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Wednesday, October 7, 2015

Asthma/COPD Inhalers: Why They Cost So Much

Some of my asthmatic friends constantly criticize pharmaceuticals as run by a bunch of evil rich people who are greedy and make money at the expense of the sick.  Their evidence is the fact that newer, non-patented, asthma medicine costs so much.  I would like to argue that pharmaceutical companies (or most of them) are run by people who simply want to make enough profit to stay in business.

It is true that asthma medicine costs too much. Consider that if your doctor prescribes Advair to control your asthma, it will cost you about $250 a month if you pay out of pocket.  If you have a copay the cost will be about $70 per month.  This copay is high, considering a typical copay for generic medicine is between $20 and $40 a month.

 Consider the following facts as reported by, "Drugs: Why they cost so much?"
  • The high price of Advair is not the result of greed, but of regulation. In fact, pharmaceuticals are constantly looking to find new medicines to help people.  They continue to do this even though they know that only one out of every 10,000 discovered compounds actually becomes approved by the FDA
  • The early stages of development are not only expensive, but much of the expense incurred will not become approved drugs.
  • It takes about 7 to 10 years and an average cost of 500 million dollars to develop each new drug. Keep in mind this money is spent before the FDA approves the drug. This means that if the drug is not approved, the company loses the money. 
  • These expenses must be covered by the revenue from compounds that successfully become approved drugs (like Advair). 
  • Moreover, only 3 out of every 20 approved drugs bring in sufficient revenue to cover their developmental costs, and only 1 out of every 3 approved drugs generates enough money to cover the development costs of previous failures. This means that for a drug company to survive, it needs to discover a blockbuster (billion-dollar drug -- like Advair) every few years. 
  • After a drug is approved, millions of dollars are spent on marketing in educating healthcare providers and conducting post-marketing studies. Drug companies spend a lot of money on marketing because of the stiff competition they face from other drug companies for their drugs, and in order to develop each drug's highest revenue-generating potential. 
  • Given the poor odds of discovering another successful drug, it is more efficient to maximize the returns on a drug that is already on the market through advertising. In this sense, drug companies are no different than any other type of company. They exist to make a profit by helping people.
  • In addition to maximizing returns on their investment through advertising, drug companies also spend money to find new uses for drugs or better ways of using them. These efforts increase the use of the approved drugs and also benefit patients. 
  • Additionally, drug companies donate millions of dollars to charities and provide free drugs to individuals or countries that cannot afford medications. In fact, it was through a program that I was able to get free Breo for a year (otherwise, I cannot afford it and I have insurance). 
Surely any person working for any company wants to become rich, but in order for this to happen the company they work for must develop, market, advertise, and sell a successful product. Due to the high risk of failure and the low risk of actually gaining FDA approval, the medicines that are approved will have a hefty cost.

Further reading:

Tuesday, October 6, 2015

Asthma Medicine: Home Versus Hospital

The following was originally published on February 16, 2015, at

Asthma Medicine: Home Versus Hospital

The goal of asthma treatment is to prevent and control asthma so you can live a normal life with it. Still, from time to time, some asthmatics require a hospital admission to get their lungs back into shape. When this happens, the medicine you normally take at home may change and be administered in a different fashion than you’re used to.

Here are some changes to expect if you ever require a hospital admission for your asthma.

Controller Medicine. Usually, if you take asthma controller medicine at home (Advair, Dulera, Symbicort, Breo) you will continue to receive the same medicine in the hospital. This is important to note, because it usually takes 2-3 weeks for the medicine to get into your system and start working. Your admitting physician surely won’t want you to start all over once you are discharged.

However, it’s important to understand that the brand used in the hospital may be different from what you use at home. For example, say you take Advair at home. The medicine in this inhaler is similar to the medicine used in Symbicort, Dulera or Breo. The hospital might only carry Symbicort, meaning you may receive a different inhaler while admitted. This is okay.

Now, some asthmatics (like myself) respond well only to a certain brands (in my case Breo), and respond not so well to the other brands. In this case, even if the hospital does not carry your brand, the pharmacist will make a special effort to get the medicine for you. Once you alert your admitting physician, there is no need to worry.

