Indications for breathing treatments

Since I write so often on these pages reasons nurses call for breathing treatments and doctors order them (my latest version is here), I think it is due time I create a list of the true indications for a bronchodilator breathing treatments.

Keep in mind a bronchodilator only treats bronchospasm. Likewise, rescue inhalers used properly with spacer are proven to be as effective in most cases as a breathing treatments.

That in mind, here we go:

1. Asthma
2. Bronchitis (acute or chronic)
3. Emphysema
4. Cistic Fibrosis
5. Airway swelling due to allergic reaction
6. Bronchiectasis
7. Pt with above diseases who cannot manage an inhaler (Albuterol, Atrovent, Flovent, etc.)
8. Bronchospasm secondary to other disease process such as CHF, pneumonia, pulmonary fibrosis, RSV, lung cancer, sinusitis, etc.
9. Bronchospasm secondary to allergic reaction (bee sting)

Note #1: The diseases in #8 do not necessarily cause bronchospasm, but may irritate the sensitive airways of people who have the diseases mentioned above

Note #2: It appears doctors believe treatments are cures for all ailments, and are indicated for all the wheezes and all that causes shortness of breath as you can see for yourself by reading the Real Physician's Creed.

Note #3: Again, I am going to file this under humor, although it is not humor it is serious. Too many doctors fail to understand the true indications for breathing treatments

27 non indications for breathing treatment

Just a friendly reminder: the following are not indications for bronchodilator breathing treatments:

1. Dr. ordered it
2. Don't know what else to do
3. Nurse wanted it
4. Pt wanted it
5. Stridor
6. Sinusitis
7. Mesothelioma
8. Lupis
9. M.S.
10. Homeless
11. Depression
12. Pt has home nebs
13. Pt likes tx
14. Pt likes company
15. Bed ridden
16. History of smoking
17. Irritating lung sounds
18. Low SpO2
19. Trach
20. Intubated
21. Post operative
22. Atelectasis
23. Fever
24. Trach
25. CHF
26. Pneumonia
27. Pleural effusion
28. Pneumo
29. Rickits
30. RSV
31. ARDS
32. RDS
33. P.E.
34. Cough
35. Sputum induction
36. All wheezes (all that wheezes is not bronchospasm)
37. All SOB (SOB is not always caused by bronchospasm)

Note #1: Many doctors are taught the opposite, as you can see by reading the Real Physician's Creed.

I'm going to file this under humor, although this is not humor, it's serious.

The 100,000 click milestone has been reached

Well, ladies and gentlemen, the RT cave has met yet another milestone. It took all of 21 months, and the RT cave has finally been clicked on 100,000 times. Again I think this is pretty cool since when I initially started this I figured I'd be writing to myself.

It seems things have progressed quite a bit here. At first I'd sit down each day wondering what I would write about, and many times I'd be scrapping just to keep up. Now the list of ideas is so deep I can't even see the bottom. It's like an endless pit.

As other bloggers can attest, we write about whatever is on the tip of our minds, which can vary from day to day. So long as I can keep myself entertained and you interested, perhaps we'll be around for another 100,000 clicks (even if some of them are only for a couple seconds, each is an ego boost for me).

So, I would like to take this moment to once again thank all of my faithful readers and clickerers for finding my blog and finding at least a partial interest in the amalgamate of respiratory minded wit and wisdom of your humble RT.

Thanks.

To call the Dr. or not to call, that is the dilemma

Here's something you will come across from time to time if you work nights. Of course as all RTs may have noticed by now, there often seems to be no rhyme or reason to "some" doctor orders, nor consistency to how a doctor will respond to a request to change the order.

Consider the following example:

The patient is a 75 YO non-COPD post operative patient with a registered SpO2 of 88% at 3-o-clock in the morning. Mind you, I did say three a.m. The patient is in no respiratory distress, and has no respiratory history. Otherwise, his vitals are normal. The order is for 2lpm. What do you do?

1. Call the doctor and wake him up
2. Increase the oxygen to 3lpm and have the RN call the doctor in the morning
3. Ignore the spo2 and pretend you didn't see it as the patients SpO2 probably always drops while he is sleeping
4. Since the SpO2 has an accuracy of plus/minus two, assume actual reading is 90%

Okay, what's your guess?

