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Friday, June 17, 2011

The 17 biggest myths about respiratory therapy

There's this old saying that we do the best with the wisdom of today, and when we learn better we do better. Yet in the medical field the saying should go like this:  "We do the best we can with what we know today, and when we're proven wrong we continue to do it the old way."

This is nothing new. The medical profession has historically been slow to adapt change.  For example, in 1847 Ignaz Semmelweis observed that moms whose babies were delivered by medical students were far more likely to die of child bed fever compared to moms whose babies were delivered by midwives.

Semmelweis proved the midwives were cleaner because the midwives washed their hands between patients. Semmelweis made it mandatory for doctors to wash their hands in chlorinated lime solutions just like the midwives did.  In the months that followed moms dying of child bed fever plummeted.  Yet Semmelweis was hated and treated like a nut.

How dare he tell the well established medical community what to do?  You see, back then medical status was determined by how much blood you had on your hands and apron.  Since Semmelweis could offer no scientific proof why handwashing did any good, Semmelweis was laughed out of town, even though he was right and they were wrong.  Of course later Semmelweis was proven right, although too late for him to get the last laugh.

Here's an even better example.  Galen lived 129-199 AD, and in in the 16th century (a whole 1,500 years later) his books were still taught in school as though Galen were a medical god. Then, Around 1543, Andreas Vesalius made observations that were pretty much rejected by the medical community.  While an assistant was dissecting a corpse, the well respected professor was reading Galen's description of what was being dissected.  Vesalius noted what many other students noted yet refused to accept:  that what he was seeing was not the same as what Galen wrote.

For example, Galen described the sternum as having eight parts, yet the human sternum had only three parts. Later, when dissecting an ape, Vesalius learned it was the ape that had an eight part sternum.  Vasalius learned Galen had made his writings based on dissections of apes.  This made sense considering in Galen's day it was illegal to dissect a human corpse.

In the 16th century artists like Michelangelo knew more about the human anatomy than physicians, so Vesalius hired Johannes Oporinus to draw accurate pictures of human anatomy, and Vesalius published the first ever book on human anatomy:  De humani corporus fabrica.  Yet Galen could nary be wrong, and Vesalius was laughed out of town.  Of course he is now considered the father of human anatomy.

So there are many times in medical history where the facts were on one person's side, yet he was put on the defense and mocked, ignored, and laughed at.  This continues to this day to be the trend in healthcare, where  much of medicine is based on old myths, and the person with science and facts on his side is mocked, ignored, and laughed at.

So physician are known to be stubborn, and to hold onto old myths for centuries.  You can consider these old myths when reading about the 15 biggest modern myths about respiratory therapy.

1.  Giving oxygen to COPD patients will knock out their respiratory drive:  This was the myth created by respiratory therapists to justify their existence back in the 1930s.  It's a myth that some COPDers have CO2 levels so high that their bodies no longer use CO2 as the drive to breath.  Instead they rely on oxygen.  So, if oxygen is set too high, they will stop breathing.

The truth.  Even COPD patients use CO2 as a drive to breath.  I have given many COPD patients 100% oxygen and never have I ever seen any COPD patient drop dead.  In fact, in my hospital every breathing treatment is given with oxygen, and not one of these patients has ever dropped dead during a treatment.

It is true on an unstable COPD patient in respiratory distress the added oxygen may knock out their drive to breath, yet it has nothing to do with the hypoxic drive, it has to do with ventilatory failure, pooping out, the haldane effect, and stuff like that.  Yet it has nothing to do with the hypoxic drive.

So, based on a myth, many COPD patients continue to be starved of the oxygen they need, and many lives have been cut short as a result.  And many more lives will continue to be cut short in the future.

To read read more about the hypoxic drive myth read: "How does too much oxygen affect COPD?"

2.  Giving oxygen to anemic patients will benefit them.  If you work in a hospital you probably have a policy whereby if the hemoglobin is below 10 you automatically place that patient on oxygen.  The idea is that since hemoglobin is low, more oxygen will be needed to feed the brain.

The truth is that giving more oxygen to these patients is useless.  If oxygen carrying hemoglobin are not in the blood, then all the extra oxygen molecules are just going to float around.  Look at it this way, if an airplane normally has 100 seats and 50 seats are missing, you can book 500 people on that plane, yet still only 50 will be able to find a seat.

