-12-13T09:36:00.002-06:00

Catagory: Asthma - BUNCHING

2008-12-13T09:29:00.002-06:00

Catagory: Asthma - BUNCHING

2008-12-13T08:36:00.001-06:00

Catagory: Smart phone and PDA - TECHNOLOGY

2008-12-09T22:46:00.012-06:00

Author Dana Oakes has published the quick reference pocket guides for over twenty-five years. Their accuracy, professionalism, and affordability have made these books the standard in portable respiratory care texts. Titles include the Clinical Practitioner’s Pocket Guide to Respiratory Care (the famous “Blue Book”) and many others. These books are now also available for smart phones and PDA (only in a Windows Mobile version) further expanding their use at the bedside and lightening up our bulging lab coat pockets.

http://www.respiratorybooks.com/

Catagory: H and P - BUNCHING

2008-12-09T22:04:00.003-06:00

Catagory: Smart phone and PDA - TECHNOLOGY

2008-12-07T22:39:00.007-06:00

Introduction -
Medical calculators on smart phones and PDA save time and help prevent calculation errors. Useful physiologic calculations are more readilyused if you do not need to rely on only your less than perfect memory.

There are many options but at this time Medcalc is my go-to calculator .
MedCalc runs on Palm OS and Windows Mobile handheld devices. It is designed for rapid calculation of common medical formulas and scores used in anesthesiology, pediatrics, emergency, intensive care and internal medicine.

Features -

free and easy to use
comprehensive (>80 formulas, see complete list)
formulas sorted by categories
units available either in S.I. or local units (defaults can be set for each item)
most formulas come with bibliographic references and clinical tips
results can be saved for later retrieval (Palm OS only)

System requirements -
A Palm OS compatible device running Palm OS 3.1 or later Windows Mobile 2003 or later .

http://med-ia.ch/medcalc/index.html

Catagory: Physical Assessment - ACRONYM

2008-12-07T22:12:00.003-06:00

Catagory: H and P - ACRONYM

2008-12-07T21:33:00.006-06:00

Physical assessment of the lungs and thorax can help us determine & evaluate 5 primary findings.

Catagory: Smart phone and PDA - TECHNOLOGY

2008-12-07T09:25:00.005-06:00

Three Free PDA (personal digital assistant) and Smart Phone Clinical References for both Palm OS or Microsoft Mobile.

If you already own a smart phone or PDA with a memory card, why not consider loading clinical references into your device. Having a clinical library in your pocket is like expanding your own memory.

ePocrates Rx
https://www.epocrates.com/
ePocrates Rx is a Peer-reviewed drug information resource. It is not quite like carrying the PDR around in your lab coat pocket but it is close. This is the free component of an extensive & comprehensive clinical suite available for the PDA. ePocrates Mobile CME and MedTools are also free resources. It is a relatively large program, but it worth the memory it eats up. It looks for updates whenever you sync your device keeping the reference up to date.

Merck Medicus
http://www.merckmedicus.com/pp/us/hcp/hcp_mobile_medicus.jsp
That’s right, a free Merck manual. MerckMedicus also provides an integrated set of useful medical resources for your PDA. Not as slick as some of the purchased comprehensive references and a bit heavy on memory use but definitely worth it.

MeisterMed and The Medical iSiloTM Depot
http://www.meistermed.com/index.htm
MeisterMed has a collection of freeware and commercial products that are designed for the iSilo document reader such as the AsthmaMeister. There is also an extensive collection of free medical iSilo documents on the web. The iSilo document reader trial is free and the full license is very reasonable.

Because of the enormous amount of information needed by Respiratory Care Practitioners during patient care and the increasing demand for that information at the bedside a technologic expansion of your memory can be a real asset.

Catagory: Sets of 3 and Memory- BUNCHING

2008-12-07T08:38:00.007-06:00

BUNCHING - Triads/Triplets. The classic children stories: The Three Little Pigs, The Three Bears, and Three Blind Mice (and many more) have something obvious in common. The authors of these classic children’s stories knew something important about the nature of human memory. People have an easier time remembering things in sets of three. Clinical instruction in sets of 3 increases the likelihood that our already overwhelmed patients (and students) can remember and use these techniques.

Catagory: Secretion Mobilization (cough) - BUNCHING

2008-12-06T08:52:00.005-06:00

Clinical instruction in sets of 3 increases the likelihood that our already overwhelmed patients can remember and use these techniques. The System of, 3 breaths with breath-holds followed by the 3 coughs after the 3rd breath-hold will be utilized as our primary framework of instruction.

Prior to all directed cough maneuvers the patient is instructed in slow deep diaphragmatic breathing and breath hold. These slow deep breaths with sustained inspiration are used both in preparation for the maneuvers and between sets of cough instruction. These controlled breaths are directed at re-expanding lung, introducing air behind retained secretions, and helping the patient reduce dyspnea and the tendency toward convulsive cough. All 3 of these effects are more likely accomplished if the deep breaths are accompanied by a breath hold.

1) Step One - Preparation
Both of the basic directed cough maneuvers I will describe are always preceded by the same initial instruction. Coach the patient to take their first slow moderately deep breath. Say slowly and out loud for the patient, “hold it, hold it, hold it” in a fashion that results in at least at three second breath hold. (Another set of 3) Encourage the patient to exhale normally. The patient is instructed to take second somewhat deeper breath and again coached to, “hold it, hold it, hold it”, encouraging a slightly longer breath hold. Encourage the patient to exhale normally. For the 3rd and concluding breath the patient is encouraged to inhale to near maximum and couched again to, “hold it, hold it, hold it”, while preparing the patient to perform one of the secretion clearance methods below.

