Healthcare bill looks goulish and scaaaary

(Editor's note: The following was written by Dracula while I was in that long dreamy trance. I'm still whoozy and my neck aches. )

Dear my friends (ahahahahahaaaaa):

I just got done sucking the blood of the RT Cave publisher (MMM!!! It was soooooo tasty!)

Now that he's out of the way I will take this time to voice my opinion about something that would make my blood boil -- well, if I had any it would boil.

I have obtained a copy of the healthcare reform bill released by the leadership of the U.S. House that merges all the versions of the bill passed thus far. This piece of work is expected to be "considered" by the full house next week.

The following are the major provisions of the bill and how it might effect you and other future sources of lunch (in blood red):

• Expansion of health insurance to an estimated 96 percent of legal US residents under 65.
• Individual mandate with penalties. (unconstitutional)
• Employer mandate for those with payrolls over $500,000 with penalty (unconstitutional).
• Subsidies for low- and middle-income families. (spreading wealth)
• Medicaid expansion for families at or near poverty level Insurance reform (paid for by taxing people who have succeeded. This bill calls for a tax on insurance companies which will fall to the taxpayers by higher premiums, thus a tax hike.)
• Ban on pre-existing condition exclusions. (a better way of doing this would be to give private insurance companies a tax break for taking the risk.)
• Ban on rate adjusting based on pre-existing conditions or gender (this I like. Insurance companies could also get a tax break for taking on the increased risk, which is rewarding the risk takers).
• Limits on rate adjustment, limited to age and family size.
• Public Option with negotiated provider payment rates (check out this post. You ll learn the public option isn't so great after all).

Here's how the bill will be paid for:

• $480 billion tax increase for singles $500,000/families $1 million. (Punish the achievers to the benefit of the have nots. This will be another disincentive for companies to take the risks needed to move up to the next income level)
• $20 billion tax on medical devices. (which will be passed down to consumers, which are mostly the middle class who were promised no tax hike).
• $400 million in spending cuts (mostly Medicare) (In a bill signed in the early 1980s, Congress promised to cut spending and never did. Can we trust Congress now. A recent poll shows 90% of Americans want all new Congressmen, a testament they don't trust the people who are responsible for this bill).

The bill also includes:

• Medicare coverage of end-of-life counseling (described as "advance care planning" in the bill). (hHmmm??? What might this lead to)?
• SSI eligibility exemption for clinical trials participation compensation - Improving Access to ..Clinical Trials. Expansion of Comparative Effectiveness Research.
• Provisions to address healthcare workforce shortages. Physician payment "sunshine" requirements - but with an exemption for industry- sponsored CME ..activities.
• Expansion of Medicare quality programs. Expands Medicare and Medicaid beneficiary access to preventive services by eliminating. cost- ..sharing. (Cost reduction is great, but can more easily be done by reducing regulations for private health insurance to improve competition)
• Strengthening of the public health infrastructure through creation of a Public Health Investment ..Fund with authorized funding of $33 billion over 5 years.
• Creation of a Prevention and Wellness Trust Fund for community-based prevention and chronic ..disease management with authorized funding of $34 billion over 10 years.

The basic premise of this bill is Congress doesn't trust private companies or people like the (tasty) publisher of this blog and you to do what is right, which is extremely scaaaary. They believe it's the role of the government to tell us what to do for your own benefit. Some people call this the nanny state.

I don't know about you, but this is enough to give even my lifeless bones the eebie jeebies. Just reading it sends a cold shiver up my dead spine. I don't trust your government with a ten foot pole. Sure your gov should have some power, but not this much. If this bill passes it will change the fabric of your lives. It'll be, excuse the pun, a pain in the neck to get rid of if it fails, if not impossible.

It should send a shiver down your spine too, especially considering the slippery slope that is bound to ensue in your neck of the woods. This post and this one describe this bloody, slippery slope.

Healthcare reform is needed, but not a government takeover. Better options would come from reforming the current system and letting people like you guys solve the healthcare problems that exist. Better options are on the table, as you can see by clicking here.

That's my take on it. Feel free to disagree.

Sincerely: Dracula

HAPPY HALLOWEEN!!!!!

Stepping Down

(Editor's Note: This is a guest post from a senior RT at Shoreline Medical)

In 100 days I will be retiring from full-time Respiratory Care, I guess I'm just not sure how I feel about that. It is what I do best. Perhaps I should supply some history. In the late 50's (think polio), I wanted to become the next Jonas Salk, become a doctor, cure disease, that was me. Of course in the 60's women were discouraged from becoming anything but teachers, nurses or secretaries. In 1966 I entered a nursing program, hospital based, on site residency, and a whole different ball game than nursing is now. About half way through the program I knew that nursing as it was then was not for me. Nurses didn't get "no respect", were not allowed to think for themselves,and above all, the doctor was Divine, and I don't mean he was a hottie! So, I left the nursing program and went into data processing; talk about boring; so I dumped that too. I knew that I really wanted to be in medicine but what? I ended up going into cosmetology and cutting hair for a living. Then in 1979 I gave birth to an infant with severe meconium aspiration. He was an 8lb 12oz fighter who spent 29 days on a Baby Bird ( anyone remember those?).
I took him home with great relief and a huge respect for the respiratory therapists and neonatal nurses who took care of him.

I graduated from a nearby RT program in Dec. of 1984 and have loved every minute of respiratory therapy since. I've seen huge changes in the field, the phasing out of OJT'S, great advances in technology, respiratory therapy driven protocols, the demise of IPPB (that's for another post), and the bottoming out of reimbursement for services rendered. Now don't get me wrong about OJT'S, a whole lot of what I learned came from OJT'S, give me a good OJT with common sense anytime. Remember, you can't teach common sense and you can't fix stupid. Time has also taken away my junk box. Every old RT knows you have to have a junk box, afterall it's what RT's do, jury rig! If you need something, just dig into a box of old spare parts and adaptors and you'll come up with a serviceable device to do whatever job it is you need done. Ah, a sink trap, a couple of one way valves, a little tubing.........!

At an MSRC conference recently, I listened to a, shall we say seasoned, therapist talk about pulse-oximeters and end tidal co2 monitors. He said he smiles to hear today's therapists complain about having to carry the pulse-ox in their pocket! We remember when a pulse-ox was the size of a small suitcase, try putting that in your pocket!

What about pagers? I remember trying to decipher a mumbled overhead page in a patient room with the Price is Right blasting away at full volume. "Fresh and hairy come on down...to umph stat" or "code blue north..." north what for crying out loud. You just gotta luv those pagers and handy little phones we have now, or not. With two pages and one or two phones hanging off you, you can't hold your scrubs up!
Dropped a pager in the john once, gee, I hated explaining why it was all wet, "I don't know why it smells that way, just give me a new one and oh yeah, don't take that one outta the glove".

Oh man, don't forget ventilators. You like microprocessors, say they make your life easier, and wow, ventilator wave forms, self weaning modes, smart care? Well, I remember standing in front of an MA-1 with a stop watch! Anyone for an H valve? In a pinch, I can still use a Bird IPPB or a Bennett PR-2 for a ventilator, no bells and whistles and I can still save your life. After all, what is a ventilator? A machine that pushes good air in and lets the bad air back out, Emerson had it down pat, does anyone besides me see the correlation between peep on an Emerson and Bubble cpap for neonates? There is nothing new under the sun, it is all slightly used, ie; non-invasive ventilation. I'm expecting a resurgence of IPPB, modified maybe but IPPB all the same. Let's see, tack on a couple of high tech monitors, paint them blue, gray or cream, change the name and jack up the price. Don't laugh,it happens all the time! Just promise me this, when all the old RT'S are gone, all the high tech equipment fails, please tell me that you youngsters can still look at a patient and know something is wrong and what to do to fix it based on good patient assessment! Is he breathing, does he have a pulse, is he pink warm and dry or blue cold and clammy? What is the most important thing to do first?

Let's not forget the drugs; we've come a long way since Isoproterenol and epinephrine. My favorite nebulized medication is Ativan, I want to have it nebulized through our ventilation system here at Shoreline, along with vats of Albuterol, otherwise known as Do-allolin. Oh well, that's going to take a little more convincing.

So, back to retirement, I'll still work, do a little relief here and there, someone has to make sure that all you youngsters are doing things right.

Thanks, Plain Old Jane

The most sagacious RT I've ever met

I'd hate to give her an ego boost, but one of the main reasons I decided to work at Shoreline Medical was because of Jane Sage. She's one of the most easy to approach people I've ever met. She's also full of RT wisdom. You can ask her any question and she'll have an answer with the snap of a finger.

