All the lab values RTs need to know

The best RTs I've ever met study patient charts at the beginning of every shift, and make recommendations as needed. You never know when the doctor or nurse might be missing something.

As an RT I love to know what high and low lab values indicate. I also like to know what they indicate from my own perspective. You never know when your mother-in-law is going to call you for some medical advice pertaining so some lab result.

Therefore, I like to keep the following information close by just in case:

Lab tests & possible reasons for abnormal results:
(Critical values in parenthesis.)

1. CK: greater than 200 (greater than 351-2000 critical) = Muscle damage (nonspecific)
2. CKMB: greater than 2.5-3.0 (greater than 5.5) = Heart muscle damage
3. Troponin: greater than 0.1 (greater than 0.4) = Heart muscle damage (most specific)
4. ALK: greater than 136 = Liver or bone damage
5. ALP: greater than 150 = Liver or bone damage
6. AST: greater than 37 (greater than 200 critical) = Liver tissue damage (nonspecific)
7. ALT: greater than 65 = Liver tissue damage (Specific for Hepatitis)
8. Biliruben: greater than 1.0 = Liver cell damage (best indicator of liver function)
9. Albumin: greater than 5.0 = Dehydration (best indicator of liver function)
   less than 3.5 (less than 1.5) = Liver disease, shock, malnutrition
10. Gamma-Gt: greater than 51 = CHF, liver damage
11. BNP: greater than 100 = CHF = heart failure (300=mild, 600=mod, 900 severe)
    OK = 125-450, less than 75 YO = 125, less than 75 YO = 450
12. Glucose: greater than 120 (greater than 350) = Diabetes (greater than 150 = insulin protocol) less than 90 (less than 40)= Liver failure if not on Insulin (sepsis?)
13. GFR: less than 60 (less than 29 critical) less than 15=Kidney failure
14. BUN: greater than 18 (greater than 45 critical) = Kidney problems, CHF, shock, stress MI, dehydration, GI bleed less than 07 = Severe liver disease, malnutrition, over-hydrated
15. Creatinin: greater than 1.7 (3.0 critical) = Kidney probs, dehydration, CHF, shock
16. Sodium: greater than 145 (greater than 160 critical) = Dehydration
    less than 136 (less than 120) Kidney disease, over-hydrated (edema), not
    eating well, CHF, effects of Lasix, diarrhea, vomiting
    sweating. (less than 126=critical, confusion, lethargy, seizures)
17. Potassium: greater than 5.1 (greater than 6 critical) Kidney failure, massive tissue trauma, (post op), metabolic acidosis (diabetes), dehydration. less than 3.5 (less than 2.8) = Not enough in diet, gastro-intestinal disorder, vomiting. Due to Insulen, Lasix, dig, steroids?
18. Magnesium: greater than 2.4(greater than 2.7) = Kidney failure, dehydration, diabetic acidosis less than 1.3 (less than1.0 critical) Malnourished (low intake), elderly, alcoholism, long-term diuretic use, diarrhea.
19. Chloride: greater than107 = Dehydration, met acidosis, hypoventilation (alkalosis)
    less than 98) = When Sodium low
20. Calcium: greater than 10.1 (greater than 13) = Bone breaks, prolonged bed rest, etc.
    less than 8.5 (less than 6) = Bone disease, malnutrition, alcoholism
21. PTT/ PT: greater than 33/ greater than 12.7(greater than 60/greater than 40) = transfusion, therapeutic, DIC. PTT is one of the best measures of liver function. less than 24/less than 10 = Impaired clotting ability
22. INR: greater than 1.2 (greater than 6) = Acute bleed, DIC or therapeutic.
23. Fibrinogen: greater than 450 = Risk for heart disease (checked often) less than 160 (less than 70) = Acute bleed, liver disease, malnutrition, DIC
24. D-Dimer: greater than 500 = DVT, PE, DIC, acute bleed, surgery, trauma
25. Platelets: less than 80,000 = bleeding problems, Heparin, DIC alcoholic, leukemia (Vitamin K increases clotting)
26. Phosphorus: greater than 4.1 (greater than 8) = Liver disease, Kidney failure, bone mets. less than 3.0 (less than 1.1) = Diabetic Keto-acidosis
27. Uric Acid: greater than 7.0 = Acidosis, alcoholism, diabetes, Kidney failure
28. Folic Acid: less than 2.0 = Malnutrition
29. Lactic Acid: greater than 19.8 = Hypoxia, O2 deprivation, shock, CHF, tissue death increases when organs failing/dying (sepsis?)
30. LDH (Lactate Dehydrogenase): greater than 136 (greater than 350 critical) = Nonspecific Tissue damage or death
31. Osmology greater than 300 = Dehydration
32. Hematocrit: greater than 47 = Dehydration
33. Keytones: Positive test = Diabetes, starvation, vomiting, increased metabolism (fever, severe illness).
34. Neutrophils: greater than 48-73% = increased levels of bacterial infection (acute)
    a. Segs greater than 60 if new infection
    b. Bands greater than 2% = worsening infection
35. Eisinophils: greater than 2% with allergic reaction (associated with asthma).
36. Lymphocytes: greater than 18-48% = may indicate viral infection (mono, measles, pox)
37. Basophils: greater than 2% = allergic reaction

Check back from time to time, as I will probably add to this list.

For a printable cheat sheet with this information and more, click here.

The plight of an artist and a writer

Why am I up so early in the morning you may be thinking? I doubt you care why? An idea struck me that I had to record, and now I can't remember what. Then as I was writing by the dim lights overhead I heard a loud, "Wah! Wah!" from the bedroom next to the living room.

Now my 11-month-old is happy and giddy on the couch next to me playing with the credit cards she stripped from my wallet. She took a few gulps from her bottle I warmed up, but at the present time that lies askew... oops, now it's time for another gulp... now it's cast aside nonchalantly... now she wants this dad...

Well, I started out writing gook. Sometimes I (we bloggers) write gook, but this blog post turned out to be pretty good. Yet sometimes when we writers look back on what we write we realize it deserves to be filed in cabinet #13, which in the blogosphere is equivalent to the delete button.

Sure most of what we write is normal blah, blah, blah. Yet, occasionally, one can't help but to write something worthy of immortality, yet one cannot judge his own creativity. I suppose that's
why Aunt Dike, who preferred to be called Leota when she turned 90, for some reason would toss her work in the trash and why grandma would pick it out of the trash for posterity purposes.

I suppose I should crop this post out and tape it to the backside of Aunt Leota's painting grandma gave me that grandma said she plucked from her sister's file cabinet #13 and I now have on my wall in my basement. My grandma said it was an awesome drawing and she appreciated it. Yet she said her sister decided long ago it was trash.

Obviously I appreciate it too. I wonder if Aunt Dike would be proud or if she would say "It's just gook like this post you're writing."

Actually, however she thought of her own art, she would never tell me mine was gook. And the only reason she'd file anything in file #13 is because there's an old saying regarding any one with artistic or creative talent: If you did it once you can do it again and better.

That's what I have to remind myself every time my blogger fails to save and I lose everything I've written over an hour, or my word processor fails, or if the power goes out. If you did it once, you can do it again and better. That's the best wisdom we can come up with for the day, gook or not.

I suppose the moral of this post is you yourself are your biggest critic. In fact, I've heard that about artists too, that they keep editing and editing and editing because they want to make it better, and then when they look at it again they feel the need to trim some more.

I think that's normal for we artists, whether we work with words or paint and pen or even chalk as my Aunt Leota did. The truth is, most of what we write is probably better than what we see in our heads as we read it. And, I suppose, that's why it's best to write and let it sit a month so we can view it as though it were someone else's creation.