Rescue Medicine. Most asthmatics carry a rescue inhaler (albuterol, xopenex) on them at all times, and use it when they feel asthma symptoms. In the hospital you will not take your rescue medicine on your own, and instead it will be delivered by a Respiratory Therapist (RT).

This is an important change, because most asthmatics are admitted for unstable asthma. An RT can keep a close eye on you during the treatment. If the treatments are not working, the RT might call your physician so you can get the help you need.

Nebulizers before inhalers. Most physicians prefer you do not use your own inhalers in the hospital, and instead rely on the nebulizer brought by the respiratory therapist. There are two very good reasons for this:]
  • Diminished Flow. During an asthma attack, air trapped inside your lungs prevents you from generating enough flow to actuate inhalers. 
  • Longer Duration. Nebulizers allow you to inhale the medicine slowly over a period of five to ten minutes, compared to a single puff of an inhaler. This assures good distribution of the medicine throughout your air passages. 
Feeling better? Once you start to feel better your physician may try to get you back onto your normal routine before you are discharged. At this time you may keep your inhalers at your bedside and use them when you normally do. You may still get breathing treatments when you need them, although you will probably have to call for one and wait for an RT.

Education. A nurse or RT will probably make sure you are well educated about your medicine and how to use it. You may be required to demonstrate proper technique prior to using it on your own. This is all good. It’s an effort to make sure you are doing everything right on your part to keep your asthma under control.

Gallant Asthmatic. Before you are discharged your physician will probably write a prescription for all your home medicines, and this may include some changes from your previous routine. By taking these exactly as prescribed, you should be able to live a normal life with asthma like Jake Gallant.

Further reading:

Monday, October 5, 2015

What patients need to know about oxygen levels

The following was originally published on April 3, 2015

Understanding Oxygen and Oxygen Levels

Oxygen is essential to a normal functioning body. The progression of COPD, and COPD flare-ups, may cause your oxygen levels to become low. So what does this mean to you? Here is all you need to know about oxygen and oxygen levels.

What is oxygen?

It’s an element with the symbol O. It makes up about 21 percent of air. When you inhale, it travels through your lungs to your bloodstream, and then travels to tissues, such as heart tissue. A cell on this tissue will use it to make energy needed for it to perform its work. Lack of oxygen may cause tissue damage, such as heart damage.

How are oxygen levels monitored?

There are two tests:
  1. Arterial Blood Gas (ABG). This involves an blood draw from your wrist or arm. Thankfully, this test doesn’t need to be done too often thanks to another, simpler test called...
  2. Pulse Oximetry. A probe is placed over your finger or earlobe. Since this is an easy test, it is often considered the fifth vital sign, and may be checked frequently.
What are oxygen levels?

They measure how efficient your lungs are at inhaling oxygen and transporting it into your bloodstream. The three most important are:
  1. SaO2. It's a percentage that shows how saturated your arterial blood is with oxygen. It's obtained from an ABG, so it's very accurate. Normal is 95-98%, although 90% or better is usually considered acceptable.
  2. PaO2. It's the partial pressure of arterial oxygen. It's obtained from an ABG, and is an accurate measure of oxygen in arterial blood. A normal range is 80-100, although 60 or better is usually considered acceptable. It's the same as SaO2, although it's estimated by pulse oximetry. A normal value is 95-98%, although 90% or better is usually considered acceptable. 
What are low oxygen levels?
  1. Hypoxemia. This is the term used when your PaO2 is less than 60 or your SaO2 and SpO2 are less than 90 percent. It means your blood oxygen level is low. Hypoxemia may lead to hypoxia.
  2. Hypoxia. This means your tissues aren’t getting enough oxygen. 
456-789 Rule. This explains why your doctor doesn’t always need an ABG to check your oxygen levels. Generally speaking, your SpO2 matches up with your PO2 as follows:
  • 90 percent SpO2 = 60 PO2 (this is your normal range, and usually no oxygen therapy is needed)
  • 80 percent SpO2 = 50 PO2 (this is your hypoxemic range, meaning oxygen therapy is needed)
  • 70 percent SpO2 = 40 PO2 (this is severe hypoxemia, immediate treatment is needed to prevent tissue damage and death)
What causes low oxygen levels? The natural progression of COPD may cause areas in your lungs where oxygen gets in but is blocked from getting to the bloodstream. This may be due to loss of lung tissue (emphysema) or airway obstruction (bronchitis). COPD flare-ups may exacerbate this problem.