It's that kind of wisdom I wanted to obtain, and for that reason I sort of adapted her as my mentor whether she knows it or not. In fact, I think everyone in my department has adapted her as a mentor. So what is a mentor. A mentor is a person (or ghost if you like Shakespeare or ancient folklore) who teaches wisdom to make you the best person you can be.

She's one of those people anyone is comfortable talking with. And even during the most stressful periods her deportment is always cool, calm and collect. And it's not just me who's impressed by her wisdom and deportment, it's everyone in my department if not the entire hospital.

When I first started working here she made it clear I could call her even during the wee hours of the morning. I took advantage of this on many occasions, even recently.

One of the first times I called her was when my first really bad asthmatic patient was admitted, and the doctor wanted her on a 700 tidal volume. All the RT wisdom I learned from RT school was shouting at me this was waaaaay too much for this patient. I was stressed because the doctor was breathing down my back while I was looking over the vent, which was alarming like crazy. The patient was fighting the vent big time. She was autotrapping. I had her on a tidal volume of 200 and that was with a pressure of 58. Even though I was fresh out of school, my gut feeling said that there was no way I should give this lady more than 200. Yet how was I, a rookie, going to tell this to the experienced and arrogant doctor.

Yes I was second guessing myself as many new RTs do, so I risked looking like an idiot to the doctor and stepped aside and called Jane. She answered the phone with her usual pleasant tone and provided some options to me. Right away she made me feel better about myself and my decisions.

Finally she decided she would come in. This turned out to be a great thing considering Jane never left the patient's room all night, and neither did the doctor. I was so thankful that she came in because ER was also swamped that night. She did not have to come in. She was not even on call.

The next time I saw Jane she said she explained to the doctor pretty much what I had already told him. I suppose he just wanted to hear the wisdom from a seasoned RT as opposed to a rookie. I quickly realized Jane had the answer to not just every RT related question, but to RN related questions as well. In fact, there have been many occasions where even doctors called upon her for her wisdom -- even calling her at her home.

Later Jane told me that I impressed her that night as well, and not just because of my gut instinct to follow the wisdom I learned in RT school, but because I bit my pride and got on the phone to call her. She'd make a good politician because she knew exactly what buttons to push.

I've had the privilege of following Jane for 12 years now. That's 12 years of watching her work, and listening to her wisdom. We've had discussions on nearly every topic from RT Wisdom to politics, from discussions about paleoconservatives to Aragon. There aren't many people around who enjoy an intelligent discussion regardless of the topic.

In fact, I can honestly say that she alone was the inspiration for me to be more than a button pusher respiratory therapist. I could have been paired up with a lazy RT, or a complainer, or someone who was just satisfied with getting a paycheck and doing as little as possible to earn it. Yet, thankfully, I was paired up with Jane, who was always striving to become a better RT; always researching; always learning; never satisfied with the status quo; always questioning; always thinking.

She is not nor ever was an RT boss, although she easily could have been. She ran the department per se but not really. She was a true leader who had plenty of wisdom to provide to the RT bosses in times of crisis, and when it came to creating new policy, or writing new protocols, or convincing doctors they were wrong or that changes were needed, Jane was up to the task.

I know that Jane spent hundreds of hours writing a ventilator protocol once, and then it sat in her locker collecting dust for probably 10 years. In this time several other protocols were written and rejected. Yet, while the other RTs gave up, Jane charged forward. Despite the low morale, despite the reluctance of the admins and RT bosses to change the status quo, Jane never stopped learning, never stopped creating.

Then one day a doctor went to the RT Boss saying that he thought it would be a good idea to have a ventilator protocol. The RT Boss directed this doctor to Jane who just happened to have a protocol in waiting. The doctor was impressed, and now that protocol has been in effect for five years. Of course that doctor took credit for the protocol, but Jane didn't care. Jane's persistence was rewarded. In fact I think just yesterday on this blog she wrote about the importance of being proactive in her advice to newbies.

I remember once driving down south to a nice restaurant where a representative of Xopenex was going to give a presentation. After several free drinks, a delicious free steak dinner (of course we ordered the most expensive items on the menu), and a buzz, Jane listened as a pediatrician asked about the use of Xopenex for his pediatric patients. Jane said something like, "Do you guys have any research regarding bronchodilators and RSV. I've read that the latest research shows that bronchodilators aren't recommended for RSV anymore. Is this true?"

I can't remember what the reps answer was, nor does it really matter. What I remember most is what Jane said to me on the way back: "You see, Rick, I was just planting seeds. That's the best way of changing doctor's minds. You do it by first planting seeds."

Later I learned that she was really good at convincing doctors to do things her way by making the doctor think it was his idea. This was perhaps one of the best skills I've picked up from Jane. You just kind of slip an idea into the doctors mind, and let him take credit for the idea. That's the way we RTs function.

Sure there have been ups and downs in the morale department, and there have been turnover of bosses, admins and nurses. Yet through it all this hospital has always seemed to have a good feeling about it. In fact, when I first started working her I remember telling Jane that I thought it was neat how well the nurses here get along with the RTs so well. Jane said to me, "This place has kind of a down home feeling about it."

She was right. This place is a great place to work. Sure there's always politics, but overall Shoreline medical is a down home place. And one of the reasons for that is people like Jane Sage with her pleasant deportment, her never get angry deposition, and her willingness to learn and share her wisdom.

She can take a joke, too, as well as dish one out. One day I came into work to learn that there were 25 patients, three vents, and that I was going to have to work alone. And just as set out to tackle this dilemma with my vexed heart racing, she said the magic words: "April Fools."

I can't imagine what Shoreline Medical will be like without Jane. She's the kind of worker no boss wants to see move on, and no coworker either. Yet, as with all good things in life, there comes a time for it to end. Tomorrow, right here at the RT Cave, Jane will announce her retirement.

Note #1: Shhhh!!! Just between you and me, this will be good for the RT Cave because she'll have more time to write for us. I'm sure we could all benefit from the wisdom of the most sagacious RT: Jane Sage.

Note #2: Calm down Jane. Don't get too big of a head. If your ego gets too big your head will expand and you'll become a doctor.

Some Sage advice to the Newbies!

(Editor's note: This is a guest post from a senior RT at Shoreline Medical)

As I continue to contemplate retirement, I worry about what will happen to all the advancements at Shoreline, that I have been a part of over the years. These advancements are hard-won, hard fought for victories that I am particularly proud of. I couldn't enumerate or name them, as they have accumulated over a twenty five year period. I worry even more about advancements of my profession here, if someone doesn't step up to the plate and take over my pro-active stance about the place of respiratory therapy at Shoreline.

When I arrived here as a rental therapist 25 years ago, I had only been in the field for a year and was the typical cocky, know it all, coming to Podunk from a much larger teaching hospital where I spent most of my time in the post open heart unit. Therapists here did not get a lot of respect from the doctors or the nurses. They were looked upon more as aerosol and oxygen jockeys and much less as professional, educated patient care givers. They were most definitely NOT a valued part of the patient care team. I would like to say that I immediately set about fixing this nasty little perception of who we were, alas, that is not how it went.

After my first three weeks, I had managed to upset and alienate at least half of the nursing staff and a couple of doctors. I'm not sure my co-workers or my director really thought I would ever fit into the establishment. I started and ended many conversations with, "Well, at Mid-Regional Hospital we did it this way". Needless to say this did not go over well at all. I finally came to realize this when one of the nursing staff looked me square in the eye and quietly said, "If it was so much better at Mid-Regional, why don't you go back there!" I was completely stunned! Why would she speak to me in such a fashion? Thankfully I was able to figure out the problem, it was me. After much soul searching I was able to see the error of my ways and was able to accept there was no one way to approach a single problem. Thanks to that nurse I was able to grow and become a better person and therapist. I still work with this woman and have been happy to do so all these twenty five years. Moral, be open minded, willing to listen and above all, a team player.

I have also learned that tho' you may lead a horse to water, you can't make him drink, is not true, with a little patience, you may lead that horse to water and waiting long enough that little bugger will get thirsty and finally drink. Moral, if you want to make changes, present the ideas, be prepared to defend them and someone will start listening. You may not get all that you ask for but like any good salesman you have now got your foot in the door and time will do the rest.

Here at Shoreline Medical the Respiratory department has been complimented and held up as an example of continued learning and expertise. Within the ranks of our staff there is a constant drive to be the best we can be, (is that a Marine axiom?). We have shadowed staff in the NICU's, MICU's and TICU's of large teaching hospitals in our area. This took some co-ordinated effort on our part and the part of the teaching institution but it was well worth it. At smaller rural hospitals you, as a therapist may never encounter certain aspects of critical care/trauma, but if you do you must do the right thing at the right time and that means being as familiar as possible in these areas. Moral, learn, learn, learn.

