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Fax initial formula

hey future respiratory therapist so it's kind of a hot topic right now and it kind of intrigues me on why it's such a hot topic it's kind of creating a lot of polarization between incoming future respiratory therapists that are yet to take their board exams and the therapists out there that have already taken their their board exams and passed it and the question comes from Katie from whether for college appreciate the question Katie I know you've been asking for this shoutout for a long time and this one's for you okay so Katie wants to know what my thoughts are on allowing the calculator to be used this simple calculator is going to be on the computer too now starting in 2020 to be used during the mvrc exam where previously no calculators were allowed you had to use scratch paper and and basically write out if you wanted to if you needed to calculate something and my answer to you Katie and to everybody else watching this video is is that I'm indifferent you know I really am I'm not one of these already passed my board exams and I couldn't use the calculator so why do you get to use the calculator like I don't care it doesn't matter to me what I'm more focused on and and and what I really care about and really what happens here is here's here's the concerns of my students they say oh and now the calculator is gonna be on the test so is the test going to get harder well I don't I first of all don't answer that is it test going to be more focused on actually calculating numbers and getting the correct number as opposed to a greater just cognitive understanding of what formulas tell us now there's a lot of formulas in respiratory therapists the person who gets into respiratory therapy because they say oh it's just breathing so it can't be that much math is your first mistake alright so as you know for those of you currently in school there's a ton of formulas in the field of respiratory therapy and the key here and what I think is most important is is is not so much I hope the test doesn't shift to becoming able to get the right answer in terms of of here's some data what's the patient's total to content what's their what's their carrying capacity like that I hope it doesn't turn into that because if it turns into that and I think a bigger focus is going to shift on being able to get the right answer instead of understanding what that particular formula tells us about our patient and that's the key the key in the formulas of respiratory therapy and I harp on my students all the time about this is not understanding so much half you don't know how because you suck at math don't worry you can Google enough and you can practice enough to learn how to get the right answer the bigger problem is is when you miss a formula that is relevant to your patient and you miss it because you don't even know to do it that's the bigger problem the bigger problem is not recognizing why this number this objective data is important to me in taking care of this patient the calculator is not going on the test the calculator now available on test is not going to address that issue it'll help with getting the right answer when when asked or question about a particular number but but it will not address the theory behind and know why are we calculating certain formulas so I got a handful of examples for you okay now this is gonna seem like okay about how many more examples you get I'm gonna give you five examples of formulas and formulas that you probably need a calculator for in most cases but why the number is not as important as the theory okay so here we go I'm gonna start with let's start with the RS bi okay this is the rapid shallow breathing index so our SVI we know is frequency divided by tidal volume and this has got to be in liters see that's another part if you if you know if if you don't understand the entire formula you're gonna get the wrong answer anyways with a calculator so you understand that you're dividing frequency which I like to use rest and I'll tell you why in just a second respiratory rate / tidal volume in liters now the first question is is have this sometimes I have patients I have students that come out and tell me they say Joe my patients are SBI is really good what is it it's 30 okay why is that good or bad that's good what's normal less than 105 okay okay now let's go in and look at the patient now we're going to look at the patient and patients on assist control no no it doesn't even matter up to breathing spontaneously or not or initiating breaths they're in assist control which means their tidal volume is set and if they're not initiating any breaths then their respiratory rate is set so this is a formula that doesn't even apply in full mechanical ventilation it only applies during spontaneous modes of mechanical ventilation in the assessment of weaning it's a weaning it's a weaning predictor you know if you have a RSV I have 150 patients probably not ready for extubation you have a RSV i've of 40 then your patients potentially ready for excavation depending on other factors right so you have to understand why am i calculating the rapid shallow breathing index because if you don't then it doesn't matter if you get the right number yeah the guy had an RSP high of 30 in assist control doesn't matter it's not it's not an applicable formula at this time so that's that's my first example on to talk about our SBI now the other thing I want to tell you and this is where the calculator also will not help and this is where people say well if you can't calculate it then you don't know what you're doing what that that's arguable especially when you got students learning all these formulas so let me give you another example day 1 of a recent clinical rotation student went in did a vent assessment on a patient that was on a mechanical ventilator in a CPAP pressure support ventilation and I went in and I said how's your patient tolerating CPAP and this student said well it seems to be tolerating pretty good and I said what objective data or what objective number can give me that supports that the patient's doing and pretty good and this particular student didn't know the the RSV I did not come to this particular students brain in that moment so I brought it back to him I said okay let's talk about this what can we do that we can compare this person's frequency of breathing to their depth of breathing and eventually we get to our SBI we practice the formula we show it we say okay this makes sense now okay now that's an example of a student who had no idea that they were even supposed to be assessing the RSV I so it was completely lost so on the board exams you're gonna