Let’s read an article a month– June 2020

Every month I try to read an open-access article. After reading the article, I share the title and associated link with my followers. This is to encourage clinicians to read articles, stay up to date, and continue to grow.

This month I found a great article on June 20th, 2020. I spent a few days with it, and now I share it with you.

Predictors of progression in systemic sclerosis patients with interstitial lung disease

  Oliver Distler, Shervin Assassi, Vincent Cottin, Maurizio Cutolo, Sonye

  K. Danoff, Christopher P. Denton, Jörg H.W. Distler, Anna-Maria

  Hoffmann-Vold, Sindhu R. Johnson, Ulf Müller Ladner, Vanessa Smith,

  Elizabeth R. Volkmann and Toby M. Maher

  Eur Respir J 2020 55:1902026; published ahead of print 2020,

  doi:10.1183/13993003.02026-2019 OPEN ACCESS


Top 3 reasons why I enjoyed reading this article:

-A well-written review of key pathways implicated in systemic sclerosis-associated interstitial lung disease (pp2-4 ). Inflammatory pathways are complex and while I enjoy reviewing them, I never tend to be able to memorize them. There is also a nice diagram that goes along with the description (i.e. Figure 1 on page 3).  

-An insider and expert view of the challenges involved with the disease diagnosis. When it comes to interstitial lung disease, there is so much for me to read and learn about. I am involved with the Pulmonary Diagnostic side of respiratory care, and mostly I see patients with confirmed diagnosis of interstitial lung disease (usually in the later stages). Occasionally I do see patients who have some indications in an imaging test, CXR or Chest-CT, and are visiting the PFT lab for additional information. “One potential barrier to diagnosis a lack of awareness within primary care of SSc, which can lead to late referrals” (p.5). 

-If you are involved with pulmonary diagnostics, you will enjoy this article as there are references to lung function values (with some references to 6MWTs) (found on pp 7-8).

Happy Learning!

Farzad Refahi
June 25, 2020


CRE Renewal

Today I recalled a conversation with Dilshad Moosa about her Certified Respiratory Educator (CRE) recertification last year.  Then I realized that a year has passed by and this year is my renewal date!!  If you received your CRE from the Canadian Network for Respiratory Care (CNRC) in June of 2015, the due date is at the end of this month!  Visit CNRC’s website for additional information:   http://cnrchome.net/recertification.html 


Farzad Refahi
June 17, 2020

Unsure? Get Tested!

A nasopharyngeal swab this past Friday followed the end of my deployment in acute care. A phone call from Markham-Stouffville Hospital confirmed a negative COVID-19 result. I endured 15 seconds of discomfort for a comfortable return to the PFT lab. It was a happy ending to being upfront.

Almost 4 months ago we stopped our pulmonary function testing. I was deployed to the acute care side of the respiratory therapy department. Helping in ICU, Emerg and wards. It was a quick refresher and a dive back to a side of respiratory care that I had not been involved with for almost 6 years.

While my exposure to COVID-19 patients and equipment were with proper PPE utilization, one could never be too sure. At the end of my rotations, and before seeing vulnerable patients in the PFT lab, I decided to get tested.
This is not the first time I have been tested over the last 3 months. With the start of spring, my seasonal allergies became evident. Mornings with red eyes and a runny nose were becoming the new norm for me. At the start of all this, and with these new symptoms, screeners and the occupational health department sent me for testing.

While I was relaxed, comfortable and calm about my recent, second test, the feeling about my first test was not the same. With my first test, I felt almost embarrassed and annoyed. Calling my manager and wondering what my colleagues would think about me being off due to COVID-19 was at the back of my mind. I didn’t want to be known as the person who didn’t use his PPE correctly or be known as the person who got deployed to be helping but now has become a vector. The only reason I am sharing my past false perception and beliefs is to share two points with you. Firstly, of course, you should do your best to follow proper hand hygiene, PPE, social distancing and other recommendations. Even if you have done all of the above correctly, it doesn’t mean that you are 100% protected. Secondly, there is no shame in getting COVID-19. Testing is becoming more readily available, so if you have any concerns that you might have contracted COVID-19, please get tested. It is important not only to look after yourself but also to protect others.