And, sometimes as I'm reading my own creations, that's exactly how it feels: as thought I'm reading your writing and not my own. How does this stuff pour out anyway?

Can you be short of breath while sleeping

Can a person be short of breath while sleeping comfortably?  I was always under the impression that the answer was no. Yet tonight I was called to do a breathing treatment because the nurse thought, "well, he just sounds like he could use one."

"So is he short of breath," I asked over the phone.

"Yes," she said.

Yet, when I arrived, the patient was sleeping.  "He's sleeping."  I stated the obvious.

"Yes.  He's short-of-breath while sleeping."

"Is that posible?" I asked. 

I listened.  "He has good air movement, a sign that he's not in bronchospasm.  And he's also snoring."

After the treatment the nurse said, "Does he sound better?"

"He's still snoring," I said.

To be honest, I can't imagine being able to sleep while being short-of-breath.  I know I couldn't do it. What do you think?

Bronchodilator is not an anti-inflammatory medicine

I know that headline is stating the obvious, yet you'd be amazed at how many bronchodilator breathing traetments I give on patients suffering from an inflammatory disease. 

Okay, so your thinking:  "Well, aren't asthma and COPD often associated with pneumonia?"

Yes, they are.  Yet those diseases are also associated with a bronchospasm (tightening of the bronchial muscles) that is often reversible with a (ahem) bronchodilator (hence the word broncho-dilate).

It is not an inflammatory medicine.  It does not treat the following inflammatory diseases:

1. Pneumonia
2. Bronchiolitis

Those illnesses are better treated with either antibiotics or anti-inflammatory medicine such as corticosteroids.

ABG on neonate? Gobble! Gobble!

I always choose to work the Thanksgiving Holliday due to the fact it's usually not busy.  Most doctors work overtime to send as many patients home as possible.  Last night, however, was the exception to the rule.  ER wasn't so bad except for the 10 EKGs, but OB gave me a challenge near the end of my shift.

We had an exceptionally nice rental neonatologist and she kept ordering things that not only were not indicated, but were not done where I work.  Yet because she was so laid back I was able to cross the line a little bit.

Even though the pt had an SpO2 of 94%, the doctor wanted me to put 1lpm nc on the patient.  She said that even though I already had the oxyhood set up.  However, I said, "That patient has a sat of 94%, that's perfect!"

"Yeah, but I want it at least 95%." 

Why?  That goes against NRP recommendations.

"I would feel more comfortable just using the oxyhood," I said, "We don't have neonatal flowmeters here."

"Why not.  This is neo ICU is it not?"

"Our neonatologists like oxyhoods. If you work here more often we'd set up any equipment you wanted."  I smiled.  What else was I to do. 

She spent ten minutes putting in an art line, and by the time she was done I had a syringe for the ABG draw I didn't even think was indicated.  But she said, "I don't want you to draw off this.  I'm afraid it will clot off."

So why the heck did you put it in then?

"I want you do do a CBG," she said.

"We don't do CBGs here."

She grimaced.  "Why not.  Why you not have CBG equip?  Why?  You scared?"

"To be honest," I said, "Dr. Harry told me a few years back CBGs aren't beneficial."  I bit my tongue due to the verbal slilppage of the tongue due to lack of sleep.

"That okay.  Draw ABG then?"

"Why don't we just draw it from the line?"

"I don't want it to clot."

Since we never do those in OB, I had to go get a needle for the syringe I had in my hand.  I had no intention of drawing it, though.  In fact, I wasn't sure what I was going to do.  Stall!  Stall! 

"You can draw it," I said to the doctor.  "I bet you're pretty good."

She was palpating the radial pulse of the baby, so I thought she was going to do it.  Then she handed me the syringe and, as she was walking away, said, "Just don't hit the central line."

By this time my relief showed up.  I handed her the syringe, "Have fun!"

"I'm not dong it.  I didn't even think you could draw ABGs on neonates.  I never heard of it."

"That's my sentiments exactly." 

"Happy Thanksgiving!" I said. 

"Happy Thanksgiving!"

A BiPAP Q&A session

I've been getting a lot of questions about BiPAP*recently, so I thought I'd take some time to answer your questions about this wonderful machine. You can learn the basics of BiPAP by cliciking on the link above.

1. What are the best initial settings to use on a critical patient?: I think most RTs will agree that the best setting to start a patient on BiPAP is an IPAP of 10 and an EPAP of 4, and to titrate to the patient tolerance from there. I think that's a good rule of thumb. FiO2 should be set as low as possible to maintain an acceptable saturation, usually around 90%.

2. What is the risk of refusing a BiPAP machine?: Actually -- ironically -- I just got called to set up a BiPAP on a patient who has refused it the past three nights. He's still alive, but barely. There are a lot of patients who refuse to have that mask over their faces, and I can understand that. But when it is used and tolerated, it can do a lot of good. In the case of this patient, it is needed to keep his lungs open and to provide some CPAP to keep his oxygen level up. His SpO2 at present is 55%. His CO2 is high also, and the IPAP would help to give him better tidal volumes to blow off some of that CO2. So, the risk for this individual is actually death. Sure the BiPAP may be inconvenient and uncomfortable, but it can be a life saving machine.

This particular patient was a DNR. If he wasn't, the risk of refusing the BiPAP would mean that to oxygenate and ventilate this man we would have to insert an ETT in his throat and to his lungs and hook him up to a ventilator.

Most patient who require a BiPAP do so for other reasons. For instance, sometimes a BiPAP machine is recommended to prevent desaturations while sleeping and to treat sleep apnea. If the BiPAP will allow you to stay oxygenated while sleeping, and keep you ventilating while you sleep, the alternative could mean that you will be risking death.

3. Is it hard to get used to BiPAP?: I asked this to all my patients who tolerate it or grow to love it and just
about all of them say it is hard at first, but the machine helps them to feel so much better than they quickly learned to tolerate it. I find that the new BiPAP machines (like the Vision in the picture) work so well with the patient, and the new masks are so comfortable, that most patients tolerate it quite well. I guess my point here is that I recommend to RT departments to splurge and get the best BiPAP machines and the best masks available, it's worth it.

4. What kind of BiPAP machine is best?: I highly recommend a high quality BiPAP machine like the Vision as opposed to a machine that is made to be used as a Ventilator but also has the BiPAP option like the LTV 1200. Sure the LTV has BiPAP, but it's not near as good as machines made to be used only for BiPAP. The Vision is also very easy to set up. I'm not trying to sell the Vision here, it's just the BiPAP machine we have, and I love it. If you have a BiPAP machine you love, list it in the comments below.

5. Are BiPAP machines in hospital different from those used by patients at home?: Yes. When a patient is admitted to the hospital for a reason other than for a respiratory related issue I recommend that they bring their BiPAP machine from home. Their home machine is tailored to fit their face, and they are also used to it. We have gone out of our way to get the best machines and masks, but they are never as good as what patients have at home. Now, if a patient is admitted with respiratory distress, I like to use our machines so we can control the settings a little better, watch graphics, and set alarms. Basically, the in-hospital BiPAP machines have more bells and whistles.

6. Do BiPAP machines prevent people from needing a ventilator?: Yes. I find that there are many patients who, if they tolerate the BiPAP, can prevent themselves from needing to be placed on a ventilator. In fact, since we purchases our Visions five years ago the number of ventilator cases has diminished by almost 80%.

7. At what point do you take a patient off the BiPAP to intubate?: That's a good question. You will want to ventilate any full code patient who absolutely cannot tolerate or refuses the BiPAP and continues to fail. A BiPAP can even be used on a DNR patient. If they continue to fail despite the BiPAP, then you will have no choice but to intubate. However, it is possible to set a rate on the Vision. But as a rule of thumb, if the patient has no rate, ventilate.

