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Monday, March 20, 2017

E-cigarettes linked to loss of lung function

It's a free country. If my niece wants to use e-cigarettes, all the power to her. However, she should also be properly educated as to the risks of using them. And, apparently, they start reducing lung function as soon as you start using them, according to studies.

They are marketed as a safe alternative to smoking. However, many experts have warned for years of the potential dangers of using them. They had no studies, however, as to which to site until now.

The study of 54 young e-cigarette smokers, 27 of whom had asthma, had increased airway inflammation and reduced lung function, even after short term use of e-cigarettes.

It only makes sense. You're inhaling a foreign substance directly into your lungs. There is a good chance that it might cause mutations on genes that are responsible for COPD or some other lung disease.

Obviously, further studies will be needed. But it appears that e-cigarettes being marketed as safe may be false advertising.

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Friday, March 10, 2017

The two types of asthma wheezes

I have written a couple posts explaining how you cannot hear bronchospasm without the aid of a stethoscope. I described it in my post, "The 9 Different Types of Wheezes" and "What albuterol does, and does not do."

Here is your question:
"My 10 year old son has asthma. Sometimes, I can hear him wheeze when he walks in the room. I put my stethoscope on him and hear wheezes throughout. He says it's hard to breathe. He uses his albuterol inhaler and feels better. I can't hear the wheezes anymore. I put my stethoscope back on him and hear improvement. So what am I hearing when I can hear him wheezing without my stethoscope? That wheezing is not his asthmatic bronchospasm?"
Here is my answer.

Great question. I observed the same thing in myself when I was a kid, that I would sometimes audibly wheeze when I was having asthma symptoms. My theory is you can't hear bronchospasm without the aid of a stethoscope. However, asthmatics also produce excessive amounts of mucus from an abnormally high number of goblet cells. This mucus makes it's way to upper airways, causing a wheeze as air moves throu them (it's usually just heard on expiration, although it may be inhalation and exhalation).

As air moves through these airways, an audible wheeze may be heard. I had many nurses tell me when I was a kid that my wheezes were audible, so they can't be bronchospasm. She was right to think that an audible wheeze was not bronchospasm. But what she failed to consider was that you can have both upper airway and lower airway (it's bronchospasm) wheezes at the same time.

Keep in mind this is just my theory. However, I have also been living with this disease, and studying this disease, for over 40 years.

Also keep in mind that both these articles were not meant to imply that albuterol has no place in the treatment of asthma attacks. It was to imply that not all that wheezes is asthma.

Monday, March 6, 2017

Here's what Albuterol really does, and does not do

Albuterol is the world's most abused medicine. Listed here are some of the medical conditions it is so often prescribed for in the hospital setting. This is followed by a pithy explanation of why it does or does not work for that particular diagnosis.

Asthma. Bronchial airways are chronically inflamed and hypersensitive (twitchy) to asthma triggers. Exposure to which causes an abnormal immune response that causes worsening airway inflammation. This irritates bronchial smooth muscles that spasm and constrict (bronchial constriction). This is responsive to bronchial dilators (beta adrenergic medicines) like Albuterol. This is because they are lined with beta 2 adrenergic receptors. Albuterol attaches to them and causes bronchial smooth muscles to relax, thereby opening airways and relieving asthma symptoms. This same type of bronchial constriction occurs with cystic fibrosis and in patients with chronic bronchitis, so it works for them too.

Pulmonary Edema. Heart failure. It causes an audible upper airway wheeze. It causes orthopnea. It causes severe dyspnea. It also causes increased intrathoracic pressure, and this squeezes airways, causing bronchoconstriction. This is not responsive to bronchodilators. Yet, because these patients wheeze and have dyspnea, the "feel good" solution here is to order a bunch of albuterol treatments, none of which do any good.

Pneumonia. I explained this in my post "Links between pneumonia and COPD."  I wrote, "It’s an infection of the air exchange units in your lungs, mainly the respiratory bronchioles and alveoli. An immune response causes this area to become inflamed. White blood cells (WBCs) are sent to the area of infection. The purpose of this response is to trap, kill, and remove the pathogens. As the disease progresses, the accumulation of WBCs cause pus to fill these areas, making them poor air exchange units. This means they become poor at allowing blood to cross into the bloodstream, resulting in a drop in blood oxygen levels."

