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Monday, August 31, 2015

The phlegmatic asthmatic

There was an asthma kit I received when I was 14 with a game a comic book and an asthma game that taught you how to deal with an asthma attack.  One of the things it mentioned was the wet noodle technique to help you relax. You just basically pretend you are a wet noodle and go limp. It was actually a nice way of teaching kids to work on relaxation techniques, or to be more like a peaceful phlegmatic asthmatic.  Thus was the topic of comic strip #6. You may also read the accompanying post: "The Phlegmatic Asthmatic."

John Bottrell has had asthma so long that it has become a normal part of his life. As a child, he used the "wet noodle" technique to keep calm during an asthma attack. It works, but he's learned that asthma management is even better. Illustrated by Dash Shaw. (Originally published at healthcentral.com/asthma)

Sunday, August 30, 2015

'Olins: Part 3

The following is a continuation of our list of various types and forms of racemic and actual ventolin-tyes (o'lins) that we doctors keep esoteric from respiratory therapists so they continue to have procedures to justify their existence.  Oh, and the treatments actually do help for the various disorders listed below. Seriously, we are not making this up.

235.  Medicine:  Historolin

Diagnosis:  Asthma

Frequency:  Q4-6

Effect:  It is proven that keeping beta 2 receptors saturated with ventolin particles will keep asthma in remission.  Such therapy may be deemed profligate in the out of hospital setting.

236.  Medicine:  Abdomnolin

Diagnosis:  Had surgery on belly

Frequency:  QID

Effect:  Only works when prescribed by surgeon to prevent atelectasis and pneumonia caused by the surgeon.  Warning to physician: side effect to second hand ventolin types is respiratory therapy apathy and grumpiness, so stay out of their way. Still order it, though, we're just saying; they are lazy and will try to convince you it's pointless, but we know it is not pointless.  Yes, a study of 100 post op patients showed that, of 100 post op patients who were treated with QID ventolin, they all eventually got better.  So we know some form of ventolin must be ordered.  Note: not ordering Abdominoilin for post operative patients was not shown to decrease length of stay.  Side effect to patient may be increased desire to go home, agitation, and possible irritation with the therapist who continues to wake them up for breathing treatments when they already know they can breathe just fine.

237. Medicine:  Desatolin

Diagnosis: Aspiration Pneumonia

Frequency:  QID

Effect:  Once inhaled the ventolin particles join with a chemical called humidolin acetate to form H2O molecules.  As these accumulate over the course of many days the patient will become filled with increased fluid so that oxygen molecules can float to the surface of the lungs so they can be exhaled. May be tried with regular or faux pneumonia, although studies show that it works best for pneumonia that was caused by reflux of stomach contents. Helicobacter pylori (H. pylori), a common bacteria found in the intestinal tract, might actually plunge out of the water and be exhaled during the exhalation phase due to helicopter-like rotors that have previously eluded the vision of scientists but may be seen when the bacteria is attached to ventolin-like substances in the air.  It's a site worth seeing when hundreds, thousands, millions, even billions of H. Pylori escape their human captors in search of life on Mars.  The good news is they die within seconds of exhalation.

238.  Medicine:   HEALButerol®

Diagnosis:  Bone fractures

Frequency:  QID

Effect:  Rather than just giving albuterol to open up the air passages that are already open, this provides Orthopedic physicians a medicinal supplement proven to diffuse into the bloodstream once inhaled and seeps into bone material to cause fractured areas to rejoin and heal faster. The exact methodology is unknown, but a study showed that of 100 post op patients given HEALButerol® all eventually got better.  So this was indication enough to confirm that the medicine magically heals bones as well as opens up airways, even if the airways are already open.  You may also wish to try Knitolin.

Medicine:  Knitolin

239.  Diagnosis:  Bone Fractures, especially fractured ribs

Frequency:  QID

Effect:  It knits bones so they heal better and the patient breathes better at the same time.  If neither of those work, try tryagainolin.  It works best when given in tandem with an incentive spirometer  (IS)and acapella. Increased turbulence created by inhaling a deep breath with the IS pushes the knitolin particles deeper into the bone (sort of like hammer nail, so to speak) thus making the medicine particles work like a filling in a tooth to further supplement healing.  The acepella helps to loosen and free any bacterial particles that might collect inside the fractured portions of the bone and inhibit healing and/ or cause an infection.