Day #1: This night the RT decides to use his common decides "b" is the best solution. The patient is stable and no harm done. If the patient's SpO2 was at a critical level, then a call to the doctor would be warranted, but not in this case.

The next day when the RT arrived at work he was lectured by said doctor who said, "Why do I write orders if you're not going to follow them?"

Day #2: Different patient but same information; different doctor, but this doctor is the spouse of the doctor in the scenario above. What does he do now?

Using the same choices above, since the RT now knows option #2 is not good, he decides to go with option #1 and wake up the doctor. The doctor says, "Why the hell are you waking me up at 3 in the morning to tell me this?"

"Um," says the RT, "Because yesterday, same scenario, your husband told me that I have to call before I increase oxygen to get an order."

"Oh," she says, "Well, then increase it to 3lpm and leave it at that."

"Well, then can we..."

Click. The doctor was no longer available.

"...get an order for protocol just in case... oh, what the heck.

So, what is the best thing to do in a scenario like this? Well, based on my experience, you're damned if you do and damned if you don't, so you might as well wake the doctor up and let her lecture you about how idiotic you are.

Thus, RN Cave Rule #72:

If you think you better call the doctor you better call him. If you think the doctor might yell at your and tell you you are an idiot because he doesn't want to be irritated in the middle of the night, call him anyway.

Tons of new meds at the asthma hosital

(Note: This is part VII of my story growing up with hardluck asthma. To view Parts I through VI you can click here and follow the links.).

Perhaps I'm submitting this list of medicine to amaze myself, but these are all the medicines I was on shortly after being admitted to NJH/NAC back in 1985.

• Theodur 400 mg: 6 a.m. and 6 p.m.
• Prednisone 60 mg: 6a.m.
• Nasal irrigations: 6 a.m., 12 noon and 6 p.m.
• Nalalide 2 squirts: 6 a.m., 12 noon and 6 p.m.
• Afrin 2 squirts: 6 a.m., 12 noon and 6 p.m.
• Tinactin Cream: 6 a.m. and 10 p.m.
• Tinactin powder: 6 a.m.
• Cromolyn: 6 a.m. 12 noon 6 p.m. midnight
• Vanceril 4 puffs 6 a.m. 12 noon 6 p.m. midnight
• Theodur 6 a.m., 2 p.m., 10 p.m.
• Blood Pressure 6 a.m, 6 p.m.
• Drixorol 6 a.m., 8 p.m.
• Amoxicillin 6 a.m. 2 p.m. 6 p.m.

Treatments:

• Alupent: 0.5cc at 6 a.m., 12 noon, 6 p.m., and midnight
• Atrovent: 4mg (.63cc) 6 a.m., 12 noon, 6 p.m., and midnight
• Terbutaline 4 mg at 9 a.m., 3 p.m., and 9 p.m.
• Spirometry: 6 a.m., 12 noon, 6 p.m., midnight
• Peak flows: 6 a.m. and 6 p.m.
• Postural drainage: 6 a.m., 3 p.m., 6 p.m., midnight

Initially when I was admitted my asthma was severely uncontrolled, so my doctor basically put me on all the asthma medicines and therapies she knew of at that time. The goal, I believe, was to start me on everything and slowly eliminate.

At that time terbutaline was still a commonly used bronchodilator (it is still available but rarely used in the U.S. I think we still have a vial in our med drawer, although I'm sure it is long since expired) even though it had a tendency to cause some side effects similar to adrenaline (epinepherine, susphrine). And I think it was for this reason I had to have twice daily blood pressure checks.

I think after I was there about 30 days or so (and after I was released from PSC after 3 days)that my doctor told me my asthma was finally stable enough so I could stop taking Terbulatine, and thus Q3 breathing treatments. That was a major day of celebration for me, as it was a major pain leave school every few hours for a treatment and meds.

Postural drainage was initiated on me thinking I was having trouble expectorating, but it was discontinued when Terbutaline was. There were some kids who still got PD, but not me. Although I received some experience performing it on some of the other kids, and them on me. this, in a sense, prepared me for RT school. In fact, all of this prepared me for RT School.