A natural response to this by physicians is to order bronchodilators. However, unless a person has asthma, pneumonia does not cause bronchospasm. Bronchodilators are 0.5 microns, ideal for impacting bronchial walls. Terminal airways, respiratory airways, and alveoli are less than 0.2 microns, so bronchodilators don't even get that far. And, even if they did, there are not beta 2 adrenergic receptors there, so they do not good. Bronchodilators are not anti inflammatory medicines, and therefore are useless for pneumonia. However, despite this fact, a common criteria or admission to the hospital is three failed breathing treatments. This is a good criteria, considering (as you now know) albuterol is useless for pneumonia. The treatments will fail no matter how many you give because pneumonia is not bronchospasm.

Some doctors have sited studies showing albuterol increases sputum production as evidence it helps with pneumonia. However, what the hell does increased sputum production do with treating pneumonia? For more on this, check out Rick's post, "A World of Bronchodilator Lies." Also check out his post called, "Does Albuterol Treat Pneumonia?"

Emphysema. I explained this in my post "Bullous Emphysema." It's caused by the destruction of elastic tissue. This results in inflammation and breakdown of alveolar walls. Alveoli lose their elasticity, or ability to regain their normal shape after normal inhalation. "They eventually rupture, creating air spaces. Lacking elastic tissue, alveoli lose their ability to contract during exhalation. When the elastic tissue of enough alveoli are destroyed, these portions of the lungs expand all the way to the rib cage, giving the person the appearance of a barrel chest.  As the lungs are pulled outward, this causes bronchial airways to become stretched, thereby making them narrow (bronchial constriction). This causes increased resistance to air flowing through airways during both inspiration and expiration, slowing the flow of air. This is airway obstruction that does not respond to rescue medicine."

But we give bronchodilators to these patients anyway. However, despite this, most emphysema patients (a.k.a. pink puffers) claim they do not notice any difference afterwords.

Lung Cancer. Lung cancer takes up space in the lungs and prevents gas exchange from occurring. It results in wheezing and dyspnea. Albuterol is often given to these patients, but it will not make the cancer go away, and will not help these patients unless asthmatic bronchospasm is occurring, which is more than likely not the case unless there is also a diagnosis of asthma or chronic bronchitis.

Pleural Effuston. This is where you have excessive fluid buildup around the lungs. Because it can cause shortness of breath, the logical solution by physicians is to order Albuterol. However, albuterol does not suck fluid out of lungs, and therefore will not benefit this medical condition. It doesn't matter, because it will be ordered anyway.

Pneumothorax.  This is also called a collapsed lung. The belief among the medical community is that albuterol will re-inflate airways. The reality is that this is not going to happen. What is needed is a chest tube. The use of a chest tube in and of itself is often an indicator of the need for albuterol. However, Albuterol does not speed up time from chest tube insertion to complete recovery, at least not since the last time I checked.

Rickets. It is the softening of the bones in children. Albuterol will not help. However, and unfortunately already busy respiratory therapists, Albuterol will probably still be ordered for these patients.

Audible wheezes. If it's audible, it cannot be bronchospasm. It's audible because secretions are sitting on the vocal cords. This is very common when a person has pulmonary edema, such as what occurs in heart failure. What I say here makes sense, because true bronchospasm can only be heard by auscultation; it cannot be heard by the unaided ear. However, despite this fact, bronchodilators are so often prescribed for audible wheezes. I would go as far to say that about 80% of breathing treatments in the emergency room are for heart failure, which is the most common cause of audible wheezes. Another cause is dehydration, something that occurs in the aging and in ETOH and detox patients.

Further reading:

Saturday, March 4, 2017

What is the usefulness of best practice medicine?

I would like to define "Best Practice Medicine" and then analyze it's usefulness as far as it pertains to the respiratory therapy community. My "theory" is that it is not used properly.

Best Practice. According to The University of Iowa College of Nursing, it means: "The use of care concepts, interventions and techniques that are grounded in research and known to promote higher quality of care and living for... people."

Best Practice Medicine. It is using the "best practices" available based on the medical research, particularly respiratory therapy research. and in real life practice.

Now, let's examine another term:

Evidence Based Medicine. According to Sackett, et al, 1996, it "is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research."

So you have researchers performing studies. They come to conclusions based on a preponderance of the evidence. They come to conclusions. They are just humans, so their analysis and conclusions may be accurate. However, they may also be flawed. This brings me to two more definitions.

