Is singulair effective for children

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: Shall i give singular to my son 2 years an 8 months to prevent asthma or is flexotide is enough for him ?

My humble answer: The best way to determine what works for any person is by trial and error. You'll basically have to work with your child's pediatrician to determine which asthma meds are worth trying. Then you'll need to be vigilant, as your child probably won't be able to tell you if the medicine is working. If you trial a medicine for a while and it appears to be working "so-so" then the doctor may recommend another medicine in conjunction with it, or he may want your child to try another medicine altogether. Once you find a medicine regime that works, you'll want to stick with it. While medicine is based on science, it's actually an art. You basically keep painting until you generate the scenerio you like best, or medicine regime that works best for the patient. Good luck.

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

Modern inhalers may equal better asthma control

The neat thing about asthma is it can be controlled. At present, the most recommended medicine to control asthma is inhaled corticosteroids. Is it possible, depending on your asthma severity one inhaled corticosteroid might be better than another? Is it possible the new HFA inhalers are better than the old CFC ones?

Recent evidence might suggest this true. While it has been proven that Flovent and Pulmicort work better than inhaled corticosteroids of old, such as Azmacort and Vanceril, mainly because they are stronger. Yet even more recent evidence suggests that a medicine called QVAR might work better if your asthma episodes involve the smaller airways as opposed to the larger airways.

As you may know, your lungs branch out like a tree (as you can see by the picture). You start out in the trachea, and from there air travels to the chorina where air can travel into your left lung or right lung. The chorina would be like the trunk of the tree.

Yet whichever way air travels (to the right or left lung), the next branch is the bronchioles. Air starts out in the large bronchioles, which would would be represented by the larger branches of a tree. As the bronchioles branch out, they get smaller and smaller. Thus, the small bronchioles would be represented by the sticks at the end of larger branches.

Now consider when you are a kid and have inflammation in your airways. This inflammation makes your lungs sensitive to your asthma triggers. When exposed to your triggers, this inflammation worsens, and this causes blockage of your airway that is the asthma attack.

In children and most asthmatics, the worsening inflammation will cause your peak flow readings to decrease. Yet, as you grow older and your airways become larger, the inflammation in your airways becomes smaller in comparison to your now larger airways. Thus, while your lungs grow, the inflammation stays the same.

So, in some asthmatics, some degree of shortness of breath can occur and this not effect the peak flow at all. This is because your peak flow readings represent what your large airways are doing. If inflammation in your large airways increases, your peak flow readings will go down. This is because air is trapped in your larger airways.

However, if your lower airways are blocked and the upper airways are not, your peak flow readings will remain the same. This, according to some asthma experts, might indicate that your asthma symptoms are the result of increased inflammation in your smaller airways.

So, while inhaled corticosteroids have been proven to benefit all asthmatics, what if you take inhaled steroids (like Flovent) and you still have asthma symptoms. Is it possible that there is an inhaled corticosteroid that does a better job of getting down to the smaller airways and reducing inflammation down there.

According to Sally M. Wenzel, MD, who is an asthma expert over at Medscapes.com, the answer to this question is yes, or probably. In answer to a question on this topic, she said, "The literature on particle deposition is actually pretty good for Qvar. It does get much better overall delivery to lungs, which means larger amounts to small airways (and alveoli). One small study (Annals Allergy) did show that adding Qvar to Flovent, as opposed to increasing the Flovent, produced slightly better symptom and lung function changes, particularly in measures of small airways. But, OBVIOUSLY each person's disease is slightly different and there are no guarantees that this will work."

Another neat thing I discovered is the following from a book I have called, "Asthma for Dummies," by Dr. William E. Berger. He notes that the U.S. government forced the phaseout of CFC propellants for inhalers like Albuterol.

Berger writes, "As a result... Proventil HFA, Ventolin HFA, and QVAR-HFA are the first oxone-friendly products on the market with this propellant, which delivers medications to the lungs more effectively than CFC propellants developed in the 1950s.

"In most cases," Berger continues, "because of a lower velocity propellant spray and smaller particle size, a non-CFC propelled product allows more of the medication to get into the smaller, more peripheral airways of your lungs."

So this adds to the growing evidence that HFA inhalers, and not just QVAR, are able to get the medicine deeper into the lungs, and to the smaller air passages.

However, it should be noted that studies have been limited, and ongoing research is necessary. Still, it's interesting to note there have indeed been some highly qualified asthma experts thinking along these lines.

So, perhaps, simply going to HFA inhalers may actually benefit chronic lungers using this medication, allowing for better overal asthma, COPD control.

Tips for dealing with the heat

As I noted in an earlier post, asthma and COPD and humidity don't always bode well together. When the heat is scorching, and the humidity high, it's good to have some tips to help you get through the day (or the entire summer as was the case in 2010).

The COPD information forum offers these tips:in t
e
1. Stay indoors whenever possible
2. Turn on the air conditioning
3. Drink plenty of fluid. It's important you stay hydrated.
4. Exercise in air conditioning, or early in the morning when it's cooler
5. Keep taking your meds as prescribed
6. Wear sunscreen
7. Keep your rescue inhaler on you at all times
8. Keep your nebulizer available at all times
9. Make sure your medicines don't run out
10. Spend time swimming at the beach or in a pool
11. Do not overeat
12. Do not cook indoors
13. Do not take long, hot steamy showers
14. Do not use humidifiers (humidity makes the air you breath thicker and harder to breathe)
15. Dress light
16. Avoid deep fried or fatty foods
17. Avoid pop and beer
18. Avoid drinking too much alcohol in general
19. If oxygen dependent, make sure you carry your lightest equipment
20. Know your asthma or COPD action plans

Here's some more tips.

Related posts: High humidity can make it harder to breathe

New study to determine how long we live

According to this post from Healthscout.com, scientists have "grouped together a series of genetic variants" that can help determine who will live long and who has the genetic disposition to die young. Ultimately, the goal of this research is to determine who is likely to die young, and to make sure these people get the medical intervention they need to live longer.

Experts who performed the study said it can be determined how long people will live simply by learning how long their parent's lived, yet events such as this study will be better capable of helping scientists pave the way for "advances in science."

Right now about 6,000 people have obtained the age of 100, and, so long as one has his mental capacity, I personally think this would be an awesome age to obtain. Could you imagine if this blog were still going, say, in 2070. If that were the case, this blogger would have been retired, hopefully, for 40 years.

But can you just imagine the changes in respiratory care in that time? Can you imagine the stories we'd be able to tell? I think it would be awesome.

Now there are many who don't want to know their genetic trends, yet I think it would be a great idea. Obviously I have a genetic disposition to asthma, yet science has proven that mild to moderate asthma (most cases of asthma) do not alter the length of someone's life. Thus, the average lifespan right now is 80. Yet perhaps in another 20 years or so that number will be increased to, say, 100.

Of course that wouldn't be so good if there were a bunch of 80 to 100 year old blobs of skin with no brains in their heads; people dependent on the government; on the hands who feed and clothe and place them in wheelchairs each morning so they can roll around mindlessly in some building redolent of pee and bleach.

The people paying the medical bills, and socialists, wouldn't like this system would they?

Yet, being the optimist I am, I believe we could be around longer, and we could enjoy life longer, so long as we continue to move forth science as this study purports to do. I think longevity is a good thing.

If, say, it is determined I have a genetic predisposition to heart disease, then my doctor would know this and be able to help me with preventative measures. I could make sure I get plenty of exercise, and never start smoking, and eat right for starters. And, if necessary, he may look into medicinal options.

So anyway, I think studies like this, however trivial they seem to you and me, are a great step forward. While we are right now in the communication era, I bet the next era may be the genetics era, where there are mega advancements in genetics and, perhaps, length of life.

Is it asthma, or croup?