240.  Medicine.  Trainwreck-uterol

Diagnosis:  Many, or Trainwreckeeeeism caused by the trainwreck virus that causes many of the organs of the body to become confused and not work right.  Trainwreck-ism is a another disorder caused by the trainwreck virus that causes nurses and respiratory therapists to make poor decisions that wreck things and people.  Trainwreckeeeism should not be confused with Trainwreck-ism.  Because trainwreckeeeism has a lot of e's in it, it can be treated the same way a wheeze is:  with an 'olin, particularly Trainwreck-uterol. Trainwreck-ism has no known treatment, and therefore you must not be anywhere withing 100 miles of such patients.  Usually they are not hired.  If they are, you should fire them immediately, because the disease is highly contagious.

Frequency:  Q4ever

Effect.  It has no effect on the disease processes, although it does attack to faux B2 receptors in throat muscles in and attempt to eeeeee-liminate the wheeze by soothing throat muscles (throatodilation) in order to make nurses and doctors happier.

241.  Medicine. Fusolin

Diagnosis:  Rib fracture

Frequency:  QID

Effect:  Increases tidal volume to prevent pneumonia and atelectasis.  Works similar to the way IPPB used to overinflate good alveoli.  May be alternated with Knitolin,  HEALButerol®, preventolin, postopulterol and tryagainolin.  May also try sputumolin to induce a cough.  Avoid using ventolin for its cough suppressant qualities, as this defeats the purpose.

242.  Medicine:  Lupisolin (aka Aligatoruterol, Sharkuterol)

Diagnosis:  Lupis

Frequency:  At least QID

Effect:  Ventolin particles go into the lungs and join with neutrophils to turn the ventolin particles into little critters that look like very sharp toothed alligators or sharks that kill and digest bacteria and viruses and other potentially harmful invaders so the immune system doesn't have to.  I guess you can say that the ventolin particles formed look and act sort of like Pac Man and Mrs. Pacman.  This works to suppress the immune system and to prevent inflammation caused by the disease, particularly in the heart, lungs, and brain (well, mostly in the lungs).

243.  Medicine:  Flapolin

Diagnosis:  Loose or damaged Mitral valve

Frequency:  Once

Effect:  Mitral valve may be heard flapping, meaning that the valve is leaky.  This form of ventolin causes an infusion of hardened, crystallized substances that are attracted only to the mitral valve to fortify it and assure the patient's safety until the valve can be replaced.

243.  Medicine:  Vasodilatolin

Diagnosis:  Hypertension

Frequency:  Q4-6

Effect:  Dilates vessels to decrease blood pressure. Will require frequent inhalations to assure a high enough dose of the medicine is in the bloodstream at all times. So this is why we recommend it be given Q4-6 rather than just QID.  A bonus is the patient will have to be awakened at least once, and this might make the patient mad and raise blood pressure that way.  It works the same as BiPAP, which has a benefit of increasing blood pressure.  May also place patient on BiPAP.  The more uncomfortable the settings the better the effect. Please, do not admit this to respiratory therapists. Oh, you did already: Doh!

244.  Medicine:  BiPAP-uterol DS

Diagnosis:  CO2 greater than 42 (boy, that's way too high, need to get it back down to normal)

Frequency:  QID, Q6, Q4, or just make something up

Effect:  Lubricates and soothes the vocal cords so you don't hear an audible wheeze (rhonchi, stridor). Works best if tried before BiPAP is ordered.  If doesn't work, order BiPAP.  Works well after BiPAP order too. If you continue to hear lots of noises in the lungs (especially if they annoy you), you probably should order BiPAP.  IN this case, the medicine mayu have a bonus of lubricating the lips and cheeks so you don't hear the BLLLLPPPPPLLLLLTTTTTTTHHHHHHHH due to the fact the seal is not tight enough.  It makes it so nurses don't keep calling respiratory because they don't feel like playing with the Velcro.  May alternate with BiPAPuterol (to ward off evil spirits so you don't have to eventually ventilate this patient).  Note:  For patients with a big scruffy beard, a double dose may be beneficial. Or, just get off your ass and tighten the mask might work just as well.  Or, if you're really brave, shave the beard)

245.  Medicine:  Normal Saline

Diagnosis.  Asthma, COPD

Frequency:  Q4

Effect:  Draws salt out of epithelial cells and Type-II alveolar cells in order to treat bronchospasm due to dehydration.

246.  Medicine: Retrospectuterol

Diagnosis. COPD, asthma, heart failure, pulmonary edema, kidney failure, lung cancer, etc.

