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Monday, July 9, 2018

Asthma Billing Code: J45

Your Question. My best friend's doctor told her that she has:j45.9 unspecified asthma. She's never heard of that type before and could not find useful information about it. I remembered this blog and the useful answer you gave me in the past, so I thought I would ask you. What does this type of asthma mean?

My Answer.  What is this unusual asthma type? J45 is the official billing code for asthma. J45.9 basically means it's unspecified. That basically means your doctor is billing for asthma but didn't list anything specific about it. It's what's officially called an ICD-10 Code.

This is not a subgroup or anything like that. It's just for billing purposes. It's a code your doctor enters into the system so the office gets paid by the insurance company or Medicare.  Here is a link if you're interested. 

Monday, July 2, 2018

Heart Failure: When Can It Lead To Death?

Heart failure, if untreated, can lead to death because other organs of the body will not be receiving enough oxygen. Usually, one of the first organs to be affected are the kidneys.

The kidneys will fail and lose their ability to excrete salts and water, and actually, cause your body to retain more fluid. Actually, kidney failure alone can lead to pulmonary edema, or exacerbate it.

Likewise, fluid will back up in the liver, which in turn will fail in its job of removing toxins from the body. Lacking oxygen, the large and small intestines will lose their ability to absorb nutrients, and thus one organ after another will fail, ultimately leading to death.

Of course, our job as healthcare workers is to prevent this. Well, it's the doctor's job.


Monday, June 25, 2018

Heart Failure: What Are Treatments?

Bronchodilators are a top-line treatment for heart failure.

Just kidding!

However, some studies do show that some bronchospasm may result from heart failure. But, this bronchospasm is secondary to fluid overload. A bronchodilator will not treat heart failure. It may relieve some of the shortness of breath if it is caused by bronchospasm.

So, you can only treat heart failure with heart failure medicine.

Here's what the Mayo Clinic says:
"You can't reverse many conditions that lead to heart failure, but heart failure can often be treated with good results. Medications can improve the signs and symptoms of heart failure."
Treatment for heart failure includes.
  1. Medicine. Medicines used to treat heart failure are those that strengthen the strength and contractility of the heart, such as Digoxin. They also include medicines to lower the blood pressure or to make patients pee, such as Lasix or Bumex. These are medicines that are often taken every day to prevent heart failure symptoms or to make symptoms less severe when they do occur. For a list of other medicines used to treat heart failure, check out my post, "Heart Failure Medicine).
  2. Lifestyle changes. These would include such things as quitting smoking, eating a healthy diet, limiting salt intake (to lower blood pressure), exercising to the best of your ability, taking your blood pressure medicines as prescribed by your physician, as well as taking all your meds as prescribed. You'll also need to manage stress, manage depression, manage anxiety, lose weight, control diabetes, and lose weight if you're too overweight.
  3. Surgery. Cardiac anomalies, such as leaky valves and tetrology of felot can be corrected with surgical procedures. 
  4. Supplemental oxygen. This may be needed during exertion and at night while sleeping. It will probably also be needed during flare-ups. 
  5. BiPAP. This reduces preload and afterload to reduce the work the heart has to do. This can often be worn at night time to improve oxygenation and reduce nighttime dyspnea. It can also be used in hospitals to reduce resistance to breathing and to make breathing easier in order to buy time for the medicines used by physicians to work their magic. 
  6. Intubation. It is usually not needed if the patient presents to the emergency room in plenty of time to get adequate treatment. Intubation is often avoided by using BiPAP. 

Monday, June 18, 2018

Heart Failure: what causes it?

Heart failure is when the heart is too weak to pump blood through the body. It poops out. The patient becomes winded on exertion as the person's heart cannot keep up with demands on the body. So, what causes heart failure? Here's what to know.

1. Hypertension: Coronary artery disease is one ailment that causes blood vessels to become narrow. Years of working hard to pump blood through narrowed vessels can cause the heart to become hypertrophied (enlarged). A large bicep is good, and it's a sign of good health. A large heart is a sign of a weak pump. It is bad. Eventually, it will tire and become an ineffective pump. In fact, 60% of heart failure cases are the result of high systemic blood pressure and coronary artery disease.

