CJRT Fall 2004, volume 40 (4)

Fall 2004, Volume 40 (4)

Features■■ Standards of Practice 13

■■ A Student’s Journey 19

■■ Nitric Oxide 20

■■ Inter-Observer Reliability of Alveolar Dead SpaceMeasurements 24

On Air■■ New Asthma Book 5

■■ Forum 2005 Information 6

Bewitching RRTMutual RecognitionAgreement 17

The journa l fo r re sp i ra to r yhea l th p ro fes s iona l s in Canada

La revue des professionnels de lasanté respiratoire au Canada

PUBLICATIONS MAIL AGREEMENT NO. 40012961REGISTRATION NO. 09846 RETURN UNDELIVERABLE CANADIAN ADDRESSES TO CSRT102 – 1785 Alta Vista DriveOttawa ON K1G [email protected]

IFC

SPIRIVA

NEW

4 COLOUR

for postion onlykey lines don’t print

Table of ContentsOn Air . . . . . . . . . . . . . . . . .5New Asthma Book Forum 2005 Message from the ChairNuggetsFanshawe Coordinator

President’s Message . . . . . .9

CSRT News . . . . . . . . . . . . . .11NRP ReportStandards of Practice

Special Interest Groups . . .18A Student’s JourneyNitric Oxide Letter

Scientific News 23AbstractsInter-Observer Reliability of AlveolarDead Space Measurements

Industry News . . . . . . . . . . .31French Glossary

The CJRT acknowledges the financial support of the Government ofCanada, through the Publications Assistance Program (PAP), toward ourmailing costs.

Cover Photo Blown of the broom — Joan Norgren, RRT at the Ottawa Hospital, getsready to cast a spell on patients at the Rehabilitation Centre. Everyoneagrees she is the best looking pulmonary witch on the premises.Photo by Carole Leblanc

For more photos please checkhttp://homepage.mac.com/colya/PhotoAlbum6.html

Autumn 2004 Canadian Journal of Respiratory Therapy — www.csrt.com 3

Contents ■ Table des matières

CSRT membership inquiries /Questions concernant l’adhésion à la SCTR :

102 – 1785 Alta Vista Dr.,Ottawa, Ontario, K1G [email protected]

Canadian Journal ofRespiratory Therapy

Revue canadienne dela thérapie respiratoire

Official Journal of the CSRTRevue officielle de la SCTR

CSRT Board Representative / Représentante duConseil d’administration de la SCTR Colya Kaminiaz, RRT

Managing Editor / Directrice de la rédactionRita Hansen

Consulting Editors / Rédacteurs-conseilMembers of the Scientific Review Committee

President. CSRT / Président, SCTRBrent Kitchen, RRT

The Canadian Journal of Respiratory Therapy (CJRT)(ISSN 1205-9838) is produced for RRT: The CanadianJournal of Respiratory Therapy, Inc., by the GraphicCommunications Department, Canadian PharmacistsAssociation and printed in Canada by Gilmore Printing.Publications mail registration no. 40012961. CJRT is pub-lished 5 times a year (in February, May, July, October andDecember); one of these issues is a supplement pub-lished for the Annual Educational Forum of the CanadianSociety of Respiratory Therapists (CSRT).

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., parCommunications graphiques de l’Association des phar-maciens du Canada et imprimée au Canada par HarmonyPrinting. Courrier de publications no 09846. La RCTRparaît cinq fois l’an (en février, mai, juillet, octobre etdécembre); un de ces numéros constitue un supplémentpublié pour le compte du Forum éducatif annuel de laSociété canadienne des thérapeutes respiratoires (SCTR).

Advertiser’s IndexSpiriva . . . . . . . . . . . . . . . . . . . . . . . . . IFC, PI 32, 33

Beausejour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Capital Health . . . . . . . . . . . . . . . . . . . . . . . . . . . IBC

Melouche Monnex . . . . . . . . . . . . . . . . . . . . . . OBC

On Air

4 Autômne 2004 Revue canadienne de la thérapie respiratoire — www.csrt.com

Welcome to the fall issue of theCJRT. There has been lots ofactivity at the CSRT over thesummer, much of which will bereported on in this issue.

The CSRT has some big issues todeal with in the coming months.At the Spring AGM the member-ship voted on making a bylawchange that would allow for a mail in voting process for thepurposes of changing CSRT Bylaws. All bylaw changes mustreceive the approval of Industry Canada before they areenacted. Industry Canada rejected this bylaw change.

The CSRT wanted this change to enable the organization tocanvass the entire membership, particularly on issues that mayhave regional variability, where the outcome might be influ-enced by the location of the Annual General Meeting.

One such issue is in regards to the CSRT's implementation ofthe Mutual Recognition Agreement. In this issue you will seea special message from the CSRT Board of Directors that willgive you more information on this important issue. You willalso be receiving information regarding this issue by mail.The CSRT is now going to call a special meeting of themembers, specifically for the purposes of resolving this issue. I strongly encourage you to read this special message fromyour Board of Directors, and contact the CSRT Head Office ifyou have any questions.

Another major issue is the implementation of the NationalCompetency Profile. This new profile will be the entry levelstandard for respiratory therapy. This document will also serveas the basis for school accreditation and exam development.This document will be rolled out at a meeting of educators inBanff, AB in early October. What makes this event so specialis that every regulatory and credentialing body for respiratorytherapy in Canada will be using this common standard.

The CSRT also continues to provide representation for RT’s onvarious national committees. In this issue we have a reportfrom Kathy Johnston, who represented the CSRT at theNeonatal Resuscitation Program Committee meeting inMontreal.

Continued on page 11

Welcome from Doug

Design and production / Conception et productionCanadian Pharmacists Association / Association des pharmaciens du Canada

Marketing and Advertising Sales / Marketing et publicitéKeith Health Care Inc.Mississauga 905 278-6700, fax 905 278-4850Montréal 877 761-0447, fax 514 624-6707

Classified Advertising / Annonces classéesCSRT102 – 1785 prom. Alta Vista Dr.Ottawa ON K1G 3Y6800 267-3422 or fax 613-521-4314

Subscriptions / AbonnementsAnnual subscriptions are included in annual membership to theCSRT. Subscription rate for 2004 for other individuals and institutionswithin Canada is $44 and $44(US) for others outside Canada. AllCanadian orders are subject to 7% GST / 15% HST as applicable.Requests for subscriptions and changes of address: Member ServiceCentre, CSRT, 102 - 1785 Alta Vista Dr., Ottawa ON K1G 3Y6.

L’abonnement annuel est compris dans la cotisation des membres dela SCTR. Le tarif annuel d’abonnement pour les non-membres et lesétablissements au Canada est de 44$ et de 44$ US à l’étranger. LaTPS de 7% ou la TVH de 15% est ajoutée aux commandes canadi-ennes. Veuillez faire parvenir les demandes d’abonnement et leschangements d’adresse à l’adresse suivante: Centre des services auxmembres, SCTR, 102 - 1785 prom. Alta Vista, Ottawa ON K1G 3Y6.

Once published, an article becomes the permanent property of RRT:The Canadian Journal of Respiratory Therapy, Inc., and may not bepublished elsewhere, in whole or in part, without written permissionfrom the Canadian Society of Respiratory Therapists, 102 - 1785 AltaVista Dr., Ottawa ON K1G 3Y6. / Dès qu’un article est publié, ildevient propriété permanente de RRT: The Canadian Journal ofRespiratory Therapy, Inc., et ne peut être publié ailleurs, en totalitéou en partie, sans la permission de la Société canadienne desthérapeutes respiratoires, 102 - 1785 prom. Alta Vista, Ottawa ONK1G 3Y6.

All editorial matter in CJRT represents the opinions of the authorsand not necessarily those of RRT: The Canadian Journal ofRespiratory Therapy, Inc., the editors or the publisher of the journal,or the CSRT. / Tous les articles à caractère éditorial dans le RCTRreprésentent les opinions de leurs auteurs et n’engagent ni le RRT:The Canadian Journal of Respiratory Therapy, Inc., ni les rédacteursou l’éditeur de la revue, ni la SCTR.

RRT : The Canadian Journal of Respiratory Therapy Inc. assumes noresponsibility or liability for damages arising from any error or omis-sion of from the use of any information or advice contained in theCJRT including editorials, articles, reports, book and video reviewsletters and advertisements. / RRT : The Canadian Journal ofRespiratory Therapy, Inc. décline toute responsabilité civile ou autrequant à toute erreur ou omission, ou à l’usage de tout conseil ouinformation figurant 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 thePharmaceutical Advertising Advisory Board. / Toutes les annonces demédicaments prescrits ont été approuvées par le Conseil consultatifde publicité pharmaceutique.

Doug Maynard

Welcome!

OnAir


New Educational Asthma Materials

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please contact our Asthma Action

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OOnn Air CSRT Educational

I would like to take this opportunity to invite you tocome and enjoy some western hospitality at the 2005CSRT Annual Education Forum and Exhibition. TheConference will be held June 2 to 5, 2005 at the ShawConference Centre in downtown Edmonton.

The Organizing Committee has been hard at work forseveral months planning this event. The educationmodules for the forum include Critical Care, Anesthesia& Perfusion, Leadership, Neonatology & Pediatrics,Diagnostics and “Taking Care of Me.” We have alreadyconfirmed several well-known speakers for our educa-tion symposium including:

Dr. Peter Papadakos, University of Rochester will bepresenting talks on ARDS: Treatment in Evolution,Update on Sedation and Management of Massive LungTrauma;

Dean Hess, Massachusetts General Hospital will pres-ent Approaches to the Discontinuation of MechanicalVentilation and Selection of Aerosol Delivery Devices;

Craig Scanlon, University of Medicine and Dentistry ofNew Jersey will talk on Assessing Competency andFostering Leadership Development through Mentoring

Richard Branson, University of Cincinnati will presentNutritional Support and the Pulmonary Patient andMechanical Ventilation: Past, Present and Future.

As well, panel discussions on Leadership andOpportunities and Barriers in Respiratory Research are also scheduled. Finally, an Educator’s Congress isscheduled for the afternoon of June 2. These sessionswill focus on various aspects of education and adultlearning.

What! All work and no play? Not likely — what’s aconference without some fun? Arrangements havebeen made for several social activities throughout theconvention. The official opening of the forum will takeplace on Thursday evening, June 2. The exhibitors willbe hosting a wine and cheese reception. The Fun Nightwill take place on Thursday, June 3 at Red’s in the WestEdmonton Mall. Plans are underway for a miniOlympics competition, simulated car races and theSputum Cup competitions. I’m sure there will also be

many other surprises throughout the evening. OnSaturday, June 4 there will be a formal banquet andawards presentation. The keynote speaker for theevening will be Mr. Stephen Lewis, Veteran Diplomatand UN Special Envoy for HIV/AIDS in Africa.

