Autumn 2006, Volume 42 (4)

Features ■ President’s Message 8

■ Board of Directors Nominations 11

■ Air/Oxygen Misconnections 15

■ Critical Care ABC’s 18

■ Smoking Women and Bladder Cancer 21

On Air ■ Assiniboine 5

■ Nuggets 7

Forum 2007 12

Up in the Air — Hiking the Assiniboine

The journal for respiratory health professionals in

La revue des professionnels de la santé respiratoire au Canada

PUBLICATIONS MAIL AGREEMENT NO. 40012961 REGISTRATION NO. 09846 RETURN UNDELIVERABLE CANADIAN ADDRESSES TO CSRT 102 – 1785 Alta Vista Drive Ottawa ON K1G 3Y6 [email protected] Table of contents table des matières

Canadian Journal of Table of Contents Respiratory Therapy On Air ...... 5 Revue canadienne de la Assiniboine thérapie respiratoire Nuggets

Official Journal of the CSRT President’s Message ...... 8 Revue officielle de la SCTR

CSRT Board Representative / Représentant du Conseil RT Week ...... 10 d’administration de la SCTR Patty Wickson, RRT

Managing Editor / Directrice de la rédaction Board of Directors Nominations ...... 11 Rita Hansen

Chair Editorial Committee Amy Reid, RRT Forum 2007 ...... 12 President CSRT / Présidente, SCTR Robert Leathey, B.Ed., RRT Scientific News ...... 14 Abstracts Air/Oxygen Misconnections Critical Care ABC’s The Canadian Journal of Respiratory Therapy (CJRT) (ISSN 1205-9838) is produced for RRT: The Canadian Smoking Women and Bladder Cancer Journal of Respiratory Therapy, Inc., by the Graphic Communications Department, Canadian Pharmacists Association and printed in Canada by Gilmore Printing. Industry News ...... 23 Publications mail registration no. 40012961. CJRT is pub- lished 5 times a year (in February, May, July, October and Disposable Sleep Apnea Screener December); one of these issues is a supplement pub- lished for the Annual Educational Forum of the Canadian Society of Respiratory Therapists (CSRT). The CJRT acknowledges the financial support of the Government of Canada, through the Publications Assistance Program (PAP), toward our mailing costs. La Revue canadienne de la thérapie respiratoire (RCTR) (ISSN 1205-9838) est produite pour le compte de RRT : The Canadian Journal of Respiratory Therapy, Inc., par Cover Photo Communications graphiques de l’Association des phar- Thrasher’s Weekend maciens du Canada et imprimée au Canada par Harmony J.J. Hodgson rock climbing for her first time at Wasootch Printing. Courrier de publications no 09846. La RCTR paraît cinq fois l’an (en février, mai, juillet, octobre et Slabs, Kananaskis, Alberta during the Alpine Club of décembre); un de ces numéros constitue un supplément Canada, Saskatchewan Section’s Annual Thrashers publié pour le compte du Forum éducatif annuel de la Société canadienne des thérapeutes respiratoires (SCTR). Weekend. Photo: Emily Wallace (May 2006) CSRT membership inquiries / Questions concernant l’adhésion à la SCTR :

102 – 1785 Alta Vista Dr., Advertiser’s Index Ottawa, Ontario, K1G 3Y6 1-800-267-3422 Reactine ...... IFC, PI 22 Symbicort ...... 24, PI 25, 26 [email protected] CSRT ...... IBC www.csrt.com GE ...... OBC

Autumn 2006 Canadian Journal of Respiratory Therapy — www.csrt.com 3 CJRT welcome

About This Issue

Welcome again to another Design and production / Conception et issue of the Canadian Journal production of Respiratory Therapy. Once Canadian Pharmacists Association / Association des again we have contributions pharmaciens du Canada from a number of respiratory therapists highlighting research, Marketing and Advertising Sales / Marketing et publicité activities, and even some per- Keith Health Care Inc. sonal accomplishments. Mississauga 905 278-6700, fax 905 278-4850 Montréal 877 761-0447, fax 514 624-6707 In this issue we have some Classified Advertising / Annonces classées preliminary information on CSRT the CSRT 2007 Annual Forum 102 – 1785 prom. Alta Vista Dr. and Tradeshow, which will Doug Maynard Ottawa ON K1G 3Y6 be held in Montreal, Quebec 800 267-3422 or fax 613-521-4314 from May 31 – June 3, 2007. The program is already shaping up Subscriptions / Abonnements and will definitely provide an outstanding opportunity to Annual subscriptions are included in annual membership to the enhance your knowledge of your profession. CSRT. Subscription rate for 2006 for other individuals and insti- tutions within Canada is $46. International orders are $50 Cdn. All Canadian orders are subject to 7% GST / 15% HST as appli- We also have a number of announcements for deadlines that cable. Requests for subscriptions and changes of address: are fast approaching. Deadlines for submitting nominations for Member Service Centre, CSRT, 102 - 1785 Alta Vista Dr., Ottawa ON K1G 3Y6. the Summit Technologies Award for Excellence in Respiratory Therapy, the Medigas Award, and for the CSRT's Robert Merry L’abonnement annuel est compris dans la cotisation des mem- bres de la SCTR. Le tarif annuel d’abonnement pour les non- Professional Achievement Award, are fast approaching. This is membres et les établissements au Canada est de 46 $. Les com- an excellent way to recognize one of your colleagues for their mandes internationales sont 50 $ Canadien. La TPS de 7% ou la TVH de 15% est ajoutée aux commandes canadiennes. Veuillez extraordinary contributions to our profession. faire parvenir les demandes d’abonnement et les changements d’adresse à l’adresse suivante: Centre des services aux membres, This issue of the Journal is also the last issue before RT Week SCTR, 102 - 1785 prom. Alta Vista, Ottawa ON K1G 3Y6. (October 22 – 28). There are lots things that you can do to pro- Once published, an article becomes the permanent property of RRT: The Canadian Journal of Respiratory Therapy, Inc., and mote our profession, both during that week, and throughout may not be published elsewhere, in whole or in part, without the year. If you are at all interested in stepping up, and being written permission from the Canadian Society of Respiratory a voice for your profession, be sure to read this issue, and con- Therapists, 102 - 1785 Alta Vista Dr., Ottawa ON K1G 3Y6. / Dès qu’un article est publié, il devient propriété permanente de RRT: tact the CSRT Head Office (1-800-267-3422) for ideas and other The Canadian Journal of Respiratory Therapy, Inc., et ne peut support that we may be able to provide. être publié ailleurs, en totalité ou en partie, sans la permission de la Société canadienne des thérapeutes respiratoires, 102 - 1785 prom. Alta Vista, Ottawa ON K1G 3Y6. I also must say welcome to all of the new RT students that have All editorial matter in CJRT represents the opinions of the just started their programs, and welcome back to all of the authors and not necessarily those of RRT: The Canadian returning students. We hope you have a productive start to the Journal of Respiratory Therapy, Inc., the editors or the publisher of the journal, or the CSRT. / Tous les articles à caractère édito- year! rial dans le RCTR représentent les opinions de leurs auteurs et n’engagent ni le RRT: The Canadian Journal of Respiratory Therapy, Inc., ni les rédacteurs ou l’éditeur de la revue, ni la SCTR. Sincerely, RRT : The Canadian Journal of Respiratory Therapy Inc. Doug Maynard, BSc, RRT, MBA assumes no responsibility or liability for damages arising from Executive Director, CSRT any error or omission of from the use of any information or [email protected] advice contained in the CJRT including editorials, articles, reports, book and video reviews letters and advertisements. / RRT : The Canadian Journal of Respiratory Therapy, Inc. décline toute responsabilité civile ou autre quant à toute erreur ou omission, ou à l’usage de tout conseil ou information figu- rant dans le RCTR et les éditoriaux, articles, rapports, recensions de livres et de vidéos, lettres et publicités y paraissant. All prescription drug advertisements have been cleared by the Pharmaceutical Advertising Advisory Board. / Toutes les annonces de médicaments prescrits ont été approuvées par le Conseil consultatif de publicité pharmaceutique.

