My answers: How do you fake a wheeze?

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. cold temperatures cause problems in copd: It's true. Cool, dry air tends to irritate already inflamed airways inducing an exacerbation of COPD. To prevent this problem you can wear a scarf over your mouth if you need to go out in the cool air. This happens with asthma too, and usually doesn't occur until the temperature is under 50 degrees.

2. how to fake wheeze: Well, believe it or not people do fake asthma. Do do so you just make a forced exhalation. What you hear, though, is not a bronchospasm wheeze, but a throat wheeze. A good doctor, nurse or therapist can always pick up on a fake wheeze.

3. a day in the life of a respiratory therapist: Hang out here and you'll learn a lot about what it's like to be an RT. You can also check out some of the other blogs I've linked to on the right. If you want to learn more you can here.

4. do i need to use ventolin if i'm using symbicort: In the United States it is recommended you never use Symbicort more than twice a day. However, I've learned that in Canada there is another program which allows Symbicort to also be used as a rescue inhaler. It's called the Smart Program. You can read about it by clicking here. As far as I know this has not been approved by the FDA for use in the United States. It is perfectly safe to use Ventolin while using Symbicort.

5. where is rhonchi in the lungs: Rhonchi is secretions that sit in the bronchioles (large air passages) in the lungs. Rhonchi is a low pitched continuous sound you hear as air travels through the secretions. Coming soon to the RT Cave will be a lungsound lexicon, so stay tuned.

6. beer asthma: Hmmm, this sounds interesting. Well, actually, if you drink beer it can dry out you lungs and act as an asthma trigger. Seriously.

7. okay to give xopenex and atrovent at the same time for copd: Yes. Xopenex and Atrovent are quite commonly prescribed to be given together. They can also be mixed in the same nebulizer treatment.

8. primitine mist: As far as I know this is no longer on the market. I wrote about it here.

9. swine flu vaccine get it or not: I highly recommend getting it especially if you have a lung disease. If you have a child under 18 I would recommend discussing with your physician getting the single use syringe which does not have mercury. I wrote about this here.


If you have further questions for me please contact me.

The best Asthma, COPD blogs & websites

The following are all the asthma, COPD, and other chronic lunger blogs and websites on the web that I am aware of, and in no particular order. Keep in mind that theese blogs are written by folks like you and me living with lung diseases, or family members caring for people like us.

Most of the websites were likewise created by folks like you and me with the intent of providing you with information and communities to broaden your wisdom and share your experience.
Here's the list:

Asthma blogs:

1. Breathin Stephen
2. The asthma mom
3. Hold your breath to breathe
4. I inhale steroids
5. Life with these lungs
6. wrong end of stethescope
7. Coughs & sneezes
8. Wheezytux
9. Asthma advocate
10. Angry asthma mom
11. Brittle asthma
12. Catching our breath
13. Life with brittle asthma
14. Not all right half left
15. Asthma Girl
16. All roads

COPD blogs:

1. Roxlyn Cole/ /COPD
2. COPD NEWS
3. Spit Happens
4. A chronic dose
5. Rare lung mom
6. Miculka Madness

Other blogs:

1. Beyond Allergy
2. Please Don't Pass the Nuts

Other useful websites:

1. Quit smoking kit
2. AAAAI - American Academy of Allergy Asthma and Immunology
3. Asthma Guidelines (National Heart and Lung Institute)
4. COPDliving.com
5. huff-n-puff.net/newforum (interstitial lung disease support)
6. Living with COPD.org
7. notallrighthalfleft.blogspot.com (asthma blogger)
8. Spit Happens
9. COPD Pulmonary Rehab
10. love your lungs, breathe for life (COPD community)
11. About.com COPD (COPD blogger)
12. Stemcellpioneers (stem cell treatments for lung diseases)
13. Breathing better living well (COPD, chronic disease resource and community)
14. AnxietyConnection.com (Sure, chronic illness can lead to anxiety)
15. Lung care cure community (lung disease community and resource)
16. Stop smoking connection/COPD (Source for all your COPD wisdom)
17. My allergy network (Source for all your allergy wisdom, community)
18. My asthma central (Source for all your asthma wisdom, community)
19. COPD-alert.com (COPD community and great resource, community)
20. healthsquare.com (Great place to learn about any drug on the market)
21. breathing magazine
22. Daily Med: Info about meds
23. COPD Support
24. Guide to quitting smoking
25. How to recognize asthma
26. Allergies and asthma
27. What is asthma
28. Allergy notes
29. Healthtalk/ asthma
30. COPD support
31. What is COPD
32. American Lung Association (all the basic information you need)
33. Guide to albuterol
34. National Jewish (the asthma hospital, great information about asthma/COPD)
35. CPAP, Sleep Apnea, snoring
36. Arthur – Lesson Plans – Buster’s Breathless
37. Asthma Action Plan (Asthma.ca)
38. Asthma in Schools
39. Asthma Society of Canada
40. Battle for the Bronchs
41. Canadian Lung Association
42. Recognizing the Severity of Asthma Attacks
43. Teen Asthma by the Children’s Asthma Education Centre
44. TeenAsthma.ca
45. The Children’s Asthma Education Centre

If I'm missing your blog, or a website you think deserves to be on this list, please leave a note in the comments below and I will it. This is your time to self advertise, or to market your favorite sites.

The best Respiratory Therapy Blogs for 2010

The following are all the Respiratory Therapy Blogs and Websites I'm presently aware of, and in no particular order:

1. Respiratory Therapy Cave
2. Jeff Whitnack's RT Page
3. RT Corner
4. Ventworld
5. wildwynd
6. Becoming an RT
7. RT Care: KISS
8. asthmadaytoday
9. Breathing your best
10. In My Opinion
11. breath harmony way
12. Consciously breathing
13. Respiratory Graduate
14. RT e-blog
15. Respiratory Links
16. Sputum happens
17. RT Scribe
18. Trauma Junkie
19. Heidi's happenings
20. Intubate Em!
21. Alpha Trauma
22. Five of Peep (Pediatric RRT)
23. RT Student Blog
24. Respiratory Report
25. Rhonchi
26. Sleepy RT medic
27. Breathing through school
28. Snot jockeys
29. RRT with ADD
30. Respitatory Therapy 101
31. Respiratory Therapy Driven
32. G's spot
33. Sometimes I Breathe
34. RT student
35. Respiratory Terrorist
36. Pulmonary Roundtable
37. Respiratory Therapy Blog
38. Respiratory Report
39. RT Magazine
40. Advance for RTs
41. AARC Resources
42. EKG similator

If you know of one I'm missing, or you have one of your own (new or old), please let me know and I will add it to this list.

Chevy Chase Vacation Syndrome

So we're not really on vacation, yet days off work are almost like a vacation. And when a dad like me tries to do fun things with his kids, and his kids continue to think only about what they want -- and fight, this is what we call Chevy Chase Vacation Syndrome.

Santa brought the older kid a Wii, and the boy who received it wants to spend all his time in the basement playing alone. The dad, on the other hand, insists he bring it upstairs so the whole family can play. The boy is unhappy.

Meanwhile the girl wants to play too, and decided it's not fair that older brother is the one who got the Wii. She wants to play. So, finally dad gets his wish and the game is set up upstairs, and as the game ensues, the kids fight like cat and mice. The older brother is mean to the daughter because he hopes she will quit, and the younger is just being herself.

The dad, meanwhile, just shrugs off the little cat scratches hoping the kids will eventually just get along. The boy continues gloating he's so good, and when he starts going bad he fusses. Then the girl starts doing good and she gloats, and the boy gets mad at her for gloating. Then daughter playfully hits brother, and brother takes it personally and yells, "Stop it! Right now!"

So then the girls mocks brother, and dad has to intervene. Then girl throws fit, and dad has to drag her to her room where she can calm down. So now brother is playing game alone like he wanted all along, and girl is moved to another room where she can watch TV. So, so much for dad's fun evening with the kids. Now both kids are happy apart, and dad's sitting at the computer typing this blog post. He'd rather be playing a game with the kids, but what's a Chevy Chase dad to do?

