neonatal tidal volumes

If you deal with neonates on a regular basis you may have a pretty good idea of what tidal volumes to set up. Yet, if you work mainly with adults and still have to be responsible for the occasional neonate and peds patient, you better have a good idea of what you are doing.

Since no RT is a genious, what I find works best if I have a cheat sheet on hand. What you see here are the ideal tidal volumes for neonates. For a printable cheat sheet, click here.

Here's what asthmatics need to know about PFTs

Here is everything asthmatics need to know about PFT testing. This was originally published at myasthmacentral.com:

Here's All You Need to Know About Pulmonary Function Testing
by Rick Frea Wednesday, January 06, 2010 @Myasthmacentral.com

When I was 14, after performing a pulmonary function test (PFT), I had a hundred questions for the respiratory therapist who performed the test. After I basically forced him to tell me, he said, "You have about a 35% lung function."

"Cool!" I said. "What does that mean?"

So, what is a PFT? Basically, it's a test where you breath into a mouthpiece to a device called a spirometer. The spirometer measures your lung function, and helps your doctor determine if you have asthma and how severe it is. This test is also called spirometry.

There are a lot of tests you do, yet the most important in diagnosing asthma is performing a forced vital capacity (FVC). In this test where you take in a breath as deep as you can, and then blow out as hard as you can until you can't exhale any more. While you're performing the FVC you'll note some pretty cool loops on the computer, from which the following calculations are made:

1. PEFR: Peak Expiratory Flow Rate. This is the maximum flow that can be generated with a forced exhalation. This is similar to what is obtained when you blow into your peak flow meter, but more accurate and reliable.

2. FEV1: This is a test that measures the amount of exhaled air during the first second of the FVC. This number cannot be faked, and is the most important value for diagnosing asthma.

3. FEV1/FEV6: This test is used as a substitute for FEV1 in adults who have significant air trapping and who get "light headed" while trying to forcibly do spirometry.

4. FEV1/FVC: This may be a more accurate measure of severity of asthma in children as compared with FEV1.

So, what use are the above measurements? To answer this question, we must have a basic definition of what asthma is. Therefore, asthma is a reversible obstructive airway disease.

Also, before you take the test, the RT will estimate your predicted normal results for the values listed above based on your height and weight.

Airflow obstruction: If your actual FEV1 is less than 80% of your predicted FEV1, you are considered to have airflow obstruction. And your lung function will be considered to be 80%.

If you happen to be a hardluck asthmatic as I was as a kid, and your FEV1 is 35%, then you are considered to have a 35% lung function.

So that's the first component of asthma. Now we must consider reversibility.

Reversibility: After you do your initial sequence of tests, you will take a breathing treatment with the bronchodilator of your doctor's choice. In most cases it will be an Albuterol breathing treatment. If your FEV1 increases by 10-15% within 15 minutes following a bronchodilator, this is indicative of airflow obstruction that is reversible.

That's basically all you need to know about PFT results. If you have obstruction and reversibility, there's a good likelihood you have asthma.

Note here that low VC, PEFR, FEV1/FEV6 and FEV1/FVC as compared with your predicted are also indicative of airflow obstruction. And if these improve following bronchodilator therapy you have the reversibility factor.

If your doctor suspects you might have asthma, yet your initial PFT results are normal, he may have you undergo bronchial provocation (also called a challenge test). This is where the RT will try to cause you to have an asthma attack.

There are many ways he may do this, but the most common are either having you run on a treadmill or having you inhale methacholine. If you do this and your FEV1 is now less than 80% of your predicted, and this is reversible after using a bronchodilator, you may have asthma.

Still, you must keep in mind that PFT results are not absolute. There really is no one single test that says, "you have asthma." Although most asthma experts believe PFT testing, particularly the FEV1 results, aren the best indicator that you probably have asthma.

Thus, If your doctor suspects you have asthma, you should have a PFT done to confirm his suspicion.

The only exception here would be little children who are less likely to cooperate with the test, and the results may not be accurate. In many cases, a PFT test cannot be completed until a child is at least five years old.

In this case, a doctor will have to use other means to diagnose asthma, such as patient and family history.

Another neat thing your physician can do with PFTs is determine if you have exercise induced asthma, and what medicine works best as a pre-treatment to prevent EIA. Likewise, follow-up PFTs can help your doctor monitor the course of your asthma over time, and how well you are responding to your current medicines.

As I noted earlier, when you're doing the PFT you'll see some cool loops on the computer screen. The one created as you do your FVC is called a flow volume loop. If you have airflow obstruction and reversibility, the loops will show this. By analyzing the loops and calculations together, your physician can obtain a good idea of what's going on in your lungs.

If you want to see some loops, I provide a brief loops 101 course using some PFT results from my medical records, and one I did recently on myself. You can check this out by clicking here.

Personally I think PFTs are hard to do. When I'm done I'm exhausted. I don't know if this is because I have asthma or if it's just always exhausting. Yet it's still an interesting series of test, and knowing how to interpret the results is definitely good asthma wisdom to have.

For further reading, you can check out my PFT Lexicon or, better yet, this link here.

Factory work was not for me

I had a job working in a factory once. I totally appreciate those who can bare to do this type of job, because the monotony is not for me. All I did all day was sod the ends of two wires together. It was hard to concentrate, and my mind often wandered to the Rolling Stone's song, "Time is on my side." Needless to say my boss kept having to nudge me.

I lasted three days.

On the first day I was told we were only to have three breaks during the 8 hour shift. On the second day I noticed that some people were taking a break every hour on the hour, and they were gone for 10 minutes. I asked the boss, "Why is it those guys get a break every hour." He said, "They go out for a smoke." I said, "Interesting." From then on out I went out every hour. When my boss questioned me about this, I humbly said, "I'm taking a non-smoking break."

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.

Your RT Queries

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:

can copd be faked ? I imagine anything can be faked. But I don't think COPD would be as easy to fake as asthma. With asthma you're relatively normal most of the time. With COPD you have a tendency to be short of breath more often, and your body makes some changes. For example, if you have emphysema your chest diameter increases as your lungs lose their elastic recoil, as you can see here. Likewise, you cannot fake the FEV1 test on a PFT. You also cannot fake the results of an ABG. However, a COPD patient might be able to fake an exacerbation. All he'd have to do is quit taking his meds or exaggerate his symptoms.

the ideal personality for a respiratory therapist: I'm going to write a post about this coming soon. Ideally, though, I think any personality can be an RT so long as you are a hard worker, have the ability to learn, don't mind being on your feet a lot, can handle making key decisions and running complicated machines under diress, and can be in a pissy mood and turn on your smile the moment you enter a room.

why did you decide to become a respiratory therapist: I became an RT because I have asthma and thought I'd have empathy for those who have trouble breathing.

serevent alone: This is an acceptable practice for COPD. But, for asthma, it is recommended if you need a long acting bronchodilator that you also need to be on an inhaled steroid, which is why most doctors should prescribe Advair or Symbicort for asthma. However, I think most doctors also prescribe Advair and Symbicort for COPD too.

when do i stop taking albuterol for pneumonia: Ideally you never should have been put on Ventolin for pneumonia. It does nothing for inflammation of the alveoli.

do people come off bipap: It depends why they are on it. Some sleep apnea and COPD patients use one while they sleep and as needed to keep their airways open, improve oxygen, and improve ventilation while sleeping

correct way to write a c-pap respiratory order: I'd like to see it written this way: CPAP to tolerance per RT protocol. Then you can adjust it to an appropriate setting. However, some doctors write CPAP 10 or whatever # they made up in their head. How they pick the number I have no idea. Ideally, you should not just make up a # but find the best CPAP for pt.

who gets better paid respiratory therapist or registered nurse: RNs make more.

did anyone go to collage wit a 75 iq: I have no idea. However, I'm curious to know.

can you die on a bipap: Yes. You can die on anything.

respiratory therapy is a horrible job: It is what you make of it.

If you have further questions for me please contact me.

What is severe COPD?

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.

Your Question: What is severe COPD?

My Humble Answer: Usually, severe COPD often refers to the last stage of COPD, where your heart is starting to wear down due to working hard to pump blood through your lungs which are severely obstructed. On an X-ray, or CT, this can be seen as an enlarged heart. Usually at this stage you become short of breath with minimal exertion. Now, I don't know if this describes you or not.

If this does describe you, our sister site has some great information to help you live well, check out this link for one example.

To receive the best answer to your question, you should discuss this with your doctor. He should be able to answer every question you have regarding your COPD.

Good luck.

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

Capnography Cheat Sheet

Here is a capnography cheat sheet. It comes in handy from time to time For a printable version of this click on cheat sheets to your left, or click here.

Generic and brand names: why are there so many names for meds?

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: Is Ventolin in Canada the same as Albuteral? I get very confused with all these names of medications. The ones in Canada I think are called something else??

My humble answer: The medicine is exactly the same in both countries.

Merck.com explains all the names. I'll give a quick review here.

Every drug has more than one name. You have the chemical name that describes "the atomic or molecular structure of the drug." Usually this name is too complex for for the public to understand

Once the product is approved by the FDA it is given a generic name, which is basically an easy to pronounce version of the chemical name. Then the company comes up with a brand name that marks that particular product as made by that company.

Likewise, "When a drug is under patent protection, the company markets it under its brand name. When the drug is off-patent (no longer protected by patent which usually takes 25 years), the company may market its product under either the generic name or brand name. Other companies that file for approval to market the off-patent drug must use the same generic name but can create their own brand name. As a result, the same generic drug may be sold under either the generic name or one of many brand names."

Most doctors, nurses and RTs will refer to the drugs generic name, because it refers to the product itself not the company that makes it. Thus, a doctor will write an order for Albuterol. The pharmacy can choose whichever brand it wants. Usually it chooses the one with the lowest cost at that time.

For Albuterol it would look like this:

Generic name: Albuterol in the U.S. (Salbutamol in Europe and Canada)

Brand names: Ventolin, Proventil (AccuNeb, Vospire, ProAir in Europe and Canada)

Every one of the above refers to the exact same medicine, and they all have the same components, and thus all work exactly the same. So, yes, the Ventolin in Canada is the same as Albuterol.

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

Ancient asthma remedies

This post is the first in a series I plan on writing about the history of asthma. This was originally published at MyAsthmaCentral.com:

Check Out These 19th Century Asthma Remedies!
by Rick Frea Friday, December 18, 2009 @Myasthmacentral.com

Being a lifelong asthmatic, I've often wondered what life would be like for us asthmatics if we lived before rescue medicine like Albuterol was invented. I bet it would have resulted in some long, agonizing days and nights.

I was surprised to find there were many books written about asthma. The most popular was a 19th Century book called "On Asthma" by Dr. Henry Hyde Salter in 1882. His book provided remedies that gave hope to many child asthma sufferers, including Teddy Roosevelt. Although you might agree with Teddy that most of these weren't remedies at all, but torture.

1. Ipecac: It causes nausea and makes you vomit (sounds like fun). Salter observed that asthmatics with full stomachs had increased trouble breathing. He also believed irritants in food may cause asthma, so if you vomit and clear your stomach contents you will have an easier time breathing. (I'm not making this up).

Modern thought: A full stomach presses up on your diaphragm and thus squishes your lungs making it harder to breath. The irritants Salter is referring to in the food may now be known as food allergies. This medicine is thankfully no longer recommended for asthma.

2. Tobacco: Salter encouraged kids having trouble breathing to smoke cigarettes. But, instead of inhaling, hold the smoke in as long as you can -- literally "ad nauseum". For prophylactic therapy, smoke a daily cigar.

Modern thought: Smoke is an irritant. Not only that, smoking will increase your chances of developing COPD, and thus making your breathing worse in the long run.

3. Strong coffee: Salter observed sleepiness and drowsiness favored asthma. So, if you stay awake you won't have an attack. Strong tea, ammonia, and ether also work to produce this same effect. Go ahead and pick your poison.

Modern thought: The caffeine in coffee is a methylxanthine, which is a mild bronchodilator. Theophyllin is a methyxantine that became popular for asthma in the 1950s because it is a much stronger bronchodilator.

4. Indian Hemp: Otherwise known as marijuana. Like coffee, it increases your mental acuity. It makes you more vivid.

Modern thought: Marijuana is an asthma irritant. It too can cause more complicated lung problems down the road. It's an absolute no-no for asthmatics.

5.Alcohol: Recommended only in the face of "horrible suffering" because it is habit forming. Salter's theory was alcohol worked similar to coffee and hemp in that it stimulates and "gives a sort of shock.. to the nervous system..." and thus stops the asthma attack.

Modern thought: Alcohol has some molds and fungus in it that may trigger asthma. It also dries out your airway and may cause or make worse an asthma attack.

6. Chloriform: Again, I'm not making this up. Taken in small doses (and always in someone's company) it induces sleep, completely relaxes all your muscles (including your bronchiole muscles) and when you wake up your asthma attack will be gone.

Modern thought: It depresses the central nervous system and causes dizziness, fatigue, headache, nausea and even death. It may also damage the kidneys and liver. It is way too dangerous and risky to use for asthma.

7. Opium: It induces a relaxed state and thus cures bronchospasm. Salter didn't usually recommend it because he believed sleepiness induced asthma.

Modern thought: Morphine is a mild bronchodilator used in hospitals to cause a relaxed state that can reduce the feeling of dyspnea (air hunger) in end-stage lung disease like COPD, pulmonary fibrosis, cystic fibrosis and cancer.

8. Strammonium: Smoked in a pipe since ancient times for shortness of breath. Salter didn't recommend it for anything other than as a preventative medicine.

Modern thought: Atropine was purified from Belladona in the 1930s, and later was refined in the form of Atrovent and Spiriva. The Belladona plant is very similar to Strammonium. This line of medicine is no longer considered a top line asthma therapy, but is still used in some cases and in hospitals.

9. Lobelia: This is also referred to as Indian tobacco, as it was used by American Indians to induce vomiting and forcibly clear the airway of mucus. It was smoked in a pipe like Indian hemp, tobacco and strammonium. It is also referred to as "puke weed." This therapy was not recommended by Salter. But he said it works for some.

Modern thought: It was recently used as a nicotine substitute to help people quit smoking, but it was banned for use in cigarettes in 1993.

10. Ether: Salter wrote, "Ether is mentioned as a remedy... by almost all writers on the disease. I have never seen but one case in which it did any good."

Modern thought: It's only used as a anaesthetic in 3rd world countries.

Well, there you have it. Aren't you happy now you were born in the modern asthma era? So, if you were born in the 19th century, what poison would you prefer? If you're like me, you now appreciate your Ventolin all the more.

Competition should lower price of asthma meds

While Advair and Symbicort are have worked wonders for many asthmatics, these meds are not available to many due to their high cost. Yet soon, improved competition may drive down the price of both. I explain in this post from MyAsthmaCentral.com

Competition Heats Up for Advair's Share of the Market
by Rick Frea Monday, March 08, 2010 from MyAsthmaCentral.com

While the economy sputters, the long acting bronchodilator/ corticosteroid combination inhaler market is booming. While big pharmaceutical companies fight it out to maintain or gain a piece of this pie, we asthmatics should be the beneficiaries.

New drugs, and new marketing ploys, may soon be available in the U.S. market to compete with Advair and Symbicort, which will provide more options for asthmatics like you and me. Plus, as we all know, more competition means lower costs.

Advair and Symbicort are asthma combination inhalers that have both a long acting bronchodilator (LAB) to treat the airway narrowing (bronchospasm) component of asthma, but also a corticosteroid to treat the chronic inflammation side of asthma.

Advair (called Seritide in Europe), which is marketed by GlaxoSmithKline (GSK) out of London, became available in the U.S. in 2001, and presently has the lead in this booming market. Adviar consists of the LAB Salmeterol (Serevent) and steroid fluticasone propionate (Flovent).

Symbicort, marketed by AstraZeneca, became available in the U.S. market in 2007 to compete with Advair. Symbicort consists of the LAB Formoterol (Foradil) and steroid Budosenide (Pulmicort).

To improve it's share of the market, AstraZeneca is hoping the FDA will approve of Symbicort as a single-use inhaler, meaning asthmatics will be able to use it as both a preventative medicine and a rescue inhaler.

In May of 2010 the patent on Advair will expire (as you can read here), providing an opportunity for other companies to make and sell generic Advairs (like Seroflo) and gain a piece of this booming market.

Although, as you can read here, GSK sees little risk from generic Advairs any time soon. We can only hope, for our sake, GSK is wrong.

To try to maintain it's share of the market, GSK is hoping to soon release a new "Super Advair," which is also known as "Son of Advair." The inhaler will consist of a new LAB, currently called LABA 444, that only needs to be taken once a day, and a new corticosteroid, perhaps fluticasone furoate.

GSK notes early studies for "Son of Advair" show improved lung function and less risk for cardiac side effects, although other studies show the new corticosteroid is not much better than fluticasone propionate, the one in Advair.

Of course the company hopes to get all it's current Advair users to switch to this new drug before Advair generics are available. We'll have to wait and see how this turns out.

Other future entrances into this market (as you can read here) are Novartis/Schering-Plough's once-daily medicine which contains the LAB indacaterol and corticosteroid mometasone, SkyePharma's Flutiform (Formoterol and Mometasone), and Nycomed's Alvesco (Formoterol and ciclesonide).

All these attempts to maintian, or gain, market shares for these pharmaceutical companies means increased completion, and -- hopefully -- lower prices for you and me. Yet it also means more options for you and me and our doctors too, and -- ideally -- better asthma control with safer medicines.

