slideshow widget

Sunday, August 6, 2017

Should You Use A Spacer With Symbicort

Your Question. If you read the package insert for Symbicort, it says not to use with a spacer. What should we make of this? It seems to me that common sense would point to using a spacer with it, considering it is an inhaler. What do you think?

My Answer. That is a very good question. There are actually two ways of looking at this.

One, that Symbicort is still a relatively new product, and it has yet to have been studied with a spacer. For this reason, their lawyers may require them to make this note on the package insert.

Two, the dose of medicine is adjusted based on estimated distribution to the airways. It is well known
that only 9% of medicine inhaled by metered dose inhalers makes it to the lower airways where it is needed. To compensate for this low distribution percentage, the dose of Symbicort was adjusted to obtain maximal results. Wanting to limit side effects, the makers of Symbicort (AstraZeneca) and their lawyers decided to put the disclaimer on the package insert that a spacer should not be used.

So, you might be thinking, so why then should you not use a spacer? The general thinking is that a spacer would improve coordination, reduce side effects, and improve distribution. A spacer will surely reduce impaction of medicine particles in your upper airway, thereby reducing side effects. However, these medicine particles cause systemic side effects only after they are swallowed. These medicine particles are broken down (metabolized) by the liver, where almost all of them are excreted in urine. Only a tiny fraction gets into your bloodstream and has a chance to cause systemic side effects. This is called first pass metabolism, meaning that your digestive tract and liver significantly breaks down the medicine before it reaches your circulation.

Now, let's look at the medicine that makes it to your airways. Studies show that 10-40% of this medicine will come into contact with blood vessels in your lungs. If you use a spacer and increase lung distribution, that means that you are getting more medicine to airways. You'd think this is a good thing, resulting in better asthma control (although modern studies can even debate that). However, while true, it also increases the amount of medicine that comes into contact with pulmonary blood vessels. These medicine particles do not participate in first pass metabolism. Instead, a majority, if not all, of these particles directly enter your circulatory system, where they might participate in systemic side effects.

So, while a spacer might improve coordination and reduce side effects, not using a spacer may reduce side effects even more so than using a spacer. This is important, because this is how pharmaceuticals like AstraZeneca prevent side effects from corticosteroids and long-acting beta adrenergic medicines.

Bottom line, the dose of Symbicort is adjusted to account for a lung distribution of only 9%. If it were assumed that 100% of patients used a spacer with Symbicort, then the dose of the medicine would be adjusted downward to compensate for the improved lung distribution. This would be necessary to prevent side effects. So, I know this was a complicated explanation, but might explain why the package insert for Symbicort recommends that no spacer be used.

So, what should you do? Personally, where I work we distribute spacers with all inhaler products. I think this is the way it will be done until the medical profession adjusts to this new wisdom. For legal and ethical purposes, I think following your hospitals policy is the best policy. However, when you are using your own inhaler product, whether you use a spacer is up to you.

References.

“A Guide for Aerosolized Delivery Devices for Respiratory Therapists,” 3rd edition, https://www.aarc.org/education/online-courses/aerosol-devices/, accessed 8/4/17

Irwin, et al., “Side Effects With Inhaled Corticosteroids,” Chest, July, 2006, http://journal.chestnet.org/article/S0012-3692(15)32956-1/pdf, accessed 8/3/17

“Spacers with inhalers: Do they make a difference,” American Academy of Allergy, Asthma, and Immunology, 2017, Jan. 18, https://www.aaaai.org/global/latest-research-summaries/New-Research-from-JACI-In-Practice/spacer-inhaler, accessed 8/5/17

Saag, Kenneth G., et al., “Major Side Effects of Glucocorticosteroids,” 2017, https://www.uptodate.com/contents/major-side-effects-of-inhaled-glucocorticoids, accessed 8/3/17

Barnes, Peter, J., "Inhaled Corticosteroids," Pharmaceuticals (Basal), 2010, March 3, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4033967/, accessed 8/1/17

Romme, “Fracture Prevention in COPD: A clinical 5-step approach,” Respiratory Research, 2014, https://respiratory-research.biomedcentral.com/articles/10.1186/s12931-015-0192-8, accessed 6/20/17

Tuesday, July 18, 2017

Are we that polarized we can't talk politics?