Scientific data. It's what is considered as fact. It's what is. Science shows that beta 2 adrenergic medicine like albuterol relaxes smooth muscles and opens airways in individuals suffering from asthma attacks. This is proven. This is fact. This cannot be debated. Trees are green. This is fact. Science has shown that albuterol does not treat inflammation, and therefore has no use in treating pneumonia. It also has no use in treating bronchiolitis, that suction of the airway is all that is needed. Science has shown that wheezing caused by airways narrowed due to increased intrathoracic pressure due to heart failure and pulmonary edema will not resolve by using albuterol, that it requires other medicines.

Theory. This is what is assumed. It is not a fact. It is what isn't or what is: we do not know. It is not up to a consensus (see below). So, a theory may be that bronchodilators benefit all that wheezes. A theory may be that albuterol will benefit heart failure, that it will benefit bronchiolitis, that it will benefit all respiratory diseases that produce annoying lung sounds.

Consensus. It is what a majority of people believe. It is often mistaken for science. It is often mistaken for fact. For example, you often hear in the news that a consensus of scientists, or 99% of them, believe in global warming. So you have people in the media using this data to claim that global warming is a fact. A consensus of doctors believe all that wheezes benefits from albuterol. A consensus of doctors is that albuterol will resolve wheezing and dyspnea caused by pneumonia, pneumothorax, pleural efffusions, heart failure, and dehydration. However, a consensus does not prove science. In science, it either is or is not. There is no in between. Trees are either green or they are not green. Bronchodilators either open airways or they do not. A consensus does not change this. Unfortunately, a consensus is usually all that is needed to make people think something that is not actually is.

Analytical data. It's what is shown. It's what happens in the clinical setting. Albuterol breathing treatments are given to many asthmatics. Asthmatics feel better after the treatment. Albuterol breathing treatments are given to heart failure patients because they produce that annoying upper airway audible wheeze as secretions sit on the vocal cords and these patients are short of breath. The treatments have no effect. In fact, as they enter more fluid into the airway, they often make that audible wheeze louder. They are given to kids with bronchiolitis. These treatments have no effect. They are given to pink puffers. These treatments have no effect. This is what happens in the clinical setting. This is what is observed before, during, and immediately after a therapy is given.

Conclusion. This is what the researchers assume based on the scientific data and the analytical data. However, conclusions are often flawed based on the bias, ignorance, or lack of clinical practice by the researchers involved. This is not a knock on researchers, it's just a fact. It can then be assumed that albuterol is useful for asthma based on the scientific data and analytical data. However, it is often assumed that albuterol is useful for all these other lung ailments, even though the scientific data and analytical data do not match. This is because there is a third element that comes into play here.

It sounds good, it makes me feel good, so it must be true. You have a patient come in with trouble breathing. You have no idea the cause. You have no idea if it's caused by bronchospasm. So, even though there are many other potential causes, you order the respiratory therapist to give beta adrenergic breathing treatments. You have no idea of the usefulness of doing this. But, if makes you feel like you are doing something. So, my argument is that this is what constitutes as best practice medicine.

Cook book medicine. You do not know what medicines will work for what patients until you obtain your definitive diagnosis. So, what you do is you throw everything you have at this patient that is considered safe. Any patient who comes into the hospital who is short of breath is treated as though they have asthma. It's the same as primitive medicine, and is often described as "all that wheezes is treated as asthma."

Protocols. This is where you assess the patient, determine a score based on an algorithm, and treat the patient based on the score. I will give two extremes here in my example. For instance, a zero means your patient has clear lung sounds, no wheezes, no paradoxical breathing, and is not short of breath. A 10 means the patient is in severe respiratory distress. A zero means you do not give a breathing treatment. A 10 means you give a continuous breathing treatment with albuterol. The experts say this protocol is based on best practice medicine. However, those who do the treatments, i.e. the respiratory therapists, think it is a waste of time in most instances. When you ask them why, they say, "Because, how do you know, that just because a person scores a 10, that they are having bronchospasm? How do you know the albuterol breathing treatments will do any good?"  You don't. And this proves my point, that the medical profession is not based on best practice medicine, or evidence based medicine, it is based on "it sounds good, it makes me feel good, so it must be true."

Okay so the researcher says, "If the bronchodilator is not working, then more are needed to open the airways." To this I say, "there are other medicines that will treat the underlying problem." So you will have researchers say, "Well, the patient says she feels better after the treatment." To this you say, "This is called the placebo effect of albuterol."

