Talking All Things Cardiopulm
This podcast is designed to discuss heart and lung conditions, treatment interventions, research, current trends, expert opinions and patient experiences.The goal is to learn, inspire and bring Cardiopulm to the forefront of conversation.
Talking All Things Cardiopulm
Episode 83: Nomenclature Matters
Time and time again, across my career, whether I’ve been in the clinic or teaching, I have come across words in healthcare that are either used interchangeably, go by different names, or simply have changed over time.
Nomenclature issues can lead to confusion, errors, and miscommunication, while also limiting data collection for research.
Join me on this opinion piece about nomenclature and share your nomenclature nuances.
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Welcome to Talking All Things Cardiopulm. I am your host, r Rachel Barisi, physical therapist and board-certified cardiopulmonary clinical specialist. This podcast is designed to discuss heart and lung conditions, treatment interventions, research, current trends, expert opinions and patient experiences. The goal is to learn, inspire and bring cardiopalm to the forefront of conversation. Thanks for joining me today, and let's get after it.
Rachele Burriesci:Today's episode is sponsored by Jane, a clinic management software and EMR. Now we all know that choosing the right EMR can feel a bit overwhelming, especially when you're just starting out. You're trying to juggle both your practice needs and your budget, and that's not always the easiest combo. Well, that's why Jane came up with the new balance plan. It includes the essential features you need to keep things running smoothly in your clinic without the extra stuff you don't. One-on-one telehealth, unlimited support, email reminders and more are included, no matter which plan you choose. So if you're looking for an EMR that helps you focus on your patients, not your cost, Jane is here for you, just like a part-time assistant. Plans start as low as $39 a month in the US. Visit Janeapp backslash pricing to learn more and if you're ready to get started, use my code CARDIOPULM1MO at the time of signup for a one- month grace period on your new account. Thanks again, Jane. All right, welcome back.
Rachele Burriesci:I guess we'll talk about the patio first, because we have officially missed our deadline. But we are so close, so I made this unofficial deadline last week for October 23rd. I was like it's a Wednesday, it is very likely that we will finish up on time and it was, you know, just a goal to set, and so we are so damn close. We got a ton done last Wednesday. We are. We almost planned perfectly. When we created the space that we were going to pave out, we didn't count the pavers to make it square. We made it square to the original patio and we are probably like a quarter of an inch off on a paver size. So every paver on the outer edge needs to get cut. And let's just talk about difficulty with cutting pavers. They're not very smooth, they crack, they break, they're brittle. It's very hard to do a clean cut and then if you have to adjust it. So the last bit is going to be a little bit tedious, but for the most part we've made some really good headway and we are almost done. And, even more importantly, we are going to have maybe one pallet left on the front driveway in a very short period of time and I am so excited for that. So I was hoping we would finish tomorrow.
Rachele Burriesci:But we have rain coming in. We've had a pretty windy two days. Rem has been a scaredy cat. She is actually in her crate at the moment. It's relatively warm this week, you know, more than seasonably warm, and I think we had highs in the 80s through the weekend. Yesterday was low 80s, but the wind was about 50 mile an hour gusts and today's supposed to be up to 70. So the wind here is just out of control. Really had to hold down everything in the yard so it doesn't blow away yesterday, so this week might be a wash. So just hoping that we get to finish this before it gets too cold, because that would not be a great way to end this project. So hopefully we'll tarp it again. It worked last week when it rained and so hopefully that'll hold us over until we have a little more time to finish up.
Rachele Burriesci:Last week I wrote an email to my newsletter and if you are not on my newsletter, click the link below. First of all, just in the world of newsletter, I've kind of, you know, try to figure out what would be the best use of said email. And some you know I'm talking about Cardiopalm on Instagram, on the podcast, on YouTube. So sometimes it's a little less Cardiopalm specific, but in the last few weeks I have been leaning more towards some Cardiopulm topics and opinions and things like that and I'm probably going to lean more that way in the future as well. Plus, it's a great place for you to know if I'm hosting any courses or MPTE prep material comes out, things like that. So if you're not on my email list, click the link below and please join.