Yes it's true, all this competition should benefit us asthmatics.

The impressive nurse

Erica was a relatively new nurse, and I had actually gotten annoyed with her before because she keeps calling me to give breathing treatments on patients where none are needed. Once she called me to give a treatment because, "the sat's only 89%."

However, oppinions are meant to be changed. A "Code Blue!" page rang out overhead, and I rushed to OB. As the code on the neonate progressed, I was getting tired of bagging and doing CPR. Then Erica showed up and joined in the rotation of bagging, cpr and rest.

She was so impressive, so calm, that I figured she had to be an old pro. Later, after the emergency was over, I approached Erica. She said, "That was the first code I had ever been to, and it just happened to be a baby."

I said, "That was your first code! Holy cow! You were so calm and cool and did such an awesome job I was sure you had done this many times before. I am very impressed!"

Nurses like this are definitely teachable, and fit onto our team well. I also think it's a good thing to compliment our fellow workers on a job well done, even if the outcome isn't what we expect.

Here's how to know if patient is a CO2 retainer

Question: How do you know how to tell someone is a CO2 retainer by looking at the blood gas?

My humble answer: It's easy. First, the CO2 will be chronically elevated. Usually, you'll find it in the 50s, but it can be as high as 80 on a good day. Second, look at the pH. If the pH is normal and the CO2 is elevated, you have a CO2 retainer.

Question: So, what if you have a patient who is laboring and has a pH of 7.20. Can you still tell if this patient is a retainer, when his CO2 is 80 or even 100?

My humble answer: Great question. Yes. What you do here is look at the BiCarb. If a patient is a CO2 retainer, his Bicarb will be chronically elevated. So, if you have a BiCarb greater than 30, chances are the patient is a retainer.

Question: Can you give an examle blood gas?

My humble answer: Sure. Consider ph 7.38, CO2 50, Po2 50, HCO3 35. That's a blood gas of a Co2 retainer on a good day. Note the CO2 is elevated and the HCO3 is elevated to compenate to keep the pH normal. This is a normal homeostatic procedure. So, if you had a patient in respiratory acidosis, his gases might look like this on room air: pH 7.20, CO2 80, Po2 36, HCO3 38.

Question: So what if the doctor sees that low Po2 and high CO2 and thinks you got venous blood. How can you prove to him it was not venous?

My humble answer: Sometimes you can't. However, you know if you got the artery by how well it filled the syringe. Still, a doctor might not believe you. You can just tell him that the HCO3 is high, so chances are the CO2 is chronically elevated. If the patient is in acidosis, chances are the CO2 is elevated even more.

MDIs: Priming the pump

Are you compliant with priming the pump before using a metered dose inhaler (MDI) like Albuterol? If you are, congratulations! I have to be honest: I'm not a pump primer.

So, what is MDI pump priming? It's when you waste 1-4 puffs of the medicine so that when you take it for real you are getting the maximum medicine available.

According to the American Associacion for Respiratory Care's "Guide to Aerosol Dellivery Devices," the following are the recommended Priming Requirements for Commercially Available MDIs:

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Medication Propellant Time to Prime # of Sprays Albuterols:

1. Albuterol* HFA Prior to first use 3 (With 3 days of nonuse 3)
2. Levalbuterol HFA Prior to first use 4 (With 3 days of nonuse 4)
3. Maxair Autohaler CFC Prior to first use 2 (With 2 days of nonuse 2)
4. Azmacort® CFC Prior to first use 2 (With 3 days of nonuse 2)
5. Flovent® HFA Prior to first use 4 (With 3 weeks of nonuse 4)
6. QVAR® HFA Prior to first use 2 (With 10 days of nonuse 2)
7. AeroSpan™ HFA Prior to first use 2 (With > 2 weeks of nonuse 2)
8. Atrovent® HFA Prior to first use 2 (With 3 days of nonuse 2)
9. Combivent® CFC Prior to first use 3 (With 1 day of nonuse 3)
10. Intal® CFC Prior to first use 1

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Despite the recommendation that all MDIs be primed before each use, I have never in my life ever done it -- not once.

I have good reason, though, for not doing it. First, when I learned how to use an MDI by my physician in 1980 the practice was never taught. Back then you were taught to place the inhaler two finger lengths from your mouth and squirt.

Second, when I was a kid I was a hardluck asthmatic and a bronchodilatoraholic. That meant that quite often my rescue inhaler (my Alupent back then) lasted me seven days or less, when it was supposed to last 4-6 weeks. So I had to do whatever I could to make the inhaler last longer, and that meant not wasting puffs.

Likewise, as a child asthmatic, I never wanted to bother my mom to run to the pharmacy, so that was another reason to make my inhaler last longer. Yet, even by not priming, my inhaler still only lasted about a week.

Third, I never heard of MDI priming until a few months ago. So after 30 years of not priming the pump, it's going to take me a while get into the habit. This is probably the stubborn me talking, but I really don't see a need to prime. Even if I'm only getting 2% of the medicine when I take my two puffs, that 2% seems to be sufficient. So I really don't see a need to prime the pump.

Yet theres an old saying this reminds me of: We do the best we can with the wisdom we have, and when we learn better we do better. So perhaps it's time to change my ways.As a respiratory therapist, I suppose I'm going to have to add pump-priming to my how-to-use-an-MDI regime.

So, what about you? Did you know about the need to prime the MDI pump? Are you an MDI pump primer? If you're an RT, do you teach this to your patients?

* Note that Proventil and Ventolin HFA have the same priming requirements.

How do you know someone is a CO2 retainer

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. how do you know someone is a co2 retainer: Their CO2 is elevated, the pH is normal and the HCO3 is elevated. An example gas on room air would be CO2 50, pH 7.40, HCO3 36, PO2 55. Usually the HCO3 will be in the 30s.

2. particle size of advair: For particles to impact in the bronchioles of the lungs the particle size has to be about 0.5 microns.

3. ink: We still need it occasionally when we write in the charts, and to take notes on our clipboards.

4. albuterol stunt growth: No! Albuterol does not stunt growth.

5. does albuterol contain alcohol: Some of the new HFA bronchodilators do contain ethonol. You'll have to check the package insert to see if your inhaler does. For more information check out #3 above.

6. too tight to hear a wheeze: Sometimes a patient's lungs are so tight you will not hear a wheeze. In fact, it is quite common that bronchospasm does not result in a wheeze in both COPD and asthma patients. I've written here before that I think most wheezes that are heard are not bronchospasm (you can read more here). The best indicators of bronchospasm in my opinion are diminished lung sounds and shortness of breath.

7. asthma go away: There is no cure for asthma. However, by working with you doctor to find the best combination of asthma medicines most asthmatics do manage to gain control of their asthma (check out this post). Be patient, however, because it may take time. You will also have to do your part by learning of and avoiding your asthma triggers, taking all your medicines exactly as prescribed (check out this post). This includes taking your asthma controller meds even when you feel well. It is also recommended you have an asthma action plan to help you decide what to do when you question yourself. Check out the links in this answer and you should be well on your way to better asthma control.

8. how success came about : How do you define success? Do you define it by how much money you make? How much love you get? How happy you are? How satisfied you are? I like to define success as satisfaction. Either way, there is only one way to achieve success and that is by using common sense and making a gallant effort to do your best at whatever you do.

10. deep breathing exercises prevent pneumonia for immobile patient: It can but there is no guarantee. What you have to realize is that healthy people sigh 3-4 times every hour, and the reason they do this is to stretch and exercise the parts of the lungs that are not used on a regular basis -- like the lung bases. This ultimately prevents the alveolar sacks from collapsing (atelectasis) and can also prevent pneumonia. It helps you to expectorate any secretions deep in your lungs, particularly in the bases of your lungs. Taking 4-10 deep breaths with a 3-10 second breath hold has been proven to prevent pneumonia.

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

Will asthma eventually go away?

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: Will underlying asthma go away?

My humble answer: Asthma a tendency to disappear for months or even years, but once you have asthma you have it forever. Some asthmatics never have symptoms, and some have symptoms all the time. But most asthmatics have occasional asthma symptoms. It is an old fallacy that asthma disappears as one grows older. Still, many child asthmatics see their asthma improve as their lungs grow bigger. Once you are diagnosed with asthma, you should continue to see your physician once a year, and continue to take the asthma controller meds he prescribes whether you are having symptoms or not. Some asthmatics will need to take controller meds all the time, and some asthmatics may eventually and successfully be weaned off their asthma meds.

Question: Should I be taking a second medication with Foradil? Likewise, if I'm on this new medicine, should I keep taking Atrovent?

(Note: Foradil is the brand name of the long acting bronchodilator Formeterol. Formeterol is one of the two medicines in Symbicort. Foradil is a similar medicine to Serevent.)

My humble answer: Great question. Asthma is now believed to be associated with chronic (always there) inflammation (swelling) of the air passages in your lungs. Therefore, most asthma experts now believe that asthma that is not controlled by other medicines should be controlled with inhaled corticosteroids. Likewise, most asthma experts also recommends (as well as the asthma guidelines) that if a medicine like Foradil is required to treat asthma, that an inhaled corticosteroid be used with it. Thus, Foradil alone does not treat the chronic inflammation. Therefore, I highly recommend you talk to your doctor about Symbicort. Check out the link and read about it. It has both Formoterol (which is what Foracort is) and Budesonide (an inhaled steroid) in it. Many asthmatics have had great success with this medicine.

Likewise, if you take Formoterol (or Symbicort) you will not need to take Atrovent unless your doctor requires it. Atrovent is no longer a top line medicine for the treatment of most asthma cases.

Peak Flow Meter Monitoring

Your peak flow meter is often considered THE primary tool for to monitor your asthma. Yet, while most asthmatics have one, few use it. And, those who do use it, few of them use it correctly. I know this because I work with asthmatics and I ask.

Read my recent post from myasthmacentral.com and learn all you need to know about peak flow meters:

Your Peak Flow Meter Is An Important Tool
by Rick Frea Wednesday, December 09, 2009, @MyAsthmaCentral.com

If you're an asthmatic, chances are you have a peak flow meter somewhere in your possession. Or, if you don't, you might want to consider requesting one from your asthma doctor. A peak flow meter is one of the best tools ever invented for helping us asthmatics monitor our asthma at home.

The problem with peak flow meters is most asthmatics don't use them, or when they do they use them improperly. When I see these asthmatics in the ER, it's my job to educate them.

So, what is a peak flow meter? Why were you given one? How should it be used? Why do asthma experts think they are so important?

The U.S. Department of Health and Human Services (HHS) recommends in their asthma guidelines that every asthmatic work with his or her doctor to create an asthma action plan. This is a plan that helps you decide when to use your rescue medicine (like Albuterol), when to call your doctor, and when to have someone take you to the emergency room.

To help you decide what to do, the asthma guidelines recommend you either monitor your asthma symptoms, use your peak flow meter, or both. What you do depends on you, your asthma and your doctor. I wrote about asthma action plans here, and monitoring asthma signs and symptoms here, so in this post we'll tackle the importance of peak flow monitoring.

When I was a kid with hardluck asthma, my peak flow meter came in handy quite a few times. I say this because I was short of breath so often that I basically became tolerant to it. So, I had to use my peak flow meter as a tool to help me decide what to do.

As an adult my peak flow meter became less useful. It seems that whether my asthma is acting up or not, my peak flow values neither increase nor decrease. This is something unique to me. Still, I monitor my peak flows daily because you never know when it will come in handy.