probably get the question wrong because you're not even thinking RSV I because you don't even know that that's a valuable tool in assessing a patient who spontaneously breathing in either pav or CPAP pressures for any other spontaneous breathing modes right now fast forward two weeks this particular student has another patient on CPAP and I go in and I say what can you tell me about this patient how are they doing on CPAP and this student rattles off they're doing well there are SBI is blah blah blah blah blah now as soon as she said it I knew that the RSV I was wrong it was not calculated correctly but the fact that the wrong numbers were used to calculate the RSV I does that illustrate less knowledge than the student who actually knew that they were supposed to be calculating RSV I because see we can fix that I can fix the right numbers I can I can do that a hundred percent you go in you take care of a patient spontaneously breathing you assess boom RSV I wrong number but theory is there the concept is there knowing that I should be understanding this and I should be assessing this value to help to help evaluate my patients readiness for extubation that to me is more important than not knowing or I'm sorry is more important than then getting the wrong number because with time and with practice the right numbers will come but you got an O to do it before you can even practice to get the right number so that's my first example okay second example let's talk about I used it in my I mentioned Toto to content or carrying capacity earlier so we're talking about cao2 here right total o2 content now first of all you have to understand the formula because do you need a calculator to calculate co2 to get the right number probably so right formula looks something like this hemoglobin time is one point three four times si O 2 plus PA o two times point zero zero three that's the formula now can you put numbers in there and get that right answer absolutely now if I ask you what that number tells you and what all of this this this formula tells you the question is can you answer that right can you tell me that the first portion of this tells me the amount of o2 bound to hemoglobin and can you tell me that this is the amount dissolved in plasma can you tell me that and then if you can tell me that and you understand that then you should be able to tell me and understand and critically think and help it make sense that when a patient comes in with a hemoglobin of six and a metabolic acidosis you can reason through this as make sense instead of you saying hey my carrying capacity for my patient Jo is is 10 okay good job weighted calculate it correctly now why is I important how does that help you understand everything else that's going on well if you can explain to me well majority and they have a stat of 99 percent their pao2 is 130 okay so hemoglobin of 6 but a pee little a o2 of 130 and you go oh they're oxygenating good well are they how do we explain the metabolic acidosis do you understand that the bulk of this formula is driven by hemoglobin and if the hemoglobin is down then your total co2 content reaching the tissues is down so your patient here is at a higher risk for tissue hypoxia which leads to anaerobic metabolism which leads to lactic acidosis which presents as a metabolic acidosis this makes more sense right can you tie this into the overall patient presentation regardless if your pao2 is 130 this patient is by far hypoxic but they're not hypoxemic and this formula critically thinking about it tells me that now again being able to reason through it like that and you don't need a calculator to do that is more important than me giving you numbers and you get the right answer and then I say now why is that important what does that tell you about your patient and you say I don't know see so does a calculator help understand the formulas just help get the right answer I think we know the answer to that right all right so let's talk about this is more or less turning more into a more or less turning into a review on formulas as much talking about calculators but it really is something that I'm really passionate about is understanding the Y is greater than the house you've heard me say that before if you watch any of my video if this is the first video you're watching then you need to understand that that's my that's my mojo that's that's what I I lean on in teaching the field of rest right there if I lean on understanding the Y greater than the house cuz if you know the Y and you know what you should be thinking and why you should be doing something then you can Google how to do it if you don't know how if you don't know how to do it or you can ask somebody how do I do this but if you fail to recognize when something is indicating and why something is important then you don't even know what you should be doing even if you know how to do it so let's talk about the arterial - end tidal co2 gradient so this is important because this gradient is normally very very close right so if I was to act ask you what's the Arturo - in tidal co2 gradient and let's say that arterial co2 was 50 and in tidal co2 was 10 then you don't need a calculator to telling me that the gradient equals 40 right you just don't need it I'm I hope I hope you don't need it 50 minus 10 is 40 if you do need it you plug those numbers in you plug them in correctly and you get the right answer 40 now the bigger question is why is that important what does that tell you about your patient well remember when the gradient gets larger like this then it could be an indication of a dead space problem meaning possible pulmonary embolism and you take this one step further and you do the dead space formula and you perform Piko Piko Piko you plug your numbers in you get 50 minus 10 equals 40 divided by 50 and that equals 80% that tells you that you have an 80% dead space which means 80% of your tidal volume that you're delivering to your patient or 80% of the tide of harm that the patient is taking is not participating in gas exchange because of this ginormous dead space problem that's more important to understanding then telling me my gradients 40a my my my dead space percentage is 80% fantastic what does it mean I don't know much more important understanding why than the half I got two more for you and then we're going to cut this off I appreciate you watching let's talk about p/f ratio a two a difference and the a two a ratio these are the three formulas that I guarantee every one of you students if you haven't done it yet or haven't learned it yet you will and you will be tested over and you will be asked to calculate these numbers now I think it's fantastic I think it's good that you know what