Rachele Burriesci:But last week I talked about nomenclature because I was quite frustrated and I did not put out a podcast last week because what I thought was going to be a quick, just double check myself turned into a giant rabbit hole, and so I'm still kind of cleaning up some references and making sure things are tidied up. So what was I looking up? I was looking up oxygen devices. So just in the world of oxygen devices, my plan is to have just a free PDF for you guys to have a quick reference guide for specific devices the FiO2 that's available, the flow rate that's available and maybe any PT indications or concerns, and there's a few things like clinical questions that have come up, that you get different answers from different people, and so I was trying to add those into some of the PT considerations, including things like the addition of extension tubing, right? So extension tubing has been shown to be fine with a normal nasal cannula, and I believe the distance is up to 100 feet. Now, in theory, a normal nasal cannula only goes up to six liters flow. So then my question is what happens when we have higher flow rates and we increase the distance? Is that going to eventually decrease FiO2? So it's just a question that I've had. I get different answers from different people and I really can't find the answer in the literature, so I'm working on that. That's probably not going to come out this week because literally that information does not exist, and so I am like bound and determined to find it.
Rachele Burriesci:And another piece is and I have known this for years because, depending on where you work depends on the brand of a device that's being used, and sometimes there's differences. So when I worked at the VA in Michigan, I was literally one mile apart from two different hospitals. I worked at two different places with similar physicians, and I had different protocols, different brand name items, different things right Just off by minutia, but still different, right? Not black and white. A lot of variability. So I have taught oxygen devices in residency and in DPT programs and I have a lot of this information available and ready to go.
Rachele Burriesci:But I always double check references and ranges prior to doing presentation, podcast, yada, yada, because I like to give the most up to date information, like to give the most up-to-date information, and I also like to make sure that the information is consistent across the board and that if you take the information that you can use it readily. So I'm going to have to put the disclaimer that there is variability. Every textbook I have double checked, in every article I have read variability, even in things as simple as nasal cannula, which should be the most straightforward one, to six liters with a 4% increase in FiO2, top FiO2 being 44%, and I've seen different end ranges for that. So, with that being said, you're the brand that is at your hospital. So what I do recommend just kind of blanket statement, and I think I said this last time is that if you have a device, before taking it out of the package, if you have the opportunity is look at the paper inside. It usually gives you instructions on use, which would include something like how many liters flow it's capable of and or FIO2 availability, but that's not what this is about. I do want to say one more thing. We updated our router and it has not connected to our mesh network because a new router, basically, is a mesh and I'm having some weird stuff with my internet, so hopefully I'm not cutting in and out Now. Obviously, if I do, I'll probably have to record this, re-record this, but just if I'm a little glitchy, that's why. So apologies for that, but let's talk a little bit about nomenclature. If you've ever come to any one of my presentations, I think there is usually some slide related to nomenclature, because there is so much variability in healthcare that it kind of makes it I don't know. I don't have a better word than annoying.
Rachele Burriesci:I did a CSM presentation on pulmonary hypertension in 2017. When I was doing that presentation, one of the biggest problems with defining pulmonary hypertension with the groupings of pulmonary hypertension was its naming, and so pulmonary hypertension is kind of what you hear right, that's the most common verbiage you hear. But when there is literature and medications specific to pulmonary hypertension, they're typically talking about group one pulmonary hypertension, which is pulmonary arterial hypertension, pah, not just PH. It sounds like minutia but it's not, because if you're not clear about the name or the group, then it's going to create misinformation about interventions available medications available treatment, available research, available stats available. And one of the biggest problems with pulmonary hypertension is the variability in naming In the literature. It's hard to then come up with information. So they created this registry called the reveal registry. It was for 20 or 30 years, I think. It ended in somewhere around the 2017 marker and then they started another one, and one of the biggest things was that the names didn't match up. So how many people have pulmonary hypertension?
Rachele Burriesci:My title of the lecture was redefining rare pulmonary hypertension. Redefining rare because we keep calling this thing rare, but I keep seeing it in almost every patient that I'm seeing. What is rare is the group one pulmonary arterial hypertension. This is not a podcast about pulmonary hypertension, but the point is that when we name things, we have to be very mindful about naming it, and now this is something that you and I are not involved with. We're usually just kind of the victims of said naming, and I think it's important that when you are teaching of said naming, and I think it's important that when you are teaching, when you are in clinic, that you are utilizing appropriate names to things, because it can create confusion and errors and problems.
