The once a day asthma medicine

All we asthmatics yearn for it:  a once a day medicine.  Thus was the topic of a recent post by me at myasthmacental.com

Asthmatics want once a day medicine

A few years ago I asked Santa for a medicine I called One Puff. It's an asthma preventative medicine you take once in the morning and then you're done for the day.

Needless to say, come Christmas 2010 this new asthma wonder medicine was not under my tree. It wasn't in my stocking either.

Actually, the One Puff does not exist. It remains a figment of my imagination. However, in light of a new survey of asthmatics, it appears I'm not the only asthmatic who yearns for such an ideal asthma medicine.

The survey (as you can read here) was completed by Decision Resources and revealed that as many as 55 percent of asthmatics would "eagerly" switch to a once-a-day asthma drug that had at least a "similar efficacy" to the medicine they are currently on.

In fact, the more likely someone is to request this switch increases with worsening asthma control. This could be because those with worse asthma tend to be those who require medicine more often and tend to miss doses.

This hits home with me because as recently as 1997 I was prescribed four puffs of Azmacort four times a day, 600 mg of Theophylline twice a day, Drixoral every four to six hours, and if I managed to be compliant with all that my asthma was still only so-so controlled.

Then my doctor introduced me to twice-a-day Advair and once-a-day Singulair and it's now much easier to control my asthma. Still, there are days when a dose is missed. Of course those are the days of diminished asthma control.

Still, none of this is enough medicine to make it so my asthma triggers don't trigger asthma. For instance, if I venture into the basement to work on a project I've had going on down there for several years now, my asthma acts up. There's no medicine available to prevent that.

However, thanks to new asthma wisdom, and modern asthma medicine, we asthmatics now have many options available to help us better control our asthma. Yet, as this study reveals, many of us continue to yearn for something like my fictitious One Puff.

The more often you have to use a medicine, the easier it is to miss doses. So if you could just take one puff in the morning while brushing your teeth, and have that control your asthma, then that would be ideal.

Of course the problem with modern medicine is cost, and that is a topic for another post.

The study also revealed that only 5 percent of asthmatics would request a switch to a new asthma treatment that would result in "improved" asthma efficacy, yet would require a once daily intravenous injection. In fact, greater than 50 percent said they would be very unlikely to request such a switch.

I just thought this research was interesting. It was probably done to help pharmaceutical companies and scientists determine how they should focus their research for new medicine to help asthmatics. Where should they focus their dollars?

According to this survey, the answer is on a medicine like One Puff.


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The only thing to fear is... not being prepared!

Franklin D. Roosevelt catered to Fear in America in 1932 by giving his famous line, "There's nothing to fear but fear itself." Although I think history has taught us that FDR was wrong. I think the best lesson learned from the Great Depression is that fear is good.

I think it was overconfidence and lack of fear that lead to the Great Depression. People were so confident the good times would continue to roll that they did not prepare. When the times were good they spent all the money they made on material things (like the story of Babel tells). Instead of saving and preparing for worse case scenario, they lived as though the good times would never end.

After the Great Depression -- for generations -- people saved. When I went to my grandma's house I would grimace every time I walked into the bathroom because it smelled like pee and the toilet always had pee in it. The reason is because she only flushed the toiled after a bowel movement.

I cringed when I looked in the sink because there would always be a container with dirty dish water in it. She only replaced it once a day. In this way, however, she did not waste water. She did this because she lived in the Great Depression years and knew what it was like to have no money to purchase anything, even simple things like water and soap.

She canned everything that could be canned and stored these in the basement. There was always enough food down there to last a year. And she never bought anything except with cash. If she didn't have cash, she never bought anything. She lived within her means. She was humble. She didn't buy all the stuff (material things) she wanted, but she was happy nonetheless.

She lived this way because she REMEMBERED the past. She remembered how hard life was in the 1930s, and she wanted to be prepared in case it happened again. My mom and dad were not as parsimonious as grandma, but they still paid cash for any material item, and they did not waste anything. Mom flushed the toilet each time, yet still saved dishwater.

Mom and dad did this because the were told story after story when they were growing up around the dinner table of how hard it was during the Great Depression. They were taught the lessons of the past and how to be prepared in the event it ever happened again. They taught about how to save every penny.

Many people forget. I look around and I see many people in my neighborhood with all the best toys for their kids and all the best toys for themselves: snowmobiles, tractors, riding lawnmowers, hunting equipment, bounce houses, trampolines, expensive wood swing sets.

Instead of saving money and preparing for the worst they assume the good times will continue on forever. So instead of saving, they spend $40 a week to have someone else mow and fertilize their lawns and spend thousands of dollars each year on landscaping. Instead of living humbly, they spend thousands on remodeling their homes just for the sake of remodeling.

They have a new car in their driveways every couple years and they finance it instead of paying cash for one they can afford. They sometimes even refinance their homes and put all their material things on the mortgage so instead of paying off their stuff they pay for it over the period of 30 years.

In essence, they are more interested in material things than being humble. It goes back to the battle between greed and materialism versus honesty and integrity and humility.

Look in my yard and you'll see I don't fit in. My yard is dirt and sand and my house has holes in the siding. It's not that I can't afford to do landscaping or to fix my house, it's that I find I don't NEED those things and chose to spend my money in more useful ways.

In a sense, if my neighbor lost his job he'd feel the recession full tilt. If I lost my job my life wouldn't change much because I'm living now the same as if I didn't have a job. I'm prepared and he is not. I read the story of the Tower of Babel and I do not forget the lesson learned. I did not live in the Great Depression, yet I don't take for granted it will never happen again.

If you always live as though you are in a recession it will matter less to you when it occurs. Why? Because you are prepared.

Fear is good. You should FEAR the Lord because he made us and has the final say in everything. When we fear Him we show respect for Him. When you respect history might repeat itself, it shows you have respect for history. And that's why we MUST never forget history.

We must educate. We must teach about depression. We must teach our kids how to spend their money frugally instead of creating a big debt. We must teach our politicians the same. We must teach them to read the Bible and to learn the lessons of it. Even if you don't believe in God you can still learn the lessons of the Bible, because it's all history (it may be allegorical, yet it's still history).

Then again, if you're a Bible follower as I am, you get a totally different view of fear. In the book of Isaiah (8: 11-15) a prophet warns: "Do not join in the schemes of the people and do not be afraid of the things that they fear. Remember that I, the Lord Almighty, am holy; I am the one you must fear... Many will stumble; they will fall and be crushed. They will be caught in a trap."

We must heed the warnings. We must be prepared.

So in the end we learn that FDR was wrong. He was wrong because in reality, fear is not the only thing to fear. In reality the only thing to fear is not being prepared.  Thoughts.

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Smoking linked to increased mucus production

It's common wisdom that if you smoke enough you'll eventually develop a smokers cough, and the chances are also pretty good you could end up with Chronic Bronchitis. A new study purports to prove that smoking itself causes excess sputum production.

A new study published online ahead of the print edition of American Journal of Respiratory and Critical Care Medicine reports that chemicals in cigarette smoke suppress a protein called Bik in your lungs that prevents the natural death of mucus producing cells.

It has been known for years that smoking destroys cilia in the lungs that are the main mechanism for bringing up excess secretions to the upper airway to be swallowed, why the increased sputum production was unknown until this recent study.

Previous such studies found that overproduction of mucus cells is in the large and small airways of people who smoke, and this chronic mucus production is responsible for airway obstruction, reduced lung function, and increased pathogens in the lungs that cause things like pneumonia.

The researchers, who studies samples from human and mouse lung tissue exposed to cigarette smoke, also showed that bik protein levels remained low even after the person (or mouse in some cases) was no longer exposed to cigarette smoke.

So permanent damage to the lungs exposed to cigarette smoke is highly likely. This might also explain why asthmatics exposed to cigarette smoke have worse asthma, because I'm sure second hand cigarette smoke decreases the bik protein in anyone exposed to cigarette smoke.

Further studies will be needed to further this research.

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The walk of the RT

A nurse today was watching me closely as I walked off the elevator, and then I moseyed by her with my hands casually behind my back. I said, "Why are you watching me so closely."

She said, "Because I can tell if you're busy or not by how you walk." She smiled. Right now you're not busy.

What are order sets?

Due to the Keystone Collaborative of Michigan, Michigan hospitals are now the envy of the nation, and have even caught the eye of President Obama. One of the key features of the commission is to encourage hospitals to install order sets for each particular diagnosis (DRG).

In the past order sets were rejected by doctors mainly because they viewed order sets as cook book medicine. So, what is cook book medicine?

Cook Book Medicine: Treating all patients with a given DRG the same way.

Obviously this wasn't thought to be a good idea. While the main goal of the commission is to help hospitals improve patient outcomes and reduce costs, I believe the main goal is to make sure a patient meets the criteria for receiving a reimbursement check from the Centers for Medicare and Medicaid Services (CMS).

As you know, CMS has set standards for minimal care they will reimburse for. It doesn't come down to the personal opinion of the doctor treating each patient according to what is best for the patient. What it comes down to is the fact CMS decided in order to reduce it's cost (not the hospital's cost), it will only reimburse if it's own reimbursement criteria is met (see this post).

Thus, if order sets were to the benefit of the patient, they would have been enacted many moons ago. The truth is, order sets were never enacted until CMS increased it's standards on what patients will meet criteria for reimbursement.

So based on Keystone Recommendations, many hospitals in Michigan have adopted Order sets. So what is an order set?

Order sets: This is a sheet of paper a nurse pulls from a drawer that has on it all the procedures that are recommended for that particular diagnosis. It pretty much lists anything a doctor might want to order, plus anything CMS might recommend for that patient to meet criteria for reimbursement (this is key). This type of order set would be ideal because it simply acts as a reminder of what the doctor might want to order to help the patient.

Pre-checked order sets: Many of the boxes on order sets at many hospitals are pre-checked. This means they are ordered automatically and are mandatory whether the doctor thinks they are needed or not. Due to government criteria, many hospitals have had no choice but to resort to doing this.

Advantages of order sets:

• Puts the doctor, nurses and all other staff (including RT) on the same page
• Assures best practice medicine is met for this patient
• Makes sure doctors don't forget to order what is recommended or needed
• Allows hospital to modify care based on evidence based practice
• Increases organization so you know what will be ordered for a patient
• Everyone knows their role in regards to that patient

Disadvantages of order sets (unintended consequences):

• Treating all patients the same
• Decreases doctor autonomy
• Decreases incentive to think outside the box (critical thinking)
• Many unnecessary orders
• Causes burnout due to too many procedures
• Causes apathy due to burnout and lack of ability (or lack of time) to do critical thinking

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Rapid breathing may cause CF lung symptoms

While science is aware that in order to get Cystic Fibrosis (CF) one has to have the CFTR gene, scientists now suspect that rapid breathing that is associated with the disease is what ultimately leads to most of the lung damage due to CF.

In his most recent blog entry (click here), Dr. Artour Rakhimov writes that as the disease progresses, one of the biggest complaints is the feeling of dyspnea. And the reason might be due to the fact the disease causes hyperventilation that washes out CO2 from the alveoli.

With a less than normal alveolar CO2 tension, the following may result:

• Average minute ventilation in CF patients ranged, according to these 7 publications from 10 to 18 l/min, while healthy subjects have between 6 and 7 l/min at rest.
• Alveolar hypocapnia (low CO2) immediately causes bronchoconstriction or constrictions of bronchi and bronchioles due to irritation or an excited state of the cholinergic nerve.
• Alveolar hypocapnia destroys lungs tissue. In their study, Canadian doctors observed that "Deliberate elevation of PaCO2 (therapeutic hypercapnia) protects against lung injury induced by lung reperfusion and severe lung stretch. Conversely, hypocapnic alkalosis causes lung injury and worsens lung reperfusion injury" (Laffey et al, 2003)
• Chronic hyperventilation reduces cell oxygen content in all vital organs due to disturbances in oxygen transport.
• Cell hypoxia leads to anaerobic energy production mechanism, elevated lactic acid level in the blood, generation of reactive oxygen species, suppression of the immune system, and cellular damage.
• Thus, if heavy breathing is the problem, there are natural therapies available to address chronic hyperventilation and restore normal breathing parameters 24/7

Basically, he believes that having the CF gene alone does not guarantee eventual dyspnea, yet if the patient develops chronic hyperventilation, then the risk is raised. "Hence," he notes, "Hence, if chronic hyperventilation is present, the gene can enhance these pathological effects."

Likewise, in a study done in 1990, respiratory frequency was associated with being a good predictor of respiratory dysfunction.

Perhaps until a cure is found, another method of preventing worsening CF might be attempts to restore normal breathing.

Treatment for sleep apnea

So if you are diagnosed with sleep apnea, or are an RT or RN taking care of such a patient, you should be aware of the treatment for this condition.

1. Weight reduction: This often decreases the severity of the condition because it reduces fat tissue in the throat area.

2. Sleep posture: Sleep on sides instead of on back.

3. Quit smoking: Smoking is believed to increase inflammation in the lungs and also increase fluid retention in your throat and upper airway*

4. Avoid alcohol: Alcohol relaxes muscles of the throat and may interfere with breathing. This explains why people are more likely to snore after drinking*.

5. Avoid sleeping pills: These also relax throat muscles*.

6. Avoid sedatives: These too relax throat muscles*.

7. Avoid Caffeine: Within 2 hours of going to bed*.

8. Avoid Heavy Meals: Within 2 hours of going to bed*.

9. Maintain regular sleep hours: This will help you relax and sleep better. This keeps your circadian rhythm in sync.

10. Elevate head of bed 4-6 inches:

11. Keep nasal passages open: Use a dilator, airway sprays, decongestants, breathing strips. See a doctor if you have chronic nasal congestion.

12. Don't be stubborn: I find many sleep apnea patients don't get the treatment they need for no other reason that they are martyrs. Be willing to seek help, and be willing to accept help options when they are presented to you.

13. Supplemental oxygen: To help offset hypoxia that might occur and prevent hypoxia induced arrhythmias and pulmonary hypertension

14. Decreasing REM sleep: Decreasing REM may decrease apnea episodes. One medicine that does this is protriptylinee, which is a tricyclic antidepressant tht markedly reduces REM sleep.

15. Reduce daytime somnolence: Central nervous system stimulants such as methylphenidate may help in this area for obstructive or central sleep apnea.

16. Surgical interventions:

• Tracheostomy: Emergency management of severe onset
• Palatopharyngoplasty: Posterior section of palate and the uvula are resected (taken out), as well as tonsils and lateral posterior wall of the pharynx to remove soft tissue that might obstruct the airway.
• Mandibular advancement: If mandibular abnormalities are believed to be the cause, this can be corrected with surgery
• CPAP: Continuous Positive Airway Pressure helps keep the airways open from the tiniest alveoli to the soft upper airway tissue. It's effective only in obstructive sleep apnea. Other names for CPAP are EPAP (End Positive Airway Pressure) and PEEP (Positive End Expiratory Pressure).
• BiPAP: Bilevel Positive Airway Pressure. This is CPAP plus air that helps the patient take in a deep breath, more commonly referred to as pressure support (PS). The CPAP helps keep the airways open, and the PS helps the patient take in an effective breath. This is more commonly used when obstructive sleep apnea is more advanced, or when it is combined with COPD (particularly end stage COPD).
• Mechanical Ventilation: This is a short term solution for when the obstructive or central sleep apnea causes respiratory failure.
• Chest cuirass: May help a patient with central sleep apnea breathe.

References:

Egans Fundamentals of Respiratory Care (6th Edition, 1995)
*helpguide.org/life/sleepapnea

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Bronchial thermoplasty new option for severe asthma

If you have hardluck or severe asthma, now there's a new option available for you.  This was the topic of a recent post by me at Myasthmacentral.com

So you have hardluck asthma. That is, you're asthma isn't responding to conventional asthma medicines on the market. If so, there is a relatively new option available to you, and it's called bronchial thermoplasty.

It may or may not be something you'd be interested in, yet at least it's another option for you to discuss with your asthma doctor. After a study of 297 patients, the Food and Drug Administration (FDA) approved the Alair Bronchial Thermoplasty System in April of 2010.

Actually, Pat Bass wrote in his asthma blog the following results of the study:

• Improved quality of life
• 32 percent reduction in asthma attacks
• 84 percent reduction in emergency room visits
• 73 percent reduction in hospitalizations
• 66 percent reduction in loss days from school and work

So, what is this procedure and how does it work?

The procedure is minimally invasive, and is therefore an outpatient procedure. The patient is sedated, and a bronchoscope with the Bronchothermoplasty System is inserted into the airway.

The physician then burns away extra smooth muscle from the air passages of the lungs by using radio frequency waves (a type of electromagnetic radiation). This procedure will need to be repeated three times approximately three weeks apart.

The idea here is that with less smooth muscle the airways have less ability to constrict, and this -- ideally -- reduces the frequency of asthma attacks, and improves quality of life. With less bronchial smooth muscle, the lungs stay open and are therefore less reactive to asthma triggers.

It should be noted here that this procedure does not cure asthma, it simply reduces symptoms. Yet studies show that it has reduced severity of asthma, reduced emergency room visits, improved quality of life, and reduced days lost from school or work.

What are the side effects?

As far as side effects of the procedure, Bass notes that, "While there were some increases in respiratory symptoms immediately following the procedure, they were similar to what one would expect following bronchoscopy in an asthma patient."

Of course as with any medical treatment you must weigh the risks with the advantages.

Who qualifies for this procedure?

To even be considered the asthmatics must be at least 18 years of age. The patient must also have severe and persistent asthma that does not respond to inhaled corticosteroids and long-acting bronchodilators (like Advair and Symbicort).

One question I had about the procedure was regarding the burning away of bronchial smooth muscle. Won't this cause other complications? Yet after extensive research about bronchial smooth muscle, I learned it serves no useful purpose other than to cause asthma (I wrote about this here).

Therefore, you should't have to worry about the loss of bronchial smooth muscle. 

Why does burning away bronchial smooth muscle make asthma better?

Asthma is a disease of chronic inflammation of the bronchioles causing the smooth muscles surrounding bronchioles to contract and tighten, and this ultimately narrows the air passages. This makes it so air cannot escape the lungs. This, in essence, is an asthma attack.

Inhaled corticosteroids and long acting bronchodilators usually work well to control this inflammation. Yet for a few, these medicines don't work. these are your Hardluck Asthmatics.  Bronchothermoplasty is now an option for them.

With less smooth muscle the air passages won't be able to contract and narrow, and this ultimately reduces (hopefully) your lungs ability to react to your asthma triggers.

So if your asthma is getting in the way of your life, and you are compliant with your asthma controller medicines, and your asthma is still out of control, perhaps this relatively new procedure is an option you can discuss with your physician.

My friend Breathin Stephen attended a focus group regarding this procedure and wrote some very good blog posts on it. So if you're interested in some further reading you can either check out the links above or the ones below.

• Bronchial thermoplasty promising?
• No Thermoplasty for Steve
• Considering Bronchial Thermoplasty
• New Treatment Reduces Asthma Symptoms

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We used to overcome hardship on our own

I remember as a kid my mom wanted to ride her bike three miles to her sister's house, and I was excited to go with her. I think I was about 8 at the time, and this was the first time I was ever allowed to ride my bike on the road.

About half way there I started to get bored, "How far now, mom?" I asked. She probably said it was just a little further, yet to a mom a mile and a half is not far. To an 8 year old it is a long way. To make the ride a little more interesting, I decided to experiment.

I started moving my front tire left and right real fast. This was fun for a while, until all of a sudden the front tire went a little too far to the left and the bike came to a sudden stop. I somersaulted over the front of the bike and skidded on the ground.

I ended up with a scrape on my hand. I cried to mom who had stopped and was now waiting for me to catch up. "Come on! Rick! Quit goofing around."

"Mom, I'm hurt!" I said. She never even got off her bike. She basically told me to be a man about it and go on. So I did. And that was the point I wanted to make. Back in the 1980s parents encouraged their kids to be tough.

When I was a kid I remember getting colds a lot. I also got the flu a lot. Yet every time this happened mom would let me lie in her bed all day and drink Brandy every four hours and gargle with salt water. The medicine tasted like crap, but we were supposed to drink it because that's what was to get us better.

I lost a job once, and instead of telling me to seek unemployment for 99 days my parents encouraged me to get another job. They wanted me to get a job so I could support myself and I didn't have to suck off them. They wanted me to have my own health insurance. They wanted me to be proud.

That's right. My parents new that people who get things for free, who have someone else making decisions for them, lack confidence. They give up. They become the bums of society. And people knew that. And now it's the opposite. We keep paying people to stay unemployed. We keep adding to unemployment thinking somehow that's going to help them.

We think them spending that money is going to put more money into the market. It's not. It's just taking money that's already been spent by you and me (our taxes) and giving it to someone else. While you and me might have bought computers or cars with that money, those unemployed are going to buy food and staples. Or so one would hope. How's that going to end a recession.

It used to be we'd say suck it up and get back on your feet.  In fact, one of our natural rights is the unalienable duty to support ourselves and not mooch off other people.

This doesn't happen any more. Now people are encouraged to treat every little cut and scrape and cold like it were the end of the world, and ERs are filled with a bunch of people who don't even need to be in there.

We don't give our kids medicine that tastes like medicine. The taste was supposed to discourage us from abusing it. Now we give kids medicine that taste like candy, and they come begging us for more every time they are sick, or are faking sick.  And then we wonder why so many people come to our ERs as medicine abusers.

Back in the good old days people didn't fake sick. If you did that you were the laughing stock of society. When I faked sick as a kid, my dad put me in my place. He called me on it every time. Now when someone is faking sick to get drugs or sympathy or whatever, we have to at least pretend to take them seriously because otherwise the liars will sue the honest folks.

It's a twist it is. To really help some of these people we should be honest with them. It's kind of like Simon Cowell on American Idol telling these people who can't sing that they can't sing, and then watching these people who can't sing wha wha about how their feelings were hurt. "Everyone tells me I'm a great singer," they say.

The truth is what Cowell would tell them. He'd basically tell them what their mommy and daddy should have told them a long time ago: that they suck at singing. Not anymore. Now we are encouraged to make our kids feel good. We are encouraged to lie to our kids. We can't keep score at T-ball games because we might hurt their feelings. We can't play dodge ball (one of my favorite games) because someone might get hurt either physically or mentally.

Yet in a capitalistic world people succeed and people fail. In order for newer and better and more productive companies who make more useful products to enter the market, those companies that are antiquated and have less popular products have to close their doors. It's a process called creative destruction.

Today we don't let people fail. We have banks giving stupid loans to people who never could afford them in the first place in order to give them a piece of the American dream, and then we are "stunned and surprised" when we learn what we should have realized all along: that the people who can't afford a home can't afford a home.

That's why we have all these foreclosures. That's why we had the housing bubble burst and the economy tank. Yet instead of allowing for creative destruction to take place we bail all these banks out. So instead of newer and better banks moving in, instead of better products, we now have the same old same old failed banks screwing more people.

I remember playing t-ball with my brother David who was a year younger than me, and the coach was hitting baseballs on the ground for us to field. The only ball the coach could find that day was a rubber ball, and when he hit it to my brother it bounced off the pitchers mound and hit David right in the mouth.

My brother was rushed to the Dentist by mom, and that was the end of it. My brother's tooth died, he now has to have it dyed white or whatever for looks, but he lives with it. It's not the end of the world. Yet today that coach would have been sued. That's right. What we used to suck up and live with we are now encouraged to sue.

I talked to a doctor friend of mine who worked in the 1980s, and he said back then the ER didn't even have 24 hour coverage. Basically if there was an emergency someone was on call to come in, yet otherwise there was no coverage.

And the ERs back then weren't packed either. Back then if there was an emergency, a true emergency, you went to the ER. Otherwise you stayed home. The reason was because there was no such thing as free health care. When something is free, people abuse it.

For some reason, when something is free, people lose all ability to think. When health care is free, instead of thinking people go to the ER even for things they should stay home with and suck up.

People don't question stupid orders either.  The other day I gave a breathing treatment to someone who came into the ER with a runny nose, and I gave him a treatment.  He was not short of breath, and never was.  Yet he never even once asked me, "Why are you giving me a breathing treatment?"

So here we are in 2010 with the Federal Government wanting to give even more people free health care, and you know what's going to happen. Swamped ERs are going to be even more swamped. And it's not going to be with more sick people either.  And there's going to be more order sets so every patient with a given diagnosis is treated the same, regardless of need.

And you can't tell me there are more sick people today than there were in 1980 or ever. The number of sick people hasn't changed. Yet our ability to suck it up has changed. We have become a nation of wimps. We have become a nanny state. "Oh, poor baby," is more commonly heard now instead of, "Be a man! Suck it up!"

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The solution to RT Apathy

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Guidelines for home BiPAP and oxygen

We in the medical profession do as we are told. That's the general logic we need to maintain our jobs and to help the hospitals we work for to get reimbursed by the Centers for Medicad and Medicair Services (CMS).

When it comes to qualifying someone for home oxygen, we are told we need to walk the patient and to monitor saturation (SpO2). If the saturation gets to 88% or less, the patient qualifies for home oxygen.

Even if you think the patient should have home oxygen, and the SpO2 does not drop to 88% during a walk, then the patient does not lie...

...which sets the ground for a little white lie. If I think someone needs home oxygen, and they only drop to 89%, I might fudge a little on my charting. Sorry, that's just the way life is. And, quite frankly, I'm sure I've saved the lives of more than one patient in this way.

I guess you can say that rules encourage lies.

Another thing we often qualify patients for is home BiPAP. Aside from doping a sleep study, sometimes we have patients that could benefit from home oxygen now, and don't have time to wait for a sleep study.

So, to qualify these patients for BiPAP we are told to chart the following:

Patients requiring BiPAP at home will need the following pulse oximetry test completed @ night prior to their discharge. During the test, the patient is to be on 2 liters of oxygen or their usual FiO2 whichever is greater.

A full five minute pulse ox test as needed, while patient is sleeping. There must be documented proof of 88% or below oxygenation for a full five minutes during the test.

Documentation example: Patient removed from BiPAP at 23:00, sleeping soundly. The patient is currently on 2 lpm oxygen. By 2304 patient pulse ox dropped to 87%. Patient remained @ or below 88% throughout next 5 minutes of test as evidenced by the following findings:

2305: 87%
2306: 86%
2307: 88%
2308: 85%
2309: 85%
2310: Patient placed back on BiPAP @ this time with 30% flow of oxygen. Pulse ox rebounded to 92%

So you can see, this is pretty dimwitted, yet it's how it is. You know in reality this situation will never happen. Nobody is going to be taken off BiPAP and fall asleep that fast. No SpO2 is going to drop and rise that fast. I've never seen it.

So I lie. I make the charting look like they want it to look, and so will you. This is a perfect example of how the people who make the policies, the rules, have no idea how things really work in the medical field.

The people who make the rules should be you and me, the people who know how it works. In reality, it works like this:

Person taken off BiPAP @ 2300. Patient does not fall asleep, yet the SpO2 drops stays at 98% until three hours later when patient falls asleep, yet I'm not around to document. SpO2 now 80%, and I come into room. I put patient back on BiPAP and SpO2 rises to 98%. I document as CMS instructs, although I'm not in room for six minutes watching the SpO2 which does change when I'm in room.

Sleep Apnea

The Greek term "apnea" literally means "without breath." So when someone stops breathing, even for a short period of time while supposedly sleeping, this is what we refer to as sleep apnea. This "apnea" results in the patient not getting enough air to the lungs.

People with sleep apnea quit breathing repeatedly during the hours of sleep, often hundreds of times, according to the American Sleep Apnea Association. It's a disease that is more common than most people think, and many who have it are unaware they have it.

According to Egans Fundamentals of Respiratory Care, the scientific definition, and the one most medical professionals go by, is cessation of breathing for 10 seconds or longer. Likewise, it's diagnosed as 30 or more episodes of apnea in a six hour period

Symptoms of sleep apnea usually include:

• Excessive daytime sleepiness
• Fatigue
• Loud snoring
• Restless sleep
• Morning headaches
• Irritability
• Mood swings
• Depression
• Learnign difficulties
• Memory difficulties (Continued drops in oxygen cause loss of brain tissue)
• Sexual dysfunction

These symptoms are secondary to the patient constantly waking up during the night. Usually the patient doesn't even know he (or she) is waking up. And this results in "unexplainable" exhaution during the day.

A common sign of sleep apnea is snoring at night, periods were it looks like the person isn't breathing (apnea), and the feeling you need to smack the person in order to wake him up. This "poor quality" sleep results in tiredess during the daytime.

These patients have a hard time staying awake in school, at meetings, or while simply sitting around the house or office. In this way, it can effect your day to day living.

A greater concern is that it can effect your health in other ways too, such that when a person stops breathing, or takes inadequate breaths, oxygen levels (PO2) may drop to critical levels, and this places a strain on the heart.

As hypoxia occurs, the heart starts to beat faster in an effort to pick up more oxygen. The only time this wouldn't occur is if the heart is already weakened due to other conditions, or due to
In this sense, those with sleep apnea are at high risk for:

• Cardiovascular disease (due to constant drops in oxygen)
• Stroke
• High blood pressure (does not drop while sleeping)
• Arrhythmias
• Diabetes
• Sleep deprived driving accidents (due to lack of adequate sleep)

Likewise, if apnea periods are long enough, this can result in chronic hypoxia and chronic carbon dioxide retention (high CO2).