4 Autômne 2006 Revue canadienne de la thérapie respiratoire — www.csrt.com On Air Hiking the Assiniboine Jeff Dmytrowich, RRT

Porcupine Trail In the midday heat and at an elevation of over 6500 feet, Jeff Dmytrowich, J.J. Hodgson and Pam Niska (far to near) take a short break on the steep trails in Provincial Park, . Photo: Chad Popik (July 2006)

It had been over six hours since we started this adventure. were having. I was hoping everyone wasn’t going to turn “How much farther to Og Lake?” had been a common on me, as I had planned this whole trip. It wasn’t going question for the past couple of hours. I was reassuring too smoothly so far. everyone that it should be no more than an hour (couple kilometers) until camp. We should be there shortly. We For the past few summers, my girlfriend J.J. and I have were all exhausted from the heat and the weight of our gone from the flat lands of Saskatchewan to spend a packs. The less than forgiving trail sure didn’t help the week backpacking in the backcountry of the group morale. But there was a glimmer of hope ahead — Mountains. We find these adventures are a great way to in the distance we saw a trail marker sign. With anticipa- get outside, enjoy nature, and leave the world behind for tion we hurried to see how close Og Lake really was. Our a little bit. All the stresses get left at the trailhead and so hope quickly turned to despair. We still had almost six do all modern annoyances. No cell phones, no pagers, no kilometers to go. It wasn’t said out loud, but we were all television, no radio and no way for work to get in contact wondering how we are going to make it another five with me with the usual question of, “Can you work days together if they were to be anything like the day we [insert date and time]”.

Autumn 2006 Canadian Journal of Respiratory Therapy — www.csrt.com 5 On Air

Hiking the Assiniboine

the elevation of 504 m/1654 ft which I am used to. I always find during hikes at such an elevation that the RRT in me always has to wonder, “If I’m at an elevation 9013 feet and a barometric pressure of 540 mm Hg

then my PAO2 would be around ...”, “I wonder what high altitude pul- monary edema feels like, I’m techni- cally at a high enough elevation ...” and “hmm, my resting resp rate sure is up a bit...”. Thankfully though, the amazing scenery and peacefulness of the backcountry quickly chases these thoughts from my mind.

The hike out always seems easier then the hike in. Probably because Sunburst Cabin Jeff Dmytrowich, J.J. Hodgson, Pam Niska and Chad Popik (left to right) our backpacks are a lot lighter, since take a relaxing break from hiking in front of an old mountain hut near Sunburst Lake in we are carrying less food. Not to Mount Assiniboine Provinical Park, British Columbia. mention we are more conditioned by Photo: Chad Popik (July 2006) this time too. The hike out always brings up mixed feelings; we always look forward to being rid of the blis- This year we headed to Mount Assiniboine Provincial Park ters and being able to eat food that hasn’t been dehy- in British Columbia with another couple from Calgary. I drated and rehydrated. We quickly begin to miss the tran- planned for us to spend six days in the backcountry, car- quility and beauty of the mountains along with cama- rying all the food and gear we would need. We would raderie of the other hikers that we meet from around the hike into Mount Assiniboine Provincial Park from globe. For that time we spend in the backcountry we Sunshine Village in and camp the first leave the world behind and just live with nature with all night at Og Lake, 23 km from Sunshine Village. I knew our worries left at home. No matter how bad the blisters, the first day was going to be challenge but I didn’t expect the weather or the food, once you leave the trail — it is it to take such a toll on us. Luckily, day two involved only only the good you remember. a short 6.5 km hike through open meadows to Lake Magog at the base of Mount Assiniboine where we Now back to reality and the everyday routines that life would camp for the next few days. The short day com- demands. It won’t be long before I start planning my next bined with the beautiful scenery and wildlife made it easy adventure and escape. Hmm, I hear that the 150 km hike for everyone to forget the first tough day. around Mount Rainer is nice, or maybe canoeing Yellowstone’s Shoshone Geyser Basin .... We spent several days at Lake Magog with Mount Assiniboine, the ‘Matterhorn of the Rockies’, towering Jeff Dmytrowich, RRT, has been with the Royal University above us. Lake Magog became our base camp from Hospital in Saskatoon since 1998. He works in all aspects which we embarked on a number of day trips. Our day of critical care medicine and is involved in Royal University trips included a trip up to Windy Ridge (elevation 2650 Hospital’s Quality & Safety Team which is a part of the m/8700 ft) which divides Alberta and British Columbia Canadian ICU Collaborative. He was a recipient for the and stands above North America’s largest non- Saskatoon Health Region’s 2006 Bravo Award for volcanic landslide. The silide contains approximately 1.1 Performance Excellence. cubic kilometers of debris.

The highest point we reached was on our trip to Nub Peak where we scrambled to an elevation of 2750 m/9013 ft above sea level. That is a lot higher than

6 Autômne 2006 Revue canadienne de la thérapie respiratoire — www.csrt.com On Air

On Air Nuggets

CSRT Awards Do you know someone who deserves Brent Kitchen special recognition? Former CSRT President, Brent Kitchen has been The CSRT is pleased to provide a series of awards in conjunction appointed as Director, with some of our Corporate Members. Awards include financial Risk Management and grants or travel costs as well as recognition within the RRT Privacy Officer at Regina community. Qu’Appelle Health Region. As the Manager of Respiratory Services and as a Registered Respiratory Therapist, Brent demonstrated Summit Technologies invites you to nominate an individual for leadership and commitment to providing the Summit Technologies Award in Respiratory Excellence. excellence in patient care. He has played a key This award focuses on the areas of respiratory care involving role at the national level and within RQHR, direct patient care, education or research. The deadline for resulting in many accomplishments and the applications is December 15, 2006. development of the Respiratory Therapy program. His experience and passion for quality patient care will support the region’s long-standing commitment to providing safe, quality care. Medigas, a Praxair company is accepting applications for the Medigas Award for Excellence for recognition of Congratulations Brent! a group of RRT’s from any facet of the profession who further the profession of respiratory therapy through their activities in their community. Continuing Education The Award recognizes the active practice of respiratory thera- Want to participate in Continuing Education pists. Nominations may come from the public, other RRT’s who Activities for career development and work with the nominees, or members of the health care team. specialization of your profession? The CSRT offers a variety of ways for you to achieve your professional development goals. Please check out our Upcoming Events Section and Canadian Society of Respiratory Therapists the “Education” section of our web site for Société canadienne des thérapeutes respiratoires on-line courses, conferences and workshops.

The Robert Merry Professional Achievement Award honours a respiratory therapist from any area of the field, who has exhibited vision, leadership and innovation to further develop CSRT National Exam respiratory care in Canada. Out of pocket expenses, accommo- dations and airfare will be paid to the award recipient to aid January 2007 in ensuring his/her presence at the award presentation at The next sitting of the CSRT National the annual educational forum. Deadline for nominations is Examination is January 8, 2007. The Deadline January 31, 2007 for application for this exam is November 15, 2006. Details for writing this exam are avail- Please check the Foundations section of the CSRT website for able on the CBRC website eligibility details on all these awards. (http://www.cbrc.ca/)

Autumn 2006 Canadian Journal of Respiratory Therapy — www.csrt.com 7 President’s message mot du président

Message from the President

A little over a year and a half ago, the CSRT developed a new Mission Statement which became the guideline for our Strategic Plan. As you have no doubt by now seen, the words “advocacy, service and unity” appear on many of our documents and publications. Rob Leathley

For some, these may appear to be just membership surveys, is the exam therapy. The CSRT not only provides words thrown around to make people process. Since the Occupational Profile information to the public and publishes feel good, without really having any has now been replaced by the NCP, an many documents which speak to the meaningful purpose. For others these update to the examination process is importance of standards in order to pro- words are the foci for our actions. If needed. Up until now we have had two tect the public; the CSRT also speaks on what we do is not directed towards one, evaluation systems; one for Quebec and behalf of its members to government or more, of these areas, we are getting one for the rest of the country. agencies as well as many international off track and in danger of loosing our- Currently the Alliance, with the CSRT’s organizations. selves. As President it is my task to participation, is working towards a ensure that we keep to our course so common evaluation process. A submis- Very shortly we will be celebrating that we will be able to accomplish all of sion has been made to Human Respiratory Therapy Week in Canada. what you, the membership, have direct- Resources and Skills Development The CSRT can provide a number of ed us to do. The Strategic Plan set out a Canada to assist in funding the devel- promotional items for you to use in number of goals, guiding policies and opment of this assessment tool. In time your local events. We will also be work- principles for us to accomplish by 2008. this will lead to the standardization of ing hard to spread the word across the I'd like to bring you up to date on how the regulatory process that will permit country about what an RT is and how we are doing on some of these. entry-level therapists to freely move they are an essential part of our health- across provincial boundaries. This will care system. As the National Alliance of Respiratory be the main topic of discussion at a fall Therapy Regulator Bodies — the meeting of the Alliance members in Advocacy. Service. Unity. These three Alliance — was formed, the CSRT Calgary. In addition, this process should words carry a big responsibility. Your began its move away from that as a be able to be developed into an evalu- CSRT has been working hard to keep to quasi-regulator. The CSRT in now in a ation system for foreign trained individ- this vision. We have participated with more appropriate position as an advo- uals to be assessed for their suitability to the members of the Alliance in the cate for the profession of respiratory the Canadian healthcare system. development of common tools to which therapy in this country and a voice for the profession can be unified. We con- those members not represented by a In order to get to this point the CSRT tinue to strive towards one country, one regulatory body. To date we have has spent a considerable amount of profession. The CSRT doesn't just offer worked closely with the Alliance to cre- time communicating with the schools a selection of promotional items for its ate a more unified view of what respi- through CoARTE and the Educator’s members, it also provides liability, auto ratory therapy is in Canada. Congress which has preceded each of and home insurance at competitive the last two National Education Forums rates through its brokers. Educationally The CSRT Occupational Profile, long in Edmonton and Saint John. We have the CSRT accredits the schools across the foundation for the curriculum taught recently begun to develop a new com- Canada and promotes their increased in most of the schools, was redeveloped munication tool to connect the schools communication and collaboration. into the National Competency Profile across Canada in order to share infor- (NCP). This document, agreed to by the mation and foster more collaboration Finally, the CSRT advocates on your members of the Alliance, replaced the on projects of national interest. The first behalf to ensure that your interests as a different occupational profiles which teleconference will have taken place by respiratory therapist are being met and contributed to the creation of barriers to the time that you read this issue of the that your voice is heard by the regula- mobility for therapists across provincial Journal. tors and the government alike. Take the boundaries. As of this September, the time to help us. Let us know how we Alliance and the CSRT’s Council on As your professional advocate, we not are doing and how we can be of assis- Accreditation for Respiratory Therapy only speak on behalf of the many ther- tance to you in your practice. Call, Education (CoARTE) will begin requir- apists who live and work in the non- write, email or fax us with your com- ing the schools to implement the profile regulated provinces, but we also speak ments and suggestions. for entry-level education. The NCP pro- on behalf of our members regardless of file can be found on the CSRT website where they live and work in Canada. under RRT Credential. Where the regulatory bodies are entrusted with the job of protecting the Rob Leathley, B.Ed., RRT Certainly one of the most important public, they often have very little to CSRT President aspects of the CSRT, according to our promote the profession of respiratory

