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Wednesday, July 6, 2016

Bronchiolitis: Everything you need to know

Bronchiolitis, otherwise known as Respiratory Syncycial Virus (RSV), is a condition common in children that have symptoms very similar to asthma, and is most common between November and April.

It's more common in children because their airways are smaller and more susceptible to narrowing. Usually it occurs within the first two years, with it's peak at 3-6 months.This condition presents nearly identical with asthma, and is often treated or misdiagnosed as such.

In fact, according to "Allergy and Asthma: Practical Diagnosis and Management," it is "clinically indistinguishable from bronchial asthma."Yet the course of treatment for bronchiolitis is different from that of asthma.

For instance, while corticosteroids and bronchodilators work great to reverse airway obstruction caused by asthma, these medicines do little for bronchiolitis (or RSV). So it's important to be able properly diagnose RSV from asthma.

According to Allergy and Asthma, "there are laboratory studies designed to identify viral antigens to pinpoint any of the six different viruses that can cause acute bronchiolitis." This test starts by the RN, RT or lab technician performing a nasal swab to retrieve cells from the nasal passage.

A viral swab won't rule out asthma, but it can rule in RSV so proper treatment can be
determined. Other viruses that might cause bronchiolitis are: Adenovirus, enterovirus, Influenza virus and Chlamydia pneumoniae.

So, technically speaking, RSV is common cause of bronchiolitis, and not a synonym for it. Yet the two are usually linked hand in hand.

We know that asthma is a disease that causes airway narrowing due to increased secretions and inflammation of the air passages in the lungs (bronchioles) due to exposure to asthma triggers. This results in bronchospasm that is reversible with time or, when more severe, bronchodilators such as Albuterol. Corticosteroids are used to treat the inflammation.

Bronchiolitis, on the other hand, is inflammation of the bronchioles due to a virus. (click here for a good picture of this). Narrowing of the airways can occur, resulting in air trapping and hypoxia.
Another complication of this is increased secretions. Bronchospasm is not a complicaiton of bronchiolitis, and therefore bronchodilators are of little use.

Bronchodilators are of little use for bronchiolitis because this medicine does not treat inflammation, it treats bronchospasm.

However, if asthma is suspected to be exacerbated by a virus (and viruses are the #1 cause of asthma exacerbations), bronchodilators should be ordered prn, or as needed.

I have heard of some doctors prescribing Atrovent for bronchiolitis. Our Pediatricians seldom use this, however our ER doctors do.

However, according to Glenn Campell, RRT and Respiratory Clinical Specialist at Children's Hospital in New Orleans, Atrovent should rarely be used to treat asthma and bronchiolitis because "it has been our experience that Iprotropium Bromide (Atrovent) will actually exacerbate the issue by possibly causing mucus plugs secondary to "thickening of secretions".

This, however, is also controversial.

Since there isn't much we can do to treat viruses, the main treatment is supportive measures.

Usually patients with this don't need to be admitted, and usually those admitted for it are obligate nose breathers and are dehydrated due to the child being unable or unwilling to take in fluids, such as refusing to breast feed, or refusing the bottle. So IV fluids is usually indicated.

Antibiotics usually are of little use unless a bacteria is the suspected cause (which is rare).

Otitis media may, however, be treated with antibiotics.

Studies show that bronchodilators should be tried, but if no improvement is observed these should be stopped.

Corticosteroids are also often used to treat this condition, however most studies show they have little to no effect on bronchial inflammation due to a virus.

However, some studies show that racemic epinepherine and dexamethasone have shown to be beneficial.

Still, most of the above therapies other than supportive measures remain controversial.

Supportive care may include oxygen and humidity, keeping the head upright, fluid intake (IV may be indicated), and constant monitoring of pulse oximetry to maintian an SpO2 between 91 and 94%.

One of the most effective therapies for bronchiolitis is simply clearing the airway of secretions, . A bulb syringe works nice, although in the hospital booger be gones work very well. Many times, if the SpO2 drops, suctioning alone will resolve the problem.