2. Coronary Artery Disease (CAD): According to the National Heart, Lung and Blood Institute (NHLBI), CAD is a disease whereby plaque builds up inside the coronary arteries (arteries that supply oxygenated blood to the heart). This plaque buildup is called atherosclerosis, and will slowly cause these arteries to narrow, and thus force the heart to work harder to oxygenate itself. This can often lead to portions of plaque to break free, forming a clot in the heart, and causing a Myocardial Infarction, otherwise known as a heart attack (I'm sure you knew that, but just saying). 
3. Myocardial Infarction: This is where plaque from diseased coronary arteries breaks free and blocks blood flow to a part of the heart, causing heart (muscle) tissue in that area to die. This can cause heart failure. In fact, it can cause severe heart failure symptoms, including dyspnea, orthopnea, hypoxia, cyanosis, and even death.

4. Pulmonary Hypertension: This is where the pulmonary vascular resistance increases to a point where it causes the right heart to become hypertrophied. This makes the right heart a weaker pump. This often leads to left heart failure. Causes of this are COPD, cystic fibrosis, and pulmonary fibrosis. I go into more detail in my post, "Links Between COPD and Heart Failure."

5. Cor Pulmonale: This right heart hypertrophy. It means the right heart has become a weak, ineffective pump. This is responsible for 10-30% of admissions for CHF. For more detail, again check out, "Links Between COPD and Heart Failure."

6. Heart Disease: About 30-40% of heart failure is caused by heart disease.

7. Heart Valve Disease: This constitutes about 20% of heart failure. When the valves of the heart fail to work properly, this causes the heart to become a weaker pump.

8. Congenital Heart Defects: These are diseases a person is born with, and you can read about this in my post, "Congenital Heart Anomalies."

9. Drug abuse: Amphetamines, heroin, cocaine and other drugs may actually numb the heart so much that it becomes a less effective pump and ultimately fails.

10. Alcohol Abuse: Years of abusing your body can cause it.

11. Infection: Influenza, mumps, and rabies are infections that can stun the heart, as are various bacterial infections (streptococcal, rheumatic heart disease). Likewise, sepsis (a systemic blood infection) can also weaken the heart's ability to pump blood.

12. Other diseases: Leukemia, neurologic disorders (Duchenne's muscular dystrophy, Multi-system organ failure, Sepsis, Trauma, cardiac tamponade (squeezes the heart), diabetes and obesity. Diseases such as hemochromatosis or amyloidosis that cause the heart to stiffen, thus decreasing the heart's ability to relax.

All of the above can cause the heart to become a weaker pump, thus resulting in a loss of cardiac output, and causing pulmonary edema and other symptoms that mimic asthma.

Monday, June 11, 2018

All that wheezes is asthma

It's asthma even if it's heart failure.
So, it was so long ago. It was in 1998. I was called to a room. The patient was extremely short of breath. The patient was winded. She was sitting in the recliner all frogged up. She was blue. Her saturation was 77%.

The nurse said, "She just went to the commode and she got like this." 

I was a new RT. I was stressed. What do I do?

Thankfully, a senior RT came to the rescue. She smoothly investigated the situation. She said, "What are the patients i's and o's." It was the first time I heard that question asked.

The  nurse said, "I don't know?"

The RT bluntly said, "I think we should check."

Later she said to me, "Sadly, RTs are the only people who ever check the i's and o's." Twenty years later, when I found myself the seasoned RT, I found myself saying the same thing to a new RT. Go figure! Twenty years on this job and not much has changed.

So, anyway, this seasoned RT gave the treatment. The patient's sats increased to 98% during the treatment. But, as soon as the treatment ended, and the patient was back on 2lpm nasal cannula (back then you didn't dare increase the flow rate without first asking the doctor's permission), her sat went back down to the mid 80s.

So, the therapist did the only logical thing. She started the treatment back up. Only this time there was no medicine. She later told me she did this to save the life of the patient. She knew the patient needed oxygen. She knew what was wrong with the patient: She needed oxygen. She also needed something other than the albuterol. She needed medicine to treat heart failure.

So, I saw this one time and I knew and I learned. I saw this one time. And, you would be amazed at how often this happens in the hospital setting. The patient uses the commode, gets winded, and RT is called to give a breathing treatment. The patient gets fluid overloaded, RT is called to give a breathing treatment.

I find that respiratory therapist learn. I feel I don't need to educate RTs about this. The people I would like to educate are the doctors and nurses. But, how do you do that without offending people?

So, that's the state of the medical profession today. Actually, it's no different than it ever has been. Medicine is based on myths, and myths prevail to this day. And one myth is that all shortness of breath is cured with asthma medicine. The myth is all that wheezes is asthma. And this may never change in an ever-present dogmatic medical world we live in.

Monday, June 4, 2018

Cardiac Asthma Treated As Asthma

So often respiratory therapists are required to give breathing treatments to patients presenting with dyspnea and wheezing. This is fine and dandy if it's asthma. But, when it's heart failure (a.ka. cardiac asthma), a bronchodilator isn't going to work. The treatment is something else, totally.

But, because we are good RTs, we do the treatment anyway. And, while the treatment is going, we investigate the patient's chart. We often begin and end with the i's and o's (ins and outs). It ends if we determine the patients I's are way more than the O's. This means the patient is probably wet. And it means that it's probably not bronchospasm and shouldn't be treated as such.

As we just proved once again, among the most common reasons for this failure is a misdiagnosis of asthma when the primary cause of symptoms is actually heart failure.

So, that said, the RT Cave participated in an unofficial poll of 2,000 respiratory therapists. Nearly 80% of them said that the most common symptom of heart failure is forced and audible expiratory upper airway wheeze. It's often loud enough that you can hear it from the door.

Likewise, this same group of therapists said that this describes 80% of the breathing treatments they do in emergency rooms. A patient presents to the ER with shortness of breath and an audible wheeze. Among the doctor and nurse community, this is immediate confirmation of the need for RT services. Yes! A breathing treatment is ordered. And RT is paged. Often we are paged STAT!

This also happens on the floors. You are the therapist on duty and you get called STAT! to do a breathing treatment on a patient presenting with dyspnea. Upon your assessment, you learn the patient was fine until she went to use the commode.

You realize right away that it is not asthma or COPD causing this flare-up. It's heart failure. The patient's heart is too pooped to make the journey. So, the patient gets extremely winded. The patient might even turn blue. Their sats may drop into the 70s. And, to some nurses and doctors (and probably some RTs too), this is an immediate indication for a bronchodilator breathing treatment. RT is called STAT!

So you, the lowly therapist with a lowly associate's degree, diagnose the patient with heart failure. Well, we don't diagnose, but you get the picture. And so, you start the breathing treatment. You give the treatment from an oxygen 50 PSI source. The estimated Fio2 is 60% during breathing treatments. The patient's oxygen saturation shoots right up.

Voila!

The patient is suddenly no longer dyspneic. You get credit for fixing the patient. The RN and patient and doctor see the nebulizer. They see the patient is feeling better after all. So, the only logical reason for this to them is that it was the treatment that helped. The cause was asthma or COPD.

Well, no!

Not!

It was not asthma or COPD. It was the oxygen boost that helped the patient. It was rest that fixed the patient. It was NOT the bronchodilator. It was not the albuterol. It was not the atrovent. In fact, more often than not, the patient is already fine by the time RT arrives.

But, this is how myths get born.

It was not the albuterol, dummy! It was the oxygen. It was the rest. But, I think most of us gave up long ago educating about this. We just apathetically do the treatment and go about our business. We are very professional in this way.

Sunday, May 27, 2018

RT Cave Rule: Sats low? Check the tubing first

So, I was called stat to the emergency room. I was told to give a breathing treatment to the lady in room 221. She was in severe respiratory distress.

I opened the door to her room. She was sitting there blue and puffing. But, I watched as the nurse disconnected her from her home concentrator and hooked her nasal cannula up to the wall

She continued to be blue and winded. She was a happy little lady, though. She never stopped chatting, despite the fact she was pretty winded. And she started talking about her cats. Oh, how she loved her cats.

And so I checked her nasal cannula. It had holes in it. She said, "My cats got into my oxygen tubing. And I didn't have any replacement tubing."

From the cabinet, in the room, I grabbed a new nasal cannula. I took her off of her cannula. I put the new cannula on her. And, lo and behold, her pulse oximeter reading perked right up to 92%. She was also no longer blue.

Of course, I still have to give her that breathing treatment. But, by the time I started it she was feeling fine.

Labs were later drawn. An x-ray was taken. And they were both normal for her. So, the doctor discharged her and we sent her on her way.

The discharge diagnosis: Catsma.

So, we will make this RT Cave Rule #62. If the patient's blue with low sats, check the tubing first.