Frequency: Q4-6

Effect:  The patient was short of breath greater than 24 hours ago, therefore albuterol is indicated today. The patient may have been short of breath yesterday, or may have experienced asthma symptoms (at the age of 6) 25 years ago.  Regardless, the retrospective qualities of albuterol-like particles have the ability to travel over the wrinkle in time scrub lungs clear of all past difficulties.

247.  Medicine. Keepmeinolin

Diagnosis. Respiratory failure, hypoxia, pneunonia, heart failure, dyspnea (all of which requires oxygen and IV medications to keep the patient alive)

Frequency. Q once

Effect.  Works similar to exercise in that it stimulates the brain to release a chemical called endorphins. They act like analgesics such as morphine to diminish the perception of pain, cause a sedative effect, reduce stress, ward off anxiety, ward off depression, boost self esteem, and improve sleep. It causes a sense of euphoria similar to that produced from morphine with out the risk of addiction.  Generally, the effect only lasts until the mist in the room clears, so it's usually only prescribed one time, as a last ditch effort, when a patient threatens to leave against medical advice (AMA).  The medicine should calm the patient down just enough to convince her that she really does need to be in the hospital.

247.  Medicine.  Transmitolin, Accousticsolin

Diagnosis.  CHF, Heart Failure, ETOH, Dehydration, old age

Frequency.  QID

Effect.  Prevents upper airway rhonchi from transmitting to other lung fields to prevent specious documenting of wheezes. It's a medicine that was concocted in the laboratory of Dr. Ven Tolin and his assistant, Paul RiTT, with the intent to discourage physicians from ordering breathing treatments due to upper airway noises confused for wheezing. The medical community generally has an aversion to this medicine, and so it has rarely been used to this point.  A Congressional Committee actually discussed this, and it almost made it into the Affordable Care Act in order to cut government spending, only to be cut from the bill at the last moment when it was discovered the individual hospitals have to absorb the costs of wasteful breathing treatments, and not Uncle Sam.

248.  Medicine.  Keepmeawakeolin

Diagnosis.  COPD, Sleep Apnea

Frequency.  Q4 ATC

Effect.  To a nerve cell, Keepmeawakeolin looks like a coffee molecule which looks like adenosine.  It then is allowed to attach to adenosine receptors, thus preventing adenosine from attaching to them.  So instead of adenosine slowing you down so you can sleep, Keepmeawakeolin keeps you awake.  Adenosine dilates blood vessels in the brain, presumably to keep your brain well oxygenated while you are sleeping and your breathing is more relaxed. Keepmealiveolin mimics this effect, thus causing vasodilation of the vessels in the brain to assure adequate oxygenation while you are not sleeping.  A side effect of this is that it may cause a headache, which is where caffeine comes in handy.  About three hours after dosing, keepmealiveolin starts to dissolve, opening up just enough adenosine receptors for caffeine to attach.  This should be enough, however, to constrict brain vessels, thus ridding you of your headache.  Still, once the rest of the keepmealiveoline molecules dissipate, the next dose should be due. A morning dose of coffee is highly recommended, although it should be given about an hour prior to the treatment is due.

A side effect is insomnia that lasts for the duration of this type of treatment.  It is typically not recommended to continue this treatment after discharge to home, as it often results in the viscous and never ending cycle of taking keepmealiveolin to improve oxygenation while you are sleeping and drinking coffee to offset the side effect of headache in the morning.  Another side effect is refractory headache, which is a headache caused by the medicine to begin with.  After doing all this reading (if you are still with me), the brain usually forgets about the bronchodilating effect.  Another idea is to only give the medicine at night, and allow the patient to refuse therapy while awake. Still, because respiratory therapists hate waking people up, an ideal order for this is Q4 ATC (Around The Clock).  This lets the RT know you mean business.

249.  Medicine. Alcurital (See Ad Here)

Effect.  This is the only medicine clinically not proven but believed to by nurses and... doctors (yes, doctors) to cure all that ails you And best of all It works even when You have clear lungsounds Hence the name: Alcurital.

Side Effects: Alcurital.for clear lungsounds. Side effects include anxiety, nervousness, headache, increased heart rate, death if consume more than 55 miligrams in a day, boredom, pissy RTs. However, studies show the medicine cures all ailments, but it has no effect on stupidity. Do not use if you have a wise physician or nurse.  Not expected to result in increased brain cells. Not expected to prevent accidents. While it can be used prophylactically, it will not prevent all ailments. Don't worry, as no studies were done to come to any of these conclusions, it's simply based on feel good: it looks good, sounds good, feels good, then it is a fact. One study of 100 post op patients given Alcurital eventually recovered, so now it only makes sense that it
works.

