Gratitude

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
www.Respiratory.Blog/gratitude/
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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
www.Respiratory.Blog/respiratorytherapist/ 
Photo of Farzad Refahi of www.Respiratory.Blog

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

[End]

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
www.Respiratory.Blog/HappyHealthyQuietNowruz/

[End]

To Acute Care for Support?

Our Pulmonary Function Lab has been closed for the past two days to reduce the risk of transmission to patients, especially the vulnerable populations.  Things are changing daily, and there many unknowns. (To non-clinicians reading this, we do know proper hand hygiene and social distancing works!)

I have worked full time in a PFT setting over the past 5 years.  With PFT lab closed, and a chance for deployment to other units, I need to do some reviewing! 

The Essentials of Respiratory Care by Robert M. Kacmarek .Fourth Edition. 2005. Elsevier Mosby

The Essentials of Respiratory Care, Fourth Edition, by Robert M. Kacmarek, Steven Dimas and Craig W. Mach is one of my resources.  This textbook was not actually a resource during my studying, however, it was a recommendation by one of the instructors (shout out to Paul Smith at The Michener Institute). Since I have not been trained in the acute care setting of my hospital, I don’t know about many of the protocols, selection of equipment and policies.  I am still going to use this opportunity to review some respiratory care knowledge.

Do you have any up to date, open access and free resources to recommend?

Farzad Refahi
www.Respiratory.Blog/AcuteCareReview/

[End]

Flattening the Curve

Hearing About Flattening The Curve While Listening to Dr Mike on YouTube As He Discuss Coronavirus.

I try to get information from multiple sources online. One of these sources is Dr Mike who is a family physician in the United States. In one of his latest videos titled ‘We NEED More Testing Kits!’, I came across a concept which I had forgotten about. At 2:10/11:40 he quickly refers to ‘Flattening The Curve’:

… Here in United States, we simply do not have enough ICU beds if everyone is to get this virus simulatenously, so by slowing the rate at which this virus infects others we doing “Flattening the Curve”

Screenshot of Dr Mike’s video https://youtu.be/DfMl6W6N7-A

What is the concept of Flattening The Curve?

A large number of people using limited resources at the same time will saturate and overwhelm the system. The system can provide better care if the same number of people access these resources over a longer period of time (versus all at once).

When it came to public health, disease prevention and elimination of spread were at the core of my thoughts. Now I have learned that slowing the spread of disease is not necessarily a total defeat. Even a slow down, is a success in better access to care (in the highly contagious disease when total isolation and zero spread is unrealistic).

You can watch the full video using the link below:

Link to Dr Mike’s video published on Mar 15, 2020 https://youtu.be/DfMl6W6N7-A , watched by Farzad Refahi on Mar 15, 2020

As healthcare providers, we can better educate the public about the nature of the disease and proper hand hygiene. Also, we can encourage unnecessarily gathering of people in public spaces. As a group, we can look after the vulnerable population.

On a personal note, my wife, who is feeling fine, cut her business trip short due to the quickly evolving situation with COVID-19. I purchased food and supplies to last her at least two weeks. I left for my parents before her taxi got to our place. She has decided to follow the recommendation of self-isolation for two weeks. We are lucky that my parents live close by and are more than happy to have me for the two weeks. Of course, it is not easy being apart even longer than planned, however it is a small price to pay for the greater good (especially when as an RT, I have face to face interactions with patients at work).

Farzad Refahi
http://respiratory.blog/flattening-the-curve/

[End]

Let’s read an article a month – March 11, 2020

Screenshot of the first page of the article by Morgan et al. Ready by Farzad Refahi and shared on www.Respiratory.Blog


An Article A Month

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 March 9th, 2020. I spent a few days with it, and now I share it with you.

Variability In Expiratory Flow Requirements Among Oscillatory Positive Expiratory Pressure Devices 


by Sherwin E. Morgan, RRT, Steven Mosakowski, RRT, MBA, Brenda L. Giles, MD, Edward Naureckas, MD, Avery Tung, MD, FCCM
Published online March 4, 2020. Available on The Canadian Journal of Respiratory Therapy (CJRT) : https://www.cjrt.ca/wp-content/uploads/cjrt-2019-025.pdf

Top 3 Reasons Why I enjoyed this Article

Firstly, this article is quick and easy to read.

Secondly, I had forgotten about the various Oscillatory Positive Expiratory Pressure (OPEP) devices on the market. This article was a nice introduction to various flows and pressures required to operate the units. The authors provide a recommendation for which units to be used by which population (small vs. larger patients) on page 10.

Thirdly, in the introduction the authors discuss the proper technique for using these devices (referencing Olsen et. al). You can find this description on pages 7 and 8.

Once again, you can view this article by visiting CJRT (which is owned by Canadian Society of Respiratory Therapists): https://www.cjrt.ca/wp-content/uploads/cjrt-2019-025.pdf

Happy Reading! Let me know what you think.