We'll tackle this again tomorrow. This dad would like to go to bed now, but the 1-year-old is not ready. She is, in fact, standing with her juicy cup, chanting, "This... This...!" I suppose, for now, happiness is each of us doing our own things. Happiness is not always getting what we want, and sometimes happiness is compromise.

Merry Christmas Hospital Style

It's nice to simply spend a day at home with the family. For the first time in 10 years I actually get both Christmas and Christmas Eve off this year.

Yet, lo and behold, one of my coworkers got kicked in the neck by a patient with a CO2 of 133, and I was called in a panic to come in and help out. My daughter was sad that I had to leave just before she was to open her gifts from the in-laws, yet I wasn't going to leave my coworkers stranded. I suppose, in a way, sacrificing my family Christmas time was my Christmas gift to Shoreline Medical. I was told I might as well plan on staying the night. My daughter frowned when I told her this news.

My coworker said she was kicked in the neck with a knee as she inserted the needle, and as she flipped the syringe under the bed, she was kicked on the other side of the neck with the other knee. Now she's in the ER while I take care of that crashing patient, and another, and another. And the other RT was in the ER taking care of yet another crashing patient. Merry Christmas indeed.

Of course as soon as I blessed the hospital with my presence all was well. My coworker was cleared of any neck ailments, and will be sore a few days and nothing more. The patient who kicked her was out of his gourd at the time, and is now on BiPAP and slowly coming to his senses. Yet I hope God's Christmas present to him is that he learn to quit being a MODEST COPDer. You know the type: they wait, and wait, and wait, and wait, thinking they will eventually get better. Yet it rarely ever happens. So they come to the ER by ambulance and become our problem.

It seems like every Christmas we get our share of MODEST lungers. Another Christmas gift we get from the community are Lonely-DEPRESSED lungers. These are the folks who are lonely around the season and come to the hospital for their annual dose of PAL-buterol. They just yearn for the company of your humble RTs.

Then you also have your dose of Break-lungers. These are they folks who's family needs a vacation from them, and they somehow -- coincidentally -- end up with fake pneumonia just in time for the holidays.

Of course we also get our share of post Christmas dinner heart attacks. Thankfully our hospital doesn't keep these folks anymore, and ships them to the cardiac hospital down state . Although if that heart attack is massive enough, our services come in handy.

It's neat how things work out this time of year. It's also neat that we have such a great team where I work, and we have good folks like you nd me who put our own selfish desires aside for the benefit of the community and spend time working.

Christmas is a time for sharing. It's a time for giving. It's a time for family. Yet, thankfully, the medical community does not close shop come Holiday time. We are available 24-7 to provide whatever services we offer. We help those who help themselves, and we help those who do not help themselves. We help the needy, and we help the fakers. That's what we do.

Thankfully we staved off the need for any intubations, and all those patients mentioned above are now fine. That, I imagine, was Gods gift to them. Within an hour after I clocked in I clocked out. My daughter smiled big time when I came through the door. She told me in less than 30 seconds all the neat little toys she got from her uncles, aunts and grandparents.

My daughter's revelation

I don’t know about you, my fellow asthmatics, but I bought my current home because I thought it would best help me on my quest to becoming a Gallant Asthmatic. I didn’t really have Santa Clause on my mind at the time.

Yet this morning my 6-year-old daughter had a revelation. She looked up at my wife with her cute little eyes and said, “So, mommy, how is Santa going to deliver my American Girl Doll if we don’t have a fireplace anyway?”

My wife humbly said, “He’ll use his magic to get into the front door.”

“Oh! Okay!” My daughter said, and then went about her business.

Indications for BiPAP

Non-invasive positive pressure ventilation (NIPPV) include machines that allow you to ventilate and oxygenate patients without the need to perform the invasive procedure of intubation. These machines can only be used on a spontaneously breathing patient.

Another acronym commonly used to describe NIPPV is NIV, which essentially stands for Non-Invasive Ventilation. You may actually see other similar acronyms, and they all essentially refer to the same thing.
The two most common forms of NIV are:

1. CPAP 
2. BiPAP 

So, what are they and how might they help your patients?
1. CPAP: This is continuous positive airway pressure. It's a pressure exhale applied during the respiratory cycle that helps keep air passages open so that the next breath comes in easier. Since it keeps the airways patent, it assures adequate oxygenation, and is often prescribed to increase oxygenation.

Indications for CPAP.

• Hypoxemia that is refractory to high concentrations of oxygen by other means. 
• Obstructive Sleep Apnea to prevent the upper airway from collapsing 

Adjusting CPAP settings. CPAP is increased or decreased to maintain a desired SpO2, which is usually greater than 90% SpO2 and 60 PaO2.

BiPAP: This is an acronym for Bi-level (or Biphasic) Positive Airway Pressure. It provides a combination of both IPAP and EPAP.

• IPAP. This is Inspiratory Positive Airway Pressure. It is a pressure during inspiration that assists a patient obtain an adequate tidal volume. Because it provides assistance with inhalation, it therefore decreases the work of breathing required to get air in. Because it assures adequate ventilation, it is often prescribed to blow off carbon dioxide (CO2). 
• EPAP. This is Expiratory Positive Airway Pressure. It is the same thing as CPAP. EPAP is simply used here so you know your talking about CPAP on a BiPAP machine. EPAP is used to improve oxygenation.

Indications for BiPAP.

• Respiratory Failure due to accessory muscles fatigue. It assures adequate ventilation to blow off CO2 and improve oxygenation. 
• COPD to decrease airway resistance, thereby decreasing work of breathing required to take in an adequate tidal volume. By increasing ventilations, it helps to blow off CO2. It also keeps airways patent to improve oxygenation. 
• Pulmonary Edema to help decrease cardiac output which decreases venous return to the right ventricle to reduce blood return to the heart. It also keeps airways patent to help improve oxygenation. It also helps keep alveoli patent to improve oxygenation (prevents alveolar collapse). By keeping alveoli patent, and redistributing alveolar fluid, it helps to reduce pulmonary compliance and reduce work of breathing. 
• Atelectasis to help keep airways patent to improve oxygenation 
• Pulmonary Embolis to improve oxygenation 
• Pneumonia to assure adequate ventilations and oxygenation

Adjusting BiPAP settings. As a rule of thumb, the following rules are true.
IPAP. Increase to blow off CO2. It should not be higher than 20 to prevent pressure from blocking the esophagus. By providing adequate tidal volumes it may also help improve oxygenation.

EPAP. Increase to improve oxygenation.

PS. Pressure Support. This is the gap between IPAP and EPAP. The greater the PS is the more CO2 will be blown off.

Patient Leak. It is important to have a small leak to prevent skin breakdown. Most modern machines will compensate for a small leak.

Alarms. Adjusted as appropriate for each patient.

Contraindications for BiPAP include.

• Inability of patient to protect own airway (decreased level of consciousness). This includes the inability of the patient to pull off the mask if it becomes full of fluid, such as vomit or spit. 
• Increased secretions (i.e. pulmonary edema, increased sputum production) 
• Any patient at risk of vomiting (post stomach surgery, drug overdose). In this case you may be able to use BiPAP if an NG is inserted. Most machines will compensate just fine for the leak around the tube. 
• Bullous lung disease (emphysema) because the high pressure may cause a pneumothorax 
• Pneumothorax may be complication due to increased pressure;;may blow out rest of good lung 
• Hypotension; High pressures decrease cardiac output 
• Non-compliant patient. Surely you cannot force a patient to use this equipment. 

Study Results. Studies show that the use of NIPPV for respiratory failure in COPD patients results in a greater reduction in CO2 and a normalization of pH, compared to those in the control group who did not use NIPPV. A study also showed those receiving conventional therapy were intubated 67% of the time, while those receiving NIPPV were intubated only 9% of the time. This prevents the complications of mechanical ventilation, particularly the difficulty associated with extubating patients with lung disease.

Studies also show that length of stay in a hospital is reduced among the COPD pupulation using NIPPV. NIPPV may also be used on the medical/ surgical floors, reducing cost. However, those in severe respiratory failure may still require a stay in the critical care unit.