I was called to the emergency room to give a breathing treatment to a 1-year-old who was having mild retractions with an audible stridor. Notice I didn't say I was asked to assess the patient, I was called because the nurses believed the doctor would want me to give a treatment, and probably a racemic epinepherine treatment.

The patient to me sounded quite diminished, and I suspected bronchospasm. I told this to the doctor, and he disagreed with me. He thought it sounded like croup, and he ordered for me to give a racemic epi treatment. I didn't have a problem with this on the grounds the race epi would also dilate the bronchioles if they were, as I suspected, truly spasming.

See, I have learned through the course of my experience that asthma sometimes sounds like croup. There are times, especially in children (yet occasionally in adults), audible stridor, coupled with diminished lung sounds, is sometimes indicative of asthma.

After the treatment the patient was obviously breathing better. The retractions were gone. And, when I listened with my stethescope, lung sounds were markedly improved, with much improved air movement.

Satisfied, I went upstairs, where I sat at my desk and the phone rang. It was the nurse of the baby. She said she thought I should set up a cool mist aerosol for the baby. "Don't you think that would help his croup," she said.

Again, I was thinking this was reactive airway and not croup, but I said, "Well, I think you better run that by the doctor, because every doctor has a different plan of action for croup." And this was true. As I set the phone on the receiver I almost made myself laugh as I thought, "Yep, every doctor believes in a different fallacy."

This is why I like to say medicine is an art more so than a science. It's based on science, although when it comes down to it medicine is an art.

We have a lot of policies, and order sets, and dogmatic doctors all that treat all patients the same, or from the same cookbook. Much of this, or so they say, is based on best practice medicine. This is great for most cases.

Doctors who treat all patients from the same cookbook often mistreat and over treat. A perfect example is my asthmatic patient here with stridor and no wheezes.

Yet there are fallacies too. For example, for croup one doctor likes to give race epi, and another xopenex, and another albuterol, and another likes to set up a cool mist, and another a shot of steroid (the actual only thing that really works). Worse, some doctors and nurses (and RTs) can't see outside the cookbook. They don't think.

It's almost funny the fallacies in medicine. It's even funnier that there is no consistency of fallacies, and it's this reason we RTs sometimes get vexed, are often apathetic, and why we call for protocols.

Thankfully the doctor on duty that night was not a cookbook doctor. He did not order a cool mist aerosol. In fact, later when I discussed with the doctor, he told me I was right. Later, as I was leaving the ER to the RT Cave, I couldn't help but to smile.

Near Drowning

Believe it or not, the U.S. Coast Guard reports that 68 people have drowned in Lake Michigan in the summer of 2010 alone, while the average for any summer is about 30. Exceptionally warm weather is believed to be the reason.

Since Shoreline medical exists just a few miles off the shoreline, and since we occasionally have to take care of near drowning victims, I thought it would be good to review the process of taking care of these patients.

I did cover it to some degree in my post about dry drownings. Yet I'll take it a step further in this post.

In fact, according to emedicine, "Near Drowning," in children aged 1-14, drownings are the second most common cause of death, next to accidental trauma. About 1,500 kids die each year of submersion injuries. In some states, like Florida and California, drowning is the #1 cause of death in children.

The rate of drownings is 1.93 per 100,000 for all age groups.

According to "Respiratory Disease," edited by Robert L. Wilkins and James R. Dexter, chapter 10, "Near Drowning," written by David Stanton, Submersion drownings account for 150,000 deaths worldwide, and between 6,000 and 8,000 deaths in the U.S. annually. Around 80,000 near drowning episodes occur in the U.S. each year, with a high incidence in men between the ages of 10 and 18 years of age, and in children under five years of age. Drownings are the 4th leading cause of death of all age groups.

Stanton writes that "poor judgement and lack of supervision are also major contributing factors in drownings" and near drownings

So here are some definitions according to emedicine:

Drowning: Death from asphyxia within 24 hours of submersion in water. If a person dies after 24 hours, the cause is attributable to the the complications, such as brain death, kidney failure, sepsis, ARDS, or secondary cause such as trauma, ceizure, stroke, heart attack, etc.

Near drowning: Survival (even if temporary) beyond 24 hours after a submersion episode.

Warm-water drowning: Occurs at water temperatures of 20°C or higher.

Cold-water drowning: occurs at water temperatures of less than 20°C. Some references include very-cold-water drowning, which refers to submersion in water at temperatures of 5°C or less.

Salt water drowning: is hyperosmolar, increases the osmotic gradient and therefore draws fluid into the alveoli, diluting surfactant (surfactant washout). Since it's hypertonic compared to the blood (approximately 3% normal saline), Stanton writes that it causes fluid from the blood into the alveoli when aspirated. Alveolar collapse occurs as surfactant is washed out and surface tension forces increase.

Fresh water drowning: considerably hypotonic relative to plasma and causes disruption of alveolar surfactant. Since it's hypotonic compared to the blood stream, when aspirated it is quickly absorbed into the blood stream increasing preload (blood going to the heart) and increases the risk of pulmonary edema and loss of cardiac output (after load).

Submersion injury: Occurs when a person is submerged in water, attempts to breathe, and either aspirates water (wet drowning) or has laryngospasm without aspiration (dry drowning). Usually at a PO2 of 25-30 the patient will become unconscious. Wikepedia notes an unconscious patient whose airway is still sealed from larygospasm (see below) stands a good chance at recovery.

Primary injury: Injuries to the body caused by sucking in water, stomach contents and lack of oxygen to vital organs while under water.

Secondary injury: Ongoing damage to organs as a result of being submerged, sucking in water, and being hypoxic for some time. This also may lead to dry drowning.

Dry drowning: Occurs when a person's lungs are unable to inhale air as a result of laryngospasm that results from emersion in water. The patient may initially appear fine, yet "drown" on dry land within the next 24 hours. I describe this in more detail in my post, "Dry drowning: drowning on dry land."

Breathing reflex: According to Wikepedia, one can hold his breath for some time, but the breathing reflex will increase until you try to breathe, even when under water. It's related weakly to oxygen and strongly to CO2. As oxygen in the blood (PO2) decreases, and CO2 increases, the urge to breath increases up to the breath-hold break point, and you will no longer be able to hold your breath. This usually occurs when the CO2 reaches 55.

Water inhalation: Once the breath hold break point has been reached, one will make the effort to suck in air. When under water, one will suck in water. The person will then try to cough up the water, and inhale more and possibly even inhale stomach contents. This ultimately results in wet drownings (see below). About 10-15% of those who drown, however, do not inhaler any water. It's believed they die of laryngospasm. For the 85-90% who do inhale water (or other fluid), it's usually a small amount, and less than 22cc/kg.

Water swallowing: A majority of drownings will swallow huge amounts of water, and this often results in regurgitation and aspiration of stomach contents. Most drownings aspirate both stomach contents and other debris present in the water, and this may result in alveolitis, bronchitis and pneumonitis. Ultimately this whole process greatly increases the risk for developing ARDS due to inflammation and pulmonary edema.

Increased Airway Resistance: This is due to the inhalation of debris, and inflammatory mediators are often released and this results in vasoconstriction that impairs gas exchange.

Laryngospasm: Once one inhales water, laryngospasm occurs. It's your bodies natural way of preventing water from entering the lungs. It causes water to enter the stomach first. This happens in conscious and unconscious victims. 10-15% maintain this seal until cardiac arrest. Getting to victims before this seal is relaxed increases the chances of survival significantly.

Hypoxia and Ischemia: Hypoxia is lack of oxygen to the tissues. Ischemia is when blood flow to organs is diminished. According to Stanton the brain often becomes hypoxic before cardiac arrest occurs, and this is because the brain cells are strictly aerobic, unlike the heart which can continue to function during anaerobic metabolism for some time.

