Wednesday, April 23, 2014

The idea RT Aerosol Protocol

I'm not a fan of protocols that are based on an algorithm.  I also do not like utilizing points systems to determine frequency of therapy.  I think the best approach is simple common sense.

In a points system you assess the patient and review the chart to determine breath sounds, pulse, respiratory rate, and level of shortness of breath.  Then you give the patient a points based on what you find.  The total points score will be between 0 and 12.  This will help you determine the frequency of therapy.

  • A total point value of 0-4 = PRN
  • A total point value of 5-7 = QID
  • A total point value of 8-10 = Q4/ PRN
  • A total point value of 11-12 = Q2
I'm not a fan of these systems at all.  First off, wheezes are totally over rated.  You could have someone with a throat wheeze, or laryngospasm, or a cardiac wheeze, and that can completely be confused for bronchospasm wheeze.  Plus dyspnea can be caused by an assortment of disorders, bronchospasm being just one.  

I think a better approach would be to determine need for treatment by giving one treatment, assessing whether or not it did any good, and then ordering subsequent treatments based on that.  

I also think that no one should get a treatment unless they are short of breath.  If you go into a room to assess a patient and he is sleeping, or otherwise is breathing fine, then you should not give the treatment.  If the doctor wants to give prophylactic beta adrenergic medicine, then he can order long acting beta adrenergic therapy.  

Bronchodilator aerosol therapies should be ordered as prn for most patients, and QID for patients who are difficult to assess, or who cannot tell you how they feel.  The only aerosolized medicines that should be given on a frequency are medicines like Pulmocort and Brovana, which need to be given twice a day.  

Tuesday, April 22, 2014

How does chronic bronchitis effect the lungs

The following was originally written for on 4/14/14.

Chronic bronchitis is a lung disease that causes a cough with increased mucus production for at least three months in two consecutive years. It generally falls under the category of chronic obstructive pulmonary disease, or COPD.

The most common cause is cigarette smoking, although the inhalation of irritants at work, air pollution and lung infections may also cause it. Considering most people develop this disease due to exposure to cigarette smoke, one might wonder: Why does smoking cause chronic bronchitis?

To best answer this question it’s helpful to understand the basics of airway anatomy, which is covered in the pithy post “Your Journey Down the Respiratory Tract.” Knowledge of lung anatomy is helpful because long-term exposure to inhaled cigarette smoke may cause changes inside the airways. These changes may include:

1. Bronchial mucous glands become bigger: This causes increased mucus or secretion production inside the lungs.

2. Goblet cells increase in number: This also causes increased mucus production.

3. Bronchial walls become inflamed: This is due to repeated exposure to the harmful chemicals of cigarette smoke. These chemicals injure the walls, and the body's attempt to fix them causes them to become inflamed or swollen. Common treatments for this are inhaled corticosteroids such as Qvar, Pulmicort, Advair, and Symbicort. Systemic corticosteroids are also sometimes needed.

4. Bronchial walls become thick and scarred: This is often referred to as airway remodeling. It occurs when inflammation lasts for such a long time that the body tries to fix it. This results in scar tissue, causing the airways to become fibrotic, or stiff. This damage is permanent and there is no treatment for it.

5. Cilia lining bronchial walls disappear: Cilia are fine, hair-like structures that act as an escalator to bring mucus to to the upper airway where it may either be swallowed, coughed up, or spit up. Lacking cilia, the airway has a tough time moving mucus to the upper airway, causing mucus buildup in the lungs.

6. Mucus plugging in the smaller airways: This means that dried up secretions block air passages.

7. Bronchospasm: Inflamed airways are extra sensitive to certain triggers (such as inhaled irritants, allergens, and strong smells) that may cause flare-ups. This may cause the muscles wrapping around the airways to spasm. Flare-ups are discussed in my recent post “COPD flare-up causes.” Treatment for this include albuterol (ventolin), levalbuterol (xopenex), ipatropium bromide (Atrovent), Duoneb, Combivent, theophylline, serevent, formoterol, Advair, and Symbicort.