Think about that the next time you're placing a nasal cannula on an anemic patient.

3.  All that wheezes must be treated with a bronchodilator.  Since the advent of time a wheeze has been associated with asthma.  If someone is wheezing they must have narrowing of the air passages in the lungs.

The truth is that many things can cause a wheeze, and a bronchodilator has no effect on most of them.  Swelling of the throat, cancer, forced exhalation, collapsed lungs, heart failure, dry throats, increased secretions and pulmonary fibrosis are some examples.  Truth is, a wheeze is perhaps the #1 most reported lung sound, and most wheezes probably aren't even real wheezes, they're rhonchi -- the sound of air moving through air passages --or even stridor or a rub.

Yet to make themselves feel like they are doing something, a respiratory therapist is called to "give a breathing treatment" every time a nurse or doctor thinks he hears a wheeze.  It's silly, yet I don't see it ending any time soon.

4.  All lung ailments must be treated as asthma:  You heard that right.  In the hospital if you're diagnosed with any lung ailment a bronchodilator is ordered.  Doctors are taught that every lung disorder will cause the air passages to spasm.

The truth is, the only lung disorder that benefits from a bronchodilator is one that causes the muscles surrounding the air passages (bronchioles) to spasm.  Bronchodilators like Albuterol and Xopenex relax these muscles, dilating the air passages, and making breathing easier.

If there is no bronchospasm -- if the air passages are already open -- they will not become more open no matter how much Ventolin you pump into that person's lungs.  

5.   Bronchodilators increase sputum production.  Many times an RT has given a Ventolin treatment to a patient to obtain a sputum sample.  Sometimes it works and sometimes it doesn't.

The truth is, while Ventolin has been proven by some studies to increase sputum production, the amount produced is so small it will generate to gob of phlegm unless the patient is already sick and ailing.  That's right, if a COPD patient already has phlegm inside, the Ventolin may relax the airways enough to help that patient bring up a gob.

This has many doctors thinking Ventolin will produce this effect even in patients with dry, non-productive coughs.  The truth is, it's a myth.  Ventolin is not an expectorant.

For further reading on this topic, read my post "Aerosols no longer indicated for airway clearance."

6.  Chest physiotherapy will speed up time to discharge.  Many doctors order post operative CPT on all their post operative patients because some study 300 years ago said it would help move secretions.  The truth is, 300 studies done on CPT have never proven this.  If there's no secretions being produced, you can pound on the patient until the cows come home and the patient isn't going to bring up anything.  Patients given CPT will be discharged eventually just like those not given CPT.  They all survive.

7.  Ventolin causes paradoxical bronchospasm.  Sure studies may show Albuterol causes paradoxical bronchospasm, yet I've never once heard of an asthmatic complain that Ventolin made his asthma worse.  To believe this is to believe that Chicken Noodle Soup will cure the common cold.

In fact, it's myths like this that prevent some patients from getting the treatment they need to feel better.

The neat thing about this myth is that it's the only one doctors ignore in lieu of myth #3 or #4 above.

8.  Breathing treatments are better than inhalers:  Once admitted to the hospital doctors stop ordering metered dose inhalers and order nebulizer treatments instead.  They believe nebulizers work better to treat and prevent bronchospasm than inhalers.

The truth is most every study completed on this subject has proven that when an inhaler is used properly with a spacer it is just as effective (if not more effective) than a nebulizer treatment.  When if comes to infants, studies have shown inhalers work much better than nebulizers.  Read my posts "Nebulizers and Inhalers, which one works best for your child?" and "Most aerosolized medicine is wasted."

There are two exceptions to this rule:
  • 1.  You have an end stage lung patient who cannot generate enough flow, and in this case breathing treatments are superior to inhalers, particularly dry powder inhalers.  For example, Brovana and Pulmicort will benefit the patient over Advair.
  • 2.  You have a patient in respiratory distress.  Keep in mind here studies do not always correlate with personal experience, and many asthmatics and COPDers have noted that breathing treatments work better than inhalers during an exacerbation.  This may be due to diminished ability to generate an adequate inspiratory flow needed to inhale the inhaler mist.  Once the patient is breathing normal again, however, inhalers can and should be used again.  
9.  Aerosolized breathing treatments help you cough up pneumonia:  It is true ventolin has been proven to increase sputum production, although the effect is minimal (see myth #5 above). The truth is that even if sputum production does increase, this has nothing to do with pneumonia.  Pneumonia is inflammation of the lung parychema (terminal bronchioles and alveoli).

Not only does Ventolin not treat inflammation, these particles are only 0.5 microns in size, too large to make it down to the parychema. And even if they did, there is no bronchiole smooth muscles and no beta adrenergic receptors in the lung parynchema for them to sit on. 

This myth is so overblown that the Centers for Medicair and Medicaide (CMS) won't reimburse for pneumonia patients unless a breathing treatment is given, and it has resulted in ventolin automatically being ordered via order sets at many hospitals so the patient meets reimbursement criteria.  This myth has given the Federal government an excuse to pay less at the expense of hospitals and patients paying more.  Likewise, it's resulted in burnout of respiratory therapists, loss of morale, and apathy.

Also, consider the following:  if ventolin increases sputum production and this treats pneumonia, then why do asthmatis, who have excessive numbers of goblet cells, still develop pneumonia?  Gobble on that question for a while.  For further reading, once again refer to "Aerosols no longer indicated for airway clearance."

10.  Ventolin prevents asthma.  Ventolin is ordered for many patients with a history of asthma, COPD, ARDS, intubation, BiPAP, trachs, somnolent, sedated, receiving blood, atelectasis, lung cancer, fever, and rickets to prevent these ailments from turning into asthma.

The truth is that Ventolin is a simple drug that is hailed by asthmatics for bronchospasm and it doesn't do much else.  It does not prevent one from getting asthma.  If the goal is to prevent bronchospasm, Advair, Symbicort and Dulera are better options.

11.  Levalbuterol is stronger and safer than Albuterol:  Early studies, free meals and alcohol convinced doctors and RTs that absence of the S-isomer made levalbuterol (Xopenex) stronger, made it last longer, and gave it fewer side effects.

More recent studies and practical observations have given us a more clear picture of this Xopenex, and we've learned it's nothing more than a more expensive bronchodilator to the inexpensive albuterol.  Read "Albuterol -vs- Levalbuterol: What have we concluded."

12:  BiPAP pushes fluid out of the lungs in patients with pulmonary edema (CHF, heart failure):  The idea that the BiPAP pushes fluid out of the lungs is a fallacy. It does nothing of the sort. If you think of it, the argument disproves itself. If BiPAP forces fluid from the lungs, where would it go? Would it miraculously go back into vessels?  

I contemplated this and did some research. The best answer I could find came from Jeffrey Sankoff, MD, from Emergency Physicians. I will post what he wrote about this topic below and the next time you have a doctor say that you can show him this report:
Contrary to popular belief, NIMV does NOT push edema fluid out of the lungs. Patients with acute CHF have an imbalance in the CO (cardiac output) of the right and left sides of the heart. With the inciting event (detailed above) the left ventricle becomes compromised but the right ventricle usually does not. So the right ventricle continues to pump forward a normal volume of blood but the left ventricle becomes unable to keep pace. Fluid backs up into the lungs resulting in capillary leak and pulmonary edema. With NIMV, the resultant positive intra-thoracic pressure decreases venous return (blood flowing back to the heart). This reduces right-sided CO to a level that the left heart can equal or even exceed. Fluid ceases to back up and will even begin to be reabsorbed as left ventricular CO improves. Pulmonary edema ceases to worsen and may even diminish, often rapidly.
Now, that said, it also keeps the alveoli patent, and redistributes intra-alveolar fluid, to improve pulmonary compliance and decrease work of breathing. Read more in my post "CPAP -vs- BiPAP: What You Need to Know."

13.  The incentive spiromter is an effecting means of preventing and treating post operative complications:  In 2001 a group of medical experts set out to determine if the incentive spirometer is truly an effective means of preventing and treating atelectisis. They reviewed all studies prior to 2001, and there was not one study that provided evidence to support IS therapy for decreasing incidence of postoperative respiratory complications. Basically, the only reason the IS was chosen among a variety of options that included Intermittent Positive Pressure Breathing, IS, Chest Physiotherapy (CPT) and blow bottles was because the IS was the simplest for the patient and the RT, and it was the least expensive. For a review of the study you can check out the following: Overland, Tom J., et al, "The Effect of Incentive Spirometry on Postoperative Pulmonary Complications: A Systemic Review," Chest, September 2001, vol. 120, no. 3, pages 971-978.  You may also read my post "History of Incentive Spirometer."