While I work in the healthcare field in Canada, this recommendation extends to all the frontline workers in the world. Thank you for your dedication and service. To those who have followed the recommendations and remained at home, thank you for your team effort. To those who have lost their jobs, became ill with this disease, or lost someone because of it, my heart goes out to you. 2019 and 2020 have been difficult but has shown me that we do great things when we come together. #StrongerTogether.

Farzad Refahi
June 13, 2020

Right After Getting The Swab

Thank you Carolyn

Image by Carolyn Greer on Instagram (Cardio-Respiratory Team)

Today one of my good colleagues retired from her part-time job at our hospital. The PFT department is thankful for her 20 years of service. While she held various roles over the years, I have known her for the past three years at Markham-Stouffville Hospital’s PFT lab. Her journey in becoming a respiratory therapist is truly inspiring, which you can read in this interview:  https://respiratory.blog/carolyngreer/ .

Without hesitation, I can recognize her as our most patient-care focused clinician who also highly valued team effort in operating a quality lab. While I will miss working with her, I’ll stay in touch with her. When I was considering to join the board of directors at Respiratory Therapy Society of Ontario, she was one of the supporters who encouraged my involvement.  Many more words of wisdom that were shared on our way to Tim Horton’s.

Carolyn, thank you for your years of service. Glad to call you a friend.

Farzad Refahi

June 4 2020

Let’s read an article a month – May 30, 2020

Every month I try to read an open-access article. After reading the article, I share the tittle and associated link with my followers. This is to encourage clinicians to read articles, stay up to date, and continue to grow.

This month I found a great editorial post on May 15th, 2020. I spent a few days with it, and now I share it with you.

Will children reveal their secret? The coronavirus dilemma
Luca Cristiani, Enrica Mancino, Luigi Matera, Raffaella Nenna, Alessandra Pierangeli, Carolina Scagnolari, Fabio Midulla
European Respiratory Journal 2020
55: 2000749; DOI: 10.1183/13993003.00749-2020 https://erj.ersjournals.com/content/55/4/2000749

You will be presented by suggestions, ideas and theories such as high angiotensin-converting enzyme 2 (ACE2) receptor concentration, innate immune response as both protective and a destructive mechanism, and constitutional elevated lymphocytes.

Happy Learning!

Farzad Refahi

Let’s read an article a month – April 30, 2020

Every month I try to read an open-access article. After reading the article, I share the tittle and associated link with my followers. This is to encourage clinicians to read articles, stay up to date, and continue to grow.

I found an article on April 25th, 2020. I spent a few days with it, and now I share it with you.

Endotracheal cuff pressures in the PICU: Incidence of underinflation and overinflation

Richard W. Wettstein MMEd, RRT, FAARC, Donna D. Gardner DrPH, RRT, FAARC, Sadie Wiatrek MSRC, RRT, Kristina E. Ramirez MPH, RRT, CHES, Ruben D. Restrepo MD, RRT, FAARC
Published online January 21, 2020 https://bit.ly/2VRHC0E

Top 3 reasons why I enjoyed reading this article

I enjoyed reading this submission to Canadian Journal of Respiratory Therapy (CJRT) as it was a quick read, and served as a nice review of reasons for using cuffed versus uncuffed ETT in paediatric population. Also, it reviewed possible benefits and drawbacks of using cuffed ETT in paeds. MOV, MLT versus pressure manometer techniques were discussed.

What you can expect from this study

In this study rate of under- or over-inflation was assessed. Also, if CP was outside of norm, possible association with gender, age, ETT size and number of days intubated prior to CP measurement was evaluated (second goal of the study. P2).


The main limitation to this study was its small size (n=20).


Happy reading. Let me know about your personal opinion on using cuffed versus uncuffed ETT in paediatric patients. Also, what’s your preferred way to monitor cuff pressures?