8. What patients other than sleep apnea is BiPAP good for?: BiPAP works well for CHF, COPD and even asthma. I have seen it work wonders for all three diseases. While some studies show that CPAP should be used for CHF and BiPAP for COPD, I recommend skipping the CPAP an jumping right to BiPAP. That way you can control the patients oxygen with the EPAP and his ventilations with the IPAP. Great machine.

9. When should BiPAP be discharged?: That depends on what you are using it for. If you are using it because the patient came into the ER in respiratory distress, then you can take it off as soon as the patient is able to ventilate on his own, and oxygenate with just supplemental oxygen. Basically, you only want to place a patient on a machine like this only to rest their lungs to help them get over the hump. Once the patient is able to ventilate and oxygenate without the machine they should be taken off of it. However, if the machine is being used to oxygenate and/or ventilate a patient while he is sleeping, it may be required permanently. However, a patient should regularly see his or her physician, and if the patient progresses enough to no longer require the machine it can be discharged. An example of a patient no longer requiring it would be a 400 pound man who lost 200 pounds and no longer had sleep apnea. However there may be other reasons for discontinuing this machine.

Any further questions or comments please emal me or leave a comment below. To read about indications for BiPAP, click here.

*Note: BiPAP is a patented name or a brand name. Ideally this device should be referred to as non-invasive positive pressure ventilation (NPPV).

Related links:
What is CPAP and BiPAP
My interview with Roxlyn Cole

My DR. giving me the runaround. What can I do?

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: I have a weird feeling in my upper back prior to asthma attacks. Is this something to be concerned about?

My humble answer: Here is a list of common early warning signs. While most asthmatics have one or more of these sighns before an asthma attack, every asthmatic also has signs that are unique to the individual. For example, when I'm about to have an attack my chin and throat itch. One of your signs MAY be a weird feeling in your upper back. If this precedes every asthma attack you have, then this might be true for you.

Question: My tonsils are enlarged and I have nasal congestion. I want to see my doctor, but he seems to give me the runaround. What can I do? I'm now using my rescue inhaler 6-10 times a day. I also take decongestants.

My humble answer: While I can't diagnose you over the Internet, nasal congestion can drip down into the lungs and cause asthma. And, perhaps, if you work with yoru doctor on treating the nasal congestion, this might prevent your asthma episodes. Another thing to consider is what is causing your congestion. Is it something you can avoid?

Unfortunately asthma is a tricky disease this way, and it's not always easy for doctors to know exactly what to do to help you.

On a side note, you have to remember that you are the boss and your doctor is working for you. If you feel he is not living up to your expectations, you have a right to seek a second opinion or another doctor in general.

Good luck.

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

Is it safe to overuse Advair when pregnant???

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: I am pregnant and have used Advair about 5 times, should I be worried?

My humble answer: According to the FDA Advair is a medicine that you should NEVER use more often than twice a day. However, there are ongoing studies to see if using it more often is safe.  We'll have to wait and see what the results are.  In the meantime, it's best to not use Adviar more than recommended.

A medicine in Advair called Serevent is long acting bronchodilator and it can cause some severe side effects if used too often. It has been linked to death, and one of the theories is when it causes death this is due to overuse of the inhaler. If you are having trouble with your asthma you should use your Albuterol inhaler as a quick relief medicine and NEVER take your Advair more often than recommended.

If you have any of the following rare but serious side effects of this Advair seek medical help:

• chest pain
• fast/slow/irregular heartbeat
• severe dizziness
• fainting
• seizures

For more information, check out this link and this post.

If you are having trouble with your asthma I highly recommend you call your asthma doctor or go to the emergency room. There are great medicines that can help you to feel better quick.

Likewise, in the future you may want to discuss with your physician how to control your asthma to prevent an asthma attack, and what to do if you have one. You should also work with your doctor on creating an asthma action plan.

For information about the effects of asthma medications on your unborn baby check out "A Concern for Expectant Mothers: Are Asthma Meds Safe For My Baby?"

Question: I can't get my peak flow meter above 150 and I also have a cold. What should I do?

My humble answer: What you need is an asthma action plan. You can read about what this is and how to implement one here.

In the meantime, I highly recommend you call your asthma doctor and get in to see him immediately. If you don't have a doctor, if his office is closed, you should consider having someone drive you to the emergency room. There are great medicines that can get you felling better if you seek help.

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

The new worldwide asthma community

When I was a kid growing up with hardluck asthma it seemed as though I was all alone in my plight. It seemed this way, I suppose, because I was the only one in my family and among my classmates with a similar ailment

When I was admitted to the asthma hospital in 1985 I learned that I was not alone, that there were lots of asthmatics just like me, and a lot of hardluck asthmatics too.

Especialy in the period before the Internet it was difficult for asthmatics to get together. Now, however, thanks to the blogosphere, no asthmatic should feel isolated.

Hey asthmatics! You are not alone!
by Rick Frea Sunday, September 27, 2009 @ MyAsthmaCentral.com

It might take another chronic lung-er to understand why I say this, but one of the best days of my life was when I realized I was not the only hard-luck asthmatic in the world.

To this day I still think it's neat to know I am not alone. Just last night at work I was called to the emergency room for a "difficult breather." I rushed down and found one of our regular asthmatics sitting on the edge of the bed gasping for each breath. After two Xopenex breathing treatments, a shot in the butt of systemic steroids, and an hour of waiting for the steroids to start working, she said, "I feel much better."

I said, "So, how often did you use your rescue inhaler at home?"

She bowed her head, as though she were ashamed, and said, "Well, I'm afraid to say this, but I usually go through about an inhaler a week."

"I can understand that," I said. "I used to go through about that many inhalers or more for about 20 years."

Her eyes lit up. "Really!" she said, "I thought I was the only one."

"Nope! You are not alone."

Why is it that so many asthmatics think they are alone? I think it's because usually there is only one bad asthmatic in a crowd. That was pretty much the case in my family, as I was the only bad asthmatic in the generation. I wrote before how I used to be a bronchodilatoraholic. I did not abuse the medicine, but I certainly used it so much I thought I held the record for most puffs in a lifetime. At least I thought I held that record until I discovered Breathin' Stephen's blog.

Another thing I did quite a bit when I was having trouble breathing was open my bedroom window late at night when my chest or throat was tight and take in a breath of fresh air. I never understood why, but that air always seemed to provide a modicum of relief. It got to the point in order to get to sleep I had to have the window open, no matter how cold it was outside. Later on I started using a fan. In fact, I became so addicted to having a fan on me at night I eventually needed the soporific drone of the fan to help me get to sleep whether I was tight or not.

I was alone in this love of cool night air and fans, right? Wrong! When I was in respiratory therapy school I met a fellow hard-luck asthmatic who also required a fan to sleep, and to breathe easier. Later on, when I became an RT, I realized this was not just something common among asthmatics, but many with chronic lung problems. Now, as soon as a chronic lung-er comes into the ER, the first thing I do is get him or her a table to lean on and fetch a fan. Many confess as I do that, "I use one all the time at home too."

Another neat thing: chronic lung-ers usually have the room nice and cool, whether via an open window in the winter, or the air conditioning cranked on high in the summer. In fact, if you ever work in a hospital and walk into a room that is ice cold, you are probably safe to assume that patient is a chronic lung-er: either an asthmatic, COPDer, someone with cystic fibrosis, or the like.

Now, one might ask: Is this a mere coincidence, or is there some reason people who have experiences being short of breath like fans and a cool breeze upon their faces? I can't remember where I read this, but some magazine about ten years ago had an article about how your face has receptors that are responsive to the wind. When the wind hits these receptors your lungs dilate ever so slightly. I have never seen any information about this since. It's a nice theory of mine I like to share with my patients who "have to have a fan."