Are we that polarized as a nation that we can't even discuss politics at work. Heck, I hear a political discussion and I salivate, and I don't care what point of view people have. And that's what happened as I pushed my cow to the nurse's station. As I stood there, innocently and cooly surfing through the computer system, I hear the following conversation at the nurse's station.

The first someone said, "I don't see how they can let it be legal to poison your brain with alcohol."

Now, to be fair, I had no idea what initiated this conversation. I'm just all ears.

The second someone said, "The same with cigarettes. People are damaging their lungs. I don't see how we can allow that to happen."

The first someone said, "I think alcohol is worse because cigarettes don't change how people think. I just think alcohol is nasty that way."

The fourth someone said, "I think it's a free country, and if people want to put stuff into their body, it's their right."

I looked at the fourth person, and said, "I agree with you. I think you have a natural right to choose what to put into your body. No one else has a natural right to tell you what you can or cannot put into your body." All along I nonchalantly clicked away on my computer, looking for a particular patient.

The fourth someone smiled.

The first someone said, "Yeah, but we are paying for their health. If someone doesn't wear a helmet, and they get into an accident, we have to pay for it. If someone smokes, and they get COPD, we have to pay for it."

I thought, "Then take the money out of it. It's that simple." I thought I intervened into their conversation enough, so I held my thought.

The sixth someone started leaving.

The first someone said to the sixth someone as he was leaving, "Why are you leaving, afraid of a good political discussion"

The sixth someone said, "I consider myself neutral. I can listen to any political discussion. But this one is getting pretty controversial."

The first someone also started leaving. While doing so, said, "Yeah! I think this is getting pretty controversial and radical."

The second someone left, while saying, "I agree."

The third someone left.

That left me and the fourth person.

Personally, I wasn't there to have a political discussion, I just so happened to be a bystander as they were discussing something. I had my say because I love politics so much. Sure, I probably should have kept my thought to myself, but they then again, they were speaking openly, so why can't I?

Is it that controversial to defend natural rights?  I personally don't think this discussion was in any way controversial. I don't think my position or #4's position was radical. In fact, I think it's mainstream.

I mean, look at it this way. Could you imagine if someone made a law banning blogging? Could you imagine if someone made a law banning reading blogs? Well, if that happened, you and I would never have met. Just a thought.

Monday, July 10, 2017

Faith Makes It Easier To Die

I'm sorry if I offend people who don't believe, but it is my belief, based on my observations as a respiratory therapist who gets to know many people near the ends of their lives, that Faith makes it easier to die. Faith makes the transition from life to death easier.

When I first started out as a respiratory therapist, I remember seeing people in the end stages of their diseases reading books. I see them watching the news. I'd see them worrying about paying bills or fixing a computer at home. I just couldn't fathom why they would be trying to educate themselves, or why they'd spend time worrying about trivial things when they knew they were going to die. How could they do that? Why would they do that?

There was one lady I remember in particular. She was told she had basically no heart left. She had an ejection fraction of 20% or something like that. She was essentially told she was going to die, and might not even make it out of the hospital. And she didn't.

But when I visited her she was more interested in me than she was herself. She was asking me about my life and my kids. She wanted to learn as much as she could about me. And I told her about me and my family. I showed her pictures, at her request, of course. And she smiled and was happy to see my kids and hear about them.

This is something I see a lot. And in nearly all of these situations, I see a Bible on the bedside table. Or, at least, I'd see some sort of emblem of Christianity. I'd see a cross, a note on the piece of paper from a grandchild saying, "God bless you, Grandma." Or sometimes they would just bring up God or the Bible in the process of whatever discussion ensued.

It was this lady, however, who gave me the idea that God needs people who are wise. When a carpenter dies, for instance, it's because God wanted a carpenter in Heaven. When a Grandma dies, it's because God needed another Grandma in Heaven. She said that we all have a gift to offer, and it's our duty to continue offering this gift all the way to the end -- which is not really the end, but the beginning.