Nasal Steroid and Neosynephrine also work well to help keep the nasal passages open.For decreased sats and increased respiratory distress, suctioning should always be attempted before a breathing treatment, and many times suctioning alone will resolve the crisis. According to emedicine, the following are common symptoms of RSV:
  • Runny nose
  • Cough
  • Low grade fever
  • Increased work of breathing
  • Wheezing
  • Cyanosis
  • Grunting
  • Noisy breathing
  • Vomiting, especially post-tussive
  • Irritability
  • Poor feeding or anorexia
  • Increased Respiratory rate (50-60 breaths per minute)
  • Increased heart rate
  • Diffuse expiratory wheezing
  • Nasal flaring
  • Cyanosis
  • Inspiratory crackles
  • Ear infection (otitis media)
There is evidence that children who experience RSV are at an increased risk to develop asthma later in life. For more information, check out the following links:

National Guideline Clearinghouse: Guidelines for management of bronchiolitisRC Journal: Respiratory Care of Bronchiolitis Patients: A Proving Ground for Process ImprovementSeattlechildrens.org: Bronchiolitis

Everything RTs need to know about Sepsis

This post was originally published on January 29, 2008. It is part of the classics of the RT Cave collection. While some of this is outdated, most of it is not.

So, in our quest to become more well rounded therapists, we must now look into another common condition, a condition that is the leading cause of death in critical care units.

For starters, we need to know that is is the leading cause of death in critical care units. Of the 750,000 patients it effects every year, 250,000 will die. These statistics cannot, and are not, being ignored. Hospitals continue to work overtime to create guidelines to help caregivers both recognize and diagnose sepsis so those who have it can get the treatment they need. Likewise, efforts can be made to recognize who is at risk for developing sepsis so it can be prevented.

These statistics have gone pretty much unchanged since the early 1980s. So, even with modern knowledge and technology, hospitals have been unable to break this trend. Yet they are, as noted above, working overtime to do just that.

But there is another side of sepsis that we must look at, and this is the financial side. While the experts will tell you and me that they are working overtime to make changes that improve lives, the bottom line is usually money. And this is the case here as well. For instance, according to the MUST protocol (which is now outdated, and the link is outdated as well), cost estimates nationwide tend to scale into the $17 billion category. I'm not sure what the data is for each individual hospital, but I imagine it's a lot of money, most of which hospitals eat.

So, sepsis is expensive. Actually, we can probably go deeper than this, and say that Medicare probably forced hospitals to look at this. Now, many hospitals had already begun their own research into it, but the government seemed to force their hands, so to speak. I'm not blaming government here, I'm just saying, sepsis kills, it costs a lot of money, and efforts are ongoing to improve upon them.

So, with the hope that hospitals would create sepsis protocols (many are now well beyond a gamut of committee) of their own, the MUST protocol was created to be used as a guideline protocol. According to the protocol itself, most hospitals have not adapted it (although this has changed since the original publication of this article). but I do know that many hospitals are looking into creating their own sepsis protocols (most already have).

So, what is sepsis. It's caused by an injury. Your body is infected by a pathogen, most likely a bacteria. Your immune system recognizes this. T-cells identify them as harmful, and initiates an all out immune response. This ultimately causes cells in the infected area to leak their fluid, and this causes inflammation. This response is necessary to trap pathogens.

Inflammatory mediators are released into the blood stream and sent to the area of infection to cause inflammation. Ironically, sepsis is a pathological process caused by the widespread release of these inflammatory markers into the bloodstream, with or without an initiating infection. When these get to organs, they can injure them, even cause them to fail, resulting in death.

There's a little more to it that what I just described, although it's all a respiratory therapist needs to know.  The basic theory here is early recognition and early treatment can greatly diminish injury, and reduce the death rate from sepsis. This, in turn, can reduce healthcare costs.

(Although, ironically, the costs to individual hospitals rises considerably. This is especially true as they do many procedures automatically on anyone who meets criteria for the sepsis protocol. Medicare will usually be the only one who saves money,and that's usually all that matters.  But I digress.)

Here are the early signs of Sepsis:

A. Suspected Infection

B. Two of the following: Meeting two of these should trigger the sepsis protocol (editors note: This may have changed slightly since then).
  1. Temperature greater than 100.4, <96 .8="" li="">
  2. Fast heart rate, or greater than 90 beats per minute
  3. Fast respiratory rate, or greater than 20 breaths per minute, or a PaCO2 that is elevated above a person's baseline (for this reason, an ABG is usually included in the sepsis protocol. Likewise, a pH that is acidotic can be an early sign of organ failure)
  4. <32>High white blood cell count (greater than 12,000 or <4000>10% bands)
C. Systemic blood pressure <90>

D. Lactate greater than 4.0 or elevated LDH

E. Decreased platelets (watch for DIC)

F. Decreased PaO2, or a PaO2 below normal for that patient

G. Altered mental status not due to drugs may signify organ failure.

Here are the signs of Severe Sepsis:

A. Patient receiving antibiotics & needs Vasopressor (this is a dangerous sign).

B. Pt showing signs of organ failure in 2 + systems for <= 24 hrs.
<90>
C. Patient showing signs of Adult Respiratory Distress Syndrome, DIC, or Multi System Organ Failure.