References:
  1. "Csomay Center - Best Practices for Healthcare Professionals," University of Iowa College of Nursing, https://nursing.uiowa.edu/hartford/best-practices-for-healthcare-professionals, accessed 3/4/17
  2. Sackett, David L., et al., "Evidence based medicine: what is it and what is it not?" British Medical Journal, 1996, http://www.bmj.com/content/312/7023/71, accessed 3/4/17
  3. Perleth, M., "What is 'best practice' in health care? State of the art and perspectives in improving the effectiveness and efficiency of the European health care systems," 2001 Jun;56(3):235-50, https://www.ncbi.nlm.nih.gov/pubmed/11399348, accessed 3/4/17

Thursday, March 2, 2017

Do handheld fans relieve breathlessness in patients – and what is the evidence?

The following article was written and provided by The National Asbestos Helpline. More information is available at www.nationalasbestos.co.uk.

There is plenty of anecdotal evidence from respiratory professionals and patients that a handheld fan can relieve breathlessness, but it is a physiological method that is not fully understood.

A number of research studies encourage the use of fans to control breathlessness. The study, ‘Does the use of a handheld fan improve chronic dyspnea? A randomized, controlled, crossover trial’ (2010), recommends the technique ‘as part of a palliative management strategy for reducing breathlessness associated with advanced disease’.

Fans are a potentially useful and cheap non-pharmalogical intervention. The technique seems to have no side effect and gives patients some control over their symptoms. Cancer Research UK, Macmillan and the British Lung Foundation all recommend the use of fans to help reduce breathlessness.

But some hospitals are wary of promoting fans as a breathlessness intervention, even banning their use, because of the lack of research evidence.  The study, ‘Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases’ (2008), states that it could not judge the evidence for the use of fans as there is insufficient research data.

The 2010 study ‘Effectiveness of a hand-held fan for breathlessness: a randomised phase II trial’ is more sceptical and concludes that ‘the preliminary evidence of effectiveness of the handheld fan could not be proved. Patients often stopped using the handheld fan but a small group seemed to benefit which was not necessarily related to a relief in breathlessness. Therefore, more work is necessary on selecting and identifying those who might benefit from the handheld fan’.

It is also not known how the fans manage to reduce breathlessness although studies theorise that it could be the cooling effect on the nose and mouth area, rather than any increase in the airflow. ‘The impact of a breathlessness intervention service (BIS) on the lives of patients with intractable dyspnoea: a qualitative Phase I study’ (2006), suggests that the air triggers the mamalian diving response (or diving reflex) when the sensitive trigeminal nerve in the nasal cavity and face is cooled. This prompts the body to conserve oxygen by reducing the heart rate and breathing through the autonomic nervous system, which controls vital body systems, such as circulation and respiration. The same relief can be replicated by a cool flannel compressed against the face.

Even without conclusive research evidence and whether or not the technique simply has a placebo effect, respiratory professionals are recommending the use of handheld fans where they benefit a patient and the management of their symptoms.

Ruth Thomas, Specialist Respiratory Nurse base in Milton Keynes, says: “I frequently use hand held fans during pulmonary rehabilitation sessions, giving to patients who are very breathless after a cardiac exercise, as aids recovery time even quicker than use of inhalers. Patients who benefit are advised to use as needed whenever more breathless than usual to help regain breathing control.”

However, the situation remains that until there is evidence that proves handheld fans are medically useful, their use will remain inconsistent and without suitable protocol. That is a shame when the technique appears to be a safe and simple way to help patients. The fans are inexpensive, portable, enhance self-efficacy and give the patient some sense of control over their breathing.

How to use the handheld fan to relieve breathlessness?

It is important to check with a GP, respiratory consultant, respiratory nurse, respiratory physiotherapist or other qualified medical professional before a patient uses the fan technique.

When a patient feels breathless after any physical activity, anxiety or stress they should:

  • Find a comfortable place to stop and rest. This could be in a chair and leaning forward on the elbows; sitting and resting forward on a table top; or standing and leaning forward on a kitchen worktop, back of a chair or even a shopping trolley.

  • Turn the handheld fan on and position it six inches or 15 cm (about the distance from the outstretched tip of the forefinger to the top of the thumb) from the face.

  • Ensure that the air from the fan blows towards the central part of the face. The cool draught should be felt around the sides of the nose and across the patient’s top lip.