My point here is that it's an awesome feeling for any person to realize that he or she is not alone. You are not alone. Thanks to the Internet, the world is a lot smaller today compared to when I was growing up with asthma. Thanks to the Internet, to great Web sites like this, asthmatics like you and me can come together and share asthma stories. Despite this smaller word, however, I still take care of lots of chronic lungers who love it when I discuss my experiences as an asthmatic, and quite often I get that look of glee as they say, "You do that too!"

"Yep," I say. "You are not alone."

You are not alone either.

Is it greener on this side of the fence?

I have to confess that the profession of RT is not the most lucrative careers, however it allows me ample time to appreciate the little things, to write, to spend with family, and to afford decent allergy free roof over my family. While I think I might benefit to jump over the fence to greener pastures where RTs are better utilized, I completely understand why one would stay on this side of the fence.

Stupid doctors can keep us RTs very busy

With his briefcase in hand the pharmacist passed me in the hallway. It was 9:30 at night and I knew he was  scheduled to clock out at 8 p.m.

"Heading out finally?" I said.

"Yep," he said as we progressed to the staircase. "It's amazing how one patient can keep you so busy so long."

"Or one stupid doctor," I said ruefully.

He laughed. "That was a good joke."

"Oh, I'm not joking," I laughed. I really wasn't.

He was still laughing as he exited the building. It is amazing how one stupid doctor can keep you busy all night long, or one lazy doctor if you don't like me calling a doctor stupid.

Tonight we had a good example of this, as the patient was extremely labored when admitted to ER. After several bronchodilators and BiPAP she was finally feeling much relief. She was even feeling well enough to joke about getting up and walking out.

And, ironically, she was off the BiPAP for 20 minutes during and after the transport to her room, and she was satting well and doing just fine. Not only that, she had gone six hours without a breathing treatment and she's still feeling fine.

Yet, I look at the chart and find out that the order says to continue the BiPAP and give breathing treatments every 2 hours.

This is one case I wish the patient would simply refuse therapy, but she's nice and she won't. So, because the doctor was too lazy to come in and assess the patient and order stuff she really needs than stuff out of habit, I'm going to be really busy tonight.

Yep, one patient can keep us busy. Yet, one stupid doctor can keep us even busier. I'm sure the admins will smile, however, when they see all the procedures I do tonight, whether those procedures are needed or not.

Treatment stacking

All RTs must understand the rules of treatment stacking. It's not ideal, but sometimes we RTs have no choice.

So, what is treatment stacking you ask? Let's make up a definition:

Treatment stacking: Giving breathing treatments to more than one patient in more than one patient room. You'll be leaving one patient unattended while treating another.

Part of being a good RT is staying in the patient room, doing a great assessment, and chatting with the patient. That's part of the fun of being an RT too: getting to know our patients.

Likewise, I hate leaving my patients unattended during a treatment. I hate it because when I was a kid I'd be alone in my room and I'd look forward to my RT visiting me. I hated RTs who left the room, or stayed in the room and paid me no attention. So I try my hardest not to do it.

So, ideally we should not stack. However, sometimes we have no choice.

Note: you must never stack treatments on any of the following patients:

1. Any patient in respiratory distress
2. Any patient with a compromised heart, or a heart you do not trust.
3. Any child who needs constant observation (any child)
4. Any unstable patient
5. Any patient that just doesn't look right

That said, you also should not stack unless you have a valid reason to do so. For example, where I work I'm the only RT on duty working nights. If I have several treatments due at 10:00 p.m. and ER has been paging me like crazy, I will stack as appropriate. Another good example is an RT working for a larger hospital who is given 50 patients all on treatments.

Another good example is if you have been at a code, or busy in the ER, and it is now 10:15 and you have several 10:00 treatments to do, and now you are way behind.

However, as a general rule of thumb, you must never leave the room of a patient you do not know. If you have been off for several days and don't know your patient, then it's a good idea not to leave the room. If you get a new admit, you should stay with that patient until you get to know him or her.

The following are patients you may consider stacking:

1. You have determined with relative certainty the treatment is not indicated (Lord knows there's plenty of these to go around)
2. You have a patient who is stable and takes treatments at home.
3. You have a patient who's comfortable taking treatments alone.
4. The patient is on a heart monitor and in the critical care unit (a place where the patient is being constantly monitored.

I also notice that some hospitals require no stacking, and also that the RT stay in the room for 10 minutes. If that's the case then you'll have to follow policy. However, there will come certain situations where you'll find yourself needing to stack, and now you know the proper way to do it.

Likewise, it is my humble experience that a treatment does not last 10 minutes. Ideally, a good assessment and treatment can be completed in less than five minutes tops. So if you're in a hurry, do the treatment right, but don't waste time in the room -- make every minute count.

COPD associated with anxiety, depression

Anyone who works as an RT will definitely see a ton of patients with COPD (Chronic Obstructive Pulmonary Disorder). It's a disease that slowly progresses with time and can cause not just breathing discomfort but also forces one to make some drastic lifestyle changes.

Being short of breath, or the fear of it, can cause anxiety. Not wanting to quit living your life and knowing you must, and knowing you have a disease that might some day take your life, can be depressing.

NationalJewishHealth.org explains this all too common situation best:

In most cases, COPD completely changes a person's life and it is hard to adjust to a new way of being in the world. You may have been active for all of your life and now you can't do the things you once enjoyed. You most likely feel slowed down, have lost much of the spontaneity you used to have.

Dragging oxygen around, sleep problems, and fatigue make it difficult to just pick up and go. You may be self-conscious about your oxygen or a chronic cough and become reluctant to go out in public. Many people miss doing the things that made their life fun like traveling, dancing, gardening, walking, spending time with family and grandchildren. Consequently, they can feel like a burden on their family.

These are important losses that must be grieved just like losing a loved one. It is normal to feel angry, afraid, sad, depressed, guilty, stressed and frustrated with all of the changes. It is critical to allow yourself to feel all of these things even when it is uncomfortable. Using the support of others will also help you feel less alone in dealing with these changes. Adjusting to an illness is a process and will not happen overnight. Be patient with yourself and learn more about coping with your emotions.

National Jewish explains there is a region in our brains that detects that there is enough oxygen in our blood. When there is not enough oxygen, or there is something wrong with the air around you, this region sends out an alarm that causes you to feel anxious.

So your anxiety is perfectly normal. National Jewish explains COPD anxiety this way:

With COPD, you regularly have trouble breathing and your suffocation alarm can become "hyperactive." You might feel anxious and edgy. Even little changes, like strong odors or being hurried, can fire off a full suffocation alarm signal. This is the reason that patients with COPD frequently complain of increased episodes of panic and anxiety. This response is common and does not mean that there is something wrong with you mentally or emotionally.

Thankfully there are medicines and even counseling that can be used to treat anxiety.

Depression is the other bugger. I'm sure we've all been depressed at some point in our lives, and it's no fun. COPD makes it hard to sleep for some patients, and that can even add to the dilemma. It can have you feeling disconnected, hopeless and lost.

According to National Jewish depression is something that must be treated:

Depression is a miserable experience that leaves us feeling disconnected from our lives and often without hope that anything will ever feel better again. When depression is left untreated, it drains both your brain and your body. You not only feel bad, but you also have less energy to do the things you want to do, including taking care of yourself and managing your COPD. It can also make you feel hopeless - as if things will never get any better - and then you might not want to bother following your treatment plan.

