Exciting Project

Over the past 2 years I have thought of writing a critical care mechanical ventilation handbook.  I know there are a few on the market, but I think I have something new to offer.  I have a different idea of what a mechanical ventilation handbook should look like.

Tonight I began writing an interactive mechanical ventilation textbook for the iPad/iPhone/iPod touch.  It will be available in the iBooks store once it is completed.  It will focus on the simplest explanation of mechanical ventilation combined with interactive images and videos.

I have laid out the chapters and what each will focus on, written a brief introduction, and I have an idea for the title.

My goal is to have completed this year.

I hope you'll like it, which means I hope you'll download it. :-).  

Design Tweaks

I made some design tweaks over at Respiratory Resource.  I also did away with the multiple discussion forums and replaced them with a general Practice Forum.  Hopefully this will encourage members and visitors to post!

Non-Invasive Ventilation and Community Acquired Pneumonia

When I graduated Respiratory Therapy in 2003 I remember having a preconceived notion that non-invasive positive pressure ventilation (NIPPV) should NOT be used with patients admitted with pneumonia. Whether it was something I was specifically taught or something that I learned during my clinical placement, it seemed to be consistent with other RTs I started working with as a staff RT.

It was many years later I learned that a study published the year I graduated (2003) by Ferrer et al. showed that the use of NIPPV in patients with acute hypoxic respiratory failure (COPD patients excluded) prevented intubation, reduced the incidence of septic-shock, and improved survival when compared with high-concentration oxygen therapy. However, there was another study by Confalonieri et al. that did not show any benefit (or harm) to using NIPPV with patients without COPD.

So why did there still appear to be such a hard stance against using NIPPV with pneumonia patients?

There is this strong belief that NIPPV will effect the ability to cough and clear secretions, and this may true with a mask strapped tightly to their face (makes sense), but conversely so does being intubated. Intubation requires heavy sedation and can be much less comfortable for a patient than a properly fit mask.

Perhaps the fear of NIPPV with pneumonia patients stems from a bad experience with someone who had pneumonia that escalated to primary ARDS with bilateral infiltrates and severe hypoxemia. Although there are no RCTs specifically designed to determine the effectiveness of NIPPV with ARDS patients, in this study by Ferrer et al. the multivariate analysis of the risk factors for intubation showed an odds ratio of 28.5 (p = 0.003). If you patient has developed ARDS the likelihood of them needing intubation is very high.

In summary, if you are called to see a pneumonia patient with SpO2 <90% on an FiO2 of 0.50 (the inclusion criteria for this study) there may be a benefit to using NIPPV. There is not strong enough evidence to support its exclusive use in these patients (because of conflicting results of other studies). However, it appears that the use of NIPPV does not cause harm. There is also an increased use of high-flow nasal canula with patients, further study is needed to determine it's true benefit with these patients other than comfort.

Keep in mind that a failure to improve within 1 hour of NIPPV (resp rate, pH, PaO2, PaCO2, etc.) is a strong predictor of failure.

Side note: There was no mention in this study as to whether humidification was used with the NIPPV patients, or the control group.

References:
Ferrer M, Esquinas A, Leon M, Gonzalez G, Alarcon A, Torres A. Noninvasive ventilation in severe acute hypoxemic respiratory fail- ure: a randomized clinical trial. Am J Respir Crit Care Med 2003; 168(12):1438-1444.

Confalonieri M, Potena A, Carbone G, Porta RD, Tolley EA, Meduri GU. Acute respiratory failure in patients with severe community- acquired pneumonia. A prospective randomized evaluation of non- invasive ventilation. Am J Respir Crit Care Med 1999;160(5 Pt 1):1585-1591.

Ready, Set, Go!

I've contemplated a professional profile site for a while now and I've finally made it happen.  The two things I do that fall under my definition of "professional" are Respiratory Therapy and Website Development.  I thought I would combine my two professional passions into one site.

Many of my blog posts will be related to Respiratory Therapy (most likely critical care), but I may have a post now and then related to some website development I might be up to.  

My current web development projects include the CSRT Respiratory Resource, my uncle's Private Sale company, and probably the most skill involving project is design implementation for the Canadian musician Matthew Good (links to all of these sites can be found on the web developer page).

I started turning Matt's web designs into reality approximately 10 months ago and now consider him a friend rather than a client.

A New Year, A New Initiative

I decided to start a personal website this year, but not for the purpose of showcasing personal things (i.e. family, friends, or things I find funny...I have a website for that already).  This website instead will serve as a personal professional website where I can write about things, exciting or not, that are occuring in my professional life.  Much like LinkedIn, but one that I control the design, layout, and content much easier.  

This site can also serve as a means to increase consultation oportunities and perhaps even website development oppourtunities.

Currently this site is under construction, so if you found it good for you, keep checking back for updates!