Acute Respiratory Acute Respiratory Failure and AsthmaFailure and Asthma

Anthony Saleh, MD, FCCPAnthony Saleh, MD, FCCP

March 18March 18thth, 2011, 2011

DisclosuresDisclosures

No financial disclosuresNo financial disclosures Avid New York Yankee fanAvid New York Yankee fan Michael Jordan admirerMichael Jordan admirer Favorite movie: “Godfather 1”Favorite movie: “Godfather 1” Major supporter of respiratory Major supporter of respiratory

therapiststherapists

OutlineOutline

Scope of the problemScope of the problem PathophysiologyPathophysiology ManagementManagement Invasive/ Non invasiveInvasive/ Non invasive Specific Ventilatory StrategiesSpecific Ventilatory Strategies

Asthma: DefinitionAsthma: Definition

A chronic inflammatory disorder of the A chronic inflammatory disorder of the airways in which many cells and airways in which many cells and cellular elements play a rolecellular elements play a role

Susceptible patients develop recurrent Susceptible patients develop recurrent episodes of wheezing, chest tightness, episodes of wheezing, chest tightness, and coughing, especially at night or in and coughing, especially at night or in the early morningthe early morning

These episodes are associated with These episodes are associated with widespread but variable airflow widespread but variable airflow obstruction, that is often reversibleobstruction, that is often reversible

PrevalencePrevalence

Increasing worldwide over the past few Increasing worldwide over the past few decadesdecades

In the United States approximately 16.1 In the United States approximately 16.1 million adults and 6.8 million children million adults and 6.8 million children have a diagnosis of asthmahave a diagnosis of asthma

Overall prevalence about 8 %Overall prevalence about 8 % Fatalities slowly declining, but still Fatalities slowly declining, but still

excessiveexcessive Multiple etiologies for poor outcomeMultiple etiologies for poor outcome

Asthma Fatalities Asthma Fatalities (cont)(cont) Peaked in 2003Peaked in 2003 Higher death rates in: Older Higher death rates in: Older

patients (greater than 65), females, patients (greater than 65), females, Puerto Ricans, non Hispanic blacksPuerto Ricans, non Hispanic blacks

Some proposed mechanisms: Inner Some proposed mechanisms: Inner city lower socioeconomic classcity lower socioeconomic class

Lack of educationLack of education Health care disparitiesHealth care disparities

PathophysiologyPathophysiology

A complex inflammatory disease of A complex inflammatory disease of the airwaysthe airways

Inflammation is the hallmark with Inflammation is the hallmark with ensuing complicated cascadesensuing complicated cascades

A variety of pathways are intertwinedA variety of pathways are intertwined Treatment focuses on multiple Treatment focuses on multiple

different sites of inflammatory different sites of inflammatory activityactivity

ManagementManagement

Acute, severe asthma remains a Acute, severe asthma remains a very difficult issuevery difficult issue

Patients typically have persistent Patients typically have persistent reductions in peak expiratory flow reductions in peak expiratory flow rates of less than 40% predictedrates of less than 40% predicted

May have progressive May have progressive hypercarbia, altered sensorium, hypercarbia, altered sensorium, and a marked increase in work of and a marked increase in work of breathingbreathing

Management (cont)Management (cont)

Pharmacologic interventions:Pharmacologic interventions: Frequent, aggressive bronchodilatorsFrequent, aggressive bronchodilators Systemic corticosteroids mandatedSystemic corticosteroids mandated Oxygen therapy to prevent Oxygen therapy to prevent

desaturationsdesaturations +/- intravenous magnesium sulfate+/- intravenous magnesium sulfate

Yankee TriviaYankee Trivia

What is Mariano Rivera’s post What is Mariano Rivera’s post season ERA?season ERA?

AnswerAnswer

0.71 (an all time low)0.71 (an all time low)

Godfather TriviaGodfather Trivia

How many shots were fired at How many shots were fired at Don Corleone (and how many hit Don Corleone (and how many hit him??)him??)

AnswerAnswer

9 fired9 fired 5 successful (but he survived)5 successful (but he survived)

Respiratory Therapy Respiratory Therapy TriviaTrivia How can you get a patient on VDR How can you get a patient on VDR

ventilation?ventilation?

AnswerAnswer

Make Felix (the “Don of VDR”) Make Felix (the “Don of VDR”) Khusid an offer he can’t refuse!!Khusid an offer he can’t refuse!!