Farzad Refahi

We Are In This Together

Post by Farzad Refahi. Photo by Tobias Mrzyk on Unsplash

Just like many of you, I have and will continue to go through changes during these challenging times.

My Journey So Far

Since our outpatient testing lab has closed, I have been deployed to assist the acute care respiratory therapy (RT) team. I have been working in Pulmonary Function Test (PFT) labs exclusively for the past 5 years.   This has made me re-assess my awareness of acute care practices. I pulled out old notes and textbooks, and have been studying daily to refresh my knowledge.  I had to reintroduce myself and get comfortable with specific ventilators and equipment (and get trained on some new ones).   Being back in acute care, even in a supporting role, has made me feel vulnerable.  I want to help the team in patient-care without being a burden to the team, without expressing false confidence, and without making mistakes that can impact patient care (and my licence to practice).

Continuous Support and Learning

Going forward, I will continue to help the acute care RTs in my hospital with steps that can make their lives easier which includes keeping an eye on the inventory, making ‘grab and go’ packages, circuiting vents, being the runner, and looking after simple respiratory assessments.  On my own time, I will continue to review my RT knowledge using available resources such as my textbooks, notes, online videos and courses, networks and colleagues.  I’ll be honest with myself and colleagues about my weaknesses and strengths, asking questions when needed, while trying to be mindful and aware of stress levels.

My Supportive Network

This transition has not been simple, but I am lucky to have a lot of support.  The RT team at Markham-Stouffville Hospital has been very supportive.  My fellow deployed RTs are amazing in team-work and supporting each other.  Thanks to all the acute care RTs, and other healthcare providers, for all your hard work.  I want to give a shoutout to the team at RTSO who have been understanding and supportive of my deployment.  Also, to RT’s like Thomas Piraino, who are contributing to knowledge sharing and best practices for Mechanical Ventilation in this crisis. Tom, I don’t know how you manage all this! Research, clinical work,  publications, family and still have time to do daily Mechanical Ventilation Q & A sessions (6 pm on his Facebook page https://www.facebook.com/respresource/ ). Your contribution to the RT profession is much appreciated!

Also, a big shoutout to my amazing wife, who supports me through all these challenging times.  I am lucky to have strong family support in my life!

Take Care of Yourself

Be honest with yourself about your strengths and weaknesses. Navigating a new environment, at work and in life, can be scary and it tests us.  Even though we may be trained, competent and capable, we all have doubts once in a while.   I know its hard to take a moment for yourself in a time of crisis, but we also need to be mindful of our own physical and mental health so we can help our patients as well. 

Final Thoughts

These are unique and challenging times.  We are in this together! I am going to finish this post with a quote from Brené Brown (Daring Greatly. 2012).

“Sometimes the bravest and most important thing you can do is just show up.”

Blog post by Farzad Refahi. Photo by TK Hammonds on Unsplash

Be safe,

Farzad Refahi
April 11, 2020


During stressful times we tend to focus on the challenges and the struggles. It is important to not lose sight of the positive in our lives and to give gratitude.

Over the past few weeks, I have witnessed many amazing people stepping up to help everyone.  Thank you, Sue Jones and Kelly Hassall, for your ongoing dedication and leadership to help RTs through Respiratory Therapy Society of Ontario (RTSO).  Thank you, Gino Luigi De Pinto and Sue A., for keeping the RTSO website up to date with the latest resources.

   Thank you, Thomas Piraino, for putting together the great resource on your website, and answering questions live on social media. 

Also, a big thank you to Carolyn McCoyAndrew WestCarole Hamp and Kevin Taylor for your ongoing hard work in the background.

  Thank you to RT programs for lending your ventilator to hospitals, and taking your third-year students out of clinical rotations to keep them safe.

Farzad Refahi
March 23, 2020

Who Are Respiratory Therapists?

I have heard this question many times and in various forms.  

Who is a respiratory therapist? What do respiratory therapists do? Where do respiratory therapists work?  

With the current COVID-19 situation, respiratory therapists have been mentioned frequently. This blog post is meant to be a very quick overview. If you have any questions feel free to contact me and get in touch with your respiratory therapy organizations. I usually write for clinicians, but this post is meant for everyone as everybody is impacted by COVID-19.  