14.  Giving 100 percent oxygen will stimulate a newborn baby to take its first breath:  In the 10 percent of cases where a newborn doesn't start breathing after birth, positive pressure breaths with 100 percent oxygen -- mainly with an AMBU-bag -- are believed to stimulate breathing.  During the 1970s it was proven that giving oxygen to premature infants increased the risk of a lifetime of disorders such as Retropathy of Prematurity.  Yet by 2010 enough evidence was available that proved that not only is too much oxygen bad for premature infants, but it can cause a variety of cancers even in term infants, and even if it's used for as short of a time as two minutes.  Studies suggest the before birth a child grows in an atmosphere where the PO2 is as low as 40.  If these children are born and you increase that PO2 to 100 too fast, this can cause severe consequences to the baby.  There are also studies available that provide no evidence that oxygen helps to stimulate a baby to breath.  It is now believed that simply giving positive breaths on 21% oxygen is enough to stimulate a baby to breathe.  Based on this research, it was initially recommended baby's in need of resuscitation be bagged with AMBU-bags that have no reservoir on them so the child can be resuscitated with 40% FiO2.  Yet now, based on the above evidence, recommend is using a T-Piece Resuscitator (NeoPuff) that is connected to an oxygen blender so a child can be resuscitated with 21-40% FiO2, and then increasing only when needed to maintain the time estimated saturation (it may take up to ten minutes for the child's spo2 to naturally reach 90%).  Newer studies suggest that no oxygen be used unless the child is non-responsive to initial resuscitation efforts. I wrote more on this in my post "Do not oxygenate neonates".

15. Patients with chest pain require 2-4lpm to make sure the heart is oxygenated: As with most of the myths above, this myth was created because it sounded like a good idea, and was based on no evidence at all. The theory here was that extra oxygen would make sure the heart was getting plenty. Common sense suggests, however, that if the patient has an SpO2 of 90 or above the patient's heart is alreadyreceiving plenty of oxygen. All the evidence in the world suggests that, in the presence of low oxygen levels, blood is shunted from non-vital tissue in favor of vita tissue, such as those of the heart. In 2010, the new ACLS Guidelines recognized this fact, and implemented the following change: "Oxygen supplementation for uncomplicated acute coronary syndrome is no longer routinely indicated and should only be applied only if the oxyhemoglobin saturation (SpO2) is less than or equal to 94 percent." Of course this change was only made because CMS is always looking for ways of saving money, but we'll take good changes any way we can get them. The problem with this is most nurses and physicians and respiratory therapists had the old myth inculcated into their cranium, so the change is usually not accepted and ignored. So if you land in the ER with chest pain, expect prongs to be stuffed into your nares for no good reason. (See "ACLS New Guidelines,",, accessed 3/24/13)

16.  Blowby treatments are useless:  It is true that nearly 90% of medicine is wasted whether an inhaler or a breathing treatment is used (with a mask or mouthpiece) as you can read here.  You can also read adnauseum, as I wrote about here, that if 90% of the medicine is wasted when given by aerosol, probably more like 99% of the medicine is wasted when you blow the medicine by a child's face.  However, I have given many breathing treatments by blowby to children, including my own, and they do work.  I have seen it too many times to deny it any more.  Surely you'd prefer to use a mouthpiece or mask, but when all other options are exhausted (or if the child is sleeping), blowby treatments do work. 

17.  B2 agonists will benefit patients with RSV/ bronchiolitis:  According to guidelines set forth by the Agency for Healthcare Research and Quality, beta 2 bronchodilators (which includes ventolin and xopenex) are not recommended for the routine treatment of bronchiolitis (RSV).  Studies show B2 agonists will work if asthma is a component, however, but not for pure RSV/bronchiolitis.  Racemic epinephrine has been shown in some studies to work, so this can be trialed.  What has been proven beneficial is nasal suctioning.  One of the main reasons for low sats and dyspnea is increased secretions and the inibility to expectorate, and thus suctioning (ideally with a Booger-B-Gone) is beneficial.  To view the guidelines, which are based on the latest research and studies, you can click here.