I think it is this type of Faith that makes living easier when the end is near. I have no proof of this but based on my own observations, and the observations of my friends, you would have a tough time convincing me otherwise. What do you think?

Friday, July 7, 2017

Pharmacology 101: Beta Agonists, Anticholinergics And How They They Impact The Autonomic Nervous System

How is it that respiratory medicines work? If your a respiratory therapist like me, a quick review is always helpful. If you're a patient, it might be neat to learn how the medicines you have in your medicine cabinet work. So, here is a quick review. Today's focus will be on beta-adrenergic medicine like albuterol and anticholinergic medicine like Spiriva.

For starters, these types of medicines have some impact on the autonomic nervous system.

What is the autonomic nervous (ANS) system? It's the system that contains all the nerves, neurons, and neurotransmitters that control all your inner organs, including your heart, blood vessels, and lungs.
It also controls other organs, but for our purposes, we'll limit our discussion to these three.

The ANS responds to your internal and external environment by releasing certain chemicals (we'll get to these in a moment) that bind to receptor sites (we'll get to these in a moment too) on specific organs to tell them what to do. It contains two parts.
  1. Sympathetic Nervous System (SNS). It stimulates your organs to respond to emergency situations. It essentially stimulates what is often referred to as the "flight or fight" response. 
  2. Parasympathetic Nervous System (PNS). It inhibits (or shuts off) the SNS response. It returns your body systems back to normal status and controls these organs during normal, ordinary circumstances. 
Here are some of the bodily responses the ANS controls that we need to be concerned with. 
  • Blood Pressure
    • SNS: Narrows blood vessels to speed up the flow of blood to increase blood pressure
    • PNS: Dilates blood vessels to slow the flow of blood to decrease blood pressure. 
  • Heart Rate.
    • SNS: Speeds up the rate and force to pump blood through narrowed vessels.
    • PNS: Slows it down as less pressure is needed to pump blood through dilated vessels.
  • Airways:
    • SNS: Dilates airways to make breathing free and easy.
    • PNS: Constricts Airways to return them to normal. 
Now we must delve into how the SNS affects these responses. To begin with, the ANS involves nerve cells that secrete neurotransmitters. There are two types of nerve cells, each of which secretes a neurotransmitter. 
  1. Adrenergic. These are nerve cells that secrete the neurotransmitter norepinephrine, which stimulates an SNS response and inhibits a PNS response. 
  2. Cholinergic. These are nerve cells that the neurotransmitter norepinephrine, which stimulates a PNS response and inhibits the SNS response. 
Neurotransmitters are transmitted through neurons and are attracted to certain receptors that are attached to certain cells in specific organs. The receptors include...
  1. Adrenergic receptors. These are receptors that norepinephrine is attracted to. Another neurotransmitter called epinephrine (adrenaline) is also attracted to them. Neurotransmitters attracted to them are called catecholamines. When a catecholamine binds to an adrenergic receptor, it stimulates some SNS response. 
  2. Cholinergic receptors. These are receptors that acetylcholine is attracted to. When acetylcholine binds to a cholinergic receptor, it stimulates some PNS response. 
There are two groups of adrenergic receptors
  • α (Alpha)
    • α-1-Adrenergic Receptors. They line blood vessels and when stimulated by catecholamines this causes vasoconstriction.  
  • β (Beta) Receptors
    • β-1 Adrenergic Receptors. They line heart muscle tissue and are attracted to catecholamines, which cause an increase in rate and force of the heart to increase cardiac output. This is needed to create the needed pressure to pump blood through narrowed arteries. The purpose of these combined effects is to assure tissues receive adequate oxygenation during a stressful event. 
    • β-2 Adrenergic Receptors. They line airway smooth muscles (from the trachea to terminal bronchioles). They are attracted to catecholamines, which cause bronchodilation to open airways. 
Sympathomimetic Medicine. These are medicines that are attracted to adrenergic receptors. They mimic catecholamine and include.