  • The position should be held and the fan used until the patient regains control of their breathing. This could be a few minutes through to 10 minutes. The time varies depending on the patient.

It may benefit the patient to use the fan while employing other methods of breathlessness management such as breathing techniques, relaxation and mindfulness. The fan technique can also be used at the same time as nasal oxygen.

Research references

Richard M. Schwartzstein, Karen Lahive, Alan Pope, Steven E. Weinberger, and J. Woodrow Weiss. Cold Facial Stimulation Reduces Breathlessness Induced in Normal Subjects. American Review of Respiratory Disease 1986; 10.1164/ajrccm/136.1.58

Booth S, Farquhar M, Gysels M, Bausewein C, Higginson IJ (2006) The impact of a breathlessness intervention service (BIS) on the lives of patients with intractable dyspnoea: a qualitative Phase I study. Journal of Palliative and Supportive Care 4: 287-293.

Bausewein C1, Booth S, Gysels M, Higginson I. Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases. Cochrane Database Syst Rev. 2008 Apr 16;(2):CD005623. doi: 10.1002/14651858.CD005623.pub2.

Bausewein C, Booth S, Gysels M, K├╝hnbach R, Higginson I. Effectiveness of a hand-held fan for breathlessness: a randomised phase II trial. BMC Palliative Care20109:22 DOI: 10.1186/1472-684X-9-22

Galbraith S, Fagan P, Perkins P, Lynch A, Booth S. Does the use of a handheld fan improve chronic dyspnea? A randomized, controlled, crossover trial. Journal of Pain & Symptom Management 2010; 39 (5):831-838.

Amy P. Abernethy, Christine F. McDonald, Peter A. Frith, Katherine Clark, James E. Herndon, Jennifer Marcello, Iven H. Young, Janet Bull, Andrew Wilcock, Sara Booth, Jane L. Wheeler, James A. Tulsky, Alan J. Crockett, and David C. Currow. Effect of palliative oxygen versus medical (room) air in relieving breathlessness in patients with refractory dyspnea: a double-blind randomized controlled trial. Lancet. 2010 Sep 4; 376(9743): 784–793.

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Monday, February 27, 2017

My concerns about getting a respiratory therapy bachelor's degree

The AARC wants every respiratory therapist to get a bachelor's degree. I actually looked into this because I would love to further my education. However, when I brought this up to my wife, she said:
"If you are going to go back to school, you should get a degree in something so you can earn $75,0000 a year. If you get this, you won't make any more money. It may qualify you to be an RT supervisor, but it doesn't guarantee you will get that job, nor that you will want that job."
My wife is smart in this way. And she is right. If I were to go back to school, I would be better off going to be a nurse. They make way more money than we do, plus their profession is far better respected.

I'm not saying I'm going to be a nurse. I'm also not implying I hate my job. But, there is some degree of apathy present. It would be nice to do something different. But, to earn a bachelor's in respiratory therapy would not make me a better therapist nor would it make me more money. It won't even earn me more respect.

I would love to go back to school. However, I would rather do something other than respiratory therapy if I were going to do this. But what?

Thoughts?

Further reading:

Monday, February 13, 2017

Smoking cessation programs not funded with tobacco income

Apparently the government makes $26.6 billion from taxes on tobacco sales or settlements from Big Tobacco. So, you would think that a good chunk of this would go towards funding programs meant to educate people about the dangers of smoking, preventing young people from smoking, and helping those who do smoke quit.

But you would be thinking wrong. Big Government does not think the way you and I do. In fact, you might be surprised to learn -- as I was (nah! I wasn't surprised. Nothing the government does or doesn't do ever surprises me. But I digress) -- that less than 2% of this money goes towards youth smoking prevention programs. This is rather pathetic to say the least.

I am not a fan of the government getting involved in most things. When politicians see a problem, their solution is say they feel your pain and then their solutions tend to be programs that involve spending other peoples money. And, worse, these programs usually make the problems they aim to solve worse.

However, when it comes to cigarettes, the governments actions are necessary. I believe this to be true because your right to smoke cigarettes ends with my right to breathe fresh air. Likewise, it was the government that was aware of the dangers of smoking even as they doled them out and got soldiers addicted during WWII.

It only makes sense that, if the government is making revenue from tobacco sales, that a majority of that money should be used to reduce the sales of cigarettes. Of course, if this happened, then this income would be lost. So, that should explain why Uncle Sam is so hesitant to spend this money where it should be spent.

Further reading:


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