Thankfully both anxiety and depression are treatable, yet first help must be sought. Usually, however, a proactive approach by the medical care team is the best way to treat COPD related anxiety and depression. I'll discuss this on Nov. 26.

How do RTs spread nosocomial diseases?

Every week I check my statcounter to see who's typing things into Google or Yahoo and being linked to my RT Cave blog. Assuming the queries were not answered, I provide in this spot each week my humble responses.And, hey, if the query is comical, it deserves a comical response. If it's serious, I treat it as serious. That in mind, here are this weeks queries:

1. hospital low census: The hospital I work for has such a low census the admins are extremely worried. In fact, Jane Sage wrote a post last month about how she respects the way the admins here at Shoreline have been able to keep this place afloat despite the low census. Why is the census low? You'd think there'd be sick people no matter what, and that's true. Part of the problem fewer people are having elective surgeries. Fewer people are electing to have testing done, such as stress testing, labs and the like. These outpatient procedures, and these surgeries, are the bread and butter for the hospital. Hopefully soon the economy will pick up and the admins will have this stressor off their backs.

2. beer and asthma: Beer and asthma don't really bode well together. I think the main reason is beer dries out you lungs. I find that when I go out and drink I almost always have some degree of breathing difficulties the next day.

3. can i mix ventolin and symbicort: Yes. You can still use your rescue inhaler when on Symbicort. The rule is that you NEVER use your Symbicort (or Advair) more than twice a day. Albuterol can be used as often as you need it, or as prescribed by your physician. However, if the Symbicort is doing its job, you shouldn't need your Ventolin very often. If you continue to need your Ventolin when you're on Symbicort you should make sure your doctor is aware of this.

4. symbicort for aspiration wheezing: Symbicort is used to treat and stabilize inflammation in the air passages and prevent bronchospasm. It is not meant to help with aspiration pneumonia.

5. using ventolin in a humidifer: I suppose you could do it, but I can't imagine other than in the mind of some quacky doctor in a fiction tale that it would do any good.

6. can people fake respiratory failure: Believe it or not I've suspected it on more than one occasion. I think if you quit taking your meds, run around the house a few times, and call the ambulance while you're having your asthma attack you might be able to fake it. I think this might be easier to do if you had COPD. I don't know why anyone would want to do it, but it is possible.

7. is symbacort simalar advair: Yes. The two medicines both have a long acting bronchodilator and an inhaled steroid component.

8. how respiratory therapist gives nosocomial diseases?: We don't wash our hands, pick our nose, and touch every patient in the hospital. We share germs. Isn't that the way to do it? Isn't that fair? I don't think we purposely share germs, but there probably are some RTs who don't wash their hands and use proper hygiene and therefore inadvertently spread germs and cause nosocomial diseases. Likewise, we RTs are taking care of patients all over the hospital, and therefore we come in contact with an array of patients with an array of diseases. The best recommendation for preventing nosocomial diseases is hand washing.

9. croup xopenex: My gosh it's used all the time for this by one particular ER doctor here at shoreline, and it never does a thing.

10. nebulized decadron: I gave this once for an adult allergic reaction that caused a croupy cough and stridor. I think studies are inconclusive as to whether it does any good.

If you disagree or agree with my opinion feel free to leave a comment below, as we are all entitled to an opinion. If you have further comments or questions, feel free to write it below or email me.

You can have asthma and still go to hunting camp

If you're like me you don't let your asthma stop you from doing anything you like to do -- within reason of course. Yet you'll want to be a gallant asthmatic as opposed to a goofus asthmatic in your efforts.

In my recent post at MyAsthmaCentral.com I write about the sorry adventures of Joe Goofus and the successful hunting trip of Jake Gallant.

Goofus and Gallant take their asthma to hunting camp
by Rick Frea Saturday, October 10, 2009 @MyAsthmaCentral.com

I'm sure you remember Joe Goofus. I introduced you to him as the asthmatic that often neglects his asthma with the intent on not missing out on any of life's fun. His most recent misadventure was last weekend at the Goofus family hunting camp.

And guess what? He ended up in the emergency room again. His asthma was so bad he ended up spending 10 days in a hospital bed. He was pretty bored, I heard, being stuck in a bed while his friends at camp had a blast.

You'll also remember Jake Gallant. He's that asthmatic -- like you and I -- who does everything right. He went to camp too, only he followed all the best asthma advice and maintained good control of his asthma.

What follows are 10 things Joe Goofus did wrong to end up in the hospital, followed by what Jake Gallant did right to be able to handle camp:

Joe Goofus quit taking his preventative medicine: In August his asthma was doing so "awesome" that he decided on his own he no longer needed to take his Advair and Singulair. What a goofus!

Jake Gallant knows it's never wise to stop taking your asthma preventative meds. So when he arrived at camp his lungs were well armored and ready to take on just about anything.

Joe Goofus premedicated himself: That's right! A few days before camp he decided to put himself back on his Advair and Singulair to get his body ready for the inevitable asthma triggers that are at camp.

Jake Gallant followed his doctor's orders. Likewise, he knew that it takes 2-3 weeks for asthma preventative medicine to get into his system, so it's best not to stop taking them even when he's feeling well.

Joe Goofus forgot his rescue inhaler: You know it. His asthma was doing so "awesome" that he didn't bother to take his albuterol inhaler with him. When the asthma beast hit in the middle of the night he had no relief and he started to panic.

Jake Gallant carried one rescue inhaler in his pocket at all times. Likewise, he also had a few backups in his suitcase that he knew would be easy to find.

Joe Goofus hung out with the smokers. There was a great game of Pinochle in the cabin, only just about every one of the card players had a cigarette or cigar lit. "Oh, well," Joe said to himself, "I'm sure I can handle it for just one night." Well, there are enough asthma triggers at hunting camp, the last thing he needed was to breathe in cigarette smoke. He should have stayed away from the smokers, or requested they not smoke while he was around.

Joe Goofus slept with old, musty, dusty bed linen. He didn't think to bring his own bed linen, and therefore had to create a makeshift bed in the musty cabin out of bed linens that had been lying around for decades. The asthma triggers were abounding in them, and by 2 a.m. he woke up with a tight chest and wheezes.

Jake Gallant stayed in a clean camper with clean bed linens. He planned ahead. He knew he wouldn't last in that old cabin for a whole night.

Joe Goofus forgot his flashlight. It was the middle of the night. He couldn't catch his breath, was anxious, and now he was starting to feel panicky as he tried to find his way to his car where his portable nebulizer was stored. He knew if he got there he'd get some relief.

Jake Gallant had a flashlight under his pillow. When he woke up wheezing in the middle of the night he reached for his flashlight, flicked it on, and used it to find his inhaler that was right where he left it on the bedside table. If he needed it, he'd be able to easily find his way to his car and his portable nebulizer (there's no electricity in the cabin).

Joe Goofus got drunk. He was still buzzing when he woke up, and struggled to even find his car where his nebulizer was. Then, he fumbled with his nebulizer and couldn't get it to work. Then he realized he needed to plug it in. Then he plugged it in and the darn thing still didn't work. He was very short of breath and started to panic. Then he remembered he owned a Dodge Ram, and Dodge products need to be turned on to supply power to things like his nebulizer. He then thought about driving to his home, but he feared he'd get in trouble for buzzed driving. The Goofus Asthmatic had to sit in his car struggling to breathe until he sobered up. It turned out to be one of the worst nights of his life.

Jake Gallant had only a few drinks. He knew that alcohol dries out your lungs and can make it hard to breath. That, coupled with the smoke from the fire and all the other asthma triggers in the woods, was the last thing he needed to deal with. Plus if his asthma started getting worse he could get in his car and leave.