8. Airway obstruction/ narrowing: The combination of increased mucus, mucus plugging, scarring, inflammation, and bronchospasm cause air passages to become permanently narrowed and frequently obstructed. Air traveling through narrowed or obstructed airways may cause a wheeze.

9. Air Trapping: Air can get past an obstruction in the airway, but has a hard time getting out. In other words, people suffering from this may feel like they can’t get air in, but the truth is they can’t get air out. This results in a prolonged exhalation. A good treatment technique for this is to exhale through pursed lips, thus allowing more time for trapped air to get out.

10. Emphysema: Most people with chronic bronchitis also suffer from emphysema, which is the breakdown or destruction of lung tissue, which is probably also caused by inflammation. More specifically, it is the breakdown of the walls of the air sacs, or alveoli. This makes it so the lungs lose their ability to expand. Due to breakdown, alveolar sacs also may become detached from the small air passages, decreasing areas available for gas exchange to occur. The treatment for emphysema is usually supportive, and often includes wearing oxygen.

11. Airflow limitation: Narrowed and obstructed airways cause increased resistance to air flowing through them, thus slowing down the flow of this air. This may lead to a feeling of dyspnea, or shortness of breath. Airflow limitation is partially reversible in chronic bronchitis, depending on the cause:
  • Reversible: Obstruction caused by increased mucus, inflammation and bronchospasm
  • Irreversible: Obstruction caused by airway remodelling and emphysema
Airflow limitation is best measured during pulmonary function testing, a test that can determine how severe your airflow limitation is, or how severe our COPD is

12. Hypoxemia: Due to the combination of the disease processes described above, there will be areas of the lungs where oxygen cannot get through to the blood. This may result in low oxygen blood levels. This makes it so the blood has less available oxygen to take to tissues, and so it takes it to vital organs before less vital areas of the body like fingertips and lips. Common symptoms of this are dyspnea and cyanosis, or a blue tinge around the fingertips and lips. Treatment for this is wearing oxygen.

13. Hypercapnia: Along with allowing less oxygen to get to the blood, less carbon dioxide (CO2) will be allowed to leave the blood and enter the lungs to be exhaled. CO2 is a waste product of cellular metabolism that the lungs exhale. If it can’t get to the lungs, CO2 builds up in the blood. Symptoms of this include feeling sleepy and confusion.

It’s important to note that not all of the above occur in every person with chronic bronchitis, which is kind of what makes this disease so complicated for physicians to understand and treat. Also, the progression of these disease processes are often so gradual that a person may not even notice them happening, especially in the early stages of the disease.

A neat thing about this disease, however, is that, while damage already done cannot be undone, quitting smoking will almost immediately slow down its progression. It is for this reason most physicians recommend people diagnosed with it quit smoking immediately. For tips on how to quit smoking check out “6 tips to help you quit smoking.”

So, now you should have a general idea how people develop chronic bronchitis, what the symptoms are, and how bronchitis physically affects the lungs.

  1. Wilkins, Robert L., James R. Dexter, “Respiratory Disease: Principles and Practice,” 1993, Philadelphia, F.A. Davis Company
  2. “Understanding Chronic Bronchitis,” American Lung Association,, accessed 4/9/14
  3. “What is COPD?” National Heart Lung and Blood Institute,, accessed 4/9/14
  4. Hanania, Nicola A., Amir Sharafkhaneh, editors, “COPD: A Guide to Diagnosis and Clinical Management,” 2011, New York, London, Springer, Dordrecht Heidelberg, pages 2-5
  5. Global Initiative for Chronic Obstructive Lung Disease (GOLD), “Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease,” updated 2014,, accessed 4/10/14, page 2, 6-7

Monday, April 21, 2014

How to use an inhaler

The following originally published at on 4/15/14. 

How to properly use an inhaler

While most asthma and chronic obstructive pulmonary disease (COPD) patient are familiar with the little blue asthma inhaler called albuterol, studies show that as many as 85 percent use it incorrectly, with at least 40 percent making at least one essential mistake.