  • Short-Acting Beta Agonists (SABA). These are medicines that are attracted to B2 receptors to relax bronchiolar smooth muscles to dilate (open) airways within minutes and only last 4-8 hours. They are non-specific to B1 and B2 receptors, and therefore offer negligible side effects. These include epinephrine (Adrenaline), albuterol (Ventolin, ProAir, Proventil), and levalbuterol (Xopenex). Some SABAs that are no longer used include Isoproterenol (isoprenaline), terbutaline, ephedrine (Ma-huang), and Metaproterenol (Alupent). These are also referred to as rescue medicine because they open airways relatively fast. As a general rule, most experts recommend all asthmatics and COPD patients have it nearby at all times. Epinephrine has the greatest risk for stimulating B1, B2, and A1 receptors and offering side effects. The other ones currently on the market have minimal effect on B1 receptors, although some studies show that they can cause an increased heart rate, increased blood pressure, and EKG changes in some individuals (although this is rare, it should be considered). The recommended dose of albuterol is 2 puffs every 4-6 ours. Studies seem to suggest that the medicine is safe for use in emergencies even at high doses, although the chronic use of high doses (using more than 6 times a day) may cause a decrease in beta 2 adrenergic receptors. This may cause tachyphylaxis, resulting in the need for even higher doses just to obtain minimal results. Excessive use of albuterol is a clear indicator of the need to seek medical attention and for physicians to consider asthma controller medicines or a step-up treatment approach for those already using controller medicines. While initial studies showed levalbuterol to offer fewer side effects to albuterol, more recent studies show it can produce the same side effects, and is therefore not superior to but equal to albuterol in as a bronchodilator, although it costs more due to a current patent. SABA's may also lower potassium. To learn more check out our post, "How Albuterol Lowers Potassium."
  • Long-Acting Beta Agonists (LABA). These are beta agonists that last 12-24 hours. These include salmeterol and formoterol. These are rarely given alone for the treatment of asthma, although they remain viable options for asthma and COPD. For asthma, they are usually included in combination with an inhaled corticosteroid in inhalers like Advair, Symbicort, Dulera, and Breo. These are generally used as asthma controller or preventive medicine, and they must be taken every day to truly be effective. For COPD, they are considered a top-line option, although some studies seem to indicate that Spiriva alone offers improved lung function and reduction in the feeling of shortness of breath compared with LABA's alone. Formoterol in Symbicort and Dulera has a rapid onset and can open airways as fast as a SABA. Serevent in Advair opens airways in about 15 minutes. 
There are two groups of cholinergic receptors
  • Muscarinic Receptors. Acetylcholine is attracted to them. When acetylcholine binds to them, this causes airways to narrow and mucus secretion to increase. 
  • Nicotine. I won't even go here. This is a discussion for another day. 
Anticholinergic/ Muscarinic Medicine. These are medicines that are attracted to Muscarinic Receptors and thereby bind to them to prevent acetylcholine from binding to them. They are called anticholinergics because they block their effects by preventing them from binding to muscarinic receptors. Cholinergic stimulation has a primary effect on COPD, so anticholinergics are a top-line treatment for COPD. Studies seem to show that anticholinergics are equal in their bronchodilation effect for a patient with COPD compared to b2 agonists, and may even have a superior bronchodilation effect. Cholinergic stimulation has a secondary effect on asthma, so anticholinergics are a second-line treatment for asthma, although they remain an option worth trying for some with severe asthma.  Anticholinergic medicine cause bronchodilation, although do not decrease mucus secretion.
  • Short-Acting Anticholinergics. They last 4-6 hours and are taken 4 times per day. Studies show they are helpful for treating acute asthma and COPD flare-ups. These include ipratropium bromide (Atrovent) and oxitropium bromide (not available in the U.S.). 
  • Long-Acting Anticholinergics. These last 24 hours. They include tiotropium bromide (Spiriva), glycopyrrolate, (Seebri), umeclidinium (Incruse), and aclidinium bromide (Ttudorza). Older medicines include belladonna, stramonium, and atropine. Anticholinergic medicine remains second-line options for asthma and top-line options for COPD. Studies show that tiotropium bromide is slightly more effective at improving lung function, improving the quality of life, and reducing COPD flare-ups, compared with short-acting anticholinergics. Studies also show it is better at opening airways than LABA's for COPD. Side effects are negligible, with the most common being dry mouth. Incruse and Tudorza are the newer LABA's and I will look into studies regarding them in the future. 
There is a reason I listed the current medicines used and older medicines that are no longer used. This is because, over time, the molecules were adjusted to eliminate side effects and to increase the desired effect. Epinephrine, for instance, has a strong effect on α-1 leading to increased blood pressure, β-1 leading to increased heart rate and palpitations, and β-2 receptors leading to bronchodilation. So, while it opened airways, it also caused cardiac side effects along with tremors and nervousness. Ventolin, on the other hand, has a strong β-2 effect with a minimal effect on α-1 and β-1 receptors, meaning it has an equal bronchodilator effect to epinephrine with negligible side effects. Tremors and nervousness continue to be side effects, although these are acceptable tradeoffs to most asthmatics. 

