Fall 2014 Adult Acute Care Bulletin

Fall 2014
Keith Lamb, RRT-ACCS
Adult Critical Care Supervisor
UnityPoint Health System
Des Moines, IA
Joe Hylton, RRT-NPS, CPFT
Brady Scott, MS, RRT-ACCS
Clinical Education Coordinator and Assistant Professor
Department of Respiratory Care
Rush University Medical Center
Chicago, IL
In this issue:

Notes from the Editors: A Call for Articles

Joe Hylton, BSRT, RRT-ACCS, RRT-NPS, NREMT-P, FAARC, FCCM, and J. Brady Scott, MSc, RRT-ACCS

Greetings all! We hope your summer was fun as well as productive, and that you are enjoying the cooler fall weather and all that goes with it—kids back in school, changing leaves, college and professional football, the World Series, and the anticipation of the late fall and winter holidays.

Speaking of change and festive times, your section leadership is looking for bright, knowledgeable folks to assist in writing articles for our section Bulletin. Our section has well over 1,000 members, so we know there are folks doing research and education every day in multiple areas of adult care. Professionalism, pharmacology, acute/critical care therapeutics—there are many topics that our members would love to read about.

Please feel free to contact either of us, or our section chair, Keith Lamb, about topics/ideas or how to submit an article. We would love to hear from you.



Notes from the Chair

Keith D. Lamb, RRT-ACCS

As Joe and Brady just noted in their column, fall is here, and that means AARC Congress 2014 is not far behind. This year’s meeting will take place Dec. 9-12 at the beautiful Mandalay Bay Resort and Convention Center in Las Vegas. The section has been busy preparing for the largest respiratory meeting in the world with abstract submissions, lecture proposals, and ramping up to participate full throttle.

As you can see when you read the rest of this Bulletin, some of us have been busy with other initiatives and travels as well.

Changes in reimbursement continue to drive many aspects of patient care, and our profession continues to move towards higher education and advanced practice. It is a great time to be a respiratory therapist. Enjoy reading the articles that follow, and feel good and proud to be part of our profession. I look forward to meeting many of you in Las Vegas this coming December. In the meantime, my virtual door is always open and I enjoy hearing your ideas and recommendations. Feel free to email me anytime, or give me a call at 302-983-6178.



Determining Tidal Volume: How Do We Do It?

Carl R. Hinkson, MS, RRT-ACCS, RRT-NPS, FAARC, Assistant Manager, Respiratory Care, Harborview Medical Center, Seattle, WA

The results of the ARDSnet trial published in 2000 forever changed the way patients with acute respiratory distress syndrome are ventilated. The current standard of care is to target a tidal volume of 6 mL/kg of predicted body weight and to target plateau pressures to be less than 30 cm H2O. But despite the demonstrated reduction in mortality from the ARDSnet trial, there remains a gap in the implementation of a low tidal volume strategy in these patients.

A retrospective trial by Chang et al. looked at the adoption of a low tidal volume strategy for patients with or at risk for ALI/ARDS, assessing the clinical use of lower tidal volumes in ARDS patients. They discovered that patients who were sicker, male, tall, and already had ARDS at the time of intubation were more likely to have a tidal volume of < 8 mL/kg of PBW. Conversely, patients who were shorter, female, and obese were more likely to be ventilated with tidal volumes that could be injurious.1

Recently, I had the pleasure of presenting this article during one of the Respiratory CareJournalCasts. During the webcast, I took a poll of the online attendees to get an idea of how many of them measured height as part of their practice in setting tidal volume. To my surprise, only 50% of the attendees (~ 400) indicated they measured height to determine appropriate tidal volume. This suggests that 200 of those attendees set tidal volumes using other criteria.

More recently, an article was published in Respiratory Care that compared different methods for determining tidal volume. Bojmehrani et al. found that of the four methods they investigated, visual assessment of height of a supine patient was associated with the most errors when compared to the patient’s reference height. They noted that out of 100 patients, 40 had a greater than 10% error in tidal volume when compared to the reference.2 Given the ease with which measuring the patient can be accomplished and the improved precision with which tidal volume can be determined by doing so, it would seem a relatively easy to adopt best practice.