So, chances are most of us could benefit from a rescue inhaler refresher course.

When asked to give me a demonstration of how they use their inhaler, many of my patients do something like this:
  • Stuff the inhaler in their mouth 
  • Squirt the inhaler while inhaling 
  • Exhale some of the mist 
Using poor technique like this simply wastes most of the medicine. Some of it is exhaled, but most of it impacts in the upper airway. Then it's swallowed, resulting in less benefit and more side effects.

The best technique of using an inhaler is to use a spacer. The experts at describe the procedure.
  • Insert the inhaler/canister into spacer and shake. 
  • Breathe out. 
  • Put the spacer mouthpiece into your mouth. 
  • Press down on the inhaler once. 
  • Breathe in slowly (for 3-5 seconds). 
  • Hold breath for 10 seconds.
Why use a spacer? 
  1. They improve coordination 
  2. Large particles stay in the spacer so only fine particles enter your airway
  3. Many have whistles to teach you to take a slow, deep breath 
  4. The medicine smoothly passes through your upper airway to your lungs 
  5. Studies show spacers make the medicine work 75% better than without it 
  6. Less medicine impacts into your upper airway, greatly reducing side effects 
  7. Studies show that proper use of an inhaler with a spacer makes the medicine work just as a nebulizer

Since spacers are proven to work so well, why do most people not use them? There are basically three reasons. 
  • Poor training: Patients are not taught best technique 
  • Forgetfulness: Patients are taught but use their inhaler so infrequently that they forget 
  • Spacers are large, bulky, and inconvenient: This is the most common reason especially among men, as they can't just carry a spacer in their pockets. 
Especially while at home, it's best to keep the inhaler with a spacer. However, since most of us don't always have a spacer, it's important to know the second best technique, which is shown at
  • Remove the cap from the inhaler. 
  • Hold the inhaler with the mouthpiece at the bottom. 
  • Shake the inhaler. This mixes the medication properly. 
  • Open Mouth Technique - Hold the mouthpiece 1½ - 2 inches (2 - 3 finger widths) in front of your mouth. Close Mouth Techinque - Seal your lips tightly around the inhaler mouthpiece. (Personally, the close mouth technique is the worse technique, and I would not recommend it) 
  • Tilt your head back slightly and open your mouth wide. 
  • Gently breathe out. 
  • Press the inhaler and at the same time begin a slow, deep breath. Continue to breathe in slowly and deeply over 3 - 5 seconds. Breathing slowly delivers the medication deeply into the airways. 
  • Hold your breath for up to ten seconds. This allows the medication time to deposit in the airways. 
  • Resume normal breathing. 
  • Repeat steps 3 - 9 when more than one puff is prescribed. 
In most instances, two puffs are recommended. Ideally, the first puff opens up the lungs, and the second puff does the mop up job. Most experts recommend allowing 1-5 minutes for the first puff to work before inhaling the second puff.

So there's your quick how to use an albuterol inhaler refresher course. We hope this helps you get the most of your rescue inhaler.

Related videos: 

Sunday, April 20, 2014

Happy Easter

This should be a happy day.  It's a day where the kids wake up to a feeling of joy that they will be able to hunt for their Easter baskets.  It should be joy for parents watching the joy of their children.

Yet, more important, it's a day for spending time with our families to celebrate the fact that Jesus Christ paid the penalty of sin by dying on the Cross on Good Friday, and then rose into Heaven in a symbolic gesture that we may all enjoy eternal life in Jesus Christ.

Let this be a good day. Let us pray that everyone receives the right message.