The diagnosis is usually made based on an evaluation and history of the patient and anyone who might be present with the patient while he is sleeping, such as a spouse. Diagnosis is generally made based on symptoms noted by the patient and family members.

Once it's believed the patient has sleep apnea, a sleep study is required to confirm the diagnosis, and to determine appropriate treatment. (see sleep study and treatment below).

There are three types of sleep apnea:

1. Obstructive (OSA): This is the most common. The soft tissue of the upper airway (throat) collapses and when the brain signals the body to take in a breath, it doesn't go in. Instead an effort is made, and perhaps a loud snore or gasp. This prevents oxygen from getting to the lungs, and results in hypoxemia (low oxygen to the blood) and hypoxia (low oxygen to the tissues).

This most commonly effects males ages 40-65, and may effect as much as 8% of the population, particularly obese males with large necks with little muscle tone. It's also more common in the elderly as opposed to young people.

Also of significance, about 20% of people diagnosed with OSA also have COPD. Hypoxia that occurs with COPD coupled with OSA may speed up the development of right heart failure.

Those at high risk for this include:

• Smokers
• Obese (the risk rises as weight rises)
• Age
• Diabetes (3 times the risk)
• Enlarged tonsils
• Enlarged adenoid
• Excessive pharyngeal tissue
• Goiter
• Large tongue
• Micrognathia
• Myotonic Dystrophy
• Shy-Drager Syndrome
• Hypothyroidism
• Accromegally
• Males (8 times the risk as females)

Usually these patients go to sleep lying on their backs and fall into a light sleep, and this is eventually followed by a deeper sleep.  In the deeper sleep the muscles and tissues of your body relax, and this is when the tissues in the throats of OSA patients collapse and thus block the airway.  The patient then reverts back into a light sleep and is easily awakened.

This can happen hundreds of times during the night.  When these patients wake in the morning they know they have been lying down for 8 hours, yet they don't remember waking up a bunch of times in the night.  The result is feeling tired all day.

2. Central: The airway is not blocked, but the does not send the usual signal to take in a breath. This is also called Cheyne-Stokes Respiration. Breathing has the following pattern: none... fastter... faster... faster... very fast... slower... slower... slower... slower... none...
Genrally, breathing cycles between periods of hyperpnea (rapid breathing), apnea and hypopnea (slow breathing). If the period of apnea (pause) is long enough, the patient's oxygen level can drop significantly.

3. Mixed: A combination of obstructive and central sleep apnea.  Symptoms of this disease have been recorded in the annuls of history for thousands of years.

There are two other types of sleep apnea that are often used:

4. Pickwickian Syndrome*: This is used to describe patients who are very obese and excess fat tissue on the chest wall and below the diaphragm prevents the lungs from becoming fully expanded. This results in shallow and ineffective breathing. This is often accompanied with obstructive sleep apnea. The term was coined in 1957 to describe the cardiorespiratory effects of ineffective breathing due to obesity.

It was about 1970 when it was determined by scientists that there was more to this condition than just obesity. They determined that these patients presented with daytime sleepiness, flaccid upper airway tissue, and respiratory abnormalities during sleep. It was from here that sleep apnea was defined as a diagnosis and divided into OSA and CSA.

Another reason Pickwickian Syndrome doesn't always apply to sleep apnea is because in some cases sleep apnea is present is patients who are not obese.

However, from time to time, you'll still see Pickwickian as a diagnosis. Yet, thechnically speaking, Pickwickian is not a form of sleep apnea, just a condition that usually presents with it.

5. Ondine's Syndrome**: According to German folklore, the nymph Ondine falls in love with a mortal who becomes unfaithful to her. When this happens, the king of the nymphs places a curse on the mortal. The curse is such that instead of breathing automatically without thinking about it, the mortal will have to think about it. If he doesn't make a conscious effort to breath -- as if he falls asleep -- he will stop breathing. If he forgets to breathe he will die.

This is the earliest description of Central Sleep Apnea and should not be used. Instead...

6. Congenital Central Hypoventilation Syndrom (CCHS)**: This is used to describe people (particularly newborns) who have periods of hypoventilation and hypoxemia without any cardiac or neuromuscular disease. They breathe normal while awake, and hypoventilate while sleeping. While hypoxemia and hypercapnia progress during hours of sleep, there is no natural inclination to wake up when CO2 gets high enough as in OSA.

However, CCHS is still often called Ondine's Curse, and still it's just another way of describing CSA.

Cardiac and pulmonary effects***:  While apnea is occuring the patient is not drawing in oxygen (O2) and not exhaling carbon dioxide (CO2), so oxygen in the blood drops (hypoxemia) and CO2 in the blood rises (hypercarbia).

Secondary to hypoxemia, the heart slows down (bradycardia).  This is the body's natural response to decrease the body's oxygen consumption when there is less oxygen available.  Once breathing resumes, the heart increases (tachycardia), and this is the body's natural tendency to find oxygen.

Systemic and pulmonary blood pressure rises during periods of apnea, probably due to hypoxemia.  This is where most cardiac dysrhymias occur, and it is also believed that it is probably a life threatening cardiac arrythmia caused by hypoxemia that causes OSA and CSA patients to die in their sleep.

Likewise, about 10% of sleep apnea patients have high blood pressure.

Conclusion:  Sleep apnea is a serious condition that may result in day time sleepiness that may effect the every day life of the patient, and may even result in premature death.  It may be up to family members and/ or the physician to recognize the symptoms, and knowing that obese men with thick necks are most at risk

More References:

*Guilleminault C, Eldridge FL, Simmon FB, et al: "Sleep apnea syndrome-Can it induce hemodynamic changes," West J. Med, 123: 7-16, July 1975

**http://emedicine.medscape.com/article/1002927-overview


***Wilkins, Robert L, Dexter, James R, "Respiratory Disease:  Principles of Patient Care," page 313, 1993

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could a fever lead up to my sons asthma attack coming on?

Your question: Could a fever lead up to my sons asthma attack coming on?

My humble answer: Asthma itself does not cause a fever. A virus may cause a low grade fever. A virus may trigger asthma symptoms. As long as you use your bronchodilator inhaler as instructed by your doctor, it is very safe. If you sense that your child is having early signs of asthma, it is a good idea to have him use his bronchodilator inhaler. At eight, he should be old enough to tell you if he feels better after using it. However, if you continue to have concerns, it's always a good idea to contact your doctor.







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Here's how to be a better asthma mom

So you have a baby with asthma. Parenting is hard enough, yet when you have an asthmatic child it's that much tougher. Actually it isn't if you are a wise and vigilant parent. Learn more by reading my latest Sharepost from MyAsthmaCentral.com

Have A Baby With Asthma: Here's Ten Signs To Watch Out For

If you're like me and have a baby at home, and also have a family history of asthma, it's important you know the baby signs and symptoms of asthma -- just in case.

Likewise, if you know your baby has asthma, or if you are a daycare provider, teacher, grandparent, or anyone else who cares for children, you also should know the baby signs and symptoms of asthma -- just in case.

This is important because a baby cannot speak for herself and tell you she is having trouble breathing. In this way, YOU are responsible for knowing when asthma is present, and YOU need to know what to do to treat it.

Actually, Asthma is very difficult to diagnose in children less than 2, and many times doctors won't diagnose asthma until the child is older. However, if there is an extensive family history of asthma, sometimes the diagnosis is made based onthat fact alone. (To learn more about diagnosing asthma, click here).