Studies also show that most patients, or about 80%, tolerate NIPPV just fine. (see references #3 and 4 below).

Bottom Line. Non-Invasive Positive Pressure Ventilation machines are ideal for many patients to improve oxygenation and ventilation. They have prevented many critical patients from having to go through the invasive procedure of intubation and mechanical ventilation. They are also useful to assure adequate ventilation and oxygenation in the home setting, especially during the nighttime when breathing seems to be more relaxed.

This post was originally published on 8/4/8 on respiratorytherapycave.blogspot.com; it has been edited for accuracy.

Further Reading.

• Good start settings for BiPAP
• My interview with Roxlyn Cole, A COPD patient who uses BiPAP at night
• Study: Non-Invasive Positive Pressure Ventilation For Acute Respiratory Failure
• Barnes, Peter J., et al, editor, "Asthma and COPD: Basic Mechanisms and Clinical Management," 2nd edition, 2009, page 842 
• Non-Invasive Positive Pressure Ventilation (CPAP or BiPAP NPPV) for Cardiogenic Pulmonary Edema
• 17 Biggest Myths of Respiratory Therapy

Can asthma be diagnosed in a baby? Does coffee help asthmatics?

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: How many people are living with asthma in the USA?

My humble answer: According to the Center for Disease Control and Prevention (CDC) that number stands currently at 16.4 million, which is 7.3% of all Americans. Seven million of those are children, which is 9.4% of all children (click here for more). The American Academy of Allergy Asthma and Immunology (AAAAI) also has some pretty interesting stats about asthma if you care to check it out here.

Question: Can asthma be diagnosed in a child under 2 years old?

My humble answer: My daughter's pediatrician said she will not diagnose asthma until a child is 2-3 years old. I have heard many times, in RT school perhaps, that the best way to diagnose asthma is by doing a PFT test, and a child under 2-3 cannot do it.

However, since asthma is genetic, if there is a long standing family history of asthma then asthma can be the "assumed" diagnosis for a child. My daughter, for example, was diagnosed with asthma long before she was 2 due to asthma-like symptoms and the fact I have asthma.

I suppose the answer to your question is yes and no. However, every doctor is different, and therefore this is something you may want to discuss with your child's pediatrician.

Question: Does coffee help asthmatics?

My humble answer:
Great question. I learned about this when I was a kid and tried it myself. It gave me some relief, but not enough to matter.

The truth is, coffee is a mild bronchodilator. It was actually used by asthmatics back in the 1800s and earlier to get some asthma relief. It was one of the options Teddy Roosevelt used when he was a kid back in the 1870s. It wasn't a great bronchodilator, but it did give some relief.

Coffee is a member of the Xanthine family the same as Theophylline is. Theophylline went on to become a front line therapy for treating asthma from around the 1950s until the late 1990s. It was actually used more as a preventative medicine the way Advair is used today.

I would not recommend using coffee as an asthma medicine. You are better off keeping a Ventolin inhaler on hand to treat acute asthma episodes, and to prevent asthma with controller medicines your doctor will prescribe.

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

Are you dependent on your rescue inhaler too?

Yep, that's right! I am dependent on my rescue inhaler. It's kind of like that old commercial for Master Card: I never leave home without it. And when I do the bronchodilator anxiety strikes.

The following is one of my favorite posts over at my asthma blog at MyAsthmaCentral.com

Bronchodilator Anxiety
by Rick Frea Tuesday, November 03, 2009 @MyAsthmaCentral.com

So it's 6 a.m. and I'm driving down I-75 South in Georgia in the wee hours of the morning when the anxiety strikes. I couldn't find my rescue inhaler. My Ventolin had gone missing.

Did I leave it in the hotel? Did I leave it in the lobby? Did my wife pack it in the bathroom bag? I looked behind me and her head was resting on a pillow. I wasn't about to wake her to ask. The kids were sleeping soundly too. So I continued to roll possibilities around in my head.

Thankfully I follow my own tips for vacationing with asthma and had three inhalers packed, and all in different places. I had one in the suitcase, but that wasn't going to help me now. And I certainly wasn't going to pull the car over to check. We were on the way to Florida (Mickey was waiting) and were already running behind.

I looked on the cup holder under the radio. It wasn't there. I felt between the door and the seat. It wasn't there. I felt in my pocket. Nope! While focusing on the road, I reached my right hand over the cooler that set between the seats. Not there either.

Then a thought occurred to me: "You're being ridiculous. You're panicking over nothing." It was true. I wasn't even short of breath. The past two days of travel from Michigan I barely even used it. My asthma has been pretty well controlled the past two years, and my rescue inhaler usage greatly diminished.

Yet that didn't matter. Old habits, they say, die a long, hard death. That old faithful inhaler had been part of my life since I was first introduced to Alupent when I was a ten-year-old boy in 1980, and later to Ventolin in 1991. I wrote about being a bronchodilatoraholic, someone who used his bronchodilator medicine (which most peope call their rescue inhaler) far too often. An inhaler in my possession was my lifeline. It was like having a third hand. Even now when I need it less often, when it's gone I feel a true sense of loss.

Like at home, every morning I woke up on my vacation, one of my first thoughts was, "Where's my inhaler?" When I was a kid I slept with one in my grip, so when it's not there I get a little anxious. Then I remembered I set it on the bedside stand. There it was in all its blue glory.

When I go to bed at night I have to concentrate where I set it last, because when I get up in the night I need to know where to find it. Sometimes, though, I wake up in the middle of the night feeling alongside the bed in the dark.

My wife woke up once when I was doing this. She said, "What are you doing?" Modestly, I lied "Nothing dear!" I inhale. The breath seems somewhat tight. Now many options fill my mind: Do I try to sleep through it? Do I turn the light on? Do I rummage the house looking for the other one's I've lost?

I remember when I was growing up with hard-luck asthma excitedly racing my brothers David and Bobby to the family car shouting, "Shotgun!" I won this time. It was always nice to ride in the front seat. It was a great day. That was until half way to grandma's my heart fluttered as I realized I didn't have my inhaler with me.

I felt my pockets several times. It was not there. While my asthma was fine when I left home, I was now feeling short of breath. I knew the only reason I was short of breath was because of my bronchodilator anxiety. If I have it I'm fine. If I don't have it I'm bound to have an asthma attack. It's an asthma rule.

So now I'm an adult. I know I have two inhalers in the car somewhere. I know for a fact I have one in the suitcase. I know my asthma is not acting up. I know my asthma is controlled, and yet my bronchodilator anxiety still strikes. I'm now starting to feel a mild shortness of breath. Or am I? Maybe it's all in my head.

Throughout the entire trip my inhaler filled a portion of my mind -- or my entire life for that matter. If you'd pay close attention to me you'd see me occasionally swiping my palm over my pocket. I need that constant reassurance it's there. If I don't feel it, I have to find it. I have to know. Otherwise I'll need it.

The weather was awesome in Florida, the kids were able to meet Mickey Mouse, swim every day, and visit with their grandparents. And, thanks to good planning, the asthma was a non issue.

Ironically even as I sit here typing this I'm wondering: Where is my inhaler? Where was I the last time I used it? I don't need it right now, but...

I bet I'm not the only asthmatic with bronchodilator anxiety. If you've experienced this or something similar let us know in the comments below.

Michigan to go smoke free, yet we still cringe

Michigan passed a seat ban on smoking in public places recently. This includes restaurants and bars. My wife came into the house and smiled as she told me she just learned this. I said glumly, "That sounds great!"

"Aren't you excited," she said.

"Well, I don't know."

"I thought you'd be excited because you always complain that people are smoking in a restaurant you're in. You hate it when you are seated in a non smoking booth, and the one next to you is a smoking booth."

"I am happy," I said. "I think the government screwed up in that they are responsible for generations getting addicted to smoking, what with their free war cigarettes and their lies. Still, whenever the government makes another law telling people what they can and can't do, I feel terrible in the pit of my stomach."

"I see," she said.

Do you guys see where I'm coming from? I think that my right to fresh air trumps your right to pollute it. Yet for legislators to decide they know what's best for us and tell us what we can and can't do just gives me the eebie jeebies.