Joe Goofus ended up in the emergency room. He was unable to gain control of his breathing on his own. He had no choice but to have a friend drive him home shortly after noon the next day.

Jake Gallant enjoyed his camping experience. He avoided smoke the best he could, he dressed for the weather, and he had warm, clean place to sleep.

The moral here is if you want to spend time at camp this year with the guys go ahead and go for it, but be a wise asthmatic like Jake Gallant. Don't be a Goofus like Joe Goofus.

Pregnancy and asthma meds

Often in my line of work I come across an expecting mother who is also asthmatic. A question I often receive is: "Are the meds you're giving me safe for baby?"

The answer is: It depends. I did an extensive study on this and reported on it in my most recent post on my asthma blog over at MyAsthmaCentral.com. There's lot's of great asthma wisdom over there, so I highly recommend you click on the link and transfer yourself over there.

A Concern for Expectant Mothers: Are Asthma Meds Safe For My Baby?
by Rick Frea Thursday, August 06, 2009, @ MyAsthmaCentral.com

She was a young asthmatic seated on the edge of the ER bed, and was leaning on the table to breath. Her lips were blue and she was in obvious respiratory distress. She said, her words choppy, "I'm pregnant. Don't hurt my baby."

"The medicines we are giving are safe," the nurse said as she gently inserted a nasal cannula to supply the patient with a low flow of oxygen. The asthmatic's lips pinked up.

Since Ventolin is a top line therapy for treating acute asthma symptoms (it relaxes lung muscles and can rapidly make it easier to breathe), I opened up an ampoule and prepared a breathing treatment. As I did this, the doctor said something that impressed me "There might be a slight risk from some of the medicines we are going to give you, but getting you to where you are breathing better is our top priority right now. If you're baby isn't getting enough oxygen because you're not, that's far worse than any risk from medicine I might give you."

I was impressed because the doctor was exactly right. To verify my feelings here, as soon as the patient was feeling better, I returned to my office and opened up a book on my desk called Allergy and Asthma: Practical Diagnosis and Treatment.

In Chapter 18, Dr. Peg Strubb writes:
"Patients need to be reassured about the safety of asthma medications and advised that the risks of treatment are much less than the risks of untreated asthma. Concern about side effects in the fetus may interfere with medication adherence and lead to undertreatment of asthma."

The following are the most commonly used medicines to get asthma under control:

1. Supplemental Oxygen: It may be needed to make sure the mom -- and baby -- are being adequately oxygenated during the asthma exacerbation in the ER. In the womb, babies require about 1/4 as much oxygen in their blood as mom. An increase in mom's oxygen intake may affect the acid-base balance babies need to thrive. On the other hand, if mom's asthma is so bad she's not getting enough oxygen, neither is her baby.

2. Bronchodilators: Strubb agrees with the asthma guidelines in noting that bronchodilators should be used sparingly. The package insert for Ventolin notes that some studies show an increased risk of cleft palate (less than 5%), although the studies are questionable. Thus, according to the package insert, "No consistent pattern of defects can be discerned, and a relationship between Albuterol use and congenital anomalies has not been established." Likewise, the insert confirmed what our ER doctor said, that this medicine should be used when "potential benefits outweigh the potential risks to the fetus." In the case of this patient, the benefits certainly outweighed the risks as the medicine helped her breath easier.

3. Long-Acting Bronchodilators: Studies for these medicines are inconclusive. Yet, while these meds are in your system for longer periods of time than short acting bronchodilators, Strubb said the recommendation is to use this medicine as an adjunct with inhaled corticosteroids to control asthma "if asthma remains poorly controlled."

4. Inhaled Corticosteroids: Strubb notes this is the current "cornerstone of therapy for the pregnant woman with persistent asthma. Multiple studies have emphasized the decrease in asthma exacerbations" with this medicine. Despite concerns, no study to date has shown any "unfavorable perinatal outcome."

5. Oral (systemic) Corticosteroids: Strubb notes that if taken in the first trimester, this medicine may increase the incidence of cleft palate 0.1% to 0.3% (according to studies). It also may decrease birth weight "approximately 200g, although without an increased incidence of small for gestational age infants." The goal for therapy is to use this medicine to "treat poorly controlled, severe, persistent asthma or for the treatment of asthma exacerbations. On occasion, a short course of oral corticosteroids may be necessary to gain control of asthma." Our asthmatic was given a shot through the IV of Solumedrol while she was taking the breathing treatment.

There are some other options for pregnant women with asthma:

Cromolyn Sodium: This medicine is considered safe to use during pregnancy. And, as Dr. Strubb writes, "It is considered an alternative but not preferred option for mild persistent asthma."

Theophylline: It is considered safe at therapeutic levels and is a viable -- although not preferred -- option for pregnant women.

Leukotriene Blockers: Singulair, for example, is a leukotriene blocker. Studies are limited, although this medicine appears safe for pregnancy.

Atrovent: Atrovent is a bronchodilator. Considered safe for use by expectant mothers. However, Dr. Strubb says it should not be used except in emergency rooms, as it is not a top line therapy for treating asthma.

By the time I completed my research I was called back down to the ER to educate this young lady how to use a Ventolin inhaler with a spacer. The nurse came in with instructions for her to "make sure she sees her doctor regularly to maintain good asthma control."

And, just before she was sent home with a prescription for prednisone, she thanked me for helping her breathe easier.

So what we've learned here is this: the risk of not treating your asthma can be far worse for you and your baby than the risk of any meds used to treat your asthma.

Trip to Florida with three kids

Well I just got back from my yearly vacation to Florida. I don't normally go this time of year, but last February I had a new baby at home and the wife and I decided it was better to postpone things. It was hard waiting so long to take a break, but in the end it was worth it. We had a great time.

My parents live in Florida not far from Orlando. They live on a gated community for folks 55-years-old or older. It's a rather new community, as all the homes are less than 10-years-old. What makes it stand out (and why my dad chose it) is that the homes are wrapped around an 18 hole golf course. The houses closest to the course have nets to stop the balls from hitting the houses. Although a few years ago when I went there the nets didn't stop my balls. I actually had to quit because I hit too many houses.

We don't normally go to Florida in October. In fact, it actually felt weird leaving Michigan when there was no snow on the ground. Usually we take this trip in February, although with a new baby at home back then traveling 22 hours in a minivan was the last thing we wanted to do. And it wasn't necessarily the baby that stopped us from going either, it was the 6-year-old-full-of-energy-and-hates-to-sit-for-long-periods-of-time girl. We figured as soon as the baby fell asleep the 6-year-old would have one of her fits. So we postponed.

The trip to Florida was uneventful until we got into Florida. By this time traffic was so slow it took us an extra two hours to get to my folks. We figured the delay was due to all the snowbirds going south for the winter. Other than that the ride was not too bad. We stopped every 2-3 hours to give the kids a break. Actually, we usually kept driving until my baby decided it was time to stop.

I have to tell you, though, that we're thinking of always going to Florida now in October. The weather was so much more tropical than in February. When we go during the winter we usually go swimming only once, and usually that's when the air and water are technically speaking too cool to be swimming. Yet, being from Michigan, we tough it out.

In October the weather was 85 degrees every day, and we went swimming in nice warm water every day. There was one day we went to Disney during the day and when we got back to the resort (we stayed at a Disney resort during this trip for three nights) I declared myself dad of the year and took my two older kids swimming at 11:00 at night. It was also raining that evening, but it was sooooo warm.

We stayed at my parents one night, and then we decided to get a Disney resort this year. My wife got some kind of deal. Normally it costs $500 a night, and we stayed for $500 for three nights. Still it was a lot, but it was worth it.