8 Autômne 2006 Revue canadienne de la thérapie respiratoire — www.csrt.com President’s message mot du président

Mot du président

Au cours du forum qui s'est tenu à SCTR sous la rubrique RRT Credential. travaillent au Canada. Bien que les Il y a un peu plus d'un an et demie, la SCTR a rédigé un nouvel organismes de réglementation aient la responsabilité de protéger le public, ils Énoncé de mission, lequel a guidé l’élaboration de notre Plan ne disposent que de très peu de ressources visant à promouvoir la profes- stratégique. Comme vous avez pu le constater, les mots sion de la thérapie respiratoire. La SCTR « défense des intérêts, service et unité » paraissent maintenant fournit des renseignements au public, elle publie une gamme de documents qui sur plusieurs de nos documents et publications. soulignent l’importance des normes visant à protéger le public, et elle Pour certains, il peut sembler qu’il ne De loin l’un des aspects les plus impor- représente ses membres auprès d’a- s’agit que de mots résolument optimistes, tants de la SCTR, selon les sondages gences gouvernementales et de nom- sans but précis. Pour d’autres, ces mots effectués auprès de nos membres, est le breux organismes internationaux. constituent le point de mire de nos processus d’examen. Étant donné que le actions. Si nos initiatives ne sont pas Profil de la profession a été remplacé par Nous célébrerons bientôt la Semaine de dirigées vers l’un ou l’autre de ces le PNC, une mise à jour du processus la thérapie respiratoire au Canada. La thèmes, nous risquons de faire fausse d’examen s’impose. Jusqu’ici, nous avons SCTR peut vous fournir des items pro- route et de nous perdre. À titre de prési- eu deux systèmes d’évaluation : un pour motionnels à distribuer lors de vos activ- dent, j’ai la tâche de m’assurer que nous le Québec et l’autre pour le reste du ités locales. Nous entendons également restons sur la bonne voie afin d’être en Canada. L’Alliance travaille présente- travailler fort à la diffusion, d’un bout à mesure d’accomplir tout ce que vous, les ment, avec la participation de la SCTR, l’autre du pays, du rôle des TR et de leur membres, nous avez demandé de faire. vers un processus d’évaluation commun. importance au sein de notre système de Le Plan stratégique renferme un certain Une demande de financement a été soins de santé. nombre de buts, de politiques et de adressée à Développement des principes directeurs à viser d’ici 2008, et ressources humaines Canada, en vue Défense des intérêts. Service. Unité. Voilà j’aimerais vous informer des progrès que d’élaborer cet outil d’évaluation. Avec le trois mots qui entraînent une grande nous avons réalisés. temps, le processus de réglementation responsabilité. Votre SCTR s’est efforcée sera uniformisé, de sorte que les de s’en tenir à cette vision. Avec les Suite à la création de l’Alliance nationale thérapeutes débutants pourront franchir membres de l’Alliance, nous avons par- des organismes de réglementation en les frontières provinciales librement. Il ticipé à l’élaboration d’outils communs thérapie respiratoire — l’Alliance — la s’agit là du principal sujet de discussion autour desquels la profession peut être SCTR a commencé à se distancer du rôle prévu lors de la réunion d’automne, à unifiée. L’objectif visé? Un pays, une pro- de quasi-organisme de réglementation. Calgary, des membres de l’Alliance. De fession. La SCTR offre à ses membres La SCTR est maintenant mieux position- plus, ce processus devrait pouvoir être plus qu’une gamme d’items promotion- née pour défendre les intérêts de la pro- adapté aux besoins des thérapeutes nels : elle fournit, par l’entremise de ses fession de la thérapie respiratoire au diplômés à l’étranger, aux fins d’évalua- courtiers, une assurance responsabilité, Canada et servir de porte-parole pour les tion de leur aptitude à pratiquer au sein auto et maison à des taux avantageux. membres qui ne sont pas représentés par du système de soins de santé canadien. Sur le plan éducatif, la SCTR est chargée un organisme de réglementation. Jusqu’à d’agréer les écoles partout au pays et de maintenant, nous avons travaillé de près Ces progrès sont le fruit du temps con- promouvoir l’accroissement de la com- avec l’Alliance afin de créer une vision sidérable qu’a consacré la SCTR à la com- munication et de la collaboration entre davantage unifiée de ce qu’est la thérapie munication avec les écoles par l’entrem- elles. respiratoire au Canada. ise du CAFTR et lors du Congrès des enseignants, qui a précédé les deux Enfin, la SCTR revendique en votre nom Le Profil de la profession de la SCTR qui derniers Forums nationaux d’éducation à dans le but d’assurer que vos intérêts à a longtemps constitué la base du curricu- Edmonton et à Saint Jean. Récemment, titre de thérapeutes respiratoires sont lum enseigné dans la majorité des écoles nous avons commencé à élaborer un défendus et que votre voix est entendue a été retravaillé pour devenir le Profil nouvel outil de communication visant à par les organismes de réglementation et national des compétences (PNC). Ce créer des liens entre les écoles partout au par les gouvernements. Prenez le temps document, accepté par tous les membres pays pour faciliter l’échange de ren- de nous aider : dites-nous si nous de l’Alliance, a remplacé les divers profils seignements et la collaboration aux pro- sommes sur la bonne voie et comment de fonctions qui créaient des obstacles à jets d’intérêt national. La première télé- nous pouvons vous aider dans votre pra- la mobilité des thérapeutes au-delà des conférence aura déjà eu lieu au moment tique. Faites-nous part de vos commen- frontières provinciales. À compter de où vous lisez ce numéro de la Revue. taires et suggestions par téléphone, par la septembre 2006, l’Alliance et le Conseil poste, par courriel ou par télécopieur. pour l’agrément de la formation en En qualité de défenseur de vos intérêts thérapie respiratoire (CAFTR) de la SCTR professionnels, nous représentons les commenceront à exiger que les écoles nombreux thérapeutes qui habitent et mettent le profil en œuvre pour l’éduca- qui travaillent dans les provinces non- Rob Leathley, B.Ed., TRA tion des nouveaux étudiants. Le PNC est réglementées ainsi que nos membres, Président de la SCTR disponible dans le site Internet de la peu importent où ils habitent et où ils

Autumn 2006 Canadian Journal of Respiratory Therapy — www.csrt.com 9 CoARTE report

CoARTE Announcement Michelle Kowlessar, Accreditation and Education Manager

Professional Development Activities at the CSRT The CSRT is currently developing Teleconference workshops for its continuing professional development activities. We are looking at developing teleconferences on Acute Respiratory Distress Syndrome, New Asthma Guidelines and/or Chronic Obstructive Pulmonary Disease.

If you are an expert in one of these fields or know someone that has expertise in one of the above areas and would be interested in participating, please contact Michelle Kowlessar, Accreditation and Education Manager, by e-mail at [email protected] or by phone 1-800-267-3422 ext. 26.

October 22 to 28, 2006 is Respiratory Therapy Week

What are you doing to celebrate our profession?

Over the past four decades, respiratory therapy has evolved to become a vital component of healthcare delivery in Canada. From teaching patients how to prevent and manage COPD symptoms to providing first response to patients in critical decline — res- piratory therapists are essential to today's health- care team.

