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Monday, November 20, 2017

The RT Cave Is 10 Years Old

On October 13, 2007, I yearned to start a blog. I had no idea what to call it. I had no idea what I was going to write. I just wanted to do it. I just knew I wanted to write.

I worked night shift back then. I remember walking around the hospital. Everyone was busy but me and the nurses working in critical care. So, that's where I hung out.

I remember rolling ideas in my head for a title for my blog. I asked my CCU friends if they had any ideas. They did. But none of their ideas impressed me.

Finally, about halfway through the night, I said, "Well, folks, I'm going back to the cave!"

My eyes lit up.

"THAT'S IT!" I said. "I will call it the cave!"

I already knew I wanted respiratory therapy in the title. that way my blog would come up during any search for respiratory therapy.

I went back to the cave and decided to write. I had no idea what to write. I ended up writing this stupid article about the beeper. I read that post every anniversary date. And every year I think, "What a stupid post."

Sure, I've thought of deleting it. I have thought of editing it. But I don't.

It's kind of like saving your belt after you lose 30 or 40 pounds. You keep it even though it's worn out and useless to you now. You save it as a memento of what was and what is now not.

I wanted to write. I have always kept a journal. I started a journal when I was in high school. I did a diary before that. I just loved writing.

My dream was to be a published author. What I planned on was writing a book and getting it published. I wanted to be like Stephen King. I mean, I knew I wouldn't write like him, but I wanted to be published like him.

But I was unable to write that book. I was more of a columnist type of writer. I liked to write columns. But, I didn't have the confidence to publish what I wrote in the local newspaper. I say this even though the opportunity was there. I was asked to do it more than once.

But then something happened that I never anticipated: the Internet. It was there in all its glory. All I had to do was tap into it. And so I did.

I started the Cave. I decided to write something every day. My early stuff was shit. But, the more I wrote the better I got at it. I learned how to write pithy. I learned how to keep articles to one thought. I learned how to write for the Internet.

A year after I started this I received an email. It started with, "I love your blog." That email turned into my job at I would write a weekly column for them for eight years.

That job came about just because I wrote. I wrote every day. And people must have liked what I wrote about. I know this because my blog was soon the #1 respiratory therapy blog not associated with a peer-reviewed journal. This is still true to this day.

But I did not make money on this blog. I just did it for fun. I did it to pay it forward, you might say.

There's this old saying that if you like to do something, and you do it and do it well, good things will come of it. I think it comes from the Bible. Well, one day I received that email. And, well, the rest is history.

I retired from Healthcentral in 2015. It was a hard decision. Now I write for and That's where most of my time is spent now.

But, this is my baby. So, you can expect for me to keep it around. If you have ideas what you want me to write about here, please do share. Like, if you have questions you want answered or whatever.

Anyway, it all started 10 years ago. It's been a great ride! It's been fun! I would like to thank YOU for making this so successful. None of this would be possible without YOU. THANK YOU!!!

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Saturday, November 18, 2017

My 20 Year Anniversary

I showed up for work on November 10, and my boss says, "Today is your anniversary?"

"What?" was my feeble response.

"Today is the 20th anniversary of your first day of work here," she said.

"Do I get a cake?" I ruefully said.

"No!" she said, laughing.

Before I had this job I never had a job longer than a year. So, it's a pretty good accomplishment to last this long.

What has changed? 

When I started, there were senior RTs who always seemed to take the easy assignments. I was happy about that because I got to take exciting ER and critical care.

Whenever I had questions I'd tap in on their wisdom. When I wasn't confident, I'd have them shadow me. When I wasn't sure about myself, I'd ask them questions.

When they were thinking about retirement, I'd think, "How are we going to replace all that wisdom?

The answer: "You don't!"

"Who is going to fill your shoes?" I ruefully asked once.

"You!" One of them said.

"What? I don't know half of what you know."

"You are! You have no choice."


"Yeah!" she said. "That's, like, part of getting old."

What you do is you add your own wisdom. You have your own experiences. You have your own wisdom from these experiences. You have wisdom from what you have read. You have wisdom from what you have heard. You have wisdom from your conversations.

This wisdom is there even if you don't know it. And you will be asked to share it, whether you're ready to or not.

Fortunately for me, I have done lots of research for the RT cave. I have spent lots of time reading science journals for articles I've written. That helps. But it's not always needed. Some RTs don't read that much and they're equally brilliant.

So, now I'm the senior RT. That's what has changed. The seniors I tapped into are retired. Now I'm the senior RT. This is not a role you seek out. It sort of just happens.

Monday, September 25, 2017

Should You Become A Respiratory Therapist?

I get a lot of emails from people who are considering going to college to become a Respiratory Therapist. But because of something a respiratory therapist said, you are now having second thoughts. My humble advice to you is:

Don't fail to do something you think you'd enjoy because of something someone else said. 

Okay? Don't do it. Don't let someone else's negativity towards their own job sway you from doing something.

Let me just give you some of my own examples. I'm 47 years old now. Often I wonder what my life would be like today if I had become a teacher. I had thought long and hard about choosing the career of teaching long before I ever became a respiratory therapist.

So, here I was a Senior in High School. I had two teachers I really respected. I asked both these guys if teaching was a good profession. To my dismay, they were both very negative about the job, "There's a lot of burnout! The pay isn't good!" Are some of the negative comments they made about their job.

I did not go into teaching simply based on what these two teachers said. And, to be honest, I have regretted it ever since. I have always thought I would have been a great teacher. I think I would have loved that profession.

The same with counseling. I had actually thought of becoming a counselor at one time. However, I had a friend who was a counselor, and she said, "There's a lot of burnout! The pay isn't good!"

I sort of became a respiratory therapist by default. It was never at the top of any of my lists. However, since I didn't have a friend trash that profession, that's what I chose.

And, don't get me wrong, I love being a respiratory therapist. It's one of the better things to happen to me in my life. It has taught me a lot about my own asthma, allowed me to meet a lot of great people, and has to lead me to this profession as a health blogger.

That said: I'm burned out, and the pay isn't that good. See my point! All jobs lead to, or most, lead to a time when you're going to realize your pay is poor and you are burned out. It's a fact of life. It's why many people switch jobs or go back to school at certain times in their lives.

Some high school students tell me that they were told by a respiratory therapist that there is no respect for the profession. Sure, there are some things that need to be improved.

But, respect isn't one of them.

Our profession is a new one, and so there is still some room for the profession to grow. And you can be a part of making it better. So, if you are thinking about becoming a respiratory therapist: Go for it!

And if you decide later on that you want to do more and make more money, then the profession of respiratory therapy is a great stepping stone for other healthcare jobs, including a Physician's Assistant. I can surely tell you that any PA with an RRT background is going to be one hell of a PA.

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.


“A Guide for Aerosolized Delivery Devices for Respiratory Therapists,” 3rd edition,, accessed 8/4/17

Irwin, et al., “Side Effects With Inhaled Corticosteroids,” Chest, July, 2006,, accessed 8/3/17

“Spacers with inhalers: Do they make a difference,” American Academy of Allergy, Asthma, and Immunology, 2017, Jan. 18,, accessed 8/5/17

Saag, Kenneth G., et al., “Major Side Effects of Glucocorticosteroids,” 2017,, accessed 8/3/17

Barnes, Peter, J., "Inhaled Corticosteroids," Pharmaceuticals (Basal), 2010, March 3,, accessed 8/1/17

Romme, “Fracture Prevention in COPD: A clinical 5-step approach,” Respiratory Research, 2014,, 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. 

  1. Low, Philip, "Overview of the Autonomic Nervous System," Merck Manual,,-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