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Saturday, March 27, 2010

A world of bronchodilator lies!!!

So, have you guys ever wondered why doctors order so many breathing treatments for pneumonia? Slowly but surely we've been learning what doctors are really learning in medical schools. And, for the most part, it's based on a series of lies.

I hate to say it, but it's true. First of all, you've seen the surreptitious Physician's Creed I've been posting on my blog as I obtain pages from my secret sources. Yet recently one of my valued readers emailed me five online articles with the note: "It is hard not to expect doctors to use bronchodilators for pneumonia when articles like these are so easy to obtain."

The first one he sent to me was this one about bronchodilators at Yourtotalhealth about bronchodilators. The worst part about it is this article was approved by a doctor. I hate to say it, but he's either ignorant about bronchodilators, living on another planet, or he's an all out liar.

Here's what the article had to say: "Bronchodilators are medications taken to improve breathing. They help expand the airways and improve the breathing capacity of patients with bronchial asthma, chronic obstructive pulmonary disease (COPD), emphysema, pneumonia, bronchitis and other lung diseases."

So right off the bat this article lies. Bronchodilators improve breathing, but only in patients who have airway narrowing due to bronchospasm. This can be the case with bronchial asthma and chronic bronchitis, but is not true with emphysema and pneumonia.

Emphysema is a disease where the tissues in your lungs break apart. There is nothing that Ventolin does to increase lung tissue. Pneumonia, as I've written a million times on this blog, is a disease of inflammation of the alveoli. Not only are bronchodilator aerosols too large to make it to the Alveoli (Ventolin is 0.5 microns, a perfect size to fit into the bronchioles, but too large to fit into the 0.1-0.2 micron alveolar sacs).

Plus, there are no beta adrenergic receptor sites in the alveoli for the bronchodilator to attach to. And, even if there were, bronchodilators relax smooth muscles in the bronchioles. There are no smooth muscles to relax in the alveoli. Plus a bronchodilator will do nothing to treat inflamed alveoli.

Some doctors claim bronchodilators open up airways of pneumonia patients so they can cough up the junk, but this is a lie too, because pneumonia does not cause bronchospasm unless the patient is an asthma or COPD patient.

Of course the article only gets worse: "Bronchodilators also help clean mucus from the lungs to improve breathing. As air passageways are opened, mucus moves more freely because it becomes thin and can be coughed out more easily."

Where's the scientific proof to back this up? What study was ever done that proves bronchodilators clean mucus from the lungs. Of course, that is why we RTs joke that doctors think Ventolin works like scrubbing bubbles, in that it gets deep down in the lungs, suds up like soap, and gives the lungs a nice washing.

Of course, if air passages are not constricted, there is no need to open them (which is the case for most pulmonary patients). Likewise, MUCUS DOES NOT MOVE MORE FREELY BECAUSE IT BECOMES THIN AND CAN BE COUGHED OUT MORE EASILY. Who the hell thought that one up?

Ventolin is not a mucus thinner. In fact, Ventolin has absolutely nothing to do with secretions. If you want a mucus thinner, you have to go to a medicine called Mucomyst, which is a medicine made to reduce the viscosity of secretions. Ventolin does not.

The article states, "They work by relaxing the bands of muscle surrounding the airways." This is correct. By reading his own article this doctor should have realized what he said above was not true. And we wonder why Ventolin is the most abused medicine in the entire hospital.

Just reading this one article ticks me off so much I don't even want to waste my time with the rest. Here, I'll let you check them out though. Perhaps you can write the authors and ask them where they get their proof for their claims. Or is science not a part of medicine anymore?

This article from Allina Hospitals and Clinics describes Xanthines like Theophylline (Theodur) as a bronchodilator that treats pretty much any lung condition, including pneumonia. Of course we know it's a bronchodilator, meaning it dilates constricted bronchioles and that's it.

My anonymous source writes, "Then this study for antibiotic use for pneumonia suggested that more bronchodilator use may be needed especially in patients that have a prior history of bronchodilator use. I know that I don't have a medical background and probably don't truly understand this study, but how do we fight against this type of information?

Likewise, she writes, "I do agree with you about the bronchodilator fallacies, but there is a lot of literature that sure confuses the rest of us non-medical folks."