As you can imagine, organizing an event such as thisrequires a significant commitment from many people.I’d like to take a moment and introduce the membersof the 2005 Organizing Committee:

Speakers

Exhibitors

Registration

Social Events

I would like to thank each of these people for theirsupport and assistance with planning this event. Aswell, the ongoing assistance and support of DougMaynard and Rita Hansen from the CSRT Head Officehas been invaluable!

As always, your feedback is important to all of us.Please send any comments or suggestions [email protected]

Compassion in ActionA Message From Darcy Andres,CSRT Forum 2005 Chair

— Dallas Schroeder

— Ann Hudson-Mason and Linda Fontaine

— Janet Thomson and Leanne Grant

— Maggie Murphy and Cindy Bouw


OOnn Air Forum 2005Edmonton, Alberta

Consider extending your stay beyond Forum 2005and take in some of the many activities Edmontonhas to offer:

■ the world’s largest shopping centre and Alberta’snumber one attraction — West Edmonton Mall,with seven theme parks and an endless variety ofshopping and restaurants

■ explore Canada’s largest living history park — Fort Edmonton Park, as well as the ProvincialMuseum of Alberta, Muttart Conservatory, theAlberta Legislature Building and Odyssium(Edmonton’s space & science centre)

■ take a nature walk, voyageur canoe ride, goldpanning and other recreational activities year-round in the longest stretch of urban parkland inCanada, the North Saskatchewan River valley

■ attractions of the Old Strathcona heritage area

■ try your luck at one of six casinos

■ tee off at one of the 70 golf courses in the region.

■ discover the of wildlife at Elk Island National Parkwithin a few minutes of the city

■ drive from Edmonton are the majestic CanadianRockies — Jasper and Banff National Parks.

CSRT Forum 2005 — Call for AbstractsThe 2005 CSRT Annual Educational Forum, “Compassionin Action” will be held in Edmonton, Alberta. The Forumprovides opportunity for respiratory therapists to networkwith colleagues, engage in professional development,share experiences and enhance the practice of respiratorytherapy in Canada. To that end, the Planning Committeeinvites the submission of abstracts for poster presentationsat Forum 2005.

Abstracts may pertain to any area of respiratory therapyincluding clinical practice, program development, researchinvestigation, evaluation, and respiratory healthcare deliv-ery. Abstracts of no more than 250 words must be sub-mitted according to the attached guidelines and will bereviewed by a Panel using a blind peer review mechanism.Check the CSRT webside for details

A chance to win free registration for Forum 2006 will begiven in each of the following categories:■ Best Poster

■ Best Student Poster

What’s in Edmonton?

West Edmonton Mall

Edmonton at DuskPhoto: Edmonton Tourism/Economic Development Corporation

OOnn Air

ON AIR NUGGETS

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Exam Application DeadlineThe deadline for application to write theJanuary 2005 CSRT National Exam, isNovember 15, 2004. This exam will be writtenJanuary 10, 2005. Check the CSRT websiteunder RRT Credential for details.

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Fanshawe’s New ProgramCoordinatorAfter five years, Dennis Hunter has steppeddown from the position of ProgramCoordinator at Fanshawe College in London,Ontario. He will pursue new academicprojects and enjoy more teaching time. He is replaced by Sandy Annett as ofSeptember 1, 2005. Thank you for all your hard work and dedication, Dennis andwelcome aboard Sandy!

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On-Line Discussion Groups Are BackThe CSRT is re-introducing on-line DiscussionForums on the CSRT website. Our email-baseddiscussion forums are similar to the service for-merly known as the Listserv.

Log on and see what your peers are discussing.Areas currently available include Anesthesia,Managers, Patient Educators, Professional Practiceand Students.

Tap into this great communications tool. It’s freeand gives you an opportunity keep current onissues in your area of practice.

Share and opinion.Ask a question.

Sign up by choosing your area of interest — youcan find it on the website under Forums.

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RT Week October 3 – 9, 2004How are you promoting RT Week? Pleasesend us a paragraph on how you showcasedthe work of RTs in your area. Share yourexperiences with others to help profile ourprofession. Photos are welcome too! [email protected].

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Congratulations TerryTerry Boone, recipient of a CSRT HonouraryLifetime Membership, recently received hiscertificate from CSRT Past-President, Daniel Paré. Terry was unable to attend theEducational Forum in Toronto in May 2004.He was presented with his certificate in SaintJohn, New Brunswick. The CSRT HonouraryLifetime Membership recognizes memberswho have made significant contribution to the Society.

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RTSNS 40th AnniversaryThe RTSNS hosts it’s 40th AnniversaryEducational Conference and CelebrationOctober 22–23, 2004 in Halifax.

The conference will include sessions on topicsranging from anesthesia, sleep studies, homecare, neonatal/pediatric and adult respiratorycare. A social night to celebrate is alsoplanned.

For more information: www.rtsns.com


In the last CJRT I wrote about what I consider to be thechanging role of the CSRT. Because the profession hasbecome self-regulated (licensed) in some provinces andwill eventually be self-regulated in all provinces, theneed for the CSRT to provide its credentialling servicesto most RTs is diminishing. Right now, approximately80% of the RTs practicing in Canada come under thejurisdiction of a licensing body (AB, MAN, ON andQC). It’s clear that the CSRT must continue to becomean organization that focuses on providing services andbenefits to its members as well as representing theinterests of RTs, rather than focusing primarily on cre-dentialling issues. To offer more benefits and to have astronger voice the CSRT needs to be an organizationthat finds ways to include all Respiratory Therapists asequal members in our Society. As individuals we alsoneed to be involved in our provincial colleges andassociations to ensure that our interests are being repre-sented in discussions on regulation.

Recently the CSRT Long-range Planning Committeedeveloped a strategic direction for our organization. Its key points are:

“The CSRT shall serve its members by:

1. Maintaining the viability of the national society inorder to effectively represent the profession.

2. Enhancing member benefits.

3. Supporting respiratory therapy education and clinicalstandards.

4. Promoting development of the respiratory therapyprofession.”

This strategic direction was broken down to more spe-cific goals. The new CSRT Board of Directors is nowfocused on reaching these specific goals. To facilitatethis, the new CSRT Board has been restructured. EachDirector is now elected by the entire membership

rather than most of the Board being automatically com-posed of the Presidents of each provincial association.Each Director now represents all CSRT members acrossCanada and can focus their attention on CSRT issues.

The new Board had its first meeting in Toronto duringthe CSRT Education Forum. Each Director now has aspecific job description. The Board took all of the spe-cific goals of the CSRT and assigned each one to a spe-cific Director. Each Director now has a list of specificgoals to accomplish. Every Board member is now creat-ing a workplan to outline how the CSRT will reachthese goals. In November the Board will meet again toreview the workplan created by each Director. TheBoard will determine the top priorities and will beginto implement these plans. This is how we will getthings done and I believe how members will begin tosee significant changes in how they and the professionbenefit from the CSRT.

Other exciting changes are happening in the CSRThead office. Our new Executive Director has changedhow budgets are created, how expenses and revenuesare tracked as well as what specific projects cost orbenefit the CSRT. This is an important tool to tell ushow we can improve as an organization. Within thenext few months, the CSRT will be investing in a newdatabase system to offer services such as on-line regis-tration, to track the movement of our members betterand to give us important demographic information thatwill allow us to improve how we serve our members.

Have you seen the new CSRT website (www.csrt.com)that was launched last month? Have you seen the fan-tastic list of presenters for the 2005 CSRT EducationForum in Edmonton that is already available. The newlistserves, now called Discussion Forums and our newCSRT Standards of Practice are also on the site. TheBOD is also reviewing proposals to improve how we


Message from the President


Brent Kitchen

“Keep interested in your own career, however humble;

it is a real possession in the changing fortunes of time.”

— Max Ehrman, Desiderata

market our profession as part of an overall plan toimprove awareness. Changes are taking place becausewe are now better organized to serve our members andmore focused on what members want.

To carry out these changes we need your support. Themore volunteers and the more resources (ie. members)we have the sooner we can reach the goals RTs inCanada have. More respect, more autonomy, betterpublic awareness, a stronger national voice for the pro-fession, reciprocity in and outside of Canada as well asan improved ability to care for our patients througheducation and awareness. No time to volunteer? Workone day a year for your profession. For most of us oneday of work will pay for your annual CSRT member

ship dues and that is the least you can do for yourprofession. As professionals, we need to care for ourprofession too. The CSRT is working hard to serve youand to speak for you wherever the voice of RTs needsto be heard. Even with new a new focus, restructuring,comprehensive plans and new tools, the CSRT can’treach our goals without your support.

Brent Kitchen, RRTPresident, CSRT



Message from the President continued from page 9

Message du président

« Aime ton travail, aussi humble soit-il, car c’est un bien réeldans un monde incertain.» — Max Ehrman, Desiderata

Dans la dernière édition de la RCTR, j’ai parlé de ce que con-sidère être le nouveau rôle de la Société canadienne desthérapeutes respiratoires. Comme notre profession est dev-enue autoréglementée (brevetée) dans certaines provinces etqu’elle sera tôt ou tard autoréglementée dans l’ensemble desprovinces, il devient moins nécessaire pour la SCTR defournir ses services d’accréditation à la plupart desthérapeutes respiratoires. À l’heure actuelle, environ 80% desTR pratiquant au Canada relèvent de la compétence d’unorganisme de réglementation (en Alberta, au Manitoba, enOntario et au Québec). Il est clair que la SCTR doit continuerà être une organisation qui met l’accent sur les services et lesavantages livrés à ses membres, en plus de représenter lesintérêts des TR, plutôt que de s’en tenir surtout à des ques-tions de reconnaissance professionnelle. Pour offrir plus d’a-vantages et disposer d’une voix plus forte, notre Société doitdevenir le genre d’organisation qui multiplie les façons derassembler sur un pied d’égalité l’ensemble des thérapeutesrespiratoires. Nous devons également, à titre individuel, nousimpliquer dans nos associations et collèges provinciaux pourveiller à ce que nos intérêts soient représentés dans leséchanges concernant la réglementation de la profession.

Le comité de planification à long terme de la SCTR a récem-ment adopté une orientation stratégique pour notre organisa-tion. En voici les principaux éléments:

« La SCTR servira ses membres par les activités suivantes:1. Maintenir la viabilité de l’organisation nationale afin de

représenter efficacement la profession.2. Bonifier les avantages livrés aux membres.

3. Appuyer l’enseignement et les normes cliniques de lathérapie respiratoire.

4. Promouvoir les progrès de la profession de thérapeuterespiratoire. »

Cette orientation stratégique comprenait des objectifs plusspécifiques, que le nouveau Conseil d’administration de laSCTR s’occupe présentement à réaliser. Nous avons procédépour ce faire à une restructuration du nouveau C.A. de laSCTR. Chaque administrateur est maintenant élu parl’ensemble de notre effectif, plutôt que d’avoir un Conseilpresque automatiquement composé des présidents de chaqueassociation provinciale. Chaque administrateur représentemaintenant les membres de la SCTR de tout le Canada etpeut consacrer son attention aux enjeux de la SCTR dans sonensemble.

Le nouveau C.A. a tenu sa première réunion à Toronto,durant le Forum sur l’éducation de la SCTR. Chaque adminis-trateur possède maintenant sa propre description de tâches.Le C.A. leur a assigné individuellement chacun des objectifsspécifiques de la SCTR. Chaque administrateur a donc main-tenant une liste d’objectifs particuliers à réaliser et s’occupeprésentement à créer un plan de travail décrivant une façonpour la Société de réaliser ces objectifs. Le C.A. se réunira denouveau en novembre pour étudier les plans de travail crééspar chacun de ses membres. Il assignera des priorités etentreprendra la mise en œuvre de ces plans. Voilà commentnous allons faire les choses et comment nos membres vont, àmon avis, commencer à voir d’importants progrès dans lesavantages qu’apporte la SCTR aux TR et à leur profession.

Le bureau central de la Société connaît également deschangements stimulants. Notre nouveau directeur général achangé notre façon de préparer les budgets et de consignernos dépenses, nos recettes et ce que chaque projet particulier

Suite à la page 31


CSRT NEWS

The National Neonatal Resuscitation Program (NRP)Committee meeting was held in Montreal on June 15,2004. Robert Martell, the CSRT representative to thiscommittee, was in Shanghai at the time, as a memberof the International Neonatal Training Program. KathyJohnston attended the NRP meeting in his seat.

The structure of this committee will be changed in thefuture due to changes in governance and managementstructure at the level of the Heart and StrokeFoundation of Canada. The membership of this com-mittee will not change, reflecting the importance of amultidisciplinary committee committed to the issuessurrounding neonatal resuscitation.

The committee discussed the myriad of neonatalresuscitation issues currently being analyzed by theInternational Liaison Committee on Resuscitation(ILCOR). The ILCOR Consensus on Science Statementwill be published in December 2005. The newAmerican Academy of Pediatrics (AAP)/AmericanHeart Association (AHA) neonatal resuscitation guidelines will follow in January 2006. The revisedTextbook of Neonatal Resuscitation, 5th edition will beavailable in the spring of 2006.

The issues being discussed reflect the current ques-tions and controversies in neonatal resuscitation. Theyinclude intra-partum and post-partum management aswell as the strategies we use to instruct providers inNRP. These issues include, but are not limited to thefollowing:

■ Use of 100% O2 in neonatal resuscitation

■ Use of CO2 detectors to confirm ETT placement

■ Role of CPAP in the delivery room management ofthe neonate

■ Initial ventilation of the neonate in the delivery room

■ Strategies to avoid temperature instability

■ Management of meconium including the role ofamnioinfusion and intrapartum suctioning

■ Role of Naloxone

■ Validation of the current evaluation process for NRP providers

More information regarding these discussions isavailable on the NRP page of the AAP web site. URL is http://www.aap.org/nrp/nrpmain.html

There is much activity in NRP in all provinces andthere is always a need for more NRP Instructors andInstructor Trainers. The number of RespiratoryTherapists who are participating in these programs is high and our knowledge and expertise is valued.We are recognized by the National NRP Committee asan integral part of the delivery room management ofthe neonate and also as potential educators within theNRP training programs.

Kathy Johnston is an RRT, with the Educator, Respiratory Therapy DepartmentIWK Health Center, in Halifax. NS. Kathy representedthe CSRT on the Neonatal Resuscitation Program (NRP)Committee.

National Neonatal Resuscitation Meeting

Kathy Johnson, RRT

Welcome continued from page 4The CSRT continues to expand the services that it isproviding to its members. We continue to enhance our web-based services and have added subscriptionbased on-line discussion forums to the new website.We encourage all members to continue to provide uswith input on and content for the new website.

Also in this issue you will find an updated CSRTStandards of Practice, current information on the CSRT Forum 2005 to be held in Edmonton, AB, anupdate on the situation of Nitric Oxide in Canada, areport from the new Student Special Interest Groupand much more.

Finally, I would like to direct your attention to the Call for Nominations that you will also find in thisissue. The CSRT is looking for nominations for thepositions of President-elect and Treasurer. Taking aposition on the CSRT Board of Directors is a fantasticway to learn about your profession, and it will alsoprovide you with the invaluable opportunity to make a positive change in the working lives of all RT’s. If you are interested in your profession, pleaseconsider running for one of these positions.

Douglas Maynard BSc, RRT, MBAExecutive Director CSRT


CSRT News

New Standards of Practice Approved

The CSRT is very pleased to announce that theBoard of Directors has recently approved a newCSRT Standards of Practice Document.

Two of the goals of the CSRT are to supportnational standards for Respiratory Therapy and tofoster the development of the profession inCanada and internationally. With these goals inmind, the CSRT has recently completely updatedthe CSRT Standards of Practice.

The purpose of these Standards of Practice is toestablish and define a set of guidelines, whichwill guide and direct all members of the CSRT aseach pursues his or her profession. It is incum-bent upon all members to provide their servicesin a manner that instills a strong sense of trustand confidence between themselves and theiremployers, patients, clients, peers and all mem-

bers of the general public. Creating and abidingby a Standards of Practice document is one ofthe elements that demonstrates that RespiratoryTherapists are no longer technicians but are, infact, true professionals.

Information regarding Standards of Practice forRespiratory Therapists is oftenrequested by individual RTs, governments,employers and other professions. The CSRT'sability to provide this information on behalf of itsmembers is paramount as the CSRT continues tomarket the abilities of RTs and support the pro-fession in Canada and around the world.

A special thank you goes to Sandra Biesheuvel,CSRT Director of Human Resources, for leadingus in this project.

CSRT Call for NominationsThe CSRT requires nominations for the two(2) positions for the 2005 elections. Don’tmiss this chance to make a difference in yourprofession.

The two positions that will be vacant are:

1. President-Elect(becoming President and Past-President)

The position of President-Elect is a three-yearterm (one year for each term covered asPresident-Elect, President and Past-President).

2. TreasurerThe position of Treasurer will have a 2-yearterm.

The job descriptions and nomination forms for these two positions are available on the CSRT website www.csrt.com or can beobtained by contacting the CSRT head officeat 1-800-267-3422.

Each nominee must be a Registered Memberof the Society. Individuals may be nominatedby forwarding the nomination papers, dulysigned by five (5) Registered members ingood standing, to the Executive Director ofthe Society.

Original signatures must be on the nomina-tion forms sent to the CSRT Head office.

Send completed forms with original signaturesto:

Executive Director, CSRTSuite 102-1785 Alta Vista DriveOttawa ON K1G 3Y6

Deadline for Nominations is December 1, 2004


1. Specialized Body of KnowledgeRespiratory Therapists possess a specialized bodyof knowledge, and base the performance of their duties on Respiratory Therapy theory andpractice.

Respiratory Therapists are essential members ofthe healthcare team, and assume a variety ofroles in different areas of practice, such as clini-cal, education, health promotion, management,research, administration, and consulting.

Respiratory Therapists practice independently,interdependently, and collaboratively, and may practice within legislated professionalregulations.

2. Safe Practice and Application ofKnowledge and Technology

Respiratory Therapists safely and effectivelyapply their skills, knowledge, and judgmentbased on the needs of their patients.

Respiratory Therapists are committed to qualityoutcomes, and intervene so as to contribute tothe best possible outcomes for their patients.

Respiratory Therapists who are involved withtechnical procedures must do so in accordancewith any regional, provincial, or manufacturerstandards or recommendations. These proceduresmust incorporate best practice standards, andshould be research based.

Respiratory Therapists, in consultation withpeers, relevant others, equipment manuals, andCSA guidelines select, operate and maintainequipment to provide safe, effective care.

Respiratory Therapists ensure that all equipmentis appropriately cleaned, disinfected or sterilized,and is properly maintained and calibrated bytrained personnel.

Respiratory Therapists will notify and discusswith the physician if he or she feels the ordered

therapy/diagnostic procedure is inappropriate forthe patient's condition. The Respiratory Therapistmay refuse to perform such therapy/diagnosticprocedure if they feel that it is detrimental to thepatient. Such refusal must be made clear to thephysician and documented.

3. Communication and CollaborationRespiratory Therapists shall understand theobjective of the ordered therapy/diagnosticprocedure and clarify with the physician ifnecessary.

Respiratory Therapists will inform the patient ofthe therapy/diagnostic procedure that will beperformed, respecting the personal and legalrights of the patient including the right toinformed consent and refusal of treatment.

Respiratory Therapists will maintain effectivecommunication with members of the healthcareteam regarding the patient’s status and progress.

Respiratory Therapists will institute immediatesupportive measures and notify relevantmembers of the healthcare team in the event ofdeterioration of the patient's condition.

Respiratory Therapists will document allinformation relevant to the provision of care asper organizational policies and procedures.

4. AssessmentRespiratory Therapists will determine the initialclinical status of the patient, and ensure theordered therapy/diagnostic procedure is consis-tent and correct for the patient’s condition.

Respiratory Therapists will collect data from thepatient, family, members of the healthcare team,health records and reference material to identifythe patient’s level of function and relevant risksaffecting and factors contributing to the patient’shealth.

CSRT Standards of Practice

CSRT News


CSRT News

5. PlanningRespiratory Therapists will develop and imple-ment the plan of care in collaboration withmembers of the healthcare team.

Respiratory Therapists use evidence-basedknowledge in selecting strategies andinterventions.

Respiratory Therapists select strategies andinterventions according to their effectiveness,efficiency and suitability in relation to the goalsof the plan, and ensure that the goals of the planare appropriate for each patient.

Respiratory Therapists will maintain, modify, or discontinue the plan in consultation withmembers of the healthcare team.

6. EvaluationRespiratory Therapists will evaluate the effective-ness of strategies and interventions by compar-ing actual outcomes to anticipated outcomes.

Respiratory Therapists will use the results of theevaluation to improve policies and procedures in Respiratory Therapy practice related to patient care.

Respiratory Therapists will evaluate his/herperformance of individual procedures and over-all practice.

7. Professional Accountability andResponsibility

Respiratory Therapists are accountable formeeting the ethical and legal requirements of theprofession of Respiratory Therapy.

Respiratory Therapists shall follow soundscientific procedures and promote ethicalbehaviour in practice and in research.

Respiratory Therapists shall demonstrate behav-iour that reflects integrity, compassion, supports

objectivity, and fosters trust in the profession andits professionals.

Respiratory Therapists shall report unsafepractice or professional misconduct of a peer or other healthcare worker to appropriateauthorities.

Respiratory Therapists will provide care withoutdiscrimination on any basis, with respect for therights and dignity of all individuals.

Respiratory Therapists shall refrain fromindiscriminate and unnecessary use of resources,both economic and natural, in their practice ofthe profession.

Respiratory Therapists promote diseaseprevention and wellness.

Respiratory Therapists promote the growth of theprofession, and present a positive image ofRespiratory Therapy to the community.

8. Continuing Education andCompetenceRespiratory Therapists are committed to life-longlearning to upgrade their knowledge and skillsin order to keep their practice current.

Respiratory Therapists shall assume responsibilityfor maintaining competence in their practice ofRespiratory Therapy, and seek opportunities forprofessional growth.

Respiratory Therapists shall acknowledgelimitations in their knowledge, skills, or judg-ment, and function within those limitations.

Respiratory Therapists strive for excellence in theprofession by participating in, and promoting theuse of self-assessment tools and feedback fromappropriate others to determine and improvetheir knowledge, skills, and judgment.

CSRT Standards of Practice


This is an important message from the CSRTPresident and Board of Directors regarding theCSRT and the full implementation of the MutualRecognition Agreement (MRA). Please read thefollowing information, as you will be asked toparticipate in person or by proxy at a SpecialMeeting of the CSRT membership for thepurpose of resolving this issue. You will receiveor may have already received more informationon this meeting by mail.

The following information is intended to provideyou with the some of the history and majorpoints of discussion regarding this issue. Weencourage you to discuss this issue with yourcolleagues, to check the CSRT website and tocontact the CSRT Head Office if you have anyquestions or input regarding this issue. At the2004 AGM the CSRT asked for a bylaw change toenable the Society to address issues like thisthrough special mail-out ballots. Although mem-bers voted to accept the mail-out ballot bylawchange, Industry Canada rejected it. So, in orderto have this MRA implementation issue addressedand in-keeping with the intent to have all mem-bers participate in this important decision, theCSRT will have a special meeting and a mail-outof proxies, as allowed for under CSRT bylaw,rather than ballots.

History In 1994 governments within Canada signed theAgreement on Internal Trade (AIT). The AITincludes a chapter on the movement of workerscalled the Labour Mobility Chapter. The objectiveof the Labour Mobility Chapter is to enableworkers qualified for an occupation in one partof Canada to have access to employment in thatoccupation everywhere in Canada.

Article 708 of the Labour Mobility Chapterinstructs Parties “to mutually recognize the occu-pational qualifications required of workers of anyother Party” and to “reconcile differences inoccupational standards.” Also under the chapter,Parties agree to assess occupations and whenthey are very similar, Parties must agree to recog-nize the qualifications of workers from otherjurisdictions without requiring additional testing,assessment or training. If there is insufficientinformation to make that determination, Partiesagree to participate in an occupational analysis.The analysis should determine whether or notthere is sufficient commonality to allow formutual recognition of qualifications. The intent is to have a full inter-provincial reciprocityagreement for each occupation within Canada.

The CSRT and RT regulatory bodies (The LabourMobility Consortium for Respiratory Therapy)have met to find a way to recognize each other’scertification processes because provincial govern-ments demand it. After reviewing the practice ofRTs in all of the provinces, the group concludedthat there was a level of commonality of greaterthan 90% among practicing RT’s across Canada.The group decided that RTs in Canada are simi-lar enough that we can recognize each other’slicensing/certification processes and we canwork towards bridging differences.

What does this mean for Respiratory Therapy?Provinces must comply with AIT. The bodies thatlicense, credential or register workers in eachprovince must therefore comply as well. CARTA,MARRT, CRTO and OPIQ license RTs in theirprovinces. Jurisdictions without self-regulation, ingeneral, use the CSRT RRT credential as a meansof credentialling RTs. To comply with AIT thesegroups must find a way to either accommodateeach other’s licenses/credentials or attempt toharmonize their processes.

Important Message

Implementation of the Mutual RecognitionAgreement

CSRT News


CSRT News

In 2002 the regulators and the CSRT signed aMutual Recognition Agreement (MRA), which isessentially an inter-provincial reciprocity agree-ment between each of the regulatory bodies andthe CSRT. The agreement stipulates that theParties agree to develop a common competencyprofile (a list of what RTs need to be competentin to work as a RT across Canada) as a steptoward harmonizing our process. After surveyingRTs in each province in Canada in 2003, aNational Competency Profile (NCP) forRespiratory Therapy was developed. All regulato-ry bodies and the CSRT have agreed to beginusing this new standard to accredit our educa-tional institutions and to create entry-to-practiceexams. What this means is that every school, inevery province in the country will be teachingto, and will be accredited to the same standard.

What does this mean for theprofession?The NCP was developed based on three individ-ual occupational profiles that were all consideredto be greater than 90% congruent. The Collegeand Association of Respiratory Therapists ofAlberta commissioned an independent study tocompare the new NCP with the current CSRTOccupational Profile. This analysis found the twoprofiles to be greater than 90% similar. Thismeans that changes in the way we currentlyteach and assess individuals entering the practiceof respiratory therapy will most likely be small.This also means that any future changes made tothe National Competency Profile and therefore tothe entry level competencies of the professionwill be made by, and adopted by every jurisdic-tion in the country. We will begin to move for-ward as one profession instead of the differentfactions that we currently operate in.

The CSRT signed the MRA. The MRA stipulatesthat, because the practice of RTs is so similaracross Canada all signatories to the agreementwill accept each other’s licenses and/or creden-tial. This means that if an RT holds unrestrictedRRT status in one jurisdiction, the individual willbe granted a license or credential to work in anyof the other jurisdictions as long as they havebeen working for at least 6 months and haveparticipated in a recognized continuing educationprogram. The CSRT, because of its bylaws, is notyet fully implementing this agreement. If we donot implement this agreement, and are no longera member of the National Alliance we will nolonger be able to participate in determining theentry to practice standards in Canada. The CSRTcould possibly have influence as an observer butwe would drastically decrease our effectivenessin advocating for national standards for ourprofession.

We want to make it clear that not participating inthe MRA does not mean that RT's won't be ablemove between jurisdictions. What it does meanis that individuals with the CSRT RRT credentialthat want to move into a regulated jurisdictionmay have to go through an accommodationmechanism (ie. an exam) established by thatjurisdiction. RTs in the non-regulated provinceswould not have reciprocity with the regulatedprovinces in Canada.

The future for the CSRT and theprofessionMost CSRT members will want to know what thedown side is. One argument that has been putforward is that this will potentially dilute theCSRT credential and lower the standards. We willbe granting the CSRT RRT credential to individu-als that may have gone through a different

Important Message — continued



CSRT News

process than current CSRT members. The CSRT'sresponse to this concern is that in Canada, allschools will be accredited by the CSRT's CoARTEaccreditation process. All graduates will be fromprograms that have met the same standard. Theonly factor that remains a variable is which entryto practice exams are accepted. With all entry topractice exams now being based on the sameprofile we feel that the high level of commonali-ty that currently exists will only increase.

The CSRT requested information from individualsthat had voiced opposition to this bylaw change,however we had not received any informationby the time this issue of the CJRT went to print.We would still like to hear from individuals thatmay oppose this change and we encourage youto contact the CSRT Head Office.

Therefore, the CSRT Board of Directors is goingto be asking for approval to revise our bylaws togrant the CSRT RRT credential to those alreadylicensed and working in the regulated provincesas per the MRA that we have agreed to. To beincluded in the MRA and to qualify for the CSRTcredential, RTs must work the equivalent of 6 months of full-time and maintain a professionalportfolio in the province they are licensed inbefore they are eligible. A copy of the MRA canbe found on the CSRT website. Each of the regu-latory bodies now accepts RTs with the CSRTRRT credential and grants them a license. TheCSRT needs to reciprocate. If we do not, we can-not expect the regulatory bodies to continue toaccept CSRT credentialled RTs without additionaltesting and assessment. Without this bylawchange not all RTs will have free movement asprofessionals in Canada. This change is particu-larly important to those RTs working in the non-regulated provinces. Without the CSRT being asignatory to the Mutual Recognition Agreementon their behalf, there is no way for these RTs to

freely move to regulated provinces withoutexpecting to undergo assessment and testing. With the diversity in the profession, with differ-ences in practice across Canada and differencesthat often exist in cities and even RT depart-ments, RTs in Canada are not all exactly thesame. The CSRT negotiated and signed the MRA.The survey that created the National CompetencyProfile and the analysis which compared the newNCP to the CSRT Occupational Profile are two ofthe very few objective reviews of RT practice inall of Canada. They prove that our practice ismore than 90% the same. We as RTs have differ-ences, but we are similar enough to accept eachother's credentials. If we want unrestricted inter-provincial mobility for all RTs in Canada and ifwe want the CSRT to grow and be able to advo-cate for RTs when it comes to advancing practicestandards we need to make this bylaw change.

CSRT Board of DirectorsAugust 23, 2004

The 4th National Canadian COPD Alliance Conference will take place in Montréal, November 26–28, 2004.

This conference targets family physi-cians, respirologists, respiratory thera-pists, physical therapists, nurses, dieti-cians, pharmacists and social workers.

For detailed information:www.lung.ca/CCA/conference

COPD the standard of care

Important Message — continued



All-Can Medical

Brathwaites Olivier Medical Incorporated

Cardinal Health

Carestream Medical Limited

Daytex-Ohmeda (Canada) Incorporated

London Scientific Limited

Methapharm Incorporated

ProResp/ProHealth

Respan Products

Roxon-Universal Medical

Source Medical Corporation

Tyco Healthcare

VitalAire Canada Incorporated

The CSRT wishes to acknowledge the on-going support of our Corporate

Members. Sponsorship by ourCorporate Members helps the CSRT

maintain the current standards of excellence in the profession.

Thank you!

CSRTCorporate Members

2004 – 2005

SPECIAL INTEREST GROUPS

Another summer has come and gone, and with thebeginning of fall comes a another new class ofRespiratory Therapy students. It is my pleasure towelcome this year’s class to the world of RespiratoryTherapy. As we prepare for another year of lectures,clinical rotations and all of the other wonderful thingsthat come with being a Respiratory Therapy student,we must take some time to step back and enjoy it all;to soak it all in.

This edition of the Journal features an article submit-ted by a Dalhousie University student who discussesher experiences on clinical rotations at different hospi-tals from the East Coast to the West. It is certainly arelevant topic as students prepare to undertake clinicalrotations throughout this year, and as hospitals pre-pare to welcome us and to show us clinical aspects ofRespiratory Therapy.

I would also like to take this opportunity to announcethe appointment of a Co-Chairperson to the Group,Melissa McPherson-Brown of Fanshawe College.Melissa is entering her 3rd year in Respiratory Therapyand will play an integral role in the development andmaintenance of the Group.

We are looking for original student submissions forupcoming editions of the CJRT. This can include litera-ture reviews, patient case presentations, or other formsof research conducted by, or in part by students.Furthermore, we have set up an on-line e-mail Forumfor students, educators and others involved in aspectsof Respiratory Therapy Education to share ideas and

opportunities. Be sure to log on to our website andget involved. Encourage others to do the same.

Have a great upcoming school year, and I look for-ward to hearing from you all with some fresh, newideas.

CSRT Student Special Interest Group

Jason Nickerson, Chairperson, CSRT Students Special Interest Group


Special Interest Groups

Are we ever really done? This is one question I don't need to ponder. Myanswer is No. This spring I completed the Diplomaportion of the Respiratory Therapy Program atDalhousie University, allowing me to enter the profes-sion as a working RT. Still, I am far from done. I willreturn to Dalhousie for another year to obtain aBachelor of Health Science Degree. In the blink of aneye, three years have passed. It seems like only ashort time ago, I was trying to remember if it was thebig “A” that stood for alveolar.

My patient professors had explained the fundamentalsof Respiratory Therapy. They provided us with theknowledge to think for ourselves. Still, no matter howmuch I studied, or how many equations that I couldrhyme, the best way for me to learn is by doing. One of the best chances to learn by doing is duringclinical rotations.

Throughout my program, I had three full time clinicalrotations that occurred at the end of each year.Rotations allow students to stay in Halifax at theQueen Elizabeth II Health Science Center or to travelto an external site. The professors believe that theexternal rotations are of such importance that every-one is required to do at least one. I have done two,and in spite of the financial load to travel to anothercenter, I recommend the experience.

My last clinical rotation was extremely advantageousbecause it was so close to when I would be steppinginto the profession myself. On April 30 I journeyedfrom Halifax, Nova Scotia to Edmonton, Alberta. As I traveled I nervously anticipated what the next fewmonths would be like. Would the technology inAlberta be so different that I would appear inept? Ihad to trust that my education would allow me toadapt in my new situations. Arriving at the Universityof Alberta Hospital, my eyes widened. Was I at thehospital or a huge mall? Had it not been for the mantoting an IV pole, I might have asked to be sure. I had not yet experienced such a large hospital, whichemploys more than a 100 RTs. The first day provided my introduction to different

technology. The familiar 7200’s I had been using werenot to be found. Instead, I was introduced to theEvita's. It was not long before I came to understandand use the different types of ventilators and BiPAPmachines in the supply room. This ability is certainlydue in a large part to Clive. When I said that I hadnever used an Evita before, he grabbed the test lungand said “Go ahead then.” He fielded my many ques-tions as I made my way through screens of modesand alarms. Eventually we worked though a variety ofequipment. Once I had hurtled the technology differ-ences, I began to realize that eventually it all cameback to basic fundamentals. With a manual and somehelpful advice, new technologies are not intimidating.Just don’t ask me to fix them!

I have had the chance to work with many great RTs.There is one that I will attempt to model my ownpreceptoring skills after. A personable, energetic RTnamed Paul whom I spent the majority of time withwhile in the Emergency Department at the Universityof Alberta Hospital. His method of quizzing, coupledwith positive comments is a technique that I learnedwhen I was becoming a swimming instructor. It wascalled the sandwich technique. Tell the learner some-thing positive, then give a constructive criticism, thenfollow with another positive comment. No matter ifyou are 4 or 24, this encourages improvements andreinforces strengths

Overall the adventure from East to West was of fantas-tic benefit to me. The opportunity to immerse myselfin an area very different from the one in which I hadtrained, showed me new ideas, technologies, equip-ment and some new tricks. Across the country much issimilar, although the technology or terminology usedmay differ slightly. The fundamental principals remain.

All RTs must know similar essential information, how-ever I strongly believe there is considerably more thatwe can learn from each other. The RTs at the QEIIHSC have taught me a wealth of knowledge. Yet bytraveling far outside my area I gained the opportunityto learn from many other excellent RTs as well.


A Students Journey; Benefits of Training inTwo Distant Hospital Systems

J. Marie Matheson, RRT

Inhaled NO therapy is now standard therapy in many ICU settings. The following letter from our dedicatedcolleagues at Summit Technologies, summarizes the recent history of the business of NO from both aCanadian and International perspective, and provides important information for RRTs. The understanding of physiology gained by RRTs in the last ten years, as a result of the clinical application this simple molecule( NO*) is truly amazing. The applications of NO* reach far beyond the pulmonary system. On behalf of theCSRT, I wish to thank our innovative Canadian RRT colleagues at both Pulmonox Medical Corporation andSummit Technologies ( ViaSys ) who have developed Nitric Oxide therapy to the standard it is at today inCanada, and I wish them continued success in the new challenges and opportunities.


Special Interest Groups

Nitric Oxide GasWrae Hill BSc RRT Director Professional Advocacy, CSRT Manager Respiratory Therapy, University of Alberta Hospitals


Foundation News

The CSRT and Medigas, congratulate the respira-tory therapy team from Acadie-Bathurst HealthAuthority. They are the recipients of this year’sMedigas Award. The all-volunteer team consistsof 25 respiratory therapists from 4 sites acrossnorthern New Brunswick. Team members havewith between one and twenty years experience.

Their focus has been on building awareness ofrespiratory issues in schools, industries, pharma-cies, nursing homes and family physician’s office.They have created a very successful smokingcessation program. The team has taken part in avariety of special events including the CanadaGames in Bathurst in 2003; Lung Run with theNew Brunswick Lung Association; RespiratoryTherapy Week activities; Smog Alerts and partici-pated at conferences on various RT topics.

This team has been actively involved in the onlyfrancophone summer camp dedicated to childrenwith asthma, outside of Québec. This asthmacamp has been operational since 1994 and hasroom for 24 children between 9 and 12. Theyhave made a great difference in their community!

The Acadie-Bathurst team effort shows a long-term commitment that goes beyond the regularjob. The team was awarded the Medigas Awardat the CSRT Annual Educational Forum held inToronto in May, 2004.

Medigas, A Praxair Health Care Company, thatemploys respiratory therapists, wished toacknowledge the contribution of respiratorytherapists as members of the Health Care Team.Medigas and the Canadian Respiratory Therapy

Foundation have worked together in developedthe Medigas award. This award is to be present-ed to a Department or Group of RespiratoryTherapists who, through their efforts, promotethe profession of Respiratory Therapy. TheMedigas award is a $2,500 education grant. The award is open to Respiratory Therapists who are active in any facet of the profession.Criteria and an application form for this awardcan be found on the CSRT website underFoundation.

Medigas Award Winners

FOUNDATION NEWS

Daniel Paré, Chairman of the Canadian RespiratoryTherapy Foundation and Jan Taylor of Medigasannounced the first winners of the Medigas Award atthe CSRT Educational Forum in Toronto in May.


CALENDAR OF EVENTSOctober 5 – 9, 200417th Congress of the EuropeanSleep Research SocietyPrague, Czech [email protected]

October 7, 200415th Annual Meeting of theEuropean Society forComputing and Technology inAnesthesia and Intensive CareToulouse, [email protected]

October 10 – 13, 200417th Annual Congress of theEuropean Society of IntensiveCare MedicineBerlin, Germanywww.esicm.org

October 14 – 17, 200414th World Congress of theInternational Society of Cardio-Thoracic SurgeonsBeijing, [email protected]

October 18 – 19, 2004The 16th Annual EdmontonPalliative Care ConferenceCalgary, Albertawww.palliative.org

October 21– 24, 2004Canadian Society of Allergy andClinical Immunology 2004Annual Scientific MeetingOttawa, Ontariohttp://csaci.medical.org/

October 22 – 23, 2004RTSNS Fall ConferenceHalifax, Nova Scotiawww.rtsns.com

October 22, 200417th annual Meeting ofAmerican Society of CriticalCare AnesthesiologistsLas Vegas, [email protected]

October 23 – 27, 2004Canadian Cardiovascular Congress 2004Calgary, Albertahttp://www.ccs.ca/

October 23 – 28, 2004CHEST 2004 – AACP’s 70thAnnual International ScientificAssemblyand the Clinical World

Congress on Diseases of theChestSeattle, [email protected]

October 23 – 27, 2004Canadian CardiovascularCongressCalgary, Albertahttp://www.ccs.ca/

October 23 – 26, 2004American Society ofAnesthesiologists AnnualMeetingLas Vegas, Nevadahttp://www.asahq.org/

October 24 – 26, 200414th Annual Canadian HomeCare Association ConferenceHalifax, Nova Scotiahttp://www.cdnhomecare.on.ca/

November 15 – 17, 2004Ontario Hospital AssociationHealthAchieve2004Toronto, Ontariohttp://www.oha.com/oha/ohawm.nsf?OpenDatabase

November 26 – 28, 2004Canadian COPD Alliance —Raising the Standard of CareMontréal, Québecwww.lung.ca/CCA/conference

December 4 – 7, 200450th International RespiratoryCongressAmerican Association forRespiratory CareNew Orleans, Louisianahttp://www.aarc.org/

Foundation News

CSRT AwardsDeadlinesApplications are now beingaccepted for the SummitTechnologies Award inRespiratory Excellence. This award focuses on theareas of respiratory careinvolving direct patient care,education or research. Thedeadline for applications isDecember 15, 2004.

Other award deadlines are also coming up — The RobertMerry Memorial Award isJanuary 31, 2005; TheAstraZeneca Award ofExcellence in AsthmaEducation is due March 31,2005 and the EducationAward for AdvancedRespiratory Practice isFebruary 1, 2005.

Please check the Foundationssection of the CSRT websitefor eligibility details on allthese awards.


Evidence-Based Clinical Practice Guideline forthe Prevention of Ventilator-AssociatedPneumonia Peter Dodek, MD, MHSc; Sean Keenan, MD, MSc(Epid);Deborah Cook, MD, MSc(Epid); Daren Heyland, MD,MSc(Epid); Michael Jacka, MD, MSc; Lori Hand, RRT; John Muscedere, MD; Debra Foster, RN; Nav Mehta, MD;Richard Hall, MD; and Christian Brun-Buisson, MD, for theCanadian Critical Care Trials Group and the CanadianCritical Care Society

Annals of Internal Medicine 17 August 2004 | Volume 141 Issue 4l Pages 305-313

Background: Ventilator-associated pneumonia (VAP) is animportant patient safety issue in critically ill patients. Purpose: To develop an evidence-based guideline for theprevention of VAP. Data Sources: MEDLINE, EMBASE, and the CochraneDatabase of Systematic Reviews. Study Selection: The authors systematically searched forrelevant randomized, controlled trials and systematicreviews that involved mechanically ventilated adults andwere published before 1 April 2003. Data Extraction: Physical, positional, and pharmacologicinterventions that may influence the development of VAPwere considered. Independently and in duplicate, theauthors scored the validity of trials; the effect size and con-fidence intervals; the homogeneity of results; and safety,feasibility, and economic issues. Data Synthesis: Recommended: The orotracheal route ofintubation, changes of ventilator circuits only for each newpatient and if the circuits are soiled, use of closed endotra-cheal suction systems that are changed for each new patientand as clinically indicated, heat and moisture exchangers inthe absence of contraindications, weekly changes of heatand moisture exchangers, and semi-recumbent positioningin the absence of contraindications. Consider subglotticsecretion drainage and kinetic beds. Not recommended:Sucralfate to prevent VAP in patients at high risk for gas-trointestinal bleeding and topical antibiotics to prevent VAP.Because of insufficient or conflicting evidence, no recom-mendations were made about systematically searching formaxillary sinusitis, chest physiotherapy, the timing of tra-cheostomy, prone positioning, prophylactic intravenousantibiotics, or intravenous plus topical antibiotics.Limitations: No formal economic analysis was performed,and patient perspectives were not considered. Conclusion: If effectively implemented, this guideline maydecrease the morbidity, mortality, and costs of VAP inmechanically ventilated patients.

Inspiratory Muscle Training Improves LungFunction and Exercise Capacity in Adults WithCystic Fibrosis* Stephanie Enright, PhD, MPhil, MSc; Ken Chatham, MCSP;Alina A. Ionescu, MD; Viswanath B. Unnithan, PhD, MScand Dennis J. Shale, MD * From the School of Health Care Professions (Dr. Enright),University of Salford, Manchester, UK; Llandough HospitalNHS Trust (Mr. Chatham, and Drs. Ionescu and Shale),Cardiff, Wales, UK; and Exercise Science Department (Dr.Unnithan), Syracuse University, Syracuse, NY.

Correspondence to: Stephanie Enright, PhD, MPhil, MSc,School of Health Care Professions, University of Salford,Manchester, M6 6PU, UK; e-mail: [email protected] objectives: To investigate the effects of high-intensity inspiratory muscle training (IMT) on inspiratorymuscle function (IMF), diaphragm thickness, lung function,physical work capacity (PWC), and psychosocial status inpatients with cystic fibrosis (CF). Design: Twenty-nine adult patients with CF were randomlyassigned to three groups. Two groups were required to com-plete an 8-week program of IMT in which the training inten-sity was set at either 80% of maximal effort (group 1; 9patients) or 20% of maximal effort (group 2; 10 patients). A third group of patients did not participate in any form oftraining and acted as a control group (group 3; 10 patients). Interventions: In all patients, baseline and postinterventionmeasures of IMF were determined by maximal inspiratorypressure (PImax), and sustained PImax (SPImax); pulmonaryfunction, body composition, and physical activity statuswere also determined. In addition, diaphragm thickness wasmeasured at functional residual capacity (FRC) and totallung capacity (TLC) [TDIcont], and the diaphragm thickeningratio (TR) was calculated (TR = thickness during PImax atFRC/mean thickness at FRC). Subjects also completed anincremental cycle ergometer test to exhaustion and twosymptom-related questionnaires, prior to and followingtraining. Results: Following training, significant increases in PImaxand SPImax (p < 0.05), TDIcont (p < 0.05), TR (p < 0.05),vital capacity (p < 0.05), TLC (p < 0.05), and PWC (p <0.05) were identified, and decreases in anxiety scores (p <0.05) and depression scores (p < 0.01) were noted in group1 patients compared to group 3 patients. Group 2 patientssignificantly improved PImax and SPImax (both p < 0.05)only with respect to group 3 patients. No significant differ-ences were observed in group 3 patients. Conclusion: An 8-week program of high-intensity IMTresulted in significant benefits for CF patients, which includ-ed increased IMF and thickness of the diaphragm (duringcontraction), improved lung volumes, increased PWC, andimproved psychosocial status. Key Words: diaphragm thickness • exercise tolerance •lung volumes • respiratory muscle training

(Chest. 2004;126:405-411.)© 2004 American College of Chest Physicianshttp://www.chestjournal.org/cgi/content/abstract/126/2/405

Abstracts

SCIENTIFIC NEWS


Inter-Observer Reliability of Alveolar Dead SpaceMeasurements in Suspected Pulmonary Embolism

IntroductionPulmonary Embolism (PE) is a common, lethaland treatable condition that is only present in aminority of those investigated with suspectedPE.1-3 PE is responsible for 5–10% of all in-hospi-tal deaths.3-5 However, less than 35% of patientssuspected of having PE actually have PE.6-8

Without a simple and reliable way of excludingPE at the bedside, many patients without PEmust be hospitalised and anticoagulated whileawaiting confirmatory testing with eitherventilation-perfusion (V/Q) scans, pulmonaryangiograms or non-invasive leg studies.

Physiologic dead space ventilation representsventilation of those parts of the lung notinvolved in gas exchange. Physiologic deadspace has two components: anatomical deadspace and alveolar dead space. Anatomical deadspace represents ventilation of the airways,which are minimally involved in gas exchange.Alveolar dead space represents ventilation ofthose alveoli that are not involved in gasexchange i.e. alveoli that are not or poorly per-fused. Many authors have demonstrated thatmeasures of physiologic and alveolar dead spaceincrease in pulmonary embolism.9-16

Investigations to date have not, however, beenable to demonstrate and validate a technique of

Scientif ic News

Marc A. Rodger MD*, Gwynne Jones MD*, Helene Djunaedi RRT, Christopher N. Bredeson MD* and Philip S. Wells MD*.*From the Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; From the Department of RespiratoryTherapy, Ottawa Hospital — General Campus, Ottawa, Ontario, Canada; Study conducted at the Ottawa Hospital —General Campus

Objective: Less than 35% of patients suspected of hav-ing pulmonary embolism (PE) actually have PE. Safebedside methods to exclude PE could save health careresources and improve access to diagnostic testing forsuspected PE. Recently, interest has been generated inusing alveolar dead space measurements to exclude PEat the bedside. Prior to widespread adoption of alveolardead space measurement in patients with suspected PEthe reproducibility of these measurements must bedemonstrated. We sought to determine the inter-observ-er reliability of three previously published techniquesof alveolar dead space fraction measurement.Design: Prospective cohort study.Setting: Tertiary care center in Ottawa, Ontario,CanadaPatients: Consecutive inpatients, outpatients oremergency room patients with suspected PE referred to Nuclear Medicine or Radiology for investigation ofsuspected PE.Interventions: All study patients had alveolar deadspace measurement performed by three techniques bytwo different respiratory therapists blinded to eachother’s results and outcome (PE or No PE).

Main Results:The steady state end tidal alveolar dead space fractionmeasurement had a Kappa of 1.00 indicating excellentinter-observer agreement. The alveolar plateau deadspace fraction measurement and the end expiredalveolar dead space fraction measurements had Kappascores less than 0.3 indicating poor inter-observeragreement.Conclusions: Alveolar plateau and end expiredalveolar dead space fraction measurements have poorreproducibility. Steady state end tidal alveolar deadspace fraction measurement is a simple reproduciblebedside test.Keywords: Pulmonary embolism, alveolar dead space,Kappa, diagnosis and reproducibility.

Abbreviations: PE – Pulmonary EmbolismV/Q scan – Ventilation Perfusion scanRT – Respiratory Therapist AVDSf – Alveolar Dead Space FractionPaCO2 – Concentration of carbon dioxide in arterial bloodPETCO2 – End tidal carbon dioxide PEPCO2 – Plateau expired carbon dioxide PEECO2 – End expired carbon dioxide

Abstract


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alveolar dead space measurement that is near100% sensitive for pulmonary embolism.9-15 Thishas limited the acceptance of this potentialdiagnostic tool in the management of patientswith suspected PE. Recently, interest has beenrekindled in using these measures in combina-tion with other sensitive bedside tests (namely D-Dimer measurement) to exclude pulmonaryembolism at the bedside. Kline used arterial toend -tidal CO2 differences (PETC02) to measurealveolar dead space fraction (AVDSf) in a studyof 170 ambulatory patients suspected of PE. Thismethod of measuring the alveolar dead spacefraction was 88% sensitive (95% confidence inter-val of 70–98%) and had a negative predictivevalue over 97% (92–99%).15 Kline further showedthat the combination of a negative latex D-Dimerand an end tidal alveolar dead space fraction ofless than 0.2 had a negative predictive value of100% (95% confidence interval of 96 to 100%).15

We recently described a technique of steady stateend tidal alveolar dead space fraction measure-ment that, in combination with D-Dimer, appearsuseful in excluding pulmonary embolism at thebedside.16 A steady state end tidal alveolar deadspace fraction less than 0.15 excluded PE with asensitivity of 79.5% (95% confidence interval of63.5–90.7%), a negative predictive value of 90.7%(95% confidence interval of 82.5–95.9%) and aspecificity of 70.3%. The combination of a nega-tive D-Dimer and a steady state end tidal alveolardead space fraction less than 0.15 excluded PEwith a sensitivity of 97.8% (95% confidence inter-val of 88.5–99.9%), a negative predictive value of98.0% (95% confidence interval of 89.4–99.9%)and a specificity of 38.0%.

However, prior to widespread adoption of this potentially useful diagnostic test the inter-observer reliability of alveolar dead space frac-tion measurements must be demonstrated andreported. Here we report on the reproducibilityof the previously published methods of estimat-ing alveolar dead space in patients with suspect-ed PE namely, steady state end tidal alveolardead space fraction measurements, alveolarplateau dead space fraction measurements and end expired alveolar dead space fractionmeasurements.

MethodsInclusion CriteriaConsecutive patients referred for V/Q scanning at the Ottawa General Hospital who were sus-pected of having pulmonary embolism wereapproached for consent to participate in thestudy between April 1998 to August 1998.

Exclusion CriteriaPatients were excluded from the study if they:1. were less than 18 years of age, 2. were unable to give informed consent, 3. had a contraindication to pulmonary

angiography,4. were ventilated or 5. were in the final stages of terminal disease.

Alveolar Dead Space MeasurementsConsenting study participants, between April 11998 to August 15 1998, had two respiratorytherapists independently and blindly performalveolar dead space fraction measurement bythree techniques: 1. steady state end tidal alveo-lar dead space fraction measurement; 2. the alve-olar plateau dead space fraction measurement;and 3. end expired alveolar dead space fractionmeasurement. Each patient had two separate res-piratory therapists perform alveolar dead spacefraction measurements using the three tech-niques. The results of the alveolar dead spacemeasurements obtained by one respiratory thera-pist were not provided to the second respiratorytherapists. The respiratory therapists were alsounaware of the outcome of investigations forsuspected pulmonary embolism, physicianassessments and the D-Dimer results.