How does your body respond to hypoxia? When your brain senses hypoxia, your blood vessels constrict and your heart pumps harder and faster, sending blood in search of more oxygen. Your body shunts freshly oxygenated blood away from fingertips, toes and lips in favor of vital organs, such as your heart.

. When your oxygen levels are low, your body will let you know. Common symptoms include a bluish tinge to your fingertips, toes and lips (cyanosis), rapid heartbeat, sweating, confusion, and feeling short of breath or winded.

Long-Term Consequences. Hypoxemia with COPD may become chronic, meaning it’s always there and your body gets used to it. This may mean that the blood vessels in your lungs are chronically constricted, forcing your heart to work extra hard to pump blood through your lungs. Over time, this causes your heart to become enlarged (hypertrophy). This makes it a weaker pump, and may lead to heart failure.

. Your doctor will usually recommend the lowest amount of oxygen needed to keep your PaO2 at safe levels, which is usually 60 or better. So this means an SpO2 of about 90 percent is the goal, although sometimes 88 percent is acceptable. Medicine like corticosteroids and albuterol may help reduce inflammation and open airways.

Be Compliant. Oxygen is essential to life. Making sure your oxygen levels stay at safe levels is essential to living well with COPD. Work with your doctor, follow your COPD Action Plan, pay attention to what your body is telling you, and use your oxygen therapy as prescribed (if prescribed).

Further reading:

Sunday, October 4, 2015

What is a medical train wreck?

So, we in the medical profession often refer to some patients as train wrecks.  The official term here is "Medical Train Wreck," although we Americans are good at shortening longer words that take too long to say, which is why some of us refer to them as MTWs.

That in mind, We figured we would officially define the term for our Faux Lexicon.

Word:  Train Wreck

Definition.  A person with greater than ten co-morbidities; treatment of one condition may exacerbate another condition

"The patient might be here forever, she is a medical train wreck."

Example #1:  A patient with heart failure, COPD, small bowel obstruction, hypertension,, CVA, myocardial infarction, chest pain, renal failure, sepsis, etc.  Surgery to repair the small bowel obstruction will probably require high doses of fluid; Due to bad lungs the anesthesiologist will refuse to extubate the patient, who will now be moved to intensive care.  The patient will be treated as exacerbation of COPD for three days until the physician realizes heart failure is the actual diagnosis. In the mean time the patient develops sepsis, pulmonary edema, and dyspnea.  Because the pulmonary edema causes an upper airway audible rhonchi, the episode may continue to be confused as bronchospasm, thus requiring a stat bronchodilator. You see, one thing leads to another.  These patients are train wrecks.

Example #2:  COPD, CHF, Diabetic, dementia, kidney failure, rib fracture from falling due to hyponatremia.  This patient has a GI bleed and is given blood, which causes pulmonary edema, which is treated with lasix, which exacerbates the hyponatremia; the patient is given an incentive spirometer, but you can't teach it to the patient due to dementia and the fact the patient is still on a ventilator due to the fact the patient was too sick to be extubated in the Operating Room.  The patient then develops pneumonia, and when the patient is extubated she has a forced expiratory upper airway rhonchi-ish wheeze that is mistaken by the physician for bronchospasm requiring Q4ever breathing treatments. This, in essence, is a medical train wreck.

Urban Dictionary Definition

Trainwreck:  A total f#@#ing disaster ...the kind that makes you want to shake your head.

The people at the party were so was a train wreck.

Trainwreck:  A person or situation that can't escape an inevitable bad outcome; hence, a trainwreck.

"The woman can't ever get a good man, a good job, or education. Her life sucks. She is a trainwreck!"