A few years ago Shoreline implemented the Michigan Keystone ICU. Accidentally, I came up the announcement of meetings where a ventilator protocol would be drafted. Now I had been singing the protocol song for a long time and had many of my own ideas of how one should be written. Not having been invited to the Keystone meetings I hurried off to my directors office to beg him to volunteer me for this committee. Thankfully, it worked and our department was represented in this most important area of our field. Moral, knee jerk reactions are too late and a dollar short. Be proactive not reactive! If you don't participate don't b""""".

Probably the most cherished complement that I have ever received was one that came from a patient's husband to my director, "Jane is an example of the consummate professional". I cannot begin to tell anyone how great that made me feel. I still see this man around the hospital today and always become conscious of who I am and who I represent to the patients, family and other staff members. Moral, to be treated like a professional, you must first act like a professional. I sure hope the man meant the statement in the manner in which it was received, otherwise that plump feather in my cap will surely be plucked!

Here's 33 reasons you'll want ot be an RT

So you're thinking about being a respiratory therapist. Here are 20 reasons this is the right profession for you:

1. You want to work in the medical profession but you don't like poop.
2. You don't mind working with spit and goobers.
3. You enjoy a good conversation.
4. You have a good sense of humor.
5. You have a friendly disposition
6. You get irritated easily with stupidity.
7. You have the grit to keep your mouth shut when your wisdom is not wanted
8. And the courage to speak up when your wisdom will help a patient.
9. You can handle being on your feet for 12 hour shifts.
10. You like flexible hours and lots of days off.
11. You like the rush and challenge of a cardiac or respiratory arrest.
12. You can handle seeing bones and brains and at least tolerate bagging over vomit.
13. You enjoy the satisfaction knowing what you did gave someone a chance.
14. You enjoy the rush of a busy emergency room.
15. Or the challenge of making a critical decision
16. Or working with complicated breathing machines
17. You enjoy learning new RT Wisdom.
18. You like drawing and interpreting ABGs.
19. You don't mind doing EKGs (usually a job of RTs at smaller hospitals)
20. You enjoy working with nurses and doctors to the benefit of the patient.
21. You love educating patients.
22. You can handle being swamped one minute and slow the next.
23. You don't get frustrated every time your beeper goes off.
24. You can handle talking with frustrated or irritated physicians
25. You like having time to surf the Internet.
26. You like eating three meals while getting paid
27. and you enjoy eating candy bars, cookies, cakes and other treats
28. You want a recession proof job
29. You want a job that is easily portable
30. You like having the freedom to roam entire hospital
31. You enjoy gossiping.
32. You like watching TV while working
33. You like blogging and playing on Facebook or Twitter.

RT profession growing and gaining respect

It's RT Care Week! It's time to reflect on the fact we are leading the charge to improving a profession that is still in its infancy. We are, as they say in sports, not rookies, but not even in our prime yet. We are, as they say in fantasy sports, the sleepers, the prospects with a lot of upside.

You'll see your friendly neighborhood respiratory therapist walking room to room giving breathing treatments, participating in friendly discussions, and cheering up overworked and exhausted nurses and sick patients with their dry humor.

Yes we are an interesting bunch. Some of us grumble and gripe at each new stupid doctor order. Some of us are cheerful no matter what. Some of us are the kings and queens of hospital gossip. Some of us trudge from room to room without saying much of anything.

Yet, no matter what personality RT is taking care of your patient area, you should always know your RT is available to lend a helping hand. If you need an extra body to boost a patient, your RT will be there. If you need help holding down a child for his daily lab draw, your RT will be there.

You also should know that any time you walk into a patient's room and the patient just doesn't look right, that you should always call your RT. He might look at the patient and say, "Oh, he looks fine," or he may say something along the lines of, "I think this patient is wet. It is my humble opinion he might need Lasix. Let's check the i's and o's, though, before we call the doctor. Perhaps we should also get vitals so the doctor doesn't get mad because we don't have all this information available."

This great profession has come a long way since the day of the OJT; since the day when RTs were nothing more than button pushers, or ancillary staff. Yet, while many physicians, nurses and RT bosses have grown with the RT profession and learned to trust the opinions and expertise of the now well trained through qualified RT programs, continued education and experience RTs, there remain many still stuck in the past who still think of RTs only as an ancillary service.

Yes, even recently I have seen both sides of this coin. I have gone down to the ER, seen a patient in respiratory distress, made the appropriate decision based on my 11 years of experience as an RT and 38 years of experience as an asthmatic, and the patient benefited as a result.

When I was finished, I approached the ER physician and informed him of what I did. He enthusiastically said, "Great job! Thank You! I love it when you take charge! You did a great job!"

I was riding high. I did not grow a big arrogant head by no means, but it felt so nice to have a physician not just respect this profession, but to realize how we can be part of the team, and because he actually told me how well he respects me.

It made me feel good because recently I started an Albuterol treatment on a patient I suspected of being in bronchospasm, and the physician working the ER that day said, "What is this?"

"The patient's short of breath and his lungsounds were diminished," I said.

"Well, we don't start breathing treatments without talking to me first. I'm the doctor and that's my job."

I was beside myself. I took the nebulizer from the patient and dumped it into the sink. If this was a rude thing to do, I wasn't thinking of that. I wanted to simply give up. I wanted to take my brain filled with RT wisdom and go home. I wanted to quit.

But I didin't. I swallowed my pride and stood there feeling like a five foot fifth grader standing in the principal's office waiting to be scolded.

The physician turned to me and said, "I want Xopenex and Atrovent."

So, while this profession was once seen as 100% ancillary and 0% professional, it is now seen as ancillary about 50% of the time and professional about 50%. It basically depends on what nurse is working, and what physician is working.

This is progress. This is good. Yet, while the nursing profession is seen as a well respected profession, the RT "profession" is still lagging behind -- yet growing.

My advice to aspiring RTs is this. If you are looking to be an RT, go for it! This is a great profession and you and I can be part of the effort to driving this profession into the future. The RN profession was once in its infancy and through the years physician's learned that by respecting RNs not only do they benefit, but so to does the patient.

The same will hold true with the RT profession, only we who are presently working in the field have a unique ability to shape it into the form of our choice. So, if we stand by and let stubborn physician's pent on holding onto the past shape this profession, they will define our future.

Yet, if we stand firm, be patient, step forth, and continue to voice our opinions in a professional manner, we will shape this profession into the mould of our choice.

Yes, this is a slow, humble, and political process. It's changing the mind of one RN, one doctor, one RT, one RT boss, one administrator at a time. But we know it can be done. We know this because, as Jane Sage wrote in a recent post, the RT profession has already grown since the days of its infancy.

Sometimes I think we RTs are underutilized. Sometimes this irritates me. Sometimes it makes me feel apathetic. Yet, I also know there are many nurses who call us every time they suspect something is wrong with OUR patients. They know that we are specially trained in an area they glossed over in RN school, and they highly respect our opinions.

I recently overheard one sagacious long-time RN say to a student: "Don't be afraid to call RT. They have saved me many times."

We assess patients. We have listened to so many lungsounds that we might just be better than physicians at noticing little trends, at noticing early pneumonia, CHF, pulmonary edema. "This patient is wet!" The RT might say. "You need to call the doctor right away!"

Or, perhaps the RT was not called when the patient was blue around the lips. The nurse who held onto the old-school belief of RT as an ancillary service may have called the physician panicky. The doctor would order an ABG and write an order for more oxygen.

The nurse who learned to respect the RT on duty called the RT, and said, "The patient is blue, and I just wanted your opinion before I called the physician."

On a whim the RT enters the room and checks to make sure the oxygen is still on and connected. As it turns out his whim turns out to be a good idea, because the oxygen was on but disconnected. Once the problem was fixed the patient pinked up. The nurse was ecstatic, and never had to call the physician. We are a TEAM. What one of us doesn't pick up the other does.

Yes, you can see that we RTs, doctors, and RNs are part of the patient care team. Like RNs, we are not only well educated, we are licenced professionals. We are trained to assess, evaluate, think and communicate. We are not physicians, we are not nurses, and we are RESPIRATORY THERAPISTS.

We are part of the patient care TEAM!

It is now RT Care Week, a time to reflect on a profession that is still in it's infancy and growing in every area. We need to feel proud and joy in all we do, and we certainly hope RNs, physicians and admins appreciate what they have by the RTs working around them.

The most important aspects of life

The religious say you don't need material items to be happy in life. They say those who are rich and who continue to seek more wealth and material items are the least happy. The older I get the more I value that old wisdom.