Another good example is atropine. It was isolated in 1833 as the active ingredient of stramonium and belladonna. By the late 19th century it was routinely recommended for the treatment of asthma. Giving atropine alone was an improvement over stramonium and belladonna, which also had a strong effect on the mind, similar to marijuana. Atrovent was a mild bronchodilator, although enhance the salivatory response in the mouth, causing oral dehydration. It may also cause tachycardia. It also dilated pupils if you ever splashed it into your eyes. Atropine was a top-line asthma medicine in the 1980's, only to be replaced by Atrovent in the early 1990's. Atrovent was formulated in a way that side effects are negligible, although it can cause a dry mouth by oral absorption (which is a good reason to rinse after each use). The nebulizer solution of Atrovent, if splashed, can cause pupil dilation. The formula was modulated again to create the long-acting anticholinergics Spiriva, Incruse and Tudorza. 

So, there you have the basics of how the ANS affects the lungs and how it relates to the respiratory medicines. Any further questions, comments, or suggestion let me know in the comments below. 

References:
  1. Low, Philip, "Overview of the Autonomic Nervous System," Merck Manual, https://www.merckmanuals.com/home/brain,-spinal-cord,-and-nerve-disorders/autonomic-nervous-system-disorders/overview-of-the-autonomic-nervous-system, accessed 7/717
  2. Golan, David E., et al., editors, "Principles of Pharmacology," 3rd Ed., 2012, Lippincott, pates 113, 827
  3. Albert, Richard K., Stephen G. Spiro, James R. Jett, editors, "Clinical Respiratory Medicine," 3rd ed., 2008, MosbyElsevier, pages 524-526

Monday, June 12, 2017

Why aren't there more RT blogs?

Your Question: Why aren't there more RT blogs like yours.

My Answer: There are a few, as you can see by the "Links" tab above. However, many of those blogs have not been updated in so long that I might as well delete them from my list. This is unfortunate, but I think fear has a lot to do with it. In fact, I know of one blogger who was told to quit blogging or he would lose his job. He had the best RT blog ever. Okay? And now he's done because he didn't want to lose his job.

I don't know if you have ever noticed this or not, but sometimes I publish posts on this blog and then think better of it and hit the delete button.  I don't do this very often, but sometimes I have to act as editor and protect the real me from the writer me. I have a tendency to be non-politically correct and truthful, and, Lord knows, the truth can get you into trouble sometimes.

Of course, you might be thinking, "What about freedom of speech?" I think that freedom of speech gets overblown sometimes. There really is no such thing as freedom of speech in the respiratory therapy cave. I can't observe a certain situation at work and then write about it, and then publish it. I mean, I could if I tread carefully. I could if I stayed on the safe side of the line. But that line is invisible, so it's often hard to tell where exactly it is. So, it's better to play it safe and simply avoid these types of articles.

Which is unfortunate, I think. I think the world would be better served if people like me could be honest about what they see at their work. So many times I see something interesting. Something that worked good. Something that didn't go so good. Something that was rare. Something that happens a lot, and shouldn't. So many things I see that have to remain in my head, only to be forgotten to time.