"The patient may never be extubated, she is a trainwreck

Trainwreck:  A name used to describe a clumsy, dangerous respiratory therapist or nurse. This person will damage things and hurt people (on accident or on purpose). They also take things too far. Rumors are also spreading about a trainwreck virus that causes these symptoms.  Ventolin is suspected as being the antiviral required to reverse Trainwreck-ism, and it will probably be recommended Q4 while in the hospital, and QID once released to home.  Some doctors catch this disease, although most are immune due to surreptitious knowledge obtained from medical school (perhaps they take ventolin at home).  

Thursday, October 1, 2015

Medicine based on some science, mostly consensus

You'll often hear the phrase: "Medicine is an art based on a science."  A more accurate phrase would be: "Medicine is an art based on some science but mostly consensus."  Lost in the discussion is the fact that science is not a consensus, or if it's a consensus it's not science.  The irony of it all is that most of the theories in medicine are based on consensus, not science.

Think of it this way.  Science is an attempt to understand things. Studies are performed, groups of data collected and then interpreted in several ways by observers.  'Consensus' is definitely important in that the more observers you have (i.e. scientists, researchers) that agree with a given interpretation, the more likely said the interpretation is accurate.

So, basically, a consensus is a group of scientists who agree with a given interpretation.  In other words, it's the results of a vote.  For instance, back in the 19th century a consensus of physicians believed that asthma was a psychosomatic disorder.  This conclusion, or consensus, resulted in researchers and scientists looking for solutions in the wrong area.  They tried to find medicines to allay the mind when they should have been looking for answers elsewhere.

So, you can see, the consensus is not always guaranteed.  If it were science, it would be guaranteed. The purpose of science is to find solutions that can be duplicated. Every time you do a certain thing, you will get the same results.  That's science.

You see, a consensus is not always guaranteed.  Those who agree with the consensus have been found to be wrong occasionally.  I can give you a ton of examples both from medicine and from the non-medical world to prove my point here.

The consensus had it that asthma was all in your head.  Later on, after years of wasted effort and resources, science learned that asthma is a physiological process that results in chronically inflamed airways that are hypersensitive, and exposure to asthma triggers causes bronchospasm and dyspnea.  This discovery created results, and now asthmatics can obtain control of their disease.

Another example is the hypoxic drive theory. It was based on a study of only four COPD patients.  Dr. EJM Campbell gave a presentation where he described the theory, and consensus of physicians began to worship it and teach it as fact.

So then once a consensus is formed it's nearly impossible to break it.  If you say the consensus is not right, then you are laughed at and mocked. Even though hundreds of studies have disproved it since that fateful day when Campbell gave his presentation, the consensus had been engrained so deep into the medical profession that even facts, even actual scientific facts, do not change consensus.

In the nonmedical world, you can look at global warming. My friends argue that a consensus of scientists believes in global warming, therefore it is a fact. I'm not going to sit here and deny global warming (but I will here), but a consensus is not evidence; it's not science.

So, based on this consensus, many regulations have been created that have prevented many people from going into business because they can't afford them, and many others have closed their doors because they can't afford them. Many jobs are not created based on a consensus, rather than proven science. This affects millions of lives every day, and it destroys economies.

Now they're talking about how they want to genetically engineer people to prevent climate change that might not even be caused by man. They want to genetically alter human eyes so we can see in the dark in order so humans can save all kinds of electricity and, therefore, pollute less, and therefore not destroy the planet via climate change.  And this theory is wholeheartedly supported and endorsed by those who support the consensus. And if you call these people lunatics they say it is you who is the lunatic even thought the facts are on your side and not theirs.

Look, I'm not bashing climate change 'theories' here, I'm just trying to make a point that it's a consensus that mankind is destroying the planet, it's not science. We should always love and respect the planet and the environment. We should always be searching for better ways to produce things, but we must not destroy what we have in the meantime based on a consensus.

So let's get back to health care. It's the same thing. Based on a consensus that bronchodilators cure everything pulmonary related, doctors order albuterol up the ying yang. This helps some patients but does nothing for most of them but make them feel we are doing something.  What it does cause is burnout and apathy among the respiratory therapy profession.