Still, many of the symptoms of asthma in small children are similar to the symptoms of other illnesses that mimic asthma, such as cough variant asthma, upper airway viral infection (like croup), foreign body obstruction (like a hotdog stuck in the airway), or other disorders such as cystic fibrosis.

In essence, asthma is sometimes diagnosed after other possible causes are ruled out.

Many of the symptoms of asthma are the same as those of older kids and adults (as you can see here), yet since she cannot speak for herself, it's your job to know she's short of breath.

Thankfully there are some classic signs specific to babies and small children that indicate they are in respiratory distress. If you are vigilant, you should be able to pick up on these signs.

Now with that said, here are some signs of pediatric asthma. If you notice any of these signs you should call your child's doctor to get proper diagnosis and treatment:

• 1.Coughing, especially at night: This is actually a classic sign of asthma


• 2. Nighttime wakenings:May be due to coughing and/or chest tightness


• 3. Wheezing: May be audible or silent

The following are signs asthma might be getting worse, and immediate attention is necessary:

• 4.Rapid respiratory rate: Breathing is faster than normal


• 5.Trouble feeding:Or lack of desire to eat


• 6. Agitation/ crying: When babies can't eat they get restless


• 7. Retractions: One great way to tell babies are having trouble breathing is if her chest isbeing sucked in with each inspiration.This is also a good sign for small children. See a video of this here.


• 8. Nasal flaring: This is theflaring out of the nares upon inspiration.It is done in an attempt to suck in extra air. A classic sign of air hunger in babies.


• 9. Grunting on expiration: This is the baby's natural attempt to keepher lungs open. Another classic sign of air hunger.


• 10. Cyanosis: This is the blue discoloration of skin caused by lack of oxygen to that area. Usually it's aroundthe mouth, nose and fingertips. This isa sign the baby not getting enough oxygen.

If you notice the last four on this list you should call your doctor right away, or go to the emergency room to have your baby checked out. Regardless, all these signs should result in a call to a pediatrician.

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Fake side effects

It's funny how some people come up with the lamest side effects of drugs.

The most recent was when I finished a breathing treatment the patient said, "I don't want any more of those."

He belched.

"They make me burp," he continued. "It gives me gastric problems." He patted his stomach as to show me.

Of course we know that nausea is not an allergy symptoms, although more often than not when you ask someone why they are allergic to a medicine, they say it makes me nauseous.

Ventolin, for example, does not cause the allergy symptom of nausea. Although I've been ordered not to give it for this reason from time to time. Silly isn't it?

Help FDA create new cigarette warning labels

Within the next year a package of cigarettes may look like a pack of Cyanide. The FDA has made a new regulation that requires the up to 50% of the package to feature warnings of the dangers of smoking.

The warnings will have to feature picture messages that would cover the top half of the front and back of the package -- 50% of the package.

Likewise, any advertisements will have to feature warnings about the dangers of smoking cigarettes covering 20% of the ad.

Once again, I'm not a fan of the government forcing people to smoke, yet considering there are still people who claim not to understand that smoking can kill and is highly addictive, I think it's about time for such a warning system.

For people that are coming to the hospital today because they can't breathe or because they have lung cancer or some other smoking related disease, they didn't know any better.

Prior to the 1980s the dangers of smoking were probably known to the manufacturers of cigarettes, and even to government officials, yet this information was not distributed to the folks. I believe the reason for this was that cigarette sales were good for the economy.

Yet there is not reason anyone on God's great earth should ever pick up a cigarette today not knowing that it's poison. And if the government has to put a big bold picture warning on cigarettes, then it's about time.

Now the FDA has listed some warning pictures to post on cigarettes, and they want you to choose which one you like best. To do this, click here.

I personally don't like any of the choices. I prefer something bolder like the following:

• SMOKE AND DIE
• SMOKING KILLS (this one is a choice)
• IT'S LEGAL TO BE STUPID! SMOKE AND YOU ARE STUPID!!!!
• SMOKE HAS 40,000 HAZARDOUS CHEMICALS, INCLUDING CYANIDE, ARSENIC, AND NICOTINE!!!!!!!!!
• If I had a nickel for every time a COPD or cancer patient said to me, "If I'd have known I'd die like this I never would have started smoking!" I'd be rich!!!
• Facebook

I actually like the one that has a picture of a sick COPD patients.

Or, better yet, how about just placing a picture of a mom and dad on the package and write something like: "Mom and dad want you to smoke!!!!" Like this comic from the Grand Rapids Press.

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The outsider

The outsider knows what he wants to do.
He wants to be a thinker, writer, teacher,
To do things that make sense,
What needs to be done,
What's proven to work.

He wants to work with people
Because he loves people,
He loves to listen to their stories,
And to teach the right way,
Based on scientific fact.

He loves the people aspect of his job,
Yet he's not allowed to think,
And not allowed to speak the truth,
Without becoming an outcast,
And without fear of losing his job.

He entered the paradigm with a fresh eye,
An ability to see what is and is not,
And he created a new paradigm,
That will make more sense for his job.
He is the paradigm shifter.

He knows how Copernicus felt,
When he proved the earth wasn't flat
And he had to keep it a secret
The last 30 years of his life
For fear that he'd be beheaded.

He feels like a pawn.
They place him where they want
And expect him to do his job
The way it's always been done
Even if what he does doesn't matter.

It's called a paradigm paralysis,
The greatest obstacle to progress.
The inability to see the truth
Or the refusal to see the truth,
Is the greatest obstacle of all.

It's a paradigm paralysis,
Not seeing beyond the current thought process.
It's not seeing out of the box.
It's being stuck in a pattern,
And not seeing a better way.

While your mind is shut, his is open.
He sees the foolishness of your ways.
He sees the observer of reality,
Watching you do that and do this,
Just as they've done for years.

"Why do you do it that way?" he asks
"That's how we've always done it," you say.
"Do you ever ask why?" he asks.
"Do you ever think to ask,
"Why do I need a bronchodilator?"

You'd think people would want the truth.
Yet for 2,000 years doctors studied Galen
And they did even after the truth got out,
That Galen never dissected a human corpse.
Instead he dissected an ape.

Galen described an eight segment sternum.
And even while the Galen passage was read,
While the chest was being dissected,
And a three segment sternum was revealed,
Nary a person thought to say, "Galen was wrong!"

Andreas Vesalius did say Galen was wrong,
And he proved Galen was wrong,
Yet he was called a liar and a quack.
"What Galen says is true!" his peers hailed.
They were stuck in paradigm paralysis

A paradigm is a set of assumptions
That helps us make sense of things,
Yet when something occurs that
Falls outside the pattern
It's called a paradigm effect.

A paradigm effect can be strong
As Copernicus and Galileo proved.
People refused to see the truth
Even when it was right under their noses.
They were trapped in paradigm paralysis.

That's why there's no cure for asthma,
Because all dyspnea is treated as asthma.
Hippocrates defined dyspnea as asthma.
And so we still treat all dyspnea as asthma,
Even though the evidence shows it's not.

Bronchodilators are bronchodilators,
Yet they are used to treat cardiac asthma,
And pneumonia, and collapsed lungs,
Lung cancer, kidney failure, croup,
And rickets along with bronchospasm.

It's called wasted medicine for no reason.
He's a respiratory therapist for 12 hours
And he sees bronchodilator abuse first hand,
He knows it has no effect on the patient,
And so does the patient.

Yet few patients question the procedure,
Because doctors have earned their trust,
And so few think to question,
Anything a doctor orders.
They just want to get better.