Non Invasive Non Invasive Ventilation in AsthmaVentilation in Asthma Paucity of studies to support it’s Paucity of studies to support it’s

useuse Advantages seen in other entities Advantages seen in other entities

(COPD, pulmonary edema) not (COPD, pulmonary edema) not matched in well controlled studiesmatched in well controlled studies

Theoretical improvement yet to Theoretical improvement yet to be proven in well designed trialsbe proven in well designed trials

NIPPV in Asthma NIPPV in Asthma (cont)(cont) 11stst study: Soroksky A. Stav D. study: Soroksky A. Stav D.

Shpirer I. Chest 2003; 123: 1018-Shpirer I. Chest 2003; 123: 1018-10251025

Randomized double blind, placebo Randomized double blind, placebo controlled trial conducted in the controlled trial conducted in the emergency department of an emergency department of an Isreali hospitalIsreali hospital

NIPPV group: 17 patientsNIPPV group: 17 patients Control group: 16 patientsControl group: 16 patients

Soroksky Study (cont)Soroksky Study (cont)

4 criteria had to be fulfilled:4 criteria had to be fulfilled: FEV1<60% predictedFEV1<60% predicted RR>30 breaths/minuteRR>30 breaths/minute Asthma of at least 1 years durationAsthma of at least 1 years duration Duration of current attack >7 daysDuration of current attack >7 days PCO2 not an entry criterionPCO2 not an entry criterion

Soroksky Study Soroksky Study (Results)(Results) NPPV group had a pressure range 8-15 NPPV group had a pressure range 8-15

cm IPAP and up to 5 cm EPAPcm IPAP and up to 5 cm EPAP Study patients had an improvement in:Study patients had an improvement in: More rapid improvement in lung More rapid improvement in lung

functionfunction Respiratory rateRespiratory rate Decreased hospitalizationsDecreased hospitalizations Small trial---uncertain clinical Small trial---uncertain clinical

significancesignificance

NIPPV in AsthmaNIPPV in Asthma

Next study: Murase, et al. Respirology Next study: Murase, et al. Respirology 2010; 15: 714-7202010; 15: 714-720

Retrospective cohort studyRetrospective cohort study Rate of endotracheal intubation (ETI) Rate of endotracheal intubation (ETI)

lower in the NIV grouplower in the NIV group This study had patients with somewhat This study had patients with somewhat

more severe asthma (based on ABG more severe asthma (based on ABG analysis)analysis)

Major limitations with study designMajor limitations with study design

NIPPV in AsthmaNIPPV in Asthma

33rdrd study: Gupta, et al. study: Gupta, et al. Respiratory Care, May 2010, Vol Respiratory Care, May 2010, Vol 55, No 555, No 5

Prospective, randomized Prospective, randomized controlled trialcontrolled trial

11stst study performed in respiratory study performed in respiratory care unit (as opposed to the care unit (as opposed to the emergency department)emergency department)

NIPPV in Asthma NIPPV in Asthma (cont)(cont) NIV similar in efficacy to standard NIV similar in efficacy to standard

therapy in improving respiratory rate, therapy in improving respiratory rate, FEV1, ph, PaO2/FiO2, and PaCO2FEV1, ph, PaO2/FiO2, and PaCO2

NIV was associated with a trend of NIV was associated with a trend of improved lung function in a larger improved lung function in a larger number of patients, shorter ICU and number of patients, shorter ICU and hospital stays, a trend toward quicker hospital stays, a trend toward quicker clinical improvement, and less need clinical improvement, and less need for inhaled bronchodilatorsfor inhaled bronchodilators

NIPPV in Asthma NIPPV in Asthma (Summary)(Summary) Theoretically advantageousTheoretically advantageous Excellent clinical utility in other Excellent clinical utility in other

conditions (COPD, Pulmonary edema) conditions (COPD, Pulmonary edema) has not been matched in asthmahas not been matched in asthma

While a few studies have shown some While a few studies have shown some benefit, larger more controlled studies benefit, larger more controlled studies are requiredare required

Easy availability of NIPPV may lead to Easy availability of NIPPV may lead to overuseoveruse

NIPPV in Asthma NIPPV in Asthma (cont)(cont) It appears reasonable to start It appears reasonable to start

NIPPV if a patient has no NIPPV if a patient has no contraindications to it’s usecontraindications to it’s use

Be cautious as to not overuse itBe cautious as to not overuse it If intubation and mechanical If intubation and mechanical

ventilation required, do not delay ventilation required, do not delay itit

Who is the greatest post Who is the greatest post season pitcher of all season pitcher of all time?time?