All of this in the name of a consensus. And no one sees it, no one knows it's going on, except respiratory therapists.  Yet no one listens to us. Here we are the ones who dole out treatments all day, we are the ones who should know, yet we are not even listened to. When we say someone doesn't need a breathing treatment just because they are short of breath, we are called liars and lazy.

 Let's look at bronchodilators.  Let's look at albuterol.  I think you will agree with me when I say that a consensus of physicians believe that albuterol breathing treatments will somehow treat pneumonia. Yet there has never been any evidence of this.

Still, in order to be admitted, pneumonia and COPD patients must have three breathing treatments that show results. So now we are required to give three breathing treatments to all these patients, and some work and most don't.  This is what passes as science today. It's infiltrated politics and not for the better.

So the consensus is not always created based on evidence. It is not always made based on proof.  It is too often based on the notion, "Well, it sounds good." Sounds good is not sound evidence. Sounds good is not science. Sounds good is not science.

Still, when you challenge the consensus, you are put on the spot; you are made fun of; you are treated like the idiot.  I always find it neat when you have all the evidence on your side yet you are treated like the idiot because you oppose the consensus.

This is the whole point of this blog.  It is here, and only here, where we challenge that of which we are forced to do but of which makes no sense at all.  For instance, we give oxygen to patients all the time, and they do not drop dead. Yet when you have a hypoxic COPD patient we can't give them oxygen based on a consensus; based on a hoax. It's a sad truth.

We give breathing treatments all day long because the medical consensus is that they treat all annoying lung sounds; that they cure all pulmonary problems.  Yet we give albuterol to these patients all day long and the only patients who benefit are those with actual bronchospasm. We complain this causes burnout and apathy, but we never get our way because our facts oppose the consensus.  It's a sad truth.

If we're going to believe in something just because of a consensus, then we're on shaky ground.  Now, you can have a consensus that agrees on something that is true, but the consensus is not what makes it true. A consensus may believe albuterol reverses bronchospasm, but the consensus does not make it true: it's true because it's reproducible.

And do you not think it's a little dangerous that doctors and nurses and some respiratory therapists sign on to medical consensus and believe it? So we have the absolute absence of science being presented as science. N science that albuterol treats pneumonia. Yet people in Washington just take it and run with it and create mandates based on it. 

It is unquestioned by anybody outside the small respiratory therapy community. And when somebody like me comes along with valid, penetrating questions rooted in common sense, that person has to be laughed at, mocked, made fun of, distracted, and distorted. Their consensus doesn't hold up, gets blown to smithereens, and they can't handle anything contrary to this belief system they've all evolved.

Look, just because 9 out of 10 scientists, or 9 out of 10 physicians, agree on something doesn't make it true. The fact that they agree is not what makes it true. Science is independent of opinion. Science is what it is. True scientific discovery is incontrovertible fact, and it is immune to whatever human beings think it is or assume it is.  So just because 9 out of 10 physicians think albuterol cures all respiratory ailments does not make it true, that's all I'm saying.

Further reading:

Tuesday, September 29, 2015

What is a severe asthma attack?

The following was originally published at on February 2, 2015

What is a Severe Asthma Attack? 

A severe asthma attack (not to be confused with severe asthma) is an asthma attack that is really bad. The medical term for this is status asthmaticus, or an asthma attack that is unresponsive to attempts to correct it.

Such an attack is caused when the muscles surrounding your air passages spasm and squeeze your airways so air can get in but not out. Increased sputum production may cause mucus plugs that also block air passages. A severe attack may include any of the following:
  • Uncomfortable coughing
  • Chest tightness
  • Wheezing (or no wheezing)
  • Chest pain
  • Unable to speak in full sentences
  • Leaning on things to breathe
  • Need to sit or stand to breathe
  • The need to keep shoulders raised to breathe
  • Sucking in stomach when inhaling
  • Bluish tinge around lips and fingertips
  • Feeling panicked
  • Confusion
  • Unable to concentrate
  • Inability to decide what action to take
  • Anxiety, may be severe anxiety
  • Retractions, nasal flaring, grunting (common in children)
  • Peak flow readings less than 60 percent
You may not experience all or only some of these symptoms, as they tend to vary from person to person. Still, when you experience these they are signs that you must take immediate action. 

