Wednesday, May 27, 2015

Littman: The best Stethescopes

Your Question: What is the best stethescope to use as an RT?

My humble answer: Good question. I'd go with a Littman. Here is a link to one site that sells them, yet I just chose this one because it has some good pictures with prices. I have a Littman cardiology III which costs about $120 and has a five year warranty. I purchased this one because it has both an adult and a pediatric head that I need because I take care of both populations.

However, any one that fits your budget will work fine. I've used them all at some point.

You have to keep in mind here that your specialty is lung sounds, and therefore you will want to have a stethescope that will allow you to hear all lungsounds. You certainly don't want to have a cheap $10 stethescope that someone else purchased at a dime or dollar store, or your local pharmacy (like the light blue one pictured below).

Another neat things about lung sounds is they help you to pre-diagnose. If you miss those fine crackles in the bases, you might get the wrong initial impression of the patient. Plus picking up on certain lung sounds with a good stethescope will allow you to be proactive.

As you start working in a hospital you'll see many nurses carrying around a cheap stethescope like the one in the picture to the right. If you see one of those, you're seeing a nurse or an RT who doesn't value hearing all lung sounds, because you won't be able to.

What I find funny is when I'm watching a show like Becker or ER and seeing well paid doctors with cheap stethoscopes. Any astute physician can easily afford a good stethoscope.  So the fact the cheap ones are often seen on TV doctors shows the naivety of Hollywood.

That's why they should hire me and pay me a million to watch movies and TV shows to make sure all the medical stuff is right.

Anyway, I know college itself can get kind of expensive, but it's especially important you get a good stethoscope before you go to your first clinical. I'll give you two more good reasons.

  1. Your preceptor will probably want to show you how to listen to lung sounds. When this happens, you'll want to make sure you're hearing what your preceptor is hearing. A good stethescope will allow you to do just that.
  2. A cheap stethescope makes you look like a cheap RT or RN, as opposed to the elite one that you are. Don't sell your self short, be the best, and have good ears.
And no this is not an advertisement for Littman.  There are probably other good stethoscopes out there, but Littman seems to have a good grasp on the market and have me brainwashed.

This post was originally published on August 7, 2010, right here on RT Cave.  It has since been edited. 

Further reading:

Tuesday, May 26, 2015

What happens when you drink Albuterol???

It's not something you do on purpose, but sometimes, when you take breathing treatments a lot, or give them a lot, the medicine squirts into your mouth. It's not like it happens on purpose, it just happens .

The good news is I don't ever remember suffering from side effects. In fact, the side effects from ingesting albuterol are probably less than when you inhale it.

Years ago, when I was a student perhaps, I gave a breathing treatment to a really awesome mentally challenged young man. I started the breathing treatment using a mask, and then a conversation ensued between me his mother.

She said she set him up with a treatment using a mask a few days earlier and then left the room. When she returned, she saw the mask was off his fact and the nebulizer taken apart.

"What did you do with this?" she said, concerned.

"I drank it," he said proudly.



She called poison control. They said that he would be fine, that the side effects from drinking Albuterol would be no different than if you inhaled it: nervousness, dizziness, tremors, etc.

So, take it from the authorities, the next time you accidentally squirt albuterol into your mouth, take note of the fact it will do no harm.

This post was originally published on August 28, 2008 and has since been edited

Further reading:

Drinking Albuterol new trend for body builders

Just like any other medicine, albuterol can be abused.  Surely you have the asthmatic or COPD patient who uses it too much.  But I'm referring to the body builder who ingests vials of albuterol to help burn fat and build muscle. describes how Albuterol is used by body builders as a fat burner. It is a stimulant much like "Benadryl with Clenbuterol" but without the shakes.

The author explains how it works:
But in my own personal experience, Albuterol produces a much "cleaner" type of stimulant effect than Clenbuterol. I don’t know how to really describe this other than to say that the "Clen-shakes" just aren’t as bad with Albuterol…in addition, I’m able to focus better on my work when I use Albuterol, while with Clen I’m stimulated but not really focused."
Like short acting anabolic steroids, the author said, albuterol is a shorter acting version of Clen, and thus burns fat quicker.

You'd think if albuterol helped with weight loss I would stick thin, considering I've been inhaling the stuff since 1985.  Apparently I haven't been taking enough.

According to the author, it works this way:
It should come as no surprise to anyone who has used Clenbuterol as well as Albuterol is that when you stimulate your beta receptors, it causes something called vasodilatation (increased blood flow). Stimulation of these receptors also stimulates the break down of fatty acids into the blood stream for use as fuel, which causes a reduction in stored fat. Of course, this increased blood flow also comes with an increased heart rate.

This explains how Beta-2 adrenergic stimulation can also increase your body temperature a bit…however this isn’t something that’s too noticeable on a hermometer…most people will feel a bit hotter, and some will even break a sweat
(I fall into the latter category). Beta-agonists work to do this by increasing heat production in the cell’s powerhouse, the mitochondria, which will also increase your basal metabolic rate, and decrease your appetite. Not too many people feel hungry after a whopping dose of stimulants.
These guys even have a dose down pat. He (or she) said it's 4-8 mg three times a day. He recommends, for those who can get their hands on it, drinking it.

Other sites I've Googled give similar advice, with a similar dosing.

There have even been some studies done to prove this.

One post I found described how some people are faking asthma just so they can get a prescription to Albuterol just for this reason. Yet the author explained that Albuterol has no bronchodilator effect on non-asthmatics, thus "technically, albuterol is not a performance-enhancing drug in a non-asthmatic."

study published in the European Journal of Applied Physical and Occupational Physiology proved that Albuterol has no effect on performance. The study followed 15 highly trained cyclists, and some of them were given 4 puffs (400 micrograms) of Albuterol 20 minutes prior to exercise, and this had no effect on performance.

However, this dosing was way less than the 4-8 mg recommended by some bodybuilders.

Albuterol, I suppose, is a lot safer than other body building drugs, such as anabolic steroids.  Still, such an abuse of a medicine could potentially result in undesirable side effects. So abuse at your own risk.

This post was originally published on August 29, 2008; it has since been edited.

Further reading:

Sunday, May 24, 2015

62 A.D.: Seneca's view of life helped him cope with asthma

I am in love with Seneca the Younger.  He was an asthmatic with allergies just like me, only he suffered with the disease over 2,000 years ago.  His descriptions of the disease were simply amazing, yet more impressive was the way he learned to cope, and the way he wrote about how asthma made him a better person simply for having experienced it.   

And even more amazing is the methods that he developed to conquer his asthma. He wrote that you cannot dwell on the past and say things like, "Oh why me?" You cannot say things like, "No one had ever been in such a bad state." You cannot say things like, "The torments and hardships I endured." These thoughts should be banned, he wrote, because they are of little use. Dewlling on what ailed you in the past does you no good. (1)

Likewise, he wrote that you cannot worry about an asthma attack that will strike you in the future either, because that will do you no good.  What you need to do is try to make the best of your life right now.  You need to clear your mind of such evil thoughts.

In his 78th letter to his friend Lucius he wrote that those who suffer through the battle of an asthma attack are like the boxer who suffers even during the trials of training. He wrote that a boxer does this for wealth and fame. He wrote, "Let us too overcome all things, with our reward consisting not in any wealth or garland, not in trumpet calls for silence for the ceremonial proclamaiton of our name, but in moral worth, in strength of spirit, in a peace that is won for every once in any contest fortune has been utterly defeated." (1)

He wrote this over 2,000 years before I wrote my post The Seven Benefits of having Asthma and Seven Ways Asthma has Benefited my Life. I wrote pretty much what Seneca wrote to his friend Lucius, only I wrote it before I ever even discovered who Seneca was.
To manage his asthma he didn't rely on witchcraft, or magic, or prayer, nor did he rely on remedies based on some poppycock superstitions or false logic. The way he learned to cope with his disease was by eating well, staying in shape, and by having many friends, diverting your mind so you don't think about the pains in your life. He generally wrote about the importance of relaxing and soothing your mind to remedy pain or dyspnea or any physical ailment. Today we refer to this as relaxation exercises.

He wrote that to think about the misery you put up with in the past, or to fear the future is senseless and will only increase your anxiety and make your disease and your life even worse; that fear and anxiety will only bring on an attack of "gasping for breath" or catarrh. (1)

He said, "'I am suffering from pain,' you may say.  'Well, does it stop your suffering it if you endure it in a womanish fashion" (1)

He continued, "Plus there are men who have suffered greater sufferings than you have and survived.  In this way you should consider yourself fortunate.  You could have something worse, like "having your arms stretched on a rack or burnt alive... There have been men who have undergone these experiences and never uttered a groan... Surely pain is something you will want to smile at after this." (10

"But my illness has taken me away from my duties and won't allow me to achieve anything," he wrote as another example of a common complaint of the suffering. (1)

He said:
"It is your body, not your mind as well, that is in the grip of ill health.  Hence it may slow the feet of a runner and make the hands of a smith or cobbler less efficient, but if your mind is by habit of an active turn you may still give instruction and advice, listen and learn, inquire and remember.  Besides, if you meet sickness in a sensible manner, do you really think you are achieving nothing?  You will be demonstrating that even when one cannot always beat it one can always bear an illness.  There is room for heroism, I assure you, in bed as anywhere else.  War and the battle-front are not the only spheres in which proof is to be had of a spirited and fearless character:  a person's bravery is no less evident under the bed-clothes. There is something it lies open to you to achieve, and that is making the fight with illness a good one.  If its threats or importunities leave you quite unmoved, you are sending others a signal example.  How much scope there would be for renown if whenever we were sick we had an audience of spectators!  Be your own spectator anyway, your own applauding audience." (1)
In essence, he is saying that you are alive and therefore you have a gift to offer to the world if you see it and if you use it.  Your job is to bring yourself up, rise up, and make something of what you have left in life.  Use what is not ailing you: your brain, your ability to speak or listen, your ability to read and write and to communicate ideas. 

The benefits I wrote about are perspective on life and an appreciation for every breath, a sense of vulnerability in that you know that you will not live forever and that you must get what you can out of life, and give what you can give while you are here.  You know that you might die tomorrow, so you live forever today.  You touch as many people as you can.  You read instead of doing things that might trigger your asthma. You write and communicate what you learn.  And, in this way, you are in effect making a difference in the world with the faculties you have left.

He said:
"Moreover, even if death is on the way with a summons for him, though it comes all too early, though it cut him off in the prime of his life, he has experienced every reward that the very longest life can offer, having gained extensive knowledge of the world we live in, having learnt that time adds nothing to the finer things in life.  Whereas any life must needs seem short to people who measure it in terms of pleasure which through their empty nature are incapable of completeness." (1)
We must never let the things that ail us set us back.  We must continue on and give what we can in this life.
  1. Campbell, Robin, Lucius Annaeus Seneca, "Letters from a Stoic: Epistulae morales ad Lucilium, " Penguin, 1969, letter LXXVII.
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Saturday, May 23, 2015

62 B.C.: Seneca the asthma philosopher

During the last three years of his life, Seneca the Younger spent much of his time writing down his thoughts about the world around him, including his thoughts about asthma and how it impacted his life.  He also gave his advice to other people suffering from this disease.

He said:
"What in fact makes people who are morally unenlightened by the experience of physical distress is their failure to acquire the habit of contentment with the spirit. They have instead been preoccupied by the body... so do not go out of your way to make your troubles any more tiresome than they are and burden yourself with fretting." 
Like the writings of Pliney the Elder, Seneca's writings became well read, and Seneca became one of the most well known philosophers.  In one of his letters to Lucilius, a friend and correspondent of Seneca's, Seneca provided a description of asthma, although he doesn't use the term asthma.

 Sculpture of Seneca by Puerta de Almodóvar in Córdoba, Spain
From his 54th letter to his friend Lucius (who also had asthma and catarrh), we get Seneca's description of asthma from "On Asthma and Death" as translated by Richard M. Gummere:
My ill health had allowed me a long furlough, when suddenly it resumed the attack. "what kind of ill-health?" you say. And you surely have a right to ask; for it is true that no kind is unknown to me. But I have been consigned, so to speak, to one special ailment. I do not know why I should call it by its Greek name; for it is well enough described as "shortness of breath." It's attack is of very brief duration, like that of a squall at sea; it usually ends within an hour. Who indeed could breathe his last for long? I have passed through all the ills and dangers of the flesh; but nothing seems to me more troublesome than this. And naturally so; for anything else may be called illness; but this is a sort of continued 'last gasp.' Hence physicians call it 'practising how to die." For some day the breath will succeed in doing what it has so often essayed (breath will succeed in doing what it is supposed to do). (2, page 361)
In letter 65 he wrote about his catarrh and the catarrh of his friend Lucius (1):
"I am all the more sorry to hear about your constant catarrh, and the spells of feverishness that go with it when it becomes protracted to the point of being chronic, because this kind of ill health is something I have experienced myself. In its early stages I refused to let it bother me, being still young enough to adapt a defiant attitude to sickness and put up with hardships, but eventually I succumbed to it altogether. Reduced to a state of complete emaciation, I had arrived at a point where the catahhral discharges were virtually carrying me away with them altogether. On many an occasion I felt the urge to cut my life short there and then, and was only held back by the thoughts of my father who had been the kindest of fathers to me and was then in his old age. Having in mind now how bravely I was capable of bearing the loss, I commanded myself to live. There are times when even to live an act of bravery." (1)
This was probably saying a lot back then, because I can imagine living in a state of shortness of breath.  And I can imagine this coupled with the misery of allergies on top of that.

Yet I cannot imagine what those two ailments would be like when there was no cure and no remedy that really provided any relief.  It must have been pure hell to live like that.  I can understand how he might be compelled to think about just ending the misery right "there and then."

Yet life is special, and there are few who get to enjoy this special gift.  Seneca realized this.  He used his father to provide himself the courage to go on. 

In letter 65 he described to his friend Lucius what he did to survive the attacks of asthma and catarrh (1). 

"Let me tell you the things that provided me consolation in those days, telling you to begin with that the thoughts which brought me this peace of mind had all the effects of medical treatment. Comforting thoughts contribute to a person's cure; anything which raises his spirit benefits him physically as well. It was my Stoic studies that really saved me. For the fact I was able to leave my bed and was restored to health I give the credit to philosophy. I owe her -- and it is the least of my obligations to her -- my life. But my friends also made a considerable contribution to my health. I found a great deal of relief in their cheering remarks, in the hours they spent at my bedside and in their conversations with me. There is nothing, my good Lucius, quite like the devotion of one's friends for supporting one in illness and restoring one to health, and for dispelling one's anticipation of dread and death. I even came to feel that I could not really die when these were the people I would leave surviving me, or perhaps I should say I came to think I would continue to live because of them, if not among them; for it seemed to me that in death I would not be passing on my spirit to them. These things gave me the willingness to help my own recovery and endure all the pain. It is quite pathetic, after all, if one has put the will to die behind one, to be without the will to life.
Another remedy he later adds...

"is to turn your mind to other thoughts and in that way get away from your suffering. Call to mind things which you have done that have been upright and courteous; run over in your mind the finest parts that have been played. And cast your memory over the things you have most admired."
No potions.  No magic.  No herbs.  Seneca might have been one of the first asthma experts to recommend, mainly due to his own experiences, the importance of relaxing to control your asthma.

"There then are your remedies," he said.

Click here for more asthma history.

  1. Campbell, Robin, Lucius Annaeus Seneca, "Letters from a Stoic: Epistulae morales ad Lucilium, " Penguin, 1969, letter LXXVII.
  2. Seneca, Lucius Annaeus, "Seneca Ad Lucilium epistulae morales: Books I-LXI," translated by Richard M. Gummere, 1917, "The Epistles of Seneca," letter LIV "On Asthma and Death," New York, London, William Heinemann, G.P. Putnam's Sons, pages 361-363
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Tuesday, May 19, 2015

Most Aerosolized medicine is wasted

According to the American Association of Respiratory Care's "Guide to Aerosolized Medications," not much of the medicine inhaled by inhalers and nebulizers makes it into airways.

By device, here's how much medicine reaches the lungs?
  • Metered Dose Inhalers:  9%
  • Metered Dose Inhalers with spacer:  15%
  • Small Volume Nebulizer:  12%
  • Dry Powdered Inhaler:  13%
So that means that most of the inhaled medicine, or a whopping 85-91% depending on the device used, "is lost in the oropharynx, the device, the exhaled breath, and the environment," according to the guidelines.

When a patient is intubated the percentage of medicine getting to airways is 2.9%, according to one study. 

It appears that the best distribution into the airway is obtained by inhaler and spacer.  Of course, this would only be possible if good technique is used.  Considering studies show that up to 93% of asthmatics do not correctly use their inhalers (93% to be exact), this kind of knocks inhalers and inhalers with spacers down to a level playing ground with nebulizers.  

While some might panic at these percentages, one should not worry. Pharmaceutical companies are well aware these when the formulate their dosing criteria.  So chances are that, regardless of the route used, most patients get plenty of medicine for maximum effect. 

Plus, it must be considered that 2.5 mg of albuterol solution mixed with 3cc of normal saline contains about twice as much ventolin as in the 200 mcg of albuterol inhaled via an inhaler.  So, again, patients are getting plenty of albuterol, and probably more than enough when an SVN is used. 

So who wins the battle of inhalers vs. nebulizers?  Well, as far as distributing medicine to airways, they all work equally well.

This post was originally published on March 11, 2010.  It has been edited for accuracy by Rick Frea.  

Further reading:

Monday, May 18, 2015

FeNO Testing To Diagnose Asthma

The following post was originally published on on June 26, 2014, at

FeNO Testing May Help Diagnose Asthma

One of the many tests used to help physicians diagnose and treat asthma is Fractional Exhaled Nitric Oxide, or FeNO. It’s a simple procedure where the patient exhales into a mouthpiece connected to a computer that measures the amount of Nitric Oxide (NO) present in asthmatic lungs.

It is now common knowledge that all asthmatics have a small amount of chronic (it’s always there) inflammation present in their lungs. When exposed to certain asthma triggers, this inflammation can worsen, resulting in an asthma attack.

According to the American Thoracic Society (ATS), clinical practice guidelines for exhaled nitric oxide levels for clinical application, the following is true of NO:
  • It is produced in the lungs
  • It is present in exhaled breath
  • It plays a key role in virtually all lung biology
  • It has been implicated in the pathophysiology of lung diseases, including asthma
  • It plays a key role as a vasodilator, bronchodilator, neurotransmitter, and inflammatory mediator
FeNO may act as a good diagnostic test for asthma because asthmatic airways have higher levels of airway inflammation compared with non-asthmatic airways, thus resulting in higher FeNO levels. Because of this, a high FeNO reading may be indicative of asthma.

To control this underlying airway inflammation, physicians will prescribe asthma controller medicines such as inhaled steroids like Flovent, or inhaled steroids in combination with long acting beta adrenergics like Advair and Symbicort, or various other combinations of medications.

Subsequent measurements of FeNO will help a physician determine if the current medicine regime is working, or whether a step up, or step down, in treatment is required. In other words, the test monitors how well current treatment is working. notes: ”FeNO testing is a two-minute point-of-care breath test that can be used to identify patients with allergic airway inflammation. Airway inflammation is widely recognized as the underlying cause of asthma. Using routine FeNO testing to guide therapy, particularly inhaled corticosteroid therapy, for asthma patients has been shown to reduce asthma exacerbations up to 50 percent, according to Aerocrine.”

The ATS guidelines note that the test was first introduced in the early 1990s and has advanced markedly since then. However, studies are still ongoing to determine how reliable the test is, and where it might be useful in the clinical setting.

While the test is not yet standard practice in diagnosing and treating asthma, “it adds a new dimension to the traditional clinical tools,” said the authors of the guidelines.

They also note that reference values for the various age groups “have been derived from large population studies, but in practice they have limited application.” The main reason here may be because each asthmatic is unique.

So, similar to the recommended usage of peak flow monitoring, the authors recommend that “when monitoring individual patients with asthma and assessing their treatment, achieving ‘personal best’ rather than ‘normal’ values is more helpful.”

Perhaps there will come a day where every hospital, and every doctor’s office, will have the ability to monitor FeNO, which will be used on a more routine basis to diagnose asthma and monitor the effectiveness of the treatment used to control it. reports that one insurance company, Health Care Service Corporation, has decided that it will pay for FeNO testing for asthmatics. If more insurance companies follow suit, such testing may be commonplace sooner rather than later.