HIPPA I think is good in a way. I think people should have some medical privacy if they want it. But I think the whole HIPPA thing also has been overblown and taken out of context to the extent that people have lost their jobs for no good reason because of it. And I also think it has been a disservice to the medical profession as a whole. So many times, for example, we package up a trauma and ship that person out, and then we never hear a peep about that patient again. What did we do right? What did we do wrong? What could have we done better? We will never know, because of that dumb law.

Actually, we shouldn't blame the law, per se. We should blame the sue happy people who ruined the healthcare system. I think the HIPPA law was the result of lawmakers saying, "We have to do something." Yet I always think that -- the way the founding fathers used to think, I believe -- is that government should leave making laws to the states and to the people, and it's best to do nothing than to do something stupid. And I think HIPPA was that something stupid that resulted from people thinking they just had to do something.

So, it is probably because of this law that you don't see more blogs like this. And it's also why you won't see an article written by me that is too overly honest about my job. That is why I almost have to take a humorous take on much of what is wrong with our job -- and there are a few things wrong, I'm sure you will agree. It's a great profession, but it's imperfect, and it's not our fault it's imperfect. But I think that laws prohibiting bloggers -- or at least scaring them away -- from telling on the job stories work to the detriment to the profession as a whole.

Thoughts?

Thursday, June 1, 2017

Nurses Describe Why It's Important To Respect Your RT's

One of my coworkers introduced me to this Youtube video where three critical care nurses describe how important it is to respect your respiratory therapists. This is pretty good.

Sunday, May 28, 2017

Study: Ventolin Shown To Prolong Life

A new version of Ventolin, aptly termed "Keep-me-alive-olin," has been shown to prolong life. This is according to analysis of studies conducted by the Real Doctor's Creed Committee.

Keepmealivolin was listed as the #61 most popular version of Ventolin prescribed by doctors by our own experts here at the RT Cave.

This version of Ventolin was first recognized by Dr. Happy Lackluster in 1985. He t he ordered a respiratory therapist to give a Ventolin breathing treatment by mask to a patient who was terminally ill, who had an ejection fraction of 20%, and who was in otherwise poor health with terminal bone cancer, diabetes, and kidney failure.

Dr. Lackluster sadly passed away in 1998. However, the RT Cave was able to get ahold of Dr. Will Chambers, a longtime coworker of the beloved Dr. Lackluster.

"He was a fine fellow," said Dr. Chambers. "We were all so impressed with his discovery. I remember Happy  telling the story. He about keeled over laughing because, as he said, 'the respiratory therapist was so unhappy to be giving the treatment.'  He said the therapist said, 'He is not even short of breath.' But, in the end (no pun intended), the therapist was proven wrong, as the patient lived an extra day, long enough to say good-bye to loved ones who had to fly all the way into California from Great Britain."

Dr. Chambers added, "But we were taught in medical school back in the 1980's that if all else fails, order a breathing treatment. Little did we know that Happy stumbled on a new version of Ventolin now aptly titled Keepmealiveolin."

While we have never revealed the true history of it on this blog before, we called the wife of Dr. Lucky Happluster and she was more than happy to provide for us a study. It was performed in 1964, and involved an entirety of four whole patients. Two were given a placebo and two were given Keepmealivolin, and they all lived a little while longer. This was all the proof needed to convince the medical community of the efficacy of keepmealivolin. Two hundred studies since then seemingly proved this initial study wrong, but those studies never changed anything: keepmealivolin is still used to this day.

So, ever since that initial study was published, whenever doctors don't know what else to do when a patient is terminal and things don't look good, it's time to order Ventolin. And, likewise, during a code, when there is nothing else to do, it's time for Keepmealiveolin. If necessary, it can be given inline with the AMBU-bag.

And it's not like this is unusual. The hypoxic drive theory is based on a study of 4 COPD patients from the late 1960's. So, who's to say 4 patients can't prove that Keepmealivolin won't prolong life. It can at least buy a patient a day or two, perhaps an opportunity to say goodbye to loved ones who live 10 or more hours away who need time to travel.

RT Cave Facebook Page
RT Cave on Twitter