To ensure our ability to realize our full profession- al potential, it is necessary that our place within the healthcare team be recognized.

The respiratory therapists’ role within healthcare delivery must be acknowledged by the general public, healthcare providers, healthcare administra- tors and government policy makers. The CSRT will award the volunteers that run the The CSRT would like to extend support to most creative, exposure-generating display with members organizing RT Week initiatives aimed at the new CSRT #1 RT WEEK DISPLAY prize. raising awareness about the profession. Promotional materials such as brochures and pens Complete contest details are available on the CSRT can be obtained by contacting the CSRT Head website. Click the RT WEEK DISPLAY CONTEST Office at (800) 267-3422. link on the website’s homepage.

Would you like to participate in RT Week First prize is free registration to Rendez-vous awareness-raising activities but do not have Montréal, CSRT Forum 2007, May 31 to June 3, 2007. anything planned? Keep in mind — opportunities to raise awareness The CSRT is looking for volunteers to man display about our profession arise every day. It is impor- tables in various locations. To find out more, con- tant to take the time to let people know what you tact Danièle Filion, Public Relations and Marketing do and how crucial our profession is to the health Coordinator, at [email protected] or (800) 267-3422, of Canadians. ext. 29.

10 Autômne 2006 Revue canadienne de la thérapie respiratoire — www.csrt.com CSRT news

2006 CSRT Leadership Survey

leadership position. Should you be a Over the course of the summer, the CSRT has promoted respiratory therapist in a leadership position and have not yet heard and disseminated the 2006 CSRT Leadership Survey about the survey please take a with the aim of establishing a database of contact minute to complete the 2006 CSRT Leadership Survey. A link to the information for Canadian respiratory therapists holding electronic version of the survey can a leadership position. be accessed via the CSRT Web Site at www.csrt.com. Simply click on the CSRT Leadership Survey link on the website’s homepage. To Your Society is proud to report that ■ Put out calls for information (to obtain a paper copy of the survey, response has been overwhelming! address various issues, to conduct contact the CSRT Head Office at The CSRT extends a heartfelt thank research, etc.) (800) 267-3422 or [email protected]. you to all who have submitted their ■ Put out calls for participation (for contact information. advocacy campaigns, for aware- ness campaigns, etc.) The success of this initiative will allow your Society to contact respi- The CSRT has made tremendous ratory therapists in a leadership posi- efforts to disseminate the Leadership tion in order to: Survey to as many sites as possible, ■ Disseminate respiratory therapy- it is impossible for the Society related information to reach every Canadian RT in a

CSRT Call for Nominations for Board Positions

Make A Difference! The CSRT invites its members to become pro-active in their profession. Nominations are now open for volunteer positions on the CSRT Board of Directors.

President-Elect Each nominee must be a Registered (to become President and Past-President) Member of the Society. Individuals may be nominated by forwarding the nomina- 2007 – 2008 (three-year appointment) tion papers, duly signed by five (5) Registered Members in good standing, to Director of National/Provincial Relations the Executive Director of the Society. 2007 – 2008 (two-year appointment) Completed forms should be sent to: Douglas Maynard Check our website under About/Board of Directors Executive Director CSRT 102-1785 Alta Vista Drive for job descriptions and nomination forms. Forms Ottawa ON K1G 3Y6 can also be obtained through the CSRT Head Office Fax: (613) 521-4314 800-267-3422. Deadline for nominations is Dec. 1, 2006.

Autumn 2006 Canadian Journal of Respiratory Therapy — www.csrt.com 11 Forum 2007

CSRT Educational Forum Montréal 2007

KEYNOTE SPEAKERS ■ Len Geiger Double lung transplant

■ Dr. Samantha Nutt War Child Canada

■ Dr. Serge Marquis Work, Meaning and Pleasure

■ Dr. Stavros Prineas Communication & Teamwork in the OR

■ Justin Trudeau Environment and Empowerment

CSRT Forum 2007 Call for Abstracts

Photo creditMontreal Skyline/C. Parent ; P. Hurteau The 2007 CSRT Annual © MINISTÈRE DU TOURISME DU QUÉBEC www.bonjourquebec.com Educational Forum will be held in Montreal, A Word from the National Forum Chair — Darcy Andres Quebec. We expect over 800 delegates at this The 2007 CSRT Annual Forum and Trade Show is fast approaching. Planning for this event and invite interest- year’s conference started many months ago and a significant amount of progress has ed parties to showcase been made. Some of the highlights of the 2007 conference include: their latest abstracts or poster presentations to ■ Keynote speaker presentations will be available in French and English through the Planning Committee simultaneous translation for consideration. ■ Education sessions presented in French and English ■ Confirmed speakers include: Justin Trudeau, Dr. Stavros Prineas, a healthcare safety Abstracts may pertain to expert, Dr. Samantha Nutt from War Child Canada and Len Geiger, a double lung any are of respiratory transplant survivor therapy including clinical ■ Annual President’s Banquet and Awards practice, evaluation and ■ Complimentary Fun Night at the Mondiale de la Bière, the annual Montreal beer respiratory healthcare festival delivery. Abstracts of no more than 250 words Check out the CSRT website for further information and updates. must be submitted according to guidelines On behalf of the CSRT Board of Director’s and myself, I would like to thank the organ- (found on the CSRT izing committee for all the hard work each of them has done and continues to do. website under About/ Annual Meetings). All Members of the 2007 Organizing Committee include: submissions will be Dallas Schroeder — Education Symposium Chair reviewed by a panel Maggie Quirion — Social Events Coordinator using a blind peer Jeff Dmytrowich — Speakers review mechanism. Josée Prud’homme — OPIQ Liaison Line Prévost — OPIQ Representative (French Language Program) The deadline for submis- sions is March 16, 2007. Special thanks to Rita Hansen from the CSRT Head Office. Rita is the driving force Detailed information can behind this event and works tirelessly to ensure a successful forum! be found on the CSRT The 2007 Forum promises to be the largest national forum ever — we expect 800 del- website under About/ egates and 80 exhibitor booths. Mark May 31 – June 3, 2007 on your calendar and Annual Meetings plan to attend this exiting event! Looking forward to seeing you in Montreal!

12 Autômne 2006 Revue canadienne de la thérapie respiratoire — www.csrt.com Forum 2007

■ Full Registration — Members 2007–2008 *Pre-registration 295.00 ❒ After April 27, 2007 365.00 ❒ ■ Full Registration — Non-members *Pre-registration 350.00 ❒ After April 27, 2007 420.00 ❒ The CSRT is pleased to host its 43rd Annual Educational ■ Forum and Trade Show in Montreal at the Hilton Full Registration — CSRT Student Members Montréal Bonaventure Hotel. In collaboration with Student Members** 50.00 ❒ OPIQ, the CSRT will have morning plenary sessions ■ Full Registration — Non-CSRT Student Members simultaneously translated. As well, many of the educa- *Pre-registration 75.00 ❒ tional sessions will be in French. After April 27, 2007 100.00 ❒ There will be a series of social events including a com- ■ Daily Registration ❒ Fri. ❒ Sat. ❒ Sun. plimentary wine and cheese reception, a free fun night Members 150.00 ❒ at Le Mondial de la bière and the Exhibitor’s Breakfast. Non-members 185.00 ❒ Registration includes admission to the exhibit hall with ❒ 80 booths and all breakfast, lunch and coffee breaks. Student Members** 50.00 The President’s Banquet and Awards will take place on ■ Options Saturday night with a live band. President’s Banquet 50.00 ❒ Additional Exhibitor Representative 150.00 ❒ The CSRT has blocks of discounted rooms booked at the Hilton Bonaventure and the Marriott Chateau Champlain. WestJet is our official carrier. Details will be * Pre-registration deadline April 27, 2007 posted as they become available on the CSRT website **Must be currently enrolled in a CSRT approved program to qualify for the student rate (www.csrt.com) under About/Annual Meeting. Registration includes Exhibitors Breakfast, Sunday Continental Confirmed speakers include: Breakfast, two lunches and breaks, Wine and Cheese Reception, ■ Justin Trudeau Fun Night all lectures and workshops, entry to Exhibit Hall. ■ Dr. Jean Bourbeau: Diagnostics GST is included in the total #119220010 RT ■ Dr. Peter Brindley:Crisis Resource Management/Team Refunds: Refunds are subject to a $50.00 administration fee. Resource Management/Severe Sepsis — Its about Time ■ Craig Campbell: Biphasic NCPAP ■ Dr. Robert Crapo: Spirometry/Improving Lab Performance NAME ■ Mark Daly: Leadership ■ Dr. Allan de Caen: PALS requirements and CSRT FILE # Rationale/Management of Pediatric ARDS EMPLOYER ■ Stephane Delisle: HFO/Effect of Tidal Volume on Work of Breathing, etc During ALI and ARDS POSITION (TITLE) ■ Dr. Alain Deschamps: Anaesthetic and Neuromuscular Diseases YOUR ADDRESS ■ Dr. Niall Ferguson: HFO/ Extubation Failure and Delay in CITY PROVINCE POSTAL CODE Brain Injury ■ Brigitte Fillion: Home Ventilator Therapy, Equipment and HOME TEL. WORK TEL. Medical Supplies E-MAIL ■ Len Geiger: Double Lung Transplant ■ Dean Hess: Critical Care METHOD OF PAYMENT ■ Dr. Josée Lavoie : Anesthésie pour l’adulte avec TOTAL PAYMENT $ cardiopathie congénitale ❒ y ❒ a ■ Dr. Serge Marquis: Work, Meaning and Pleasure ■ Dr. Pierre Mayer : Le Kilimandjaro comme terrain d’étude ■ Dr. Samantha Nutt: War Child Canada CARD NUMBER EXPIRY DATE ■ Dr. Michel-Antoine Perrault : Échographie transoesophagienne SIGNATURE ■ Dr. Stavros Prineas: Communication/Teamwork in the OR PRINT NAME ■ Rita Troini: Televisit