These methods were taught in a two-hour train-ing session to the approximately 40 respiratorytherapists in our institution. The sitting patientbreathed through an airway adapter attached to amouthpiece. The airway adapter had a main-stream CO2 and volume sensor ( CapnoSTAT andCOSMO+ by Novametrix Medical Systems Inc.New Haven, Connecticut, USA). This devicemeasures breath by breath volume with an accu-racy of +/- 50ml and CO2 with an accuracy of 2 mmHg. The calibration of the device was


confirmed prior to each use with a known gas(4% CO2). Once the patient had stabilised (respi-ratory rate +/- 2 breaths per minute over 2 min-utes) the RT recorded this as the stable respirato-ry rate. With the patient breathing at the stablerespiratory rate, the end tidal CO2 was recordedif it was stable (+/- 1 mmHg over 2 minutes)(PETCO2). Arterial blood gas was then obtainedby a single arterial blood gas puncture but onlyif the patient was breathing at the stable respira-tory rate and the stable end tidal PCO2

(PETCO2). The alveolar plateau pCO2 (PEPC02)was measured as follows: If a plateau was seenon Phase III of the expired breath capnogramduring tidal breaths we recorded this as theplateau pCO2 (PEPC02). If a plateau was not seenduring regular tidal breaths we asked patients todeeply expire. Patients were coached to expireas deep as possible at the end of a normal tidalinspiration. We recorded the plateau CO2 valueduring the deep expired breath as the plateaupCO2 (PEPCO2). Finally, we recorded the endexpired pCO2 on the deep expired breath as theend expired pCO2 (PEECO2).

The respiratory therapist calculated the steadystate end tidal alveolar dead space fraction asfollows:Steady State End tidal AVDS Fraction = PaCO2 – PETCO2

PaCO2

PaCO2 = Concentration of arterial carbon dioxide inarterial blood with the patient breathing at the stablerespiratory rate and stable end-tidal CO2.PETCO2= Stable end tidal PCO2

The respiratory therapist calculated the alveolarplateau dead space fraction as follows:Steady State End tidal AVDS Fraction = PaCO2 – PEPCO2

PaCO2

PaCO2 = Concentration of arterial carbon dioxide inarterial blood with the patient breathing at the stablerespiratory rate and stable end-tidal CO2.

PEPC02= Alveolar plateau PCO2

The respiratory therapist calculated the endexpired alveolar dead space fraction as follows:End Expired AVDS Fraction = PaCO2 – PEECO2

PaCO2

PaCO2 = Concentration of arterial carbon dioxidein arterial blood with the patient breathing at thestable respiratory rate and stable end-tidal CO2

PEEC02= End expired PCO2

Data AnalysisThe inter-observer reliability of each method ofalveolar dead space measurement was deter-mined by calculating a two rater unweightedKappa statistic. Kappa (K) is defined as:

K= Po-Pe1-Pe

where Po is the actual probability of agreementand Pe is the expected agreement by chance.17

A kappa score above 0.8 is considered excellentreliability, a kappa score above 0.6 is consideredgood reliability and a kappa score below 0.4 isconsidered poor reliability.17 Exact binomialninety-five percent confidence intervals were cal-culated for each kappa.

Pearson correlation coefficients were also calcu-lated to compare the correlation of the PETCO2,PEPCO2, PEECO2 and the volume of expiredbreaths measured by the two different respiratorytherapists.

ResultsFifty-eight patients were approached to partici-pate. Forty-eight completed a single RT assess-ment and 33 completed two RT assessments. Allof these 33 patients were able to undergo twosteady state end tidal alveolar dead space meas-urements however three of these patients did notcomplete a deep expired breath. Twenty-threerespiratory therapists performed the 129 assess-ments that are the subject of this analysis.

Steady state end tidal alveolar dead spacemeasurements had excellent reproducibility

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(see Tables I and IV). The two components ofthis measurement individually also had excellentreproducibility: 1) PETCO2 measurements had aPearson correlation coefficient of 0.839; andPaCO2 measurements had a Pearson correlationcoefficient of 0.919.

Alveolar plateau dead space measurements hadpoor reproducibility (see Tables II and IV). )PEPCO2 measurements by the independentobservers were moderately correlated with aPearson correlation coefficient of 0.668.

End expired alveolar dead space measurementshad poor reproducibility (see Tables III and IV).PEECO2 measurements by the independentobservers were poorly correlated with a Pearsoncorrelation coefficient of 0.136. The volumes ofthe deep expired breaths upon which thePEECO2 measurements were based were alsopoorly correlated with a Pearson correlationcoefficient of 0.136.

DiscussionPulmonary embolism is a common, lethal yettreatable disease. The diagnostic management ofsuspected pulmonary embolism is limited by thelack of specificity of ventilation perfusion scan-ning.6 Safe and reliable bedside methods toexclude PE are desirable. We and others havedemonstrated that alveolar dead space measure-ments in combination with D-Dimer are poten-tially safe bedside tests to exclude PE.15,16

However, prior to widespread adoption of thesetechniques the inter-observer reliability of thesetechniques of alveolar dead space measurementmust be demonstrated. In this paper we haveshown that steady-state end-tidal alveolar deadspace measurement is reproducible but alveolarplateau and end expired techniques of alveolardead space measurement are not reproducible.

Dead space ventilation represents ventilation ofthose parts of the lung not involved in gasexchange. Gas is exchanged in the alveoli(Alveoli are represented in Figure 1 as the circlesin the Tracheo-Broncho-Alveolar unit schema).In alveoli, oxygen diffuses from the alveolar gasto the blood vessels and carbon dioxide diffuses

from the blood vessels to the alveoli (blood ves-sels represented in Figure 1 as double linesinterfacing with the alveoli). Physiologic deadspace has two components: anatomical deadspace and alveolar dead space. Anatomical deadspace is ventilation of the airways. The airwaysconduct air to the alveoli and are minimallyinvolved in gas exchange. Alveolar dead spacerepresents ventilation of those alveoli that arenot involved in gas exchange i.e. alveoli that arenot perfused.

Robin first published the concept of using theend tidal CO2 to arterial CO2 difference in thediagnosis of pulmonary embolism in the NewEngland Journal of Medecine in 1959.9 He sug-gested that an estimate of alveolar dead spacecould be derived from an expired breath capno-gram. An expired breath capnogram tracing isshown in Figure 1. This tracing demonstrates acarbon dioxide concentration versus time curvefor an expired breath. Phase I of the curve isthought to represent the emptying of large air-ways. These large airways aren’t involved in gasexchange and hence have the same carbon diox-ide concentration as inspired air (i.e. negligible).Phase II represents emptying of a mixture of air-ways and alveoli and hence has an increasingamount of carbon dioxide. Phase III representsemptying of alveoli (shown as a solid line in

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Figure 1 — Dead Space

Schematic of Tracheo-Broncho-Alveolar lung unit, acapnograph (CO2 vs Time) tracing of a normal tidalbreath and the Alveolar Dead Space Fraction equation.


Scientif ic News

normal patients on the capnograph tracing inFigure 1). Alveoli that are involved in gasexchange have high carbon dioxide concentra-tions. The increased contribution of dead spacealveoli to expired alveolar gas in pulmonaryembolism patients results in a diminished slopeof Phase III (phase III in pulmonary embolismpatients is marked with dashed line in Figure 1).An estimate of alveolar dead space can beexpressed in the form of an equation, the alveo-lar dead space fraction, as shown in Figure 1.PaC02 represents the arterial blood C02 concen-tration that is obtained routinely at the bedsideby arterial blood gas sampling. PEC02 is theexpired breath C02 concentration obtained froma capnograph tracing. PEC02 can be obtainedfrom one of many points in Phase III. Thesepoints include: 1) the end of Phase III of normaltidal breaths i.e. the end tidal C02 concentration

(PETC02),9,10,18 the alveolar plateau C02 concen-

tration (PEPC02)15,19 or at the end of a deep

expired breath (PEEC02).10,20

Alveolar dead space fraction may increase in dis-ease states other than pulmonary embolismincluding obstructive lung disease and other pul-monary vascular conditions.11,12 Physiologic fac-tors may influence alveolar dead space includingposture, lung volume and ventilatory pattern.11,13

Previous authors have suggested that alveolardead space fraction should only be measuredunder steady state conditions (i.e. in a patientwith a stable respiratory rate and end tidal car-bon dioxide).11 The data presented here supportthese assertions.

The plateau and end expired method of alveolardead space fraction measurement had poorreproducibility. This seems to result from theneed for at least some patients to deeply expirefor both techniques. Deep expiration is bothpatient effort dependent and patient comprehen-sion dependent and as we demonstrated the vol-umes of deep expired breaths are poorly repro-ducible between measurements. Inconsistentdeep expired breaths resulted in variable PEPCO2

measurements and PEECO2 measurements whichin turn contributed to poorly reproducible alveo-lar dead space measurements. In addition, the

plateau method requires a respiratory therapists’interpretation of a plateau on a capnograph trac-ing further introducing inter-observer variation inthis method of alveolar dead space fractionmeasurement. These factors likely contribute tothe poor reproducibility we observed with theplateau and end expired methods. This studycalls into question the generalisability of methodsof alveolar dead space measurement that rely onplateau or end expired PCO2 measurement.

The steady state end tidal alveolar dead spacemeasurement does not require any alteration in a

Table I — Inter-observer reliability of steadystate end tidal alveolar dead space fractionmeasurements

Observer #2

Steady state endtidal

AVDS fraction*<0.2


AVDS fraction*>0.2


AVDS fraction*<0.2

29 0


AVDS fraction*>0.2

0 4

Observer # 1

Table II — Inter-observer reliability of alveolarplateau dead space fraction measurement

Observer #2Plateau

AVDS fraction*<0.1

PlateauAVDS fraction*

>0.1


<0.121 7


>0.11 1

Observer # 1


Scientif ic News

patient’s breathing pattern or a respiratory thera-pist’s interpretation of what constitutes a plateau.As shown in this study, steady state end tidalalveolar dead space measurement had excellentreproducibility (see Table I and IV). If care istaken to ensure that alveolar dead space meas-urements are conducted on a sitting patient withstable respiratory rate and stable end tidal carbondioxide, good inter-observer reliability and repro-ducibility is achievable. However, further valida-tion of the reproducibility of steady state end

tidal alveolar dead space measurement in otherclinical settings (e.g. primary or secondary caresettings) and other centers will be required.

In conclusion, plateau and end expired alveolardead space fraction measurements appears tohave poor inter-observer reliability. Steady stateend tidal alveolar dead space measurementsappear to have excellent inter-observer reliabilityin patients with suspected pulmonary embolism.Further development of alveolar dead spacemeasurements as a diagnostic tool for suspectedPE should focus on steady state end tidal alveo-lar dead space measurements.