AnswerAnswer

Mariano RiveraMariano Rivera

Invasive Ventilatory Invasive Ventilatory ManagementManagement Fortunately, a minority of patients Fortunately, a minority of patients

with asthma require mechanical with asthma require mechanical ventilatory assistanceventilatory assistance

Frought with potential Frought with potential complicationscomplications

Patients are frequently anxious Patients are frequently anxious and require deep sedation and at and require deep sedation and at times paralysistimes paralysis

Invasive Ventilatory Invasive Ventilatory Support (cont)Support (cont) Obstruction in asthma is different Obstruction in asthma is different

from the obstruction in COPDfrom the obstruction in COPD Bronchospasm, edema, and Bronchospasm, edema, and

increased secretionsincreased secretions Obstruction is fixed in asthma, Obstruction is fixed in asthma,

making inspiration as difficult as making inspiration as difficult as exhalationexhalation

Invasive Management Invasive Management (cont)(cont) Major concern: Development of Major concern: Development of

intrinsic PEEPintrinsic PEEP Increased work of breathing also Increased work of breathing also

very worrisomevery worrisome Once instituted, must pay very Once instituted, must pay very

close attention to specific close attention to specific ventilator detailsventilator details

Invasive Management Invasive Management (Initial Ventilator (Initial Ventilator Settings)Settings) Mode: Volume assist/controlMode: Volume assist/control Inspiratory time: 1-1.5 seconds to Inspiratory time: 1-1.5 seconds to

allow gas to move past obstructionsallow gas to move past obstructions Flow waveforms: deceleratingFlow waveforms: decelerating Tidal volume: 5-8 cc/kg IBWTidal volume: 5-8 cc/kg IBW Peak flow: Appropriate to allow tidal Peak flow: Appropriate to allow tidal

volume delivery in allotted timevolume delivery in allotted time

Initial Ventilator Initial Ventilator Settings (cont)Settings (cont) PEEP: 0-5 cm H2OPEEP: 0-5 cm H2O Plateau pressure: less than 30 cm Plateau pressure: less than 30 cm

H2OH2O Rate: 8-16 breaths/min, producing Rate: 8-16 breaths/min, producing

minimum auto-PEEPminimum auto-PEEP Permissive hypercarbia: unavoidablePermissive hypercarbia: unavoidable FIO2: to maintain PaO2>60 mm HgFIO2: to maintain PaO2>60 mm Hg

Invasive ManagementInvasive Management

As with ARDS/ALI, asthmatics are As with ARDS/ALI, asthmatics are at risk of developing ventilator at risk of developing ventilator induced lung injury (VILI) because induced lung injury (VILI) because of the pressure required to of the pressure required to ventilateventilate

Although high peak pressures are Although high peak pressures are seen, plateau pressures usually seen, plateau pressures usually remain below 30 cm H2Oremain below 30 cm H2O

Invasive ManagementInvasive Management

It is not uncommon to have peak It is not uncommon to have peak pressures in excess of 60-70 cm pressures in excess of 60-70 cm of H2Oof H2O

Dramatic drop off in peak/plateau Dramatic drop off in peak/plateau characteristiccharacteristic

Hypercarbia common and Hypercarbia common and expected in many instancesexpected in many instances

Question 1Question 1

A 25 year old asthmatic is intubated for A 25 year old asthmatic is intubated for severe respiratory distress. He is quite severe respiratory distress. He is quite agitated and thrashing about, in spite of agitated and thrashing about, in spite of heavy sedation and is out of synch with heavy sedation and is out of synch with the ventilator. He is on a tidal volume of the ventilator. He is on a tidal volume of 8cc/kg and his ABG on 100% FiO2 and 8cc/kg and his ABG on 100% FiO2 and PEEP of 5 is: 7.15/75/67/93/26. His PEEP of 5 is: 7.15/75/67/93/26. His plateau pressure is 31 cm H2O. The plateau pressure is 31 cm H2O. The next best intervention would be to: next best intervention would be to:

A: Increase the tidal volume to A: Increase the tidal volume to 10cc/kg10cc/kg

B: Increase the PEEP to 10 cm B: Increase the PEEP to 10 cm H2OH2O

C: Start neuromuscular blockadeC: Start neuromuscular blockade D: Decrease FiO2 to 80%D: Decrease FiO2 to 80%

AnswerAnswer

C: Start neuromuscular blockadeC: Start neuromuscular blockade

Neuromuscular Neuromuscular Blockade in AsthmaBlockade in Asthma British Journal of Hospital British Journal of Hospital

Medicine, January 2009, Vol 70, No Medicine, January 2009, Vol 70, No 11

These agents help prevent These agents help prevent respiratory dysynchronyrespiratory dysynchrony

Help lower peak pressuresHelp lower peak pressures Allow longer expiratory times to Allow longer expiratory times to

reduce dynamic hyperinflation reduce dynamic hyperinflation

Neuromuscular Neuromuscular Blockade (cont)Blockade (cont) Many of these patients are young, Many of these patients are young,

males, and can be difficult to sedatemales, and can be difficult to sedate Unfortunately, these agents have a Unfortunately, these agents have a

variety of adverse, potentially serious variety of adverse, potentially serious side effectsside effects

Must weigh the potential risks/benefits Must weigh the potential risks/benefits of using these agentsof using these agents

If these agents are to be used, they If these agents are to be used, they should be stopped as soon as possibleshould be stopped as soon as possible

Neuromuscular Neuromuscular Blockade (cont)Blockade (cont) Neuromuscular blocking agents Neuromuscular blocking agents

alone can be associated with alone can be associated with prolonged muscle weaknessprolonged muscle weakness

Combination of corticosteroids and Combination of corticosteroids and aminosteroid neuromuscular aminosteroid neuromuscular blocking agents (such as blocking agents (such as vecuronium) may be associated with vecuronium) may be associated with an increased risk of neuromuscular an increased risk of neuromuscular weaknessweakness

Summary of Summary of Neuromuscular Neuromuscular BlockadeBlockade Asthma represents a group of Asthma represents a group of

patients who may particularly patients who may particularly benefit from this modalitybenefit from this modality

Use with caution and be prepared to Use with caution and be prepared to stop as quickly as possiblestop as quickly as possible

Be aware of potential complicationsBe aware of potential complications Avoid aminosteroid blocking agentsAvoid aminosteroid blocking agents

Yankee TriviaYankee Trivia

How many innings did Mariano How many innings did Mariano Rivera pitch in game seven of the Rivera pitch in game seven of the 2003 ALCS against the rival 2003 ALCS against the rival Boston Red Sox?Boston Red Sox?

AnswerAnswer

3 shut out innings in a dramatic 3 shut out innings in a dramatic 6-5 Yankee win (Aaron Boone’s 6-5 Yankee win (Aaron Boone’s walk off home run)walk off home run)

How many NBA How many NBA Championships are Championships are here?here?

AnswerAnswer

1717 Bill Russell:11Bill Russell:11 Michael Jordan:6Michael Jordan:6

Ventilatory Ventilatory ManagementManagement Intubation and Mechanical Ventilation Intubation and Mechanical Ventilation

of the Asthmatic Patient in Acute of the Asthmatic Patient in Acute Respiratory FailureRespiratory Failure

Brenner B, Cobridge T, and Kazzi A. Brenner B, Cobridge T, and Kazzi A. Proceedings of the American Thoracic Proceedings of the American Thoracic Society. Volume 6 pp 371-379, 2009Society. Volume 6 pp 371-379, 2009

Reviewed evidence based data Reviewed evidence based data regarding intubation and mechanical regarding intubation and mechanical ventilation of acute severe asthma in ventilation of acute severe asthma in emergency departmentsemergency departments

Invasive ManagementInvasive Management

7 Key areas addressed7 Key areas addressed Prevention of intubationPrevention of intubation Criteria for intubationCriteria for intubation Intubation techniqueIntubation technique Ventilator settingsVentilator settings Immediate post intubation careImmediate post intubation care Medical management in the ventilated Medical management in the ventilated

patientpatient Prevention and treatment of Prevention and treatment of

complicationscomplications

Prevention of Prevention of IntubationIntubation Best intubation is NO intubationBest intubation is NO intubation Mortality 10-20% in patients Mortality 10-20% in patients

requiring intubationrequiring intubation Aggressive medical therapy, ?? Aggressive medical therapy, ??