And, yes, it is true government lies got our grandparent's or great grand parents addicted to smoking. Then, even while there was documented evidence that smoking was dangerous as early as 1920, the government hid this information to the benefit of the big tobacco companies who were helping out the economy.

So it only seems just that the government undo the lies and get the U.S. un-addicted. And through public relations and public choice that is exactly what has happened over the past 60 years.

While smoking was once the in-thing, cool, and most people smoked, today smoking is rare, uncool, and very few people do it. Consider the following trends in adult smoking by sex as recorded in the U.S. between 1955 and 2005, and reported by the Center for Disease Control:

• 1955 Males = 54% smoked, females 24%
• 1965 Males = 52% smoked, females 34%
• 1975 Males = 44% smoked, females 30%
• 1985 Males = 34% smoked, females 28%
• 1995 Males - 23.9% smoked, females 18.0%

This is a perfect example of how, by our own accord, most Americans have decided not to smoke. They did not need a law to ban their right to do so.

Likewise, many restaurants and bars are going smoke free, and many of those that do go smoke free are thriving even more so than bars that allow smokers. Which shows by providing such competition, well educated consumers make wise choices. In this way, through capitalism, smoking has become the uncool thing, extremely unpopular, the outward trend, and the exception instead of the rule.

Still, we must consider that high taxes on cigarettes has almost made them unaffordable, which baffles me when I see a person who doesn't have a job, or who can't afford food, or who can't afford healthcare, lighting up. It simply baffles me.

Yet, because government lies caused the smoking crisis, I have always believed it is the job of the government to educate and end the smoking crisis. Now the smoking beast is "butt" on it's last breath, withering and moaning yet refusing to die a timely death. And so it's time for Uncle Sam to come in for the final jab and end it all -- it's time to go in for the kill.

Granted it is unconstitutional for the Federal government to step in here based on the 10th Amendment leaving anything that is not covered in the U.S. Constitution up to the states and to the people to decide. And I hereby give my permission for my state to ban smoking in public places to protect our right to clean air.

Still I cringe. I cringe because as I give my state government this permission, I wonder what freedom they will want to take away next. And the next time it may be a freedom that I don't want to give up. So, it only makes sense that I cringe as I learn the news that Michigan's legislature has ruled to ban smoking in public places as of 2010. We all should cringe.

My advice to physicians

Doctors are among the most respected profession on the planet, and rightfully so. Still, to continue to deserve that respect, doctors must earn it. There's nothing I hate more than when a doctor orders something that's not indicated, and yet a patient says something like, "Well, if the doctor ordered it, I must need it."

That's some pretty good respect. Literally, I've seen doctors order invasive procedures, and the patient just lets the doctor do it. I've seen suction ordered for a patient whose awake and alert, and the patient says, "Well, if the doctor ordered it."

I've seen BiPAP ordered on a patient with normal blood gases and no respiratory distress, and the patient said, "Well, if the doctor ordered it." Sure this is also a sign of ignorance among the patient community, but it may also be a sign that doctors, however well respected, must continue to better themselves.

That in mind, I've come up with a list of my humble advice to those among this greatly respected profession:

1. You ought to take a step beyond just assessing, diagnosing and prescribing.
2. By that, you ought to educate, educate, educate. Whether this is done by you or your staff, you ought to be sure that every patient understands fully their disease.
3. You ought to follow up with each patient to make sure they understand their disease and are following the treatment plan you prescribe.
4. If a patient is not being compliant, you ought to inquire of them as to what you can do as a physician to help them become more compliant. "What advice do you have for me?" Every doctor should ask that question of their patients.
5. You also must monitor prescription usage. If you see, for example, that an asthmatic is using three Albuterol inhalers a month, then you ought to be aware of this. If your patient has hardluck asthma, you need to know this. If your patient has poorly controlled asthma, you need to know this too.
6. You need to use common sense in your approach to medicine
7. You need to be open minded in your approach to medicine
8. You need to continue the education process yourself (for one thing, you need to read up on the real purpose of bronchodilators. You can learn about this by hanging around this blog, or clicking here).
9. You need to be proactive. Don't wait until a crisis hits to act.
10. You need to teach the people you rely on: such as RNs and RTs.
11. You need to learn to trust and rely on those who are with the patient: such as RNs & RTs
12. Other than that, continue doing what you're doing.

I understand that most doctors are the best at what they do. I respect most surgeons, because I know I'd never want that job. I respect Internists and family doctors, because I certainly wouldn't want to be bothered at 2 in the morning each night. Plus I wouldn't want the liability.

Still, I think all physicians, no matter how well you are at what you do, should take the next step at improving the patient/physician relationship.

How to stop nosocomial diseases?

Over the years there have been various efforts to reduce the risk of nosocomial infections, or infections that occur during a hospital admission.  We pick our noses, blow our noses, sneeze snot, spit when we talk,  reach our hands in our pockets and touch our dirty stethoscopes and beepers.  Plus there are many patients and visitors who carry a plethora of germs to share.  

I'm sure you've heard all this before. But, just for the sake of it, here are some common methods of preventing the spread of germs.

• Use hand sanitizer often
• Wash hands often
• Wear gloves often, and then wash hands too
• Gown, glove and wear a mask to prevent droplets from getting on you if patient is suspected of having the flu or MRSA. These bugs are not airborne, so you don't need an airtight mask (I say this despite the CDC recommendations, but they have to err on the side of caution). Actually, you really only have to wear a mask just in case the patient coughs or sneezes in order to prevent you from inhaling their droplets. 
• Wear a mask if a patient is coughing (common sense). Again, this prevents you from inhaling droplets
• Wear a mask during all breathing treatments (nebs produce droplets. You are basically spreading germs). Make sure than anyone else in the room wears a mask too, especially during treatments. 
• Wear a gown in a patent's room (droplets may land on you and live up to 45 minutes) 
• Use hand sanitizer after touching anything in a patients room 
• Use hand sanitizer before and after touching your stethoscope 
• Use hand sanitizer before and after touching your beeper 
• Use hand sanitizer upon entering a room 
• Use hand sanitizer upon leaving a room 
• Use cleaning wipes to wash your beeper or pulse oximeter after each use.
• Use cleaning wipes to clean off equipment, such as EKG machines.
• Wash your hands with soap and water after you are done with your rounds 
• Wash your hands with soap and water after leaving an isolation room 
• Wash your hands after every time you take off your gloves. 

COPD: What is a blue bloater

In RT school we learn that there are two types of COPD (Chronic Obstructive Pulmonary Disease) patients: emphysema and chronic bronchitis. The non-politically correct term for these two respective diseases are pink puffers and blue bloaters. The question of the day is: What is a blue bloater?

It's probably wrong that we call all chronic bronchitis patients blue bloaters, as it is generally not true. As Deborah Leader writes at About.com writes, ""COPD does not cause edema per se."

That's true. This usually does not occur until the later stages of the disease. As the disease progresses the lungs eventually become so swelled and full of thick secretions that the pressure in the blood vessels in the lungs increases as the right side of the heart works extra hard to pump blood through them.

This results in two things:

1. If the heart works extra hard to pump blood through the lungs for a long period of time this can result in cor pulmonale. This is basically a large heart. The heart is a muscle like any other in the body, and when you work out muscles they grow. It's the same as when a body builder works out his muscles to make them bigger. Only in this case it's not so pretty.

2. This results in pulmonary hypertension. In it's "severe" stages this can lead to feet and leg swelling. Leader notes that this "increased pressure causes damage to the vessels causing blood to back up in the veins of the body. This results in an excess amount of fluid which leaks into the surrounding tissues. When you add gravity to the mix, you now have dependent edema as the fluid pools in your legs, ankles and feet."

Chronic bronchitis can be prevented by stopping smoking and by taking medicines prescribed by a doctor and being compliant with the medicine regime and other therapies he prescribes.

To remedy this complication of end stage COPD patient can put her feet up "higher than your heart and as often as possible will help reduce the edema in your lower extremities.