 Autumn 2006 Canadian Journal of Respiratory Therapy — www.csrt.com 13 Scientific news

Abstracts

Alteration of the Pulmonary Methods: Lung tissue of infants with Intrapulmonary Bronchogenic Cyst Surfactant System in Full-Term URDS was analyzed for the expression and Cerebral Gas Embolism in an Infants with Hereditary ABCA3 of ABCA3 in type II pneumocytes. Aircraft Flight Passenger* Deficiency Coding exons of the ABCA3 gene were sequenced. Surfactant protein expres- Francisco Aécio Almeida, MD; Bryan X. Frank Brasch*, Sven Schimanski*, sion was studied by immunohistochem- DeSouza, MD; Thomas Meyer, MD, Christian Mühlfeld, Stefan Barlage, istry, immunoelectron microscopy, and FCCP; Susan Gregory, MD, FCCP and Thomas Langmann, Charalampos Western blotting. Lee Greenspon, MD, FCCP Aslanidis, Alfred Boettcher, Ashraf Results: ABCA3 protein expression Dada, Horst Schroten, Eva * From the Division of Critical Care, was found to be greatly reduced or Pulmonary, Allergic, and Immunologic Mildenberger, Eric Prueter, Manfred absent in 10 of 14 infants with URDS. Ballmann, Matthias Ochs, Georg Diseases (Dr. Almeida), Thomas Direct sequencing revealed distinct Jefferson University Hospital, Johnen, Matthias Griese and Gerd ABCA3 mutations clustering within vul- Schmitz Philadelphia; and the Divisions of nerable domains of the ABCA3 protein. Neurology (Dr. DeSouza), and Institute of Pathology, and Institute of A strong expression of precursors of Pulmonary Diseases and Critical Care Occupational Medicine (BGFA), surfactant protein B (pro-SP-B) but only (Drs. Meyer, Gregory, and Greenspon), University of Bochum, Bochum; low levels and aggregates of mature Lankenau Hospital, Wynnewood, PA. Division of Electron Microscopy, surfactant protein B (SP-B) within elec- Department of Anatomy, University of tron-dense bodies in type II pneumo- Correspondence to: Francisco Aécio Göttingen, Göttingen; Institute of cytes were found. Within the matrix of Almeida, MD, Division of Critical Care, Clinical Chemistry and Laboratory electron-dense bodies, we detected Pulmonary, Allergic, and Immunologic Medicine, University of Regensburg, precursors of SP-C (pro-SP-C) and Diseases, Thomas Jefferson University Regensburg; Department of General cathepsin D. SP-A was localized in small Hospital, 834 Walnut St, Suite 650, Pediatrics, University of Düsseldorf, intracellular vesicles, but not in elec- Philadelphia, PA 19107; e-mail: francis- Düsseldorf; Department of Pediatrics, tron-dense bodies. SP-A and pro-SP-B [email protected] Charité, Campus Benjamin Franklin, were shown to accumulate in the Although it is estimated that > 1 billion and Klinikum Neukölln, Berlin; intraalveolar space, whereas mature SP- passengers travel by air worldwide each Department of Pediatrics, Bethesda B and SP-C were reduced or absent, year, the incidence of in-flight emer- Hospital, Wuppertal; Department of respectively. gencies is low. However, due to non- Pediatrics, Hannover Medical School, Conclusion: Our data provide evidence standardized reporting requirements Hannover; Pediatric Pneumology, that ABCA3 mutations are associated for in-flight medical emergencies, the Childrens' Hospital of the Ludwig- not only with a deficiency of ABCA3 true incidence of pulmonary barotrau- Maximilians-University, Munich, but also with an abnormal processing ma in airplane passengers is unknown. Germany; and Institute of Anatomy, and routing of SP-B and SP-C, leading We describe the case of a passenger Experimental Morphology Unit, to severe alterations of surfactant with an asymptomatic intrapulmonary University of Bern, Bern, Switzerland homeostasis and respiratory distress cyst in whom a severe case of cerebral Correspondence and requests for syndrome. To identify infants with gas embolism developed during an air- reprints should be addressed to Prof. hereditary ABCA3 deficiency, we sug- craft flight. The decrease in ambient Dr. G. Schmitz, M.D., Institute for gest a combined diagnostic approach pressure during the aircraft climb Clinical Chemistry and Laboratory including immunohistochemical, ultra- resulted in expansion of the cyst vol- Medicine, University of Regensburg, structural, and mutation analysis. ume based on Boyle’s law (pressure x Franz-Josef-Strauss-Allee 11, D-93053 Key Words: ABCA3 • cathepsin D volume = constant). Due to the cyst Regensburg, Germany. E-mail: • immunoelectron microscopy expansion, we believe tears in the wall [email protected] • immunohistochemistry • surfactant led to the leakage of air into the sur- Rationale: ABCA3 mutations are American Journal of Respiratory and rounding vessels followed by brain gas known to cause fatal surfactant defi- Critical Care Medicine Vol 174. pp. emboli. Adult patients with intrapul- ciency. 571-580, (2006) monary cysts should be strongly consid- Objective: We studied ABCA3 protein © 2006 American Thoracic Society ered for cyst resection or should at least expression in full-term newborns with doi: 10.1164/rccm.200509-1535OC be advised to abstain from activities unexplained respiratory distress syn- leading to considerable changes in drome (URDS) as well as the relevance ambient pressure. of ABCA3 mutations for surfactant Key Words: air embolism • homeostasis. bronchogenic cyst • gas embolism • pulmonary cyst (Chest. 2006;130:575-577.) © 2006 American College of Chest Physicians

14 Autômne 2006 Revue canadienne de la thérapie respiratoire — www.csrt.com Scientific news

Air/Oxygen Misconnections Wrae Hill, BSc RRT, Interior Health B.C.. Chuan Yong, BSc RRT and Carmella Duchscherer, RRT BHS(RT), Calgary Health Region, AB.

In April of 2005, a 71 year old lady receiving palliative care for severe COPD died in hospital in the Interior Health Authority (IH) of British Columbia. Her autopsy identified two major contributing factors for her death: atherosclerotic disease and a reduced blood oxygen level (hypoxemia). A thorough root cause analysis (RCA) of the circumstances of this death was conducted by the local Quality Improvement (QI) Department. The primary contributing factor of her hypoxemia was that she was inadvertently attached to medical air instead of oxygen, as a result of staff confusion with identical looking air and oxygen flowmeters. The RCA also identified several system issues including: gaps in nursing education, ward orientation, and shift to shift communication. The hospital and Interior Health Authority (IH) treated this case as a systems level adverse event (AE) and began to look for ways to prevent it’s recurrence across IH. This report summarizes collaboration between provinces, system changes within IH over a year, and changes planned within the Calgary Health Region. Permission of those involved in this patient’s care has been received.