The asthma guidelines recommend the following asthmatics use peak flow meters:

Moderate asthmatics: They are at increased risk over mild asthmatics

• Severe asthmatics: They are at highest risk exacerbations
• History: Patients who have a history of severe exacerbations
• Dyspnea intolerant: They poorly perceive airflow obstruction and worsening asthma
• Children: They have a harder time communicating how they feel, and this provides a good tool for parents to monitor their child's asthma.
• Personal preference: Some asthmatics prefer this method
• Doctor preference: Doctors can use this as a monitoring tool

A peak flow meter is a handy, easy-to-use, hand-held device that you blow into as hard as you can. It basically measures your peak expiratory flow rate (PEFR), or how much air you can blow out with maximum exhalation.

Because measurement of PEFR is dependent on your effort and technique, it's important you work with your doctor, nurse or respiratory therapist to make sure you are using it properly. To review proper peak flow technique, click

here.

Ideally, you can use your peak flow meter as part of your asthma action plan. According to National Jewish Health, the plan would work like this:

1. You blow into your peak flow meter every day for two weeks when you are feeling well. Whatever PEFR was your best, that one is considered your personal best.

2. You use your daily PEFR readings, along with your personal best, to help you decide what to do:

1. If your peak flow is less than 80% of your personal best, you take your rescue medication, then wait 20 to 30 minutes and check your peak flow again.

• 1 If your peak flow is not back above 80%, report this to your doctor.
• If your peak flow is back above 80%, re-check your peak flow about every 4 hours for a day or so. Call your doctor if you continue to need rescue medicine

2. If your peak flow is less than 60% consider this an emergency: Take your rescue medicine, and call your doctor or go to the emergency room right away.

It's really quite simple.

You should blow into your peak flow meter every day in the morning, and in the evening. This is important, because your peak flows may be normally lower in the morning. Then, if you notice your peak flows trending down, you can use this as an

early sign of an impending asthma attack, and you can act now to nip it in the bud.

Likewise, if you do need to make a visit to the ER or doctor's office, your doctor can use your personal best as an indicator of how well you are doing, whether you need another breathing treatment, or if you need to be admitted. This can save you a lot of time, and maybe even prevent you from needing to be admitted.

Also, your doctor can use your peak flow readings to monitor how well your treatment regimen is working, and as a "quantitative measurement" of how good or bad your asthma is doing.

So, even when you're feeling well, use your peak flow meter. Get it out of the box, out of the closet, dust it off, and place it next to your bed near your asthma diary to record the results. Then use it daily like the gallant asthmatic we're sure you are.

Note: The Asthma guidelines recommend all asthmatics either use symptoms monitoring or peak flow monitoring as part of their asthma action plan, or both. The guidelines note that both methods are equally effective.

A job well done is a job well done

Recently a code blue rang out over head, and the destination was OB. I swear I ran all the way from the RT Cave to OB in less than 15 seconds. And, yes, the adrenaline was flowing through my veins and I was even a bit shaky. I'm sorry, but even after 12 years on the job, this was the first time my neonatal resuscitation skills were needed.

I took over ventilations as soon as I got there while someone else did CPR. The doctor from ER showed up and immediately intubated the baby. He already had an umbilical art line in, so we we drew a gas and sent it to lab. Epi was given again and again and again. The heart came back, and then it faded, and then it came back and then it faded.

And while we held up strongly during the event, as soon as it was called several hours later the doctor slumped over the patient and said a long prayer. The rest of us stood by in utter disbelief that we had to whiteness this; in utter disbelief of what we had to do here at our small town hospital.

We prepare for this throughout the year hoping to never use these skills. We have to do special training to remind ourselves how to use these skills because we aren't a large hospital and we don't do this stuff on a regular basis. As I wrote above, this was my first in 12 years. And, except for the doctor and one nurse, it was the first neonatal code blue for all the rest of us.

Later I sat down to talk to the ER doctor who came up to help us. He said something along these lines, "When I arrived there you were bagging, another nurse was doing CPR, and every body else was just standing around. I think that you guys ought to be trained to do things better."

My jaw dropped. How could he say such a thing. Then my jaw dropped even lower when he said, "I hate having to go up to the floor at this hospital. Here I'm an ER doctor, and I have to go up and have my name put on a chart of a patient upstairs, so if there's a lawsuit my name is going to be in it."

How can you be so selfish? Is all I could think to say. Still riding on the rush, I couldn't let this slide. I had to defend my coworkers: "I think things went excellent up there. Considering that most of the people at that code never did that before, I thought things went awesome."

"Really, you thought that?"

"I have never left a code where I said to myself, 'Gee, Rick, I think everything went perfect.' I don't because there is always room for improvement. But considering the limited staff and the limited experience we have here, I think we did awesome."

Yet he continued to explain to me how there could be a lawsuit. I said, "Still, it's in your job description to help us. If there is a code blue you have to come, unless you're tied up with another more important situation. But I can't think of anything more pressing than a neonate that's not breathing. Can you?"

"Well, no," he said. Yet he spun off again on another rant about lawsuits. He's an awesome doctor, and I respect him deeply. I really do. And I understand where he's coming from. Yet sometimes it's best to do what's right now, do good charting, and worry about a lawsuit some other day.

Besides, all he did was put in the ETT and tried to save the baby's life. In fact, that's what we all did. Are we supposed to stand idly by and let a baby die because we might get sued. I don't think so.

In fact, I think we ought to make this RT Cave Rule #42:

RT Cave Rule #42: It's best to do what's right now, do good charting, and worry about a lawsuit some other day.

Dr's Creed: Bronchodilators now lowers Fever

The following might seem like nonsense to thinkers like you and me, but the Real Physician's Creed teaches doctors otherwise. Heed, what follows is surreptitious wisdom previously shared only with physicians.

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Page82

Section B7

A study performed by the Dr's Creed Association of America, and in association with the University of Michigan, provided a nearly conclusive conclusion that all post-operative patients that develop a fever should be provided with bronchodilator therapy.

The study included giving 2,000 post-operative patients at four key hospitals in the State of Michigan a bronchodilator if they developed a fever. Care providers for these patients eventually noted normal temps eventually, and the patients all eventually got better and were discharged.