Diuretics like Lasix are often prescribed to help get rid of some of this fluid. If you're a COPDer and aren't familiar with diuretics, they cause your bladder to absorb fluid from your body and make you pee -- sometimes a lot.

Is BiPAP good for CHF?

As always I've been thinking too much lately. This time about BiPAP and CHF. The goal here is to make sure we are dealing with facts and not thinking BiPAP is doing something it's not.

So, that in mind, I created this Q&A. I did the research and then had a discussion with myself.

My Question: BiPAP is ordered for a patient who is labored, has a low PO2 despite 75% non-rebreather, and increased excessory muscle fatigue. Why does it work?

My humble answer: It works because the IPAP helps the patient take in a breath without having to use his excessory muscles. In this way it decreases muscle fatigue by decreasing work of breathing. The EPAP helps increase the patients FRC and thus increases oxygen delivery to the blood and to the tissues.

My Question: I understand that, but why is it every time I ask a doctor why he ordered BiPAP on a patient who shows signs of pulmonary edema yet has no signs of muscle fatigue and normal blood gases, he always says, "Because it pushes fluid out of the lungs?"

My humble answer: The idea that the BiPAP pushes fluid out of the lungs is a fallacy. It does nothing of the sort. I contemplated this and did some research. The best answer I could find came from Jeffrey Sankoff, MD, from Emergency Physicians. I will post what he wrote about his topic below and the next time you have a doctor say that you can show him this report:

Contrary to popular belief, NIMV does NOT push edema fluid out of the lungs. Patients with acute CHF have an imbalance in the CO (cardiac output) of the right and left sides of the heart. With the inciting event (detailed above) the left ventricle becomes compromised but the right ventricle usually does not. So the right ventricle continues to pump forward a normal volume of blood but the left ventricle becomes unable to keep pace. Fluid backs up into the lungs resulting in capillary leak and pulmonary edema. With NIMV, the resultant positive intra-thoracic pressure decreases venous return (blood flowing back to the heart). This reduces right-sided CO to a level that the left heart can equal or even exceed. Fluid ceases to back up and will even begin to be reabsorbed as left ventricular CO improves. Pulmonary edema ceases to worsen and may even diminish, often rapidly.

My Question: So does this explain why patients are still on BiPAP hours after their episode has been resolved and they are awake, alert, orientated, breathing normal, and irritated that they are still have the BiPAP mask strapped to their face?

My humble answer: I can't answer that for sure, but it's possible.

My Question: See, I have listened to doctors and nurses discuss how, "the BiPAP saved that patient's life." Yet I often wonder if it was the BiPAP at all but the medicine we use to fix the patient. What are your thoughts on this.

My humble answer: I think you guys are all right. I agree with you in that I have always thought of BiPAP as the machine version of Ventolin, that it does not cure, it treats the symptoms. A Ventolin treatment does not resolve the asthma episode, it merely treats the symptom of bronchospasm, thus buying time for other medicines (corticosteroids or antibiotics) to take effect. BiPAP is a treatment to relieve work of breathing and thus buy the patient some time while the medicines the doctor orders and the nurses give make the pump work better (Dopamine) and get the fluid out of the lungs (Lasix).

However, as you can see from the discussion we had above, BiPAP can also help decrease the amount of fluid in the lungs. Yet, still, it is just treating the symptoms while other therapies treat the CHF. Usually about 2-3 hours after treatment is started the patient feels great and the BiPAP is given credit for curing the patient. In this way, it is just like Ventolin.

Question: So, technically speaking, once the patients heart is stronger, the cardiac output improved, the fluid is off the lungs, and the patient is breathing better, the BiPAP can be discharged from the patient. Right?

My humble answer: Absolutely. When I was a student working at a larger hospital, back when these type of patients were put on Ventilators instead trialed on BiPAP, once the patient was better he was extubated. I work at a smaller hospital and the doctor won't extubate CHF patients who are intubated, and won't discharge the BiPAP now that this is the therapy of choice. That's just the way doctors work. It made the patient better and now they are afraid to take it off the patient.

Question: So are they being lazy, or is it because they think the BiPAP is keeping the fluid out of the lungs?

My humble answer: Your guess is as good as mine on that one.

So, while the main goal of BiPAP with CHF is to decrease work of breathing, it can also help increase cardiac output and decrease the amount of fluid in the lungs. It does not, however, push fluid out of the lungs. So we have once again debunked another RT fallacy.

Is it asthma or out of shapeness?

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: Asthma or out of shape? I get very short of breath walking uphill or up stairs - would this be linked to asthma or being out of shape?

My humble answer: It's really hard to answer this question over the Internet. This is something you might be better off discussing with your physician as he or she can see you and interview you personally.

That said, I'll try to answer it based on my own personal experience with asthma.

If you are getting short of breath to the point you are needing to use your rescue inhaler, then it's possible it could be your asthma. If you are just getting winded while going up stairs, and then you feel fine with rest, then this is probably just being out of shape.

However it could be a combination of the two. I have noticed when I go a long period of time without exercising I seem to get more winded going up stairs and such than my friends do who are equally out of shape. My theory is this is because I have asthma and they don't. However, I could be wrong.

I find that when I exercise regularly I do not get winded no matter what I do (or at least most of the time). I believe this is because, as science has proven , exercise makes both your heart and your lungs stronger, as well as giving you more energy.

That is also why most asthma experts recommend all asthmatics exercise to some extent no matter how bad their asthma is.

In case your interested I expound upon this topic in the following posts:
Come on asthmatics! It's time to exercise
Even we asthmatics can run

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

Swine flu strikes asthmatics more than others

I have made a decision and a reservation regarding the swine flu (h1n1) vaccination I would like to share with my readers.

First for the decision. I have written earlier that I would not let my children get the vaccination due to the fact it has Mercury in it as a preservative. Some kids have a mitochondrial disorder where they can't get rid of Mercury, and this can cause other disorders later in life. It's also been linked with the increased incidence of autism.

So, rather than risk it, I'd rather my kids not get any more Mercury. I have, however, learned since then that while mercury is used in the multi use vials as a perservative, it is not used in the individual use syringes of the vaccine.

I therefore will allow my children to get the vaccine if the doctor has these individually wrapped syringes.

Now for the observation. A recent report has been released showing that while 10% of the U.S. population is asthmatic, 25% of those admitted with H1N1 have asthma. The report notes:

"Less than 10% of the total population has asthma. But this spring, those with the disease accounted for nearly a third of all hospitalizations for H1N1 flu. It's not known exactly why this group is at higher risk. Asthma medications may blunt a person's immune response to the new flu or the person's decreased lung function may play a role. In an effort to better protect those with asthma, Dr. William Busse, is leading a clinical trial that involves giving some participants twice the dose of vaccine than others. He says the trial will answer important questions about the effectiveness of the vaccination and if those with asthma are responding normally to the vaccination.

Doctors won't know until next year how well --or poorly-- asthma sufferers in the study fight off the virus with different amounts of vaccine. In the meantime, Busse advises those with asthma to get vaccinated against H1N1."

What went through my mind as I read this was: What? They're going to spend thousands of dollars doing a study to determine why 25% of those admitted with the swine flu have asthma?

Hello! I can save you the wasted money. The reason there are more asthmatics than anyone else is because asthma is a lung disease, and the swine flu is a lung disease, and the combination results in some of them needing to be hospitalized.

It's not rocket science.

The elite amongst us need to wise up

"I imagine you're spending your money more wisely now that we're in a recession," the journalist said to the middle-aged lady who was shopping at the mall.

Every day I hear on the TV, radio or read here on the Internet or in some newspaper how people are spending their money more wisely now that we are in a recession. Of course we have to believe here that the same people who say this, or write this, must expect that people are going to start spending their money "unwisely" again once the recession is over.

You see, this is the kind of bunk that amazes me about the way the "elite" in this country think. They want us to spend, spend, spend so they can make money off of us. This is even true of the media that make money off money we spend. So it only makes sense that they want to encourage us to spend our money on material things we do not need. Or, in other words, they want us to spend money we do not have to help out the economy.