Scope of the Problem In September 2005, Interior Health hazards. Below, is an example of a Very little is documented on miscon- initiated conversations with the hierarchy of interventions adapted to nection of medical gases in the liter- Canadian Standards Association reduce the risk of medical gas mis- ature and no data existed within IH (CSA) 12 on the topic of air and oxy- connections: on these types of AEs. A survey of gen flowmeter misconnections, 1. Education alone (Least effective ) which led to discussions among CSA selected Registered Respiratory 2. Policy clarification Therapy (RRT) leaders across members of two Technical 3. Improved signage Canada revealed that these AEs Committees (TC) — the Anaesthesia occur and are often not reported. and Drug-Related Standards TCs. 4. Reconfigure devices to better Discussions with the Calgary Health The CSA Technical Committees indi- differentiate between air and Region (CHR) revealed that their cated that CAN/CSA 15002-02 speci- oxygen (Medical Air Valve) incident reporting system identified fies gas-specific distal fittings on air 5. Restricted access to air 44 incidents in 15 months.1 It is rec- and oxygen flowmeters but that in flowmeters (ie. only accessible ognized that reporting is not a true practice, these voluntary standards through a respiratory therapist) indicator of actual events or close are ignored by the medical commu- nity. Unfortunately these (voluntary) 6. Complete removal of air calls, and thus it is impossible to flowmeters (Most effective) accurately quantify the magnitude of safeguards have not been universal- the problem. ly applied to prevent misconnections between air flowmeters and com- Interior Health Region A core issue is a hazard that exists in mon oxygen tubing. The results of Interior Health’s RCA the design of air and oxygen deliv- were applied across the Health ery devices. Air and oxygen flow- Implementing System Changes to Authority. The Quality and Patient meters have common threaded fit- Reduce Adverse Events Safety office coordinated a task force tings at the flow meter outlet. While In a Safety Alert, the ISMP10 dis- of respiratory therapy leaders to Federal regulations for medical gas cussed a hierarchy of fixes for med- 1) Update nursing education and piping and fittings ensure gas specif- ication safety, from the least effec- orientation materials 1 and 2) Design ic connections, these safeguards tive to most effective. We believe and source a Medical Air Valve have not prevented misconnections this hierarchy can be used as a (MAV) device to prevent this recur- between air and oxygen flowmeters. guideline for mitigating all safety rent problem. This approach took Continued on the next page

Autumn 2006 Canadian Journal of Respiratory Therapy — www.csrt.com 15 Scientific news

Air/Oxygen Misconnections continued from previous page

into consideration the comments and recommendations from respira- tory therapy leaders within Interior Health (listed below), the principles of Quality Improvement, Human Factors engineering, as well as tech- nical factors such as wear and tear on bayonet type wall outlets.

Why a Medical Air Valve ? Across an entire health region, we could not simply remove all air flowmeters as is done in some terti- ary care centers with full time RRT staffing.4 The compromise in this case was to replace the Thorpe tube Air flowmeter with a different look- x ing, well labelled device designed solely for aerosol medication deliv- ery.The Medical Air Valve (MAV) (West Care Medical, British Columbia) Figure 1: Thorpe tube Flowmeters (Oxygen, left , Medical Air, right) simply looks different than a thorpe tube flowmeter and has a different on/off design, horizontal vs. vertical configuration and a preset flow of 7–8 Lpm. It is recognize that this device will not completely eliminate the potential for a misconnection because the outlet barb still fits nor- mal oxygen tubing.

The Medical Air Valve (MAV) has been implemented across Interior Health at 19 acute care sites, replac- ing 1445 medical air flowmeters, at a cost under $65,000. Some users have opted for a 90 degree elbow to direct the connection downward. Three months after implementation, no near misses or adverse events have been reported.

The Calgary Health Region The Calgary Health Region is trialing restricted access of air flowmeters. Particular patient care units are being targetted, specifically those Figure 2: Oxygen flowmeter and MAV that have a Safety Action Team func- tioning that has already identified Both medical air and oxygen flow meters look almost identical and have a common air-oxygen misconnections as a safe- thread pattern at their outlet,and making misconnection possible. In June 2006, all ty concern for their unit. In the trial, Medical air flowmeters within Interior Health have been replaced by a Medical air Valve (MAV) which is designed specifically for Aerosol medication administration with air flow meters will be removed a preset flow of 7–8 Lpm. While medical gas misconnections are less likely, they are from these nursing units and still possible. Reference — Policy AH 0500 will only be accessible through a

16 Autômne 2006 Revue canadienne de la thérapie respiratoire — www.csrt.com Scientific news

Air/Oxygen Misconnections

respiratory therapist. Nebulized 5. Patient Safety Advisory Veterans Respiratory Therapy Patient medications will be administered via Health Administration Warning System , Safety Task Group — 2005/6 oxygen, unless otherwise indicated March 5, 2002 Interior Health B.C. 6. Air-Oxygen Flowmeter Confusion. by a physician. Based on the results ■ Greg Rollins — Kootenay of this trial, a decision to either Anaesthesia. 2003,.58 A. Waite , I. Macartney Boundary Regional Hospital, implement this across the Calgary Trail B.C. Health Region or to try another fix 7. Thin Air — Spotlight Case on a ■ will be made. patient being erroneously given medical Peter Borsato — East Kootenay air rather than oxygen. David M. Gaba, Regional Hospital , Cranbrook B.C. MD Agency for Healthcare Research & Summary ■ Diane Biro & Peter Lock — Quality — October 2004 Penticton Regional Hospital , Air/oxygen misconnections are a www.ahrq.gov/casearchives Penticton , B.C. well-recognized hazardous situation, 8. Oxygen or Air? Anaesthesia 2001; 56: with contributing factors that exist at 1205 Arepalli N, Jones N. ■ Lorne Yelland & Richard Milo — the system and design levels. Rather 9. Interchangeable Oxygen and Air Kelowna General Hospital, than accept air-oxygen misconnec- connectors. Anaesthesia 2001; 56: 1205 Kelowna, B.C. tions as inevitable or offer solutions Thomas AN, Hurst W, Saha B. ■ Lloyd Main — Vernon Jubilee applicable to only a few acute care 10. Medication Error Prevention Toolbox. Hospital, Vernon, B.C. sites, we presented two different Institute for Safe Medicine Practices ■ Lynda Moreau & Barb Nickerson changes chosen by two different (ISMP). ISMP Medication Safety Alert! — Royal Inland Hospital , health regions. Both solutions are June 2, 1999. Retrieved July 28, 2006 Kamloops , B.C. relatively simple system fixes aimed from at reducing miss-selections of med- http://www.ismp.org/Newsletters/acute- ■ Todd Gale — Community ical air instead of oxygen. Next steps care/articles/19990602.asp Respiratory Therapy, Kelowna, B.C include evaluating the effectiveness 11. CAN/CSA - Z9170-1-00(R2005) of these changes by monitoring near Terminal Units for Medical Gas Pipeline misses and adverse events. systems — Part 1: Terminal Units for Use With Compressed Medical Gases & Vacuum (Adopted ISO 9170 - 1:1999, References first edition, 19999-12-15) 1. Air Oxygen Misconnections — Identifying contributing factors and Acknowledgement recommended solutions Chuan Yong The authors would like to acknowl- RRT , Calgary Health Region 2006 edge the contributions of Interior 2. Oxygen Therapy & Respiratory Care Health’s Respiratory Therapy Patient Guidelines Wrae Hill — Respiratory Therapy Patient Safety Task Group 2005- Safety Task Group for both the 6, Interior Health, British Columbia update of orientation guidelines and the design and implementation 3. Use of Medical Air Valves (MAV) and Medical Air Flowmeters Policy AH 0500 of the Medical Air Valve (MAV) Interior Health Authority, Kelowna, B.C. solution. 4. Guidelines for the use of air flowme- ters to power small volume nebulizers (SVN) Patient Care Practice Guideline 9.3.1.1 April 2005, Capital Health , Edmonton, Alberta

The Canadian Journal of Respiratory Therapy accepts submissions for science articles, information pieces and opinions on an on-going basis. First-time authors are also encouraged to submit. Forward material to [email protected]

Autumn 2006 Canadian Journal of Respiratory Therapy — www.csrt.com 17 Scientific news

Critical Care Outreach: Who Knows Their ABC’s? Stephane Labrosse RRT, Margaret Clark RRT

