From the President
Abstract Accepted by AARC
From the Editor
Sputum Bowl Winners
Article Reviews
Spouting from the President-Elect
SNF Horror Stories Impress Chairman of Senate Finace Committee
Notes on the 1999 NSRC State Meeting
Back to NSRC Home Page
It was great seeing many of you at the State Meeting in Kearney. I hope this year's meeting met your expectations from an educational perspective as well as allowing you to network with other respiratory care practioners in the state. The meeting appeared to be extremely successful to me. Attendance this year was over 200 and our continued vendor support was phenomenal. Jan Wilwerding-Matsui and the program committee members did an outstanding job! The new vice president, Melody Bero, is in the process of preparing for the 2000 State Meeting in Kearney. I encourage you to contact Melody if you can help with the meeting. Also, watch for information on additional eductional meeting that the N.S.R.C. is planning.
This next year proves to be an exciting one for all respiratory professionals. We have many challenges and opportunities facing us. One of these challenges is the PPS that HCFA has implemented for SNF's. I can assure you that the AARC and its' affiliates are not taking this lightly. From both the national level as well as state level, senators and representatives are being contacted so that this PPS ruling will be changed to provide SNF patients with the best respiratory care by the most appropriate individuals - the respiratory care practitioner.
The SNF perpesctive payment issue is only one area which is affecting all respiratory care practitioners whether they are an AARC member or not! Once we succeed in addressing the SNF issue, I can guarentee other issues and challenges lie ahead. The AARC is working in conjunction with the Nebraska Society and all other affiliates to take a proactive position when issues arise. We have established a communication network that enables affiliates to rapidily send messages to other affiliates and the AARC. This has proven to be an extremely valuable tool for providing feedback to affiliates experiencing some difficulties with their practice act. For example, a Wisconsin affiliate sent a message to all affiliates and the AARC asking if nurse assistants should be allowed to check ventilators and suction patients in SNF's, which was occuring. Within a couple of hours Wisconsin had received enough feedback from affiliates around the country to formulate a response to take to nursing home administrators disputing this practice.
This lead me to my soapbox.... For any one practitioner in Nebraska to say the NSRC or AARC is not dealing with or helping with issues that effect them is ludicrous. Eventually, some type of legislation or directive from you institution/company or other group of healthcare providers will want to adversly impact each and every one of you. It is my hope that each and every one of you feels that there is an organization advocating solutions to issues that deal with our career and livelihood. GET INVOLVED!! Whether it is merely becoming a member of the AARC and doing nothing else, you are showing your support of an active organization that works for you. I hope many of you take the next step and become involved in the NSRC. Seeing only a handful of individuals year after year representing approximately 900 practioners in Nebraska distrubs me. As far as I know, the NSRC is the only advocate specifically for the respiratory care profession that exists in Nebraska. However, less than one-third of the practioners in Nebraska are NSRC members. Even more disturbing is the fact that our Nomination/Election committee must year after year beg people to run for office. What is wrong with this picture?? Get involved, seek election for a Board position or serve on a committee!!!!!! The time commitment is small compared to the rewards of having accomplished something for the good of the respiratory care profession, your profession. Call any Board member or me, we can utilize your talents. I challenge each and every one of you to become involved. Start your involvement with membership!!
Lincoln therapists Kristie Hoch, Chad Poggemeyer, and Shane Blake from BryanLGH Medical Center West along with Lincoln Pulmonologist Dr. Sean Barry have presented an abstract dealing with arterial line insertion and complication rates that will be presented in the November 1999 issue of Respiratory Care. Selected authors will be invited to present posters at the OPEN FORUM minisymposia at the AARC International Respiratory Congress in Las Vegas, Nevada, december 13-16, 1999. Each year, the AARC's scientific journal Respiratroy Care invites submission of brief abstracts related to any aspect of cardiorespiratory care. These abstracts highlight important case reports, methods, devices, protocol evaluations, and clinical studies. All accepted abstracts are also automatically considered for an American Respiratory Care Foundation research grants. In the September, 1998 (Volume 8, Number 4) issue of The Inspiration, a concise article detailing the groups project over arterial line insertation was presented for those NSRC members. The NSRC wishes to congradulate these individuals on the acceptance of their abstract by the AARC's scientific journal.
Hello!! Inside you will find a lot of information about the State Meeting, this one
was fantastic. Not only were Nebraska’s RCPs given a chance to get together for some
fun, but we were also given a chance to learn from each other. We had a great turn out
for this meeting from members and vendors. Without the support of everyone this meeting
could not have happened. I especially want to thank Jane Wilwerding-Matsui for all of her
efforts in making this meeting possible and the vendors for their support of our meeting.
