Wednesday, July 23, 2014

What are the advantages of NIV?

Sometimes there is confusion regarding the advantages of NIV, otherwise referred to as BiPAP. I have had doctors order it because it "forces fluid out of the lungs" in heart failure, and because it "increases blood pressure." Yet neither of these are actual benefits of NIV. That said, what are the benefits of NIV? The are:
  1. IPAP increases ventilation and helps to blow off CO2 
  2. CPAP increases FRC and therefore keeps the lungs open so the next breath comes in easier
  3. Both IPAP and CPAP help to reduce work of breathing
  4. Both the IPAP and CPAP help reduce work of heart
So, how does BiPAP reduce work of heart because the increased intrathoracic pressure decreases preload to the heart, thereby decreasing cardiac output, and thereby decreasing blood pressure.  In this way, it helps to decrease the patients work of heart.  That is how it helps with heart failure.  It does not force fluid out of the lungs. It does not increase blood pressure.


Tuesday, July 22, 2014

Is asthma psychological?

The following was originally published on May 13, 2013 at healthcentral.com/asthma.

Is asthma all in your head?

In a series of articles written throughout the 1850s, Dr. Henry Hyde Salter, himself an asthmatic, wrote a series of articles about asthma that were published in the book "On Asthma: It's Pathology and Treatment." In this book he wrote that "Asthma essentially a nervous disease." 

He offered the following proof:
  • Many patients feel fine as soon as they enter the doctor's office
  • Mental emotion can bring on a paroxysm of asthma
  • Mental emotion can resolve a paroxysm of asthma
  • Remedies that relax the nervous system resolve asthma, such as tobacco,antispasmodics, sedatives, and nervous depressants. Examples include tobacco, alcohol, morphine, and especially chloroform.
So there you have it: asthma is a nervous disease. This was the belief about asthma that prevailed even up to the 1980s, and even beyond that. This myth continued to live on despite it being disproved in the 1950s.

Dr. Salter did such a good job inculcating the idea that asthma was nervous, that many asthma websites and books have to go to make light of it even to this day. In noting the common triggers of an asthma attack, the experts atNational Jewish Health note:
Emotions do not cause asthma, but can make asthma worse because strong feelings can lead to changes in breathing patterns. Times of "good" stress and "bad" stress can cause problems for people with asthma. However, it is important to express your emotions, and good asthma management can minimize the effect of stress.
Dr. Salter was a very good doctor for his time, yet his idea asthma was "all in your head" was incorrect. Yet he wasn't the only asthma expert of old who was fooled, as so too were Hippocrates (the father of medicine) around 400 B.C.,Galen of the 1st century, Thomas Willis and Jean Baptise van Helmont in the 17th century, and William Osler (the father of modern medicine) in the late 19th and early 20th century. They were all fooled.

They were fooled mainly because asthma, in its uncomplicated or pure form anyway, left no visible scars on the body. Even upon autopsy, doctors found the lungs of asthmatics to be normal. So they simply speculated it must be nervous in nature.

We don't fault them, however, because they didn't know about the immune system. Dr. Osler probably knew about it, but knowledge of it during his time was primitive. Yet the link between the immune system and asthma was eventually discovered, and now we know asthma is not nervous at all.

Today we know asthma is a disorder of the immune system; it's an autoimmune disease. It occurs because your immune is tricked into thinking things that are innocuous (harmless) -- like dust mites, mold, fungus, cockroach urine -- to most people are harmful to your body.

So instead of ignoring these things when inhaled, yoor body develops a defense against them, and attacks them, and this is why you have an asthma attack. So I personally don't fault doctors like Dr. Salter for thinking asthma was nervous.

Reference: 
  1. Salter, Henry Hyde, "On Asthma: It's Pathology and Treatment," 1868, London, page 24-30. Other references are provided in the posts linked to above.
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Monday, July 21, 2014

Emotional State Lexicon

The following are the emotional states.
  • Anxiety/ nervousness: An emotional state; indicative of a patient watching every movement; asthma, respiratory failure, hypoxia
  • Depressed: An emotional state indicative of quiet, denial, in hospital too long
  • Anger/ combative/ irritable: An emotional state which often presents with electrolyte imbalance
  • Euphoria: An emotional state which usually presents with drugs or overdose.
  • Panic: An emotional state which resents often with hypoxia, tension pneumothorax, status asthmaticus
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Sunday, July 20, 2014

Level of consciousness lexicon

The following are the levels of consciousness.