Farzad Refahi
http://respiratory.blog/lets-read-an-article-a-month-march-11-2020/
[End]

Thank you, Dan Pinard!

The other day I received a Pulmonary Function Testing question that I had not dealt with lately. I provided a short answer but did mention that I will connect with a trusted expert. Here is a quick shoutout to Dan Pinard from Novus Medical Inc. Thank you for the quick and comprehensive answer!

If you have read any of my annual Thank You posts, that I write during RT Week, Novus Medical Inc. is a recurrent name. Once again, they are supporting the PFT Symposium in Canada. This year, 2020, the symposium is on September 18th and 19th and takes place at Radisson Vancouver Airport Hotel.

From my understanding, more information will become available as soon as speakers have confirmed their invitations. For more information, you can visit https://www.cacpt.ca/conference/ . Also, to learn more about the great team at Novus Medical Inc. visit: https://www.novusmedical.ca/about-us .

I will let you know as I find out more about the event!

Farzad Refahi

Let’s read an article a month – March 06, 2020

Snapshot of the first page of the article.

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 Feb 27th, 2020. I spent a few days with it, and now I share it with you.

A spatially restricted fibrotic niche in pulmonary fibrosis is sustained
by M-CSF/M-CSFR signalling in monocyte-derived alveolar macrophages by Nikita Joshi et al.
 
 Eur Respir J 2020 55:1900646; published ahead of print 2019, doi: 10.1183/13993003.00646-2019 https://erj.ersjournals.com/content/erj/55/1/1900646.full.pdf

This article is well written and easy to follow. I must admit that it is too specialized and technical for my comfort level, but I still enjoyed it.

What this study demonstrates? Many elements were discussed but here is a very simple summary to get you interested:

“Our findings suggest that inhibition of M-CSFR (macrophage colony-stimulating factor receptor) signalling during fibrosis disrupts an essential fibrotic niche that includes monocyte-derived alveolar macrophages and fibroblasts during asbestos-induced fibrosis.” p1

Happy reading!

Farzad Refahi

Get Involved

There are various ways that you can get involved with your respiratory therapy organizations in Canada. Some take a minute to do, some five minutes, and some requiring a few hours a week on an ongoing basis. You can make a difference, and you should not take that lightly or for granted.

Fast and Easy Involvement

Takes a minute to find your respiratory therapy organizations on social media platforms. Follow them. It helps you stay up to date, and by sharing the relevant and important posts, you help with spreading the word, advocating and promoting the profession.

Takes a Few Minutes but You Will Help Shape Things On a Larger Scale

Our national organization, Canadian Society of Respiratory Therapists, is filling a few spots on the board of directors. Put aside 5 minutes to read the biographies and letters of intent. The voting process takes just a minute. Have your say, and help shape the future of our profession on the national level. Go to www.CSRT.com and vote! The deadline is tomorrow!

Have Some Time To Volunteer On An Ongoing Basis?

Have a desire to help and support your provincial organization? RTSO is recruiting for various position and roles. Visit www.RTSO.ca for more details. I have been volunteering with RTSO for more than 2 years, and have assisted with various projects. I have learned from many amazing volunteers over this time.

Together, We Are Stronger!

We can make a difference. Renew your national and provincial RT memberships!

Farzad Refahi

Cleaning Products

Exposure To Cleaning Products in Childhood

A few days ago I was listening to CBC radio, as I was driving to work, when I heard about a recent study that has shown an association between household cleanings products and increased risk of developing childhood asthma. I totally forgot about it until today when I noticed Mr. Noel Pendergast RRT sharing a link to the content on his Facebook page. My reaction when I first heard about this was: “Of course!”. We never actually think about it, but it sure makes sense.

A Known Concept?

It’s interesting that I can recall a childhood memory when during a family gathering, Dr. Nehzhat shared his concerns about bleach as a routine household cleaning solution. Side note, he is a chemist and one of the most wonderful people I have ever met. Back to the main point… “Please stop using bleach. Don’t breathe that in. Cannot imagine what that will do to your lungs”. Ongoing exposure to the fume, specially in a non vented area, could lead to respiratory changes for any individuals (regardless of the age).

Various Cleaning Chemicals

I worked as a lifeguard for few summers and even then I wondered how dealing with concentrated liquid chlorine may impact people’s breathing.

If I had to share my thoughts with my patients, I would recommend limiting exposure to harmful fumes and chemicals. Also, make sure that the area is well vented. I am not sure if I would be as comfort recommending masks as THE solution, as this false hope may lead to unnecessarily and higher and longer exposure periods. Side note- realistically, how many people are properly mask fitted and educated about the right mask for the right task?

Be Aware and …Clean

This is not to take away anything from proper hygiene, clean environment and limitation of irritants including known triggers.

Thoughts?

What are your thoughts on this?

Resoures

https://www.cmaj.ca/content/192/7/E164

A screenshot of the highlights from the article's abstract
For the full article please visit the following link:https://www.cmaj.ca/content/192/7/E164