On a sad note, the Lincoln Pulmonary Conference has been canceled for this year.
Anyone who has been involved in producing conferences knows what skill and dedication
are required to put on a conference. It is impossible for a few people to coordinate
putting on a conference the size of the Pulmonary Conference. I have heard several
people comment on how the cancellation of the Pulmonary Conference leaves them
without the standard option for achieving CEUs, but I have not heard one of these people
express an interest in helping with the work involved in putting together the next
conference.
To those few people who have constantly and consistently given their time and
skill to the NSRC, it’s committees and offices I commend you. To those of you who
believe that the NSRC just makes things happen without your input or assistance I have to
say that change and progress take hard work and dedication which translates to
manpower. The few who volunteer cannot by themselves carry our entire group.
I believe that the NSRC functions as our advocate in matters which can make or
break our profession. The NSRC is my advocate for issues which could end up affecting
my paycheck. Although I donate my time and talent to this newsletter, because my life is
not as busy as yours, no actually I consider volunteering a part of my responsibility to my
profession. Respiratory care has come a long way in 50 years and newer technologies are
helping the field move ahead, but we need your help. Become involved, the job you save
might be your own!
I have been reading old issues of the Inspiration, well all right you got me, I have
been reading the from the editor parts, hoping to find some insight from Shane Blake. In
the Volume 6, Number 4, dated December 31, 1996 I found this quote: “To hold one’s
breath and ride the roller coaster of changes in your profession in a hypoxic dream state
can only lead to the organization’s demise.” Well said Shane, it is as appropriate now as it
was then.
The opinions and beliefs expressed in this newsletter are those of the various writers and not the NSRC or AARC.
The NSRC wishes to congratulate the winners of the NSRC's 1999 Sputum Bowl Competition and those that took their time and effort to participate. Two teams from the BryanLGH Medical Center West were represented as for a student team from Metro Community College. Nebraska will be represented by BryanLGH Medical Center West team members Jacob Geier-Craft, Douglas Philippi, Chad Poggemeyer and Shane Blake in December 1999, at the AARC's National Convention in Las Vegas, Nevada.
Two Article Reviewsby Becky Boucher, RCS, SECC
The flexible fiberoptic bronchoscopy, or FOB, has gained popularity over the years
becoming a useful tool in the diagnosis of many thoracic diseases. Included within this
journal review entitled “Flexible Fiberoptic Bronchoscopy in 1998”, (Poe, MD & Isreal,
MD. Resir. Care 1998; 43(10):811-819) 871 brochoscopists were surveyed to list their 5
most common indications for performing FOB which were then ranked, listed and
discussed. The number one indication was roentgenographic abnormalities suggesting
cancer. With little disagreement that FOB is indicated, each presenting case yields its
limitations. For this reason, the bronchoscopist must evaluate and treat individually
exercising various available modalities such as direct forceps biopsy, needle aspiration,
fluoroscopic guidance and retractable needles to maximize the likelihood of diagnosis.
Hemoptysis was the second indication for FOB. If performed without delay during acute
bleeding events, the FOB heightens identification of the bleeding site but does not present
any more conclusive diagnoses. The third most common indication was that of pneumonia
and its usefulness in identifying the cause in immunocompromised patients. FOB used
with brochoalveolar lavage (BAL), assists widely in patients displaying a lack of response
to broad spectrum antibiotics. Bronchoalveolar lavage has proved to be very effective
with FOB in diagnosing pneumonia due to P. Carinii in AIDS patients. Interstitial lung
disease in the immunocompetent patient holds the fourth most common indication. FOB
with transbronchial forceps biopsy has an established success rate among pulmonary
physicians with ILD. Bronchoalveolar lavage on the other hand, holds no clear diagnostic
rate with interstitial lung disease but does provide clues to many associated disorders. The
fifth and final common indication for FOB is with therapeutic utility. In atelectasis, FOB
is widely practiced and provides a successful method for assessing and treating this
disorder. Other uses that are beneficial with FOB are control of the airway with
intubation, foreign body obstruction and the management of advanced airway obstructive
diseases incorporating therapeutic maneuvers of brachytherapy and/or laser
photcoagulation. FOB has also become a valuable tool with diagnosing, assessing and
surveying in post-transplantation patients.