Wednesday, April 16, 2014

COPD Comorbidities

Since the number of pre-existing co-morbidities in patient's with COPD is associated with increased hospital mortality, I thought I would make a list of some of the most common COPD co-morbidities, many of which are caused by increased inflammatory mediators in the circulation as a result of inhaling cigarette smoke.
  1. Hypertension
  2. Diabetes
  3. Coronary artery disease
  4. Congested Heart Failure
  5. Pulmonary infections such as pneumonia
  6. Cancer
  7. Pulmonary Vascular Disease
  8. Atrial Fibrillation
  9. Skeletal Muscle wasting and cachexia
  10. Osteoporosis
  11. Normocytic anemia
  12. Metabolic syndrome
  13. Depression
  14. Confusion and Dementia
There are also other co-morbidities that are associated with increased mortality risk.
  1. Chronic Renal Failure
  2. Cor Pulmonale
  3. Pulmonary Vascular Disease

  1. Hanania, Nicola A., Amir Sharafkhaneh, editors, “COPD: A Guide to Diagnosis and Clinical Management,” 2011, New York, London, Springer, Dordrecht Heidelberg, pages 9-10
  2. Global Initiative for Chronic Obstructive Lung Disease (GOLD), “Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease,” updated 2014,, accessed 4/10/14, page 7
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Tuesday, April 15, 2014

Joe Goofus and the empty inhaler

I'm going to violate the patient confidentiality code and give you an update on our good friend Joe Goofus.  He's not informed enough to know about laws, so I'll take a risk here and assume I'm right.

He has been showing up in the emergency room a lot recently, requiring me to give him a boatload of Ventolin, and the nurse to give him bursts of corticosteroids to open up his lungs.  The medicine works every time, although as soon as it's out of his system he's right back in the ER.

It's frustrating, I'm telling you.  I educate him on how to care for his asthma, and it goes in one ear and out the other.  To be honest with you, it gets kind of annoying.  This guy is his own worst enemy.

I think this guy is in a world of hurt.  One of these days he's going to pick up a virus, like the flu virus, and he's going to end up with an asthma episode so severe we will not be able to save him.  I'm serious.  This guy is a quintessential example of a low informed asthmatic.

As a concerned asthmatic respiratory therapist, I screen out guys like Joe.  I ask all my asthmatics the following questions:
  • Do you have an asthma doctor
  • Do you take your asthma medicine as prescribed
Joe Goofus answers NO and YES.  Whoa, that may have surprised you there, but not me.  I don't fall for the "yes I have an inhaler bit." 

I say, "You been using your inhaler a lot, haven't you?"

"Well, yeah, I guess I do." He says, nodding his head, rolling his eyes.  

A bronchodilatoraholic can't fool me.  I know them like I know the backs of my formerly Ventolin stained fingers.  

After a few hours in the emergency room, his breathing is better.  The nurse reads him his discharge instructions knowing he's not going to follow them.  

I'm telling you his story because I don't want you to be a Joe Goofus.  I want you to take care of your asthma so you don't have to keep seeing guys like me.  I do not want YOU to be a goofus asthmatic.  

If you are a Goofus -- and most of us are, actually, so don't be embarrassed -- you'll want to get on the path to being more like Jake Gallant.  Ah, our friend Jake Gallant even makes me look like a Goofus he's so perfect.  

Yet Joe has some advice for us:
  1. See your asthma doctor at least once a year
  2. Take your asthma medicine exactly as prescribed
  3. Create and utilize an asthma action plan
There, how's that for keeping it simple?  

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Monday, April 14, 2014

What is pulmonary wasting?

The following is from the COPD community at

Your Question:  What is pulmonary wasting?

My answer:  I believe what you're referring to is the wasting of muscles due to inactivity as a disease like COPD progresses. A significant reason for inactivity may be progression of the disease, which may be indicitive of incresased shortness of breath, decreased energy, and depression. Muscles that may become wasted are those used for walking, standing, and eventually breathing. This is one of the reasons why the medical community encourages all people diagnosed with COPD to stay as active as possible, such as can be done at a pulmonary rehabilitation program. Another reason it may occurr is the loss of ability of your body to absorb necessary nutrients. For this a physician may refer a patient to a dietician, who may recommend eating smaller meals more often, and eating food high in nutrients (such as protein) that your body needs for muscle growth.