  • Lethargic: somnolence: sleepy
  • Stuporious: confused: responds inappropriately, OD, intoxication
  • Semi-comatose: responds only to painful stimuli
  • Comatose: does not respond to painful stimuli
  • Obtunded: drowsy, maybe decreased cough/gag reflex

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Saturday, July 19, 2014

Types of breathing lexicon

The following are terms associated with types of breathing.
  • Unconscious breathing: Most of the time you don't think about breathing, yet you continue to do it. This is an important safety net for life, because if we had to think about breathing 24-7 we'd accomplish little and most life would cease to exist. Air goes into your lungs because a negative pressure is created that sucks air in, kind of like a vacuum. Normal exhalation is passive. Normal unconscious breathing is generally called quiet breathing.
  • Diaphragm: The main muscle of respiration is this large muscle that contracts during inspiration. When it contracts it moves downward making more room in the lungs and creates a negative pressure, causing air to be drawn in.
  • External Intercostal Muscles: These are positioned between the ribs and contract during normal breathing, pulling the ribcage outward. These assists the diaphragm in lifting the rib cage and creating negative pressure in the lungs. They also assist with expiration.
  • Scalene: This might assist the diaphram.
  • Exhalation: Normally passive. It occurs when the muscles of respiration relax. When this occurs the rib cage is drawn in, and the lungs are compressed. This increases the pressure in the lungs, and air is pushed out. This is also referred to as normal elastic recoil of the lungs.
  • Conscious breathing: When you take in a breath by thinking about it. When you do so you will be using your accessory muscles of respiration. 
  • Normal Muscles of Respiration: These are the muscles you use during most breaths. Generally, these include the diaphragm, external intercostals and scalene muscles.
  • Negative recoil of lungs: Natural relaxation of muscles of respiration causing air to be released from the lungs.
  • Forced exhalation: If the lungs lose their elasticity (if they become stiff and unable to recoil), your body will have to use all the above mentioned muscles to force air out of your lungs. This is generally called active forced breathing or forced exhalation. It is generally active or conscious, and is often referred to as labored breathing. Other examples of this are emphysema and pulmonary fibrosis .Muscles that assist with forced exhalation include: Abdominal Muscles, Internal Intercostals, and Innermost Intercostals
  • Diaphragmatic breathing: When you are breathing normally you are using your diaphragm. This allows you to get the most out of each breath. When this occurs, your stomach moves out, and your chest does not move.
  • Accessory Muscles of Respiration: Muscles you normally don't use to inhale, and when you do use them they will be sore the next day. Examples include: 
The main accessory muscles are:
The minor accessory muscles are:
  1. Serratus Anterior (minor role, side of chest)
  2. Pectoralis Major (minor role, chest)
  3. Pectoralis Minor (minor role, chest)
  4. Upper Trapezius (back, shoulder and neck)
  5. Latissimus Dorsi (side of chest and abdomen)
  6. Erector Spinae (deep back)
  7. Iliocostalis Lumborum (deep back)
  8. Serratus Posterior (mid back)
  9. Serratus Inferior (mid back)
  10. Serratus Superior (mid back)
  11. Levatores Costarum (chest)
  12. Tranversus Thoracis (chest)
  13. Subclavius (chest)
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Friday, July 18, 2014