Stanton notes that blood flow can continue under anaerobic conditions for some time even after the oxygen supply has been depleted, thus keeping the heart functioning.

He notes that "most people will lose consciousness after 2 minutes or anoxia and brain damage may occur after 4-6 minutes with exceptions. Some people have their bodies trained to hold their breaths longer, and cold water conditions can create an environment where your body will conserve oxygen (see cold water near drownings below).

Calcium and Potassium transport: Active transport mechanisms slow down and eventually quit working altogether, "owing to the diminished supply of energy," Stanton writes. "Cellular integrity becomes jeopardized as potassium is lost from within the cell and calcium flood into it."

Tissue Swelling: Stanton writes that during hypoxic events, as cellular integrity becomes compromised, calcium is absorbed by cells, and through a complicated process, this results in energy depletion and this compromises cellular metabolism. Then, water follows sodium and calcium into the cell, and this results in cell and tissue swelling.

Lactic Acid: Under continues anaerobic conditions, lactic acid is produced, and this decreases body pH and alters enzyme function, leading to cell death if oxygenation and perfusion are not restored, Stanton writes.

Wet drowning: Usually larygospasm will continue until the patient is unconscious for some time, when it will relax and the person will inhale water and stomach contents and other debris, and this is called wet drowning. Asphyxia will soon result in death.

Most drowning victims aspirate both water and stomach contents, and most near drownings who inhale water do the same. Although 10-15% of near drownings do not aspirate water or stomach contents.

Emedicine notes that ingestion of greater than 11cc/kg of water may result in increase blood volume, and ingestion of greater than 22cc/kg can cause electrolyte changes that may be life threatening. Swallowing water can also cause electolyte changes.

Atelectasis: Inhalation of fluid, whether seawater or freshwater, may result in atelectasis, and this increases V/Q mismatches, functional residual capacity, and lung compliance (the lungs become stiff).

Impaired gas exchange: Even minute amounts of water can cause problems with gas exchange in the lungs. Loss of surfactant can make it almost impossible to open the alveoli, which results in atelectasis. Of course you'll also have pulmonary edema.

Hypovolemia: Emedicine notes that hypovolemia (loss of blood) results because of "increased capillary permeability" in the lungs, and this results in hypotension. Depending on length of hypoxic episode, arrythmias may be present.

Cardiac muscle damage: This is due to hypoxia may decrease cardiac output, further decreasing blood pressure, and the release of mediators of inflammation will cause vasodilation and pulmonary hypertension.

Multi organ failure: Patients should also be observed for multi organ failure, which can be monitored by creatinin levels, BUN, etc, and these will be managed accordingly.

Brain injury and death: Likewise, submersion injuries to the CNS are typically the main cause of death, especially those caued by hypoxia.

Signs of sustained brain injury include:

• including tachycardia
• hypertension
• tachypnea
• diaphoresis
• agitation
• muscle rigidity

Infections: Brain infection is rare, yet possible, and generally occur 30 days after the episode. Pneumonia is rare, although most near drowning victims are often treated with antibiotics. Antibiotics may also be given to prevent sepsis.

Other complications: Emedicine notes, "Submersion injuries that are associated with prolonged hypoxia or ischemia are likely to lead to both significant primary injury and secondary injury from reperfusion, sustained acidosis, cerebral edema, hyperglycemia, release of excitatory neurotransmitters, seizures, hypotension, and impaired cerebral autoregulation, especially in older patients who cannot rapidly achieve core hypothermia."

Initial Assessment: Stanton write that "the initial assessment of drowning victims should be rapid and directed toward the victim's level of consciousness, pulse, and breathing rate. Information from onlookers can also be very helpful in determining extend of injury.

When you get one of these patients, here are some questions to ask that might help with how you treat the patient:

1. How long was the patient submerged. In most cases, the answer is unknown.

2. Was there alcohol or drug use?

3. What was the water temperature? If cold, you'll have to rewarm patient.

4. Were rescue meneuvers attempted?

5. Was there a secondary cause of drowning?

• Trauma (unintentional and intentional) (under 1 yr consider child abuse or poor parenting)
• Seizures
• Cardiac disease, dysrhythmias, and syncope
• Exhaustion and hypothermia
• Hypoglycemia
• Alcohol and drug use

Signs and symptoms of near drowning:

1. Asymptomatic: especially if brief, witnessed submersions with immediate resuscitation

2. Symptomatic:

• Cough
• Dyspnea
• Wheezing
• Hypothermia
• Bradycardia or tachycardia
• Vomiting, diarrhea, or both
• Anxiety
• Altered mental status
• Cardiopulmonary arrest
• Cardiac arrhythmias (ventricular tachycardia, ventricular fibrillation, bradycardia)
• Apnea
• Death

Vital signs: (will be variable depending on how long submerged and temperature of water. This information comes from Stanton's writings in "Respiratory Disease)

• Heart rate: Patient may be in full arrest or have normal respiratory rate and cardiac rythm. Common dysthrythmias are bradycardia or asystole.
  
• Respiratory rate: May be not breathing and may have normal rate
• Temperature: Will depend on the temperature of the water, body surface area, and duration of submersion. If hypothermic, careful rewarming techniques are required.
• Pupils: May be dilated due to resuscitation efforts and meds used to revive patient. They may also respond slowly to light
• Head and neck: Should be inspected for trauma
• Auscultation: Wheezing as a result of bronchospasm, foreign body aspiration, and/or late inspiratory crackles associated with atelectasis. Coarse crackles may indicate patient aspirated and/or has pulmonary edema and is at high risk for pneumonia or ARDS.
  
• Extremities: Cool to touch due to hypothermia and peripheral vasoconstriction. A slow capillary refill is resent when peripheral circulation is reduced. Cyanosis is common.
  
• ABG: Hypoxemia, especially when aspiration has occurred, and metabolic acidosis. The more severe the metabolic acidosis the more severe the hypoxic episode was.
  
• Other labs: Hemoglobin, hematocrit, and electrolyte concentration may decrease when large volumes of fresh water is swallowed or aspirated. This is the result of the dilution effects of the water when it enters the circulating blood volume.
  

Cold water near drownings: This causes the deoxyhemoglobin dissocotiation curve to shift to the left, causing the body to conserve oxygen. This also results in bradycardia and peripheral vasoconstriction to assure what oxygen is available gets to vital organs.

So those who are submerged in cold water (less than 21 degrees celcius or 70 degrees F) are able to be submerged for greater amounts of time. Stanton notes that some children have been under as long as 40 minutes and still survived.

Signs of sustained brain injury include:

• including tachycardia
• hypertension
• tachypnea
• diaphoresis
• agitation
• muscle rigidity

Treatment: Appropriate BLS and ACLS as appropriate. Other treatment is based on your initial assessment and x-ray and lab results. Oxygen is often necessary. Bronchodilators can be used to treat bronchospasm. Intravenous IV access is usually necessary to restore electrolyte management to normal, and to allow quick access for any other medications.

Discharge: Stanton writes that "if a patient is stable and no neurologic or pulmonary detterioration has occurred within 12-24 hours, the patient may be discharged. Physician follow up within 2-3 days after discharge is strongly recommended and may detect a developing pulmonary infection.

While you're at it, add this to Our Job Title

Regular readers of my blog know that I'm an ardent believer that the best way to get people to quit smoking is through education.

So when Tim Frymyer, RRT, and creator of StopSmokingHelper.org informed me about his new website, and his desire to write a guest post for the RT Cave, I eagerly accepted his proposal.

Check out his post published below, and then be sure to check out the new website he created with the intent of helping smokers quit. Enjoy.

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I'd like to first thank Rick for letting me post something in The Cave. I believe it is an honor and I hope the information lives up to his standards. Let me start off by telling you all a little about my experience as a therapist. I started 20 years ago in Dallas at the county hospital and then moved on to a private non-profit. All the time, I’ve worked exclusively with adult and geriatric patients. I have all the respect in the world for RTs who work with neonates and peds, because to this day, they still scare me. I'm not sure why exactly, I'm just more comfortable with adult patients. My co-workers would tell you it’s because I like to talk. They might be right.

Anyway, I've been a bedside therapist, run a pulmonary lab, presented numerous educational seminars and finally, managed my department for about 5 years. So given all that experience, I've come to realize that RTs who work in the adult-side of patient care have 1 industry to thank for our job security, our bread and butter as it were. Yes, that would be the tobacco industry. No real surprise here.

Sure, we treat asthmatics, post-op patients, and we can't wait for that next difficult ARDS case, but our primary energies are spent taking care of people who have bad lungs, a bad heart or some other disease related to their smoking. This is what compelled me from the bedside world to the virtual world and hence, the creation of "http://www.stopsmokinghelper.org/". I figured it was time to be a little more proactive instead of reactive. If I could help just one person stop smoking, then that would be one less patient some therapist may have to treat.

Currently, smoking in this country costs us, the taxpayers, over $193 Billion. That total is based on lost productivity and both direct and indirect healthcare costs. Back in 2004, COPD by itself costs Americans $37 Billion. So while everyone is talking about healthcare reform and Obamacare, think what would happen if everyone just stopped smoking?

Let that sink in for a while. We'd be talking about the roughly 20% of our population that smokes, laying down their packs and lighters. That sounds like some kind of Twilight Zone episode doesn't it?But right off the top, you're talking about eliminating the 90% of all lung cancer cases related to smoking. What would happen to the lesser known diseases that smoking is a risk factor for like: osteoporosis, oral cancer, stroke, prematurity of infants, SIDS, bladder cancer, your kid's childhood ear infections, etc.? All these are risk factors of smoking. Now we're talking about making a real impact on universal healthcare reform.

What about the human element though? How many people would you say die in the U.S. because of smoking; 10,000, 50,000, 100,000 people? Well, you're getting warmer, roughly 400,000 deaths every year are attributable to smoking. That's 1 in 5 deaths in the United States (according to the CDC). It's kind of funny, because I will occasionally still read pro-smoking blogs that deny the overwhelming statistics associated with smoking and smoking related disease. To them, it's all one big conspiracy created by the government and big pharma. They believe that people who suffer from COPD, lung cancer or other smoking related illnesses, are just the exception to the rule, rather than the rule itself. Oh, if they could only round with us for one week in the hospital, then they’d see the truth.

Well, I hope I have convinced you that part of our job as respiratory therapists is to educate our patients and their families to the very real dangers of smoking. Most of my patients are very glad to discuss the topic in the hospital setting, but will typically dismiss the idea once they're discharged and feeling better. However, if we had a way of giving them something or following up with them on discharge, they might have a greater motivation and/or desire to quit smoking. We have to strike while the proverbial iron’s hot. Getting them in contact with a program or service while still in the hospital is a great way of helping the patient become smoke-free. Simply getting the patient to talk with his or her physician can greatly improve their chances of success, so feel free to employ their GP in your education efforts.

Here is one example of what this might look like. When I left the acute care world, we had just implemented a therapist-based smoking cessation program that did involve a 1-week post-discharge phone call by one of our therapists. We were fortunate in that these therapists were also in our asthma clinic, so it wasn't a stretch on our staff's resources to have them perform this task. I know not every facility has this luxury. But at the very least, you can leave them with some kind of a resource in their hands like a phone number to a quit center. Then you’ve at least done your part.

Ultimately though, it's up to the patient, isn't it? I never met a patient who quit because I asked them to. They have to be convinced and committed to the idea that smoking cessation is in their best interest. It's simply up to us, to help paint that picture while we're waiting for the albuterol to nebulize. So make use of your time wisely and help get the message out. Oh, and one of the best times to bring it up is when the family is in the room. Grandkids and little children can be the best motivation to help someone quit.

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Stay tuned. This post is part 1 of a series. To view part 2 click here.

Related links:

• Smoking cessation program
• Smoke and have asthma: here's 20 incentives to quit
• More good reasons to quit smoking
• Stop smoking in front of your kids. Period!
  

Respiratory arrest and asthma attack

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: Is it appropriate to intubate a person during an asthma attack with respiratory arrest or cardiac arrest?

My humble answer: First of all, allow me to say it's very rare that a person having an asthma attack will stop breathing. However, if untreated long enough, this can happen.

By definition, respiratory arrest means cessation of breathing or breathing that is very difficult and inefficient. So, if a person goes into respiratory arrest, there is no alternative but to "artificially" breathe for that person. One way to do this is by bag and mask, although eventually the person will need to be intubated and placed on a ventilator.

The ventilator actually allows the person's lungs to completely relax, at which time bronchodilators, steroids and other medicines will be used to open up the person's lungs.

Just remember that any time an asthmatic is intubated it is usually only done as a last resort and is very temporary. Basically it allows trained medical professionals time to work their magic.
Usually an asthmatic will be intubated before he goes into respiratory arrest. If a patient looks like he is pooping out, and it appears what we are doing is not working, then the doctor may make the call to intubate.

If respiratory arrests progresses to full cardiac arrest (heart probably not getting enough oxygen), medical professionals will have no choice but to ventilate for that patient, and follow appropriate Adult Cardiac Life Support to get that patient's heart started up again.

Actually, while sometimes asthma attacks can progress rapidly, most of the time asthma shows signs that it is coming on, and this is why it's important to know your signs and symptoms of asthma, and have a good asthma management plan.

The key here is that by managing asthma right away, and knowing when it's time to get to the emergency room, respiratory arrests caused by asthma can be avoided -- and in most cases they are.

While it doesn't happen very often, I have taken care of asthmatics in this situation. Just about every one was breathing fine in a day or two.

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

Three simple rules for stocking the RT Cave

My rule for stocking is simple: If you take the last one, either a) replace it, or b) make a note of this during report.

Yet, some believe that stock should be done at all times by whomever is available. If you're slow, you better stock. If stock is low, you have to stock it.

These people tend to be more anal than me, and may even get upset that I didn't stock. Yet I never let anything run out. My rule for stocking works pretty well, I think.

The only exception is if you are really busy, like if you have a code and use up a big machine like a Ventilator or BiPAP, you need to make sure you properly put back together the machine so it's ready for the next emergency, or at least make note of this in report.

Otherwise, when that machine is needed STAT, you'll be scrounging around for parts to get it working. And you'll be viewed by others around you as an unprepared RT, and a bumbling idiot because some other idiot was lazy.

Plus, make sure you restock the airway box. I find nothing worse than opening this box up at a code only to find there is no AMBU-bag or no suction equipment. Now you have to go on a hunt for equipment, and you'll again look like an unprepared bumbling idiot.

RT Cave Rule # 44: Stocking rule #1: If you take the last one, replace it.

RT Cave Rule #45: "Stocking rule #2: if you use a big machine like a Ventilator or BiPAP, make sure you properly put it together, clean it, and do a function test so it's ready for the next emergency."

RT Cave Rule #46: "Stocking rule #3: Restock the airway box right away after you use it."

The funny thing is if you follow these simple rules chances are no one will notice, yet no one will be forced to scrounge around in an emergency looking for parts that are needed right now to save a life.

Hence, even when it's not my fault equipment is not where it's supposed to be, I'm the one who looks unprepared. Because of your laziness, I look like a bumbling idiot.

What is a real man's sport

So what are the toughest man sports?