There, that's pretty much all you need to know. These are all things you can learn from a quick assessment, which may entail talking to the patient or family members, talking with doctors and nurses, or simply by looking into the patient's chart. We at the RT Cave think it's always a good idea to look a the patient's laboratory results anyway, if time allows.

From there doctors and nurses use their magic potions to fix the patient. This may entail Activated Protein C, the only drug to show any efficacy in sepsis. It may also entail antibiotics and steroids. It may also include vasopressors to control blood pressure.

Central Venous Catheter administration may be indicated to adjust vasopressors, to monitor fluids, and to determine if a blood transfusion is indicated. These and other therapies may be prescribed just in case it might do something, which is often the issue with administering albuberol for sepsis and heart failure. So, you never know, albuterol might also be indicated for sepsis.

It's nice to know all this, although it comes secondary to whatever our job is at the time. The hardest part about treating patients is getting to the bottom of what's causing their symptoms, and you and I both know a breathing treatment with albuterol is often a top-line option. So, while you're standing there waiting for the treatment to get done, you can do some investigating for the true cause of that shortness of breath, or whatever symptoms you are treating.

Still, I have had times when the true diagnosis eludes even the best nurses and doctors, and in these cases it's nice to have a well rounded RT come into the scene and say, "Hey, maybe this is what the true cause is!"

Edited on July 5, 2016, by John Bottrell 

Everything RTs need to know about Sepsis

This post was originally published on January 29, 2008. It is part of the classics of the RT Cave collection. While some of this is outdated, most of it is not.

So, in our quest to become more well rounded therapists, we must now look into another common condition, a condition that is the leading cause of death in critical care units.

For starters, we need to know that is is the leading cause of death in critical care units. Of the 750,000 patients it effects every year, 250,000 will die. These statistics cannot, and are not, being ignored. Hospitals continue to work overtime to create guidelines to help caregivers both recognize and diagnose sepsis so those who have it can get the treatment they need. Likewise, efforts can be made to recognize who is at risk for developing sepsis so it can be prevented.

These statistics have gone pretty much unchanged since the early 1980s. So, even with modern knowledge and technology, hospitals have been unable to break this trend. Yet they are, as noted above, working overtime to do just that.

But there is another side of sepsis that we must look at, and this is the financial side. While the experts will tell you and me that they are working overtime to make changes that improve lives, the bottom line is usually money. And this is the case here as well. For instance, according to the MUST protocol (which is now outdated, and the link is outdated as well), cost estimates nationwide tend to scale into the $17 billion category. I'm not sure what the data is for each individual hospital, but I imagine it's a lot of money, most of which hospitals eat.

So, sepsis is expensive. Actually, we can probably go deeper than this, and say that Medicare probably forced hospitals to look at this. Now, many hospitals had already begun their own research into it, but the government seemed to force their hands, so to speak. I'm not blaming government here, I'm just saying, sepsis kills, it costs a lot of money, and efforts are ongoing to improve upon them.

So, with the hope that hospitals would create sepsis protocols (many are now well beyond a gamut of committee) of their own, the MUST protocol was created to be used as a guideline protocol. According to the protocol itself, most hospitals have not adapted it (although this has changed since the original publication of this article). but I do know that many hospitals are looking into creating their own sepsis protocols (most already have).

So, what is sepsis. It's caused by an injury. Your body is infected by a pathogen, most likely a bacteria. Your immune system recognizes this. T-cells identify them as harmful, and initiates an all out immune response. This ultimately causes cells in the infected area to leak their fluid, and this causes inflammation. This response is necessary to trap pathogens.

Inflammatory mediators are released into the blood stream and sent to the area of infection to cause inflammation. Ironically, sepsis is a pathological process caused by the widespread release of these inflammatory markers into the bloodstream, with or without an initiating infection. When these get to organs, they can injure them, even cause them to fail, resulting in death.