Today PD is no longer recommended for asthma as it is thought that it might loosen up a mucus plug (common with severe asthmatics) and cause even worse asthma.

I think one of the main reasons I wanted to post this list is to show how many medicines asthmatics with allergies had to take to control their asthma. In fact, it should be known that asthmatics with allergies are more likely to develop severe persistent asthma, if not controlled. Likewise, smoking too can speed up the severity of asthma. Thankfully I did not smoke, and only had the allergies to worry about (in case you're wondering, I had allergy testing done three times in my life, once before NJH, once during, and once after. Each time I had a possitive reaction for nearly everything outdoors).

While I was in the asthma hospital I had nothing else to think about, yet when I was discharged to home it became difficult to live a normal life (as they say we should be able to with asthma) and take all our meds as prescribed.

So, for the first three months I was at NJH/NAC I was basically on the meds as listed above. The red were eliminated when the terbutaline was eliminated, and the meds listed in orannge were added. I imagine some of the others were temporary too, but since I didn't cross them out I imagine I was on them a while too.

I have no idea why I was on Tinactin. The Nasal irrigations and nasalide and Drixoral were the only means of treating allergies. While I was in the hospital I wasn't exposed to my asthma triggers anyway, so I don't thing I even needed them while there (the nasal washes were a pain in the arse to do). Yet I imagine my sinus passages were swelled up big time when I was admitted.

I had a major case of sinusitis (common among child asthmatics), so that explains the amoxicillin. The chromolyn was a new medicine available, and it was the first dry powder inhaler (DPI) ever made (I think). You took it with a spinhaler (see picture) which crushed the capsule and you inhaled the powder. It was worse than the new DPIs in that it often caused asthmatics to cough and go into bronchospasm. I had this happen a few times.

The Spirometry was actually fun to do. It let me know how much my asthma was improving not just before and after treatments, but overall. Later on I will publish one of my Spirometry flow sheets. Peak flows were no different back then than today, as every doctor and RT recommended you use one. Although pre-NJH I was not very compliant with mine.

The Vanceril was the common corticosteroid at that time. I think before I left NJH/NAC I was switched to the new Azmacort. Neither were as effective as the newer corticosteroids available today, which is why we had to take so many puffs so often. And yes, it was a pain to remember all the puffs and doses. When I was discharged to home, it was hard to remian compliant with this regime.

Alupent (recently discontinued) was the bronchodilator with the least side effects back then, although it did leave me with a palpable thump-thump-thumping in my chest after each use, but not as bad as the Terbutaline. Atropine was the equivelent to the Atrovent and Spiriva we use now adays, although this line of back door bronchodilators is no longer recommended for the treatment except for when other meds don't work (as in Hardluck asthma).

Asthma Action Plans did exist back then, and before I went home I was given an oxygen tank, a box of epinipherine amps, syringes, and I was instructed how to give myself it. I was told only to go to the ER if the Epi didn't work. I digress though. That's for a later discussion.

There was an incentive to get your pills at the nurses station on time, and to take your treatments on time, and that was a points system. We had to carry a points sheet with us throughout the day and have each of our teachers sign it to prove we attended class. We had to have whomever we had appointments sign for the same reason. Of course if we were bad in class, the teacher (Mr. Rose) would threaten to take away points.

Likewise, every time we left the floor (and returned) we had to sign in and out on a recording sheet. If we forgot, we didn't get those points. The more points we earned in a week the greater likelihood we moved up to the next level. Actually, you moved up levels as you proved you were responsible with your meds and rules. Moving up levels wasn't really too hard on 7-Goodman.

If I remember right, the levels were 1 (poor behavior) 2, 3 and Honors. There was a bulleton board behind the nurses station that monitored our progress.

With each level you get new resonsibility. Such, if you are on level one you cannot leave the floor except for school and appointments. On level 2 you got to participate in anything, but you could not leave the floor without a nurse, a counselor, P.E. instructor, etc. Level 2 is where all new patient's start. Also on level 2 you have to have a nurse supervise when you are mixing your nebs.