According to the evidence, the best practice for determining tidal volume is based on a measurement of the patient in the bed, or measurement of the forearm or lower leg and height calculated.


  1. Bojmehrani A, Bergeron-Duchesne M, Bouchard C, Simard S, Bouchard PA, Vanderschuren A, L’Her E. Comparison of usual and alternative methods to measure height in mechanically ventilated patients: potential impact on protective ventilation. Respir Care 2014;59(7):1025-1033.
  2. Chang SY, Dabbagh O, Gajic O, Patrawalla A, Elie MC, Talmor DS, Malhotra A. Adesanya A, Anderson HL, Blum JM, Park PK, Gong MN. Contemporary ventilator management in patients with and at risk for ALI/ARDS. Respir Care 2013;58(4):578-588.



Section Members on Efforts to Promote the Art and Science of Respiratory Care in China

Keith D. Lamb, RRT-ACCS—

Shortly after returning from Prague in June of 2012, I found myself packing my bags again, this time for a seven-day trip to China. I was invited to speak at the 2012 Tongji University Ventilation Forum in August. The conference drew experts in mechanical ventilation from around the world who came together to share the latest evidence-based science on the care and treatment of patients requiring ventilatory support.

In addition to speaking at the conference I had the chance to tour the ICU at the hospital. I also boarded a bullet train to visit the historic city of Nanjing with several of the ICU staff. These opportunities were a great way to catch up on the latest progress being made by the profession in China, which first began training RTs back in the late 1990s. According to our Chinese colleagues, therapists are now working in a number of Chinese hospitals, and the country’s National Council is in the process of drafting a legal job description for RTs in China.

The introduction of RTs to China, along with a guideline for the treatment and diagnosis of acute respiratory distress syndrome (ARDS) that’s based on lung protective ventilation and other cutting-edge strategies, appears to be having a significant impact on patients. One of my hosts at the conference, and a 1998 AARC International Fellow, Xiangyu Zhang, MD, FCCP, FCCM, director of the ED and ICU at Shanghai Tenth People’s Hospital and professor at Tongji University School of Medicine, and his colleagues are currently in the middle of a research study that’s looking at how these factors may be affecting mortality for ARDS. A previous study showed an in-hospital mortality rate of 68.5% and 90-day mortality rate of 70.4% for people with the condition. Preliminary findings from the new study indicate a 60-day mortality rate of 33.3% for patients receiving care under the new paradigm.

J. Brady Scott, MSc, RRT-ACCS—

Over the summer, I also had the unique opportunity to travel to China with Daniel Rowley, MSc, RRT-ACCS, FAARC, to help support the growing field of respiratory care in that country. While there, we had the chance to participate in many different endeavors aimed at advancing the care of patients suffering from pulmonary compromise. Our visit lasted for three weeks, and I came back to the United States with an extraordinary feeling of optimism that our profession and the overall care of respiratory patients in China is continuing to advance.

We spent time in Hangzhou, Shanghai, and Beijing. There were different objectives in each location, but it was easy to notice they were all uniquely intertwined, as the common theme was the importance of advancing the profession of respiratory therapy. It was clear that many hospitals had embraced the art and science of respiratory care and the unique skill set RTs bring to the bedside. It was energizing to see many wonderful people working to provide quality care to patients struggling to breathe.

I look forward to seeing adult acute care respiratory care develop in China and in many other places around the world. We see that international respiratory therapists are stepping up to the plate to meet the needs of their patients. From a firsthand point-of-view, I can attest to the incredible efforts being made in places like China. It is a great time to be in our field, as we are growing rapidly here in the United States and around the globe.

Editor’s Note: If you’re attending the AARC Congress this December, be sure to go to the Awards Ceremony on the first day to see one Chinese member receive a very special honor from our section.



Section Connection

Recruit a New Member: Know an AARC member who could benefit from section membership? Direct them to online sign-up. It’s the easiest way to add section membership to their overall membership package.

Section Microsite: Visit our microsite to network with fellow section members via AARConnect.

Bulletin Deadlines: Winter Issue: December 1; Spring Issue: March 1; Summer Issue: June 1; Fall Issue: September 1.