There's a little more to it that what I just described, although it's all a respiratory therapist needs to know.  The basic theory here is early recognition and early treatment can greatly diminish injury, and reduce the death rate from sepsis. This, in turn, can reduce healthcare costs.

(Although, ironically, the costs to individual hospitals rises considerably. This is especially true as they do many procedures automatically on anyone who meets criteria for the sepsis protocol. Medicare will usually be the only one who saves money,and that's usually all that matters.  But I digress.)

Here are the early signs of Sepsis:

A. Suspected Infection

B. Two of the following: Meeting two of these should trigger the sepsis protocol (editors note: This may have changed slightly since then).
  1. Temperature greater than 100.4, <96 .8="" li="">
  2. Fast heart rate, or greater than 90 beats per minute
  3. Fast respiratory rate, or greater than 20 breaths per minute, or a PaCO2 that is elevated above a person's baseline (for this reason, an ABG is usually included in the sepsis protocol. Likewise, a pH that is acidotic can be an early sign of organ failure)
  4. <32>High white blood cell count (greater than 12,000 or <4000>10% bands)
C. Systemic blood pressure <90>

D. Lactate greater than 4.0 or elevated LDH

E. Decreased platelets (watch for DIC)

F. Decreased PaO2, or a PaO2 below normal for that patient

G. Altered mental status not due to drugs may signify organ failure.

Here are the signs of Severe Sepsis:

A. Patient receiving antibiotics & needs Vasopressor (this is a dangerous sign).

B. Pt showing signs of organ failure in 2 + systems for <= 24 hrs.
<90>
C. Patient showing signs of Adult Respiratory Distress Syndrome, DIC, or Multi System Organ Failure.

There, that's pretty much all you need to know. These are all things you can learn from a quick assessment, which may entail talking to the patient or family members, talking with doctors and nurses, or simply by looking into the patient's chart. We at the RT Cave think it's always a good idea to look a the patient's laboratory results anyway, if time allows.

From there doctors and nurses use their magic potions to fix the patient. This may entail Activated Protein C, the only drug to show any efficacy in sepsis. It may also entail antibiotics and steroids. It may also include vasopressors to control blood pressure.

Central Venous Catheter administration may be indicated to adjust vasopressors, to monitor fluids, and to determine if a blood transfusion is indicated. These and other therapies may be prescribed just in case it might do something, which is often the issue with administering albuberol for sepsis and heart failure. So, you never know, albuterol might also be indicated for sepsis.

It's nice to know all this, although it comes secondary to whatever our job is at the time. The hardest part about treating patients is getting to the bottom of what's causing their symptoms, and you and I both know a breathing treatment with albuterol is often a top-line option. So, while you're standing there waiting for the treatment to get done, you can do some investigating for the true cause of that shortness of breath, or whatever symptoms you are treating.

Still, I have had times when the true diagnosis eludes even the best nurses and doctors, and in these cases it's nice to have a well rounded RT come into the scene and say, "Hey, maybe this is what the true cause is!"

Edited on July 5, 2016, by John Bottrell 

Tuesday, July 5, 2016

What is Disseminated Intravascular Coagulation (DIC)?

Classics of the RT Cave. This post was originally published March 18, 2008.

First off, I worked a bunch of years in the hospital setting before I had a clue what DIC was. I had observed the symptoms many times. I remember many patients, most of them on ventilators, who seemed to be seeping fluid from their pores. Yet I heeded this condition little attention, mainly because I was a newer RT who was intently focused on getting my own work done.

Then one day I remember one of our senior therapists told me in report she told the nurses to keep a particular close watch on this trauma patient because he was at high risk for DIC and ARDS. It later turned out she was right, and the patient developed both ARDS and DIC. So, it did not pass me by how this senior was correct in her prediction. I was curious to know what she knew.

So I asked her, and she said, "Do some research on DIC, and then get back to me. Do a Google search." She paused, then added, "I think that all therapists coming out of school should focus on doing their jobs and doing them well. However, there comes a time when you should take a look at the other aspects of the healthcare industry, and in this way become well rounded therapists. I say this because well rounded therapists are better team players. While nurses are busy looking in one direction, you can say, "Hey, look here!"

So, that said, here is what I learned about DIC. Here is how you can predict what patients might develop DIC.

First of all, DIC is an acronym for Disseminated Intravascular Coagulation. It is almost always a secondary disease, or a consequence of other diseases, disease conditions, or circumstances. In our patient, it was secondary to trauma.