Lung Anatomy Lexicon

The following is basic lung anatomy terms.
  • Nares (nostrils): You waft through the nasal openings, barely inching between hairs meant to keep particles out. This begins the upper airway.
  • Nose: It's not just an organ of smell, it also aids in phonation and easily lets air in. It's also the first line of defense against inhaled particles. 
  • Epithelial cells: You'll see these cells lining the air passages from the oropharynx to the respiratory bronchioles. Their main function is protection of underlying tissue and secretion. Note the wavelike movement of hair-like structures on the surfaces.
  • Goblet cells: These are specialized epithelial cells that are randomly scattered along the way. Their job is to secrete mucin, which dissolves in water to form mucus.
  • Mucus: This is formed by goblet cells and traps particles in inspired air to prevent them from getting to the lungs. It then rides up on those fine hair-like structures to the mouth. Once in the mouth it's called sputum.
  • Cilia: These are those fine hair-like structures referred to above. They wave in rhythmic fashion and act as an escalator to move mucus to the mouth. Each ciliated cell has 200 cilia, and there are 1 to 2 billion cilia per square centimeter.
  • Nasal septum: This is what divides the two nasal passages from the nare to the nasopharynx. 
  • Vestibule: This is the main cavity of the nose. Air is warmed to 98.6° Fahrenheit and humidified.
  • Turbinates: These are three bone-like shelves that project into the nasal cavity from the lateral wall. They help with the sense of smell and warm and humidify inspired air. 
  • Pharynx: This is a funnel shaped passage where are travels from the nasal cavity to the larynx. It too aids in phonation. Both food and air travel this way.
  • Nasal pharynx: This is the upper portion of the pharynx.
  • Oropharynx: This is the middle portion of the pharynx, and from here you travel to the larynx. Look down! That dark opening is called the glottis, and those white objects on either side are the vocal cords.
  • Vocal cords: These are only open when you inhale. This is another means to keep particles out of the lungs. As air brushes past them when you breathe out they vibrate, creating sound.
  • Epiglottis: This is the object projecting upward and guarding the opening to the glottis. When you swallow it lies down to keep food out of the lungs. 
  • Glottis: Only air is allowed to pass (yet a few particles sneak by). This is the opening to the Larynx.
  • Larynx: This is a very short passage that protects the lungs during swallowing, helps produce a voice, and is often referred to as the voice box.
  • Laryngeal skeleton: The larynx is kept open by nine cartilages, the largest of which is the thyroid cartilage, better known as the pomas adamus, or Adams Apple. Just inferior to the Thyroid cartilage you'll see the cricoid cartilage in the neck.
  • Trachea: This is the main tube-like passage to the lungs, and is often referred to as the windpipe. It's kept open by 16-20 c-shaped cartilages.
  • Carina: This is a fork in the road. Go right to the right lung, and left to the left lung. The respiratory tract from this point is called the lower airway.
  • Lungs: The lungs are normally kept sterile by many of the mechanisms we described on our journey. Occasionally particles make it this far and cause havoc. Yet healthy lungs move particles out within 24 hours. Most particles are filtered by the upper airway. A porous and spongy organ, the lungs provide a space whereby large amounts of air and blood can come in contact for rapid exchange of gases to occur.
  • Right lung: It's actually larger than the left and has three lobes.
  • Left lung: This side has only two lobes. Can you guess why? I'll give you a clue. Listen! Lub dub... lub dub... lub dub... lub dub... lub dub...
  • Bronchus (large airways): This is the passage air takes as it begins its travel through the lungs. Air passes through the lobar region, segmental, then subsegmental. These airways divide into smaller and smaller but more numerous airways.
  • Bronchioles (small airways): These airways continue to get smaller and divide exponentially. Air travels through the terminal then respiratory airways. There's no cartilage to keep the airways open here, which isn't good during an asthma attack (see picture). 
  • Bronchial tree: The bronchus, bronchioles and alveoli make up the bronchial tree.
  • Bronchial Smooth Muscle: Crisscrossing and spiralling the outside the bronchial airways are smooth muscle fibers. During asthma these spasm and contract, narrowingthese hallways, making it hard to breathe.
  • Beta 2 Adrenergic Receptors: On the bronchial walls are tiny receptors. When you inhale beta-adrenergic medicine like Ventolin or Xopenex, the medicine binds to these receptors, and the reaction causes bronchial muscles to relax, opening the airway, and making breathing easier.
  • Alveolar Duct: The respiratory bronchioles leads air to these fine ducts that terminate in clusters of 10-16 fine balloon-like structures called alveoli.
  • Alveoli: Most adults have over 300 million of these in their lungs, and this is where most gas exchange occurs. Oxygen molecules inhaled wait here for an available hemoglobin molecule.
  • Red Blood Cells (RBC): These look like little red boats or donuts. In the middle is a protein called hemoglobin. RBCs ride single file down the capillary beds in the lungs where they come into contact with the alveoli.
  • Capillary: These tiny vessels transports RBCs that have carbon dioxide (a cellular waste product) attached to the hemoglobin instead of oxygen. These RBCs are purplish-blue in color.
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Thursday, July 17, 2014