Complications of FOB are reviewed well. Included are problems with
premedication, procedure related trauma such as airway injury or laryngospasm, and
problems associated with topical anesthesia. More than half of the complications are
associated with medication and anesthesia and not the FOB procedure. Emerging
technologies such as the ultrathin bronchoscopes are helping to ensure the FOB as a safe
modality. Changing times are continuously creating new indications for the FOB. It has
revolutionalized the diagnostic approach to airway and parenchymal disease with its
versatility and abilities. The flexible fiberoptic bronchoscopy continues to be a most safe
and widely used treatment modality, but the complications remain ever present and must
be monitored closely.
Tuberculosis is a chroni, baterial infection that primarily affects the lungs although it can occur in almost any part of the body. In review of the journal article “Detecting and Treating Tuberculosis in Older Persons” (Idicula, MS, RRT, AARC Times, 1998; 22(11):35-39), TB is discussed relating to issues of its prominence, diagnosis, treatment, infection control and prevention. With the ever increasing cases of HIV and the baby boom generation aging, the prominence of this disease remains steady among the elderly. People age 65 and over are the second highest risk group next to HIV due to poor nutrition, aging and reactivation. The presence of other illnesses such as COPD or lung cancer may make the diagnosis of TB more difficult and delay needed therapy. The diagnosis of TB is concentrated around the Mantoux tuberculin skin test with PPD (Purified protein derivative). A positive reaction results in an elevation in the skin greater than or equal to 10mm for those 35 years or younger and 15 mm for those 35 years and older. Persons who have suggestive symptoms of TB such as anorexia, weight loss, fever and a cough should be evaluated with a chest x-ray and sputum samples for confirmation of infection when they do not respond to antibiotic therapy. Treatment includes the initial regimen of Isoniazid (INH) and Rifampin (RIF) for nine months. A six month regimen adding Pyrazinamide (PZA) follow titrating to sensitivity levels and individual resistance. Older patients have difficulty with this regimen due to memory loss, poor eyesight, confusion and the various side effects of the medications. This is especially a problem because inadequate treatment or failure to comply results in relapse and drug resistance. The infectious ability is related to the TB bacilli released into the air through coughing, aerosol procedures and sputum. The proper infection control requires early detection, isolation in a negative pressure room and vigorous drug treatment. With older patients, especially those in long term facilities, this action is of the highest importance. This is due to the increased number of host available within the facility, as well as the altered physiologic functioning and impaired defense mechanisms with the elderly population. For this reason, the TB patient and family members should be educated on the transmission and infection control procedures needed to prevent cross-contamination and re-infection. Although tuberculosis is still a common disease, it is both treatable and preventable. Key strategies include early detection, good infection control and maintaining appropriate antimicrobial drug regimens. With the elderly and within long term care facilities; these strategies must heighten even more to offset the ability of TB bacilli transmission that may go undetected due to the compromised defenses of the older patient in today’s health care.
Two Article Reviewsby Julie Alfaro, RCS, MCC“Changing Practice Patterns in the Workup of Pulmonary Embolism”: Henschke, Claudia I., AMD, PhD, Mateescu, Ion, BS, Yankelevitx, David F., MD: Chest, 1995, 107(4): 940.
According to autopsy studied, pulmonary embolisms are estimated to be the leading unsuspected diagnosis at the time of death. The “gold Standard” for the detection of pulmonary embolisms (PE’s) has been pulmonary angiograms (PAG). It has a high degree of certainty in the detection of PE’s and is recommended when a ventilation/perfusion scan is inconclusive with the physical findings. Doctors have been hesitant in the use of PAG because it is an invasive procedure with the risk of allergic reaction to the dye or potential lethal arrhythmias. The authors of this article wanted to see if given an algorithm, i.e.: flow chart, doctors would follow it in the detection of pulmonary embolisms.
In 1985 and 1986 a clinical trial, the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED), was done to see how accurate V/Q scans were compared to the PAG. The outcome determined that a high percent of the people in the low and intermediate group of the V/Q scan were diagnosed with a PE after having the PAG. This study showed that further diagnostic testing needs to be done on the patients in the low and intermediate probability range. Further testing was already done on the high probability group, so that did not change. The authors of this article wanted to see if the results of the clinical trials had an impact on physicians after the study had been published. So, the physicians looked at the records of patients in their hospital who were suspected of having PE’s in 1988 and compared them to patients in 1991. There were 316 patients in 1988 and 334 in 1991. Just about the same percentage of patients were in each category for both years. The study confirmed that in 1991, more diagnostic testing was done, i.e.: Doppler Leg Sonograms (SOD). However, the treatment of possible PE’s did not change, i.e.: anticoagulation therapy. This seems to suggest that the PIOPED study did have significant impact on how physicians are diagnosing pulmonary embolisms.