6. Soccer is an okay sport when kids are playing it, yet it's not even near as exciting as the rest of the American sports. Basically, the field is too big, and there isn't enough scoring. Professional soccer is even worse. And, in case you're wondering, the reason it's called soccer in the U.S. and not football, is because football is more of a masculine name for a sport, and soccer is a sissy sport thus is deserving of a sissy name. I'd still encourage my kids to play the game, and I'll enjoy watching it, yet it's not even close to my favorite. And understandably so do the rest of the United States folks think this sport is sissy. So why is soccer called soccer in the U.S. (as this post asks)? Now you know. It's boring. It's like watching a game of ping pong. Actually, the reason it's called football is because the game was called association football in England. This was to differentiate it from rugby football. Hence, since the English like to shorten names, they called the game SOCer, with S-O-C coming from the word association, and the er tagging along.

5. Boxing would be #1 on this list, except you cannot watch it on regular TV, which has made the sport nonexistent to the rest of the world. It's one tough sport, but the last time there was a game worth watching the likes of Mike Tyson and George Forman were still playing.

4. Basketball is a good sport, but as one of my friends from college used to say, it's basically a bunch of tall idiots running up and down a court with their knuckles scraping on the ground. And any sport that you have to have the best player in the world on your team to win anything isn't an exciting sport at all. Think the best players in the history of the game, and you'll find a winning team. Since the Celtics and the Lakers have won more than half of all NBA championships, this basically shows you where the best players have landed, and not where the best all time teams have landed. So, basketball can be a very good sport, and I rank it behind baseball and football as my favorite sports, yet as far as for being a man's sport, it's not even close because only the tall can play.

3. Baseball is a good sport all the way around. I love how it lasts three hours or longer. I love a well pitched game, and I love a game where the home team scores a lot of points. I love baseball statistics, and I love baseball statistics. This is a game for everyone. You can be small and you can be tall, you can be round and you can be square. You can fight, and you can sit on the bench and dump whipped cream down your pitcher's underwear. This is a time tested sport that anyone of any age and any size can play. This is truly one of the greatest all time sports. And while I rank baseball as my favorite sport, I have to rank it here as #3 on the all time greatest man's sports.

2. Hockey is a tough sport. You can hit on the run and trip and hope you don't get caught. You can stop the action and get into a brawl. And while you might pay a penalty, it's often worth it. And while you might get a chance to actually play hockey, that's not why you attend the game. Hockey is about fighting, and if that fight were taken out of the sport, it would be a sissy sport like soccer.

1. Football is by far the best sport in America, and worthy of the name football. It's a tough sport. The only exception I'd have to this sport are all the rules. I think they should take out rules that protect the quarterback, and the whistles that call a play dead. I think anytime the ball is free the ball should be in play. This would make it even tougher. Sure there would be more injuries, but it would be worth it. The injury risk alone makes this sport manly.

Sure there's other sports that can be fun, like swimming or ping pong or volley ball or dodge ball (which could have made my list), yet none of them compare with top 5 on my list. What do you think is the toughest sport?

She gave me the bird

I walked into her room and she showed her utter respect for me by placing her hand up in front of her face, and then, slowly, purposefully, and with a big smile on her face, she fully extended her arm high up over her head, and extended her middle finger.

Believe it or not, that was her way of showing respect for me. I worked damn hard the other day to get her off the vent, and she passed the weaning screen with flying colors, was awake and alert, and chomping at the bit to get off the vent. Then the doctor came in and basically gave me the big, "Rick, she's not coming off the vent."

Ahhhhhhhhhhhh!!!!! That was the first time I ever begged to extubate. "RICK! I am NOT EXTUBATING that lady today!!!!!"

So she needlessly stayed on the vent an extra day. She was awake and alert, able to read a newspaper, sit on the edge of the bed, watch TV, write notes on her sheet of paper, and the doctor refused to extubate.

She was one of my favorite patients ever. She showed her appreciation for my friendship and my hard work with the bird. Yep, that one event made me proud to be an RT. I smiled and had a nice long discussion with her about books.

Explain this to me: Hepa filters protect against TB?

Okay, so even while I wrote a facetious poem a while back titled, "I wish I was stupid," I actually hate stupidity, which is actually what makes my poem more relevant. I hate it when people make rules based on feelings as opposed to science.

It's true I've already written adnauseum about the logic of doing bronchodilator breathing treatments for every bronchospasm and every other lung disease in the book (bronchodilator reform), or giving Tylenol for reasons other than what it's intended for (17 non-indications for Tylenol) , or suctioning patients that don't need it and are awake and alert (as I wrote here).

Today I'm trying to figure the logic of infection control. Today our doctor thinks a patient on a mechanical ventilator "might" have TB, and wants the patient to be in isolation. So the infection control lady walks into the patient's room and says to me, "Why aren't you wearing a hepa mask."

I said, "The patient is on a ventilator and breathing through a closed circuit, and on the exhalation port is a hepa filter. So there is no way any TB particles are in the air in here."

"Well, I want you to wear one anyway."

"Well, that's ridiculous." I protested.

"Well, that's the way it is."

So I did as told.

That's the wisdom of not thinking is that there is no wisdom at all. So someone explain this logic to me, or tell me I'm the idiot. If a patient is on a ventilator, with a hepa filter, isn't that scientifically proven to protect the air from germs from the patient.

If that's not the truth, then why do we bother putting a hepa filter on the vent in the first place?

Of course we have this senseless duplicate hepa filtering when back during flu season we had every patient with the flu getting breathing treatments and thus spreading all those germs all through the hospital. Yes, the flu is spread by airborne contamination.

It's also neat to note there is no filter system in the rooms, and the door is open 24-7. So you don't think, if the hepa filter on the vent isn't doing its job as well as the hepa mask as our infection control person says, that TB particles can't escape out that door.

If this is not senseless stupidity, tell me what it is or is not. I've been wrong before and not afraid to admit it. So do clue me in if you are all the wiser.

Early antibiotic therapy essential for COPD ?

A new study performed throughout the United States shows that COPD patients who are treated with antibiotic therapy in the first two days of admittance to a hospital were more likely to have quicker discharge dates.

This actually makes sense considering a majority of COPD patients have both emphysema (loss of lung tissue) combined with chronic bronchitis. With chronic bronchitis they have a loss of cilia, and the loss of the immune system's ability to bring up phlegm from the lungs.

Due to this, it's easier for colonies of bacteria to grow in COPD lungs. I suppose I had always assumed that antibiotic therapy was the first line of action for COPD patients, yet obviously this is not the case.

While this is just one study, perhaps it's evidence this research will aid COPD doctors better take care of their physicians, and encourage physicians to treat all COPD patients, regardless of x-rays and lab values, prophylactically with antibiotic therapy.

guidelines to adjusting ventilator settings

So you're tired of doctors just making up ventilator changes. Here are the recommended AARC guidelines for adjusting ventilator settings. Study these, and impress a doctor or a nurse with your wisdom:

1. PaCo2 greater than 45 (or EtCo2 greater than 50)

• Increase RR
• Increase VT

2. PaCo2 less than 35 (or EtCO2 less than 30)

• Decrease Rate
• Decrease VT

3. PO2 less than 60 (or SpO2 less than 90%)

• Increase FiO2 to 60%
• Increase PEEP
  
• Increase FiO2 to 100%

4. SpO2 greater than 95% (or appropriate oxygenation for patient)

• Reduce FiO2 to 60%
• Reduce PEEP to 5
  

This is to act as a guideline only to assist you in making the appropriate ventilator changes based on invasive ABG results and/ noninvasive EtCO2 and SpO2 monitoring. Of course you'll need to know your patient.

For a great review of EtCO2 monitoring check out this post.

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

For a printable cheat sheet for EtCO2 monitoring click here.

Are you out of touch? It's easy to do these days

I said to my son the other day, "You sound like a broken record."

His response, which came with a dumbfounded look, was: "What's a broken record."