Therefore, based on this study, we recommend all post-operative patients who develop a fever be given a bronchodilator.

Now, it has been noted that some respiratory therapists complain that a placebo of normal saline should have been given to 2,000 different post-operative patients who developed a fever to see if those patients would have eventually gone home too. Although we Docs know that would have been a wasted of time and money.

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Most Aerosolized medicine is wasted

I thought this was some interesting information. According to the AARC's "Guide to Aerosolized Medications," the following are percentages of medications that actually reach a patients lungs:

1. MDI: 9%
2. MDI with spacer 15%
3. SVN: 12%
4. DPI: 13%

The rest of the medicine "is lost in the oropharynx, the device, the exhaled breath, and the environment," according to the guidelines.

This is interesting. You can see clearly here that more medicine as a percentage that is taken reaches the lungs of a patient using an MDI with a spacer compared to that of an SVN and even a DPI.

However, we must also consider how much medicine is given. A typical SVN provides 2.5mg of a solution, which is usually twice the amount of medication as 2 puffs, or 200 micrograms (μg) of albuterol.

Still, even while there is more medicine delivered with an SVN, the 2 puffs generated similar results as the SVN. This is interesting. And I imagine this is the proof many hospitals have used in changing to using MDIs in the stead of SVNs.

Also, an MDI is much less expensive than an SVN.

Cord blood gases: Here's all you need to know

Every respiratory therapist dreads having to draw cord blood gases, and all OB nurses dread the circumstances that require them to be drawn. So, that said, what are the indications for drawing cord blood gases, what is the significance of drawing them, and why do we draw them in the first place?

Basically, the reason we draw cord blood gases is in case their is a lawsuit that might take place years down the road accusing the delivering doctor of causing an anoxic brain injury that resulted in diseases such as cerebral palsy.

The cord blood can prove that neurological deficits that develop in infants were caused by an anoxic brain injury that occurred after delivery or before delivery and was not the result of an anoxic episode at birth. The cord blood gas has been shown to be proof positive in about 80% of the cases (According to PubMed.com), and has in many cases cleared physicians from litigation.

A cord blood gas does not need to be drawn unless a baby is born has a low APGAR score within 5 minutes of delivery, such as a 3 or less. When the APGAR score is low a cord blood gas should automatically be drawn.

When we refer to cord blood we are referring to blood drawn from the placenta after delivery. If you look at a placental cord (see picture) you will see one large vein surrounded by two arteries that wrap around the vein.

According to PubMed.com, the Umbilical Vein delivers freshly oxygenated blood from the mom to the baby. Since an anoxic brain injury in baby in not likely to change the pH of the Umbilical Vein, this is not where you will want to draw a cord gas from.

The Umbilical Artery is where the baby's venous circulation dumps unoxygenated blood. This is blood that was on its way back to the mom's heart and lungs to pick up oxygen. Thus, when you draw a cord gas for litigation purposes you will want to draw from one of the two Umbilical Arteries.

Blood from the Umbilical Artery is called a Cord Arterial Blood Gas (CABG), and basically shows how the baby was doing prior to birth.

From this blood we want to watch for acidosis. Since anaerobic metabolism occurs during the absence of oxygen, the acid base balance (pH) of the baby's body increases due to increase in the amount of lactic acid produced. Therefore pH is the most important indicator in the CABG.

If the pH of the CABGis above 7.10, then we know that the baby was not hypoxic during the delivery, and if there was a hypoxic episode it occurred prior to the delivery process. It may have occurred weeks or months prior to birth, or it may have occured hours before birth. Either way, this proves the episode did not occur as a result of the delivery and should clear the physician of litigation.

If the pH is less than 7.10 the episode was more likely acute and the episode may have occurred during the delivery. If the pH is greater than 7.10, the episode typically occurred before the delivery.

According to obgyn.org, Some experts believe a pH of 7.0 with a significant metabolic component is a more significant sign of asphyxia at birth, and may lead to significant neurological dysfunction during life, or possibly even death.

Also according to obgy.org, "Even when this low pH threshold is used to define significant acidemia, most newborns in this category will be neurologically normal, with no apparent morbidity."

The baby's at greatest risk of anoxic brain injury are premature infants, according to obgyn.org. They are at higher risk of "intracranial hemorrhage and subsequent neurological dysfunction, such as cerebral palsy. Without umbilical cord blood gas analysis, these neurological complications could be incorrectly attributed to intrapartum or birth asphyxia, especially if the latter is solely based on APGAR scores. Normal umbilical cord blood values in the premature infant virtually eliminate the diagnosis of significant intrapartum hypoxia or birth asphyxia."

So, ideally, you will want the pH to be normal. If it is normal and there is an anoxic brain injury the doctor can prove by the CABG results that since the pH had time to return to normal the injury occurred prior to delivery and the injury did not occur as a result of delivery. If the pH less than 7.1 chances are the injury occurred during delivery.

Once a CABG has been drawn it can be set aside. Most studies now show that a CABG does not need to be placed on ice, and is good for up to an hour.

• pH: 7.28 (+/-.5)
• pCO2: 49 (+/-8)
• pO2: 18 (+/- 6.2)
• HCO3: 2.5-3.5
• BE: 10

Critical values that might show anoxic brain injury during birth (acidosis):

• pH less than 7.0
• CO2 greater than 50
• PO2 variable (remember this is the baby's venous blood, so the PO2 is relatively low)
• BE is normal or low (10 or less)

Critical values that might show injury due to metabolic cause:

• pH less low (less than 7.25, critical is 7.10 as mentioned above)
• PO2 less than 20
• CO2 is normal or high
• BE greater than 10 (Best indicator of metabolic cause

The following are conditions that would warrant a CABG:

• Any abnormality during delivery process
• Low 5 minutes APGAR score (less than 3)
• Any abnormality in patient condition that occurs within 1st 5 minutes after birth
• Premature birth
• Post term birth
• Meconium in amniotic fluid
• Intubation
• Positive pressure ventilation (Neo-puff or bag mask ventilation)
• Suctioning
• Cesarean-section
• Severe growth retardation
• abnormal fetal heart rate tracing
• maternal thyroid disease
• intrapartum fever
• multifetal gestation

The following are sources used for this post:

• OBGYN.org: Cord Blood Gases to Determine Umbilical Artery Acid Base Balance
• Umbilical Cord Blood Gas Analysis
• Cord blood analysis
• FamilyPracticeNotebook.com
• Tips for how to draw CABGs
• Umbilical cord blood gases: routine measurement may exonerate ob.gyns

What do parents need to know about asthma?