these numbers tell and while they're important but here's the deal guys if your p/f ratio is decreased then you should understand without having to calculate anything I obviously have to calculate APF ratio divided pao2 divided by fio2 from there you should understand that if your p/f ratio sucks then your ada a difference is going to be increased and your ADA a ratio is going to be decreased why because the p/f ratio is your indicator of efficiency of oxygenation meaning of the fio2 we're putting into this patient's lungs what's the resulting pao2 and if it's not good then you understand that more oxygen more of the fio2 you put in is being left in the alveoli which is this number here if more is left here and is not diffusing over into here then this gap is going to get larger and then when you flip these numbers and do a ratio this number is going to be larger this number is going to be smaller your ratio is going to go down so yeah fantastical guerrilla error equation to get your pao2 - you're fantastic and you know how to calculate the right answers now what do you do with those right answers and what do they tell you about your patient they're telling you when you have this scenario that you have a shot present you've got venous admixture that's diluting your arterial oxygenation and this giant shunt is affecting diffusion of the fio2 you're putting into your patient that's the important thing how you going to treat this you're going to turn the fio2 up because if that's your answer you're just gonna make all of this stuff moved but it's all going to stay in the same direction it's still gonna be increased ain't any difference it's still gonna be a decreased at a ratio you're p/f ratio it's probably going to stay the same because your efficiency of diffusing from now viola to the pulmonary capillaries is is is by something there's a diffusion block so you can put more fio2 and it's not gonna help what do you need to do you need to add positive pressure you need to increase P P increase mean airway pressure you need to get the the increased surface area so that there's more surface area for the fio2 that's being delivered to efficiently cross over into the pulmonary capillaries that's how you have to fix it and that's how these formulas come into play last one and I'll keep it short I'll try to keep it short again if you've watched any of these videos before you probably know that this is my favorite formula this is also what I consider probably the most useful and most basic this is the formula you have got to know as a respiratory therapist you've got to understand you got to know all of them but this one is the one that on any given day you've got to be able to look at your patient and assess minute ventilation and understand what changes are happening in minute ventilation and you need to understand that minute ventilation is a result of respiratory rate times tidal volume if respiratory rate goes up manipulations going to go up if tidal volume goes up then minute ventilation goes up it's just that simple now there's times that this doesn't always fit with what I just said so I want to give you an example this is understanding this is going to help you understand that when you have your patient on CPAP CPAP of five with a pressure support of five this is going to help you understand that when this patient is breathing 30 times a minute with a tidal volume of 200 they have a minute ventilation of 6 liters okay you say well that doesn't look good right well why not because now my RSV is crappy right so what can we do for this patient we can increase pressure support we turn the pressure support up to let's just take it up to 10 our rate comes down to 20 what's gonna happen we would take our rate up to 10 our tidal volume is going to go up so let's say it goes up to 300 well guess what our minute elation doesn't go up it's probably going to stay the same the minute ventilation is what is required to remove co2 to keep a normal pH balance the brain knows this your RT you as an RT you know it too but the patient doing the breathing their brain is what is in control of minute ventilation based off of pH and co2 if the tidal volume goes up and they they're they're saying that their neural drive to breathe there's six liters per minute to maintain that normal that normal co2 and pH then you're gonna see their rate go down but your minute ventilation stays the same that's in spontaneous when a patient is breathing spontaneously now if you're in if you're in assist control right at twelve and a title I'm a five hundred patients not breathing spontaneously or initiating any mechanical breaths then if your patient comes back with a high co2 so their their pH is seven point two zero and their co2 equals sixty then what do you need to do the most common answer is I need to increase the rate okay is that the only thing you can do some people say well no I can increase the tidal volume say okay so what's really the goal here what's really when you think about this formula and you can calculate it hopefully and you'll have a calculator in your test so it'll work for you plug your numbers in right you'll be able to tell the NBR see what the minute ventilation is but what you need to understand is that in this scenario this minute ventilation twelve times five hundred is six liters this is this is leaders what you really should be thinking is is my minute ventilation is not adequate it's not where it needs to be so how do I fix my minute ventilation well I know it's rest trigger rate times tidal volume if I need to get my co2 down to get my pH back up then by increasing rate I will increase minute ventilation or if I increase tidal volume I will increase minute ventilation that will help remove co2 and and get our pH back up to a range that we like it okay that's just a few examples of the way these formulas are more driven towards theory based and I hope the NBR see by adding this calculator which I'm not against I'm in favor of and I don't care I just hope the test doesn't take a route to where the answers become driven I'm getting the correct number and eliminating everything that we just discussed just start talking through five basic formulas okay okay - I appreciate you asking me for my input on this let me know what this conversations are sounding like out there I would love to hear what what what the the old-timers as we call them are saying about it not being fair that you get to use the calculator look the knowledge level is in the Y's remember that be able to critically think through the formulas you're doing and apply them to your situation rather than a focus on good job you got the right number okay hope everybody's having a great day