Hmmm. I Had never thought he might not know. That's a good one.

The reason I mention this is because an AP News writer Dinesh Ramde, "Wear wristwatch? Use e-mail? Not for Class of '14," writes that kids entering high school today would have no reason to know what a record is.

He writes, "For students entering college this fall, e-mail is too slow, phones have never had cords and the computers they played with as kids are now in museums.

"The Class of 2014 thinks of Clint Eastwood more as a sensitive director than as Dirty Harry urging punks to 'go ahead, make my day.' Few incoming freshmen know how to write in cursive or have ever worn a wristwatch."

Beloit College creates a list each year called the "Beloit College Mindset List" to remind teachers what to elude to and what not to elude to in order to stay in touch with today's kids.

"The list," she writes, "is meant to remind teachers that cultural references familiar to them might draw blank stares from college freshmen born mostly in 1992."

"Of course," she adds, "it can also have the unintended consequence of making people feel old."

That's about how I felt when my son asked, "I was looking at grandmas records you have in the basement, and I don't recognize any of those music groups."

Of course the groups he was referring to were The Beatles, The Rolling Stones, and The Eagles. Yet they were just flash in the pan bands. Right?

Well, not really. Yet why would an 11-year-old heading into the 7th grade know about those "classic" groups anyway.

A few months ago I went into a local music shop looking for a Brian Adam's Greatest Hits album, one my wife inadvertently threw away, and I couldn't find it anywhere. So I asked the clerk, who said:

"Classics and oldies are in the discount rack by the door."

"Oh." I said, feeling insulted. I turned to leave, and, lo and behold, there was Brian Adams, a bit of a film of dust over the top of the package, sitting in a bin with a bright orange sign overhead, "Classic tunes: 50% off."

The good news was the tunes I wanted were at a discount price. The bad news was that I was made aware how old and out of touch I was with my son.

Which also reminds me that when our phone service was out last week I went to my neighbor's house with my son to borrow a phone. I needed a phone because my wife was expecting, and she was working. If she was to go into labor she was going to call me.

So my neighbor hands me a tiny phone with a bunch of buttons on it. "You can use this," she said.

After I looked at this science fiction phone (as far as I was concerned) for a minute, pressing a button with no results, my son ripped it from my grasp saying, "Let me do that for you."

Yes, there comes a time when you realize you ARE out of touch.

In the 1980s the computer came along, and the microwave, and VCRs that were difficult to explain to our grandparents. Yet now every year an amalgamate of these new innovations comes out, and it's to the point you have to pick and choose which one you take the time to learn.

So try explaining all of these to your grandparents, or even your parents, or even yourself.

To me facebook is hard to figure out, yet I use it. This blog was hard to figure out, and still is. Yet I'm still here.

Yet I don't think it was always this way. From Caesar to George Washington there were never any changes, and so it is said that Caesar could have communicated with Washington (had he lived that long) quite easily.

Yet due to industrial changes Washington would have had a tough time communicating with Lincoln, and yet Lincoln would have had a tough time communicating with Teddy Roosevelt because changes were rolling around faster and faster.

Now we have adults, like me at 40, who have trouble keeping in touch with their own children, like my 11-year-old son. Here we have electronic games, computer updates yearly, telephone evolutions going on each year if not daily, and it's hard to keep up with it all.

So one can see why things like the Beloit College Mindset List might come in handy for not just teachers but anyone who communicates with kids, including moms, and even dads like me.

5 reasons asthma is worse in summer months

I've noticed an increase in the number of asthmatics and COPD patients this summer, and quite frankly I have to say I've been using my own rescue inhaler more than normal lately. Apparently other asthma experts have made a similar observation.

Dr. James Thompson over at MyAsthmaCentral.com , "Why My Asthma has Been So Difficult to Control this Summer?," writes that the number of referrals for asthma and allergy consultation has been up across the board. He writes that fall is usually the peak asthma season, yet this year summer appears to be "a close runner up."

He lists five reasons why he thinks this is so:

1. A mild winter: A warmer than normal winter that ended with some really nice days in April lead to a very early pollen season. So this year allergy season lasted from February to May and grass season from May to July hit allergy sufferers double hard.

2. Rain and humidity: There was a lot of rain early, and now humidity levels are very high. As compared to 2009 when July had 1 day over 80, 2010 has had 20 such days which also included high humidity. Dr. Thompson writes, "People with multiple allergen sensitivity (pollen and mold allergy) may experience a priming affect from early spring triggers. In other words, summer allergens (grass and mold) may cause worse symptoms when preceded by spring tree pollen allergy."

3. Changes in weather patters: Actually it's been relatively warm this season, although when the temperature changes some asthmatics have stronger symptoms before the storm, especially when a storm is precipitated by a drop in barometric pressure as you can see by this article.

4. Poor air quality: Ground level ozone can be increased on hot, humid days and can lead to worsening asthma symptoms. He notes that ground level ozone represents 90% of the smog in urban areas. Likewise, ground level ozone peaks in afternoons of warm summer days.

5. Disrupted routines: When school ends, so does the school year routine. He writes that even while the mom and dad continue their daily work routine, the routine of children is changed and medicine normally taken in the morning is not taken. This form of non-compliance can result in worsening asthma control in the summer months. Personally I think this is the key, and I have experienced this myself.

Dr. Thompson also offers some tips for getting through the summer months with asthma

1. Run your air conditioner: This will purify the air in your home and get rid of any humidity. It will likewise reduce mold and dust in your home.
2. Exercise in early morning: Air quality is better in morning, and some allergens are less prevalent. With three little kids this is often hard to adhere to.

3. Alter your medication routine: Do this to account for the change in summer routine so that you are always taking your medicines as prescribed.

4. Plan ahead for vacations: Actually, I offer some tips for traveling with asthma here.

5. Make appointment with your doctor: Do this to plan ahead what you can do to improve your asthma control during the rest of the hot, humid summer months

So just keep in mind you're not alone in having a bit more trouble with your asthma this summer. Yet with planning, you should be able to manage it just fine.

The truth

The truth will set you free, but first it will make you miserable." James Garfield

Isn't that a great quote?

I think it is. I can think of so many great examples my head almost spins. Recently I've heard the following quotes:

1. "I'm giving that baby 100% oxygen, I don't care what the research says." Family practitioner
2. "That patient's CO2 is rising, give a breathing treatment to get it down." Internist

Yet, this also reminds me of another great quote from a nurse I work with:

"Don't some doctors realize what they learned in med school 20 years ago might have changed?"

Yeah. Some among us are brilliant, yet brilliance is not determined by where we get our degrees, nor that we have them at all, as there are tons of well educated people who are so dogmatic they refuse to see the truth.

They have to be exposed to it. They are exposed to it. And if they are not, it's us, and it's our kids, who will continue to suffer as a result. Because while it may make sense by 1980 wisdom to hold off oxygenating a CO2 retainer, it doesn't by 2010 wisdom.

While it may make sense to oxygenate neonates with 100% oxygen to initiate that first breath, by 2010 wisdom this may cause cancer later in life. "Well, I don't see the cancer now, so I'm going to ignore it."

That's basically what they are saying when they refuse to read the writing on the wall. Again, the truth may set you free. But first it will make you miserable.

If you're open minded it won't, but if you're closed minded it will.

RT Supermarket

I remember as a kid visiting my aunt who owned a mom and pop grocery store out by the state park. I always thought it was cool that my aunt would cheerfully greet every customer as though they were all her best friends.

When I questioned her about this later she said, "Basically my business comes from the same people. If you're friendly, they just keep coming back for a sucker here and a beer here and a ham there. They're all regulars."

In a way, that's the general feeling I get as I'm working as an RT. Even today we have eight patients on our list, and every single one of them is a regular. I know them all by name, and they know about as much about me as I know about them.

Earlier today I was called to the emergency room, and we were waiting for the ambulance to arrive. "So, I wonder what regular it is this time," one of the nurses said.

"Well, the call was out by Cracker Road," another nurse said, "so maybe it's Mr. Wilcox. He's a wildly old coot. A sick guy, but fun to take care of."

As a matter of fact that's who it was. Since it was relatively slow that night (low patient census) I ended up talking to him for over an hour after giving him his usual concoction of Albuterol and Ventolin.

He ended up going home, the old coot.

What we have here is an RT Supermarket, full of a bunch of regulars. In fact, this might be one of the advantages of working for a smaller hospital like Shoreline.

Oral steroids to treat COPD???

There was an interesting study done recently regarding steroid use in COPD patients admitted to the hospital.

The study, reported in the June 16 issue of The Journal of the American Medical Association, shows that COPD patients who are given high doses of steroids are more likely to need a longer stay in the hospital, with a greater chance of needing a ventilator, than COPD patients treated with low dose oral steroids.

Likewise, the study shows the benefits of high dose systemic steroids is no greater than low dose oral steroids.

This is contrary evidence to the standard practice of treating patients suffering from COPD exacerbations with high doses of steroids to control inflammation in their lungs. Currently, up to 90% of COPD patients admitted are treated with high dose steroids.

The report was discussed in this Web MD article by Denise Mann. You can check it out if you so desire. Mann notes that COPD experts are still at odds as to what the actual best dose of steroid is, although this study used a dose of 20-60 milligrams as the oral steroid dose.

Of course the requirement of high doses of steroids places COPD patients at risk for many side effects, and therefore if all that is needed is a smaller dose this would be great news for many patients. Although more research, and many years of convincing, will probably be needed before any significant recommendations are made in this regards.

However, according to Dr. Richard Mularski, a pulmonologist who wrote an editorial on the study, "We really think that doctors should be following hospital guidelines and treating patients with oral steroids, at least for those who are able to take oral steroids."

Obviously this is just one study, yet it'll be interesting nonetheless.

ABG interpretation made easy: Oxygenation

An arterial blood gas can help you determine how well patient is oxygenating. Essentially, all you have to do is memorize the following chart.

	PaO2	SpO2
Normal	80-100	95-99%
Mild Hypoxemia	60-79	90-94%
Moderate Hypoxemia	40-59	75-89%
Severe Hypoxemia	< 40	< 75%

Oxygen Therapy.  Using oxygen therapy to improve oxygenation.  It generally involves inhaling an FiO2 greater than that which is contained in room air.

Fraction of Inspired Oxygen (FiO2).  This is the percent of oxygen in the air inhaled.  Room air contains 21% FiO2.  Oxygen Therapy may supply an FiO2 from 22-100%, depending on the device used. To learn more, check out "Oxygen Therapy Made Easy."

Goal of Oxygenation.  Most protocols now recommend the least amount of supplemental oxygen to maintain an SpO2 of 90% and a PaO2 of 60.  For some patients with lung disease, lower SpO2s may  be acceptable. For instance, with some cases of advanced COPD, an SpO2 of 88% may be acceptable.

Responsive Hypoxemia.  Supplemental oxygen improves oxygenation levels.  Or, increasing FiO2 increases SpO2 and PaO2 to acceptable levels.

Refractory Hypoxemia.  Supplemental oxygen does not improve oxygenation levels.  Or, increasing FiO2 does not result in an increase in SpO2 and PaO2.  It's commonly described as an SpO2 of less than 60 despite receiving 100% FiO2.

Hypoxemic Respiratory Failure.  Failure of the heart and lungs to oxygenate the blood despite the application of supplemental oxygen via oxygen therapy.

• PaO2 less than 60 on 50% or greater FiO2
• PaO2 less than 40 on any FiO2

Desired FiO2.  Calculated:  Desired PaO2 + Known FiO2 divided by known PaO2

How to use ABG results to determine if oxygen therapy is working over time. 

1. Expected PaO2 = FiO2 * 5
• Example.  If a patient is on 100% oxygen, you should expect a PaO2 of 500.  If the PaO2 is only 200, you know the patient is not oxygenating well.  
2. Actual PaO2/ Expected PaO2 = % of patient expected PaO2:
• Should be recorded daily 
• Shows if patient is oxygenating better
• Better indicator than simply looking at actual PaO2 and FiO2
• Normal = zero (patient requiring no supplemental oxygen)

Examples of % expected PaO2: (Despite lower PaO2, patient still oxygenating better)

• January 1 PO2 40 on 100% FiO2 = 80%
• January 5 PO2 60 on 40% FiO2 = 30%
• January 6 PO2 55 on 50% FiO2 = 20%

Another example of % expected PaO2 (PO2 look good, but is patient really oxygenating?)

• January 1 PaO2 200 on 100% FiO2 = 40%
• January 5 PaO2 100 on 100% = 20%
• January 6 PaO2 100 on 90% = 22%
• January 10 PaO2 55 on 80% = 13%

You don't necessarily need to use these formulas to see if patient oxygenating well, yet sometimes they can be useful. Especially for the more complicated cases, it helps to see the numbers and the trends.

Post originally published on 8/11/10 on respiratory therapy cave; updated by Rick Frea for accuracy and simplicity.

Further Reading

• ABG interpretation made easy: interpretation of acid base balance 
• The ABG lexicon
• Learn about the 4-5-6, 7-8-9 rule
• Oxyhemoglobin Dissociation Curve
• How to know if your patient is a CO2 retainer
• Cord Blood Gases made easy
• The argument against ABGs
• What is an ABG
• Respriatory Therapy Formulas

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Why peak flow readings are higher than normal?

The following is a question I recently received:

Question: mom with asthma wrote:

I was recently diagnosed with bronchitis on top of my asthma in the ER. When the nurse took my oxygen level it was 99%. My husband made a comment about it, and assumed that meant there wasn't a problem. I remember she said that it didn't mean a whole lot, just that I had good oxygen saturation in my blood. I don't remember what she said after that. Could you explain what the oxygen level means when you are having an asthma attack? Why do they monitor it?

Since having this problem, I have begun to notice that often when I use my peak flow meter, I get a high number, like 100 higher, than has been normal for me. Can you make any suggestions as to what is going on? I mentioned it when I saw the doctor, but didn't really get an answer.

My humble answer: Good questions. An oxygen level (SpO2 or sat) of 99% is perfectly normal. Usually we like to see it at 90% or better, so 99% is great. A normal SpO2 is usually about 98%, while it is impossible to be at 100% unless you are on supplemental oxygen.

We monitor sats on all patients who come in with respiratory problems, even asthmatics. However, I find that it is rare that an asthmatics sats decrease, this can happen with severe asthma attacks. For this reason, it is important to monitor.

I wrote a post recently about peak flow meters. You can read it by clicking here. One reason your peak flow rates might be higher after you seek treatment for an asthma attack is because you are getting better asthma control now. Perhaps you're on some good asthma medicines (perhaps systemic steroids?), and this can work to improve your lung function. This would be my theory.

Maybe your above normal peak flows are what you are really capable of. I'm sure you know this, but there are medicines meant to improve lung function in asthmatics and prevent asthma flare ups, such as Advair and Symbicort, or Singulair, and sometimes Spiriva. By working with your doctor, and by trial and error, perhaps the right combination of these medicines (all with very few side effects) will help you maintain your higher peak flow readings.

Keep in mind I don't know you as well as your doctor, and this is just my guess. It surprises me, however, that your doctor didn't have a better answer for you.

The effects of alcohol on asthma/ allergies

Have you ever had a drink and had trouble with your allergies or asthma later that night, or the next day. Science has proven it may not be so much the hangover, yet the alcohol itself. Read my latest post from MyAsthmaCentral.com to learn more.