DIC is a condition, more so than a disease. It is a process that occurs when the proteins in the bloodstream that normally cause clotting in an injured area overreact, form tiny clots all over the body. Then, clotting factors now exhausted, this causes the patient to bleed abnormally. Bleeding occurs from nearly every orifice, including skin pores, the anus, etc. It just leaks out. It's kind of gross. You better wear gloves when you touch such a person (well, you should always wear gloves, but int his case you'll definitely want to).

When you do an ABG, for example, you might hold the site for the recommended five minutes and the patient still doesn't stop bleeding. Usually, when this happens, the RN will have to wrap gauze around the puncture site and bind tape around the patients arm to act like a tourniquet. I've seen this done on many occasions.

Technically speaking, on these patients, a doctor will want to limit the number of blood draws (ABGs included), because of the complications of bleeding. Another thing for us therapists to remember is to be very careful when suctioning. Ideally (and I think this should be standard procedure anyway), the catheter should not be advanced all the way to the corina so as not to puncture it and cause it to bleed.

In severe cases, the patient will seep ooze right out of the pores on his skin. This can be quite disgusting. This is what I described above. But I've seen it quite a few times already. I will probably see it more times in the future. If you work in the critical care or emergency settings, you will see it too.

DIC can also cause sudden bruising, clotting, and, as I described, bleeding from multiply parts of the body, and can lead to severe bleeding, stroke, and lack of blood flow to arms, legs and organs. So, it's not good.

That said, how do you know who is at risk. Here is a list of who to watch.
  1. Infection in blood (Sepsis)
  2. Severe tissue injury, as in burns, trauma (particularly trauma to the head and brain)
  3. Recent surgery or anesthesia
  4. Reaction to transfusions
  5. Labor and delivery problems
  6. Liver disease
Trauma patients not only are at risk for getting DIC, but also ARDS and Sepsis. And sepsis in itself is primary cause of DIC in the hospital setting. And, if that wasn't enough, DIC may lead to acute renal failure and, ultimately, to multiple organ failure -- including the lungs.

It was about this time I started to understand the point my senior therapist was trying to make about being a well rounded therapist. This is why it's a good idea to go through and review the charts of all your patients, particularly the laboratory results. Yes, we can learn a lot from lab results. The following are some lab results that might show DIC:
  1. PTT: Again, I'm no expert here. However, according to Medline Plus, this is a test to determine how long it takes for the blood to clot. If a patient is on a blood thinner like Coumadin, the PTT may be therapeutically high. A high PTT is anything greater than 33, and greater than 60 is considered critical, and may be indicative of DIC.
  2. PT: Same as PTT, except for the high value is greater than 12.7 and greater than 40 is critical
  3. D-Dimer: Greater than 500 may be indicative of acute bleed, but can also indicative of pulmonary embolism and DVT.
  4. Platelets: A normal platelet count is 150,000 to 400,000. This is what is needed in order for normal clotting to occur. A low value will be 150,000, meaning abnormal bleeding may occur, and below 50,000 can mean a simple bump can cause bleeding. <80>
  5. INR: Greater than 1.2 is considered high, but greater than 6 is critical. This is indicative of DIC or acute bleed.
Now, keep in mind these critical values will vary from hospital to hospital, but at least this gives you an idea of what critical is, and what the labs of a patient in DIC might look like.

Also, you should know that there is a lot more involved in the DIC process than what I describe here, but this is pretty much all that a well rounded respiratory therapist needs to know.  Now, see if you can put this wisdom to good use and impress someone the next time you find one of these patients.

Edited on July 5, 2016, by John Bottrell

Friday, July 1, 2016

The RT Cave Blogosphere

So I need to make a few comments about this blog. First, as you may have observed, there are no longer ads on it. This is because Goodle Adsense fired me. They will not tell me what I did, which is unfortunate.

I was actually getting to the point I was making about $100 every 2-3 months, so it's not like I was getting rich off ads. And I wrote on this blog many years before I ever put ads on here, so it's not like I need the money as an incentive to write.

Still, I am also at a point in my life where I was seriously considering donating what I made on this blog to some respiratory charity. But that idea is gone now. It's not a big deal, but it still kind of stinks.

So that pretty much means this entire blog is a charity.