becoming clear. By establishing this More than a year has passed since the initiation of the mobile ICU team, this service could be offered, and patient care Critical Care Outreach team at the Ottawa Hospital. Now improved. Secondly, in a study of called RACE (Rapid Assessment of Critical Events), it was 64 patients admitted to ICU from the ward with cardiac arrest, 84 % had created to bring the practice of “ICU without walls”to documented observations of clinical our hospital. We have successfully established this team deterioration or new complaints within eight hours prior to arrest. as a major contributor in the treatment of critically ill Seventy percent had either deteriora- patients within our hospital. Consisting of an ICU inten- tion of respiratory or mental function observed during this time.6 It was sivist, a critical care nurse and a respiratory therapist the recognized that early identification outreach team has impacted management of critical care of these patients could prevent ICU admissions and improve outcomes. patients improving outcomes, decreasing length stay, ICU This program was also established in admissions and readmissions and reducing cardiac arrests the UK and has had varying degrees (ref.1). of success when looking at the evi- dence.4 Overall the response has been positive with some recent stud- ies showing a reduction in cardiac 7,8 General Campus Civic Campus arrests, a reduction in unanticipat- ed ICU admissions and non-DNR Total number calls / patient consults 288 178 deaths,9 and improved survival before hospital discharge and reduc- Total follow-ups 800 781 tion in ICU readmission.10 ICU Admissions from consults or 74 48 follow up In North America an initiative from Transfer to higher level of care the American Institute for Healthcare 17 NA (CCU, N-Obs): Improvement (IHI) and the Canadian Safer Healthcare Now Average number of calls per day 1.35 0.84 (SHN) identified a Code blue call reduction since MET Team as one of six strategies to 29% 33% January 1, 2005 reduce hospital mortality.3 The ICU admissions — non-outreach — 109 NA Ministry of Health supported these # of patients -mortality 37% NA strategies and funding was provided -length of stay 6.51 48 to help hospitals across Canada start their own MET. This project was ICU admissions — outreach — 74 NA introduced as a goal for the # of patients -mortality 31% NA -length of stay 5.73 NA Canadian Collaborative for Critical Care and we now have many estab- Reference 1: Race data first six months at the Ottawa Hospital lished MET across Canada. The course taken was based on the UK and Australian models relying on the Other sites across Canada have also The idea of Critical Care Outreach evidence they have generated. been very successful. Data generat- originated in Australia and was ed from centers such as The developed for two reasons.7 Firstly, A “calling criteria” (figure 1) was University of Alberta Hospital (UAH) the health care system was financial- developed where by a ward health- and the Trillium Health Centre in ly strained, bed space was limited, care professional recognizing any Mississauga clearly show just how and patient acuity was increasing. patient deterioration could activate valuable a MET can become.1,2 The need to extend ICU support to the emergency medical team, to help the ward patient and personnel was manage a patient in possible crisis.

18 Autômne 2006 Revue canadienne de la thérapie respiratoire — www.csrt.com Scientific news

Critical Care Outreach: Who Knows Their ABC’s?

In our own experience many inter- ventions are respiratory in nature. (table 3). Some evidence suggests as much as 78% (ref. 1) of the calls have a respiratory element.11 Recent data from the University of Alberta Hospital3 supports this statement. In their first year of service, more than 50% of the calls were strictly respira- tory in nature and more than 90% of the calls had a respiratory element. This is strong evidence to support the respiratory expert to be included in the funding, and in North America that expert is the Respiratory Therapist.

This was recognized in our hospital, and with the support of our admin- istration and our ICU management, it was possible for RT’s to be involved in this program. The positive out- comes noted in table 1 are a reflec- tion of the efficiency of care this team can provide. The cohesion of knowledge and skill between the physician, the nurse and the respira- tory therapist play a major role in this success. It just made sense that an RT was included, since the goal of RACE is to bring the people with the right skills at the bedside to face any critical situations, assess them and manage them in the most effi- cient way possible.

Setting up oxygen therapy, perform- ing an ABG, initiating non-invasive ventilation, or protecting an airway are skills where RTs excel. This expertise and our presence on the RACE call ensures that there will be no delay in providing this care. This Figure 1: Calling Criteria certainly improves the outcome in most RACE situations. We also help This team included an ICU physi- to our profession that respiratory with any tasks we can, from looking cian, a critical care nurse and other therapists do not exist in the UK and up blood work, charting in the ICU personnel sometimes a physio- Australia. Nurse specialists, physio- progress notes, to talking with fami- therapist, (all experts in managing therapists and other healthcare pro- ly. Education is also a priority as the critically ill) to respond to critical fessionals perform their role. This is raising awareness about this team is events happening outside ICU walls. not obvious to administrators who an ongoing task and providing guid- The glaring question to the hold the purse strings, and they are ance and support to any staff, Respiratory Therapy profession is: relying on the published evidence to patient or family goes a long way in where is the RT? It may be obvious support funding. reducing those critical events. This

Autumn 2006 Canadian Journal of Respiratory Therapy — www.csrt.com 19 Scientific news

Critical Care Outreach: Who Knows Their ABC’s?

Therapeutic interventions — respiratory 4. Hillman K., Chen J, Cretikos M, Bellomo R, Brown D, Doig G, Finfer S, No action taken # % Flabouris A, Introduction of the Medical Oxygen therapy 52 12.84 Emergency Team system: A cluster ran- domized control trial. Lancet 2005 Oct 1; CPAP / BiPAP 144 35.46 366(9492):1164. Intubation 30 7.41 5. Lee A, Bishop G, Hillman KM, Daffurn K. The Medical Emergency Team Trach suctioning 16 3.95 Anesthesia Intensive Care, 1995; 23; Trach change 18 4.44 183-186 6. Schein RMH, Hazday N, Pena M, et al. Ventolin / atrovent 1 0.25 Clinical antecedents to in-hospital car- Assessment only 53 13.09 diopulmonary arrest. Chest 1990; 98:1388-92 162 40.10 7. Buist MD, Moore GE, Bernard SA, Waxman BP, Anderson JN, Nguyen TV. Table 3: Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospi- tal: BMJ. 2002 May 18; 324(7347): 1215 responsibility, of course, is shared resources, such as crash carts, drugs, amongst all team members. and labor cost (i.e., cardiac arrests). 8. Buist MD, Moore GE, Bernard SA, et al. Effects of a medical emergency team This allows better use of ICU beds on reduction of incidence of and mortali- The opportunity to be part of this and resources. ty from unexpected cardiac arrests in team has not come without a few hospital: preliminary study. BMJ 2002; challenges. As previously noted, the The benefits of having such a team 324 concern is that there is practically no in our hospital are numerous. In 9. Peter J Bristow, Ken M Hillman, Tien defined Ministry of Health funding addition, it is important to realize Chey, Kathy Daffurn, Theresa C Jacques, for our involvement in this team. We that working closely as a team all Sandra L Norman, Gillian F Bishop and E are managing to cover 50% of the across the hospital greatly improves Grant Simmons:Rates of in-hospital day by stretching our resources, but relationships and trust between team arrests, deaths and intensive care admis- we cannot handle the uninterrupted members and with other staff sions: the effect of a medical emergency team MJA 2000; 173: 236-240 attention this team needs. Our pres- throughout our hospital. The end ence on RACE is required seven result is better and more efficient 10. Carol Ball, Margaret Kirkby, Susan days a week, 24 hours a day. We are patient care. We would urge other Williams, Effect of the critical care out- reach team on patient survival to dis- fortunate here in Ottawa to be par- Respiratory Departments across charge from hospital and readmission to tially covered, as it is understood Canada to get involved funding or critical care: non-randomised population that patient care is greatly improved no funding. We are an integral part based study by the addition of an RT in the team. of total patient care and must be 11. Baxter A, Ottawa Hospital RACE In the long run, we believe that the involved. It is our hope that in the Team, unpublished data, 2004-2006 improvement of patient care future, funding and support will be 12. Baxter A, Critical Care Outreach throughout the hospital, the adequate for us to continue to move comes to Canada, CMJA, 2006;175:613- decrease in ICU admissions and forward with this team, as we enter 614 readmissions, the decrease in car- our second year of service. diac arrests, the decrease in lengths of stay and the continuing education References this team provides to all staff, will 1. University of Alberta Hospital (UAH) financially benefit our hospital, as MET update for November 2005, ppt. well as greatly improve patient care. We are still in the process of assess- 2. Trillium Health Centre, Mississauga (ON), MET results for 2005, ppt. ing those financial benefits as the team is in its early stages and only 3. Hill W, Canadian Society of Respiratory Therapists, Canadian Patient time will assure this to be factual. It Safety Initiatives developing Rapid is well established that better patient Response Teams using Collaboratives, care leads to a decrease in the use of CSRT Journal, summer 2005;26-29 (http://www.csrt.com)

20 Autômne 2006 Revue canadienne de la thérapie respiratoire — www.csrt.com Scientific news

Smoking Women and Bladder Cancer Jennifer Wider, M.D., Society for Women's Health Research