On level three you are now able to draw up your own meds unsupervised as you have proven that you are capable and responsible. You can also leave 7-Goodman without an adult escort so long as you are with someone on Honors.

The same is true when we went on excursions to the mall, movies, mountains, etc. If you are on level 2 you can go, but you have to stay with the adult escort the entire trip. If you are on level 3 you can go alone if you have an Honors escort, and if you are on Honors you can do whatever you want so long as you return to the designated meeting area at the designated time. If you prove not to be resonsible enough to hold up the responsibilities provided to you, you had points taken away and risks moving down a level

I guess I'd have to say that my brother David was right in that it was like a camp in a way. They kept us so busy we barely had time to sit around and be bored. However it did happen. And in the initial days it was hard not to feel homesick -- especially the first several weeks.

As far as my treatments were concerned, the nurses initially drew up my meds and watched me take a treatment, but eventually (as I moved up levels) it was my responsibility to draw up my own meds, but I had to find a nurse to watch me. Eventually, though, I earned the right to take my treatments unsupervised (which occured on level 3). On 7-Goodman no patients were allowed to have their own pills in their rooms.

As I wrote before, there were basically 2 air compressors set on a table in the lobby of 7-Goodman and we had to take turns using it, so I usually tried to be the first one considering I was usually tight and wheezing and didn't want to wait for relief (of course I wasn't the only one who was tight, so with only 2 machines one of us had to wait).

Within days after I was admitted I had to attend classes so I could learn about asthma and asthma meds. Back then asthma was basically treated as a disease of airflow obstruction secondary to bronchospasm. In class, we were taught about the acronym ROAD, which stood for Reversible Obstructive Airway Disease. The main treatment for the disease was to control bronchoconstriction.

Today, airway obstruction is considered a component of asthma, but is mainly considered as a marker for airway hyperresponsiveness due to inflammation. If your inflammation is uncontrolled, your airways are more resonsive to your asthma irritants. Thus, asthma today is considered more a disease of chronic inflammation, and the efforts of treatment are mostly aimed at treating this underlying inflammation. Once controlled, your airways become less hyperresponsive, and you'll have acute episodes of acute bronchospasm less often.

Back then, however, we were taught about ROAD. In fact, when I entered RT School I asked about ROAD, and my teachers had never heard of it. So by the time they had become RTs that old acronym had expired in favor of new wisdom. However, to be considered asthma, the bronchospasm component has to have some degree of reversibility, which is why all asthmatics must always have a rescue inhaler handy. (Perhaps ROAD is still in use, as I've found it here and here.)

You have to realize here that the goal was to teach us asthmatics to be gallant asthmatics, and this was the method the asthma hospital used at this time. Since most doctors back then were not privy to the asthma wisdom of NJH back in the 1980s, if you had severe asthma NJH/NAC was the best place for you.

However, the good news is that in the late 1990s several doctors got together and decided something had to be done to improve the way asthma was treated by regional doctors (like mine back home), and the asthma guidelines were created. With the new asthma guidelines, new asthma wisdom, and new medicines, it became easier for local doctors to treat asthma.

In fact, even better for good asthma control, new asthma meds like Adviar and Symbicort allow for puffs to be needed only twice a day. This greatly helps in the comliance department. With greater compliance comes greater asthma control.

In fact, I recently talked with a person in charge of public affairs at National Jewish Health (that's the new name) and she said that 7-Goodman no longer exists because local doctors do such a great job now of managing asthma.

She said one of the reasons it was able to close was because of the asthma guidelines, and another reason is the fact that NJH sends doctors to regional areas to make sure that all doctors are aware of the latest asthma wisdom of how to care for asthmatics. And the Internet I'm sure is also a factor in improved asthma wisdom among both doctors and patients alike.

(I will try to have part VIII of my asthma story up on Sunday, July 19, 2009)

Rules of the RT Cave

Today I'd like to list the rules of the RT Cave:

1. I have nothing to do with the ads that appear on my blog, so if you see something that offends you keep this in mind.

2. The #1 purpose for this blog is to share RT ideas, facts, opinions and humor so we can all learn in a pithy and/or entertaining manner.