As an RT I'm not able to provide much for my family, at least not as much as some of my neighbors. While I have a great family in a nice new neighborhood, I can't afford a new camper, 2 new motorcycles, a huge camper, a new lawn and monthly fertilizing of it, the best toys for my kids, daily golf outings, and yearly upgrades on my house.

I have none of that. I'm not saying I don't want it all, but I can't afford it unless I packed it all on my debt. However I've been advised against that.

I'm not saying I'm taking the frugal route because I'm religious, because I'm certainly a flawed person (aren't we all?). But it is the religious who will say it's funner, wiser, and better to take the frugal route for no other reason than it teaches you to appreciate and value the most important assets in life -- life itself and people.

Perhaps this is why you'll see this humble RT lying on the front lawn on a blanket with his baby absorbing not rays because his daughter cannot be exposed to the sun yet, but simply the time well spent enjoying the warm weather and appreciating not just the weather but the wisdom of a good book. And, most important, time with the wife and children.

After all, no one on his death bed wishes he purchased more stuff. And one rarely hears one saying he regretted time well spent appreciating the most important aspects of life.

Determining level of consciousness

This is pretty much RT 101 stuff, but the following are the various levels of consciousness one might observe of others. A wise RT will be familiar with these terms and use them accordingly.

1. Lethargic: somnolence: sleepy
2. Stuporious: confused: responds inappropriately, OD, intoxication
3. Semi-comatose: responds only to painful stimuli
4. Comatose: does not respond to painful stimuli
5. Obtunded: drowsy, maybe decreased cough/gag reflex

Indications for intubating neonates

The following are the indications for intubating a neonate:

1. PaO2 less than 45mmHg while breathing 80 – 100% FiO2
2. PaCO2 greater than 65mmHg
3. Intractable metabolic Acidosis(B.E. less than -10 meq.)
4. Marked retractions on CPAP
5. Frequent episodes of apnea and bradycardia on CPAP

How do RT departments make money?

How do RT departments make money? To answer this question, I think I'll take a backward step and ask a slightly different question: How do hospitals make money?

Unless the patient is paying out of pocket, the admitting diagnosis is what determines how much money the hospital makes on a particular patient visit. According to "Egan's Fundamentals of Respiratory Care," each patient is designated a specific Diagnosis Related Group (DRG) based on the diagnosis.

The Healthcare Financing Administration assigns a set reimbursement for each DRG. Thus, according to Egans, "Because the amount remains fixed for each admitting diagnosis, hospitals know in advance exactly how much reimbursement they will receive... Hospitals that can provide care for less than the fixed rate can keep the difference, thereby realizing a 'profit.'

"On the other hand, hospitals whose cost of care exceeds the fixed rate must absorb the cost and thus take a financial loss. By placing hospitals at risk financially, this system provides a powerful incentive for cost efficiency."

The best way to cut cost is to use the fewest procedures needed to make the stay as short as possible.

This in mind, the RT department really doesn't make any money off the therapies it does, unless those therapies get the patient better and fast.

Now, considering I believe that about 80% of the bronchodilator breathing treatments we do are not indicated, it's amazing to me that no one ever cracks down on this. I imagine what keeps this RT Cave intact is the RT Cave bosses not allowing admins to catch on to this in order to keep the procedure count up in order to keep your humble RT on the job.

Ideally, according to Egan, the goals of therapy should be clearly written in the patient's chart, and once they are met the therapy should be stopped. Egan notes that "To be cost effective, all therapy must be justified adn discontinued when no longer needed."

Yet this isn't usually the case. Rarely if ever have I seen an RT treatment discharged. Egan mentions that RT Driven Protocols are great here. I know many hospitals have them. Still, many hospitals that have protocols don't use them properly to discontinue therapies.

One reason is because RT departments need procedures to keep RTs on the job. A second reason is the hospital needs to meet intensity of service in order to get reimbursed. In this regard, often treatments are given even when not needed. A good examle of this are order sets wehre treatments are ordered automatically just so the hospital covers it's intensity of service bases.

So we can see how a hospital might make money. The greater question is: So, how do RT departments make money? I don't have an answer to that. Do you?

Can Advair & Spiriva be taken together?

The following question and answer is from a Q&A session at the HealthCentral network.

Question: What is the point of taking Advair and Spiriva together?

My humble answer: Great question. They are both preventative medicines. As you know every person is unique, and one person's asthma may be more difficult to control than another person's asthma. Therefore, it is the job of the doctor to work with you to find the best concoction of medicines to control your asthma.

There are basically your usual front line medicines that are recommended to treat asthma, and your second line medicines that aren't usually needed but sometimes can help control asthma. Advair is a front line medicine because it usually works fine by itself to get asthma under control. If, on the other hand, Advair alone isn't getting the job done, your physician may resort to trying second line medicines like Spiriva.

That said, Advair has both a corticosteroid (Flovent) to treat the underlying inflammation component of asthma, and long-acting bronchodilator (serevent) to prevent the bronchospasm (airway narrowing) component of asthma. Serevent is a beta-adrenergic medicine that causes bronchodilation (relaxes smooth muscles). It attaches to beta receptors in the lungs, and when this happens the lung muscles relax.

Spiriva is a long acting bronchodilator that works by blocking cholinergic receptors in the lungs that cause bronchoconstriction (airway narrowing) when stimulated. Thus, Spiriva is an anticholinergic medicine. In this sense, it is often referred to as a "back-door bronchodilator." It is not as good of a bronchodilator as Serevent, and therefore is a second-line therapy for asthma.

Recent studies, however, do show Spiriva improves lung function in COPD patients and some difficult to control asthma cases. Therefore, if front line asthma medicines like Advair do not control asthma, Spiriva is a good medicine to "try" in conjunction with the recommended front line medicines.

Of course, there's always the chance your doctor has a different reason for prescribing both Advair and Spiriva for you. Therefore, it is always a good idea to talk to your doctor so you are on the same page with him or her.

For more information, click here and here.

What happens to cause asthma?

Question: what in the body happens to give you asthma? I have to do a report for school.

My humble answer: You've come to the right place to find everything you need to know about asthma. The best place to start is by clicking here or, better yet, here. By following these links you should get a good overall understanding of what asthma is and what "triggers" an asthma attack and what an asthma attack is.

No one really understands what causes a person to develop asthma in the first place, but there are theories, such as this one I wrote about.

The airways of most asthmatics are always inflamed (swollen) to some degree. Depending on the severity of this inflammation determines how bad one's asthma is and how sensitive the air passages are to asthma triggers.

When an asthmatic is exposed to his or her asthma triggers, this triggers the asthma response you can read about in the second link above. This ultimately leads to the air passages in your lungs (check out this link) to become increasingly inflamed (swollen) causing them to constrict (become narrow).

When this happens air you breath can enter your lungs, but the narrowed airway traps the air in your lungs (this is called air trapping). Since an asthmatic during an asthma attack has this extra air in his lungs, it feels as though he can't get air in, but the truth is he can't get air out. He then feels like a fish out of water.

Fortunately there are medicines to treat an acute (ongoing) asthma attack like this and even more medicine to prevent an asthma attack. You can read about asthma medicines here.

If you want to read a very thorough writing about what asthma is, you should check out the asthma guidelines I will link to here. Actually, the answer to your question should be in this section.

Good luck.

Setting up ventilator on neonate

Guidelines for setting up a Neonatal Ventilator:

1. Patient range: Set to neonate (Maximum VT = 40cc)

2. Mode: Pressure Control (works best for un-cuffed ETT)

3. Tidal Volume (VT)*:

• less than33 weeks gestation 4 – 6 cc/kg
• greater than33 weeks gestation or chronic 5 – 7 cc/kg

4. Peak Inspiratory Pressure (PIP)*:

• less than27 weeks gestation set at 24 CWP
• 27 – 32 weeks gestation set at 26 CWP
• 33 – 40 weeks gestation set at 28 CWP
• Start low (best to err on low side to prevent barotraumas.)
• Increase to obtain target VT and adequate chest rise
• Frequently monitor & adjust PIP to accommodate changes in lung compliance altering tidal volume.

5. Positive End Expiratory pressure (PEEP):

• Start at minimum 4 – 5 CWP
• Increase to 6 – 7 CWP if FiO2 needs greater than 60%
• Adjust to maintain acceptable PaO2 and SpO2
• 8 – 10 CWP PEEP if directed by physician
• Remember that Pressure Control (PC) setting is “above PEEP”

6. Fraction of Inspired Oxygen (FiO2)**:

• Start low at 40%
• Adjust to maintain target SpO2
• If SaO2 less than target range, FiO2 may be increased by 2–5, & then allowing 4 minutes for stabilization after each change. (consider adjustment of PIP and PEEP also.)
• Continue assuring AW patent, HR greater than100 & baby not apneic.
• If SaO2 greater than target range, FiO2 may be decreased by 2 – 5,
  allowing 4 minutes for stabilization after each change.
• Consider increasing PEEP prior to FiO2
• Maintain neonate on ROOM AIR whenever possible.