urination. Treatment of the disease A study from the University of Southern California varies by case, but surgery is usually involved and yields the best out- says women’s bladders may be more susceptible to cancer- come. Depending on the extent of causing agents in tobacco. Researchers found that when the disease, chemotherapy, radiation and biological therapies, which stim- women and men smoke at comparably high levels, ulate the body’s immune system, may women’s bladder cancer risk is 30 to 50 percent higher. be involved. Because smoking is the largest known risk factor for bladder cancer, it is vital for tobacco smokers to be The study comes on the heels of the Another explanation for the higher aware of their risk. Relatives and peo- U.S. Surgeon General’s June 27 decla- mortality rate in women is because a ple who spend time with a smoker ration that second-hand smoke is a greater number of women experience are also at risk, given the established serious health hazard, triggering a delay in diagnosis. Women with dangers of second-hand smoke. The many cancers, including bladder can- bladder cancer are diagnosed six to growing number of ways we know cer. So how does cigarette smoke nine months later than men with the smoke harms health is a good reason affect the bladder? disease, and women’s cancers are to stop smoking or help those around detected at a more advanced stage. you stop. “Smoke contributes to bladder cancer because carcinogens in cigarette “The warning signs of bladder cancer Beyond smoking, occupational expo- smoke are absorbed from the lungs typically include blood in the urine or sures to chemicals found in some into the bloodstream,” said Viviana a change in urinary habits such as dyes, paints, solvents, leather dust, Simon, Ph.D., director of scientific urinary frequency, urgency or inks, combustion products, rubbers, programs for the Society for Women’s dysuria, which is pain while urinat- and textiles can increase the risk of Health Research, a Washington, D.C. ing,” according Waleed Hassen, M.D., bladder cancer. As a result, hair- based non-profit research, education, director of urological oncology at the dressers, machinists, painters, print- and advocacy organization. “The car- Mount Sinai School of Medicine in ers, truck drivers, and those who cinogens are then filtered by the kid- New York, N.Y. “These symptoms work with the drugs used in neys, concentrated in the urine, and can be sometimes confused with uri- chemotherapy need to be aware of can then damage the cells that line nary tract infections, especially in their risk and the cancer’s symptoms. the bladder.” women, which can sometimes delay diagnosis.” References The incidence of bladder cancer has 1. American Cancer Society. Cancer Facts been steadily increasing, according to If the diagnosis is delayed and and Figures 2005. Atlanta, Ga: American statistics from the American the disease progresses, the patient Cancer Society; 2005. Available at: Urological Association. Cigarettes top usually has different symptoms. http://www.cancer.org/downloads/STT/C the list of risk factors. Risk increases “Later warning signs of the bladder AFF2005f4PWSecured.pdf. Accessed with the duration of smoking, and cancer include weight loss, pain and December 18, 2005. decreases when smokers quit. fatigue,” Hassen said. 2. Gender- and smoking-related bladder Increasing age is also a risk factor. cancer risk. Castelao JE, Yuan JM, A timely diagnosis is crucial to survival. Skipper PL, Tannenbaum SR, Gago- The influence of tobacco on bladder For patients with non-invasive bladder Dominguez M, Crowder JS, Ross RK, Yu cancer susceptibility is not the only cancer, the five-year survival rate is MC. University of Southern California/Norris Comprehensive Cancer way that the disease differs between over 90 percent. The rate drops below Center, Keck School of Medicine of the women and men. For example, blad- 50 percent, if the cancer spreads over University of Southern California, Los der cancer is more common in men, the pelvic region. If it progresses to Angeles 90089-9181, USA. : J Natl 3. but women are more likely to die other organs, the five-year survival rate Cancer Inst 2001 Apr 4;93(7):538-45 from the disease. One explanation for falls to just six percent. 3. CancerMail from the National Cancer the difference is that women are Institute Information from PDQ -- for more likely than men to suffer from That’s why it is so important to see Health Professionals Screening for blad- rarer types of bladder cancer, accord- your doctor right away if you have der cancer 208/10681 ing to the National Cancer Institute. any symptoms or problems related to http://medhlp.netusa.net/lib/cancer- net/310681.htm

Autumn 2006 Canadian Journal of Respiratory Therapy — www.csrt.com 21 Reactine PI

2/3 page CSRT Prescribing Info New Corporate Members

All-Can Medica

Astra Zeneca

Bayer Healthcare 1 COLOUR BomiMed Cardinal Health

for postion only Carestream Medical key lines don’t print Fisher & Paykel

KEGO Healthcare

ProResp/ProHealth

O-Two Medical Technologies

Summit Technologies

22 Autômne 2006 Revue canadienne de la thérapie respiratoire — www.csrt.com Industry news

Disposable Sleep Apnea Screener

Sleep apnea is a serious medical disorder, affecting 4% of men and 2% of women.

It is characterized by repetitive reductions of airflow during sleep due to the collapse of the pharyn- geal airway, causing loud snoring, brief awakenings, hypoxemia and elevated blood pressure. Millions of apnea patients suffer from excessive daytime sleepiness, headaches and hypertension. There is growing evi- dence that chronic sleep apnea runs in families, and is associated with increased morbidity and mor- tality. Sleep apnea is relatively unknown, with only about 15% diagnosed so far.

Until now, sleep apnea could only be diagnosed by waiting six months for an overnight sleep study, at the hospital, or paying anywhere from $600 to $1,500 for an overnight study at a private lab.

The Sleep Strip is a novel, low-cost device designed to help physicians screen patients for sleep apnea reli- ably and conveniently. To fully The SleepStrip is, in fact, a “one-channel sleep lab” exploit the advantages this innova- tive device offers, it is helpful to normal respiration cycles, peak-to- minutes after the study has ended. know and understand its inner peak amplitude for each consecutive The SleepStrip’s intended use is for workings and technology. breath cycle, and other parameters screening purposes only. It should of the respiration pattern. be used on patients who are consid- A “one-channel sleep lab” ered high risk for SAS and require The SleepStrip is, in fact, a “one- An apnea event is counted when additional information for diagnosis. channel sleep lab” comprising signal respiration amplitude drops to under If the indication of the SleepStrip is detection, acquisition, analysis and 12% of the average for more than 10 positive and the patient exhibits display in one easy-to-use dispos- seconds. A hyponea event is count- additional indications and risk fac- able package. The flow signals ed if respiration amplitude drops to tors such as obesity, hypertension, are derived from three thermistors less than 50%, but more than 12% of heavy snoring, and/or a family histo- (respiration airflow temperature the average for more than 10 sec- ry of SAS, he or she can then be sensors) similar to those used in onds. Respiratory events (apneas referred for further evaluation. standard sleep-lab sensors. These and hypopneas) are counted for the sensors are located under the three duration of the study. These values For more information about blue dots on the nose and mouth were selected for maximum correla- SleepStrip, contact: prongs. The signal is processed ten tion with polysomnographic results. times each second by SleepStrip’s After a study is complete, the apnea Roxon Medi-Tech at 1-800-361-6991 internal microprocessor (CPU). The and hypopnea counts are used to or visit: www.sleepstripcanada.ca CPU tracks the signal continuously, calculate the final test score, which calculating average amplitude of is readable on the display 30

Autumn 2006 Canadian Journal of Respiratory Therapy — www.csrt.com 23 Calendar of Events

September 29, 2006 October 25 – 27, 2006 RTSO Education Day and Critical Care Symposium AGM 2006 London ON Toronto, ON http://www.rtso.org/ http://www.tccms.com/ind ex.htm Symbicort Sept. 27 – Oct. 1, 2006 October 26, 2006 8th World Congress — Sleep Apnea 2006 2006 Mount Sinai PI Montreal QC Hospital OB Anesthesia http://www.wcsa2006.com Conference Toronto ON October 1 – 3, 2007 5th National Conference November 1 – 4, 2006 1/3 page on Tobacco or Health CARTA Respiratory Shaw Conference Centre Conference and Trade Edmonton, Alberta Show pickup from 2006 Calgary, Alberta October 14 – 18, 2006 http://www.carta.ca/index. American Society of htm Forum Issue Anesthesiologists, 2006 Annual Meeting November 3 – 5, 2006 Volume 42 Chicago, USA Anesthesia http://www.asahq.org/ Assistant/CPAS confer- ence number 1 October 20 – 21, 2006 Vancouver BC Congrès de l’OPIQ http://www.csrt.com/com- Mont-Tremblant, QC mittees.php?display&en&18 Spring page 42 http://www.opiq.qc.ca/hom e.htm November 6 – 10, 2006 Prescribing Info 12th Asian Australasian October 20 – 23, 2006 Congress of 20th Anniversary of Anaesthesiologists AACVPR Suntec, Singapore. Milwaukee Wisconsin http://www.aaca2006.com/ www.aacvpr.org/meeting/ November 9 – 15, 2006 October 21 – 26, 2006 Annual Meeting of CHEST 2006 ACAAI Salt Lake City, UT Philadelphia, USA www.chestnet.org/ http://www.acaai.org/

October 25 – 27, 2006 November 19 – 22, 2006 2006 OPHA Annual 11th Congress of the 1 COLOUR Conference, Asian Pacific Society of Cooperation, Respirology Collaboration, Synergy: A Kyoto, Japan Foundation for Public http://www.apsr2006.org/ for postion only Health. key lines don’t print Cornwall Ontario November 20, 2006 http://www.ophaconfer- GOLD Symposium ence.ca/ Kyoto, Japan http://www.goldcopd.org/

November 21 – 22, 2006 ESCMID/ECDC/SMI Conference on Infectious Disease Surveillance and Preparedness Stockholm, Sweden Photo: Denise Picanco STETHOSCOPES. NOT JUST FOR DOCTORS.

The Canadian Society of Respiratory Therapists is committed to act as an advocate, nationally and internationally, for respiratory therapists as leaders in the promotion of health and the delivery of quality respiratory care. We provide national leadership through advocacy, service and unity for Respiratory Therapists in Canada. Visit www.csrt.com for more information.