Another change made here is that I will no longer submit posts on this blog about myself. I actually made this change quite a few years ago, and some of you have already discovered by asthma blog, "Hardluck Asthma."

I actually started writing the history of asthma on Hardluck Asthma, before writing about the history on this blog. Then I decided to just make a new blog called, "Asthma History."

For the record, asthma was once an umbrella term for all that is short of breath, so every lung disease is covered there, not just asthma as we now know it. So, if your'e interested in a history, check out my history blog.

If you are interested in politics, you can check out my political blog. Actually, it's not so much a political blog, mainly a place I can write about things other than respiratory therapy, other than me, other than medical. So you can find me over at "Articulating Ideas."

Now, if you read my political blog, keep in mind I have an opinion. It's actually a place I can share ideas I have with my kids, if they so care to read what I write. Perhaps in the future they might get interested. Although, in all due fairness, I don't even think they know it exists because I don't talk about it much.

And, as is true on all my blogs, I am not politically correct. So, if you go over there, be nice. You can be honest, but be nice.

And, as is the case with this blog, there are no ads on my other blogs either. So, they are all charities.

That said, I also do blogging where I get paid. From 2008 to 2016 I was an asthma and COPD expert over at healthcentral.com. Some of those posts I republished here (come to think of it, maybe that's what Adsense didn't like).

Beginning this year I am an asthma and COPD expert at COPD.net and Asthma.net. These posts will not be republished here, per my contract. So, if you want to read them, you'll have to go there, or follow me on Facebook or Twitter. Or, you can like COPDdotnet on Facebook and Asthmadotnet on Facebook.

So you can find me all over the place. And that should explain why this blog has been less active of late. Still, I will post here from time to time, and I will link to it at the Respiratory Therapy Cave Fakebook page and on RT Cave on Twitter. So, you can follow me and I'll keep you posted.

Anyway, hope you are all doing well.

Monday, June 6, 2016

10 Links Between Poverty and COPD

Originally published at healthcentral.com/copd

Research published in January, 2014, suggests an inverse relationship with Gross National Income (GNI) and the incidence of COPD. Data from 170 countries showed the incidence of COPD was highest in areas where the GNI was below $15,000. The data seems to confirm a suspected link between COPD and poverty.

This information noted, we thought we'd list 10 possible reasons why those in poverty may be at an increased risk for developing COPD, or at an increased risk for having COPD flare-ups. 

1.  Tobacco smoke.  CNN reported in 2014 that as smoking rates have declined in more affluent areas, they have stayed relatively unchanged in poor and working class areas.  The report quotes a study showing cigarette companies advertise cheaper cigarettes in such areas. Being that studies overwhelmingly show that cigarette smoking is responsible for about 80 percent of COPD cases, it only makes sense the impoverished would have a greater incidence of COPD.

2.  Wood Smoke.  Studies seem to suggest this may be just as harmful to airways as tobacco smoke. It contains many of the same chemicals and irritants contained in tobacco smoke. Studies have linked it with both asthma and COPD. Wood as a source of heating and cooking seems to be more prevalent in impoverished neighborhoods and underdeveloped nations. It’s a significant source of both indoor and outdoor air pollution in such areas.

3.  Occupations.  Those in poverty are more likely to take on high risk jobs. This may expose them to harmful chemicals, irritants or fumes that may harm airways, cause COPD flare-ups, and even cause COPD.

4.  Crowding.  Too many people in small, enclosed rooms may increase the risk of spreading germs that cause infections. This is even more important during winter months when doors and windows are closed and homes are heated and poorly ventilated. Respiratory infections may trigger asthma attacks and COPD flare-ups.

5.  Education.  Lack of access to education, or lacking the time to educate one's self, may cause impoverished people to expose themselves to situations that the educated would otherwise avoid. This may explain why smoking rates are higher in impoverished areas.

6.  Stress. Of course, another reason explaining high smoking rates may be pressure caused by poverty. Lacking the ability to support yourself and your family may result in stress leading to risky behaviors such as smoking cigarettes. Stress may also trigger flare-ups, result in poor compliance with medicine, and result in poor COPD control.  

7.  Housing. Older homes, or homes in poor repair, may increase exposure to mold due to water leaks and humid basements. Mold spores can get into the air inhaled and trigger COPD flare-ups.  Dust mites thrive in warm and humid environments, and feed off flakes of skin that land on pillows, mattresses, and upholstered furniture. Lack of money may make it difficult, if not impossible, to remedy these problem areas.