7. Rate:

• 50 – 60 if less than 34 weeks gestation or less than 3 kg
• 40 – 50 if greater than 34 weeks gestation or greater than 3 kg
• 30 – 40 if 40 weeks gestation; slightly higher if indicated.
• Watch for air trapping at rates greater than 40 (adjust I-time).

8. I-time:

• Start at 0.3 plus or minus 0.5 (post-term may need more.)
• Neonatal initial I-time setting
• less than 1kg 0.25 – 0.30 sec minimum 0.20 seconds
• 1-2kg 0.30 – 0.40 sec minimum 0.20 seconds
• 2-3kg 0.35 – 0.45 sec minimum 0.25 seconds
• 3-4kg 0.40 – 0.60 sec minimum 0.30 seconds
• Ideally set using Flow-time graphics
• This alters I-time and I:E ratio
• Increase & decrease to reach target settings as appropriate
• Watch for air trapping at rates greater than 40 in neonates greater than 3kg; they may need I-time greater than 0.40 to complete inspiration & prevent air trapping.
• If neonate using expiratory muscles, try decreasing I-time
  slightly (increasing flow).
• If I-time gets too short, consider switch to PRVC.

9. I-Rise time:

• 10 if less than 33 weeks gestational age
• greater than 5 if greater than 33 weeks gestational age
• Basically, the smaller the ETT the higher this should be to
  create laminar flow and a pseudo sign wave.
• Increase for bronchospasm (slow rise time, longer e-time)

10. PIP limit: 2 – 3 greater than PIP (all other alarms as appropriate.)

*Note: Higher PIP and VT may be needed in certain cases. Consult physician if unable to ventilate at recommended settings. Settings may also be unique to particular ventilator, guidelines, or protocol.

**Note #2: New studies show that high levels of oxygen, even in term babies and even for periods of less than a minute, can result in long term consequences to the child such as Retnopathy of Prematurity. Proper ranges to strive for will be the topic of a future post.

Note #3: The above information may be slightly different for your institution and the equipment available, yet the principle remains the same regardless of where you work.

For a cheat sheet with the above information, click here.

Thoughts of living long

When my 1-year-old girl is 40 I will be 80. And I think how fast my 40th birthday is approaching (I'll be 40 in January). That 80 years will be here in a heartbeat.

I think I want to be here to lend a hug and an ear to not just my daughters and son but my grandchildren. I imagine I'll have some by then. Perhaps that's the greatest incentive to eat well and exercise and live well.

Perhaps I ought to print this post and tape it to the fridge so I can be reminded of this incentive daily, because it sure isn't easy to eat right, exercise and live well.

I mentioned this to my dad who is 66. He said when he turns 80 his youngest daughter (my sister) will be 40. So, dad is in the same position in a way as me. The only thing is, when I turn 80 my dad will be 106.

I wonder if we'll be in the same nursing home by then. That wouldn't be so bad, because my dad's pretty cool. He seems to always know how to find fun. Perhaps his daughter and granddaughter can visit us regularly.

Inhaled steroids don't cause pneumonia

Aha! Another fallacy debunked. Well, surely we are aware that this is one study, but the results of a recent study confirm that inhaled corticosteroids like Flovent or Pulmocort, or combination inhalers like Advair and Symbicort, do not cause pneumonia.

Yet, it is true that pneumonia is common among COPD patients, however the reason is not because these individuals are taking steroids. And sure steroids can knock down the immune system in your mouth slightly, thus causing thrush. Yet this minor side effect can be almost completely "washed" away simply by rinsing after each use.

Advair is said, according to most studies, to not cause any systemic side effects -- so long as you (ahem) rinse after each use. Thus, what causes pneumonia is not the inhaled steroids, but something else. Perhaps it's the fact that many COPDers have excessive phlegm trapped within their lungs, which creates a breeding ground for bacteria. This, I would suspect, causes most cases of pneumonia in COPDers.

The fact they are taking an inhaled steroids to reduce inflammation and prevent bronchospasm is not what is causing pneumonia. In fact, there have been many COPD patients over the years who were not on inhaled steroids, and they were equally likely to have pneumonia.

So, fallacy debunked? Perhaps. While we have common sense enough to know this is just one study, we also have common sense enough to not believe every little rumour about a new medicine that comes around.

The truth is, there are many people who don't take medicine their doctor prescribes to treat their lung diseases out of fear of side effects from the medicine. As an asthmatic and a person who's used inhaled corticosteroids for over 30 years to treat severe asthma, I can honestly state that the risks of not taking your COPD/asthma medicine are far worse than the risks of the medicine itself.

In fact, I think we ought to make this RT Cave #38:

RT Cave Rule #38: The risk of not taking asthma and COPD medicine is far worse than the risks of the medicine taken to treat these diseases.

The Sputum Lexicon

Sputum is what we RTs are all about. We become RTs because we aren't afraid to suck it up. If you are an RT you've probably seen all of these at some point. If your an RT student, you'll become familiar with these soon enough.

Hey, if you're a lunger (COPD, asthma, bronchiectasis, cystic fibrosis), you also should be familiar with the various types of sputum. If you notice changes you should call your physician.

Sputum sample: A good sputum sample is of mucus from deep inside the lungs. You do not want it to be contaminated by mucus of the upper airway++.

Normal secretions*: Clear, thin, none, and with no odor

White*: May be first sign of a problem. May be normal with asthma.

Thick white*: May be sign of problem. May be normal with asthma. May also be sign of dehydration.

Light Yellow: May be sign of viral infection (especially if they have small grade or no fever). May be normal with COPD.

Yellow*: This can be a sign of an upper airway infection. May be normal variant with COPD. May be thick. May have an odor. (Bacterial infections may come with high grade fever)

Dark yellow or green*: Sign of worsening lung infection (bacterial).

Brown: Sign of bacterial pneumonia. May also be a sign of aspiration pneumonia.

Bloody: Sign of pneumonia or tuberculosis (hemoptysis).

Pink Frothy: A sign of pulmonary edema and cardiac failure.

Cream colored*: This may also be thick and will probably have an odor. This is puss coming from the lungs, and may be a sign of an infectious disease.

Chunky and dark brown*: May be aspiration pneumonia, gangrenous lung, really bad lung infection.

Bad odor**: May be sign of anaerobic infection or bronchiectasis

Mucoid secretions***: Clear or white in color. Generally they are produced in response to inflammation, and are seen commonly during acute asthmatic attacks and in uncomplicated chronic bronchitis*.

Purulent secretions***: Dark yellow or green and are seen mainly in bacterial infections. They tend to be very viscous. If caused by anaerobic bacteria it can have a disagreeable (fetid) odor and terrible taste. Examples of where this might be seen: aspiration pneumonia, lung abscess, and bronchiectasis *. Likewise, when normally clear mucus comes into contact with pus it becomes purulent. Thus, the word purulent comes from the word "pus." The presence of eosinophils ,which may be increased during an asthma exacerbation or during the common cold, may make mucus appear purulent.

Mucopurulent secretions***: A mix of mucoid and purulent secretions. They tend to be light to medium yellow and less viscous than purulent. They probably represent either the early or late (resolution) stage of an infection process.*

Antibiotics: These are only indicated if the sputum or nasal discharge color change is caused by an infection. Usually, an infection is indicated by purulent secretions. However, recent studies show purulent secretions only indicate a bacterial infection 31% of the time+++.

++Note: It must be noted here that green or yellow nasal secretions may indicate an infection in the nasal passages and not necessarily a lung infection. This is why the best sputum sample is one that bypasses the upper airway.

+++Anahad O'Connor, a NYTimes.com blogger, recently wrote a great post about this I will link to here.

*Nursinghomesabuseblog.com
**familypracticenotebook.com
***"Egan's Fundamentals of Respiratory Care, 6th Edition, 1995)

The PFT Lexicon

I promised this a long time ago, and I finally have completed it. What you have here is everything most RTs and respiratory patients need to know about pulmonary function testing (PFT).

Much of the following information was obtained from the asthma guidelines and "Fundamentals of Respiratory Care" and reorganized so it's easy for us humble RTs and respiratory patients to understand.

Pulmonary Function Test (PFT): Synonym: Spirometry. This is a test where you breath into a mouthpiece to a device called a spirometer. The Spirometer measures your lung function, determines if you have lung disease and if you do how severe your lung disease is.