Studies Link Alcohol to Worsening Asthma/Allergies

by Rick Frea, Wednesday, May 19, 2010, from MyAsthmaCentral.com

If you're like me, you enjoy an alcoholic beverage from time to time. Likewise, if you're like me, you've noticed your asthma sometimes worsens afterwards, particularly the next day.

I'm not talking about a hangover here. If you drink in moderation you shouldn't experience one of those. But that's beside the point.

What I'm referring to here is increased nasal stuffiness, sneezing, wheezing and chest tightness. Sometimes I find myself using my rescue inhaler more frequently.

I know I'm not alone in making this observation because many studies have been performed on the topic in recent years. RespiratoryReviews.com notes a study done in Berth Australia in 2000.

The study noted that, "'Of the 366 respondents, 33 percent indicated that "alcoholic drinks had been associated with the triggering of asthma on at least two occasions.' In most cases, the asthma attack developed within one hour of alcohol consumption and was of moderate severity."

Although 92 percent of those who said they had asthma symptoms after drinking alcohol noted this occurred after drinking either white or red wine.

The researchers reported that, "Wine-induced asthmatic reactions were reported more often by women, by those taking oral steroids, by individuals who had reported their first asthma attack at a younger age, and by those who had previously visited an alternative health practitioner for asthma."

An April 19, 2010, article at the New York Times, "The Claim: Alcohol Worsens Allergies," links alcohol with allergy and asthma symptoms.

A study done in 2004 in Sweden basically confirmed the findings of the Perth, Australia study, that alcohol, particularly red and white wine, triggered asthma symptoms, and most of the attacks occurred in women.

So why does alcohol trigger asthma/allergies?

1. Histamines: A natural product of the fermentation process to make beer, wine and liquor results in natural chemicals that resemble histamine, which can cause an allergic reaction. Histamine, as you may know, is a chemical in your body that's released during allergic reaction, and causes swollen glands, increased sputum, uncomfortable feeling, runny eyes, and airway inflammation that worsens asthma.

2. Sulfites: These are preservatives used mostly in beers and wines that are found naturally in grapes and can increase symptoms of allergies/asthma. It's harmless in people without asthma.

3. Gastrointestinal Reflux Disease (GERD): Alcohol can worsen the degree of acid reflux. This is where stomach acid works its way up the esophagus to the upper airway and then down the trachea. This can also be worse after eating too much, drinking too much, or while sleeping.

4. Dehydration: Many experts agree that alcohol causes dehydration. When your lungs become too dry this can trigger asthma, particularly the day after drinking too much.

5. Bloating: As I wrote in this post, carbonated beverages, meaning beer and pop, "can also cause excess gas and bloating, which may result in the diaphragm being pushed up against the lungs, further compromising them and making it even more difficult to breathe."

Ironically, despite this recent string of evidence supporting the claim that alcohol makes asthma worse, alcohol was used in ancient times, and as recently as the 1930s, as a remedy for asthma.

Even some recent studies, which you can see here, have shown that alcohol does have a bronchodilating effect -- it dilates the air passages in your lungs. However, this effect is mild.

Likewise, as I wrote about in this post, up until about the mid 1950s asthma was believed to be a disease caused by the mind, or anxiety and depression. In his 1860 book, asthma expert Henry Hyde Salter wrote that a shot of brandy, in desperate situations, would give the body a "shock" to knock out the asthma attack.

Of course cigarette smoke was also once recommended for asthma, and now we know the risks of smoking cigarettes far outweigh the advantages. The same may be true regarding alcoholic beverages for some asthmatics. The jury, though, is still out.

Actually, some recent studies have confirmed that pure alcohol does mildly dilate the air passages in the lungs, and studies are ongoing to determine if this should be used in the future for severe asthma nonresponsive to other therapies.

Still, the wise recommendation of most asthma experts is that if you have a history of asthma and/or allergies, you should at least be aware that alcoholic beverages, particularly beer and wine, do have the potential to trigger an asthma/ allergy attack.

So, as with anything in life, it's up to you to decide if the benefits of what you put in your body outweigh the risks.

For a related post, check out Understanding Alcohol Allergies by Kathleen MacNaughton.

RT history: All SOB still treated as asthma

You see me write often on these pages about how Ventolin and Xopenex and Atrovent are -- much like Tylenol -- given to patients way more often than they need to be. Like tylenol, bronchodilators are among the most abused medicines on the market.

Yet there is a historical reason behind this abuse. If we go back just 50 years you'll see many myths about asthma, and many myths about asthma treatments. Well, if you've ever heard the myth that chicken noodle soup will cure the common cold you'll understand where I'm coming from.

Actually, a really good example of how history can effect how we think today all you have to do is look at the history of the name of America. We know that Columbus discovered America for Europe, yet America was named after Amerigo Vespucci.

The king of Spain had it named so because Columbus didn't write about his ventures, Amerigo did. Years later when it was learned Columbus discovered America first historians tried to change the name to Columbia, but by then it was too late: the name America was already firmly planted in the minds of many.

So you can see it's hard to change old thinking, even if it's wrong.

If you read books about asthma that were written prior to the late 1990s, you will not see asthma defined the same way it is today. In fact, asthma, as defined prior to the 1930s may not even be asthma at all.

Now I'm sure Teddy Roosevelt had the disease, yet even physician's like J.B. Berkart, who wrote his version of "On Asthma: It's pathology and treatment" in 1878 noted the following:

"ALL early historical traces of the affection at present called asthma are lost. Although the disease is said to be mentioned in the Bible, and described by Hippocrates, Areteaus, Galen, and Celsus, there is not the least evidence that those remarks apply to the asthma of to-day. For in the former systems of medicine, all cases presenting the same conspicuous symptoms were, regardless of their anatomical differences, considered as of a kindred nature, and grouped into classes according to imaginary types."

In this regard, any disease that caused shortness of breath, or dyspnea (being winded) were all called asthma. Chronic bronchitis, emphysema, COPD, cystic fibrosis, pneumonia and heart failure all result, at times, in symptoms similar to asthma, and, thus, were all grouped in the class of asthma.

Now, it should be important to note that since this is the old way of thinking, it only makes sense that many doctors STILL often confuse these diseases, and often treat all that wheezes and all that causes shortness-of-breath as asthma. So now perhaps you'll understand why I often make fun of this on this blog.

The funny thing is, that even while Berkart noticed this, he himself believed asthma was caused by Rickets, and he also believed asthma was psychosomatic. Likewise, he himself said that he had never performed an autopsy on an asthmatic and not seen emphysema. Emphysema, as you and I know today, causes permanent air trapping in the lungs, while asthma causes air trapping only during an exacerbation (with a few exceptions). Yet that wisdom is relatively new.

During most of the 19th century asthma was thought to be a psychosomatic disease, in that asthma experts believed asthma was all in the head of the asthmatic. With good psychiatric care, and good medicines like opiates and caffeine, one asthmatic was expected to relax and the asthma attack will go away, and asthma itself will go away with age (a fallacy that still exists).

In fact, there are and were (are) so many asthma myths that I can hardly scratch the surface, although I try in this post.

I have also observed that once science proves something to be true, it usually takes about ten years to convince physicians at larger hospitals to change. Then, once larger hospitals adapt new policies based on facts (which may take up to 10 years), it takes another 10 years for smaller hospitals (like Shoreline) to catch on.

So, you can see, progress is slow. While the wisdom may be out there, progress is frustratingly slow.

So this should explain why we are STILL giving bronchodilators for all that wheezes. It also explains why we are still overoxygenating newborn babies even though every study ever done of the subject going on 15 years now shows that oxygen, even to term babies, has been linked to cancer later in that child's life.

I guess this is why they say: patience is a virtue. When you work in the hospital you have to be exceptionally virtuous.