Early NIPPVEarly NIPPV

Criteria for IntubationCriteria for Intubation

4 Indications for intubation:4 Indications for intubation: Cardiac arrestCardiac arrest Respiratory arrest or severe Respiratory arrest or severe

bradypneabradypnea Physical exhaustionPhysical exhaustion Altered sensorium, such as lethargy Altered sensorium, such as lethargy

or agitationor agitation Good clinical judgement always Good clinical judgement always

supercedes numberssupercedes numbers

Intubation TechniqueIntubation Technique

Some advocate awake intubationSome advocate awake intubation Main method used is rapid Main method used is rapid

sequence intubation with sequence intubation with ketamine and succinylcholineketamine and succinylcholine

Propofol preferred over ketamine Propofol preferred over ketamine in hypertensive patientsin hypertensive patients

Avoid succinylcholine in patients Avoid succinylcholine in patients with hyperkalemiawith hyperkalemia

Invasive Management Invasive Management (Initial Ventilator (Initial Ventilator Settings)Settings) Mode: Volume assist/controlMode: Volume assist/control Inspiratory time: 1-1.5 seconds to Inspiratory time: 1-1.5 seconds to

allow gas to move past obstructionsallow gas to move past obstructions Flow waveforms: deceleratingFlow waveforms: decelerating Tidal volume: 5-8 cc/kg IBWTidal volume: 5-8 cc/kg IBW Peak flow: Appropriate to allow tidal Peak flow: Appropriate to allow tidal

volume delivery in allotted timevolume delivery in allotted time

Initial Ventilator Initial Ventilator Settings (cont)Settings (cont) PEEP: 0-5 cm H2OPEEP: 0-5 cm H2O Plateau pressure: less than 30 cm Plateau pressure: less than 30 cm

H2OH2O Rate: 8-16 breaths/min, producing Rate: 8-16 breaths/min, producing

minimum auto-PEEPminimum auto-PEEP Permissive hypercarbia: unavoidablePermissive hypercarbia: unavoidable FIO2: to maintain PaO2>60 mm HgFIO2: to maintain PaO2>60 mm Hg

Immediate Post Immediate Post Intubation Intubation ManagementManagement Adequate sedation mandatedAdequate sedation mandated ??? Heliox??? Heliox Selected cases: Paralytic agentsSelected cases: Paralytic agents Avoid excessive propofol Avoid excessive propofol

(propofol infusion syndrome)(propofol infusion syndrome) When lung mechanics improved, When lung mechanics improved,

rapidly wean sedationrapidly wean sedation

Medical ManagementMedical Management

Systemic steroidsSystemic steroids Frequent bronchodilatorsFrequent bronchodilators ??? Magnesium sulfate??? Magnesium sulfate

Prevention and Prevention and Treatment of Treatment of ComplicationsComplications Intubation-induced bronchospasmIntubation-induced bronchospasm Well known entityWell known entity Pretreatment with bronchodilators Pretreatment with bronchodilators

helps prevent this complicationhelps prevent this complication

HypotensionHypotension

Multiple potential etiologiesMultiple potential etiologies Most important ones to recognize Most important ones to recognize

immediately are auto-PEEP and immediately are auto-PEEP and pneumothoraxpneumothorax

Fluids bolus immediatelyFluids bolus immediately STAT chest x-raySTAT chest x-ray Increase flow rate to definitively Increase flow rate to definitively

treat auto-PEEPtreat auto-PEEP

Ventilatory StrategiesVentilatory Strategies

If patient failing “ conventional If patient failing “ conventional ventilation” can try newer modalitiesventilation” can try newer modalities

VDR: Volumetric Diffusive RespirationVDR: Volumetric Diffusive Respiration Excellent theoretically for patients with Excellent theoretically for patients with

ARDS or airway issues (including ARDS or airway issues (including asthma)asthma)

Secretion removal is unprecedentedSecretion removal is unprecedented

Question 2Question 2

A 30 year old woman with status A 30 year old woman with status asthmaticus has been endotracheally asthmaticus has been endotracheally intubated and is supported by intubated and is supported by mechanical ventilation. She has had a mechanical ventilation. She has had a progressive decline in her BP over the progressive decline in her BP over the past 30 minutes, to 80/40 mm Hg, as past 30 minutes, to 80/40 mm Hg, as well as decreasing oxygen saturation, well as decreasing oxygen saturation, which is now 91%. Her heart rate is which is now 91%. Her heart rate is 126/min. Examination of her chest 126/min. Examination of her chest reveals hyperinflation and faint breath reveals hyperinflation and faint breath sounds, with inspiratory and expiratory sounds, with inspiratory and expiratory wheezes bilaterally.wheezes bilaterally.