Then again, the same media folks who are making up comments like this are basically repeating the same bunk inculcated upon them by the people who make the news -- politicians, rich business folk, media moguls, etc.

Has it ever occurred to these good folks that the person who spends his money wisely, and saved accordingly, every day of every year is the person who is not effected by a recession. But instead of encouraging this kind of behavior, the elite amongst us are constantly encouraging us to spend, spend, spend even when we don't have any money because we spend unwisely when the economy is doing well.

A wise person wouldn't have $5,000 in credit card debt. Instead he'd have $5,000 saved in a bank. A wise person wouldn't buy a house he cannot afford only to later have that house foreclosed upon by a bank. A wise person would buy a small humble home he can comfortably fit his family in. A wise person doesn't jump at every advertisement on TV and say, "Oh, I gotta have that!" A wise person enjoys a humble life and buys only things he can afford.

A wise person doesn't have to live above his or her means and have all the best toys. A wise person, therefore, will not be effected by a recession. Yet, in the media, all we hear about is how Jane or Jack is spending "wisely because these are hard times."

Any person who loses his or her job bypasses recession mode and jumps right into depression mode. For the rest of us, what mode we are in is up to ourselves and our own money habits.

I'm certainly not a financial expert. I'm merely a humble RT who relies on simple common sense to get through my humble life. Likewise, I would like the people who report the news to wise up the same way I want the people inculcate their values on these media folk to wise up.

It's easier to be ignorant

Here's the Quote of the Year:

"There are a lot of ignorant people in the world, because it is a lot easier to do nothing than it is to spend quality time learning."

Allow me to relate this quote to the field of respiratory therapy:

1. Doctors who order breathing treatments for anything other than bronchospasm.
2. Insurance and government agents who require breathing treatments be ordered on all RSV and pneumonia patients in order for the hospital to get reimbursement.
3. Nurses who call for breathing treatments just because the patient wheezed, and without further assessing the patient for signs of bronchospasm.
4. Respiratory therapists and nurses who accept all breathing treatment orders as needed.
5. Patients who never question a doctor's order.
6. Doctors who refuse to utilize the skill and expertise of respiratory therapists or nurse.
7. Doctors who think they know more about a patient than the nurses and respiratory therapists standing at the bedside while the doctor is home in bed.
8. Doctors who think everything should always go as planned.
9. Patients who quit taking the medicine the doctor prescribed.
10. Patients who don't read up on the diseases they have, and therefore continue to make return trips to the ER at our expense.

If you want to add to this list feel free.

It seems bronchodilator fallacies trump scientific facts

So why do we have science if nobody is going to use it? Why do we have truth when it's easier to believe a fallacy? Why? Why? Why?

Am I the only one to ask questions like this? I doubt it, although I don't think there are many of us.

I have two examples to what I'm questioning here: global warming and bronchodilator usage.

We've been studying weather patters for over 100 years not. If you put that into consideration, that's 100 years in something like 100+ billion years. If you do the math, I bet that's a shorter amount of time that 0.00000000000001% of our history. Yet, based on the numbers we have accumulated, people have come to a conclusion.

I find this funny, because most scientists (as you can see by this post) are still questioning the science. Not even scientists can come to a logical conclusion regarding global warming. Yet you have a majority of politicians willing change our economic landscape based on this theory, and a majority of the world population willing to buy into it.

To be honest here, I am neither a believer nor a disbeliever in the theory of global warming. I think it's best to let science decide. It's best to look at the trends which show constant periods of warming, followed by periods of cooling, and so forth.

Yet some people fail to look at this big picture, and they make political opinions based on the current trend. For example, in the 1970s the trend was toward global cooling, and you had scientists actually proposing melting the polar ice caps to warm the planet. Aren't we glad that never happened?

From the late 1970s to about 1998 the trend trended upward, and you had the global warming scare which is ongoning, despite stagnant global temps since 2000.

You have people like the honorable Al Gore claiming that if we don't clean up our planet it won't exist in 10 years. To me, this is a scare to get people to send more money his way. It's all about money. It's all about selling a political view over science.

Personally, I think it's a good idea to be environmentally conscious. I think it's a good idea to reduce, reuse and recycle. I think it's a good idea to look for alternative energy sources. Yet let's not get drastic and force one view based on a theory.

The same can be said of bronchodilators like Ventolin. You have doctors and nurses believing that Ventolin is needed every time they hear a wheeze or see a short of breath patient. Yet the science proves otherwise.

Still, when you go to correct a nurse or a doctor, when you share the facts and the science about bronchodilators, they say that I am being lazy. A great example of this occurred last night when I was called to do a breathing treatment for a person who was dyspneic due to pneumonia.

I approached the nurse and said, "You know Ventolin does nothing for pneumonia."

She said, "Yes it does. It opens the airways and helps the patient cough up the pneumonia."

"That's a fallacy," I said. "Science has proven that Ventolin is a bronchodilator you are right. But pneumonia does not cause bronchoconstriction, so the air passages in that person's lungs are already dilated. Thus, a bronchodilator will not expand these air passages beyond what they already are. In fact, there is no need to because pneumonia is not in the bronchioles. There are no secretions trapped in the bronchioles."

"Where did you hear that from?" the nurse said angrily.

"Not only that," I said, continuing on with the facts I've learned through my many years of research, "Pneumonia is a disease of inflammation of the alveoli. Bronchodilators don't treat inflammation, that's the job of corticosteroids and perhaps even antibiotics to kill the bacteria down there if it's bacterial, which it usually is.

"Likewise, I added," her face was red as a beat by now, "Ventolin is 0.5 microns, just the perfect size to fit into the air passages to get to the beta one receptors there. The Alveoli are 0.1-0.2 microns wide, so Ventolin doesn't even get down there.

"And to top that off," I said patting the side of the nurses station in my confident rage, "I don't even believe there are beta adrenergic receptors in the alveioli."

"You're just trying to get out of work," she said. She smiled. She's a great person, although she needed the education regardless that it was going to sink in or not.

By this time Dr. Q1 is standing right next to her, and she interjected: "Jill is right. Ventolin relaxes the bronchioles so the patient can cough up that junk."

My point by relaying this conversation is this: why is it that we folks with the facts on our side always have to be on the defense? Why do we have to prove that we are right? Now, I'm not perfect, but I think I have my bronchodilator wisdom down pretty well. I have actually studied it. I've read books. I read every magazine article I can on the topic.

In fact, I even read the package insert once, which states, "This medicine is for asthma and COPD to treat bronchospasm." So, what is bronchospasm? Bronchospasm is the spasming of muscles. Ahem, there are no muscles in the alveioli to spasm.

I know! I know why people like you and me who have the facts on our side have to defend ourselves. I know why we are always on the defense. It's because it's easier to be ignorant. It's easier to believe in fallacies that make us feel good about ourselves, than to think. It actually makes those RNs and DRs feel good about themselves to order a a breathing treatment because it makes them feel they are doing something good for the patient. It's easier to believe in hoax theories and bronchodilator fallacies than to think.

Yet I'm being lazy. All us RTs are being lazy when we question why a bronchodilator is being ordered. We are lazy because we think we RTs with science on our side, two years of studying bronchodilators at school, and 14 years experience should decide who gets breathing treatments and not some a doctor or nurse and their fake science.

It's the same way with the crowd of people that aren't so quick to believe in global warming. They are lazy and refuse to believe in science. Yet they are the ones who look at the same science and see that the facts show inconclusive results. We must not be to quick to judge, and be more open minded to the facts at hand. We must not be sheep caught up in a movement.

Ladies and gentlemen, this is why it's frustrating to be a thinker. This is why it is frustrating to be a person who always reads to learn the facts. This is why there is so much apathy by RTs because we know the facts and yet no one will listen. They choose to believe the fallacies because it's easier to be ignorant than it is to pick up a book or magazine and read.

Here are signs of worsening COPD

Way too often I see COPD patients (and asthmatics too) come to the emergency room too late to fix them up quick and send them back home. It's not uncommon for a chronic lunger to stay home with the thought, "If I just wait a while longer I'll start to get better."