• It's a test that uses a spirometer that measures airflow, usually before and 15 minutes after using rescue medicine. The test is not used to diagnose but to determine the type of airway disease a patient has (obstructive or restrictive), the degree or severity of airflow obstruction, and whether it is reversible over the short term.
• It measures the maximal volume of air forcibly exhaled from the point of maximal inhalation (FVC) and the volume of air exhaled during the first second of this meneuver (FEV1). It is valuable for children greater than 5 years old (some children cannot do it until they are 7).
• it can help a doctor determine if shortness-of-breath is due to restrictive diseases like obesity, pregnancy, pneumonia, cancer, pleural effusion, etc., or an obstructive
  disorder like COPD and asthma. Also, it can also be used to differentiate COPD from asthma. Thus, if you are considering Asthma or COPD, this is a great test to rule out other disease processes.
• A test used most often for assessing the risk of future adverse events in asthma and COPD patients. It is the best test for determining severity of obstruction.
• Patient's perception of airflow obstruction is highly variable, and spirometry sometimes reveals obstruction much more severe than would have been estimated from the history and physical examination.
• For diagnostic purposes, spirometry is generally recommended over measurement with a peak flow meter, because values for each brand of peak flow meter can be specific to that particular brand. (peak flow meters should be used for patient monitoring only, not diagnosing).
• Followup spirometrymeasures are indicated as asthma control improves.

Spirometry frequency: Spirometry is recommended at the following frequencies: (1) at the time of initial assessment, (2) after treatment is initiated and symptoms and PEF have stabilized, (3) during periods of progressive or prolonged loss of asthma control, and (4) at least every 1-2 years.

Abnormalities of lung function: Are considered as restrictive or obstructive defects.

Restrictive Diseases:

• Is indicated by proportianately reduced FVC (or FEV6 in adults) with a normal or increased FEV1/FVC (or FEV1/FEV6) ratio.
• are caused by anything that decreases the lungs ability to expand and properly ventilate the patient by getting rid of CO2 from the blood and adding O2 to the blood stream. The following are restrictive diseases:Sarcoidosis, pulmonary, fibrosis, pneumonia, cancer, granulomatous disorder, obesity, pregnancy, pneumothorax, pleural effusion, kyphoscoliosis, emphysema (loss of lung tissue), Neuromuscular and neurologic (Guillain-Barre Syndrome, polio myelitis or myasthenia gravis), Pickwickian syndrome, and Pleurisy.

Obstructive Diseases:

• a) Is indicated by a reduced ratio of FEV!/FVC or FEV1/FEV6
• b) Airway obstruction is anything that causes narrowing or blocking of the Air passages that results in a decreased exhaled airflow. The causes of airway obstruction are as follows:
• Upper Airway obstruction: Rhinitis/ pharyngitis, Diptheria, Croup,
  Epiglottitis, Obstructive Sleep Apnea, Laryngeal paralysis, Tracheal
  stenosis, Tracheal malacia, Foreign body, Tetanus
• Lower Airway obstruction: Emhysema, Chronic bronchitis, Asthma, Cystic
  fibrosis, bronchiectasis, Bronchiolitis, Bronchial cmpression (tumor, lymph
  nodes), Endobronchial tumors, Foreign body, and Mucus plugging.

Significant reversibility: Is indicated by an increase in FEV1 of greater than 200 ml and greater than 12% from the baseline measure of inhalation of rescue medicine (Albuterol breathing treatment or 2 puffs Albuterol MDI).

Severity of abnormality of spirometric values: is evaluated by comparison of the patient's results with reference values based on age, height, sex and race.

Impairment: An assessment of the frequency of intensity of symptoms and functional limitations that a patient is experienciencing or has recently experienced.

Risk: is an estimate of the likelihood of either asthma or COPD exacerbations or of progressive loss of pulmonary function over time. Some degree of the risk of exacerbations can be obtained from the medical history and patient assessment. Patients who have had exacerbations requiring ER visits, hospitalization, or ICU admissions, especially in the past year, have a great risk of exacerbations in the future.

Dyspnea tolerance: The inibility of a patient to notice when he or she is dyspneic (feeling like he or she cannot get air in). Patients who perceive the degree of airflow poorly. Usually they are hardluck asthmatics who are short of breath so often they lose the objective means of perceiving degree of dyspnea. Or, patients who have unconsciously accomodated to their symptoms. Spirometry or peak flow monitoring are useful tools in monitoring asthma for these patients.

Percent predicted: This is a formula for determing the predicted normal for a person based on age, height and weight and body mass index. You can find a calculator for finding your percent predicted by clicking here.

FVC: The maximum volume (in liters) of air that you can exhale after taking in as deep a breath as you can. FEV1 and FEV6 are both calculated from the FVC. In severe cases where airway obstruction is present (asthma, COPD) the FVC may be reduced due to air trapping of air in the lungs.

FEV1:

(1)A measurement made during a spirometry test which measures the amount of exhaled air during the first second of FVC. One is considered to have "airflow obstruction" when this value is low in comparison to patient predicted. This measurement is considered the best way of diagnosing obstructive disorders
because it cannot be faked.

(2)The post bronchodilator FEV1 can be used to determine lung growth paterns over time.

(3) A low FEV1 indicates current obstruction and risk for future exacerbation.

(4) A baseline FEV1 (before using bronchodilator) that is lower than normal but that increases by at least 12-15% 15 minutes after inhaling rescue medicine (Albuterol) is indicitive of airflow obstruction that is reversible. This appears to be a useful measure indicating risk of exacerbations.

(5) Normal FEV1 is 80% of the predicted value. The predicted value is based on a formula using age, weight and height.

FEV1/FEV6: A measurement made during a spirometry test which measures the amount of exhaled air during the first six second of the meneuver. This test is used as a substitute for FEV1 in adults who have significant air trapping and who get "light headed" while trying to forcibly do spirometry.

FEV1/FVC: FEV1 expressed as a percent of the predicted value or as a proportion of the forced vital capacity. This appears to be a more sensitive measure of severity in the impairment domain, especially in children. It may be more reliable in assessing asthma severity in children as opposed to FEV1 because it is more sensitive.

FEV0.5: Used instead of FEV1 in children because some asthmatic children have a hard time exhaling for a full second.

FEV 0.75: Used instead of FEV1 in children because some asthmatic children have a hard time exhaling for a full second.

Percent change: This is used to determine how much a patient's lungs improve following a bronchodilator. % change =(post-test FEV1 - Pretest FEV1/ Pretest FEV1 X 100. An increase in expiratory flow greater than 15% indicates beneficial effects of the medication.

Peak flow meter: This is a device used to determine "how well your lungs are functioning," according to National Jewish Health. This is recommended as part of the asthma action plan for children and anyone who has difficulty perceiving asthma symptoms. It should be noted that peak flows are a great tool for monitoring asthma status, but should not be used to diagnose.

Diffusion capacity: The surface area of the lung where oxygen can 'get in' to the body is very limited in people with COPD. For example, in patients with emphysema, both the small air sacs (alveoli) and the small blood vessels (capillaries) that run past them are destroyed, leaving a smaller area for oxygen to come in contact with the oxygen-carrying proteins in the blood (hemoglobin).

"Diffusing capacity" refers to the capacity of the lung to release carbon dioxide and take in fresh oxygen. This lung function test measures the amount of area of the lung where oxygen can move into the blood vessels. It is performed much like the spirometry test, except that during this test, you breathe in a small amount of carbon monoxide gas. Carbon monoxide is used because it binds very quickly and well with hemoglobin and the amount is easily measured.

The test is usually performed during a single breath. To measure the diffusing capacity, you have to have certain minimal lung volumes and be able to hold your breath for a brief period of time. Also since diffusing capacity varies with the concentration of hemoglobin in the blood, the values obtained need to be revised if your hemoglobin level is not normal. (Definition by nbcnewyork.com)

Severity of obstruction: How severe is your asthma? How severe is your COPD? This can be determined by your pre-bronchodilator percent of predicted FEV1. Degree of severity:

• Normal: FEV1 80% of predicted value or greater
• Mild: FEV1 65-79% of predicted value
• Moderate: FEV1 50-64% of predicted value
• Severe: 35-49% of predicted value
• Very severe: FEV1 below 35% of predicted value

Degree of Reversibility: (as determined by pre and post bronchodilator FEV1):

• Slight: 15-25% change
• Moderate: 25-50% change
• Marked: Greater than 50% change
  
  Check back, because I will add to this as I obtain new information.

Biking with oxygen for the COPD cause

I wrote about Breathin Stephen and how he runs marathons despite his severe persistent asthma. I also wrote about Mike McBride and how he also runs marathons despite being an oxygen dependent COPDer.