Question 2 (cont)Question 2 (cont)

The breath sounds are more faint than The breath sounds are more faint than previously noted, but equal bilaterally. Minimal previously noted, but equal bilaterally. Minimal secretions are recovered with tracheal suction. secretions are recovered with tracheal suction. She is deeply sedated with midazolam and She is deeply sedated with midazolam and fentanyl. Her current ventilator settings fentanyl. Her current ventilator settings include pressure-targeted assist-control include pressure-targeted assist-control ventilation with a set rate of 20, inspiratory ventilation with a set rate of 20, inspiratory pressure of 25 cm H2O, inspiratory time of 1 pressure of 25 cm H2O, inspiratory time of 1 sec, PEEP of 5 cm H2O, and FiO2 of 50%. Her sec, PEEP of 5 cm H2O, and FiO2 of 50%. Her total respiratory rate is 20/min, and the total respiratory rate is 20/min, and the expired tidal volumes have decreased from expired tidal volumes have decreased from 500 to 350 cc’s, with no change in ventilator 500 to 350 cc’s, with no change in ventilator settings.settings.

Question 2 (cont)Question 2 (cont)

A chest radiograph shows the A chest radiograph shows the endotracheal tube to be in good endotracheal tube to be in good position, with bilateral position, with bilateral hyperinflation and clear lung hyperinflation and clear lung fields. ABG analysis shows: ph: fields. ABG analysis shows: ph: 7.24/ pCO2: 60 mm Hg/ paO2 70 7.24/ pCO2: 60 mm Hg/ paO2 70 mm Hg. Among the following mm Hg. Among the following options, the BEST is:options, the BEST is:

Question 2 (cont)Question 2 (cont)

A: Deep tracheal suction with saline lavage, A: Deep tracheal suction with saline lavage, and then increase the inspiratory pressure to and then increase the inspiratory pressure to 30 cm H2030 cm H20

B: Deep tracheal suction with saline lavage, B: Deep tracheal suction with saline lavage, and then change to volume-assist control and then change to volume-assist control mode with set tidal volume of 500 ccmode with set tidal volume of 500 cc

C: Briefly disconnect the ETT from the C: Briefly disconnect the ETT from the ventilator tubing and then reduce the set ventilator tubing and then reduce the set rate to 12/minrate to 12/min

D: Briefly disconnect the ETT from the D: Briefly disconnect the ETT from the ventilator tubing and then increase the ventilator tubing and then increase the inspiratory pressure to 30 cm H20inspiratory pressure to 30 cm H20

AnswerAnswer

C: Briefly disconnect the ETT from C: Briefly disconnect the ETT from the ventilator tubing and then the ventilator tubing and then reduce the set rate to 12/minreduce the set rate to 12/min

SummarySummary

Acute respiratory and asthma is a Acute respiratory and asthma is a common scenariocommon scenario

Be aware of best available medical Be aware of best available medical managementmanagement

Try to avoid intubation if at all Try to avoid intubation if at all possiblepossible

Consider NIPPV if no Consider NIPPV if no contraindications existcontraindications exist

Summary (cont)Summary (cont)

If needed proceed to intubation If needed proceed to intubation and mechanical ventilationand mechanical ventilation

Use guidelines described Use guidelines described specifically for asthmaspecifically for asthma

Be able to rapidly diagnose and Be able to rapidly diagnose and treat complicationstreat complications

Always exercise good clinical Always exercise good clinical judgementjudgement

Final QuestionsFinal Questions

What is the name of the drug What is the name of the drug dealer who Don Corleone refuses?dealer who Don Corleone refuses?

AnswerAnswer

Virgil “The Turk” SolozzoVirgil “The Turk” Solozzo

Who will win the 2011 Who will win the 2011 World Series?World Series?

AnswerAnswer

Hopefully--- New York YankeesHopefully--- New York Yankees

Thank you toThank you to

Felix Khusid (the Don of Felix Khusid (the Don of Respiratory therapists)Respiratory therapists)

All therapists who make their All therapists who make their physicians look better than they physicians look better than they really are!!!really are!!!