The truth is, this way of thinking usually results in your breathing only getting worse. If it gets bad enough you may need to be rushed to the ER by ambulance, and we may even need to put a tube in your throat to help you breath and allow your lungs time to heal. In a worse case scenario, you could actually even die.

So, to prevent worsening asthma, there are signs you should be aware of. When you observe any of these signs you should call your physician immediately:

1. Increased shortness of breath
2. Increased cough
3. Increased sputum production
4. Sputum changes colors (brown, yellow, red, blood tinged, etc)
5. Sputum becomes thicker
6. Wheezing
7. Signs of a cold (sniffling, sneezing, runny nose)
8. Chest tightness
9. sore throat
10. Increased shortness of breath when doing normal daily activities (increased dyspnea)
11. Increased fluid retention (the most common sign is swollen ankles)
12. Increased fatigue
13. Increased respiratory rate
14. Increased confusion
15. Bluish tinge around lips or fingers (cyanosis)
16. Pursed lip breathing (breathing through pursed lips)

Lungsound lexicon

As an RT I've done a lot of bronchodilator breathing treatments on patients just because a doctor, nurse, or fellow RT heard a wheeze and made the suggestion. What many of us fail to realize is that not all that wheezes is bronchospasm.

What follows are the five types of wheezes:

1. Expiratory wheezes: This is a continuous high pitched whistling sound heard only by auscultation. It is caused by an obstruction caused by narrowing of the air passages in the lungs due to bronchospasm, secretions or inflammation. Generally, if the expiratory wheeze is heard throughout the lungfields you have bronchospasm. This is indicitive of bronchospasm, and the main therapy for this is a bronchodilator breathing treatment. Bronchospasm may also be associated with diminished lungsounds, distant wheezes that you have to listen real closely to hear, or no wheeze at all. You can read more by clicking here.

2. Inspiratory Wheezes: This is a continuous high pitched whistling souind heard only by auscultation. It is caused by bronchitis, foreign body obstruction, tumors, and fibrosis. Differential diagnosis can further be made by isolating the location of the wheeze. If it is isolated to one part of the lobe it can be indicitive of foreign body obstruction and tumors.

3. Audible wheeze: It's low pitched noise you hear as soon as you enter the patient's room. It is most commonly associated with upper airway secretions or dehydration. It is often heard radiating throughout the lungfields. Pay close attention. If you auscultate the throat and hear it resonating there, chances are it is an upper airway wheeze. Audible wheezes are also caused by cardiac failure, pulmonary edema and pneumonia (see below).

4. Upper airway wheeze (cardiac wheeze): This is a low pitched noise that might be audible and can usually be heard resonating throughout the lungfields by auscultation. Pay close attention. If you auscultate the throat and hear it loud the chances are you are hearing this type of wheeze. It is usually associated with fluid around the vocal cords and/ or fluid build up in the lungs caused by pneumonia or heart failure (CHF). Increased pressure and fluid in the lungs squeezes the bronchioles from the outside causing the wheeze. It may also be associated with a forced or prolonged expiration that mimics bronchospasm. An X-Ray and labs are best used to differentiate between CHF or pneumonia. It is important to note that this wheeze mimics bronchospasm, yet treatment for it is completely different. It is also important to consider dehydration as a possible diagnosis as well (check the labs for signs of dehydration).

5. Rhonchi: Low pitched continuous sounds that are similar to wheezes, although they really aren't. Sometimes they are referred to as Coarse lungsounds. They actually sound somewhat like snoring. It is not caused by bronchospasm. This lung sound is caused by air trying to get through the partially obstructed, inflammed and thick secretion filling the airways. This is indicitive of COPD, increased or thick secretions, inflammation, bronchospasm, and bronchitis (inflammed airways).

6. Stridor: This is a noise heard only on inspiration. It is not a wheeze but sometimes can be confused for one. It is generally caused by swelling or similar obstruction around the vocal cords, and as air rushes it it can make the harsh vibrating noise. It may also be associated with a harsh barky cough. Common cuases are croup in children and post extubation in adults. Since children with this condition often present appearing as asthmatics, they are often mistakenly treated as such. Quite often you'll hear good air movement in the lungfields (the exception will be an underlying condition such as COPD). Stridor heard on expiration may be indicitive of obstruction in the air passeges of the lungs (lower airway) caused by a forein body such as a coin or a hotdog.

7. Rub: This is a continuous or discontinuous"creaking sound" caused by the inlfammed pleural spaces around the lungs rubbing against oneanother. The main cause of this is pleuritis, pneumothorax (collapsed lung), or pleural effusion (fluid in the lung spaces). They are usually isolated to the infected part of the lung. Otherwise you should hear normal air movement in the lung fields unless the patient has an underlying condition. It is very rare to hear this and takes a trained ear, however you can become a hero if you pick up on it.

8. Fine crackles or dry crackles: This is the sound you hear as the alveolar sacs in the lungs pop open with inspiration. They are usually heard on end inspiration and sound like hair when you rub it together or when you pull velcro apart. The location of these crackles can help with difinitive diagnosis. If it is isolated to one lobe, it can be caused by pneumonia. If it is heard in both bases it can be indicitive of COPD or atelectasis or pulmonary fibrosis. They also do not clear with cough.

9. Coarse or wet crackles: This is crackles that sound wet and usually fill both bases of the lungs and sometimes all the lungfields. They are discontinuous and start at early inspiration and continue through expiration. It can only be heard by auscultation. These crackles are caused due to fluid buildup in the alveolar sacs. Coarse crackles that clear with a cough may be caused by secretions in the lungfields. Coarse crackles that do not clear with cough may be indicitive of bronchiectasis, pneumonia or cardiac failure. If it's caused by pulmonary edema it may also be audible.

(Check out the Crackles Lexicon by clicking here)

10. Rales: (Pronounced Raahls): See coarse or wet crackles above. Rale comes from the French word rale which means rattle. This term is not used much anymore. May be audible.  This term was first used by Rene Laennec when he invented the stethescope and is a retired term generally replaced with coarse crackles.

11. Crepitance: Although not a lung sound, it is something all RTs should be familiar with. It refers to air under the surface of the skin. It sounds like crackling or bubbling sound similar to the noise heard when pulling velcro apart or salt being poured on paper. You may also be able to feel the air bubbles with your fingers. Causes of this are pneumothorax or trachs.

12.  Cardiac Wheeze:  It usually sounds like a coarse wheeze or rhonchi and is generally heard over the upper airways.  It's caused not by bronchospasm but due to increased pulmonary pressures due to heart failure and fluid squeezing the air passages.  It's often confused for a bronchospasm wheeze.

Further Reading:

• Respiratory Auscultation
• Crackles
• All that wheezes is not asthma
• Where to listen to lungsounds
• How to listen to lungsounds
• Crackles Lexicon

It's easier to be ignorant than to learn

Perhaps you can tell one of my favorite quotes is: "It's easier to remain ignorant that to take the time to educate yourself." I don't know who came up with it, but there's a heck of a lot of truth to it.

This quote explains a lot, such as why:

1. Many pediatricians, including our own, still have a 100% non-rebreather mask on standby for each birth, despite all the evidence that too much oxygen can significantly increase the risk of cancer for even term babies later in life.


2. Too many physicians still believe in the hypoxic drive theory despite ample evidence to the contrary and prefer to allow their patients suffer from hypoxia.


3. Many nurses and physicians think a bronchodilator is the cure for anything that wheezes or for anything that causes shortness of breath, when the truth is this is not even close to the truth.

We'll stop there lest I get into trouble. I thought about delving into politics there, but I'll leave that to you guys.

I'm not necessarily questioning the intelligence of anyone, merely suggesting that effort can make even the most intelligent person wiser. Or, even the most intelligent among us can do stupid things. Or, even the best doctors and nurses can still believe in false wisdom. Or, even the most intelligent and best doctors among us can still write stupid doctor orders, as we see nearly every day in the medical field.

Either way, a wise person isn't necessarily the most intelligent person, but the one who takes the time to obtain as many facts as possible and gives and allows these facts to take precedence over old, antiquated wisdom. He also knows the difference between fallacy and fiction.