Basic respiratory therapy lexicon

Here are some basic terms used by respiratory therapists.
  • Ventilation: Moving air in and out of the lungs. Measured by respiratory rate, tidal volume, chest movement, breath sounds, Measurement of Carbon Dioxide (PaCO2), etc. This is your first priority in an emergency (establish and open the airway)
  • Oxygenation: Getting oxygen from the air, to the lungs, and then to the bloodstream. Measured by Heart rate, color, sensorium, Oxygen (PaO2 and SpO2), color (cyanosis, gray or normal), sensorium, etc. This is your second priority in an emergency (increase FiO2). This is also the most common problem.
  • Circulation: Moving the blood through the body. Measured by pulse and heart rate and strength, cardiac output (blood pressure). This is your third priority in an emergency (chest compressions, defibrillate, heart drugs, etc.)
  • Perfusion: Getting blood and oxygen to the tissues. Measured by blood pressure (cardiac output), sensorium, temperature, urine output, hemodynamics. This is your fourth priority in an emergency, raise the blood pressure.
  • Signs: Objective information, those things that you can see or measure. Examples include color, pulse, edema, blood pressure, pulse ox, etc.
  • Symptoms: Subjective information, those things that the patient must tell you. Examples include dy spnea, pain, nausea, muscle weakness, etc.
  • Objective:  Judgement not based on personal feeling; opinions based on fact; what you find upon assessment; examples include blood pressure, pulse oximetry, lung sounds, temperature, level of consciousness, etc. 
  • Subjective:  Judgement or opinion based on personal feelings.  Examples include pain level, level of dyspnea, anxiety, etc. 
  • Smoking history: How many years and how many packs per day. Measured by # of packs per day times years smoked.
  • Advanced directives: Set of instructions documenting what treatment a patient would want if he was unable to make medical decisions on his own. Does the patient want to be a full code, or does he want all measures to be taken to restart his heart if it stops beating. Does he want to be placed on a ventilator. These are questions that should be answered.
  • Do not Resuscitate (DNR): This is an order from a patient requesting that no efforts be made to restart the heart if it should so happen to stop, and no efforts should be made to intubate the patient (No Mechanical Ventilation) should he stop breathing. Otherwise, the patient should be treated, but no invasive procedures should take place.
  • Arterial Blood Gas: A sampling of arterial blood drawn from the radial, brachial or femerol arteries to determine PAO2, PCO2, HCO3 and accurate SaO2, and pH. Used to monitor respiratory status and metabolic status.
  • Venous Blood Gas: In a patient who is not showing signs of respiratory distress, recent research shows this should be just as useful as an ABG (unless your goal is to monitor oxygenation status). Venous pH and HCO3 are basically similar, and PO2 is expected to be a normal of 75, so if it is low, you can be assured PO2 is low. Actually, VBG is just as useful as ABG so long as you can momitor oxygen status with a pulse oximeter (SpO2).
  • Capilary Blood Gas: Used to determine pH, HCO3 and pH values in a newborn, especially when no cord blood access is available, or if it's difficult to get an ABG. With the exception of oxygen status, the values are similar as an ABG and just as useful. CBGs are now coming back into play, as for a while they were not being ordered much.
  • Pulmonary Function Test: A test that measures lung function. It measure how much air you exhale, and how fast this air flows.  It's a very useful tool to help physicians diagnose various lung diseases.
  • Urine output: This is the measure of the normal output of a person per day. Normal is 40 ml/hour or 1 liter per day. When input is greater than output, this results in weight gain, electrolyte imbalance, increased hemodynamic pressures, decreased lung compliance, etc. (see central venous pressure below)
  • Sensible water loss: Water lost by urine, vomiting.
  • Insensible water loss: Water lost by lungs and skin
  • Hypervolemia: Too much fluid in the body.
  • Hypovolemia: Too little fluid in the body, dehydration, also indicated by a high hematocrit.
  • Level of Consciousness: Normal is awake, alert and orientated (AAOx). Abnormal is lethargic, somnolent, stuporiouis, confused, obtunded, coma.
  • Lethargic: Very sleepy, somnolent. May be too many sedatives or possible CO2 toxicity (although rare).
  • Confused: Stuporious; change in mental status; responds inappropriately from patients normal; also consider drug overdose, too many sedatives (valium, morphine, psychotropic drugs, etc.)
  • Obtunded: This is a drowsy state where the patient is so tired he can barely plop his eyes open. At this point you should consider high CO2, decreased gag reflux and decreased cough. May consider drug toxicity, respiratory failure, sepsis, etc. You'll have to problem shoot.
  • Coma: Patient does not respond even to painful stimuli. This may be an end stage disease condition, or it may be drug induced, or it may be a sign of drug toxicity, etc. You'll have to problem shoot. May also be normal in a ventilated patient to allow their lungs and system to relax while the body heals.
  • Orthopnea: Shortness of breath when lying down, have to be sitting up to breath. Common with congested heart failure
  • Malaise: Geneeral feeling of nausea or pain; flu-like symptoms, headache, tired, weakness, fatigue.
  • Dyspnea: A feeling that you can't catch your breath. It's a subjective measure.   It's the medical description of shortness of breath (see #73). Shortness of breath, or breathing discomfort, or uneasy breathing feelings. You may feel dyspnea after a long sprint, and this is normal and it resolves itself. More severe is dyspnea at rest. Dyspnea while slowly walking is less severe than dyspnea while walking fast. Chronic end stage lung patients may feel dyspnea doing normal tasks like shaving, preparing food, etc.
  • Clubbing of fingers: This is caused by any disease that caused chronic hypoxia, such as lung cancer of cystic fibrosis. The anlge of the nails is increased, almost smooth looking.
  • Venous distention: A popping out of the veins, especially in the neck. Common in patients with end stage lung disease due to high pressure needed to pump blood through lungs and body
  • Edema: This is excess fluid somewhere in the body, causing swelling, such as in the ankles. It's common with heart failure, or kidney failure.
  • Ascites: Accumulation of fluid in the abdomen; liver failure
  • Diaphoresis: Sweating. May be sign of heart failure (CHF), fever, infection, anxiety, nervousness, etc.
  • Jaundice: Yellow skin; liver failure; increased biliruben (new born infants). If newborn, patient may be placed under radiant light and the problem will resolve itself.
  • Barrel Chest: Increased a/p diameter of chest, and a result of air trapping. This may be a short term condition (asthma) or chronic (end stage emphysema, COPD)
  • Nasal flaring: A flaring out of the nostrils during inspiration. This is usually a signs of respiratory distress in newborn babies and infants
  • Retractions: This is a sucking in of the chest during inspiration, and is a sign of respiratory distress in neonates. The higher up in the chest the retractions are the more severe the respiratory distress.
  • Grunting: A grunting on expiration, and is usually a common sign of respiratory distress in neonates. It's the patients natural attempt to keep the alveoli open and get more oxygen.
  • Tracheal deviation: This is when the trachea is moved either to the left or right. The trachea is usually pushed away from pathologies such as pleural effusions, tension pneumothorax, neck or thyroid tumors, large mediastinal masses. ( or things that take up space in the lungs). It moves toward pulmonary atelectasis, pulmonary fibrosis, pneumonectomy and diagphragmatic paralysis (or things that make more room in the lungs).
  • Crepitis: A crunchy feeling felt by the hand over the chest wall, neck, and around a chest tube. It's usually air that creeps and bubbles under the skin. Subcutaneous emphysema.
  • Vesicular: Normal lung sounds
  • Bronchial: Normal lung sounds heard over the upper airway (trachea and bronchi).
  • Adventitious: Abnormal lung sounds (wheezing, rhonchi, rhales, crackles, etc.)
  • Coarse lung sounds: Rhonchi (see rhonchi below)
  • Wheezes: High pitched sound heard on inspiration and or expiration, and is usually indicitive of bronchospasm. Don't get upper airway wheezes confused for bronchospasm, because all that wheezes is not necessarily bronchospasm. Usually, if it's audible, it's not a wheeze technically speaking.
  • Crackles:  The sound of fluid in the lungs or the alveoli popping open with inspiration.  There are two types:  1) Coarse crackles (a.k.a. rhales) are heard on inspiration and expiration and represent fluid in the lungs, 2) Fine crackles are heard on inspiration only and represent alveoli popping open with inspiration; often a sign of atelectasis; may be sign of early pneumonia.