3. This blog is published, edited and written by one lone night shift respiratory therapist who works full time, has three kids, and whose main mission on this planet is not as a writer, but as a husband and a dad.

4. If the author ignored his priorities (as mentioned above in #3), he would be able to delve deeper into a broader array of topics. This would be great for you guys and I'd love to do it, but it would come at the expense of time with my family, and that wouldn't be good, nor wise.

5. Due to #3 above, on occasion an error, typo, or inaccuracy may slip through the cracks. Keep in mind the editor (who's also the author) reads, re-reads, re-reads again, and again most posts. Although due to time factors, this sometimes does not occur.

6. While this isn't ideal, on occasion the publisher (who's also the writer) decides getting an idea out is more important than having an error less publication.

7. The editor has a minor in English, and therefore knows the difference between their and there. Yet, his publisher insists that he not edit while writing. Since the editor often shows up during kid time, he sometimes misses the boat at the expense of #6 above.

8. Due to #2 above, on occasion my political views become as obvious as a neon sign in a small town. While the editor makes a gallant attempt to limit this, on occasion it is necessary to make a point.

9. Besides, this is a blog, which (according to Dictionary.com) is "an online diary; a personal chronological log of thoughts published on a Web page."

10. I invite comments, and this includes criticism, praise, opinions, ideas, praise, ideas, praise, thoughts, praise...

11. The editor is committed to deleting any personal attacks. Thankfully these come seldom.

12. The publisher (who's also the writer and editor) tries to maintain a schedule for what gets posted what day, although he often violates this policy for the sake of sharing ideas that are seeping from the writer's pores and dying to get on this screen.

12. The authors writings often reflect his mood for the day. For example, if he's working he's often inclined to write about work related things. If he is on vacation he's more likely to write about something like asthma or other.

13. The frequency and length of posts often reflects upon how busy the author is. If he is burned out from working, his writings won't be as involved as when he is working and has no patients to take care of.

14. The publisher, writer and author (otherwise known as me, myself and I) try to cater to all his audiences on a regular basis, although sometimes he gets on a roll. A perfect example is last week the writer (me) didn't feel like writing about asthma, and today he doesn't feel like writing the next installment of his asthma story (that should come tomorrow).

15. I imagine these rules are true for most blogger.

I think it's important to remind my readers of this once in a while.

Here's a great con to Nationalized Healthcare

Here is one very good reason I am against a nationalized health care system. I discussed with my boss yesterday about the budget. He said his bosses want him to come up with "everything and anything" ideas for further cutting the budget.

He asked me, "Any ideas."

I said, "Create a treatment protocol so we can get rid of all the breathing treatments that are not needed. That would save us a ton of money." (To learn how much money this would actually save our hospital, click here.)

He said, "Rick, you should be happy just to have a job. We need all the procedures right now we can get."

Here's something to consider. The hospital does not get paid by the government per procedure completed, it gets one flat rate for the patent's stay. So, the fewer procedures done while the patient is admitted the more money the hospital would make.

Thus, if Shoreline Medical Center could come up with a protocol to prevent doctors from giving an asthma/COPD medicine just because a patient is short of breath or sounds bad or looks funny (or to prevent bronchodilator abuse), that would save the hospital hundreds of thousands of dollars a year.

What I understand here is that when it comes to cutting the hospital's budget my boss only thinks in terms of his own wallet, while ignoring the wallet of everyone else. What he fails to understand (what many people seem to misunderstand these days) is the government's wallet is OUR money too.

My boss is afraid if we get a protocol, the number of procedures in our department will go down, and someone will lose his or her job. It seems to me many hospital bosses would prefer the procedure than to prevent government waste.

Yes government reform is needed, but not in the direction the current House, Senate and Executive Branch visions. The change we need is to provide an incentive for hospital admins to spend the government's money as wisely as it spends it's own.

As the old saying goes: people are more likely to spend their own money wisely, yet when it comes to spending someone else's money, they appear to be less wise (or is that a saying I just made up). Anyway, it's true.

Feel free to discuss because, as always, I could be mistaken.

(Other than the links above, for more of my opinion on Nationalized Healthcare, click here.)