18.  Lavage and Suction will thin, enhance, and mobilize secretion clearance: The new recommendation is that lavage and suctioning should only be performed by a qualified respiratory therapist, and only in the presence of a mucus plug.  This subject is discussed in greater detail here.

19.  Albuterol nebulizer treatments will thin, enhance, and mobilize secretion clearance:  The latest evidence is analyzed here.

20.  You cannot use IPAP settings greater than 20: As a general rule, BiPAP should not be set at settings of greater than 20-25, as such high pressures prevent opening of the upper esophageal sphincter, which could result in gastric insuffluxation, gastric distension, emesis, and aspiration. If you do go above this, you might need to suction the stomach with an NG tube or OG tube. When an NG or OG tube is in place, BiPAP settings may be set at greater than 20, although I would not do this without direct approval of a qualified physician.

21.  IPPB will help patient take deeper breaths in order to cause greater distribution of bronchodilator in lungs.  I disproved this in the post "Down with IPPB."  However, thankfully, most hospitals no longer use IPPB.  An alternative view is represented in the post "Up with IPPB."

In conclusion:  So while science has proven the above myths wrong, many in the medical profession continue to treat their patients the way they were taught back in the 1980s.  Until these debunked myths are rejected by the medical community, it's the patients who suffers.

These myths have resulted in poor patient care, respiratory therapist burnout, and increased costs.


Anonymous said...

My RT teacher was just telling us yesterday to not give oxygen to CO2 patients. That their brains will think they are ok and make them quit breathing! lol..

Rick Frea said...

It's funny how theories become facts. Rather, it's not funny really. Despite the myth status, we RTs have to do what we're told, and therefore aid and abet the myths.

Anonymous said...

#1: do no harm. I can't speak for all rts, but most of my pts improve with the therapy given. Some pts despite all efforts whether mythical or not do not. I've never killed anyone with an albuterol. Sure, some docs think it cures everything, but it can make people feel better even if its just in their head. Now lets talk nurses overmedicating and rts having to fix their mistakes

Rick Frea said...

It's actually a fallacy that ventolin causes no harm. We must not for get the s-isomer, which has been proven to cause inert bronchspasm. The more you take the medicine, the more you need it. It's an endless cycle.

I do see your point though. Patients do get the psychological benefit of thinking we're doing something, and the company of an RT.

Yet this has been a problem that has plagued the entire history of medicine, is that most medicine has no benefit other than psychological. Ventolin, like charms, amulets, prayers, and incantations of the primitive world, provides nothing more than the best remedy of all time: HOPE.

In other words, there are times when Ventolin has a real scientific benefit to the patients who receive it. The other 90% of patients receive nothing more than mythical benefits.

Does this "mythical benefit" and "false hope" justify the $120 it costs insurance companies for every treatment given.

Think of it this way, you give a treatment that's not needed every four hours, that's $720 a day, and $5,040 in a week. Is that price worth hope?

Rick Frea said...

Also, taking up a respiratory therapist's time giving a treatment that's not needed takes away time from someone who does need attention.

Also, and I'd like to see a study on this, when an RT is burned out at the end of a day due to too many frivolous therapies, it diminishes his ability to make good decisions at the end of his shift. A burned out therapist is not always at the top of his game. This, in my opinion, may work to the detriment of good patient care. A burned out RT who is grumbling and griping at yet another useless ventolin order is probably not good for public relations either.

Now, these are simply thoughts. Although in all the years I've communicated such thoughts, I have never had anyone come up with a counter argument. Not one person has ever come up with any facts to prove that ventolin is needed for CHF, pneumonia, cancer, pleural effusion, and other lung diseases that provide asthma like symptoms.

I have had many doctors say things llike, "I think that ventolin helps with heart failure." I ask this doctor, "Do you have the evidence to support this claim, or is it just a feeling?" Never has a doctor proffered any evidence.

This, in my opinion, is no better than treating diseases the primitive way with a medicine man dancing, rattling his shakers, beating his drums, and chanting incantations.

Anonymous said...

...Many, Many Times, Nebulizers Are FRivolously ordered By ARNP, residents, PA's, And Hospitalists Who Have Way Less Understanding Of AnyIf This, Yet Feel Its A Safe Enough And Harmless order That Wouldn't Hurt. Ughh!!!