AcknowledgementsWe are grateful to Dr. Alan Karovitch and themany busy clinicians that completed data collec-tion forms including Dr. Jim Quinn and Dr. MarkReardon. Many thanks to Dr. Francois Raymondand the staff of the Nuclear Medicine Departmentfor there co-operation. Similarly, many thanks toDenise Blanchette, and the many RespiratoryTherapists who participated co-operated and pro-vided valuable input in alveolar deadspace analy-sis. Thank you to Jane Browing and Ted Taborfrom Novametrix for valuable input and supportwith alveolar dead space measurement. Thanksto Julie Beck and Ann Marie Harkness for datacollection, data entry and analysis. Thanks toMichèle Willson for assistance in preparing thismanuscript.

Financial support obtained from theOntario Thoracic SocietyRunning title: Inter-observer reliability of alveolar spacemeasurements

Address correspondence and requests for reprints to Dr. Marc Rodger, Suite 7205, Ottawa Hospital - GeneralCampus, 501 Smyth Road, Ottawa, Ontario, K1H 8L6,Canada. Telephone 613-737-8981, fax 613-739-6102,e-mail [email protected].

Table III — Inter-observer reliability of endexpired alveolar dead space fraction measurement

Observer #2End expired

AVDS fraction*<0.1

End expiredAVDS fraction*

>0.1


<0.124 3


>0.13 0

Observer # 1

Table IV — Inter-observer reliability of alveolardead space measurements

Predictor Kappa Lower95% CI

Upper95% CI

AVDSf <0.2 –Steady state end tidal

AVDS fractionmeasurement method

1.000 1.000 1.000

AVDSf <0.1 –Plateau AVDS fraction measurement method

0.104 -0.238 0.421

AVDSf <0.1 –End Expired

AVDS fractionmeasurement method

-0.111 -0.199 -0.023


Scientif ic News

References1. Anderson FA, Wheeler-Brownwell H, Goldberg J, et

al. A population-based perspective of the hospitalincidence and case-fatality rates of deep vein throm-bosis and pulmonary embolism. Arch.Intern.Med.1991;151:933-938.

2. Silverstein MD, Heit J, Mohr DN, Petterson TM,O’Falloon WM, Melton LJ. Trends in the incidence ofdeep vein thrombosis and pulmonary embolism: a25-year population-based study. Arch Int Med1998;158:585-93.

3. Nordstrom M, Lindblad B. Autopsy-verified venousthromboembolism within a defined urban popula-tion--the city of Malmo, Sweden.APMIS.1998;106:378-84.

4. Dismuke SE and Wagner EH. Pulmonary embolismas a cause of death. The changing mortality in hos-pitalised patients. JAMA 1986;255:2039-2042.

5. Dalen JE, Alpert JS. Natural history of pulmonaryembolism. Prog.Cardiovasc.Dis.1975;17:257-270.

6. PIOPED Investigators. Value of the ventilation/perfu-sion scan in acute pulmonary embolism.Results ofthe prospective investigation of pulmonaryembolism diagnosis study (PIOPED). JAMA1990;263:2753-2759.

7. Wells PS, Ginsberg JS, Anderson DR, et al. Use of aclinical model for safe management of patients withsuspected pulmonary embolism. Ann Intern Med1998;129:997-1005

8. Hull RB, Hirsh J, Carter CJet al. Pulmonary angiogra-phy, ventilation lung scanning, and venography forclinically suspected pulmonary embolism withabnormal perfusion lung scan. Ann.of Intern.Med.1983;98:891-899.

9. Robin ED, Julian D, Travis D, Crump C. A physiologicapproach to the diagnosis of acute pulmonaryembolism. New Engl J Med 1959;260:586-591.

10. Hatle L, Rokseth R. The arterial to end-expiratorycarbon dioxide tension gradient in acute pul-monary embolism and other cardiopulmonary dis-eases. Chest 1974;66:352-357.

11. Erikson L, Wollmer P, Olsson CG, et al. Diagnosis ofpulmonary embolism based on alveolar dead spaceanalysis. Chest 1989;96:357-362.

12. Burki NK. The dead space to tidal volume ratio inthe diagnosis of pulmonary embolism. Am RevRespir Dis 1986;133:679-685.

13. Burton GG, Fowkes WC. Effect of posture on arte-rial-alveolar carbon dioxide gradient and physiolog-ic dead space measurements. Am Rev Resp Dis.1965;92:806-809.

14. Massumi RA, Nutter DO. The arterial to end-expira-tory carbon dioxide tension gradient in acute pul-monary embolism and other cardiopulmonary dis-eases. Chest 1974;66:352-357.

15. Kline, J.A.; Israel,E.G.; Michelson,E.A.; O’Neil,B.J.;Plewa,M.C.; Portelli,D.C. Diagnostic accuracy of abedside D-dimer assay and alveolar dead-spacemeasurement for rapid exclusion of pulmonaryembolism: a multicenter study. JAMA2001;285(6):761-768.

16. Rodger MA, Jones GN, Rasuli P, Raymond F,Djunaedi H, Bredeson C, Wells PS. Steady-stateend-tidal alveolar dead space fraction and D-Dimer:Bedside tests to exclude pulmonary embolism.Chest 2001;120(1):115-119.

17. Flack VF, Afifi AA, Lachenbruch PA, Schouten HJA.Sample size determinations for the two rater kappastatistic. Psychometrika 1988;53:321-325.

18. Nutter DO. and Massumi RA. The arterial-alveolarcarbon dioxide tension gradient in the diagnosis ofpulmonary embolus. Diseases of the Chest.1966;50:380-387.

19. Vereerstraeten J, Schoutens A, Tombroff M, et al.Value of measurement of alveolo-arterial gradientof PCO2 compared to pulmonary scan in diagnosisof thromboembolic pulmonary disease.Thorax1973; 28: 306--312.

20. Grosbois JM., Bart F., Douay B. et al. Intérêt de laconcentration expiratoire maximale de CO2 (CEMCO2) pour le diagnostic négatif de l’embolie pul-monaire aiguë au cours de bronchopneumoniechroniques obstructives. Rev Mal Resp. 1995; 12:35-41.

A Student’s Journey; continued from page 19

I have heard the saying, “Students must string theirown pearls,” by taking from each preceptor a gem ortwo. I would like to thank my many preceptors fromboth east and west for the wonderful pearls of wisdomthey have given me. I know that I will continue to addto my string from co-workers and hope that I willbestow some gems to others.

It is because we work in a field of innovation that apractical education is required to prepare future RTsfor situations that do yet exist. As each situation willcontinue to be different, we will draw on our experi-ence to make decisions, and although our experiencewill grow, there will always be new challenges.

Which is why we are never really done.

Janice Marie Matheson, RRT, is a CSRT member and is aGraduated Respiratory Therapist and Primary CareParamedic living in Halifax N.S, working as a casual RTat the Queen Elizabeth II Health Science Centre. Thisfall, she will complete her final year for an Bachelor ofHealth Science Degree at Dalhousie University.


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The “Glossaire canadien sur la prestation sécu-ritaire des soins et services au patient” is nowavailable on-line. This Glossary was an initia-tive of Le Centre hospitalier de l’Université deMontréal (CHUM), in partnership with theRoyal College of Physicians and Surgeons ofCanada and is sponsored by Health Canada. It was created to meet the needs of Franco-phone managers, clinicians, researchers and patients.

Since 2000, Canadian national and provincialhealth organizations have consulted each otheron issues related to patient safety within healthand social services. They identified a need fora glossary on patient safety terms. Terms in theGlossary were identified from recognizedresources and research in patient safety.Dictionaries, glossaries and a wide range ofother health care reference resources fromAustralia, Canada, the United Kingdom and the U.S. formed the core resource of thedevelopment process.

With at least 372 terms, the Glossary wasdeveloped in accordance with the values andobjectives shared by the authors of the Englishedition and by the Canadian Patient SafetyInstitute (CPSI). The 223-page pdf glossary canbe downloaded from the Le Centre hospitalierde l’Université de Montréal website at:http://www.chumontreal.qc.ca/pages/publications.htm

s u r l a p re s tat i o n s é c u r i ta i re d e s s o i n s e t s e rv i c e s a u p at i e n t

g l o s s a i re c a n a d i e ns u r l a p re s tat i o n s é c u r i ta i re d e s s o i n s e t s e rv i c e s a u p at i e n t

g l o s s a i re c a n a d i e n

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Message du président — suite de lapage 10 coûte ou apporte à la SCTR, Il s’agit d’un outil primordialpour apprendre la façon d’améliorer notre organisation. D’iciquelques mois, la SCTR investira dans un nouveau systèmede base de données afin d’offrir des services comme l’adhé-sion en ligne, de mieux repérer les mouvements de notreeffectif et de nous fournir d’importantes données démo-graphiques qui nous aideront à mieux servir nos membres.

Avez-vous vu le nouveau site Web de la SCTR(www.csrt.com), inauguré le mois dernier? Avez-vousremarqué, toujours sur notre site, le fantastique répertoire desspécialistes qui prendront la parole au Forum sur l’éducation2005 de la SCTR, à Edmonton? Surveillez nos nouvelles listesde discussion et nos nouvelles Normes de pratique de laSCTR. Notre C.A. se penche également sur des propositionsvisant à améliorer la façon dont nous faisons valoir notreprofession, dans le cadre d’un programme général demeilleure sensibilisation. Ces changements ont lieu parce quenous sommes maintenant mieux organisés pour servir nosmembres et mieux informés de leurs souhaits

Cependant, la mise en œuvre de ces avancées requiert votresoutien. Plus nous disposerons de bénévoles et de ressources(c.-à-d. de membres), plus nous atteindrons rapidement lesobjectifs des TR au pays : plus de respect, plus d’autonomie,une meilleure sensibilisation du public, une voix plus fortepour la profession à l’échelon national, des mécanismes deréprocité tant au pays qu’au-delà de ses frontières et unecapacité accrue de servir notre clientèle grâce à l’éducation età la sensibilisation. Pas le temps de vous porter volontaire?Consacrez une journée par an à votre profession. Pour laplupart d’entre nous, une journée de travail suffit à payervotre cotisation annuelle de la SCTR; c’est bien le moins quevous pouvez faire pour votre métier. Notre conscience pro-fessionnelle doit également s’appliquer à notre profession. LaSCTR travaille fort pour vous servir et pour parler en votrenom partout où la voix des TR doit être entendue. Maismême avec sa nouvelle orientation, une restructuration, desplans de travail détaillés et de nouveaux instruments, la SCTRne saurait atteindre ses objectifs sans votre appui.

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Compétences requises :■ Avoir complété avec succès un cours de formation en thérapie respiratoire;■ Être membre en règle de l’Association canadienne des thérapeutes

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CJRT Fall 2004, volume 40 (4)