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: We just found out that our 2 year old son has asthma.We do not know anything about this condition

My humble answer: You've come to the right place. There are lots of materials here that should help you in your quest to learn more about asthma. Plus you can read shareposts from asthma experts like myself (I grew up with asthma, in fact, I was diagnosed when I was 2). We write about what it's like to live with asthma, our advice to asthmatics and parents like you, and share the latest wisdom we learn.

Here is some basic information about asthma. Follow the links as there are several pages.

Here and here are posts I wrote a while back with you in mind. This post here is good too.

You should be able to recognize the asthma symptoms so you can act.

Which asthma meds work best. Here's a good post. While this is written for adults, the basic information is the same. You should discuss with your child's pediatrician which asthma meds work best for him or her though.

You should work with your child's doctor to create an asthma action plan to help you decide what to do when you observe the early signs of asthma.

You should know your child's asthma triggers so you can help him or her avoid them, or work with his or her pediatrician to treat them.

This should get you started.

The thing about childhood asthma to keep in mind is there is still a lot about this disease we don't know. Yet, with a good asthma doctor, asthma trigger avoidance, well educated and observant parents (like you), every child asthmatic should be able to live a normal life.

Good luck. And if more questions arise, please feel free to ask.

Symbicort may be new asthma miracle drug

While the FDA is spending it's time recommending to doctors to get asthmatics off medicines like Advair and Symbicort once asthma is controlled, more common sense research seems to be looking in the opposite direction.

Read on, and decide for yourself if Symbicort might actually be the future asthma miracle asthma medicine

Symbicort May Offer New Option for Asthmatics
by Rick Frea Monday, February 22, 2010 @ MyAsthmaCentral.com

While it has not yet been approved in the United States, Symbicort may some day be available as a rescue inhaler as well as a preventative medicine. In this sense, it may be the dream inhaler we asthmatics have been yearning for.

In Europe, Australia, and recently Canada, Symbicort has been approved for this purpose. The program is called the SMART program, and you can read about it by clicking here.

According to asthmansw.org, SMART is an acronym for "Symbicort Maintenance And Reliever Therapy." The SMART program is explained here:

"It is a daily asthma management approach that allows you to use a single Symbicort inhaler as both a preventer and a reliever. Currently Symbicort is the only medication available for use as BOTH a maintenance preventer and reliever.

SMART works this way as it contains two different types of medicine in the same inhaler - a preventer (Pulmicort [Budesonide]) as the long-acting reliever which helps to control redness and swelling in the airways, and a reliever (Oxis [Eformoterol]) which can not only work quickly, but can also last a long time.

A person using the SMART approach to manage their asthma would take a maintenance dose of Symbicort, usually morning and night to maintain or establish asthma control AND they would also take additional inhalations of Symbicort as needed to relieve symptoms.

SMART is suitable for all people aged 12 years or older who are currently recommended to take combination medication for their asthma.

Symbicort has been available in Europe since since 2000, and was first made available in the U.S. in 2007 as a combination inhaler to compete with Advair (which presently is No. 1 in the U.S. market).

Symbicort works as a rescue inhaler because Formoterol starts to open the air passages in your lungs in two to three minutes as compared to 10 to 20 minutes for Serevent (the long acting bronchodilator in Advair).

Still, while it's approved as a rescue inhaler, the SMART programs limits the patient to eight puffs of Symbicort in any given day.

Likewise, it should always be used in concordance with an asthma doctor, and always as part of a physician directed asthma action plan like the ones linked to from this site.

By using Symbicort as a rescue inhaler, the asthmatic receives a boost of corticosteroid every time there is an asthma episode, instead of just using a rescue inhaler (like Albuterol). This basically allows the patient to increase his corticosteroid when he needs it, and decrease it when he's doing well. In this way the asthmatic has more control

Thus, "Studies have shown that people using Symbicort SMART - an additional way of taking the existing Symbicort inhaler - took no extra inhaled steroids and needed fewer oral steroids compared to traditional treatment methods. They also experienced fewer asthma attacks."

An Astra Zeneca sponsored study (the makers of Symbicort) noted the SMART program resulted in a 28 percent reduction in severe exacerbation compared to a regimine of using Symbicort twice a day while using something like Ventolin as a rescue inhaler in between.

According to this article at news-medical.net, researchers in the U.S. are reviewing data currently available and have "found no significant reduction in the number of asthma exacerbations that required hospitalization among the patients who used single inhaler therapy. However, the reviewers did find that fewer adults on single inhaler therapy had exacerbations needing a course of oral corticosteroids"

Researchers are also awaiting the results of five not yet to be released trials.

The pros of using Symbicort as a single inhaler are convenience, improved control, improved compliance, and that you will automatically be getting an additional boost of steroids right when you need it. This may especially benefit those who are compliant with their controller meds. (This asthma blogger does not like the SMART program).

A con of using Symbicort as a single inhaler is that for those who do not regularly use it, it usually takes two to three weeks for inhaled corticosteroids to start working, and therefore the added boost of corticosteroid may prove to be of no benefit.

So research is ongoing, and the debate, I am sure, will continue.

Whether the SMART program or something like it will ever be approved by the FDA is still open to debate. Yet if this is someday approved it will make available yet another alternative for physicians and asthmatics to try.