Who are respiratory therapists?

“Respiratory Therapists are health care professionals who monitor, assess and treat individuals who have difficulty breathing”

-College of Respiratory Therapists of Ontario (https://www.crto.on.ca/public/what-is-respiratory-therapy/ )

How and why was the profession of respiratory therapy initiated?

The origin of this profession is from the second world war. It began as a technician role to reduce the workload of physicians and nurses. With a focus on the cardio-respiratory system, the role has evolved into a therapist and now includes various responsibilities.  

What are the roles and responsibilities of respiratory therapists?

To keep things simple, I am going to give you a few different scenarios. They are not referring to any specific patient or organization. The teams are made of many amazing and dedicated clinicians who will be omitted in these scenarios so we can focus on the RT role!

Here are three scenarios to put things in perspective:

Case One: Asthma Exacerbation

Mary, and her parents, had felt that her asthma was not fully controlled for a few days and the recent cold has made her breathing much more difficult. Today her mother took her to an emergency department (ER) due to the severity. In the ER, a respiratory therapist is called to initiate the nebulized Salbutamol and to re-assess the patient. Despite various interventions, Mary continues to deteriorate and the decision is made to assist Mary’s breathing with the use of a ventilator.  An RT places a breathing tubing in the trachea and attaches it to a unit that breathes for the patient (i.e. a ventilator). The RT continues to monitor and adjust the ventilator to optimize Mary’s breathing. When Mary’s condition improves, assistance from the ventilator is discontinued and the breathing tube is removed. Mary is now able to breathe on her own. Part of the discharge process, an RT sits down with Mary and her parents to discuss self-assessment and monitoring, and proper inhaler techniques. A follow-up appointment, in a couple of weeks, is scheduled for Mary at the Asthma Clinic.  In the Asthma clinics RTs perform a breathing test, called Spirometry, and provide patient education which includes understanding the disease, management, prevention and optimization in case things don’t feel like the norm. 

Case Two: COPD Exacerbation 

Michael ignores the worsening of his cough, chest tightness and difficulty breathing with even short distance walks. Today he finally decides to consult his family doctor. A decision is made for him to visit an ER. In the emergency department, various tests and treatments are done, and an RT is called to start supporting Micahel’s breathing (using a mask and a supportive unit called BiPAP). Michael’s breathing is optimized over the next day. He is transferred to the general ward for monitoring. Before discharge, an RT meets with Micahel for a smoking cessation conversation.  The RT also provides education about the need for ongoing oxygen. A follow-up Pulmonary Function Testing and respirologist/pulmonolgist consult are scheduled. An RT with a Home Oxygen Company/team would visit Michael to set up the equipment, perform assessments, and provide further education. During Pulmonary Function Testing, an RT walks Michael through various breathing tests. At the respirology/pulmonology visit, an RT may sit down with Michael to review the proper inhaler technique. Same RT may also provide a smoking cessation consult. A follow-up PFT and respirology/pulmonology visit are scheduled.  

Case Three: Mona and Baby Lisa – Labour and Delivery

Based on the assessments and monitoring of Mona, a difficult delivery is suspected. The team, including a respiratory therapist, is present in the delivery or operating room. Immediately after birth, RT and nurses perform the routine assessments and provide the required care. In this example, the RT puts a small “mask” on Baby Lisa’s nose to deliver a small amount of airflow or pressure.  This will help to keep the lungs open slightly longer, and in turn, make breathing easier for Baby Lisa. The RT, part of the team, transfers Baby Lisa to the intensive care unit for further monitoring. Baby Lisa’s breathing is optimized by adjusting the CPAP unit as required. Use of CPAP will be weaned off as Baby Lisa starts feeling better. If Baby Lisa requires even more support, the RT can use a breathing tube to establish a better pathway, and a ventilator to deliver a more controlled breathing support.