250.  Medicine.  Mucinexolinuterol

Diagnosis.  COPD, pneumonia, Cystic Fibrosis

Symptom.  Thick secretions; difficult expectoration

Efficacy.  The fact that the suffix olin and the suffix uterol are in the name means it has 10 times the ability to loosen thick secretions as Mucinex and albuterol alone.

Further reading:
  1. Fake 'Olins Part 1
  2. Fake 'Olins Part 2
  3. Faux Physician's Creed

Saturday, August 29, 2015

Albuterol leading treatment for random dyspnea

While it has always been assumed, the Real Physician's Creed Association has now officially declared Albuterol a top line treatment for all dyspnea.

"Treat as bronchospasm first and then differentiate.  Never doubt that there is underlying bronchospasm," said RPCA chair Dr. Ven Tolin.

The decision was the result of a five minute panel discussion based on a complaint by RATS NEST president Mike Olin.  "We are deeply disappointed in this decision," Olin said, "We figured they would have at least given equal time to considering FUROSESONEROLAQUINOX, the latest treatment for miscellaneous dyspnea.

Olin added, "I'm very frustrated.  The medical profession has a long history of being resistant to change unless that change results in more needless work for respiratory therapists and nurses. This sort of adds credence to the saying, 'Why think when you can just order albuterol?'"

Dr. Muster of the Faux Society for the American Medical Association responded to Olin's comments by saying: "I think Olin is one of the brightest men in the medical profession.  Still, all the studies in the world that show albuterol only cures bronchospasm simply don't make sense.  The fact that ordering albuterol makes us feel we did something good is all the proof you need that all pulmonary disorders --and many other disorders too -- benefit from a dose of nebulized albuterol."

Tuesday, August 25, 2015

How to spot a bronchodilatoraholic

Bronchodilatoraholics often hide when puffing, as they do not want to seek attention or sympathy. While hardluck asthmatics may rely on their inhalers regardless that they are gallant asthmatics, it's still a good idea to know how to spot a bronchodilatoraholic, especially if the bronchodilatoraholic is a goofus asthmatic and is abusing the inhaler. You can read the accompanying article how to spot a bronchodilatoraholic.  Otherwise, here is comic strip #5.

Do you sleep with your inhaler under your pillow? Do people call you "puffer head?" Do you have inhalers hidden all over your home? If you do, you just might be a bronchodilatoraholic. Here are 31 signs that you might be overusing your quick-relief asthma inhaler.

Monday, August 24, 2015

The Bronchodilatoraholic

I first heard the term bronchodilatoraholic from fellow asthmatic and friend, Stephen Gaudet.  He mentioned it in one of his blog posts at breathinstephen.com. I think the general definition was initially intended to refer to asthmatics who rely heavily on bronchodilators.  My publisher, on the other hand, defined it as asthmatics who abuse their inhalers.

So this was my first disagreement I had with my publisher.  I insisted that being dependent on, and abusing, are two different things.  In the end, especially considering I was new to the business at the time, she won. The term bronchodilator became synonymous with depended on and abuser of inhalers. 

Regardless, the term was one of 11 types of asthmatics.  You can also read about my confession: Confessions of a recovering bronchodilatoraholic.  You can also learn how to spot a bronchodilator, although you'll have to be vigilant, because often they surreptitiously puff.  And if you do find yourself puffing frequently, you are not alone

John Bottrell had long overused (and sometimes abused) his quick-relief asthma inhalers, joining the ranks of asthmatics known as bronchodilatoraholics. Find out how he broke the habit. Illustrated by Dash Shaw. (Originally published at healthcentral.com/asthma.)

Saturday, August 22, 2015

Study: Secondhand albuterol linked with side effects

A new report published in the Journal of the Respiratory Creed suggests that second hand albuterol has side effects that may include grumpiness, apathy, burnout, a dry sense of humor, increased wisdom, and the ability to differentiate pneumonia and heart failure from bronchospasm without even seeing the patient.

Researchers followed 1,600 newly graduated respiratory therapists over a period of ten years between July 7, 2002 and July 14, 2012.  Six hundred sixty of the therapists gave an average of 10 albuterol breathing treatments in a given day.  A control group of 720 therapists was given a placebo to give to their patients.  But they were told to just sit in the RT Cave and watch movies on Netflix or play on their iPhones.  Six hundred twenty therapists were disqualified for already having been diagnosed with respiratory therapy apathy syndrome (RATS).