In fact, even most doctors know the truth,
Yet they have no choice but to order them,
Because that's how it's been done forever.
And doing it any other way would make sense,
Yet it wouldn't make sense to them.

Even if a doctor knows the truth he can't speak it,
Because he'd be an outcast among his peers,
He'd be castigated by the doctor clique,
And reminded that the truth doesn't matter,
Because bronchodilators are thought to cure everything.

The COPD patient was on 100% oxygen
For eight hours in the Emergency Room,
And the patient did not stop breathing.
Yet later he was ordered on 28% oxygen
Because of the hypoxic drive myth.

He watched as the patient's dyspnea worsened,
As his skin turned from pink to blue.
He called the doctor who refused more oxygen.
The patient suffered as a result,
Of the paradigm paralysis.

Yet even if the doctor knew the truth,
He'd have to accept the myth as truth,
Because the clique accepts the myth,
And the courts accept the myth,
And, hence, the myth becomes the truth.

He knows it and you may know it too,
Yet what is he, what are you to do?
You know about paradigm paralysis.
You know it from your observation.
You know it by scientific fact.

He doesn't' want to be the first to speak,
And neither do any of his peers.
So he keeps his mouth shut,
And you keep your mouth shut,
And nothing ever changes.

He knows we could probably cure asthma
Because the wisdom exists right here.
Yet it's just beyond our scope of understanding.
It exists just outside the box,
Just outside the paradigm.

Paradigm paralysis prohibits people
From seeing valuable information,
even what's right before our eyes.
Yet he sees it, and he remains silent,
Just like Copernicus did.

So progress is slow, even STALLED!
Morale among the workers is low,
And resources are wasted,
Money is wasted,
Time wasted.

He is a pawn riding on the wrong path,
Yet it's not wrong to anyone else,
Because they don't see path B.
All they see is the same pattern, path A,
The same rut we've been stuck in forever.

He knows what he wants to do.
He wants to be a thinker, writer, teacher,
To do things that make sense,
What needs to be done,
What's proven to work

He feels like a pawn.
They place him wherever they want
And make him do what they want him to do.
He knows what he wants to do:
He wants a paradigm shift.

Actually, he discovered a new paradigm,
and he's therefore the outsider.
He doesn't understand the current paradigm,
Yet he does understand the new one .
He's an outcast if he says what he knows.

He's the fresh eye and the hope
For everyone who wants to fix the system.
Yet he needs courage to speak up.
And he knows what to do:
He must make waves,

Yet he knows that's not going to happen,
Because he's got four young mouths to feed.
So he's going to have to suck it up,
And keep his mouth shut tight,
Doing what he loves to do.

He loves reading, observing and listening to new ideas.
He loves to question the things he's ordered to do.
He loves to draw a line from point A to point B,
And ask, "Why can't we do it this way?
He's the outsider.

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Tips on how to spoof up your blog

Your Question: Do you have any tips to where I can get some tutorials on blogger site design, you have done quite will with yours.

My humble Answer: I still wouldn't consider my self a blog expert, although by copying what other people did on their blogs, and searching the net for tips on how to do things, and playing around with HTML (eeks), I've managed to learn a few things.

Here is everything I did (or would like to do, or have yet to master, or have given up on) and how I did it. I had to download GIMP to create a header, although you might have a better method. It took me a while to figure it all out, but it was worth the effort.

By creating a niche and writing a lot I've also managed to draw in some ad revenue. Not enough to quit my day job ($60 a month won't do that), although it does help around Christmas time.

If you have any questions about anything let me know and I'll help you out where I can.

Good luck

The evolution of COPD

I wrote a post earlier about asthma being more than just a lung disease. It appears now that experts are now thinking of Chronic Pulmonary Lung Disease (COPD) as more than just a lung disease too.

Nussbaumer-Ochsner Y, Rabe wrote an article in Chest 139 (1), 165-73 (Jan 2011), "Systemic Manifestations of COPD", where he discussed the fact that COPD effects the lungs, yet it also effects the heart, the brain, and even the skin.

He writes that "poorly reversible airflow limitation caused by inflammation is mainly a result from smoking." More recent evidence has caused an evolution of the diagnosis of this disease to more of a "heterogeneous" disorder.

He notes that "extrapulmonary" complications complicate the treatment of the disease. I wrote earlier about end stage COPD, where the heart becomes large because it works so hard to push blood through stiff lungs. This ultimately causes heart failure, or otherwise called Chronic Heart Failure (CHF).

A weakened heart often causes fluid to back up into the lungs, and this causes breathing to become even worse. So now not only does bronchodilator and other hyperinflation therapy become routine treatment, medicines to strengthen the heart, and diuretics, are also indicated.

Likewise, a heart that is overtaxed for many years may revert to an abnormal rhythm called atrial fibrillation. This can become chronic over time. So now medicine must be used to control this rhythm and the rate.

Heart failure often also results in pedal edema, or leg edema. If these comorbidities become severe enough they can effect mobility.

And the more comorbidities associated with COPD the more difficult the management is. For example, diuretics are needed to help get excess fluid from the body may cause electrolyte imbalances that may cause more cardiac arrhythmias, some that may be fatal if not diagnosed and treated right away. Overuse of diuretics may cause renal failure too.

So there is a balancing act. Beta blockers are often used to treat heart failure, yet these meds may cause bronchospasm, especially in asthma and COPD patients.

Heart complications may be attributed either to end state COPD, yet they can also be attributed to smoking. Smoking hardens the arteries and makes the arteries weaker. Smoking also weakens the heart and can cause heart failure.

However, other complications of COPD cannot, Nussbaume writes, cannot be attributed to smoking. These include:

• musculoskeletal wasting
• metabolic syndrome
• Depression
• weight loss
• muscle wasting
• tissue depletion

Muscle and tissue and skeletal loss, coupled with lung obstruction, may lead to a "reduced capacity to exercise." Poor exercise may "directly impact poor prognosis."

He writes that, " The mechanisms underlying weight loss and muscle wasting are incompletely understood but likely involve an imbalance in ongoing processes of protein degradation and replacement. This may include alterations in the relative levels or activities of endocrine hormones such as insulin, growth hormone, testosterone, and glucocorticoids."

The use of steroids may also cause insulin to get out of whack to, and this will cause the physician to require the patient to monitor his sugar and take medicines to treat this too. So all the medicines involve a fine balancing act. You can't do too much of this because it could cause that to go out of whack.

However, it's believed chronic inflammation is a key cause of the lung component of COPD. Now it's believed that chronic inflammation may be systemic more so than just in the lungs. This chronic inflammation may be what causes the extrapulmonary complications.

I'ts believed that "altered" inflammatory mediators may be circulating in the bloodstream of COPD patients, and this may result in "altered" organ function.

I think physicians have known about these other comorbidities for years. I've seen many COPD patients being treated for depression and anxiety. However I'm not sure about the musculoskeletal wasting and the metabolic syndrome.

However, I'm wondering if these might also be complications of the treatment of COPD, thus caused by medicines such as systemic corticosteroid therapy used to treat inflammation.

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What do you need to know about liability insurance

It's rare that this happens, but there may come a time when you have to be a participant in a lawsuit where you or the hospital is being sued by a patient or patient's family. The question of the day is: Are you as an individual covered by the hospital's malpractice insurance?

This was the topic of a column by Anthony L. DiteWitt in the February, 2011, issue of the AARC Times. He writes that Insuranse policies are like "contracts" and they only cover those who are named on the contract. In most cases, the name on the contract is not the individual RT or RN or doctors, it is the institution -- the hospital.