8.  Crowding.  People with limited resourses are increasingly likely to shack up with other people in similar situations. Many people in closed in spaces can create a breeding ground for germs that may cause respiratory infections. Sneezing and coughing can help them spread from person to person. This is compounded when the heat is on and all the doors and windows are closed. Lung infections are a major source of COPD flare-ups.

9.  Poor nutrition.  A simple way of staying healthy is by eating a healthy diet. This may be difficult if you don’t have the funds to afford healthy foods.  Or, worse, if you cannot afford food altogether. Proper nutrition is essential to maintaining healthy lungs. Proper nutritian is also necessary so you have the strength to stay active and reduce loss of muscle mass caused by sedentary living. Those in poverty are also more likely to eat at affordable fast food restaurants like McDonald’s. This is not good, as high fat foods have been linked to asthma, and of course asthma is linked to COPD.

10. Healthcare.  Many governments have attempted to make healthcare more affordable. Sometimes, however, even affordable healthcare isn’t so affordable. Also posing a problem here is poor awareness of healthcare options, poor access to physicians, and poor access to funds needed to pay for COPD medicine, which tends to be rather expensive.

What does this mean?  It means that those in poverty are at an increased risk for developing lung diseases like COPD. This spotlights the ongoing need for governments to create economic environments that encourage economic growth and prosperity. It also spotlights the need for creating programs to help those in poverty gain access to healthier neighborhoods, healthier homes, health care education, health care coverage, physicians, and medicine.

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What does STAT really mean????

Okay, so I'm a new respiratory therapist and my pager goes off. I look at it and see, "EKG in recovery STAT!" What does this mean? What do I do?

I am taught that if something is STAT, that means that immediately or without delay. It means I must drop everything I am doing and rush to the patient. In my mind, it means the patient is in dire straights, and my services are needed immediately to fix the patient.

So, I do just that: I stop the breathing treatment I am presently doing, even though my patient is somewhat short of breath. I have to do this because, by my definition of STAT, someone needs me more than this guy. So I rush down to recovery and...

... what I find is a patient who is awake and alert and in no apparent respiratory distress. Okay, he is fine. He is talking. When asked, he says he has no chest pain. And the nurse says, "Yes, the doctor just wanted an EKG before he left the unit, and didn't want to wait."

Eh! This is where the respiratory therapist gets a little perturbed. He grumbles under his breath, but he does the EKG to keep the peace. He is pleasant to the patient, pleasant to the nurse, and pleasant to the doctor. Then he quickly returns to the person in need of a treatment.

Still a note is made in the back of the therapist's mind: don't rush the next time the term STAT is used. And, a few hours later, another STAT page to recovery is observed on the beeper. This time, the RT finishes what he is doing and then walks to recovery.

So, you see, in this way, the word STAT is watered down so that it is essentially irrelevant. The word STAT becomes no more useful than that word ASAP, which means As Soon As Possible. To me, by my definition, ASAP means finish what you are doing and then come down.

You see, at some point the watered down version of STAT is going to get me and a patient in trouble. However, considering about 99% of STAT pages are not to save a life, it would be frivolous to have an RT rushing to the scene of every STAT page.

Now, this brings me to the definition of STAT that doctors go by. Doctors, or so it seems to me, define it as "per my convenience, I need you to get this done immediately, or without delay."

It does not matter what you are doing, you have to drop it to rush to the scene of the STAT page. It doesn't matter who the patient is you are presently taking care of, or how sick your patient is: you drop what you are doing and run.

But I do not like this definition. I wish there was a more universal definition of STAT and ASAP. This would help prevent frustration on both the part of the therapist, nurses, and physicians.

Here's how I would define these terms:

  • STAT: You are needed immediately, or without delay, because something you do can help save this person's life. A delay might result in increased morbidity or mortality. 
  • ASAP: You are needed as soon as you finish up what you are currently doing. A delay will not result in increased morbidity or mortality, although your services are requested as soon as you can possibly fit them into your schedule. 
  • AYC:  This means at your convenience. Your services are needed, although you can do them whenever they fit into your schedule. There is no rush to get them done. In most instances, this is assumed. 
These new definitions allow physicians to get the rapid service that they require, although they also allow the therapist time to prioritize. This would result in greater satisfaction of workers, while making sure the patient's get the care they need when they need it. What do yo think?