The results showed that 100% of the therapists who gave albuterol breathing treatments developed the symptoms, with 75% experiencing increased incite within the first year doling out treatments (a minimum of 36 hour work week was required of all participants), and 82.5 developing a dry sense of humor within the first eight months.

Level of IQ was tested using a typical IQ scale, although adjusted for respiratory therapy wisdom.  A typical question might entail, "Is heart failure treated with Ventolin?"  Members of the control group were too bound to their fantasy world's to have time to answer the question.  Members of the non-control group all answered the question correctly, with one scratching a comment in the margins of the test (taken on paper because because), "Are you kidding me!  Of course not."

The study was the first ever study to study the study abilities of respiratory therapists and the possible impact that ventolin may have on their demeanor.

"It was just amazing the results that we discovered by doing this simple scientific study," said Dr. Carl Olin of Westbrook University where the study was conducted.  "Who ever would have thought that people with only an associate's degree could actually know more about respiratory therapy than physicians?"

Cal Tripper, Medical Director of Respiratory Therapy at Buterol University, said, "It has been observed for years that respiratory therapists display a unique wisdom, particularly regarding respiratory therapy, although it was tough to put a finger on the reason before this study.  I highly recommend to other physicians to talk to a respiratory therapist, ask them if they have an opinion or a recommendation, the next time a patient has respiratory complications.  The truth to the matter is, even though they only have associate's degrees, they may actually know more than we do about how to manage respiratory therapy.  And it's all because of second hand albuterol."

Friday, August 21, 2015

Clinical Trials Made Easy


In the ancient world, and throughout most of history, whether or not a medicine worked was determined by speculation.  In the modern world, it is determined by a clinical trial.  Let us assume that albuterol is the medicine being tested, and we will walk you through the process.

In order to find out if albuterol actually makes asthmatics feel better, we have to have something to compare albuterol with. For this reason, we are going to create two groups:
  • Experimental Group.  When a medicine is tested, these are the individuals who actually get to take the medicine.  If albuterol were being tested, these folks would actually get the medicine. 
  • Control Group.  When a medicine is tested, these are the individuals who do not get to take the actual medicine.  They take a placebo instead.  This is needed so the examiners have something to compare the results with. If albuterol were being tested, these folks would just inhale normal saline.
  • Tested Drug. Albuterol with 3 cc normal saline
  • Comparator.  Normal Saline
  • Placebo.  The comparator. A harmless or fake medicine. 
  • Null Hypothesis.  To begin, experimenters will assume that both the tested drug and the comparator are equal, that there is no difference between the two.  The study will then prove whether this is true, or whether the tested drug generates a benefit. 
So now let us assume that all the people in the experimental group and all the patients in the control group have been diagnosed with moderate to severe asthma and have uncontrolled asthma.  None of the patients have taken any asthma medicine within the previous 12 hours.  Pulmonary function testing is done on all the patients, followed by a period of 20 minutes of rest.  The experimental group is then given the tested drug (albuterol with 3cc of normal saline) and the control group is given the placebo (3cc normal saline). Both the tested drug and the placebo are inhaled over 10 minutes using a nebulizer. 

All the patients now take another pulmonary function test.  Obviously, many such studies were performed in the past showing that albuterol improves lung function while the placebo did not improve lung function.  The null hypothesis is now proven wrong as albuterol is shown to improve lung function while normal saline alone does not. 

Let us take another example here.  Many respiratory therapists have said that a majority of patients who receive an albuterol breathing treatment say they feel better after the treatment.  The hypothesis here is that a placebo will work just as well as albuterol in generating a perceived benefit.  This hypothesis was tested recently on 39 mild to moderate asthmatics

This calls for some more definitions. 
  • Perceived Response. This is when people who participate in the control group and received a placebo document that they feel better.  Of course we know it's not possible because they did not even receive the medicine. 
  • Placebo Response (Placebo Effect).  This is where a patient reports a perceived response from the placebo.  They think they received albuterol so they think they feel better.  The study showed that 50% of those in the placebo group reported a perceived response to the medicine. 
As I wrote regarding this study before: "This is interesting to say the least.  We know that albuterol really does make breathing easier in patients who are having actual bronchospasm.  However, evidence also suggests that giving albuterol to anyone who is short of breath may produce the placebo response.  So now you know why doctors treat all pulmonary diseases as asthma."

You also now know how clinical trials work. You also now understand how we must take the interpretations of clinical trials with a grain of salt, because they are not always accurate.  

Further reading:
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