You should work with your asthma physician to create a plan to help you determine what action to take. Usually this will involve the following:
Still, the best way to prevent severe asthma attacks is to prevent all asthma attacks. The best way to do this is to obtain good asthma control, which can be obtained by following these ten simple steps.

Monday, September 28, 2015

Links between COPD and sleep disorders

The following was originally published on March 25, 2015, on

The Link Between COPD and Sleep Disorders

About 50 percent of people with COPD also suffer from sleep disorders, or conditions that prevent a restful sleep. Here are three of the most common sleep disorders associated with COPD, signs and symptoms to watch out for, and possible treatments.

1. Hypoventilation

This is a medical term describing a decreased rate and depth of breathing. Reduced breathing activity is normal during sleep, but generally causes no problems. Even if oxygen levels drop slightly, they remain at safe levels. However, people with lung disease may already have chronically decreased oxygen levels, so relaxed breathing activity may result in oxygen levels becoming dangerously low.

Complicating this is the COPD disease process itself. Some have chronically elevated carbon dioxide levels. Some use accessory muslces to breathe, and these muscles are paralyzed while sleeping. Both of these processes may cause hypoventilation and unsafe oxygen levels while sleeping.

Signs and Symptoms. This may result in disturbances in sleep quality at night, resulting in feelings of sleepiness and fatigue during the day. It also increases the risk of bronchospasm or COPD flare ups at night. It also increases the risk of dying at night.

. The simplest treatment is to wear oxygen while sleeping. Usually this is accomplished with a low flow of oxygen through a nasal cannula. Some studies have proven that nighttime oxygen may increase life expectancy in patients with COPD.

2. Obstructive Sleep Apnea

About 4 percent of men and 2 percent of women have this, and the risk is the same among the COPD population as the general population. This is a medical condition that causes a person to stop breathing for a few seconds to a minute while sleeping. It's caused when tissues in the upper airway become too relaxed, thus blocking the airway. These episodes are ended by the person waking up slightly to an audible grunt or snore. A typical person may have 30 or more such episodes each night.

During episodes oxygen levels drop, although will usually rise back to normal levels. Since COPD may result in chronically lowered oxygen levels, these may drop to critical levels while sleeping. Lower oxygen levels then cause blood vessels to constrict, and the heart rate to work harder to pump blood through the lungs in search of more oxygen that is not there. Over time, this may cause heart failure or even death.

Signs and Symptoms. While most patients are unaware of these episodes, a bed partner may recognize them, along with the grunts and snores. Daytime symptoms may include trouble staying awake, trouble concentrating, morning headaches and depression.

Treatment. Some patients may benefit from wearing an oral appliance to keep the airway open at night. Others may benefit from CPAP at night. This involves wearing a mask that supplies pressures during exhalation to keep the airway open. If these treatments don’t work, surgery is another option.

3. Insomnia

Anxiety due to the disease process itself may result in trouble sleeping. Bronchodilators, including theophylline and albuterol, may act as stimulants and cause trouble sleeping, especially when taken in higher doses. Corticosteroids may also make it difficult to sleep.

Signs and Symptoms. Lack of quality sleep may result in the feeling of not being well rested. It may also result in daytime headaches, irritability, anxiety and depression. It may also result in poor concentration, and an increased risk of making errors at work.

Treatment. The simplest treatment for this may be a medicine to help induce sleep at night. However, a physician will want to be careful here, as some sleep medicines may relax breathing and further complicate the problem. The medicine should ideally be short acting and low dose.

The bottom line

Seek Help. It's bad enough having a lung disease, let alone a sleeping disorder to go along with it. If you recognize any of these symptoms, it's time to seek help. If a loved one is concerned about pauses and snoring while you are sleeping, it's time to seek help. Getting proper treatment should help you live better with COPD. It may also help you live longer.

Further Reading: