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Monday, August 3, 2015

Why I switched from Advair to Breo

The following was originally published on October 28, 2014 at

Why I Switched My Asthma Medication

We live in a day and age where asthmatics are blessed with a plethora of medicinal options. I personally think it’s a good idea for all asthmatics to keep an open mind and, when appropriate, be willing to try something new.

Personally, as a life-long asthma and allergy sufferer, I’ve always been willing to try something new. One of the latest medicines I’ve tried is a newer medicine called Breo. Although approved for COPD, it may also be prescribed to help control asthma.

Breo is the latest in a line of combination medicines that contain both an inhaled corticosteroid (fluticasone furoate) and a long acting beta adrenergic (vlanterol). The inhaler is made by GlaxoSmithKline, the same company that makes Advair.

Advair has introduced to the market in the mid 1990s as the first combination inhaler containing an inhaled steroid (fluticasone) and LABA (salmeterol). It has since gone on to become one of the best selling asthma medicines of all time.

Advair was approved by the FDA for asthma, but has commonly been prescribed for COPD. Around the year 2000, my asthma doctor prescribed Advair to help me better control my asthma. It worked great. Yet by the spring of 2014 Advair was no longer working, and so my physician suggested I try Breo.

He handed me about two months' worth of free samples, and said, “I want your honest opinion on this new medicine. I trust your judgement.”

In the past he had me replace Advair with Symbicort and then Dulera, but both of those made me too jittery. So when he offered for me to try Breo I wasn’t too optimistic.

However, after a month of taking it, not only were there no side effects, but my asthma was under much better control. Of course I could easily consider it a coincidence, but in this case I’m going to give credit to Breo.

There are two reasons I think Breo works better for me. I personally think that after eight years, my body developed a tolerance to it. I've noticed a trend of this happening in the past. I think there comes a point where a change becomes necessary.

The inhaler I used prior to Advair was Azmacort. One of the main problems with this medicine is I needed four puffs four times a day. It was hard to be compliant with this high dose. Advair was nice because it required only one puff twice a day. That made compliance much easier.

The second reason is because every time a new inhaled corticosteroid or LABA is introduced to the market, it is slightly better than its predicessors. It's possible that Breo simply works better than Advair.

Another nice thing that makes Breo better than Advair is Breo only requires one puff once a day. While the Advair Discus was easy to use, the Breo elipta is even easier to use (all you do is open the top and inhale).

Once I decided that Breo was right for me, I called my pharmacist to see if it was affordable. This was necessary because newer asthma medicines tend to be quite expensive. He said that the cost, after deductible, was right about $60. This was actually a few dollars less than Advair, so it was worthwhile for me to call my physician to get a prescription for Breo.

My point here is not to give an endorsement to Advair or Breo or any other product. My point is that, if your asthma is not as controlled as you’d like, perhaps it’s time to look into some of the newer asthma medicines that are now available.

Sunday, August 2, 2015

CMS passes Absent Frequency Bill

Washington D.C. - The Centers for Medicare and Medicaid Services announced the passages of the Absent Frequency Bill, a controversial bill that bans physicians, notably emergency room physicians and hospitalists, from ordering any medicine on a frequency for admitted patients..

As noted by a press release: "No longer will physicians be allowed to order Q4, Q6, QID, TID, or Q1 hour breathing treatments.  Physicians will also be banned from ordering serial labs and EKGs.  This will be significant, because, over the past several years, hospitalists have become famous for ordering, for instance, QAM EKGs until discharge.  No more will this occur."

L. Buterol, director for cardiopulmonary services at Breatheasy Medical Center (BMC), said the new law "may hurt the overall department because it will result in fewer procedure counts.  However, our therapists are excited about it because they believe it will result in less burnout and apathy."

What will happen now is doctors will be forced to order as needed (PRN) therapies.  This will require increased responsibility for both physicians, nurses and respiratory therapists.  For instance, rather than just deciding that a patient will be short of breath every four hours, physicians will have to rely on nurses and therapists to assess and treat when needed.  This will be a serious moral booster.

"It will also save a ton of money for hospitals," said Mike Olin, president of RATS NEST.  "No longer will physicians be required to order a bunch of needless procedures just so the hospital can get reimbursed. With CMS generally paying a flat fee for patient stays, hospitals have been eating this cost.  No more. Woo hoo!  W'hat a great day for both the medical community and the RT community."

T'he RT Cave will keep you posted on how this is accepted by the medical community, or whether or not it can even be enforced.  Or, perhaps this is all just a pipe dream. 

Wednesday, July 29, 2015

What not to say to end stage COPDers

Sort of a touchy subject for physicians is dealing with end of life issues. We respiratory therapists see this quite often, particularly when it comes to end stage COPD.  We have patients who are at the extremes of the limits of what medicine can offer them.  While we have to somehow manage to help them keep up their spirits and live somewhat normal lives, we also have to be honest with them. 

This subject was recently brought up at the facebook page when a patient wrote: 
"I'm a 66 yo just had my Dr tell me there is nothing else I can do or take to improve or even stay where I am. Working that through before my next lung evaluation in 2 weeks."
A similar comment I once heard was:
"You have two weeks to live." 
Another similar comment was:
"If you go home you're gonna die."  
Now, how does a physician know when a patient is going to die?  Surely you don't want patients thinking they are going to miraculously get better. Still, you don't want to deflate all  hope either.

In fact, the last time I heard a physician tell a patient with end stage COPD that he only had a few weeks to live, that patient went on to live two a few more years. Surely he lived within the limits of COPD, but he was still able to do things.

The patient who was told by one doctor he was going to die if he went home became very confused and depressed.  This only added to his problems.  I assured him that if he is a gallant COPD patient, takes all his medicine exactly as prescribed, wears his oxygen 24-hours-seven-days a week, and wears his BiPAP at night, that he has a very good chance of gaining a few more quality years.

This seemed to cheer up this patient.  The next day I worked he was breathing so much better that he was euphoric.  He was back to enjoying Westerns and telling jokes that made us all laugh.  He was breathing a whole lot better and feeling alive again.

The patient who was told there was nothing else he could do was advised by us moderators to seek a second opinion, preferably that of a pulmonologist.  He has since informed us that this is exactly what he expects to do at his next appointment.

As healthcare providers, we must be aware that we are caring for people, not just objects on assembly lines. We must be honest with our patients, but not in a way that deflates their will to live.

Tuesday, July 28, 2015

When should you seek help for COPD?

The following post was originally published at on February 09, 2015.

When to seek help for your COPD

When you have COPD, your body sends off signals when things aren’t right inside you. If you experience any of these, it's time to seek medical help.

Cyanosis. A gray or bluish tinge on your fingertips or lips is a sign that your oxygen level in your blood is low.

Anxiety. When your body craves oxygen, or when you can’t catch your breath, it’s normal to feel anxious or panicked. Yet this may cause your body to become increasingly tense, making matters worse.

Cough. Coughing more than usual may be a sign a flare-up is oncoming or ongoing.

Sputum. Coughing that produces abnormally large amounts of sputum. Or, coughing up sputum that is a different color than usual, such as yellow, brown, green or red (blood tinged).

Dyspnea. You are more short of breath than usual or cannot catch your breath even with rest.

Paradoxical breathing. Your shoulders are abnormally hunched to breathe. Your stomach goes in when you inhale, instead of out. Your chest moves upward when you inhale, perhaps revealing ribs.

Rescue Medicine. You find yourself needing or using your rescue medicine -- albuterol, xopenex -- more frequently than normal.

Edema. New or worsening swelling in your ankles, legs, or abdomen is a sign your body is retaining fluid. There are different things that could cause this, such as heart failure.

Taciturn. You find that you are unable to talk, or you are only able to talk in short, choppy sentences. This is a common sign when you can’t catch your breath.

Leaning. You find you must lean on things such as tables and chairs to breathe.

Exertion. You find you are unable to walk, or get abnormally winded when walking. You find you have to lean on things to breathe while walking. You find you have to rest more than usual to catch your breath after exerting yourself. Rest after exertion does not help you catch your breath.

Activities. You find you are unable to do things you normally do, such as brushing your teeth or eating.

Adventitious noises. You hear abnormal noises when you are breathing, such as wheezing or gurgling. An audible wheeze or rhonchi is the sound of air moving through obstructed or secretion filled airways. It may be due to worsening bronchitis, or it may be due to heart complications.

Orthopnea. You must sit up to breathe. You must sit in a reclined position (recliner) to sleep.

Insomnia. You have difficulty or are unable to sleep due to anxiety about your breathing. You simply cannot get into a comfortable sleeping position due to your breathing.

Angina. You’re experiencing chest pain. This may be a sign of heart trouble, or it may also be a sign you are working harder to breathe than normal. It may be a sign of pneumonia. It’s common to have chest pain when you are using your accessory muscles to breathe. Accessory muscles are those of muscles you only use when you are having trouble breathing (see paradoxical breathing above).

Monday, July 27, 2015

6 ways to control asthma at work

The following was originally published at on September 18, 2014

Managing Asthma At Work

Asthma can post a problem in the workplace, considering many jobs involve working with or near asthma triggers. But thanks to improved work environments and better asthma treatment, people with asthma can participate in various occupations without major troubles.

Here are six tips for managing asthma at work.

1. Get your asthma under control. This can be accomplished by seeing an asthma doctor at least once a year and taking your asthma controller medicine exactly as prescribed. Learn how to gain good control of your asthma.

3. Avoid asthma unfriendly jobs. While farming may have been the most common job for most of history, it’s simply not an ideal job for asthmatics. If you have outdoor allergies or severe asthma, you may want to avoid jobs that come with asthma triggers and that may make your asthma worse.

4. Have quick access to an albuterol inhaler. Albuterol is a rescue inhaler that is relatively inexpensive, small, compact, and easily stored in a pocket, purse, or desk drawer. All asthmatics should have one nearby at all times to treat those inevitable flare-ups.

5. Have an asthma action plan for work. If you’re having a flare-up at work, and your albuterol inhaler doesn’t seem to be working, it’s a good idea to have a back-up plan to help you decide what action to take. Should a second dose of albuterol be taken? Should a doctor be called? Should an ambulance be called? An asthma action plan should make answering these questions easy.

6. Tell a co-worker you have asthma. When working with a disease like asthma, it’s essential this information be shared with a co-worker. This person should be someone trustworthy and capable of helping when flare-ups occur. This person should know the location of your asthma action plan and how to use it.

For most of history asthma often posed as a barrier to a normal functioning life, and limited a person's ability to function at work. Thankfully, the modern world has created an environment that allows asthmatics to live a normal life, and to function well in the work setting. Still, the thing with asthma is inevitable flare-ups may occur from time to time. By planning ahead and being prepared, these challenges may be easily handled so you can go on with daily routine.

Sunday, July 26, 2015

HEALButerol® will heal fractures

A new form of albuterol has been introduced to the market and approved by the Food and Drug Administration (FDA).  This one is called HEALButerol®.

Rather than just giving albuterol to open up the air passages that are already open, this provides physicians with a better choice.  The medicine diffuses into the bloodstream, seeps into bone material and causes 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.  It knits bones so they heal better and the patient breathes better at the same time.  If neither of those work, try tryagainolin.

Saturday, July 25, 2015

Two types of lung sounds

Lung sounds are generally broken down into two types:

  1. Quantitative:  How much air movement is there? Normal (can hear air movement), diminisshed (can't hear much), absent (barely moving air)
  2. Qualitative:  How is it moving?  Is it moving through secretions (rhonchi), through junk in lungs (such as a tumor or object), or through obstruction (wheeze)