Respiratory Therapist – Professional Physician Extender

I am strongly looking forward to hearing Garry W. Kaufman’s presentation – the key phrase

that drew my attention is PROFESSIONAL PHYSICIAN EXTENDER.

We all know it … first sign of trouble (desat, cardiac arrest, strange noise, etc.)  and the first words out of anyones mouth is “get respiratory”.



I really am looking forward to this and other’s commentary that know the respiratory therapist’s role in the medical field.

(MORE TO FOLLOW … from my soap box).


To ALL (RN, RT, MDs).

If you can discern the intervertebral space thru the heart on film , the CXR technique was good!

How was the radiology techs technique in taking an cxr?

resplearn-intravertebral space 001resplearn-intravertebral space 002

It is suggested that if the intervertebral space can be discerned thru the heart, the radiology technician

had good technique.

The x-ray had to travel thru (from front (ventrum) to back (dorsum) :

front of patient > skin > muscle > bone > front of heart muscle > blood in heart >

intracardiac structure > back of heart muscle > bone > muscle > skin > back of patient …

and yet one can discern the intervertebral space, technique was good!

The lung is visible thru the heart when there is minimal atelectasis.


As a general rule, the lung is visible thru the heart when there is minimal atelectasis.




X-rays have to travel thru (from front (ventrum) to back (dorsum)) in this order :

patient front > skin > muscle > bone > lung > heart muscle > blood in heart >

heart muscle > lung > bone > muscle > skin > patient back > to x-ray plate.

The more atelectatic, the more denser the pulmonary tissue, and therefore the x-ray

has higher potential for being deviated / obliterated / absorbed.  The less atelectatic,

the less chance of deviation / obliterated / absorption.


BiVent as a Quick Differentially Diagnosing Tool For Elucidating Pathologic Disease

Please enjoy this presentation on BiVent.

As with any discussion, please discuss enacting BiVent with your medical director, resp dept director, supervisors, managers, coordinators, resp peers, medical attending, medical resident, icu intensivist, physician’s assistant, nurse practioner, and nurse.

We present it as a differentially diagnosing tool to keep amidst our armamentarium of tools.

The beauty of this paradigm is that while awaiting any other tool required to diagnose or “rule-in” another diagnosis, the diagnosis of “run away atelectasis” can be ruled-in or ruled-out starting immediately.










Resident lecture – requisite mandatory ventilatory parameters to order.

REMEMBER : Always discuss all aspects of respiratory care with the respiratory therapist, the resident, the nurse and the attending physician.

The physician should always order :

orders for initiation of mechanical ventilation to include :

type of ventilation : VCV vs. PCV vs. PRVC

mode of ventilation : full vs. partial vs. minimal ventilatory support (aka AC vs. SIMV vs. PSV)

RRset : 6 vs. 10 vs. 16

Vt(set) : 6ml/kg vs. 8ml/kg vs. 10ml/kg vs. 12ml/kg (and PBW(-predicted body weight) vs. IBW(ideal body weight) vs. actual weight)

alternatively to Vt(set), dP(set) : dP=30

alternatively to Vt(set), Time(inspiratory) : T(inspir) =2sec

FiO2 : 100% vs. 30% & appropriate PEEP (suggested=14cmH2O).

PEEP : 14cmH2O.

Pressure Support : targeted for tidal volume ~ 5ml/kg.


Resident lecture – what to set mandatory RR at.

REMEMBER : Always discuss all aspects of respiratory care with the respiratory therapist, the resident, the nurse and the attending physician.

Keeping it simple, there are only 3 general categories to set for mandatory RR.

RR= 16          as a transient solution to increased intracranial pressure (hyperventilation should cause cerebral vasoconstriction and thru the “mass effect”, allow a relative decrease in intracranial pressure to allow for the space occupying lesion that is the head injury.

RR= 6           for any patient deemed “difficult to ventilate” to include status asthmaticus and ARDS.  Lungs should be envision not as two organ systems but rather as individual alveoli.  Then, envision those alveoli inflating and deflating at 24 to 34 time per minute.  It is only a matter of time before a micro-tear appears and now the bioinflammatory cascade is evoked.  It will then be only a matter of time before early ARDS signs & symptoms appear.  Permissive hypercapnea should be entertained.  An acidic cellular milieu should be considered.  Acidemia in itself is a protective environment.  A slow RRmandatory will minimize mechanical trauma.

RR= 10         everyone else not mentioned above.

QoW 2015 – 003 (Where does APRV fit in the grid of modes vs. types of ventilation)

Where does APRV fit in the grid of Mode vs. Type of ventilation?

Modes of Ventilation



[ full support ]               [  partial support ]         [  minimal support ]

[ Assist Control]               [Synchronized IMV]      [Support Ventilation]

[  AC  ]                              [  SIMV  ]                                 [  SV ]

[TYPES                    [  VCV ]             >>         AC-VCV                           SIMV-VCV                              VSV

OF                             [  PCV ]             >>         AC-PCV                           SIMV-PCV                               PSV

VENTILATION]    [  PRVC ]          >>         AC-PRVC                        SIMV-PRVC                             VSV

[  Neural ]         >>             —                                         —                                       NAVA