Let's consider that final study first. Here a study was performed to see if a bronchodilator breathing treatment would be as efficacious as using antibiotics to treat childhood pneumonia, which is often caused by a virus. The conclusion was this: "Treating children with non-severe pneumonia and wheeze with a placebo is not equivalent to treatment with oral amoxycillin."

First of all, antibiotics, like bronchodilators, are of no use when it comes to treating viruses. It's like pouring tap water on a wound and saying it's disinfected. Basically, this study is saying that 100 pneumonia patients were treated with a bronchodilator and they all eventually recovered. There's no scientific basis behind this study. It's poppycock.

It's studies like this that have us still using Chest Physiotherapy in hospitals. One study 50 years ago showed that 100 post operative patients were given CPT and they all recovered. So from then on it's ordered on all post operative patients. It's all based on poppycock studies, and it's given merit too.

So basically this study shows that bronchodilators are just as ineffective for childhood pneumonia as antibiotics. Although the results were interpreted otherwise.

Well, I understand how this can be confusing. Doctors, nurses and even RTs are confused about what bronchodilators do. It's not just a few, because I'd say about 80% of all bronchodilators given in the hospital are not indicated. I know, because I'm standing by the side of the bed before, during and after every single treatment a patient receives in the 12 hours I'm on duty.

Because I've been using bronchodilators for 40 years and have never once used it for anything other than for bronchospasm. And because I do my research and have studied bronchodilators ad nauseum. Something doctors don't do. And that's fine. But it would be nice if they would admit their ignorance instead of denying it and letting it go to their head. Instead of doing that, wise doctors and hospitals are going more and more to RT driven protocols so we RTs can use our experience, wisdom and education to the benefit of not just the patient, but the hospital too. Can you imagine how much money would be saved if stupid bronchodilator orders were even cut by 25%? It would be millions of dollars.

It seems to me that too often in this life we do things the opposite way we should in medicine. It seems to me that we'd be skeptical to give a medicine for a disease until it is proven to be effective. But, in medicine, we don't want to spend too much time or money on research when we can just give the medicine and CHOOSE to believe it is doing something. And then we have to deal with the consequences no matter how harsh those consequences are.

What's going in with healthcare reform is another perfect example. Here we pass all this healthcare reform while we have zero, zilch, nada evidence that it will actually work. Which is why it's sometimes better to do nothing than to do something we think is good but we don't really know. What we really should do is leave it to the experts. When it comes to bronchodilators, the people in the room assessing the patients are the true experts.

Yet that's not what happens. Those in Washington didn't vote for healthcare reform because there is proof it will work. They passed it because it makes them feel good. It makes them feel like they're helping people. It doesn't matter if there's evidence it won't work or not: it makes them feel good.

That's the case with bronchodilators. We give them for every respiratory disease, every patient who is short of breath, every irritating lung sound, and doctors and nurses and even some RTs simply feel good that we are doing something, and they CHOOSE to believe the medicine is doing something for them.

It's kind of like the lady who's given laxis and a bronchodilator because she had heart failure and was in pulmonary edema. Five hours later she says, "Wow! That breathing treatment really helped." See, this patient saw the bronchodilator so she gave it credit. The same is true for doctors and nurses. They give credit for what they CHOOSE to believe helped the patient. When the rest of us know it was not the bronchodilator that helped the patient. The bronchodilator did nothing but add more fluid into that patient's lungs. The real credit goes to the Lasix, which helped the patient pee out the excess fluid from her body and lungs.

Of course we intelligent folks know that cardiac asthma must not be confused for asthma. The patient can get them confused, but we medical workers never should -- yet there are those amongst us who do all the time.

Allow me to say here, folks, that the battle for bronchodilator reform is not going to be won over night. It's going to take no longer being enablers for doctors and nurses. We need to quit just giving the treatments, and we need to educate one doctor and nurse at a time.

Although, the only problem is we are merely humble RTs who want to keep our jobs. So quite often it's better to keep our mouths shut and do what we are asked rather than try to change ignorance we have no control over.

For more information on how doctors abuse bronchodilators, see my Physician's (Doctors) Creed in the links above, or click here. Click here to read more about bronchodilator reform. Click here to read about the benefits of RT Driven Protocols. Click here to read my apology for my tone in this post, and my apology to the websites and doctors above mentioned.

12 comments:

Glenna said...