Now we have Mark Junge, 66, who is also an oxygen dependent COPDer who is riding his bike on an "arduous" trek around the U.S. He said his wife drives the care and he rides his bicycle. In total, according to a column he wrote for the Wyoming Tibune Eagle Online, he has trekked 7,000 miles.

Of course he's doing this for the exercise, but he also has a purpose:

"Our mission is to alert the public to the problem of chronic obstructive pulmonary disease, or COPD, a catch-all term for lung ailments that many people do not recognize.Ever since that first transcontinental trip, I have noticed another pattern: The number of COPD victims is increasing.New York pulmonologist Dr. Neil Schachter writes that in little more than a decade, COPD will be the third-deadliest disease in the world behind circulatory problems and cancer. He estimates that COPD already affects 35 million Americans."

He also writes:

"Awareness of COPD comes when you see older men and women walking around with canulas attached to their noses, carrying oxygen bottles in backpacks or pushing carts with metal tanks. Some are not so obvious because they have transtracheal tubes implanted in their necks. Others camouflage their oxygen-dependency with custom eyeglasses.But I suspect that most oxygen-dependent folks are hidden from public view in homes or healthcare facilities. They are a segment of the population that is out of sight and out of mind, except to those who care for them."

He notes that he would also like to get the word out to to other COPD patients who are oxygen dependent that they can get out and exercise, and all they need is to talk with their care providers and get portable oxygen.

"It's pretty obvious that people who would benefit from portable oxygen do not get enough encouragement to be mobile in their lives...," he writes. "Mobility means freedom. Freedom means improved physical and mental health that lead to productivity. Individual productivity leads to societal productivity and so forth and so on."

What folks like Breathin Stephen, Mike Mcbride and Mark Junge do for the COPD and severe asthma community is show the rest of us chronic lungers that exercise is a must, and no lung condition should stop you from getting out and walking, jogging or biking. Just do it!

Related posts:
congratulations breathin' stephen and mike
breathin stephen's greatest accomplishment
2 chronic lungers in boston marathon

What's a good replacement for Intal

Every day at MyAsthmaCentral.com we get lots of asthma related questions. Below are some questions I thought my readers at the RT Cave would enjoy.

Question: my mom says i cant drink or eat anything cold cause it "affects my asthma"

My humble answer: I have never heard of hot or cold foods being listed on any asthma trigger list. For a current list of asthma triggers check out this link.

Question: does singulair have steroids in it and could it cause weight gain. would like to know for my daughter who just turned 6 and she has been gaining weight?

My humble answer: I have never heard of Singulair causing weight gain. For a complete list of possible side effects of this medicine check out this link.

Question: My asthma symptoms are only present when I run, do I need to take meds when I am not running?

My humble answer: Your doctor is wise. Advair is a medicine that works so well to control asthma that it may actually prevent your exercise induced asthma (EIA) from occurring. Most asthma experts now believe that EIA should be treated as any other type of asthma. Since you are having asthma symptoms while running, chances are you have some underlying (chronic) inflammation in your lungs that is only aggravated when you run, thus causing your asthma symptoms. If you treat this underlying inflammation, you may be able to exercise without asthma symptoms. Advair is a great medicine to not only treat this underlying inflammation, but prevent any bronchoconstriction (airway narrowing) that might occur when you exercise. You may also learn that after being on Advair a while you may not even need to use your Maxair anymore. But, as always, whatever you decide to do please talk with your doctor first.

On a side note here, I can tell you from personal experience that Advair works great. I use it to control my asthma, and I am now able to exercise without my asthma flaring up (most of the time). My advice to you is try it and see what happens. You may really like the results.

Question: Intal is being discontinued. Is there any alternative medicine I can use.

My humble answer: Intal was once a top line asthma therapy for treating inflammation and preventing asthma and it was very safe. In fact, for about 15 years I used it. In fact, I used it way back in the 1980s when it had to be taken with a spinhaler which has been obsolete for quite a few years now.

With the advent of newer asthma wisdom, and the advent of medicines like Advair and Symbicort that are better at treating inflammation and equally safe, Intal is no longer considered a top line asthma therapy. Intal works rather well, but you may find that trying medicines like Flovent, Advair, Symbicort or Singulair may work even better than Intal at managing your asthma.

Personally, while Intal worked great for me for years, I find that Advair works much better. However, I have learned that many people I talk to that are on Intal today are on it because they had a bad reaction to the above mentioned medicines. If this is the case, your best option is to work with your doctor to find the best available medicine to help you.

At least now you have some options you can discuss with your physician. For more information, here is an excellent post you should read.

If you have any further questions email me, or Visit MyAsthmaCentral.com's Q&A section.

Early warning signs of COPD

We asthmatics have a list of early warning signs of an impending asthma attack, and when we observe any of these signs we have an Asthma Action Plan that helps us decide what to do, what medicines to take, and when to call our doctors or an ambulance.

Since Chronic Obstructive Pulmonary Disease (COPD) is similar in many ways to asthma, there are similar early warning signs that you can watch out for. When you observe the following signs you know you need to take immediate action*:

• Increased shortness of breath with exertion (while walking or doing normal daily activities)
• Increased shortness of breath at rest (a sign of severe exacerbation)
• Increased cough
• Increased mucus production
• Increase in thickness of mucus produced
• Thick yellow sputum
• Chest tightness
• Increased wheeziness
• cold-like symptoms
• chest pain
• insomnia
• irritibility or restlessness
• fatigue or lack of energy
• general feeling of ill health
• ankle swelling
• unexplained increase or decrease in weight
• using more pillows to keep your head up to help you breathe at night
• sleeping in a recliner instead of a bed to help you breathe
• increased morning headaches
• increased dizzi spells
• Urinary incontinence

*I gathered this list from a variety of the best COPD websites and books and my own experience with COPD patients. However, my favorite list is the one at NationalJewishHealth.com.

What is a Goofus Asthmatic?

So, I've been doing a lot of thinking about what a goofus asthmatic actually is. I've described him as the asthmatic who does everything wrong, but how exactly do we define the phrase, "everything wrong?"

Ideally a Gallant asthmatic would avoid his asthma triggers. So does that mean if an asthmatic is allergic to dust that he is a Goofus Asthmatic if he is unable to keep up with the dust in his room. I mean, it's inevitable that it's going to build up there.

If that's the case, then I'm not a Gallant asthmatic at all. Like you, I'm a busy person. I work. I raise kids. I blog. I like to go out and have fun from time to time. And in doing all that I am inevitably going to be exposed to asthma triggers.

So what if I go to a restaurant and that restaurant has a smoking section. Sure I sit in the nonsmoking section, but you know you can still smell smoke. When you leave the place your throat is burning even though you were not even close to THAT section.

Is a Gallant asthmatic supposed to avoid restaurants with smoking sections? Is he not ever supposed to go to a bar with his friends? Is he never supposed to go camping where campfire smoke fills the air? I wrote about this in a recent post called: Asthma, hunting camp don't bode well together.

Think about it! How perfect do you have to be? Do you want to live in a bubble just because you have asthma? (I recently blogged thatAsthmatics can't live in a bubble). Do you have a completely allergy proof home? Not me. I have carpet. I have a big bed in my bedroom and I seldom dust under it. I would, but it's a ton of work. Call me lazy if you will (err, didn't I write that Jake Goofus was the lazy asthmatic? Eek!)

Am I a Goofus Asthmatic if I forget to take my Advair one morning? Or am I just a Gallant asthmatic who forgot? Well, then what if I forget two days in a row? Have you ever forgotten to take your asthma meds? I bet you have. So does that make you a relative of Joe Goofus.

You and I are asthmatics. We aren't supposed worry about perfection. What we are supposed to do is strive to be the best. We are supposed to take our meds and see our doctors regularly and otherwise be normal. Yep, asthmatics are supposed to be as normal as possible. Yes we can live normal lives. I do. Or at least I like to think so.

Yet we do have to never forget we have asthma. I think that's the most important revaluation for us asthmatics. We have to never forget. We have to Strive.

Perfection is not possible, and therefore Jake Gallant is merely a figment of my own imagination. For that matter, I bet Joe Goofus is a figment of my imagination too. I can't believe someone would be that much of a failure.

However, I bet most of us are closer to Joe Goofus than Jake Gallant. Yet, the goal for all of us is to keep up on our asthma wisdom and strive to be like Jake Gallant as I wrote about in this post: Being the best asthmatic you can be. So long as we strive we can maintain control of our asthma. Or is striving not good enough?

Quite frankly, asthma remains a conundrum; a riddle. Not even the worlds best asthma scientists know all the answers. Not even a lifetime asthmatic as myself does. Asthma expert or
not, I don't know all the answers? Do you?