Or something like that.

What are normal oxygen sats for asthmatics?

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: What are normal oxygen levels for my daughter who has asthma. My daughter's oxygen level was 88 and she was sent home from the doctor's office. Should I be concerned.

My humble answer: I'm going to assume that by "oxygen level" you are referring to a pulse oximetry reading, otherwise known as an SpO2 or a pulse ox or sat (some people incorrectly call it a stat). You can see a picture of one here. This is where they take a little gadget and place it over your daughters finger and it checks her oxygen level.

First let me explain what a pulse ox is.

What is a pulse ox? It is a device that allows medical people like me, your nurse or doctor, to determine how much of the oxygen that you breath in is actually getting to your tissues. Thus, the # 88 means that 88% of the air your daughter was breathing in was getting to her tissues.

What is a normal pulse ox? Perfectly normal is 98%, although for most people anything greater than 88-92% is acceptable, although the actual range can fluctuate with some hospitals, doctors, or patients.

If you have concerns about your daughters pulse ox, you should probably talk to the doctor and ask him why he thinks 88% is okay. In my opinion, so long as a patient is relatively stable, I wouldn't worry about a sat of 88. For one thing it's just a number generated by a machine and can fluctuate +/- 2%. It's best not to treat a number but the patient.

A reading of 88% is worth noting, but is not critical. Perhaps this is what your daughter's doctor was thinking. I have seen asthma patients go home with similar readings and they did just fine. In fact, my daughter had an asthma attack a few years ago and her sat was 84% and she was sent home with me and ended up just fine.

If your daughter continues to have trouble breathing, or her breathing gets worse, call your doctor or return to the emergency room. And it's always a good idea to continue to monitor your daughter for these signs of asthma, which I'm sure you already do.

I don't know if this was the case with your situation because I wasn't there, but I know from my own personal experience taking care of children in the emergency room that it sometimes is very hard to get an accurate saturation reading. That's another thing to consider anyway. My wife took my asthmatic daughter to see the pediatrician a few years ago and her oxygen level was 83%. However, since I wasn't there I wonder if that was truly accurate. The doctor sent my daughter home anyway and she was fine after a few days of breathing treatments and antibiotics.

Question: What is a good o2 sat level? For a child having an asthma attack is there an O2 SAT level that is a red flag that you should call an ambulance?

My humble answer: A normal O2 Sat is 98%. For most asthmatics, the O2 Sat does not drop except for during severe exacerbations. Some severe asthmatics may have a lower O2 Sat.

Where I work an acceptable O2 Sat is anything above 92 (+/- 2). If you notice your O2 sat drops significantly and stays there, then you should call your physician or go to the ER. You should also discuss with your doctor what your normal O2 sat is what to do if it drops.

That said, a pulse oximeter is not normally used as a monitor to help asthmatics decide what to do. Ideally, you should be acting before your O2 sat drops. However, I'm saying this not knowing how severe your asthma is.

You may already know this (but I have to say it), the asthma guidelines recommend every asthmatic work with his or her physician to create an asthma action plan to help you decide what to do when an attack is impending or ongoing. Some plans will have you utilize a peak flow meter, some will have you simply monitoring your symptoms, and some will have you using both methods. I describe this more fully in this post. Some asthmatics may incorporate other methods into the plan, such as the use of a pulse oximeter to monitor O2 Sats.

I provide more information on this topic here.

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

The asthma lexicon

I have created on my blog an asthma lexicon you can access any time by clicking on the lexicon link above or by clicking here. In a recent post on my asthma blog at MyAsthmaCentral.com I defined the most important asthma terms that pop up.

An Asthma Lexicon: Important Terms You Should Know
by Rick Frea Wednesday, October 21, 2009 @MyAsthmaCentral.com

Part of being a gallant asthmatic -- like you and me -- is keeping up on our asthma wisdom. That in mind, I've created an asthma lexicon for asthma termonology that often pop up in your questions or whenever you talk to your doctor:

Asthma gene: It is believed asthma is somehow linked to genetics. When people have asthma, something might have happened to "turn on" the genes that may cause the disease. Approximately 10% of Americans have this gene. Many asthma experts believe the age a person is when this gene is "turned on" determines whether one has childhood-onset or adult-onset asthma. Others think that for most people, the gene is "turned on" during the first few months of life, regardless of when one first has asthma symptoms.

Childhood-onset asthma: This is when a person first shows signs of asthma during childhood, or under the age of 18. Most common triggers of this are allergies, respiratory infections, and exercise-induced asthma.

Adult-onset asthma: This is when a person first shows signs of asthma during adulthood. One common trigger of this is gastroesophageal reflux disease, or GERD. You many know that term more commly as simply heartburn or acid reflux.

Acute Asthma: This is shortness of breath due to narrowing of the air passages in your lungs that occurs suddenly. The most common way of treating this is with bronchodilators (known medically as short-acting bronchodilators or SABAs). People sometimes call these medicines "rescue inhalers." (see below).

Chronic asthma: This refers to the underlying inflammation that is always present in the lungs of asthmatics. The degree of this inflammation is what determines the severity of your asthma when exposed to your asthma triggers. The best way of treating this is with asthma controller medicines, which are most commonly inhaled steroids. (see below).

Twitchy airways: This usually occurs in children, who have smaller air passages than adults. It occurs when the air passages are very inflammed and thus extremely sensitive to asthma triggers. Asthmatics with twitchy airways are often referred to as Brittle Asthmatics.

Brittle Asthma: These asthmatics have severely inflammed air passages that are highly sensitive to triggers. Even the simplest exposure can set off a major attack. In most cases today, brittle asthma can be prevented by compliant use of your asthma controller medications. In some instances asthma is so severe that even controller medicines don't help as much as they should. I refer to these asthmatics as hardluck Asthmatics.

Airway remodeling: (Sometimes known as "lung scarring") These is irreversible changes that can occur in your lungs if your asthma is not diagnosed in a timely manner and treated appropriately and agressively. This can make asthma more difficult to control. This is one great reason why it is extremely important to see your doctor regularly and take your asthma medicines exactly as prescribed.

Asthma triggers: These are normally non-threatening things like dust mites, molds, stress and scents that "trigger" asthma symptoms. The immune systems of people wityh asthma may overreact to these typically harmless substances. Airways that have a greater degree of inflammation are more sensitive to these triggers, and may result in "more severe" asthma attacks.

Rescue medicines: Medically known as bronchodilators, these "quick relief" asthma medicines dilate and relaxe the air passages in your lungs. The most common ones used in the U.S. are Ventolin and Xopenex.

Controller medicine: These are typically inhaled steroids, somtimes combined with long-acting bronchodilators (or LABAs), and are also called preventative meds. When taken correctly and as directed, they are meant to prevent one from having an asthma attack, to limit the severity of attacks, and to help one maintain good control of asthma. Some commonly used medicines in this group are Azmacort and Flovent. Advair and Symbicort are examples of combination medicines that contain both a steroid and a LABA. The drug Singulair is an example of a "controller" medicine that is NOT a steroid.

Asthma Action Plan: The asthma guidelines recommend all asthmatics develop a partnership with their doctors to create a plan to help them understand when to take action (use rescue inhaler, call physician or go to the ER). The guidelines note that
"either peak flow monitoring or symptom monitoring, if taught and followed correctly, may be equally effective."

Asthma Symptoms: These are "symptoms" an asthmatic experiences when an asthma attack is impending (early warning signs) and when an attack is ongoing (Asthma attack symptoms).

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.

Controlled Asthma: This is the ultimate goal of all asthma doctors for all their asthmatic patients. 1) Asthma symptoms are minimized. 2) Functional impairments are minimized. This means school and work are rarely missed due to asthma. One should be able to maintain a relatively normal activity level and a normal standard of living. 3) The risk of future asthma attacks is minimized. 4) The goals set forth by you and your physician are met. For most asthmatics, this means you rarely need your rescue medicine, and rarely need to make unscheduled visits to the ER.

If you come across an asthma term you want defined, leave a note in the comments below, or ask a question in our Q&A section.