I agree with everything you said. Not only does it not work, I hate running up the bills of people knowing it doesn't work.

PHS doctor said...

You should consult the journal Chest as bronchiodilators have, in fact, been shown to remove mucus.

If you wish to be taken seriously by anyone with even a basic knowledge of medicine and pharmocology, I suggest that you change the tone of your writing. Simply stating things are 'lies' makes you look uneducated and uninformed. You repeatedly lambast other websites for failing to accurately reference, yet you do the same thing yourself. You also have a significant tendency to simply ignore the reserach which doesn't support your position.

I agree that bronchiolators are over-prescribed (HMOs are in large part to blame for this). But the way your site is presented it is the last site I would send anyone to for information.

Rick Frea said...

Just keep in mind this is a blog and not a science journal. However, if you've read my other posts, I've provided ample evidence that bronchodilators dilate bronchioles and nothing more. And yes, they will help move secretions IF those are secretions trapped by bronchspasm.

Rick Frea said...

Also, yes you are correct that most needless breathing treatments are ordered due to things like Medicaid and Medicare that will only reimburse the hospital if the patient meets intensity of service. And, according to this, a breathing treatment qualifies a patient for reimbursement (at least in Michigan).

Yet how a committe decided that a bronchodilator will help a patient with pneumonia is based not on science but theories that are unfounded. It's either ignorance or lies.

Rick Frea said...

However, all this extra work does keep us small town RTs in business. It's all those poor RTs who work for larger hospitals who are overwhelmed and burned out because they have to wake patients up for therapies they don't need.

Rick Frea said...

For evidence that beta adrenergics do not have a significant enough mucociliary clearance effect, check out this link. The name of the article is "Inhaled Adrenergics and Anticholinergics in Obstructive Lung Disease: Do They Enhance Mucociliary Clearance?" By Ruben D. Restrepo, MD, RRT, of the September, 2007, issue of Respiratory Care (Vol 52, No 9).

Here is the highlight of the article: "The involvement of the cholinergic and adrenergic neural pathways in the pathophysiology of mucus hypersecretion suggests the potential therapeutic role of bronchodilators as mucoactive agents. Although anticholinergics and adrenergic agonist bronchodilators have been routinely used, alone or in combination, to enhance mucociliary clearance in patients with obstructive lung disease (CF, COPD, asthma), the existing evidence does not consistently show clinical effectiveness."

Anonymous said...

Great post, Rick. I have to say I agree with everything you write here. You should also note that doctors are quick to use a study that shows beta adrenergics slightly enhance sputum clearance to justify giving more treatments, regardless that the effect of this is pretty much insignificant. Yet they ignore studies that show that Albuterol may actually cause bronchospasm. It's one of those I-like-the-study-when-it-supports-my-argument, and ignore it when it disproves my argument kind of deal. John B. RRT

Mkai0 said...

Very good info!

john bottrell said...

Just the fact albuterol increases sputum production in no way proves it benefits patients with pneumonia. If this were true, then patients with asthma and COPD, who are known to have excessive goblet cells and increased sputum production, would be immune to pneumonia.

Tim Short said...

Wow, reading this page is just painful. Stop thinking you're some kind of expert, because you're obviously not.

Of course bronchodilators work best in athsma where there is a lot of bronchoconstriction, but you don't seem to understand that small amounts of bronchoconstriciton can be present in the acutely ill lung!

Furthermore, you need to understands that bronchodilators are not "anti-bronchospasm medicines"....they actually just relax the muscles in the lungs. That means, even someone with emphysema, yes emphysema, will have every so slightly increase in lumen size of the airways simply due to the muscles relaxing.

Lastly, your remark on mucous clearance is laughable. It is a cornerstone of chest physiotherapy that bronchodilators open up the airways and make it more EFFECTIVE for chest clearance techniques. E.G. you can get a much more effective cough if your airways are open.

Geez, you are a disgrace.

Rick Frea said...

Evidence that the truth hurts before it makes you better. What you say sounds good in theory, but the clinical evidence does not match the theory. This is often the case in medicine.

john bottrell said...

Breathing treatments are expensive, and should not be doled out unless there is a notable indication. Just because a person has a disease is no indication for bronchodilators. Mr. Short, we appreciate your comments, and respect your opinion. Still, we are still looking for evidence to support the profligate use of albuterol.