Reversing a Bullying Culture

A dire situation is looming in the U.S. healthcare system. It has been noted that respiratory therapy dissatisfaction and related intent to leave the work environment and being powerless to do anything about it are believed to be key factors contributing to a significant increase in RT dry humor and a significant increase in RT complainers.

Moreover, exposure to incivility, including workplace bullying, particularly by RT Bosses, and lack of turnover, is one of the primary factors influencing RT dissatisfaction, and can be a reason why some leave the the profession altogether, or yearn to do so.

Evidence suggests workplace bullying by RT Bosses and related disruptive behavior are commonplace, and on the rise. The combination of a busy healthcare setting, difficult patient situations, and the requirement for interdependent relationships can serve as a breeding ground for incivility and bullying behaviors.

In response to a survey by the Joint Commission, more than 75% of RTs reported having been a victim of bullying and/or disruptive behavior by RT bosses at work, and more than 90% stated that they witnessed the abusive behavior of others.

Despite the subsequent Joint Commission Sentinel Alert requiring healthcare facilities to design and implement a system wide approach to ensure employee awareness of disruptive and/or bullying behaviors, bullying continues and still is perceived to be steadily on the rise.

The implications for RT's work environments are noteworthy, since the health and availability of RTs are vital for the provision of a safe environment for our most vulnerable population -- the patients we serve.

At the core of incivility and bullying seems to be, according to most RTs surveyed, complaint due to stupid doctor orders, or doctors who simply have no clue what the purpose of a bronchodilator
is.

"When we talk to our bosses about questionable therapies, they simply blow us off," wrote one of the surveyed RTs. "The comment we get most often is: 'we need these procedures so you can keep your jobs, so we hate to start cornering doctors and holding them accountable for their stupid orders."

Of the 75% of dissatisfied RTs, studies show 80% of them develop a keen sense of humor, as noted over at the Respiratory Therapy Cave and again over at Respiratory Therapy 101.

Dr. Ven T. Olin, president of the National Physician's Association of America noted that "all this extra humor in the hospitals has created an aura of lack of respect for physicians and RT Bosses by RTs, but thankfully no RT Bosses have the nerve to cross the physicians ordering stupid procedures for fear of losing procedure counts.

In a letter to this author, Mr. Olin noted, "if our RTs don't chart their procedures correctly, we expect RT Bosses to hound them until they become perfect. It's not something we want to do, but we have to do it."

So, instead of crossing the physicians, RT Bosses often cross the irritated RTs, and sometimes even become irate to the point of shouting. RT Bosses have been known to force RTs to be perfect, or suffer through humiliating notes that make them aware of all their flaws.

"Yes," Mr. Olin notes, "It happens at hospitals across the nation. It has been the beaming topic of RT blogs across the nation."

According to the joint commission, a committee is currently performing an extensive review in response to concerned RTs, and is currently looking for additional information about effective approaches to address these challenges.

COPD: What causes anxiety and tremors?

The following is a question and answer session from MyAsthmaCentral.com

Question: My mother has chronic COPD she is on a xopenex inhaler & xopenex liquid for a nebulizer. PLUS she is using Spiriva once a day & Advair twice a day. She is on oxygen 24/7. She is suffering tremendously from tremors, shakes anxiety attacks as well as panic attacks that simply exacerbate her inability to breath...... She is 70 years old & weight approximately 82 pounds! Her pulmonary doctor has all but told her she has to "deal with it & stop bothering him" this is after ONE office visit & a follow up phone conversation from her to him because she is scared to death....... Can these symptoms be being caused by too many inhalers/ albuterol products?

My humble answer: Wow! I can't believe a doctor would say that. Perhaps your mom should seek another doctor? I can actually understand where he might be coming from, but one would think he could be more tactful than that.

That said, great question. First it's important you know your concerns are not uncommon, and that developing tremors is a common side effect from both the Xopenex and the Serevent in the Advair. If your mom is taking systemic corticosteroids (or was recently on them), this too can cause tremors, as well as other medicines your mom might be on.

Xopenex is supposed to be the best bronchodilator available with the fewest side effects. So, if this medicine is working to control your mom's COPD, there really is no better alternative. You certainly wouldn't want your mom to stop taking a medicine that can help her catch her breath as well as this medicine can. You just want to make sure she is only using it when needed, or as prescribed.

I am not aware of any COPD medicine causing anxiety attacks or panic attacks. While it could possibly be the meds, another option worth discussing with your mom's physician is anxiety caused by the COPD itself. The "fear" of becoming short of breath -- or being short of breath -- has been known to cause anxiety. A lot of the COPD patients I take care of are on some type of anti-anxiety medicine like Xanax. This is perhaps an option your mom might want to discuss with her doctor.

I wish there was an easy answer to your questions, but there really isn't. I wish you and your mom the best of luck.

What causes COPD exacerbations?

The goal of health care providers in caring for patients Chronic Obstructive Pulmonary Disease (COPD) is to help them maintain a normal quality of life, and continue to be a productive member of society by using the least amount of medications.

Regardless of how well COPD is controlled, many COPD patients have worsening episodes of their symptoms, which is referred to as an exacerbation. Exacerbation's of COPD may include but are not limited to the following:

• Increased shortness of breath with exertion (while walking or doing normal daily activities)
• Increased shortness of breath at rest (a sign of severe exacerbation)
• Increased cough
• Increased mucus production
• Thick yellow sputum
• Chest tightness
• Increased wheeziness
• cold-like symptoms
• chest pain
• insomnia
• irritibility
• fatigue

If you start to notice any of the above listed above what you normally experience with your condition, then you need to seek medical advice immediately.

I can tell you front hand as an RT that those COPD patients who think their new symptoms will just go away on their own are the one's who end up most often being admitted, and having the greatest risk of requiring that a tube be inserted in their throat so we can help them breath and provide their lungs time to heal. Those who wait too long also have the greatest risk of death.

I have had many COPD patients experience what I described in the above paragraph and survive to tell me about. They all usually say something along the lines of: "Never again will I wait that long to come in."

They learn to be gallant COPD patients: see their doctors regularly, take their medications compliantly, know and avoid things and places that trigger their COPD, make necessary lifestyle changes, and call their doctor at the earliest signs of trouble (see list above).

My advice as a respiratory therapist to all my COPD patients is just that: Know the early warning signs of an exacerbation, and call your doctor right away. By doing this, your doctor may be able to treat you from his office and prevent your condition from getting so bad you have to be admitted to the hospital, or rushed to the emergency room by ambulance, or worse.

Be a responsible COPD patient, and know the early warning signs.

That said, there are various things that might cause or contribute to an acute episode of COPD, or contribute to poor COPD control. The following is a list that you should also be aware of:

• Continued Smoking (we have smoking cessation programs available for you)
• Bacterial infection (pneumonia) (the #1 cause of COPD exacerbation's)
• Viral infection
• Weather changes (this triggers exacerbations of asthma too)
• Cold weather (be wary of any temperature under 50)
• overexertion (do you get short-of breath doing normal activities)
• increased inflammation of unknown origin
• airway obstruction (You've tried your rescue medicine to no avail)
• poor compliance with medicine (you feel good so you quit taking it)
• improper use of inhalers (This is very common. For proper method click here)
• Poor hygiene
• Poor education about disease
• Lack of desire to make necessary lifestyle changes (quit smoking, make home free of things that trigger COPD, such as dust mites, molds, wood smoke, cigarette smoke)
• Refusal to see a physician (Perhaps the most important after quitting smoking)
• Refusal to exercise or attend pulmonary rehab (exercise increases your chance of living a normal life. It also strengthens your heart and lungs)
• Denial (Very common. To get help you first have to seek it)
• Depression (Also very common and very treatable)
• Anxiety (Likewise very common.)

Most of these can be treated by the methods listed in this post, "strategies to treat COPD".

The most common ways of treating exacerbations of COPD is with systemic corticosteroids, increased use of bronchodilators such as Xopenex, Albuterol or Duoneb, and possibly antibiotics. If your COPD can't be treated out of your doctor's office, it is very common for COPD patients having exacerbations to be admitted to the hospital.

Most exacerbations last for only a few hours to a few days, depending on how long you wait to see a doctor, and the severity of your disease, and the actual cause of your exacerbation.

Some of my patients I see on a yearly basis. One such patient I've come to know and like (He's a Happy COPDer). He often jokes, "Yep, I've come in for my yearly recharge."

If you have COPD, keep in touch with your doctor. Let him know immediately of any changes, and follow what he says to a tee. Likewise, stay up to date on your COPD wisdom by hanging our right here, at the COPDConnection.com, or by reading blogs of famous COPD patients like yourself such as COPD News of the Day and Roxlyn's Blog.