  • Fluid challenge: If you have a patient who has a low blood pressure, shock, hypovolemia, etc. you'll challenge him with a rapid bolus of fluid to try to get blood pressure up.
  • Blood pressure: Normal is 120/80. Greater than 140/90 should be treated as hypertension, and less than 90/60 should be treated as hypotension. Consider normal values for patinet however.
  • Pulmonary Hypertension: High blood pressure in the lungs, which is usually indicative of end stage pulmonary disease, such as COPD, lung cancer, pulmonary fibrosis, cystic fibrosis, etc. It means the heart is working extra hard to push blood through the lungs, and often results in a large right heart (Cor pulmonale) that eventually results in a large left heart and heart failure.
  • Cor pulmonale: An enlarged right heart secondary to long term high pulmonary blood pressure (pulmonary vascular resistance) secondary to end stage chronic lung disease.
  • Auscultation: Listening to lung sounds
  • Bronchial Hygene therapy: positioning a patinet to drain secretions (done in cystic fibrosis patients)
  • Chest percussion: Clapping with cupped hands over chest wall to create vibrations in an attempt to move thick and stubborn secretions so they may be expectorated.
  • Expectoration: Spitting up phlegm
  • Chest physiotherapy (CPT): Using bronchial hygene and chest percussion to stimulate expectoration of secretions; pulmonary toilet.
  • Pulmonary toilet: Doing whatever is necessary to help a patient expectorate thick and stubborn secretions; COPD; breathing treatment with bronchodilator and sometimes with Mucomyst; chest physiotherapy; PEP therapy, Flutter valves, etc.
  • Suctioning: Removing secretions from the patients airway by artificial means. It is invasive and should never be done on any patient who is awake and alert. It can traumatize the patient and the airway. It is a necessary procedure in an intubated patient.
  • Intubation: The process of inserting an endotracheal tube into a patients airway to the lungs to facilitate breathing for that patient. It is necessary for patients who cannot breath on their own. A patient is usually hooked up to mechanical ventilation.
  • Mechanical Ventilation: The process of breathing for a patient with a machine called a ventilator.
  • Prone position: Lying on belly
  • Supine position: Lying on back
  • Fowlers position: Sitting up straight
  • Semi fowlers position: Sitting up withe the head of bed at a 30-40 degree angle.
  • Death Rattle: Increased saliva and secretions in throat due to loss of ability to swallow and clear oral secretions. It's harmless to the patient, but can often be stressful for the family member not familiar with it, or not ecucated about it.
  • Cardiac Wheezes: These are usually coarse wheezes, sometimes audible, and often of the upper airway that are caused because of increased pressure around the bronchial tree of the lungs due to heart failure and increased pulmonary edema. The increased pressure and fluid actually squeeze the bronchial tubes, thus causing them to wheeze. This presents similar to asthma, and is often confused as asthma, thus the name.
  • Cardiac Asthma: See Cardiac Wheeze. This is asthma-like symptoms caused by heart failure. It presents as dyspnea at rest or on exertion and wheezes. It is often confused for asthma
  • Ventilator Delirium: (synonym is psychosis) According to RT Magazine: "Delirium, as defined by the DSM-IV, requires an acute disturbance of consciousness with reduced clarity or awareness of the environment (eg, an inability to focus or to sustain or shift attention) and either (1) a new cognitive change (eg, deficits in memory or orientation, or a language disturbance) or (2) a new perceptual disturbance (eg, hallucinations or misinterpretations).2 Delirium frequently develops over hours or days, and fluctuates over time.
  • Ventilator Acquired Pneumonia: This is pneumonia acquired once a patient is on a Vent. For the most part, a vent cannot cause pneumonia, however the term sticks.
  • Circadian Rhythm Sleep Disorder: This is what happens to people who work nights. It's the totally whacking out of your circadian rhythm, thus making it difficult to sleep. The only cure is to stop working nights.
  • Concurrent therapy:  See treatment stacking
  • Treatment stacking:  When you do more than one breathing treatment at a time. 
  • Nauseated: You feel sick
  • Nauseous:  You make others feel sick
  • Shortness of breath (SOB): It's a subjective measure. It's how your breathing feels to you. Do you feel winded? Do you feel you can't get air in? Do you feel dypneic. (see above)

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