There is more…

Respiratory therapists are involved with other roles such as managers, researchers, teachers, inventor, remote support using the phone/video-chat, transport team, consultant, policymaker, in-hospital code blue/pink resuscitation teams, operating rooms, sleep labs, CPAP educators, and others. 

What can an RT do for someone with COVID-19?   

Respiratory therapists can be part of the team who does the initial assessment.  By applying nasal prongs or a mask, an RT can improve the body’s oxygen levels.  When needed and indicated, inhalers can be given to optimize breathing. Assistance in breathing can be provided using non-invasive, such as CPAP and BiPAP, and invasive measures (Ventilators). 

How to become a respiratory therapist?

Most clinicians in Canada complete their undergraduate studies and then apply for one of the many respiratory therapy programs in Canada. For the list of available programs in Canada, I will refer you to the website of the Canadian Society of Respiratory Therapists: https://www.csrt.com/rt-profession/#education.  The training usually involves two years of academic and simulation learning, and a final year of clinical placements.

How much do respiratory therapists get paid? 

Based on Payscale.com, the median hourly rate is $31.80 in Canadian dollars ( as of March 22, 2020, https://www.payscale.com/research/CA/Job=Respiratory_Therapist/Hourly_Rate ). As you can guess, the pay is higher with more years of experience, and with roles that entail more responsibilities and that in the acute care settings.

Where can I get more information about respiratory care and respiratory therapists?

On the national side, visit the Canadian Society of Respiratory Therapists: www.CSRT.com.  

On the provincial side visit the College of Respiratory Therapists of Ontario: www.CRTO.on.ca, and Respiratory Therapy Society of Ontario: www.RTSO.com.   

On a personal RT perspective, there is my website: www.Respiratory.Blog . In my interviews with different respiratory therapists, I try to share different perspectives and insights. Here is one example: Mieke Fraser’s post at http://respiratory.blog/mieke/ (published on October 25, 2017).

Thanks for your interest in respiratory care and respiratory therapists! Share this with others who may find it helpful!

Stay safe. Frequently wash your hands.  Practice social isolation.

Here is a PDF version of this post for ease of sharing:

Farzad Refahi
Photo of Farzad Refahi of www.Respiratory.Blog

Simulation lab for the PALS certification course.
Simulation lab – Part of the PALS certification course.


Quiet First Day of Spring

Today is March 20th, 2020. The first day of spring. Happy Nowruz to all those who celebrate the new year. Iranians, among few other nations, have the first day of spring as their new year.

While new year celebrations involve visiting others and sharing delicious food, this year will be quiet. I hope it is quiet. Let’s continue the social isolation. Let’s continue to practice proper hand hygiene. Let’s self-isolate if you are feeling unwell. Let’s think about the vulnerable population and the elder members of the family.

My blog posts are usually meant for clinicians. This time, I am writing to every one, since dealing with COVID-19 is beyond the work of clinicians and healthcare system.

While you monitor your physical health, please don’t forget about your mental health. There are various electronic and video communication options that allow you to connect with others. Call the elderly to check-up on them. If you know someone in isolation, ask if they require groceries (being dropped behind their door).

Those who experienced SARS in 2003 may experience higher levels of anxiety around this time (especially clinicians). Make sure you connect with proper resources, support and intervention if required.

Give yourself mental breaks. Find a few trusted sources for news and COVID-19, and only review those. Constantly reading about it may induce increased anxiety. ( www.RTSO.ca is one of my trusted sources.)

Find appropriate stretches and exercises that can be safely done at home. Stay hydrated. Use this opportunity to stop smoking. Pick up that book that you always intended to read!

Don’t forget about the positive. Give gratitude for the good in your life. There are many great people who are doing their best to help out. A quick shout out to respiratory therapists and clinicians who continue to work to keep us healthy. Fatima Foster is creating a supportive online community for clinicians who are experiencing some anxiety around this time. John Meloche from Melotel Inc. is using the resources in his company to support communities and organizations who have non-for-profit COVID-19 support groups. There are many more examples if you look for them!

Have a happy, healthy, and quiet Nowruz!

Farzad Refahi