Most liability contracts also list the officers of the hospital, such as administrators. Yet it's rare for RNs, RTS and doctors to be listed. So then, is it essential that you as an individual care provider at a hospital get your own malpractice (liability) insurance?

He says it's up to you to decide, and then he provides some examples.

You as a worker have a personal liability to the patient. Howeve, under the law of respondeat superior, "the hospital is also accountable for the negligent acts of its employees. This is also called vicarious liability."

He expounds:

"In most cases the plaintiff sues the hospital because the hospital is more likely to have assets than the employee, and the hospital's policy provides coverage to the corporation for the negligent acts of its employee. But if the patient sued only the employee and did not sue the hospital, the hospital's insurer would provide no coverage to the employee. While this is rare, it can and does happen, particularly where the patient has a personal grudge or doesn't use a lawyer."

Then there is indemnity and contribution.
So, what is indemnity? He defines it this way:

"Indemnity provides that where a master pays for the wrongs of his servant under respondeat superior the servant must indemnify (or repay) the master. Most hospital insurance policies provide for the insurer to seek indemnity from any liable employee. Thus, if the hospital pays $300,000 to settle a claim arising from the negligence of a therapist, the insurance company can sue the therapist for indemnity to recover what it paid. Again, while this is rare, it does occur."

So what is contribution? He defines it this way:

Contribution is a separate doctrine and arises where, for example, the physician and not the hospital is sued for negligence. Suppose the physician settles a claim for $300,000 and alleges that had the therapist communicated the blood gas values to him, the harm would not have ensued. He can sue the therapist for contribution and force him to pay all or part of the amount he paid in settlement.

He adds that some hospital administrators might tell you that you don't need your own malpractice insurance and yet they say this because they don't fully understand what was described above. They'll tell you that the hospital policy will protect you, yet, as you see above, that is not necessarily the truth.
The hospital lawyer is not your lawyer, he is the hospital's lawyer. "If you ask the lawyer whom he represents and he is honest, he will tell you that he represents the hospital. He may provide you with legal advice and help defend your case; but he is duty-bound to protect the hospital, and not you."
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is it alright to discontinue theo-dur anytime

Your question: is it alright to discontinue theo-dur anytime

My humble answer: This is a good question for me to answer, because I was on Theo-dur for 25 years, and every time I'd skip a dose I'd have an asthma attack. So I thought I'd be on it for life. The idea here was that once you have a certain theophylin level in your system, your body expects it to be there always. So, if you suddenly stop taking it, your body may punish you the way it punished me.

That is why a slow wean is important with theodur. Ideally, you should work with your doctor on a good plan for weaning yourself off this once popular and now essentially out-dated medicine because of all the aweful side effects.

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Are you a good asthma parent?

Are you a good asthma parent? Find out by reading my latest asthma post at MyAsthmaCentral.com

Josie Goofus: The Asthma Parent You Don't Want To Be

Josie Goofus is the asthma mom who does everything wrong. She's the antithesis of Jane Gallant, our asthma mom who does everything right. So while Jane was sitting in the principal's office discussing her asthma daughters asthma action plan, Josie was snoozing on her couch dreaming of her upcoming vacation to the Bahamas.

Josie is a wonderful person. She's assistant vice president at the local bank, and was recently elected to serve as a member of the county commission. And on the side, she organizes fund raisers to make money for cancer victims. She's cordial, gregarious, and just a fun person to be around.

Yet, still, when it comes to managing her daughter's asthma she's so far out in left field she might as well be in the stands. Don't get me wrong here, for she's a good mother to Jill, her asthmatic daughter.

Yet while she knows Jill has asthma, has sat with Jill many nights in the emergency room, she has yet to realize the importance of being proactive when it comes to preventing asthma. To Josie, if Jill is not right now having an asthma attack, then she doesn't need to be thinking asthma.

So instead of thinking about her daughter's asthma on this nice, warm day, Josie has the air conditioner cranked, and is in a deep sleep as the cuckoo bird sings its mid day song. Startled, she hops off the couch and waddles through the kitchen where preventative asthma medicine (in this case Azmanex) has been collecting dust for over two months.

She grabs her cell phone and quickly clicks in a number. "Hello, Sarah, how're the kids?"

BANG! The sound of the front door slamming startles her. Little Jill trudges through the living room, shoulders high.

"Your inhaler is on the counter, honey," Josie says to her five-year-old daughter when she realizes her plight. "Here. Take two puffs of this, honey," she says as she scoops up the inhaler and proffers it to her precious little baby.

The spacer, by the way, was thrown in the trash probably about a year earlier. Josie thinks about this a second, then shrugs off the thought. "Yeah," she says into the speaker, "I am soooo burned out. The Bahamas can't come soon enough."

She watches as her daughter takes two quick puffs of her inhaler, and rush back to the front door. SLAM! "She must be feeling better," Josie thinks, then says into the receiver, "Yeah, it can't come soon enough."

Josie presses end and sits back down on the couch. She smiles as she thinks how independent Jill has become. It was a year ago she had her last really bad asthma attack, and now it appears her asthma is gone. Thank God we don't have to take her to the doctor for her asthma anymore," she thinks. "When was that last visit? Gosh, it must have been the day of the asthma attack."

And now school's coming up soon. She read about asthma action plans, and that she should talk to the teacher and principal about making sure they knew what to do in case Jill has an asthma attack at school, yet Jill's fine now. She doesn't have asthma anymore, so it seems.

Her mind drifted to hot beaches and sunny days.

Fast forward one month. The school principal called and said she was taking Jill to the hospital, and that Josie should meet them there. "She's having a bad asthma attack," the principal said.

So what all did Josie do wrong in this story?

1. Josie did not have Jill take her preventative medicines every day

2. She did not supervise Jill while taking her inhaler

3. She did not have Jill use a spacer, which makes the inhaler work 75 percent better and last longer

4. She did not take Jill for regular doctor's office visits

5. She did not work with her doctor on creating an asthma action plan

6. She did not work with Jill's teachers on creating a school asthma action plan

Jill wanted what was best for Jill, yet she failed to read up on the latest asthma wisdom. While she was a good mom overall, she didn't fully understand the scope of her daughter's disease, and what she could do to prevent asthma exacerbations.

While we don't want to admit it, many of us asthma moms and dads are just like Josie Goofus. We have the best interest of our asthmatic children in mind, or do we really?

Are you a Josie Goofus? Or are you more like Jane Gallant, or somewhere in between?

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The 13 virtues to being a good kid

A virtue by nature is a good quality in you that will help you be the best person you can be, and who is well respected by the people you come into contact with.

1. Harmony: Stay calm at all times; do not get angry over trifling things
2. Silence: Speak only what is useful to you and others; speak only when spoken to
3. Refrain: Don't go on the defense, it makes you look guilty
4. Restraint: Do not talk bad about other people
5. Respect: Think of the other person before yourself
6. Responsible: Get your homework and chores done first, and then have fun
7. Compassion: Be friendly to everyone, as this makes up for any flaws you have; treat others as you would expect to be treated
8. Honesty: Telling the truth encourages others to respect you; do what you promise
9. Charity: Sacrifice your own pride to keep the other person happy.
10. Humility: Read the Bible and pray often, and always imitate Jesus
11. Industry: Work hard at everything you do; do the best job you can
12. Reliable: Do what is expected of you in a timely manner
13. Honor: Listen to and obey the commands of your parents, teachers and elders