I'm more of a follower, but my wife is one of those Disney nerds. She knows every thing about Disney -- all the tricks. When we arrive there are long lines. She got a tip once that people in America tend to move to the right. So, if you go to the left the lines are shorter. We usually are through the ticket booths before most people even budge in their respective lines. It's kind of neat how that works.

Then we get into Disney and we get a fast pass to whatever the main ride is, and then we go to the other rides until it's time to use up our fast pass. Another tip is that wherever you like to be most, whatever section of Disney you like best, you should go there first, because it's not as busy early in the morning.

And, for lunch, we usually make a reservation at one of the restaurants that allow you to enjoy a buffet while your kids get to meet certain characters. Of course everything is expensive at Disney, and eating in these places is even more expensive. At Disney we take our kids to the Crystal Palace where they get to meat Winnie the Pooh and friends. If I remember right, lunch was $25 an adult plate (and my 11-year-old son was considered an adult). While the kids and my wife were concerned about meeting the characters and taking pictures of such, I was busy getting our money's worth of food. I'm telling you I never left one of these places without my stomach sticking three feet out and my belt loosened to make room for it. Yet I was a happy trooper upon exiting. Plus it was nice to sit for a while.

We ended up going to one of these places somewhere in Disney three times. We went to the Crystal Palace in the Magic Kingdom and I can't remember the place in MGM Studios (I guess it's now called Hollywood Studios) and then again on my baby's first birthday at Micky's something at one of the more attractive Disney resorts. This is where the kids met Mickey, Minnie, Donald, Daisy and Goofy.

Another advantage to paying for these places is you get to go on rides instead of waiting forever in the parks to meet the characters.

Now, here's a tip I have for any one who is interested in going to Disney with kids. I highly recommend you skip all the parks except the Magic Kingdom. The Magic Kingdom has a bunch of rides the whole family can go on and there are a ton of them. You never have to just stand around. The other parks have fewer rides, they are far apart, and the rest of the stuff they have are shows that you have to attend at certain times. The shows are boring for adults (at least me), and the kids usually fight over where to go next. With my son being 11 and my daughter 6, you can see why there might be some anxiety. I felt bad for the boy because most of the places we went were for really little kids. Although he was a champ.

So, my tip is to skip all the other parks and just go to Magic Kingdom. The exception is if you go alone with our spouse or adult friend. If you want to go on a good date, or getaway at Disney, Epcot is the place to go. We didn't do this this year due to lack of time, but we did a few years ago and it was great.

Whatever Disney location we go, we usually try to go when there is a night parade. You have never seen a great parade until you see a parade at Disney at night. If nothing else it's an amazing light show. Of course to get a good spot you have to be in Main Street about an hour before the parade. You'll have to find a spot on a curb and sit there all that time. Not fun to do with kids. This year the boy and I saved the spot while the girls shopped. It's worth it though, in the end, to have a good spot on the curb -- trust me.

However, this year we were too late to get a spot on the curb and ended up sitting against one of the shops. The parade is up high, so this spot turned out to be just fine. However, with a spot way back here I had to hold my daughter so she could see. Thankfully an elderly man let my daughter stand on his scooter so I didn't have to hold her.

With temperatures at 85 degrees nearly every day this trip to Florida I will have to say was one of the best ever. It may have been the best since our honeymoon

Reason for most needless treatments

Some RT departments have RT driven protocols. This, one would think, would be the ideal way of preventing needless therapies. However, most RTs who work at hospitals that have such protocols note that, "I discontinued the therapy only to come in the next day to see the order was rewritten."

Either that, or senior RTs refused to discontinue un-needed therapies. Why would this be? Well, the answer appears to be obvious: It's called criteria. In order for the hospital to get reimbursement, certain criteria needs to be met. At least this is according to my RT Boss.

For example, if a patient is admitted with pneumonia, most insurance companies (and the government) will not reimburse the hospital unless a breathing treatment is ordered. By golly, if a patient isn't sick enough to need a bronchodilator they don't need to be admitted.

This is funny (irritating would be a better word), because some person in Washington who had no clue what he or she was doing made this decision, when the truth is that bronchodilators have no effect on the inflammation in the alveoli that pneumonia is. Bronchodilators don't even get down into the alveoli.

Regardless, this pretty much explains some of the stupidity. This is why we have a pneumonia protocol (order set I call it) that requires all pneumonia patients to receive Q6 hour Ventolin.

Yes this is frustrating, but it's the way it is.

The carbon copy blue bloater

You'd think with only five patients on my clipboard I'd have an easy night, right? Wrong! I have five very highly demanding patients. And, the funny thing is, they are all exactly the same. In fact, they all seem to be carbon copies of the other.

Yeah! Tonight I have the carbon copy patients. They all have or are:

1. end stage COPD and lung cancer
2. blue bloaters
3. severe dyspnea with even minimal exertion
4. members of the 50/50 club (chronic po2 50 and co2 50)
5. basically bed bound or recliner bound
6. severe anxiety
7. severe restlessness
8. highly demanding
9. somewhat annoying after a while
10. challenging
11. enjoying to talk with
12. exceptionally cordial and pleasant underlying dispositions
13. insist you stay in the room until their treatment is done
14. want you to stay in room after the treatment is done ("Please, don't go!")
15. clock watchers
16. want their treatments every two hours
17. require BiPAP to catch their breath
18. refuse to wear their BiPAP most of the time
19. call to have BiPAP hooked up when they get panicked
20. demand you increase their nasal cannula liter flow at their request (one insists on the liter flow being 10lpm even though he's wearing a nasal cannula)

Only five patients. I did enjoy the challenge.

COPD blogs and resources

I preach over and over again that if you have a lung disease you must keep up to date on that disease. You must, in a sense, become an expert. This is especially true if you have COPD.

There are some sources for COPD wisdom on the Internet I utilize on a regular basis. Yet, as a search the web I find tons more. Below I'm going to list the COPD resources on the web that I use plus some others people have referred me to.

If you want me to add your site to this list, or if you have a sit you use that you think would benefit others like you, please email me or leave a comment on this post and I will add it to this list.

1. Roxlyn's COPD blog
2. COPDConnection.com
3. COPD News of the Day
4. COPD and so much more
5. Living out loud with COPD
6. About.com COPD blog
7. Love your lungs, breath for life
8. COPD Alert (community support and advocacy group)
9. Lung care cure community
10. Breathing: Your guide to living well
11. COPD Support1.com
12. Guide to quitting smoking (American Cancer Society)
13. COPD Support
14. National Heart Blood Institute (What is COPD?)
15. American Lung Association
16. National Jewish Health (COPD)
17. CPAP, Sleep apnea, snoring

Books

1. COPD for dummies
2. 100 questions and answers about COPD
3. Some more books here
4. Coping with COPD: Understanding, Treating, and Living with Chronic Obstructive Pulmonary Disease
5. The Chronic Bronchitis and Emphysema Handbook
6. Asthma and COPD, Second Edition: Basic Mechanisms and Clinical Management (For medical people or for those who want more indepth information)

Your RT Queries: How do you treat thrush?

Every week I check my statcounter to see who's typing things into Google or Yahoo and being linked to my RT Cave blog. Assuming the queries were not answered, I provide in this spot each week my humble responses.And, hey, if the query is comical, it deserves a comical response. If it's serious, I treat it as serious. That in mind, here are this weeks queries:

1. can atrovent be given q2: Absolutely. This is a very safe medicine that can be used Q2 hours and even continuous if needed in the emergency room. However, I wouldn't recommend using it any more frequently than Q4 at home. You really should have no reason to use it more often than that. If you do, you ought to be calling your doctor.

2. can a albuterol inhaler cause high co2 in your blood?: No. Albuterol in no way is related to CO2. Albuterol is a bronchodilator that relaxes the air passages in your lungs and can make it easier to breath.