Rachele Burriesci:So when I moved to the Midwest and I was orienting to a new hospital, I kept feeling like I was learning these new devices. I was like I've never heard of that. So here in the Midwest they say core pack. So you know you're doing your competency or orientation to said devices that you might see and I'm like I have no idea what a core pack is. A core pack is a Dobhoff, a Dobhoff tube.
Rachele Burriesci:So something that you also might see in clinic is that we might use brand names for certain things and device names for others, right? So naming becomes an issue, right? You're calling something by a brand name Foley is one of those things, right? Like Foley catheter, something by a brand name. Foley is one of those things, right. Like Foley catheter Brand name. There's a whole bunch of those brand name versus actual device name that you'll see quite a bit.
Rachele Burriesci:Diagnosing names COVID, my COVID lecture. I had a whole slide on names COVID-19, sars-cov-2, long COVID. Long hauler, post-acute sequelae something, something. Pacs, post-acute COVID sequelae. There's like 14 different names for long hauler. It creates confusion, it creates errors and it creates difficulty in gathering data in research. Another one that drives me nuts is auscultation. So Rails switched to Crackles years ago, before I was even in residency. So pre-2013, rails had already switched to Crackles. But you have to learn both, because you still see rails in the literature and rails in documentation and people articulating rails in clinic. Well, if you never heard what rails is, you have to learn both terms, otherwise you're going to be lost.
Rachele Burriesci:Wheezes I've talked about this one before. I'm going to say it again because I'm doing a podcast on nomenclature about this one before I'm going to say it again because I'm doing a podcast on nomenclature. Why did we switch Ronkai to low-pitched wheezes? Why it didn't need a change. Its name was its name, it was distinct, it had purpose, it was defined, we knew it meant mucus. Why do we have to switch it to wheezes? So Ronkeye is now low-pitched or coarse wheezes, but it's kind of just grouped in with wheezes. So now sometimes in clinic you'll be reading a chart and it's like patient has positive wheezes to you know, blank lobe. And then you go and you auscultate and they are junky, mucusy and I'm like well, I didn't see that one coming. I thought he was going to be high-pitched wheezes. Right, it's different. So if it's different, call it something different. I don't know.
Rachele Burriesci:This is an opinion piece. This is just a little bit ranty here. I actually want to hear what nomenclature things that you have come across that either are confusing or drive you nuts. One other thing, medication-wise, is furosemide and Lasix. Same thing, right? Trade name, generic name. Why use both names interchangeably in the same note? I actually had a resident one year. She was doing her morning report and we were going through the medications on the list and she had mentioned both Rosamide and Lasix because of the way that it was written in the chart, and so it was a great learning opportunity to learn that it is the same medication, indeed. Opportunity to learn that it is the same medication indeed. But that is one of those medications that literally are used just as frequently. Trade name versus generic, or you know class. It's crazy. Why in one paragraph, would you use both names? Just stick with one at that point. Would you use both names? Just stick with one at that point.
Rachele Burriesci:So what brought me to this nomenclature debacle annoying, you know research situation that I was in rabbit hole maybe I should say nomenclature rabbit hole was high flow nasal cannula. I really did not think that this one was going to take me more than a check of my reference, check of my numbers. Move on, high flow nasal cannula. Hfnc is usually the abbreviation If you were to tell me hey, go grab a high flow nasal cannula, I'm going to come back with a green nasal cannula.
Rachele Burriesci:Looks like this that's what I'm coming back with and very easily available or readily available, has a great variety in its ability 1 to 15 liters is what I've always been told with, you know, fio2 up to near 100%. But there's variability because it's through the nose you're breathing in room air. It depends on the patient's tidal volume. All those things right, but in theory can go up to 100% or near Very non-invasive. You see it on the floors, you see them in the ICU. They're a good transition device if your person requires higher levels. As they're exercising right, you have ability to move, much more convenient than a regular nasal cannula that stops at six.
Rachele Burriesci:But if I put it, if someone says high flow nasal cannula, that's what I'm grabbing. So I'm doing my search. Start with Google, just to do like a quick. Can I get a NIH article about it. Okay, so I put in high flow nasal cannula, I get a ton of hits. I should actually just do it right now.