2) Step Two - The Three Step Cough
After the 3rd deep breath and breath-hold instruct the patient produce 3 small coughs from the same deep inspiration. Immediately have the patient inhale again to near maximal inspiration and coach them one again to, “hold it, hold it, hold it”, and then encourage 3 slightly more vigorous coughs from the same held breath. And finally, encourage the patient one final time to inhale maximally and to, “hold it, hold it, hold it”, and produce 3 final vigorous coughs from the final breath-hold. The patient is then encouraged to return to slow moderately deep diaphragmatic breathing with a periodic breath hold. Additional instruction, performance and return demonstration can be repeated as appropriate. As compared a traditional single step cough, this system increases the patient’s control of their cough and decreases incisional pain. This technique would be most suitable for patient’s you do not suspect of airway collapse associated with cough and with minimal suspicion of mucus plugging.

If any time during the directed cough the patient begins to lose control of their cough immediately instruct the patient to take a somewhat deep breath (not maximal) and help them control the breath by instructing them to “hold it, hold it, hold it”. A primary trigger of paroxysmal coughing is an uncontrolled coughing to full exhalation. Avoiding this full cough exhalation by encouraging a moderately deep inspiration and breath hold can help many patients control the paroxysmal cough tendency.

As always, as mentioned above, return the patient to slow deep diaphragmatic breathing and breath hold between sets of cough maneuvers.

3) Step Three – The Alternative of Three Step Huffing
This alternative technique is potentially most useful in patients where you may be concerned with airway closure during cough. The identical preparation and sequence is used but the typical closed glottis cough is replaced buy the open glottis forced expiratory technique. Rather than the 3 sets of increasing vigorous 3 step coughs, the patient is instructed in the performance of 3 sets of increasing vigorous 3 step “huffs”. The huff technique is performed nearly identically to the above mentioned three-step cough with an open glottis “Huff” replacing the typical closed glottis cough.

Huff maneuvers (forced expiratory technique) have been traditionally considered a method of mobilizing secretions without generation high expiratory flows and its accompanying airway collapse with patients with less patent airways.
Coaching of directed cough by the practitioner must still be aimed at optimizing the individual components of airway clearance as discussed in the related training but it must always be reinforced in such a manner as to not overwhelm the patient.

Catagory: H and P - ACRONYM

2008-12-04T22:00:00.005-06:00

Catagory: Quiting Smoking - ACRONYM

2008-12-04T21:52:00.004-06:00

Prepare a strategy based on your 4 “W”s and R.A.C.E.

R emove yourself from situations that trigger your need to smoke.
A lter your schedule and environment to not center around smoking.
C ontain the urge. Remember the urge to smoke “just that one” will pass whether you smoke or not.
E mploy techniques that reduce the urge. e.g. Take a deep breath and hold it, suck on a mint, stretch or take a quick walk, visualize the poisonous effects of smoking on your body.

Catagory: Quiting Smoking - ACRONYM

2008-12-04T21:38:00.006-06:00

Become conscious of your habit – Plan ahead

As a smoker:

When did you smoke? e.g. Morning, Meals, Breaks.
Where did you smoke? e.g. Home, Car, Work.
Who did you smoke with? e.g. Alone, Friends, Co-worker.
Why did you smoke? e.g. Nervous, Relaxation, Habit.
What were your 3 most notable daily cigarettes?

Be ready to change your behavior or avoid your smoking triggers.

Catagory: H and P - ACRONYM

2008-12-03T21:47:00.008-06:00

Memory tools for Respiratory K.I.S.S. in this Blog:

2008-12-03T21:21:00.012-06:00

BUNCHING or CHUNKING - To make it easier to remember a long list of almost anything, break the list into small and manageable groups, or "chunks." (Often in sets of 3, Triads/ Triplets)
ACRONYMS - You form acronyms by using each first letter from a group of words to form a new word. This is particularly useful when remembering words in a specified order. Acronyms are very common in ordinary language and in many fields.
SENTENCES/ACROSTICS - Like acronyms, you use the first letter of each word you are trying to remember. Instead of making a new word, though, you use the letters to make a sentence.
RHYMES & SONGS - Rhythm, repetition, melody, and rhyme can all aid memory.
TABLES & ALGORITHMS - Tables and algorrithms attempt to place information in organized grids and and flowcharts to assist with organization of information and decision making.
TECHNOLOGY - Smart phones and PDAs. Keeping a mobile library in your pocket and easy web resources.

2008-12-03T21:07:00.002-06:00

DISCLAIMER - The information contained in this website is not medical advice. While a licensed respiratory therapist presents the content, the author is not a physician. Questions relative to your health, the health of a friend or family and/or patient care concerns should be directed to a qualified physician.

Respiratory Care K.I.S.S.

2008-11-30T20:49:00.004-06:00

Keeping it short and simpler for Respiratory Therapy. (K.I.S.S.)

We would like to believe that patients and students remember the majority of the instruction we provide. But as bedside practitioners, we must be honest with ourselves and appreciate the opposite is actually true. Our students and overwhelmed patients remember very little of what we teach. It is within this reality that I would like to discuss and introduce relatively “simplified” methods that can help our patients and our students remember important clinical information and technique.