3. would symbicort stop croupy cough?: Symbicort is a medicine that is meant to be taken no more often than twice a day and is not recommended to be used for acute asthma symptoms. Symbicort will not relax the muscles in the throat and should have no effect on croup or a croupy cough. However, some asthmatics get a croupy cough as one of their signs of asthma, and if this is the case a rescue medicine like Albuterol might help. Again, symbicort should never be taken more often than twice a day (BID).

4. advair substitute: Symbicort is the best substitute for Advair. There are also some generic Symbicort inhalers available.

5. ippb therapy: My co-writer for this blog is going to write a post for the RT Cave stating that IPPB is good in some rare cases. So, stay tuned!!!

6. ventimask 50% bad: It depends. If 50% FiO2 is required to maintain an SpO2 of at least 90% then this can be a good thing.

7. atrovent in tx of croup: I can find no documented evidence that Atrovent does anything for croup. However, if you can find any such evidence let me know and I will publish it on this blog.

8. can i smoke while on ventolin: Yes you can. Smoking is good for your lungs and is highly recommended, especially if you have asthma. Just Kidding! Of course you should stop smoking if you need to use Ventolin. Smoking is a trigger of both COPD and asthma and any doctor wouldl highly recommend you quit.

9. white stuff growing on roof of mouth inhaler: Sounds like thrush. This is a common side effect if you are using a steroid inhaler. This can be prevented by rinsing your mouth after each use. It can be treated by calling your doctor and getting either a pill or a rinse. I prefer the pill because you only have to take it for four or five days. For more information click here. I mention the medications that will help here.

10. respiratory therapist who became a physician: I think I've written about this before, that I think RTs would make the best doctors. I highly recommend every doctor step on the RT rung of the ladder on the way to the more prominent career of physician.

If you have further questions for me please contact me.

Weekly asthma FAQ

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: I have been getting recurring pneumonia, could this be from advair?

My humble answer: You are not the lone person to come up with this idea as there has been much written on it, as is the case with this post here and this link here, and this one, and again here in this study. However, this study shows budosenide (an oral corticosteroid siilar to that of which is in Advair) does not cause pneumonia. So, I would imagine more research will be needed to come to a conclusion either way. The ideal thing for you to do is continue talking with your physician to make sure that the benefits to using this medicine outweigh the risks. In most studies, Advair (and Symbicort too) have been proven to be very effective for managing inflammation for asthma and COPD patients.

That aside, there are certain things you can do to try to prevent getting pneuonia that I describe in this post here: "Pneumonia: here's what you can do to prevent it."

Question: What in the body happens to cause asthma?

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.

Question: I have asthma and taking 4 life transfer factor as remedy. i was told by a friend that he has taken 4life transfer factor pills for his immune system and that his asthma has gone away . is this 4 life product as good as they say it is ?

My humble answer: I can neither deny nor confirm this claim. However, I'm sure if this worked to "cure" asthma it would be all over the news and on the front pages of this site. You have to realize that asthma has a tendency to appear to "hibernate" for weeks, months, and sometimes even years. It may be a coincidence that your friend started taking this 4 life transfer factor at the same time his asthma went into hiding. However we want to remain open minded, so the best thing for you to do if considering this is to discuss it with your asthma doctor and continue to keep up on your asthma research for the latest asthma wisdom.

Question: Coughing lots especially at night. Sometimes it leads to vomiting. My doctor says I just have a cold. Is he right?

My humble answer: We really cannot diagnose over the Internet. It is not completely abnormal for a coughing spasm to lead to vomiting and a headache. A common cold can cause nasal drainage which would induce a cough. Bronchitis, asthma, and a lung infection may also cause increased sputum production and induce a cough. Which one of the above is causing your symptoms is something only your doctor can determine.

Question: I am 25 yrs old girl I always get breathing problem whenever i cry a lot or get tired. Is this a symptom of Asthma?

My humble answer: Actually, what you are describing is not a symptom of asthma. To see what the symptoms of asthma are click here. That said, emotions can be an asthma trigger. Asthma triggers are things that can "trigger" an asthma attack. To learn more about asthma triggers click here.

There are some things you can do to help prevent emotions from effecting your asthma. First, you should discuss this with your asthma doctor. Second, you might want to learn and work on some relaxation exercises. When you get emotional you can work on "relaxing" and this can help prevent this from causing asthma.

Better yet, setting aside 5-15 minutes each day to concentrate just on relaxing your body might prevent emotional asthma altogether. Trust me, I've tried this and it works great.

When I was a teenager I had asthma that was triggered similar to what you describe here. Whenever I was tired, stress or anxious I'd have trouble breathing. Fortunately I knew a great asthma nurse who taught me some great relaxation techniques. One I mention in this post, although this post describes relaxation techniques better.

You should also mention this to your doctor, because he or she might have some more ideas that might help.

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

The link between asthma and COPD

A doctor told me once that if you have childhood asthma that doesn't go away when you grow up you are said to have COPD. As a former child asthmatic. He also said once, "If you ever smoke I might as well just kill you."

I think about what he said often. Recently I decided to do some research.

I've learned that most of the time when we refer to COPD (Chronic Obstructive Pulmonary Disease) (COPD) we are referring to people who smoke. This is rightly so because, according to nationaljewishhealth.org, 94% of those with COPD are people who smoked cigarettes.

That said, there are still 5% of COPD patients that often go unaccounted for. Almost 1% of these get COPD "by genetic-based deficiencies in an enzyme called alpha-1 antitrypsin," according to National Jewish.

The other 5% get COPD either get the disease from "exposure to various types of dust such as coal, grain, or wood or by recurrent or significant lung infections in infancy and early childhood."

People with asthma are among those most likely to be hospitalized with lung infections, and therefore asthmatics fall into this 5% too.

So now we see where the slight overlap of Asthma and COPD comes into play (see picture). A small percent of asthmatics, if their asthma is not controlled appropriately, can develop lung scarring over time that results in permanent lung damage that can cause them to have chronic persistent asthma/ COPD.

It is these asthmatics who are your hardluck asthmatics (I think). It is these asthmatics who are staged to become your bronchodilatoraholics, and who require the use of rescue medicine on a daily basis.

I have written here before how I have a need for my rescue medicine on a daily basis for relatively mild symptoms, and have to constantly be vigilant for my asthma triggers because my lungs are "more sensitive" than the lungs of most asthmatics.

I also learned that asthma is often misdiagnosed as bronchitis. From my medical records I've learned I had frequent bouts of "bronchitis" before I was 2. Chances are I was misdiagnosed, because I was diagnosed with asthma when I was 2-years old. Plus there were lots of asthma attacks. All of this, I bet, caused my asthma to get as bad as it did.

Keep in mind here I'm just speculating, but it makes sense to me. To be honest, I don't think even the worlds formost asthma experts would know exactly why asthma sometimes gets so bad. Although there are many theories.

There is a small area where the circles of asthma and COPD overlap (again, see picture). I would guess that less than 10% of asthmatics fall into the COPD category. Yet I've read in "Egans Fundamentals of Respiratory Care," that anywhere from 15-70% of those with COPD have the asthma gene.

From my own asthma history and from my recent research I've learned two things I would like to share with my asthmatic readers.

1. Childhood asthma is better diagnosed and better treated today as compared to when we were kids. So chances are our asthmatic kids won't get as bad as we are, and won't push their asthma into the COPD category.

2. If you had asthma as a kid you better never touch a cigarette. If you do you're playing with fire (literally), as you are risking pushing your asthma into the COPD category, as I would imagine the Recovered Asthmatic is doing.