The results of this study showed that for the patients in the low or intermediate range of suspecting PE’s, further testing is definitely beneficial. Nevertheless, the results of this study did not change the minds of the physicians when it came to pulmonary angiograms. The physicians would rather try a less invasive procedure. The fact remains that the mortality rate is significantly low for PAG’s and remains quite high for PE’s and anticoagulation therapy. This leads to the need for standardized testing in the workup of pulmonary embolisms because the mortality rate is still extremely high. 83% of patients that died of unsuspected PE’s already had DVT’s and only 19% were showing symptoms. Therefore, the necessity for less invasive and more accurate testing is still in need before we can safely say that PE’s can be definitively diagnosed.“A Comparison on In-line MDI Actuators for Delivery of a Beta Agonist and a Corticosteroid with a Mechanically Ventilated Lung Model”: Rau, Joseph L., PhD, RRT, Dunlevy, Crystal L., EdD, RRT, and Hill, Richard L.: Respiratory Care, September 1998, 43(9).
This article was a study to compare the various types of actuators that are on the market today for the use of delivering medication in-line with ventilator cicuits. There has been a variety of opinions on the use of MDIs verses in-line nebulizer treatments. This study was to compare the actuators and to see how effective they compared to each other. The actuators that were studied were the Hudson In-line, the Aerovent, The Minispacer, the Ace and the Medispacer.
To insure consistency and accuracy in the study, a Puritan Bennet MA-1 ventilator was used that was hooked up to a test lung by a size eight mm endotracheal tube, a filter was placed between the tube and the test lung to collect the medication. The same settings were maintained throughout the entire study to maintain the consistency. The MDI canister and ETT were used, but rinsed and dried in between each use. For each canister of medication, whether it be Albuterol or Steroids, it was shaken five times and primed once before each use. The medication was delivered during the inspiratory phase and twelve actuations were delivered for the Albuterol and five actuations were delivered of the steroids. The medication on the filter was then measured as a dose per actuation.
The different type of actuatiors ranged from a rigid plastic tube to a flexible accordion type bellows. One type, the Ace reservoir was actually placed in a reverse firing position. The results of this study were as follows: In the delivery of the Beta Agonist: He Hudson In-line delivered 12%, the Minispacer delivered 17.2% the Aerovent delivered 17.7% the Ace delivered 30%, the Medispacer delivered 31.8%. In the delivery of the Corticosteroid the Hudson In-line delivered 5%, the Aerovent delivered 11.4%, the Ace delivered 12.4%, the Minispace delivered 13.1% and the Medispacer delivered 21%.
Concernignt he efficacy of medication delivery, none of the actuators that were tested had superior performance. 30% was the top range of medication delivery and that seem marginal. When looking at the device of choice in this particular group the determination would lean toward the Medispacer by Airlife. The soft accordion type of actuators seem to do a superior job of delivering the medication down the endotracheal tube.
The results of this study showed that there is a variety of efficacy in the delivery of medication down the endotracheal tube with the mechanically ventilated patient. This article also raised some interesting questions in reagrds to the delivery of medications with the intubated patient. Since the highest percentage was only 30% should the dosage automacticlly be tripled when using an in-line MDI. Another consideration that needs to be thought of would be is using MDIs the best way to deliver medication to the mechanically ventilated patient. Maybe the best way is to aerosolize the drug in-line close to the patient. This study supports the need for further evaluation between the use of MDIs verses in-line aerosolized medication and the need for increasing the dosage when using a MDI.
All invitations must proceed from heaven perhaps; perhaps it is futile for men to initiate their own unity, they do but widen the gulfs between them by the attempt.” -E.M. Forster, A Passage to India.
I found myself routinely coming back to this one quote, as I have slowly progressed through my nighttime reading A Passage to India. For me it is a book just for that purpose -- nighttime reading, yet to others it is a masterpiece about the clash of two cultures. I know you are thinking this is not suppose to be a book report or some great plug for literature, but bear with me for a moment.
This quote has lingered in my thoughts as I surveyed an article about the demographics and numbers of Respiratory Therapists in the US. There are approximately 154,000 Respiratory Care Practitioners in the US today with approximately 34,000 or 22% of those RCP’s choosing to be members in the AARC. I would like to think that E.M. Forster’s quote is wrong and the old revolutionary cry of “united we stand, divided we fall” still holds some truth today. Yet, at times the participatory efforts of our own profession seem to hold some evidence that E.M. Forster was on to something. What makes unity a success or failure? Sounds like a dissertation in itself, but sometimes it is the challenges of what is presented to the group in question. What faces our profession is hard to encapsulate into one single momentary and emotional battle cry or for that matter one article. But do we acknowledge E.M. Forster’s quote with resounding agreement or with disagreement? How do we respond to a challenge as a group?