Rachele Burriesci:And there was one about high flow nasal cannula used to help treat hypoxemia. So I was like, oh, let's just take a peek. I was reading and I was thinking, huh, this is not sounding like the device that I'm thinking about. So I go to the next article and it was something similar. It was like high flow nasal cannula post intubation to prevent reintubation, something along that line. And they're talking about how high flow nasal cannula has been this great device to utilize post intubation to prevent reintubation. And it had mentioned something around 30 to 60 liters. And I was like, whoa, what are we? What are we talking about here? And then it talked about heat and high humidification. I was like, okay, we are 100% talking about something different.
Rachele Burriesci:So I went into PubMed obviously I think I've already made it there at this point and I do a similar search high flow nasal cannula, fio2 and flow rates available, something just like plain and simple. See what comes up. Well, moral of the story here is high flow nasal cannula is defined as high flow, as a heat exchanger and high humidification ability. So humidification up to 100%, fio2 availability up to 100% and a flow leader up to 60 liters with a heat exchange system. Now, if you were to describe those things to me, I would say that is a heated high flow nasal cannula which looks like this, and yes, I bought all of the devices while I was looking for this stuff.
Rachele Burriesci:This is very different. This is very different than this, very different, very different devices. A heated high flow is high level, typically used when we have severe hypoxemia and I have been seeing it more frequently post-extubation and apparently the research is showing that it's helping to prevent re-intubation because it can create higher support. I literally cannot find a plain and simple statement for a regular high flow nasal cannula. So I did find one article from a respiratory care journal and it has the green tubing as a type of high flow nasal cannula and the heated high flow nasal cannula as part of that same grouping. So essentially it's a type of, but to find said information and to call these two things literally the same thing is absurd to me. Again, this is my opinion High flow nasal cannula green tubing, heated high flow nasal cannula, something like Ervo.
Rachele Burriesci:Very different devices, very different patient, very different level of support. I really can't believe that they have the same name. I have never come across this in the clinic. We say high flow nasal cannula for the green tubing. We say heated high flow for anything, or airvo right, that's a very common thing. You'll just hear a patient is on airvo and then you know it's a heated high flow system. But never in my, however many year career would I assume they had the same name.
Rachele Burriesci:And I'm working with these patients and I'm using these devices and I'm teaching these things. So to come across this roadblock based on a nomenclature thing is wild to me. I also have a respiratory care textbook and I really actually recently bought it because I wanted to cross-reference it with some of my PT textbooks as well as some of the journal articles and just make sure, like I have the best information. The green tube high flow nasal cannula is not in the respiratory care textbook. It's not even listed. So then I have a follow-up question, which is some define high flow nasal cannula as anything that can provide 20 liters of flow or greater. Technically, this green tubing deal is 15 liters because that's usually where the oxygen exchanger taps out, and also that's what it's listed on the actual device. Like the device says this is 1 to 15 liters. So if it only goes up to 15 liters, is it technically a high flow nasal cannula?
Rachele Burriesci:I know throwing a lot lot at you, probably from every different angle, but really to me this is problematic, right? The research doesn't line up right. All of the research related to high flow nasal cannula is actually related to heated high flow nasal cannula, quick check of flow range and FiO2, difficult to find and in clinic. Now say you're learning these devices, which one is it right? You get into clinic and we're calling something different? It's going to create error. Obviously, you're going to learn on the job. You're going to learn that there's a different name for this thing or maybe it's just a type of and right and that might just be a different perspective to see it from. So that's really all I have on this matter.
Rachele Burriesci:It um, threw me for, threw me a little bit for a loop. I did not expect to have that much difficulty just confirming an fio2 range for a device that is so readily available and so commonly used in the acute care setting. So if you have any nomenclature things in your setting, in your practice in your learning or teaching. Please reach out to me, shoot me a DM, let me know. I'm actually curious. These are those things that you know, that you just kind of chat about and you can learn from each other in these episodes and these moments. So if you have one of those weird nomenclature things that you're just like I don't know why it's called this or it also goes by this name, reach out to me, let me know I'm curious. Maybe I'll do a fun post about it. All right, I hope you all have a wonderful day and whatever you have to do, get after it.