I present to you one incidence. One article, entitled “O.T.’s: The New Case Managers” appeared in the Rehab Management’s Case Review magazine. Its author Doris Shriver, OTR, FAOTA, owner of OT Resources, a private practice in Denver, CO., contends that occupational therapists (given their depth of training and experience) are more suited for case managing asthma patients than even respiratory care practitioners. Shiver suggests, “The RCP is best equipped for the hands-on care an asthma patient requires. But, for case management purposes, an OT has an advantage over the RCP in that the occupational therapist knows how to take into account the broader range of factors that can trigger an asthma episode--not merely the physiologic and physical environmental factors that the practitioner is accustomed to dealing with, but also the psychological and social issues that affect a patient’s sense of well-being.”
How do we respond to this? Do we respond at all or is it as E.M. Forster contends a “futile” matter to unite against such circumstances? I leave it to you. Do you aide your profession by becoming united together for the purpose of crossing the “gulfs” that E.M. Forster eludes to?
Senate Finance Committee Chairman Bill Roth (R - DE) has aske the AARC to draft “legislative language” that could be used in potential legislation whiche would effectively address the lack of respiratory therapy competency requirements in skilled nursing facilities. This development is especially significant because the Senate finance Committee is the influential “gatekeeper” of Medicare legislation in the Senate.
The request occurred after Delaware Society President John Rendle and several other respiratory therapists (RTs) met with Senator Roth’s key health staffer about the quality of care skilled nursing facility (SNF) patients are receiving in the absence of RTs. This is an issue the AARC has been encouraging its membership to press with Congress for many months, and AARC government affairs director Cheryl West helped ensure the Delaware therapists had the information they meeded to make a strong impression at the meeting.
Rendle and his colleagues went to Senator Roth’s office armed with stories of serious medical erros made by unqualified caregivers attempting to deliver respiratory care to patients who should have had the attention of skilled RTs. In some cases these errors led to patient deaths. These tragic stories impressed upon Senator Roth’s assistant the grave situation facing many skilled nursing facility patients who are not receiving the competent, quality respiratory care they deserve.
Soon after this meeting, the Senate finance health staffer contacted AARC Director of Government Affairs Cheryl West on behalf of Senator Roth. The health staffer from Senate Finance Subcommittee reqested the “legislative language” from West. Although this development is by no means a final step in assuring competent care for SNF patients, it is a very positive step in that direction. With Senator Roth’s support, legislation presented to address the competency of care issue should be well received by Congress.
The implementation of the SNF prospective payment system (PPS) has brought with it many new challenges; however, the most crucial of these is to guarantee SNF respiratory patients they will receive care from qualified, competent professionals. Sadly, thus fare this has not been the case for many such patients. Thanks in part to the recent efforts of RTs in Delaware, however, regulations may soon be forthcoming.
The recent state meeting was held May 11th-13th in Kearney, NE. If you could find the hotel (Ramada Inn formerly the Holiday Inn or vice versa) you participated in an excellent educational and enjoyable meeting. Several sponsors made this meeting a huge success. They are:
Apria Healthcare for the BBQ
Nebraska Health Systems for the speakers Dr. Sisson Dr. Goodrich
Abbott Labs for the speaker Dr. Boken
Glaxo Wellcome for the speaker Dr. Boguniewcz
Respironics for the NIPPV seminars
The Linda K. Sturdevant award scholarship winners were:
Julie M Alfaro, MCC
Becky J. Boucher, SECC
Awards were given to:
Shane Blake for his 3 years of service to the Inspiration newsletter
Sue Waggoner for her year as president
BryanLGH West for winning the 1999 Sputum Bowl
Thanks to all member s of the planning committee that helped make the conference a success:Jeff Gonzales, Bruce Anderson, Marcy Wyrens, Cindy Rocker, Mikki O’Kane, Ed Conklin, Karen Riva, Faye Sorenson, Sue Waggoner and Donna Miller.Special thanks to the following individuals who dedicated additional time to make the following events successful:Helen Soreson for the Sputum Bowl competitionSue Roland for the golf outingDonna DiPaulo for student scholarshipsJane Wilwerding-Matsui as chair of the program committee, deserves special recognition. Jane’s time and effort on this year’s meeting was seen throughout all the events. Her countless hours decicated to bringing an outstanding educational opportunity; as well as social activities, were evident in all the conference functions. This year’s meeting has record attendance, this attendance was due in part to Jane’s hard work and all her efforts.Thank you to all the companies and individuals that donated prizes